Currently, most preterm babies in intensive care are placed in the prone position (face down) to sleep as it is believed this improves breathing and increases oxygen to the brain.
Supine sleeping is recommended to prevent sudden infant death syndrome (SIDS). Low birth weight infants are at increased risk for SIDS, which is increased further if they are placed prone.
Prone sleeping, however, also has advantages for preterm infants, such as a reduced apnoea rate, an increased lung volume and more quiet sleep. In their first weeks of life, these infants are usually on a monitor and under continuous observation. SIDS is extremely unlikely under these circumstances.
Because of the advantages above, these infants may be placed prone during their first few weeks of life in the hospital. One week before discharge, however, they should be changed to back sleeping, and the parents are explained that their baby is now nearing discharge and should thus be placed as it should also sleep at home: on its back and in a sleeping sack.
We do not prescribe home monitors for SIDS prevention but occasionally use pulse oximeters at home for a few weeks if an infant continues to exhibit apnoea of prematurity.
Baby Nursery FAQs
Even though preemies may be positioned for sleep on their stomachs in the nursery while on monitors, your baby should not be positioned on their stomach or side for sleeping at home unless specifically requested by your baby's doctor. You should put your baby lying down on their back for sleep.
Prone positioning was shown to have many advantages for prematurely born infants. But the longer, deep sleep period and fewer awakenings associated with a prone position would support higher vulnerability for preterm infants to sudden infant death syndrome (SIDS).
Because preterm babies often remain in the hospital for several days to weeks before discharge, the AAP Task Force recommends that these infants be placed on their backs to sleep as soon as possible after the respiratory condition has stabilised.
Premature babies tend to sleep even more than full-term newborns, up to 22 hours per day — but only for an hour or so at a stretch, thanks to the need to fill their tiny tummies. Another difference: is the quality of sleep.
While you can begin tummy time as early as the first day you bring your baby home, by the time your baby reaches one month, it's time to begin daily exercises to help her strengthen her neck and back.
Sleep time for premature babies
- Make sleep time easier by using a cradle or bassinet, keeping a comfortable temperature, rocking or patting them and playing soft background music.
- Sudden infant death syndrome (SIDS) is the sudden and unexpected death of less than one-year-old.
- Ways to avoid SIDS include putting your baby to sleep on their back, avoiding soft mattresses and pillows, and keeping your baby in the same room as you but not in the same bed.
- Premature babies should sleep in different positions to avoid plagiocephaly and get plenty of tummy time when awake.
Newborn babies do a lot of sleeping, about 18 hours each day. However, a newborn baby’s sleeping pattern is different from that of adults. Newborn babies spend only 20% of their sleeping time in a deep, sound sleep.
The rest of the time, they drift in and out of sleep, which means that by the time you put your newborn baby down and try to take a nap, they will be awake and crying again.
Newborn babies do a lot of sleeping. Although you may not get much sleep during this time, your newborn baby spends about 18 hours each day doing just this. However, a newborn baby’s sleeping pattern is different from that of adults.
Newborn babies spend only 20 per cent of their sleeping time in a deep, sound sleep. The rest of the time, they drift in and out of sleep, which means that by the time you put your newborn baby down and try to take a nap, they will be awake and crying again.
Some newborn babies have their days and nights mixed up: they sleep during the day and want to play at night. This is a carry-over from their days in the womb.
During pregnancy, the unborn baby is most active when the mother is at rest, usually at night; they slow down when their mother is up and moving around, usually during the day.
A mother’s active motions soothe the unborn baby and help them rest. After birth, some newborn babies continue this pattern, much to the dismay of their overtired parents.
Try to understand your newborn baby’s perspective on the sleep issue. Newborn babies have shorter sleep cycles and more frequent periods of light sleep than older babies.
They are prone to waking up every hour, and once awake, they sometimes have trouble going back to sleep.
Also, newborn babies have needs for feeding, burping, diaper changing, and playing that must be met 24 hours a day; it doesn’t make sense to sleep for long periods yet.
Tips for making sleep time easier
Here are a few tips for making sleep time easier:
- Keep things cozy: Many newborn babies do not like the large, vast crib space. Try using a cradle or bassinet for those early weeks to make your newborn baby feel cozier. Just make sure that the mattress is firm and no pillows or loose blankets that could smother your baby. You might also want to try swaddling your baby by wrapping them snugly.
