Ask the Pediatrician FAQ

I have probably been asked more questions about bassinets and their use as a sleeping area for infants in the early months of life than any other topic. I have been amazed to see how many different products are out there on the market, each one with a slightly different bell or whistle. In many cases, it is impossible to talk about these products without naming brands, so in this discussion you will see some specific products named.

A bassinet/cradle, as defined by the CPSC, is a small bed designed for use by an infant that is usually supported by freestanding legs and has a stationary frame/stand but may be on wheels or have a rocking base. It cannot have a sleep surface that is elevated more than 10 degrees. Standards for bassinets also apply to products that are accessories to play yard s or non-full size cribs and to bedside sleepers.

From November 2007 through March 2013, the CPSC received notice of 426 incidents involving infants in bassinets/cradles including 132 fatalities, prompting a review of their safety. Many of these and additional deaths reported after this time period occurred to infants under five months of age and were related to asphyxiation from the presence of soft or extra bedding in the bassinet, prone placement of the infant and/or wedging of the infant between the side of the bassinet and additional bedding. These events were not primarily related to product failure but to nonadherence to recommendations for creating a safe sleep environment for the infant. Most of the non-fatal incidents related to bassinet use were due to falls out of the device, particularly when the product continued to be used after the baby could get up on his hands or knees.

In 2014 CPSC issued new regulations for bassinets/cradles. With this they set new standards for spacing of rigid components/fabric-sided enclosed openings with the intention of preventing entrapment between slats or their equivalent, similar to the types of recommendations that had been made earlier for full-size cribs. Static load limits were increased to address increased weight use by consumers and further requirements to increase stability of units at risk for tipping were set. Sleeping pad thickness and dimensions were addressed to prevent suffocation from gaps between the sleeping pad and the side of the unit. A new specific height for the sides was set at 7.5 inches measured from the top of the mattress. Flatness of segmented mattresses was addressed with the intent of preventing asphyxia of an infant lying face down in a segmented mattress joint. An upper limit for rock/swing angle was set to prevent entrapment due to swing angle. Warning labels intended to alert the caregiver to the risk of infant falls and suffocation hazards within bassinets were required, as were the need that all parts of the product meet previous set flammability requirements. (I know that all of this sounds very technical but it is these regulations that set the stage for many of my replies!)

The sleeping area of a bassinet is surrounded on all sides by some type of fabric-covered barrier or by mesh. As stated above, per regulation, it must also be at least 7.5 inches deep from the top of the mattress when it is not pressed down. It does not specify what the actual size of the sleeping area should be so some bassinets are larger or smaller than others. The CPSC does address inter-slat distance, if slats are present, which is more likely an issue with cradles. Inter-slat distance must be no greater than 2 3/8 inches.

With all this being said, rest assured that any new product that you purchase in this category that has the Juvenile Products Manufacturer’s Association (JPMA) seal on it must conform to all of the standards that I have discussed above. However, there is more to the story.

Air Flow Within the Bassinet/Cradle Sleeping Area

A common question that I have been asked is about airflow within the sleeping area. Currently there is no CPSC regulation that specifically addresses this. I know of no studies that address this issue either. Questions as to the merit of solid versus mesh sides on bassinets, however, are among the most common that I receive. Clearly if the baby’s nose and mouth were to become lodged up against the side of the sleeping area, it would be much more difficult to continue to achieve good airflow if the sides were made of a solid, non-porous material. Mesh sides, on the other hand, would offer the advantage of the continued ability to draw air through the sides of the bassinet even under these circumstances. Many bassinets, both old and new, do not have mesh sides. If I were selecting one to buy for a newborn, I would recommend purchasing one with mesh sides. Here is how I answered the following question about mesh sides.

Question

Are bassinets safe for newborns if they don’t have mesh sides? Is there really enough air flow?

My Answer

Bassinets are a common sleeping area for many infants during the early months of life. These products are compact and are readily adaptable to placement in the parents’ sleeping area when a full-size crib is not. Most newborns are not able to move around in their sleeping area to any significant degree in the early months of life, so a sleeping area that has solid sides that are relatively close to the infant is not generally an issue. Once an infant shows signs of being able to roll over and scoot, however, I think it is time to move her to a larger sleeping area, even if she is not at the 15 pound upper weight limit that is set for most bassinets. Not only does the infant need more room to perform his motor skills, but more importantly, it will be more likely that his nose and face could come into contact with the sides of the bassinet. If the side is solid (and particularly if it is cushioned), the infant has some risk of having his nose or mouth pressed against the side where he will not be able to breathe. If the sides were mesh this would not happen. I think having mesh on all sides of a bassinet is ideal!

Bassinets and cradles that rock (from side to side that is!)

I think that having a bassinet that provides a gentle rock (a side-to-side or up-and-down motion) can be a good thing as it can help to comfort some (unfortunately, not all) babies to sleep, a very desirable event in most households! I am all for it, but you must be careful of how much angle there is to the rock! Devices that have excessive lateral movement can cause an infant to roll or be tossed up against the sides of the unit. If the side is made of a solid, non-porous material the infant’s nose and mouth may become wedged against the side creating a suffocation hazard. If the sides are mesh, however, this would clearly be less of an issue. (See discussion above about mesh sides). All cradles, by definition, rock, so this is an extremely important issue with these types of units in particular. Per current ASTM standards, all bassinets and cradles that rock cannot have a deflection beyond a 20 degree angle to assure that this type of action does not occur. As cradles are a relatively common hand-me-down item, it is very likely that an older product would not meet these standards. Once again, use these older products for teddy bear storage, not as a sleeping place for your baby!

Mattress Firmness and Fit in Bassinets and Cradles

Another issue that I have gotten many questions about is the mattress that comes with the bassinet. Many are concerned that it is too thin or too firm and ask if it is okay to use some type of softer cover to make the baby more comfortable. The current ASTM standard for bassinet mattresses is that they can be no thicker than 1.5 inches and “firm”, although there is no specific definition of firm in the US. (New Zealand and Australia have developed a standard. You can view their rather novel assessment technique for assessing infant mattress firmness if you search for “Identifying a Properly Firm Infant Mattress” on YouTube. )

Why is firmness so important? Here’s why: If an infant were placed to sleep on a surface into which he or she could “sink”, and the sides of the “too soft” surface (think adult “pillow topped” mattress, pillow or boppie) were to get too close to the baby’s face it could create a pocket of stale air where the baby either re-breathes carbon dioxide (our body’s breathing waste product) or does not get enough oxygen. This is particularly relevant if the infant were placed on the stomach for sleep. Even an infant who has demonstrated that she can roll over well and has good head control could have trouble getting her nose and face out of the way if she rolled over onto a soft pillow. A firm sleep surface is one of the cornerstones of safe sleep for infants.

We make the mistake of thinking that an infant knows what soft and fluffy is and that he would be more comfortable and prefer that. Not true! This is a learned experience. Whatever you expose your baby to is what is natural and normal to him. It is one of the basic tenets of safe sleep that the infant sleep on a firm surface at all times. You want to make sure your baby knows all about that from early on because his crib mattress is going to be firm as well!

I have been asked questions about the safest materials to use to make a mattress for an antique cradle. Making a mattress for a bassinet or cradle is not something that I would recommend. For general information purposes, however, infant mattresses are either made of a high density foam or are innerspring based. Infants should never be placed on memory foam, a very low density foam product. This is probably one of the worst sleep surfaces for an infant. Also do not use any sheep skin to soften up the sleep area. All of these products defeat the purpose of creating a safe sleep environment for your infant.

Other Issues with Mattresses for Bassinets or Cradles

Make sure the mattress for the bassinet or cradle fits snugly into the sleeping area for the infant. There should be no gaps between the mattress and the sides of the unit. It is best to only use the mattress that came with your unit. Attempts to replace it, unless it is from the original manufacturer who is selling a replacement product made specifically for your exact unit, are not advisable as you are unlikely to find a product that provides the exact fit that you need. The same is true for sheets or covering for the mattress. Purchase only sheets that are made for your product. Otherwise you will have an issue with poor fit that will result in bunching and/or loose bedding when the edges of the sheet dislodge from the mattress. All of these factors can create a risk of suffocation in your infant’s sleep environment. Never just put a pillowcase over the mattress or try to use one as a sheet. It never works.

