Sudden Infant Death 

Syndrome (SIDS) and 

Other Sleep-Related

Causes of Infant Death:

Questions and 

Answers for 

Health Care 

Providers 

U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES

National Institutes of Health 

Eunice Kennedy Shriver National Institute 

of Child Health and Human Development
Dear Colleague:

As Director of the Eunice Kennedy Shriver National Institute of Child Health and 

Human Development (NICHD), I am pleased to provide this updated version of 

Sudden Infant Death Syndrome (SIDS) and Other Sleep-Related Causes of 

Infant Death: Questions and Answers for Health Care Providers. This booklet lists 

the latest recommendations on reducing the risk of SIDS and other sleep-related 

causes of infant death from the American Academy of Pediatrics (AAP) Task Force 

on SIDS and briefly describes the supporting research.

This piece is among several items that we offer as part of the Safe to Sleep®

campaign, an expansion of the Back to Sleep campaign that addresses SIDS as 

well as other sleep-related causes of infant death. 

Why the expanded campaign? Because although we have made great 

progress in reducing SIDS rates—more than 50 percent since the original AAP 

recommendation about back sleeping in 1992—there is still much to do. Based 

on their proportion in the U.S. population, African American and American Indian/

Alaska Native infants are at higher risk for SIDS than are white or Hispanic infants. 

Further, as the SIDS rate has decreased, the rates of other sleep-related causes 

of infant death—such as accidental suffocation—have increased. As long as our 

babies are dying, we will continue these efforts.

Your contribution to reducing the risk of these deaths by sharing safe infant sleep 

messages is critical. Research shows that advice from health care providers makes 

an impact on parent and caregiver choices with regard to infant sleep position and 

infant sleep environment. 

With this booklet, we aim to capitalize on your influence by providing you with 

answers to common questions about SIDS and other sleep-related causes of infant 

death and the scientific rationale that supports these answers, so you can alleviate 

concerns parents and caregivers might have. I encourage you to read this booklet 

and to discuss these messages with your patients, with families, and with anyone 

who cares for infants younger than 1 year of age.

Thank you for all you do to care for infants and to educate parents and caregivers 

about ways to reduce the risk of SIDS and other sleep-related causes of infant 

death. Let us continue this important work together to help ensure that all children 

grow into healthy adults.

Sincerely yours,

Alan E. Guttmacher, M.D. 

Director, NICHD 

National Institutes of Health 

U.S. Department of Health and Human Services
1

Research shows: Health care provider 

advice MATTERS! 

Since its beginnings, the Safe to Sleep® campaign (formerly the Back to Sleep 

campaign) has relied on research evidence as its foundation: 

■ Research, some of it supported by the NICHD, led to the 1992

recommendation from the American Academy of Pediatrics (AAP) Task Force

on SIDS that infants be placed on their backs or sides to sleep to reduce

the risk of SIDS.

■ Research on the need for widespread education about SIDS and SIDS risk

reduction led the NICHD, the AAP, and other collaborators to launch the

Back to Sleep campaign in 1994.

■ Additional research from the NICHD and other organizations led the AAP

Task Force to issue a revised recommendation in 1996 saying that infants

should be placed wholly on their backs—the sleep position associated with

the lowest risk of SIDS—to reduce the risk of SIDS.

■ After research and statistics showed that safe sleep messages were not

reaching all groups equally—specifically that they weren’t getting into African

American and American Indian/Alaska Native communities—the NICHD and

its collaborators began tailored outreach efforts to spread risk-reduction

messages in these communities.

■ Research findings led the NICHD and its collaborators to expand Back to

Sleep into the Safe to Sleep® campaign to formally address issues related

not only to SIDS, but also to other sleep-related causes of infant death, a

safe infant sleep environment, and other infant health issues.

Now research confirms what we have 

known all along: Advice from health care 

providers makes a difference in parent and 

caregiver decisions about sleep position and 

sleep environment.

Parents and caregivers who took part in the NICHD-supported National Infant 

Sleep Position (NISP) study and other large-scale research efforts reported that 

advice from a health care provider influenced their decisions to place babies on 

their backs to sleep and to avoid sharing an adult bed with their baby.1 Health 

care provider counseling is also known to influence other kinds of health-risk 

and health-promoting behaviors as well. For example, a large-scale review and 

meta-analysis found that advice on weight loss from primary care physicians 
2

had a significant impact on patient 

attempts to change behaviors related to 

their weight.2

This booklet provides answers to 

common questions about safe infant 

sleep recommendations, as well as 

some of the research evidence and 

scientific references that support 

those recommendations. By informing 

all health care providers about SIDS, 

other sleep-related causes of infant 

death, such as accidental suffocation, 

and ways to reduce the risks for these 

situations, these important and lifesaving messages can better reach 

parents and communities.

What advice should health care providers give 

to parents and caregivers about ways to reduce 

the risk of SIDS and other sleep-related causes of 

infant death? 

Health care providers should encourage parents and other caregivers to 

reduce the risk of SIDS and other sleep-related causes of infant death in 

the following ways:

■ Always place baby on his or her back to sleep, for naps and at night,

to reduce the risk of SIDS. The back sleep position is always the safest

position for all babies, including preterm babies. Keep in mind that every

sleep time counts.

