Safe sleep for babies: the evidence-based guidance

Newborn · Sleep · Reviewed 20 June 2026 · All articles

Every parent and caregiver wants to put their baby down knowing they are as safe as possible. Sudden infant death syndrome (SIDS), known in Italian as morte in culla or death in the crib, is a heartbreaking and still partly unexplained event. The good news is that decades of careful research have identified a set of practical, evidence-backed steps that consistently reduce risk. Following these steps for every sleep, day and night, is the most powerful thing a caregiver can do. This article explains the guidance published by the Istituto Superiore di Sanita (ISS), the American Academy of Pediatrics (AAP), and the NHS, together with the reasoning behind each recommendation.

Why safe sleep matters

SIDS is defined as the sudden, unexplained death of an infant younger than one year of age that remains unexplained even after a thorough investigation, including a complete autopsy, examination of the death scene, and review of the clinical history. It is distinct from accidental sleep-related deaths caused by suffocation, entrapment, or strangulation, though these are sometimes grouped with SIDS under the broader term Sudden Unexpected Infant Death (SUID) because the underlying risk factors overlap.

SIDS deaths peak between two and four months of age and decline through the rest of the first year. Risk is not spread evenly: male sex, premature birth, low birth weight, and a family history of SIDS are all associated with higher risk, as are certain environmental factors that caregivers can directly control.

In Italy, the ISS has published guidance on preventing morte in culla that aligns with the international consensus. Italian paediatricians and midwives (ostetriche) follow this evidence when advising families. The ISS recommendation is clear: always place babies on their backs, use an appropriate sleep surface, share a room but not a bed, avoid overheating, and maintain a smoke-free environment.

The transformative power of these recommendations is demonstrated by history. After the "Back to Sleep" campaign launched in the early 1990s, SIDS deaths fell by more than 50 percent in countries that adopted the guidance. That reduction happened because caregivers changed their behaviour, not because medicine discovered a cure. The same potential is available to every family who applies the guidance consistently.

The back-to-sleep rule

The single most important recommendation is to place your baby on their back for every sleep, every time, for the entire first year of life. This includes overnight sleeps and all daytime naps, whether at home, at a grandparent's house, or in any other setting.

Compared with back sleeping, prone (tummy-down) sleeping increases the risk of SIDS by a factor of approximately two to four. The reasons are not fully understood, but current evidence points to several mechanisms. Babies sleeping face-down may rebreathe carbon dioxide from a small air pocket beneath their face. They may have a reduced ability to arouse from deep sleep when placed on their tummy. They may also overheat more easily because the tummy-down position limits heat dissipation from the front of the body.

Side sleeping is not a safe alternative. A baby placed on their side may roll onto their tummy, especially as they grow stronger, and tummy sleeping carries the risks described above. The AAP, ISS, and NHS all specify the back as the only consistently safe position for unsupervised sleep.

A common worry is that a back-sleeping baby will choke if they spit up. This concern is understandable but not supported by evidence. Babies have effective airway-clearing reflexes, and the anatomy of the infant airway (the trachea sits in front of the oesophagus) means that liquid regurgitated from the stomach flows toward the oesophagus, not the airway, when the baby is supine. If a doctor has diagnosed a specific medical condition requiring a different sleep position, follow that medical advice specifically.

Once your baby can roll from back to tummy and from tummy to back independently, they may find their own position during sleep. At that point it is safe to leave them in the position they roll to. Until that milestone, always start every sleep on the back.

The safe sleep environment

A safe sleep surface is firm, flat, and designed for infant sleep. Approved options include a cot (lettino), bassinet (culletta), or play yard that meets current national safety certification standards. In Italy, products sold for infant sleep should carry CE marking and comply with applicable European safety standards for cots and mattresses.

Firmness matters because a soft surface can conform to a baby's face, reducing the space around the mouth and nose. A useful test: press your palm firmly into the mattress and watch how quickly it returns to its flat shape. A safe mattress springs back immediately. Memory foam and padded mattress toppers are not appropriate for infant sleep.

The mattress should fit snugly in the cot frame. Gaps between the mattress edge and the cot sides allow a baby to become wedged, which can restrict the airway. The gap should be no more than two finger-widths.

Keep the sleep space clear. Remove all of the following:

Cot bumpers were once used to prevent babies bumping their heads on the rails, but evidence now shows they provide no meaningful benefit and add suffocation and entrapment risk. They are not recommended by the ISS, AAP, or NHS and are banned from sale in some jurisdictions.

To keep your baby warm without loose bedding, use a well-fitting sleep sack (sacco nanna) with a tog rating appropriate for the room temperature. Dress your baby in one extra layer compared with what you would find comfortable in the same room.

Car seats, bouncers, swings, and strollers are not designed for unmonitored sleep. The semi-reclined position in these devices can cause a young baby's head to fall forward, folding the airway. If your baby falls asleep during travel, transfer them to a flat sleep surface as soon as you arrive at your destination.