Support Base for the Bassinet and Cradle

Although I have never been asked about this specifically, I think this is an important issue. Many bassinets can be lifted off of their base to become portable units. 2014 CPSC regulations require that there is a secure (fail-safe) mechanism for locking the cradle back in to the base so that the user cannot possibly walk away thinking that the unit is attached when it is not. (This applies to any product manufactured after 2014 that has a JPMA seal on it.) As falls are the most common injury that occur to infants while in bassinets, I suggest that you get a product that does not come off of its base.

I have always had an issue with the A-frame design of many bassinet stands because I think it would be easy for a pet or an errant adult or child leg (particularly in the dark) to catch the edge of the frame and knock over the device. I prefer a base that has a rectangular design for support. If the legs or frame of a product can collapse for storage, make sure they lock in place when the unit is set up.

As strange as it may sound, the answer to this question is a resounding YES! The evidence is overwhelming. Pacifier use is one of the single most effective strategies to reduce the risk of a sleep-related infant death — by anywhere from 50-90%! This is true even for infants who slept on their sides or stomach, bedshared or slept on soft bedding. WOW! Why aren’t we talking about this more? That I can’t answer, but I do want to share this information even though I have never specifically been asked a question about pacifier use.

What is this protective effect all about? Although we don’t know for certain, it is thought that the act of sucking on a pacifier, particularly at the onset of sleep, makes a sleeping infant more arousable or more easily awakened from sleep. Sucking may enhance some of the normal autonomic controls that are present in the brain stem, making the infant more responsive to both internal and external stimuli. As many researchers believe that an infant’s ability to arouse during sleep is an important factor in reducing the risk of a sleep-related death, pacifiers may enhance this vital brainstem function.

Let me give you a few scenarios where an infant being more arousable would be a good thing. Let’s take the situation of a baby who managed to get his or her face too close to some extraneous object in the sleep environment, such as a pillow, stuffed animal or bumper. (I know that none of these items should be there, but sometimes they are.) In this situation, a stale pocket of air could develop around the nose or mouth allowing him to rebreathe his own bodily waste product (carbon dioxide). Too much carbon dioxide in the body for too long dulls the brain and, if the situation is not corrected quickly enough, could cause the baby to die. The use of a pacifier may make an infant better able to respond to this stress because she is more easily aroused from sleep and better able to respond by moving her head to another spot where she can breathe in clean, fresh air again. Even though sleeping on the stomach makes a baby less arousable, this same scenario is also potentially true for stomach sleepers. Other categories of infants who we think of as at risk for decreased arousability during sleep are babies who are exposed to tobacco smoke or opioids while still in the uterus. We know that both of these categories of infants are at a significantly higher risk for a sleep-related death. The use of a pacifier seems like a simple enough intervention and should be particularly encouraged under these circumstances. The bottom line is pacifiers are a known factor that can decrease the risk of a sleep-related death.

By the way, you don’t have to continually put the pacifier back in your baby’s mouth when it falls out. The benefit still seems to be there. Also, do not force your baby to take a pacifier. Some will take it avidly while others are not interested in it at all. If that is the case, then just move on.

Are there downsides to pacifier use? Well, maybe. Some studies have suggested that infants who are given pacifiers too early are less likely to breastfeed successfully. That is why it is recommended by the AAP SIDS Task Force that pacifiers not be introduced until breastfeeding is well established. Pacifier use over the long haul, meaning once breastfeeding has been well established, has not been shown to decrease the duration or the exclusivity of breastfeeding.

Many caregivers use infant sitting devices as alternative sleeping or resting areas, particularly when not in the home setting. However, car seats and devices such as swings, strollers, and bouncy chairs should only be used for their intended purposes and not for extended periods of unobserved sleep. Why is this so important? Infants, particularly those under six months of age, lack the necessary upper-body tone and strength to hold the upright position that these devices require. When infants are placed in them, particularly for an extended sleep, they might slump or slip down, putting excess pressure on the stomach and abdomen. Also, their necks can fall forward and to the side. As babies use their abdominal muscles and diaphragms as part of their normal breathing process, the slumped-down position limits the use of both of these vital breathing muscles. As an infant’s airway is soft and compliant, it can easily kink when the neck falls forward and/or to the side, limiting airflow through the trachea, the major path air takes to get to the lungs. The bottom line is any device that fosters the sitting position for an infant can have major negative effects on breathing and even increase the likelihood that they will spit up, so it is not safe to use one of these devices as a place for your infant to sleep.

A recent report from the Consumer Product Safety Commission described the car seat deaths of thirty-one children less than two years of age. All of the deaths occurred when the car seat was being used as a sleeping device outside of the car and were almost evenly attributable to either strangulation from the straps or positional asphyxia. It is important to emphasize that there were no deaths in infants when the car seat was being used for its intended purpose. There were sixteen reported deaths in other types of sitting devices, all of which occurred by eight months of age and were all due to positional asphyxia.

This is a sober warning about the improper use of these products. Make no mistake, they are only meant to be used for their intended purposes while the infant is being directly observed.

Here is a question I received about the use of a car seat during a long car trip for a two-month-old infant:

Question

We’re going on vacation in two weeks. Our youngest is only going to be two months old. Our drive is seventeen hours and we will not be stopping. Will she be okay in her seat for that long? We will be stopping for feedings but not stopping overnight. I’m just paranoid because someone told me that carriers raise the risk of SIDS.

My Answer

Putting a two-month-old in a car seat for that long a time period is not ideal. The slumped down neck position that infants usually assume in the car seat, particularly when they are asleep, makes it harder for them to breath. Make sure someone is sitting next to her and watching her during the entire trip to make sure she is okay. I also recommend you not only take her out of the car seat for feeding but give her an additional one-half hour out of the seat afterward as well. This will give her a chance to empty her stomach a bit before she has to go back into the sitting position in the car seat, which is not ideal for her digestion.

Slings

As long as they are used properly, slings can be a great way to carry an infant — either while awake or sleeping. However, there have been reports of infants dying while using these products improperly. Dangerous scenarios include the unobserved baby’s nose being pushed up against the mother’s body causing suffocation and/or the infant’s neck becoming excessively flexed resulting in a kinked airway that decreases airflow and results in suffocation. All of these potential issues can be avoided if the sling is used properly, however.

Excessive reports of infants suffocating while in slings caused the Consumer Product Safety Commission to issue new mandatory standards for the manufacture of infant slings in 2017. (See section on Slings) Slings must now be tested for loading to ensure that they can carry up to three times the manufacturer’s maximum recommended weight; they must meet enhanced structural integrity testing to ensure there are no seam separations, fabric tears, or breakage during testing; and they must have occupant retention features that prevent the baby from falling out of the sling during normal use. New warning labels must now be attached to both sides of the sling and picture the proper position of a child in a sling. The warning statements must include information about the suffocation hazard posed by slings (and prevention measures), and the dangers of children falling out of slings, as well as a reminder for caregivers to check buckles, snaps, rings and other hardware to make sure no parts are broken. A good rule of thumb is that the infant’s face should be “visible and kissable” at all times to avoid the possibility of positional asphyxia. Once again, this product can be great but only if it is used in accordance with all of the above safeguards.

Swings

If a swing is able to soothe a fussy baby it can be a godsend. My problem with swings is that many of them require that the infant be in a sitting position which promotes the slumped-down position. (Remember flat is good, slumped is bad!) Placing an infant in the sitting position when she is not developmentally ready for it means that she will end up in the slumped position. The slumped position not only promotes a kinked neck making breathing more difficult at the level of the trachea but also puts extra pressure on the infant’s stomach promoting reflux. It also makes it harder for the infant to use his or her abdominal muscles to help with breathing. I am not a fan, but if you cannot live without a swing, then get one that can go into a fully- or almost-fully-reclined position (as many of them can). This drastically reduces the chances of the infant assuming any of these harmful positions. Once again, however, I am not recommending that they be used as sleeping areas. They can serve their role in soothing fussy babies, though.

Strollers

Everyone wants to take their baby out for a stroll. Cabin fever can set in sooner than you think! Many of my comments about car seats, however, apply equally to strollers as these are products where the child is strapped in and is typically not in a fully-reclined position. The same issues with neck kinking and the slumped position may apply, so beware! Also, remember that strollers are not meant for sleeping. If baby falls asleep on a walk, be sure to gently place him in his safe sleeping area — be it a crib, bassinet, or play yard — when you arrive home. If you follow these rules, you can relax and have a great time!

