Chapter 10 – Safe Sleep Guidelines

Sadly, even today, too many infants die in their sleep. Often, these deaths are linked to tragic events such as falls, suffocation, strangulation, or as a result of serious illnesses. Some remain unexplained—even after a post-mortem examination.

All unexplained infant deaths have been classified as Sudden Infant Death Syndrome, (SIDS), the sudden and unexpected death of a seemingly healthy baby. It is a rare event, affecting about 1 in 2,000 infants in Italy, and typically occurs between 2 and 4 months of age (29).

The scientific community has yet to fully understand the phenomenon, but it is believed that affected infants may have a dysfunction in the brain centers responsible for wakefulness. In situations of hypoxia (oxygen deprivation), these centers may not activate as they should and fail to trigger an immediate awakening.

To reduce the risk of SIDS and other sleep-related infant deaths, the American Academy of Pediatrics (AAP) has issued a set of recommendations, updated every five years. The latest report, from 2016, outlines the following guidelines (30):

• Room-sharing with parents: Babies should sleep in the same room as their parents, in a crib or bassinet placed next to the bed, for at least the first 6 months—ideally up to 1 year. Research shows that room-sharing (without bed-sharing) can reduce the risk of SIDS by up to 50%. The first 6 months are especially critical due to the higher incidence of SIDS. Placing the crib next to the parents’ bed makes it easier to monitor, breastfeed, and comfort the baby. Although the AAP has not taken an official stance on side-sleeping cribs, their main message is to avoid bed-sharing. A side-sleeper crib that allows parents to return the baby to their own space easily can be a safe compromise.
• Always place the baby on their back to sleep (supine position) until 12 months. This is the safest position for sleep. Side-sleeping is not considered safe, as babies may roll onto their stomachs during the night. Once the baby can roll both ways (back to tummy and tummy to back), they can remain in the position they assume. Back-sleeping may lead to some flattening of the head (positional plagiocephaly), which can be mitigated by supervised tummy time while awake to promote motor development.
• Use a firm and flat mattress. Avoid soft surfaces and memory foam mattresses, which may conform to the baby’s shape and increase the risk of suffocation. The sleep surface must remain flat and stable.
• Keep soft objects and loose bedding out of the crib: Remove pillows, stuffed toys, loose blankets, and crib bumpers, as they pose a suffocation and entrapment hazard.
• Secure sheets and blankets properly: Sheets and blankets should not cover the baby’s head and must be tightly tucked. Place the baby with their feet at the foot of the crib to prevent sliding under the covers.
• Offer a pacifier: Studies show that pacifier use reduces the risk of SIDS. The exact reason is unclear, but it may promote lighter sleep and frequent sucking. However, never force a pacifier on a baby, and avoid using clips, ribbons, or cords.

• Avoid overheating: Babies should not be overdressed. Dress them in layers similar to what an adult would wear for comfort in the same room. To check for overheating, place your hand on the baby’s chest or the back of the neck. The ideal sleep environment temperature is around 20°C, with humidity between 50–60%, to avoid drying out the airways. Avoid overheating in winter and ensure ventilation during the summer. A fan or air conditioner may help, but never direct cold air onto the baby.
• Breastfeeding: Breastfeeding reduces the risk of SIDS by 60% or more, especially when exclusive. Breast milk adapts to the baby’s needs and supports the development of the central nervous system, improving respiratory control during sleep.
• No smoking: Both parents should quit smoking as early as possible—ideally before pregnancy. Passive and third-hand smoke (residues on clothes, surfaces, etc.) significantly increase the risk of SIDS. Even if smoking occurs outdoors, toxic particles remain on clothing and surfaces. After smoking, it’s essential to wash hands, brush teeth, and change clothes before handling the baby. Many studies have confirmed the harmful effects of household smoking and its association with increased risk of SIDS.