Safe Sleep for Babies – PediaCast 527

Show Notes


  • Drs Leah Middelberg and Taylor Hartlaub visit the studio as we explore guidelines for safe baby sleep. SIDS and suffocation are the most common causes of death between the ages of one month and one year. Most of these deaths are preventable by following a few simple rules. We hope you can join us!


  • Safe Sleep for Babies




Announcer 1: This is PediaCast.




Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.


Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.


It's Episode 527 for October 19th, 2022. We're calling this one, "Safe Sleep for Babies".  We want to welcome all of you to the program.


So we have a really, really important episode for you this week, because we all love babies. And we want babies to be safe and to grow up. And as we consider baby wellness and safety, we have to consider sleep time because the leading cause of death in children between the ages of one month and 12 months of age is SIDS, sudden infant death syndrome, and suffocation. So things that happen to cause babies to die during sleep.




And many of these cases, it turns out, in fact, the majority of the time, these deaths are preventable if we follow a few simple rules and guidelines, which we are going to explore today.


Now, you may be thinking this is all fine and good and very important but I don't have a baby at home. Well, before you tune out or pick a different episode or a different podcast, consider this. You probably know somebody who has a baby. And you can guide that family to this important safety information.




And all of us, at one time or another, may be called upon to watch a baby for a friend or a family member. Maybe your grandparent or a daycare worker or babysitter.


Certainly, it's important information if you take care of babies. And the rules and guidelines for safe baby sleep is something that's going to be really important for you.


And I maintain the general public really ought to know these rules because the more of us who know and act and share these guidelines, the safer babies will be everywhere.


So please stick around as we cover the basics of safe baby sleep, the ABCs, if you will. Which can be quickly stated by saying that babies should sleep A, Alone, B, on their Back, and C in a Crib.


But there's more nuance to these rules, and there are more advanced topics to consider. Things like swaddling and the risk of overheating. The impact of second-hand smoke and immunizations and breastfeeding on sleep-related deaths. And the tragic consequences of co-sleeping. We have to talk about that as well.




We'll also offer advice on sleep accessories such as positioners, which are marketed for babies with reflex, for example. And advice on sleeping in car seats and carriers and baby swings and bouncy chairs and high chairs, all of those things, are those safe for baby sleep?


We'll cover all of these topics and many more as we consider safe baby sleep and the prevention of sleep-related deaths during the first year of life.


To help us explore these topics, we have two terrific guests joining us in the studio this week. Dr. Leah Middelberg is a pediatric emergency medicine physician at Nationwide Children's Hospital. And Dr. Taylor Hartlaub is a pediatric resident at Nationwide Children's.




Before we get to them, let's cover our usual quick reminders. Don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.


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So, let's take a quick break. We'll get our guests settled into the studio and then we will be back to talk about safe sleep for babies. That's coming up right after this.




Dr. Mike Patrick: Dr. Leah Middelberg is a pediatric emergency medicine physician at Nationwide Children's Hospital and an assistant professor of Pediatrics at the Ohio State University College of Medicine. Dr. Taylor Hartlaub is a second-year pediatric resident at Nationwide Children's.


Both have a passion for caring for babies and keeping them safe, which includes the prevention of sleep-related deaths because these tragic deaths are often preventable by following some pretty simple rules, which we are going to outline today.




But first, let's give a warm PediaCast welcome to our guests, Dr. Leah Middelberg and Dr. Taylor Hartlaub. Thank you so much for visiting us today.


Dr. Leah Middelberg: Thank you for having us.


Dr. Taylor Hartlaub: Yeah, happy to be here.


Dr. Mike Patrick: Yeah, really glad that both of you are here. And thanks for taking time out of your busy schedules.


Leah, I wanted to start with you. People are pretty familiar with the term S IDS. And here we are using sleep-related death as kind of the catch-all for the topic. What is sleep-related death and how is that different from SIDS?


Dr. Leah Middelberg: That's a great question. Sleep-related infant death is a sudden unexpected infant death that occurs during a sleep period. So essentially, while a baby is in their sleep environment. The more commonly known term SIDS that you just used stands for sudden infant death syndrome. That's a subcategory, assigned infant deaths that are sleep-related but they can't be explained even after an investigation.




And so studies have shown that majority of sleep-related deaths are caused by accidental suffocation, accidents like someone rolling over on the baby or laying on the baby, a child suffocating on something like soft bedding, the baby getting wedged between two objects such as the bed and the wall or couch cushions. 


In fact, most sudden infant deaths have been associated with at least one unsafe aspect of the sleep environment. But the good news is accidents are preventable and the better we understand them, the better we can prevent them.


Dr. Mike Patrick: Yeah, absolutely. So SIDS is one type of sleep-related death, but we know suffocation is another type and sometimes maybe what had been called SIDS in the past may have actually been suffocation, we just don't know the exact mechanism because  no one was there, obviously, when the baby expired. And so, you just may find the baby in the bed, you don't know exactly what happened. 


Dr. Leah Middelberg: Yes, exactly.


Dr. Mike Patrick: But we know more and more that suffocation is common.


Dr. Leah Middelberg: Yeah, exactly.


Dr. Mike Patrick: How common is this problem? Is it getting worse, getting better? What do you think?




Dr. Leah Middelberg: So every year, around 3,500 babies in the United States die suddenly and unexpectedly white they're sleeping. In the US, that means more infants’ dies from sleep-related infant death than all children die from car crashes in a single year.


In fact, infant sleep-related death is the leading cause of death in infants under a year of age. And that really peaks between the ages of one to four months.


And unfortunately, there's a notable and persistent racial and ethnic disparity in the space. It's just reflecting broader inequities. And mortality rates for non-Hispanic, Black, and American Indian or Alaskan Native infants are significantly higher than their White infant counterparts. So we really need to address the potential impact of structural racism and the differences in resources and work closely with communities that are affected and really engage healthcare and public health professionals for some thoughtful conversations about how we can improve that as well.




