Infant Sleep Position and SIDS

Questions and Answers for Health Care Providers 

 




U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

National Institute of Child Health and Human Development 
Dear Colleague: 

As Director of the National Institute of Child Health and Human 

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

Infant Sleep Position and SIDS: Questions and Answers for Health Care 

Providers. This booklet includes information and references that reflect 

the most recent recommendations from the American Academy of 

Pediatrics (AAP) Task Force on Sleep Position and Sudden Infant Death 

Syndrome (SIDS) and scientific research on reducing the risk of SIDS. 

Since the NICHD and its partners launched the national Back to Sleep 

campaign in 1994, we have made tremendous progress in helping to 

reduce the incidence of SIDS. Since 1994, the overall SIDS rate in 

the United States has declined by more than 50 percent. This is an 

extraordinary accomplishment, but our job is far from over. 

Although the overall rate of SIDS has declined dramatically, African 

American communities and American Indian/Alaska Native communities 

continue to be at increased risk. We share a common commitment 

to safeguarding the health and well-being of our nation’s children. 

Together, we can continue to make a difference, so that our messages 

reach every parent, every grandparent, and every infant caregiver in 

every community in the United States. 

Each of us has a responsibility to learn more about SIDS and to share 

what we learn with our families, friends, neighbors, and communities. 

As a health care provider, you are uniquely positioned to advance this 

important cause. I encourage you to read this booklet carefully and to 

discuss its contents with patients who care for infants younger than one 

year of age. 

Thanks for all you have done to educate families and caregivers about 

reducing the risk of SIDS. Let us continue to work together to help all 

infants grow into healthy adults. 

Sincerely yours, 

Duane Alexander, M.D. 

Director, NICHD 
definitive answers. 

In 2005, the American Academy of Pediatrics (AAP) Task Force on 

Infant Sleep Position and SIDS (hereafter, the AAP Task Force) issued 

revised recommendations for reducing the risk of SIDS.1  Among them 

was the recommendation that healthy babies be placed on their backs 

to sleep as the main way to reduce SIDS risk. 

The AAP first published this recommendation in 1992,2 after many 

research reports showed that babies placed on their stomachs to 

sleep were at greater risk of dying from SIDS. The AAP confirmed its 

recommendation in 1994,3 in 2000,4 and most recently in 2005.1 

Along with the AAP and other partners, the NICHD has maintained 

the Back to Sleep campaign since 1994. The Institute has prepared 

the following answers to commonly asked questions to help educate 

health care providers about the latest findings of SIDS research and 

risk-reduction strategies. Please note that some answers are based 

on expert opinion because current evidence is not sufficient to provide 

Healthy babies should be placed 

on their backs to sleep. 

1 
 

What advice should health care providers 

give to parents about the ways to reduce 

the risk of SIDS? 

Health care providers should encourage parents to do the following to 

reduce the risk of SIDS: 

• Always place your baby on his or her back to sleep—for naps 

and at night. The back sleep position is the safest, and every 

sleep time counts. 

• Place your baby on a firm sleep surface, such as a safetyapproved crib mattress, covered by a fitted sheet.* Never 

place your baby to sleep on pillows, quilts, sheepskins, and other 

soft surfaces. 

• Keep soft objects, toys, and loose bedding out of your baby’s 

sleep area. Don’t use pillows, blankets, quilts, sheepskins, or 

pillow-like crib bumpers in your baby’s sleep area, and keep all 

items away from your baby’s face. 

2 
 

 

 

 

 

 

 

 

• Do not allow smoking around your baby. Don’t smoke before 

or after the birth of your baby, and don’t let others smoke around 

your baby. 

• Keep your baby’s sleep area close to, but separate from, 

where you and others sleep. Your baby should not sleep in a 

bed or on a couch or armchair with adults or other children, but he 

or she can sleep in the same room as you. If you bring your baby 

into bed with you to breastfeed, put him or her back in a separate 

sleep area, such as a bassinet, crib, cradle, or a bedside cosleeper (infant bed that attaches to an adult bed) when finished. 

• Think about using a clean, dry pacifier when placing the infant 

down to sleep, but don’t force the baby to take it. (If you are 

breastfeeding your baby, wait until your child is one month old or 

is used to breastfeeding before using a pacifier.) 

• Do not let your baby get overheated during sleep. Dress your 

baby in light sleep clothing, and keep the room at a temperature 

that is comfortable for an adult. 

• Avoid products that claim to reduce the risk of SIDS. 

