Safe Sleep Environment

Despite a major decrease in the incidence of sudden infant death syndrome(SIDS) since the American Academy of Pediatrics (AAP) released
its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently,
other causes of sudden unexpected infant death that occur during sleep (sleep-related deaths), including suffocation, asphyxia,
and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last
statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the
modifiable and non-modifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations
from focusing only on SIDS to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths, including
SIDS. The recommendations include:

• Baby sleeps on his or her back.

• Baby sleeps alone.  (Room-sharing not bed-sharing)  This arrangement reduces SIDS risk and removes the possibility of suffocation, strangulation, and
  entrapment that might occur when the infant is sleeping in the adults’ bed. It also allows close parental proximity to the infant and facilitates feeding, comforting, and monitoring of the infant.

• Baby sleeps on a firm sleep surface.  A firm crib mattress, covered by a fitted sheet, is the recommended sleeping surface to reduce the
  risk of SIDS and suffocation.  Baby does NOT sleep on the couch, sofa or other soft furniture.

• Breastfeeding.  Breastfeeding is associated with a reduced risk of SIDS. If possible, mothers should exclusively breastfeed or feed with expressed human
  milk for 6 months.  However, any breastfeeding has been shown to be more protective against SIDS than no breastfeeding.

• Routine immunizations.  Infants should be immunized in accordance with recommendations of the AAP and the Centers for Disease Control and Prevention—There is no evidence that there is a causal relationship between immunizations and SIDS. Indeed, recent evidence suggests that immunization might have a protective effect against SIDS. Infants should also be seen for regular well-child checks in accordance with AAP recommendations.

• Consideration of using a pacifier. Consider offering a pacifier at nap time and bedtime— Although the mechanism is yet unclear, studies have reported a
  protective effect of pacifiers on the incidence of SIDS.The protective effect persists throughout the sleep period, even if the pacifier falls out of
  the infant’s mouth.  Because of the risk of strangulation, pacifiers should not be hung around the infant’s neck. Pacifiers that attach to infant clothing should not be used with sleeping infants.  For breastfed infants, delay pacifier introduction until breastfeeding has been firmly established, usually by 3 to 4 weeks of age.

• Baby sleeps in an area that is free of toys, pillows, loose blankets, bumper pads or other soft items to reduce the risk of SIDS, suffocation, entrapment,and strangulation

• Avoid overheating.  In general, infants should be dressed appropriately for the environment, with no more than 1 layer more than an adult would wear to be comfortable in that environment. Overbundling and covering of the face and head should be avoided.

• Baby sleeps in a smoke free, drug free, alcohol free environment.  Both maternal smoking during pregnancy and smoke in the infant’s environment after birth are major risk factors for SIDS.  There is an increased risk of SIDS with prenatal and postnatal exposure to alcohol or illicit drug use.

• Remember, babies need tummy time while awake for proper development.  Supervised, awake tummy time is recommended on a daily basis, beginning as early as possible, to promote motor development, facilitate development of the upper body muscles, and minimize the risk of positional plagiocephaly (head flattening).

“Technical Report—SIDS and Other Sleep-Related Infant Deaths: Expansion
of Recommendations for a Safe Infant Sleeping Environment,” which is
included in this issue, Pediatrics 2011;128:1030–1039

Oct. 19, 2011  AAP