Back to Sleep- What's a Parent to do?

Printed in the SIDS Horizons_ June 1996
Article by Elsa L. Weber, M.S., CHES., Editor
Consultation provided by:
Andrea N. Herron, R.N., M.N., C.P.N.P. Lactation Consultant in private practice, San Luis Obispo, and
Thomas G. Keens, M.D. Childrens Hospital, Los Angeles, California

In 1992, when the American Academy of Pediatric began to recommend that healthy babies be placed on their back or side to sleep a whole new set of sleep issues arose for parents, as well as for the health professionals they turn to for help. The growing body of literature examining the association between SIDS rates and sleep practices such as sleep position, swaddling, types of bedding, and room temperature, etc., is confusing. Many of the traditional methods used and recommended by health professionals to comfort a fussy baby and to help him sleep better and longer are now being questioned. More and more often health professionals and parents are asking about "tried and true" methods and how using them will affect the individual baby's risk of SIDS. Here is some information that may help you make recommendations to the parents and professionals asking for advice.

Keep things in perspective
When it comes to SIDS, health care providers need to help calm parents' fear of SIDS, and to keep their baby's sleep position and their infant care practices in perspective. First, educate parents so they understand that the possibility of their baby dying of SIDS is very low, regardless of the baby's sleep position. Parents should do everything they can to get their baby to sleep on his back or side, but shouldn't lose sleep over a resistant infant that will not.

When baby won't sleep on his back, try side sleeping
Some infants who are resistant to sleeping on their backs may be willing to sleep on their side. Side sleeping allows the infant to easily move into the fetal position, which may help comfort a fussy baby and lessen the possibility of some babies starling themselves with their own jerky movements. Extending the baby's lower arm straight out from his body will help stabilize the baby in the side position and help reduce the chances of him rolling onto his stomach if he moves.

Changing the sleep position of an older infant
Older infants, who are able to move by themselves, should never be restricted or forced to sleep on their backs. An older infant, who has been conditioned to sleep on the tummy may be very resistant to change and it may not be necessary. Explain to parents that the highest risk period for SIDS is between 2-4 months. In addition, they should know that back sleeping is not a guarantee that SIDS won't happen, it only reduces the possibility of SIDS; some babies die of SIDS while sleeping on their back and most babies that sleep on their stomach do not die of SIDS. If parents are still concerned they can try letting the tummy sleeper fall asleep on his tummy first than switch him, or hold and rock or breast feed the tummy sleeper to sleep before they put him down. Under no circumstances should parents be losing sleep by getting up during the night to continually keep switching the baby onto his back. A firm sleeping surface not cluttered with soft, fluffy bedding and stuffed toys may be the best risk reduction that parents of a confirmed tummy sleeper can provide. For most babies that will be enough.

Wedges
SIDS experts do not endorse the use of wedges and those that restrict the baby's freedom of movement should never be used. Parents who use wedges should be shown the correct positioning for side sleeping (as described above) and if they persist in using wedges should be encouraged to use a front wedge only, this will help the baby to roll onto his back, not his stomach if he moves.

Swaddling
Information about the association between over bundling and overheating and SIDS has made many professionals and parents nervous about using swaddling. Some studies, from Tasmania, have suggested that swaddling is one of the factors that increases the SIDS risk for infants sleeping on their stomach. However, swaddling in itself does not cause SIDS. It is currently believed that SIDS is caused by a number of factors occurring at the same time, of which swaddling may be one. In fact, a later study from the same country found that the association between swaddling and SIDS was not significant in infants who were sleeping on their back. So, swaddling can be used if the baby sleeps on his back.

Overheating
Vague information about overdressing may not help parents (and grandparents) who believe that the (normally cold) hands and feet of infants is an indication that the infant is cold. Teach parents to check for sweating around the face, head and neck as an indication that the baby is over dressed and that less clothes are needed. A good rule of thumb is to tell parents to dress their baby with the same amount of clothing that they are wearing.

Dealing with old wives' tales
Changing health practices is not an easy task, especially when it comes to child care. It is very common for new parents to ask for advice. Unfortunately, most of the information that parents receive come from mom, another relative, the neighbor down the street, or the media. Far too often the information is based on myth, is conflicting and is often presented in a way that produces fears and guilty feelings. Placing an infant on the back to sleep has been considered dangerous for a long time; parents are likely to have many concerns about adopting the practice. They need to be assured that back sleeping is safe, that countries which have switched to it extensively have not experienced increases in the number of infant deaths from aspiration. Parents and professionals in the SIDS community can help combat misinformation by staying knowledgeable and providing a non-judgmental environment in which parents can ask questions. This will help eliminate fears and help parents understand and use the risk reduction practices.

How parents and health professionals can help in their communities
Newborn babies most often get into the habit of sleeping in the position they are first put down. Because of that, education on sleep position should begin with those professionals that have contact with mothers before birth and right after the birth. Make sure that your local pediatricians, OB/GYNs, and hospitals have the latest information on SIDS and sleep position.