AAP Safe Sleep Guidelines. How to Prevent SIDS and other Baby’s Sleep Related Death

Last Updated on 3 August 2022 by Dott. Sandro Cantoni

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Each year, there are approximately 3500 sudden unexpected infant deaths in the United States. Deaths occur in the first year of life, especially in the first six months. No definite cause is found.  The three causes of sudden unexpected infant deaths are these: 

  1. Sudden infant death syndrome (SIDS).
  2. Unknown cause. 
  3. Accidental suffocation and strangulation in bed. 

In this article, you can read about things you can do to make your baby’s sleep safe, especially in the first year of life.

Why do parents often fail to adopt safe sleep practices? 

The reasons are varied. The most common are: 

Bed-sharing is part of their culture or family habits.

There is no money to buy a safe crib. 

Older relatives, such as grandparents, recommend putting the baby to sleep in the prone position. 

Parents are afraid that the supine position is risky. For example, if the baby has a regurgitation, they are afraid that the baby will choke. 

There is concern that the baby will not sleep well without sheets or blankets. Or that he or she will be cold. 

Some research has shown that many parents think their baby is “immune” to SIDS. That it can only happen to others. 

Regarding the last point, it must be remembered that every baby is at risk for SIDS. 

For the reasons mentioned above, many parents do not put their babies to sleep safely. For example, according to various research, 25% of parents put their baby to sleep on their side, or prone, on their stomach. 60% use sheets, pillows, or other soft objects in the baby’s crib. 

In Baltimore City, Maryland, the cause of babies dying in their sleep, with SIDS or otherwise, was studied. 85% of babies died while sleeping out of their cribs. 79% died while bed-sharing. 

Because of this, a public campaign was done to encourage safe sleep.

“SLEEP SAFE: Alone, Back, Crib. No Exceptions,”

In the following chapters, you will find the recommendations of the American Academy of Pediatrics.

Position

Back to sleep for every sleep.

The baby should always be put to sleep supine, completely lying on his or her back. This reduces the risk of SIDS. 

The baby should be placed on his or her back every time he or she sleeps, both day and night. 

Sleeping on the side is not recommended because it is unsafe. 

Even premature babies, who are at higher risk for SIDS, should be put to sleep on their backs. 

The supine position does not increase the risk of suffocation in a baby with regurgitation. In fact, babies have reflexes that protect them, AND prevent milk from going into the airway, even during a heavy regurgitation. 

Only in some infants is the prone position recommended. These infants have some severe upper respiratory tract diseases. In these cases, the risk of death from gastro-oesophageal reflux disease is higher.

Parents of children with regurgitation often raise the head of the child’s bed. To try to reduce regurgitation. 

This is not recommended. Because it is ineffective and can be dangerous for the baby. Who can slip to the bottom of the crib. And get into a position that makes it difficult to breathe. 

Back to sleep even a few hours after delivery. 

In the first 1-2 hours after delivery, when the mother is medically stable and awake, skin-to-skin contact with the newborn is recommended. Thereafter, the baby should be placed supine in the crib. It is often believed that it is better to put the newborn on his side after birth. To eliminate amniotic fluid and avoid aspiration. There is no evidence of this. It is better to put the newborn on his back from birth.   

When can you put the newborn in the prone position, on his or her stomach?

The side or prone position is risky up to one year of age. 

What to do if the baby turns on his own from the supine to prone position?

This often happens when the infant is 5-6 months old. If the newborn turns over to sleep on his stomach, you can leave him in this position. 

But be careful that in the crib there are no sheets, pillows, or other soft objects, such as crib bumpers or stuffed toys. Because rolling over in these conditions is very risky for the baby. 

Until the first year of life, there should be nothing in the crib. 

Be consistent. 

Research indicates that consistency in sleep position is crucial to reducing the risk of SIDS. So, everyone who cares for the baby-parents, grandparents, relatives, and babysitters must do the same. Always put the baby back to sleep, every sleep, night and day, for naps, and at bedtime.

Safe Crib or Bassinet. 

