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Pediatrician checking heart rateAlways stress the ABC’s of Safe Sleep! Infants should always sleep Alone, be placed on their Back to sleep or nap, and in a Crib.

In 2005, the American Academy of Pediatrics published a policy statement with recommendations for a proper safe sleep environment for infants including the sleep position, sleep surface, and co-sleeping. Here is a brief summary of the recommendations:
  • Infants should always be placed on their backs to sleep and nap.
  • Infants should be placed in a crib or on a firm sleep surface and not on soft surfaces such as an adult bed or couch.
  • Keep soft objects like toys, pillows, and loose bedding out of the crib.
  • No co-sleeping, infants should never share a sleep space.

What is the link between SIDS and Safe Sleep?

The frequency of SIDS deaths in the United States has decreased by 15% since introduction of the “Back to Sleep” campaign in the 1990s. However, the main focus of this initiative was the sleep position and not the sleep environment as a whole. As SIDS cases decreased and infant deaths due to Accidental Suffocation and those labeled Undetermined with risk factors for an unsafe sleeping conditions started to increase, it has forced researchers, clinicians, medical examiners, and public health professionals to look at the bigger picture of an infant’s sleep space through a different lense. Identification of where the risk factors overlap has led to increased awareness efforts to prevent Accidental Suffocation while simultaneously reducing the risk of SIDS. In addition, shifting the focus to the overlapping risk factors has resulted in a more comprehensive approach to disseminating education of proper safe sleep practices to caregivers and communities.

Education at the provider/patient level presents an opportunity to increase awareness of the safe sleep environment. It is important for you to discuss with your patients how deaths from Accidental Suffocation can be prevented and the risk of SIDS can be reduced at the same time. Since the exact cause of SIDS is unknown, it is not considered preventable and the focus is on risk reduction. OBGYN offices should discuss safe sleep practices with their patients in the office and in the hospital setting. The more people are aware of the risks the more they can be empowered to take the appropriate steps to lower their infant’s risk of injury or death. Information is key!

Answers to Frequently Asked Questions


Although all adults and children can be injured or in some cases die from unsafe sleeping arrangements, infants less than 1 year of age are at HIGHEST RISK of dying from Accidental Suffocation and SIDS. Due to their limited physical and developmental capabilities, they are not able to protect their own airway or be easily aroused during sleep. In addition, the research shows there are some populations in which deaths due to Accidental Suffocation resulting from unsafe sleep practices occur more frequently and are at greater risk. These include African Americans, Hispanics, infants born premature, and infants sleeping with adults who under the influence of drugs or alcohol.


  • Review the current safe sleep practice guidelines outlined by the AAP with your patients and discuss the risks of co-sleeping. Educate parents on what they’re doing right, and provide them with additional guidance on what they can change to make their baby safer. This is also a good opportunity to discuss the Period of Purple Crying to help prevent Shaken Baby Syndrome.
  • Print appropriate educational materials to share with parents and caregivers. Encourage parents to discuss safe sleep practices with older caregivers, other family members, and babysitters.


The "Safe Sleep Environment" is a way to describe the position (on stomach or back) an infant is put down to sleep in, the area around where the infant is sleeping, and the surface they are put to sleep on. All of these areas are important for keeping an infant safe during sleep.

Unlike adults, infants have limited physical and developmental capabilities to get themselves out of unsafe conditions. Their reflexes are a little slower and do not always allow them to protect their own airway or cause them to arouse during sleep.

The safest way to put an infant to sleep is dressed in a sleep sack or appropriate clothing for the temperature of the room, put on their back, in a crib alone, with a firm safety approved mattress and tightly-fitted crib sheet, with no bumper pads, stuffed animals, blankets, or pillows.

Check out the brochure What does a safe sleep environment look like?.


A 2008 report published by the Centers for Disease Control (CDC) noted that nationally there has been an increase in the number of infants dying from Accidental Suffocation due to unsafe sleeping arrangements and sleep position. In the past, these types of deaths were mostly commonly classified as Sudden Infant Death Syndrome (SIDS). However due different ways of examining infant death data we are learning that some of these deaths may not have been due to SIDS but may have been caused by Accidental Suffocation due to safety hazards in the sleep environment and are completely preventable.


Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant less than one year of age that cannot be explained after a through investigation including: a complete autopsy, examination of death scene, and review of clinical history (CDC). When an infant dies and there is no obvious explanation for the death, an investigation is conducted by law enforcement and the medical examiner.

If there is no obvious explanation for the death due to trauma or physical signs of asphyxia, the infant was not ill, and consistent information on how the death occurred was provided by the caregivers and law enforcement, the death is thought to be SIDS. However, most SIDS deaths in Mecklenburg County have risk factors for an unsafe sleep environment present.

