Safest sleeping positions by age and associated risks

By Megan Petchel & Julie Monson Jun 8, 2021

A big concern on many parents' minds when their baby is sleeping is the risk of them passing away suddenly from unknown causes (SIDS).

As your baby grows and develops, it is important to know which sleeping positions are safe and suitable for their age and milestones, in order to keep your baby safe while sleeping and reduce the risk of SIDS.

The Risk of Sudden Infant Death Syndrome (SIDS):

SIDS is the main cause of death in babies between the ages of a month and a year with the rate peaking during the first 4 months of life. It is reported that over 90% of SIDS deaths occur before a baby reaches 6 months of age.

In the USA, SIDS reportedly contributes to 37% of all deaths of children between the ages of 1 to 12 months with the majority of these deaths occurring during the first six months of life.

Whilst there has been a significant amount of research done on SIDS over many years, there is still no clear indication as to the root cause. Various risk factors which can increase the risk of SIDS have been identified. These include:

Babies who sleep on their tummy or side rather than their back
Babies who sleep on a soft surface
Babies who sleep with blankets, soft toys or cot bumpers
Babies who overheat whilst sleeping
Babies who were born prematurely or with a low birth weight
Mothers who smoked during the pregnancy (a SIDS related death is 3 times more likely to occur)
Mothers who were exposed to secondary smoke from other members in the same house
Mothers who had little or no prenatal care during their pregnancy
Babies who have a sibling pass away from SIDS
Babies who sleep in the same bed as their parents
Babies who sleep in a car seat, couch or baby swing

Recommended Safe Sleep Practice:

In order to reduce the number of SIDS associated deaths, the American Academy of Paediatrics (AAP) put in place specific sleep recommendations which were most recently updated in 2022.

These recommendations have fundamental evidence supporting safe sleeping practices and have halved the number of babies dying from SIDS.

They strongly advise that the following are put in place for every nap and overnight sleep:

Ensuring they sleep on a flat and firm surface
Placing them to sleep on their back
Keep their cot empty with no blankets, pillows or soft toys etc
Sharing a room (but not a bed)

BIRTH - 2 MONTHS OLD
Developmental Milestones & Possible sleep changes	At this stage, your newborn is likely to sleep for the majority of the time with wake periods not lasting longer than 40-60 minutes.
Recommended sleep position	The safest position at this age for your baby is to sleep flat on their back on a firm and flat mattress with no loose items in their cot. Swaddling your baby is recommended for the first two months. This helps mimic the warmth and comfort of the womb and is soothing and reassuring for them. Swaddling your baby with their hands together in the middle near their face helps them to self-soothe. Read our guide on how to swaddle safely to prevent hip dysplasia here
What to avoid	Using a positioner, baby nest/pod, or rolled up towel to prevent your baby from rolling over is not recommended. These devices pose a suffocation hazard if your baby was to turn their face into it. Your newborn has limited control over their movements and it is unlikely that they will roll over onto their side or tummy if laid to sleep on their back. The risk of using a towel, positioner, or baby nest/pod outweighs any benefit it could provide. Do not place your baby to sleep on their tummy. Their face may get pushed into the mattress which can lead to suffocation and an increased risk of SIDS. Similarly, do not place your baby to sleep on their side. Their breathing could become compromised should they roll onto their tummy as they would not be able to turn their head or place themselves in a safer position. Avoid letting your baby sleep in devices such as sleeping pods, baby swings or bouncers. Not only are the surfaces of these products too soft, they can also place your baby in a dangerous position which could lead to positional asphyxiation.

2 - 3 MONTHS OLD
Developmental Milestones & Possible sleep changes	Around this time, your baby can: Start pushing up on arms whilst on their tummy Able to lift and hold their head up when lying on their tummy Open their fists Move their legs and arms off the surface
Recommended sleep position	Placing your baby to sleep on their back on a firm and flat surface is still the safest position, even as their muscles become stronger. Although your baby will start pushing up on their arms and lift their head when lying on their tummy, it is still not safe for them to be put to sleep in that position. The risk of them not being able to move their head into a safe position is too high. This is because your baby is likely to enter a deeper state of sleep when on their stomach. Once you no longer swaddle your baby, it is recommended that you use an age-appropriate sleep sack.
What to avoid	Any loose items in their cot which could possibly entrap or strangle them must be removed. This includes cot bumpers. It is very unlikely that they will bump their head against the edge of the cot as they are not yet able to roll. However, the risk of suffocation or entanglement is very high should it become loose. Swaddling your baby once they are able to roll on their own is dangerous. They could become trapped in a compromising position or the swaddle could cover their face. Both of which increase the chance of suffocation and SIDS.

