TECHNICAL REPORT

SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment Rachel Y. Moon, MD, FAAP, 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), ill-defi ned deaths, and accidental suffocation and strangulation in bed. This document is copyrighted and is property of the American After an initial decrease in the 1990s, the overall sleep-related infant death Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy rate has not declined in more recent years. Many of the modifi able and of Pediatrics. Any confl icts have been resolved through a process nonmodifi able risk factors for SIDS and other sleep-related infant deaths approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial are strikingly similar. The American Academy of Pediatrics recommends a involvement in the development of the content of this publication. safe sleep environment that can reduce the risk of all sleep-related infant Technical reports from the American Academy of Pediatrics benefi t deaths. Recommendations for a safe sleep environment include supine from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American positioning, use of a fi rm sleep surface, room-sharing without bed-sharing, Academy of Pediatrics may not refl ect the views of the liaisons or the and avoidance of soft bedding and overheating. Additional recommendations organizations or government agencies that they represent. for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking illicit drugs; breastfeeding; routine immunization; and use of a pacifi er. New into account individual circumstances, may be appropriate. evidence and rationale for recommendations are presented for skin-to-skin All technical reports from the American Academy of Pediatrics care for newborn infants, bedside and in-bed sleepers, sleeping on couches/ automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location DOI: 10.1542/peds.2016-2940 are included. The recommendations and strength of evidence for each PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). recommendation are published in the accompanying policy statement, “SIDS Copyright © 2016 by the American Academy of Pediatrics and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a FINANCIAL DISCLOSURE: The author has indicated she does not have a Safe Infant Sleeping Environment, ” which is included in this issue. fi nancial relationship relevant to this article to disclose. FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential confl icts of interest to disclose. SEARCH STRATEGY AND METHODOLOGY

Literature searches with the use of PubMed were conducted for each of To cite: Moon RY and AAP TASK FORCE ON SUDDEN INFANT the topics in the technical report, concentrating on articles published DEATH SYNDROME. SIDS and Other Sleep-Related Infant Deaths: since 2011 (when the last technical report and policy statement were Evidence Base for 2016 Updated Recommendations for a published 1, 2). All iterations of the search terms were used for each topic Safe Infant Sleeping Environment. Pediatrics. 2016;138(5): e20162940 area. For example, the pacifier topic search combined either “SIDS,”

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 :e 20162940 FROM THE AMERICAN ACADEMY OF PEDIATRICS “SUID,” “sudden death,” or “cot TABLE 1 Defi nitions of Terms death” with “pacifier,” “dummy,” Caregivers: Throughout the document, “parents” are used, but this term is meant to indicate any infant “soother,” and “sucking.” A total of caregivers. 63 new studies were judged to be Bed-sharing: Parent(s) and infant sleeping together on any surface (bed, couch, chair). of sufficiently high quality to be Cosleeping: This term is commonly used, but the task force fi nds it confusing and it is not used in this document. When used, authors need to make clear whether they are referring to sleeping in close included in this technical report. In proximity (which does not necessarily entail bed-sharing) or bed-sharing. addition, because the data regarding Room-sharing: Parent(s) and infant sleeping in the same room on separate surfaces. bed-sharing have been conflicting, Sleep-related infant death: SUID that occurs during an observed or unobserved sleep period. the independent opinion of a Sudden infant death syndrome (SIDS): Cause assigned to infant deaths that cannot be explained after biostatistician with special expertise a thorough case investigation including a scene investigation, autopsy, and review of the clinical history. 4 in perinatal epidemiology was Sudden unexpected infant death (SUID), or sudden unexpected death in infancy (SUDI): A sudden and solicited. The strength of evidence unexpected death, whether explained or unexplained (including SIDS), occurring during infancy. for recommendations, using the Strength-of-Recommendation Taxonomy, 3 was determined by occur during an unobserved sleep diagnostic of oronasal occlusion 7 the task force members. A draft period (ie, sleep-related infant or chest compression ), even with version of the policy statement and deaths), such as unintentional strong evidence from the scene technical report was submitted to suffocation, is challenging, cannot be investigation suggesting a probable relevant committees and sections of determined by autopsy alone, and unintentional suffocation. the American Academy of Pediatrics may remain unresolved after a full case investigation. A few deaths that (AAP) for review and comment. After US Trends in SIDS, Other SUIDs, and the appropriate revisions were made, are diagnosed as SIDS are found, with Postneonatal Mortality a final version was submitted to the further specialized investigations, to be attributable to metabolic AAP Executive Committee for final To monitor trends in SIDS and other disorders or arrhythmia-associated approval. SUIDs nationally, the United States cardiac channelopathies. classifies diseases and injuries Although standardized guidelines according to the International SUDDEN UNEXPECTED INFANT for conducting thorough case Statistical Classification of Diseases DEATH AND SUDDEN INFANT DEATH investigations have been developed (ICD) diagnostic codes. In the United SYNDROME: DEFINITIONS AND (http:// www. cdc. gov/ sids/ pdf/ States, the National Center for Health DIAGNOSTIC ISSUES suidi- form2- 1- 2010. pdf),5 these Statistics assigns a SIDS diagnostic Sudden unexpected infant death guidelines have not been uniformly code (International Classification (SUID), also known as sudden adopted across the >2000 US medical of Diseases, 10th Revision [ICD-10] unexpected death in infancy (SUDI), examiner and coroner jurisdictions. 6 R95) if the death is classified with is a term used to describe any Information from emergency terminology such as SIDS (including sudden and unexpected death, responders, scene investigators, and presumed, probable, or consistent whether explained or unexplained caregiver interviews may provide with SIDS), sudden infant death, (including sudden infant death additional evidence to assist death sudden unexplained death in infancy, syndrome [SIDS] and ill-defined certifiers (ie, medical examiners and sudden unexpected infant death, deaths), occurring during infancy. coroners) in accurately determining SUID, or SUDI on the certified death After case investigation, SUID can the cause of death. However, death certificate. 8, 9 A death will be coded be attributed to causes of death certifiers represent a diverse group “other ill-defined and unspecified such as suffocation, asphyxia, with varying levels of skill and causes of mortality” (ICD-10 R99) if entrapment, infection, ingestions, education. In addition, there are the cause of the death is reported as metabolic diseases, and trauma diagnostic preferences. Recently, unknown or unspecified. 8 A death (unintentional or nonaccidental). much attention has focused on is coded “accidental suffocation SIDS is a subcategory of SUID and reporting differences among death and strangulation in bed” (ICD-10 is a cause assigned to infant deaths certifiers. On one extreme, some W75) when the terms asphyxia, that cannot be explained after a certifiers have abandoned the asphyxiated, asphyxiation, strangled, thorough case investigation including use of SIDS as a cause-of-death strangulated, strangulation, autopsy, a scene investigation, and explanation. 6 At the other extreme, suffocated, or suffocation are review of clinical history. 4 (See some certifiers will not classify a reported, along with the terms bed Table 1 for definitions of terms.) death as suffocation in the absence or crib. This code also includes The distinction between SIDS and of a pathologic marker of asphyxia deaths while sleeping on couches and other SUIDs, particularly those that at autopsy (ie, pathologic findings armchairs.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS FIGURE 1 Trends in SUID by cause, 1990–2013. Source: Centers for Disease Control and Prevention/National Center for Health Statistics, National Vital Statistics System, compressed mortality fi le. (Figure duplicated from http:// www. cdc. gov/sids/ data. htm.)

Although SIDS was defined with the most dramatic declines rates also remained fairly unchanged somewhat loosely until the mid- in the years immediately after (from 231 to 222 per 100 000 live 1980s, there was minimal change in the first nonprone sleep position births), and then have declined the incidence of SIDS in the United recommendations, and this decline yearly since 2009 to a rate of 193 States until the early 1990s. In was consistent with the steady per 100 000 live births in 2013.14 1992, in response to epidemiologic increase in the prevalence of supine Several studies have observed that reports from Europe and Australia, sleeping (Fig 1).12 The US SIDS rate some deaths previously classified the AAP recommended that decreased from 120 deaths per as SIDS (ICD-10 R95) are now being infants be placed for sleep in a 100 000 live births in 1992 to 56 classified as other causes of sleep- nonprone position as a strategy deaths per 100 000 live births in related infant death (eg, accidental to reduce the risk of SIDS.10 The 2001, representing a reduction of suffocation and strangulation in “Back to Sleep” campaign (which 53% over 10 years. From 2001 to bed [ASSB; ICD-10 W75] or other is now known as the “Safe to 2008, the rate remained constant ill-defined or unspecified causes Sleep” campaign 11) was initiated (Fig 1) and then declined from 54 [ICD-10 R99]), 15, 16 and that at least in 1994 under the leadership of per 100 000 live births in 2009 to some of the decline in SIDS rates the National Institute of Child 40 in 2013 (the latest year that data may be explained by increasing rates Health and Human Development are available). In 2013, 1561 infants of these other assigned causes of 13 (now the Eunice Kennedy Shriver died of SIDS. Although SIDS rates SUID. 15, 17 To account for variations National Institute of Child Health have declined by >50% since the in death certifier classification and and Human Development) as early 1990s, SIDS remains the to more consistently track SIDS and a joint effort of the Maternal leading cause of postneonatal (28 other sleep-related infant deaths, and Child Health Bureau of the days to 1 year of age) mortality. the National Center for Health Health Resources and Services The all-cause postneonatal death rate Statistics has created the special Administration, the AAP, the SIDS follows a trend similar to the SIDS cause-of-death category SUID. The Alliance (now First Candle), and and SUID rates, with a 26% decline SUID category captures deaths with the Association of SIDS and Infant from 1992 to 2001 (from 314 to 231 an underlying cause coded as ICD- Mortality Programs. Between 1992 per 100 000 live births). From 2001 10 R95, R99, and W75. 13 In 2013, and 2001, the SIDS rate declined, until 2009, postneonatal mortality SIDS accounted for 46% of the 3422

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e3 SUIDs in the United States. Similar to the SIDS rate, the SUID rate also declined in the late 2000s, from 99 per 100 000 live births in 2009 to 87 in 2013.

