SIDS

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This section is meant for parents who have the question, "What can we do to reduce the risk of our baby dying from SIDS?" In no way should it be interpreted as a SIDS-free guarantee, or imply that parents who had a bay who died of SIDS could have prevented this tragedy from happening. The following information represents our best efforts to compile the latest research on SIDS reduction in hopes that parents who are more informed will worry less.

In light of new research, SIDS should no longer be considered a mysterious cloud that hangs over cribs and causes babies to take their last breath. Armed with a new understanding of SIDS, parents can at least do something to reduce their worry and reduce the risk. SIDS seems to be a combination of many factors: immature development of cardiorespiratory control mechanisms, defective arousability from sleep in response to breathing difficulties, medical conditions that compromise breathing, and unsafe sleeping practices. Therefore, this SIDS risk-reduction program is designed to help these factors:

Medical and family circumstances may prevent you from doing all seven of these risk-lowering practices, but do the best you can.

Prematurity and low birthweight constitute two of the highest risk factors for SIDS. The increased risk and the fact that premature infants show more episodes of irregular breathing and stop-breathing (called apnea) is possibly because the respiratory control center in these infants is immature. Although the SIDS risk in premature babies is higher, the good news is that over 99 percent of premature infants don't die of SIDS and that mothers of premature babies who take good prenatal care of themselves and practice the rest of the SIDS prevention tips mentioned in this section can reduce the risk of losing their baby to SIDS. While prematurity is not always preventable, here are three ways you can increase your chances of giving your baby the best prenatal start.

1. GET GOOD PRENATAL CARE
Babies whose mothers get the least prenatal care have the highest risk of preterm birth, and therefore SIDS. Just as well-baby care is important after birth, periodic checkups during pregnancy give your in-the-womb baby the best chance of a healthy start. During prenatal checkups your healthcare provider will monitor your health, counsel you on nutrition and exercise, check the growth and health of your baby, and offer you advice on creating the healthiest womb environment for your baby.

2. FEED YOUR BABY RIGHT BY FEEDING YOURSELF RIGHT
Good nutrition during pregnancy lowers the risk of SIDS in two ways: it lowers the risk of prematurity, and it prevents anemia. With anemia, there are fewer red blood cells to carry oxygen to the baby. Anything that lowers oxygen to the baby increases the risk of SIDS, probably by harming the development of the baby's respiratory control system in the brain. The risk of SIDS is compounded in an anemic mother who also smokes.

3. GROW YOUR BABY IN A SMOKE-FREE, DRUG-FREE WOMB
Taking illegal drugs and smoking while pregnant increase the risk of SIDS in two ways: First, these harmful habits increase the chances of your baby being born prematurely. Second, these pollutants, primarily by decreasing oxygen supply to developing tissues, can harm baby's brain, specifically the respiratory control center that regulates breathing. The risk of SIDS increases eight times in infants of substance-abusing mothers (abbreviated as ISAM) and as much as twenty times in infants of opiate abusing mothers.

One of the most significant risk factors for SIDS � and one that mothers can do something about � is smoking when their babies are in the womb or in the same room. Studies show that exposure to cigarette smoking at least doubles the risk of SIDS. The risk of SIDS increases proportionally to the number of cigarettes mother smokes. Heavy maternal smoking (more than twenty cigarettes a day) increases the SIDS risk fivefold. If mother and father smoke, the risk of baby dying of SIDS doubles, compared with maternal smoking alone. Anything that retards infant development, interferes with infant breathing, or lessens maternal sensitivity increases the risk of SIDS. For an in-depth discussion on how smoking harms babies, see "How Smoking Harms Babies."

Between 1989 and 1993 SIDS researchers in cooperation with the British government launched a "Back to Sleep" campaign, advising parents to put their babies to sleep on their backs rather than their stomachs. A few years after this risk-reduction campaign was launched in England, SIDS rates plummeted throughout the United Kingdom by as much as seventy percent. A similar "Back to Sleep" SIDS-reduction campaign occurred in New Zealand and Australia followed by a fifty percent decrease in national SIDS rates in these two countries. The Netherlands, Sweden, Denmark, Germany, and Ireland saw a similar decrease in SIDS rates following "Back to Sleep" campaigns in these countries. Eight countries doing similar risk-reduction campaigns and all getting similar results. This had to be more than a coincidence. These findings were a breakthrough in SIDS-prevention research � and in SIDS-prevention attitude. Instead of the previous belief � that SIDS was a mysterious and hopeless tragedy � the changing sleep-position advice was finally something practical that professionals could agree upon and parents could do.

In 1994, the U.S. Public Health Service organized a national "Back to Sleep" campaign, and it paid off. In the past few years, SIDS rates have dropped around 30 to 40 percent in the United States.

1. Back-sleeping babies awaken easier. Arousability from sleep in response to a life-threatening event is a healthy, protective mechanism and one that is thought to be diminished in infants at risk of SIDS. Back-sleepers arouse from sleep more easily and sleep less deeply than tummy-sleepers. Mothers have observed, and research has confirmed, that infants sleep more deeply on their tummies. Yet, sleeping more deeply does not mean sleeping more safely.

2. Back-sleeping babies have a lower chance of getting overheated. Overheating, possibly by interfering with the central nervous system control of breathing, is another risk factor for SIDS. Lying on your back leaves your face and internal organs exposed so that they can radiate heat more readily than when sleeping on your tummy. (That's why when your cold, you probably curl up on your front or side to conserve heat.) Also, front- sleeping babies are more likely to slip down under the covers than those sleeping on their backs, another factor that may contribute to overheating, since a baby's prime avenue for heat loss is through their head and face. In the back position, even the baby who slips down underneath the covers would be more likely to throw them off. The contact of a cover with the face is more likely to be noticed and protested by a back-sleeping baby than the contact of the cover with the back of the head would be in a front-sleeping baby.

