Babywearing to Promote Safer Sleep for Preemies


(photo description: new mother reclining in a hospital bed at a 45 degree angle with a new baby wrapped snugly to her with his cheek on her chest)

The initiation of the Back to Sleep campaign in 1994 resulted in a dramatic decrease in cases of Sudden Infant Death Syndrome (SIDS). Since then a frustrating plateau has persisted. Researchers and epidemiologists have struggled to determine why the number of SIDS cases remain relatively stable. The American Academy of Pediatrics released updated Safe Sleep Guidelines in October 2016 in an effort to address this plateau and encourage another downward trend in infant loss to SIDS.

The Triple Risk Model of SIDS was revised in 1994 and attempts to describe what types of factors put babies at higher risk. The three types of risks that can compound SIDS risks include vulnerable infants, external stressors, and critical developmental periods (Galland & Elder, 2014).  Preterm infants are at increased risk for sudden infant death syndrome due to being vulnerable (Moon, 2016).

While there are risks for SIDS that are not modifiable, there are many preventive strategies and risk avoidance that caregivers can employ.

The following is an excerpt from the 2016 recommendation summary by the AAP (Moon, 2016). Added are the possibilities for using baby carriers to meet these safe sleep recommendations. Levels are graded A, B, or C with A being recommendations based on the highest level of evidence.

A-level recommendations

Back to sleep for every sleep. Prone and side-sleeping positions are advised against until the infant reaches one yeear of age or can independently roll from supine to prone and back again. Babywearing can provide upright sleeping that may be beneficial for infants with reflux or who find supine sleeping during the day unacceptable.

Use a firm sleep surface. The caregiver becomes the infant’s place of rest. There is no temptation to allow an infant to sleep with a pillow or other soft bedding when sleeping in a baby carrier. Strangulation risks during sleep are essentially eliminated when the infant is constantly monitored by the caregiver while being carried.

Breastfeeding is recommended. Babywearing promotes breastfeeding length and duration (Pisacane, Continisio, G., Filosa, Tagliamonte, & Continisio, P., 2012).

Room-sharing with the infant on a separate sleep surface is recommended. It is easier to follow the guideline for room-sharing while using a baby carrier during infant sleep.

Avoid overheating. Skin-to-skin contact keeps caregivers aware of infant skin temperature.

Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. Parents may be less likely to depend on home cardiorespiratory monitors for daytime infant sleep if they are not separated from the infant.

B-level recommendations

Avoid the use of commercial devices that are inconsistent with safe sleep recommendations. Infants should not be allowed to sleep in commercial infant care devices not developed for sleeping such as sitting devices, swings, or car seats. Infants younger than four months of age or with low muscle tone, such as preemies, are at higher risk for positional asphyxia. This happens when the child’s body position doesn’t allow their airway to stay open, for example, chin-to-chest positioning (Batra, 2015). Premature and low-birthweight infants should be carried in kangaroo position, as defined by the World Health Organization and pictured below. Baby carriers used to carry premature and low-birthweight babies should mimic kangaroo position.KangarooPositionWHO

   (Description of figure demonstrating kangaroo position: Mother with a tiny baby in the middle of her chest. Baby is lying tummy to tummy, with cheek on her chest, both arms are bent at the elbow with hands near head, and knees bent. Mother’s hands are keeping the baby close and upright. Baby’s head is tipped upward very slightly for optimal airway positioning)

Supervised, awake tummy time is recommended to … minimize development of positional plagiocephaly. Holding infants is preventive for positional plagiocephaly.

C-level recommendations

There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. For infants who enjoy swaddling, baby carriers can provide even pressure to promote relaxation and sleep. Baby carriers eliminate the risk of prone sleeping while swaddled.

Caregivers should not fall asleep while wearing a child in a baby carrier. Though there is no evidence to recommend against this, it stands to reason that the risk could be similar to caregivers falling asleep in a chair or on a couch while holding an infant (Moon, 2016).

Babywearing is an invaluable tool for caregivers. Further study is needed to examine and explore more applications for infant care that promote safety, development, and positive behavioral outcomes.


Batra, E. K., Midgett, J. D., & Moon, R. Y. (2015). Hazards associated with sitting and carrying devices for children two years and younger. The Journal of Pediatrics, 167(1), 183-187.

Galland, B. C., & Elder, D. E. (2014). Sudden Unexpected Death in Infancy: Biological Mechanisms. Paediatric Respiratory Reviews, 15(4), 287-292.

Moon, R. (2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics, 138(5), e20162940-e20162940.

Pisacane, A., Continisio, P., Filosa, C., Tagliamonte, V., & Continisio, G. I. (2012). Use of baby carriers to increase breastfeeding duration among term infants: The effects of an educational intervention in Italy. Acta Paediatrica, 101(10), E434-E438.

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