How the fear of SIDS keeps infant sleep positioners on the market

I hate infant sleep positioners. They are not safe or helpful. If you have one or know a family/friend who uses one for their infant, throw it out. Trash compact it. Stomp on it. Cut it up in bits. This is one rare thing you should feel good about putting in landfill.

When I was first started in practice, I didn’t even know sleep positioners existed; I was shocked at how many parents told me they were using them. We are led to believe (by manufacturers) that positioners confer safety by keeping babies on their back.

Since 1994, the Back to Sleep campaign has helped parents become vigilant (yes!) about putting babies to sleep on their backs. But after my sons were born, and while roaming the super-store aisles for bottles, crib sheets, overpriced silicon, and breast pads (oh the glory), I realized why parents get so confused.

In the infant sleep section, I found plenty of products designed for babies I would never recommend. Never. Sleep positioners, head positioners, comforter-like blankets for the crib, bumpers and stuffed animals. Many products went against what I was taught in my pediatric training and what I’ve learned thereafter. Like so many things in life and medicine, less is more. When asked about setting up a safe infant crib I say, “Boring, bare, basic.”

In 2005, the AAP (American Academy of Pediatrics) issued an updated guideline on the prevention of SIDS. Though the message has been effective, sleep positioners have persisted to sell. Two weeks ago, prompted by 12 deaths (over 13 yrs)  due to sleep positioners, the AAP reiterated their position citing the dangers from sleep positioners after the CPSC and FDA (photos seen here) sent out a warning. Even though these positioners go clearly against safety data and medical advice, companies have kept them on the market.


Fear. Plenty of products designed for infant sleep target those parents who fear sudden infant death syndrome (SIDS). Which, to be honest, is most of us. Products like sleep positioners claim to keep babies on their backs yet go entirely against what we know in protecting infants from unexplained death or SIDS.

The bad news: SIDS, although extremely rare, is the number one killer of infants beyond the neonatal period.

The good news: Over the past decade and a half, the rate of SIDS has been cut in half since pediatricians and providers have advised placing babies on their backs to sleep. In half. Getting rid of a positioner is one change that could prevent an avoidable death. A positioner is made of soft bedding material. Boring, sparsely decorated cribs with firm mattresses, are the preferred, perfect sleeping environment for babies.

Boring, bare, basic is best.

When you leave the hospital, you need very few material goods: breastmilk (or formula), a bare crib or bassinet (with a firm mattress), diapers & wipes, a few outfits, and thin receiving blankets. And the non-material one: love. But that comes naturally.

The causes of SIDS are poorly understood. I don’t necessarily like talking about SIDS on a parenting blog where I am committed to minimizing fear. The below information is not to scare you, rather inform you of ways to minimize the risk. Research continues on preventing SIDS. Theories of what causes SIDS surround concerns for suffocation from soft bedding, re-breathing of the air when babies sleep on their tummies, and overheating. Goals for families to reduce the likelihood of an event demand constructing a safe sleeping environment.

Preventing SIDS:

  • Position: Always put your baby to sleep on their back. Remember since the 1990′s death from SIDS has been cut in half since we’ve advised back sleeping. There is no questioning this. Always put a baby to sleep on their back. If your baby rolls over, after you’ve placed them on their back, there is no need to continue re-positioning them.
  • People: Tell Grandmas, babysitters, nannies, & the nice-friend-that-helps-you-out to always put your baby to sleep on their back. Babies who are used to sleeping on their back, who are then placed on their tummy by a different caregiver, are at far increased risk of SIDS.
  • Bedding: avoid soft bedding, sleep positioners, head positioners, bumpers, stuffed animals, thick blankets, or pillows of any kind in the first year. Talk to your pediatrician if you have any concerns or want to clarify. Boring, bare, basic.
  • Lifestyle: Babies who have parents who smoke are at increased risk for SIDS; avoid cigarette smoke and help loved ones quit. Your baby is the perfect reason.
  • Pacifier: Pacifiers have been shown to decrease the likelihood of SIDS (the why behind this recommendation is debatable). Offer a pacifier for your baby after 1 month of age when feeding is well established. If the pacifier falls out during the night, there is NO data to support your need to put it back in a baby’s mouth. (Just try to get some sleep while baby is sleeping!)
  • Cool: Don’t jack up the thermostat because there is a baby at home. Ideal temperatures for sleeping infants is about 65-68 degrees. New data suggests that using a fan to circulate air (not directly on the baby) may improve the condition as well. Keep the room cool. In the summer use a circulating fan to keep the room comfortable.
  • Where: The AAP recommends babies sleep in their own crib or bassinet in their parent’s room until 6 months of age. This makes overnight feeding easier, too (quick commute).
  • Inform: Know the facts so you don’t make false assumptions and increase your worry. Share what you know.
  1. SIDS is rare, but more common in infants who have a family member who died of SIDS or have parents who smoke. If you are concerned about your family’s history, talk with your pediatrician.
  2. SIDS is most common between 2-4 months of life with 90% of cases occurring in babies under 6 months of age.
  3. SIDS is possible up until a baby turns 1 year of age. Follow precautions and back to sleep positioning until your infant turns 1 year of age. Following these precautions decreases risk.
  4. SIDS risk can be decreased by following recommendations and clearing out the crib of soft clutter. Remember SIDS cases have cut in half since we started recommending following these guidelines.

