Swings, slings, and car seats are not for sleeping

The Pediatric Insider

© 2015 Roy Benaroch, MD

An April, 2015 report from the Journal of Pediatrics graphically illustrates the dangers of babies sleeping in gizmos not designed for sleep.

As I’ve written about before, the American Academy of Pediatrics has established specific guidelines on the safest ways for healthy babies to sleep. I last reviewed them in detail here. In summary, babies should always be put down on their backs to sleep on a firm, flat surface, like a crib or bassinet. Baby sleep positioners that hold an infant in place are a bad idea. Things that hold babies in an upright or semiupright position, like the Fisher-Price Rock ‘n Play Sleeper, are also a bad idea. Why?

They’re dangerous because little babies have big, heavy heads, and they lack the strength and muscle control to protect their little baby airways. If their heads fall forward, or their necks get entangled in a strap, they can die.

The new report (summarized here) points out that sleep-related deaths are the most common cause of death in infants from 1-12 months of age. The authors reviewed 47 deaths reported to the US government involving sitting or carrying devices, including car seats, slings, and bouncer-type devices.

I’m going to quote a few of the case histories, here. This material is cold and clinical and disturbing. Feel free to skip ahead a bit.

An 11-month-old boy was placed with a bottle in a car seat for a nap at a home day care center. He was covered with a fleece blanket. The chest buckles were secured, but the lower buckles were unsecured. One hour and 20 minutes later, the child care provider went into the room to check on the child. She saw that he had slipped down in his car seat, such that at least one strap was up against his neck, his color was pale, and he was gasping for breath. EMS was called and the victim was transported to a hospital, where he was declared dead.

A mother was attending a breastfeeding class with her 26-day-old son. She was wearing a cloth baby sling that was placed like a sash across her chest. The child was breastfeeding inside the sling. The child stopped nursing and was believed to have fallen asleep. Approximately 10 minutes, later the mother noticed that her son was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated. The child was transported to a hospital and pronounced dead.

A 3-month-old boy was placed for sleep on his back in a bouncer. The father buckled the infant into the seat with the restraint belt and placed a blanket on him up to his waist. Ninety minutes later, the father found the victim face down and unresponsive, with his neck over the top of the bouncer. 911 was called and CPR started; the baby was pronounced dead at the scene. The detective related that the victim had apparently rolled over and pushed up to the top of the bouncer by pushing on the blankets.

An 8-month-old girl was sleeping unattended in a stroller at the mother’s workplace. The restraint belt was not fastened. The mother returned to the room after 5 minutes and found her partially hanging out of the stroller, her head wedged between the lower edge of the tray and the front edge of the seat. She was unconscious and not breathing, so CPR was initiated. She was resuscitated but was in a vegetative state, and life support was withdrawn 2 days later.

Some important lessons can be learned from the details of the report. Death can occur quite quickly—deaths in car seats and strollers were reported after a minimum of only 4 or 5 minutes. And they can occur at almost any age, from 10 days old in a sling to 2 years old in a car seat.

About half of the time, car seat deaths were caused by strangulation on unfastened straps. You might think that once a car seat is out of a moving vehicle, it would be safe to undo the straps—but those same straps that are so effective in keeping a child safe in a crash can strangle a baby. Many of the other deaths were caused either by positional asphyxia, with the head falling forward to close off the airway, or by a device tipping over and smothering the baby.

There’s some good news buried in this report, too. There were no deaths using a sling for breastfeeding—only when the babies were sleeping in a sling. And almost all of the car seat deaths were when using a car seat outside of a car. Based on this and other reports, the correct use of a car seat in a vehicle (baby strapped into the car seat correctly, and car seat strapped into the car correctly) is very safe. It’s the unintended use of car seats and other devices as sleeping devices in homes and daycares that’s dangerous. As the authors conclude, “It is possible that most, if not all, of these deaths might have been prevented had the device been used properly and/or had there been adequate supervision.”

