At what age can infants begin sleeping on their stomachs? is 4, 5, or 6 months safe? or are there any benefits to tummy sleeping or what if they roll over during their sleep?
If you have questions like these, I’ve got you covered. I’ve compiled detailed and helpful guidelines based on the latest safe sleep recommendations. They will help you understand the risks, benefits, appropriate age, and safe practices for transitioning your infant to tummy sleeping, whether supervised or unsupervised.
- AAP recommends infants sleep on their backs(babies aged 1 to 12 months)
- Tummy sleeping before their 1st birthday can increase the risk of SIDS.
- Tummy sleeping can have benefits for babies, such as strengthening their upper body and improving motor skills.
- Once your baby learns to roll over independently, it is safe to let them sleep on their stomachs.
- While some infants may prefer sleeping on their tummies facing down, you can train them to sleep on their back following the tips in this guide.
In this guide:
- When can babies sleep on their backs?
- Myths about baby sleeping on their backs;
- What research says about supine sleep position:
- Benefits of babies sleeping on their backs:
- Challenges associated with having babies sleep on their backs:
- Is it safe for babies to sleep on their stomachs?
- Is it safe to place your baby on their stomach?
- How to mitigate back-sleep flat head syndrome challenge:
- Is it OK for the baby to sleep on the side?
- Tips for Safe Sleep for Babies:
As a new parent, you may have heard conflicting advice about when it is safe for your infant to begin sleeping on their stomachs. Some sources may suggest that tummy sleeping can be beneficial for babies, while others warn against the potential risks of Sudden Infant Death Syndrome (SIDS).
It can be overwhelming and confusing to navigate these recommendations, but it is important to prioritize your child’s safety when making decisions about their sleep.
When can babies sleep on their backs?
According to the American Academy of Pediatrics (AAP), placing infants on their backs to sleep is the safest position, especially for babies aged 1 to 12 months. This position helps reduce the risk of SIDS, which is the leading cause of death in infants between 1 month and 1 year old. By following this recommendation, parents can significantly reduce the risk of SIDS.
Ever since AAP’s first safe sleep report in 1992, which advocated for placing babies on their backs for sleep, several subsequent studies, almost 10 in total, have emerged to support this recommendation.
Below is a snapshot of AAP’s safe sleep guidelines. I have highlighted the back sleep guidelines;
Ensuring that babies are placed to sleep on their backs is particularly crucial for minority communities, specifically African Americans. Research has demonstrated their increased susceptibility to Sudden Infant Death Syndrome (SIDS), prompting the American Academy of Pediatrics (AAP) to launch a campaign dedicated to addressing this concern.
Another reputable organization under the US Department of Human Services, the National Institute of Child Health and Human Development (NICHHD) also recommends back sleeping, and below is a direct quote from its website;
The most effective action that parents and caregivers can take to reduce baby’s risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related death is to always place baby on their back to sleep, for naps and at night.
The back sleep position is the safest sleep position for all babies, including those born preterm and those with reflux, until they are 1 year old.NICHHD
Below is a snapshot;
The sleep position of an infant has a significant impact on their health and safety. Following the correct sleep guidelines is essential, and it is encouraging to see reputable organizations uniting in advocating for the back sleeping position.
As a parent or caregiver, always remember that placing babies on their backs to sleep reduces the risk of SIDS and other sleep-related deaths. It is also crucial to note that this sleeping position should be followed for both naps and nighttime sleep until the baby reaches one year old. After this age, babies can roll over and change their sleeping positions independently.
However, it is essential to point out that some exceptions apply. In certain medical conditions, a doctor may recommend a different sleep position for an infant. These conditions include severe gastroesophageal reflux (GERD), congenital heart diseases, or any other condition that affects the airway. In such cases, it is vital to follow the doctor’s instructions and ensure that the baby sleeps safely.
Myths about baby sleeping on their backs;
There is or used to be a widespread myth/belief that if a baby sleeps on their back, it increases the risk of choking on their spit-up. This is not true, however, as infants have reflexes that allow them to swallow or cough up any fluids or solids that enter the wrong pipe so this can be ruled out as a potential risk.
There is research to back up this claim.