Dr. Mike Patrick: Absolutely. So it's not something intrinsic with different races that would make them have more sleep-related deaths. It's really more health literacy and awareness of the dangers and just getting the word out about what those simple rules are and then hopefully encouraging parents to follow those rules. But that can be difficult if there's inequity in getting information out.


Including through podcasts, in terms of we ought to be helping families who come from poor backgrounds have access to any kind of information sources and encouraging them to use them as often as possible , right?


Dr. Leah Middelberg: Yeah, exactly. Like many things in healthcare, this is multifactorial. But really trying to engage more affected communities so that we can provide information, we can have enough healthcare professionals to get that information out there and kind of see what's going on with families and ways that we can help them help keep their children safe.




Dr. Mike Patrick: Absolutely. I mentioned this in the intro to the show. But I think that this is also important for all of us to keep in mind even if you don't have a baby at home or even if you're not in a high-risk category.


And we should all be talking about this because the more, just at the general public level, that people are aware of these simple rules for safe sleeping, the more likely it is that someone who needs to hear it is going to hear it and hopefully follow those steps.


One of the first things that comes to mind now, maybe a little bit different for me since I'm a doctor, but I'll bet a lot of listeners out there too have heard you should always put your baby to sleep on their back.


So Taylor, tell us how does infant sleep position, sort of how they're laying in their crib, why is that important and how does it protect babies from sleep-related death?


Dr. Taylor Hartlaub: So what we know is babies are safest on their back. And when they're placed on their stomach or their side position that actually doubles the risk of death. Because what we know is when babies sleep on their stomach, they can actually have blocked breathing and they can overheat.


And babies who are placed on their side are unstable and tend to go down to stomach sleeping from that position. So what we know is sleeping on their back is the safest.




Dr. Mike Patrick: I mean, that's a huge number. When we say that if a baby is sleeping on their stomach or their side, that the risk of death while they're sleeping is double, I mean that's a lot. If you can decrease the risk of them dying in their sleep by half, simply by putting them to sleep on their back, that seems to be a pretty easy thing to do that everybody can follow and understand.


When I've talked to parents about this, kind of the feedback that you get is might they choke on their back. So babies spit up a lot and especially if they eat and fall asleep and they are put down for nap, they may spit up and then there's this feeling that well, maybe they could choke on their formula or the breast milk. Is that something that we actually see? Is that a real danger?


Dr. Taylor Hartlaub: So that's a great question because that's a common concern we hear from parents in the clinic. And what we've learned is that when babies are placed on their back, their feeding tube or what we call the esophagus is actually below the level of their airway or their trachea.


So if the baby spits up, the contents will come out of their mouth, and then the remaining amount will go back down the feeding tube simply because of gravity.




If they're on their stomach, their airway will be above the feeding tube and would be aspirated at that point.


Dr. Mike Patrick: If you'd just look at the position of the airway and the esophagus which connects the back of the mouth to the stomach, so when on their back, the esophagus is below. So if you're just thinking about gravity, it's not going to take any formula, it comes up and make it go up into the trachea.


Whereas, if they're on their belly, now that the esophagus is above the trachea, so gravity would pull food down and they could possibly what we could call aspirate, which is when food goes down into the lungs. So just another reason why on the back is better, even if they do spit up.


Dr. Taylor Hartlaub: Exactly, yeah. And this is actually a good point to make. This is true even with infants with reflux. So even if your baby has reflux, it's still safest to put them on their back.




Dr. Mike Patrick: Now, sometimes, when babies are on their back and maybe they do have a little spit-up, they'll cough and so parents will think, "Oh, they're coughing, this is a problem. I better put them on their belly." But that cough is really just a protective mechanism. I mean, we want them to cough. That's one of the ways that they keep that food out of the airway, right?


Dr. Taylor Hartlaub: Exactly. So it's important to remember that coughing does not equal choking. And you and me, we cough to clear and protect their airway. So it’s healthy response.


Dr. Mike Patrick: Now, there is suffocation where we're not getting enough air. And so, if a baby is on their belly and there's a pillow or blanket, we'll talk more about this sleep environment and what should and should not be in the crib. But if their face is against something, obviously, they can suffocate. I think that's easy for everybody to understand.


But there's also this concept of rebreathing where maybe their airway is not 100% included but rebreathing their own air in an enclosed space may be a problem. Tell us more about that, Leah.




Dr. Leah Middelberg: Rebreathing is when the baby breathes their own breath that they already kind of breathe out. They breathe it back and that leads to an increasing carbon dioxide, which is what we all exhale as we're breathing. As carbon dioxide builds up, it lowers your oxygen levels and leads to them stopping breathing eventually.


And you're exactly right, soft surfaces, blankets, pillows, bumper pads, stuff animals, anything that’s kind of soft increases the risk for that rebreathing.


Dr. Mike Patrick: So it doesn't have to be that the pillow or the blanket or the stuff animal is completely and totally right smooched up against their face. Even if there's a little bit of space there, if it's just not enough to really exchange carbon dioxide and oxygen and they're just rebreathing the air that they're breathing out, that can be a problem. And so, even more reason for babies to be sleeping on their back.


Dr. Leah Middelberg: Yeah, exactly.


Dr. Mike Patrick: So then that leads to the question, when can a baby sleep on their stomach? When can we make the switch?




Dr. Leah Middelberg: As all the parents who suddenly see their kid roll over in the middle of them, and you panic and go, "Oh no, what does this mean, what do I do?" Infants who can roll from their back to their front and from their front to the back can be allowed to remain in a sleep position that they assume. But every time you put your baby down for sleep, still put them on their back to start.