3. Back-sleeping babies breathe more oxygen. When sleeping face down, a baby may press her head into the mattress or wiggle her face against a soft object. This can form a pocket of air around her face, leaving her to rebreathe her own exhaled air, which has diminished oxygen.

4. Back-sleeping babies are less likely to suffocate. Conventional wisdom has always taught that suffocation is a rare cause of SIDS. Yes, babies are sturdy little persons who, even as newborns, are able to lift their heads and keep their noses clear to breath. The often quoted "study" that even tiny infants have the ability to lift their heads and wiggle their noses clear of obstruction was not really a scientific study; it was more of an observation. Yet, new insights cast doubt on the rareness of suffocation. A growing belief among SIDS researchers is that many babies presumably diagnosed as SIDS may have in reality died from suffocation on soft surfaces

While no one knows exactly why the front-sleeping position is linked to SIDS, the overwhelming number of studies that all come to the same conclusion � back sleeping decreases the risk of SIDS � make it clear that for healthy infants, back-sleeping is safer. Parents should note that there are some medical conditions, such as gastroesophageal reflux or structural abnormalities of the jawbones and airway, in which it is safer for babies to sleep on their tummies rather than on their backs. Be sure to check with your doctor to see whether or not your baby has a medical reason to sleep on his tummy rather than his back.

Anything that improves the overall health of a baby and sensitivity of its mother should lower the risk of SIDS. In both of these categories, breastfeeding shines. Here's how.

The authors of the NICHD study concluded that SIDS rates were higher in formula-fed infants even after correcting for other factors, such as socioeconomic status. They also concluded that breastfeeding was protective against respiratory and gastrointestinal infections, two factors that have been implicated in increasing the risk of SIDS. SIDS infants between two and eleven months of age showed increased upper respiratory infections within two weeks prior to death if they had never been breastfed. Another important finding in this study was that 74 percent of Caucasian and 86 percent of African-American infants who died of SIDS were mostly, or only, fed artificial baby milk (formula). The researchers in this study concluded that infants who were never breastfed had two to three times a greater risk of SIDS.

Even though statisticians have tried to separate the effects of breastfeeding from other maternal factors, (and some researchers, such as those performing the NICHD study, "corrected" for these factors) a definite separation of factors is nearly impossible. A Copenhagen study showed that SIDS infants were more likely to be formula-fed or breastfed for a shorter period of time than other infants. These authors concluded, however, that differences in breastfeeding between SIDS cases and controls merely reflected other features that were associated with SIDS, particularly socioeconomic factors and maternal smoking. But recent data from one of the largest and most reputable SIDS studies, the previously cited Avon Project in England, shows that SIDS is lower in breastfeeding infants, even after correcting for educational and other socioeconomic factors. According to Dr. Fleming, the more the Avon study progressed, the more it became evident that the incidence of SIDS is lower among infants of breastfeeding mothers. They concluded that breastfeeding is second only to back position as a protective factor against SIDS.

The Avon researchers feel that one of the reasons SIDS was lower in breastfeeding infants was that breastfeeding mothers, due to their higher educational level, were more likely to be informed about, and follow, the advice of the overall SIDS reduction campaign. A breastfeeding mother is usually one who takes good prenatal care of herself, and therefore her baby; she is unlikely to smoke prenatally or postnatally, and if she does, she is more likely to quit when pregnant; and she tends to sleep with her baby and wear her baby a lot in a baby sling�all factors which I believe also lower the risk of SIDS. Because there are so many other parenting factors that play a part in affecting the SIDS rate, let's rely on our innate common sense, as did the writers of the Declaration of Independence when they drafted the words "We hold these Truths to be self-evident." The authors did not say "And we are going to try these Truths out until they can be proven by a double-blind controlled study and replicated by three different researchers." Breastfeeding matters. Experiments, experience, and common sense tell us that. (See 8 Reasons Breastfeeding Reduces SIDS

Because SIDS occurs during sleep, most of the SIDS prevention program focuses on providing a safe sleeping environment.

Keep your baby comfortably warm, but not too warm. Overbundling, and consequently overheating, has been shown to increase the risk of SIDS. Overheating may disrupt the normal neurological control of sleep and breathing. The respiratory control center in the brain is affected by abnormal changes in temperature, and SIDS researchers believe that overheating may cause respiratory control centers in some babies to fail.

2. Put baby to sleep on side or back. When baby sleeps on her stomach (prone) with her cheek and abdominal organs against the bedding, these prime areas of heat release are covered, thus conserving heat. So the phrase "prone to get hot" appears to have a physiological basis. When a baby is sleeping on her side, more heat-releasing areas are exposed, and sleeping on the back releases the most heat. Also, a prone-sleeping baby is more likely to slide her head under the covers and not protest having her head covered; the baby sleeping on her back or side is likely to protest if her head becomes covered, because her face is more sensitive than the back of the head.

3. Don't bundle up a sick baby. Parents often tend to overwrap sick babies, as if extra bundling were a part of extra nurturing. This is one of the instances where social customs and baby's basic physiology don't agree. Sick babies are likely to have a fever and when you cover a hot body, it becomes hotter. A mother may feel, "If I don't bundle her well she'll catch cold." Baby already has a cold. Studies show that in the first three months of life a baby's metabolic rate either decreases or it does not change during a respiratory infection. For infants older than three months of age, the metabolic rate tends to increase with an infection. Thus infants older than three months of age (the age at highest risk of SIDS) respond to upper respiratory tract infections by conserving heat. This biologic quirk may further increase the baby's risk of being overheated when sick, and overwrapping a baby with a respiratory infection piles one risk factor on top of another. Observers have also suggested that, paradoxically, the infant's sleeping room may be warmer in the winter time than it is in the summer, so that the risk of overheating is greater in the winter; researchers have also observed that babies dying of SIDS were more likely to be overwrapped than appropriately wrapped if they had been ill.

