We support the Back-to-Sleep Campaign as a successful initiative in reducing the incidence of SIDS/SUID but the improvement rates have plateaued making additional efforts necessary to continue to bring these numbers down.  The literature and product testing support an air permeable sleep surface that does not retain high levels of carbon dioxide as a safer option than the firm fiberfill crib mattress with a sheet to address the situation of the inexperienced infant who is placed supine and rolls prone.  Deaths of infants placed on their backs and found face down on firm fiberfill crib mattresses and pads continue to occur because nothing prevents these infants from rolling.

2016 SIDS and other Sleep Related Infant Deaths:

Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment,

“Certain crib mattresses have been designed with air-permeable materials to reduce rebreathing of expired gases, in the event that an infant ends up in the prone position during sleep, and these may be preferable to those with air-impermeable materials.”


Relevant Scientific Studies Supporting Air-Permeable Crib Mattresses:

Patrick L. Carolan, MD; William B. Wheeler, MD; James D. Ross, RRT, RCP; and James S. Kemp, MD, (2000), Potential to Prevent Carbon Dioxide Rebreathing of Commercial Products Marketed to Reduce Sudden Infant Death Syndrome Risk, Pediatrics, 105:4 774-779.
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Bar-Yishay, E., Gaides, M., Goren, A., and Szeinberg, A. (2011), Aeration properties of a new sleeping surface for infants. Pediatr. Pulmonol., 46: 193–198. doi: 10.1002/ppul.21351.
Click here to open.

Colditz PB, Joy GJ, Dunster KR. Rebreathing potential of infant mattresses and bedcovers. J Paediatr Child Health. 2002;38(2):192–195.
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William W. Fox, MD and Thomas H. Shaffer, Carbon Dioxide Rebreathing Assessment of SafeSleep Crib Mattress Sample.  Intertek.,  wouso7330
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Infants in the prone position on fiberfill sleep surfaces with a tight-fitting sheet show increased risk of rebreathing of carbon dioxide which leads to hypoxia – a condition commonly associated with SIDS.  Scientific evidence shows air permeable mattresses provide a “significant” decreased risk of rebreathing of carbon dioxide.  For medical professionals unfamiliar with air-permeable mattresses, ask yourself, “is a baby less likely to asphyxiate with their face down on a firm 6-inch-thick pillow, a 1-inch plastic encased play yard mat or a 1/8 inch thin open weave 3D fabric with nothing but air underneath it?”

Avoidance of Potentially Asphyxiating Sleep Environments

“Asphyxia has long been thought to be the primary cause of death in many instances of SIDS, based both on the practices (eg, supine positioning and/or lack of soft bedding) known to be protective against SIDS and on the frequent autopsy finding of pulmonary edema, which is often seen with asphyxiation. Infants resting in the prone position or lying with soft bedding may rebreathe exhaled carbon dioxide, potentially leading to hypercarbia and hypoxia. If infants’ environment does not change or infants are unable to extract themselves from the hazardous situation, they will ultimately die of asphyxia.” 

JAMA Pediatrics February 2017 Volume 171, Number 2

“Risk-reduction strategies are based on the best-available evidence in large epidemiologic studies. These studies have been largely focused on the correlations between the sleep environment and SIDS. Our current understanding is that the cause of SIDS is multifactorial and that death results from the interaction between a vulnerable infant and a potentially asphyxiating sleep environment. Thus, claims that sleep devices, mattresses, or special sleep surfaces reduce the risk of SIDS must therefore be supported by epidemiologic evidence.  At a minimum, any devices used should meet safety standards of the CPSC, the Juvenile Product Manufacturers Association, and ASTM International (known previously as the American Society for Testing and Materials).  The AAP concurs with the US Food and Drug Administration and CPSC that manufacturers should not claim that a product or device protects against SIDS unless there is scientific evidence to that effect.”


Randomized Case Controlled Study vs. Retrospective Analysis

If rebreathing of carbon dioxide is thought to be a causal factor in SIDS deaths and studies show exhaled gas retained on a breathe-through mattress is significantly less than on a fiberfill surface, why can’t we say that sleeping on a breathe-through mattress reduces the risk of SIDS?  To make this claim would require randomized case-controlled studies comparing rates of SIDS deaths for infants who sleep on air permeable mattresses versus those on fiberfill mattresses. These gold standard studies do not exist for any safe sleep recommendation and likely never will because they are not feasible.  This is why products are not able to say they reduce the risk of SIDS.  Most current safe sleep guidelines are based on limited retrospective analyses.

It’s important to point out that absence of data is not the same as negative findings. While we cannot say with scientific evidence that air permeable mattresses lower the risk of SIDS, we also cannot say with scientific evidence that air permeable mattresses do not lower the risk of SIDS

Join the multiple medical professionals and safe sleep advocates recommending and using our air-permeable/breathe-through crib mattresses to protect infants from sleep related death when they roll face down.