In a comprehensive analysis conducted in 2005 by Ruth Gilbert et al., examining over 30 books that recommended various sleep positions from 1940 to 2002, it was discovered that several researchers had mistakenly advocated for stomach sleeping positions, as indicated in the chart below. Notably, there were no further recommendations for infant stomach sleeping after 1988. This finding sheds light on the evolution of sleep position recommendations over time.
What research says about supine sleep position:
A comprehensive study conducted in 2022 by Mayank Priyadarshi et al. examined 54 studies involving a total of 474,672 participants, including 43 observational studies and 11 intervention trials. This study yielded compelling evidence regarding the impact of sleep position on the risk of Sudden Unexpected Death in Infancy (SUDI) and Sudden Infant Death Syndrome (SIDS) in infants.
The findings suggest that the supine sleep position offers a potential reduction in these risks. The odds ratio for SUDI in relation to the back-sleep position was found to be 0.39 with a 95% confidence level, while the odds ratio for SIDS was 0.51, also with a 95% confidence level.
It is noteworthy that for infants below 6 months of age, the supine position increased the odds ratio to 1.67, but its impact on children up to 18 months was negligible. Additionally, it is worth considering that positional plagiocephaly may potentially increase in infants between 2 and 7 months of age who sleep in the supine position.
Moreover, it is worth noting that over 90% of all SIDS deaths occur within the first 6 months of a child’s life and 72% happen within the 1st and the 4th month as per NIH report here.
Benefits of babies sleeping on their backs:
Apart from reducing the risk of SIDS, there are other benefits to having babies sleep on their backs. These include:
- Clear airway: When a baby sleeps on its back, gravity pulls the tongue forward, allowing for an open airway. This is especially crucial in cases where the infant has a condition that affects their breathing.
- Rebreathing carbon dioxide: When an infant is placed on their stomach, they may rebreathe carbon dioxide from their exhaled breaths as there is no way for the air to escape. This can lead to dangerously high levels of carbon dioxide in the bloodstream.
- Regulating body temperature: Placing an infant on their back allows for better regulation of their body temperature. Sleeping on their stomach can cause overheating, which is a risk factor for SUIDs. Sleeping on the back allows heat to dissipate from the body, reducing the risk of overheating.
- Preventing suffocation: Babies who sleep on their stomach are at a higher risk of suffocation as they may accidentally bury their face in the mattress or bedding. This can lead to difficulty breathing and even death.
- Better quality sleep: It is easier for a baby to achieve deep sleep when sleeping on their backs. This is because they are not required to maintain a specific position, allowing them to move and shift naturally.
- Less pressure on the skull: When an infant sleeps on their back, there is less pressure exerted on the skull, reducing the risk of cranial deformities.
- Easier for caregivers: Caregivers can easily check on a baby’s breathing and reduce the risk of suffocation when they sleep on their backs.
Challenges associated with having babies sleep on their backs:
While it is highly recommended for infants to sleep on their backs, there are some challenges associated with this sleeping position. These include:
- Flat head syndrome: Sleeping on the back can increase the risk of developing a flat head or plagiocephaly in infants. If you place an infant to sleep on their back for several hours a day a spot in their heads can start to flatten. Read more about positional Plagiocephaly here.
- Reflux: Babies who suffer from gastroesophageal reflux (GER) may have difficulty sleeping on their backs as it can worsen their symptoms. In such cases, it is important to consult a pediatrician for proper management and positioning advice.
- Obstructive sleep apnea: In rare cases, infants may experience obstructive sleep apnea when sleeping on their backs. This condition occurs when the airway becomes blocked during sleep, leading to breathing difficulties. If your baby shows signs of difficulty breathing or excessive snoring, consult a pediatrician for further evaluation and management. Read the symptoms at Mayo’s website here.
- Difficulty with rolling over: As babies grow and develop, they may naturally start to roll over onto their stomachs while sleeping. However, some infants may struggle with this milestone if they are used to sleeping on their backs. Caregivers need to monitor their baby’s progress and encourage tummy time during playtime to help strengthen their muscles and promote successful rolling over.
Is it safe for babies to sleep on their stomachs?
