11.5.2: Sleep

Learning Objectives

1. Describe typical infant sleep patterns and changes during the first two years of life.
2. Explain the major categories of Sudden Unexpected Infant Death (SUID) and related risk factors.
3. Identify current safe sleep practices recommended to reduce the risk of SIDS and other sleep-related deaths.
4. Compare and contrast cultural perspectives on co-sleeping and evaluate the influence of sleeping environments on infant safety.

Sleep Patterns

A newborn typically sleeps approximately 16.5 hours per 24-hour period. This is typically polyphasic sleep, in which the infant accumulates 16.5 hours over several sleep periods throughout the day (Salkind, 2005). The infant averages 15 hours per 24-hour period by one month and 14 hours by 6 months. By the time children turn two, they are averaging closer to 10 hours per 24 hours. Additionally, the average newborn will spend close to 50% of the sleep time in the Rapid Eye Movement (REM) phase, which decreases to 25% to 30% in childhood.⁷⁰

Safe Sleep

Sudden Unexpected Infant Deaths (SUID)

Each year in the United States, there are about 3,500 Sudden Unexpected Infant Deaths (SUID). These deaths occur among infants less than one year old and have no immediately obvious cause (CDC, 2015). The three commonly reported types of SUID are:

• Sudden Infant Death Syndrome (SIDS): SIDS is identified when the death of a healthy infant occurs suddenly and unexpectedly, and medical and forensic investigation findings (including an autopsy) are inconclusive. SIDS is the leading cause of death in infants 1 to 12 months old, and approximately 1,529 infants died of SIDS in 2018 (CDC, 2022)¹. Because SIDS is diagnosed when no other cause of death can be determined, possible causes of SIDS are regularly researched. One leading hypothesis suggests that infants who die from SIDS have abnormalities in the area of the brainstem responsible for regulating breathing (Weekes-Shackelford & Shackelford, 2005).
• Unknown Cause: The sudden death of an infant less than one year of age that cannot be explained because a thorough investigation was not conducted, and the cause of death could not be determined.
• Accidental Suffocation and Strangulation in Bed: Reasons for accidental suffocation include: Suffocation by soft bedding, another person rolling on top of or against the infant while sleeping, an infant being wedged between two objects such as a mattress and wall, and strangulation such as when an infant’s head and neck become caught between crib railings. The percentages of infants who died based on each of the three types are listed in Figure \(\PageIndex{1}\).

Figure \(\PageIndex{1}\). According to the CDC's 2022 statistics, there were approximately 3,700 SUID cases in the United States. Source: CDC/NCHS, National Vital Statistics System¹

Risk Factors

Babies are at higher risk for SIDS if they:

• Sleep on their stomachs
• Sleep on soft surfaces, such as an adult mattress, couch, or chair, or under soft coverings
• Sleep on or under soft or loose bedding
• Get too hot during sleep.
• Are exposed to cigarette smoke in the womb or their environment, such as at home, in the car, in the bedroom, or other areas
• Sleep in an adult bed with parents, other children, or pets; this situation is especially dangerous if:
  • The adult smokes, has recently had alcohol, or is tired.
  • The baby is covered by a blanket or quilt.
  • The baby sleeps with more than one bed-sharer.
  • The baby is younger than 11 to 14 weeks of age.

Figure \(\PageIndex{2}\): A baby sleeping safely. Image by the U.S. Department of Health and Human Services is in the public domain.

Reducing the Risks

There have been dramatic improvements in reducing baby deaths during sleep since the 1990s, when recommendations were introduced to place babies on their back for sleep. However, since the late 1990s, the decline has slowed.

Figure \(\PageIndex{3}\): A graph showing the decline in sleep-related infant deaths. Image by the CDC is in the public domain.