Dress a sick baby as you would yourself. When it's warm outside or your body is hot, you dress more lightly. During an illness, parents tend to overwrap babies when it's cold outside, even though the temperature of the baby's room is comfortably toasty. Be especially sensible about bundling sick babies for sleep. Don't overcompensate by overinsulating when it's cold outside.

4. Don't overheat the room where baby sleeps. Central heating may not be the most comfortable, or the safest, for sleeping babies. SIDS death-scene investigators sometimes notice an overheated room where the central heating has been left on all night.

As a general guide, a sleeping environment temperature of around 68 degrees Fahrenheit (20 degrees celsius) is preferable. Preterm infants or newborns weighing less than eight pounds may require a temperature a few degrees higher. Healthy, term newborns weighing more than eight pounds usually have sufficient body fat and mature enough temperature-regulating mechanisms to allow them to sleep comfortably in a room temperature that you find comfortable.

Recent research has also supported what grandmothers have always claimed�that if babies get cold, they catch a cold. The cooler the sleeping environment, the more likely babies are to get respiratory infections. Yet babies who are overheated have an increased risk of SIDS. In this study, the fewest respiratory infections occurred in bedroom temperatures around 68 degrees Fahrenheit (20 degrees Celsius)

Consider humidity levels, too. Besides insuring a safe sleeping temperature for baby, pay attention to the relative humidity in baby's room. Best humidity is around 60 to 70 percent. Less humidity may dry out a baby's breathing passages, making his nose stuffy and thickening the mucous in his airways. High humidity, on the other hand, favors the growth of respiratory allergens and may peel off the paint or wallpaper in older houses. As you might expect, most central heating is not friendly to breathing passages, because the air is either too dry or full of allergens. We have come up with a healthier alternative: Turn the central heating down or off during the night and turn on a warm-mist vaporizer in baby's room. (Because steam kills bacteria, it is healthier than cool mist.) This inexpensive steam producer (available at pharmacies and department stores for around ten dollars at this writing) provides two benefits: It increases the humidity in the room and it warms the room. From high school physics you know that when steam condenses, it releases heat. That's how the vaporizer warms the room. As a precaution, don't let the humidity get so high or the room so hot that the paint or wallpaper begins to peel off, or mold begins to grow.

Be especially vigilant about bedroom temperature when traveling. Electric baseboard heaters, such as those typically found in ski chalets and motels, have a particularly drying effect on the air. It's worth taking along a warm-mist vaporizer or buying one locally. Except in extremely cold weather, a warm-mist vaporizer will keep a draftless motel-size bedroom comfortably and safely warm with the heater turned off.

5. Dress baby for safe and comfortable sleeping. Consider three things when dressing your baby for sleep: comfort, warmth, and safety. What style and fabric are most comfortable to your baby is a matter of observation. It won't take you long to figure out whether your baby sleeps better in footed sleepers or loose, tie-at-the-bottom "sacques." Learning how to dress your baby appropriately is really only a matter of common sense and getting a feel for your individual baby. Also, an appropriately clothed baby is more likely to reward you with a longer night's sleep. Overheated infants tend to be more restless. As a general guide, dress and cover your infant in as much, or as little, clothing and blankets as you would put on yourself. Then, let your hands be a thermostat. Feel your baby's head or the back of her neck. If these areas feel too hot, baby is sweating, or her hair is damp, remove one layer. If baby feels cold, add a layer. In general, it's safer to adjust baby's sleeping temperature by changing clothes than by piling on more blankets. Baby's hands and feet are not accurate indicators of body temperature, since in most babies, these parts are usually cooler than the rest of the body.

While overheating is a risk factor for SIDS, you don't have to become thermal engineers in order to get the temperature of baby's sleeping environment perfect. Babies are sturdy little persons with efficient temperature-regulating systems. If you use common sense and the above sleep-dressing suggestions, there is little risk of overinsulating your baby. In fact, under laboratory-controlled conditions, studies that compared usual night-dressing practices with ideal wrapping showed that 95 percent of mothers intuitively wrapped their babies correctly, so that their infants were able to maintain normal body temperature while sleeping.

The biggest breakthrough in SIDS risk-reduction is the discovery that parenting practices can influence SIDS rates. A dramatic testimony to this change occurred in New Zealand, a country noted for its high SIDS rates and respected for the validity of its SIDS statistics. Following a national SIDS intervention program that discouraged front sleeping and maternal smoking, and encouraged breastfeeding and safe-sleeping practices, SIDS rates plummeted from 6.3 per thousand in 1979 through 1984 to 1.3 per thousand in 1990�a whopping 80 percent reduction.

These groundbreaking findings are a wake-up call to SIDS writers who cling to the conventional thinking that SIDS is a non-preventable tragedy. While the non- preventability of SIDS is still a popular and emotionally correct belief, in light of recent research this concept is no longer scientifically correct. In the final step of this risk-reduction program, I propose that an overall style of caregiving called attachment parenting will further reduce the risk of SIDS. (For more information see 4 Ways Attachment Parenting can Reduce the Risk of SIDS and 3 reasons Babywearing reduces SIDS)

In the early 1980s, after years of studying the effects of what parents do and how their children turn out, I coined the term "attachment parenting," and wrote about it in my first book, Creative Parenting. In 1985, in my book Nighttime Parenting, I described how this high-touch style of parenting could reduce the risk of SIDS.