Racial and Ethnic Disparities

SIDS and SUID mortality rates, like other causes of infant mortality, have notable and persistent racial and ethnic disparities.14 Despite the decline in SIDS and SUIDs in all races and ethnicities, the rate of SUIDs among non-Hispanic black (172 per 100 000 live births) and American Indian/Alaska Native FIGURE 2 SUID by race/ethnicity, 2010–2013. Source: Centers for Disease Control and Prevention/National (191 per 100 000 live births) Center for Health Statistics, National Vital Statistics System, period-linked birth/infant death data. infants was more than double (Figure duplicated from http://www. cdc. gov/ sids/ data. htm.) that of non-Hispanic white infants (84 per 100 000 live births) in 2010–2013 (Fig 2). SIDS rates for Asian/Pacific Islander and Hispanic infants were much lower than the rate for non-Hispanic white infants. Furthermore, similar racial and ethnic disparities are seen with deaths attributed to both ASSB and ill-defined or unspecified deaths (Fig 2). Differences in the prevalence of supine positioning and other sleep environment conditions between racial and ethnic populations may contribute to these disparities.18 The prevalence of supine positioning in 2010 data from the National Infant Sleep Position Study in white infants FIGURE 3 was 75%, compared with 53%, 73%, Prevalence of supine sleep positioning by maternal race and ethnic origin, 1992–2010. Source: and 80% among black, Hispanic, and National Infant Sleep Position Study. Note that data collection for the National Infant Sleep Position Asian infants, respectively (Fig 3).19 Study ended in 2010. The Pregnancy Risk Assessment Monitoring System also monitors the than among other racial/ethnic after 8 months of age. 16 A similar age prevalence of infant sleep position groups.23 – 25 distribution is seen for ASSB. 16 in several states (http://www. cdc. gov/prams/ pramstat/ index. html). Age at Death In 2011, 78% of mothers reported PATHOPHYSIOLOGY AND GENETICS OF that they most often lay their infants Ninety percent of SIDS cases occur SIDS on their backs for sleep (26 states before an infant reaches the age of reporting and most recent year 6 months. 16 SIDS peaks between 1 A working model of SIDS available), with 80.3% of white and 4 months of age. Although SIDS pathogenesis includes a mothers and 54% of black mothers was once considered a rare event convergence of exogenous triggers reporting supine placement. Parent- during the first month after birth, or “stressors” (eg, prone sleep infant bed-sharing 20 – 22 and the in 2004–2006 nearly 10% of cases position, overbundling, airway use of soft bedding are also more that were coded as SIDS occurred obstruction), a critical period of common among black families during this period. SIDS is uncommon development, and dysfunctional

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS and/or immature cardiorespiratory 4% carbon dioxide or a 60° head-up and/or arousal systems (intrinsic tilt is greater than expected. 48 These vulnerability) that lead to a failure of changes in autonomic function, protective responses ( Fig 4).26 The arousal, and cardiovascular convergence of these factors may reflexes may all increase an infant’s ultimately result in a combination of vulnerability to SIDS. progressive asphyxia, bradycardia, hypotension, metabolic acidosis, A recent large systematic review and ineffectual gasping, leading to of the neuropathologic features death. 27 Thus, death may occur as a of unexplained SUDI, including result of the interaction between a only studies that met strict vulnerable infant and a potentially criteria, concluded that “the most asphyxiating and/or overheating consistent findings, and most 28 FIGURE 4 sleep environment. Triple risk model for SIDS. Adapted from Filiano likely to be pathophysiologically 26 significant, are abnormalities of The mechanisms responsible and Kinney. serotonergic neurotransmission in for intrinsic vulnerability (ie, the caudal brain stem.” 49 Brainstem dysfunctional cardiorespiratory and/ and medullary neurotransmitter abnormalities that involve the 5-HT or arousal protective responses) receptors, including nicotinic 35–37 system in up to 70% of infants who remain unclear but may be the receptors, in baboons. From die of SIDS have now been confirmed result of in utero environmental a functional perspective, prenatal in several independent data sets and conditions and/or genetically exposure to nicotine causes laboratories. 29, 50 –52 These include determined maldevelopment hypoventilation and increased 38, 39 decreased 5-hydroxytryptamine or delay in maturation. Infants apnea ; reduces hypercarbia 1A (5-HT1A) receptor binding, who die of SIDS are more likely and hypoxia-induced ventilator 38–40 a relative decreased binding to to have been born preterm and/ chemoreflexes in mice, rats, 41 the 5-HT transporter, increased or were growth restricted, which and lambs ; and blunts arousal in 40 numbers of immature 5-HT neurons, suggests a suboptimal intrauterine response to hypoxia in rats and 41 and decreased tissue levels of environment. Other adverse in lambs. 5-HT and the rate-limiting enzyme utero environmental conditions In human infants, there are strong for 5-HT synthesis, tryptophan include exposure to nicotine or other associations between nicotinic hydroxylase. 53 Moreover, there is components of cigarette smoke and acetylcholine receptors and no evidence of excessive serotonin alcohol. 29 serotonergic (5-HT) receptors in the degradation as assessed by levels Recent studies have explored how brainstem during development, 42 and of 5-hydroxyindoleacetic acid (the prenatal exposure to cigarette there is important recent evidence of main metabolite of serotonin) or smoke may result in an increased epigenetic changes in the placentas of ratios of 5-hydroxyindoleacetic risk of SIDS. In animal models, infants with prenatal tobacco smoke acid to serotonin. 35 This area of exposure to cigarette smoke or exposure. 43 Prenatal exposure to the brainstem plays a key role in nicotine during fetal development tobacco smoke attenuates recovery coordinating many respiratory, alters the expression of the nicotinic from hypoxia in preterm infants, 44 arousal, and autonomic functions, acetylcholine receptors in areas decreases heart rate variability in and when dysfunctional, might of the brainstem important for preterm 45 and term46 infants, and prevent normal protective responses autonomic function and alters the abolishes the normal relationship to stressors that commonly occur numbers of orexin receptors in between heart rate and gestational during sleep. Importantly, these piglets, 30, 31 reduces the number age at birth. 45 Moreover, infants of findings are not confined to nuclei of medullary serotonergic smoking mothers exhibit impaired containing 5-HT neurons but also (5-hydroxytryptamine [5-HT]) arousal patterns to trigeminal include relevant projection sites. neurons in the raphe obscurus in stimulation in proportion to Other abnormalities in brainstem mice, 32 increases 5-HT and 5-HT urinary cotinine concentrations. 47 projection sites have been described turnover in Rhesus monkeys, 33 alters It is important to also note that as well. For example, abnormalities neuronal excitability of neurons prenatal exposure to tobacco smoke of Phox2B immune-reactive in the nucleus tractus solitarius alters the normal programming of neurons have been reported in the (a brainstem region important for cardiovascular reflexes, such that homologous human retrotrapezoid sensory integration) in guinea pigs, 34 the increase in blood pressure and nucleus, a region of the brainstem and alters fetal autonomic activity heart rate in response to breathing that receives important 5-HT

