Everything you ever needed to know about Safe Sleep Practices + (un)Safe Sleep Products
Here at The Sleep Dept, we get asked regularly about specific sleep products and why they may be a risk factor when it comes to reducing the risk of SIDS. When you’re exposed to babies and sleep on a daily basis (mum life + work life), there is a level of responsibility that comes with that and it’s not something we take lightly – which is also why we will never do a sponsored post. It’s far more important to us that you feel you have a trusted source to reference than for us to make $$$ from a biased viewpoint. We really love helping educate parents and caregivers on safe sleep practices.
It’s a confusing world out there when it comes to baby sleep products. Safety takes a backseat for a lot of retailers. There are a number of common misconceptions about infant products. One is that all products are tested for safety before being sold in Australia and two is that all products that are sold are safe. Unfortunately neither is true.
The internet is full of contradicting advice and the world of influencer marketing has zero responsibility attached to it. So, how are you meant to know what is and isn’t safe?
A good rule of thumb we like to follow is that if it’s not flat and not firm, it doesn’t belong in your baby’s sleep space. Your baby’s sleep space is meant to be boring and not over stimulating. A fitted sheet, a swaddle or sleeping bag and a firmly tucked in blanket (if the baby is not rolling yet) is all your baby needs. A comforter is ok from 7 months of age.
We have created an easy to reference blog post for you. Please note that all the information has been taken from the Red Nose Australia, SIDS and Kids & CHOICE websites. Red Nose Australia has invested millions of dollars of research into the information you will read below. With this research, Red Nose Australia has saved the lives of thousands of babies..
What is SUDI?
SUDI is a broad term used to describe the sudden and unexpected death of a baby for which the cause is not immediately obvious. The only means to find out the reason why a baby has died suddenly and unexpectedly is to perform an autopsy, review the clinical history and to investigate the circumstances of death, including the death scene, thoroughly. Following this thorough investigation, some deaths are explained, such as accidental deaths, asphyxiation by bedclothes, pillows and overlaying whilst co sleeping, infection, metabolic disorders, genetic disorders or non-accidental injury such as homicide, while others are unexplained.
Sudden Infant Death Syndrome (SIDS) is an unexplained subset of SUDI. When no cause can be found for the death, it is called SIDS.
Why are Safe Sleeping recommendations so important?
It is often stated by parents and grandparents, ‘I slept on my tummy and I slept my babies on their tummies and they were fine’ or ‘I smoked around my babies and they are all grown up and ok – they didn’t die of SIDS!’ This is thought to be due to reduced arousal responses. However, arousal and swallowing mechanisms are needed to protect the baby’s airway and work best when a baby is placed to sleep on the back.
Although many studies have identified underlying risk factors for SUDI, the causative or pathophysiological mechanism that make some babies more vulnerable than others still remains uncertain. However, it is currently widely believed that SIDS is multifactorial. The Triple Risk Model (Figure 1) is useful for understanding why SIDS may occur with particular babies and why it is important to follow the Red Nose safe sleeping practices when caring for every baby. This model suggests there are three interacting factors: when all three are present, SIDS is more likely to occur.
Figure 1 Triple Risk Model for SIDS, illustrating the three overlapping factors: (1) a vulnerable infant; (2) a critical developmental period where the peak incidence of SIDS is 2-4 months; and (3) an exogenous stress
What are these three factors?
The first significant factor of the triple risk model represents a baby with an underlying weakness or abnormality which may only become apparent when the baby is exposed to stress. At this stage it is still unknown exactly what this factor is, but we know that babies born preterm or whose mothers smoked during pregnancy are more vulnerable to SIDS. Theories include a dysfunction in the brainstem, a genetic factor or a problem with a baby’s arousal mechanism. Research is still ongoing for this factor.
critical development period
The second factor of this model refers to the critical and vulnerable development period of a baby less than one year of age, particularly when under six months of age.
exposure to an external stressor
The third factor of this model involves the exposure of the baby to an outside stressor that may include known risk factors such as tobacco smoke, tummy or side sleeping position, overheating, head covering or an upper respiratory infection or illness.
The Triple Risk Model proposes that a vulnerable baby, at a critical period of their development, is exposed to a stressor with which he or she is unable to cope. According to the triple risk model, SIDS does not depend, therefore, on one independent cause but may occur if there is an interaction of these three factors/circles occurring simultaneously. If you can remove one of the three interacting factors, SIDS is unlikely to occur.
There are some factors that we cannot change such as the age of the baby (critical period of development) or identify, e.g. which babies may have an underlying vulnerability.
However, if parents and all care providers can remove as many as possible stressors to which babies are exposed, such as placing them on their back to sleep instead of on the tummy or side, reducing second-hand tobacco smoke, overheating, head covering, loose bedding and unsafe sleep surfaces, they will minimise the risk of SIDS.
