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No Bed Sharing with Infants Among New AAP Safe Sleep Guidelines

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A policy statement issued by the American Academy of Pediatrics (AAP), published online June 21 in the journal Pediatrics, updated recommendations for a safe infant sleep environment.  Importantly, the statement includes updates in 14 safe sleep categories “that have been substantially revised” since their last issuance in 2016, the statement notes.

The statement emphasizes the need for infants to sleep on their backs on flat non-inclined surfaces without soft bedding and details the risks of bed-sharing under various scenarios within its first update to safe its infant sleep recommendations issued since 2016.

The policy statement promotes human milk feeding and tummy time, and also addresses questions about popular products such as home cardiorespiratory monitors, which are not recommended as a strategy to prevent sudden infant death syndrome.  Also included are updated advisories on swaddling, tummy time duration, head covering, pacifier use, sleep surface recommendations, in addition to other recommendations and cautions to parents and providers.

Rachel Y. Moon, MD, FAAP, professor of pediatrics at the University of Virginia School of Medicine in Charlottesville, served as lead author of the statement and accompanying technical report generated by the AAP Task Force on Sudden Infant Death Syndrome and the AAP Committee on Fetus and Newborn.  Moon and colleagues developed the updated evidence-based recommendations for a safe sleeping environment in order to reduce the risk for sleep-related infant deaths which account for the loss of ∼3,500 children in the United States each year according to the AAP.  These include those who die of “sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed,” according to the organization.

Stagnant progress in prevention, disparities in at-risk communities

Following a considerable decline in sleep-related deaths in the country in the 1990s as the result of a national educational campaign to put babies on their backs to sleep, the overall death rate attributable to sleep-related infant deaths in the US has remained stagnant since 2000.

However, while overall numbers of deaths declined, persistent racial and ethnic disparities exist that reflect broader societal inequities, according to research.  “The rate of sudden unexpected infant deaths (SUIDs) among Black and American Indian/Alaska Native infants was more than double and almost triple, respectively, that of white infants (85 per 100 000 live births) in 2010-2013,” the AAP cites in a news release accompanying the policy statement issuance.

The proposed “triple risk model” regarding many of these deaths hypothesizes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period.

Alarming behavioral risk statistics

The risks of sleep-related infant deaths are up to 67 times higher when sleeping with someone on a couch or soft armchair or cushion; and 10 times higher when sleeping with someone who is impaired due to fatigue or use of sedating medications or substances such as alcohol or illicit drugs; or is a smoker, AAP data cites.

Risks of sleeping on the same surface with someone else also increase 5 to 10 times when an infant is under 4 months of age; is sharing the surface with someone other than a parent; or is a pre-term or low-birthweight—regardless of other factors.

In its newly updated statement, the AAP recommends a safe sleep environment to reduce the risk of all sleep-related deaths.  Its text includes guidance on supine positioning; use of a firm, non-inclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating.  Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier.

Sleep topics not previously addressed

New recommendations are presented regarding non-inclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. Additional information is also included to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations. The recommendations and strength of evidence for each recommendation are included in this policy statement and the rationale for these recommendations is discussed in detail in an accompanying technical report.

Legislation may help

The AAP’s statement draws particular attention to and caution against the use of sitting devices, such as car seats, strollers, swings, infant carriers, and infant slings for sleep, none of which are recommended for routine sleep either in the hospital or at home, particularly for infants younger than 4 months.  It emphasizes that “Parents should not use products for sleep that aren’t specifically marketed for sleep.”

The organization expresses optimism that the education efforts fostered by the new policy guidelines will be further empowered by the provisions of the newly enacted federal Safe Sleep for Babies Act which aim to discontinue potentially dangerous baby sleep products such as inclined sleepers, in-bed sleepers, loungers, and travel/compact sleepers.

Parting words for parents

Finally, co-author Moon encourages healthcare providers to continue to help educate new parents about what constitutes “normal” infant sleep patterns.

“Parents might think that their infant is waking up too much during the night and fear that something is wrong,” she says.  “But babies by their nature wake up frequently during the night.  Although this can be understandably frustrating for parents who are exhausted and losing out on their own sleep, babies have to wake to feed every 2-3 hours, so this is normal and healthy, and should be expected.”

And of, course, she counsels, when parents have questions about their infant’s sleep, they should always ask their pediatrician or healthcare professional for guidance.

Find the AAP’s complete updated policy statement here:  “Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment.”

 The rationale for these recommendations is discussed in detail in the AAP’s accompanying technical report found in full here.

The AAP Parenting Website HealthyChildren.org offers media-rich safe sleeping resources for you to share with parents including:

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