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Safe Sleep (BONUS module) : Rebecca Scott-pillai

Safe Sleep (BONUS module)

Introduction

When you watch the sleep science module, you’ll know that newborn babies have a lot more light sleep than adults do.  This is protective against SIDS.  The fact that babies wake frequently, and have light sleep, are both factors that help to protect against SIDS.  Therefore, we have to be careful that any interventions or sleep strategies on our part don’t inadvertently increase the risk of SIDS. We don’t want our babies sleeping so soundly that they struggle to wake up. There is a balance between safe sleep for your baby and and making sure YOU get enough sleep too.

WHAT IS SIDS?

Sudden infant death syndrome (SIDS) is the sudden, unexpected and unexplained death of an apparently healthy baby. (Source:  NHS website)

The risk of SIDS is highest in the first six months of life, but statistically, SIDS is also very rare.  Around 200 babies in the UK die from SIDS a year.  To put this in context, in 2020 there were around 700,000 births in the UK.  

There are definite risk factors for SIDS but simple interventions on your part can reduce this risk significantly.  You can find more information on the Lullaby Trust website.  There are safety checklists included in the materials section of this module for you to use as well.

Where your baby sleeps

The official advice is that your baby should sleep in his/her own space – this could be a moses basket, a crib, or a cot.  Some parents will choose a crib that has a drop down side so that the baby can sleep next to the parents’ bed but still in his/her own space. Bear in mind that sleep should be supervised for the first six months.  This means that if you choose to put your baby in a bedroom for daytime sleep, you should stay with them. For this reason, many parents will have a moses basket in the living room for naps during the day.  Some parents may choose to use a pram or carrycot for day sleep – if you use this option, make sure that your pram model is approved for sleep, as not all of them are. 

Some parents will choose to co-sleep, or share a bed with with baby.  Adult beds are not designed with the safety of infants in mind.  Therefore, it is important that if you decide to co-sleep, you make the environment as safe as possible.  Even if you don’t intend to co-sleep with your baby, it is worth having a look at your bed and making it as safe as possible as a lot of parents will bring their baby into bed and accidentally fall asleep, even though they weren’t planning to co-sleep.  There is a co-sleeping checklist in the course materials.

Co-sleeping can be beneficial for parents and babies.  Often, babies will settle and sleep better in close proximity to their parents, and so therefore, parents get more sleep.  If you are breastfeeding, there is a definite link between co-sleeping and duration of breastfeeding.  Basically, if you want to breastfeed, co-sleeping will make the process easier and you are more likely to continue breastfeeding for several months/years, depending on your breastfeeding goals.  Dr James McKenna coined the phrase “breastsleeping” where mother and baby engage in a synchronous sleeping and feeding pattern:  neither baby nor mum wake up fully during the night, but the baby feeds and falls back to sleep.  In the morning, mum knows that baby has fed, but isn’t sure how often or when.  When it works, breastsleeping can be a very natural, low stress way of sleeping and feeding.  However, it doesn’t work for all parents!

IS BEDSHARING SAFE?

This is an interesting question that has been debated for quite some time.  Many of the research papers that have looked at SIDS in relation to bedsharing haven’t done a great job of differentiating between SIDS which occurred when there were no risk factors and SIDS which occurred when there were risk factors (for example: smoking, drug use, or prematurity), and often didn’t differentiate between safe bedsharing where baby fell asleep in bed with a parent, and a baby falling asleep on a sofa with a sleeping parent.

Falling asleep with a baby on a sofa is much more dangerous, as babies can roll off a parent and get trapped between the parent and the sofa, or get trapped between sofa cushions. The irony is that there is a risk that parents will avoid bedsharing (because they think it is dangerous) and get up to sit on a sofa, and fall asleep there instead, which is far riskier than bedsharing.

UNICEF, the Lullaby Trust and BASIS all have guidelines for safe bedsharing, and the general consensus is that if bedsharing is done safely, it is no more risky than having your baby sleep in a separate cot or moses basket. 

What about sleeping in car seats, slings and bouncy chairs?

CAR SEATS

It is ok if your baby falls asleep in a car seat. If possible, fix a mirror to the back of the seat so that you can see them while they sleep. Alternatively, an adult may choose to sit next to them when practical. If you are lifting the car seat out of the car, and your baby is still asleep, the safest option is to take your baby out of the car seat and lie them flat for the rest of their nap. 

SLINGS

Babies will often sleep very well in a sling, on a parent. This mimics that “default” position that I talk about – where babies lie curled up on your chest. They find this position particularly soothing and regulating. While very similar to contact napping, at least with a sling you can move around and get stuff done while they sleep!  Provided babies are positioned safely in a sling, they are safe to sleep there. It is important that you can see their face at all times and that they are positioned in a way that their airway is clear. I have a blog post on sling use and a video on positioning in a sling which ensures that their airway is clear. 

BOUNCY CHAIRS

Bouncy chairs or baby swings can be a real life-saver, buying you a few minutes of time in those early weeks. It isn’t recommended that babies sleep in them though, as they may end up curled up and block their airway. 

What if my baby only sleeps on me?

