Monday, July 12, 2010

Belly-sleeping and SIDS

When Daniel was about 2 weeks old, I officially gave up the idea of making him sleep on his back. He just wouldn't do it. He was tired, and I was tired. I felt like an evil selfish mom for letting him belly-sleep against all of the SIDS recommendations. When I mentioned it to my pediatrician and asked his opinion (he's generally super laid back) he said "well, if your baby died of SIDS could you live with yourself for letting him belly sleep?" I was dumbfounded. What a thing to say!
Still, I was so tired, as was he, that I continued to let him sleep on his belly. I'm not typically a worrying-type mother, but I would go in and check on him frequently, convinced I was setting him up for death. It wasn't until he was about 6 months old (about when the SIDS risk drastically reduces itself to nearly nothing) that I decided to do some research around belly-sleeping.

I do not wish to downplay the risk or tragedy of SIDS. I just want to point out some factors mommies often do not consider.

The official recommendations about no longer belly-sleeping came about because of the "Back to Sleep" campaign in the early 90s (previous recommendations were to make them sleep on their belly to avoid suffocation from spit-up). The scientific community noticed a huge correlation between the time the campaign ran and a reduction in SIDS deaths- an over 50% reduction by some accounts. That, and that alone, is the reason for the recommendation. I'm not doubting the correlation exists- I do believe less belly-sleeping will mean less SIDS. Just like other common-sense guidelines that were also a part of the Back To Sleep campaign (no soft bedding, and importantly- no smoking near baby) can also be tied to the reduction in infant deaths. But a correlation does not establish cause-and-effect. It's also important to note that while the number of SIDS diagnoses went down drastically, the overall number of infant deaths hardly changed- just the number of SIDS diagnoses (by the way, the only way to really diagnose SIDS is to rule out every other possible cause of death.) It's also important to note that during this period- where the reduction in SIDS deaths is tied to just back-sleeping- there was a huge cultural push for breastfeeding (shown to reduce your SIDS risk by 2 or 3 times) and stopping second-hand smoke, and could also be tied to the drop in SIDS deaths.

To this day, there is no official stance on what causes SIDS. Most lay people think it's a kind of suffocation- though officially a SIDS diagnosis rules out death by suffocation- that's a different diagnosis. Some think it's a genetic defect. Recent studies favor the idea that it's a form of sleep apnea. That makes the most sense to me, though I wouldn't be surprised if it's a combination of genetics and sleep apnea or maybe something else entirely.
But why, if it's apnea (or even genetics), would belly vs. back matter? Because SIDS affects babies when they're in their deepest form of sleep. And most babies sleep much more deeply on their stomaches. ALL of the SIDS guidelines (back-sleeping, keeping the room cooler, having a fan blowing on the baby- they've even noticed in studies a decrease in SIDS when caffeine was administered to the babies) have one thing in common: they keep the baby from sleeping as deeply.
Now, some babies are deep sleepers no matter what you throw at them. This, I believe, is why some babies still die of SIDS even while sleeping on their backs. Unfortunately, that means there isn't much their moms can do to reduce the risk of SIDS. You can follow every SIDS guideline and still lose your baby. The odds are low to begin with and lower if you follow all the guidelines- but there is no way to eliminate the risk altogether. Sorry if that's a depressing way to view it.

 This study shows that babies who slept on their bellies had far more "efficient" sleep but also more instances of apnea (the non-fatal kind)- which goes hand-in-hand with the SIDS-is-linked-to-apnea-during-deep-sleep theory. Babies that were studied who later actually died of SIDS were much less likely to have arousals during their sleep than babies who were never affected by SIDS. In other words, belly-sleeping babies slept more deeply, and longer, than their back-sleeping counterparts. But the deep-sleepers were also at more risk for SIDS.

The problem is, not letting a baby sleep deeply carries its own set of risks. I'm borrowing this straight from the wikipedia article on the Back to Sleep campaign (I added the emphasis):
"...According to the study, at 6 months of age, the infants who were placed to sleep in the prone position had statistically significant higher social skills scores, gross motor scores, and total development scores than those infants who were put to sleep in the supine [back] position. [A different study] reported that "Typically developing infants who were sleep-positioned in supine had delayed motor development by age 6 months, and this was significantly associated with limited exposure to awake prone positioning."" (to be fair, it goes on to note that how much time the babies had on their tummies while awake was not factored into the study and might have an effect).

In other words, babies need that deep sleep for their development. Without deep sleep, they are likely to hit their milestones later. On top of that, back-sleeping leads to an increase in problems like cradle cap (not a huge deal), asphyxiation from reflux (a very big deal), and since the Back to Sleep campaign, there has been a huge increase in the amount of babies with plagiocephaly or cranial asymmetry problems (funky-shaped heads from laying on their soft skulls)- not to mention the temporary and less worrisome cradle bald spots.

In other words, there is a set of risks, whether you sleep your baby on the belly or their back. I won't judge a mother either way. The risk of SIDS for a normal, healthy baby is very small compared to the risks that come from back-sleeping, but obviously death is infinitely more tragic than an asymmetrical head or hitting milestones a few months later. I do think that parents of babies that are more prone to SIDS (respiratory problems, prematurity, diagnosed apnea, snoring...) should consider follow all possible SIDS guidelines to the letter. But if a mommy lets her baby sleep on his or her belly, it's possible that instead of being a negligent parent, they are choosing a different set of (scientifically based) benefits and risks- longer sleep periods, deeper sleep, and more likely to meet milestones on time.
If it's worth the risk to you, then go for it. I do. I personally feel that letting my baby sleep deeply is more important than the small risk of SIDS. But, I also understand that there's validity to valuing protection from SIDS above deep sleep. I really don't think you'd be "right" or "wrong" either way- or rather, I think both ways can be right, depending on what risks you're most comfortable with. No mother should ever feel judged for making an informed decision.


