POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment TASK FORCE ON SUDDEN INFANT DEATH SYNDROME

Approximately 3500 infants die annually in the United States from sleep- abstract related infant deaths, including sudden infant death syndrome (SIDS; International Classifi cation of Diseases, 10th Revision [ICD-10], R95), ill- This document is copyrighted and is property of the American defi ned deaths (ICD-10 R99), and accidental suffocation and strangulation Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy in bed (ICD-10 W75). After an initial decrease in the 1990s, the overall death of Pediatrics. Any confl icts have been resolved through a process rate attributable to sleep-related infant deaths has not declined in more approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial recent years. Many of the modifi able and nonmodifi able risk factors for SIDS involvement in the development of the content of this publication. and other sleep-related infant deaths are strikingly similar. The American Policy statements from the American Academy of Pediatrics benefi t Academy of Pediatrics recommends a safe sleep environment that can from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American reduce the risk of all sleep-related infant deaths. Recommendations for a Academy of Pediatrics may not refl ect the views of the liaisons or the safe sleep environment include supine positioning, the use of a fi rm sleep organizations or government agencies that they represent. surface, room-sharing without bed-sharing, and the avoidance of soft The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking bedding and overheating. Additional recommendations for SIDS reduction into account individual circumstances, may be appropriate. include the avoidance of exposure to smoke, alcohol, and illicit drugs; All policy statements from the American Academy of Pediatrics breastfeeding; routine immunization; and use of a pacifi er. New evidence automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. is presented for skin-to-skin care for newborn infants, use of bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, DOI: 10.1542/peds.2016-2938 and use of soft bedding after 4 months of age. The recommendations and PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). strength of evidence for each recommendation are included in this policy Copyright © 2016 by the American Academy of Pediatrics statement. The rationale for these recommendations is discussed in detail FINANCIAL DISCLOSURE: The author has indicated she does not have a in the accompanying technical report (www.pediatrics. org/ cgi/ doi/ 10. 1542/ fi nancial relationship relevant to this article to disclose. peds.2015- 3147). FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential confl icts of interest to disclose.

BACKGROUND To cite: AAP TASK FORCE ON SUDDEN INFANT DEATH SYNDROME. Sudden unexpected infant death (SUID), also known as sudden SIDS and Other Sleep-Related Infant Deaths: Updated 2016 unexpected death in infancy, or SUDI, is a term used to describe any Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2016;138(5):e20162938 sudden and unexpected death, whether explained or unexplained

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 :e 20162938 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Defi nitions of Terms SUIDs, particularly those that occur Bed-sharing: Parent(s) and infant sleeping together on any surface (bed, couch, chair). during an unobserved sleep period Caregivers: Throughout the document, “parents” are used, but this term is meant to indicate any infant (sleep-related infant deaths), such caregivers. as unintentional suffocation, is Cosleeping: This term is commonly used, but the task force fi nds it confusing, and it is not used in this challenging, cannot be determined document. When used, authors need to make clear whether they are referring to sleeping in close proximity (which does not necessarily entail bed-sharing) or bed-sharing. by autopsy alone, and may remain Room-sharing: Parent(s) and infant sleeping in the same room on separate surfaces. unresolved after a full case Sleep-related infant death: SUID that occurs during an observed or unobserved sleep period. investigation. Many of the modifiable Sudden infant death syndrome (SIDS): Cause assigned to infant deaths that cannot be explained after and nonmodifiable risk factors for a thorough case investigation, including a scene investigation, autopsy, and review of the clinical SIDS and suffocation are strikingly history.1 Sudden unexpected infant death (SUID), or sudden unexpected death in infancy (SUDI): A sudden and similar. This document focuses on unexpected death, whether explained or unexplained (including SIDS), occurring during infancy. the subset of SUIDs that occur during sleep. The recommendations outlined TABLE 2 Summary of Recommendations With Strength of Recommendation herein were developed to reduce A-level recommendations the risk of SIDS and sleep- Back to sleep for every sleep. Use a fi rm sleep surface. related suffocation, asphyxia, and Breastfeeding is recommended. entrapment among infants in the Room-sharing with the infant on a separate