Approximately 3,500 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome (SIDS) and other sleep-related infant deaths. By following the Safe Sleep Guidelines developed by the American Academy of Pediatrics these deaths can be significantly reduced.

AAP recommendations on creating a safe sleep environment include:

 

Back to sleep for every sleep.

To reduce the risk of SIDS, infants should be placed for sleep in a supine position (wholly on the back) for every sleep by every caregiver until the child reaches 1 year of age. Side sleeping is not safe and is not advised.

 

Use a firm sleep surface.

Infants should be placed on a firm sleep surface (eg, mattress in a safety-approved crib) covered by a fitted sheet with no other bedding or soft objects to reduce the risk of SIDS and suffocation.

A firm surface maintains its shape and will not indent or conform to the shape of the infant’s head when the infant is placed on the surface. Soft mattresses, including those made from memory foam, could create a pocket (or indentation) and increase the chance of rebreathing or suffocation if the infant is placed in or rolls over to the prone position.

Soft materials or objects, such as pillows, quilts, comforters, or sheepskins, even if covered by a sheet, should not be placed under a sleeping infant. If a mattress cover to protect against wetness is used, it should be tightly fitting and thin.

The infant should sleep in an area free of hazards, such as dangling cords, electric wires, and window-covering cords, because these may present a strangulation risk.

Sitting devices, such as car seats, strollers, swings, infant carriers, and infant slings, are not recommended for routine sleep in the hospital or at home, particularly for young infants.

Infants who are younger than 4 months are particularly at risk, because they may assume positions that can create a risk of suffocation or airway obstruction or may not be able to move out of a potentially asphyxiating situation. When infant slings and cloth carriers are used for carrying, it is important to ensure that the infant’s head is up and above the fabric, the face is visible, and the nose and mouth are clear of obstructions. After nursing, the infant should be repositioned in the sling so that the head is up, is clear of fabric, and is not against the adult’s body or the sling. If an infant falls asleep in a sitting device, he or she should be removed from the product and moved to a crib or other appropriate flat surface as soon as is safe and practical. Car seats and similar products are not stable on a crib mattress or other elevated surfaces.

 

Breastfeeding is recommended.

Breastfeeding is associated with a reduced risk of SIDS. Unless contraindicated, mothers should breastfeed exclusively or feed with expressed milk (ie, not offer any formula or other nonhuman milk-based supplements) for 6 months, in alignment with recommendations of the AAP.

The protective effect of breastfeeding increases with exclusivity. However, any breastfeeding has been shown to be more protective against SIDS than no breastfeeding.

 

It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.

There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%. In addition, this arrangement is most likely to prevent suffocation, strangulation, and entrapment that may occur when the infant is sleeping in the adult bed.

Placing the crib close to the parents’ bed so that the infant is within view and reach can facilitate feeding, comforting, and monitoring of the infant. Room-sharing reduces SIDS risk and removes the possibility of suffocation, strangulation, and entrapment that may occur when the infant is sleeping in the adult bed.

Couches and armchairs are extremely dangerous places for infants. Sleeping on couches and armchairs places infants at extraordinarily high risk of infant death, including SIDS suffocation through entrapment or wedging between seat cushions, or overlay if another person is also sharing this surface. Therefore, parents and other caregivers should be especially vigilant as to their wakefulness when feeding infants or lying with infants on these surfaces. Infants should never be placed on a couch or armchair for sleep.

 

Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and strangulation.

Soft objects, such as pillows and pillow-like toys, quilts, comforters, sheepskins, and loose bedding, such as blankets and nonfitted sheets, can obstruct an infant’s nose and mouth. An obstructed airway can pose a risk of suffocation, entrapment, or SIDS.

Infant sleep clothing, such as a wearable blanket, is preferable to blankets and other coverings to keep the infant warm while reducing the chance of head covering or entrapment that could result from blanket use.

 

Consider offering a pacifier at nap time and bedtime.

Although the mechanism is yet unclear, studies have reported a protective effect of pacifiers on the incidence of SIDS. The protective effect of the pacifier is observed even if the pacifier falls out of the infant’s mouth.

The pacifier should be used when placing the infant for sleep. It does not need to be reinserted once the infant falls asleep. If the infant refuses the pacifier, he or she should not be forced to take it. In those cases, parents can try to offer the pacifier again when the infant is a little older.

Because of the risk of strangulation, pacifiers should not be hung around the infant’s neck. Pacifiers that attach to infant clothing should not be used with sleeping infants.

Objects, such as stuffed toys and other items that may present a suffocation or choking risk, should not be attached to pacifiers.

For breastfed infants, pacifier introduction should be delayed until breastfeeding is firmly established. Infants who are not being directly breastfed can begin pacifier use as soon as desired.

There is insufficient evidence that finger sucking is protective against SIDS.

 

Avoid smoke exposure during pregnancy and after birth.

Both maternal smoking during pregnancy and smoke in the infant’s environment after birth are major risk factors for SIDS.

Mothers should not smoke during pregnancy or after the infant’s birth.

There should be no smoking near pregnant women or infants. Encourage families to set strict rules for smoke-free homes and cars and to eliminate secondhand tobacco smoke from all places in which children and other nonsmokers spend time.

The risk of SIDS is particularly high when the infant bed-shares with an adult smoker, even when the adult does not smoke in bed.

 

Avoid alcohol and illicit drug use during pregnancy and after birth.

There is an increased risk of SIDS with prenatal and postnatal exposure to alcohol or illicit drug use.

Mothers should avoid alcohol and illicit drugs periconceptionally and during pregnancy.

Parental alcohol and/or illicit drug use in combination with bed-sharing places the infant at particularly high risk of SIDS.

 

Avoid overheating and head covering in infants.

Although studies have shown an increased risk of SIDS with overheating,the definition of overheating in these studies varies. Therefore, it is difficult to provide specific room temperature guidelines to avoid overheating.

In general, infants should be dressed appropriately for the environment, with no greater than 1 layer more than an adult would wear to be comfortable in that environment.

Parents and caregivers should evaluate the infant for signs of overheating, such as sweating or the infant’s chest feeling hot to the touch.

Overbundling and covering of the face and head should be avoided.

There is currently insufficient evidence to recommend the use of a fan as a SIDS risk-reduction strategy.

 

Pregnant women should obtain regular prenatal care.

There is substantial epidemiologic evidence linking a lower risk of SIDS for infants whose mothers obtain regular prenatal care. Pregnant women should follow guidelines for frequency of prenatal visits.

 

Infants should be immunized in accordance with recommendations of the AAP and Centers for Disease Control and Prevention.

There is no evidence that there is a causal relationship between immunizations and SIDS. Indeed, recent evidence suggests that vaccination may have a protective effect against SIDS.

 

Avoid the use of commercial devices that are inconsistent with safe sleep recommendations.

Be particularly wary of devices that claim to reduce the risk of SIDS. Examples include, but are not limited to, wedges and positioners and other devices placed in the adult bed for the purpose of positioning or separating the infant from others in the bed.

 

Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly.