Essential Baby Sleep
By
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Dr Maud Meates-Dennis
MB ChB, FRACP, FRCPCH
(Specialist Pediatrician)
Copyright © 2012
M Meates-Dennis
All Rights Reserved
Published by Baby Medical Questions and Answers
First Published as eBook pdf April 2012
ISBN: 978-0-473-21184-4
Introduction!
8
Terminology!
9
Disclaimer!
9
About the Author!
9
Understanding Normal Sleep!
10
Adult Sleep!
10
Newborn Sleep!
11
Transition to More Mature Sleep Patterns!
11
Normal Newborn Sleep Behavior!
12
Sleep Duration!
12
Naps!
13
Sleep and Learning!
14
Sleep and Obesity!
15
When Your Baby Cries!
Crying is Normal for Babies!
16
17
The Period of PURPLE CRYING!
17
Soothing Strategies!
18
Settling your baby for sleep in the first few weeks!
Controlled Settle Technique!
Settling the infant who is over 6 months of age!
19
19
22
Controlled crying technique!
23
Camping out method!
23
How to Know if Your Crying Baby is Unwell!
25
Sleep Routines!
26
Day Routine!
26
Sleeping through the night!
27
For babies from 6 weeks of age!
28
Baby Sleep Strategies!
For older babies!
Safe Sleep!
SUDI and SIDS!
28
29
30
30
SIDS!
30
SUDI!
31
Conflicting Advice / Misconceptions!
32
Risk Factors for SIDS!
33
Sleep Position!
33
Tobacco Exposure!
34
Breast Feeding!
34
Pacifier Use!
34
Overheating!
35
Head Covering!
35
Immunizations!
35
Risk Factors for SUDI!
36
Recommendations for Safe Sleep!
37
Baby’s Sleep Environment!
Crib / Bassinet!
38
38
Alternative Sleeping Environments!
39
Tucking Your Baby In!
41
Baby Sleeping Bags!
41
Around the Crib!
42
Keeping your Baby Warm!
42
Room-Sharing!
43
Bed-Sharing!
43
Making Bed-Sharing Safer!
44
Using a PepiPod (Baby-Pod)!
44
When Bed-Sharing is Most Hazardous!
45
Away From Home!
Swaddling!
46
47
Safe Swaddling of your Baby!
48
How to wrap your baby!
49
Arms Across the Chest, Hands Up!
49
Arms Across the Chest, Hands Down!
49
Arms By the Side!
50
Which Swaddling Method Should I Use?!
50
Swaddling - photos!
52
Protecting Your Baby’s Head Shape!
Plagiocephaly!
Positional Plagiocephaly (Deformational Plagiocephaly)!
57
57
58
Back to sleep!
58
Tummy time!
59
Torticollis!
59
Strategies for Protecting the Head Shape!
60
Normal head shape!
60
Plagiocephaly!
61
Helmets for Plagiocephaly!
62
When to Seek Medical Attention!
Appendix 1!
Safe and Healthy Sleep Reminders for Your Baby!
62
63
63
Appendix 2!
66
References!
66
Appendix 3!
68
Abbreviations!
68
Introduction
This book is written for expectant parents and parents of babies. It is
designed to give you all the key information on baby sleep you need in one
place in a format that is easy and quick to read as I know you will be busy.
Babies spend more time asleep in the first few weeks than they are awake.
Parents often seek medical help with infant sleep problems and the aim of
this book is to prepare you for what to expect with your infant when he or she
is sleeping and hopefully arm you with the information you need so you won’t
need to seek medical attention.
One of the most common causes of concern for parents that bring them to
see me, a pediatrician, is when their baby wakes at night or is difficult to
settle. This book has information on normal sleep patterns in babies, sleep
routines and strategies that you can put in place from early on in your baby’s
life to ensure healthy sleep for your baby (and you) once your baby is
developmentally able. Don’t expect to have an uninterrupted night for a few
weeks and sometimes for a few months, but once your baby reaches that
age, if you have put your strategies in place, you should have a baby
sleeping soundly and you should feel rested.
Another important consideration is that sleep is a relatively dangerous time
for babies, especially between the ages of one and twelve months which is
when Sudden Unexpected Death in Infancy (SUDI which is also known as
SUID) is the commonest cause of death. My intention is not to scare you but
give you the information you need to make safe decisions about your baby’s
sleep environment. There is some extremely sound evidence on how you can
reduce the risk to babies by modifying the sleep environment, but
unfortunately many parents don’t put these factors into practice because they
don’t know them or they have been confused by conflicting information. This
book has the latest up-to-date research on safe sleeping for babies, so you
can make safe choices for your baby.
Some problems are much easier to deal with by preventing them in the first
place and you should find the chapter on protecting your baby’s head shape
helpful in this regard.
Terminology
To make it easier to read, chapters either talk about a boy baby or a girl baby
but the information is true for both sexes.
I also use the term crib, but the same applies if you call it a cot. Similarly I use
stroller and again the information is the same if you call it a buggy. I use
diaper but if you say nappy, the information is the same. Just substitute cot
for crib, buggy for stroller and nappy for diaper.
I also use SUDI for Sudden Unexpected Death in Infancy, but many people
use SUID (Sudden Unexpected Infant Death). They can be used
interchangeably and they mean the same thing.
I use American spelling, but the information is just as accurate if you live in
the United Kingdom or Australasia.
Disclaimer
This book is for educational purposes. No information given in the book is a
substitute for medical advice or health care from your medical practitioner.
The information is general in nature and so does not override any specific
recommendations made for your child from your doctor or health practitioner.
About the Author
Dr Maud Meates-Dennis is a specialist pediatrician with over 20 years
experience in New Zealand and the United Kingdom. She currently works in
New Zealand as a general pediatrician working in hospital inpatient and
outpatient clinics.
Dr Maud also has a website, Baby Medical Questions and Answers, where
she provides health information for parents of babies and toddlers.
Understanding Normal Sleep
This chapter will give you a brief overview of normal sleep physiology of
babies and how it changes with time. Understanding what is normal will help
you understand your baby’s sleep patterns.
Most newborn babies spend most of their time in the first few days just
sleeping and waking only to feed. By one week or so, there may be short
periods of wakefulness after feeds before your baby falls asleep again.
However, it is normal for your newborn baby to spend most of his time asleep
and newborn babies can spend up to 70% of time asleep.
The total time a baby spends asleep decreases over the first few weeks and
months and with the reduction in sleep time is an increase in awake time. By
3 months of age or so, most babies will be having their longest sleep at night
with more awake time in the day, but they will still have some daytime sleep in
the form of naps.
The way a newborn baby sleeps is different from older babies and adults and
it is important to understand that to understand your baby’s sleep. Parents
often expect their baby to sleep like they do or like older siblings, but newborn
babies do not have the same sleep cycles as older infants or adults.
Adult Sleep
Adults and older children and infants have sleep cycles lasting about 90
minutes when sleep changes in quality between non-REM (non-Rapid Eye
Movement) and REM (Rapid Eye Movement) sleep.
We go from the awake state to a non-REM state. The initial sleep is a light
non-REM sleep state but we then move to deeper and deeper non-REM
sleep. We then move back from deeper to lighter non-REM sleep before
changing to REM sleep. This cycle takes about 90 minutes and the time
spent in each of the states (light, deep and very deep non-REM states and
REM) varies at different parts of the night. The majority of very deep nonREM sleep occurs in the earlier part of the night and the majority of REM
sleep occurs in the early hours of the morning. About 20 -25% of our total
sleep is in REM sleep which is the sleep where dreams occur. A sleep period
will have 4 – 5 sleep cycles.
Our sleeping pattern is driven by 2 main factors:
• circadian rhythm related to day and night (light and dark). Anyone working
shifts will know that it is much harder to sleep in daylight.
• homeostatic mechanisms which relate to how tired we are. Bodies need
sleep and we get messages when we are tired that tell us we need to sleep
and the body shuts down - think of those times when you are trying to stay
awake when you are tired.
Newborn Sleep
Newborn babies do not develop circadian rhythm until a couple of months of
age, which is why it is so easy for them to sleep at any time of the day in the
first few weeks. Most babies will have developed a diurnal rhythm by 12
weeks of age, so day-night routines can be established by that time.
Newborn babies also have less developed non-REM stages and a difference
in the basic sleep cycle. A newborn baby has a sleep cycle that lasts about
50 - 60 minutes which consists of active (REM) and quiet (non-REM) sleep
and a state termed indeterminate that is midway between the active and quiet
sleep states. At least 50% of this cycle is spent in REM (active) sleep which
is thought to be important for learning. A newborn baby will go from awake
straight to REM sleep (remember we go from awake to non-REM sleep first).
Each sleep period may only last 2 sleep cycles, so just 2 hours or so.
A newborn baby who is in active (REM) sleep will make sounds, yawn, smile,
make sucking movements and may have limb movement like jerking of the
legs or arms. Your baby may also seem to breathe erratically in this active
sleep phase. On the other hand, when in quiet (non-REM) sleep a newborn
will breathe regularly and quietly and not move much or make sounds. This is
what parents often refer to as “sleeping soundly”. A baby may change from
active to quiet sleep after only 10 minutes or so.
Transition to More Mature Sleep Patterns
The more mature sleep pattern seen in older infants and adults develops
gradually from a few months of age. By 6 months of age, most babies will go
from wake to non-REM sleep and the movement that is characteristically
seen in active (REM) sleep in newborns will decrease. REM sleep duration
will decrease so the adult pattern of REM sleep only taking up 20 – 25% of
total sleep will have been achieved by 2 years of age. By a year of age,
infants will have developed very deep non-REM sleep as part of their normal
pattern. During this very deep non-REM sleep it will be very hard to rouse
infants. As we age, it is easier to rouse even from very deep non-REM sleep.