sleep surface is recommended. general population. As defined Keep soft objects and loose bedding away from the infant’s sleep area. by epidemiologists, risk refers to Consider offering a pacifi er at naptime and bedtime. the probability that an outcome Avoid smoke exposure during pregnancy and after birth. Avoid alcohol and illicit drug use during pregnancy and after birth. will occur given the presence of a Avoid overheating. particular factor or set of factors. Pregnant women should seek and obtain regular prenatal care. Although all 19 recommendations Infants should be immunized in accordance with AAP and CDC recommendations. are intended for all who care for Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. infants, the last 4 recommendations Health care providers, staff in newborn nurseries and NICUs, and child care providers should endorse and model the SIDS risk-reduction recommendations from birth. also are directed toward health Media and manufacturers should follow safe sleep guidelines in their messaging and advertising. policy makers, researchers, and Continue the “Safe to Sleep” campaign, focusing on ways to reduce the risk of all sleep-related infant professionals who care for or work deaths, including SIDS, suffocation, and other unintentional deaths. Pediatricians and other primary on behalf of infants. In addition, care providers should actively participate in this campaign. because certain behaviors, such as B-level recommendations Avoid the use of commercial devices that are inconsistent with safe sleep recommendations. smoking, can increase risk for the Supervised, awake tummy time is recommended to facilitate development and to minimize infant, some recommendations are development of positional plagiocephaly. directed toward women who are C-level recommendations pregnant or may become pregnant in Continue research and surveillance on the risk factors, causes, and pathophysiologic mechanisms the near future. of SIDS and other sleep-related infant deaths, with the ultimate goal of eliminating these deaths entirely. Table 2 summarizes each There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. recommendation and provides the The following levels are based on the Strength-of-Recommendation Taxonomy (SORT) for the assignment of letter grades strength of the recommendation, to each of its recommendations (A, B, or C). 2 Level A: There is good-quality patient-oriented evidence. Level B: There is inconsistent or limited-quality patient-oriented evidence. Level C: The recommendation is based on consensus, disease- which is based on the Strength-of- oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or Recommendation Taxonomy. 2 It screening. Note: “patient-oriented evidence” measures outcomes that matter to patients: morbidity, mortality, symptom should be noted that there are no improvement, cost reduction, and quality of life; “disease-oriented evidence” measures immediate, physiologic, or surrogate end points that may or may not refl ect improvements in patient outcomes (eg, blood pressure, blood chemistry, randomized controlled trials with physiologic function, pathologic fi ndings). CDC, Centers for Disease Control and Prevention. regard to SIDS and other sleep- related deaths; instead, case-control (including sudden infant death nonaccidental). SIDS is a subcategory studies are the standard. syndrome [SIDS] and ill-defined of SUID and is a cause assigned The recommendations are based on deaths), occurring during infancy. to infant deaths that cannot be epidemiologic studies that include After case investigation, SUID can be explained after a thorough case infants up to 1 year of age. Therefore, attributed to suffocation, asphyxia, investigation, including a scene recommendations for sleep position entrapment, infection, ingestions, investigation, autopsy, and review and the sleep environment, unless metabolic diseases, arrhythmia- of the clinical history. 1 (See Table otherwise specified, are for the associated cardiac channelopathies, 1 for definitions of terms.) The first year after birth. The evidence- and trauma (unintentional or distinction between SIDS and other based recommendations that

Downloaded from www.aappublications.org/news by guest on September 25, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS follow are provided to guide health is observed and awake, particularly As stated in the AAP clinical report, care providers in conversations in the postprandial period, but “skin-to-skin care is recommended with parents and others who care prone positioning during sleep can for all mothers and newborns, for infants. Health care providers only be considered in infants with regardless of feeding or delivery are encouraged to have open and certain upper airway disorders method, immediately following birth nonjudgmental conversations with in which the risk of death from (as soon as the mother is medically families about their sleep practices. GERD [gastroesophageal reflux stable, awake, and able to respond to Individual medical conditions may disease] may outweigh the risk of her newborn), and to continue for at warrant that a health care provider SIDS.” 11 Examples of such upper least an