Accidental Suffocation (also called positional asphyxiation) is when an infant is accidentally suffocated during sleep which can be caused by several factors such as:

  • An infant being placed on his/her stomach to sleep on a pillow or blankets, causing the infant’s airway can become obstructed not allowing the infant to breathe.
  • An infant is sleeping in an adult bed with a parent/caregiver or other siblings, making it possible for a person to rollover on or wrap an arm or leg over the infant’s face and cause suffocation.
  • An infant is put to sleep on its stomach on a soft surface such as an adult bed or sofa and the infant becomes wedged in the cushions, or between the mattress and headboard or footboard. On a sofa an infant can roll towards a cushion and suffocate.
  • In some cases an exact cause of death is unclear and/or the risk factors for SIDS and Accidental Suffocation overlap and create uncertainty upon completion of the autopsy, review of medical history, and review of the death scene investigation. In these cases, the death may be classified as Undetermined. Unsafe sleep practices are identified in a majority of infant deaths classified as “Undetermined” in Mecklenburg County.


The risk factors for SIDS and Accidental Suffocation are basically the same with a few exceptions for SIDS because it is a medical diagnosis of exclusion and no clear cause has been identified. Since we do not know what causes SIDS, we can focus on the risk factors for Accidental Suffocation which is completely preventable and will also help reduce an infant’s risk of SIDS.

Sudden Infant Death Syndrome (SIDS):

Although there are some risk factors known to be associated with SIDS, there is no clear cause of SIDS. The strongest risk factor associated with SIDS is an infant’s sleep position and it is highly recommended that an infant be placed on its back to sleep, alone in a crib (or firm surface), with no other blankets, pillows, stuffed animals, loose bedding or bumper pads.

Risk Factors for SIDS:

  • Age - All infants from birth to 1 year of age are at risk.
  • Sleep position – infants who are placed on their backs to sleep are less likely to die of SIDS than infants who are placed on their stomachs. Placing an infant on its back to sleep is the number one way to reduce the risk of SIDS. Infants should be placed on their back to sleep and nap.
  • However, there can be cases where it is medically necessary that an infant sleep on its stomach. It is okay to place infants on their stomachs to play or when they are not sleeping. Placing an infant on its stomach to play will help the infant in develop the physical capabilities to lift the head and body.
  • Sleep Surface – infants should be placed in a crib with a safety approved crib mattress and tightly-fitted sheet. Infants should NOT be placed on adult beds, pillows, quilts, loose bedding, sofas, or any other soft surface to sleep or nap.
  • Sleep Area – it is important for an infant to sleep alone and NOT to surround an infant’s sleep space with soft objects such as big pillows, loose blankets, quilts, sheepskins, stuffed animals, bumper pads or pillow- like bumpers.
  • Overheating – An infant should be dressed properly for the temperature of the room which should be between 65-72 degrees but no higher than 75.
  • History of Chronic Illness – Studies show infants with a history of chronic illness (i.e. respiratory illnesses) are at greater risk of dying from SIDS.
  • Prematurity – Studies show infants born premature (less than 37 weeks) are at greater risk of dying from SIDS than infants who are not born premature. Infants who are born premature are more likely to be born with chronic respiratory illnesses. Parents/caregivers are more likely to co-sleep with premature infants than infants who are not premature.
  • Co-Sleeping – infants should NEVER sleep next to or with adults, other children, or other infants. Infants are safest when they sleep alone in the proper sleep environment.
  • Smoking – Smoking during pregnancy, around an infant, or exposure to clothing and objects that contain smoke residue (i.e. furniture) can increase an infant’s risk of SIDS.
  • Risk Factors for Accidental Suffocation:

  • Age – All infants from birth to 1 year of age are at risk.
  • Sleep position – infants who are placed on their backs to sleep are less likely to die of SIDS than infants who are placed on their stomachs. Placing an infant on its back to sleep is the number one way to help reduce the risk of SIDS. Infants should be placed on their back to sleep and nap.
  • Sleep Surface – infants should be placed in a crib with a safety approved crib mattress and tightly-fitted sheet. Infants should NOT be placed on adult beds, pillows, quilts, loose bedding, sofas, or any other soft surface to sleep or nap.
  • Sleep Area – an infant’s sleep space should be free from toys and soft objects such as pillows, loose blankets, quilts, sheepskins, stuffed animals, bumper pads or pillow-like bumpers.
  • Co-Sleeping – infants should never sleep next to or with adults, other children, or other infants. Infants are safest when they sleep alone in the proper sleep environment.