Introducing a sleep routine by 6 – 8 weeks of age will help your baby
transition to more settled sleep, particularly being able to self-settle when he
wakes as night (as all babies will do) and to have the longest period of sleep
at night when you and the rest of the family are also sleeping.
Normal Newborn Sleep Behavior
So, you can see that it is perfectly normal for a baby to be fidgety and make
sounds and facial movements during sleep – that is part of normal active
sleep and it will be present for about half of your baby’s entire sleep. It is also
normal for a newborn baby to wake frequently every few hours.
Sleep Duration
As mentioned, newborn babies spend most of their time asleep, but sleep
duration changes as babies get older.
The table below gives the average sleep duration for different ages with the
upper limits. The time is the total time asleep during a 24 hour period which
includes both night time sleep and any naps. As you see in the first few
weeks, babies are awake for less than 10 hours total in a day.
AGE
Average Sleep Dura/on (hrs)
Upper limit sleep (hours)
0 – 2 months
15
20
3 – 6 months
14
17
6 – 12 months
13
17
1 – 2 years
13
15
2 – 5 years
12
14
6 – 12 years
9 -­‐ 10
12
Naps
As your baby spends more time sleeping at night, which could be happening
by 12 weeks of age, he will be having shorter sleeps (naps) during the day.
Watch out for signs that your baby is sleepy and use them as a guide for
putting your baby to bed for a nap.
Signs your baby is ready for sleep include:
•yawning
•eyes starting to close, like in the photo on the left
•your baby becoming a bit irritable
Every baby is different but on average in the first
6 months babies have 3 naps per day. Between 6
and 12 months of age, babies generally have 2
naps per day and in the second year of life (12-24
months), most babies only need 1 nap per day.
Most toddlers do not need a nap after 3 years of age, although some children
still have a nap up until about 5 years of age.
AGE
Average no. of naps/day
Less than 6 months
3
6 -­‐ 12 months
2
12 -­‐ 24 months
1
3 -­‐ 5 years
0
Naps generally last about 30 -120 minutes each.
Some parents incorrectly believe that if they don’t put their baby down for a
nap in the day, that he will sleep longer at night. This is not actually correct
until your child is about 3 years and ready to give up naps altogether. When
that time comes, he will sleep slightly longer at night when naps cease.
However, until that time, your baby will need daytime naps because he will be
tired and his body will be expecting and needing a sleep. If your baby
becomes over-tired because he has not had a daytime sleep, he will find it
harder to fall asleep and will be generally unsettled. He will also miss out on
valuable learning time (you can read more below). The answer is to make
sure your baby gets adequate naps during the day as that leads to a good
night’s sleep as well.
Once your baby is having only one nap per day (so after the first year of life),
avoid having that nap too late in the afternoon. Late morning / early afternoon
is the best time for a nap once your baby is only having one nap per day. Also
avoid letting your baby sleep for more than about 2 hours for a nap. If he
wants to sleep for more than 2 hours for a nap, it suggests he is not getting
enough naps in the day or he is not getting long enough sleep at night.
It will be quite common for your baby to fall asleep in the car or in the stroller.
This sleep is not as restful as sleep in a designated sleeping area like a crib
or bassinet. As a rule, you should plan your day so that your baby has naps
in his crib or bassinet. Don’t assume that because your baby has fallen
asleep in the car or the stroller that you can omit the normal nap. You might
want to move your baby from the car seat or stroller as soon as possible and
put him in his crib or bassinet.
Ideally, you and your baby will find a sleep pattern that works for you both.
Once you do, keep to that routine as babies thrive on routine.
Sleep and Learning
We know that babies actually learn while they are asleep. Sleep is a time
when the newborn brain consolidates memory of things learned while awake
and also a time that allows maturation of neural (nerve) pathways. Babies
can also learn new things while asleep. Studies have shown that infants’
learning is enhanced after a nap, so that there is understanding rather than
just memory.
It is postulated that the relative increase in active (REM) sleep seen in
newborns (so about 50% of total sleep time compared to 20-25% in adults) is
important for this learning process which is so important as that is how babies
learn to adapt to their environment.
Being able to learn while asleep is important for survival and babies learn
how to cope with what they know. From a safety point of view, this is
important. Once your baby learns how to sleep, he will be in danger if he is
put in another position or has more blankets or clothing than he is used to.
This is why it is so important that everyone puts your baby to sleep in the
same way. It is particularly dangerous for a baby used to sleeping on his back
(which is the safest way to sleep) to then be put on his tummy to sleep (often
by someone other than his usual carer).
Sleep and Obesity
Good baby sleep patterns are also important for a number of other
conditions. Babies who sleep well are less likely to be obese later in life. A
study has shown those infants of 6 months or more who sleep less than 12
hours total per day are at increased risk of being obese at the age of 3 years,
compared to those infants who do sleep for more than 12 hours per day. So
this is another reason for you to help your baby develop a good sleep habit.
When Your Baby Cries
I am often asked by parents what to do if their baby cries - should they pick
them up, should they leave them to cry? They are usually worried about
creating “bad habits” for their baby.
When you have a newborn baby, the important thing is that you develop a
good relationship. When your baby cries, it is a sign that she is asking for
support of some kind. A human baby is dependent on her parents for all her
needs. Imagine how scary it must feel when she realizes she is alone. She
will signal you and in the early part of life, this communication is usually by
crying. You want your baby to feel secure and loved. That means attending to
her needs when she asks.
So for the first few months of your baby’s life, pick her up and attend to her
needs and wants when she asks (cries). You will teach her that she is loved
and secure. Other lessons can come later.
As you will read in the next section of this chapter, crying is normal for babies.
It doesn’t mean that you are a bad parent, it doesn’t mean that your baby will
be maladjusted later in life and in most cases it doesn’t mean that anything is
seriously wrong with your baby. It is just something that babies do.
With time, you will become better at understanding your baby’s particular cry
and will know when it is different from usual and this is when you should
consider if there are other features that mean you need to seek medical
attention - the last section in this chapter deals with the features that should
make you concerned your baby is unwell and needs medical attention.
Crying is Normal for Babies
Parents can get frustrated or anxious when their baby cries. However, it is
normal for babies to cry and over the first few months they have a what is
often called a “fussy” period when they cry more and seemingly for no
reason. This “fussy” period is also known as the period of PURPLE CRYING.
Like all things, some babies will not cry so much and some babies will cry a
lot more than the average baby. However, all babies will cry to an extent over
the first few months - this is the period of PURPLE CRYING.
The Period of PURPLE CRYING
This normal crying pattern seen in all babies to some degree has been
described as PURPLE CRYING not because the baby looks purple but
because the letters of the PURPLE help describe the characteristics of the
crying.
• P - there is an increase in crying every week from about 2 weeks of age
until a Peak at about 2 months of age, then the crying gradually becomes
less over the next few weeks
• U - the crying is Unpredictable and Unexplained. You don’t know what is
causing it
• R - the crying Resists soothing. Nothing you do seems to help
• P - the baby looks as if she’s in Pain, so she may have a grimace on her
face or be pulling up her legs. As babies are generally well and happy when
not crying, we know that the crying is not due to anything serious and is not
likely to be due to severe pain, despite how she looks and acts
• L - the periods of crying can be Long - they can last up to 5 hours or more
at a time
• E - the episodes of crying often occur in the Evening.
All babies have this period of PURPLE CRYING. Some babies have it a lot
and this excessive crying is often referred to as colic. The important thing to
remember is that this crying is normal for babies, it does not cause them any
harm or long term emotional distress, it is not a failing of you as a parent and
it will get better in time.
The first time your baby has a long period of crying, you may be concerned
and it is completely reasonable to get medical advice in this circumstance.
However, once you see the pattern of crying with long periods of your baby
being well and happy in between, you will be able to recognize this as
PURPLE CRYING.
Soothing Strategies
The list below outlines things you can do to try to soothe your crying baby, but
remember that some things will work some of the time, nothing will work all of
the time and sometimes nothing will seem to work at all.
Don’t chase a solution. If you try a couple of things and they don’t work, don’t
be stressed. This may be a time that nothing will work. You don’t have to
frantically go through all of these techniques - they are just ideas about what
helps some babies sometimes.
• Make sure your baby is dry and fed and burped.
• Make eye contact with your baby.
• Pick your baby up and try changing her position. Don’t chop and change
positions. Instead just try a different position from the one she is already in.
• Try a baby sling. Being close is comforting for babies as is gentle
movement.
• Take your baby for a walk in the stroller – the fresh air will be good for both
of you. Avoid bright sunshine, though.
• Talk gently or sing to your baby. Tell her everything is going to be okay (and
believe it).
• Kiss your baby on the forehead– it will calm you both!
• Some babies respond to a warm bath and / or a massage (massage in a
clockwise direction on the tummy).
• Some babies respond to white noise, like the vacuum cleaner. You can try
that.
• Some babies respond to car rides. Interestingly, car ride simulators do not
have so much success, so I don’t advise you spend money on one.
• Don’t stop these things immediately your baby settles. Keep doing them as
your baby is likely to remain settled for longer if you do
• Give your baby to someone else to soothe if there is someone available
• Have a plan for what to do if you are alone and your baby won’t settle
• if you feel frustrated, put your baby in the crib and leave her to cry. Go
into another room. That’s okay. You can go back when you feel calmer
• Never shake a baby.
Settling your baby for sleep in the first few weeks
You can start to teach your baby a routine from about 6 weeks of age that will
prevent sleep problems later - see Sleep Routines.