It is not recommended by healthcare experts to put an infant under 1 year old to sleep on their stomach. The American Academy of Pediatrics advises caregivers to place infants on their back until they are at least 1 year old, including during daytime naps. After the child turns 1 year old, there is no need to enforce back-sleeping
Below are some of the risks of transitioning to tummy sleep before your baby turns 1 year;
- Overheating: Sleeping on the stomach can cause your baby to overheat, especially if they are swaddled or dressed too warmly. This can increase their risk of sudden infant death syndrome (SIDS).
- Breathing in exhaled air (air that has already been breathed out), which can result in decreased oxygen levels (hypoxia) or increased carbon dioxide levels (hypercapnia).
- Temporary alterations in cardiovascular and respiratory function and regulation may impact the brain’s oxygen supply.
While tummy time is recommended as a strategy to reduce risk, swaddling is not. According to the latest safe sleep guidelines by AAP in 2022, there is insufficient evidence to recommend swaddling as a strategy to reduce the risk of SIDS.
If infants are swaddled, it is important to always place them on their back. Weighted swaddles, clothing, or objects near the baby are not safe and not recommended. Once an infant starts showing signs of attempting to roll, typically around 3 to 4 months but possibly earlier, swaddling is no longer appropriate as it could increase the risk of suffocation if the swaddled infant rolls onto their stomach.
Infants below 6 months should particularly sleep on their backs:
To reduce the risk of Sudden Infant Death Syndrome (SIDS), it is vital to adhere to safe sleep guidelines. During the first 6 months, when infants lack the strength and coordination to roll over effortlessly while sleeping, placing them on their back for sleep is crucial. This precaution becomes even more important considering that most SIDS deaths occur before infants reach 6 months of age.
It’s not that infants aged 7 months and older are out of danger. It’s just that at this age, they possess better head control, so when babies turn their heads during sleep, they can still get enough air to breathe.
The safe sleep guidelines emphasize that infants should be placed on their backs for all sleep times until they are 1 year old, including daytime naps. This is because the risk of SIDS is highest during the first year of life and decreases significantly after a baby turns 1 year old.
The exact cause of SIDS is still unknown to doctors, but research has uncovered various factors that heighten an infant’s risk. While experts consider sleeping position as the primary risk factor for SIDS, there are also other contributing factors to be mindful of;
- Resting on plush surfaces such as couches, chairs, or adult-sized mattresses
- Using soft or loose bedding, including blankets, while sleeping
- Experiencing excessive warmth during sleep
- Being exposed to cigarette smoke in the bedroom, car, or other environments
- Sharing a bed with caregivers, other children, or pets
What if Your Baby Rolls Over on Their Stomach During Sleep?
Babies reaching the milestone of rolling over from back to stomach or vice versa is a natural part of their development. Typically occurring between 4 to 6 months old, this increased mobility allows them to reposition themselves comfortably during sleep.
While it’s important to start each night with the baby sleeping on their back in a safe sleep environment, you do not need to constantly check on them if they roll onto their stomachs. Just ensure the sleeping area is free from blankets and other loose objects.
However, if your baby is consistently rolling onto their stomach and having trouble returning to the back position, it may be a sign that they are not yet ready for that sleeping arrangement. In this case, consult with your pediatrician for guidance on when and how to transition to stomach sleeping.
Is it safe to place your baby on their stomach?
It is generally recommended that healthy infants be placed on their backs to sleep. This is because the supine position (on the back) allows for better air flow and reduces the risk of suffocation. However, there are some situations where placing a baby on their stomach may be safe or even necessary:
- During supervised tummy time sessions, which help promote motor skills and prevent flat spots on the head
- When a baby is strong enough to roll over on their own and chooses to sleep on their stomach
According to experts, it is recommended that babies engage in at least 30 minutes of tummy time each day. You can start with short periods of 3 to 5 minutes multiple times throughout the day. As the child begins to enjoy tummy time, these sessions can be gradually extended. It is important to note that tummy time requires close supervision and should not be used as a sleep position for infants.
Tummy time during playtime:
Although tummy sleep is not recommended for infants, tummy time during playtime is highly encouraged. This allows babies to strengthen their neck and shoulder muscles, build motor skills and promote healthy development. Some tips for successful tummy time during playtime include:
- Start with short periods of 3 to 5 minutes each day
- Use a blanket or mat on the floor as a soft surface
- Place toys in front of them to keep them entertained
- Get down on the floor with your baby to encourage interaction
- Gradually increase the duration of tummy time as the child becomes more comfortable
The updated 2022 Safe Sleep Guidelines by AAP introduced tummy time as a measure to reduce infant sleep-related deaths. This recommendation emphasizes the importance of providing infants with supervised time on their tummies as part of safe sleep practices. Below is a direct quote from the guidelines;
Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of positional plagiocephaly. Parents are encouraged to place the infant in tummy time while awake and supervised for short periods of time beginning soon after hospital discharge, increasing incrementally to at least 15 to 30 minutes total daily by 7 weeks of age.