■ Use a firm sleep surface, such as a mattress in a safety-approved*

* For more information on crib safety guidelines, call the Consumer Product Safety Commission

at 1–800–638–2772 or visit its website at http://www.cpsc.gov/en/Safety-Education/SafetyEducation-Centers/cribs/.

 crib,

covered by a fitted sheet, to reduce the risk of SIDS and other sleeprelated causes of infant death. Firm sleep surfaces can include mattresses

in safety-approved* cribs, bassinets, and portable play areas. Do not use a

car seat, carrier, swing, or similar product as the baby’s everyday sleep area.

Never place babies to sleep on soft surfaces, such as on a couch or sofa,

pillows, quilts, sheepskins, or blankets.
■	 Room sharing—keeping the baby’s sleep 

area in the same room where you or others 

sleep—reduces the risk of SIDS. Your baby 

should not sleep in an adult bed, on a couch, or 

on a chair alone, with you, or with anyone else. 

If you bring baby into your bed to feed, make 

sure to put him or her back in a separate sleep 

area, such as a safety-approved* crib, bassinet, 

or portable play area, in your room next to where 

you sleep when you are finished. 

■	 Keep soft objects, toys, crib bumpers, and 

loose bedding out of your baby’s sleep area 

to reduce the risk of SIDS and other sleeprelated causes of infant death. Don’t use 

pillows, blankets, quilts, sheepskins, or crib 

bumpers anywhere in your baby’s sleep area. 

Evidence does not support using crib bumpers 

to prevent injury. In fact, crib bumpers can cause 

serious injuries and even death. Keeping them 

out of baby’s sleep area is the best way to avoid 

these dangers. 

■	 To reduce the risk of SIDS, women should: 

» Get regular health care during pregnancy, and 

» Not smoke, drink alcohol, or use illegal drugs during pregnancy or 

after the baby is born. 

■	 To reduce the risk of SIDS, do not smoke during pregnancy, and do not 

smoke or allow smoking around your baby. 

■	 Breastfeed your baby to reduce the risk of SIDS. Breastfeeding has many 

health benefits for mother and infant. If you bring your baby into your bed to 

breastfeed, make sure to put him or her back in a separate sleep area, such 

as a safety-approved* crib, bassinet, or portable play area, in your room next 

to where you sleep when you are finished. 

■	 Give your baby a dry pacifier that is not attached to a string for naps 

and at night to reduce the risk of SIDS. But don’t force the baby to use it. 

If the pacifier falls out of the baby’s mouth during sleep, there is no need to 

put the pacifier back in. Wait until the baby is used to breastfeeding before 

trying a pacifier. 

3 
4

■ Do not let your baby get too hot during sleep. Dress your child in no more

than one layer of clothing more than an adult would wear to be comfortable.

Keep the room at a temperature that is comfortable for an adult.

■ Follow your health care provider’s guidance on your baby’s vaccines

and regular health checkups.

■ Avoid products that claim to reduce the risk of SIDS and other sleeprelated causes of infant death. These wedges, positioners, and other

products have not been tested for safety or effectiveness.

■ Do not use home heart or breathing monitors to reduce the risk of

SIDS. If you have questions about using monitors for other health conditions,

talk with your child’s health care provider.

■ Give your infant plenty of Tummy Time when he or she is awake, and

when someone is watching. Supervised Tummy Time helps the baby’s

neck, shoulder, and arm muscles get stronger. It also helps to prevent flat

spots on the back of your baby’s head. Holding the baby upright and limiting

time in carriers and bouncers can also help prevent flat spots on the back of

the baby’s head.

What is SIDS? 

SIDS is defined as the sudden death of an infant younger than 1 year of 

age that remains unexplained after a thorough case investigation, including 

performance of a complete autopsy, thorough examination of the death scene, 

and review of the infant’s and family’s clinical histories.3

SIDS is associated with a sleep period but is unpredictable. It is often referred 

to as a “diagnosis of exclusion” because it is determined only after ruling out 

other causes of death, including suffocation, infection, or other illnesses. A 

diagnosis of SIDS is made by collecting information and conducting forensic 

tests, and by talking with parents, other caregivers, and health care providers.4

In the absence of an identifiable cause of death after this process, infant 

fatalities may be diagnosed as SIDS.5
5

What are Sudden Unexpected Infant Death (SUID) 

and sleep-related causes of infant death? 

SIDS is not the cause of every sudden infant death. Each year in the United 

States, thousands of infants die suddenly of no immediately obvious cause. 

These deaths are classified as SUID. SUID is the death of an infant younger 

than 1 year of age that occurs suddenly and unexpectedly. 

SUID includes all unexpected deaths: Those without a clear cause, such as 

SIDS, and those from a known cause, such as accidental suffocation. Many 

unexpected infant deaths are accidents, but a disease or another external factor, 

such as poisoning or neglect, can also cause an infant to die unexpectedly. 