Room-sharing without bed-sharing

Both the ISS and the AAP recommend that babies sleep in the same room as their caregiver for at least the first six months of life, and ideally for the full first year. Babies who share a room with their caregiver (but not the same sleep surface) have a substantially lower risk of SIDS. The most plausible explanation is that a nearby sleeping adult is more likely to notice and respond if the baby is in distress. Room-sharing also makes night feeding easier, and breastfeeding is itself protective (see below).

Room-sharing is not the same as bed-sharing. Sharing an adult bed with an infant significantly increases the risk of accidental suffocation and SIDS, particularly in the presence of soft mattresses, duvets, and pillows. The risk is considerably higher when the adult has consumed alcohol, taken sedating medication, or is severely sleep-deprived. The ISS, AAP, and NHS all recommend against routine bed-sharing.

Practical room-sharing options that keep the baby close without the risks of the adult bed include:

These setups allow you to feed, check, and comfort your baby without either of you leaving the room or compromising sleep safety. If you feed your baby in bed and think you may fall asleep, consider sitting in a chair or moving to a sofa, taking your baby back to their cot as soon as feeding ends.

Temperature, smoking, and other risk factors

Overheating is a well-established risk factor for SIDS. Keep the room where your baby sleeps at a temperature between 16 and 20 degrees Celsius. This range may feel cool to adults who are used to warmer bedrooms, but it is appropriate for a sleeping baby.

Signs that a baby may be too warm include sweating, damp hair, flushed cheeks, a heat rash, and rapid or noisy breathing. When checking your baby's temperature, feel the skin at the back of the neck or across the chest, not the hands or feet, which are normally cooler than the core even when the baby is comfortable.

Avoid putting a hat on your baby for sleep indoors. The head is an important surface for releasing excess body heat, and covering it during sleep can contribute to overheating even in a well-regulated room.

Tobacco smoke, both prenatal and postnatal, significantly raises SIDS risk. Maternal smoking during pregnancy roughly doubles the risk for the baby. Postnatal exposure to second-hand smoke, sometimes called passive smoking, adds further risk. Third-hand smoke, the chemical residue that clings to clothing, furniture, and walls, is also a concern. If anyone in the household smokes, keeping the baby away from smoking areas, changing clothes before handling the baby, and working toward quitting are all steps that reduce risk. Many Italian health services offer free or subsidised cessation support during pregnancy and the postnatal period.

Breastfeeding is consistently associated with a reduced risk of SIDS across multiple large studies. Any amount of breastfeeding appears to offer some protection, and the benefit increases with duration and exclusivity. The protective mechanisms are not fully understood but likely include immune factors in breast milk, the natural arousal patterns of breastfed babies, and reduced exposure to respiratory infections. This protective effect is one of several reasons both the ISS and international bodies recommend breastfeeding where possible, without creating additional pressure on mothers for whom breastfeeding is not feasible.

Dummy or pacifier use at the start of sleep is associated with a modest reduction in SIDS risk. The mechanism is not certain, but one theory is that suckling keeps the airway slightly more open and increases the frequency of arousal from deep sleep. The protective association is present even when the dummy falls out after the baby is asleep. If you are breastfeeding, most guidelines suggest waiting until breastfeeding is established, typically around three to four weeks, before introducing a dummy, to avoid potential interference with latch and supply. Do not attach the dummy to a cord or ribbon for sleep.

Frequently asked questions

When can my baby sleep on their tummy?

Always place your baby on their back to start every sleep for the entire first year of life. Once your baby can roll independently from back to tummy and tummy to back, it is generally safe to let them stay in the position they find overnight. Continue to place them on their back to begin every sleep, and keep the cot free of loose items that could obstruct the airway if they do roll.

Is room-sharing safe to continue past six months?

Yes. Health authorities including the AAP recommend room-sharing for at least the first six months and ideally for the full first year. After 12 months the risk of SIDS drops significantly and you can transition your baby to a separate room when you and your baby are ready. Room-sharing simply means your baby's separate sleep surface is in your bedroom, not that you share the same bed.

What temperature should my baby's room be?

Aim for a room temperature of 16 to 20 degrees Celsius. Overheating is an independent risk factor for SIDS. Use a sleep sack rated for the room temperature instead of loose blankets, dress your baby in one extra layer compared with what you would wear comfortably, and avoid indoor hats during sleep. Check warmth at the back of the neck rather than the hands or feet, which are naturally cooler.

Do sleep positioners or wedges help keep a baby safe?

No. Sleep positioners, wedges, and rolled-blanket supports marketed to keep a baby in a specific sleeping position are not recommended by any major health authority, including the ISS or AAP. They add material to the sleep space that can cause suffocation or entrapment. The safest sleep surface is a firm, flat, empty cot mattress with a fitted sheet and nothing else.

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