FSID's formal reply to request for guidance re Tizzie Hall's advice (PART 3)

As those who have been following this blog know - I recently asked both Tizzie Hall and FSID for guidance regarding bedding and SIDS.  If you missed that post you can read it here.


Tizzie Hall replied here & I responded again to Tizzie here.


FSID have now also sent me a formal reply from Prof Haycock which you can read below :)  It includes both FSID's official advice and also the relevant research supporting.  Huge thank you to FSID for taking the time to respond with such detailed information and evidence.

FSID believes that it is vital that all parents are offered safe sleep advice which is supported by independent, peer-reviewed scientific research. 

Babies are all very different so it is important for parents to be aware of their baby’s temperature by feeling their tummy or the back of their neck - not their hands or feet - and if they do feel hot they should remove a layer. 

Here is our advice:

1. Babies do not need hot rooms and all night heating is rarely necessary.  Keep the room at a temperature between 16-20ºC.  18ºC (65ºF) is just right. 

2. Adults find it difficult to judge the temperature in the room, so use a room thermometer in the rooms where your baby sleeps 

3. When you check your baby, if they are sweating or their tummy feels hot to the touch, take off some of the bedding or clothing. Don't worry if their hands or feet feel cool, this is normal. 

4. Use lightweight blankets or a baby sleeping bag. If your baby feels too warm, reduce the number of layers or use a lower tog baby sleeping bag. In warm summer weather, your baby may not need any bedclothes at all. Do not use a duvet, quilt or pillow for babies under 12 months. 

5. Even in winter, babies who are unwell and feverish need fewer clothes and bedclothes. 

6. Babies need to lose excess heat from their heads. Make sure their head cannot be covered by the bedclothes by sleeping them 'feet to foot' (with their feet to the foot of the cot) so they don't wriggle down under the covers. 

7. Babies should never sleep with a hot water bottle or electric blanket, or next to a radiator, heater or fire, or in direct sunshine. 

8. When it's warm, you can cool the room where your baby sleeps by closing the curtains and opening the windows during the day.  Offer your baby plenty to drink, and in very hot weather, sponge them down regularly with tepid water.  Use a fan but do not place it directly onto your baby. 

9. Remove hats and extra clothing as soon as you come indoors or enter a warm bus, train or shop, even if it means waking your baby. 

10. A car can become very hot in the summer. Avoid direct sunlight on your baby.  In winter, keep the heating low, and remove your baby's outdoor clothing.  A thermometer may be helpful. 

Research Evidence:

The most important publication implicating over-wrapping of babies as a risk factor for SIDS is the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report ¹ which had a very large dataset. Some of the data in the report had been published before. ^2-4 In the chapter Thermal Environment and Arrangement of Bedding the authors state 

 “For both the usual sleep and last/reference sleep, the SIDS infants were wrapped significantly more warmly than the control infants. The difference in the distribution of tog values remained significant when adjusted for socio-economic status. Notably twice as many SIDS infants put down for the last/reference sleep were covered by 10 tog or more bedding, and three times as many were found this way compared to the control infants.”

CESDI indicated that worrying about overheating might actually be protective:

“Significantly more control than index mothers worried about their baby getting too hot, suggesting a protective effect…”

It was the mothers of the SIDS infants who worried most about their baby being too cold:
27.8% of the mothers of SIDS infants compared to 15.8% of controls. 

There is no scientific evidence to suggest babies roll over because they are cold, indeed, the peak age of death for SIDS infants is 2-3 months, an age when most babies are unable to roll.

Two other studies examined the relationship between wrapping and SIDS risk, one from Tasmania ⁵ and one from New Zealand ⁶. Both of these found that the risk was only significant for infants slept prone, but the numbers were relatively small. The New Zealand study also found an interaction between over-wrapping and maternal smoking. 

There is also evidence to show that overheating interacts adversely with infection so it would be unsafe to overwrap a baby who was unwell and there are two studies that show that SIDS may occur against a background of minor illness^7-8: 

The current evidence-based advice is that over-wrapping increases the risk of SIDS especially for infants slept prone, who are unwell and for those of smoking mothers. All parents should check that their baby is not too hot by feeling their tummy or the back of their neck.  FSID encourages parents to follow the Reduce the Risk guidelines because they are supported by externally reviewed, scientific studies conducted by leading SIDS researchers. 

1. Fleming PJ, Bacon C, Blair PS, Berry PJ, editors. Sudden unexpected deaths in infancy. The CESDI SUDI studies 1993-1996. London: The Stationery Office, 2000.
2. Fleming P, Berry J, Gilbert R, Rudd P. Bedding and sleeping position in the sudden infant death syndrome. Bmj 1990;301(6756):871-2.
3. Gilbert R, Rudd P, Berry PJ, Fleming PJ, Hall E, White DG, et al. Combined effect of infection and heavy wrapping on the risk of sudden unexpected infant death. Arch Dis Child 1992;67(2):171-7.
4. Fleming PJ, Blair PS, Bacon C, Bensley D, Smith I, Taylor E, et al. Environment of infants during sleep and risk of the sudden infant death syndrome: results of 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. Bmj 1996;313(7051):191-5
5. Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med 1993;329(6):377-82.
6. Williams SM, Taylor BJ, Mitchell EA. Sudden infant death syndrome: insulation from bedding and clothing and its effect modifiers. The National Cot Death Study Group. Int J Epidemiol 1996;25(2):366-75.
7. Stanton AN, Downham MA, Oakley JR, Emery JL, Knowelden J. Terminal Symptoms in children dying suddenly and unexpectedly at home. Preliminary report of the DHSS multicentre study of postneonatal mortality. Bmj. 1978 Nov 4;2(6147):1249- 51.
8. Gilbert RE, Fleming PJ, Azaz Y, Rudd PT. Signs of illness preceding sudden unexpected death in infants. Bmj. 1990 May 12;300(6734):1237-9. 

Tizzie replies to FSID here.