Safe from harm

    The urge to protect your children is probably the most basic of all parental instincts. For this reason fears about cot deaths are prevalent, even though in Hong Kong parents should be reassured by the fact that the risks are low. Maintaining a safe sleeping environment for your baby is easy when you know how.

    Cot death, crib death and Sudden Infant Death Syndrome (SIDS) are all names for the same thing – the unexpected and unexplainable death in their sleep of an apparently healthy baby during the first year of their life.


    By the end of the 1980s the rates of SIDS in New Zealand, Australia and Europe were alarmingly high. In 1987, New Zealand had a rate of 4.2 cot deaths for every 1,000 babies, a statistic that prompted the New Zealand Cot Death Study. The findings from that study have been the foundation for reducing the worldwide rate of SIDS, and by 2004 the New Zealand SIDS rate had dropped to 0.8 cot deaths for every 1,000 babies – a remarkable improvement.

    The good news for Hong Kong parents is that historically we have had one of the lowest rates of SIDS in the world. A study by Professor Tony Nelson and his colleagues from the paediatrics department at the Chinese University of Hong Kong (“Hong Kong case-control study of sudden unexpected infant death” in the New Zealand Medical Journal, December 2005) looked at SIDS deaths in our city. Their data showed that the incidence has fallen from 0.3 cot deaths for every 1,000 babies in 1987 to 0.16 cot deaths for every 1,000 babies between 1999 and 2002.

    The Hong Kong study revealed that babies who sleep on their tummies, who have a mother that smokes, who share a bed with someone other than their parents, or whose heads are covered when sleeping are at a higher risk of cot death. Although the causes of cot death are unknown, the following straightforward and practical measures have been proven to dramatically decrease your baby’s risk. These recommendations should be collectively followed and parents should never be complacent when preparing their baby’s sleeping environment.

    How to decrease the risk of SIDS
    Back to sleep

    Put your baby to sleep on its back – babies who sleep on their sides or tummies have a higher risk of SIDS. Babies get hotter on their tummies and do not have the ability to roll over to cool down. Don’t worry about them choking, or inhaling vomit if they are sick. In fact, this is less likely to happen when they are on their backs because the baby’s airway is opened up and the baby has the freedom to move his or her head to the side if they vomit. “Back to sleep” is the safest position for your baby. This recommendation has been around for over 15 years and the reduction of SIDS in that time speaks for itself. The highest risk time for SIDS is in the first six months so try to keep babies of this age on their backs. Babies who sleep on their sides often roll on to their fronts earlier, which could be why they are more at risk of SIDS.

    Many parents worry that their baby will develop a flat pressure spot on their head as a result of sleeping in the same position for long periods of time. Positional plagiocephaly, as this condition is called, can be alleviated by following some simple steps.

    • If your baby favours one side of their head to the other when they are lying down, try changing the position of the cot in the room or the end of the cot that your baby sleeps in. You could also place something really interesting, such as a mobile or other toy, in their direct line of vision, which will encourage them to settle with their heads in another position.
    • Place your baby on his or her tummy to play – this is safe if the baby is awake and an adult is present. Tummy time helps develop a more attractive round head but also works on the muscles in the neck, arms and back, which are necessary to help your little one when he or she starts crawling. Older babies of around five to six months may start to roll on to their tummies during the night, so it’s even more important that they have tummy time during the day and can develop the muscles needed to roll back.

    You might also try wrapping or swaddling your baby as this can give them more stability on their backs, making them feel more secure and settled there. It’s important to make sure your baby doesn’t overheat – leave their head and face uncovered, and ensure that they are not overdressed under the wrap. Lightweight cotton wraps should be used in place of blankets. A snug but not tight wrap will allow for hip and chest wall manoeuverability and for the baby to make hand to mouth movements when they wake up, which is important in developing breastfeeding skills.


    Temperature control

    Babies largely control their temperatures through their faces and heads. A covered face or head may lead to your baby getting too hot. A sweaty or clammy child with a red face is probably overheating. The best way to gauge a baby’s temperature is to feel their chest or back. The temperature of hands and feet may be misleading; they are particularly cool in newborns.

    Place your baby’s feet at the foot of the cot and use only lightweight blankets. These can be added or removed easily to keep your baby comfortable. They can be also be tucked in easily and securely but should come up only as far as the baby’s chest. The reason for this is so that your baby can’t wriggle down under the blankets and smother or overheat. Never use electric blankets or hot water bottles for babies and don’t put heaters near their cots. Young babies don’t have the ability to move away or kick the bedding off as we do when we get hot!

    In Hong Kong room temperatures vary significantly even on the same day – just think how cold it is at the cinema! We all like to sleep in different temperatures and air-conditioning units vary considerably in efficiency. In the UK the guideline is to keep a baby’s room between 16 and 20 degrees Celsius, but in Hong Kong this would be a challenge for most air-conditioners, not to mention your pocket! In hotter countries sensible advice would be to let your baby get used to the environment but make sure that whilst they are doing so, you check that they are not overheating. If you have the air-conditioner on, try to arrange the cot under it so your baby does not receive blasts of cold air. Look at what you are wearing and dress your baby accordingly. If you go to sleep in a vest and shorts under little or no covers, then do the same with your baby, adding a light cotton covering. Dress your baby according to the room environment.