Most of these products have not been tested for effectiveness 

or safety. 

• Do not use home monitors to reduce the risk of SIDS. If you 

have questions about using monitors for other conditions, talk to 

your health care provider. 

• Reduce the chance that flat spots will develop on your baby’s 

head. Provide “tummy time” when your baby is awake and 

someone is watching; change the direction that your baby lies in 

the crib from one week to the next; and avoid too much time in 

car seats, carriers, and bouncers. 

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

Commission at 1–800–638–2772 or visit its Web site at www.cpsc.gov. Urge 

patients who do not have a crib to check with their state health department or local 

SIDS foundation about a crib donation program. 

* 

3 
What sleep position is safest for full-term 

babies in hospital nurseries? 

Healthy babies who are born full-term should be placed on their 

backs to sleep in hospital nurseries. Research shows that mothers 

and caregivers use the same sleep position for their babies at home 

that they see being used at the hospital.5,6 Therefore, hospital nursery 

personnel should place babies on their backs to sleep—for naps and 

at night. 

If hospital personnel have concerns about possible choking for the first 

few hours following birth, they can place infants on their sides, propped 

up against the side of the bassinet for stability. However, after several 

hours, the baby should be placed wholly on his or her back to sleep. 

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 sleeping 

wholly on the back. Studies have found that the side sleep position 

is unstable and increases the chance that infants will roll onto their 

stomachs7—the sleep position associated with the highest SIDS risk. 

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

backs to sleep—for naps and at night. 

Can infants be placed to sleep on their 

stomachs for naps or for short periods 

of rest? 

Studies show that babies who are used to sleeping on their backs, 

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

at significantly higher risk for SIDS.8 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.9 

Evidence suggests that many secondary caregivers and child care 

center personnel are not aware of this increased risk.10,11 Therefore, 

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

in recommending that anyone who cares for a baby—including 

grandparents, child care providers, and babysitters—knows that babies 

should be placed on their backs to sleep, and that every sleep 

time counts. 

4 
Are ther

babies 

e any circumstances when 

should be placed on their 

stomachs to sleep?

Healthy babies should 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 relieved by prone 

positioning15 and some physicians believe that babies with severe 

gastroesophageal reflux may benefit from being placed in the stomach 

position with the head elevated following eating.1  However, no recent 

literature supports or refutes the benefits of this therapy. 

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

stomach sleeping. Health care providers should consider the potential 

benefit to the baby when recommending infant 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 be sure to advise parents and caregivers to 

reduce the risk of SIDS in other ways, such as avoiding soft bedding 

and ensuring that babies do not overheat. For most babies, however, 

stomach and side sleeping are not advised.1 

 

5 
1 Figure 2

Will babies choke if they regurgitate or 

throw up while sleeping on their backs? 

No, babies automatically swallow or cough up fluid if they throw up 

while on their backs. This reflex operates to make sure the airway is 

always open. 

There is no evidence that healthy babies placed on their backs are 

more likely to have serious or fatal choking episodes than those placed 

on their stomachs.12,13

Figure 

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. 

Conversely, when babies are in the stomach sleep position, anything 

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

it easier for babies 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 

when the baby is lying supine. Of the very few reported cases of death 

due to choking, most of the infants were in the stomach sleep position. 

Furthermore, in countries (including the United States) that have seen 

a major change in infant sleep position—from mainly stomach to mostly 

back sleeping—the incidence of serious or fatal choking has 

not increased.14 

6 
 

 

for 

Will electronic cardiorespiratory 

monitoring prevent SIDS? 

The AAP Task Force supports the earlier conclusion of an NIH 

Consensus Conference that recommended against using home 

monitors as a strategy to prevent SIDS.1,16 In the past, health care 

providers considered the use of cardiorespiratory monitors to reduce 

risk in certain groups such as siblings born in families who had 

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

deems this practice as necessary or effective. In fact, the 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.17 For this 

reason, home monitors are not recommended as a way to reduce the 

risk of SIDS. 

There may still be circumstances where clinicians will prescribe a 

home monitor for babies who have already had a life-threatening event 

or for babies who are considered to be at particularly high risk for 

airway obstruction, such as those with persistent apnea of prematurity, 

those with congenital airway malformations, or those who are being 

positioned prone during sleep for specific medical or surgical reasons. 

Should preterm infants be placed on their 

backs for sleep? 

Yes. Recent research has shown that preterm infants are at higher risk 

for SIDS; therefore, placing preterm infants on their backs for sleep is 

critically important.18,19 

Some preterm babies 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. However, 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 

SIDS than babies born full term. 

