7th Mar 2021

Safer sleep for babies

Babies need a lot of sleep, as it promotes their physical and mental development. The pituitary gland releases growth hormones (key hormones that stimulate growth) throughout the day, but secretes at a much faster rate while babies sleep. That's why newborns need up to 16-18 hours of sleep every day, and wake every two or three hours only for feeding and changing. Hence, newborns tend to grow rapidly in their first five months, and most even double their weight by this time. As babies get older, their growth continues at a steady pace, but somewhat slows down, and they sleep less during the day than at night. A 9 month old baby, for instance, generally needs only two hours of sleep during the day and an average of 10-12 hours at night.

As babies spend such a considerable amount of their time sleeping, it's important to ensure they do so in a safe and healthy sleep environment. Unsafe sleeping arrangements and practices can increase the risk of SUDI (Sudden Unexpected Death in Infancy), including SIDS (Sudden Infant Death Syndrome) and fatal sleeping accidents.

Following are the key things to remember when putting your baby to sleep so your baby sleeps in a safe and healthy environment. Please keep in mind this article is purely a reference guide based on the recommendations of health professionals and Safe Sleep organisations around the world, and thus is to be used as such.

Always sleep baby on their back, not on the tummy or side

Back is the best and safest position for babies to sleep in. There are mainly two reasons for this;

1.) Better heat loss: Overheating is a major SIDS risk. As such, one of the key strategies to reduce SIDS is by avoiding overheating. As babies regulate their temperature through their head, particularly their face, they are more likely to avoid overheating if put to sleep on their back. In fact, research has shown that heat loss in tummy sleeping babies is 60% less effective than for non tummy sleeping babies with the same insulation values for clothing and bedding (Tuffnell et al., 1995).

2.) Regurgitation: Healthy babies placed to sleep on the back are less likely to choke on vomit than tummy sleeping babies. This is so because, in the back position, baby's upper respiratory airways sit above the oesophagus (digestive track), unlike the tummy position (where the digestive track sits above baby's upper airways) therefore regurgitated milk can be easily swallowed without being inhaled into the baby's airways and lungs.

Tummy play is an important part of your baby's development, and is safe when done while baby is awake, with adult supervision. But remember, do not put baby on the tummy to sleep, as it increases the risk of SIDS.

Always ensure baby sleeps with head and face uncovered

There are mainly two reasons behind this;

1.) Overheating: Babies regulate their temperature through their head, particularly the face. If the head and face is covered, this normal method of heat loss is restricted, which significantly increases the risk of overheating.

2.) Depressed sleep arousal: Babies have depressed arousal from sleep when the face is covered (Franco et al.,  2002). Arousal from sleep is an important protective response to life-threatening stimuli, and failure to arouse from sleep is thought to be a possible mechanism leading to SIDS (Scheers-Masters et al., 2004).

The best way to sleep your baby with face uncovered is to use a baby sleeping bag (or a swaddle bag for newborn babies). Baby sleeping bags reduce the risk of bedclothes covering the baby's face. Baby sleeping bags also delay baby rolling onto the tummy during sleep, and help keep baby's temperature at a more constant level while sleeping at home.

Avoid doonas,  loose bedding or fabric, pillows, lambswool, bumpers or soft toys in the cot. Also check that your baby has no head coverings, such as bonnets, beanies, hats, or hood clothing, when indoors or in a car.

SIDS is the sudden death of an infant when no known cause was found to explain the death after a thorough investigation. It is the most common category of deaths between one month and one year of age.

SUDI is the term used for the sudden unexpected death of an infant in which the cause is not immediately obvious. Investigations after death shows factors that may have contributed to the death, e.g. an infection. SUDI includes SIDS and fatal sleeping accidents, and many of the risk factors for SUDI are common to SIDS and fatal sleeping accidents.

Keep baby smoke free during pregnancy and after birth

Exposure to cigarette smoke before and after birth have a significantly higher risk of SIDS and the risk increases if a baby sleeps with a parent who is a smoker. These risks still remain even if parents smoke outside, away from their baby. If a mother smokes during pregnancy, the risk of SIDS is approx 4 times greater compared to non-smokers. If the father smokes, the risk is almost double.

To reduce the risk of SIDS, don't let anyone smoke near your baby - not in the house, the car, or anywhere else that your baby spends time.

Provide a safe sleeping environment night and day

Safe cot: Use a cot that meets all current safety standards and recommendations in your country/region. In Australia, check your cot meets the current mandatory Australian standard for cots is AS/NZS 2172, and refer to the guide to infant and nursery products publication 'Keeping baby safe' available from the Australian Competition and Consumer Commission's website

Safe mattress: Use a flat, firm, clean, well fitting mattress that is in good condition. In Australia, check that your mattress is compliant with the new Voluntary Standard (AS/NZS 8811.1:2013 for firmness). This is important because if the mattress is not firm and well fitting, baby can get stuck in gaps between the mattress and the cot sides. A soft mattress or sleep surface can increase the risk of SIDS if baby rolls over onto the tummy.

Tilting a mattress up is never recommended because of the increased risk of SUDI. Health professionals and safe sleep organisations maintain that elevating the head of a cot does not improve reflux, and can increase the likelihood of baby slipping down under the bedding and covering baby's head.

Safe bedding: Always remove pillows, duvets, loose bedding or fabric, lambswool, bumpers and soft toys from the cot, as they may cover baby's face and obstruct baby's breathing. A baby sleeping bag (or a swaddle bag for newborn babies) with a fitted neck, armholes, and without hoods is a safer alternative to blankets and sheets.

Sleep baby in their own safe sleeping environment in the same room as an adult care-giver for the first 6 to 12 months

Safe sleep organisations around the world recommend sleeping baby in their own sleeping place in the same room as the parents for the first six to twelve months, because parents can see the baby and easily check to see baby is safe. Remember to keep the room smoke-free.

Sharing a sleep surface with your baby may increase the risk of sleeping accidents because baby could slip under bedding (e.g. pillows and duvets or doonas), or get trapped between the bedding and the wall or bed rails, or fall off the bed, and the sleep surface may not be ideal for babies (e.g., if the mattress is too soft, or the surface is a sofa, chair, beanbag, or waterbed, or if there are other children and pets sleeping  on the same surface as the baby). Sharing a sleep surface can also be dangerous if the parent is a smoker, or under the influence of alcohol or drugs, or if the parent is excessively tired.

Babies who are most at risk of sleeping accidents whilst sharing a sleep surface are babies less than four months of age, and babies born preterm or small for gestational age (low birth weight).


Tuffnell, C. S., Petersen, S. A., Wailoo, M. P. (1995). Prone sleeping infants have a reduced ability to lose heat. Early Human Development. 43 (2), 109-116.

Franco, P., Lipshutz, W., Valente, F., Walker, A. M., Walker, D. W., & Adamson, T. M. (1998). Dynamic changes in arousals threshold during sleep in the human infant. Pediatric Research. 43 (5), 697-703.

Scheers-Masters, J. R., Schootman, M., & Thach, B. T. (2004). Heat stress and sudden infant death syndrome incidence: A United States population epidemiologic study. Pediatrics 113 (6), 586-592.

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