  1. Interesting! Having a new baby again (my 2nd), this comes to mind once in awhile. It's nice to have more info on the subject.

  2. I just fell upon your blog today from the Gift of Giving Life Blog and I can absolutely relate to this post and love it. Thank you. I started putting my one month old to sleep on his stomach and decided to not even ask my Dr. knowing what she would say. I was like you, not a nervous mom but for the first 4 months he only slept on his belly for naps and in the same room as me, but I decided if I as HIS Mom felt ok with it, that is what mattered. Just last week on my blog I posted this quote "Trust your motherly instincts, at the end of day (or in the middle of the night!), no book, medical expert or even experienced mom knows YOUR Baby better than YOU! Trust your God given innate ability to care for your Baby"
    Thank you again for this post it is so nice to read other mothers comfortable with their decisions and not afraid to blog about :)

  3. I just found this post after replying to Birthing Beautiful Thoughts. I really enjoyed your insight for commentary, complete with references! It is almost everything I have thought about in regards to the subject, but written more clearly than I could have.
    My son is a belly sleeper, and has been since around 3 weeks of age for naps and around 6 weeks at night. I was able to 'justify' it to myself by saying my son was never able to get the sleep he needed on his back. He is just too light of a sleeper. In my poor postpartum mind, I was able to tell myself that he slept on his belly the same level of deep sleep as other babies do on their backs.

  4. Great post. I have been putting P on his tummy to sleep for naps. We cosleep so at night he's usually on his back or on his side, but for naps he either rolls himself onto his belly or I end up laying him that way. I've been working on getting over the "guilt" associated with it and feeling like I'm going to go to mommy hell (as my one friend put it) for letting my child sleep on his tummy.

  5. Found you through Busca's blog (birthfaith) . . . I really debated sleeping my latest baby on his stomach (since my first two were HORRIBLE sleepers -- in the end we just left him on his back 'cause he does well sleeping on his back.) I was going to go with whatever worked best, no matter the 'recommendations'. This might surprise some people, since I had a sister die of SIDS (while sleeping on her stomach, the recommendation at the time.) My Mother has said it would've made no difference if she'd slept the baby on her stomach or her back, so she's never wondered if there was a cause and effect here -- basically she believes that babies who die of SIDS will pass away no matter their sleep position, that for whatever reason, those particular babies will not wake up one morning, because it is there time; because (for whatever reason) their time here is supposed to be short. And nobody, or no sleep position, or no precaution, will trump what their bodies are going to do -- which is to stop breathing and peacefully pass away.

  6. Great info. My babies have always started turning onto their bellies to sleep very early on, and they much preferred sleeping that way. So I let them. My mother gut told me they'd be fine. Thanks for putting this together.

  7. Wow! I have to really research some of this more. My daughter slept TERRIBLY for months!!! At first she would only sleep in a glider at night. Then she would only sleep in a swing for naps. She is tired enough to usually sleep at night, but naps have ALWAYS been (and at 23months CONTINUE to be) hard.
    I had her sleep on her side for a while (about 4-6months) because it was before sleep positioners were banned and before she started rolling and moving around.
    At about 10 months whenever I would lay her on her back for bed, she would IMMEDIATELY roll over to her tummy! She still sleeps this way.

  8. Thanks for this level-headed post. Like semi-crunchy mama I was afraid of going to "Mommy hell" so I did some research and it led me to similar conclusions. I calculated that putting a baby on his back rather than his tummy made a difference with respect to SIDS for less than 0.25% of babies and decided it wasn't worth worrying about. I let our son sleep however he wanted to, which made us both happier. He started crawling at 4 months and cruising at 6 months. It took me four months to get up the courage to tell our doctor that we let our son sleep on his back. Why do the SIDS and other recommendations come with fear and guilt and not information? Surely fearful, insecure mothers are not what's best for babies. Parents should be given information and not judgment if they question current recommendations. Thankfully my doctor was cool with it. It would have been hard if he'd given me the same line yours gave you!

  9. Excellent. I came to the same risk/benefit conclusion that you did when my 2nd child was an infant. He simply would not sleep on his back. (He didn't sleep all that well on his tummy, either, but there was *some* improvement -- longer stretches of sleep and gentler wakings.) For extra piece of mind, I bought one of those under-the-mattress monitors that would go off if he stopped breathing for any length of time. (He never did.)

    Besides the issue of his sleep, I justified my actions by thinking of relative risks. When he was sleeping on his back, I was *severely* sleep deprived -- to the point of being very sleepy while driving even short distances. I reasoned that the risk to my baby from being in a car with a sleepy driver was *many* times greater than his risk of SIDS from tummy sleeping! (Not to mention the added risk to me and his 2 year old sister!) I never hear anyone address this relative risk, but it still seems like a significant one to consider.

  10. Thank you! What a great burst of intelligent analysis. I'll be sharing this with some friends.