That's just really how we know that we can give him the safest of their environment. And also keeping in mind that the environment like we've been discussing includes more than just their position but the stuff around them. So if your child is rolling, for instance, soft bedding is definitely out.


It's an important risk factor for sleep-related death. And sleep environment should really be clear of everything except the fitted sheet. 


Dr. Mike Patrick: And so always put your baby to bed on their back until they're a year old. And if they are able to get themselves under their belly on their own, you don't have to keep flipping them over.


Dr. Leah Middelberg: Yeah, exactly.


Dr. Mike Patrick: But at the same time, put them on their back and them let them get into that position. That's the safest approach, all the way up to a year of age.




Dr. Leah Middelberg: Yes, exactly.


Dr. Mike Patrick: And so, that's what we have sort of termed back in the early 90s, the Back-to-Sleep Campaign where we really tried to raise awareness that back sleeping is by far the safest.


So Taylor, describe the impact that that has had. Because we mentioned that there's about 3,500 sleep-related deaths in babies each year in the United States. Before 1992, it was a lot more than that, right?


Dr. Leah Middelberg: Yeah, exactly. So in 1992, the American Academy of Pediatrics really put an emphasis on infants being placed on their backs to sleep. And after this Back-to-Sleep Campaign, SIDS rate declined by almost 75%. And it's estimated that around 80,000 babies' lives were saved, which is about almost an NFL stadium full of people, which is pretty incredible.


Dr. Mike Patrick: So I just want to back up and just say that one more time. So 80% babies' lives have been saved since 1992 simply by putting babies to bed on their back. I mean, that's just such an impressive number. So again, back sleeping decreases the risk of death by half. So this is really an important thing.




Now, in addition to sleep position, we also want to talk about the sleep surface, so where a baby is sleeping. Taylor, tell us what the rules are for the place that the baby sleeps.


Dr. Taylor Hartlaub: So infants can be protected from SIDS and sleep-related death if they sleep on a firm surface, which means a safety-approved mattress covered with a tight-fitting sheet. So never putting them in a crib with pillows, clothes, sheepskin or any other soft surface.


Using soft bedding increases the risk of death by five times, so it's pretty significant.


Dr. Mike Patrick: So you really just want to get the mattress. You want a tightly fitted sheet on top and then baby in their clothes. And that's really it, nothing else.


Dr. Taylor Hartlaub: Yep, that's it.


Dr. Mike Patrick: What about other bedding? And what about bumper pads? 



Dr. Taylor Hartlaub: So that's a great question and a common question asked by parents. So there are new crib requirements that actually reduces the distance between the slots. So it actually eliminates the need for bumper pads altogether, which is really nice. 


And like we were saying earlier, nothing should be placed in the bed with the baby, just the tight fitted sheet. Because we know we've heard horror stories of babies suffocating against the soft pads of the bumper, being strangulated by the bumper pad ties. Even getting their head caught between the crib and the bumper pad.


So what we recommend as a general rule of thumb, because there are lots of cute things advertised for babies' rooms, is just to decorate the room but not decorate the crib.


Dr. Mike Patrick: That makes sense. So you had mentioned that the newer crib standards, a lot of people may get a hand-me-down crib. And that may be something like a grandparent was saving all these years. And they're really are excited to be able to share that with their grandkids.


But it's really important that those slats are not too far apart so that baby's heads can get entrapped between the slats. And that's why, originally, there were bumper pads to prevent that from happening.




And then, I was reading that the best way to tell whether yours is safe or not is to see if a can of soda protocol will fit through the slats. And if the can of soda will fit through, then it's more than that 2-and-3/8-inches standard. So as long you can take a standard 12-ounce can of soda and it won't go through those slots, then you know you're pretty safe. Is that correct? Did you hear that as well?


Dr. Taylor Hartlaub: Yep, that's perfect.


Dr. Mike Patrick: And then bumper pad, of course, it is a soft fabric and so we worry about suffocation. We worry about that rebreathing, if they're right up against it. Oftentimes, those bumper pads have ties and some babies have even been strangulated, gotten the tie around their neck.


And your head could get trapped between the bumper pad and those slats, if the baby was really squirmy and cut their head between those two items. So again, decorate the room, not the crib. And nothing in the crib except the baby.


Dr. Taylor Hartlaub: Exactly.




Dr. Mike Patrick: Okay, another thing that has been related to sleep-related death is cigarette smoking. And this is a case where maybe it is more whatever SIDS is rather than suffocation that cigarette smoke may play a role. Tell us about that, Leah?


Dr. Leah Middelberg: Yeah, we know that smoke exposure, even while pregnant with baby, can result in having altered brain signals that could decrease the infant's ability to respond to changes in oxygen. So if a baby is starting to suffocate, they’re less likely to be able to respond and kind of change position or do what they need to do in order to change that oxygen level.


And that risk of smoke exposure extends past birth. Second-hand smoke exposure after the baby is born can double a baby's risk of SIDS. And this includes residual particles from smoke on surfaces like furniture and caregiver's clothing and hair.




Dr. Mike Patrick: So when you smell cigarette smoke, I think we all understand what we're talking about. A family who smokes comes in the exam room, when you walk in you can smell that cigarette smoke. I don't think it's as big of occurrence as it was like ten years ago. So there's less of it which is fantastic.


But when you smell that smoke, you have to understand those are those particles that you're smelling. And those particles have all sorts of chemicals in them, things like formaldehyde, methane, butane, arsenic, ammonia, nicotine, lots of chemicals.


And so when you breathe those in, if you're an adult-sized body, maybe your body can sort of take care of those up to an extent. But we're talking little babies and they're breathing that smell in. All those chemicals are getting in their body and we worry about that, right?