One-half of SUID cases are SIDS.6

Sleep-related causes of infant death are those linked to how or where a 

baby sleeps or slept. They are due to accidental causes, such as: Suffocation; 

entrapment, when baby gets trapped between two objects, such as a mattress 

and wall, and can’t breathe; or strangulation, when something presses on or 

wraps around baby’s neck, blocking baby’s airway. These deaths are not SIDS.

What sleep position is safest for term babies in 

hospital nurseries? 

Healthy babies who are born at term 

should be placed wholly on their 

backs to sleep in hospital nurseries.

Keep in mind that term includes early 

term (37 or 38 weeks) births, full-term 

(39 or 40 weeks) births, or late-term 

(41 or 42 weeks) births.7, 8 Research 

shows that mothers and caregivers 

often use the same sleep position for 

their babies at home that they see being 

used at the hospital.9, 10 Therefore, all 

hospital nursery personnel should place 

babies on their backs to sleep—for 

naps and at night.

Nursery staff sometimes believe that newborn infants need be on their sides to 

clear their airways of amniotic fluid. There is no evidence to suggest that such 

fluid is cleared more readily while in the side position. The AAP recommends 
6

that infants be placed on their backs as soon as they are ready to be placed in 

a bassinet.11

Health care providers should also expressly tell parents and caregivers that 

babies should sleep on their backs for all sleep times, for naps and at night, 

once they go home to reduce the risk of SIDS.

Should preterm infants be placed on their 

backs for sleep? 

Yes. Research shows that preterm infants 

are at higher risk for SIDS simply because 

they were born preterm, defined as before 

37 weeks’ gestation; therefore, placing 

preterm infants on their backs for sleep 

is a critically important way to reduce 

the risk of SIDS.12, 13

Preterm infants who have active respiratory 

disease may have improved oxygenation if 

they are placed on their stomachs. Thus, 

the stomach sleep position during acute 

respiratory disease may be appropriate 

for infants in a highly monitored, inpatient 

setting. Because preterm babies often 

remain in the hospital for several days to weeks before discharge, the AAP Task 

Force recommends that these infants be placed on their backs to sleep as soon 

as possible after the respiratory condition has stabilized.14 This practice will 

allow parents and caregivers to become familiar with the position they should 

use at home.

In addition, providers should clearly state and strongly recommend that parents 

and caregivers be especially diligent about making sure their infants are placed 

in the back sleep position for every sleep time to reduce the risk of SIDS. 

Epidemiological studies have shown that, when placed on their stomachs to 

sleep at home, low birth weight or preterm babies may be at higher risk for 

SIDS than babies born at or after 37 weeks’ gestational age.15
7

Is the side position as effective as the back sleep 

position in reducing the risk of SIDS? 

No, the side position is not considered a safe alternative to the back sleep 

position. Studies show that the side sleep position is unstable and increases 

the chance that infants will roll onto their stomachs—the sleep position 

associated with the highest SIDS risk.16

The AAP Task Force recommends that infants be placed wholly on their backs 

to sleep for naps and at night to reduce the risk of SIDS.

Can infants be placed to sleep on their stomachs 

for naps or for short periods of rest? 

This practice is not recommended. Studies show that babies who are used to 

sleeping on their backs, but who are then placed on their stomachs or sides to 

sleep, such as for a nap, are at significantly higher risk for SIDS.17 This risk is 

actually greater—sometimes seven to eight times greater—than that of infants 

who are always placed on their stomachs or sides to sleep.18

Evidence suggests that secondary caregivers and child care providers are 

not always aware of the increased risk from unaccustomed sleep position.19, 20

Therefore, health care providers, parents, and caregivers need to be very clear 

in recommending that everyone who cares for baby—including grandparents, 

child care providers, and babysitters—knows that babies should be placed on 

their backs to sleep for naps and at night, and that every sleep time counts.

Are there any circumstances when babies should 

be placed on their stomachs to sleep? 

Healthy babies should always be placed on their backs to sleep for naps and 

at night.

Babies with certain upper-airway malformations (e.g., Robin syndrome) 

may have acute airway obstructive episodes that are relieved by prone 

positioning.21 However, these cases are rare; health care providers should 

clearly state the reasons for the prone recommendation to the parents 

and caregivers in these cases.
8

There has been concern about aspiration among babies diagnosed with 

gastroesophageal reflux who are placed in the back position for sleep. Current 

evidence suggests that even infants with gastroesophageal reflex should be 

placed on their backs to sleep, with the rare exception of infants for whom the 

risk of death from gastroesophageal reflux is greater than the risk of SIDS.22

There may be other infants for whom the risk/benefit balance favors stomach 

sleeping. Health care providers should consider the potential benefit to the 

infant when recommending sleep position.

If medical personnel determine that the stomach sleep position is necessary 

because of a medical condition or other concern, health care providers should 

advise parents and caregivers to reduce the risk of SIDS in other ways, such as 

by avoiding soft bedding and ensuring that infants do not overheat during sleep. 

For most infants, however, stomach and side sleeping are not advised.23

Will babies aspirate if they regurgitate while 

sleeping on their backs? 