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e5 projections and is critical to carbon heart rate, thermoregulation, and Rognum. 62) Several categories dioxide chemoreception and sleep and arousal, and upper of physiologic functions relevant implicated in human congenital airway patency. Engineered mice to SIDS have been examined for central hypoventilation syndrome. 54 with decreased numbers of 5-HT altered genetic makeup. Genes The brainstem has important neurons and rats or piglets with related to the serotonin transporter, reciprocal connections to the limbic decreased activity secondary to cardiac channelopathies, and the system comprising both cortical and 5-HT1A autoreceptor stimulation development of the autonomic subcortical components, including show diminished ventilator nervous system are the subject of 63 the limbic cortex, hypothalamus, responses to carbon dioxide, current investigation. The serotonin amygdala, and hippocampus. These dysfunctional heat production transporter recovers serotonin from areas of the brain are important in and heat loss mechanisms, and the extracellular space and largely 57 the regulation of autonomic function, altered sleep architecture. The serves to regulate overall serotonin particularly in response to emotional aberrant thermoregulation in these neuronal activity. There are reports stimuli. Thus, the brainstem and models provides evidence for a that polymorphisms in the promoter limbic system constitute a key biological substrate for the risk of region that enhance the efficacy of network in controlling many aspects SIDS associated with potentially the transporter (L) allele seem to be of autonomic function. Recently, overheating environments. more prevalent in infants who die of abnormalities in the dentate gyrus In addition, mice pups with a SIDS compared with polymorphisms 62 (a component of the hippocampus) constitutive reduction in 5-HT– that reduce efficacy (S) ; however, were observed in 41% of 153 producing neurons (PET1 knockout) at least 1 study did not confirm 64 infants who died unexpectedly with or rat pups in which a large fraction this association. It has also been no apparent cause and 43% of the of medullary 5-HT neurons have reported that a polymorphism subset of deaths classified as SIDS. been destroyed with locally applied (12-repeat intron 2) of the promoter This finding suggests that dysfunction neurotoxins have a decreased ability region of the serotonin transporter, of other brain regions interconnected to auto-resuscitate in response to which also enhances serotonin 58,59 with the brainstem may participate asphyxia. Moreover, animals with transporter efficiency, was increased 63 in the pathogenesis of SIDS. 55 5-HT neuron deficiency caused by in black infants who died of SIDS 62 Dentate gyrus bilamination is also direct injection of a 5-HT–selective but not in a Norwegian population. found in some cases of temporal neurotoxin had impaired arousal in 60 lobe epilepsy. A future potential response to hypoxia. It has been estimated that 5% to line of investigation is a possible 10% of infants who die of SIDS link in brainstem-limbic–related Some cases of SUID have a clear have novel mutations in the cardiac homeostatic instability between SIDS genetic cause, such as medium-chain sodium or potassium channel genes, and sudden unexpected death in acyl-coenzyme A dehydrogenase resulting in long QT syndrome, as epilepsy and febrile seizures noted deficiency. A recent study in well as in other genes that regulate 63 in some cases of sudden unexpected California showed that the frequency channel function. Some of these death in childhood. 55 of mutations for undiagnosed inborn mutations may represent an actual errors of metabolism was similar in cause of death, but others may There are significant associations SIDS and controls and that newborn contribute to causing death when between brainstem 5-HT1A receptor screening was effectively detecting combined with environmental binding abnormalities and specific medium-chain and very-long-chain factors, such as acidosis.65 There SIDS risk factors, including tobacco acyl-coenzyme A dehydrogenase is molecular and functional smoking. 52 These data confirm deficiencies that could potentially evidence that implicates specific results from earlier studies in lead to SUID. 61 There is no evidence SCN5A (sodium channel gene) β humans 29, 53 and are also consistent of a strong heritable contribution subunits in SIDS pathogenesis. 66 with studies in piglets that reveal for SIDS; however, genetic In addition, 2 rare mutations in that postnatal exposure to nicotine alterations that may increase the connexin 43, a major gap junction decreases medullary 5-HT1A vulnerability to SIDS have been protein, have been found in SIDS receptor immunoreactivity. 56 observed. Genetic variation can cases and not in ethnically matched Serotonergic neurons located in take the form of common base controls.67 In vitro assays of 1 the medullary raphe and adjacent changes (polymorphisms) that mutation showed a lack of gap paragigantocellularis lateralis play alter gene function or rare base junction function, which could lead important roles in many autonomic changes (mutations) that often have to ventricular arrhythmogenesis. functions, including the control highly deleterious effects. (For a The other mutation did not appear of respiration, blood pressure, comprehensive review, see Opdal to have functional consequences.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e6 FROM THE AMERICAN ACADEMY OF PEDIATRICS A recent study also adds weight RECOMMENDATIONS TO REDUCE THE after weighing the relative risks and to the need to perform functional RISK OF SIDS AND OTHER SLEEP- benefits. assays and morphologic studies of RELATED INFANT DEATHS the altered gene products. Several The recommendations outlined of the missense variants in genes INFANT SLEEP POSITION herein were developed to reduce encoding cardiac channels that the risk of SIDS and sleep- To reduce the risk of SIDS, infants have been found in SIDS cases had related suffocation, asphyxia, and should be placed for sleep in the a high prevalence in the National entrapment among infants in the supine position (wholly on the Heart, Lung, and Blood Institute general population. As defined back) for every sleep period by GO Exome Sequencing Project by epidemiologists, risk refers to every caregiver until 1 year of age. Database.68 A large study in a the probability that an outcome Side sleeping is not safe and is not nonreferred nationwide Danish will occur given the presence of a advised. cohort estimated that up to 7.5% particular factor or set of factors. of SIDS cases may be explained The prone or side sleep position Although all recommendations by genetic variants in the sodium can increase the risk of rebreathing are intended for all who care for channel complex. 69 These estimates expired gases, resulting in infants, some recommendations are in the range of those previously hypercapnia and hypoxia. 79 – 82 The are also directed toward health reported. However, it is important prone position also increases the policy makers, researchers, and that for each channelopathy risk of overheating by decreasing the professionals who care for or work variant discovered, the biological rate of heat loss and increasing body on behalf of infants. In addition, plausibility for pathogenicity is temperature more than the supine because certain behaviors, such as investigated to consider it as a cause position.83, 84 Evidence suggests that smoking, can increase risk for the of or contributor in SIDS. prone sleeping alters the autonomic infant, some recommendations are control of the infant cardiovascular directed toward women who are The identification of polymorphisms system during sleep, particularly at 2 pregnant or may become pregnant in in genes pertinent to the embryologic to 3 months of age, 85 and may result the near future. origin of the autonomic nervous in decreased cerebral oxygenation. 86 system in SIDS cases also lends The recommendations, along with The prone position places infants at support to the hypothesis that a the strength of the recommendation, high risk of SIDS (odds ratio [OR]: 87–91 genetic predisposition contributes are summarized in the accompanying 2.3–13.1). In 1 US study, SIDS PACAP to the etiology of SIDS. The policy statement. 78 It should be risk associated with the side position (pituitary adenylate cyclase- noted that there are no randomized was similar in magnitude to that activation polypeptide) gene and the controlled trials with regard to SIDS associated with the prone position PAC1 88 gene of 1 of its receptors ( ) have and other sleep-related deaths; (ORs: 2.0 and 2.6, respectively), received recent attention because instead, case-control studies are the and a higher population-attributable of the apparent racial differences in standard. risk has been reported for the side their expression. For example, there sleep position than for the prone were no associations between PACAP The recommendations are based on position.90, 92 Furthermore, the risk and SIDS found in white infants, epidemiologic studies that include of SIDS is exceptionally high for but in SIDS cases in black infants infants up to 1 year of age. Therefore, infants who are placed on the side a specific allele was significantly recommendations for sleep position and found on the stomach (OR: 8.7). 88 associated.70 Although in a recent and the sleep environment, unless The side sleep position is inherently study, a strong association between otherwise specified, are for the unstable, and the probability of an variants in the PAC1 gene and SIDS first year after birth. The evidence- infant rolling to the prone position was not found, a number of potential based recommendations that follow from the side sleep position is associations between race-specific are provided to guide health care significantly greater than rolling variants and SIDS were identified; practitioners in conversations with prone from the back. 90, 93 Infants these warrant further study.71 There parents and others who care for who are unaccustomed to the prone have also been a number of reports of infants. Health care practitioners position and who are placed prone polymorphisms or mutations in genes are encouraged to have open and for sleep are also at greater risk regulating inflammation,72, 73 energy nonjudgmental conversations with than those usually placed prone production,74 – 76 and hypoglycemia 77 families about their sleep practices. (adjusted OR: 8.7–45.4).88, 94, 95 It is in infants who died of SIDS, but these Individual medical conditions may therefore critically important that associations require more study to warrant that a health care provider every caregiver use the supine sleep determine their importance. make different recommendations position for every sleep period.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e7 This is particularly relevant in positioning is acceptable if the infant acclimated to supine sleeping before situations in which a new caregiver is observed and awake, particularly discharge.”127 Furthermore, the task is introduced: for example, when an in the postprandial period, but force believes that neonatologists, infant is placed in foster care or an prone positioning during sleep can neonatal nurses, and other health adoptive home or when an infant only be considered in infants with care providers responsible for enters child care for the first time. certain upper airway disorders organizing the hospital discharge Despite these recommendations, in which the risk of death from of infants from NICUs should be the prevalence of supine positioning GERD [gastroesophageal reflux vigilant about endorsing the SIDS has remained stagnant for the past disease] may outweigh the risk of risk-reduction recommendations 122 decade. 19 One reason often cited by SIDS.” Examples of such upper from birth. They should model parents for not using the supine sleep airway disorders are those in which the recommendations as soon as position is the perception that the airway-protective mechanisms are the infant is medically stable and infant is uncomfortable or does not impaired, including infants with significantly before the infant’s sleep well. 96 –104 However, an infant anatomic abnormalities, such as type anticipated discharge from the who wakes frequently is normal 3 or 4 laryngeal clefts, who have hospital. In addition, NICUs and should not be perceived as a not undergone antireflux surgery. are encouraged to develop and poor sleeper. Physiologic studies There is no evidence that infants implement policies to ensure that show that infants are less likely to receiving nasogastric or orogastric supine sleeping and other safe arouse when they are sleeping in the feedings are at increased risk of sleep practices are modeled for prone position. 105 – 113 The ability to aspiration if placed in the supine parents beforeo discharge from the 128,129 arouse from sleep is an important position. Elevating the head of the hospital. infant’s crib while the infant is protective physiologic response to As stated in the AAP clinical report, supine is not effective in reducing stressors during sleep, 114 – 118 and the “skin-to-skin care is recommended gastroesophageal reflux 123, 124; in infant’s ability to sleep for sustained for all mothers and newborns, addition, elevating the head of the periods may not be physiologically regardless of feeding or delivery crib may result in the infant sliding advantageous. method, immediately following to the foot of the crib into a position birth (as soon as the mother is The supine sleep position does not that may compromise respiration and medically stable, awake, and able increase the risk of choking and therefore is not recommended. aspiration in infants, even in those to respond to her newborn), and with gastroesophageal reflux. Preterm infants should be placed to continue for at least an hour.”130 supine as soon as possible. Thereafter, or when the mother Parents and caregivers continue to needs to sleep or take care of other be concerned that the infant will Infants born preterm have an needs, infants should be placed choke or aspirate while supine. 96 – 104 increased risk of SIDS, 125, 126 and supine in a bassinet. Parents often misconstrue coughing the association between the prone or gagging, which is evidence of a position and SIDS among low birth Placing infants on the side after normal protective gag reflex, for weight and preterm infants is birth in newborn nurseries or in choking or aspiration. Multiple equal to, or perhaps even stronger mother-infant rooms continues to be studies in different countries have than, the association among those a concern. The practice likely occurs not shown an increased incidence born at term. 94 Therefore, preterm because of a belief among nursery of aspiration since the change to infants should be placed supine for staff that newborn infants need to supine sleeping.119 – 121 Parents and sleep as soon as clinical status has clear their airways of amniotic fluid caregivers are often concerned about stabilized. The task force concurs and may be less likely to aspirate aspiration when the infant has been with the AAP Committee on Fetus while on the side. No evidence that diagnosed with gastroesophageal and Newborn that “preterm infants such fluid will be cleared more reflux. The AAP concurs with the should be placed supine for sleeping, readily while in the side position North American Society for Pediatric just as term infants should, and the exists. Perhaps most importantly, Gastroenterology and Nutrition parents of preterm infants should if parents observe health care that “the risk of SIDS outweighs be counseled about the importance providers placing infants in the side the benefit of prone or lateral sleep of supine sleeping in preventing or prone position, they are likely to position on GER [gastroesophageal SIDS. Hospitalized preterm infants infer that supine positioning is not reflux]; therefore, in most infants should be kept predominantly in important 131 and therefore may be from birth to 12 months of age, the supine position, at least from more likely to copy this practice supine positioning during sleep is the postmenstrual age of 32 weeks and use the side or prone position recommended…. Therefore, prone onward, so that they become at home. 101, 104, 132 Infants who are

