The American Academy of Pediatrics (AAP) updated their safe sleep recommendations for infants (through the first year of life after birth), published in the July 2022 issue of Pediatrics. Several recommendations remain the same as those made in 2016. For example, babies younger than one-year-old are safest when placed on their backs on a firm flat surface without any pillows, blankets, bumpers, other soft bedding, or toys in the sleep environment. Other recommendations, such as the recommendations against putting a baby to sleep on an inclined surface, or using heart and breathing monitors to reduce the risk of SIDS, have been included.
The full set of recommendations contains complete explanations of why these recommendations are made and how they relate to protecting against Sudden Infant Death Syndrome (SIDS), suffocation, strangulation, or other unexplained infant death during sleep. Below is an abbreviated list of recommendations:
• Put your baby on her back to sleep for every sleep.
• Use a firm, flat, noninclined sleep surface. Couches and armchairs are particularly problematic, as are other soft surfaces such as memory foam.
o An incline of more than 10 degrees is not safe as a sleep surface.
o Although there is no sleep safety information regarding cradleboards used by some American Indian/Alaskan Native communities, the National Institute of Child Health and Human Development (NICHD) supports cradleboards as a sleep surface that is culturally appropriate. Families should be careful to not overbundle or overheat a baby using a cradleboard.
o Any sleep surface or product should adhere to federal safety standards for cribs, bassinets, portable cribs, play yards, and bedside sleepers.
o Temporary use of a different firm, flat, non-inclined surface with a thin, firm padding may be used in an emergency – with replacement as soon as possible. Some examples provided by the AAP include a box, basket, or dresser drawer.
o Even babies with gastroesophogeal reflux (GER) should sleep on a firm flat surface, and products that elevate a baby’s head should be avoided.
• Feeding human milk (for example, breastfeeding or chestfeeding, feeding breastmilk from a bottle) is recommended, as it is associated with a lower risk of SIDS, unless the parent is unable to do so. Revised AAP recommendations in 2022 support people who wish to give human milk to their baby for the first two years of life.
o It may be particularly important for babies born preterm or at a low birth weight to be given human milk, given their increased risk for SIDS.
o We share the AAP’s recommendations that when providers counsel caregivers who are unable to or choose not to feed their baby human milk, they should do so in a nonjudgmental, respectful, and culturally appropriate way.
• Room-sharing without bedsharing – It is recommended that infants sleep in the parents’ or caregivers’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first 6 months. The AAP does not recommend bed sharing with an infant under any circumstances, and can be extra risky in some cases. Further, although not recommended, unintentional bed sharing with an adult on a bed seems to be less problematic than on a sofa or armchair.
• Keep soft objects (e.g., pillows, pillow-like toys, quilts, fur-like materials) and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment/wedging, and strangulation.
• Do not use weighted blankets, swaddles, sleepers, or other items on or near the infant.
• Consider offering a pacifier at nap time and bedtime – it’s protective against SIDS. Be sure the pacifiers are not attached to clothing or have anything hanging from them. It is also recommended to wait to introduce a pacifier until breastfeeding is established, if you choose to breastfeed.
• Avoid smoke exposure during pregnancy and after birth.
• Avoid alcohol, marijuana, opioids, and illicit drug use during pregnancy and after birth.
• Avoid overheating and head covering in infants. Overheating is a risk for SIDS. Unless in the first few hours of life in a hospital setting, avoid using hats on infants while indoors.
o Use an extra layer of clothing (including wearable blankets if you choose) instead of blankets to keep your baby warm without overheating, if necessary.
• Pregnant women should obtain regular prenatal care. Having regular prenatal care is protective against SIDS.
• Infants should be immunized in accordance with recommendations by the AAP and Centers for Disease Control and Prevention. Immunizations do not cause SIDS and in fact may protect against it.
• Avoid the use of commercial devices that are inconsistent with safe sleep recommendations – particularly ones that claim to reduce the risk of SIDS such as devices that are placed in the adult bed that claim to make bed-sharing safe. Also, there are no safety standards for in-bed sleepers, but there are safety standards for sleepers that attach to the bed.
o Do not use home cardiorespiratory monitors (heart and breathing monitors) as a strategy to reduce the risk of SIDS. These monitors, including wearable devices, should not replace following AAP safe sleep guidelines.
• Supervised, awake tummy time is recommended to promote development and to minimize positional plagiocephaly (flat back of head). Increasing tummy time to 15-30 minutes daily by 7-weeks-old is recommended.
• There is no evidence that swaddling reduces the risk of SIDS. When an infant shows signs of starting to roll over, stop swaddling your infant during sleep.
Model and endorse safe sleep practices
Recommendations were also made for and about people and entities outside of the family, such as physicians, other clinicians, companies that make consumer products, and the media.
• Clinicians and child care providers should model and endorse safe sleep guidelines from the beginning of pregnancy.
• Media and manufacturers should model safe sleep practices in advertisements and product promotion.
• Providers and others who support maternal-child health should continue to provide support in line with the “Safe to Sleep” campaign.
• Families should avoid the use of commercial products that do not adhere to safe sleep guidelines.
• Communication in sleep education should be culturally appropriate, respectful, and nonjudgmental.
See, also, when bed-sharing is considered to be extra-risky by the AAP.
The complete set of AAP recommendations can be found at Healthy Children or via the Pediatrics publication.