Safe Sleep Questions: You Asked, We Answered

We asked if you had questions about newborn safe sleep practices on Facebook and you delivered! Here are the answers to some of your questions:

My 6-week-old baby has bad acid reflux and starts spitting up about an hour after feeding…is it still safe to put him on his back? I’m getting little to no sleep always checking on him, I’m always worried he’s going to choke and I won’t hear him.

It is frightening to hear your baby making choking noises, but it is safe for him to sleep on his back as long as he does not have a medical condition where there is an anatomic abnormality that has not been repaired. Sleeping on the back does not increase the baby’s risk of choking, even if the baby has reflux like yours does. This is because the anatomy of the infant’s airway prevents the baby from aspirating, or breathing into their lungs, their vomitus. 

The noise you heard is your baby clearing his airway, which means your baby’s protective airway is working. Click here to see why babies do not aspirate when laying on their back. All babies have some degree of reflux due to the relaxed muscle between the stomach and esophagus. This will improve with time – usually around 7 or 8 months of age. If your baby’s spitting up is concerning to you, please contact your baby’s healthcare provider immediately.

Why is it unsafe for baby to sleep on their belly? (Assuming the surface isn’t able to close in around their nose.) What’s the logic/thinking about belly is bad?

There are several reasons for having a baby sleep on their back. Research shows that placing a baby on their back to sleep at nighttime and naptime decreases the chance of sudden unexplained infant deaths (SUIDS), with the best known SUID being sudden infant death syndrome or SIDS. SUIDs are the number one cause of infant deaths between 28 days of age and one year of age in Ohio and in the United States. Researchers are not sure why back sleeping decreases the risk of SUIDs, but the thought is that babies that sleep on their stomachs sleep too deeply, may get less oxygen or have trouble getting rid of carbon dioxide and end up “re-breathing” the carbon dioxide.

There is also research that suggests one of the causes of a sudden infant death could be an underdeveloped region of the brain. At this point we cannot determine by looking at an infant if they may have an underdeveloped region of their brain that would put them at an increased risk for SIDS. Because of this, the recommendation is that all babies sleep on their back for the first year of life, in order to decrease the number of babies who die from SIDS. Since the recommendation came nearly 17 years ago for babies to only sleep on their backs, the number of babies that die from SIDS has dropped dramatically.

When can babies start to sleep with a blanket or lovey?

Babies can start to sleep with a blanket or lovey at one year of age, at which point the infant is able to rescue themselves out of unsafe situations.

Is a Rockn Play™ safe for overnight sleeping?

No, a Rock ‘n Play™ is not safe for overnight sleeping or for naps. It does not conform to the safety standards of the Consumer Product Safety Commission for a safe sleep surface for newborns. A safe sleep surface has the infant sleeping on a flat firm surface. The surface should maintain its shape when the infant is placed on the surface and does not conform to the infant’s head. Any surface that does not stay flat with the infant on it, increases the risk of the baby re-breathing exhaled air or suffocating.

Let’s talk about co-sleeping. In reality, with safe sleep practices, this is best for mom and baby over generations in many cultures. So why do you promote against it instead of teaching safe co-sleeping ways, especially when many moms are doing it already?

First let me say that it is not any health care provider’s goal to make mothers feel guilty about their sleeping choices, but it is our responsibility to educate mothers and fathers on what the current recommendations, based on strong evidence, are for safe sleeping. We want you to make an educated decision about what you are doing.

There are several reasons why we promote a baby sleeping in the same room as the parents, but on a separate sleep surface and we do not promote co-sleeping in the United States, even though it is something that is done here, as well as every country in the world.

The first reason is the knowledge that there is an increased incidence of SUIDS/SIDS in babies who co-sleep with their mother and/or father and a decreased incidence (as much as a 50% decrease) for babies who have their own sleep surface. When a baby has their own sleep surface there is less chance of baby suffocating, strangulating or becoming entrapped which is what can occur with co-sleeping. As health care providers we question ourselves when a baby dies, if there was something we could have said or done to prevent that baby’s death. If we did not talk to parents about this topic and follow the recommendation of the leading pediatric organization in the United States, we would be neglectful of our duties.

Secondly, adult sleeping environments are significantly different they are in most other countries. When you travel you realize that pillow-top mattresses which are overly soft and dangerous to a baby are not found in other parts of the world. The mattresses found in other countries are thinner and firmer than what we have in the United States, and many people actually sleep on mats on the floor.

You state that generations have co-slept with their babies, which is true, but that was usually out of necessity as there were only one or two beds in a household. When you look at infant mortality rates in the United States when co-sleeping or bed-sharing was more common, it was much higher. We are doing everything we can now to make sure that all babies have a chance to celebrate their first birthday, which includes teaching parents about safe sleep for their baby.

As for how to safely co-sleep or bed-share, there is no strong evidence to suggest there is a safe way to bed-share or co-sleep with a baby. Devices that are marketed to promote safe co-sleeping have not been proven to prevent SIDS or suffocation and until there is evidence that proves that they do, as health care providers we cannot recommend them.

Evidence has shown which circumstances make bed-sharing or co-sleeping more dangerous to a baby and we recommend to always avoid them. Those circumstances are:

  • bed-sharing with term normal weight infants less than 4 months of age
  • infants born preterm or low birthweight even if they are being breastfed which is a protective factor to prevent SIDS
  • bed-sharing if you or your spouse is a smoker
  • bed-sharing when you or your spouse are impaired by sedating medications, alcohol, drugs or exhausted from lack of sleep
  • bed-sharing with a person that is not the infant’s parent
  • bed-sharing on soft surfaces such as soft mattresses, waterbeds, sofas, or an arm chair
  • bed-sharing with soft bedding, accessories, pillows or blankets

For more information on Safe Sleep Practices, click here for our Helping Hands.

Gail Bagwell, DNP, APRN, CNS
Gail A. Bagwell, DNP, APRN, CNS is a member of the Nationwide Children's Hospital Division of Neonatology team. She completed her undergraduate degree in nursing at West Virginia Wesleyan College, her master's in nursing at the University of Cincinnati and her doctor of nursing practice at Chatham University. Gail joined Nationwide Children's in 1993 as the Clinical Nurse Specialist in the NICU. In 2000, she became the Clinical Nurse Specialist for Perinatal Outreach where she works with the healthcare providers caring for neonates in Nationwide Children's large referral area of Central, Southeast, Northwest and Northeast Ohio. In this role, she provides education to healthcare providers on the well-newborn as well as care of the sick and premature newborn, and serves as a resource on neonatal and quality improvement initiatives. Gail's interests are neonatal abstinence syndrome, breastfeeding, safe sleep and parent transition. Gail is a member of NANN, AWHONN and Sigma Theta Tau. Gail is a regional trainer for NRP, a lead S.T.A.B.L.E. instructor and a published author having written chapters in all five editions of the Kenner and Lott "Comprehensive Neonatal Care" textbook.

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