4 - 6 MONTHS OLD
Developmental milestones & possible sleep changes	Your baby’s strength continues to grow. Now they can: Roll from their back to tummy Use both hands to play with their feet whilst lying on their back Start using hands to support themselves while sitting.
Recommended Sleep Position	Even though your baby is probably able to roll over on their own now, it is still best practice to place them on their back on a firm and flat surface. Should you find your baby on their side or tummy, there is no need to panic. They have more strength and coordination which will help them lift their heads if need be. While it is safe for your baby to sleep on their side, it is still not recommended. If they get there on their own then it is ok to leave them there. However, do not lay them down on their side to sleep. It is around this time that the cot should be lowered to the halfway notch. Once they are able to roll over independently and can start pushing up on their arms, it is important that their cot be lowered to prevent them from falling out.
What to avoid	It is still imperative that you do not leave any loose items in their cot. This includes a blanket as they are still too young. If they had a blanket over their legs and lifted their legs up while playing, the blanket could fall on their face and they may not have the coordination required to push it away. This could lead to suffocation. Make sure that the TOG (warmth indication value) of the sleeping sack that you place your baby in as well as what you have dressed them in is appropriate for the temperature of the room to prevent overheating. Overheating can increase the chance of SIDS.

safest sleeping position for babies 4-6 months

7 - 10 MONTHS OLD
Developmental milestones and possible sleep changes	From 7 months of age, your baby is now able to: Sit without support Reach for a toy while sitting and not fall Move into sitting from their tummy or back Starts with alternating arm and leg movements such as creeping and crawling. Shows increased control when rolling and sitting
Recommended sleep position	While your baby is certainly becoming more mobile, it is still recommended that they be placed on their back on a firm and flat surface when sleeping. Although the risk of SIDS is not as high, the AAP still advocates that this position be used until they are 12 months of age. Your baby will likely move into various other positions whilst they sleep which is nothing to be concerned about if their cot is empty and there are no loose items which could be a hazard.
What to avoid	You may think that because your baby has more control over their movements, that adding a blanket, pillow or toy to their cot is safe. The AAP states that they are still at risk of SIDS and so their cot should remain empty until at least 12 months of age

safest sleep position for 7-10 month old babies

10 - 12 MONTHS OLD
Developmental milestones & possible sleep changes	Your baby is becoming more and more mobile, they are now able to: Pull themselves up to stand and cruise along furniture Stand alone and start taking a few steps Easily move into different positions to explore their environment
Recommended sleep position	While your baby is certainly becoming more mobile, it is still recommended that they be placed on their back on a firm and flat surface when sleeping. Your baby will soon start showing signs of trying to pull themselves up and may use the sides of the cot to do this. As they get stronger they will start standing in their cot. To ensure their safety, lower the cot to the lowest setting before the toddler bed stage. This will help ensure their safety and reduce the possibility of them trying to climb out of their cot.
What to avoid	You may think that because your baby has more control over their movements, that adding a blanket, pillow or toy to their cot is safe. The AAP states that they are still at risk of SIDS and so their cot should remain empty until at least 12 months of age.

is it safe for my baby to sleep with a blanket

With your baby being encouraged to sleep predominantly on their back, a few developmental and other safety concerns may arise. It is important to address these and put your mind at ease. Read our article on how to avoid Container Baby Syndrome here

CAN MY BABY CHOKE IF THEY VOMIT WHILE ON THEIR BACK?

One of the biggest concerns that arises when parents are instructed to place their babies on their backs to sleep is "will they choke if they vomit?"

The National Institute of Health confirms that in fact the opposite is true. Your baby has a lower chance of choking whilst on their backs.

This is because babies have a reflex which makes them cough or swallow anything that comes up. This means that it is easier for them to clear their airway when they are on their backs.

We understand that many paediatricians in South Africa still recommend that babies with reflux sleep on their sides and/or with wedges. We suggest that you discuss the AAP recommendations with your doctor before you decide to place your baby on their side or on a wedge.

When is it safe for my baby to sleep on their side OR FRONT?

Allowing your baby to sleep on their front against your chest is safe as long as you are alert and awake, to ensure that you can monitor their breathing and assist them should they move into an unsafe position.