What are the risk factors for SUDI?
Sleeping baby on tummy or side
Sleeping baby on a soft surface (mattress, pillow, waterbed)
Sleeping baby on a sofa (with or without a parent)
Loose, soft and fluffy bedding, including pillows. Doonas, soft toys, cot bumpers or sheepskin/lambswool anywhere in baby’s sleep environment
Sleeping baby with face or head covered
Exposing babies to tobacco smoke before or after birth
Sleeping baby in an unsafe cot or unsafe environment
Sharing a sleep surface with a baby
There are several potential hazards:
The baby sleeps in a curved position trying to mimic the baby’s position in the womb; newborn babies need to have a straight neck to maintain an open airway
The baby’s head is elevated. Red Nose recommends that all babies, including those with reflux, sleep on their back on a firm, clean and well fitting mattress that is flat (not tilted or elevated) to reduce the risk of SUDI
COMFORTERS + LOVEYS
The general advice from Red Nose is that all extraneous objects and soft and puffy items, including soft toys, should be kept out of the baby’s sleeping environment. However, there is a recognition that some babies will benefit from an object of comfort. The information statement “Soft Toys in the Cot” states: “Seven-month-old babies are more likely to explore objects in their sleeping environments than younger babies. Some babies over seven months of age may appreciate a small object such as a soft toy to provide comfort and connection (transitional object) during times of separation from their parents.
BABY SLEEP LOUNGERS
Babies can suffocate if their face becomes pressed against a sleep pod or positioner. US agency CPSC has reported 12 deaths over 13 years related to sleep positioners.
Parents should remember that these products have no safety standards and manufacturers and retailers are under no obligation to ensure the products they sell are safe.
Essentially, It’s a soft sleep surface with an inbuilt bumper – it doesn’t meet any of our criteria for safe sleep.
Red Nose recommends that the safest place to sleep baby is in a cot (with mandatory AS/NZS standards) in the parents’ room.
There are no standards for bassinets in Australia, including 3 sided which attach to the parents bed (sidecar cots).
Red Nose has the following information about side-car cots.
There has been a reported death in the home using a side-car crib. Currently in Australia there are no AS/NZS Standards for side-car cribs or portable sleep spaces, with trials ongoing.
If a parent is thinking about using products where there are no AS/NZS Standards, they need to ascertain not only whether the product may be effective but also is it safe to use under all circumstances and where the baby may be unsupervised.
Are there any potential hazards such as entrapment, strangulation, suffocation or fall risks associated with using this product? The safety of the baby needs to be ensured at all times.
If you are considering purchasing a bassinet, keep in mind that unlike cots, there is no Australian standard or regulations for bassinets and this is why they can be made from different types of materials and why they are available in many different shapes, styles, designs and sizes. Choice recently safety tested a number of bassinets and 2 out of 3 failed their in-house safety tests. To date, the most frequent accidents associated with bassinet use are falls and suffocation hazards.
One of the most popular nursery design trends is a canopy flowing over the corner of the cot to create what some parents see as a ‘dreamy’ fairytale look.
But cot canopies are dangerous for babies and young children and the ACCC previously recalled them because of the risk of strangulation. Excess fabric should never hang on or over the cot.
COT BUMPERS (INCLUDING MESH ONES)
Bumpers can do more harm than good. A US study found that 27 children died over a 20-year period due to suffocation or strangulation related to cot bumpers.
When babies roll for the first time, they aren’t able to roll back the other way, creating a serious danger if the bedding is too soft and bumpers are in the cot.
The reason Red Nose suggests against bumpers/air mesh wraps are that there is a slight increased risk with these types of products from a suffocation/entrapment point of view. While is it miniscule, Red Nose view possible suffocation/entrapment as a possible life-threatening accident, as compared to lodged limbs/head knocks.
As your child gets older, babies in a cot can be at an increased risk of a sleeping accident by using bumpers as a step to climb up and fall out of the cot. It is safer to wait until the child starts to sleep in a bed before introducing these items.
BABY SWINGS + ROCKERS + BOUNCINETTES
As there is no Australian Standard for bouncinettes, we are careful to keep up to date with reports of accidents associated with their use. To date, the most frequent accidents associated with bouncinette use are falls and entrapment hazards. Furthermore, deaths have occurred when a baby has been placed to sleep in a bouncinette.
Red Nose recommends that babies be slept on the back on a firm and flat surface.
When a baby falls asleep in a propped up device the head can fall forwards, pushing the chin down towards the chest. This can lead to the airway becoming blocked and reducing airflow.
Tilt your own head forward and place your chin on your chest. Try to breathe through your nose. Can you breathe freely? No. Babies breathe better when they are lying on their back on a firm, well fitting, flat (not tilted or elevated) mattress.