Below is a snapshot;
How to mitigate back-sleep flat head syndrome challenge:
Below are ways to prevent flat head syndrome with back-sleeping;
- Tummy time: As mentioned earlier, supervised and awake tummy time can help prevent flat spots on the head. Aim for at least 15-30 minutes of tummy time daily, gradually increasing as your baby grows.
- Sleeping direction: Rotate the direction in which a child lies on their mattress every week.
- Changing head position: Alternate the side of your baby’s head that they rest on while sleeping, to prevent prolonged pressure on one spot.
- Minimize seat time: Restrict the usage of seats that exert pressure on the back of a child’s head, such as carriers and bouncy seats.
- Cradle an infant in an upright position: Take the time to hold a child upright while they are awake.
Do NOT use an infant head-shaping pillow:
There is some misleading guidance that recommends the use of infant head-shaping pillows. Note that these pillows are not safe and FDA recently put out a notice warning parents against using the pillows as they can increase the risk of suffocation. If you already own one, FDA recommends that you throw it away.
Below is a snapshot of the warning;
Is it OK for the baby to sleep on the side?
No. Side-sleeping is not a safe position for infants, as they are prone to rolling onto their stomachs, which is associated with an increased risk of Sudden Infant Death Syndrome (SIDs).
Research shows that there is an increased risk of SIDS for infants who initially sleep on their sides and later roll onto their stomachs, compared to infants who are consistently placed to sleep on their stomachs.
As I reviewed materials on side sleeping I was surprised that it was recommended more frequently by studies before 1988. Certain studies even indicated that placing a baby in a side position shortly after birth facilitates the removal of amniotic fluid and reduces the risk of aspiration. See the snapshot below;
The myth that propagated side-sleeping was due to the belief that it may assist in reducing the incidence of SIDS compared to sleeping on the stomach. The rationale behind this presumption was that vomiting is more likely to occur while lying on the back, increasing aspiration risk, especially with newborns whose esophagus is positioned above their airways.
However, all these claims turned out to be false when Dr. Peter Fleming, who is now an Emeritus Professor of Infant Health and Developmental Physiology at the University of Bristol in England, discovered that babies are more likely to awaken from sleep on their stomachs.
According to Dr. Fleming, while sleeping on the back or side, it’s easier for a baby to move around upon reaching the rapid eye movement (REM) phase of sleep. From an evolutionary perspective, newborns may have been prone to rolling onto their stomachs for survival since it’s easier to swallow and breathe in this position.
Other studies also show that babies who sleep on their backs are less likely to develop plagiocephaly (flat head syndrome) or positional plagiocephaly. This condition occurs when a portion of the baby’s skull becomes flat due to prolonged pressure on one spot. It’s why parents are now advised to give their babies belly time when they’re awake and supervised.
Furthermore, side-sleeping does not reduce the risk of SIDS, and it may actually increase the chances.
It was not until the revised AAP Safe Sleep recommendations in 2016 that side-sleeping was emphasized as an unsafe sleep position for infants up to the age of 1 year.
AAP indicated in the 2016 revised guidelines that side sleeping was a SIUD risk factor. It went further to recommend that “infants should continue to be placed supine until 1 year of age. Once an infant can roll from supine to prone and from prone to supine, the infant can be allowed to remain in the sleep position that he or she assumes.”
Tips for Safe Sleep for Babies:
In addition to the supine sleep position, there are other measures that you can take to ensure your baby’s safety while they sleep. These include:
Create a safe sleep space:
- Use a firm and flat sleep surface, such as a crib or bassinet.
- Remove all soft objects from the sleep space, including pillows, blankets, stuffed animals, and bumper pads.
- Avoid using inclined surfaces for sleeping, such as rockers or car seats.
