Sleep-Related Infant Deaths: Reducing Infant Deaths in the Sleep Environment

Publication Date: June 20, 2022
Last Updated: June 23, 2022

A Level Recommendations

To reduce the risk of sleep-related death, it is recommended that infants be placed for sleep in a supine (back) position for every sleep by every caregiver until the child reaches 1 year of age. Side sleeping is not safe and is not advised. (A)
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Use a firm, flat, noninclined sleep surface to reduce the risk of suffocation or wedging/entrapment. (A)
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Feeding of human milk is recommended, as it is associated with a reduced risk of SIDS. (A)
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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 at least 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. (A)
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Keep soft objects, such as pillows, pillow-like toys, quilts, comforters, mattress toppers, fur-like materials, and loose bedding, such as blankets and nonfitted sheets, away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment/wedging, and strangulation. (A)
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Offering a pacifier at nap time and bedtime is recommended to reduce the risk of SIDS. For breastfed infants, delay pacifier introduction until breastfeeding is firmly established. Established breastfeeding is defined as having sufficient milk supply; consistent, comfortable, and effective latch for milk transfer; and appropriate infant weight gain as defined by established normative growth curves. The time required to establish breastfeeding is variable. Infants who are not being directly breastfed can begin pacifier use as soon as desired. (A)
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Avoid smoke and nicotine exposure during pregnancy and after birth. Both smoking by pregnant people and smoke in the infant’s environment after birth are major risk factors for SIDS. Pregnant people are advised not to smoke during pregnancy or after the infant’s birth. (A)
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Avoid alcohol, marijuana, opioids, and illicit drug use during pregnancy and after birth. There is an increased risk of SIDS with prenatal and postnatal exposure to alcohol or illicit drug use. Use of alcohol, marijuana, opioids, and illicit drugs periconceptionally and during pregnancy is strongly advised against. The risk of SIDS is also significantly higher with concomitant smoking and alcohol use. Parental alcohol, marijuana, opioid, and/or illicit drug use in combination with bed sharing places the infant at particularly high risk for SIDS and suffocation. (A)
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Avoid overheating and head covering in infants. Although studies have demonstrated an increased risk of SIDS with overheating, the definition of overheating in these studies varies. Therefore, it is difficult to provide specific room temperature guidelines to avoid overheating. (A)
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It is recommended that pregnant people obtain regular prenatal care. There is substantial epidemiologic evidence linking a lower risk of SIDS for infants when there has been regular prenatal care; however, limited prenatal care often results from social determinants of health that are also associated with increased risk of SIDS. Pregnant people are advised to follow guidelines for frequency of prenatal visits. (A)
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It is recommended that infants be immunized in accordance with guidelines from the AAP and Centers for Disease Control and Prevention (CDC). There is no evidence that there is a causal relationship between immunizations and SIDS. Instead, vaccination may have a protective effect against SIDS. (A)
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Avoid the use of commercial devices that are inconsistent with safe sleep recommendations. Be particularly wary of devices that claim to reduce the risk of SIDS or other sleep-related deaths. There is no evidence that any of these devices reduce the risk of these deaths. Importantly, the use of products claiming to increase sleep safety may provide a false sense of security and complacency for caregivers. It is important to understand that use of such products does not diminish the importance of following recommended safe sleep practices. (A)
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Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. Use of cardiorespiratory monitors has not been documented to decrease the incidence of SIDS. These devices are sometimes prescribed for use at home to detect apnea, bradycardia, and, when pulse oximetry is used, decreases in oxyhemoglobin saturation for infants at risk for these conditions, including some preterm infants with an unusually prolonged course of recurrent, extreme apnea. (A)
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Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of positional plagiocephaly. Parents are encouraged to place the infant in tummy time while awake and supervised for short periods of time beginning soon after hospital discharge, increasing incrementally to at least 15 to 30 minutes total daily by 7 weeks of age. (A)
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There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. Swaddling, or wrapping the infant in a light blanket, is often used as a strategy to calm the infant and encourage use of the supine position. There is a high risk for death if a swaddled infant is placed in or rolls to the prone position. If infants are swaddled, always place them on the back. Swaddling should be snug around the chest but allow for ample room at the hips and knees to avoid exacerbation of hip dysplasia. Weighted swaddle clothing or weighted objects within swaddles are not safe and therefore not recommended. When an infant exhibits signs of attempting to roll (which usually occurs at age 3 to 4 months but may occur earlier), swaddling is no longer appropriate because it could increase the risk of suffocation if the swaddled infant rolls to the prone position. (A)
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It is essential that physicians, nonphysician clinicians, hospital staff, and child care providers endorse and model safe infant sleep guidelines from the beginning of pregnancy. (A)
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It is advised that media and manufacturers follow safe sleep guidelines in their messaging, advertising, production, and sales to promote safe sleep practices as the social norm. Media exposures (including movie, television, magazines, newspapers, websites, and social media), manufacturer advertisements, and store displays affect individual behavior by influencing beliefs, attitudes, and social norms. Media images, social media posts, and advertising messages contrary to safe sleep recommendations may provide a false sense of security and create misinformation about safe sleep practices. (A)
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Continue the Eunice Kennedy Shriver National Institute of Health and Human Development “Safe to Sleep” campaign, focusing on ways to reduce the risk of all sleep-related deaths. Pediatricians and other maternal and child health providers can serve as key promoters of the campaign messages. (A)
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Continue research and surveillance on the risk factors, causes, and pathophysiological mechanisms of sleep-related deaths, with the ultimate goal of eliminating these deaths altogether. (A)
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B Level Recommendations