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e8 FROM THE AMERICAN ACADEMY OF PEDIATRICS rooming in with their parents or clear of soft or loose bedding and infant in the crib because of concerns cared for in a separate newborn other objects. Parents may be that the crib is too large for the nursery should be placed in the reassured in being advised that the infant or that “crib death” (ie, SIDS) supine position as soon as they are incidence of SIDS begins to decline only occurs in cribs. Alternate sleep ready to be placed in the bassinet. after 4 months of age. 16 surfaces, such as portable cribs, play To promote breastfeeding, placing yards, and bassinets that meet safety the infant skin-to-skin with mother standards of the CPSC, 137, 138 can be after delivery, with appropriate SLEEP SURFACES used and may be more acceptable observation and/or monitoring, is Infants should be placed on a firm for some families because they are the best approach. When the mother sleep surface (eg, a mattress in a smaller and more portable. needs to sleep or take care of other safety-approved crib) covered by a Bedside sleepers are attached to the needs, the infant should be placed fitted sheet with no other bedding side of the parental bed. The CPSC supine in a bassinet. or soft objects to reduce the risk of has published safety standards for Once an infant can roll from supine SIDS and suffocation. bedside sleepers,139 and they may to prone and from prone to supine, To avoid suffocation, rebreathing, be considered by some parents the infant may remain in the sleep and SIDS risk, infants should sleep on as an option. There are no CPSC position that he or she assumes. a firm surface (eg, safety-approved safety standards for in-bed sleepers. The task force cannot make a Parents and caregivers are frequently crib and mattress). The surface recommendation for or against concerned about the appropriate should be covered by a fitted sheet the use of either bedside sleepers strategy for infants who have learned without any soft or loose bedding. or in-bed sleepers, because there to roll over, which generally occurs A firm surface maintains its shape have been no studies examining the at 4 to 6 months of age. As infants and will not indent or conform to association between these products mature, it is more likely that they will the shape of the infant’s head when and SIDS or unintentional injury and roll. In 1 study, 6% and 12% of 16- to the infant is placed on the surface. death, including suffocation. Studies 23-week-old infants placed on their Soft mattresses, including those of in-bed sleepers are currently backs or sides, respectively, were made from memory foam, could underway, but results are not yet found in the prone position; among create a pocket (or indentation) and available. Parents and caregivers infants ≥24 weeks of age, 14% of increase the chance of rebreathing or should adhere to the manufacturer’s those placed on their backs and suffocation if the infant is placed in or 81,135 guidelines regarding maximum 18% of those placed on their sides rolls over to the prone position. weight of infants who use these were found in the prone position. 133 A crib, bassinet, portable crib, or products. 140, 141 In addition, with the Repositioning the sleeping infant play yard that conforms to the use of any of these products, other to the supine position can be safety standards of the Consumer AAP guidelines for safe sleep outlined disruptive and may discourage the Product Safety Commission (CPSC) in this document, including supine use of the supine position altogether. is recommended. positioning and avoidance of soft Because data to make specific Cribs should meet safety standards objects and loose bedding, should be recommendations as to when it of the CPSC, 136 including those for followed. is safe for infants to sleep in the slat spacing, snugly fitting and firm prone position are lacking, the AAP Mattresses should be firm and mattresses, and no drop sides. The recommends that all infants continue maintain their shape even when AAP recommends the use of new to be placed supine until 1 year of the fitted sheet designated for that cribs, because older cribs may no age. If the infant can roll from supine model is used, such that there are longer meet current safety standards, to prone and from prone to supine, no gaps between the mattress and may have missing parts, or may be the infant can then be allowed to the wall of the bassinet, playpen, incorrectly assembled. If an older remain in the sleep position that he portable crib, play yard, or bedside crib is to be used, care must be taken or she assumes. One study analyzing sleeper. Only mattresses designed to ensure that there have been no sleep-related deaths reported to for the specific product should be recalls on the crib model, that all of state child death review teams found used. Pillows or cushions should not the hardware is intact, and that the that the predominant risk factor for be used as substitutes for mattresses assembly instructions are available. sleep-related deaths in infants 4 to 12 or in addition to a mattress. Soft months of age was rolling into objects For some families, the use of a crib materials or objects, such as pillows, in the sleep area. 134 Thus, parents may not be possible for financial or quilts, comforters, or sheepskins, and caregivers should continue to space considerations. In addition, even if covered by a sheet, should keep the infant’s sleep environment parents may be reluctant to place the not be placed under a sleeping infant.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e9 Mattress toppers, designed to make car seat or similar sitting device. 144 a crib mattress or other elevated the sleep surface softer, should not However, there are multiple concerns surfaces.152 –156 Infants should not be used for infants younger than 1 about the use of sitting devices as a be left unattended in car seats and year. Any fabric on the crib walls or usual infant sleep location. Placing an similar products, nor should they be a canopy should be taut and firmly infant in such devices can potentiate placed or left in car seats and similar attached to the frame so as not to gastroesophageal reflux 145 and products with the straps unbuckled create a suffocation risk for the positional plagiocephaly. Because or partially buckled. 151 infant. they still have poor head control and often experience flexion of the Infants should not be placed for sleep head while in a sitting position, BREASTFEEDING on adult-sized beds because of the infants younger than 4 months in risk of entrapment and suffocation. 142 Breastfeeding is associated sitting devices may be at increased Portable bed rails (railings installed with a reduced risk of SIDS. The risk of upper airway obstruction on the side of the bed that are protective effect of breastfeeding and oxygen desaturation. 146 – 150 A intended to prevent a child from increases with exclusivity. recent retrospective study reviewed falling off of the bed) should not be Furthermore, any breastfeeding is deaths involving sitting and carrying used with infants because of the risk more protective against SIDS than devices (car seats, bouncers, swings, of entrapment and strangulation. 143 no breastfeeding. strollers, and slings) reported to the The infant should sleep in an area CPSC between 2004 and 2008. Of the The protective role of breastfeeding free of hazards, including dangling 47 deaths analyzed, 31 occurred in on SIDS is enhanced when cords, electric wires, and window- car seats, 5 occurred in slings, 4 each breastfeeding is exclusive and covering cords, because these may 160–162 occurred in swings and bouncers, without formula introduction. present a strangulation risk. and 3 occurred in strollers. Fifty-two Studies do not distinguish between Recently, special crib mattresses percent of deaths in car seats were direct breastfeeding and providing and sleep surfaces that claim to attributed to strangulation from expressed milk. In the Agency for reduce the chance of rebreathing straps; the others were attributed to Healthcare Research and Quality’s carbon dioxide when the infant is positional asphyxia. 151 In addition, “Evidence Report on Breastfeeding in in the prone position have been analyses of CPSC data report injuries Developed Countries,” 6 studies were introduced. Although there are no from falls when car seats are placed included in the SIDS-breastfeeding apparent disadvantages of using on elevated surfaces, 152 – 156 from meta-analysis, and ever having these mattresses if they meet the strangulation on unbuckled or breastfed was associated with safety standards as described partially buckled car seat straps, 151 a lower risk of SIDS (adjusted previously, there are no studies that and from suffocation when car seats summary OR: 0.64; 95% confidence 160 show a decreased risk of SUID/SIDS. overturn after being placed on a interval [CI]: 0.51–0.81). The German Study of Sudden Infant (See section entitled “Commercial bed, mattress, or couch.155 There are Death, the largest and most recent Devices” for further discussion of also reports of suffocation in infants, case-control study of SIDS, found that special mattresses.) particularly those who are younger exclusive breastfeeding at 1 month of than 4 months, who are carried in Sitting devices, such as car age halved the risk of SIDS (adjusted infant sling carriers. 151, 157 – 159 When seats, strollers, swings, infant OR: 0.48; 95% CI: 0.28–0.82).161 infant slings are used for carrying, carriers, and infant slings, are Another meta-analysis of 18 case- it is important to ensure that the not recommended for routine control studies found an unadjusted infant’s head is up and above the sleep in the hospital or at home, summary OR for any breastfeeding fabric, the face is visible, and the nose particularly for young infants. of 0.40 (95% CI: 0.35–0.44) and a and mouth are clear of obstructions. pooled adjusted OR of 0.55 (95% CI: Some parents choose to allow their After nursing, the infant should be 0.44–0.69) ( Fig 5).162 The protective infants to sleep in a car seat or repositioned in the sling so that effect of breastfeeding increased other sitting device. Sitting devices the head is up and is clear of fabric with exclusivity, with a univariable include, but are not restricted to, and the airway is not obstructed summary OR of 0.27 (95% CI: 0.24– car seats, strollers, swings, infant by the adult’s body.151 If an infant 0.31) for exclusive breastfeeding of carriers, and infant slings. Parents falls asleep in a sitting device, he any duration. 162 and caregivers often use these or she should be removed from the devices, even when not traveling, product and moved to a crib or other Physiologic sleep studies showed because they are convenient. One appropriate flat surface as soon as that breastfed infants are more study found that the average young is safe and practical. Car seats and easily aroused from sleep than their infant spends 5.7 hours/day in a similar products are not stable on formula-fed counterparts. 163, 164 In

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e10 FROM THE AMERICAN ACADEMY OF PEDIATRICS addition, breastfeeding results in a decreased incidence of diarrhea, upper and lower respiratory infections, and other infectious diseases165 that are associated with an increased vulnerability to SIDS and provides overall immune system benefits attributable to maternal antibodies and micronutrients in human milk. 166, 167 Exclusive FIGURE 5 breastfeeding for 6 months has been Multivariable analysis of any breastfeeding versus no breastfeeding. Adapted from Hauck et al.162 found to be more protective against log[ ], logarithm of the OR; Weight: weighting that the study contributed to the meta-analysis (by infectious diseases, compared with sample size); IV, Fixed, 95% CI, fi xed-effect OR with 95% CI. exclusive breastfeeding to 4 months of age and partial breastfeeding arrangements, the AAP recommends 2001–2010, 46% of parents thereafter. 165 Furthermore, exclusive the use of the terms bed-sharing responded that they had shared breastfeeding results in a gut and room-sharing (when the infant a bed with their infant (8 months microbiome that supports a normally sleeps in the parents’ room but on a or younger) at some point in the functioning immune system and separate sleep surface [crib or similar preceding 2 weeks, and 13.5% protection from infectious disease, surface] close to the parents’ bed) reported that they usually bed- and this commensal microbiome has (see Table 1). shared.174 In another national survey, any bed-sharing was reported by been proposed as another possible The AAP recommends room-sharing, 42% of mothers at 2 weeks of infant mechanism or marker for protection because this arrangement decreases 168 against SIDS. the risk of SIDS by as much as 50% 89, age and 27% of mothers at 12 175 91, 172, 173 and is safer than bed- months of infant age. In a third sharing89, 91, 172, 173 or solitary sleeping study, almost 60% of mothers of INFANT SLEEP LOCATION (when the infant is in a separate infants from birth to 12 months of It is recommended that infants room).89, 172 In addition, room-sharing age reported bed-sharing at least 176 sleep in the parents’ room, close to is most likely to prevent suffocation, once. The rate of routine bed- the parents’ bed, but on a separate strangulation, and entrapment that sharing is higher among some surface. The infant’s crib, portable may occur when the infant is sleeping racial/ethnic groups, including crib, play yard, or bassinet should in the adult bed. Furthermore, black, Hispanic, and American be placed in the parents’ bedroom, this arrangement allows close Indian/Alaska Native parents/ ideally for the first year of life, but proximity to the infant, which will infants. 20, 22, 174 There are often at least for the first 6 months. facilitate feeding, comforting, and cultural and personal reasons monitoring of the infant. Most of the why parents choose to bed-share, The terms bed-sharing and epidemiologic studies on which these including convenience for feeding cosleeping are often used recommendations are based include (breast or formula), comforting a interchangeably, but they are not infants up to 1 year of age. Therefore, fussy or sick infant, helping the infant synonymous. Cosleeping is when the AAP recommends that infants and/or mother sleep better, bonding parent and infant sleep in close room-share, ideally for the first year and attachment, and because it is a proximity (on the same surface or after birth, but at least for the first 6 family tradition. 175, 177 In addition, different surfaces) so as to be able to months. Although there is no specific many parents may believe that their see, hear, and/or touch each evidence for moving an infant to his other. 169, 170 Cosleeping arrangements own vigilance is the only way that or her own room before 1 year of they can keep their infant safe and can include bed-sharing or age, room-sharing during the first 6 that the close proximity of bed- sleeping in the same room in close months is especially critical because 170,171 sharing allows them to maintain proximity. Bed-sharing refers the rates of SIDS and other sleep- vigilance, even while sleeping. 178 to a specific type of cosleeping when related deaths, particularly those Some parents will use bed-sharing the infant is sleeping on the same occurring in bed-sharing situations, 170 specifically as a safety strategy if surface with another person. The are highest during that period. shared surface can include a bed, the infant sleeps in the prone sofa, or chair. Because the term Parent-infant bed-sharing for all or position23, 178 or there is concern cosleeping can be misconstrued and part of sleep duration is common. about environmental dangers, such does not precisely describe sleep In 1 national survey for the period as vermin or stray gunfire. 178