A crib, bassinet or playpen with a firm mattress is the safest place for your baby to sleep. Make sure there are no soft objects or loose bedding like pillows, blankets or toys in the sleeping area. Make sure you purchase a secure sleep product that complies with the June 2021 rule set by the Consumer Product Safety Commission. According to this rule, any sleep product for infants must meet the established federal safety standards for cribs, bassinets, play yards, and bedside sleepers of being firm and flat, not inclined or soft.
Choose appropriate bedding:
- Use a fitted sheet that fits snugly on the mattress.
- Dress your baby in a sleep sack or swaddle instead of using loose blankets.
When choosing bedding for your baby’s sleep space, it is important to choose items that are appropriate and safe. This includes selecting fitted sheets that fit snugly on the mattress to prevent suffocation or entrapment risks. It is also recommended to dress your baby in a sleep sack or swaddle instead of using loose blankets, as this reduces the risk of suffocation and Sudden Infant Death Syndrome (SIDS).
Keep the room at a comfortable temperature:
- The ideal room temperature for a baby’s sleep space is between 68-72 degrees Fahrenheit.
- Avoid overdressing your baby and use lightweight, breathable fabrics for their sleepwear.
According to a study conducted in 1995 by A. Sawczenko and P. J. Fleming, overheating has been linked to an increased risk of Sudden Infant Death Syndrome (SIDs). The study emphasized that excessive wrapping, wearing hats, and covering the head can disrupt thermal balance and elevate the risk of SIDs. Here is the Study(PDF)
A separate study conducted in the United Kingdom revealed an interesting finding – while only a small number of babies wore hats, a significantly higher proportion of babies who experienced Sudden Infant Death Syndrome (SIDS) had their heads covered compared to the control group. Specifically, 18% of SIDS babies versus 2% of controls were found to have their heads covered. Remarkably, complete head covering emerged as the most influential risk factor among all.
Thermal stress can result in fatal outcomes through direct hyperthermia or hypothermia. Additionally, it can affect central control mechanisms by interfering with respiratory drive, the laryngeal closure reflex, or arousal mechanisms as per Lodemore et al. Study
Practice safe co-sleeping
Co-sleeping, also known as bed-sharing, is a common practice among parents with young babies.
According to the American Academy of Pediatrics, it is recommended that infants sleep in the same room as their caregivers, but on a separate surface, for the first year after birth. Research has shown that having a child sleep in the same room as their parents can decrease the risk of Sudden Infant Death Syndrome (SIDS) by as much as 50%.
Also, follow the ABCs of safe sleep (Alone, on their Back, in a Crib). Remember to always place your baby on their back for every sleep, including naps. Avoid placing soft objects or loose bedding in the crib as these can increase the risk of suffocation. Keep the room at a comfortable temperature and dress your baby appropriately for sleeping conditions.
Avoid second-hand smoke exposure:
Exposure to second-hand smoke has been linked to an increased risk of SIDS. Make sure to avoid smoking around your baby and keep them away from areas where others are smoking. See this Study.
Smoke reduces the amount of oxygen available to your baby and can damage their developing lungs. It is recommended that parents and caregivers avoid smoking, especially during pregnancy, as it increases the risk of SIDS even further.
Offer a Pacifier During Sleep Time
According to a study conducted in 2005 by Fern R. Hauck, MD et al., offering a pacifier to an infant before naps and nighttime sleep can reduce the risk of Sudden Infant Death Syndrome (SIDS) by up to 90%. It is recommended to introduce pacifiers to infants right away, although parents who breastfeed may want to wait for about 3 to 4 weeks until the baby is well-established with breastfeeding.
If your infant appears unwilling to use a pacifier before sleep, it’s best not to force it. Similarly, if their pacifier falls out during sleep, there is no need to disturb the child or reinsert it into their mouth. Make sure that the pacifier is not attached to clothing or blankets, and it should be kept free from any objects that could pose a hazard to the child during sleep, such as soft toys or strings.
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Sandra W. Bullock is a highly skilled expert in baby safety, specializing in both indoor and outdoor safety. With her previous experience in retail support, she has successfully assisted numerous parents in installing essential safety equipment such as baby gates, cabinet locks, and outlet covers. Additionally, Sandra has collaborated with various child care facilities, providing valuable safety consultations and comprehensive training to caregivers.