There is no evidence that aspiration is more common among healthy infants 

who sleep in the supine position than among healthy infants who sleep in the 

prone position.24, 25 Furthermore, in countries (including the United States) 

that have seen a major change in infant sleep position—from mainly stomach 

sleeping to mostly back sleeping—the incidence of serious or fatal choking has 

not increased.26

In fact, babies may actually clear secretions better when placed on their 

backs. When babies are in the back sleep position, the trachea lies on top 

of the esophagus (see Figure 1). Anything regurgitated or refluxed from the 

esophagus must work against gravity to be aspirated into the trachea.

Figure 1 Figure 2
9

Conversely, when an infant is in the stomach sleep position, anything 

regurgitated or refluxed will pool at the opening of the trachea, making it easier 

for the infant to aspirate (see Figure 2). Also, chemosensitive tissue that initiates 

the reflex is more prominent on the posterior versus anterior pharyngeal wall, 

thus suggesting an even greater protection against aspiration when the baby is 

lying on his or her back. 

Of the very few reported cases of death due to choking, most of the infants 

were in the stomach sleep position.

Should parents or caregivers be advised to 

reposition their infant if he or she rolls onto the 

stomach from the back position? 

Studies show that, during early infancy, it is unusual for a baby who is placed in 

the back sleep position to roll onto his or her stomach.27 However, once infants 

are more developmentally advanced, they often roll over on their own. In this 

situation, when infants roll over on their own, there is no evidence that they 

need to be repositioned to reduce the risk of SIDS. It is most important that the 

infant starts sleep in the back sleep position for every sleep time. Keeping the 

sleep area clear of soft or loose bedding also increases safety for the infant if 

he or she rolls onto the stomach.

What is the best sleep surface for reducing the 

risk of SIDS and other sleep-related causes of 

infant death? 

A firm sleep surface, such as a mattress in a safety-approved*

* For more information on crib safety guidelines, call the Consumer Product Safety Commission

at 1–800–638–2772 or visit its website at http://www.cpsc.gov/en/Safety-Education/SafetyEducation-Centers/cribs/.

 crib, bassinet, or 

portable play area, covered by a fitted sheet, is associated with the lowest risk 

of SIDS and other sleep-related causes of infant death. 

Sleeping on soft surfaces or soft bedding, such as quilts, duvets, and pillows, 

is associated with increased risk of SIDS. Sleeping under soft bedding, 

particularly pillows, quilts, and extra bedding, is also associated with increased 

risk of accidental suffocation.28
10

In addition, infants should not be placed on 

adult mattresses, beds, sofas, or chairs for 

sleep. These surfaces are typically softer 

than mattresses in safety-approved* cribs. 

Consequently, they pose additional risks for 

other sleep-related causes of infant death, 

such as entrapment (between the mattress 

and the wall) and accidental suffocation.

Car seats and other sitting devices, such as 

strollers, swings, infant carriers, and infant 

slings (for extended sleep periods), also are 

not recommended for routine sleep, but this 

recommendation is related more to sleep 

position than to sleep surface. Infants younger than 1 month who are placed in 

sitting devices for sleep might be at increased risk of upper airway obstruction 

and oxygen desaturation.29 Increased rates of injuries resulting from car seats 

being placed on elevated surfaces and then falling have also been reported; in 

some cases, this situation results in suffocation.

Does bed sharing reduce the risk of SIDS? 

Current evidence does not support bed sharing as a protective strategy 

against SIDS. On the contrary, evidence is growing that bed sharing increases 

the risk for SIDS and other sleep-related causes of infant death, such as 

accidental suffocation and entrapment, or injury. 

A mother room sharing with her infant.

To communicate the risk of SIDS and 

other sleep-related causes of infant death 

to parents and caregivers effectively, it is 

important to understand the meanings of 

the terms—bed sharing, co-sleeping, and 

room sharing—defined below.

■ Room sharing: When an infant

sleeps in the same room as parents, but 

in a separate sleep area, such as a crib, 

bassinet, or play yard next to an adult 

bed. Room sharing is known to reduce 

the risk of SIDS and other sleeprelated causes of infant death and is 

recommended by the AAP.
11

■ Bed sharing: When an infant sleeps on the same surface as another person.

This surface can be a bed, couch, or chair. Sleeping with a baby in an adult

bed increases the risk of accidental suffocation and other sleep-related

causes of infant death.

■ Co-sleeping: When a parent and infant sleep in close proximity to one

another, either on the same surface or on different surfaces. This is done so

that they are able to see, hear, and/or touch each other. Co-sleeping can

refer to either room sharing or bed sharing.

Bed sharing and co-sleeping are often used interchangeably, but they mean 

different things. Room sharing is a fairly new term and is recommended by the 

AAP to aid in feeding, comforting, and monitoring the infant. Room sharing 

without bed sharing has also been shown to reduce the risk of SIDS by half.

Bed sharing among infants and family members, particularly among adults and 

infants, is common in many cultures.30 Many mothers share a bed with their 

infants because it makes breastfeeding easier and enhances bonding. Even 

though some believe that bed sharing may reduce the risk of SIDS because the 

parent is nearby to monitor the baby, studies do not support bed sharing as a 

protective strategy for SIDS.

