Safe Sleep Guidelines Updated
for infants under 1 year
The American Academy of Pediatrics recently updated their safe sleep guidelines. The new recommendations for home sleep safety are summarized below.
Back to sleep
Infants should be placed on their back to sleep on a flat surface until they are one year of age. There is a very high correlation of stomach sleeping and sudden infant death syndrome (SIDS). Side sleeping is not advised due to risks.
This video explains why it is important for babies to sleep on their back:
When they roll
Infants who can roll from back to tummy and tummy to back can sleep in their position of comfort. It is especially important that the sleep surface is firm and there is no soft bedding, stuffed animals, or other objects into which the baby can bury their head.
No incline
The sleeping surface should be flat. If it is inclined more than 10 degrees, it is not safe.
This recommendation is for all babies, including those with gastroesophageal reflux.
If the surface is more than 30 degrees, the baby is at risk of sliding down and having the airway compromised.
Infants sleeping at lesser inclines can more easily flex their trunk and lift their head, making it easier to roll onto the side or onto the stomach, at which point they are at higher risk for muscle fatigue and potential suffocation.
Sleep area and surface
The sleep surface should be firm. This means that it does not indent when the infant is placed on it.
The best sleep surface is one purchased specifically for infant sleep, such as a crib, bassinet, portable crib or play yard. Bedding designed for older children and adults is often too plush for a baby to sleep on. It should meet the safety standards of the Consumer Product Safety Commission (CPSC).
A fitted sheet should be used. Do not use a mattress topper to make the surface softer.
No blankets, comforters, bumper pads, pillows, stuffed toys, or other soft objects should be in the sleeping area.
There should be no gaps between the mattress and the wall of the crib, bassinet, portable crib, or play yard.
Cribs with missing hardware or missing instructions should not be used. Many deaths have occurred in cribs that were broken or missing parts, even after they were thought to be fixed.
There is insufficient evidence to recommend for or against the use of devices promoted to make bed sharing “safe.” If used, these devices should adhere to the June 2021 CPSC rule that any infant sleep product must meet existing federal safety standards for cribs, bassinets, play yards, and bedside sleepers.
Some American Indian/ Alaska Native communities use cradleboards for infant sleep. Safety data of cradleboards for sleep is not available, but the Eunice Kennedy Shriver National Institute of Health and Human Development-led Healthy Native Babies Project suggests cradleboards are a culturally appropriate infant sleep surface. Care should be taken so that infants do not overheat in the cradleboard.
There is no evidence that special sleep surfaces claiming to reduce the chance of rebreathing carbon dioxide reduce the risk of a sleep-related death. They may be used if they meet all other safety standards.
Infants should not be placed for sleep on adult beds or mattresses because of the risk of entrapment and suffocation.
Portable bed rails should not be used with infants because of the risk of entrapment and strangulation.
The area around the infant sleep area should be kept free of dangling cords, electric wires, and other hazards due to strangulation risk.
Car seats, strollers, swings, infant carriers, and infant slings are not recommended for routine sleep. When infants fall asleep in one of these, remove them and move them to a safe flat surface as soon as it is practical. Do not leave infants unattended in car seats and similar products. Do not leave infants in car seats or similar products with the straps unbuckled or partially buckled.
When infant slings and cloth carriers are used for carrying, it is important to ensure that the infant’s head is up and above the fabric, the face is visible, and the nose and mouth are clear of obstructions. If the infant’s head is covered for breastfeeding, the infant should be repositioned in the sling after feeding.
Short-term emergency situations
There may be disasters, such as house fires or tornados, that result in displacement with a lack of access to an approved safe sleep surface.
In an emergency, an alternative device with a firm, flat, non-inclined surface (such as a box, basket, or dresser drawer) with thin, firm padding may be used temporarily.
The alternative device should be replaced as soon as a CPSC-approved surface is available.
The device should contain no pillows or loose or soft objects.
Social service agencies and emergency assistance organizations should provide resources for free or low-cost CPSC-approved surfaces.
Human milk helps
Feeding of human milk is associated with a reduced risk of SIDS.
Unless it is contraindicated, it is recommended that infants be fed with human milk whenever possible.
Because preterm and low birth weight infants are at higher risk of dying from SIDS, it is strongly recommended to use human milk when possible.
Room sharing
It is recommended that infants sleep in the parents’ room for at least the first 6 months. They should be near the parent’s bed but in their own safe sleep surface.
There is evidence that sleeping in the parent’s room but on a separate surface decreases the risk of SIDS by as much as 50%.
Couches and chairs
Couches and armchairs are extremely dangerous places for infants and should never be used for infant sleep.
Sleeping on couches and armchairs places infants at extraordinarily high risk for infant death. Causes of death include SIDS, suffocation through entrapment or wedging between seat cushions, or overlay by another person holding the infant.
Bed sharing
Bed sharing increases the risk of infant death three times compared to room sharing without bed sharing.
