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Reducing a Preemie’s Risk of Sudden Infant Death Syndrome

Unless you have received special sleep position instructions from your baby’s care provider, remember that all babies, including premature and low birth weight infants, should be placed on their back to sleep.

For premature infants with respiratory distress (bronchopulmonary dysplasia or chronic lung disease) and for infants or premature babies with certain upper airway malformations (such as Robin Syndrome), gastro-esophageal reflux disease, or other medical problems, sleep studies may be required prior to discharge from the hospital in order to determine the safest sleep position. Any alteration from the Back to Sleep recommendation must be discussed with your health care provider.

You may have seen your baby nested on her stomach in the NICU, on top of a soft pad and surrounded by rolled blankets (or commercial positioning cushion) in order to promote flexion. This positioning was done at an earlier time in your baby’s life to decrease gastrointestinal reflux, improve developmental tone, or decrease other symptoms such as apnea, and while under close medical supervision and cardiorespiratory monitoring. Do not position your baby on her tummy or her side to sleep at home. Place your baby on her back to sleep.

Things You Can Do To Reduce the Risk of SIDS:


  • Don’t overdress or overbundle your baby or overheat your baby’s room. Your baby should be lightly clothed for sleep, and the bedroom temperature should feel comfort- able to a lightly clothed adult. Your baby should not feel hot to the touch and should not be moist or sweating. Be aware that continuing to use the knit hat at home may result in overheating your baby and is therefore not recommended. Your baby should be able to maintain her body temperature without the knit hat by the time she goes home.
  • Some studies suggest running a ceiling fan or turning on a small fan in your baby’s room for better circulation—which may help decrease the risk of SIDS (not proven at this time).
  • Place your baby on a firm mattress covered only with a sheet. Avoid soft sleep surfaces, such as fluffy bedding, pillows, beanbags, or water beds, which may increase your baby’s risk of suffocation.
  • Avoid maternal and household smoking. Maternal smoking during pregnancy has been identified as a major risk factor in almost every SIDS study. Household smoking has emerged as a separate risk factor for SIDS. Avoiding an infant’s exposure to secondhand smoke is advisable for numerous health reasons in addition to the SIDS risk.
  • Consider offering a pacifier at naptime and bedtime throughout the first year of life. Although the reason is unknown, pacifiers have been shown to decrease the risk of SIDS. If your baby doesn’t want it or if it falls out of her mouth, do not force it or prop the pacifier in place.
  • Avoid commercial devices marketed to reduce SIDS or developmental tools used in the NICU to foster flexion and containment. None have been tested sufficiently to show efficacy or safety.
  • Do not use home cardiorespiratory monitors in an effort to reduce the risk of SIDS—they do not.

Concerns About Back Sleeping

Most new parents are aware of the recommendations for positioning babies on their back for sleep. Your own parents or grandparents, however, raised “tummy sleepers,” and may have the following concerns about back sleeping:


  • Choking. The most common fear about the back sleeping position is that the baby will spit up and choke while asleep. If your NICU graduate has special issues that put her at risk, you will know this prior to discharge and receive special sleep positioning instructions. Healthy NICU graduates are able to turn their heads or protect their airways if they spit up.
  • Flat head. Technically called positional plagiocephaly, your baby’s head may be flat in the back and narrow on the sides. The head usually rounds out as the baby matures, holds her head up independently, and spends less time on her back. In the meantime, encourage plenty of supervised tummy time when your baby is awake, and avoid placing your baby in car seat carriers or “bouncers” for excessive lengths of time. Change the position your baby faces in the crib every few weeks or change the crib to the other side of the room (the baby’s attention will be drawn to the center of the room rather than the wall) so that she is not always lying on the same side of her head. These strategies should help take the pressure off of the back of the head. If plagiocephaly occurs despite these preventive measures, talk with your health care provider about a referral to an occupational or physical therapist.
  • Delayed motor development. Some worry that because the baby spends so much time on her back, it will take a long time to master the skill of rolling over. Allowing the baby plenty of supervised time on her tummy while she’s awake will build the necessary neck and shoulder muscles she needs to roll over.

Be sure that everyone who cares for your baby knows the importance of positioning her on her back for sleep. Babies who are accustomed to a back sleeping position who are then placed on their tummy for sleep (for example, at naptime) have a very high risk of SIDS.

Last Updated
Newborn Intensive Care: What Every Parent Needs to Know, 3rd Edition (Copyright © 2010 American Academy of Pediatrics)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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