In 2012, the "Back to Sleep" campaign was renamed the "Safe to Sleep" campaign. Safe to Sleep aims to educate all caregivers about SIDS and safe sleep practices. Current recommendations to reduce the risk of SIDS and other sleep-related causes of infant death:

• Always place the baby on their back to sleep (for naps and at night).
• Use a firm and flat surface.
• Use only a tight-fitting sheet on the sleep surface; no other bedding or soft items in the sleep area.
• Breastfeed.
• Share your room with a baby, but on a separate surface designed for infants (not your bed).
• Do not put soft objects, toys, crib bumpers, or loose bedding under, over, or anywhere near the baby’s sleep area.
• Do not smoke during pregnancy or allow smoking around the baby.
• Consider giving the baby a pacifier.
• Do not let the baby get too hot during sleep.
• Get regular health care (including vaccines).
• Avoid products that contradict safe sleep recommendations, especially those that claim to prevent or reduce the risk of Sudden Infant Death Syndrome (SIDS).
• Do not use heart or breathing monitors to reduce the risk of SIDS. ⁷⁴

Should infants sleep in the same bed as their parents?

Colvin, Collie-Akers, Schunn and Moon (2014) analyzed a total of 8207 deaths from 24 states during 2004–2012 that were contained in the National Center for the Review and Prevention of Child Deaths Case Reporting System, a database of death reports from state child death review teams. The results indicated that younger victims (0-3 months) were more likely to die from bed-sharing and sleeping in an adult bed/on a person. A higher percentage of older victims (4 months to 364 days) rolled into objects in the sleep environment and changed position from side/back to prone. Carpenter et al. (2013) compared infants who died of SIDS with a matched control and found that infants younger than three months old who slept in bed with a parent were five times more likely to die of SIDS compared to babies who slept separately from the parents, but were still in the same room. They concluded that bed sharing, even when the parents do not smoke, take alcohol, or use drugs, increases the risk of SIDS. However, when combined with parental smoking and maternal alcohol consumption and/or drug use, risks associated with bed sharing greatly increase.

The two studies discussed above were based on American statistics. What about the rest of the world? Co-sleeping is a common practice in many cultures, primarily due to a more collectivist perspective that fosters a close parent-child bond and interdependent relationship (Morelli, Rogoff, Oppenheim, & Goldsmith, 1992). In countries where co-sleeping is common, however, parents and infants typically sleep on floor mats and other hard surfaces, which minimize the suffocation that can occur with bedding and mattresses (Nelson, Schiefenhoevel, & Haimerl, 2000).

References, Contributors and Attributions

1. Centers for Disease Control and Prevention. (2023, October 10). Data and statistics for SIDS and SUID. U.S. Department of Health and Human Services. https://www.cdc.gov/sids/data.htm

70. Lifespan Development: A Psychological Perspective by Martha Lally and Suzanne Valentine-French is licensed under CC BY-NC-SA 3.0

71. Lifespan Development: A Psychological Perspective by Martha Lally and Suzanne Valentine-French is licensed under CC BY-NC-SA 3.0

74. Ways to Reduce the Risk of SIDS and Other Sleep-Related Causes of Infant Death by the CDC is in the public domain

Carpenter, R., McGarvey, C., Mitchell, E. A., Tappin, D. M., Vennemann, M. M., Smuk, M., & Carpenter, J. R. (2013). Bed sharing when parents do not smoke: Is there a risk of SIDS? An individual level analysis of five major case–control studies. BMJ Open, 3:e002299. doi:10.1136/bmjopen-2012-002299

Colvin, J.D., Collie-Akers, V., Schunn, C., & Moon, R.Y. (2014). Sleep environment risks for younger and older infants. Pediatrics Online. Retrieved from http://pediatrics.aappublications.or…-0401.full.pdf

Morelli, G., Rogoff, B., Oppenheim, D., & Goldsmith, D. (1992). Cultural variations in infants’ sleeping arrangements: Questions of independence. Developmental Psychology, 28, 604-613.

Nelson, E. A., Schiefenhoevel, W., & Haimerl, F. (2000). Child care practices in nonindustrialized societies. Pediatrics, 105, e75.

Salkind, N. J. (2005). Child development (4th ed.). Thomson Wadsworth.

Weekes-Shackelford, V. A., & Shackelford, T. K. (2005). Methods of death: Can the type of physical trauma influence the classification of infant deaths? Journal of Forensic Sciences, 50(3), 513–518. https://doi.org/10.1520/JFS2004075