Dr. Leah Middelberg: Yeah, exactly. And I think the stat of smoke exposure, exactly what you're talking about, just exposure to the environment the baby is in doubles the risk of SIDS.  So again, something that's preventable for us to help keep our children safe.




Dr. Mike Patrick: Yeah, really important. So the best thing, as a parent of a new baby at home, the best thing for you is to stop smoking. And that's going to also have an impact on other illnesses in your own life, which could then help you live longer and enjoy your children longer. So it's really important to stop smoking.


But if you can't, for whatever reason, the best thing would be to go outside and smoke and then change your clothes when you come back inside, right?


Dr. Leah Middelberg: Yeah, exactly. Because like we talked about those particles kind of stick to surfaces like furniture, clothes, hair, covering surfaces that the smoke may land on, that the child could then be exposed to.


Dr. Mike Patrick: And smoking in the car is a really bad idea.


Dr. Leah Middelberg: Please, yeah.


Dr. Mike Patrick: Please don't do that.


Dr. Leah Middelberg: Yeah, exactly.


Dr. Mike Patrick: Another thing that we talked about as we think about safe baby sleep. And that is bed sharing and room sharing. So tell us a little bit about the dangers or the safety of either of those two things.




Dr. Leah Middelberg: Yeah, it's important to keep an eye on your baby's sleep area. And so room sharing is something that can actually really benefit you, benefit your baby. But you want the baby sleep area to be separate from your own.


So bed sharing can increase the baby's risk of sleep-related death by ten times. And your baby should never sleep on a couch or a baby or a chair, any surface with an adult, another child, or a pet. The risk of your child being suffocated by a soft surface like a loose blanket becoming wedged or trapped between a wall and a bed or between couch cushions.


And then, obviously, the terrible instance we hear about how parents accidentally rolling on their baby really make bed sharing a bad idea. Remember, as you're having a new baby and you're a new parent that fatigue is not something you can always control. So as much as we think bed sharing keep our baby safe, it's nothing parents themselves can sometimes control because that fatigue is just really real.




Half of infants in the US who die of sleep-related deaths are found sleeping with their parents. And as a pediatric emergency doctor, these deaths are so heartbreaking.


Sharing the room, however, can reduce the risk of SIDS by 50%. So some good stats here. So room sharing is a yes but bedsharing is a no.


Dr. Mike Patrick: Okay. I think this is so important to get across. And on social media, you even see some pediatricians who say bedsharing is okay. Like I've seen this, I've seen arguments back and forth on social media, they're not pediatricians who work on emergency departments.


I think that you and I have seen babies who have come in, who die from suffocation because a parent rolled over on them. And to see that mom in such distress, which is totally understandable and like you said, it's heartbreaking, that changes your tune on this pretty quick, right?




Dr. Leah Middelberg: Yeah, absolutely. All deaths for children is heartbreaking and hard for us medical professionals. But these particularly, the emotions you can see from the families, in the parents that may have been involved is just devastating.


Dr. Mike Patrick: Yeah, it's like imprinted on your brain as a doctor. And I think that's one that I'm so passionate about, no bedsharing, don't fall asleep on a recliner, don't fall asleep on the couch. Because I've seen it, I've seen these babies come in, and like you said, it's just heartbreaking.


So even if you see a pediatrician online, in social media, on Twitter saying, "Oh, it's fine to nurse your baby and fall asleep," it's not fine. Really, it's not.


And as you said, it increases the risk of death by ten times if you bed share. So please don't do that.


And then, Taylor, you said that room sharing is okay. And in fact, that may reduce the risk of SIDS by 50%, by actually the child being in the same room, in their own crib but sharing the room with their parent. What are some tips for doing that safely, for room sharing?




Dr. Taylor Hartlaub: So what we recommend is just placing the cribs away from windows. And along an interior wall of your home is the best way to position them in your room.


Dr. Mike Patrick: What is the reason for the interior wall? In case gunshots come through? I was trying to picture it in my mind, while I was prepping for this, trying to figure out why that's an important thing.


Dr. Taylor Hartlaub: I think it goes along with keeping the crib away from the window because in the exterior wall or window has a chance of other things from the environment outside that you potentially can't control coming in and affecting baby.


Dr. Mike Patrick: All right, and then one was place your bed between the crib and the exterior wall. I mean, I guess, okay.


Dr. Taylor Hartlaub: I mean, sure if you have room for it and it makes sense in your room. But I think just as long as it's away from the windows, it's probably not important.


Dr. Mike Patrick: I can see if it's a toddler and you're worried if they're going to go toward the window, wake you up, because they have to crash your bed or something. But babies that are in their crib aren't probably going to be risk for opening the window and getting out, right?






Dr. Mike Patrick: So the important thing is though that's safer than having a nursery and the baby being in a different room away from you. Because then, if the baby was struggling, there were some noise the baby's making, you're more likely to wake up and hear and be able to intervene than if the baby's down the hall in a separate room. That's the idea, right?


Dr. Taylor Hartlaub: Exactly.


Dr. Mike Patrick: And then, we've said nothing in the crib except for the baby and clothes. What about bottles and pacifiers?


Dr. Taylor Hartlaub: So this is something that I learned through residency, that pacifiers are actually encouraged and very safe. So we don't really know the mechanism behind why it reduces your risk of SIDS, but it does. And we're just recommending you can offer a clean dry pacifier to your baby. But you don't need to force it if he or she doesn't want to take it.




And one of the things that parents tend to ask, "Well, what if I'm breastfeeding?" We don't want to discourage that. And as long as you establish breastfeeding, it's okay to offer the pacifier.


And we just recommend not putting anything on the pacifier, just having it be dry. And the same thing kind of goes along with the bottle just because once baby's teeth come in, it can predispose them to getting cavities.