31

Bed sharing is very risky when: 

■ The adult smokes cigarettes or has consumed alcohol or medication

that causes drowsiness.32, 33, 34

■ The baby shares a bed with other people or with more than one person.35, 36

■ The sleep surface is a couch or sofa.37, 38, 39

■ The baby is younger than 11 to 14 weeks of age.40, 41, 42

■ The mattress on the shared adult bed is softer than a safety-approved*

* For more information on crib safety guidelines, call the Consumer Product Safety Commission

at 1–800–638–2772 or visit its website at http://www.cpsc.gov/en/Safety-Education/SafetyEducation-Centers/cribs/.

crib mattress.43, 44
12

Does bed sharing reduce the risk of other 

sleep-related causes of infant death? 

No. Sleeping with a baby in an adult bed increases the chance for overlay 

or suffocation.

Room sharing—having baby’s sleep area in the same room where parents 

sleep—is less risky than bed sharing because it eliminates the possibility of an 

adult rolling on to the baby and other similar injuries. It is also recommended by 

the AAP. Sharing a room with baby allows for easy monitoring and offers many 

bonding opportunities. It also makes breastfeeding easier.

Mothers who bring baby into their bed to feed should return the infant to a 

separate sleep area, such as a safety-approved*

* For more information on crib safety guidelines, call the Consumer Product Safety Commission

at 1–800–638–2772 or visit its website at http://www.cpsc.gov/en/Safety-Education/SafetyEducation-Centers/cribs/.

 crib, in their room next to 

where they sleep. 

Can twins and multiples be placed in the same 

crib or bassinet to sleep? 

Twins and higher-order multiples should have separate sleep areas. The 

potential for overheating and rebreathing is higher among infants who share a 

bed, increasing the chance of accidental suffocation. In addition, most twins 

who share a bed are placed on their sides to sleep rather than on the back, 

putting them at increased risk for SIDS.45

Co-bedding twins and higher-order multiples in the hospital setting might 

encourage parents to continue this practice at home. Therefore, infants should 

be placed in their own bassinets in the hospital nursery as soon as possible 

after birth. Parents and caregivers should also be advised to provide separate 

sleep areas in the home.
13

Should crib bumpers be used in the baby's 

sleep area? 

No. Evidence does not support using crib bumpers (sometimes called bumper 

pads) or similar products that attach to the crib sides or slats to prevent injury. 

Statistics actually suggest the products may be harmful. A recent study of 

crib injuries concluded that the risk of suffocation or strangulation from using 

crib bumpers far outweighed the potential benefits of using them to prevent 

minor injuries.46 In fact, crib bumpers can cause serious injuries and even 

death. Stricter crib safety standards requiring crib slat spacing to be less than 

2 3⁄ 8 inches eliminated the need to use the bumpers to prevent infants from 

falling through the slats.47

Is it safe to put other items in the crib, such as 

blankets or stuffed toys? 

Parents and caregivers should be advised to keep soft objects, toys, and loose 

bedding out of the infant’s sleep area. Loose bedding and other items in the 

baby’s sleep area could end up covering the baby’s face. This puts the baby 

at higher risk for rebreathing air that is low in oxygen and for suffocation or 

strangulation.48 Pillows, quilts, comforters, sheepskins, and other soft items 

are hazardous when placed under the infant or loose in the infant’s sleep 

area. Research shows that they can increase the risk for SIDS up to fivefold, 

regardless of the sleep position. 

Can swaddling reduce the risk of SIDS? 

Research on whether swaddling—wrapping the infant in a light blanket—might 

reduce the risk for SIDS is inconclusive. Many cultures and nurseries have 

traditionally used swaddling as a strategy to soothe infants, and in some cases, 

encourage sleep in the back position. However, statistics clearly show that 

incorrect swaddling can lead to injury and sometimes death. Studies have found 

that incorrect swaddling can cause hip and shoulder dysplasia, head covering, 

and strangulation.49 Parents and caregivers should be advised to use caution if 

they decide to swaddle an infant. Swaddling also does not reduce the necessity 

to follow other recommended safe sleep practices. The AAP offers guidelines 

for safe swaddling at http://www.healthychildren.org/English/ages-stages/

baby/diapers-clothing/pages/Swaddling-Is-it-Safe.aspx.
14

Does prenatal care play a role in reducing the 

risk of SIDS? 

There is evidence linking a lower risk of 

SIDS with obtaining regular prenatal care.50

Risk of SIDS is particularly increased for 

women who seek prenatal care late in their 

pregnancy, that is, in the third trimester, or 

not at all.51 Women should seek prenatal 

care early in the pregnancy and continue 

to obtain regular prenatal care during the 

entire pregnancy. 

How do smoking during pregnancy and secondhand smoke in the pregnant woman's and 

infant's environment affect the risk of SIDS? 

