Safe Sleep for Infants - AAP recommendations

"We know that parents may be overwhelmed with a new baby in the home, and we want to provide them with clear and simple guidance on how and where to put their infant to sleep"
- Rachel Moon, lead author of the AAP report on safe sleep recommendations.

The American Association of Pediatrics (AAP) recommends a safe sleep environment in an effort to reduce the risk of all sleep-related infant deaths. In 2016 the AAP issued a 21 page technical report called: “SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for Safe Infant Sleeping Environment.”

The report outlines 19 recommendations for all who care for infants and 15 specifically for parents. Recommendations include always placing babies on their backs, using a safe sleep space with a firm sleep surface, room-sharing without bed-sharing and the avoidance of soft bedding, overheating and sleeping on couches/armchairs and in sitting devices.

Additional safety recommendations include routine prenatal care and infant immunization, and the importance of avoidance of exposure to smoke, alcohol, and illicit drugs for mother and child.

In the following text we aim to summarize the highlights of the report for parents.

All recommendations, unless mentioned otherwise, are for the first year after birth.

1. Back to sleep for every sleep

Infants should be placed wholly on their back until 1 year of age.
Side sleeping is not safe and is not advised.
Letting babies sleep on their tummy is not safe and not advised. Preterm infants should be placed on their backs as soon as possible.
When an infant is able to roll from back to tummy, and from tummy to back, you can allow it to remain in the sleep position it assumes.
Elevating the head of the infant’s crib is not recommended as it may result in the infant sliding to the foot of the crib into a position that may compromise their breathing.
Skin-to-skin care is recommended for all mothers and newborns immediately after birth (or as soon as the mother is able to hold her newborn), for at least an hour.

2. Use a firm sleep surface

Check that the infant’s sleep space (crib/bassinet, portable crib, or play yard) confirms to the safety standards Consumer Product Safety Commission (CPSC). Make sure that the product has not been recalled.
Do not attempt to fix broken components of a crib and do not use cribs with missing hardware.
Only use a mattress designed for the specific product. The mattress should be covered tightly by a fitted sheet. Be sure that there are no gaps forming on the sides of the mattress.
Make sure the mattress is firm and that it does not indents to the shape of the infant’s head when they lay on it.
CPSC has published safety standards for bedside sleepers that are attached to the side of the parental bed but there are no CPSC safety standards for in-bed sleepers yet.
Soft material or objects should not be placed under a sleeping infant, even if covered by a sheet. These include pillows, cushions, quilts, comforters and sheepskin.
Be careful that the sleep area is free of hazards, for example dangling cords, wires, window-covering cords etc.
Do not use any sitting devices for routine sleep. These include car seats, strollers, swings, infant carriers and infant slings. This is particularly for infants younger than 4 months old. If an infant falls asleep in a sitting device, it should be moved to a more appropriate sleep space as soon as possible.
Never leave your child unattended in car seats and similar products. If you place your child in a car seats and similar products remember to always buckle up them up securely.
If you use an infant slings and cloth carrier, make sure that the infant’s head is up and above the fabric, the face is visible, and the nose and mouth are clear of obstructions.

3. Breastfeeding is recommended

Breastfeeding is associated with a reduced risk of SIDS.
Exclusive breastfeeding is recommended up to 6 months of age.
——According to the World Health Organization breastfeeding along with appropriate complementary foods is recommended for up to two years of age or beyond.——

4. Room sharing with the infant on a separate sleep surface is recommended

There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%
Place the infant’s sleep space in the parents room and preferably close to the parents’ bed so the infant is within view. This is especially important for babies under 6 months.
The AAP cannot make a recommendation for or against the use of either bedside sleepers or in-bed sleepers, because there have been no studies examining the association between these products and infant death.
Infants who are brought into the bed for feeding or comforting should be returned to their own sleep space when the parent is ready to return to sleep.
Couches and armchairs are extremely dangerous places for infants. Infants should never be placed on a couch or armchair for sleep.
There are special circumstances that have been shown to increase the risk of unintentional injury or death while bed-sharing and these should be avoided at all times! These are if the baby; is under 4 months old, was born prematurely or with low birth weight, is put to sleep on a soft surface, with soft bedding or with soft objects. Also if the parent smokes, is impaired, overly tired or using sedatives or other mind altering substances. It is also never advised to bed-share with anyone who is not the infant’s parent.

5. Keep soft objects and loose bedding away from the infant’s sleep area

Keep the infants sleep space free of all soft objects, such as pillows and pillow-like toys, quilts, comforters, sheepskin and loose bedding, such as blankets and non-fitted sheets, as they could obstruct an infant’s nose and mouth.
Sleep clothing is preferable to blankets and other coverings.
Bumper pads are never recommended for infants.
While infants are at heightened risk for SIDS between the ages 1 and 4 months, new evidence shows that soft bedding can continue to pose hazards to babies who are 4 months and older.

6. Consider offering a pacifier at nap time and bedtime

The pacifier should be used when placing the infant for sleep. It does not need to be reinserted once the infant falls asleep as studies show that there is a protective effect of pacifiers on the incidence of SIDS - even if it falls out of the infant’s mouth.
If the infant refuses the pacifier, he or she should not be forced to take it.
For breastfed infants, pacifier introduction should be delayed until breastfeeding is firmly established.

7-8. Avoid smoke exposure, alcohol and illicit drug use during pregnancy and after birth

There is an increased risk of SIDS with prenatal and postnatal exposure to smoke, alcohol or illicit drug use.
Parental smoking, alcohol and/or illicit drug use in combination with bed-sharing places the infant at particularly high risk of SIDS.

9. Avoid overheating

Overheating increases the risk of SIDS but the definition of overheating in studies varies so there is no room temperature guidelines.
Caregivers should evaluate the infant for signs of overheating, such as sweating or the infant’s chest feeling hot to the touch.
Avoid covering the face and head.
As a rule of thumb, infants should be dressed in no more than 1 layer more than an adult would wear to be comfortable in that environment.

10. Pregnant women should seek and obtain regular prenatal care

There is lowered risk of SIDS for infants whose mothers obtain regular prenatal care.

11. Infants should be immunized in accordance with AAP and CDC recommendations

Recent evidence suggests that vaccination may have a protective effect against SIDS.

12. Avoid the use of commercial devices that are inconsistent with safe sleep recommendations

Manufacturers should not claim that a product or device protects against SIDS unless there is scientific evidence that supports it.

13. Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS

There are no data that commercial devices that are designed to monitor infant vital signs reduce the risk of SIDS.

14. Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly (flat head)

15. There is no evidence recommending swaddling as a strategy to reduce the risk of SIDS

There is a high risk of death if a swaddled infant is placed on or rolls on to its tummy. Always place an infant on its back and when an infant exhibits signs of attempting to roll, swaddling should no longer be used.

If you or your child have a medical condition please talk to your health care provider to review your situation. The list above is only a summary from the report. You can access the report that was published in Pediatrics - Official Journal of the American Academy of Pediatrics here.

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