In a recent article in the journal Pediatrics, Moon et al., update the recommendations for reducing infant death during sleep. Some of the most important recommendations indicate that (1) all infants should be placed for sleep in the supine (back) position until age 1 year; (2) the supine sleep surface should be firm, flat, and noninclined, which is safe even if infants have gastroesophageal reflux; (3) infants should sleep in the same room as their parents on a Consumer Product Safety Commission-approved portable crib, bassinet, or play yard with a tight-fitting sheet; and (4) blankets, pillows, bumper pads, nonfitted sheets, quilts, and comforters should not be in the infant's sleep area.
In this editorial, Nancy Maruyama, whose first-born son died of sudden infant death syndrome (SIDS) in 1985, provides her thoughts as a counselor to families who have lost infants due to sleep-related deaths for more than 3 decades.
Background
In 1992, the American Academy of Pediatrics (AAP) implemented the Back to Sleep National Campaign where infants were to be placed supine or on their sides to reduce the risk of SIDS. By 2011, the recommendations were updated to wholly supine sleep for infants. In 2016, the recommendations were once again updated to instruct parents and caregivers to not allow infants to sleep in any sitting devices because of the possibility for accidental suffocation, entrapment, asphyxia, or an obstructed airway. It was also recommended that infants sleep in the same room as their parents, close to the parent's bed (but not right up against the side of the parent's mattress) in a separate sleeping area for at least 6 months, but ideally up to age 1 year. Maternal smoking during pregnancy and after delivery should be avoided and infants should be in a strictly nonsmoking environment.
Latest Sleep Safety Guidelines
In 2022, the AAP published updated recommendations to prevent sleep-related infant deaths. Although similar to the 2016 guidelines, they offered a more detailed explanation along with some new advice. For example, we will continue to ask parents and caregivers to place babies without comforters, sheets, and stuffed toys on their backs on a firm, flat surface in a safety-approved crib, bassinet, or portable play yard. In-bed sleepers should not be recommended due to lack of risk-reduction evidence. Some in-bed sleepers may be much more dangerous because they are soft and pillowy, which increases the risk of death due to suffocation, asphyxia, and entrapment.
The three safest sleeping environments are (1) a full-size crib manufactured after June 28, 2011; (2) a portable play yard manufactured after February 28, 2013; and (3) a bassinet manufactured after April 23, 2014.
The new guidelines add that the sleep area be a firm, flat, and noninclined surface. However, there are still inclined sleepers marketed and sold on social media sites as well as via well-meaning friends and family and at garage sales, so there is still much education to be done. Breast-feeding is associated with a decreased risk of SIDS. Based on evidence gathered, the AAP does not recommend any form of bedsharing under any circumstance. The risk of death when parents bedshare with infants is increased by more than 10 times when these factors are present:
Bed sharing with someone who is impaired in their alertness or ability to arouse because of fatigue or use of sedating medications (eg, certain antidepressants, pain medications) or substances (eg, alcohol, illicit drugs)
Bed sharing with a current smoker (even if the smoker does not smoke in bed) or if the parent smoked during pregnancy
Bed sharing on a soft surface, such as a waterbed, old mattress, sofa, couch, or armchair
Another new guideline is to not recommend the use of weighted sleep sacks or blankets, which are available for sale in some big box retail stores. This has been tough to explain to new parents and to grandparents because they have been told anecdotally that they are a “game changer” when it comes to getting infants to sleep. A reminder for all parents, grandparents, and caregivers is that “just because they sell it, doesn't mean it is safe for infants or small children.”
To keep babies comfortable during sleep, it is significantly safer to dress them in a properly sized wearable blanket or sleep sack, or in layers of clothing to keep them warm, rather than using any type of loose blanketing. Using a blanket to keep babies warm increases the chance of the head and face being covered during sleep, which can lead to suffocation or asphyxiation. Likewise, hats are no longer advised for infants while indoors except in the first few hours of life or while in the neonatal intensive care unit.
The use of home cardiorespiratory monitors has been ever increasing. Direct-to-consumer heart rate and pulse oximetry monitoring devices, including wearable monitors, are sold as consumer wellness devices and do not meet the same regulatory requirements as medical devices. Apnea monitors that are prescribed by a physician are not included in this recommendation. A major concern in using these over-the-counter products is that parents and caregivers may become complacent and not adhere to safe sleep recommendations because the baby is being “monitored,” thus increasing the possibility of accidental death due to suffocation, asphyxia, entrapment, overlay, and other sleep-related deaths.
Tummy Time and Swaddling
Tummy time is critical for the proper development of an infant. It should begin at birth, and by age 7 weeks (adjust for gestational age), babies should be getting 15 to 30 minutes of supervised tummy time each day. Parents should be reminded that infants only need to be placed supine when sleeping up until at least age 1 year. Waking hours are great for bonding, supervised tummy time, holding infants closely so that they can hear, see, and smell the parents/caregiver, reading and singing, and other activities that support building connection.
Once babies are competent rolling from supine to prone, and back again, they should still be placed supine for sleeping, but if they roll to the side or prone, they do not have to be repositioned to supine. The sleeping area must still be free of anything other than a properly fitted mattress and a tightly fitted sheet. A pacifier may be used in the sleeping area if it is not tethered to infant.
Infant swaddling after hospital discharge has been a hot topic for a long time. If infants do not want to be swaddled, then there is no need to continue. If parents do swaddle with the baby's arms flexed and inside of the blanket, and the infant shows any signs of trying to roll (usually around 3 to 4 months) it is time to stop swaddling. It is never safe to use a weighted swaddle for any infant at any time. Using a swaddle sack or a receiving blanket is sufficient. However, parents and caregivers need knowledge regarding over layering (which can result in overheating) and proper swaddling techniques that do not interfere with breathing. There is no evidence that swaddling aids in reducing the risk of SIDS.
Final Thoughts
One of the most important things we can do as health care professionals is to consistently model the correct behavior to parents and caregivers. Parents and caregivers may not always remember what is said, but they will remember what they saw. Parents need to know that, even when they are discharged from the hospital, they must be placed supine to sleep (unless otherwise directed by physician). Explaining how and, most importantly, why we follow these recommendations, helps parents and caregivers to not only listen to the recommendations, but to follow them. We must always be aware of our implicit and explicit biases and be respectful of cultural norms within the families we care for while doing our best to increase parental compliance with infant safe sleep. My personal goal is to reach the point with families in which it is not only my need for them to follow safe sleep practices, but when it becomes their need to follow the safe sleep practices.
References
- 1. Moon RY, Carlin FR, Hand I. Sleep-related infant deaths: updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics. 2022;150(1):e2022057990.
- 2. Orenstein SR, Mitchell AA, Ward SD. Concerning the American Academy of Pediatrics recommendation on sleep position for infants. Pediatrics. 1993;91(2):497–499–.
- 3. Moon RYTask Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128(5):1030–1039–.
- 4. Moon RY, Darnall RA, Feldman-Winter L, et al. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162938.
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