Dr. Mike Patrick: So pacifiers, yes. Bottles, no, basically.


Dr. Taylor Hartlaub: Yep.


Dr. Mike Patrick: And that's really interesting that pacifiers are protective against SIDS. I mean, whatever brain reflex is making you suck as you're sleeping is also helping you breathe while you sleep. But that's again, just a theory, who knows, but it's interesting.


Dr. Taylor Hartlaub: Yes, it's really interesting, and the fact that we don't quite know why.


Dr. Mike Patrick: And then the other thing is babies are smart, and so they probably aren't going to have much in the way of nipple confusion if you're breastfeeding.


And they can tell that this is a breast, and it's mealtime. This is a pacifier and I have to suck a little bit differently. And most babies do fine with the transition between the two of those.




And then you had mentioned overheating at some point here. Tell us more about overheating and why that's dangerous. 


Dr. Taylor Hartlaub: So overheating can lead to sleep-related death. So we recommend dressing your baby and lightweight sleep clothing, such as a sleep sack or other wearable blanket.


We don't recommend tucking your baby in with a sheet because the risk of suffocation increases it can cover their face. You can swaddle your baby in a lightweight blanket, just ensuring that the blanket and the swaddle is below the level of the shoulder. So that there's no increased risk of it kind of going up around their face.


And we decide to keep the thermostat at a temperature that's comfortable for you. Because if it's comfortable for you, it's going to be comfortable for the baby.


Dr. Mike Patrick: That's something that parents ask about a lot. If I feel warm or I feel cold, does my baby feel the same way? Do I have to put an extra layer on my baby?




And really, you just want your baby to dress like you're dressed, maybe one more layer. But don't overdo it with a whole bunch of layers.


Dr. Taylor Hartlaub: Right. So we say, yeah, one layer or whatever clothes you're wearing plus one extra light layer.


Dr. Mike Patrick: And that maybe a wearable blanket is okay. So we've said, we know there are blankets that are they're more blanket material but they're actually your arm go through and it's made for baby wearing at night. Those are okay.


But if you swaddle them like a burrito with your own sheet, then you want the level of that blanket to be below the level of the shoulders. So again, the top of the blanket doesn't get up around that face, so that's really important.


And then you don't want them to overheat so you don't want to do too many layers, plus swaddle them in a blanket and all that.


All right, let's cover some other comments, questions that come up. And Leah, I'm going to ask you these. There's a lot of products out there that are marketed toward helping babies sleep better.




And you may think as a parent, well, if these products are out on the market, I can buy them in the store, they must be safe, they must be recommended. But that's not necessarily the case, right?


Dr. Leah Middelberg: Yeah, that is exactly right. And anybody that has dug through the what you need to register for a new babies, you can see all kinds of advertising of products that unfortunately may make the family thinks that they're safe but should not be used for sleep.


So just because something's marketed for sleep doesn’t mean it’s actually safe for sleep. So co-sleepers and bed sleepers or pillow positioners are just a few of those.


Additionally, car seats and swings and seating devices shouldn't be used for routine sleep for infants. Infants can suffocate on these type of devices because of what we call positional asphyxia. Basically, the upright position can cause their muscles to fatigue so they can't breathe right.


If the baby falls asleep in one of these sitting type devices or while you're driving, relocate the sleeping child to a safe sleep environment as soon as it's safe and practical.




Dr. Mike Patrick: And sometimes you see kids like in a swing and they're sleeping and their chin is on their chest, right? So their neck is flexed and that can cause some airway problems.


And as you said if they get fatigued and they're really sleeping deeply and they're now repositioning their head that could be a problem. So it's going to be really important not to let you child sleep in swings and other car seats and carriers and all those things.


Unless, you're in a moving car and you're going to grandma's house, but then as you get there, take him out of the car seat and lay him down on a flat surface that's a safe sleeping environment.


Dr. Leah Middelberg: Right, exactly. So when you get to that destination, you get to grandma's, you get to your house and your baby's sleeping, still take him out of the car seat at that point and make sure they're in that good environment.


Dr. Mike Patrick: And then, kids with reflux, there are those wedges that are out there, those are not safe either, right?




Dr. Leah Middelberg: Yeah, those are obviously extraneous things that are going to be in your child's sleep environment which we all know now is really increasing the risk for sleep-related death .


Dr. Mike Patrick: So if your child does spit up a lot and does have reflux, still the recommendation is to sleep on their back. If your doctor is telling you otherwise, maybe push back a little bit. Because these are newer recommendations, and so if your doctor trained 20 years ago, maybe they do recommend getting those wedges.


But now, studies show that those sleep positioners do no decrease the risk of sleep-related death. They don't decrease the risk of SIDS. So maybe push back a little bit.


Dr. Leah Middelberg: Yeah, so just recently, the American Academy of Pediatrics, AAP, released a new policy statement regarding safe sleep. And this is one of the bigger changes, is that flat surface for sleeping is best.


So you might have in the past heard about inclined sleeping and things like that. But really, we know that for a number of kind of anatomy reasons, physiology, how things work when you're breathing, reasons a flat environment is best.




Dr. Mike Patrick: And they can tell that because you can look and see SIDS and infant suffocation, all sleep-related deaths and ask the parents what were you doing and you do see that those kids with reflux who have positioners of one kind or another don't really have a decreased incidents of SIDS or suffocation or sleep-related death compared to the babies with the same condition that were just put to bed on their back. So we know that's the safest based on those kinds of studies.


And you mentioned that policy statement from the American Academy of Pediatrics that are just brand new out on infant sleep and safe sleeping guidelines. And we'll put a link to that in the show notes over for this episode, 527, so folks can find that easily. Especially if you're a pediatrician or family practice doc, nurse practitioners, physician assistant, if you take care of kids, you definitely want to be up-to-date on safe sleep and want to read the new guidelines from the American Academy of Pediatrics.