Some newborn babies seem very unsettled and always cry when you put
them in their crib.
Swaddling (or wrapping) has been shown to help babies sleep for longer and
wake less when sleeping. It can also help babies who cry excessively and
reduce unsettled crying episodes in newborn babies but it must be done
safely. Read how to swaddle your baby in the Swaddling chapter.
Swaddling (wrapping) may be enough to settle your baby in the first few
weeks. Swaddling prevents babies from startling themselves awake. Babies
in the first 3 months of life have a startle reflex that involves the arms moving
out suddenly and this sudden jerk can wake them. Swaddling works by
limiting the movement the arms can make and so reduces the waking
associated with the startle reflex. Do not put your baby on her tummy to
sleep - some people advise this position because they believe it reduces
startling but it is not a safe sleep position for your baby and you can use
swaddling to reduce the startle reflex and keep your baby on her back which
is a safe sleeping position.
If your baby seems unsettled, you could also try this controlled settle
technique.
Controlled Settle Technique
The controlled settle is something you can do with your newborn baby when
she doesn’t settle well to sleep. It is a slow step by step process of making
your baby comfortable as she is separated from you.
• Wrap (swaddle) your baby so she feels secure. There are various safe ways
to wrap. I prefer to wrap with the baby’s arms coming across her chest
rather than held by her sides but you can choose. See Swaddling for more
information and photos on how to wrap your baby safely
• It is common for mothers to feel a bit stressed when their baby is unsettled,
but just for the time you are settling your baby, try to let any stress or worry
just wash off you and just give all of yourself to your baby. Marvel at how
beautiful she is, her tiny fingers etc - anything to keep your mind focused on
your baby in this moment and keep your attention
away from stressful thoughts. Just take some deep
breaths and relax
•Hold your baby upright against your chest until
she is settled. She will hear and feel your heartbeat
which will be comforting to her. See the upper
photo on the left
•Once settled upright, lower her into the crook of
your arm so she is horizontal like the lower photo.
You can rock her gently if you want. Hold her there
until she is settled and calm. If she gets very upset,
go back to the upright position against your chest
again
•Once settled in this horizontal position, put her in
the crib initially on her side and keep a hand on her
back. Give her gentle pats on the back and make
calming noises, eg. “shh”. Do not leave your baby
in this side position. It is just a transition until she is
on her back
•Once settled in this position, roll your baby onto
her back for sleep
The time you take in each of these steps may vary and it may be that each
one takes 15-20 minutes or so. This is okay. Take your time and your baby
will settle.
Once your baby has settled leave the room but if she cries go back to your
baby and gently place your hand over her tummy and lower chest or on her
shoulders. If you want, you can say “shh” or “sleep now” or anything else that
is gentle and calming. Some people advise that you pat her back but this
involves rolling your baby onto her side which is likely to unsettle her more. I
prefer to place my hand on her tummy and keep her on her back. See which
works best for your baby, but remember to leave your baby on her back to
sleep.
When your baby settles a bit you can leave the room. You don’t have to wait
until she is completely asleep or settled before you leave. If your baby
unsettles again, return in a few minutes and do your soothing strategy again.
Then leave the room, returning as often as necessary until she sleeps. This
will make your baby feel loved and secure. She will learn that even when you
are not with her that you will always return.
At first, you will wait till she is quite settled but as time goes on, you might feel
comfortable leaving her to do the last settling alone.
The aim is not to rock your baby to sleep before putting her in the crib but if
that happens occasionally, don’t be too worried but don’t make it a habit.
Ideally, babies are awake when they are put in their crib as this enables them
to learn how to self-settle, or go to sleep alone. This is important for babies to
learn so they can go back to sleep alone when they wake in the night. If your
baby is always rocked to sleep, she will expect that every time she wakes,
and in the long run, this could be exhausting for you.
You can read more about developing good sleep practices in Sleep Routines.
Settling the infant who is over 6 months of age
When babies get older, they may use crying as a way of getting you to do
what they want even if it isn’t best for them, so crying when they are put to
bed because they want to stay up in the interesting world. If that becomes an
issue, there are ways of managing this, but this would be after the age of 6
months or so, not before.
There are techniques you can use for settling your baby once he is over 6
months of age if he wakes at night. Many parents are happy to get up and
tend to their baby at night and if this is you, then that's fine. However, I see
many parents who are exhausted and frustrated by their baby waking and
who seek help getting their baby to stop waking them at night. This section is
for those parents who don’t want to be up frequently at night and for parents
who have trouble with their infant going to bed awake, eg. Infants who are
used to being rocked to sleep or who regularly fall asleep somewhere other
than their crib.
The 2 techniques that I use the most are:
• The controlled crying technique
• The camping out method
These are both methods designed to change your baby' s behavior. Like all
behavior modification techniques it is very important once you start that you
continue on and don't give up. If you don't feel you can commit to seeing it
through it's best not to start until you do feel more committed. The reason for
this is that often things seem to get worse before they get better. When you
do something different, eg. Not pick your baby up immediately, your baby will
often just cry more to get the desired response. If you "give in" at that time,
what your baby learns is that he just has to cry more to get what he wants
which isn't what you are trying to teach him.
Controlled crying technique
This can be used to get infants to go to sleep or to get them to settle if they
wake at night and cry and wake you.
• When your baby wakes at night, wait a minute (or 5 minutes if you feel
strong) before you go to him.
• If you need to pick him up to settle him, do so. If you can settle him by just
gently talking, do that.
• Stay close to the crib and talk gently or rock him quietly until he settles
• As soon as he is settled or there is a pause in his crying, put him back in the
crib and leave the room, saying "go to sleep now, everything's alright" or
something soothing.
• If he cries when you leave, wait a bit longer before you return, so if you
waited 1 minute at the beginning, wait 2 minutes (if you started with 5
minutes, wait 6 or 7 minutes next).
• Go through the same process as before, putting your infant in his crib the
moment he pauses for breath.
• Go through the above steps for as long as it takes. In the first instance you
may have a night where you are up to your baby for hours, but if you
persevere for a few nights, your baby's behavior will change and you can all
have a better night's sleep.
You can use a similar method to get your baby to learn to go to bed awake.
Camping out method
This can be used to teach your baby to go to bed awake or for waking in the
night. It involves less crying and many parents are more comfortable doing
this.
• Put your infant in his crib. Sit next to the crib, put a hand on your baby's
chest or foot if you find that is comforting to him
• If he protests, talk calmly and tell him everything is alright. Stay sitting close
and talking or touching your infant. If you have to pick your infant up and
comfort him do so but as soon as he settles or pauses for breath, put him
back in his crib
• When your infant is settled, try moving a little further from the crib
• If your infant tries to get up or cries, tell him to lie down and go to sleep. Tell
him you are there and everything is alright
• Eventually you will be able to be further away from the crib so that your
infant may not even see your face but he will know you are there.
• Use your voice to comfort him and tell him to lie down if he gets up
• After a few days of doing this, you may be able to stand at the door and just
talk to your infant if he is unsettled
• Once, you have successfully got out of the room, his behavior should
change so that he settles when put down to bed and you won't need to pick
him up.
The same technique can be used for night waking with you sleeping on a
camp bed next to your infant's crib initially. That way you can reach out a
hand to settle him when he wakes without having to actually get out of bed.
Use whatever method you feel comfortable with. But remember that it might
seem as if things are getting worse before they get better. This is to be
expected. If you give in half way, it will take longer to change the behavior
and so longer for everyone to finally have more settled sleep routines.
Consider leaving a piece of your clothing close to your infant’s crib so that if
he wakes at night, he will have a familiar comforting smell close by. Do not
leave loose clothing in the crib, though.
How to Know if Your Crying Baby is Unwell
There will be times when your baby is unwell. Being unwell can cause babies
to cry. Parents are generally very good at being able to distinguish the cries of
their baby from something that is fairly typical (although unexplained) to
something out of the usual and associated with other features that concern
you. In these cases where you are concerned about your baby not being well,
don’t hesitate to get medical attention.
The following list gives symptoms and signs that should alert you to your
baby being unwell.
Seek medical attention if you are worried about your baby or if your baby:
• has poor feeding - especially if she is feeding less than half what she
normally would
• is very lethargic and uninterested in her surroundings
• has difficulty breathing - you may notice her ribs are very prominent with
each breath and she is struggling to breathe
• is cold to touch - press your thumb over her breast-bone for 5 seconds until
the skin goes white. Take your thumb off and count in seconds until the
color returns to the skin. (1000-1, 1000-2, 1000-3 etc is equivalent to 1
second, 2 seconds, 3 seconds etc). If the color has not returned within 3
seconds (1000-1, 1000-2, 1000-3), she needs urgent medical attention
• is very irritable and difficult to settle
• is blue in color around the lips or mouth
• is grey or mottled in color
• has bile-stained vomiting - this is bright green vomit and is seen in
blockages of the bowel
• has high fever and misery for more than 5 days
• has a red rash that does not blanch (go away) when pressed. This rash can
look like tiny pinpricks and can be a sign of serious illness. Perform the
glass test to see if the rash disappears.The photos below are of the same
rash - when the glass is pressed on the rash, it doesn’t disappear
Sleep Routines
In the first few weeks, babies will be feeding frequently, often every 3 hours or
so, and you need to be responsive to your baby’s needs so don’t worry about
a routine too much for this time. However, from about 6 weeks of age, you
can put some simple strategies to teach your baby a sleep routine that in the
long run will reduce the amount of night-time waking you will be involved in.