hour.” 17 Thereafter, or when recommend otherwise after weighing airway disorders are those in which the mother needs to sleep or take the relative risks and benefits. airway-protective mechanisms are care of other needs, infants should be For the background literature impaired, including infants with placed supine in a bassinet. There is review and data analyses on anatomic abnormalities, such as type no evidence that placing infants on which this policy statement and 3 or 4 laryngeal clefts, who have not their side during the first few hours recommendations are based, refer to undergone antireflux surgery. There after delivery promotes clearance of the accompanying technical report, is no evidence to suggest that infants amniotic fluid and decreases the risk “SIDS and Other Sleep-Related Infant receiving nasogastric or orogastric of aspiration. Infants in the newborn Deaths: Evidence Base for 2016 feeds are at an increased risk of nursery and infants who are rooming Updated Recommendations for a aspiration if placed in the supine in with their parents should be Safe Infant Sleeping Environment,” position. Elevating the head of the placed in the supine position as soon available in the electronic pages of infant’s crib is ineffective in reducing as they are ready to be placed in the 12 this issue (www. pediatrics. org/ cgi/ gastroesophageal reflux and is not bassinet. doi/ 10. 1542/ peds. 2016- 2940).3 recommended; in addition, elevating the head of the crib may result in the Although data to make specific infant sliding to the foot of the crib recommendations as to when it is safe for infants to sleep in the prone RECOMMENDATIONS TO REDUCE THE into a position that may compromise or side position are lacking, studies RISK OF SIDS AND OTHER SLEEP- respiration. RELATED INFANT DEATHS establishing prone and side sleeping as risk factors for SIDS include Preterm infants should be placed 1. Back to sleep for every sleep. infants up to 1 year of age. Therefore, supine as soon as possible. Preterm the best evidence suggests that To reduce the risk of SIDS, infants infants are at increased risk of infants should continue to be placed should be placed for sleep in a supine SIDS, 13, 14 and the association supine until 1 year of age. Once an position (wholly on the back) for between prone sleep position and infant can roll from supine to prone every sleep by every caregiver until SIDS among low birth weight and 4–8 and from prone to supine, the infant the child reaches 1 year of age. preterm infants is equal to, or can be allowed to remain in the sleep Side sleeping is not safe and is not perhaps even stronger than, the 5, 7 position that he or she assumes. advised. association among those born at Because rolling into soft bedding is The supine sleep position does not term. 15 The task force concurs with an important risk factor for SUID increase the risk of choking and the AAP Committee on Fetus and after 3 months of age, 18 parents and aspiration in infants, even those with Newborn that “preterm infants caregivers should continue to keep gastroesophageal reflux, because should be placed supine for sleeping, the infant’s sleep environment clear infants have airway anatomy and just as term infants should, and the of soft or loose bedding. mechanisms that protect against parents of preterm infants should aspiration.9, 10 The American Academy be counseled about the importance 2. Use a firm sleep surface. of Pediatrics (AAP) concurs with the of supine sleeping in preventing Infants should be placed on a firm North American Society for Pediatric SIDS. Hospitalized preterm infants sleep surface (eg, mattress in a Gastroenterology and Nutrition should be kept predominantly in safety-approved crib) covered by a that “the risk of SIDS outweighs the supine position, at least from fitted sheet with no other bedding or the benefit of prone or lateral sleep the postmenstrual age of 32 weeks soft objects to reduce the risk of SIDS position on GER [gastroesophageal onward, so that they become and suffocation. reflux]; therefore, in most infants acclimated to supine sleeping before from birth to 12 months of age, discharge.”16 NICU personnel should A firm surface maintains its shape supine positioning during sleep is endorse safe sleeping guidelines with and will not indent or conform to recommended. …Therefore, prone parents of infants from the time of the shape of the infant’s head when positioning is acceptable if the infant admission to the NICU. the infant is placed on the surface.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 3 Soft mattresses, including those should not be used as substitutes in the sling so that the head is up, is made from memory foam, could for mattresses or in addition to a clear of fabric, and is not against the create a pocket (or indentation) and mattress. Mattress toppers, designed adult’s body or the sling. If an infant increase the chance of rebreathing or to make the sleep surface softer, falls asleep in a sitting device, he suffocation if the infant is placed in or should not be used for infants or she should be removed from the rolls over to the prone position. 