Bouncers

There seems to be an almost infinite number of these types of products and each one seems a little different from the next. However, most place the infant on an incline and require that she be strapped in. Some also have soft, cushiony materials close to and around the infant’s face. As these products are intended for times of wakefulness and do not tend to promote sleep (as car seats in moving cars and moving strollers do) they should never be used as sleeping environments. Sleeping infants should be removed from these devices immediately if they fall asleep in them. The safe use of these products can be gauged by whether the infant has enough truncal tone to avoid slumping down in the seat. This is a skill which is generally not achieved until the baby is well over six months of age. Once again, beware of the straps and make sure they do not place the infant at risk for a kinked neck.

One of the cosmetic downsides of using most products in this category (except for the slings) is that they provide a very flat and firm surface upon which to rest the infant’s head. If an infant spends excessive time with his head against a firm surface he can develop a flat and/or obliquely-shaped head. I can usually tell which babies spend excessive time in a sitting device or lying in their crib by the extreme flatness of their heads! Tummy time, tummy time, tummy time is what we say to prevent or decrease the severity of this effect of back sleeping. Of course, limiting time spent in sitting devices is critical, as well. Strategies that can be used to limit excessive flat (officially called brachycephaly ) or even obliquely-shaped heads (officially called plagiocephaly ) include switching the position of your sleeping infant’s head from one side to the other on alternating days and changing the position of your infant’s head from one end of the crib to the other on a regular schedule as infants tend to turn their heads toward the door or wherever the action is.

Devices that are marketed as home baby monitors provide a way for parents to have real-time information about almost everything that their infant is doing, depending on the sophistication of the device. Most have capabilities to transmit an audio and/or visual feed from a baby’s room to either a docking station, a computer or any suitably-equipped mobile device. Baby monitors used to be (and many still are) simple devices that monitored sound so that a parent or care provider would know when the infant awakened and was stirring or crying. To me, this is still the most important rationale for their use.

The basic principle behind the use of such devices has evolved considerably over the years to something much grander. Many units broadcast both sound and live video feed of an infant to other locations of the home or even remotely (think watching your baby sleep while at your desk at work). Instead of just monitoring sound and images, they also provide information about breathing, heart rate, oxygen saturation and movement. Some can interface with your home thermostat so you can remotely control the temperature in your baby’s room. Others provide the ultimate in spreadsheet parenting, allowing parents to print and analyze complete reports of an infant’s responses.

But to what purpose? These devices are advertised as being able to decrease anxiety and increase household sleep. Often these ads talk vaguely about keeping the baby safe. Safe from what? A sleep-related death or SIDS, of course! The reality is that no surveillance product can protect against SIDS or a sleep-related infant death. My personal opinion is that these devices provide a false sense of security about the risk of an infant having a sleep-related death. There is no substitute for practicing all of the principles of infant safe sleep and for continued parental surveillance!

There was a time when we thought that home infant apnea monitors were the answer to SIDS. This turned out to be a much too simple solution as the “science” that started this craze was later proven to be false. Apnea monitors are now pretty much exclusively used for preterm infants who have apnea of prematurity, which is a tendency to have excessive pauses in respiration that result in dangerous lowering of the heart rate. It is a developmental phenomenon that preterm infants ultimately mature out of, usually when they are four weeks beyond the date they were due to be born. There is absolutely no role for these devices in the prevention of a sleep-related infant death.

In December 2011,* the Committee on Practice and Ambulatory Medicine, and the Section on Neurological Surgery of the American Academy of Pediatrics issued a clinical report on the prevention and management of positional skull deformities in infants. Although flat or misshapen heads can occur for a variety of reasons, it is true that one of the consequences of the AAP’s 1992 recommendation for the use of the non-prone sleep position for infants caused a dramatic increase in the number of babies with flattening of the back of the head. Indeed, the flat (or brachiocephalic) head is now the normal shape of an American infant’s head! (I can always tell by the shape of an infant’s skull whether he is being placed to sleep on his back.) Concern regarding the development of an excessively flat or even oblique shaped head is frequently cited as a reason why some are reluctant to use the supine sleeping position for their infant. This document was issued in part to help educate health care providers on how to distinguish between benign skull deformities such as those that occur from the supine sleep position to those related to a congenital condition called craniosynostosis or premature closure of suture lines that requires neurosurgical attention. Its other purpose was to give recommendations for parents on how to prevent significant skull deformities that can result from environmental influences.

To prevent an infant from having an extremely flat head, parents should be counseled during the early weeks of life to alternate the position of their baby’s head, from right to left, when the baby is sleeping and to periodically change the orientation of the infant while in the crib to outside activity (i.e to the door of the room) to encourage turning of the head in both directions. I also encourage parents to alternate arms when holding their infant for bottle feeding. A right-handed person will tend to hold an infant in her left arm to feed so that she can use her dominant hand to offer the bottle and vice versa for a left-handed person. As infants frequently have preferences from their in-utero experiences for keeping their head turned to one side or the other, this will force the infant to turn his head in both directions on a regular basis and encourage free movement of the head and neck.

When the baby is awake, and being observed, I recommend that an infant have at least five minutes of tummy time at least five times per day. Remember, more is better; this is the minimum amount that they should have! The purpose of tummy time is twofold: first, to ensure that for at least a portion of the day, the infant’s head is not subjected to any physical pressure that could contribute to the ongoing molding of the head; second, to promote the development of the muscles in both the shoulders and upper arms. The latter is particularly important when the infant is able to roll from the back to the stomach and may find herself with her face looking straight down into the mattress. At this point, it is essential that she have the necessary muscle strength in her neck and shoulders to pick up her head, turn it to the side and continue breathing good, clean, fresh air!

Prolonged placement of infants in car seats, swings or any other type of sitting devices which have firm headrests should also be discouraged as they put constant pressure on the relatively soft infant skull, favoring the development of either an excessively flat or even an obliquely-shaped head. As tempting as it is, don’t leave your baby in her car seat to sleep, even if she has fallen asleep there during the car ride. Place her in her crib, bassinet or play yard as soon as possible as this is the safest place for her to be. (You can find information about the dangers of allowing babies to sleep in sitting devices throughout this website.)

If your baby is developing an obliquely- shaped (or plagiocephalic) head, it is important that he or she be checked for torticollis. This is a condition in which there is a tightness in the muscle that allows the head to turn freely from side to side. If this is the case, the baby can’t physically turn his head completely to one side and ends up keeping his head at a slight angle. This condition can be corrected by exercises that either your doctor or a physical therapist can show you. In extreme cases, a helmet is prescribed for the baby that keeps all physical pressure off of the skull bones so that they do not continue to grow in a skewed manner.

In another very rare circumstance, an infant may have a condition where her head starts to grow in an oblique fashion because of early closure of suture lines between some of the bones that make up the skull. This condition is called craniosynostosis. Suture lines are places where the many bones that make up the skull come together and ultimately fuse. Your doctor can check to see if this condition is present from a physical examination, but an x-ray of the skull may be needed as well.

The risk for positional skull deformities is greatest during the first four months of life and generally shows improvement by six months of age as the infant becomes more mobile and able to turn his head on a regular basis on his own. In addition, as the infant gets older, the bones of the skull become harder and are less prone to molding.

Families may also be concerned that positional skull deformities contribute to developmental delay. There is some data that suggests that supine-placed infants have some delay in acquisition of early motor skills related to upper body strength and rolling over, which resolve over time. (Tummy time, tummy time, tummy time!) There are no studies to date that suggest any relationship between positional skull deformity and long-term motor or intellectual developmental delay, however.

Always remember, flat heads are almost always just cosmetic and go away with time or with a few simple exercises. Sleeping on the back, on the other hand, is an essential part of keeping your infant safe during sleep and literally may save your baby’s life. Don’t let concern over your baby not having a perfectly-shaped head stop you from doing the right thing. Put her on her back for sleeping at all times!

* Prevention and Management of Positional Skull Deformities in Infants, Committee on Practice and Ambulatory Medicine, Section on Neurological Surgery; Pediatrics 2011;128;1236

I have received many questions about how best to keep a baby warm without using the traditional baby blanket. The 2016 AAP SIDS Task Force statement specifically warns against the use of blankets, particularly soft cuddly ones, because they can easily become loose bedding and create a suffocation risk for an infant. As handmade and other special blankets made specifically and traditionally for infants can be part of the cultural traditions of many families, this recommendation can be a particularly hard one to understand and explain. After all, everyone else uses a blanket to keep themselves warm at night, why not a baby? When the use of blankets was first addressed by the AAP in their 2005 Statement, (and reiterated in the 2011 Statement) the Task Force sanctioned the use of a thin blanket as long as it did not come any higher than the infant’s chest and was tucked firmly under the mattress and the baby’s feet were kept close to the foot of the crib. This was recommended to decrease the risk of the infant’s head or face being covered and was called the “feet to foot” technique. In the Task Force’s 2016 statement, the use of wearable, correctly-sized blankets (sleep sacks) is described as being preferable to the use of blankets, stressing the hazards of freestanding blankets in the infant sleep environment. The “feet to foot” technique is not even mentioned. I am a big fan of the use of sleep sacks for the entire first year of life, as they can keep a baby warm and eliminate the risk of loose bedding in the sleep environment. (Please this website’s section on sleep sacks for a broader discussion of this issue) . Their major downside, however, is cost, as they can run from $20-25 apiece. As a baby will need a generous supply to avoid daily laundering, I recommend putting them on the baby wish list that you share with family and friends. I think you should have at least three or four to be comfortable. (Remember, you will need the larger sizes as well since your baby will rapidly outgrow the newborn size!)

