Safe to Sleep

Pediatric Pathways

Safe to Sleep

Our Authors

Pediatric Pathways from American Family Children's Hospital: Dr. Kristin Shadman

Kristin Shadman, MD


Pediatric Pathways from American Family Children's Hospital: Nan Peterson

Nanette Peterson, RN, MS


Our Services

Safe to Sleep Program

After reading this article and answering the review questions the reader will be able to:

  1. State the risk factors for unsafe sleep in infants.
  2. Describe best practice recommendations for infant safe sleep.
  3. Describe strategies to promote a safe sleep environment for infants in the home.


A 25-year-old African American woman comes into your office with her 3-month-old male infant for a well-child check. She is a single mother with three other children and works thirty hours a week. She had her first child when she was 16 and her 3-month-old was born preterm with low birth weight. The mother has tried several times to quit smoking but has been unsuccessful. While she is at work the grandmother takes care of the infant and a couple of other children in her home.

When asking the mother about the sleeping arrangements for her infant, she tells you that she was given a used, older crib and blankets, bumper pads and sheets from a friend. She notes that she places the infant on its back to sleep. The crib is set up in a room across the hall with two younger siblings. The infant wakes up frequently to eat during the night. The mother tells you that she lies down with baby in her bed to breastfeed and is usually too tired to return the infant to his crib.

Overview of Infant Sleep-related Deaths

Sudden unexpected infant death (SUID) is the death of a previously healthy infant without an immediately obvious cause prior to investigation. After case investigation, SUIDs can be attributed to suffocation, asphyxia, entrapment, infection, ingestions, metabolic diseases, cardiac arrhythmias, and trauma (accidental or nonaccidental). These deaths may be further categorized as: 1) SIDS (sudden infant death syndrome), sudden death of an infant younger than 1 year of age that cannot be explained even after a full investigation that includes a complete autopsy, examination of the death scene, and review of the clinical history; 2) ASSB (accidental suffocation and strangulation in bed); or 3) other unspecified causes. One type of SUID, ASSB is a cause-of-death code used for vital statistics purposes. This code is used to identify infant deaths caused by suffocation or asphyxia in a sleeping environment, for example:

  • Suffocation by soft bedding: When soft bedding, a pillow, or a waterbed mattress blocks the infant’s airway.
  • Overlay: When another person shares the sleep surface with the infant and lays on or rolls on top of or against the infant while sleeping, blocking the infant’s airway.
  • Wedging or entrapment: When an infant gets trapped between two objects, such as a mattress and wall, bed frame, or furniture, blocking the infant’s airway.
  • Strangulation: When something presses on or wraps around the infant’s head and neck blocking the airway.

The infant mortality rate in the United States for 2010 was 6.15 infant deaths per 1,000 live births. Sudden infant death syndrome (SIDS) is the 3rd leading cause of infant death for 2010 and the leading cause of death among infants ages 1 to12 months. In 2010, there were a total of 3,610 or 0.9 SUIDs per 1,000 live births, accounting for 15% of all infant deaths. Of these deaths, 2,063 were attributed to SIDS (ICD-10 code R95); 918 attributed to unknown cause (ICD-10 code R99), and 629 attributed to accidental suffocation and strangulation in bed (ASSB, ICS-10 code W75).

There has been a vast shift in the classification of sudden infant death that has taken place in the United States over the last 15 years. Since 1998, according to the Centers for Disease Control and Prevention (CDC), it appears that medical examiners and coroners are moving away from classifying deaths as SIDS and calling more deaths accidental suffocation or unknown cause. In addition, practices in investigation and cause-of-death determination are inconsistent, thus limiting the ability to monitor national and state trends, ascertain risk factors, and design and evaluate programs to prevent these deaths. CDC’s SUID Initiative is aimed at improving the investigation and reporting practices of SIDS and SUID.

The SIDS rate remains significantly higher among certain racial and ethnic groups, including non-Hispanic Blacks and American Indian/Alaska Natives. In 2009, the infant mortality rate for non-Hispanic black women was 12.40 infant deaths per 1,000 live births, 2.8 times greater than the lowest rate of 4.40 for infants of Asian or Pacific Islander mothers. Rates were also higher for infants of American Indian or Alaska Native (8.47) and Puerto Rican (7.18) mothers.

A CDC and Wisconsin Department of Health Services sponsored survey (PRAMS) of mothers in Wisconsin reported that:

  • 1 out of 5 infants are not put on their back to sleep (1 out of 3 for Black infants)
  • Over 1/3 of mothers frequently bed share with their infant (over ½ for Black/Hispanic)
  • Only 52% of infants consistently sleep on their backs and in their own sleep space.

Risk Factors

The Triple-Risk Model describes the convergence of three conditions that may lead to the death of an infant from SIDS.

  • Vulnerable infant. An underlying defect or brain abnormality makes the baby vulnerable. In the Triple-Risk Model, certain factors—such as defects in the parts of the brain that control respiration or heart rate or genetic mutations—confer vulnerability.
  • Critical developmental period. During the infant’s first 6 months of life, rapid growth and changes in homeostatic controls occur. These changes may be evident (e.g., sleeping and waking patterns), or they may be subtle (e.g., variations in breathing, heart rate, blood pressure, and body temperature). Some of these changes may destabilize the infant’s internal systems temporarily or periodically.
  • Outside stressor(s). Most babies encounter and can survive environmental stressors, such as a stomach sleep position, overheating, secondhand tobacco smoke, or an upper respiratory tract infection. However, an already vulnerable infant may not be able to overcome them. Although these stressors are not believed to single-handedly cause infant death, they may tip the balance against a vulnerable infant’s chances of survival.