Wendy Sue Swanson is a pediatrician who blogs at Seattle Mama Doc.

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  • Rob Lindeman

    I like your approach. More pedies ought to be in the business of spreading the good news about child health rather than scaring the crap out of parents, as the Zeitgeist seems to suggest.

  • Steven Park, MD

    Dr. Swanson,

    You’re right in that SIDS dropped about 50% since the back to sleep recommendations, but it still happens, even in children who sleep on their backs. You’re probably not going to like what I have to say, but here’s some background first:

    There are tons of research in the various risk factors that can cause SIDS, and it’s probably multifactorial. However, one area that is underemphasized is the role of laryngeal development and descent during the first few months of an infant’s life.

    At birth, the epiglottis overlaps the soft palate. This is why infants can suckle and breathe together. But as the voice box descends slowly, a critical point is reached around 2-4 months, where a space is created between the soft palate and the epiglottis, called the oropharynx. It continues to drop into our adult years (and even further well into our 60s and 70). The more the voice box drops, the more the tongue can fall back when in supine sleep.

    With an infant, she’s still learning how to react to breathing pauses and the protective reflexes are underdeveloped. Any kind of partial or total obstruction, from tongue collapse to thick blankets, to inflammation from smoking, can upset the delicate balance in breathing for an infant.

    One of the proposed mechanisms of why placing infants on their back lowered the SIDS rate is that you’re keeping them in a lighter state of sleep. They become much more arousable as a result. However, by definition, if this is one of the mechanisms, you’re depriving infants of deep sleep. A newborn is in a REM-like state during sleep 50% of the time. REM is also when muscles are most relaxed. Add back sleeping and you’re going to stop breathing. Ask any severe snorer or person with severe obstructive sleep apnea, and they will tell you that they just can’t sleep on their backs.

    Many adults with smaller jaws (anyone with dental crowding) are unable to sleep on their backs. Rather, they prefer their sides or sometimes their stomachs. If you force a side or stomach sleeper to sleep on their backs, they’ll keep waking up and won’t sleep at all. For you side and stomach sleepers out there, remember the last time you injured yourself and had to sleep on your back, or when you underwent surgery, and was forced to sleep on your back? How well did you sleep?

    Infants need quality, deep sleep for proper brain development, memory consolidation and motor coordination. This has huge possible implications. The first year of life is critical for neurologic development. If you’re deprived of deep sleep for the first year of your life, imagine how this could aggravate, if not lead to various childhood conditions such as autism, ADHD, and others.

    Most older, traditional cultures let infants sleep on their tummies. They also breast fed. Dentists are saying that bottlefeeding promotes dental malocclusions and increases your risk for developing obstructive sleep apnea. There are other reasons by modern humans’ jaws are not growing to its’ genetically predetermined size. Our modern diet is another major reason.

    I’m not saying that we should abandon pediatricians’ recommendation for back sleeping. However, I believe it’s important to investigate this possibility and prove my hypothesis right or wrong. Perhaps there can be a way to make this recommendation only for high-risk infants.

    At least once every few months, I have mothers in tears in my office after being chastised by their pediatricians for letting their babies sleep on their tummies, despite the mommy’s insistence the baby won’t sleep at all. I’ve had more than a handful of mothers that stay up most nights watching their infants sleep on their stomachs, making sure they they don’t stop breathing.

    There have been many other recommendations in medicine which has saved lots of lives, but at the cost of causing harm to others. I hope this is not one of them.

  • Brian Loveless, DO

    Good post. I do have a disagreement, thoigh, with regards to where baby should sleep. Lots of good research shows that, in an appropriate home environment (no drugs, no smoking, etc.) babies are much safer co-sleeping with mom. Here’s a link :

    • Dr. Mario

      I’d have to disagree that “babies are much safer co-sleeping with mom,” as you suggested. The AAP maintains its recommendations regarding supine sleep for infants and warns against the dangers of, if not outright recommending against, infant bedsharing. Granted, the jury is still out, as the results from the 2000 study published in Pediatrics noted controversial results with regard to infant bedsharing, but that shouldn’t be construed as an affirmation by parents.

      The link you provided notes some viable challenges to the AAP recommendation, but all come with cautions — even the heading notes “Safe Cosleeping,” which leaves me (at least) with the inference that there may still be UNsafe cosleeping arrangements. The site is specific about how the baby should sleep with mother, too — information that will be important to a parent considering this sleeping arrangement.

      Bottom line: infant bedsharing may be a viable sleeping arrangement under certain circumstances, but declaring the practice as “much safer” is dangerous.

    • Dave

      Why not just get an approved bedside bassinet? All the benefits of co-sleeping and none of the risks.

      You won’t be able to accidentally roll over on the baby. it’ll also have a firmer mattress/no bedding so there is less of a SIDS risk.

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