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Safe Sleep Practices for Infants

Alabama has the highest rate of sleep-related infant deaths per year in the United States. In this episode of the Inside Pediatrics Podcast, Dr. Erinn Schmit explains how we can prevent these tragic accidents, and how we can all practice the "ABC's" of safe sleep at home.

For more information about safe sleep practices for infants, Dr. Schmit recommends these resources:   (National Institutes of Health site) (American Academy of Pediatrics site)
Safe Sleep Practices for Infants
Featured Speaker:
Erinn Schmit, MD
Dr. Erinn Schmit is an assistant professor of pediatrics in the Division of Hospital Medicine at the University of Alabama at Birmingham (UAB).  She earned her medical degree from the UAB School of Medicine followed by pediatric residency training at UAB and Children’s of Alabama, where she also served as a chief resident.  Following a fellowship in Pediatric Hospital Medicine at UAB, she became an assistant professor in the division.  Dr. Schmit also holds a Master’s of Education degree from the University of Cincinnati. She currently serves as director of Pediatric Medical Grand Rounds at Children’s of Alabama, associate program director for the Pediatric Hospital Medicine fellowship program and chair of the Safe Sleep Task Force at Children’s of Alabama.

Tiffany Kaczorowski: Welcome to Inside Pediatrics, a podcast brought to you by Children's Hospital of Alabama in Birmingham. I'm Tiffany Kaczorowski. In this episode of Inside Pediatrics, we're drawing attention to safe sleep in infants. Did you know that Alabama has the highest rate of sleep-related deaths per year in the United States? Here to help us understand more about safe sleep initiatives in our state and beyond is Dr. Erinn Schmit. She is an assistant professor at UAB, the University of Alabama at Birmingham, and is a pediatric hospitalist here at Children's of Alabama. Welcome, Dr. Schmit.

Dr. Erinn Schmit: Thanks so much for having me.

Tiffany Kaczorowski: So that's a pretty startling statistic. We have the highest rate of sleep related deaths, about 3,500 sleep-related deaths per year in the United States.

Dr. Erinn Schmit: Yeah, nationally, every single year, there's about 3,500 sleep-related deaths in infants under 12 months that are found in a sleeping environment, typically an unsafe sleep environment. And unfortunately, Alabama has the highest rate of sleep-related deaths. Around a hundred or higher babies every single year are dying from these unsafe sleep environments.

Tiffany Kaczorowski: And so what are we seeing? What types of unsafe sleep environments are there?

Dr. Erinn Schmit: One of the most common things that we see is co-sleeping or babies sleeping with a parent or caregiver or a sibling, any other person. And we know that that greatly increases their risk for suffocation. We also see some deaths from suffocation due to soft bedding, like pillows, blankets, sleeping on an adult mattress or in a chair or in a couch. These environments are not meant for babies to sleep on. They should be sleeping on a firm sleep surface that doesn't allow for any air pockets that they can get their faces stuck in.

We also see a lot of babies sleeping on their tummies before they're able to roll over. Once they're rolling over, it's fine for babies to roll and sleep on their tummy. But before that, they need to be sleeping on their back every single time. We have lots of data that shows us that's the very safest way that they can sleep.

Tiffany Kaczorowski: And which babies are at the highest risk? At what age do the deaths typically happen?

Dr. Erinn Schmit: So the very highest risk for SIDS, sudden infant death syndrome, and other sleep-related deaths is between one and four months. And overall, the highest risk is up to about six months or so. After six months, the risk drops off, but we still recommend that families follow safe sleep practices until 12 months.

Tiffany Kaczorowski: Okay. And what about swaddling?

Dr. Erinn Schmit: Swaddling can be very helpful for young babies, little tiny newborns who have a startle reflex that wakes them up. But we should stop swaddling when babies start to roll over. So usually, that's around three or four months for most babies. So when they're showing signs of rolling over, you could either go cold turkey and stop swaddling altogether. You can swaddle just one arm in at a time, kind of wean them. But we know that swaddling while babies are trying to roll can actually increase that risk of suffocation.

Tiffany Kaczorowski: So let's go ahead and talk about the best practices and the tips for parents and caregivers right now. What can we do about this? What can we do to mitigate the risk of our babies having some kind of awful incident while they're sleeping? They have to be on their back every time, right?