According to the Triple-Risk Model, all three elements must be present for a sudden infant death to occur: The baby’s vulnerability is undetected, the infant is in a critical developmental period that can temporarily destabilize his or her systems, and the infant is exposed to one or more outside stressors that he or she cannot overcome because of the first two factors.

If one or more outside stressors is removed, such as placing an infant to sleep on his or her back instead of on the stomach to sleep, they can reduce the risk of SIDS.

Reducing the Risk of SIDS

In 2011, the American Academy of Pediatrics (AAP) expanded its recommendations for a safe infant sleep environment to address an increased incidence of sleep-related infant deaths and provide more specific guidance to health care providers. The new recommendations aim to reduce the risk of infant death from known sleep-related causes, such as suffocation from soft bedding materials and entrapment from inappropriate sleep situations, such as becoming lodged between a mattress and headboard.

Summary of AAP Recommendations using the US Preventive Services Task Force levels of recommendations:

Level A Recommendations

  • Back to sleep for every sleep
  • Use a firm sleep surface
  • Room-sharing without bed-sharing is recommended
  • Keep soft objects and loose bedding out of the crib
  • Pregnant women should receive regular prenatal care
  • Avoid smoke exposure during pregnancy and after birth
  • Avoid alcohol and illicit drug use during pregnancy and after birth
  • Breastfeeding is recommended
  • Consider offering a pacifier at nap time and bedtime
  • Avoid overheating
  • Do not use home cardiorespiratory monitors as a strategy for reducing the risk of SIDS
  • Expand the national campaign to reduce the risks of SIDS to include a major focus on the safe sleep environment and ways to reduce the risks of all sleep-related infant deaths, including SIDS, suffocation, and other accidental deaths; pediatricians, family physicians, and other primary care providers should actively participate in this campaign

Level B recommendations

  • Infants should be immunized in accordance with recommendations of the AAP and Centers for Disease Control and Prevention
  • Avoid commercial devices marketed to reduce the risk of SIDS
  • Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly

Level C recommendations

  • Health care professionals, staff in newborn nurseries and NICUs, and child care providers should endorse the SIDS risk-reduction recommendations from birth
  • Media and manufacturers should follow safe-sleep guidelines in their messaging and advertising
  • Continue research and surveillance on the risk factors, causes, and pathophysiological mechanisms of SIDS and other sleep-related infant deaths, with the ultimate goal of eliminating these deaths entirely

Talking with Families: The Safe Sleep Discussion

As health care providers we play a critical role in educating parents and caregivers about the risks of an unsafe sleep environment while consistently promoting evidence-based safe sleep practices for families. Using the Triple-Risk Model assessment in the case scenario above, there are many opportunities to educate and translate best practices into the home environment for this infant.

  • Recognize that the mother has a lot going on in her life; acknowledge her using the supine position initially at night and the fact that she is breastfeeding. Provide information on the risks of smoking, and refer to community smoking cessation resources.
  • An older, used crib may be unsafe as it no longer meets current safety standards, might have missing parts, or be incorrectly assembled. is a resource for families to review if the crib they are using is recalled.
  • Quilts, bumper pads, and other soft objects are hazardous in the sleep environment, and increase the risk of suffocation and rebreathing. Encourage the mother to remove soft objects and loose bedding, reinforce need for a firm mattress covered by a tightly fitted sheet
  • Room-sharing without bed-sharing is recommended. Encourage the mother to use a pack-and-play placed next to her bed to enable her to more easily breastfeed the infant and allow for a separate sleep environment. If she cannot afford a pack-and-play, there are many community programs that provide them to families at no cost.
  • If the mother continues to insist that she wants to co-sleep, investigate with her at what point does she think she will feel comfortable with the infant sleeping by himself? How does she plan on making the transition? These discussion points can get her thinking about the routine she is establishing with her infant. Sleep is a learned behavior and it takes time for an infant to adjust.
  • Review with the mother:
    • Establishing a routine is important to allow the infant to wind down and prepare to sleep. During this time you can give the infant a bath, turn the nights down, and try infant massage.
    • A healthy infant wakes up several times during the night and this is important. Not only does it promote healthy brain function, it keeps the infant from falling into a deep sleep.
    • Consider offering a pacifier for sleep o Importance of maintaining immunization schedule.
    • All caregivers should know how to correctly place the infant to sleep. Many older adults are not aware of the new safe sleep recommendations.

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CME Questions

References and Resources

  1. AAP POLICY STATEMENT: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment
  2. AAP TECHNICAL REPORT: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment
  3. Centers for Disease Control and Prevention: Filiano JJ, Kinney HC. A perspective on neuropathologic findings in victims of the sudden infant death syndrome: the triple-risk model. Biol Neonate. 1994;65(3– 4):194 –197
  4. Hauck FR, Thompson J, Tanabe KO, Moon RY, Vennemann M. Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics. 2011;128(1):103–110
  5. National Center for Health Statistics. Deaths: Final Data for 2010. National Vital Statistics Report v. 61, no. 4, May 8, 2013.
  6. National Institute of Child Health and Human Development. PRAMS data link:
  7. SUID/SIDS Resource Center Data
  8. Venneman MM, Hense HW, Bajanowski T, Blair PS, Complojer C, Moon RY, Kiechl-Kohlendorfer U. Bed Sharing and the Risk of Sudden Infant Death Syndrome: Can We Resolve the Debate? Original Research Article. The Journal of Pediatrics, Volume 160, Issue 1, January 2012, Pages 44-48.e2
  9. UW Health/American Family Children’s Hospital Safe Sleep website resources