Positioning Your Baby for Sleep

Changing advice over the years: 'Back to sleep' and 'Feet to foot'

In 1958 the first edition of Dr Spock's Baby and Child Care advised parents to lie a baby down to sleep on his stomach, so as to avoid the risk of baby swallowing his own vomit. Trends have come and gone, with experts and non-experts alike propounding their views on how a baby should be put down for sleep. In your own family, there are probably members of older generations who will tell you that they always put you, your siblings or your own parent down to sleep on their tummy and it 'never did any harm'. But that was then. The overwhelmingly consistent message from all government health agencies and research studies is that babies should always be put down to sleep on their backs.

Since the mid-80s and the launch of the American Academy of Paediatrics 'Back to Sleep' campaign, it is quite possible that thousands of potential Sudden Infant Death Syndrome (SIDS) deaths have been avoided as a result of this single piece of advice, as the incidence of cot-death in Western nations has, during the last thirty years or so, been reduced by up to 50%. (For more information on SIDS, see our article Breathing patterns in sleeping babies.) Current guidance is also consistent on the issue of whereabouts in their cot babies should be laid down, with the simple phrase 'feet to foot' encapsulating the essence of the advice. Your baby should be placed with his feet towards the bottom end of his cot, so that if he moves during his sleep, he has room to move upwards and therefore away from his sheets and blankets, which of course have the potential to restrict the flow of air to his nose and mouth. There is also less chance of him bumping his head and inadvertently waking himself up!

My baby doesn't seem to sleep so well in this position!

It is true that if left entirely to their own devices babies might well choose to sleep on their side or their stomach. It is possible that a particular issue, for example, suffering from acid reflux, is preventing your baby from sleeping well. What follows is a quick guide to some of the causes of interrupted sleep and what to do about them.

• Parents of babies who seem to suffer particularly from the 'startle reflex', where arms are flung suddenly up in the air and baby is awakened, often report that it's impact is lessened if they move to a different sleep position. The startle reflex is usually a passing phase, and will subside as your baby matures, and in the meantime the advice remains the same; lay him down to sleep on his back. You may find that swaddling your baby closely, with arms 'held' down by his sides, reduces the reflex's capacity to wake him up, and there are specialist swaddling blankets now available, specifically designed for this circumstance. However, it is important to understand that tight swaddling is considered to be bad for the development of babies' hips. Freedom for them to move their legs upwards and outwards is imperative for the recovery and prevention of hip development problems.
• Babies suffering from acid reflux (a condition perhaps best described as 'baby heartburn') can also find it uncomfortable to sleep on their backs, as the acid can travel back up the oesophagus towards their mouth. In this situation sleeping with the head and upper body raised at a gentle angle can reduce the problem, and again, there are specifically designed wedges and other products available so that you can elevate your child safely. The same applies to a child with congestion from a head cold.
• Other babies appear to sleep much easier in either their car seat or pram/pushchair, but be warned against allowing them to sleep in these locations too frequently or for overly-long periods of time. There is some evidence that the sleeping position children necessarily adopt in car seats or pushchairs causes their chest cavity to be flexed inwards, limiting their breathing and in rare cases leading to SIDS. So, retrain your baby to be comfortable lying flat on their backs to sleep, reducing their opportunity to nap in other places as much as you can.

And finally, there are a small number of medical conditions in which it may be better for your baby to sleep on his side, but he should only be put down to sleep in this position on the advice of a medical professional, and only for the duration of the illness or condition.

My baby is rolling over in his sleep!

Once a baby is strong enough to roll from back to front and front to back by himself, you don't need to worry about him rolling onto his stomach during sleep. But you should continue to put him down to sleep on his back until he is a year old. The point at which babies reach this developmental milestone varies enormously. Some experts promote the idea of 'tummy time', encouraging your to put your child down to play on his tummy as often as possible, to increase his torso strength and therefore help him reach a point where he can move from back to front and vice versa with ease. So, the first time you go in to your baby's room and find him sleeping on his tummy, it will come as a surprise, and you may well have a fleeting moment of worry, but, if he is capable of these movements when awake, then he's fine to do them in his sleep. If you are concerned that this is not the case for your child but you are finding him sleeping on his tummy, there are 'sleep positioners' available on the market that will ensure that he stays on his back.

What about 'Flat Head Syndrome'?

Flat Head Syndrome or positional plagiocephaly is a controversial subject. In essence those who argue for its increased incidence say that the switch to having babies sleeping on their backs has brought about a new problem; sections of their soft developing skulls being subject to damaging periods of time pressed down on sleeping surfaces. An increasing number of products such as specifically designed helmets, pillows and mattresses are available for parents who have concerns about the shape of their child's skull are available, but the evidence for and against a correlation between sleep position and problems with skull development continues to be argued over within the research community. A stronger argument against the over-use of car seats and pushchairs, as another possible cause of the syndrome, is also evident in the literature and possibly more amply supported.