Dr. Erinn Schmit: Yes. Every single sleep session, naps, bedtime, they need to be on their back. The way I like to teach parents is by talking about the ABCs of safe sleep. And so that stands for Alone, Back and Crib. Every single time babies should be in their own sleep environment. So that's an approved consumer product safety-rated device, like a crib, Pack 'n Play or bassinet. They should not be with any other people and they should be on their backs every single time. The crib should be empty except for a crib mattress that's rated for infants. That's a firm mattress with just a fitted sheet. No loose blankets. No stuffed animals. No pillows. No bumpers. Bumpers look beautiful, but they're dangerous. And we don't need to be using them in our cribs. They just pose a suffocation risk.

Tiffany Kaczorowski: Yeah. I can imagine the baby, you know, their head getting caught in that bumper, wedged in between the bumper and the mattress.

Dr. Erinn Schmit: Yeah. They can rollover, and just kind of get their face smooshed up against that bumper and that's a suffocation risk. Some things that people don't always think about are making sure that there are not cords that are close by either. So if you have a video monitor, if the crib is next to a window with blinds, making sure there's no strings that babies could pull on. Because, unfortunately, every year, we see strangulation deaths where babies get it stuck around on their neck.

Tiffany Kaczorowski: So pulling that crib or that Pack 'n Play away from a window or any type of cord.

Dr. Erinn Schmit: Yeah. Or if you have a video monitor mounting on a wall or a bookcase nearby, but not on the edge of the crib itself.

Tiffany Kaczorowski: And then talk about sleep sacks because they've become really popular. They zip up and everything is contained.

Dr. Erinn Schmit: Yeah. So I think this is a great option to get rid of loose things in the crib that can pose a risk. So sleep sacks are wearable blankets. They have a hole for the neck and the arms, and then they either zip or snap-up, kind of depending on who makes them. And there's not enough loose material that it can get up over the baby's face. So it's a wearable blanket. That's a safe alternative to loose blankets. There's lots of them out in the market for younger babies. They have ones that swaddle with Velcro. And then older babies, they have ones just with the arm holes and no swaddles. So, you know, around three to four months when babies are starting to roll is when we recommend that we stop swaddling and can switch to the sleep sack without the swaddle.

Tiffany Kaczorowski: And then also we had talked about sharing a room. It's okay to share a room, just not sharing a bed.

Dr. Erinn Schmit: Exactly. So the American Academy of Pediatrics recommends that families share a room with their baby for up to 12 months, but not share a bed or a sleep space. So kind of sharing the room can be protective. You're both kind of hearing each other's noises and sleep a little bit lighter and that can really help with the risk of SIDS and other sleep-related deaths.

Tiffany Kaczorowski: Other risk factors that we talked about, exposure to cigarette smoking.

Dr. Erinn Schmit: Yeah. Exposure to cigarette smoking both prenatally, when babies are in their mother's tummies, and postnatally, after they're born, can increase their risk. And it's actually estimated that if we could eliminate maternal smoking in pregnant mothers, we were to reduce the SIDS rate by a third. That rate has been pretty stagnant for the past 20 years or so, so that's a pretty dramatic number. Mothers, caregivers, anyone in the home, we want to try our very best to eliminate exposure to tobacco smoke.

Tiffany Kaczorowski: Drug use, obviously.

Dr. Erinn Schmit: So yeah, drug and alcohol use, especially in the setting of co-sleeping greatly raises the risk. So any families that are choosing to co-sleep, realizing this is not a safe situation and using any drugs or alcohol just increases that risk even more.

Tiffany Kaczorowski: And then what about tummy time? Because the American Academy of Pediatrics does recommend some tummy time, but you're saying just not while they're sleeping.

Dr. Erinn Schmit: Exactly. So the kind of thinking behind tummy time is both to prevent positional plagiocephaly or the flat back of the head that some people worry about and that's mostly a cosmetic problem, but also to work on the head and neck strength, that's really important. When you're putting babies in their tummies and they can start working on lifting that head up and propping up on their forearms, that's good for their motor development.