    Ensure your baby’s mattress is firm, clean and the right size for the cot. A firm surface is important and putting babies to sleep on sheepskins, beanbags or pillows is not recommended as they sink into the soft surface and get too hot. In the same vein, avoid bumpers and duvets. Don’t put large or multiple soft toys in the cot; they may shift and cover your baby’s head. A safe time to use a duvet and pillow is when your little one moves to their own bed.

    Some parents like to use baby sleeping bags or “grobags”. These may help with keeping your baby sleeping on their back and at the foot of the cot as he or she grows older and more mobile. With baby sleeping bags, the important thing is that they are of a safe design and the correct size for your baby. The baby sleeping bag should have a fitted neck and armholes (or sleeves for the winter) and no hood. If you need to provide additional warmth dress your baby in more layers within the sleeping bag rather than using blankets; one of the benefits of using a sleeping bag is that there are no bedclothes to ride up and cover your baby’s face.

    It would be great to see a Hong Kong-wide ban on companies advertising unsafe bumpers, pillows and duvets for cots. Often families have already bought cots and soft bedding before they start learning about SIDS. With all your baby’s equipment and toys, check that they are marked as safe by a reputable organisation. UK products will be kitemarked if they are regarded as safe.


    Babies who are exposed to tobacco smoke before and after birth have a much higher risk of SIDS. So if anyone in the household smokes, now is the time to give up! Having a baby is a new chapter in your life and a great opportunity to start afresh and kick old habits. If you are struggling to give up, see your family doctor, who will be able to help.

    Bed-sharing and co-sleeping

    Since time immemorial, babies have slept with their mothers. Co-sleeping or sleeping in the same room is recommended for at least the first six months. This may be one of the preventative measures for SIDS that is least known or adhered to, and it may be one of the most important. Co-sleeping encourages “arousal” episodes as mum and dad wake up the baby and vice versa with their natural sleep noises and movements. It has been suggested that arousal episodes may be vital in rescuing babies from potentially dangerous situations during sleep. This may be why incidences of cot death are low in Hong Kong, where it is not uncommon for families to share rooms, resulting in plenty of arousal episodes for everybody!

    Bed-sharing is different to sleeping in the same room and opinions are divided as to whether it is safe. Some SIDS experts say it’s fine, some disagree. Bed-sharing can be a heaven-sent solution for a sleep-deprived family and it can facilitate breastfeeding. However, bed-sharing increases the risk of SIDS for the children of parents who are smokers, who drink too much alcohol or who take sedative medication. If this applies to you, then your baby will be safer in a cot or bassinette beside the bed. If you choose to bed-share, avoid putting your little one in between you and your partner, under a duvet or near the pillows as they have more chance of getting their heads or faces covered. As in any other situation, put them to sleep on their backs.

    The Hong Kong study found bed-sharing to be fairly common in Hong Kong. As there is a low SIDS rate here, it follows that bed-sharing in Hong Kong tends to be practised safely. The baby should only share a bed with his or her parents.

    Avoid dropping off to sleep on the sofa with your baby. By doing so you could risk them getting trapped in between the cushions or at the back of the sofa. This type of sleeping arrangement can be one of the most risky for SIDS.



    The use of dummies or pacifiers is controversial. The latest evidence suggests that using them may have a protective effect against SIDS but other evidence points to their interference with breastfeeding and increase of ear infection risk. The reason why using dummies might reduce the risk of SIDS is unclear. It is possible that sucking a dummy makes it harder for the baby to roll on to their front. Also, a dummy can help a child settle, meaning that they are less likely to wriggle around and get smothered by a blanket. A dummy-user may also sleep less deeply, leading to more wakeful episodes during the night. Hopefully, you will not have more wakeful episodes too, as you get up to replace the dummy that has fallen out of an indignant baby’s mouth! If you do choose to use a dummy, try to wait until breastfeeding is well established, probably not before the baby is three to four weeks old. Be meticulous with sterilising the dummy, especially with young babies; you’ll need plenty of spares. Have a plan of how long you want your child to use a dummy. Babies are at risk from SIDS during the first year of their lives. The longer after that your baby uses a dummy the harder it is to extract it from the sleep routine. Prolonged dummy use may cause delayed speech if your child sucks on it during the day when they should be beginning to speak.


    In the past it has been argued that vaccinations might be a
    cause of SIDS, primarily as the high-risk period for SIDS
    coincides with the time that babies receive their Diptheria, Tetanus and Pertussis (DPT) vaccinations. However, parents should be reassured that recent research shows that not only do immunisations not cause SIDS they are actually associated with halving the risk of it.


    Studies on SIDS and breastfeeding versus formula feeding are conflicting in their results. This is thought to be because some definitions of breastfeeding in the research were unclear, and because SIDS has several risk factors, such as those discussed above. However, breastfeeding is associated with many health benefits in babies. These include boosting your baby’s immune system; breastfed babies have fewer infections. If you are able to breastfeed, there are many clear benefits for both mothers and babies.

    If you have any questions or worries, approach your family doctor, paediatrician or midwife for help. Health professionals all over the world are united in recommending the SIDS guidelines for safe sleeping. Put your baby down in a safe environment so all the family can sleep without worries.

    Checklist to Reduce the Risk of SIDS:
    • Put your baby to sleep on their back from birth, not on their tummy or side
    • Put your baby to sleep with their face and heads uncovered (no hats, duvets, unsafe pillows, sheepskins, bumpers or soft toys)
    • Avoid exposing babies and infants to tobacco smoke, both before birth and afterwards
    • Provide a safe sleeping environment (safe cot, safe mattress, safe bedding)
    • Put your baby’s cot next to your bed for the first six to 12 months


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