Attachment parenting is a way of caring that helps mothers and infants get connected, become mutually sensitive, and develop the skills that help them both thrive. With this parenting style, mother and baby, during at least the first six months, spend most, if not all, of their time in physical and emotional touch with each other. Attachment parenting helps parents build a relationship with their baby. You and your baby become so attuned to one another that you enhance each other's behavior and physiology. Each of you is necessary to the other's sense of well-being.

Here's what mothers and fathers who practice this style of parenting have to say about what it does for their relationship with their baby:

CHOKING
My mother and mother-in-law think I'm crazy to put my son to sleep on his back. They're sure he'll choke. Until recent "Back to Sleep" campaigns, conventional Western wisdom taught that babies should sleep on their stomach for fear of choking. I dutifully recorded it as my own advice to parents in my book Nighttime Parenting, published in 1985. But it turns out that not only is aspiration (inhaling of milk, food or spit-up into the lungs) or choking rare, but SIDS experts no longer even consider it a possible cause of SIDS. In fact, studies show that after a change from front to back sleeping, there was no increase in aspiration; in fact, the problem may have even decreased.

Another reason for the front-sleeping preference was the observation of mothers, confirmed by researchers, that many babies settled better, slept better, and cried less when placed to sleep on their tummies. It seems newborns settle better on their stomachs or sides because they feel more contained and are less vulnerable to startle. Because we are a culture whose parenting practices have traditionally fostered an uninterrupted night's sleep, it seems odd to put our babies to sleep in a position that might encourage them to wake up more easily. Conventional parenting wisdom says, "Why change what works? Let sleeping babies lie." In a 1992 survey of two thousand United States households, 74 percent of infants slept prone, 14 percent slept on their sides, and 12 percent on their backs. For a culture that treasures its sleep, this change will require some savvy public relations.

Some babies sleeping on their tummies also seemed to settle better and spit- up less after feeding. If an infant has gastroesophageal reflux, it is still recommended that he sleep tummy down, at least for two hours after a feeding.

Martha, my wife, believes there is another reason why babies are put to sleep on their tummies. If a mother is putting her baby to sleep, rather than parenting her to sleep, the front position works better. Many babies do not like being flat on their backs when they are tired, and most babies will resist by crying when they are plunked down this way awake. When put tummy-down, a baby is more able to comfort herself off to sleep by assuming the fetal position and sucking on her fingers. A front position would also encourage a baby who does awaken to return to sleep on her own.

A final reason for the traditional front-sleeping position is that new mothers see nurses put babies down this way in the hospital, and mothers often do what they see nurses do. (Also, young doctors in training see nurses place newborns to sleep on their stomachs, so they pass on this habit to the mothers in their practice, and the cycle continues.) Nurses are accustomed to putting babies to sleep on their tummies because that's what they have learned is best for premature babies or babies with breathing difficulties; the still partially collapsed lungs of some prematures tend to expand better when front-sleeping. Yet this benefit is only for preterm babies and babies with breathing difficulties. Once babies are well and at home, the front-sleeping position is unlikely to benefit their breathing.

What if my baby prefers sleeping on her tummy?Unless advised to the contrary by your doctor, it is best to let your baby sleep in a position she prefers. If baby doesn't settle well, or stay on her back or side, front sleeping is all right. Also, you may find that your baby prefers different sleep positions at different ages. After all, there is a meaningful wisdom of the body, even in a baby. If a baby repeatedly doesn't settle in a certain sleeping position, this may be a clue that this position may not be the safest for this individual baby. This is just one example of how babies often try to tell us what is in their best interest. Parents should not be afraid to listen.

Still, because of the new research, it is best to try to get baby accustomed to sleeping on her back or side. Newborn babies tend to get in the habit of sleeping the way they are first put down. The older babies get, the more resistant they seem to be to changes in sleeping position. Newly-born babies do well sleeping on their tummies, but they also do well on their sides, since both positions allow a baby to assume the fetal position, which is more soothing than back-lying. Thus, if you have been putting your baby down on her stomach and now wish to get her used to sleeping on her back or side, it may take some patient conditioning. If you've made a diligent effort to encourage back-sleeping and your baby still sleeps best on her stomach, let her, and don't fear that she is going to die of SIDS, especially if the other risk factors are not present. Studies on large numbers of babies show a statistical increase in SIDS if baby sleeps tummy-down, but your baby is an individual. The front-sleeping risk factor for SIDS doesn't mean that you should worry every time you place your baby down to sleep. Just be sure to place your baby to sleep on a safe bedding surface. After all, over 99.9 percent of tummy-sleeping infants wake up every morning.

Is it safer for baby to sleep on his back or side?New Zealand studies show that SIDS is least likely to occur when babies sleep on their backs, and most likely when sleeping on their tummies. Sleeping on the side falls somewhere in between. This statistical difference is not enough that parents should avoid putting babies to sleep on their sides.

Sleeping on the back, however, is a more stable position than on the side. Many infants do not develop the desire or the motor capability to roll from back to tummy until around five or six months, when the risk of SIDS begins to diminish. Yet even newborns have the capability of rolling from side to back or side to tummy. While most babies less than six months who are put to sleep on their tummies or backs tend to stay there, many infants who are put down to sleep on their sides will change position, most of the time rolling onto their backs rather than onto their tummies. Yet the number of SIDS infants who rolled from their sides to the front position in the Avon study, led experts in England and New Zealand to suggest that the risk of SIDS for side-sleeping may be two times that of back-sleeping. (Once again, parents should be aware that these are purely statistical findings and of questionable meaning for individuals.) At present, most authorities agree that research only supports discouraging the front position, and that both side- and back-sleeping are safe alternatives.