MOSES BASKETS + WICKER BASSINETS
These are made of a softer, more pliable type of wicker and are commonly used for newborn babies, but there’s no Australian safety standard for Moses baskets (or bassinets in general) and CHOICE’s experienced baby-product testers rarely recommend them.
“There are typically non-breathable zones on all sides, the handles can be a strangulation hazard and once your baby can roll or pull up, there’s a fall risk, especially if the basket is placed unsecured on a stand,” says CHOICE head of household testing Kim Gilmour.
Bassinets woven from natural plant materials such as rattan or cane are a favourite among online influencers, but they carry some risks, according to Gilmour.
While they can be strong, some types of wicker may be more pliable and could cause head, limb or finger entrapment in gaps in the weave.
Parents should also be aware that there’s no Australian safety standard for bassinets.
There are various recommendations for travelling with your baby in a car seat or capsule.Safe Sleep guidelines recommend that once the car journey is over it is very important that you remove the baby from the car seat or capsule, even if this means waking the baby. It is not safe for babies to spend long periods in a car seat/capsule as there is potential for the infant to end up in the “chin to chest” position which can result in breathing difficulties.
The Lullaby trust, a UK charity which provides safe sleep advice, funds research and supports bereaved families, advises that parents should avoid travelling in cars with preterm and very young babies for long distances. On longer journeys give your baby regular breaks and if possible have an adult sit with the baby in the back of the car, or use a mirror so you are able to keep an eye on them. If a baby changes its position and slumps forward, then parents should stop and take the baby out of the car seat. The Lullaby Trust advises that babies should be taken out of the car seat when not travelling and they should not sleep in a car seat for long periods of time. Many sources recommend a maximum of 2 hours in a car seat/capsule.
FLAT HEAD PILLOWS + COT PILLOWS
Pillows are not necessary for baby and increase baby’s risk of sudden unexpected death in infancy including SIDS and fatal sleep accidents
Red Nose recommends delaying offering a pillow until baby is over two years of age and is no longer sleeping in a cot
Pillows are not necessary for babies while babies are sleeping unobserved. Red Nose is aware of research showing that the use of a pillow in baby’s sleep environment increases the risk of Sudden Unexpected Death in Infancy (SUDI), including Sudden Infant Death Syndrome (SIDS) and fatal sleep accidents. They may cover the baby’s face and obstruct breathing or cause overheating. Older babies in a cot can be at an increased risk of a sleeping accident by using pillows as a step to climb up and fall out of the cot.
Case reports have also shown an increased risk of SUDI with pillow use. The Coroners Prevention Unit (Vic) examined a total of 72 infant deaths occurring in a sleeping context in Victoria from 2008 to 201012. A statistically significant association was identified for infants less than four months and the presence of a pillow with deaths occurring in a co-sleeping context13.
Some physiotherapists and chiropractors have recommended the use of a pillow to relieve the flattening a baby’s head, a relatively common condition, known as positional plagiocephaly14. This is not suitable while baby sleeps unobserved. If a baby’s medical practitioner recommends the use of a pillow during unobserved sleep, it is recommended that the medical practitioner puts this advice in writing.
For the majority of children, positional plagiocephaly is a preventable condition, responding well to simple repositioning techniques and by minimising pressure on the head when the baby is awake. These simple measures are described in the Red Nose information statement on baby’s head shape.
Red Nose does not recommend placing a pillow where baby sleeps unobserved. It is safer to wait until the child starts to sleep in a bed before introducing a pillow. The Australian government states it is safer not to use a pillow at all for children under two.
AMBER TEETHING NECKLACES
The Australian Government has recently issued a warning notice about the use of amber teething necklaces (bracelets and necklaces of amber beads). Testing of several of these products indicated that they could break into small parts and present a choking hazard to children under three years of age
In 2011, Parliamentary Secretary to the Treasurer, David Bradbury recently issued a warning notice to the public in relation to amber teething necklaces.
Amber teething necklaces and bracelets consist of amber beads which are a fossilised tree resin and range in colour from yellow to white and beige to brown.
The warning notice was issued after ACCC testing of several of these products indicated that they could break into small parts and present a choking hazard to children under three years of age.
Suppliers claim that when worn close to the skin, succinic acid will be released by the amber beads to relieve the symptoms of teething.
Consumers using this product are advised to:
Always supervise the infant when wearing the necklace or bracelet
Remove the necklace or bracelet when the infant is unattended, even if it is only for a short period of time
Remove the necklace or bracelet while the infant sleeps at day or night not allow the infant to mouth or chew the necklace or bracelet
Consider using alternate forms of pain relief
Seek medical advice if you have concerns about your child’s health and wellbeing.
All portable cots sold in Australian stores must meet the mandatory Australian Standard AS/NZS 2195 for portable cots (portacot). When assembling a portable cot it is important to read the instructions carefully, the instructions are there to help keep baby safe from sleeping accidents.
