There’s no doubt that the Back to Sleep campaign launched in 1994 to get parents to stop putting babies to sleep on their tummies has been a success. In the 1970s and 1980s, the rate of infant deaths per 1,000 live births was 1.5; it’s now 0.5.

Within a generation, most babies are now put to bed on their backs, and yet 2,500 U.S. infants still die each year in the U.S. Researchers trying to understand why have noticed a curious byproduct of the trend toward back-sleeping: as fewer babies were being put to sleep on their bellies, more babies were documented engaging in other pediatric no-nos — sleeping with their parents, for example — which is another risk factor for SIDS.

A study published Monday in the journal Pediatrics takes a look at how risk factors for SIDS have evolved over the years. In an analysis of the 954 babies who died suddenly and unexpectedly in San Diego County between 1991 and 2008 — 568 of these deaths were attributed to SIDS — researchers found that the percentage of babies put to sleep on their backs increased from 30% to 85%. Meanwhile, the rate of bed-sharing at the time of a SIDS death jumped from 19% to 38%; the incidence of babies asleep in an adult bed instead of in a crib increased from 23% to 45%. Being put to sleep in a standard bed is concerning to doctors because beds generally have generous amounts of bedding — fluffy pillows and layers of blankets — which can lead to infant suffocation.

Risk factors for SIDS include being born prematurely, being male and being exposed prenatally to alcohol or cigarettes; after birth, parents can unwittingly pile on other risk factors, such as overbundling baby or tucking him in for the night with a cozy quilt. When analyzing the data, lead author Henry Krous, a pediatric pathologist and director of the San Diego SIDS Research Project at Rady Children’s Hospital, noticed that the number of risk factors hadn’t actually decreased; it had just changed. “Most babies had two or more risk factors,” says Krous. “What that says to us is that Back to Sleep should emphasize multiple risk factors.”

In other words, Back to Sleep should stress much more than just back-sleeping. Just putting a baby on his back at bedtime is not the entire solution; parents bringing a new baby home from the hospital should be educated about avoiding baby’s exposure to all the risk factors for SIDS.

Co-sleeping, for example, is associated with a greater risk of SIDS, so much so that Milwaukee last year launched a graphic blitz against the practice, with posters showing babies asleep in adult beds right next to butcher knives. The caption: “Your baby sleeping with you can be just as dangerous.” As with almost any parenting practice, the issue isn’t straightforward: proponents insist that bed-sharing — when done correctly — can be safe.

Furthermore, despite the prevailing message of Back to Sleep, 30% of babies are still being put to bed on their bellies. “We still have a lot of work to do,” says Krous. “The problem isn’t solved yet.”

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