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March 21, 2001
Staving off SIDS
When it comes to safe sleeping, back is best

first letter Xs I watched my baby nephew breathing softly in his sleep, I thought, "Thank goodness he's past that hurdle." As a doctor I recognized that, at age 12 months, Brian had survived the critical first year of life, when most cases of sudden infant death syndrome (SIDS) occur. I breathed a sigh of relief.

Ounce of Prevention


By Elizabeth Smoots, M.D.

Our good fortune probably has something to do with how Brian's parents have been putting him to sleep. Every night and naptime when they tuck him in, he's lying on his back. I wish more parents did the same.

But a recent survey conducted by the U.S. Consumer Product Safety Commission (CPSC) says the majority do not. According to the survey, only 43 percent of American parents put babies to sleep on their back, as recommended by health and safety officials to reduce the risk of SIDS. The survey also indicates that, in general, too many parents still follow unsafe infant sleep practices, further increasing SIDS risk. Out of a total of almost 500 families polled, 51 percent of parents said they placed babies to sleep on their stomachs or sides, and 67 percent said they regularly used soft bedding in cribs.

Among African American parents, the numbers are even more alarming -- only 31 percent put babies to sleep on their back, and 85 percent use soft bedding in their baby's crib. This may help explain why, according to the American Lung Association, African American babies are more than twice as likely to die from SIDS.

We know tragic deaths from SIDS are largely preventable. But as the survey points out, much work remains to be done.

Solving the mystery of SIDS

So far we're making progress. In the spring of 1992, based on scientific evidence available at the time, the American Academy of Pediatrics (AAP) first began recommending that healthy infants sleep on their back to reduce the risk of SIDS. Then, in June 1994, the AAP and U.S. Public Health Department launched a national "Back to Sleep" campaign aimed at spreading this sound advice. The rate of SIDS deaths in the United States has since dropped by a dramatic 40 percent.


Some parents fear babies will choke if they sleep on their back, but evidence has not borne this out. Studies show the highest risk of SIDS is associated with stomach sleeping.


We still have a ways to go, however. In countries where stomach sleeping has been reduced to no more than 5 to 10 percent, reductions in the SIDS rate have approached 70 to 80 percent.

Expert still can't explain exactly why an infant's sleeping position might affect the risk of SIDS. Many theories focus on breathing problems. Studies suggest that stomach sleeping may increase SIDS risk by forcing babies to rebreathe their own expired air -- leading to carbon dioxide build-up and low oxygen levels. This is especially likely to happen if soft bedding becomes molded around a baby's head while the baby is lying face down. Belly sleeping also interferes with a baby's ability to dissipate body heat; this may contribute to overheating, which could inhibit the baby's ability to awaken if he or she had trouble breathing.

Safe sleeping

From a SIDS risk-reduction point of view, I usually counsel parents that "back is best." Some parents fear babies will choke if they sleep on their back, but evidence has not borne this out. Studies show the highest risk of SIDS is associated with stomach sleeping. The side-lying position hangs in the balance because babies have a tendency to roll toward their tummy.

This advice holds for healthy infants, like my nephew Brian. Be sure to consult your health care provider if your baby has a medical condition. Then safely put a babe under age 12 months to sleep with the following recommendations from AAP and CPSC:

  • Place your infant in a crib that meets current safety standards and has a firm, tight-fitting mattress and snug-fitting bottom sheet specifically made for crib use.
  • Remove all pillows, quilts, comforters, fluffy bumper pads, sheepskins, stuffed toys, and other soft products from the crib.
  • Consider using a sleeper, with no other covering, as an alternative to blankets.
  • If using a blanket, put your baby with his or her feet at the foot of the crib. Tuck a thin blanket around the crib mattress, only as high as the baby's chest.
  • Make sure your baby's head remains uncovered during sleep.
  • Do not place your baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to slumber.

Now you can sleep soundly, knowing you've helped ensure a safe slumber for your baby.

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Elizabeth Smoots, M.D., F.A.A.F.P., is a board-certified family physician in Seattle, Washington. A fellow of the American Academy of Family Physicians, Dr. Smoots specializes in prevention and primary care medicine.