19, 20 younger than 1 year. product and moved to a crib or other A crib, bassinet, portable crib, or There is no evidence that special appropriate flat surface as soon as play yard that conforms to the crib mattresses and sleep surfaces is safe and practical. Car seats and safety standards of the Consumer that claim to reduce the chance of similar products are not stable on Product Safety Commission (CPSC), rebreathing carbon dioxide when the a crib mattress or other elevated 32–36 including those for slat spacing infant is in the prone position reduce surfaces. Infants should not less than 2-3/8 inches, snugly the risk of SIDS. However, there is be left unattended in car seats and fitting and firm mattresses, and no no disadvantage to the use of these similar products, nor should they be drop sides, is recommended.21 In mattresses if they meet the safety placed or left in car seats and similar addition, parents and providers standards as described previously. products with the straps unbuckled or partially buckled. 30 should check to make sure that the Soft materials or objects, such product has not been recalled. This as pillows, quilts, comforters, or 3. Breastfeeding is recommended. is particularly important for used sheepskins, even if covered by a Breastfeeding is associated with a cribs. Cribs with missing hardware sheet, should not be placed under a reduced risk of SIDS. 37 – 39 Unless should not be used, nor should sleeping infant. If a mattress cover contraindicated, mothers should the parent or provider attempt to to protect against wetness is used, it breastfeed exclusively or feed with fix broken components of a crib, should be tightly fitting and thin. expressed milk (ie, not offer any because many deaths are associated Infants should not be placed for formula or other nonhuman milk- with cribs that are broken or with based supplements) for 6 months, in missing parts (including those that sleep on beds, because of the risk of entrapment and suffocation. 23, 24 alignment with recommendations of have presumably been fixed). Local the AAP. 40 organizations throughout the United In addition, portable bed rails should States can help to provide low-cost or not be used with infants, because The protective effect of breastfeeding 39 free cribs or play yards for families of the risk of entrapment and increases with exclusivity. with financial constraints. strangulation. However, any breastfeeding has been shown to be more protective against Bedside sleepers are attached to the The infant should sleep in an area SIDS than no breastfeeding. 39 side of the parental bed. The CPSC free of hazards, such as dangling 4. It is recommended that infants has published safety standards for cords, electric wires, and window- sleep in the parents’ room, close to these products, 22 and they may covering cords, because these may the parents’ bed, but on a separate be considered by some parents as present a strangulation risk. an option. However, there are no surface designed for infants, Sitting devices, such as car seats, CPSC safety standards for in-bed ideally for the first year of life, but strollers, swings, infant carriers, and sleepers. The task force cannot make at least for the first 6 months. infant slings, are not recommended a recommendation for or against for routine sleep in the hospital There is evidence that sleeping in the use of either bedside sleepers or at home, particularly for young the parents’ room but on a separate or in-bed sleepers, because there infants. 25 – 30 Infants who are younger surface decreases the risk of SIDS by have been no studies examining the 6, 8, 41,42 than 4 months are particularly at as much as 50%. In addition, association between these products risk, because they may assume this arrangement is most likely to and SIDS or unintentional injury and positions that can create a risk of prevent suffocation, strangulation, death, including suffocation. suffocation or airway obstruction and entrapment that may occur when Only mattresses designed for the or may not be able to move out of a the infant is sleeping in the adult bed. specific product should be used. potentially asphyxiating situation. The infant’s crib, portable crib, play Mattresses should be firm and should When infant slings and cloth carriers yard, or bassinet should be placed maintain their shape even when the are used for carrying, it is important in the parents’ bedroom until the fitted sheet designated for that model to ensure that the infant’s head is child’s first birthday. Although there is used, such that there are no gaps up and above the fabric, the face is is no specific evidence for moving an between the mattress and the wall visible, and the nose and mouth are infant to his or her own room before of the crib, bassinet, portable crib, clear of obstructions. 31 After nursing, 1 year of age, the first 6 months or play yard. Pillows or cushions the infant should be repositioned are particularly critical, because