7 
8

 

 

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. 

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.18 This practice will allow the 

parents to become familiar with the position they should use at home. 

How often should parents or caregivers 

check on infants during sleep to make 

sure they haven’t rolled into the stomach 

position 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.20 

However, once infants are more developmentally advanced, they often 
 

 

What advice should health care providers 

give to parents or caregivers whose 

infants have difficulty sleeping in the 

back position? 

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 may be fussy or cry. However, the absence of 

very deep sleep is believed to help protect infants against SIDS.21, 22 

Compared with infants sleeping on their backs, babies who are placed 

on their stomachs sleep more deeply, are less reactive to noise, 

experience less movement, and are less able to be aroused. All of 

these characteristics are believed to put infants at higher risk of SIDS. 

Some have found swings or swaddling23 helps to calm babies, but there 

are no large studies showing efficacy regarding SIDS risk reduction. 

Use of a pacifier may also help to calm a baby before sleep and has 

been associated with decreased SIDS risk. 

What advice should health care providers 

give to parents of babies in child care? 

Health care providers should strongly recommend that parents and 

caregivers be especially diligent about making sure their infants are 

placed to sleep on their backs, for every sleep time, while in child care. 

Some of the reasons are given below. 

• Studies show a marked increase in SIDS risk associated with 

unaccustomed sleep position.16 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.17 So, 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.24 

This finding is significant, given that two-thirds of infants younger 

than 12 months of age are in non-parental child care at least 

some of the time.25 

9 
• Many child care deaths are associated with the stomach sleep 

position, especially when the infant is unaccustomed to being 

placed in that position. 

• Despite Back to Sleep and other SIDS awareness campaigns, 

many child care providers continue to place infants on their 

stomachs to sleep. Evidence shows 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.18 

• 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.26 Studies have 

found that education programs for child care providers are 

effective both in increasing knowledge of safe sleep 

positions and in promoting the development of written policies 

on sleep position.24 

If parents use a blanket, they should place the baby 

with feet at the end of the crib. The blanket should 

reach no higher than the baby’s chest and should be 

tucked under the crib mattress to ensure safety. 

10 
 

Based on the evidence, consistency in sleep position is extremely 

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

caregivers tell anyone who cares for their baby—including 

grandparents, child care providers, and babysitters—that the infant 

should be placed on his or her back to sleep, and that every sleep 

time counts. 

At what age can parents and caregivers 

stop placing their babies on their backs 

to sleep? 

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

than one year of age.27 Parents and caregivers should continue to 

place babies on their backs to sleep throughout the first year of life. 

Once babies are older than one year, the back sleep position is no 

longer necessary. 

The first six months, when infants are forming their sleeping habits, are 

probably the most important in terms of the back sleep position and 

reducing SIDS risk. 

What is the best sleep surface for babies?
 

Parents and caregivers should use a firm sleep surface, such as a 

safety-approved crib mattress with no more than a thin covering, 

such as a fitted sheet or rubberized pad, between the infant and the 

mattress. Babies should not sleep on sofas, armchairs, waterbeds, or 

an adult mattress. 

The Back to Sleep campaign sponsors and the U.S. Consumer Product 

Safety Commission warn against placing any soft, plush, or bulky items 

(such as pillows, quilts, comforters, pillow-like bumpers, sheepskins, 

or stuffed toys) in the baby’s sleep area. These items could come in 

contact with the baby’s face, which may hinder exposure to oxygen, 

cause the baby to get overheated, or suffocate the baby—all possible 

contributors to SIDS. 

11 
 

 

 

Does bed sharing reduce the risk of SIDS?
 

Despite some claims to the contrary, current evidence does not support 

bed sharing as a protective strategy against SIDS. However, there is 

substantial evidence that bed sharing under a variety of circumstances 

significantly increases the risk of SIDS, while conversely, that room 

sharing without bed sharing reduces the risk of SIDS. Therefore, the 

AAP Task Force recommends that infants sleep in an area close to, but 

separate from, where adults sleep. 

Bed sharing among infants and family members, particularly among 

adults and infants, is common in many cultures.28 Many mothers share 

a bed with their infants because it makes breastfeeding easier and 

enhances bonding. Some believe that bed sharing may reduce the risk 

of SIDS because the parent is nearby to monitor the baby. 

On the contrary, evidence is mounting that bed sharing is hazardous. 