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e11 Parent-infant bed-sharing continues bed-sharing (excluding bed-sharing The task force, recognizing to be highly controversial. Although on a sofa) for infants in the absence the controversial nature of the electrophysiologic and behavioral of parental alcohol or tobacco use recommendations about bed- studies offer a strong case for its effect of 1.1 (95% CI: 0.6–2.9). For infants sharing and the different methods in facilitating breastfeeding, 179 – 181 younger than 98 days, the OR was 1.6 and interpretations of these 2 sets and although many parents believe (95% CI: 0.96–2.7).200 These findings of analyses outlined previously, that they can maintain vigilance were independent of feeding method. requested an independent review of the infant while they are asleep The study lacked power to examine of both articles by Dr Robert Platt, and bed-sharing, 178 epidemiologic this association in older infants, a biostatistician with expertise in studies have shown that bed-sharing because there was only 1 SIDS case perinatal epidemiology from McGill is associated with a number of in which bed-sharing was a factor University in Canada. Dr Platt has conditions that are risk factors for in the absence of other risk factors. no connection to the task force, nor SIDS, including soft bedding, 182 – 185 Breastfeeding was more common does he have a vested interest in the head covering, 186 – 189 and, for infants among bed-sharing infants, and the recommendations. Dr Platt provided of smokers, increased exposure protective effect of breastfeeding was the following conclusion: to tobacco smoke. 190 In addition, found only for infants who slept alone. bed-sharing is associated with an The controls in these analyses were The fundamental difference in increased risk of SIDS; a recent meta- infants who were not bed-sharing/ conclusions is that Blair et al analysis of 11 studies investigating sofa-sharing regardless of room conclude that bed-sharing in the association of bed-sharing location; thus, they included infants the absence of other risk factors and SIDS showed a summary OR who were room-sharing or sleeping (smoking, alcohol) does not convey of 2.88 (95% CI: 1.99–4.18) with in a separate room. In addition, the an increased risk of SIDS, while bed-sharing. 191 Furthermore, bed- control infants included those whose Carpenter et al conclude the opposite. sharing in an adult bed not designed parent(s) smoked or used alcohol. It In both studies, the no-other-risk- for infant safety, especially when is possible that this choice of controls factors group is limited in size, associated with other risk factors, overestimated their risk, leading to and the number of exposed cases exposes the infant to additional smaller ORs for risk among the cases is very small. In Blair et al, there risks for unintentional injury (ie, biasing the results toward the are only 24 cases who bed-shared and death, such as suffocation, null). in the absence of these hazards. In asphyxia, entrapment, falls, and Carpenter et al, although the total 201 strangulation.192, 193 Infants younger Carpenter et al analyzed data number of SIDS cases (1472) is than 4 months 194 and those born from 19 studies across the United more than 3 times the number of preterm and/or with low birth Kingdom, Europe, and Australasia to cases in the Blair study (400), the weight 195 are at the highest risk, determine the risk of SIDS from bed- number of cases who bed-shared in possibly because immature motor sharing when an infant is breastfed, the absence of these hazards was skills and muscle strength make the parents do not smoke, and the only 12 (personal communication, it difficult to escape potential mother has not taken alcohol or Professor Robert Carpenter, January threats. 191 In recent years, the drugs. When neither parent smoked, 25, 2016). Therefore, the Carpenter concern among public health officials in the absence of other risk factors, results should be interpreted with about bed-sharing has increased, the adjusted OR for bed-sharing some caution as well. In conclusion, because there have been increased versus room-sharing for all breastfed both studies have strengths and reports of SUIDs occurring in high- infants was 2.7 (95% CI: 1.4–5.3). 201 weaknesses, and while on the surface risk sleep environments, particularly For breastfed infants younger than the studies appear to contradict bed-sharing and/or sleeping on a 3 months, in the absence of other each other, I do not believe that their couch or armchair.196 – 198 risk factors, the adjusted OR for bed- data support definitive differences sharing versus room-sharing was 5.1 between the 2 studies. There is some On the other hand, some breastfeeding (95% CI: 2.3–11.4). The study lacked evidence of an increased risk in advocacy groups encourage safer bed- power to examine this association in the no-other-risk-factor setting, in sharing to promote breastfeeding,199 breastfed infants 3 months and older. particular in the youngest age groups. and debate continues as to the safety Moreover, the large proportion of However, based on concerns about of this sleep arrangement for low-risk, missing data for maternal alcohol and sample size limitations, we are not breastfed infants. In an analysis from drug use is a limitation, although the able to say how large that increased 2 case-control studies in England authors used appropriate multiple risk is. Clearly, these data do not (1993–1996 and 2003–2006), Blair imputation techniques for addressing support a definitive conclusion et al 200 reported an adjusted OR of these missing data. that bed-sharing in the youngest

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e12 FROM THE AMERICAN ACADEMY OF PEDIATRICS age group is safe, even under less to report exclusive breastfeeding The safest place for an infant hazardous circumstances. (adjusted OR: 2.46; 95% CI: to sleep is on a separate sleep 1.76–3.45) or partial breastfeeding surface designed for infants close There is insufficient evidence to (adjusted OR: 1.75; 95% CI: 1.33– to the parent’s bed. However, the recommend for or against the use 2.31).204 Although bed-sharing may AAP acknowledges that parents of devices promoted to make bed- facilitate breastfeeding, 175 there are frequently fall asleep while feeding sharing “safe.” other factors, such as intent, that the infant. Evidence suggests that There is no evidence that devices influence successful breastfeeding. 205 it is less hazardous to fall asleep marketed to make bed-sharing Furthermore, 1 case-control study with the infant in the adult bed than “safe” reduce the risk of SIDS or found that the risk of SIDS while bed- on a sofa or armchair, should the suffocation or are safe. Several sharing was similar among infants in parent fall asleep. 87, 89, 90, 173, 200, 207 products designed for in-bed use are the first 4 months of life, regardless It is important to note that a large currently under study, but results are of breastfeeding status, implying percentage of infants who die of SIDS not yet available. Bedside sleepers, that the benefits of breastfeeding are found with their head covered by which attach to the side of the do not outweigh the increased bedding. 186 Therefore, there should parental bed and for which the CPSC risk associated with bed-sharing be no pillows, sheets, blankets, published standards in 2013, may for younger infants. 194 The risk of or any other items in the bed that be considered by some parents as an bed-sharing is higher the longer the could obstruct infant breathing 87, option. The task force cannot make duration of bed-sharing during the 182 or cause overheating.208 – 211 a recommendation for or against night, 91 especially when associated Parents should follow safe sleep the use of either bedside sleepers with other risks. 89, 90, 206, 207 Returning recommendations outlined or in-bed sleepers, because there the infant to the crib after bringing elsewhere in this statement. Because have been no studies examining the the infant into the bed for a short there is evidence that the risk of association between these products period of time is not associated with bed-sharing is higher with longer and SIDS or unintentional injury and increased risk. 90, 207 Therefore, after duration, if the parent falls asleep death, including suffocation. (See the infant is brought into the bed for while feeding the infant in bed the section entitled “Sleep Surfaces” for feeding, comforting, and bonding, the infant should be placed back on a further discussion of sleepers.) infant should be returned to the crib separate sleep surface as soon as the when the parent is ready for sleep. parent awakens. 89, 90, 206, 207 Infants who are brought into the bed for feeding or comforting Couches and armchairs are There are specific circumstances should be returned to their own extremely dangerous places for that, in case-control studies and crib or bassinet when the parent is infants. case series, have been shown to ready to return to sleep. substantially increase the risk of Sleeping on couches and armchairs SIDS or unintentional injury or Studies have found an association places infants at an extraordinarily death while bed-sharing, and between bed-sharing and longer high risk of infant death, including these should be avoided at all 202 duration of breastfeeding, but SIDS, 87, 89, 90, 173, 200, 207 suffocation times. most of these were cross-sectional through entrapment or wedging The task force emphasizes that studies, which do not enable between seat cushions, or overlay if certain circumstances greatly the determination of a temporal another person is also sharing this increase the risk of bed-sharing relationship: that is, whether bed- surface. 197 Therefore, parents and for both breastfed and formula-fed sharing promotes breastfeeding or other caregivers should be especially infants. Bed-sharing is especially whether breastfeeding promotes vigilant as to their wakefulness when dangerous in the following bed-sharing, and whether women feeding infants or lying with infants circumstances, and these should be who prefer one practice are also on these surfaces. It is important to 203 avoided at all times: likely to prefer the other. However, emphasize this point to mothers, a more recent longitudinal study because 25% of mothers in 1 study • when one or both parents provides strong evidence that bed- reported falling asleep during the are smokers, even if they are sharing promotes breastfeeding night when breastfeeding their infant not smoking in bed (OR: duration, with the greatest effect on one of these surfaces. 176 Infants 2.3–21.6)89, 90, 191, 200, 201, 206, 212; among frequent bed-sharers. 202 should never be placed on a couch or • when the mother smoked during Another recent study has shown that, armchair for sleep. pregnancy 89, 90, 191, 206, 212; compared with mothers who room- shared without bed-sharing, mothers Guidance for parents who fall • when the infant is younger than who bed-shared were more likely asleep while feeding their infant. 4 months of age, regardless of

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e13 parental smoking status (OR: increases the potential for overheating covered by loose bedding.90, 225, 226, 230 In 4.7–10.4)89, 91, 173, 191, 201, 207, 213, 214; and rebreathing, and size discordance addition, infants who bed-share (share between multiples may increase the a sleep surface) have a higher SIDS risk • when the infant is born preterm risk of unintentional suffocation. 220 when sleeping on a soft as opposed to 195 and/or with low birth weight ; Most cobedded twins are placed on a firm surface.215 • when the infant is bed-sharing the side rather than supine.218 Finally, on excessively soft or small cobedding of twins and higher-order In addition to SIDS risk, soft objects surfaces, such as waterbeds, multiples in the hospital setting may and loose bedding in the sleeping sofas, and armchairs (OR: encourage parents to continue this environment may also lead to 134,224, 235 5.1–66.9)87, 89, 90, 173, 200, 207; practice at home. 220 Because the unintentional suffocation. A evidence for the benefits of cobedding review of 66 SUID case investigations • when soft bedding accessories such twins and higher-order multiples is in 2011 showed that soft bedding as pillows or blankets are used not compelling and because of the was the most frequently reported (OR: 2.8–4.1) 87, 215; increased risk of SIDS and suffocation, factor among deaths classified as • when there are multiple bed- the AAP believes that it is prudent to possible and explained unintentional 224 sharers (OR: 5.4)87 ; provide separate sleep areas for these suffocation deaths. In addition, a CPSC report of sleep-related infant • infants to decrease the risk of SIDS when the parent has consumed deaths in 2009–2011 found that 91,196, 200, 201 and unintentional suffocation. alcohol (OR: 1.66–89.7) most deaths attributed to suffocation 201 and/or illicit or sedating drugs ; (regardless of whether infant was and USE OF BEDDING sleeping in a crib, on a mattress, or in • when the infant is bed-sharing with Keep soft objects, such as pillows, a play yard) involved extra bedding, someone who is not a parent (OR: pillow-like toys, quilts, comforters, such as pillows or blankets.235 Soft 5.4).87 sheepskins, and loose bedding, bedding (eg, blankets and stuffed such as blankets and nonfitted animals) may also be a stronger risk A retrospective series of SIDS cases sheets, away from the infant’s factor for sleep-related deaths among reported that mean maternal body sleep area to reduce the risk of infants older than 3 months than it weight was higher for bed-sharing SIDS, suffocation, entrapment, and is for their younger counterparts, mothers than for non–bed-sharing strangulation. especially when infants are placed in mothers.216 The only case-control or roll to the prone position. 134 study to investigate the relationship Soft objects and loose bedding can between maternal body weight and obstruct an infant’s airway and increase Parents and caregivers are likely bed-sharing did not find an increased the risk of SIDS, 87, 182 suffocation, and motivated by good intentions and risk of bed-sharing with increased rebreathing. 79, 81, 82, 135, 222 – 224 In the perceived cultural norms when they maternal weight. 217 United States, nearly 55% of infants opt to use bedding for infant sleep. are placed to sleep underneath or on Qualitative studies show that parents The safety and benefits of cobedding top of bedding such as thick blankets, who use bedding want to provide a twins and higher-order multiples quilts, and pillows.25 The prevalence comfortable and safe environment for have not been established. It is of bedding use is highest among their infant.236 For comfort, parents prudent to provide separate sleep infants whose mothers are teenagers, may use blankets to provide warmth areas and avoid cobedding (sleeping from minority racial groups, and or to soften the sleep surface. For on the same sleep surface) for twins among those without a college safety, parents may use pillows as and higher-order multiples in the education. barriers to prevent falls from adult hospital and at home. beds or sofas or as a prop to keep Pillows, quilts, comforters, sheepskins, their infant on the side.236 Images of Cobedding of twins and other infants and other soft bedding can be infants sleeping with blankets, pillows, of multiple gestation is a frequent hazardous when placed under the and other soft objects are widespread 87,182, 210, 225 –229 practice, both in the hospital setting infant or left loose in the in popular magazines targeted to 218 90,182, 215, 224, 228 –234 and at home. However, the infant’s sleep area. families with newborn infants. 237 benefits of cobedding twins and Bedding in the sleeping environment Parents and caregivers who see these higher-order multiples have not increases SIDS risk fivefold, images may perceive the use of these 219–221 87,182 been established. Twins and independent of sleep position, items as the norm, both favorable and higher-order multiples are often and this risk increases to 21-fold when the ideal, for infant sleep. born preterm and with low birth the infant is placed prone. 87, 182 Many weights, so they are at increased risk infants who die of SIDS are found in the To avoid suffocation, rebreathing, and of SIDS.125, 126 Furthermore, cobedding supine position but with their heads SIDS risk, infants should sleep on a firm