So we recommend that all babies have tummy time each day while awake and while they're being observed, not while they're asleep. Babies should only be put down on their back to sleep. And once they are starting to roll and can roll themselves over onto their tummy, it's okay to let them roll into that position, but still put them down on their back. That kind of tells us that their head and neck are strong enough that they can move themselves out of any kind of soft places or air pockets that they might roll into.

Tiffany Kaczorowski: And some old wives' tales, some things that we might hear from the older generation is that if the child has reflux, they should be on their tummy.

Dr. Erinn Schmit: Yes. I hear this a lot from concerned family and I understand kind of where it's coming from and how we would think that. But if you actually kind of look at a cross section, if you're looking at the anatomy, when babies are laying on their tummy, their food pipe is actually above the windpipe or where the air goes in. And so just gravity-wise on their tummy, it would be easier for them to choke. Now, a baby with a normal brain and neurologic system is not going to choke. We have mechanism in place to protect against that. But gravity-wise, it's actually safer on their back, because then their food pipe is below the windpipe.

Both the American Academy of Pediatrics and the National Pediatric Gastroenterology Association, which is NASPGHAN for short. It's a long acronym. They both agree that sleeping on their back is safest for all babies even those with reflux. The only situations when babies should sleep on their tummy are if they have an unrepaired surgical airway or some kind of serious issues that your doctor would recommend otherwise.

But there's no benefit to propping up the head of the bed for reflux either. It doesn't help with reflux. It's just something that babies kind of have to grow out of, unfortunately. And usually, it kind of starts to get better around six months or so. But propping up the head of the bed just puts babies in an unsafe situation where they could kind of slide down that slope and kind of crunch off their airway and can put them in a worse situation for breathing freely. And then a lot of times when we're elevating the head of the bed, ends up with positioners and blanket rolls and stuff to try to keep them in this position, which we already know is unsafe. So you're just adding unsafe things to the crib in what's already an unsafe environment.

Tiffany Kaczorowski: Okay. So absolutely nothing in the crab, right?

Dr. Erinn Schmit: Yes. Just an empty crib.

Tiffany Kaczorowski: What about Rock 'n Plays and the sleeping in the car seat? I know sometimes parents have been known to drive around the neighborhood to get their child to go back to sleep.

Dr. Erinn Schmit: You know, I had a colicky baby, so I get it. I have done this myself, driving around, trying to get my baby to sleep. It's recommended that once babies are outside the car, we don't leave them in the car seat to sleep. If they fell asleep in the car, that's fine. But once they're inside the house, taking them out of the car seat and putting them into a flat crib on their backs is recommended.

The Rock 'n Plays that you brought up, so those were an inclined sleeper, that rocks that was recalled a couple of years ago due to being linked to multiple infant deaths around the country. And primarily, this is in situations where babies were strapped in and then rolling over and suffocating. And so that was kind of the risk that it posed. But it led to all inclined slippers being recommended against because of that risk.

Best practices if you're looking for approved baby devices, I would suggest either talking with your pediatrician. You can look at the AAP website,

Tiffany Kaczorowski: So some good resources, some places where parents can get more information and tips.

Dr. Erinn Schmit: There are multiple great resources out there. One of my favorites is the Safe to Sleep Campaign. That's a national collaborative by the National Institutes of Health or the NIH, the NICHD, the Eunice Kennedy Shriver Foundation. And this has wonderful information for parents, grandparents. It has information in Spanish. It's got information focused on native babies. It's got lots of different target audiences.

So if you Google Safe to Sleep, it should be one of the first hits. It'll say Safe to Sleep NIH. The official website is But just Google Safe to Sleep and you'll be able to find it. Other resources that I would recommend is the AAP website, ,has some great information for parents as well.

Tiffany Kaczorowski: And that's the American Academy of Pediatrics.

Dr. Erinn Schmit: Yes, exactly. And then, talking with their pediatrician as well, and they should be able to give good information about safe sleep practices and approved devices.

Tiffany Kaczorowski: Okay. Well, thank you so much Dr. Schmit, for joining us today. We really appreciate it.

Dr. Erinn Schmit: Thank you for having me.

Tiffany Kaczorowski: Thanks for listening to Inside Pediatrics. More podcasts like this one can be found at