Smoking during pregnancy and smoke in the infant’s environment contribute to 

an increased SIDS risk.52, 53 In fact: 

■ Infants whose mothers smoke during or after pregnancy are at an overall

greater risk of SIDS.54

■ Infants born to mothers who smoked during pregnancy are twice as likely to

die of SIDS.55 

■ Exposure to passive smoke in the householddoubles a baby’s SIDS risk.56

Exactly how smoking during pregnancy and passive smoke in the environment 

increase SIDS risk is not clear, but smoking may negatively affect development 

of the fetal nervous system. Studies of the mechanisms underlying the 

association between smoking and SIDS have found that during the last half 

of pregnancy changes occur in nicotine-binding sites in the fetal brain stem, 

specifically in areas involved with arousal from sleep, heart and breathing 

functions, sleep, and body movement control.57 Also, infants whose mothers 

smoked during pregnancy and who died from SIDS had a higher nicotine 

concentration in their lung tissue than do infants who did not die from SIDS.58

This finding supports the statement that postnatal environmental tobacco 

smoke exposure plays a role in SIDS risk.59,60 However, the mechanism for the 

association between thirdhand smoke and SIDS is unknown.
15

Does maternal substance use—smoking, alcohol, 

and illicit drugs—during pregnancy or after 

delivery affect SIDS risk? 

Evidence shows that women who smoke, drink alcohol, or use illegal drugs 

during pregnancy or after the baby is born put their infant at increased risk 

of SIDS. Maternal smoking during pregnancy is a major risk factor in almost 

every epidemiologic study of SIDS.61 Similarly, an infant’s exposure to alcohol 

and illicit drugs in the womb increases his or her risk of SIDS. One study of 

Northern Plains American Indians found that alcohol consumption (particularly 

binge drinking) during the periconceptional phase and the first trimester were 

associated with increased SIDS risk.62 Another study showed infants were at 

increased risk for SIDS when their mother used cocaine or other illicit drugs 

while pregnant.63 For these and other reasons, women should not smoke, drink, 

or use drugs during pregnancy or after delivery. 

Does breastfeeding reduce the risk of SIDS? 

Studies show that babies who are breastfed are at lower risk of SIDS than are 

nonbreastfed babies.64, 65, 66 The evidence in these published reports supports 

the protective role of breastfeeding on SIDS. In one of the cited reports, this 

protective effect was more pronounced with exclusive breastfeeding. 

Physiologic studies show that breastfed 

infants are more easily aroused from sleep 

than their formula-fed counterparts, which 

might explain some of the protective effect of 

breastfeeding against SIDS.67

In addition, breastfeeding offers other health 

benefits, including decreased incidence 

of diarrhea, upper and lower respiratory 

infections, and other infectious diseases, 

which are associated with an increased 

susceptibility to SIDS.68

The AAP recommends that, unless 

contraindicated by health problems, women 

exclusively breastfeed their infants for at least 

the first 6 months after birth.69
16

Do pacifiers reduce the risk of SIDS?
	

Yes. Several studies have found that 

infants who used pacifiers during their 

last sleep were at significantly lower risk 

of SIDS compared with infants who did 

not use pacifiers.70, 71 A meta-analysis 

reinforced findings of the protective 

effect of pacifiers against SIDS.72 The 

protective effect persists throughout 

the sleep period, even if the pacifier 

falls out of the infant’s mouth. The exact 

mechanism for this protective effect 

is unclear, but lowered sleep arousal 

thresholds, favorable modification of 

autonomic control during sleep, and 

maintaining airway patency during sleep 

have been proposed.73

The AAP Task Force recommends the use of pacifiers within the 

following parameters: 

■ Parents and caregivers should offer the pacifier, but should not force the

infant to take it if she or he refuses it.

■ Pacifiers should be clean and dry and not coated with anything sweet

or sticky.

■ Pacifiers should not be attached to infant clothing by a string or tether.

■ If the pacifier falls out of the infant’s mouth during sleep, there is no need to

reinsert it.

■ Parents should wait until breastfeeding is well established before

introducing a pacifier.
17

If blankets and other items should not be used 

in the sleep area, how can parents and caregivers 

keep their baby warm during sleep? 

Babies should be kept warm during sleep, but not too warm. Studies show 

that an overheated baby is more likely to go into a deep sleep from which it is 

difficult to arouse.74, 75, 76, 77, 78 Some evidence indicates that increased SIDS risk is 

associated with excessive clothing or blankets and a higher room temperature. 

In general, if the room temperature is comfortable for an adult, then it is also 

warm enough for an infant.79 Parents and caregivers should be advised to dress 

the baby in no more than one layer more of clothing than an adult would wear 

to be comfortable. Infant sleep clothing, such as a wearable blanket or onepiece sleeper, can be used to keep the baby warm during sleep without using a 

blanket in the sleep area. 

The increased retention of body heat—through excessive insulation from 

bedding and clothing—can be dangerous for some infants and may contribute 

to SIDS.80, 81Head covering during sleep is a particular concern. One study 

found a sevenfold increase in the risk of SIDS associated with head covering.82 

Studies have also found that overheating may increase the risk of SIDS for a 

baby who has a cold or infection.83 

Do vaccinations have a protective effect 

against SIDS? 

Receiving recommended vaccinations may have 

a protective effect against SIDS. Some research 

shows that immunizations reduce the risk of SIDS 

by 50 percent.84 Additional research has shown 

no causal relationship between immunizations 

and SIDS. 