To lessen the chances of a side-sleeping baby rolling onto his tummy, stretch his underneath arm forward. This arm can act as a stabilizer to keep baby from rolling onto his tummy. If the baby's arm stays closely tucked into his side, it will be easier for him to roll onto his tummy. Wedges to keep baby sleeping on his side are helpful, but never use just a back wedge. Rolling up a towel as a wedge between baby's back and the bed may encourage baby to roll from side to stomach rather than from side to back. Be sure not to use props that totally restrain the infant's movement. Freedom of breathing implies freedom to adjust body position as needed. I'm concerned that the multitude of commercial baby wedges may be more restrictive than necessary, and they have not been proven either safe or effective. For these reasons, SIDS organizations and researchers do not endorse these products. If you choose to use a wedge to keep baby on his side, it seems the most sensible to use a front wedge only, which allows baby to roll onto his back if desired.

If your baby is experiencing increased drool associated with teething, or mucous from a respiratory infection, the side position may help him handle it. The excess mucous is likely to collect in the lower cheek pocket or run out of the mouth rather than puddle in the back of the throat, as may occur when baby is sleeping on his back. So, if your back-sleeping teether is having difficulty clearing the mucous (evidenced by coughing, noisy breathing, and night-waking), try the side position.

Don't overbundle . Best not to restrain baby's upper extremities. This allows baby to adjust himself to the safest position for breathing.

It is unlikely that the warning against front sleeping is just a passing fad. In view of what we know at this time, prudent parents should avoid placing their babies in the tummy-sleeping position for at least the first six months.

What if your baby protests any position except tummy-sleeping? Try these tips to encourage back or side-sleeping:

1. Let the tummy-sleeper first fall asleep on her stomach; then after she is soundly asleep gently turn her over onto her back.

2. Rock or nurse baby off to sleep in your arms or while wearing baby in a babysling. As soon as she is about to drift off to sleep, place the half-asleep infant on her back. If she still refuses to fall asleep in this position, dangle an oscillating mobile (out of baby's reach and moving around 60 rotations per minute) to entice the mobile-gazer to sleep.

3. Promote the crib-sleeper to your bed. Following this nighttime upgrade, most solo-sleepers will prefer to sleep on their sides or backs for easier access to parents.

4. Don't worry if the back-sleeper persistently turns over onto her side or front to sleep. By the time babies are developmentally able to perform this flip, they are usually past the age of high risk for SIDS.

5. If after trying all the above suggestions and your tummy-sleeper refuses to sleep on his back the best you can do is provide a safe sleeping environment for your front sleeper. Use a firm sleeping surface and survey baby's sleeping environment for potential nose-blockers. Use fitted crib sheets. Remove cushy crib toys and pillows. Be sure crib bumpers, if used, are secured tightly and there are no large crevices between the mattress and crib sides or bumpers. (See Crib Safety)

Whether it is the milk, the mother, or the method that is responsible for the lower SIDS risk in the breastfed infant is hard to tell. It's probably a combination of all three.

THE MILK
There are hundreds of substances in human milk that aren't in artificial milk. These cannot be manufactured or bought; they can only be made by mother. Each year researchers discover new factors in human milk that are beneficial to baby. I suspect that researchers have only scratched the surface of what amazing factors exist in human milk. The following is what we know. What is even more intriguing is what we do not yet know about how human milk benefits human babies in general and how it lowers the risk of SIDS in particular.

1. Breastmilk fights against infection. Respiratory and gastrointestinal infections contribute to the SIDS risk, and breastfeeding infants get fewer respiratory and gastrointestinal infections. Breastfeeding protects against RSV (respiratory syncytial virus) infections, and this virus has been implicated in causing inflammation of the lungs that could contribute to SIDS.

Between two and six months of age (which, you'll recall, is also the peak period of SIDS risk), a baby's immunity is lowest and the vulnerability to infection is highest. The newborn baby derives much of his immunity from his mother's antibodies while in the womb. After birth these antibodies gradually disappear. Meanwhile, baby is making his own antibodies, so that by age six to nine months he is more capable of defending himself against infection. Between two and six months, when the antibodies derived prenatally from mother are at low levels and baby has not yet made enough of his own, the immunity factors in breastmilk fill in, taking over where the placenta left off and protecting the baby while his own immune system matures.

One of the ways in which breastmilk protects the infection-vulnerable infant is through the enteromammary immune system. When mother is exposed to a new germ, glands in her intestine make infection-fighting cells specifically for this germ. These special cells travel through her bloodstream to her breasts, where they announce the presence of the enemy germ. The breast glands respond by manufacturing antibodies, which are delivered to the baby through the milk. Because she can make new antibodies better and more quickly than her tiny baby can, mother updates her baby's immunity with every feeding. Would it be presumptuous to call breastmilk a SIDS vaccine? Read on.

2. Breastmilk builds better brains. "MOTHER'S MILK: FOOD FOR SMARTER KIDS." This was the headline in USA Today on February 2, 1992. While both experience and research have long suggested that breastfed babies are intellectually advantaged, the difference has usually been attributed more to the nurturing or to the character of the mother than to the type of milk. But new research suggests that it's human milk itself rather than (or in addition to) the process of breastfeeding (or the skills of the mother) that enhances brain growth. Brain-building substances and elements called "growth factors" have recently been discovered in human milk. Researchers in England studied three hundred babies who were very premature and weighed less than four pounds, a group that is at high risk for SIDS. They divided their subjects into two groups: those who were fed their mother's milk and those who were not. Because of their prematurity, these infants received the milk by tube rather than directly from the mother's breasts, thereby separating the effects of the milk from the effects of the nurturing. Those premature babies who got their mother's milk during the first five or six weeks of life averaged 8.3 points higher on IQ tests at age seven-and-a-half to eight years. Also significant in this study was that the more breastmilk the babies received, the higher these children scored. Since this study, over eleven more studies have concluded that breastfeeding builds better brains.

