Experts on Camera

Dr. Rachel Moon: Safe sleep for infants

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October is Safe Sleep and SIDS Awareness Month.

On Wednesday, October 12, 2022, SciLine interviewed: Dr. Rachel Moon, a professor of pediatrics at the University of Virginia and the chair of the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome (SIDS). She discussed topics including: statistics on SIDS, including trends over time; the safest ways for babies to sleep, and the evidence behind those recommendations; what parents and other caregivers should know about the recent viral headlines claiming a study had found “the cause” of SIDS; and her research on factors that influence parental decisions about where and how their infants sleep.

Declared interests:

Dr. Moon is chair of the American Academy of Pediatrics Task Force on SIDS and a board member of the International Society for the Prevention of SIDS and Stillbirth, both volunteer positions. She receives grant funding from the National Institutes of Health.

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RACHEL MOON: My name is Rachel Moon. R-A-C-H-E-L—last name, M-O-O-N. I am a professor of pediatrics. I’m a general pediatrician and a SIDS researcher at the University of Virginia.


Interview with SciLine

October is SIDS Awareness Month. What is SIDS?


RACHEL MOON: SIDS is technically—it stands for sudden infant death syndrome. And it is a term that describes when babies die suddenly and unexpectedly. It has been superseded by a more comprehensive term called sudden and unexpected infant death, which encompasses SIDS and then other sleep-related deaths, so deaths that occur when a baby is sleeping or in a sleep-related—or in a sleep environment.

What exactly causes these babies to die?


RACHEL MOON: That’s a little bit of a complicated question, and it probably depends upon the baby. But ultimately what happens is that for most babies, there is a lack of arousal. They can’t wake up to respond when they are not getting enough oxygen or there’s too much carbon dioxide in their system. Most of us and most babies would wake up, but for whatever reason—and probably it is an innate defect or issue with that baby—they cannot wake up. And this is not something that you can see in a lab test or a blood test or any kind of test. We only find out when the baby has died.

What is the Back to Sleep campaign, and what effect has it had?


RACHEL MOON: The Back to Sleep campaign was started in the 1990s, and it was a cooperative effort by the National Institutes of Health, the American Academy of Pediatrics, the Centers for Disease Control and several other organizations to encourage families to put their babies on the back. At that point, back positioning had recently become known as a major risk factor for sudden, unexpected death. However, since then, we understand that it’s more than just a sleep position. It’s also the sleep environment. So, where the baby is sleeping, what the baby is sleeping with. And so, the Back to Sleep campaign has now been supplanted by the Safe to Sleep campaign, which encompasses all of those aspects of the sleep environment.

Can you share some statistics, and trends in the data, on Sudden and Unexpected Infant Death?


RACHEL MOON: When we talk about trends, we know that with the Back to Sleep campaign, which started in the 1990s and encouraged families to put their babies on the back, that the rates of sudden and unexpected infant death declined by about 50%. That number has not changed at all since about 1995. So, for the past almost 30 years, the death rate of children who die suddenly and unexpectedly has been about 3,400-3,500 deaths a year.

What is the safest way for babies to sleep, and why?


RACHEL MOON: We want every baby to sleep on their back on a surface that is firm and flat, which means not inclined, and safety-approved. So, ideally a crib, a bassinet, a playpen or another product that is approved by the CPSC, the Consumer Product Safety Commission, as—and has safety standards. And then nothing should be in that area but the baby. We also want babies to be in a smoke-free environment and ideally to get as much human milk, breast milk, as possible.

What should parents and other caregivers know about the recent headlines claiming a study had found “the cause” of SIDS?


RACHEL MOON: These researchers—they looked at dried blood spots. And these are the tests that are done on your baby when your baby is born. And these tests look for genetic diseases. And then they took these dried blood spots and looked for a particular chemical that’s in the body called butyrylcholinesterase. And butyrylcholinesterase they found to be at a different level in babies who died from SIDS than babies who did not die from SIDS. The problem is that when you look at the levels, statistically the mean levels were the same. But there is a tremendous amount of overlap in the levels. And so, 50% of the babies who did not die actually had levels that were abnormal. And 50% of the babies who died had levels that were normal. And so, that—you can’t really have a screening test when 50% of the results are incorrect and are not predictive. So, while I think it’s an interesting result, and while it may lead to other tests and other studies, at this point, it is not the be-all and end-all. And we don’t have a test that can diagnose who is going to die from SIDS and who’s not. And so, you still have to follow the safe sleep guidelines.

What is known about the safety of letting a baby nap in a sling or baby carrier?


RACHEL MOON: When babies sleep in a sling or a baby carrier, there—first of all, there are a lot of different types of baby carriers and slings. And the thing that we worry about is that when a baby is in that kind of device, that the baby—the baby’s body position can be such that it blocks their airway or that they are—their face is up against something that can obstruct their airway. So, it’s fine for the baby to be in a carrier or a sling, but we recommend that the baby be upright so that the head and neck are straight and that the airway is straight. And then we also recommend that the baby’s head and neck be above the top of the carrier so that you can always see the baby’s face and that there’s no obstruction of the of the nose and the mouth.

What is known about the safety of letting a baby nap in a car seat?


RACHEL MOON: So, with regards to car seats, we know that babies who sleep flat, that—are the safest. And the reason for that is that when—there is actually some really compelling biomechanical data that led to the CPSC, the Consumer Product Safety Commission, restricting and hopefully banning inclined sleep products such as rockers and products such as that. And the reason is that when babies are at an incline, it’s actually harder for them to keep their airway straight. Their heads are really big and heavy for the size of their bodies. And so, it takes a lot more work when they are at an angle than if they’re flat on their back. And so, when they are at an angle, they actually use more muscles. They use more muscles in their head and neck area. They use more muscles in their abdominal area. And they can actually fatigue—they can develop muscle fatigue, and that can actually be dangerous for them. So, we don’t recommend that babies sleep for prolonged periods of time on an inclined sleep product. With regards to car seats, if you are traveling, a car seat is absolutely the safest place for your baby to be. However, when you get to where you’re going, then it is best if you take the baby out of the car seat and then put the baby on a flat, firm surface.

What sleeping situations are dangerous for babies?


RACHEL MOON: Babies should never, ever, ever sleep on couches, sofas or stuffed armchairs because that is probably the most dangerous place for babies to sleep.

What is the evidence on the safety of “co-sleeping,” where babies sleep in bed with their parents?


RACHEL MOON: The safest place for your baby to sleep is in a crib or bassinet or another safety-approved device that is next to your bed. We know that babies who sleep in the same bed as their parents are at higher risk for death. And so, the safest place is going to be in a space right next to your bed. We recommend for the space to be right next to your bed because that makes it easy for you to turn and pick up the baby or comfort the baby or bring the baby into bed for feeding. If you do bring the baby in for—into the bed for feeding, that’s fine. And—but when you and/or the baby gets ready to fall asleep, then just move the baby back into the crib. And that’s going to be the safest place for your baby. And I think that you’ll sleep more comfortably as well because you’ll know that your baby is safe, and you don’t have to worry about your baby.

How are reporters doing covering infant sleep issues?

[Posted October 12, 2022 | Download video]