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e14 FROM THE AMERICAN ACADEMY OF PEDIATRICS surface (see section entitled “Sleep data from the scene investigations, Multiple case-control Surfaces” for a definition of a firm autopsies, law enforcement records, studies 87, 91, 207, 244 –250 and 2 meta- surface).135 Because pillows, quilts, and and death certificates often lacked analyses 251, 252 have reported a comforters can obstruct the infant’s sufficiently detailed information to protective effect of pacifiers on airway (nose or mouth), they should conclude how or whether bumper the incidence of SIDS, particularly never be used in the infant’s sleeping pads contributed to the deaths. Two when used at the time of the last environment. Infant sleep clothing, more recent analyses of CPSC data sleep period, with decreased risk such as sleeping sacks, are designed also came to different conclusions. of SIDS ranging from 50% to 90%. to keep the infant warm and can be The CPSC review concluded again Furthermore, 1 study found that used in place of blankets to prevent that there was insufficient evidence pacifier use favorably modified the the possibility of head covering or to support that bumper pads were risk profile of infants who sleep in the entrapment. However, care must be primarily responsible for infant prone/side position, bed-share, or taken to select appropriately sized deaths when bumper pads were used use soft bedding. 253 The mechanism clothing and to avoid overheating. per the manufacturer’s instructions for this apparent strong protective Nursing and hospital staff should and in the absence of other unsafe effect is still unclear, but favorable model safe sleep arrangements to new sleep risk factors. 241 Scheers et al, 242 modification of autonomic control parents after delivery. in their re-analysis, concluded that during sleep 254 and maintaining the rate of bumper pad–related airway patency during sleep255 Bumper pads are not deaths has increased, recognizing have been proposed. Physiologic recommended; they have been that changes in reporting may studies of the effect of pacifier use implicated in deaths attributable account for the increase, and that on arousal are conflicting; 1 study to suffocation, entrapment, and 67% of the deaths could have been found that pacifier use decreased strangulation and, with new safety prevented if the bumper pads had arousal thresholds, 163 but others standards for crib slats, are not not been present. Limitations of CPSC have found no effects on arousability necessary for safety against head data collection processes contribute with pacifier use. 256, 257 It is common entrapment. to the difficulty in determining the for the pacifier to fall from the mouth Bumper pads and similar products risk of bumper pad use. soon after the infant falls asleep; attaching to crib slats or sides even so, the protective effect persists are frequently used with the However, others239, 243 have concluded throughout that sleep period. 163, 258 thought of protecting infants from that the use of bumper pads only Two studies have shown that injury. Initially, bumper pads prevents minor injuries, and that pacifier use is most protective when were developed to prevent head the potential benefits of preventing used for all sleep periods. 207, 250 entrapment between crib slats. 238 minor injury with bumper pad use However, these studies also showed However, newer crib standards are far outweighed by the risk of an increased risk of SIDS when the requiring crib slat spacing to be serious injury, such as suffocation pacifier was usually used but not <2-3/8 inches have obviated the need or strangulation. In addition, most used the last time the infant was for crib bumpers. In addition, infant bumper pads obscure infant and placed for sleep; the significance of deaths have occurred because of parent visibility, which may increase these findings is yet unclear. bumper pads. A case series by Thach parental anxiety. 236, 238 Other products et al, 239 which used 1985–2005 CPSC exist that attach to crib sides or crib Although some SIDS experts and data, found that deaths attributed to slats and claim to protect infants from policy makers endorse pacifier use bumper pads occurred as a result of 3 injury; however, there are no published recommendations that are similar to mechanisms: (1) suffocation against data that support these claims. Because those of the AAP,259, 260 concerns about soft, pillow-like bumper pads; (2) of the potential for suffocation, possible deleterious effects of pacifier entrapment between the mattress entrapment, and strangulation and lack use have prevented others from or crib and firm bumper pads; and of evidence to support that bumper making a recommendation for pacifier (3) strangulation from bumper pad pads or similar products that attach use as a risk-reduction strategy.261 ties. However, a 2010 CPSC white to crib slats or sides prevent injury Although several observational paper that reviewed the same cases in young infants, the AAP does not studies262– 264 have shown a correlation concluded that there were other recommend their use. between pacifiers and reduced confounding factors, such as the breastfeeding duration, a recent presence of pillows and/or blankets, Cochrane review comparing pacifier that may have contributed to many of PACIFIER USE use and nonuse in healthy term infants the deaths in this report. 240 The white Consider offering a pacifier at who had initiated breastfeeding found paper pointed out that available naptime and bedtime. that pacifier use had no effects on

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e15 partial or exclusive breastfeeding rates infections and oral colonization with Smoking during pregnancy, in the at 3 and 4 months. 265 Furthermore, Candida species were also found to pregnant woman’s environment, a systematic review found that the be more common among pacifier and in the infant’s environment highest level of evidence (ie, from users than nonusers. 275 – 277 should be avoided. clinical trials) does not support an adverse relationship between pacifier Because of the risk of strangulation, Maternal smoking during pregnancy use and breastfeeding duration or pacifiers should not be hung around has been identified as a major risk exclusivity. 266 The association between the infant’s neck. Pacifiers that attach factor in almost every epidemiologic 285–288 shortened duration of breastfeeding to the infant’s clothing should not be study of SIDS. Smoke in the and pacifier use in observational used with sleeping infants. Objects, infant’s environment after birth has studies likely reflects a number of such as stuffed toys, that may present been identified as a separate major 286,289 complex factors, such as breastfeeding a suffocation or choking risk, should risk factor in a few studies, difficulties or intent to wean. 266,267 not be attached to pacifiers. although separating this variable However, some have also raised from maternal smoking before birth There is insufficient evidence that the concern that studies that show is problematic. Third-hand smoke finger sucking is protective against no effect of pacifier introduction on refers to residual contamination SIDS. breastfeeding duration or exclusivity from tobacco smoke after the cigarette has been extinguished 290; may not account for early weaning or The literature on infant finger there is no research to date on the failure to establish breastfeeding. 268 sucking and SIDS is extremely significance of third-hand smoke The AAP policy statement limited. Only 2 case-control studies with regard to SIDS risk. Smoke “Breastfeeding and the Use of Human have reported these results. 248, 249 exposure adversely affects infant Milk” includes a recommendation One study from the United States arousal 291 – 297; in addition, smoke that pacifiers can be used during showed a protective effect of infant exposure increases the risk of breastfeeding but that implementation finger sucking (reported as “thumb preterm birth and low birth weight, should be delayed until breastfeeding sucking”) against SIDS (adjusted both risk factors for SIDS. The effect is well established. 269 Infants who are OR: 0.43; 95% CI: 0.25–0.77), but of tobacco smoke exposure on not being directly breastfed can begin it was less protective than pacifier SIDS risk is dose-dependent. The pacifier use as soon as desired. use (adjusted OR: 0.07 [95% CI: risk of SIDS is particularly high when 0.01–0.64] if the infant also sucked the infant bed-shares with an adult Some dental malocclusions have the thumb; adjusted OR: 0.08 [95% smoker (OR: 2.3–21.6), even when been found more commonly among CI: 0.03–0.23] if the infant did not the adult does not smoke in pacifier users than nonusers, but the suck the thumb). 249 Another study bed.89, 90, 191, 200, 201, 206, 212, 298 It differences generally disappeared from The Netherlands did not is estimated that one-third of after pacifier cessation. 270 The show an association between usual SIDS deaths could be prevented American Academy of Pediatric finger sucking (reported as “thumb if all maternal smoking during Dentistry policy statement on oral sucking”) and SIDS risk (OR: 1.38; pregnancy was eliminated. 299, 300 habits states that nonnutritive 95% CI: 0.35–1.51), but the wide CI The AAP supports the elimination sucking behaviors (ie, fingers or suggests that there was insufficient of all tobacco smoke exposure, both pacifiers) are considered normal in power to detect a significant prenatally and environmentally. infants and young children and that, association. 248 in general, sucking habits in children Avoid alcohol and illicit drug use to the age of 3 years are unlikely to PRENATAL AND POSTNATAL during pregnancy and after the 271 EXPOSURES (INCLUDING SMOKING cause any long-term problems. infant’s birth. Pacifier use is associated with an AND ALCOHOL) approximate 1.2- to 2-fold increased Pregnant women should obtain Several studies have specifically risk of otitis media, particularly regular prenatal care. investigated the association of between 2 and 3 years of age. 272, 273 SIDS with prenatal and postnatal The incidence of otitis media is There is substantial epidemiologic exposure to alcohol or illicit drug generally lower in the first year evidence linking a lower risk of SIDS use, although substance abuse often after birth, especially the first 6 for infants whose mothers obtain involves more than one substance months, when the risk of SIDS is the regular prenatal care. 280 – 283 Women and it is often difficult to separate highest.274 –279 However, pacifier use, should obtain prenatal care from out these variables from each other once established, may persist beyond early in the pregnancy, according to and from smoking. However, 1 study 6 months, thus increasing the risk of established guidelines for frequency in Northern Plains American Indian otitis media. Gastrointestinal tract of prenatal visits.284 infants found that periconceptional