Why does human milk build better brains? Special nutrients in human milk that are not in artificial baby milks may be the answer. Human milk contains substances (such as cholesterol, linolenic acid, and taurine) that enhance the development of the central nervous system in several ways, the most convincing of which is that it provides vital fats, namely DHA for myelin, the insulating sheath around nerves that helps impulses travel faster. (Postmortem examinations have shown deficient myelination�the covering around nerves that lets impulses travel faster�in the nerves around the respiratory control center in some infants who died of SIDS). These areas show changes that could be the result of delayed development and/or oxygen deprivation. So vital are these brain builders that if a mother's milk is short on these special nutrients, the mammary glands themselves make and deposit them into her milk. Although myelination continues well into early childhood, the greatest degree of myelination occurs during the first six months of life.

3. Breastmilk is kinder to tiny airways. Besides reducing respiratory infections that clog baby's air passages, breastfeeding also helps keep little airways open by not exposing them to the allergens in foreign milk. Stuffy noses and airways and recurrent respiratory-tract infections are frequent signs of allergies to artificial milk made from cow's milk or bean milk (such as soy). Breastfeeding helps breathing in two ways: by helping the brain systems that control breathing to mature, and by helping to keep tiny air passages open. It is also interesting to note that breastfeeding infants have higher blood levels of the hormone progesterone, and progesterone stimulates breathing. In summary, babies who get breastmilk breath better.

As a final perk, even if human milk goes down the wrong pipe and enters baby's lungs, it does not irritate the lungs as much as formula can. Human milk is not a foreign substance. Also, studies on experimental animals have shown that the introduction of water or cow's milk into the upper trachea (the beginning of the airway) can lead to apnea. This did not occur when normal saline (a physiological solution similar to the infant's own blood) or the species' own milk was squirted into the trachea. These researchers concluded that aspiration of water or foreign milk may cause a stop-breathing episode in infants, a life-threatening episode that might not occur if mother's milk accidentally goes down the wrong way.

4. Breastfeeding reduces reflux. Gastroesophageal reflux (GER) is less severe in breastfed infants than in infants fed artificial baby milks, probably due to the fact that human milk is emptied faster from the stomach. Since GER has been implicated in apparent life-threatening events (ALTEs) and ALTEs may be a forerunner of SIDS, reducing GER could also reduce SIDS.

6. Breastfeeding organizes baby. I believe that an important piece of the SIDS puzzle is that some babies at risk of SIDS have an overall "disorganized physiology." Breastfeeding has a calming effect on a baby. The harmony between a breastfeeding mother and her suckling infant has an organizing effect on baby's sleep/wake cycles, probably as a result of the cue-response sensitivity of the breastfeeding pair.

THE MOTHER
Not only does breastmilk have protective qualities for baby, breastfeeding does good things for mother, which indirectly may reduce the risk of SIDS.

7. Breastfeeding increases mother's awareness. Breastfeeding is an exercise in babyreading. It increases the sensitivity of a mother to any changes in her baby. The increased maternal hormones (primarily prolactin and oxytocin) that are stimulated by baby's sucking appear to provide a biological basis for the concept of mother's intuition. During my 30 years of watching mothers and babies, I have been impressed by the increased sensitivity breastfeeding mothers have toward their babies. They're able to read subtle cues and changes in their infants. Cindy, a breastfeeding mother, told me: "I can tell when my baby has an ear infection by the way she sucks." Breastfeeding mothers tend to sleep with their babies, a nighttime parenting style that I believe decreases SIDS risk. A breastfeeding mother also sleeps differently than her formula-feeding friends. She may be more aware of changes in her baby, even while they both are sleeping. (See Co-sleeping and SIDS)

Can formula-feeding mothers attain this high level of sensitivity to their babies? I suspect they can, especially if they practice the rest of the attachment-parenting package, such as sharing sleep and wearing their baby. Yet without the hormonal boost that breastfeeding provides, bottle-feeding mothers have to work harder at developing this heightened awareness.

THE METHOD
Besides the good stuff in breastmilk and the act of breastfeeding itself with its increased "touch time," the way an infant breastfeeds may also lower the risk of SIDS.

8. Breastmilk improves breathing/swallowing coordination. Newborns have to learn to coordinate breathing and swallowing during feeding. For premature infants (those at highest risk for SIDS), this is a gradual learning process. Studies show that premature babies who breastfeed coordinate sucking, swallowing, and breathing more efficiently than do their bottlefeeding mates. Breastfeeders also tend to feed more frequently than their bottlefeeding friends, therefore getting more practice coordinating their swallowing and breathing. Since tiny infants tend to have weak points in muscle support of their upper airways, their breathing passages are narrower, especially during sleep. Any exercise of the mouth and throat muscle is helpful in keeping the airways open.

