back to sleep

baby in cotBaby says “I sleep on my back and that is that”

This is one of the key things you can do to make your baby’s sleep time safe. It is important to make sure baby is lying on their back for every sleep, no matter what time and no matter how long you intend them to sleep for. Safe sleep is for short nap times too.

Why should babies sleep on their back?

Back (supine) sleeping reduces the risk of SUDI and should be the only position infants are placed for all sleeps until they reach 12 months of age. It is important that a baby is placed completely flat on their back.

Front (prone) and side sleeping are known to increase the risk of SUDI and an infant should never be placed in either position for any sleep UNLESS instructed by a neonatologist or paediatrician. A very small number of babies will have to lie in a position other than on their back due to a medical condition. The reasons why a baby should not sleep on their back will be well explained to you if this is the case.

Why is tummy sleeping dangerous for a baby?

There are several reasons why. Babies can rebreathe the air they have already breathed out, which can reduce the oxygen levels they are breathing in. Some babies can have an immature or dysfunctional response to reduced oxygen and cannot respond appropriately. The increased rebreathed air and reduced oxygen in the lungs, and blood supply may affect a baby’s cardiovascular and brain function.

Babies can overheat when lying on their tummy because they are less able to lose heat in the normal way, which means their core body temperature increases.

During the critical developmental period of between 2 – 4 months of age (remember babies are all unique and develop at different rates), a baby’s ability to regulate certain functions during sleep can be affected by tummy sleeping. This means that functions such as blood pressure and respiratory rate are affected and can lead to reduced levels off oxygen getting to a baby’s brain.

What about side sleeping?

Some research suggests that side sleeping is just as risky for a baby as tummy sleeping. Many babies who have died were reported to have been placed on their side and then found on their tummy. When an infant is placed on their side they are more likely to roll onto their tummy.

Back position for every sleep

Having a regular routine is important – babies are at even greater increased risk of SUDI if they usually sleep on their back but sometimes or maybe just one time are placed on their front or side.

Baby SleepingMake sure that anyone caring for your baby knows about safe sleep and places your baby to sleep on their back.

Parents and caregivers should NEVER place their baby to sleep on their front because they think they will be more comfortable or because they are worried that they will choke if positioned on their back. Some parents think that tummy sleeping is better because their baby sleeps more soundly.

Let’s link some of these messages to what we know about anatomy and some of the factors already mentioned.

Young babies are meant to wake frequently – their physiology (the way they function) means they need to feed often and sleep for many shorter sleeps rather than very few long sleeps. This changes as they grow but in the first few months waking frequently is normal and healthy.

Research shows that babies who sleep on their tummy wake less easily. Is this a good for baby? The simple answer is no, as it means that if they are in a stressed environment or their breathing is challenged, they are less likely to arouse and protect themselves from the factor stressing their breathing.

When we look at baby’s anatomy, we can clearly see that the risk of choking is actually higher if baby sleeps on their tummy.

This is the opposite of what some parents understand and means that the reasons given why infants sleep on their tummy puts them at greater risk of the thing parents are trying to avoid.

What about reflux?

Many parents say they cannot place their baby flat on their back because they have reflux and sleeping on their back will make this worse.

Sleeping on their back does not increase reflux. This has been shown in research. The risk of a baby dying is something parents and caregivers should prioritise over reflux. When a baby coughs or even gags, this is normal behaviour for them clearing their throat. It is not the same thing as choking.

Prone and side positioning are no longer recommended unless babies are awake and supervised, or reflux is life-threatening itself.

The following key points should be noted for any baby who has reflux and parents or caregivers are concerned about sleep position.

  • Reflux is the same or worse in babies placed ‘ion their back with their head elevated’ vs ‘on their back and flat’. Therefore ‘on their back and flat’ when babies are asleep should be recommended for both managing reflux and reducing the risk of SUDI.
  • Reflux is made worse in the ‘car seat’ position (‘not fully lying on their back – semi reclined’).
  • Reflux is reduced in the full upright position.
  • There is no evidence supporting reduced reflux from having the ‘head elevated’ for any position.

Babies with reflux should sleep in the same back position as recommended for all babies. Raising their head off the mattress or even tilting the head end of the cot will not reduce the symptoms of reflux but may make the baby’s sleep environment less safe. Babies with reflux should not sleep in car seats.

Why did my baby sleep on their tummy in the neonatal unit at hospital?

If an infant is born premature or is unwell and requires to be stabilised in the neonatal unit, they will often be ventilated and cared for with them lying on their tummy in an incubator. This is routine practice I this clinical environment and can help to stabilise the baby’s basic functions.

Remember that a hospital environment when a baby is being monitored by medical equipment and has staff looking after them 24 hours a day is different to your home environment when you and baby will be sleeping at the same time for some of their sleeps.

Before your baby is discharged home, staff caring for your baby should begin to place them for sleeps on their back so that baby becomes used to this and that this change happens first in the hospital setting. No baby should be discharged home with instruction to sleep on their tummy unless there is a medical reason for doing so. If this is the case this will have been explained to you by doctors caring for your baby.

Babies who were born prematurely or who were unwell and needed to be cared for in the neonatal unit shortly after birth are more vulnerable to SUDI. It is more important that safe sleep messages such as back to sleep are followed for these babies.

Will my baby develop a flat head?

A flat head (plagiocephaly) is when the back of a baby’s head has a flattened rather than rounded appearance. Parents may worry that baby sleeping on their back is harmful and causes this flat head. When placing baby for a sleep their head can be positioned turned to alternate sides for sleep time to reduce the incidence.

Whilst sleep position can be a factor in flat head, it is often associated with infants having too little time on their tummy when awake or spending awake hours with their head against a surface (pram back, bouncy chair or a nest) It is important that babies have ample opportunity for supervised tummy time when they are awake and that they spend time being held rather then placed in seat or other positioning device. This helps their development and reduces the chances of developing a flat head.

In children without certain other developmental conditions, the appearance of a flat head will resolve itself in 97% of babies by the time they become toddlers.

My baby is rolling onto their side or tummy, is it ok to place them this way for sleep now?

Baby’s will all learn to roll onto their side and eventually all the way onto their tummy at some stage. Many babies will reach this milestone between 4 and 6 months of age. Babies will begin to roll before they have fully mastered free rolling from one position and back again when they choose to do so. Before this, babies will roll into one position and sometimes remain that way not rolling back. This is why a clear sleep space is important. Baby may roll against something next to their face and not be able to move away from this.

If when you check on your baby, you find they have rolled, gently move them onto their back again and continue to place them on their back for every sleep until they are six months of age. After six months of age, there is no need to re-position them if you find they have rolled, but you should continue to place them on their back for every sleep until they are 12 months of age. You will find that your baby finds their own sleep position once they are free rolling from back to front and back again. This means that they are also capable of moving themselves out of a situation if they end up with their face against a surface.


Evidence For Our Back-Positioning Message

Tummy sleeping has been shown to increase the risk of SUDI by anything from a 2.5 fold increase to a 13 fold increase. This means that even without any other risk factors a baby is more at risk of SUDI.

If a baby is sleeping on their side, research has shown that they are around 2.5 times more likely to suffer a SUDI. Baby’s placed on their side were also almost 9 times more likely to be found lying on their tummy.*

If a baby is  normally placed on their back and then for one particular sleep are placed on their side or tummy they are at greater risk of SUDI. Research shows that the risks increase from almost 9 up to 45 fold increase. This is why a sleep routine for every sleep is important.**


Read the research articles