Downloaded from www.aappublications.org/news by guest on September 25, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS the rates of SIDS and other sleep- Infants should never be placed on a • Bed-sharing with someone who is related deaths, particularly those couch or armchair for sleep. impaired in his or her alertness or occurring in bed-sharing situations, The safest place for an infant to sleep ability to arouse because of fatigue are highest in the first 6 months. is on a separate sleep surface designed or use of sedating medications Placing the crib close to the parents’ for infants close to the parents’ bed. (eg, certain antidepressants, pain bed so that the infant is within view However, the AAP acknowledges that medications) or substances (eg, 8, 48,51, 52 and reach can facilitate feeding, parents frequently fall asleep while alcohol, illicit drugs). comforting, and monitoring of the feeding the infant. Evidence suggests • Bed-sharing with anyone who is infant. Room-sharing reduces SIDS that it is less hazardous to fall asleep not the infant’s parent, including risk and removes the possibility with the infant in the adult bed than nonparental caregivers and other of suffocation, strangulation, and on a sofa or armchair, should the children. 4 entrapment that may occur when the parent fall asleep. It is important to • infant is sleeping in the adult bed. Bed-sharing on a soft surface, such note that a large percentage of infants as a waterbed, old mattress, sofa, There is insufficient evidence to who die of SIDS are found with their couch, or armchair. 4, 6, 7, 42, 43 recommend for or against the use head covered by bedding. Therefore, • of devices promoted to make bed- no pillows, sheets, blankets, or any Bed-sharing with soft bedding sharing “safe.” There is no evidence other items that could obstruct infant accessories, such as pillows or 4,53 that these devices reduce the risk breathing or cause overheating should blankets. of SIDS or suffocation or are safe. be in the bed. Parents should also • The safety and benefits of Some products designed for in-bed follow safe sleep recommendations cobedding for twins and higher- use (in-bed sleepers) are currently outlined elsewhere in this statement. order multiples have not been under study but results are not yet Because there is evidence that the risk established. It is prudent to provide available. Bedside sleepers, which of bed-sharing is higher with longer separate sleep surfaces and avoid attach to the side of the parental bed duration, if the parent falls asleep cobedding for twins and higher- and for which the CPSC has published while feeding the infant in bed, the order multiples in the hospital and standards, 22 may be considered by infant should be placed back on a at home. 54 some parents as an option. There are separate sleep surface as soon as the 5. Keep soft objects and loose no CPSC safety standards for in-bed parent awakens. bedding away from the infant’s sleepers. The task force cannot make There are specific circumstances sleep area to reduce the risk of a recommendation for or against that, in case-control studies and SIDS, suffocation, entrapment, and the use of either bedside sleepers case series, have been shown to strangulation. or in-bed sleepers, because there substantially increase the risk of 19,20, 55 –58 have been no studies examining the SIDS or unintentional injury or death Soft objects, such as association between these products while bed-sharing, and these should pillows and pillow-like toys, quilts, and SIDS or unintentional injury and be avoided at all times: comforters, sheepskins, and loose death, including suffocation. bedding, 4, 7, 59 – 64 such as blankets • Infants who are brought into the bed Bed-sharing with a term normal- and nonfitted sheets, can obstruct for feeding or comforting should be weight infant younger than 4 an infant’s nose and mouth. An 6, 8, 42,43, 45,46 returned to their own crib or bassinet months and infants born obstructed airway can pose a risk of when the parent is ready to return to preterm and/or with low birth suffocation, entrapment, or SIDS. weight, 47 regardless of parental sleep. 7, 43 Infant sleep clothing, such as a smoking status. Even for breastfed wearable blanket, is preferable to Couches and armchairs are extremely infants, there is an increased risk of blankets and other coverings to dangerous places for infants. Sleeping SIDS when bed-sharing if younger keep the infant warm while reducing on couches and armchairs places than 4 months. 48 This appears to the chance of head covering or infants at extraordinarily high risk of be a particularly vulnerable time, 4,6, 7, 42, 43 entrapment that could result from infant death, including SIDS, so if parents choose to feed their blanket use. suffocation through entrapment or infants younger than 4 months wedging between seat cushions, in bed, they should be especially Bumper pads or similar products or overlay if another person is also vigilant to not fall asleep. that attach to crib slats or sides sharing this surface. 44 Therefore, were originally intended to prevent parents and other caregivers should • Bed-sharing with a current smoker injury or death attributable to head be especially vigilant as to their (even if he or she does not smoke entrapment. Cribs manufactured to wakefulness when feeding infants or in bed) or if the mother smoked newer standards have a narrower lying with infants on these surfaces. during pregnancy. 6, 7, 46, 49, 50 distance between slats to prevent