Only use the firm, thin, well-fitting mattress that is supplied with the portable cot. Never add a second mattress or additional padding under or over the mattress, which has been specifically designed for the portacot, as baby may become trapped face down in gaps between the mattress and the sides.
If you are accepting a second hand portable cot, look for a label or sticker that says that it complies with the mandatory standard; never place baby in a cot or portable cot that does not definitely meet the current Australian safety standard.
Wear and tear can expose baby to hazards. Only use a portable cot that has the mesh intact and that has no broken parts. Ensure that the base is flat and regularly check the portacot for signs of damage.
Do not use bedding that has exposed elastic as this presents a strangulation hazard for babies.
Do not use a portable cot if your child weighs more than 15kg (or check instructions of your particular model).
Red Nose does not recommend positional products such as anti-roll devices and items that fasten a baby into a sleeping position. Products that restrict the movement of a baby or a baby’s head should not be used. This is because there are no Australian Standards for these products and case studies have shown that these products can be unsafe.
There is strong scientific evidence to show that the best way to reduce the risk of SIDS and sleep accidents is to sleep babies on their back with face and head uncovered, to avoid exposing babies to tobacco smoke and to provide a safe sleeping environment. These may also impede baby’s natural development.
LAMBSWOOL + SHEEPSKINS
Red Nose guidelines state that a baby should be on a firm and flat mattress. Adding a lambswool/sheepskin – even if it is under the fitted sheet – creates a soft sleeping space, increasing the risk of suffocation and breathing being obstructed.
“Using a baby sling incorrectly is a suffocation risk, because babies do not have the physical ability to move out of dangerous positions that can block their airways,”
“This includes lying in a sling with a curved back, with their chin to chest; or lying with their face pressed against the fabric of the sling or the wearer’s body.”
Babies who are under four months of age, were born premature or low birth rate, or have breathing difficulties, are at greater risk of suffocation.
Currently, there are no Australian standards when it comes to using baby slings.
Red Nose Australia urges parents and carers to take care when using slings, and recommends following the below steps:
Make sure you can see your baby’s face and that your baby’s airway is free at all times (not snuggled against the fabric or the wearer’s body)
Correctly position the baby in the sling, which means your baby’s back is supported in a natural position, so their tummy and chest are against you
Ensure the baby’s chin does not rest on their chest
Your baby’s back is supported in a natural position so their tummy and chest are against you
Regularly check your baby. You should be able to see your baby’s face at all times by simply glancing down
When using a sling, follow the product instructions, and do not use products that are cocoon-like or womb shaped
Injuries can also occur from the baby falling from the sling when the caregiver trips and falls; the product malfunctions or its hardware breaks; or the baby slips and falls over the side.
Remember and follow the TICKS rules:
T — Tight: Slings should be tight enough to hug your baby close to you.
I — In view at all times: You should always be able to see your baby’s face by simply glancing down.
C — Close enough to kiss: By tipping your head forward you should be able to kiss your baby on the head.
K — Keep chin off the chest: A baby should never be curled so that their chin is forced onto their chest as this can restrict their breathing.
S — Supported back: The baby’s back should be supported in a natural position so their tummy and chest are against you.
HANGING BASSINETS + BABY HAMMOCKS
There is no Australian standard covering the use and manufacture of hammocks for babies.
Red Nose recommends that a baby should sleep on a firm and flat surface. One safety concern with the hammock is that it holds the baby in a curved position, this may cause the baby’s neck to flex forward which may block the baby’s airway not allowing airflow. A baby needs to be placed to sleep flat (not elevated or curved with chin on chest) to maintain an open airway
There is also a risk of injury or death from falls.
We are aware of case and injury reports documenting a number of hospital admissions of babies following a fall from a hammock and tragically two deaths of infants sleeping in hammocks in separate incidences in the USA in 2009 and an infant death in Victoria, Australia in 2011.
Research into these deaths in particular and the use of hammocks in general for babies concluded that they are not suitable for a baby to sleep in while unsupervised.
There are no mandatory standards in Australia for bassinets.
Product Safety information includes allowing enough height (300mm) from the top of the mattress to the top of the sides. Use a firm, clean, well-fitting mattress no more than 75mm thick.
The mandatory safety standards for the use of prams are not directly related to the baby’s sleep environment. Product safety includes the following in their information:
“Avoid sleeping children in prams or strollers. Never have an unharnessed child asleep in a pram or stroller as they can move about and may be at risk of falling or entrapment. If they are asleep, maintain regular supervision.”
Red Nose information states the following in relation to pram use: “Never leave your baby unattended in a pram or stroller. It is not a substitute for a cot.”
Also, remember to ensure the baby cannot become entangled in the restraints, particularly as sleep overnight is mostly “unsupervised”.