Advising parents to follow the vaccination 

schedule and attend all well-baby visits will help 

ensure infants are immunized and monitored 

according to AAP and Centers for Disease 

Control and Prevention recommendations. See 

the immunization schedule published by the 

Advisory Committee on Immunization Practices at http://www.cdc.gov/vaccines/

schedules/hcp/child-adolescent.html. 
18

Can use of products such as wedges and 

positioners prevent SIDS? 

Wedges, positioners, and other devices that claim to be able to prevent SIDS 

or correctly position infants for sleep are not recommended. These products 

have not been tested for safety or effectiveness. In fact, the Consumer Product 

Safety Commission (CPSC) has reports of deaths attributable to accidental 

suffocation and entrapment associated with wedges and positioning devices. 

Most of these deaths occurred when infants were placed in the prone or sidelying position with these devices. The infant can roll onto his or her stomach 

and become trapped and suffocate between the device and side of the crib or 

bassinet. Also, the infant’s movement can cause the nose and mouth to press 

into or underneath the device, posing a risk for suffocation. This is particularly 

true for products made with foam rubber or Memory FoamTM. 

The U.S. Food and Drug Administration, the CPSC, and the AAP warn against 

using any of these products because of the dangers they pose to babies. To 

read the warning, visit http://www.fda.gov/ForConsumers/ConsumerUpdates/

ucm227575.htm. 

Does electronic cardiorespiratory monitoring 

prevent or detect SIDS? 

No. Such monitors are not recommended as a strategy for preventing 

or detecting SIDS. 

In the past, health care providers considered the use of cardiorespiratory 

monitors for reducing SIDS risk in certain groups, such as siblings in families 

that had previously lost a child from SIDS. However, no national consensus 

deems this practice as necessary or effective. The NICHD-funded Collaborative 

Home Infant Monitoring Evaluation (CHIME) study, which used specially 

designed electronic monitors in the home to detect cardiorespiratory events 

in infants, raised serious questions about the relationship between SIDS and 

events detected by home monitors.85 For this reason, home monitors are not 

recommended as a way to reduce the risk of SIDS. 

The AAP Task Force supports the conclusions from the CHIME study in 

recommending against using home monitors as a strategy to prevent SIDS.86, 87

There may still be circumstances in which clinicians will prescribe a home 

monitor for an infant who has already had a life-threatening event or for those 

considered at particularly high risk for airway obstruction, such as those with 
19

persistent apnea of prematurity, those with congenital airway malformations, 

or those who are being positioned prone during sleep for specific medical or 

surgical reasons. These monitors are not prescribed to prevent or detect SIDS.

Does back sleeping cause positional 

plagiocephaly or brachycephaly? 

Plagiocephaly—a flattened or misshapen head—can occur for various reasons. 

Positional plagiocephaly results from an infant being placed in the same 

position (usually on the back) for long periods of time. Brachycephaly (flattening 

of the back of the skull) may occur along with positional plagiocephaly. The 

primary causes of positional plagiocephaly and brachycephaly are: Too little time 

spent upright; too little Tummy Time when the baby is awake and supervised; 

and too much time in car seats, carriers, and bouncers.

Positional plagiocephaly and brachycephaly are usually harmless and often 

disappear on their own within the months after babies start to sit up. There is no 

evidence to suggest that such flat spots are harmful to infants or that they are 

associated with any permanent effects on head shape.88, 89 

Many cases of positional plagiocephaly can be prevented (and sometimes 

corrected) by repositioning, which relieves pressure from the back of an infant’s 

head.90 Techniques for repositioning include:

■ Alternating the baby’s head position when he or she is placed to sleep so that

the baby is not always sleeping on the same side of the head

■ Changing the direction the baby faces in the crib every week or so (feet at one

end of the crib one week, at the other end of the crib the next week)

■ Periodically moving the crib around the room so the infant has to turn his or

her head in different directions to see what is going on

■ Getting “cuddle time” with the baby by holding him or her upright over one

shoulder often during the day

■ Limiting the amount of time the baby spends in car seats, carriers, swings, and

bouncy seats

In addition, getting ample supervised Tummy Time is also important for reducing 

the likelihood of positional plagiocephaly. 

Positional plagiocephaly is very different from craniosynostosis (premature 

fusion of the sutures of the skull), congenital muscular torticollis (twisted 
20

neck present at birth), and other types of plagiocephaly. These other types of 

plagiocephaly often require special molding helmets or surgery to correct.91

Can babies ever be placed on their stomachs? 

Yes. Infants need Tummy Time when 

they are awake and when someone is 

watching them. Supervised Tummy Time 

strengthens muscles in the shoulders 

and neck that help infants to achieve 

developmental milestones. It also helps to 

prevent flat spots on the infant’s head. 

Health care providers should advise 

parents and caregivers that a certain 

amount of Tummy Time is a very important 

and necessary part of an infant’s 

development. Infants need two or three 

sessions of supervised Tummy Time every 

day. Older babies need even more Tummy 

Time to help their bodies get ready to sit up, roll over, crawl, and walk. Tummy 

Time should begin as early as possible to promote motor development, facilitate 

development of the upper body muscles, and minimize the risk of positional 

plagiocephaly.92

What advice should health care providers give 

to parents or caregivers whose infants have 

difficulty sleeping in the back position? 