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e16 FROM THE AMERICAN ACADEMY OF PEDIATRICS maternal alcohol use (adjusted drug use occurs in combination with the definition of overheating in the OR: 6.2; 95% CI: 1.6–23.3) and bed-sharing. 89– 91, 305 studies that found an increased risk maternal first-trimester binge of SIDS varies. It is therefore difficult drinking (adjusted OR: 8.2; 95% CI: Studies investigating the relationship to provide specific room temperature 1.9–35.3)211 were associated with of illicit drug use and SIDS have guidelines to avoid overheating. increased SIDS risk, independent of focused on specific drugs or illicit It is unclear whether the relationship prenatal cigarette smoking exposure. drug use in general. One study to overheating is an independent A retrospective study from Western found maternal cannabis use to be factor or merely a reflection of the Australia found that a maternal associated with an increased risk increased risk of SIDS and suffocation alcoholism diagnosis recorded during of SIDS (adjusted OR: 2.35; 95% CI: with blankets and other potentially pregnancy (adjusted hazard ratio: 1.36–4.05) at night but not during the asphyxiating objects in the sleeping 6.92; 95% CI: 4.02–11.90) or within 1 day. 306 In utero exposure to opiates environment. Head covering during year postpregnancy (adjusted hazard (primarily methadone and heroin) sleep is of particular concern. In ratio: 8.61; 95% CI: 5.04–14.69) was has been shown in retrospective 1 systematic review, the pooled mean associated with increased SIDS risk, studies to be associated with an prevalence of head covering among and the authors estimated that at increased risk of SIDS. 307, 308 SIDS victims was 24.6%, compared least 16.41% of SIDS deaths were With the exception of 1 study that did with 3.2% among control infants. 186 attributable to maternal alcohol use not show an increased risk, 309 It is not known whether the risk disorder.301 Another study from population-based studies have related to head covering is due to Denmark, based on prospective data generally shown an increased risk overheating, hypoxia, or rebreathing. on maternal alcohol use, has also with in utero cocaine exposure.310 – 312 shown a significant relationship However, these studies did not Some have suggested that room between maternal binge drinking control for confounding factors. ventilation may be important. One and postneonatal infant mortality, A prospective cohort study found study found that bedroom heating, including SIDS. 302 Parental alcohol the SIDS rate to be significantly compared with no bedroom heating, and/or illicit drug use in combination increased for infants exposed in increases SIDS risk (OR: 4.5), 315 and with bed-sharing places the infant utero to methadone (OR: 3.6; 95% another study showed a decreased at particularly high risk of SIDS and CI: 2.5–5.1), heroin (OR: 2.3; 95% risk of SIDS in a well-ventilated unintentional suffocation. 91, 196 CI: 1.3–4.0), methadone and heroin bedroom (windows and doors open; (OR: 3.2; 95% CI: 1.2–8.6), and OR: 0.4). 316 In 1 study, the use of a Rat models have shown increased cocaine (OR: 1.6; 95% CI: 1.2–2.2), fan appeared to reduce the risk of arousal latency to hypoxia in rat even after controlling for race/ SIDS (adjusted OR: 0.28; 95% CI: pups exposed to prenatal alcohol. 303 ethnicity, maternal age, parity, birth 0.10–0.77).317 However, because of Furthermore, postmortem studies weight, year of birth, and maternal the possibility of recall bias, the small in Northern Plains American Indian smoking. 313 In addition, a meta- sample size of controls who used infants showed that prenatal analysis of studies investigating fans (n = 36), a lack of detail about cigarette smoking was significantly an association between in utero the location and types of fans used, associated with decreased serotonin cocaine exposure and SIDS found and the weak link to a mechanism, receptor binding in the brainstem. an increased risk of SIDS to be this study should be interpreted with In this study, the association of associated with prenatal exposure to caution. On the basis of available maternal alcohol drinking in the 3 cocaine and illicit drugs in general. 314 data, the task force cannot make a months before or during pregnancy recommendation on the use of a fan was of borderline significance on as a SIDS risk-reduction strategy. univariate analysis but was not OVERHEATING, FANS, AND ROOM significant when prenatal smoking VENTILATION and case versus control status was IMMUNIZATIONS Avoid overheating and head in the model. 29 However, this study covering in infants. Infants should be immunized in had limited power for multivariate accordance with AAP and Centers analysis because of the small sample The amount of clothing or blankets for Disease Control and Prevention size. One study found an association covering an infant and the room recommendations. of SIDS with heavy alcohol temperature are associated with an consumption in the 2 days before the increased risk of SIDS. 208 – 211 Infants The incidence of SIDS peaks at a death. 304 Several studies have found who sleep in the prone position have time when infants are receiving a particularly strong association a higher risk of overheating than numerous immunizations. Case when alcohol consumption or illicit supine sleeping infants.210 However, reports of a cluster of deaths shortly

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e17 after immunization with diphtheria- COMMERCIAL DEVICES the lack of evidence that they are tetanus toxoids-pertussis vaccine in Avoid the use of commercial effective against SIDS, suffocation, or the late 1970s created concern of a devices that are inconsistent with gastroesophageal reflux and because possible causal relationship between safe sleep recommendations. of the potential for suffocation and vaccinations and SIDS.318 – 321 Case- entrapment risk, the AAP concurs control studies were performed to Risk-reduction strategies are based with the CPSC and the US Food and evaluate this temporal association. on the best-available evidence in Drug Administration in warning Four of the 6 studies showed no large epidemiologic studies. These against the use of these products. relationship between diphtheria- studies have been largely focused on If positioning devices are used in tetanus toxoids-pertussis vaccination the correlations between the sleep the hospital as part of physical and subsequent SIDS322 – 325; the other environment and SIDS. Our current therapy, they should be removed 2 suggested a temporal relationship, understanding is that the cause from the infant sleep area well before but only in specific subgroup of SIDS is multifactorial and that discharge from the hospital. analysis. 326,327 In 2003, the Institute death results from the interaction of Medicine reviewed available data between a vulnerable infant and Certain crib mattresses have been and concluded the following: “The a potentially asphyxiating sleep designed with air-permeable evidence favors rejection of a causal environment. Thus, claims that materials to reduce rebreathing relationship between exposure to sleep devices, mattresses, or special of expired gases, in the event that multiple vaccinations and SIDS.”328 sleep surfaces reduce the risk of an infant ends up in the prone Several analyses of the US Vaccine SIDS must therefore be supported position during sleep, and these Adverse Event Reporting System by epidemiologic evidence. At a may be preferable to those with air- database have shown no relationship minimum, any devices used should impermeable materials. With the use between vaccines and SIDS.329 – 331 In meet safety standards of the CPSC, of a head box model, Bar-Yishay et al 341 addition, several large-population the Juvenile Product Manufacturers found that a permeable sleeping case-control trials consistently have Association, and ASTM International surface exhibited significantly better found vaccines to be protective (known previously as the American aeration properties in dispersing against SIDS332 – 335; however, Society for Testing and Materials). carbon dioxide and in preventing its confounding factors (social, maternal, The AAP concurs with the US Food accumulation. They also found the birth, and infant medical history) may and Drug Administration and CPSC measured temperature within the account for this protective effect.336 that manufacturers should not claim head box to be substantially lower It also has been theorized that the that a product or device protects with the more permeable mattress, decreased SIDS rate immediately against SIDS unless there is scientific concluding that it was due to faster after vaccination was attributable evidence to that effect. heat dissipation. This finding could to infants being healthier at the time be potentially protective against of immunization, or “the healthy Wedges and positioning devices are overheating, which has been identified vaccinee effect.”337 Recent illness often used by parents to maintain as a risk factor for SIDS. Colditz et al 342 would both place infants at higher the infant in the side or supine also performed studies both in risk of SIDS and make them more position because of claims that these vitro and in vivo, showing better likely to have immunizations products reduce the risk of SIDS, diffusion and less accumulation of deferred.338 suffocation, or gastroesophageal carbon dioxide with a mesh mattress. reflux. However, these products However, Carolan et al 343 found that Recent studies have attempted to are frequently made with soft, even porous surfaces are associated control for confounding by social, compressible materials, which might with carbon dioxide accumulation maternal, birth, and infant medical increase the risk of suffocation. The and rebreathing thresholds unless history.332, 334, 338 A meta-analysis CPSC has received reports of deaths there is an active carbon dioxide of 4 studies found a multivariate attributable to suffocation and dispersal system. In addition, although summary OR for immunizations and entrapment associated with wedges rebreathing has been hypothesized SIDS to be 0.54 (95% CI: 0.39–0.76), and positioning devices. Most of to contribute to death in SIDS, indicating that the risk of SIDS is these deaths occurred when infants particularly if the head is covered or halved by immunization. 338 The were placed in the prone or side when the infant is face down, there evidence continues to show no causal position with these devices 339; other is no evidence that rebreathing, per relationship between immunizations incidents have occurred when infants se, causes SIDS and no epidemiologic and SIDS and suggests that have slipped out of the restraints or evidence that these mattresses vaccination may have a protective rolled into a prone position while reduce the risk of SIDS. The use of effect against SIDS. using the device. 240, 340 Because of “breathable” mattresses can be an

