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Melanie Cole (Host): There’s no handbook for your child’s health, but we do have a podcast. Featuring world-class clinical and research physicians, covering everything from your child’s allergies to zinc levels, this is Kids Health Cast by Weill Cornell Medicine and our topic today, is infant sleep and my guest is Dr. Paul Chung. He’s the site Medical Director for Brooklyn Heights and an Assistant Professor of Clinical Pediatrics at Weill Cornell Medicine. Dr. Chung, I’m so glad to have you with us today to talk about this topic. So many parents wonder about how to get their kids to sleep and more importantly, how to get them to sleep safely. So, we heard it’s safe to put babies to sleep on their back. Why is that best?

Paul Chung, MD (Guest): Hi Melanie. It’s good to be talking to you about this. Sleeping on the back as an infant is the safest position to prevent any kind of problems with breathing and to prevent sudden infant death syndrome. There are about 3500 cases per year of sleep related deaths which has gone down from previous years, but it is still a strong consideration and we like to talk to parents about how to best ensure safe sleep.

Host: So, when we are putting them to sleep on their backs, we hear that we are supposed to swaddle. I swaddled my babies like a couple of little burritos and then we put them in there. Some parents worry, you put them in all swaddled, they can move. Are they not supposed to be able to move?

Dr. Chung: Well the burrito wrap that you described can be very cute and can be a comfort in certain situations. So, there is a couple issues that you brought up that I can comment on. So, first of all, swaddling in general is not necessarily recommended or required at any age. The younger infant is about the first two months of life, it can be very comforting for the infant. So, that swaddling can provide a sense of security and for infants who are having issues with fussiness or trouble falling asleep, then it’s an option that parents can use to provide that security and comfort to help an infant get to sleep or to get back to sleep.

The issue that you bring up about how tight you swaddle. One consideration if it’s swaddle is too tight around an infant’s legs and the infant’s legs are kept in a tight downward position; then there is a risk for hip dysplasia or hip instability. So, that’s one thing you have to be aware of of not wrapping the infant’s legs too tight downward. And the age for which swaddling that we recommend to be best is in the first two months of life. And the reason that we say that is that after about two months of life, and the newborn is approaching the age when you are going to start rolling back and forth; and if an infant rolls back onto their stomach after you put them down and they are swaddled then that can present a risk for breathing problems and suffocation.

Host: So, once a child, whether they are swaddled or not at that point I would think that they’re not swaddled, can roll over Dr. Chung, are we as parents, I know I did it, because I was afraid; are we supposed to run back in and roll them back over ten times a night if they are trying to become a tummy sleeper? What do we do if they start to roll over onto their stomachs?

Dr. Chung: Right, that’s a frequent question that comes up. Now the age where infants are going to be approaching rolling back and forth, back and forth frequently is going to be approaching around four to six months of age. So, as I said earlier, the swaddling, you are going to want to be careful of and consider not using after about two months old. And when an infant is actively rolling back and forth; it’s not realistic. Parents have enough issues with sleep deprivation and trying to take care of a new human being, so, it’s not expected or realistic that every time an infant rolls over they are going to be there to watch them and roll them back onto their backs. So, when an infant past about six months old is rolling back and forth actively on their own; then no, you put them to sleep on their backs, but you don’t need to be continuously flipping them over. And the SIDS risk, sudden infant death syndrome risk doesn’t completely disappear after six months old, but it does go down around that time and so those are some of the factors that go into not continuously needing to be so extra vigilant about that.

Host: That’s a great point and thank you for making that so, their cribs. If we are not swaddling them, are there things we can put in their cribs we should be putting anything, are we allowed to lay a nice little blanket over them at some point, if we feel like they are cold? What should we be putting in their cribs Dr. Chung and what shouldn’t we be putting in their cribs.

Dr. Chung: Yeah, this can be confusing because there are so many products that are marketed as being safer for children but that haven’t been tested or proven to do that by research. So, there is an age eventually when it becomes safer to put blankets and a transitional object a thin blanket or a stuffed animal safely, but that’s going to be after about 12 months old. So, until that time, it’s relatively simple guidance that you don’t want to be putting anything inside the crib. So, the safest sleep surface is going to be a flat, firm mattress with a fitted thin sheet on top and that’s it. Anything else that is out there as far as blankets, stuffed toys, bumpers, aren’t going to be safe. It’s a risk for affecting the infant’s breathing. And then the question comes up that you posed is then how do we keep our infant warm.

So, you don’t want to overdress the infant either because overheating is also a risk for sudden infant death syndrome. So, the best recommendation is the most layers of clothing that you want to do is maybe one more layer than the adult is wearing, and good options are wearable blankets or wearable sleep sacks.

Host: So, wearable sleep sacks are okay to use?

Dr. Chung: They should be as long as they are well-fitted, they are covering the legs, there isn’t anything loose that’s going to be obstructing the face area.

Host: That’s great to know. I don’t think they had those when my babies were little. But one thing I did Dr. Chung, as I ran back in the room a million times; was search around for the pacifiers to give them back to the baby so they could soothe themselves. Are we allowed to be putting our babies to sleep with a pacifier?

Dr. Chung: Another great question that comes up frequently. So, a pacifier has been shown to actually decrease the risk of sudden infant death syndrome, so in fact, it’s recommended. So, putting – offering your infant a pacifier when they take a nap or when they go to bed is recommended. And the reason I say recommended and not required or to use some other wording is because not every newborn infant is going to want the pacifier. So, you can offer it, but you shouldn’t be forcing it. if they spit it out, again, you don’t need to be super vigilant about putting back into the infant’s mouth every time, but you can offer it and it can be helpful. The one caveat I’ll make to that is that it’s recommended that you delay the pacifier use after about three weeks old which is a time around when if you are breastfeeding that the breastmilk is going to be in more steadily and breastfeeding is more well-established. And so to delay it until around that age just to prevent any type of texture confusion.