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 5 head entrapment. Because bumper There should be no smoking regular prenatal care. 71 – 74 Pregnant pads have been implicated as near pregnant women or infants. women should follow guidelines for a factor contributing to deaths Encourage families to set strict rules frequency of prenatal visits.91 from suffocation, entrapment, and for smoke-free homes and cars and to 11. Infants should be immunized in 65,66 strangulation and because eliminate secondhand tobacco smoke accordance with recommendations they are not necessary to prevent from all places in which children and of the AAP and Centers for Disease 75,76 head entrapment with new safety other nonsmokers spend time. Control and Prevention. standards for crib slats, they are not The risk of SIDS is particularly high recommended for infants. 65, 66 There is no evidence that there when the infant bed-shares with an is a causal relationship between 6. Consider offering a pacifier at adult smoker, even when the adult immunizations and SIDS. 92 – 95 Indeed, 6,7, 46,49, 50,77 nap time and bedtime. does not smoke in bed. recent evidence suggests that Although the mechanism is yet unclear, 8. Avoid alcohol and illicit drug use vaccination may have a protective studies have reported a protective during pregnancy and after birth. effect against SIDS.96 – 98 effect of pacifiers on the incidence of There is an increased risk of SIDS 12. Avoid the use of commercial 67,68 SIDS. The protective effect of the with prenatal and postnatal exposure devices that are inconsistent with pacifier is observed even if the pacifier to alcohol or illicit drug use. safe sleep recommendations. falls out of the infant’s mouth. 69, 70 Mothers should avoid alcohol and Be particularly wary of devices that The pacifier should be used when illicit drugs periconceptionally and claim to reduce the risk of SIDS. placing the infant for sleep. It does not during pregnancy. 78 – 85 Examples include, but are not limited need to be reinserted once the infant to, wedges and positioners and other falls asleep. If the infant refuses the Parental alcohol and/or illicit drug devices placed in the adult bed for the pacifier, he or she should not be forced use in combination with bed-sharing purpose of positioning or separating to take it. In those cases, parents can places the infant at particularly high the infant from others in the bed. try to offer the pacifier again when the risk of SIDS. 8, 51 Crib mattresses also have been infant is a little older. 9. Avoid overheating and head developed to improve the dispersion Because of the risk of strangulation, covering in infants. of carbon dioxide in the event that the pacifiers should not be hung around Although studies have shown infant ends up in the prone position the infant’s neck. Pacifiers that attach an increased risk of SIDS with during sleep. Although data do not to infant clothing should not be used overheating, 86 – 89 the definition of support the claim of carbon dioxide with sleeping infants. overheating in these studies varies. dispersion unless there is an active Objects, such as stuffed toys and Therefore, it is difficult to provide dispersal component,99 there is no other items that may present a specific room temperature guidelines harm in using these mattresses if they suffocation or choking risk, should to avoid overheating. meet standard safety requirements. not be attached to pacifiers. In general, infants should be dressed However, there is no evidence that any of these devices reduce the risk of For breastfed infants, pacifier appropriately for the environment, SIDS. Importantly, the use of products introduction should be delayed until with no greater than 1 layer more claiming to increase sleep safety breastfeeding is firmly established. 40 than an adult would wear to be does not diminish the importance of Infants who are not being directly comfortable in that environment. following recommended safe sleep breastfed can begin pacifier use as Parents and caregivers should practices. Information about a specific soon as desired. evaluate the infant for signs of product can be found on the CPSC overheating, such as sweating or the There is insufficient evidence that Web site (www.cpsc. gov). The AAP infant’s chest feeling hot to the touch. finger sucking is protective against concurs with the US Food and Drug SIDS. Overbundling and covering of the Administration and the CPSC that 90 7. Avoid smoke exposure during face and head should be avoided. manufacturers should not claim that pregnancy and after birth. There is currently insufficient a product or device protects against SIDS unless there is scientific evidence Both maternal smoking during evidence to recommend the use of a to that effect. pregnancy and smoke in the infant’s fan as a SIDS risk-reduction strategy. environment after birth are major 10. Pregnant women should obtain 13. Do not use home risk factors for SIDS. regular prenatal care. cardiorespiratory monitors as a Mothers should not smoke during There is substantial epidemiologic strategy to reduce the risk of SIDS. pregnancy or after the infant’s evidence linking a lower risk of SIDS The use of cardiorespiratory birth. 71 – 74 for infants whose mothers obtain monitors has not been documented