If there is a beautiful quilt or blanket that has been given to you, I suggest that for the first year of life you hang the quilt on the wall in the baby’s room as a beautiful decorative touch. You can also use it for your baby during tummy time. After the first year of life it is fine to use a blanket in your baby’s sleeping area.

Can a baby get too warm in a sleep sack, particularly one that is made of fleece? Absolutely! The key is not to overdress your baby underneath the sleep sack (one additional layer should be sufficient) and do not use a hat. Babies do not like to be hot! Excess heat, believe it or not, is more dangerous to an infant than being too cold and is another risk factor for a sleep-related infant death.

If your baby’s face is red or sweating or if he is breathing rapidly and shallowly, she is too hot! This can be because the baby is overdressed, over bundled, has a fever or the room is too hot. When in doubt, take your baby’s temperature. I recommend that you take your baby’s temperature under the arm. To determine core body temperature, add one degree to the reading you get under the arm. It should not be greater than 100.4 degrees Fahrenheit. If the room is not too hot and your baby is not overdressed or over bundled, he or she may have a fever. Monitor her closely for other signs and symptoms of an infection and call her doctor for further advice.

At the other end of the spectrum, If you think your baby is cold, immediately take her temperature as described above. A baby who is dressed adequately and who is not in a room that is too cold, will almost never be cold. If your baby’s body temperature is below 98 degrees, you should immediately take steps to warm her up. You should also consult with your baby’s doctor to make sure this is not a sign of an infection or some other type of illness.

If you are using a commercial swaddler or blankets to swaddle your baby, you should be mindful that if the swaddle is too tight or the material in the product is inappropriate for the temperature of the room, the infant can become overheated. Monitor him for overheating as described above to be sure he is okay.

Just a quick word about hats: they are generally only used in the hospital soon after the baby is born to aid in achieving a normal body temperature. Babies can have large evaporative heat losses from their skin after birth and delivery rooms can be quite cold. Routine and immediate skin-to-skin contact between mother and child post delivery may decrease the need for hats in many instances; if they are needed, it is appropriate to use one, however. They are not meant for routine use in either the hospital or home setting under ordinary circumstances. Hats carry the risk of sliding down over the baby’s nose or face creating a suffocation risk and/or making the baby too hot. Do not use a hat in the indoor home environment.

Can I put socks or mittens on my baby’s hands if they seem cold? 

I think it is fine to put a snugly fitting pair of socks or mittens on an infants’ hands if they seem cold. I do not see any problem with this.

What temperature should my baby’s room be?

The AAP SIDS Task Force does not specify what temperature a baby’s room should be. I think a common sense answer to this, however, is between 68 and 72 degrees. If there is any question whether the baby is too hot or too cold, follow the steps outlined above.

I have received many questions about various types of napper stations that can be purchased with many of the play yards that are on the market. Napper stations are infant carrier-like devices that are attached to the top of a play-yard railing. They have a slightly-inclined surface where the infant is placed for the ostensive purpose of napping. The sitting/reclining area is frequently lined with a soft fabric such as velour or fleece that is very soft and the purpose of which is “to cuddle” the newborn infant, even around the face.

Calling this product a “napper” has fed into the confusion that napping is somehow different from sleeping and that the rules for safe sleep are different if the baby is “just taking a nap.” This, of course, is not true! The AAP SIDS Task Force has made it very clear that all sleeping events for infants are and should be treated exactly the same. To make it even more confusing, the phrase “supervised sleeping” is used in the product description of nappers implying that their use is fine as long as the parent is awake and constantly watching their infant during the nap. The bottom line is newborn napper products do not meet the requirements of a safe sleep environment for infants and should not be used as a sleeping environment for them, no matter what time of day it is!

Here is an example of one of the many questions I have received on this topic and how I responded.

Question

I am planning on using a Pack N’ Play for our son’s first months before transitioning him to a crib in his own room. I have been looking at a Graco play yard with a newborn napper station because it seems more comfortable for a newborn to be confined to a smaller napping space. The napper is made with a micro-fleece material. If using a Pack N’ Play as a primary sleeping device, would you recommend putting the baby in the napper or simply putting him directly on the play-yard mattress? Also, I have also read that it is helpful to separate daytime sleeping environments from the nighttime environment. What would you think of letting my baby sleep in the Pack N’ Play at night but use the napper station during the day?

My Answer

Thank you for your question. I do not recommend the newborn napper station that is sold on so many play yard models. All sleep environments for infants, whether for sleeping or napping, must meet all of the requirements for a safe-sleep environment for infants. Remember, for the baby, there is no difference between sleeping and napping. To them, it is all the same! For sleeping, infants should always be placed on their backs, on a flat and firm surface (such as a safety-approved mattress) that is not cluttered with soft, cushiony objects such as blankets, pillows or stuffed animals. My first concern with the newborn napper is that it places the infant on an incline. Many infants lack the necessary strength and muscle tone to keep their bodies upright while seated in inclined devices. They tend to slump downward, putting extra pressure on both their diaphragm and their abdomen, two major organs that contribute to respiration in infants. Also, the neck can fall forward leading to kinking or even occlusion of an infant’s soft and pliable airway. All of these factors can contribute to making breathing more difficult for an infant while seated in this device. In addition, I am concerned about how close the soft materials come to the baby’s face. It would not take much for even a slightly active infant to get his nose caught up against these surfaces, creating a suffocation hazard. My recommendation is to use either the bassinet feature or the bottom section of the play-yard as your infant’s sleeping area.

Although it is not possible to identify at birth whether a specific infant will succumb to a sleep-related death, there are categories of infants who we know are at particular risk. One of these categories is the preterm infant or the infant who is born at less than 38 weeks gestation. Although the “Back to Sleep” message of 1994 decreased SIDS and sleep-related infant deaths across all gestational age categories, these types of deaths are still much more likely to occur to the preemie. In fact, the more premature the infant, the greater the risk of a sleep-related infant death. Why is this so?

Several theories have been put forth to try to answer this question. The Triple Risk Model of SIDS and sleep-related infant deaths discusses three critical factors that can converge to create a “perfect storm” of risk for a sleep-related death for any infant: developmental stage, inherent vulnerability, and exogenous or outside stressors. Let’s explore how these factors may be applicable to the preemie.

Developmental: By definition, the preterm infant is not as developmentally mature as a full-term baby. One major difference is the decreased muscle strength and tone of the shoulder and neck muscles. In addition, the relative size and weight of the head of a preemie is much greater. Putting these two factors together makes it more difficult for a preemie to pick his head up off of a surface and/or move it to the side. These abilities are critical if an infant finds himself face down or with his face pressed up against a pillow, blanket or stuffed animal. This is a major reason why the “Back to Sleep” message is particularly critical for the preterm infant.

Inherent Vulnerability: One of the critical issues for preventing a sleep-related infant death is assuring that an infant has a normal level of arousability during sleep. This means that if either the level of oxygen in the blood became too low or the level of waste products in the blood (carbon dioxide) became too high, an infant would be able to respond immediately by awakening, moving her head and breathing faster and/or deeper. We know that in utero or postnatally smoke-exposed infants have blunted responses to low oxygen, making it less likely for them to respond adequately to such challenges. We also know that many preterm infants are exposed to cigarette smoke either before or after birth. Perhaps this explains why some preemies are at increased risk for a sleep-related death.

Many preemies are placed on their tummies for sleep during their hospital stays. If a parent follows this practice in the home environment, the infant is at an even higher risk of a sleep-related death than a full-term infant. Prone sleeping makes all infants less arousable, but specifically for the preemie, it may also decrease the delivery of oxygen to the brain. The heaviness of a preemie’s head and the lack of muscle strength to move it makes the preemie inherently more vulnerable to a sleep-related death if he or she is not placed on her back in an uncluttered sleep environment!