- Control the temperature: Newborn babies do not like a room that is too warm or too cold. Also, overheating is dangerous for your newborn baby.
- Keep them moving: Movement tends to soothe newborn babies and help them sleep. Try rocking, patting, or swaying them to music.
- Try some background noise: Background noise can be quite comforting to newborn babies. Soft music or white noise from a fan can be very soothing.
- Don’t deny the daytime naps: You may be tempted to keep your newborn baby awake during the day, even when they want to sleep so that they will sleep “better” at night. This approach will not work because it will make your newborn baby overtired. An overtired baby has more problems sleeping than a well-rested one. Still, if your newborn baby is mixing up their days and nights, you can try limiting the length of their naps and keeping them active when they are awake.
- When your newborn baby wakes at night for a feeding, try feeding them in a darkened room, and throughout the feeding, burping, and diaper changing, keep your talking and stimulation to a minimum. When your baby wakes for a day feeding, increase the light, conversation, and stimulation. This will help your newborn baby learn that nighttime is a sleepy time and daytime is a fun time.
Sleep and sudden infant death syndrome
Sudden infant death syndrome (SIDS) is the sudden and unexpected death of a baby less than one-year-old, which remains unexplained after a thorough investigation and autopsy.
Babies who succumb to SIDS do so in their sleep. To help prevent SIDS, the Canadian Paediatric Society, the American Academy of Pediatrics, and many other medical associations have made the following recommendations:
- Put your baby to sleep on their back, not their side or tummy.
- Avoid soft mattresses, bedding, and pillows.
- Do not smoke during pregnancy, and do not expose your baby to second-hand smoke after they are born.
- Avoid overheating your baby.
- Keep your baby in your room.
The debate about co-sleeping
Sleeping with your baby in bed is a controversial topic. On the one hand, it makes breastfeeding at night much easier, which provides a great health benefit to your baby. Night-time breastfeeding is more common in babies who co-sleep, leading to an increased milk supply.
Babies who co-sleep with their mothers tend to cry less and are generally more content at night.
On the other hand, some studies have shown that co-sleeping is hazardous and increases the risk of SIDS. As a result, the Canadian Paediatric Society, the American Academy of Pediatrics, and many other medical associations recommend that babies be put to sleep in a crib, bassinet, or cradle in the same room as the mother.
The baby can be brought into the bed for nursing or comforting and then returned to the crib, bassinet, or cradle for sleeping.
The debate rages, as other researchers feel that the abovementioned studies have not explained the whole picture. They indicate that usually, when a co-sleeping baby has died of SIDS, there have been other risk factors present such as parental drug use, sleeping on the tummy, or sleeping on unsafe surfaces such as couches or waterbeds.
If you do decide to co-sleep with your baby, here are a few preventive measures:
- Put your baby to sleep on their back.
- Make sure your mattress is firm and flat and that there are no gaps between the mattress and headboard where your baby can get stuck.
- Remove any fluffy pillows, heavy comforters, or soft bedding that could interfere with your baby’s breathing.
- Do not co-sleep with your baby on a couch, waterbed or armchair.
- Do not smoke.
- Do not co-sleep if you have taken medications or other substances that could impair your alertness.
- Do not co-sleep if you are excessively tired.
- Do not let your baby co-sleep with other children, and do not bring your other children into your bed if you are co-sleeping with your baby.
Positioning your premature baby
Supporting your baby’s position is essential for their growth and development. It can help make them feel secure, help with their breathing, strengthen their muscles and reduce the risk of sudden infant death syndrome (SIDS), also known as cot death.
In the last weeks of pregnancy, babies are curled up tightly in the womb with little space. Pushing against the walls of the womb helps to strengthen their muscles. This helps with their growth and development after they’re born.
But when a baby is born prematurely, they miss out on this time in the womb. As a result, their muscles aren’t strong enough to lift their arms and legs against gravity. Their shoulders and hips flatten against the bed, with their arms forming a ‘W’ shape and their legs in a ‘frog’ shape.
Premature babies can find it stressful and tiring to try moving against gravity. They need help to lie in a comfortable position, develops their muscles and helps them feel more secure.
