Last week the American Academy of Pediatrics published its latest recommendations for a safe sleep environment for infants, hoping to decrease rates of unexplained sleep related infant deaths in this country. Nineteen evidence-based recommendations aimed at protecting infants up to 1 year of age are featured in SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment, an AAP policy statement and technical report from the Task Force on Sudden Infant Death Syndrome. The guidance, updated from 2011, considers data from 63 new studies as well as a recent AAP clinical report on the benefits of skin-to-skin care for newborns.
More than 3,500 babies in the U.S. die suddenly and unexpectedly every year while sleeping, often due to sudden infant death syndrome (SIDS) or accidental deaths from suffocation or strangulation. The latest guidelines still promote the following: putting baby on back on a flat mattress when sleeping without any other fluffy or loose bedding or items surrounding it; mothers breastfeeding baby; using pacifiers (after breastfeeding established)to put baby to sleep; avoidance of parent or family member sharing bed with baby; avoidance of smoke exposure; and parents avoiding alcohol and drug usage.
One of the recommendations concerns when baby should be placed in its own room. According to this recent 2016 policy statement:
It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.
There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%. In addition, this arrangement is most likely to prevent suffocation, strangulation, and entrapment that may occur when the infant is sleeping in the adult bed.
The infant’s crib, portable crib, play yard, or bassinet should be placed in the parents’ bedroom until the child’s first birthday. Although there is no specific evidence for moving an infant to his or her own room before 1 year of age, the first 6 months are particularly critical, because the rates of SIDS and other sleep-related deaths, particularly those occurring in bed-sharing situations, are highest in the first 6 months. Placing the crib close to the parents’ bed so that the infant is within view and reach can facilitate feeding, comforting, and monitoring of the infant. Room-sharing reduces SIDS risk and removes the possibility of suffocation, strangulation, and entrapment that may occur when the infant is sleeping in the adult bed.
There is insufficient evidence to recommend for or against the use of devices promoted to make bed-sharing “safe.” There is no evidence that these devices reduce the risk of SIDS or suffocation or are safe. Some products designed for in-bed use (in-bed sleepers) are currently under study but results are not yet available. Bedside sleepers, which attach to the side of the parental bed and for which the Consumer Product Safety Commission has published standards, may be considered by some parents as an option. There are no CPSC safety standards for in-bed sleepers. The task force 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 SIDS or unintentional injury and death, including suffocation.
Infants who are brought into the bed for feeding or comforting should be returned to their own crib or bassinet when the parent is ready to return to sleep.
Couches and armchairs are extremely dangerous places for infants. Sleeping on couches and armchairs places infants at extraordinarily high risk of infant death, including SIDS, suffocation through entrapment or wedging between seat cushions, or overlay if another person is also sharing this surface. Therefore, parents and other caregivers should be especially vigilant as to their wakefulness when feeding infants or lying with infants on these surfaces. Infants should never be placed on a couch or armchair for sleep.
The safest place for an infant to sleep is on a separate sleep surface designed for infants close to the parents’ bed. However, the AAP acknowledges that parents frequently fall asleep while feeding the infant. Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep. It is important to note that a large percentage of infants who die of SIDS are found with their head covered by bedding. Therefore, no pillows, sheets, blankets, or any other items that could obstruct infant breathing or cause overheating should be in the bed. Parents should also follow safe sleep recommendations outlined elsewhere in this statement. Because there is evidence that the risk of bed-sharing is higher with longer duration, if the parent falls asleep while feeding the infant in bed, the infant should be placed back on a separate sleep surface as soon as the parent awakens.
There are specific circumstances that, in case-control studies and case series, have been shown to substantially increase the risk of SIDS or unintentional injury or death while bed-sharing. Bed-sharing should be avoided at all times when with:
a) a normal-weight infant younger than 4 months and infants born preterm and/or with low birth weight, regardless of parental smoking status. Even for breastfed infants, there is an increased risk of SIDS when bed-sharing if younger than 4 months. This appears to be a particularly vulnerable time, so if parents choose to feed their infants younger than 4 months in bed, they should be especially vigilant to not fall asleep.
b) a current smoker (even if he or she does not smoke in bed) or if the mother smoked during pregnancy.
c)someone who is impaired in his or her alertness or ability to arouse because of fatigue or use of sedating medications (eg, certain antidepressants, pain medications) or substances (eg, alcohol, illicit drugs).
d) anyone who is not the infant’s parent, including nonparental caregivers and other children.
e) a soft surface, such as a waterbed, old mattress, sofa, couch, or armchair.
f) soft bedding accessories, such as pillows or blankets.
The safety and benefits of cobedding for twins and higher-order multiples have not been established. It is prudent to provide separate sleep surfaces and avoid cobedding for twins and higher-order multiples in the hospital and at home.