What about home monitors? We talked about babies in your bedroom, in their own crib is the safest. If they are in a nursery, do home monitors, is that a helpful thing?


Dr. Leah Middelberg: Home monitors can be useful in alerting you of your baby crying or something like that. But fortunately, they don't reduce the risk of SIDS. So relying on a home monitor might give you a little bit of a false sense of security. So you still want to make sure you're following those safe sleep practices.


Just because you have a monitor doesn't mean we can now give baby fuzzy cuddly blankets and things like that. Really, we want to make sure the safe sleep practices are what's going to help.


Dr. Mike Patrick: Yeah, that makes sense. So a monitor maybe a good if you want to know if your baby is crying or not. But in terms of keeping them alive, don't rely on it. It's better to make sure that the sleep environment is safe, which again means just a flat mattress with a tight-fitting sheet and nothing in the bed except your baby on their back and clothes.


Dr. Leah Middelberg: Exactly.




Dr. Mike Patrick: Okay. So having said all of that, tummy time is still important. So Taylor, why is tummy time important and how is that best provided?


Dr. Taylor Hartlaub: Yeah, tummy time is super super important. It helps with many many things that lead to babies meeting their developmental milestones. In regards, to safe sleep it really helps with strengthening their neck and shoulder muscles and improving head control.


So tummy time needs to be supervised. The baby needs to be awake and alert. And it should be on a firm surface and we encourage it as frequently as possible throughout the day when baby's awake.


And the important thing is that tummy time doesn't always have to be on the floor. It can be on when you're holding the baby, when you're burping baby on your lap, but it does every time you need to be supervised. That's important.


Dr. Mike Patrick: So tummy time every day. It's a great opportunity to socialize with your kids and you get down on the floor too, on your belly, and kind of play together. And then that really helps with strengthening arms and legs and neck muscles.




And parents talk about developmental milestones, what is my baby supposed to be doing at this age or that age? And reaching those milestones happens easier when your baby’s working and using all those muscles.


And so tummy time is great. But again, as you said, it has to be supervised and sleeping is not the time for tummy time.


One of the things that I noticed on my own practice soon after like in the 90s when back to sleep became a thing, parents would put their kids on their back. Of course, not only at night time but also during naps. But a lot of times, if kids are in their carrier, they're not getting a lot of tummy time, they're on their back a lot.


And so we'd start to see flat spots on baby's heads. Tell us about those, Leah. Is that something that we should be concerned about?


Dr. Leah Middelberg: Flat spots can develop if your child is on their back in the same position all the time. The best way to combat this is tummy time like Taylor just actually talked about. But if flat spots do develop, don't worry, they will go away in the months after you baby learns to sit up and craw and roll and basically, they're kind of up and off of their back.




But changing the position your child sleeps in or the way they're looking, for instance, if they're kind of flat on their back while awake can also help decrease the chance that they have that one area that they're really kind of laying on more likely.


And also limiting the amount of time your baby lies on bouncers, carriers, things that keep them on their back when they're awake as well.


Dr. Mike Patrick: So especially if your baby likes to look out or likes to look toward the wall because maybe there's pictures or something. Hopefully, nothing within their reach. But they may have a preference for looking in one direction.


And so then, if you simply, each week, have them sleep a different direction in the crib, then where they want to look, their heads are going to rest in a different position, so that it's not always the same one, right?


Dr. Leah Middelberg: Yeah, exactly.




Dr. Mike Patrick: And then, you may see a lot of babies out there with the helmets on. A lot of times, that is for other conditions of the skull where it's not growing properly. So there are certain instances where your baby may have a misshapen head and we'd done shows on this before where the helmets may help.


But flat spots from sleeping in and of itself, there's a little controversy with this. But for the most part, most of them get better as babies get older and start moving around. They get plenty of more time for that skull to grow and to not have the flat spot anymore.


Dr. Leah Middelberg: Right, yeah, really, after the first four months or so, kids are going to moving a little bit more. And at that point, you'll really start to get more even distribution of how your kiddo's holding her head in certain positions and you're going to see all that kind of even out.


Dr. Mike Patrick: But if you get to six to nine months of age and there is a flat spot that seems really pronounced, you could always see, be referred to pediatric. Usually, it's the plastic surgery folks who kind of look after those and get someone's opinion.


It's better to be safe sleeping on your back and dealing with a flat spot than to have a baby who dies because they were sleeping on their belly.




Dr. Leah Middelberg: Right, we can fix a lot of flat spot related concerns but safe sleep is something we can always fix after the fact.


Dr. Mike Patrick: Yep, absolutely. So Taylor, another thing I hear from parents is often, well, they prefer to sleep on their belly. Like it's uncomfortable sleeping on their back, but they can't fall asleep on their back. They're much fussier.


How do you respond to those parents? 


Dr. Leah Middelberg: We just say sleeping on their back is comfortable, especially when the habit is established early on. That's what they're used to. That's a position that they've always slept in. And then it's a comfortable.


And we have to remind ourselves that babies have a different sleep cycle than adults do. They wake up every three to four hours. They need to feed or need to be consoled in some way and this is normal.


And even though it's frustrating to the parents who's taking care of them or the caregiver who's taking care of them, it is just normal for them to wake up. And if they're fussy, you can swaddle them or offer them a pacifier. But never never never, if they're fussy, let them sleep on their stomach.




Dr. Mike Patrick: So again, a fussy baby is better than a dead baby. And so, sleeping on the back is really the most important thing, even if they were more fussy with sleeping on their back.


Something else I wanted to bring up, Leah, is a lot of guidelines change over time. So the American Academy of Pediatrics just put out a new policy statement on updated guidelines for safe sleeping. Why should parents trust us if the guidelines keep changing?