Host: Dr. Chung, one of the things, I mean this is such a great topic, because parents want their children to sleep so that we have a chance to rest as well. Sometimes, babies fall asleep in their car seats and we’re like okay, I’m just not even going to pick them up because I want them to just stay in that car seat and sleep so I can run around an do laundry. Should we be letting our babies nap in their car seats or not?

Dr. Chung: And we are always supportive of answering parents questions about how can they get enough rest because they are doing whatever they can to not be sleep deprived, to be well-rested because infants are waking up intermittently at all times during the day but with this question, any surface that’s not going to be a firm flat surface like a mattress in the crib; isn’t going to be as safe for the infant. So, infant car seats for example is curved and has some soft padding and again that is going to be a risk for breathing problems.

Host: So, what’s going on with rock-n-plays? Why did that CPSC put out a warning about them?

Dr. Chung: Rock-n-plays are a specific product that’s an inclined padded sleeping surface and so like we’ve already mentioned, anything like that that an infant can turn into with their face or roll on their stomach is not going to be safe. And there unfortunately have been deaths reported with infants who are in the rock-n-plays so they’ve – all models of the rock-n-plays have been recalled and products like this shouldn’t be used.

Host: Well thank you for clarifying that for confused parents. So, now let’s talk yikes about sleep training Dr. Chung. At what age can we start sleep training a child because this is something every parent, new parents are like okay, I’ve got to get some sleep and the kids aren’t – we’re not interested in routines, we just want to get them comfortable in those first couple of months, when can we start or look to some of those sleep training methods?

Dr. Chung: Of course, this is an important issue that comes up especially where families, where they are having to go back to work and manage everything else that’s going on with taking care of a new infant. In the first month of life, the newborn doesn’t have the type of cognitive ability to establish good habits or get trained in any kind of way. So, we encourage that parents provide as much emotional support as needed if the infant seems uncomfortable or fussy, it’s fine to pick up and comfort and that’s very soothing for your newborn to know that you are there for them as they get used to that.

Starting at about six to eight weeks old, that’s when they start to have the developmental level to establish good habits. So, we say around that age is a good time to establish good habits that will help the infant soothe themselves back to sleep, if for example, one hour after they fell asleep, they wake up and they are crying and if that cycle is happening continuously over many days.

Host: So, now on to all those methods out there. There are so many. There’s Camping Out, there’s Cry It Out, there’s sitting next to the child and then crawling out of the room. Do you have any advice or recommendations to sleep training methods that you prefer?

Dr. Chung: We give a lot of advice to parents when they come in for the well-child checks and this is another frequent question that comes up. There’s countless number of methods and they break down into two broad categories. The first category will be methods that are more regimented and stricter that give specific numbers of hours of sleep an infant should have by specific ages. The other category is a little bit more flexible that allows some flexibility knowing that every child is individualized and not every child is going to fit a one-size fits all pattern of how long they are going to have uninterrupted sleep during the night.

At the same time, there are recommendations and strategies to help parents get their infant to soothe themselves back to sleep. And I more recommend the second type of flexible strategy because that’s more in line with what the American Academy of Pediatrics recommends on their literature on their websites also.

Host: Some parents feel that it’s easier to co-sleep because then if they’re nursing, they can just kind of wake up in the night and do that. What do you and the American Academy of Pediatrics say about co-sleeping?

Dr. Chung: And that can be a temptation. Now there is a middle ground to co-sleeping that is recommended. So, in the first six to twelve months of life, the best recommended sleep situation is have the infant in a separate crib and the type of surface that we talked about, but in the same room as you. So, you get the benefits of being close to your infant, more easily accessible to feed, but co-sleeping should not mean that you are going to be in the same bed. So, along the same lines of what we’ve covered; in an adult bed, the surface is too soft, blankets, the edges has crevices that the infant can get trapped under and this is a risk for sleep related deaths and with the relative sleep deprivation or tiredness that can occur from taking care of a newborn; there is a risk for the parent rolling onto the infant and not being aware of that because of the tiredness.

Host: I’m glad you cleared that up. Because it is such an important thing and many people have questions about that. As we wrap up, give us your final sleep tips as a child starts maturing and what do want us to know as the most important bits of information about infant sleep and safe sleep so the parents can get some rest as well.

Dr. Chung: If parents are looking for a resource to get some more information for their newborn, then I would suggest the website www.healthychildren.org which is put out by the American Academy of Pediatrics. And it provides good information but not an overwhelming amount of information so it’s easy to understand and another good resource would be Your Baby’s First Year which is also put out by the American Academy of Pediatrics. And the message that I will leave them with is that there isn’t one strategy that is perfect for every infant. You don’t need to compare yourself to other families if they’ve achieved this amount of uninterrupted sleep by a certain age. Pediatrician is there to help you to guide you and give you some suggestions to establish good habits.

Host: What great information for our patients to hear. Thank you to our guest Dr. Chung and to our listeners.

This concludes today’s episode of Kids Health Cast. Please remember to subscribe, rate and review this podcast and all the other Weill Cornell Medicine podcasts.

For more health tips and updates on the latest medical advancements and breakthroughs, follow us on Facebook and Twitter.Until next time, I’m Melanie Cole.