Some babies are determined not to sleep on their back!  This is a really tricky situation. I often talk about this curled up position on your chest as being the default position for babies, as is soothing and helps regulate their emotional state. Dr James McKenna, who I mentioned before, feels that this is the biologically normal way for infants to sleep. In this position, parents help regulate a baby’s breathing and the risk of SIDS is reduced, even though babies are sleeping on their tummies. It is likely that for millennia babies have slept like this. However, this would have been in times where sleep surfaces were probably safer for babies – firm mattresses, or none at all, no fluffy pillows or duvets. While from an evolutionary perspective, I can understand that this may a biologically normal position for babies to sleep in, I think it would be difficult to advise this sleeping position if parents are asleep too. The current advice is that babies should sleep on their backs, therefore I’d work towards getting a baby to sleep on his/her back in the first instance, unless parents/carers are able to take turns sitting awake with baby on their chest – I realize that this is NOT practical in most situations. There is a separate section in the sleep shaping module about trying to move away from contact napping.

To swaddle or not to swaddle

I am not a fan of swaddling, to be honest. I find that swaddling:

  • Can interfere with feeding cues – babies often put their hands to their mouth when they are hungry.
  • Babies self-soothe by touching their face – when their arms are swaddled they lose this opportunity.
  • Babies need to be weaned off a swaddle by the time they are rolling (around 14-16 weeks) and need to learn to integrate that startle reflex. Using a swaddle merely delays the process of babies learning to sleep without their arms tucked in.
  • A tight swaddle around the hips can increase the risk of hip dysplasia.
  • There is some evidence that babies are at increased risk of SIDS from swaddling. 

Below is a video of how to put your baby down without triggering that startle reflex.

Do dummies/pacifiers reduce the risk of SIDS?

There is a bit of confusion on the topic of dummies/pacifiers. Some babies will adjust to sleeping with a dummy. It is thought that the frequent sucking on a dummy helps to keep babies in lighter sleep, which in turn helps them rouse quicker if necessary. The evidence would suggest that it’s not so much that babies are given a dummy that reduces SIDS. Rather, it’s that taking a dummy away may increase the risk of SIDS. For this reason, it’s recommended that if you’ve started giving a dummy, it’s best not to take it away until your baby is over the age of six months, when the risk of SIDS reduces dramatically.

How your baby sleeps – a summary of the recommendations

BACK TO SLEEP 

Following on from that last section, it’s really important that your baby is put down to sleep on his/her back – this one intervention has seen a dramatic reduction in SIDS over the last few decades. Once babies can roll front to back, and back to front, you don’t need to reposition them on their back during the night. However, always start them off on their back. 

FEET TO FOOT

If your baby is sleeping in a cot or crib, it’s important to position them so their feet are at the bottom of the cot. This reduces the risk of babies wriggling down under covers.

NOTHING ELSE IN THE COT

Cot bumpers and sleep positioners should not be used. Comfort objects like loveys or teddies should also not be used for sleep before the age of a year. Basically, there should be nothing in your cot except for a baby!

TEMPERATURE REGULATION

The ideal temperature for your baby’s room is around 16-20 degrees. If you use a blanket it should be well tucked in below the level of your baby’s shoulders. Sleeping sacks are another option, however it’s important to make sure that the neck opening isn’t big enough that the baby could slip inside the sleeping bag – most of them come with weight guidance. Babies will often have cold hands and feet at night time – this is ok. The best way for you to check their temperature is to place your hand on the back of their neck or chest. If they feel hot and clammy, you will want to reduce the layers they have on, and if they feel cool, you can add another layer. 

DON’T SMOKE NEAR YOUR BABY

This probably goes without saying, but you should never smoke near your baby or in the room where they sleep, as this increases the risk of SIDS considerably.

As your baby gets older

Over the age of six months, sleep no longer needs to be supervised. This means that you can, if you want, let your baby sleep in a separate room. Some evidence would suggest that it’s still safer to sleep in the same room as them for the first year. If you decide to let them sleep on their own after six months, it’s important to still maintain the same level of safety: feet to foot, back to sleep, nothing in the cot except the baby, secure covers, and good temperature control.

Once your baby starts pulling him/herself to standing, you’ll want to make sure that the cot base is at the lowest position to reduce the risk of your baby falling out of the cot. 

Parents who chose to bedshare often wonder what to do when baby starts to roll – there is a risk that the baby will roll out of the bed! Mesh cotsides designed for adult beds aren’t safety tested for babies – there is often the potential for babies to slip down between the mattress and the cotside. Options for co-sleeping families include: pushing the bed up against a wall (make sure there are absolutely no gaps between the mattress and the wall), or moving to a floor bed – placing the mattress on the floor or on a small platform. 

Once your baby is over 12 months, you can relax some of the safety rules a little. Comfort objects are ok, and they can fall asleep in any position they like! It’s worth making sure that they can’t climb out of their cot and if there is a risk that that might happen, you could consider moving to a toddler bed or a floor bed. It’s a good idea to childproof their bedroom as well, and have as little as possible in the room, as well as making sure they can’t wander out of their room and down stairs.

BASIC SLEEP SAFETY 0-6 months

Back to sleep

Feet to foot

Room isn’t too warm (16-20 C)

Nothing else in the cot

Secure covers

No smoking near the baby

Supervised sleep

 

BASIC SLEEP SAFETY 6-12 months

Back to sleep 

Feet to foot

Room isn’t too warm (16-20 C)

Nothing else in the cot

Secure covers

No smoking near the baby

 

BASIC SLEEP SAFETY 12-18 months

Clear sleep space, although a safe comfort object is ok

Make sure they can’t climb out of the cot

Safety proof their room

Published by Rebecca Scott-Pillai

Rebecca Scott-Pillai is a paediatric sleep consultant and lactaction consultant (IBCLC) based in Lisburn, Northern Ireland. She lives there with her two kids, two cats and dog! With over 20 years experience working with families, Rebecca uses her knowledge and experience to provide collaborative flexible plans for gentle, responsive families.