Exogenous Stressors: Clutter in the sleep environment (such as pillows, blankets, stuffed animals, bumpers, and another person sharing the same sleep surface with an infant) puts any baby, but particularly the preterm infant, at high risk for death from suffocation or asphyxia. The preterm infant who has delayed development of the motor skills necessary to move his head, nose, and mouth away from potentially hazardous elements in their environment is at increased risk for a death due to suffocation or asphyxiation.

It is critical that all parents of preemies are educated about infant safe sleep and see the principles of safe sleep modeled by the NICU nursing staff long before their infant is discharged. It is a sign of well being and a marker that a baby is getting that much closer to being discharged. This is a critical piece to ensure the well being of the preemie in the home environment! If you have a preemie, it is extra important that you practice the A, B, C’S of infant safe sleep: Alone, On the Back, in a Crib in smoke-free air!

I frequently am asked about the advisability of using previously-owned cribs, bassinets and cradles. Because these items have often been passed down through generations, this can be a very emotional topic, so I try to tread lightly. Unfortunately, most of the time I have to say that this is not a good idea. If it is just the issue of wanting to use a secondhand crib that a friend used for her child, the answer is quick and easy: NO! The use of secondhand cribs is generally a bad idea. When cribs are stored, invariably the assembly instructions or some piece of vital hardware (screws, brackets, etc.) are lost in the process. This presents the very real likelihood that the crib will be unstable and unsafe when reassembled. In addition, the use of a second hand crib almost always requires the purchase of a new mattress to replace the old soiled one. It is almost impossible to find a new mattress that will fit the old crib snugly enough to eliminate the risk of the baby becoming trapped between the mattress and the side of the crib.

The other important part of this discussion is that many/most vintage cribs do not meet current safety standards. In 1995, the Consumer Product Safety Commission not only warned against the use of secondhand cribs for all of the above reasons, but also issued regulations that the distance between crib slats could not be greater than 2 and 3/8 inches wide (the width of a soda can) because of the risk of an infant’s body or head becoming entrapped. Many cribs manufactured before that time had wider crib slats.

In 2011 the Consumer Product Safety Commission issued new regulations that required that drop-sided cribs no longer be manufactured or sold in the US due to the risk of a baby falling out of the crib either from a faulty or broken side rail locking mechanism or a parent forgetting to put up the side rail. At the same time, they mandated that wood slats on cribs be made of stronger wood to prevent breakage, crib hardware have anti-loosening devices, mattress supports be more durable, and safety testing, in general, be more rigorous. It is unlikely that older cribs would meet all of these new, stringent manufacturing standards. In fact, it is currently illegal to sell or donate a secondhand crib in the US or Canada. For all of these reasons, it is not a good idea to use a secondhand crib. The bottom line is, for complete safety, don’t use a crib that was manufactured before 2011!

What is the recommendation for the use of new and old bassinets?

These products are regulated by the CPSC as well and specific guidelines for their manufacture were issued as recently as 2013/2014. From November 2007 through March 2013, the CPSC received notice of 426 incidents involving infants in bassinets/cradles including 132 fatalities, prompting a review of their safety. Many of these deaths — and additional deaths reported after this time period — occurred in infants under five months of age and were related to asphyxiation from the presence of soft or extra bedding in the bassinet; prone (face down) placement of the infant and/or the infant becoming wedged between the side of the bassinet and the bedding. These events were not related to product failure but to failure to follow infant safe-sleep recommendations. For example, most of the non-fatal incidents related to bassinet use were due to falls from the device, particularly when the product continued to be used after the baby could get up on his hands and knees and/or he was older than five months of age. However, lack of structural integrity — such as instability, loose hardware, and product collapse — was identified in both fatal and non-fatal events.  That shows that it is critical that all hardware in all products, whether they be new or used, be secured and checked on a regular basis to ensure the stability of the unit.

The 2014 CPSC recommendations set new standards for spacing of rigid components/fabric-sided enclosed openings (bassinets) to keep babies from being trapped between slats. This is similar to the types of recommendations that had earlier been made for full-size cribs. Standards were also changed to ensure that bassinets can hold more weight and had increased stability. Sleeping pad thickness and dimensions were addressed to prevent suffocation from gaps between the sleeping pad and the side of the unit. Bassinet side height was set at 7.5 inches (measured from the bottom of the unit) and an upper limit for rock/swing angle was set to prevent entrapment due to the swing angle.

After reviewing all of this, I think it would be very difficult (impossible?) for a vintage bassinet or cradle to meet all of these safety standards!

Here is a question I received about the use of a vintage bassinet and my response:

Question

My first baby is due any day now and my mother-in-law is very excited for him to use some of the same things her children (as well as other family members) used as infants. I can understand her sentimental feelings, but I don’t want to put my baby at risk for the sake of nostalgia. My concerns are that the vintage bassinet may not meet modern safety standards. It has been painted several times and I don’t know if any of the layers had lead in them. It is not as deep as modern bassinets and the mattress is not as firm. It can sit on the floor or a raised surface like a table or bed. What is your opinion of this item?

My Answer

Thank you for your question. I think the ideal use for these precious family heirlooms is to use them to decorate the baby’s room or for storage. I would not use them for baby care at all. What if you use the old bassinet to store all of those adorable stuffed animals that can’t go in your new son’s crib? The dangers associated with lead paint, ill-fitting mattresses and low side rails make this a no-brainer! I am confident that your mother-in-law will understand once you explain these safety issues to her. Good luck!

Question 2

Subject: Cradle

My mom gave me a wooden cradle that I slept in when I was little. I’m not sure what the brand is, but the base of the cradle is wide and sturdy. The spindles are no more than 2 inches apart and the mattress seems firm. It does come with bumpers but I plan to remove them. I really want to use it because it is compact enough for us to keep in our bedroom, but my husband is nervous about it and thinks we should just put her in her room to sleep in her crib. Do you think it will be safe to use the cradle? It rocks east to west and does not rock on its own.

My Answer

If you are describing an old-fashioned wooden cradle that sits low to the floor and has all of its’ screws and bolts present, tightened and secure, then I think the structural part of the cradle is probably okay. The slat distance is less than the recommended maximum of 2 3/8 inches. I am concerned about the mattress, however. Can you be certain that it doesn’t have mold in it? After twenty-five years, is it still firm enough? If you need to replace it, would you be able to find something that will fit the space exactly, without gaps between it and the cradle’s sides? If you can answer yes to all of these questions, then I think it can be safely used. Another safety issue that has been identified with cradles is their angle of swing. Cradles by definition rock from side to side. If the angle of the swing is too great, the infant can be thrust over to the side, potentially pushing the nose and face into the side of the unit ,creating a suffocation hazard. A better alternative is to use beautiful, older pieces like this to display those adorable stuffed animals, toys, and soft quilts you received until she is old enough to play with and appreciate them. There is a protective effect to having her sleep in your bedroom between six months and one year of age. However, there are many inexpensive safe-sleep environments, such as play-yards, that you can use to achieve this goal. I would explore those options first before having her sleep apart from you this early in life. I hope this has been helpful.

Here is a question that I have received about rolling over and when a parent no longer needs to worry about a baby who just does not want to stay on his back.

Question

My five-month-old son will not sleep flat on his back. He constantly rolls to his side and puts his face into the mattress. Sometimes he even rolls to his stomach. I am getting no sleep because I am up all night constantly flipping him back over. I have been reading a lot about SIDS and babies rebreathing their carbon dioxide and it really freaks me out! What can I do? Is it okay if he sleeps like this? 

My Answer

Thank you for your question. As you are observing, infants between the ages of four to six months begin to gain significant mobility and can do more than just roll to their side. Stomach-to-back rolling usually occurs first as it is relatively easy for babies to do during tummy time when their heads are held high. Generally, all they need to do is turn their head to the side, and they go over. Back-to-stomach, however, takes a little more effort, as an infant has to have the ability to get one leg over the top of the other to allow the full rollover to occur. This is helped by the roll to the side which is the first step in the process.

The first question I have for you is, is your son able to pick up his head and shoulders high off the crib mattress when he is placed on his stomach? The answer to this question should be yes if he has been getting his tummy time on a regular basis, unless he was premature. If you are uncertain about this, check with his pediatrician. As a general rule, if an infant can reliably get from his stomach to his back and from his back to his stomach and can hold up his head well when he is on his stomach, he can safely be left in the stomach position to sleep if he assumes it on his own. I would, however, continue to place him on his back when you first put him down to sleep. Most likely from here on out, however, he will pretty much sleep where and how he wants! Also, remember that it is now more important than ever to keep his sleep area free of all loose bedding, pillows, stuffed animals, bumpers, etc. as he will be more likely to come into contact with these items as he begins to travel around his sleep area. I hope this has been helpful!