Dr. Leah Middelberg: Yeah, it's common to hear from maybe more experienced relatives that they put babies to sleep on their stomach and they were all fine. And so your baby will be fine, too.


But every day, we gain more knowledge and we learn more things than we previously thought were maybe true but are actually incorrect.




You've heard us say a lot of good statistics during this conversation. And that's because we have a lot of great data on this area. And we know there's a lot of things we can do to really help babies.


This constantly evolving knowledge is not just exclusive to this category, but car seats, for example, that information has evolved over time. We know what's safest for kiddos. Concussions and sports, there's all different areas where we know, as we get more information, it changes what we do.


And so, we just want to make sure we're always putting our babies on their back, in an empty crib, because we do know that that is safest.


Dr. Mike Patrick: Absolutely. And we really solve that sort of accelerated in real time during the pandemic. Because recommendations changing, especially early in the pandemic, like week by week. Like don't wear mask, now wear mask, now distancing, and okay now, we can take the mask off. And now, you can't sing around each other if you don't have a mask on or at all.




And so a lot of people then start to get suspect, like "What’s the truth? Do doctors even know?" And I love the way that you put it. Just each day, we learn more. And as we learn more and new studies come out, we change our recommendations because that's how science works. 


Dr. Leah Middelberg: Yeah, and we've had decades of observation and data on this topic, right? That condensed couple-year period of all the data trying to keep up with it in real time was just, you're exactly right, like that hyper-focused kind of a little bit of a confusing time period. But decades of data have given us more information about this topic.


Dr. Mike Patrick: Yeah, absolutely.


And then, the other thing I wanted to really drive home here is that even if you don't have a baby at home. This is a really important message. And I really likened it to just the general public really needs to know what the safest way for babies to sleep. Would you agree with that?


Dr. Leah Middelberg: Oh, absolutely. And the fact that actually one in five SIDS does occur while the baby is in the care of someone other than the parents really speaks to the fact that there are many other caregivers in our world. And so we need to make sure everybody knows the same message.




Sibling, baby sitters, friends, grandparents, childcare staff, anyone who'd be taking care of that baby needs to know that safest way to put them to sleep. And especially, children are used to sleeping on their backs because parents for instance know that great recommendation.


Actually, them being placed on their stomach, they're going to be even more likely to be susceptible to injury because they're not used to that position. So as many caregivers who could be taking care of your child, they all need to be aware of it.


Dr. Mike Patrick: This is was a particularly impressive statistic, that if you have a baby who usually sleeps on their back and them someone else is watching them that doesn't know about this, and then places them on their belly to sleep, that's called unaccustomed tummy sleeping, because the baby's not used to ever doing, which is good. They're not supposed to be used to doing it.




But it results in 18 times increase in the risk of sleep-related death. Eighteen times, I mean, that's a lot. To your point, it's really important that anyone who takes care of our babies knows these rules.


Dr. Leah Middelberg: Yeah, even those well-meaning siblings who see baby crying and wants to give him a stuff animal, just gently reminding them, "Oh no, baby can't have anything in their bed." Just the people that you don't necessarily think about are going to be important to your baby's sleep are good people to make sure that know this as well.


Dr. Mike Patrick: Absolutely. So we want babies to be safe when they sleep, that's what this whole episode has been about. But we also want them to enjoy sleeping and to sleep well. And hopefully, we said they do wake up on their own every three to four hours. But we still want them to go to three to four hours so that as a parent with a new baby at home, hopefully, you're getting some sleep too at night.


What are some things that we can do that are still safe but will also maybe improve or enhance baby's sleep. One of the pneumonic for this is the five S's of improved sleep for babies. Taylor, tell us about those.




Dr. Taylor Hartlaub: So the five S's are a trick you can use when your baby's fussy or starts crying and you want to go to sleep. It stands for Swaddling, Side Stomach Position, Shushing, Swinging, and Sucking.


So swaddling makes the baby feel warm and secure. It's important to know that once your baby starts to roll over, to stop swaddling them so they have free movement of their arms. Side stomach position is holding your baby on the left side because it helps aid in digestion. But then, once they're asleep, always returning them back to their back in the crib.


Dr. Mike Patrick: So if you're supervising them and they're drifting off to sleep, being on their side, in your arms and you're right there, and you're fully awake, that's going to be okay. But then when they do fall asleep, still on their back in the crib.


Dr. Taylor Hartlaub: Exactly, yeah. And shushing, just imitates the noise that they heard while they were inside mommy's belly.


Swinging means rocking the baby in your arms or in a swing while they are awake. And then, once they fall asleep, returning them to the crib.


And then sucking, babies enjoy sucking even when they're not hungry. And they can't cry and suck at the same time. So it's kind of a great mechanism to use a pacifier.




And then if the five S's don't work, you can always try doing a soothing bath or infant massage and seeing if that works or moving environments to a more calm and quiet area of the house.


Dr. Mike Patrick: Yeah, really important tips. What about vaccines? Are vaccines important to the prevention of sleep- related deaths and babies?


Dr. Taylor Hartlaub: Yes, so vaccines are protective against SIDS and actually reduce the risk of SIDS by half, which is a significant amount. And vaccines also have the added benefit of protecting your baby against serious and potentially deadly illnesses. So they have dual importance.


Dr. Mike Patrick: And they're recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. And all of the vaccines that we routinely give in childhood had been extensively studied. And then, once they come out, they're continually watched. And if there are trends that seem unsafe that are noticed, our recommendations change.




And we have seen in the last 20 years, particularly with the rotavirus vaccine and then changing it to a different one. So we do respond when problems are noticed. But you're going to see a lot of stuff out there on vaccines and can be confusing for parents. I think the most important thing is to really trust the sources that you trust.