However, allowing them to sleep in either of these positions in their cot drastically increases the risk of SIDS and suffocation especially when they are not yet able to roll on their own.

A baby who is placed to sleep on their side may roll onto their front and may not be able to turn their head or move out of that position in order to breathe.

This means that their face may be pushed into the mattress and their mouth and nose become covered, making it difficult for them to breathe. This can increase the risk of SIDS as well as suffocation should their position not be corrected quickly.

The AAP recommends that your baby should not be placed in their cot in either of these positions if they are younger than 12 months.

Despite your best efforts you may find that they have rolled onto their side or front while they are sleeping. There is no need to be alarmed if they are older.

At this stage your baby should be able to roll from their tummy onto their back and vice versa. Thus if they are able to get into that position on their own then they should be able to roll over to breathe, provided they are on a firm surface in order to be able to do so.

Can I safely prevent my baby from sleeping on their tummy?

Parents may be tempted to use an incline positioner or a rolled up towel to place next to their baby to prevent them from rolling onto their tummy while they sleep. Unfortunately, placing these items in your baby’s cot adds more of a risk than any benefit and contradicts the AAP indications of having no loose items around them.

These items pose a risk of suffocation if your baby were to turn their face into them and a risk of getting stuck in a compromised position should the towel or blanket unravel whilst they sleep.

When can a baby start using a blanket, pillow or stuffed animal in their cot?

There is no specific age at which a child can start using a pillow or blanket or have a stuffed toy in their cot.

The AAP does, however, recommend that this should not be before your baby is 12 months old. The longer your baby sleeps in an empty cot on a flat and firm mattress, the safer they are.

A general consensus is that these items can be introduced when your baby moves into a toddler bed as the risk of SIDS is considerably less. Babies usually move into toddler beds around 2 years of age.

Is it safe to use a pillow in my baby's cot

Although it is safe to introduce these items to your baby once they are a year old, care should still be taken to use blankets which are thin and lightweight.

It is advised that blankets which have any tassels or ribbons attached should be avoided as these still pose a choking hazard.

Steering away from using a pillow too early is also important as a pillow can place unnecessary strain on your baby's neck and push their heads forward.

When considering what stuffed animal to give your baby, it is wise to choose something that does not have any parts which could become loose such as eyes as these can be a choking hazard.

Will my baby develop enough back strength if they are always on their back?

Concerns about back muscles not developing or becoming strong enough due to sleeping on their back have been raised. This has sparked concerns about developmental milestones being slowed down as baby’s do not get enough time on their tummies.

The limited research which has been done shows that babies who sleep on their tummies acquire several motor skills earlier than those who sleep on their back. Despite this, it is important to note that all babies achieved the required milestones in an appropriate time.

A baby needs both their tummy and back muscles to be equally strong as this forms the foundation for sitting, crawling and walking. Their back muscles develop and strengthen first by lying on their tummy. But if a baby spends most of their time on their back there is limited opportunity for these to develop appropriately. This is why daily tummy time during your baby’s awake hours is crucial to their development.

Are there any other things I can do to reduce the risk of SIDS?

Research indicates that letting your baby sleep with a dummy for the first 6 months has been linked to lower SIDS rates, if your baby will take a dummy.

Ensuring that your baby’s room is not warmer than 22℃ and they are appropriately dressed prevents them from overheating which can increase the risk of SIDS.

As rewarding as parenthood is, navigating your way through all the information and advice about how to keep your baby safe can be overwhelming. Following these safe sleep guidelines which have been researched and put forward by professionals can provide you with some peace of mind knowing that you are keeping your baby as safe as possible while they sleep.

Resources

https://www.ncbi.nlm.nih.gov/books/NBK513389/

https://www.childrenshospital.org/conditions-and-treatments/conditions/s/sudden-infant-death-syndrome-sids/symptoms-and-causes

https://pediatrics.aappublications.org/content/138/5/e20162938

https://www.lullabytrust.org.uk/safer-sleep-advice/sleeping-position/

https://safetosleep.nichd.nih.gov/safesleepbasics/SIDS/fastfacts

https://safetosleep.nichd.nih.gov/safesleepbasics/tummytime

https://www.nichd.nih.gov/sites/default/files/2019-02/Safe_Sleep_Environ_update.pdf

https://www.healthline.com/health/baby-sleeping-on-side#The-most-serious-risk:-SIDS

https://pediatrics.aappublications.org/content/102/5/1135?ck=nck

https://www.medicalnewstoday.com/articles/baby-sleeping-on-side#changing-positions

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