When I’ve written about safe sleeping before, I’ve gotten many colorful comments from people who say that their babies have unique health circumstances, and that their own pediatricians have made recommendations that differ from the usual guidelines. (That’s my translation of their comments, which are more-typically worded “You are an idiot.” or “How dare you question the advice of my pediatrician who has won a Nobel Prize and you are an idiot.”) The AAP sleep guidelines are for routine, healthy babies. If you think your babies need to sleep in a manner different from the typical guidelines, I suggest you speak their pediatricians about it, as soon as they return from Stockholm.


edit 4/12/2016: A reader sent me this link, about a baby who died in a car seat. An entirely preventable, tragic death: http://www.popsugar.com/moms/Baby-Died-From-Sleeping-His-Car-Seat-40838059.

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8 Comments on “Swings, slings, and car seats are not for sleeping”

  1. Katie Says:

    This post is wonderfully informative! I only wish I had read this when my daughter was younger and still (routinely) sleeping in a rock n’ play. I had no idea that this was considered unsafe and would not have even thought to ask my pediatrician about it. Shame on me for not doing so.

    I wish the manufacturer would have taken note of your suggestions and made a move to stop referring to this as a “sleeper”.


  2. Alexis Says:

    While there is ample and compelling evidence about the potential issue with car seats and safety (schlumping, strangulation, lower rates of oxygenation) I don’t feel this study made a reasonable case to support the position that swings are an unsafe sleep location. I actually struggle with much of Dr. Moon’s research although I fully respect what she’s striving to do. We ALL want kids to be safe because the alternative is horrific and the scant cases presented in this study are nightmarish. But they also highlight (at least in the case of the few swing deaths) some pretty gross misuse of the device. So to me a more reasonable conclusion is that a) further research is necessary and b) safe use guidelines should be more clearly communicated. The AAP keeps telling parents that only a crib is acceptable and now is even suggesting that parents stop swaddling at 2 months. Very few babies sleep reasonably under those circumstances. If you give desperately tired parents no tools to work with you end up with even worse things happening (babies sleeping on top of parents, babies sleeping with parents who inadvertently fell asleep on couches).
    We need to give parents workable alternatives that are also safe. Hopefully there is some middle ground in this?


  3. Dr. Roy Says:

    Alexis, it’s a quandry that comes up again and again– if a product is unsafe as it’s typically or possibly used (as opposed to the way it’s supposed to be used), is that really “unsafe”? Agree most of the deaths reviewed in the study where when products used in unsafe manner (with straps loose or on a table, etc.) But, still, that’s the way people use those things.

    Better education, better testing, better studies are a good idea.

    Also: I don’t think the AAP has a position on swaddling, one way or the other– am I wrong? What’s this about no swaddling after 2 months?


  4. Alexis Says:

    I guess it’s not the “sanctioned” recommendation but this made the rounds on the Internet and freaked many out: http://aapnews.aappublications.org/content/34/6/34.1.full


  5. Dr. Roy Says:

    There’s a few important points in there, Alexis:

    Safe swaddling does not include swaddling the legs tight, or in an extended position. In some cultures, swaddling is done with the legs poking out straight and tight, and that can lead to hip problems. We don’t see families from US doing that, but I do try to counsel people from other areas about safe swaddling. Also, a swaddle shouldn’t be a tight as wrapping a baby in duct tape. You need to be able to get a hand in there, and baby is allowed to wiggle a little. As with anything else, swaddling isn’t safe if you kind of go crazy with it.

    Also, whether swaddled or not, babies should be placed down on their backs to sleep, every time.

    RE: how long to swaddle, there’s no firm data on that, but to me it seems reasonable to at least start to loosen the swaddle to allow more movement by about four months. That’s when babies are starting to try to roll and move around. Swaddling much past then would interfere with ordinary opportunities to move.

    From that link, I think Dr. Moon is overstating the evidence. Her quote: “Given that we see deaths from babies who are swaddled and end up on their stomachs by 2-2½ months, I get really nervous when babies are swaddled past the age of 8 weeks,” Dr. Moon said. Yes, “swaddled” AND “end up on their stomachs.”


  6. Chelsea Ceyler Says:

    My son is 4 months old and will ONLY sleep while in his swing. He is obsessed with the movement, I want him to sleep flat so badly but I’m at a loss for what to do. I try to wean him off and it just doesn’t work, as soon as he realizes he’s not moving he instantly wakes up screaming. In desperate need of help.


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