Although the baby’s comfort is important, safety is more important. Parents and 

caregivers should be advised to place infants on their backs to sleep even if 

they seem less comfortable or sleep more lightly than when on their stomachs. 

It is helpful to understand that, compared with infants sleeping on their backs, 

infants who are placed on their stomachs sleep more deeply, are less reactive 

to noise, experience less movement, and are less able to arouse from sleep. It is 

theorized that these factors may put an infant at higher risk of SIDS.

It is true that some infants who lie on their backs do not sleep as deeply as 

those who lie on their stomachs. Similarly, infants who are placed on their backs 

to sleep may be fussy or cry. For information you can share with parents about 

how to help babies get to sleep while on their backs and sleep through the 
21

night, visit http://www.healthychildren.org/

english/ages-stages/baby/sleep/Pages/

default.aspx.

Moreover, while some parents report 

that using swings or swaddling helps to 

calm babies, there are no large studies 

showing efficacy of these practices in 

reducing the risk of SIDS.93 It also is 

important to note that swaddling does 

not reduce the necessity to follow other 

recommended safe infant sleep practices.

For babies in child care, what advice should 

health care providers give to parents and 

caregivers about reducing the risk of SIDS? 

Health care providers should strongly recommend that parents and caregivers 

be especially diligent about making sure infants are placed to sleep on their 

backs with nothing else in the sleep area, for every sleep time: For naps, at 

night, and while in child care. Consider the following: 

■ NICHD-supported research and other studies found that infants who are

accustomed to sleeping on their backs but who are then place to sleep on

their stomachs or sides are at very high risk of SIDS.94 This risk is actually

greater than the increased SIDS risk experience by infants who are always

placed on their stomachs or sides to sleep.95 If parents and caregivers place

an infant to sleep on his or her back at home, but child care providers use a

different sleep position, the infant is at significantly higher risk for SIDS.

■ In the United States, approximately

20 percent of SIDS deaths occur while

the infant is in the care of a child care

provider.96 This finding is significant, given

that more than 61 percent of children

younger than 5 years of age are in

some type of child care at least some of

the time.97

■ Many child care deaths are associated

with the stomach sleep position, especially

when the infant is unaccustomed to being

placed in that position for sleep.
22

■ Despite the Safe to Sleep® campaign (formerly Back to Sleep) and other

SIDS and safe infant sleep awareness campaigns, many child care

providers continue to place infants to sleep on their stomachs. Surveys

have documented that some secondary caregivers, even licensed child care

center workers, are either unaware of or are misinformed about the dangers

of placing infants to sleep on their stomachs.98

■ Although child care providers are more likely to use the back sleep position

when centers have written sleep policies, licensed child care centers seldom

have such policies.99 Studies have found that education programs for child

care providers are effective both in increasing knowledge of safe infant

sleep positioning and in promoting the development of written policies on

sleep position.100

Based on the evidence, consistency in sleep position is extremely 

important for reducing the risk of SIDS. It is crucial that parents and 

caregivers tell everyone who cares for their baby—including grandparents, child 

care providers, and babysitters—that the infant be placed on his or her back for 

every sleep time, for naps and at night. 

At what age can parents and caregivers stop 

placing infants on their backs to sleep to reduce 

the risk of SIDS? 

SIDS is defined as the sudden unexplained death of an infant younger than 

1 year of age that remains unexplained after a thorough investigation.101 Parents 

and caregivers should continue to place babies on their backs to sleep until 

their first birthday. 

Statistics indicate that the first 6 months after birth, when infants are forming 

their sleeping habits, are probably the most important in terms of using the back 

sleep position to reduce SIDS risk.102 Research shows that 90 percent of SIDS 

deaths occur in infants younger than 6 months of age, with a peak between 

1 month and 4 months of age.103

However, SIDS can occur at any time during an infant’s first year, so parents 

and caregivers should continue to be advised to use back sleeping and other 

ways to reduce the risk of SIDS and other sleep-related causes of infant death 

until their baby’s first birthday. 
23

Spread the word!
	

As a health care provider, you have 

multiple and unique opportunities to share 

safe infant sleep messages with parents 

and caregivers to help reduce the risk of 

SIDS and other sleep-related causes of 

infant death. Specifically: 

■ Always place infants on their backs

to sleep. The back sleep position

carries the lowest risk of SIDS.

■ Every sleep time counts. Infants

accustomed to sleeping on their back

who are then placed on their stomachs

to sleep are at significantly higher risk

for SIDS.

■ Sleep surface matters. Infants who sleep on top of an adult bed or under

soft surfaces (such as blankets or quilts) are at higher risk for SIDS and

other sleep-related causes of infant death.

Communities across the nation have made great progress in sharing safe infant 

sleep messages! With your help, we can spread these important messages to 

every community in the nation.
24

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1

For more information, contact the 

Safe to Sleep® campaign:

Phone: 1-800-505-CRIB (2742)

Email: NICHDInformationResourceCenter@mail.nih.gov 

Website: http://safetosleep.nichd.nih.gov

Fax: 1-866-760-5947

Mail: P.O. Box 3006, Rockville, MD 20847

NIH Pub. No. 14-7202

August 2014