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The Transition from Back to Sleep to Safe to Sleep®

Safe to Sleep logoIn 1994, the NICHD, the American Academy of Pediatrics (AAP) and other collaborators launched the Back to Sleep campaign to inform parents and caregivers about ways to reduce the risk of Sudden Infant Death Syndrome (SIDS), defined as the sudden, unexplained death of an infant younger than 1 year of age.

The primary recommendation of the Back to Sleep campaign was that babies should be put on their backs to sleep to reduce the risk of SIDS. At that time, SIDS rates were quite high, claiming more than 4,000 infant lives1 each year, while back-sleeping rates were quite low, with fewer than 30% of babies2 sleeping on their backs.

In 2012, the NICHD, with the support of its campaign collaborators, created the Safe to Sleep® campaign as an expansion of the Back to Sleep campaign.

But why? Are infants still dying from SIDS? Yes, they are. In 2010, the most recent year for which statistics are available, slightly more than 2,200 infants died of SIDS2.

Do caregivers put infants on their back to sleep? No, not all caregivers use the back sleep position. In 2010, 74% of infants were placed on their backs to sleep3. The remaining 26% were placed on their stomach to sleep—the position associated with the highest SIDS risk—or on their sides to sleep—a position that carries higher risk than does back sleeping.

Then why the need to change the campaign? Because these numbers only tell part of the story.

First, the U.S. SIDS rate has plateaued in recent years. Between 2001 and 20091, the U.S. SIDS rate—although low, especially compared to rates in the early 1990s—remained relatively unchanged.

The largest decline in SIDS rates occurred between 1992 and 1999. Between 1994 and 1999, the overall U.S. SIDS rate dropped by more than 50%, and the rates among certain racial and ethnic groups also declined by 50%. In addition:

  • In 19941, 4,073 babies died from SIDS, and in 20094, 2,226 babies died from SIDS.
  • In 19941, 1,235 African American babies died from SIDS. In 20094, 665 African American babies died from SIDS.
  • In 19955, 77 American Indian/Alaska Native babies died from SIDS. In 20094, 52 American Indian/Alaska Native babies died from SIDS.

More importantly, while SIDS rates were declining and then stabilizing, rates of other sleep-related causes of infant death—deaths that are related to where a baby sleeps or slept—were increasing. Communities saw increases in “accidental suffocation or strangulation in bed (ASSB)”, strangulation, entrapment (when a baby gets caught between two objects, such as a mattress and a wall, and can't breathe), and other accidental causes of infant death partly because of unrecognized dangers in the baby’s sleep environment.

Several recent studies suggest that much of the decrease in SIDS rates since 1999 might be explained by changes in classification6 of cause of death. Some deaths that were once classified as SIDS were now being classified as other causes of death, such as accidental suffocation or other ill-defined and unspecified causes.

To help address all sleep-related causes of infant death, including SIDS, the AAP released updated safe infant sleep recommendations External Web Site Policy in 2011.

At the same time the updated recommendations were released, the NICHD and its collaborators—the Maternal and Child Health Bureau of the Health Resources and Services Administration; the Centers for Disease Control and Prevention, Division of Reproductive Health; AAP; the American Congress of Obstetricians and Gynecologists; First Candle; and the Association of SIDS and Infant Mortality Programs—launched the Safe to Sleep® campaign as an extension of the Back to Sleep campaign that would go beyond back sleeping and SIDS risk to address ways of reducing the risk of other sleep-related causes of infant death, such as accidental suffocation.

The revised campaign messages, based on the 2011 AAP recommendations, emphasize breastfeeding and eliminating known risks to infant health including overheating and exposure to tobacco smoke. The expanded Safe to Sleep® messages address some prenatal care and infant care issues as they relate to SIDS and provide information on ways to make baby's sleep area safer in terms of risks for accidental sleep-related deaths.

Through the Safe to Sleep® campaign, the NICHD and its collaborators continue the tradition and success of the Back to Sleep campaign. Relying on joint efforts with collaborators, Safe to Sleep® champions, and other outreach activities, Safe to Sleep® will continue its important work of reducing the risk of SIDS and other sleep-related causes of infant death to help save babies' lives.

Visit the new Safe to Sleep® campaign website to learn more about the campaign, about ways to reduce the risk of SIDS and other sleep-related causes of infant death, and about how to spread safe sleep messages in your community.

Originally Posted: October 17, 2013


All NICHD Spotlights

  3. External Web Site Policy (PDF - 20 KB)
  4. (PDF - 527 KB)
  5. (PDF - 251 KB)
  6. External Web Site Policy
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