Every baby will be different, though, and there is no right sleep routine. The
information given here is an overview. Following a routine may not mean that
your baby “sleeps through the night” for several months after you start the
routine, particularly if your baby is breast-fed, but setting up a routine early
will lead to less problems later in the first few years of your baby’s life.
Day Routine
In the daytime, when your baby wakes follow a routine similar to the one
below:
• Feed
• Playtime - this is time that you can talk to your baby, give her lots of
cuddles, give her time on her tummy while you are with her.
• Put your baby down for sleep 2-3 hours later when she shows signs of
being sleepy. In the first week or so, your baby may only be up for an hour
or so after a feed.
• Signs babies are ready for sleep include her yawning, her eyes starting to
close, your baby becoming a bit irritable
It is important to put your baby in her crib when she is still awake. If your baby
always falls asleep being rocked in your arms, that is what she will always
expect. When she wakes at night, she will need to be rocked in your arms to
fall asleep again. A baby who learns how to fall asleep by herself in her crib
will have less sleep problems later in infancy.
In the daytime, it is not necessary to insist on absolute quiet in the house.
Your baby does not need this and by having normal daytime noises (but not
rowdy loud noises near the baby’s bed), your baby will start to learn about the
difference between day and night. You will also want to be able to attend to
normal household duties like vacuuming when your baby is asleep.
Sleeping through the night
The normal baby sleep cycle is about 60 minutes and a sleep period is about
2 sleep cycles, so all babies wake at night. However, once your baby has
learned to self-settle, she will be able to go back to sleep when she wakes
without signaling you. So, from your point of view, she will be “sleeping
through the night”. For the rest of this book, sleeping through the night refers
to babies who are able to self-settle so don’t wake their parents at night.
Babies who can’t self-settle will signal - you will be alerted to the fact she is
awake. You will often need to help your baby get back to sleep.
By 12 weeks of age, about 50% of babies will be sleeping through the night
and by 4 months of age, about 70% of babies will be sleeping through the
night. By one year of age, about 80% of babies are sleeping through the
night. So, be reassured that your baby will eventually sleep through the night
but it might take time particularly if your baby has not learned to self-settle
from a young age.
By setting up early routines from about 6 weeks of age that will eventually
teach your baby to self-settle, you will set yourself up for a situation in the
long term where sometime after 12 weeks of age your baby will be sleeping
through the night.
This will only be once your baby can manage without a night feed and breast
fed babies tend to have night feeds for longer. So babies who are breast
feeding may take longer to sleep though the night. Don’t worry if this is the
case with your baby. The benefits of continued breast feeding are immense.
Some babies are still waking at night at one year of age. That’s okay.
However, by setting up a good sleep routine, your baby will settle back to
sleep quicker and in the long run, you will have less sleep problems with your
baby’s sleep as she becomes older.
For babies from 6 weeks of age
To help your baby learn to self-settle rather than signaling that she is awake
and involving you, there are some simple strategies that you can put in place
to help your baby learn what is expected. Remember that your baby is
unlikely to self-settle before 12 weeks of age and it may even take longer for
some babies.
Baby Sleep Strategies
• when your baby seems sleepy, put her in her crib. Put her to bed awake but
sleepy. This is one of the most important things you can do to avoid sleep
problems later. Signs your baby is ready for sleep include yawning, eyes
starting to close, or your baby becoming a bit irritable.
• at night, avoid feeding or cuddling your baby to sleep. If you do feed or
cuddle before sleep as a routine, this teaches your baby that these are
required for falling asleep and she will “need” them when she wakes at night
which all babies do.
• when your baby wakes for a night feed, keep the lights low and reduce any
social interaction, so do not play or laugh or even talk much with your baby.
This is night. Your baby will learn that this is a different time and that night is
for feeding only and not for playing, so will fall back asleep more easily. By
contrast, when your baby is sleeping during the day, don’t worry about
keeping noises low, so you can vacuum, the other children can play etc. At
night, it is different, it is time for quiet and sleep - you can teach your baby
this from an early age. Waking at night may be necessary for a feed, but
then it’s back to sleep.
• when your baby wakes at night have a short delay before feeding her, so
you could change the diaper first, for example. Don’t let her cry for too long,
though. What you are doing is avoiding immediately rewarding her waking
with feeding. You could start this short delay between waking and feeding as
early as 3 weeks of age as long as your baby is well and putting on weight.
Again, this is teaching your baby that waking and feeding are not
necessarily associated, so as she gets older and doesn’t need a night feed
for nutritional purposes, she will be able to fall back asleep without a feed.
For older babies
Once your baby is 6 months or so, you should establish a routine for bed so
your baby knows what’s coming and knows what to expect and what is
expected of her. Babies like consistency and routine.
A fairly standard routine would be:
• have dinner
• have play time
• have a bath
• change into sleepwear
• your baby may have a before-bed milk feed after a bath
• quiet time which may involve a bedtime story
• bed
Like all things, you may find a slightly different routine suits you and your
baby. That’s okay. The important thing is that your baby learns what your
routine is and knows that it’s coming up to sleep time.
Safe Sleep
This chapter deals with Sudden Unexpected Death in Infancy (SUDI) which is
also known as Sudden Unexpected Infant Death (SUID). The term refers to
cases where babies have died in the first year of life, often during sleep.
SUDI is the commonest cause of death for babies between 1 month and 1
year of age. The purpose of this chapter is not to scare you but to give you
the information you need to make safe choices for your baby.
SUDI and SIDS
The first year and particularly the first six months of a baby’s life are a time
when there is increased risk that the baby will die during sleep. However,
there are several factors that can be modified so you can reduce this risk. It is
heart-breaking to have to deal with parents who have lost a baby
unexpectedly and suddenly and more so when they say, “why didn’t anyone
tell me about this”.
SIDS
Sudden Infant Death Syndrome (SIDS) describes unexplained sudden death
of an infant while sleeping. It was previously known as crib death or cot
death. Understandably, this is a devastating event for any parent to suffer.
90% of cases of SIDS occur in the first six months of life with the peak
between the ages of one and four months of age. SIDS is uncommon after
the age of 8 months.
Although, the cause of SIDS is not known, we do know that some babies
(those that are born small or prematurely) are more at risk and that there are
some factors associated with increased risk that can be modified to reduce
the risk. So these are things you can do to make your baby safer.
Studies looking at SIDS in different countries and comparing how babies
normally slept in those countries showed markedly reduced cases of SIDS in
those countries that routinely put their babies to sleep on their backs. Further
studies confirmed this finding and in the early 1990’s, major campaigns were
launched around the world to highlight the importance of a baby sleeping on
her back - the so called “Back to Sleep” campaigns.
This change in sleeping position so that babies sleep on their backs has led
to a major reduction in the incidence of SIDS. In the United States, there was
a 53% reduction in the incidence of SIDS over a 10 year period from 1992.
Similar reductions were seen in other countries around the world. Putting
babies to sleep on their backs has saved lives.
SUDI
However, even with this major reduction in death in babies from SIDS, some
babies continued to die and on investigation some of the deaths were found
to be preventable. Preventable causes included accidental suffocation while
sleeping often caused by entrapment in bedding and accidental strangulation.
The term Sudden Unexpected Death in Infancy (SUDI), also know as Sudden
Unexpected Infant Death (SUID), was coined to include all unexpected infant
deaths in the first year of life, so this term includes Sudden Infant Death
Syndrome (SIDS), where there is no known cause for death, on one end of
the spectrum as well as cases for which there is a clear cause and that are
very preventable, like accidental suffocation and strangulation, on the other
end of the spectrum.
It is important that you as a parent feel empowered to make safe choices for
your baby. Knowing the risks associated with SUDI means you can take
action to actively reduce risks and make sleep safer for your baby. The risks
for SUDI and SIDS are discussed in detail below with recommendations for
safe sleep.
Having been in the unenviable position of having to counsel parents who
have lost a baby because of SUDI, one thing is clear and that is they would
have done anything they could to have reduced any risk to their baby if only
they had known. This chapter will give you the information you need to make
safe choices for your baby.
Conflicting Advice / Misconceptions
When discussing sleep position with parents, they often say they feel
confused as older family members have told them “we put our babies on their
tummy to sleep and they were fine” or “we were advised by our doctor to put
our baby to sleep on her tummy”.
The reality is that most babies who sleep on their tummy will be fine but the
risk to them is doubled compared to sleeping on the back. When a baby dies
who was put to sleep on her tummy parents are devastated and almost
always express frustration that they were not told about the risks or the
danger of sleeping on the tummy was not emphasized enough.
In the past, some doctors did advise sleeping on the tummy but this was
before the 1990’s when the evidence against sleeping on the tummy became
overwhelming. Advice to sleep on the tummy is now only given for a few rare
cases where there is abnormality of the airway. Unless you have written
advice from your doctor advising sleeping on the tummy, then put your baby
to sleep on her back.
Another cause of confusion for parents is when they have premature babies
who are nursed on their tummy in the first few weeks of life. This is because
in premature babies lying on the tummy improves breathing. However, this is
only the case for the first few weeks and once a baby nears term there is no
advantage to sleeping on the tummy and, in fact, it is a risk for SUDI just as in
babies born on time.
It is difficult to have to explain to a parent that a decision they have made
may have put their baby at greater risk.
One mother who had lost her baby told me that she had never put her baby in
a crib because she didn’t want her baby to have a crib death. Instead she
slept with her baby in her bed and accidentally rolled over and suffocated her
baby. It is a heart-breaking story. The risk of SUDI with bed sharing is
increased compared to a baby sleeping in her own crib. This mother was
devastated when she found this out.