In full-term infants, breastfeeding helps keep tiny airways open by helping the jawbone and muscles of the upper airway develop better. Dental studies show that breastfeeding babies develop better alignment of the oral cavity. Dr. Shirley Tonkin, a New Zealand researcher, told me she believes that breastfeeding infants are more likely to use their jaws and pharyngeal muscles in a sucking motion that enhances the development of muscles, bones and lips�all of which helps keep their airways open better than those of bottlefeeding babies. Dr. Tonkin, a pathologist, speculated that the different muscle actions involved in bottlefeeding may contribute to the growth of larger tongues, thus further narrowing the already unstable airway of tiny infants. A recent postmortem finding that SIDS babies have larger tongues lends support to Tonkin's theory. The more stable the airway to breathing, the lower the risk of SIDS.

Putting infants to sleep on their backs or sides rather than on their stomachs may lower the risk of SIDS. When my wife, Martha, breastfed our eight babies, she invariably put them to sleep on their backs or sides, believing that in this position the breastfeeding pair had easier access to nursing at night. Breastfeeding mothers I have interviewed, especially those who share a bed with their infant, most often place their babies on their sides facing them; or the infant often sleeps in the crook of mother's arm, necessitating a back or side position.

As we await the results of more research, we can continue to rely on common sense. The milk of each species of mammal is different and designed to insure the best chances of survival for the young of that species. (Consider what happens if you put the wrong fuel into a car. Sooner or later it doesn't run right and its engine control systems fail.) I believe that someday a researcher will discover what savvy mothers have long suspected: there are nutrients in mother's milk that help keep new lives living. In the meantime, it's possible that any one of the protective effects of breastfeeding could lower the SIDS risk, even slightly. When you put together all the benefits of breastfeeding, the good stuff in breastmilk, the special touch of breastfeeding, and the special actions of breast suckling, you have a compelling case that breastfeeding increases an infant's chances of health and well-being.

If SIDS is basically a disorder of respiratory control and neurological immaturity (and I believe it is), anything that can help a baby's neurological system mature overall will lower the risk of SIDS. That's exactly what babywearing does.

While wearing our own babies, I noticed how my breathing affected theirs, especially when I was sitting still with a sleeping baby nestled in a sling against my chest. Whenever I took a deep breath, so did baby. Sometimes the stimulus was the rise and fall of my chest, at other times the air exhaled from my mouth and nose against baby's scalp or cheek-stimulated baby to take a deep breath.

Have you ever wondered why mothers in other cultures have for centuries worn their babies in homemade slings? I used to believe this old custom's purpose was simply to protect babies from jungle dangers or to enable mothers to do manual labor. Wrong! When I was researching parenting styles in other cultures, I interviewed African mothers who wore their babies in slings that were extensions of their clothing. They agreed that babywearing protected their infants from dangers, but that wasn't the main reason for doing it. Instead, they said, "It makes life easier for the mother," or "It does good things for babies." "What good things?" I inquired. These mothers replied, "The babies seem happier," or "They cry less," or "They seem more content," or "The babies grow better."

Note: these observations were not from mothers who attended parenting classes, read books on baby bonding, or relied on scientific studies. These were mothers whose "sources" were their own powers of keen observation and centuries of tradition, both of which told them babies thrive better when carried in slings. Now, modern researchers have scientifically proven what these intuitive mothers have long known: Something good happens to babies who spend a lot of time nestled close to nurturing caregivers. Here's why.

1. Babywearing gives a vestibular connection. Babywearing exerts a regulatory effect on the baby, primarily through the vestibular system. This tiny system, located behind each ear, controls baby's sense of internal balance. It is as if there are three tiny carpenter levels back there�one tracking side- to-side motion, another for up-and-down motion, and a third for back-and-forth motion�all functioning together to keep the body in balance. Every time the baby moves, the fluid in these "levels" moves against tiny hair-like filaments that vibrate, which sends messages to the brain to help baby balance her body.

In the womb, the baby's very sensitive vestibular system is constantly stimulated because a fetus experiences almost continuous motion. Babywearing provides the same kind of three-dimensional stimulation and "reminds" the baby of the motion and balance he enjoyed in the womb. The rhythm of the mother's walk, which baby got so used to in the womb, is experienced again in the "outside womb" during babywearing.

Activities such as rocking and carrying stimulate the baby's vestibular system. Vestibular stimulation is a recently appreciated tool for helping babies breath and grow better, especially premature infants�those at highest risk of SIDS. Some studies showed premature babies placed on professionally-monitored, oscillating waterbeds grew better and had fewer apnea episodes than other preemies did (although one study disputed this.) Babies themselves recognize that they need vestibular stimulation; infants deprived of adequate vestibular stimulation often attempt to put themselves into motion on their own, with less efficient movements, such as self-rocking. Researchers believe that vestibular stimulation has a regulating effect on an infant's overall physiology and motor development.

Kangaroo care. Newborn nurseries have recently begun using a method of vestibular stimulation called "kangaroo care," in which a premature baby is wrapped, skin-to-skin, up against the mother's or father's chest. The parent rocks, holds, and gently moves with the baby. The rocking motion, the skin contact, and the rhythmic motion of the parent's chest during breathing produces the following beneficial effects:Babies show:

Researchers believe that using kangaroo care helps the parent act as a regulator of baby's physiology, including reminding the baby to breathe. In other experiments, infants with breathing difficulties were placed next to a teddy bear stuffed with a mechanism that seemed to "breathe"; these babies also had fewer apnea episodes. When this "breakthrough" in teddy technology hit the newspapers, a reader wrote in, "Why not use the real mother?"