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e18 FROM THE AMERICAN ACADEMY OF PEDIATRICS acceptable alternative as long as the Positional plagiocephaly, or swaddling, or wrapping the infant other manufacturing requirements plagiocephaly without synostosis in a light blanket, as a strategy are met, including being designed for (PWS), can be associated with a to soothe infants and, in some a particular crib, having a firm surface, supine sleeping position (OR: 2.5).350 cases, to encourage sleep in the and maintaining its shape even when It is most likely to result if the infant’s supine position. Swaddling, when the fitted sheet designated for that head position is not varied when done correctly, can be an effective model is used, such that there are no placed for sleep; if the infant spends technique to help calm infants and gaps between the mattress and the little or no time in awake, supervised promote sleep. 358, 359 side of the crib, bassinet, portable crib, tummy time; and if the infant is Some have argued that swaddling or play yard. not held in the upright position can alter certain risk factors for SIDS, when not sleeping. 350 – 352 Children thus reducing the risk of SIDS. For with developmental delay and/or HOME MONITORS, SIDS, AND BRIEF instance, it has been suggested that RESOLVED UNEXPLAINED EVENTS neurologic injury have increased rates the physical restraint associated with (FORMERLY APPARENT LIFE- of PWS, although a causal relationship swaddling may prevent infants placed THREATENING EVENTS) has not been shown.350, 353 – 356 In supine from rolling to the prone healthy normal children, the incidence There is no evidence that apparent position.358 One study suggested a of PWS decreases spontaneously life-threatening events are decrease in SIDS rate with swaddling from 20% at 8 months to 3% at 24 precursors to SIDS. Furthermore, if the infant was supine, but notably, months of age.351 Although data to infant home cardiorespiratory there was an increased risk of SIDS if make specific recommendations as to monitors should not be used as a the infant was swaddled and placed how often and how long tummy time strategy to reduce the risk of SIDS. in the prone position.210 Although should be undertaken are lacking, another study found a 31-fold the task force concurs with the AAP For many years, it was believed increase in SIDS risk with swaddling, Section on Neurologic Surgery that “a that brief resolved unexplained the analysis was not stratified by certain amount of prone positioning, events (BRUEs; formerly known as sleep position.196 Although it may be or ‘tummy time,’ while the infant apparent life-threatening events more likely that parents will initially is awake and being observed is [ALTEs]) were the predecessors of place a swaddled infant supine, this recommended to help prevent the SIDS, and home apnea monitors were protective effect may be offset by the development of flattening of the used as a strategy for preventing 12-fold increased risk of SIDS if the 344 occiput and to facilitate development SIDS. However, the use of home infant is either placed or rolls to the of the upper shoulder girdle strength cardiorespiratory monitors has prone position when swaddled.210, 359 necessary for timely attainment of not been documented to decrease In addition, an analysis of CPSC data 345–348 certain motor milestones.”357 The the incidence of SIDS. Home found that deaths associated with AAP clinical report “Prevention and cardiorespiratory monitors are swaddling were most often attributed Management of Positional Skull sometimes prescribed for use at home to positional asphyxia related to prone Deformities in Infants”357 provides to detect apnea and bradycardia sleeping, and a large majority of sleep additional detail on the prevention, and, when pulse oximetry is used, environments had soft bedding.360 diagnosis, and management of decreases in oxyhemoglobin Thus, if swaddling is used, the infant positional plagiocephaly. saturation for infants at risk of these should be placed wholly supine, and 349 conditions. Routine in-hospital swaddling should be discontinued as cardiorespiratory monitoring before soon as the infant begins to attempt to SWADDLING discharge from the hospital has not roll. Commercially available swaddle been shown to detect infants at risk There is no evidence to recommend sacks are an acceptable alternative, of SIDS. There are no data that other swaddling as a strategy to reduce particularly if the parent or caregiver commercial devices that are designed the risk of SIDS. Infants who are does not know how to swaddle to monitor infant vital signs reduce swaddled have an increased risk an infant with a conventional thin the risk of SIDS. of death if they are placed in or roll blanket. There is no evidence with to the prone position. If swaddling regard to SIDS risk related to the arms TUMMY TIME is used, infants should always be swaddled in or out. placed on the back. When an infant Supervised, awake tummy time There is some evidence that exhibits signs of attempting to roll, is recommended to facilitate swaddling may cause detrimental swaddling should no longer be used. development and to minimize physiologic consequences. For development of positional Many cultures and newborn example, it can cause an increase plagiocephaly. nurseries have traditionally used in respiratory rate, 361 and tight

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 e19 swaddling can reduce the infant’s however, that routine swaddling has case-control studies found that functional residual lung only minimal effects on arousal. In wrapping mattresses in plastic to capacity. 358, 362, 363 Tight swaddling addition, there have been no studies reduce toxic gas emission did not can also exacerbate hip dysplasia if investigating the effects of swaddling protect against SIDS. 230, 379 the hips are kept in extension and on arousal to more relevant stimuli adduction, 364 – 367 which is such as hypoxia or hypercapnia. HEARING SCREENS particularly important because some Finally, there is no evidence with have advocated that the calming regard to SIDS risk related to the arms Current data do not support the effects of swaddling are related to swaddled in or out. use of newborn hearing screens as the “tightness” of the swaddling. screening tests for SIDS. In summary, it is recognized that In contrast, “loose” or incorrectly swaddling is one of many child care One retrospective case-control applied swaddling could result in practices that can be used to calm study examined the use of newborn head covering and, in some cases, infants, promote sleep, and encourage transient evoked otoacoustic emission strangulation if the blankets become the use of the supine position. hearing screening tests as a tool to loose in the bed. Swaddling may However, there is no evidence to identify infants at subsequent risk also possibly increase the risk of 380 recommend routine swaddling as a of SIDS. Infants who subsequent overheating in some situations, strategy to reduce the risk of SIDS. died of SIDS did not fail their hearing especially when the head is covered The risk of death is high if a swaddled tests but, compared with controls, or there is infection. 368, 369 However, infant is placed in or rolls to the prone showed a decreased signal-to-noise 1 study found no increase in abdominal position. If infants are swaddled, ratio score in the right ear only, at skin temperature when infants were they should always be placed on the frequencies of 2000, 3000, and 4000 swaddled in a light cotton blanket back. When an infant exhibits signs of Hz. Methodologic concerns have been from the shoulders down. 362 attempting to roll, swaddling should raised about the validity of the study 381,382 no longer be used. Moreover, as many methods used in this study, Impaired arousal has often been have advocated, swaddling must be and these results have not been postulated as a mechanism correctly applied to avoid the possible substantiated by others. A larger, contributing to SIDS, and several hazards, such as hip dysplasia, but non–peer-reviewed, report of 383 studies have investigated the head covering, and strangulation. hearing screening data in Michigan relationship between swaddling Importantly, swaddling does not and a peer-reviewed retrospective 383,384 and arousal and sleep patterns in reduce the necessity to follow study in Hong Kong showed infants. Physiologic studies have recommended safe sleep practices. no relationship between hearing shown that, in general, swaddling screening test results and SIDS cases. decreases startling,361 increases sleep Until additional data are available, duration, and decreases spontaneous POTENTIAL TOXICANTS hearing screening should not be awakenings.370 Swaddling also considered as a valid screening tool There is no evidence decreases arousability (ie, increases to determine which infants may be at substantiating a causal cortical arousal thresholds) to a nasal subsequent risk of SIDS. Furthermore, relationship between various pulsatile air-jet stimulus, especially in an increased risk of SIDS should not toxicants to SIDS. infants who are easily arousable when be inferred from an abnormal hearing not swaddled.361 One study found Many theories link various toxicants screen result. decreased arousability in infants at 3 and SIDS. 372 – 374 Although 1 ecological months of age who were not usually study found a correlation of the EDUCATIONAL INTERVENTIONS swaddled and then were swaddled but maximal recorded nitrate levels of no effect on arousability in routinely drinking water with local SIDS rates Educational and intervention 361 375 swaddled infants. In contrast, in Sweden, no case-control study campaigns are often effective in another study has shown infants to be has shown a relationship between altering practice. more easily arousable370 and to have nitrates in drinking water and SIDS. increased autonomic (subcortical) Furthermore, an expert group in Intervention campaigns for SIDS have responses371 to an auditory stimulus the United Kingdom analyzed data been extremely effective, especially when swaddled.371 Thus, although pertaining to a hypothesis that SIDS with regard to the avoidance of prone swaddling clearly promotes sleep and is related to toxic gases, such as positioning.385 Furthermore, primary decreases the number of awakenings, antimony, phosphorus, or arsenic, care–based educational interventions, the effects on arousability to an being released from mattresses376, 377 particularly those that address external stimulus remain unclear. and found the toxic gas hypothesis caregiver concerns and misconceptions Accumulating evidence suggests, unsubstantiated. 378 Finally, 2 about safe sleep recommendations,

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e20 FROM THE AMERICAN ACADEMY OF PEDIATRICS can be effective in altering practice. sites), manufacturer advertisements, CONSULTANTS For instance, addressing concerns and store displays affect individual Marian Willinger, PhD – Eunice Kennedy Shriver about infant comfort, choking, behavior by influencing beliefs and National Institute for Child Health and Human and aspiration while the infant is attitudes. Frequent exposure to health- Development sleeping supine is helpful. 19, 96, 97,386 related media messages can affect Carrie K. Shapiro-Mendoza, PhD, MPH – Centers for Disease Control and Prevention However, many families report not individual health decisions, 399, 400 receiving information consistent and media messages have been very STAFF with AAP recommendations. When influential in decisions regarding James Couto, MA a nationally representative sample sleep position. 101, 104 Media and of mothers of young infants were advertising messages contrary to safe asked about information received sleep recommendations may create ABBREVIATIONS from their pediatricians, only 54.5% misinformation about safe sleep AAP: American Academy of had received a recommendation to practices. Pediatrics place their infant supine for sleep, ASSB: accidental suffocation or Media and manufacturer messaging 19.9% had received information strangulation in bed and advertising should follow safe about appropriate sleep location, CI: confidence interval sleep guidelines in text, photos, and 11.0% had received information CPSC: Consumer Product Safety and illustrations. In addition, about pacifier use. 387 Primary care Commission public health departments and providers should be encouraged ICD: International Statistical Clas- organizations that provide safe sleep to develop quality-improvement sification of Diseases and information should review, revise, initiatives to improve adherence to safe Related Health Problems and reissue this information at least sleep recommendations among their ICD-10: International Classifi- every 5 years to ensure that each patients. cation of Diseases, 10th generation of new parents receives Revision appropriate information. In addition, modeling of unsafe sleep OR: odds ratio practices by health care and child care PWS: plagiocephaly without providers may increase the prevalence synostosis RECOMMENDATIONS of these unsafe practices.388 – 390 SIDS: sudden infant death Modeling of unsafe practices may The recommendations for a safe syndrome occur because professionals are not infant sleeping environment to SUDI: sudden unexpected death convinced of the utility of the safe reduce the risk of both SIDS and in infancy sleep recommendations or have other sleep-related infant deaths are SUID: sudden unexpected infant concerns about the supine sleep specified in the accompanying policy death position, particularly with regard statement. 78 5-HT: 5-hydroxytryptamine to infant comfort, choking, and (serotonin) aspiration.391 – 395 Interventions that 5-HT1A: 5-hydroxytryptamine address provider concerns ACKNOWLEDGMENTS 1A (serotonin 1A) are effective in improving We acknowledge the contributions 391,396 –398 behavior. provided by others to the collection and interpretation of data examined REFERENCES in preparation of this report. We 1. Moon RY; Task Force on Sudden Infant MEDIA MESSAGES are particularly grateful for the Death Syndrome. SIDS and other sleep- Media and manufacturers should independent biostatistical report related infant deaths: expansion of follow safe sleep guidelines in submitted by Robert W. Platt, PhD. recommendations for a safe infant sleeping environment. Pediatrics. their messaging and advertising. 2011;128(5). Available at: www. pediatrics. LEAD AUTHOR A recent study found that, in magazines org/cgi/ content/ full/ 128/ 5/ e1341 Rachel Y. Moon, MD, FAAP targeted toward childbearing women, 2. Moon RY; Task Force on Sudden Infant more than one-third of pictures of Death Syndrome. SIDS and other sleep- TASK FORCE ON SUDDEN INFANT DEATH sleeping infants and two-thirds of related infant deaths: expansion of SYNDROME pictures of infant sleep environments recommendations for a safe infant portrayed unsafe sleep positions Rachel Y. Moon, MD, FAAP, Chairperson sleeping environment. Pediatrics. Robert A. Darnall, MD 237 2011;128(5):1030–1039 and sleep environments. Media Lori Feldman-Winter, MD, MPH, FAAP exposures (including movie, television, Michael H. Goodstein, MD, FAAP 3. Ebell MH, Siwek J, Weiss BD, et al. magazines, newspapers, and Web Fern R. Hauck, MD, MS Strength of Recommendation

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