The healthcare team will show you how to change your baby’s position to help strengthen their muscles.
A good position for your premature baby
Babies require regular position changes. The healthcare team will place your baby on their front, side or back. The amount of time spent in each position will depend on your baby’s individual needs and what they prefer.
Putting your baby on their front at home can increase the risk of sudden infant death syndrome. Only put your baby on their front while being monitored in the baby unit.
If babies lie in one position for too long, they can develop flat patches on their heads. They may also get used to turning their head in the same direction, making it uncomfortable for them to face the other way. Changing your baby’s position regularly will help prevent this.
The healthcare team will use supports or rolled-up bedding to make a ‘nest’ that keeps your baby in a position where they feel secure. They may also place a weighted cover over your baby. Supports and covers give your baby something to push against, which helps to strengthen their muscles and helps them move their arms and legs more easily.
Some baby units tilt the incubator or cot slightly, so your baby is lying flat but with their head higher than their feet. This may help with breathing, blood flow and digestion. A baby should always be lying completely flat, regardless of the angle of the cot.
When your baby’s muscles are stronger, and they can control their movements better, the healthcare team will gradually reduce the amount of support around their body.
Taking your premature baby home
If you are travelling by car, your baby will need to travel in a car seat. Premature babies are more at risk of breathing problems when in car seats, so the healthcare team in some units may do a ‘car seat challenge.
This is where your baby sits in their car seat on the baby unit while the healthcare team checks for any breathing problems or changes in your baby’s heart rate. If there are any problems, they may change your baby’s position in the seat or suggest a ‘car bed’, which allows your baby to lie flat.
Find out more about taking your premature baby home.
Caring for your premature baby at home
Before you take your baby home, they will spend time getting used to sleeping on their back with no support. This is safest for your baby at home because it lowers the risk of sudden infant death syndrome (SIDS).
The healthcare team will give you information about caring for your baby at home. Unless you have been told otherwise, you should:
- avoid placing supports, nests or bumpers in your baby’s cot
- avoid putting any comforters or toys in your baby’s cot
- avoid putting any soft layers, such as sheepskin, between your baby and the mattress
- keep the mattress level – don’t raise the head of the mattress or bed
- lie your baby on their back
- Place your baby’s feet at the bottom of the cot – feet to foot – so they can’t wriggle under the covers.
Avoiding cot death and breathing problems: front, back or side?
Lying on their front is fine in the baby unit.
In hospitals, babies are constantly monitored, so it's safe to lie on their front. This position can help babies with breathing problems.
The healthcare team will gradually get your baby used to lie on their back before they go home.
Putting your baby on their back at home
Once you take your baby home, you should lie them on their back because sleeping on their front is linked with cot death, also known as sudden infant death syndrome or SIDS.
Baby on the move? Put your baby on their front or side.
When your baby starts moving around and is awake for longer periods, they can spend some time on their front or side.
This ‘tummy time’ helps prepare them for crawling, sitting and standing. Only place them in these positions when they’re awake and never leave them alone.
The healthcare team in the baby unit can give you more information about the best position for your baby.
Fewer spontaneous arousals during prone sleep in preterm infants at 1 and 3 months corrected age.
- Objective: This study was performed to determine fewer spontaneous arousals in prone sleep than in supine sleep.
- Study design: Home polysomnography/video recordings were done during daytime naps in 14 preterm infants: four at corrected age of 1 month, nine at both 1 and 3 months, and one only at three months. A body movement lasting 3 to 60 s during sleep was used to indicate spontaneous arousals.
- Results: Most arousals had a heart rate increase and change in respiration pattern. The mean duration of the intervals between successive arousals inactive and quiet sleep was significantly longer in prone at 1 and 3 months of age. The duration of arousals was significantly shorter at three months corrected age than one month corrected age during active sleep. The duration of arousals was shorter during quiet sleep at one month compared with active sleep.
Premature newborns should sleep in different positions to avoid plagiocephaly or an abnormal asymmetrical head shape. Although more a cosmetic issue than anything else, plagiocephaly is caused when the skull bones are moulded by carrying weight more on one side or in one place, such as the back of the head.
Preterm infants should sleep on their backs or maybe propped up on their sides. Try to alternate between these positions during sleep time. Premature babies should also get lots of “tummy time” when awake.