Downloaded from www.aappublications.org/news by guest on September 25, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS to decrease the incidence of placed in or rolls to the prone 17. Media and manufacturers SIDS. 100 – 103 These devices are position. 88, 105, 106 If infants are should follow safe sleep guidelines sometimes prescribed for use at swaddled, they should always be in their messaging and advertising. home to detect apnea or bradycardia placed on the back. Swaddling should Media exposures (including movie, and, when pulse oximetry is used, be snug around the chest but allow television, magazines, newspapers, decreases in oxyhemoglobin for ample room at the hips and and Web sites), manufacturer saturation for infants at risk of these knees to avoid exacerbation of hip advertisements, and store displays conditions. In addition, routine dysplasia. When an infant exhibits affect individual behavior by in-hospital cardiorespiratory signs of attempting to roll, swaddling influencing beliefs and 88, 105,106 monitoring before discharge from the should no longer be used. attitudes. 107, 109 Media and hospital has not been shown to detect There is no evidence with regard advertising messages contrary infants at risk of SIDS. There are no to SIDS risk related to the arms to safe sleep recommendations data that other commercial devices swaddled in or out. These decisions may create misinformation about that are designed to monitor infant about swaddling should be made on safe sleep practices. 110 vital signs reduce the risk of SIDS. an individual basis, depending on the physiologic needs of the infant. 18. Continue the “Safe to 14. Supervised, awake tummy Sleep” campaign, focusing on time is recommended to facilitate 16. Health care professionals, staff ways to reduce the risk of all development and to minimize in newborn nurseries and NICUs, sleep-related infant deaths, development of positional and child care providers should including SIDS, suffocation, and plagiocephaly. endorse and model the SIDS risk- other unintentional deaths. reduction recommendations from Pediatricians and other primary Although there are no data to make 107–109 birth. care providers should actively specific recommendations as to Staff in NICUs should model and participate in this campaign. how often and how long it should be implement all SIDS risk-reduction undertaken, the task force concurs Public education should continue for recommendations as soon as the with the AAP Committee on Practice all who care for infants, including infant is medically stable and well and Ambulatory Medicine and parents, child care providers, before anticipated discharge. Section on Neurologic Surgery that “a grandparents, foster parents, and certain amount of prone positioning, Staff in newborn nurseries should babysitters, and should include or ‘tummy time,’ while the infant model and implement these strategies for overcoming barriers to is awake and being observed is recommendations beginning at behavior change. recommended to help prevent the birth and well before anticipated The campaign should continue to development of flattening of the discharge. have a special focus on the black and occiput and to facilitate development All physicians, nurses, and other American Indian/Alaskan Native of the upper shoulder girdle strength health care providers should receive populations because of the higher necessary for timely attainment of education on safe infant sleep. Health incidence of SIDS and other sleep- 104 certain motor milestones.” care providers should screen for related infant deaths in these groups. Diagnosis, management, and other and recommend safe sleep practices The campaign should specifically prevention strategies for positional at each visit for infants up to 1 year include strategies to increase plagiocephaly, such as avoidance old. Families who do not have a safe breastfeeding while decreasing of excessive time in car seats and sleep space for their infant should bed-sharing, and eliminating changing the infant’s orientation in be provided with information about tobacco smoke exposure. The the crib, are discussed in detail in the low-cost or free cribs or play yards. campaign should also highlight the AAP clinical report on positional skull Hospitals should ensure that hospital circumstances that substantially 104 deformities. policies are consistent with updated increase the risk of SIDS or 15. There is no evidence to safe sleep recommendations and that unintentional injury or death while recommend swaddling as a infant sleep spaces (bassinets, cribs) bed-sharing, as listed previously. strategy to reduce the risk of SIDS. meet safe sleep standards. These recommendations should Swaddling, or wrapping the All state regulatory agencies should be introduced before pregnancy infant in a light blanket, is often require that child care providers and ideally in secondary school used as a strategy to calm the receive education on safe infant sleep curricula to both males and females infant and encourage the use of the and implement safe sleep practices. and incorporated into courses supine position. There is a high risk It is preferable that they have written developed to train teenaged and of death if a swaddled infant is policies. adult babysitters. The importance

