We all know to put infants "back to sleep." But babies have a habit of falling asleep in all sorts of positions, in all sorts of places, at the most inconvenient times.
While SIDS awareness campaigns have dramatically reduced the numbers of infants dying in their sleep, they have also dramatically increased the number of parents needlessly panicking about their children's sleep.
Carseats, cribs, and couches: all come with dire warnings about the dangers of laying down your baby the wrong way. This piece breaks down the actual risks of sleeping in non-ideal conditions.
In the carseat
You spent the last three hours trying to get your infant daughter to nap before you had to take her with you to a meeting. True to form, she dozes off in her carseat about five minutes before you need to be inside. You've read that you're not supposed to let babies sleep inside their carseats anyplace outside of the car. Do you wake your daughter up, knowing that she'll likely howl through the next hour? Or do you let her sleep?
Although it's difficult to calculate a precise number of children who died while sleeping in carseats used as carriers, we know that the number is small. The Consumer Product Safety Commission recorded 47 infant deaths between 2004 and 2008 related to devices for carrying kids (slings, strollers, carseats, etc.). 31 of those deaths happened in carseats, so we can estimate that approximately 6 infants per year die in carseats doubling as carriers.
The CPSC reported that the carseat deaths occurred in two ways: strangulation due to improper use of straps or positional asphyxiation, which means that the infants wriggled into positions that obstructed their breathing.
Those numbers may make you terrified to let your child nap in a carseat. But the case studies included in the CPSC report suggest that the carseat itself should not be an object of terror. In one case study, a caregiver left an infant in a carseat with only the chest straps buckled, and came back one hour and twenty minutes later to find that the child had shifted down in the seat, strangling himself. In another case, a child was left unbuckled in a carseat placed within a crib, surrounded by three pillows and a blanket.
These cases, as well as others included in the report, suggest that the problem is not with the carseats themselves, but with either inappropriate use or inappropriate supervision. The authors conclude that "most, if not all, of these deaths might have been prevented had the device been used properly and/or had there been adequate supervision."
Rest Easy. The data suggests that if your child is appropriately buckled in the carseat, and you continue to supervise her, she can snooze safely.
In the wrong crib
Back to sleep, in a brand-new CPSC-approved crib, without pillows, blankets, or stuffed animals. You memorized those basics even before your baby was born. But then you bring your baby to your parents' house, and find with horror that they refinished your old drop side crib and expect your baby to sleep in it. Do you risk co-sleeping? Do you drive to Target to buy a new crib? Or do you just use that death trap for two nights?
Infants spend more unsupervised time in cribs than anywhere else, so cribs of course need to be safe. Concern for crib safety has led to an incredible number of product recalls. Crib recalls are so common that they've been parodied not once, but twice on the Onion. But how dangerous is an old crib?
In the early 2000s, the CPSC recalled over 7 million cribs due to suffocation and strangulation hazards. Those 7 million recalled cribs all had drop sides, which were connected with 32 infant deaths between 2000 and 2010. The problem wasn't with the drop side itself, but with detached, poorly-repaired, or incorrectly-assembled drop side cribs.
Although the vast majority of these cribs caused no harm and were deemed safe for use, the CPSC determined that drop side cribs were not as safe as cribs with four fixed sides. That's because the CPSC's mission is not to create products that are safe when used properly. They want products to be as safe as possible even when used improperly. The CPSC therefore uses "foreseeable use" to set its product safety standards. That means that, when the CPSC develops crib safety standards, it considers both the person who saves the Allen wrenches and re-tightens a crib monthly alongside the person who duct tapes a crib together.
One consequence of the foreseeable use standard is that parents using a product properly needlessly panic about safety risks that would only exist if they used the product improperly. In the case of cribs, the danger is not so much "drop side crib" as "broken side crib."
Rest Cautiously. Cribs themselves appear to be safer than ever. And the babies sleeping in them are safer, too. If grandma's crib is in good condition, with a mattress that fits appropriately and side slats that are not set too wide apart, it is a reasonably safe short-term solution.
On the couch
Your cluster-feeding infant woke up on the hour all night. Today, despite drinking every ounce of caffeine that your doctor recommends you can safely consume while nursing, you can't sit down without starting to nod off. You've read terrifying accounts about babies who died after their parents nodded off while holding them. Each time you sit down to nurse, you set alarms to make sure you won't fall asleep, but the house is so quiet, the baby is finally sleeping, and you know if you move you'll wake her up. Can you take a nap, too?
A study recently published in Pediatrics determined that couches make up almost thirteen percent of infant sleep deaths, which may make you never want to snuggle on the couch again. But thinking about that percentage in context may let you rest easier.
If couches were responsible for thirteen percent of infant deaths, you would be justified in listing your couch on Craigslist. But that would be the wrong way to interpret this study, which concludes that thirteen percent of infant sleep deaths happen on couches. That is, for every 100 infants who die from sleep-related causes (SIDS and SUIDS), 13 die on a couch. That's not necessarily a reason to be scared of couches. What's most terrifying about sleep-related deaths isn't where the babies are dying. It's that they are dying in their sleep at all.
The proportion of infants dying in their sleep is already low to begin with. The proportion of infants dying in their sleep on the couch is even smaller. The study identified 1,024 couch-related infant deaths that occurred between 2004 and 2012. The study included 24 states, so it's hard to know exactly how that figure would translate to the entire country, but assuming that the 24 states were roughly representative, that is 2,000 deaths over a 9 year period. The birth rate in the U.S. is approximately 4 million per year, so that's roughly 2,000 deaths for over 36 million births (a rate of .006 percent).
In the majority of the cases in the study, the deaths occurred in a "shared surface"; that is, there was a caregiver sleeping with the child. That fact has led to many articles about the dangers of allowing kids to fall asleep on snoozing caregivers.
Some other details from the study suggest other already-known risk factors may contribute more to infant deaths on couches. For example, many of the infants in this study were placed on their side (13%) or on their stomach (29.9%), both of which are considered unsafe sleep positions. The study also drew a connection between maternal tobacco use and couch deaths.
Rest Warily. The risk of SIDS is incredibly small, but SIDS risk does appear to be slightly more elevated when parents and babies sleep on couches together. Sleeping with an infant on the couch also increases risk of falls. If you do nod off, be gentle with yourself. In an imperfect world, with tired parents and colicky babies, it's helpful to know that the couch is statistically unlikely to lead to death.