I was asked a similar question by a childbirth educator who was concerned about telling parents not to worry when their infant can reliably roll from the back to the stomach. When you are giving out advice as a healthcare professional, you always have to be a bit more cautious in your recommendations.

Although I gave her a similar answer, I added the following caveat:

Can we be 100% sure that every time a baby securely rolls onto his stomach that nothing will ever happen to him? No, of course not. Safe sleep recommendations are about reducing risk, not a guarantee of zero risk of a sleep-related infant death. As back sleeping is safer than tummy sleeping at any time during the first year of life, we should continue to recommend it as the primary sleeping position for infants throughout the first year of life.

This statement was part of the most recent AAP SIDS Task Force recommendations detailing the requirements for a safe infant sleep environment. The 2011 statement by the Task Force similarly recommended room sharing but was not as specific about how long room sharing should go on other than a global statement that all recommendations should be followed for the first year of life. Both the 2011 and the 2016 statements quoted the same studies (no new data was presented) that had shown that sleeping on a separate surface in the parents’ room decreased the risk of SIDS by as much as 50 percent, an impressive statistic. The SIDS risk reduction statistics for room sharing do not provide insight into what the protective effect is, however. Is it a parent’s heightened sense of awareness of every little movement or sound that baby makes, demanding direct observation of the infant? Or is it some other yet unidentified protective factor in the environment that is associated with room sharing? The truth is no one know for sure. We just know that it is a good thing and it would be unwise to ignore the clear benefit of room sharing.

The specifics of the duration of the recommendation caught the attention of the lay press, even resulting in mentions in national news broadcasts. This spread the word quickly and aroused the interest of both parents and infant health care providers Why? Traditionally, pediatricians have recommended that infants stay in the parents’ room for only the first six months of life. After six months of age, it is considered good sleep training to allow slightly roused infants to self-soothe back to sleep after a brief awakening. The goal is to sustain longer periods of uninterrupted sleep with ever-decreasing assistance from the parents with the aim of developing independent sleep hygiene and practices.

I think it is important to recognize the importance of sleep for both infant and parent. Women in our culture have many responsibilities, including the need to care for their other children and their households, often while working outside of the home. The need for some degree of uninterrupted sleep that will allow Mom to perform all of these other responsibilities at the high standard that is expected of her cannot be dismissed as unimportant. Sleep deprivation is a powerful thing and can cause people who really do want to do everything right to make bad choices. I wonder how many infants will end up being brought into the parents’ bed to get everyone back to sleep again as quickly as possible as the realities of the desperate need for sleep and the next day’s responsibilities loom? Some of these concerns have been borne out by a study by Paul, et al that was published in Pediatrics in June 2017. It suggested that continued room sharing (in this study defined as after four, not six, months) promoted bed sharing and less nighttime sleep in both the short- and long-term. The counterargument to this, however, is that the gains in sleep with non-room sharing were relatively small and that many of the issues identified could possibly have been alleviated with more structured bedtime routines. Also, room sharing promotes breastfeeding, a worthy goal in and of itself!

I do not think that one size fits all. The choice of where an infant should sleep must take into consideration the needs of mother, baby and family. For instance, what about the 9-10 month old who pulls himself up and starts to bounce up and down on the crib railing in the middle of the night looking for attention. If this is happening, I think it is time to move him out of the room regardless! On the other hand, infants who fall into extremely high-risk categories for sleep-related deaths such as premature infants or infants who were exposed to smoke in utero and/or live with smokers should stay in the parents’ room for the entire first year of life.

If the decision is made to remove the infant from the parents’ room for sleeping after six months, however, it is mandatory that the baby sleep alone in an uncluttered crib (or other safety-approved sleep area) that has a firm mattress and no bumpers, excess bedding, pillows or toys.

Although every family will make their own decision about this, it is important to remember that the official recommendation of the American Academy of Pediatrics Task Force is to continue to room share for the entire first year of life.

Part of the recommendations that were included in the 2011 American Academy of Pediatrics SIDS Task Force statement included the avoidance of co-bedding of twins and higher-order multiples. (That means triplets and beyond.) As the director of a well-baby nursery and a neonatal intensive care unit before this recommendation was issued, I know how common it was to bed twins together in the same bassinet. The rationales usually given for this practice were, “Twins shouldn’t be separated.” and “Don’t they look cute together?” (I am not making this up!)

If twins were born either slightly preterm or at a lower birth weight, they frequently could fit side-by-side in this small sleeping area, and it was quite common practice to see them co-bedded. If you think about it, however, why would it be okay for two babies to share the same sleeping space when we recommend that an infant’s sleep area be kept free of all extraneous objects, including another person — adult or child? Statistically, we know that one of the most dangerous sleep environments for an infant is sleeping with another child as the risk of a sleep-related death under these  conditions increases by 5.4 fold! Twins, triplets and beyond deserve their own separate, uncluttered sleep areas just like every other baby. Parents who see this practice in the hospital get the message that it is acceptable and are more likely to co-bed at home.  Unfortunately, this practice can have a disastrous outcome.

I have gotten many questions about the play yards that have a twin bassinet sleeping area on top. These products are fine for the short amount of time that they can be used. The space allotted per infant is half of what it would be if there was a single bassinet on top, so as soon as one of the infants shows any mobility at all it will be time to move them to a larger sleeping area. One solution is to start with two play yards with bassinet features. The bassinet feature of this product can be used until the infant is fifteen pounds or until he or she starts to roll to the side (which is generally around four months). At this point, the baby can be moved to the bottom part of the play yard or to a full-sized crib. If this is not an option because of limited space, there are mini play yards that can be used. I do not recommend putting both infants in the bottom section of the same play yard, even at opposite ends. Babies can too easily end up in each others’ sleeping areas with the potential for a suffocation death.

The bottom line is that all infants — regardless of whether they are singletons, twins, triplets or more — deserve separate and safe sleeping areas!

In my mind sleep sacks, or wearable blankets, are the answer to providing both warmth and an uncluttered sleep environment for an infant. There is no worry about blankets that can become untucked and can wander up and around an infant’s nose and face, presenting a suffocation hazard.

Indeed, in a study published out of the Netherlands (Eur J Pediatr (1998) 157:681-688) the use of a sleep sack reduced the risk of cot death and was associated with placing an infant on his back. It also noted that it was harder for an infant to turn over while in a sleep sack with the average age of babies rolling over in sleep sacks being 8.5 months compared to 6 months for infants not in sleep sacks Are there any downsides to using a sleep sack or wearable blanket? From 2004-2012, the Consumer Product Safety Commission received reports of 36 incidents with wearable blankets, swaddle wraps and swaddling with ordinary blankets. Of the five cases involving wearable blankets, there was one death and four injuries. Clearly there can be issues with the use of wearable blankets or sleep sacks, but most can be avoided with proper fitting of the garment.

This report also covered adverse events with swaddle wraps and swaddling with blankets, so let’s talk about them next. Swaddling as a technique has been used for centuries and descriptions and depictions of its use abound in both literature and art. Newborn infants are traditionally swaddled in receiving blankets when presented to their mothers in the hospital setting. This serves two roles: providing warmth and producing a state of calmness in the infant. Indeed swaddling has been called the “calming reflex”. In utero, babies exist in a very restrictive environment and are calm — most of the time! The close-to-the-body positioning of the naturally-flexed arms and legs that swaddling produces mimics normal in utero positioning. It is the antithesis of the Moro reflex, the “primitive” brain stem reflex that causes an infant’s arms to fling out to the side then back towards the body and makes them cry. (Some call this the startle reflex.) Swaddling prevents the Moro from occurring. Its goal is to bring the infant back to that state of calmness that they knew in utero. This reflex is generally extinguished by four months of age with remnants of the arm movements occurring only at the time of sleep.

I have had many questions about the use of commercial products called “swaddlers” and the technique and safety of swaddling itself. One questioner aptly described swaddling as equivalent to being in a straight jacket! I couldn’t agree more, but that is the whole point as it forces infants to keep their arms close to their body mimicking the calmness of the in utero environment. Given that it is equivalent to being placed in a straight jacket, however, I must emphasize right away that the prone or side position should NEVER be used when an infant is swaddled. Why? Because if the swaddled infant ends up face down on a surface, he or she may not be able to move their head to the side to breathe and they will most likely suffocate. Without the use of their shoulder or upper-arm muscles to help them move their head out of the way, they are sitting ducks for this type of catastrophe to occur. Infants who are swaddled and placed on their sides are at risk as well, because they so often fall forward onto the stomach from this position leading to the same risk and outcome.