As an example of how closeness regulates a baby's breathing, a mother shared the following story with me: "My baby was born four weeks premature at five pounds, fifteen ounces. I held her all day long and never put her in a bassinet. She breastfed well. She seemed perfectly healthy, pink, and breathed normally. The evening the pediatrician came to check her, she took her into the nursery and put her in a bassinet. As soon as our baby was lying in the bassinet alone she had a stop-breathing episode, which alarmed the neonatologists, and she was put into intensive care for nine days. They never found out why she had apneic episodes, although they thought it was due to a 'slight seizure disorder.' All they had to do was touch her and she would start breathing again. She never had any stop-breathing episodes when she was in my arms, only when she was lying alone. The doctors told me she was a prime candidate for SIDS. They convinced me that she needed to be on an infant monitor at home. I agreed, but it turned out to be a nightmare for our whole family. They told me not to put her in my bed, so she slept alone with the monitor. The monitor went off all night long, probably from false alarms, and no one got any sleep. I left her on the monitor but put her next to me in bed. We both slept wonderfully, and the monitor alarm never sounded. I strongly feel that my presence stimulated her to breathe until she outgrew her stop-breathing tendencies. My touch and closeness to her was all she needed. In fact, while she was in my arms, all day long, in the hospital no one ever knew she had a 'breathing problem.'"

2. Motion regulates babies. Motion calms babies. Carried infants show a heightened level of quiet alertness, the behavioral state in which infants best interact with and learn from their environment. Researchers believe that during the state of quiet alertness, the child's whole physiological system works better.

3. Carried babies cry less. Parents in my practice commonly report, "As long as I wear her, she's content!" Parents of fussy babies who try babywearing relate that their baby seems to forget to fuss. This is more than just my own impression. In 1986, a team of pediatricians in Montreal reported on a study of ninety-nine mother-infant pairs, half of whom were assigned to a group which was asked to carry their babies for at least three extra hours a day and were provided with baby carriers. The parents in this group were encouraged to carry their infants throughout the day regardless of the state of the infant, not just in response to crying or fussing, although the usual practice in Western society is to pick up and carry the baby only after the crying has started. In the control, or non-carried group, parents were not given any specific instructions about carrying. After six weeks, the infants who received supplemental carrying cried and fussed 43 percent less than the non-carried group. Anthropologists who travel throughout the world studying infant-care practices in other cultures agree that infants in babywearing cultures cry much less. In Western culture we measure a baby's crying in hours per day, but in other cultures, crying is measured in minutes. We have been led to believe that it is "normal" for babies to cry a lot, but in other cultures this is not accepted as the norm. In these cultures, babies are normally "up" in arms and are put down only to sleep�next to the mother. When the parent must attend to her own needs, the baby is in someone else's arms.

In addition to the physiological effects of vestibular stimulation, there appear to be psychological benefits. Sling babies seem to show a feeling of rightness, enabling them to adapt to all that is unfamiliar about the world to which they are now exposed, lessening their anxiety and need to fuss. As baby senses mother's rhythmic breathing while worn tummy-to-tummy and chest-to-chest, the babywearing mother acts as a regulator of her infant's biology.

What is SIDS? SIDS is the sudden death of an infant under one year of age that remains unexplained after of a complete post-mortem investigation, including an autopsy, an examination of the scene of death, and a review of the case history.

How often does SIDS occur? SIDS is the leading cause of death in infants between one month and one year of age. In the United States, it occurs in approximately 1 in 1,000 babies. In the past few years, around 3,000 babies die from SIDS each year in the United States.

When is SIDS most likely to occur? Ninety percent of SIDS occurs by six months of age, with most cases occurring between two and four months of age. SIDS occurs during an infant's sleep, either nighttime or naptime and occurs most frequently between 10 p.m. and 10 a.m., with the peak time of death around 5 a.m. SIDS is more common during the winter months. For unknown reasons, SIDS is higher in males than females by a ratio of 1.5 to 1.0.

Are some babies more at risk for SIDS than others? Yes. While most babies dying of SIDS have no previous warning signs or apparent risk factors, some infants are at higher risk than others. The term "risk factor" refers to some element in the baby's environment or development that increases the chances of dying of SIDS. Remember, "risk factor" is a clue, something associated with SIDS, not a cause. It means only that there is a statistical increase in SIDS among the overall population of babies who have that factor. The main risk factors for SIDS are:

SIDS researchers have taken the above risk factors and translated this information into suggestions for reducing the risk of SIDS. These risk factors are a clue, but not a cure to the mystery of SIDS.

Ever since parenting books found their way into the nursery, sleep trainers have touted magic formulas promising to get babies to sleep through the night. Most are just the old cry-it-out method in disguise, and technology has also provided us with a variety of sleep-inducing gadgets designed to lull baby off to sleep alone in his crib. Oscillating cradles, crib vibrators that mimic a car ride, and teddy bears that "breathe" all promise to fill in for parents on night duty.

While sleep-training may be necessary for some babies, for others it may be unrealistic, even risky. Be discerning about using someone else's technique to get your baby to sleep. Weigh these schemes on your inner-sensitivity scale before trying them with your baby.

Especially in the first six months, avoid sleep trainers who advise you to let your baby "cry it out." Only you know what "it" is and how to respond appropriately to your baby. The first SIDS baby in my practice awakened frequently. Her mother responded intuitively to her and nursed her back to sleep. When that baby was four months of age, a friend warned this mother that she was "spoiling that baby and that she should let her cry it out." That night her cries went unanswered � permanently. While there is no scientific evidence that sleep-training causes SIDS, the memory of my first SIDS patients has made me wary of the hard-line approach to getting babies to sleep through the night.

I believe that training babies to sleep too deeply, too long, too soon, while convenient to parents, is not in a baby's best biological interest. Sleep- training done before their cardiopulmonary control mechanisms are mature enough to handle prolonged deep sleep could be risky. Training a baby to fall asleep and stay asleep alone in his own room in his own crib may be the "modern" way, but for some infants sleeping lighter and for shorter stretches may be the safer way.