Cultural preferences, ease of breastfeeding, and other reasons lead many parents to choose bed sharing.
The AAP does not recommend bed sharing under any circumstances due to safety concerns, but they specifically warn of the following risk factors:
Bed sharing with someone who is impaired in their alertness or ability to arouse because of fatigue. (Over 10 times the risk)
Bed sharing with someone under the influence of sedating medications (certain antidepressants, pain medications) or substances (alcohol, illicit drugs). (Over 10 times the risk)
Bed sharing with a current smoker (even if the smoker does not smoke in bed) or if the pregnant parent smoked during pregnancy. (Over 10 times the risk)
Bed sharing on a soft surface, such as a waterbed, soft mattress, mattress made of memory foam, sofa, couch, or armchair. (Over 10 times the risk)
Term, normal weight infant aged less than 4 months, even if neither parent smokes and even if the infant is breastfed. (1/2 to 10 times the risk)
Bed sharing with anyone who is not the infant’s parent, including nonparental caregivers and other children. (1/2 to 10 times the risk)
Preterm or low birth weight infant, even if neither parent smokes. (0.2 to 5 times the risk)
Bed sharing with soft bedding accessories, such as pillows or blankets. (0.2 to 5 times the risk)
Any potential benefits of co-bedding for twins and higher-order multiples are outweighed by the risk of co-bedding. Separate sleep surfaces is recommended for each infant.
Blankets, wraps, and more
Weighted blankets, weighted sleepers, weighted swaddles, or other weighted objects should not be placed on or near infants.
Dress the infant in layers of clothing rather than using blankets and other coverings to keep the infant warm. This helps to reduce the chance of getting the head and face covered.
Wearable blankets and wraps can be used.
Bumper pads or similar products that attach to crib slats or sides are not recommended because they have been implicated in deaths attributable to suffocation, entrapment/wedging, and strangulation. They do not provide any safety benefit.
Pacifiers
Offering a pacifier for sleep is recommended to reduce the risk of SIDS.
For breastfed infants, delay pacifier introduction until breastfeeding is well established.
Studies have reported a protective effect of pacifiers on the incidence of SIDS. The benefits are seen even if the pacifier falls out of the infant’s mouth during sleep.
Infants who refuse the pacifier should not be forced to take it. Offer the pacifier again as the baby gets older. Many who initially resist it will take it once they lose the tongue thrust reflex.
Never hang a pacifier around the infant’s neck or attach it to infant clothing when the infant is sleeping.
Never attach objects (such as blankets, plush or stuffed toys, and other items that may present a suffocation or choking risk) to pacifiers.
There is insufficient evidence that finger sucking is protective against SIDS.
Nicotine exposure
Avoid smoke and nicotine exposure during pregnancy and after birth.
Smoking by pregnant people and smoke in the infant’s environment after birth are major risk factors for SIDS.
Although there is no evidence on the relationship of vaping or electronic cigarette use and SUID, electronic cigarettes contain nicotine, which has been implicated in sleep-related infant deaths. Use around infants should be avoided.
Overheating
Avoid overheating and head covering in infants.
Studies have demonstrated an increased risk of SIDS with overheating.
Dress infants appropriately for the environment. They often will use one layer more than adults in the same room.
Signs of overheating include sweating, flushed skin, or feeling hot to the touch. If you notice these signs, remove layers of clothing. .
It is advised not to place hats on infants when indoors except in the first hours of life or in the NICU.
Fans
There is currently insufficient evidence to recommend the use of a fan as a SIDS risk-reduction strategy.
Immunizations
It is recommended that infants be immunized in accordance with guidelines from the AAP and Centers for Disease Control and Prevention (CDC).
Vaccination may have a protective effect against SIDS and there is no evidence that vaccines lead to SIDS.
SIDS safety devices and monitors
There is no evidence that any of the devices that claim to reduce the risk of SIDS marketed to parents are effective.
Even the use of prescription cardiorespiratory monitors used for high risk infants has not been shown to decrease the incidence of SIDS.
These products may provide a false sense of security, leading to less safe sleep conditions.
Information about specific products can be found on the CPSC Web site.
Tummy Time
Supervised tummy time while infants are awake is recommended. This can help infant development and decreases the risk of development of a flat head (positional plagiocephaly).
Place the infant in tummy time while awake and supervised for short periods of time beginning soon after birth. Increase the time on tummy to at least 15 to 30 minutes total daily by 7 weeks of age.
Swaddling
There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS.
Swaddling can help to calm the infant and help them stay on their back for sleep.
There is a high risk for death if a swaddled infant is placed in or rolls to the tummy, so when the infant starts to roll, stop the swaddle. This usually begins around 3-4 months of age.
Swaddling should be snug around the chest. Leave room below so babies can move their legs around easily.
There is no evidence that placing arms in or out of the swaddle is preferable to prevent SIDS. Use arms in or out based on your baby’s preference.