I do teach and recommend swaddling to my new parents because I think it is an important tool for them to have for soothing a fussy baby and for promoting sleep. Fussy and/or poor-sleeping babies are huge challenges for many parents and can lead to a whole host of behaviors and habits, including bed sharing, that should not be encouraged or promoted. It is critical, however, that if swaddling is done, it must be done correctly! This means that the legs of the infant must always be in the flexed or folded position.  They can NEVER be straight as this promotes hip dysplasia. In addition, loose swaddle material can become the equivalent of loose bedding and create a suffocation risk in the sleep environment. Hence the swaddle must be tight enough to prevent this from happening. If the infant is wrapped too tightly, however, it can compromise breathing or the infant can become overheated. If the infant is sweating, he or she is too hot and should be unwrapped immediately.

The infant must ALWAYS be placed in the supine position (on her back) and swaddling must be discontinued when she shows any signs of beginning to roll to the side. Generally, this occurs around three or four months of age, so I counsel that swaddling should not be used after the infant is two-and-a-half months old to be on the safe side.

I have shared many reasons why the swaddle could be dangerous. Believe it or not, however, I am personally a fan of this practice as I think it can work wonders for many fussy babies when done safely and discontinued at the earliest time that an infant begins to roll to the side.

In the 2016 AAP SIDS Task Force statement, it was stated that there is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS.

I have been asked about the use of a sleep sack as opposed to swaddling with a receiving blanket:

Question

Could you please address pros and cons of using either a sleep sack or swaddling with a receiving blanket. Does the AAP have a position one way or the other? I understand many hospitals are switching to the sleep sack for safe sleep reasons. Should this be the best practice regarding safe sleep for infants?

My Answer

The primary purpose of swaddling an infant with a receiving blanket (or a commercial device designed to achieve the same end) is not only to provide a source of warmth, but to soothe a crying baby and to promote sleep. In the hospital setting it achieves all three goals but its primary purpose is generally heat retention as it obviates the need for additional clothing for the infant, other than the traditional undershirt, of course. The purpose of a sleep sack, on the other hand, is only to provide a source of warmth for the infant as a wearable blanket. It’s only drawback would be if the sleep sack were too large for the infant (as can be a particular issue with smaller infants, either term or preterm) and the baby slipped through the neck opening and cloth ended up over his nose or face.

As with everything, these products must be used, both in the hospital and in the home, with common sense and safety in mind. The need for soothing an infant in the first few days of life is probably not as great as it will be later on, so non-swaddling practices in the hospital setting seem to work. Also, the use of a sleep sack in the hospital setting sets a good example for parents to follow when they go home. There is a commercial line of swaddlers that provide both the warmth of a sleep sack and an easy way to swaddle a baby. These are nice products but somewhat pricey. I would advise putting several of these on an expectant mother’s wish list for her infant!

Swaddling is a technique for soothing and keeping infants warm that has been practiced for thousands of years. A family’s first exposure to this technique typically occurs early after the birth when their nurse skillfully wraps the infant into the swaddle using the standard hospital receiving blanket. Nursery nurses have used this technique for as long as I can remember to achieve the goals of warmth, calming and sleep for infants.

Many have described the swaddle as equivalent to placing the infant in a straight jacket which is an apt characterization. An effective swaddle must pull the infant’s arms close to the body and is best done with the arms pulled down and straight. This is the essence of the swaddle as it is only when an infant’s arms are restrained at the sides that the Moro reflex is contained. The Moro is a brain stem reflex that infants in the early months of life possess. Basically, the Moro reflex causes an infant to arouse and cry when the arms are flung out to the sides. Swaddling prevents the activation of the Moro which is why swaddling is one of the prime techniques that we have to soothe and calm an infant.

I have been asked many questions about swaddling, particularly as it relates to safe sleep. I do recommend the use of this technique to families of newborn infants. With that being said, inappropriate use of the swaddle can be dangerous. The first rule of safety is that the infant must only be on his back when swaddled! The stomach sleeping position is an extremely hazardous position for a swaddled infant as the excess pressure on his chest and abdomen makes breathing much more difficult and it keeps him from being able to lift his nose and mouth away from the mattress surface. The side position makes it more likely that the infant will roll forward onto the stomach so it is viewed as extremely dangerous as well. Having personally witnessed a swaddled infant in a well baby nursery who had been placed on his side who then flipped onto his stomach and turned purple, I can attest to the danger of both the side and the prone position for the swaddled infant.

Another important issue with swaddling is that the legs of the swaddled infant should always be placed in the flexed or folded position. The legs should not be held straight as this promotes hip dysplasia. Never do this!

Another important issue with swaddling is the potential for overheating. If the room is hot, the swaddle may overheat the baby. This must be monitored closely. Hats can contribute to overheating as well and they are not recommended for routine use. I recommend that the baby’s room temperature be kept between 68 and 72 degrees and that the baby wear light clothing, usually just a onesie, under the swaddle.

All of the products sold as swaddlers receive a TOG score which reflects the ability of the garment to retain heat. It reflects both the material used and the layers of the garment and should be below 4 to avoid overheating of the infant. Check the TOG score of any commercial swaddler that you purchase to be confident that it will not make your baby too hot.

If your baby’s face is red or sweating or if she is breathing rapidly and shallowly (to rid herself of excess heat) she is too hot! This can be because the room is too hot, the baby is overdressed or over bundled or she has a fever. When in doubt, take your baby’s temperature. I recommend taking your baby’s temperature under the arm. To determine core body temperature, add one degree to the reading you get under the arm. It should not be greater than 100.4 degrees Fahrenheit. If the room is not too hot and your baby is not overdressed or over bundled, she may have a fever. Monitor her closely for other signs and symptoms of an infection and call her doctor for further advice.

Commercial swaddlers primarily utilize the properties of Velcro to swaddle the infant into place. This style of swaddler is now being used by many hospitals rather than receiving blankets because the Velcro eliminates the need to master the wrapping technique. Velcro adhesiveness may weaken over time, especially with repeated laundering, so make sure that the ties are always secure so they do not come loose and pose the same threat as loose bedding. (If a blanket is used for the swaddle it can become loose in the bed and become a suffocation hazard, too.)

It is also critical that swaddling be discontinued once an infant approaches the time in development when she is capable of rolling onto the side (around four months). To be on the safe side, the standard recommendation is to stop swaddling between two and three months of age. If your baby is showing signs of early development and can roll to the side earlier, then swaddling must be stopped even sooner. It is these types of warnings and judgments that have made many think of swaddling as too dangerous to use. I am not in that camp and still see it as a very useful technique to soothe fussy and crying babies. I say use it correctly, and you will have a happier baby (and happier parents)!

Several recent studies have re-emphasized the potential hazards of swaddling. The vast majority of the deaths (yes, deaths) that were reported as associated with swaddling were related to the infant having been found on the stomach at the time of death. It is vitally important that the baby always be placed on the back for sleep and that as soon as the baby  begins to look like she is capable of rolling to the side that the swaddling is stopped.

There have been some studies that have found swaddled infants to be less arousable , meaning that they were in a deeper state of sleep, which we think can promote a sleep-related death. The AAP SIDS Task Force’s most recent statement (November, 2016) says, “There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. Infants who are swaddled have an increased risk of death if they are placed in or roll to the prone position. If swaddling is used, infants should always be placed on their backs. When an infant exhibits signs of attempting to roll, swaddling should no longer be used.”

Should swaddling be done in daycare centers?

As most infants are not accepted into daycare centers until they are six weeks to two months of age, many states have chosen to take the position that infants should not be swaddled while they are in state-licensed daycare centers. I won’t comment on this but I can see where these regulations are coming from.

One question that I have been asked is how do you transition an infant out of a swaddler? I recommend that one arm at a time be released to acclimate the baby to non-swaddled life. Like most things, slow and steady wins the race!

Although ideally, I would prefer that most infants stay home for their first two months (except for trips to the pediatrician, of course) I know that some babies are already on the road very early in life. Some are just traveling short distances to Grandmother’s or Dad’s house while others are going camping. It is important that safe-sleeping areas be provided at each of these locations. There are two types of products made for these purposes, portable cribs/play yards and travel cribs. Travel cribs are made to be easily transported on an airplane or other type of public transportation and are generally lightweight and compact. Portable cribs and play yards are typically heavier and bulkier and are transported more easily in a car, if available. Both have safety features that allow them to be used as safe-sleeping areas.