Avoid the use of commercial devices that are inconsistent with safe sleep recommendations. (B)
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C Level Recommendations

There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. (C)
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Continue research and surveillance on the risk factors, causes, and pathophysiological mechanisms of sleep-related deaths, with the ultimate goal of eliminating these deaths entirely. (C)
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Recommendation Grading

Overview

Title

Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

Authoring Organization

American Academy of Pediatrics

Publication Month/Year

June 20, 2022

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

Document Objectives

Each year in the United States, ∼3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Classification of Diseases, 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths has remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. Additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is also included. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report.

Target Patient Population

Infants

Target Provider Population

Pediatricians and allied providers caring for infants

Inclusion Criteria

Male, Female, Infant

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Prevention

Diseases/Conditions (MeSH)

D013398 - Sudden Infant Death

Keywords

sleep, SIDS, Sudden Infant Death Syndrome, Sleep-Related Infant Deaths, SUID, Sudden unexpected infant death

Source Citation

Moon RY, Carlin RF, Hand I; TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN; Task Force on Sudden Infant Death Syndrome, Abu Jawdeh EG, Colvin J, Goodstein MH, Hauck FR, Hwang SS; Committee on Fetus and Newborn, Cummings J, Aucott S, Guillory C, Hudak M, Kaufman D, Martin C, Pramanik A, Puopolo K; Consultants to Task Force on Sudden Infant Death Syndrome, Bundock E; National Association of Medical Examiners, Kaplan L; Eunice Kennedy Shriver National Institute for Child Health and Human Development, Brown SP; Centers for Disease Control and Prevention, Koso-Thomas M; Eunice Kennedy Shriver National Institute for Child Health and Human Development, Shapiro-Mendoza CK; Centers for Disease Control and Prevention; Consultants to Committee on Fetus and Newborn, Barfield W; Centers for Disease Control and Prevention, Miller R; American College of Obstetricians and Gynecologists, Narvey M; Canadian Pediatric Society, Jancelewicz T; AAP Section on Surgery, Lucke A; AAP Section on Neonatal and Perinatal Medicine, Grisham L; National Association of Neonatal Nurses; Staff, Couto J. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022 Jun 21:e2022057990. doi: 10.1542/peds.2022-057990. Epub ahead of print. PMID: 35726558.

Supplemental Methodology Resources

Technical Review