Your baby must sleep in a crib, or bassinet, that meets the Consumer Product Safety Commission (CPSC) safety rules, which are as follows. 

1. slat spacing less than 2-3/8 inches (6 cm)

2. snugly fitting and firm mattresses

3. no drop sides

Be very careful if you buy used cribs. Check to make sure that the product has not been recalled. They must be in perfect condition, with no broken or missing parts. Do not try to repair a broken crib.

Bedside and in-bed sleepers

Bedside sleepers are placed on the side, often attached or overlapping in part, to one side of the parents’ bed. 

They are mainly used in the first few months. The CPSC has published safety standards for these products. 

In-bed sleepers are small beds placed directly in the parents’ bed. There are no safety standards for these products. 

There is no research on whether or not bedside or in-bed sleepers are safe. It is not known whether they are associated with the risk of SIDS or other bedside injuries or deaths. So no recommendations can be made for or against their use.

No sleep in a normal, adult, bed

Children should not be put in a regular bed to sleep. Such as a parent’s bed. Not even with portable bed rails. There is a risk of entrapment and suffocation.

No cords or wires near the crib

In the bed where the baby sleeps, nor in the rooms, there should be no ropes or wires. Because these can cause strangulation of the infant. Such as electric wires, window-covering cords, and dangling cords. 

No soft objects and loose bedding in the crib

During sleep, the baby moves. He turns his head and can move his body. Therefore, if there are objects in the crib, they can be dangerous. They can block the baby’s mouth and nose. And cause suffocation, SIDS, or strangulation. 

For this reason, nothing should be in the crib. Do not put pillows, stuffed toys, sheets or blankets, or another object.

No blankets. Use baby sleeping bags.

But how to keep the baby warm in his crib?

Don’t cover him with sheets or blankets, but protect him with a sleepsuit. Like a wearable blanket or a sleeping bag. 

No pillows or cushions

Do not put any pillows or supports in your baby’s bed. The baby does not need them to sleep well. These items increase the risk of SIDS or suffocation. 

No bumper pads

Bumpers pads should have the function of protecting the baby’s head. And prevent it from getting stuck between the bars of the bed. 

However, the new cribs are built to avoid this eventuality. With a narrower distance between the bars. 

Moreover, bumper pads have been responsible for the death of children from suffocation. For this reason, it is better not to use them. They are unnecessary and dangerous.

No baby wedges and positioners

Items such as wedges and positioners are not useful and are dangerous. They are claimed to reduce the risk of SIDS, but there is no evidence of their effectiveness. And according to the FDA, they increase the risk of choking.

Mattress. Use a firm sleep surface.

The baby must be put to sleep on a firm surface. That is, in a suitable mattress in a secure crib. The mattress must be covered with a tight, snug-fitting mattress cover. There must be nothing in the crib, not sheets, or any other objects or toys, or covers. 

The mattress must be stiff enough to hold its shape. It should not fit over the baby’s head or body. Because this creates pockets that can cause suffocation if the baby turns his head, or gets on his stomach. 

For this reason, soft mattresses, or those made from memory foam are not good.

The mattress must be specific to a particular crib and fit perfectly into it. There should be no space between the mattress and the walls of the crib. Use a fitted sheet specific to the mattress you are using. Do not use mattress toppers, which create a soft surface that is dangerous for a child up to one year of age.  

There are special mattresses for cribs, called “breathable” mattresses. They are supposed to reduce the chance of the baby breathing in his own carbon dioxide if he turns over on his belly. They can be used, although there is no research showing that these mattresses reduce the risk of SIDS.

Avoid overheating and head covering in infants.

One of the most common mistakes is covering your baby too much. Parents are often afraid that the baby will get cold. So they increase the temperature of the room and overdress the baby (e.g. a heavy suit and a sleeping bag). 

The ideal temperature of the room where the baby sleeps should be about 18-19°C (64-66 °F). The child should be covered with one more light layer than a parent would wear. 

As mentioned above, blankets or cloths should be avoided. And no object that can cover the baby’s face or head should be placed in the crib. 