So, it is easy to see how parents might get confused. The risk factors that are
discussed below, and particularly sleeping on the back, have been found in
multiple research studies to alter the risk of SIDS and SUDI. There is no
conflict regarding the evidence.
Risk Factors for SIDS
Sleep Position
Prone sleeping (sleeping on the tummy) has been shown to increase the risk
of Sudden Infant Death Syndrome (SIDS). Side sleeping has also been
shown to increase the risk of SIDS. Side sleeping is unstable and babies
often roll onto their tummy. Some parents put a wedge or rolled blanket in the
crib to stop the baby rolling, but these wedges are suffocation hazards and
can increase the risk of Sudden Unexpected Death in Infancy (SUDI).
Sleeping on the tummy or on the side can result in rebreathing expired gases
that can lead to high carbon dioxide and low oxygen in the blood and so low
oxygen to the brain. Sleeping on the tummy can also increase the risk of
overheating.
Babies who are accustomed to sleeping on their backs who then are put
prone (on their tummy) are at even more risk than babies routinely put on
their tummy to sleep. This is why it is so important that all caregivers follow
the same sleep guidelines.
For a very few babies who have congenital abnormalities of the airway,
sleeping on the tummy may be safer than sleeping on the back. However,
these babies will have specific advice from their doctor that they should sleep
on their tummy. If your baby doesn’t have written advice from an appropriate
medical professional, then she should sleep on her back.
Parents are often concerned that lying on the back may put their baby at risk
of choking or aspirating if they vomit. Babies have a very effective gag reflex
which will stop this occurring. This gag is often misconstrued as choking.
Studies from around the world have not found that babies aspirate vomit from
being on their back. What we know from numerous research studies is that
sleeping on the back is the safest position for babies.
Premature babies in neonatal units are put on their tummy in the first few
weeks to improve oxygen supply. However, by the time they are ready to be
discharged home, this is no longer necessary. So, even if you have had a
baby who was born early and who has been in a neonatal unit, the safest way
for you to put your baby to sleep once she is home is on her back.
There is clear evidence that sleeping on the back is the the safest way for
babies to sleep. Once babies can roll from back to front and from front to
back, there is no need to reposition them if they roll over while sleeping. But
until that time, always place your baby to sleep on her back.
Tobacco Exposure
Prenatal exposure to tobacco smoke is a major risk factor for Sudden Infant
Death Syndrome (SIDS). Not only does it lead to an increased risk of
premature birth and low birth weight, which are both independent risk factors
for SIDS, but tobacco exposure also affects infant arousal in an adverse way,
so babies are less able to rouse even when there is danger.
Breast Feeding
There has been some conflicting advice regarding whether breast feeding
has an effect on SIDS risk in the past but recent studies have shown that
breast feeding has a protective effect and reduces the risk of SIDS.
Babies who were exclusively breast fed for 1 month had half the risk of SIDS
compared to those who were not breast fed. Breast feeding for 6 months has
been shown to have other beneficial effects such as protection from infectious
disease as well.
Breast fed babies are often brought into bed with the mother at night for a
feed. Bed sharing, which is the baby sleeping in bed with the mother, has
been shown to increase the risk of SIDS. It is therefore important that once
the baby has fed she is put back in her crib after the feed. Bed sharing is
discussed in more detail in the next chapter.
Pacifier Use
Several studies have shown that sucking on a pacifier (also known as a
dummy in the UK and Australasia) as the baby falls asleep has a protective
effect and reduces the risk of SIDS by more than 50%. Even if the pacifier
falls out after the baby falls asleep and is not replaced, the protective effect
remains.
So as not to confuse babies who are learning to breast feed, it is
recommended that pacifiers are not introduced until breast feeding is
established. Fears that using a pacifier will reduce the duration of breast
feeding are unfounded.
Overheating
Babies who are overheated with either too many bedclothes and blankets or
who are in an artificially heated room that is above 20 degrees Celsius (68
degrees Fahrenheit) are at increased risk of SIDS. On the other hand, babies
who sleep in a well ventilated room (one with windows open) have a reduced
risk of SIDS.
As a general rule, an infant requires one more layer of clothing than an adult
is comfortable with. Look out for signs that your baby is too hot such as
feeling hot to touch on the chest or being sweaty or having damp hair. If your
baby is hot, remove a layer of clothing or bedding.
Babies are much more likely to die from being too hot than from being too
cold, so don’t overheat your baby.
Head Covering
Loose blankets or clothing that cover the face are particularly dangerous and
head covering is seen more often in babies who have died from SIDS
compared to babies who don’t die. Babies are nose breathers so anything
that covers or blocks the nostrils is potentially very dangerous. It is important
that when your baby sleeps, her face is kept clear. Make sure there are no
loose blankets or toys that could potentially cover your baby’s face.
Immunizations
In the past, there has been some concern that immunizations may cause
SIDS in babies. However, this is not founded and in fact it has been shown
that being immunized actually has a protective effect and reduces the risk of
SIDS by about half.
Risk Factors for SUDI
The risk factors for SUDI include all the risk factors for SIDS mentioned
above, plus hazards in the baby’s sleeping environment that may cause
accidental suffocation or strangulation.
The hazards that are associated with SUDI are discussed in detail in the next
chapter on the sleep environment but in short:
• There should be a firm sleeping surface that fits snugly into the crib or
bassinet so there is no possibility of the baby getting trapped between the
mattress and crib. Soft surfaces like pillows, sheepskins and quilts are not
appropriate sleep surfaces for babies
• Babies should share a room with their parents, particularly for the first six
months of life, but babies should not bed-share. Room-sharing without bedsharing reduces the risk of SUDI by about 50%
• Soft objects and loose blankets are a risk for accidental suffocation. The
whole face of a baby doesn’t need to be covered for suffocation to occur.
Babies are preferential nose breathers so just the nose has to be covered
for suffocation to occur
• Bumper pads can be a hazard as babies can get trapped and there have
been deaths due to bumper pads. This risk far outweighs any potential
benefit that bumper pads may have in reducing other injuries, so do not use
them
• Loose cords, such as blind cords, are a strangulation hazard and babies
and toddlers have died from being strangled by loose cords
Recommendations for Safe Sleep
The following list gives recommendations for safe sleep:
• Sleep on the back
• Avoid exposure to tobacco smoke, particularly before birth
• Breast feed your baby for as long as you can but at least for the first month
• Consider using a pacifier for your baby as she falls asleep (but wait until
breast feeding is established)
• Avoid overheating. Do not artificially heat the room above 20 degrees
Celsius (68 degrees Fahrenheit) and open windows in hot climates
• Keep the face clear
• Immunize your baby
• Ensure your baby has a firm sleeping surface that fits snugly in the crib
• Room-share but do not bed-share. If you are breast feeding your baby, put
her back in her crib once she has fed at night
• No loose blankets, toys or bumper pads in the crib
• No loose ties or cords around the crib
• Once you have put your baby in her crib have a 360 degree look around
looking for any dangers
Baby’s Sleep Environment
As mentioned already in Safe Sleeping, the sleep environment is very
important to keep babies safe when sleeping. Sudden Unexpected Death in
Infancy (SUDI) is devastating to families and medical research has shown
that there are things parents can do to reduce the risk of their baby dying
while sleeping.
Again, this chapter is not meant to frighten you, rather it is here to alert you to
dangers that may affect your baby’s sleep. I am sure you want to consider
these before your baby suffers any tragic event.
In the past, Sudden Infant Death Syndrome (SIDS) was known as crib death
or cot death. This just reflected that babies died during sleep.The truth is that
babies are safest in a designated sleeping space like a crib or bassinet.
Crib / Bassinet
The surface your baby sleeps on is very important. Babies seem to be able to
sleep anywhere, but it is up to you as the parent to ensure your baby sleeps
on safe surfaces. Just because a baby seems to sleep soundly on a surface
does not mean that surface is safe for your baby.
Your baby needs a sleep surface that is designed for sleep, so the stroller, a
carseat or the sofa are not appropriate for routine baby sleep. If your baby
falls asleep while in the stroller or carseat or sofa, you need to move your
baby to a designated sleep surface as soon as possible and you should not
leave him unsupervised until he is in his crib or bassinet.
When choosing your baby’s crib or bassinet in the first year of life, consider
the following:
• The crib or bassinet should comply with the national standard of your
country. It should not be damaged in any way or have had repairs done.
• The crib or bassinet should not have any protrusions that may cause injury
to a baby.
• The mattress should be firm and flat and fit snugly. There should be no
space between the mattress and the sides of the crib. Use the mattress
designed specifically for the crib or bassinet.
• Pillows should not be used. A pillow is not necessary for a baby as babies
have relatively large heads compared to older children and adults, so they
don’t need anything under their head when sleeping in the first year of life.
• The crib or bassinet should have adequate ventilation - either wooden slats
or a breathable mesh material. Slats in cribs should be close enough
together so that a baby head cannot fit through.
• The crib should not have drop sides. There are instances of babies getting
caught up in these mechanisms and suffocating as well as the drop side
failing and babies falling out of the crib.
• There should not be posts at the corners of the crib. These are potentially
hazardous, particularly in older babies, as clothing can catch on the posts
and this could cause strangulation.
• Do not put anything on the mattress such as a sheepskin or a quilt or
additional padding or mattresses. Pillows and cushions should not be used
instead of a mattress. Babies are more likely to suffocate on soft surfaces.
• Do not use bumper pads. There is no evidence that they prevent major
injury in the crib and they have been associated with babies being trapped
and suffocated while in bed.
• If using portable beds, make sure the legs lock so they cannot collapse. The
mattress should be firm and fit snugly as for any other crib.