Infants who are not put to sleep safely are at risk for Accidental Suffocation. Death can occur when an infant:

  • falls off a bed or sofa
  • becomes entangled in bedding (bumper pads, sheets, blankets)
  • snuggles up against a soft object in the bed (stuffed animal, bumper pad, pillow, couch cushion)
  • becomes trapped between an adult bed and a wall
  • is put to sleep on a couch and rolls over face first on the sofa cushion or falls between the sofa cushions
  • is sleeping on a sofa with an adult (or older sibling) and gets wedged between the adult and the sofa
  • falls asleep on an adult’s chest and becomes wedged between the adult and the furniture
  • is sleeping with an adult on a bed
  • is overheated by too much clothing, too many blankets
  • put to sleep in a crib or pack-n-play with too many blankets and /or stuffed animals
  • or when an adult or child completely or partially rolls over on the infant while sharing a bed
  • or when an adult or child places their hand on the infant’s back or chest while sleeping
  • breathes in smoke, compromising their respiratory system


In an adult bed there are pillows, big blankets, and spaces where an infant can be at risk of suffocation, injury, or death. The risk of suffocation is higher for infants who sleep in an adult bed (with our without an adult) compared to infants who sleep in a crib alone. The two most common causes of death among infants, who are put to sleep on an adult bed, are entrapment and overlaying which can both lead to suffocation.

  • Entrapment occurs when an infant becomes wedged in-between the bed and the wall or between the bed and the headboard or footboard.
  • Overlaying can occur when a child or an adult accidentally covers an infant’s airway with their arm, leg, or whole body while sleeping together.

The mattress on an adult bed is less firm than those found in infant cribs. Due to this type of safety issue, mattresses in infant cribs are purposely made extra firm. It is important for infants to sleep on a firm mattress because they lack the motor skills to escape potential threats to their safety and breathing. In an adult bed threats to an infant’s safety are soft bedding such as pillow top mattresses, big pillows, and big blankets.


It can be dangerous for an adult to sleep with an infant due to the risk of overlaying. A parent/caregiver can roll over on an infant while they are sleeping or shift their body in a way that an arm, leg, or part of the body interferes with the infant’s ability to breathe. This can lead to suffocation.


Yes. If your patient wants to breastfeed in bed, you should encourage the mother to put the infant’s crib next to her bed or somewhere in the bedroom nearby. After she is done breastfeeding, she should place the infant in the crib on its back. This will allow the mother to get the proper rest she needs to care for an infant and the infant to sleep safely alone.


The research today shows the issue of safe sleep is too strong to ignore. Infant deaths due to Accidental Suffocation resulting from unsafe sleeping conditions are preventable. It is understandable that people take risks all the time but the more we educate ourselves and others about proper safe sleep practices, the more infants we will prevent from dying of Accidental Suffocation and reduce the risk of injury and SIDS.


Playpens, pack n plays, and portable cribs can be used as a sleep surface when away from home as long as there is NOTHING ELSE in it except the infant. It should be free of any pillows, blankets, stuffed animals, bumper pads, couch or other cushions, other children, or any other objects. The infant should be placed on its back with nothing else around it. A car seat can be used but should NOT be a sleep space for the long-term.

Encourage your patient to review the manufacturer’s instructions to make sure the infant is the appropriate age or weight to sleep in one of these types of items.

Strollers and swings are NOT safe sleep spaces for infants.

If your patient does not have a crib for the infant to sleep in, it is best to find an empty drawer or large box she can set on the floor near where she is sleeping to put the infant to sleep in. She can place a thin, small blanket or sheet in the drawer or box and place the infant on its back. This will help keep the infant safer during sleep while they are away from home.

You may also visit the following websites to view and print educational materials to give to parents:

Sleeping an Infant in a Pack n Play
Consumer Product Safety Commission Playpen Safe Sleep information English | Spanish

 
Resource Documents
 
  
  
2011 Meck CFPPT Epidemiology Report.pdf2011 Meck CFPPT Epidemiology Report
AAP Recommendations 2011.pdfAAP Recommendations 2011
CPSC Playpen Sleep Info - English.pdfCPSC Playpen Sleep Info - English
CPSC Playpen Sleep Info - Spanish.pdfCPSC Playpen Sleep Info - Spanish
Deaths in Portable Cribs and Playpens.pdfDeaths in Portable Cribs and Playpens
NC Fact Sheet Infant Sleep Position.pdfNC Fact Sheet Infant Sleep Position
New CPSC Crib Guidelines.pdfNew CPSC Crib Guidelines
Safe sleep and pack n play.pdfSafe sleep and pack n play
Safe Sleep Environment.pdfSafe Sleep Environment
Safe Sleep Training Data.pdfSafe Sleep Training Data
SIDS Deaths in Mecklenburg.pdfSIDS Deaths in Mecklenburg


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