No routine sleep in sitting devices

The baby should not sleep in sitting devices, such as car seats, strollers, swings, infant carriers, and infant slings. If the baby falls asleep in these devices, the baby should be moved to the crib or bassinet as soon as possible. 

Young children, under 4 months of age, are at higher risk. Because they may assume positions that obstruct the airway and cause suffocation. And they are unable to move from these dangerous situations. 

When using infant slings and cloth carriers, to carry your baby, you need to be careful about this. The baby’s head should be up and above the fabric, with nothing obstructing the nose or mouth. 

Breastfeeding is associated with a reduced risk of SIDS.

Sleep in the parents’ room at least for the first 6 months. 

Research shows that if your baby sleeps in the parents’ room (room sharing), in a crib or bassinet, there is about a 50% reduction in the risk of SIDS. At least in the first 6 months, although the ideal would be the entire first year. 

This is because the risk of SIDS, or other sleep-related deaths, is greater in the first 6 months.

The baby’s crib should be close to the parents’. This makes it easier to breastfeed, observe and care for the baby. 

During breastfeeding or cuddling, the baby is usually taken to the parents’ bed. When the parents are ready for bed, the baby should be placed in his or her own crib or bassinet.

No sleep in couches and armchairs.

Your baby should never sleep on a couch or armchair. This situation greatly increases the risk of SIDS. Or suffocation if the child ends up between the various cushions or padding of the sofa. Also, it has occurred that the baby is suffocated by a parent who falls asleep with him on the couch. 

So if you breastfeed the baby while sitting here, be especially careful not to fall asleep. And never put the baby to sleep on a sofa or armchair.

Twins and multiples in separate cribs or bassinets?

The risks and benefits of co bedding for twins or multiples are not known. For this reason, it is more prudent to put them to sleep in separate bassinets or cribs. 

Offer a pacifier before sleep

Several studies indicate that a pacifier before nap time and bedtime reduces the risk of SIDS. It is not necessary to put the pacifier back in the mouth if the child loses it during sleep. 

If the child does not want it, it is not advisable to force it. You can try to offer it after one or two weeks.  

The pacifier should not be attached to the child with cords or ribbons. This increases the risk of suffocation by strangulation. No objects or toys should be attached to the pacifier. 

The pacifier should be introduced when breastfeeding is well underway. 

No smoke exposure

Cigarette smoking, in pregnancy and in the baby’s home, is a major risk factor for SIDS. Make sure the environments where the baby lives, e.g., the home and car, are smoke-free. Also the homes of grandparents or relatives. 

No alcohol or illicit drugs.

Alcohol or drug use before and after birth increases the risk of SIDS.

The home cardiorespiratory monitors do not reduce the risk of SIDS. 

You may think that if you use a cardiorespiratory monitor, which beeps in the event of apnea, you avoid SIDS. Research shows that this is not true. 

Also, apnea is normal in newborns. And the monitor may give many false alarms. With increased parental anxiety. 

Swaddling does not reduce the risk of SIDS

There is no evidence that swaddling, or wrapping the infant in a light blanket, reduces the risk of SIDS. 

It seems that this method is quite safe as long as the baby is able to roll onto his or her tummy. So when you see that the baby wants to get on his side, for example around the second month, stop swaddling him.

If the baby rolls over while swaddled, this increases his risk of suffocation and SIDS.

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About the author

Hi. My name is Sandro Cantoni. I’m a Pediatrician. I work in the General Pediatric Clinic. Hospital of Neuchatel, Switzerland.

References

Li DK, Petitti DB, Willinger M, et al. Infant sleeping position and the risk of sudden infant death syndrome in California, 1997-2000. Am J Epidemiol. 2003;157(5):446–455

Moon RY, Hauck FR, Colson ER. Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change?. Curr Pediatr Rev. 2016;12(1):67-75.

Ashley H. Hirai, e al. Prevalence and Factors Associated With Safe Infant Sleep Practices. Pediatrics Nov 2019, 144 (5) e20191286;

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