Safety in the sleeping environment

There are many things to consider when creating a safe sleep-environment for our children, and I would like to start by taking you through the recommendations issued by the American Academy of Pediatrics (AAP) regarding a safe sleep environment.

The AAP is the leader in infant mortality research in the United States, and these recommendations are based on their research.

Sudden infant death syndrome (SIDS) is a subcategory of sudden unexpected infant death (SUID) and occurs when no explanation is found for the death after a detailed investigation of the incident and autopsy. Distinguishing between cot death (SIDS) and other causes (SUID) such as accidents during sleep can be difficult, because it is often not possible to distinguish whether it was an accident during sleep, e.g. suffocation or not with an autopsy. The reason may therefore still be unclear after a full investigation. Many risk factors for SIDS and suffocation are very similar.

These recommendations are issued with the aim of reducing the risk of SIDS and sleep related accidents in the child’s first year.

  • Back to sleep for every sleep
  • Use a firm, flat mattress. The sleeping pad should not curve down at the buttocks, if the curve is greater than 10° it is not considered safe.
    • A firm mattress keeps its shape when the child is placed on the mattress, it doesn’t get dented where the child’s head lies.
  • Breastfeed if you can.
  • The child should sleep in the parents’ room, close to the parents’ bed but in their own sleeping space, ideally for the first 6 months.
  • No loose beddings or soft objects in the bed.
    • The bed should be completely empty.
    • Do not use weighted blankets or other weighted products.
    • Dressing the child in layers is preferable to loose blankets.
  • Consider offering a pacifier at bedtime. If the child is breastfed, the pacifier is not offered until breastfeeding is well established.
  • Avoid smoking during pregnancy and after giving birth. Avoid smoking around the infant.
  • Avoid alcohol and drugs during pregnancy and after delivery.
  • Avoid overheating and covering the child’s head or face.
    • Do not put a cap on the child indoors, except in the first hours after birth or in the neonatal intensive care unit.
  • Pregnant women should have regular prenatal check-ups.
  • Infants should be vaccinated according to procedure.
  • Avoid using advertised products that do not conform to a safe sleep environment.
  • Do not use cardiorespiratory monitoring devices as a means of reducing the risk of SIDS.
    • These devices have not been shown to reduce the risk of SIDS.
    • There are no contraindications to using these devices, but they do not replace a safe sleep environment.
  • Give the child time to lie on its stomach (tummy time) under supervision when it’s awake. Start soon after returning home for short periods at a time, gradually increasing the time to 15-30 minutes total per day by 7 weeks of age.
  • Swaddling does not reduce the risk of SIDS.
    • Swaddling is often used as a way to calm newborns. If the child is swaddled, it should always be placed on its back, the risk of cot death increases if a swaddled child is placed on its stomach or rolls over onto its stomach.
    • The swaddle should be tight around the chest but looser around the hips to support normal hip development.
    • Weighted swaddles are not safe and therefore not recommended.
    • When the child shows signs of trying to roll over (usually around 3-4 months of age), you should stop swaddling the child.

These recommendations state that the organization understands and respects that many parents choose to share a bed with their child for various reasons, e.g. to facilitate breastfeeding or in the belief that it is better and safer for the child. However, the organization cannot, based on research, advise parents to share a bed with the child under any circumstances. The following factors increase the risk if a bed is shared with the child:

  • A parent has reduced alertness or the ability to wake up due to alcohol, drugs or overtiredness.
  • A parent smokes or the mother smoked during pregnancy.
  • You sleep on a soft mattress such as a water mattress, an old mattress, a sofa or an armchair.
  • The child is younger than 4 months, even if the parents do not smoke and the child is breastfed. This is a particularly sensitive time.
  • A bed is shared with someone other than the parents.
  • The child is premature or at low birth weight, even if the parents do not smoke.
  • A bed is shared with soft blankets, pillows or blankets.

See the full AAP article here.


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A bed shared safely


Scholars such as James McKenna have criticized the push away from sharing a bed with the child. He believes that if it’s done safely, it does not increase the chance of cot death. The conditions he sets to allow to share a bed safely are quite strict.


  • The child should sleep on an empty, firm mattress. A mattress out in the middle of the floor without a headboard is the most unsuitable.
  • The child should live in a smoke-free environment.
  • The child should be placed to sleep on its back. If the child is breastfed, it should be placed back on its back after feeding.

You should not share a bed with your child if:

  • The child is not breastfed.
  • Parents have reduced alertness or ability to wake up due to alcohol or drugs.
  • Either parent is sick, so tired that it is difficult for them to respond to the child, or if the parent who sleeps next to the child is more tired than usual.
  • If there is a gap between the bed and the wall in which the child could get stuck. The mattress should fit snugly into the headboard and footboard or remove all headboards if possible.
  • The parent who sleeps next to the child is very overweight, unless measures have been taken to compensate for this large weight difference.
  • Older siblings who do not understand the danger of suffocation also sleep in the bed.
  • Animals sleep in the bed.
  • You use thick blankets or sheets. Pillows, blankets and other bedding should be kept away from the child and a sheet or a breathable blanket should be used, preferably made of cotton. In cold weather, more layers of thin bedding should be used instead of thick blankets or comforters.

  • Nothing should cover the child’s head or face.
  • Don’t over-dress the child, if you feel comfortable, the child will most likely feel comfortable as well. Physical intimacy with the child increases body temperature.
  • If you have long hair, you should tie it up and make sure there are no laces or strings on your pajamas that could get tangled in the child.
  • Never leave the child alone and unattended in the parents’ bed.

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