And so the people who study these and make their living taking care of babies and seeing lots and lots of kids in the office like your pediatrician is really the person that you want to get information from about vaccines, not strangers on the internet, right?


Dr. Taylor Hartlaub: Yep.


Dr. Mike Patrick: And then, breastfeeding, does breastfeeding protect against sleep-related deaths, Leah?


Dr. Leah Middelberg: Yeah, if you're able to breastfeed, it obviously has numerous benefits, including reducing a baby's risk of SIDS by about half. Breastfeeding can decrease infections which are also associated with increase in SIDS. So mom's milk can contain antibodies and proteins and nutrients and lots of things that really help promote a healthy immune system for baby.




And an important caveat to all that is just to make sure you're breastfeeding safely. Make sure you're always placing your baby back in their crib or their basinet or never breastfeeding on a couch or recliner, particularly if you're really tired.


Dr. Mike Patrick: Absolutely. So I want to just say those numbers again really fast. Vaccines cut the rate of infant sleep -related death by 50% and breastfeeding also cuts it by 50%. So having that safe sleeping environment, knowing that your baby should be on their back with nothing in the crib and not smoking around your baby, breastfeeding if possible and getting them up to date on their vaccines, all of those things are going to really decrease the incidents of sleep-related deaths, correct?


Dr. Leah Middelberg: Mm-hm.




Dr. Mike Patrick: So then Taylor, if we want to sum all of these up into the most important points, a lot of folks have heard the ABCs of safe sleep. Tell us what's the basic message here?


Dr. Taylor Hartlaub: So the basic message is that thousands of babies die every year in the United States due to unsafe sleep environments and we know how to prevent that. So always place your baby on their back, in an empty crib basinet or portable crib when they're sleeping for every sleep.


Dr. Mike Patrick: And the ABCs, A is alone, only your baby in the crib. B is on their back and C is in the crib, or a something that is, again, a firm flat surface or contained and there's nothing else in them. So a Pack 'N Play or something like that may be fine. Right?


Dr. Taylor Hartlaub: Yeah, exactly. There are options for sleep environment being crib basinet or a portable play yard, as long as they have that firm bottom and can be empty.


Dr. Mike Patrick: And we don't get a kickback, Pack 'N Play sounds like a brand name.


Dr. Taylor Hartlaub: Right.






Dr. Mike Patrick: We're not getting kickback from them. I'm using that generically. But at the same time, those things are all okay, but carriers, car seats, swings, infant seats, things that babies are supposed to be awake are not good for sleeping.


Dr. Taylor Hartlaub: Right. Those should not be used for any kind of routine sleep for your baby.


Dr. Mike Patrick: And as a pediatrician and other pediatric providers, even though this is our parent show, we do have a lot of providers who listen. This would be a great learning opportunity because a lot of times, those babies come in into the office or in an urgent care and the emergency room in a carrier. And they're in their car seat when they come in.


And a lot times, the nurses let them stay in there until we can get in the room. So if we walk in, and there's a baby in the car seat sleeping, there may be a good idea to say, "Oh, I understand this is okay because you're here right now. But you never let them sleep like this on their own." I mean, just that comment may make a difference from us.


Dr. Taylor Hartlaub: Yeah, making sure that they're in any kind of inclined sleep or sitting kind of position that they're not unsupervised. They're being watched the whole time.




Dr. Mike Patrick: Absolutely. So all important points. And again, really important that your baby sleeps alone, on their back, in that dedicated sleep space with nothing else in there. So so important.


All right, well, thank you both so much for stopping by and sharing this message with us. Leah, can you tell us a little bit more about emergency medicine here at Nationwide Children's Hospital.


Dr. Leah Middelberg: Emergency Medicine is just a great area of Pediatrics. You get to meet lots of different people. You get to see a lot of different things. And you get to kind of really help people when they really want it and need it the most.


And so I really love getting to interact with our families. They come in a lot of times nervous and kids come in nervous. So it's nice to put them at ease and help them feel better. And we've got a great team that I work with, and so that makes a huge difference as well.


Dr. Mike Patrick: And we're an academic hospital and so we're also teaching medical students and residents and fellows all about pediatric medicine. That's an important part of our department as well, right?




Dr. Leah Middelberg: Yeah, we get to work with great residents like Taylor here and hopefully teach them a little something they always teach us too.


Dr. Mike Patrick: And then, we, of course, are very involved in research as well. And if you are a family that comes into the emergency department at Nationwide Children's Hospital, you may very well be approached by a research assistant to be enrolled in a study.


Dr. Leah Middelberg: Yeah, how we get this great statistical information to share with you guys about what's safe and what we should do to best take care of your kids. We get that through research.


So being able to participate in that and help keep children safe in the future and even save lives in the future is so huge.


Dr. Mike Patrick: Yeah, absolutely. And we'll put a link to Emergency Medicine at Nationwide Children's Hospital, so folks who are interested in learning more about what we do. And then, also to the Pediatric Residency Training Program at Nationwide Children's, we'll put a link to that.


And then, also the AAP Policy Statement that just came out hot off the presses, reducing sleep related infant deaths and we'll put a link to that in the show notes as well.


So, Dr. Leah Middelberg with Pediatric Emergency Medicine at Nationwide Children's Hospital and Dr. Taylor Hartlaub, pediatric resident here at Nationwide Children's, thank you both so much once again for being here today.




Dr. Leah Middelberg: Thanks for having us.


Dr. Taylor Hartlaub: Thanks so much.




Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.


Also, thanks to our guests this week, Dr. Leah Middelberg, pediatric emergency medicine physician, and Dr. Taylor Hartlaub, pediatric resident, both from Nationwide Children's,


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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long, everybody.




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