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 7 of maternal preconceptional aspects of the aforementioned taxonomy (SORT): a patient-centered health, infant breastfeeding, and research. approach to grading evidence in the the avoidance of substance use medical literature. Am Fam Physician. (including alcohol and smoking) ACKNOWLEDGMENTS 2004;69(3):548–556 should be included in this training. We acknowledge the contributions 3. Moon RY; AAP Task Force on Sudden Infant Death Syndrome. SIDS and Safe sleep messages should be provided by others to the collection other sleep-related infant deaths: reviewed, revised, and reissued at and interpretation of data examined Evidence base for 2016 updated least every 5 years to address the in preparation of this report. We recommendations for a safe infant next generation of new parents and are particularly grateful for the sleeping environment. Pediatrics. products on the market. independent biostatistical report 2016;138(5):e20162940 submitted by Robert W. Platt, PhD. 19. Continue research and 4. Hauck FR, Herman SM, Donovan M, surveillance on the risk factors, et al. Sleep environment and the risk LEAD AUTHOR causes, and pathophysiologic of sudden infant death syndrome in an mechanisms of SIDS and other Rachel Y. Moon, MD, FAAP urban population: the Chicago Infant sleep-related infant deaths, with Mortality Study. Pediatrics. 2003; the ultimate goal of eliminating TASK FORCE ON SUDDEN INFANT DEATH 111(5 pt 2):1207–1214 SYNDROME these deaths altogether. 5. Li DK, Petitti DB, Willinger M, et al. Education campaigns need to Rachel Y. Moon, MD, FAAP, Chairperson Infant sleeping position and the risk Robert A. Darnall, MD be evaluated, and innovative of sudden infant death syndrome in Lori Feldman-Winter, MD, MPH, FAAP intervention methods need to be California, 1997-2000. Am J Epidemiol. Michael H. Goodstein, MD, FAAP 2003;157(5):446–455 encouraged and funded. Fern R. Hauck, MD, MS 6. Blair PS, Fleming PJ, Smith IJ, et al; Continued research and improved CESDI SUDI Research Group. Babies surveillance on the etiology and CONSULTANTS sleeping with parents: case-control pathophysiologic basis of SIDS should Marian Willinger, PhD – Eunice Kennedy Shriver study of factors infl uencing the risk National Institute for Child Health and Human be funded. of the sudden infant death syndrome. Development BMJ. 1999;319(7223):1457–1461 Standardized protocols for death Carrie K. Shapiro-Mendoza, PhD, MPH – Centers scene investigations, as per Centers for Disease Control and Prevention 7. Fleming PJ, Blair PS, Bacon C, et al; for Disease Control and Prevention Confi dential Enquiry into Stillbirths protocol, should continue to be STAFF and Deaths Regional Coordinators implemented. Comprehensive James Couto, MA and Researchers. Environment of autopsies, including full external and infants during sleep and risk of internal examination of all major the sudden infant death syndrome: ABBREVIATIONS organs and tissues including the brain; results of 1993-5 case-control study for confi dential inquiry into complete radiographs; metabolic AAP: American Academy of stillbirths and deaths in infancy. BMJ. testing; and toxicology screening Pediatrics 1996;313(7051):191–195 should be performed. Training about CPSC: Consumer Product Safety how to conduct a comprehensive Commission 8. Carpenter RG, Irgens LM, Blair PS, et al. death scene investigation offered to SIDS: sudden infant death Sudden unexplained infant death in 20 regions in Europe: case control study. medical examiners, coroners, death syndrome Lancet. 2004;363(9404):185–191 scene investigators, first responders, SUID: sudden unexpected infant and law enforcement should continue; death 9. Malloy MH. Trends in postneonatal and resources to maintain training aspiration deaths and reclassifi cation and conduct of these investigations of sudden infant death syndrome: impact of the “Back to Sleep” program. need to be allocated. In addition, child Pediatrics. 2002;109(4):661–665 death reviews, with involvement of REFERENCES pediatricians and other primary care 10. Tablizo MA, Jacinto P, Parsley D, providers, should be supported and 1. Willinger M, James LS, Catz C. Defi ning Chen ML, Ramanathan R, Keens funded. the sudden infant death syndrome TG. Supine sleeping position does (SIDS): deliberations of an expert panel not cause clinical aspiration in Improved and widespread convened by the National Institute of neonates in hospital newborn surveillance of SIDS and SUID cases Child Health and Human Development. nurseries. Arch Pediatr Adolesc Med. should be implemented and funded. Pediatr Pathol. 1991;11(5):677–684 2007;161(5):507–510 Federal and private funding agencies 2. Ebell MH, Siwek J, Weiss BD, 11. Vandenplas Y, Rudolph CD, Di Lorenzo should remain committed to all et al. Strength of recommendation C, et al; North American Society

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