Alternative Sleeping Environments
This section outlines why some environments a baby may fall asleep in are
not appropriate as routine sleeping surfaces and gives you the information
you need to adequately assess any dangers in these environments your baby
may fall asleep in.
• Stroller - babies should sleep flat. Although babies often fall asleep in the
stroller, this should not be used as a routine sleeping surface. Babies can
get trapped by harnesses and also often sleep with the neck flexed which
can cause obstruction of the airway, so do not leave your baby sleeping in a
stroller unsupervised.
• Carseat - again babies often fall asleep in the car while traveling. However,
as with the stroller, the baby may become trapped in harnesses or obstruct
his airway when flexing his neck while asleep in a carseat. So again, babies
should not be left unsupervised to sleep in carseats. Carseats are
specifically designed to protect your baby in the event of a crash while
traveling, not for sleeping. Having said this, there will be times that you are
traveling long distances and your baby will sleep in the carseat. That’s ok as
you will be in the car with your baby and so your baby is not unsupervised.
Just check your baby’s neck position regularly - make sure the chin isn’t on
the chest.
• Baby Slings / Soft Carriers - babies love the closeness that baby slings and
carriers allow. However, these can be dangerous for sleeping babies. Your
baby must have an unobstructed airway, so the neck should not be overly
flexed,( ie. the chin to chest position), and the mouth and nose should not
be covered by the sling or be pressed up against your body. Babies can
overheat and you should not zip up jackets covering your baby in a sling. So
when using a baby sling, ensure the head is up above the fabric and the
mouth and nose are clear of obstruction.
• Adult beds - these have been shown to be unsafe for babies. The
mattresses are often soft and babies are at risk of suffocation and of getting
trapped between the mattress and the wall or the headboard.
• Soft surfaces such as sofas, bean bags and water-beds - these are
particularly dangerous for babies. A baby can get trapped between the
cushions of sofas and if the surface is soft, the baby can suffocate as the
material of the surface envelops them.
Tucking Your Baby In
Follow these simple but safe steps when putting
your baby down to sleep.
• When you put your baby in his crib or bassinet, put
his feet at the end of the bed. This will prevent
your baby slipping to the bottom of the crib and
going under the blankets which may cover his
head and obstruct his breathing
• Tuck the blanket securely at the bottom of the crib
and at the sides. Loose blankets can cover the
baby’s face and cause suffocation.
• The blanket should not come above the level of the
baby’s shoulders. The face must remain uncovered
so there is no obstruction to breathing.
• If swaddling is not used, the baby’s arms should be free, not tucked under
the blanket.
• Do not use loose blankets or duvets for infants under 12 months of age.
Again loose bedding can cover a baby’s face and cause suffocation.
• Do not put soft toys in the crib or bassinet. This is for the same reason that
you shouldn’t use loose bedding. Soft toys may end up against your baby’s
face causing obstruction to breathing and subsequent suffocation.
Baby Sleeping Bags
Baby sleeping bags, that have a fitted neck, armholes or sleeves and no
hood, are very useful for keeping your baby warm and safe as there are no
loose blankets and you don’t have to worry about your baby kicking the
blanket off. When a baby sleeping bag is used instead of blankets, place your
baby at the foot of the bed.
If you are using a baby sleeping bag, make sure that it is the correct size for
your baby.
Dress your baby as appropriate for the temperature before putting them in the
sleeping bag.
Around the Crib
After you have tucked your baby in, have a 360 degree glance around to see
if you can see any hazards, such as dangling cords from blinds or electric
wires or anything else that may pose a risk of strangulation. This is
particularly important when you baby is away from his usual sleep
environment.
Keeping your Baby Warm
It may seem surprising, but it is not good for your baby to be too warm.
Overheating in babies is dangerous and has been the cause of death in
babies. It is more dangerous for your baby to be too hot than too cold when
sleeping.
To avoid overheating, follow these guides:
• Babies only need one more layer than you are wearing for comfort. If you
are wrapping (swaddling) your baby, ensure your baby is not overdressed
under the wrap. Consider the wrap as one layer.
• Do not cover your baby’s head while sleeping. Babies lose heat from their
from their heads - while it important to protect your baby from cold outdoors
with a hat, keep the head uncovered for safe sleep indoors.
• Do not overheat your baby’s room in winter. The room temperature should
not be above 20 degrees Celsius (68 degrees Fahrenheit).
• Do not overdress your baby or cover with too many blankets. If your baby is
sweaty, has damp hair or feels hot to touch on the chest then he has too
many layers on. Remove at least one layer and recheck how your baby
feels then.
• When babies are unwell, they often have a slight fever and they do not need
to have extra layers. You may need to remove a layer. If your baby’s chest is
warm and he is not sweaty and does not have damp hair, he is probably
okay. If he feels hot on the chest and has damp hair and is sweaty, then he
has too many layers.
• If you are carrying your baby in a baby sling, your baby will have the benefit
of your body temperature, so don’t zip your jacket over your baby’s head.
• If you are bed-sharing, do not swaddle your baby and do not let your
bedclothes cover the baby. Again, your baby will get your body heat.
Room-Sharing
Babies are safest when they share the same room as their parents to sleep at
least for the first 6 to 12 months of life. Room-sharing reduces the risk of
Sudden Infant Death Syndrome (SIDS) by as much as 50%.
Ideally, your baby will have his own crib or bassinet that will be close to your
bed. Room-sharing with the infant close to your bed allows you to be close to
your baby which will make feeding, comforting and monitoring your baby
easy. Babies can be brought into your bed for night-time feeding but you
should then put your baby back in his crib or bassinet to sleep.
Bed-Sharing
Bed-sharing is when the baby sleeps in a bed with another person, usually
the parent.
Bed-sharing is associated with an increased risk of SIDS and of SUDI.
However, the whole bed-sharing issue is complex. There are some cultures
that traditionally bed-share and they have low rates of SIDS, while other
cultures that traditionally bed-share have high rates.
Problems can occur because parents can roll onto and suffocate the baby,
the baby can get trapped between the bed and wall, the baby can overheat or
suffocate under the bedclothes, as well as for unexplained reasons (SIDS).
For this reason, most policy on infant sleeping, which is based on safe
practices to reduce SUDI, is to advise against bed-sharing but to advise
room-sharing.
Having said that, there are exponents of breast feeding who believe that
having the baby sleeping in the bed with the mother enhances and prolongs
breast feeding as the baby is close and it is easy to initiate night feeds with
the baby in the bed and this keeps the milk supply up. Policy makers would
argue that if the baby is in his own crib close to the parent’s bed that night
feeding and being responsive to your baby is just as effective as with the
baby sleeping in the bed. Many mothers successfully breast feed their baby
with the baby sleeping close but not in the same bed as the mother, so roomsharing but not bed-sharing.
Making Bed-Sharing Safer
Bed-sharing is relatively common and is often dictated by your culture. The
important thing is that if you choose to bed-share that you know what factors
make it dangerous so you can avoid those and so you can put in place safer
practices.
Follow these guidelines on bed-sharing if you choose to do it:
• don’t smoke
• do not bed-share if you have been drinking or are excessively tired
• have a firm mattress. Having the mattress on the floor reduces the risk of
injuries as a result of falling out of the bed
• keep the area where your baby is sleeping free from duvets and pillows
• have a lightweight blanket and make sure it cannot cover your baby’s face
• make sure that there is no way your baby could get trapped between the
bed and wall or bed-head
• do not put your baby in the middle. Your baby should only be next to one
adult
• do not have other children or pets in the bed
• your partner should be aware that your baby is sharing the bed
• do not swaddle (wrap) your baby if he is sharing the same bed
• put your baby on his back to sleep
• lie on your back or on your side with your front towards your baby. Do not
sleep with your back to your baby
• do not leave your baby unattended in your bed
Using a PepiPod (Baby-Pod)
A baby-pod, like the pepi-pod used in New Zealand, is a low-cost safe
sleeping surface for babies to protect them from suffocation and has been
used when families choose to bed-share. It is relatively mobile, so is good for
traveling and also for emergencies when the family may be displaced from
normal sleeping quarters, as in the Christchurch earthquakes of 2010 and
2011 when pepi-pods were an invaluable resource.
A pepi-pod is made from a virgin polypropylene (food safe) plastic box like an
under-bed storage box. Material covers can be made so the sides of the box
are covered. The mattress is firm foam rubber that fits snugly in the box. An
under-blanket (like a merino wool blanket) is placed on the mattress and then
the mattress and blanket are covered with a sheet - a pillowcase that
envelops the mattress and under-blanket works well for the 72 cm x 37 cm
storage box. The baby is covered with a sheet that tucks in firmly leaving the
face clear and then a light blanket that is firmly tucked in goes on top. Just as
with other safe sleeping places, the baby’s feet should be at the bottom of the
pepi-pod.
For more information on pepi-pods, click here.
When Bed-Sharing is Most Hazardous
There are some instances when there is no doubt that it is dangerous for a
baby to bed-share.
The factors that make bed-sharing particularly dangerous for babies are:
• when either one of the parents is a smoker
• when the parent is intoxicated
• when the parent is excessively tired
• when the mattress is very soft or there is a water-bed
• when loose blankets or pillows are used near the baby
• when there are children or pets in the bed
• when the adult in the bed is not the parent
• when the baby is swaddled
• when the baby is put on the tummy to sleep
• when the mother and baby fall asleep on a sofa. If you are tired, do not feed
your baby on the sofa
• when the infant is less than 3 months of age
Away From Home
It is important when you are away from home that you take particular care to
ensure your baby has a safe sleeping environment. It is also important that if
someone else is caring for your baby that they are aware of creating a safe
sleep environment for your baby.