In some situations, bed sharing can compound the SIDS risk posed 

by other factors. For example, bed sharing is shown to increase SIDS 

risk29-36 when: 

• The mother smokes, has recently consumed alcohol, or 


is fatigued;
 

• The infant is covered by a blanket or quilt; or 

• There are multiple bed sharers. 

Research has shown that the presence of other children in the bed 

increases the risk of SIDS more than fivefold.32,35,37 Bed sharing with 

young infants—even when mothers do not smoke—also is a risk factor 

for SIDS.32,35,37,38 

Based on the most recent research,39 the AAP Task Force recommends 

room sharing, a situation in which the infant shares a room with the 

parent but has his or her own crib, bassinet, or bedside co-sleeper (an 

infant bed that attaches to an adult bed). 

If a mother wants to bring her infant into bed with her to feed or 

comfort, she should put the infant back in a separate sleep area, such 

as a bassinet, crib, cradle, or co-sleeper, when finished. 

12 
 

 

 

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.40 A recent meta-analysis reinforced 

findings of the protective effect of pacifiers against SIDS.41 The exact 

mechanism for this protective effect is unclear, but lowered sleep 

arousal thresholds is one possible explanation.42 

The AAP Task Force recommends 

that, for infants younger than 

one year of age, parents and 

caregivers consider using a 

pacifier when placing the infants 

down to sleep. Parents and 

caregivers should offer the 

pacifier, but not force the infant 

to take it if she or he refuses it. 

Pacifiers should be clean and dry 

and should not be reinserted after 

the infant is asleep. If a mother is 

breastfeeding, parents should wait 

until the infant is one month old or 

until breastfeeding is established 

before introducing a pacifier. 

Does back sleeping cause positional 

plagiocephaly or brachycephaly? 

Positional plagiocephaly—a flattened or misshapen head—may result 

when an infant is placed in the same position (usually on the back) for 

long periods of time. Brachycephaly—a 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. 

13 
 

Positional plagiocephaly and brachycephaly are usually harmless and 

often disappear within months after babies start to sit up. There is no 

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

is associated with any permanent effects on head shape.1,43 

Most cases of positional plagiocephaly can be prevented (and 

sometimes corrected) by repositioning,1,38 which relieves pressure from 

the back of an infant’s head. Techniques for repositioning include: 

• Providing “tummy time” when the baby is awake and someone 

is watching. Tummy time not only helps prevent flat spots, 

but it also helps strengthen muscles in the baby’s head, neck, 

and shoulders. (See the Can babies ever be placed on their 

stomachs? section of this booklet for more information.) 

• Changing the direction that the baby lies in the crib on a regular 

basis to ensure he or she is not resting on the same part of the 

head all the time. For example, have the baby’s feet point toward 

one end of the crib for a few days, and then change the position 

so his or her feet point toward the other end of the crib. 

• Avoiding too much time in car seats, carriers, and bouncers while 

the baby is awake. 

• Getting “cuddle time” with the baby by holding him or her upright 

over one shoulder often during the day. 

• Changing the location of the baby’s crib in the room so that 

he or she has to look in different directions to see the door or 

the window. 

Positional plagiocephaly is quite different from craniosynostosis 

(premature fusion of the sutures of the skull) and congenital muscular 

torticollis (twisted neck present at birth), and it seldom requires special 

molding helmets or surgery to correct.44 

14 
Can babies ever be placed on their 

stomachs? 

Yes. Infants need “tummy time” while they are awake and are being 

supervised. Spending time on the stomach strengthens muscles in 

the shoulders and neck that help infants to acquire 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. While there has been limited research 

on the issue of how much tummy time is ideal, the results of one 

study suggest that more tummy time is associated with better motor 

development.40 More research is needed before a specific amount of 

time can be recommended. 

Spread the word! 

As a health care provider, you can reach many parents and caregivers 

with safe sleep messages that can help reduce infants’ risk of SIDS. 

Tell parents, caregivers, and families that babies sleep safer on their 

backs, that sleep surface matters, and that every sleep time counts. 

Communities across the nation have made great progress in reducing 

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

every community in the nation. 

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17 

41 
For more information on SIDS and 

SIDS risk reduction, contact: 

Back to Sleep Campaign 

Phone: 1–800–505–CRIB (2742) 

Fax: 301–496–7101 

Mail: 31 Center Drive, Room 2A32, 

Bethesda, MD 20892 

Internet: http://www.nichd.nih.gov/SIDS 

National Institute of Child Health and Human Development 

NIH Pub. No. 07-7202 

June 2007