Realistically, the sleeping unit that baby has at Mom’s house is rarely transported to another household. In my own practice, when I inquire where baby is sleeping when she goes to Dad’s house, I too often get the response that she is in bed with Dad and all of the other children, as well. This makes me cringe. It places the infant in an environment that violates all of the rules of safe sleep. There are many relatively inexpensive, safe alternatives for babies traveling or visiting. (Please see my full discussion about bassinets.) I suggest the purchase of a no-bells-and-whistles play yard with a bassinet feature that can be left at the home where the baby is a regular visitor. If the baby is truly just visiting briefly or intermittently, you can buy a smaller version of the traditional play yard that still includes the bassinet feature for infants under fifteen pounds. Play yards (even the small versions) can be used until the child is thirty-five inches or is able to climb out. Travel cribs will do the job just as well but they are relatively expensive, so are not my first choice. Infants quickly outgrow travel bassinets and then often end up in adult beds when they are most at risk for sleep-related death, so I do not recommend those, either.

If your child is sleeping in an unsafe environment because you’re unable to afford a crib or play yard, a local Cribs for Kids program can help. Visit the Cribs for Kids website (www.cribsforkids.org) to find contact information for a Cribs for Kids program near you. They will provide you with a full-size play yard with bassinet feature that can serve as a safe-sleep area for your child for up to two years in most cases (up to thirty-five inches or when the child can climb out).

Realistically, when baby travels, many families choose none of these options and use the car seat as a place for baby to sleep. Although infants love to sleep in them and they are vital to safe transportation, car seats are not meant to be used as sleeping areas for infants! By definition, these units are not flat which is an essential component of a safe sleeping environment for infants. Why is this so important?  When infants are placed in a semi-upright position, their necks are generally not in a straight position. The infant airway is much more flexible (overly-compliant is the scientific term) than that of an adult and can actually fold in on itself when the neck is flexed or not in a straight position. This decreases the effective cross-sectional area through which air passes. Even in adults, the breath you can take when your neck is flexed is much deeper than the one you can take when your neck is straight. (Try it, you’ll see. Now, imagine falling asleep like that!) The difference is more pronounced for infants, putting them at a significant disadvantage. The upright position also causes infants to slump down in the device placing additional pressure on the abdomen, an important muscle for breathing in infants. To help illustrate my point, watch an infant breath. You can count his respiratory rate by watching his abdomen move up and down because he is using these muscles to help him breath. You can’t do that with an adult or older child unless that person is in respiratory distress and needs to call upon the abdominal muscles as backup. For infants, these are not backup respiratory muscles. They are primary. Hence, anything that puts extra pressure on an infants’ abdomen, such as sitting in a car seat or in any other type of sitting device, can potentially compromise breathing. Long story short, car seats are meant to provide safe transport during car travel not as long-term sleeping areas. I always recommend that babies not take long trips in the car for all of these reasons. Car trips should be short and sweet. The early months of life are not the time to take baby on a cross-country adventure!

Strollers are frequently used as an alternative sleeping area. Some strollers do have a feature that allow them to flatten into a full reclining position. This is fine if the baby is strapped in securely. An infant will rapidly outgrow this type of sleeping arrangement, however, so it is a short-term solution, only. If your stroller does not allow the baby to lie almost completely flat however, it is not advisable to allow her to sleep there for any length of time.

Without an alternative, like a full-size bassinet or play yard to sleep in while away from home, baby will most likely end up in an adult bed which is fraught with hazards for her. Please consider all of these issues when she spends the night at someone else’s house. Your baby’s life may depend on it.

Here is a question I received about camping:

Question

We are having a baby in October and will be camping a few weeks later. We also camp every year for four days over the 4th of July weekend. Is it safe for baby to sleep in the smaller version of the traditional play yard while we are camping?

My Answer

Yes, I think a portable play yard is a great choice for both travel and in-home sleeping for a baby. It can provide all of the essentials for a safe sleep environment and can be used anywhere. A portable play yard is generally smaller (by 20%) than a regular play yard and weighs less (17 pounds rather than 21). It still can be used as a play yard until the child is 30 pounds, 35 inches tall, or until the child is able to climb out, whichever comes first. It is just slightly smaller in square footage. There are other lighter-weight products available as well in the “travel crib” category. Some of them are very attractive but tend to be quite pricey.

The most recent (2016) statement from the American Academy of Pediatrics SIDS Task Force is very clear about its concerns for the use of bumpers in an infant’s crib or sleep environment. Simply put, they say bumpers pose a suffocation, entrapment and strangulation hazard for babies. Why were bumpers created in the first place? Their history goes back to the time when cribs were made with their slats positioned much further apart than they are today, leading to instances of infants getting their arms, legs and heads stuck between the slats. This caused not only an occasional bruise or broken bone but, in some tragic cases, strangulation and death. Bumpers were created to decrease the risk of these events from occurring.

Due to these risks and hazards, the Consumer Product Safety Commission (CPSC) issued a mandate that all cribs and bassinets that are manufactured and/or sold in the US must be made with less than 2 3/8 inches (about the width of a soda can) between the slats. To a large extent, this addressed the reason why bumpers were created in the first place but the use of bumpers continued. It is important to note that the CPSC has not officially banned the sale of bumpers in the US and they continue to be available to consumers (except in Chicago and the state of Maryland where the sale of all but mesh bumpers is banned).

So what’s going on? If they are so dangerous, why hasn’t the CPSC, the agency whose mission it is to protect the American consumer from unsafe products, not taking a stronger stance on this? The answer is a bit complicated. The Commissioner of the CPSC has issued a statement that he believes that “the public should stop using padded crib bumpers”. He goes on to say, “The overwhelming evidence shows that they do nothing more than contribute to the deadly clutter in many of our nation’s cribs. Based on the real risk they present, it is a mystery to me why they continue to be made and sold.”

WOW! That is a pretty strong statement and makes very clear where he stands on this issue. However, the CPSC has not issued a formal statement against their use. After a review of the data reported to them, the CPSC concluded that there was not conclusive evidence that bumper pads were responsible for the deaths that were reported to them because of the existence of other unsafe sleep risk factors. It is important to remember that not all injuries or deaths thought to be related to a particular product are reported to the CPSC.

In 2012, however, the CPSC was asked by the Juvenile Product Manufacturers Association (JPMA) to make rules distinguishing “hazardous pillow-like” crib bumpers from “non-hazardous traditional” crib bumpers. In their white paper issued in 2017, the CPSC clearly felt that bumpers, no matter what kind were “essentially decorations that also happen to limit limb entrapment which were by and large very minor injuries”. They pointed out that bumpers are not to be used as protection against a child bumping his head after he begins to pull himself up to standing as it is clearly stated on all bumper products that they should be removed from the crib when a child can sit up on her own, which is generally around six months. This is because the bumper can be used as a step and make it easier for the baby to climb out over the railing.

In attempting to address these differences, the CPSC concluded that the best definition of “pillow-like” was not only thickness (greater than two inches) but the tendency of the bumper to conform to the face of the infant. Unfortunately, they had no answers as to how to develop a test that could demonstrate that a crib bumper was firm enough to not conform to the face of an infant, but the challenge is now out there. In addition, they addressed the issue of airflow through the product. Using mesh as the standard, they recommended the development of a means to “demonstrate that a crib bumper matches or exceeds the airflow characteristics of mesh or mesh-like materials.”

A formal statement by the CPSC on the risk of injury or death associated with the use of crib bumpers is on its 2017 Operating Plan. We await their conclusions and advice!

I have received many questions about the use of bumpers, as many parents are concerned about the occasional stray arm or leg that finds its way through a crib slat. (Indeed my daughter-in-law has recently questioned me about this since my new grandson wakes himself up when his arm or leg goes through the crib slat. She wonders why can’t she use bumpers to prevent this.) My strong recommendation is that cloth bumpers, “pillow-like” or not, should never be used in an infant’s crib due to the risk of suffocation and strangulation. I do hope, however, that someday a mesh bumper is deemed to be safe for use in an infant crib as I think it would answer many people’s concerns regarding injuries to arms and legs. Unfortunately, that day has not yet arrived and the use of any type of bumper in an infant’s sleep environment is not recommended. The safe alternative right now is to use a play yard with mesh all along the side, requiring no bumpers and posing no risk for suffocation, strangulation or limb entrapment.