This is particularly so as babies learn during sleep and they learn to cope with
the sleeping position they know. However, this means that babies are
particularly at risk when they have to cope with a new position, so a baby who
is used to sleeping on his back who is then put on his tummy is at particular
risk during that sleep.
Remember:
• Firm flat mattress that fits snugly in a secure crib or bassinet that is stable
• No pillow, no loose blankets, no soft toys
• Baby put to sleep on his back
• Baby’s feet at the foot of the bed
• Baby not overdressed or not too many blankets
• Blanket tucked in securely with baby’s face free
• 360 degree look before you leave your baby to ensure there are no hazards
In Appendix 1, you can print out pages on Safe Sleep and Healthy Sleep and
customize them to your baby’s routine, then laminate and give to any carer.
Swaddling
Swaddling or wrapping babies in light cotton or muslin cloth can be very
comforting for them. It probably reminds them of being in the uterus before
birth where they were “contained”. It is very useful in the first few weeks to
months of life, particularly to help babies sleep with less arousals. Many
parents also swaddle their baby to manage unsettled and crying behavior.
Babies have exaggerated startle responses and these responses and jerks
can startle and wake babies up so swaddling helps by reducing the limb
movement with these jerks making it less likely for your baby to startle and
wake.
Studies have shown that infants who are swaddled above the waist rouse
less when asleep and sleep longer. It can also help babies who have
excessive crying. Being swaddled and lying on the back is thought to further
reduce the risk of Sudden Infant Death Syndrome (SIDS) over just being on
the back to sleep. Swaddling may keep the baby’s temperature more stable
as well.
However, it is important that swaddling (wrapping) is done safely as there can
be problems if it is not done safely. Swaddling is used widely in the United
States, the United Kingdom and Australia and New Zealand. Some countries,
like Canada, discourage the use of swaddling because of potential problems
so if you are using swaddling, follow the guidelines for safe swaddling below.
Safe Swaddling of your Baby
It is important that you follow a few simple points to swaddle your baby safely:
• use a light material such as muslin, or cotton (ie. a fabric that breathes) for
the wrap (swaddle) material
• the wrapping should be firm but never so tight that chest movement is
restricted - your baby needs to breathe
• the head should never be covered. The swaddling should not be above
shoulder level
• your baby should not be too hot. If your baby feels hot or sweaty to touch
(on the chest or between the shoulder blades) or has damp hair, remove
some layers of clothing. In summer, have light clothing on your baby under
the wrap, eg. a light vest (singlet) and a diaper
• the legs should not be restricted in a straight out (extended) position. This
can lead to dislocation or subluxation of the hips. Babies’ hips should be
held in a flexed and slightly abducted position - so slightly bent at the hips
and knees in a frog-like posture. Swaddling should be firm above the waist
but loose below the waist.
• it is important that you put your baby to sleep on her back. Putting a
swaddled baby on her front to sleep increases the risk of SIDS over and
above the risk of just being on her tummy without being swaddled. Once
your baby gets to the stage she is rolling over onto her front you need to
stop swaddling
• babies who bed share should not be swaddled. They are at risk of
overheating as a result of other bodies
• to prevent overheating, make sure you do not heat the baby’s room to more
than 20 degrees Celsius (68 degrees Fahrenheit) at night. If you live in a hot
environment where the temperature is above 20 degrees Celsius (68
degrees Fahrenheit), make sure your baby doesn’t have extra clothing that
would prevent sweating or evaporation
• once babies can get themselves out of swaddling, stop using it as loose
blankets can be dangerous for babies
How to wrap your baby
There are various ways of wrapping your baby.
Some methods of swaddling have the baby’s arms held by the side. I prefer
the arms across the body and there are at least a couple of ways of doing
this. I think this is more natural for your baby and less like a straight-jacket!
However, if it is important that your baby can’t get her hands out, eg. in
severe eczema where you want to limit scratching, the arms by the side
method may work better for your baby. Find out which one works best for you
and your baby.
Watch your baby for cues as to what is comforting. Some babies like to touch
their face with their hands or suck their thumb. In those cases, you could
leave one or both hands out.
I have described the step-by-step process for a few methods of swaddling
below and there are photos in the next section.
Arms Across the Chest, Hands Up
1. Put the wrap in a diamond position or a rectangular position
2. Fold the top of the blanket down (about 10-20 cm)
3. Put the baby on the blanket with her shoulders at the level of the turneddown blanket
4. Place the left hand under the folded down blanket on that side
5. Fold the left side of the blanket across the baby and tuck the blanket under
the right side of the chest (leaving the area below the waist free and not
tucked in)
6. Put the right hand under the folded blanket on that side
7. Fold the right side of the blanket across the baby and tuck under the left
side of the chest
8. Make sure the baby’s legs are in the frog position and loosely twist and
fold the bottom of the blanket under.
Arms Across the Chest, Hands Down
1. Put the wrap in a diamond position or a rectangular position
2. Fold the top of the blanket down (about 10-20 cm)
3. Put the baby on the blanket with her shoulders at the level of the turneddown blanket
4. Hold the left arm out at 45 degrees and bring the blanket over and under
the arm
5. Fold the left side of the blanket across the baby and tuck the blanket under
the right side of the chest (leaving the area below the waist free and not
tucked in)
6. The arm will be wrapped across the lower chest at the level of the lower
ribs
7. Hold the right hand out at 45 degree and bring the right side of the blanket
over and under the arm
8. Fold the right side of the blanket across the baby and tuck under the left
side of the chest. The right arm will be at the level of the lower ribs
9. Make sure the baby’s legs are in the frog position and loosely twist and
fold the bottom of the blanket under.
Arms By the Side
1. Put the wrap in a diamond position or a rectangular position
2. Fold the top of the blanket down (about 10-20 cm)
3. Put the baby on the blanket with her shoulders at the level of the turneddown blanket
4. Place the left arm by her side
5. Fold the left side of the blanket across the baby and tuck the blanket under
the right side of the chest (leaving the area below the waist free and not
tucked in)
6. Put the right arm by her side
7. Fold the right side of the blanket across the baby and tuck under the left
side of the chest
8. Make sure the baby’s legs are in the frog position and loosely twist and
fold the bottom of the blanket under.
Which Swaddling Method Should I Use?
Every baby is different, and some babies will not like being wrapped up while
others will like to have a hand out. Watch your baby as you swaddle him to
get cues about what will be comforting for him.
You may change the style of wrap as your baby gets older. For example, the
arms across the chest with the hands up will not generally be enough to keep
the hands in the wrap for larger babies. As mentioned above, older babies
with severe eczema are probably better wrapped with the arms by the sides
to prevent them getting their hands out and scratching.
As babies get older, they like to be wrapped less or wrapped more loosely.
Again, watch your baby for cues, like struggling when you try to wrap him.
On average, babies are swaddled for about 12 weeks but the practice can be
used throughout the first year of life.
Swaddling - photos
Blanket orientation - rectangle / square! !
Blanket orientation - diamond
Place baby with his shoulders at level of top of
blanket
Across the Chest, Hands Up
Tuck the hand under the fold of the blanket
Fold the blanket over and
tuck under the chest
Tuck the other arm under the
fold of the blanket
Bring the blanket over the
chest and tuck under firmly
but not too tightly
Make sure the legs are in the frog-leg position
Leave the blanket loose at the bottom
Alternative Hands across the Chest
Fold the top of the blanket over the arm that is held at 45 degrees (unlike the
earlier photos, the hand is not under the fold in this method).
!
!
!
!
Tuck under the chest on
the other side, then bring
the top of the blanket over
the other arm held at 45
degrees
Bring the blanket over and tuck. The arms are across the chest but lower than
in the first method. Make sure the legs are in the frog leg position as in the
first method.
Straight Arms
Start with the arm down by the baby’s side
Bring the blanket over the
chest and tuck, keeping the
arm by the side.
Bring the other arm down by the side and take the
blanket over the chest and tuck.
Make sure the legs are in the frog leg position as in the earlier methods.
Protecting Your Baby’s Head Shape
Plagiocephaly
Plagiocephaly refers to an abnormally shaped head. Babies commonly get
plagiocephaly, most often a flat spot on the head. In the majority of cases, this
plagiocephaly is positional and will resolve spontaneously if the baby is
positioned correctly as baby’s skull bones are relatively soft and malleable
and if pressure on the flat spot is removed, the skull will have space to
remold. Positional plagiocephaly (which is also known as deformational
plagiocephaly) does not cause brain damage and does not cause problems
with development of normal baby milestones.
The picture on the left shows typical positional
(deformational) plagiocephaly with a flat spot on the
left side of the head.
In a small proportion of cases, abnormal head shape
is due to abnormal fusion of the skull bones which
means that over time there will not be enough room
for the brain to develop. In these cases of
pathological plagiocephaly (which is called
craniosynostosis) where there is abnormal fusion of the skull bones, surgery
will be required to separate the skull bones allowing them to grow as the
brain grows to enable normal brain development.
Generally the shape of the baby’s head, when you
look down on it from above, has a different look to it
when there is positional plagiocephaly compared to
craniosynostosis. Positional plagiocephaly has a
parallelogram look from above, so the opposing
sides are relatively even in size, like the photo on the
left - it looks as if everything has just been moved
around a bit, so the forehead and the ear are further
forward on the side of the flat spot.
On the other hand, in craniosynostosis, the opposing sides look different and
one side may be much shorter than the other or the head can be very flat or
very pointed and narrow. If this is the case with your baby, see your doctor as
an x-ray or sometimes a CT scan may be needed to check whether the skull
bones are fused.
Positional Plagiocephaly (Deformational Plagiocephaly)
Sometimes, babies are born with a flat spot on their head because of the way
they have been positioned in the uterus before birth. If allowed, the head
shape will remold to a normal oval. If not allowed to remold because the flat
spot always has pressure on it, the flat spot will persist and may even get
worse.
Babies can also be born with normal shaped heads and because of the way
they lie, they can develop a flat spot on the head because there is always
pressure on one spot. Sometimes, babies have tighter neck muscles on one
side so they tend to look towards that side more - this muscle tightness is
called torticollis. This can lead to plagiocephaly because the baby always
tends to hold the head to one side and there is always pressure on one spot
of the head.
There are simple things you can do to protect your baby’s head shape if it is
normal or to allow the head to naturally remold if there is already
plagiocephaly. The key is to allow space for the head to remold. The sooner
you start the better the result.
Back to sleep
Since the Back to Sleep campaign, where we advise that babies sleep on
their backs to reduce the risk of Sudden Infant Death Syndrome (SIDS), there
has been an increase in positional plagiocephaly. However, this is not a
reason to change the sleeping position. It is safest for babies to sleep on their
backs. There are strategies you can adopt to reduce plagiocephaly while still
putting your baby to sleep on his back. The most important things are
reducing the time your baby is on his back when not sleeping and by
changing the position of the head when he sleeping to take pressure off the
flat spot. These strategies will be outlined below but the key is to limit time
that the baby is immobile on his back when not sleeping and to encourage
spontaneous and unhindered movement.
Tummy time
An important strategy for reducing or preventing plagiocephaly is tummy time.
This is time your baby spends on his tummy when awake. We don’t know the
exact time that is necessary but try to have your baby on his tummy for at
least 5 minutes per day. If your baby doesn’t seem to like being on his tummy
at first, start by lying him on your chest, talk gently and make eye contact.
Alternatively, get on the floor with your baby making eye contact and giving
him reassurance that everything is okay.
It is important that your baby is awake and supervised when having tummy
time. Tummy time is time when the head has no pressure on it, so it can
remold to a normal shape.
Tummy time has an additional benefit - it is very good for baby’s development
as it helps develop good tone in the trunk muscles which is necessary for
later milestones like sitting, which will also allow the head room to remold.
Torticollis
Torticollis occurs when there is an imbalance in the sternomastoid muscles in
the neck, with the muscles on one side being shorter and therefore tighter
than the other side. This means that the head will tend to turn to that side.
This can occur because of the way the baby was lying in the uterus. It can
predispose to plagiocephaly because the baby always tends to look to one
side and as the bones on the head are relatively soft and malleable, that side
of the head will be flatter.
Treatment of torticollis is usually physiotherapy (physical therapy) to gently
stretch the tight muscles. This may need to be supervised by a professional if
the torticollis is severe, but less severe cases can be treated at home with
caution.
The American Academy of Pediatrics (AAP) has issued the guidelines below
on what you can do as a mother if your baby has torticollis. Remember when
turning your baby’s neck from side to side, never force it and keep the stretch
gentle.
• At every diaper change, holding one hand on your baby’s chest, use the
other hand to:
• gently turn your baby’s head to each side (chin to shoulder) three times
in all, holding at each side for a count of 10. So right side hold for 10, left
side hold for 10 and then repeat two more times on each side.
• gently lean your baby’s head to each side (ear to shoulder) three times in
all, holding at each side for a count of 10. So right side hold for 10, left
side hold for 10 and then repeat two more times on each side.
If there is no improvement after a couple of weeks, see your doctor as referral
to a physical therapist (physiotherapist) may be required.
Strategies for Protecting the Head Shape
Normal head shape
The list below gives strategies for protecting the head shape if your baby has
a normal head shape.
• When you put your baby to sleep on his back, alternate the side his head
lies on. Some parents put a picture on the side of the crib and change this
from side to side at each sleep time (to remind them which side to put the
baby's head to sleep and to give the baby something to look at).
• When your baby is on his back, make sure you alternate where all the
interesting things to look at are. You might want to turn the crib around at
each sleep or alternate the end you put your baby's head to make sure your
baby doesn't get in the habit of always looking one way.
• When your baby is awake and you can watch him, give him supervised
"tummy time". Put him on his tummy for at least 5 - 10 minutes per day
when you can watch him.
• Do not let your baby spend too long on his back if he is not sleeping.
• Do not let your baby spend too long in car seats if he is not traveling.
• Do not leave your baby in a baby hammock for prolonged periods
Plagiocephaly
If your baby has plagiocephaly already, you need to take the pressure off the
flat spot so there is space for it to remold. Use the strategies below.
• Place your baby to sleep with the rounded part of the head on the mattress.
The purpose is for the flat spot on the head to be free from pressure.
Wedges that sit under the flat spot to maintain the baby's head on the
rounded part have been advocated in the past but as these are a potential
hazard for babies, they are no longer recommended. Also the baby may end
up with pressure from the wedge on the flat spot and that defeats the whole
purpose.
• If your baby moves from the initial position back onto the flat spot, reposition
his head onto the rounded part.
• Make sure that the interesting things to look at are on the side away from
the flat spot on head.
• Vary the holding positions so the head has no pressure on it, eg. hold with
the baby over your shoulder.
• Give your baby at least 5 - 10 minutes of supervised "tummy time" every
day. Your baby must be awake and you must be supervising this, though.
Never let your baby fall asleep on his front.
• Do not let your baby spend too long on his back if he is not sleeping.
• Do not let your baby spend too long in car seats if he is not traveling.
• Do not leave your baby in a baby hammock for prolonged periods hammocks that encase the baby’s head do not allow any space for
remolding to occur.
• When your baby is on his back, make sure the interesting things to look at
are on the side away from the flat spot on his head to encourage him to look
that way and take the pressure off the flat spot.
• Continue to put your baby to sleep on his back - this is the safest way for
babies to sleep.
It may take 2-3 months to see an improvement in head shape. The flat spot
on the head will remold if it has no pressure on it, so if there is space for it to
remold. The earlier you start, the more likely you are to see results.
Helmets for Plagiocephaly
Some countries treat plagiocephaly with helmets. The helmet is made so
there is space for the flat part of the head to remold and to remove pressure
from that part of the head. When helmets are used, they are worn for 23 out
of 24 hours and it is essential that the helmet is designed individually for the
baby’s head shape. Helmets work best when used between 4 and 8 months
of age.
There is no conclusive evidence that helmets are better in the long run than
positioning and the other strategies outlined above.
If helmet therapy is not available to you, don’t despair as just following the
strategies outlines above will eventually give the same result as a helmet.
When to Seek Medical Attention
See your doctor if:
• your baby's head shape is getting more asymmetric despite your
interventions
• your baby has a very tight neck muscle - your baby may need to see a
physiotherapist
• when you look from above, your baby's head looks more like a rhomboid
shape (the opposing sides are not the same length) - your baby may have
fused skull bones. Positional plagiocephaly looks more like a parallelogram
from above (so the opposing sides are similar lengths)
• your baby's head is very flat
• your baby's head is very narrow and long
• your baby's head is very asymmetrical
• you are concerned about your baby's development
Appendix 1
Safe and Healthy Sleep Reminders for Your Baby
You can print out the 2 pages that follow, laminate them and have them near
your baby’s sleep area. You can also give them to carers, including
grandparents, so everyone does the same safe things for your baby
regarding sleep.
Safe Sleep Guide for ______________________
I sleep on my back
I sleep with my face clear
I sleep with my feet at the end of the crib
I sleep on a firm flat mattress that fits snugly in the crib
I do not need a pillow
I have my bedcovers tucked in firmly
The bedcovers only come up as high as my shoulders
There are no loose blankets or objects in my crib
I do not like to be too hot
I do not need a hat when sleeping inside
If the room is heated, please do not heat the room temperature above 20 degrees C
(68 degrees F)
Other (delete as appropriate):
I suck on a pacifier as I go to sleep
I like to be swaddled
What you can do for me
After you tuck me in, have a 360 degree look around the room to check there are no
hazards, eg. Dangling cords
Do not smoke around me and keep my room smoke free
Make sure I don't always sleep on the same side of my head, especially if I have a flat spot
Alternate the side my head lies on at every sleep
Reposition my head so I am not lying on the flat spot
Healthy Sleep Guide for ___________________
Please put me in my crib to sleep when I start to look tired and before I fall asleep
Signs I am getting sleepy include:
Yawning
My eyes closing
Becoming irritable
___________
___________
I like having a sleep routine
I usually go to bed at __________ for my night sleep
I usually have naps at ________
________
________
My usual nighttime routine is:
________________________
________________________
________________________
________________________
________________________
________________________
Eg. Feed, play time, bath, quiet time
Appendix 2
References
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Management of Positional Skull Deformities in Infants. Pediatrics 2003;
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• Royal Children's Hospital, Melbourne. KidsInfo Factsheets. Deformational
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• Ministry of Health, New Zealand. Protecting your baby's head shape.
February 2004. Code 1227. Ministry of Health, New Zealand
• Period of PURPLE CRYING - information website on Purple Crying
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• van Sleuwen et al. Swaddling. A Systematic Review. Pediatrics 2007, Oct.
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Appendix 3
Abbreviations
SUDI! !
!
Sudden Unexpected Death in Infancy
SUID! !
!
Sudden Unexpected Infant Death (same as SUDI)
SIDS! !
!
Sudden Infant Death Syndrome
REM ! !
!
Rapid Eye Movement (sleep state)
non REM!
!
non Rapid Eye Movement (sleep state)
UK!
!
United Kingdom
!
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