AAP Recommendations

AAP Safer Sleep Recommendations

In June 2022 the American Academy of Pediatrics released updated infant safe sleep guidelines. These are developed for physicians and other health care providers.

We know from talking with families that sometimes parents can be confused by this information and/or not have the opportunity to speak with their health care provider about them.

To help families and caregivers understand what these mean and why they are important, we have taken the recommendations that relate directly to families and provided further information and an explanation on how it’s relevant.

Place baby on his/her back for every sleep by every caregiver until the child reaches 1 year of age. Side sleeping is not safe and is not advised.

Why: Babies sleeping on their stomach have their cheek on the mattress, with their fist on either side of their head. They are curled up and the airway is not as open as babies sleeping on their backs. Side sleeping is not advised because it makes it easier to roll from their side to their stomach. Sleeping on the stomach can also increase the infant’s body temperature, making babies overheated. The risk of sudden death also increases when an infant usually placed on his/her back, or even stomach, is placed in a different than usual sleep position.

What you need to know: After the Back to Sleep campaign launched in the 1990s, the rates of Sudden Unexpected Infant Death (SUID) were cut in half. You might have heard that it’s safer to have baby sleep on his stomach in case he spits up but it’s actually the opposite.  When a baby is on his back and spits up, he can turn his head left to right to clear his airway but if he’s on his stomach he can only turn his head into the mattress.  Also, when he’s on his back gravity will pull the spit-up, down and back into his food pipe (stomach) rather than his windpipe (lung.)

Trachea is the windpipe and Esophagus, below it, is the food pipe.

Won't My Baby Choke Image

Recommendation #2The safest place for a baby to sleep is on a separate sleep surface designed for infants close to the parents’ bed, ideally for at least the first 6 months.

Why: Research indicates infants sleeping in a separate room are at a higher risk of sudden death than infants who are room sharing without bed sharing.

Safe Sleep GuidelinesWhat you need to know: It feels as if keeping your baby right next to you is the safest spot to protect him/her and to bond but even the tiniest baby can “root and scoot” up towards a pillow, under a blanket, into your chest or roll over onto your soft mattress or into the corner between the wall and your bed.  These are all the ways in which accidental suffocation can occur and can increase the risk of SUID.

Recommendation #3: Baby should sleep in a crib, bassinet, portable crib, or play yard on a firm, flat, non-inclined sleep surface on a tightly fitting mattress covered by a fitted sheet with no other bedding or soft objects to reduce the risk of suffocation or wedging or entrapment.

Why: Soft mattresses and those made of memory foam increase the chance of rebreathing or suffocation if the infant is placed on or rolls over to the prone (tummy) position. Products with inclines of more than 10 degrees are unsafe for infant sleep, because it has been found that it increases the chances that babies can roll over onto their stomachs, even if they haven’t before, and in some babies their oxygen levels dropped. 

What you need to know: It’s important for your baby to sleep on a firm and flat surface on his or her back for every nap time and bedtime to avoid the risk of suffocation or aspiration (spitting up and having it go down the food pipe).  Sleeping on a soft fluffy surface can be dangerous if a baby rolls over and the soft bedding comes up and around the baby’s nose and mouth. A great way to test if a surface is too soft is to press your hand down and then lift it up.  If your hand leaves an indentation, it’s too soft.

Cribs, bassinets, portable cribs and play yards are the only products that meet safety standards developed by the Consumer Products Safety Commission (CPSC) for infant sleep. What’s in the area is just as important! Pillows, blankets, stuffed animals, and fluffy bumpers make a baby’s sleeping area unsafe.

Unfortunately, there are emergency situations due to temporary homelessness, domestic violence, or natural disasters. In these cases, an alternative device with a firm, flat, non-inclined surface (such as a box, basket, or dresser drawer) with thin, firm padding can be used temporarily until a safer sleep space is available.

Recommendation #4Sitting devices, such as car seats, strollers, swings, infant carriers, and infant slings, are not recommended for routine sleep.

Why: Infants falling asleep in a sitting device can obstruct their own airways. As babies relax and fall asleep and their chin falls onto their chest it can cause their airway to close.

Safe SleepWhat you need to know: All of these products are great for when baby is awake and supervised but they’re not for sleep. Always follow the manufacturer’s instructions for the safe and proper use of these products. If you’re tired and/or need to place your baby down to do something and won’t be able to watch her, place her in a safe sleeping area like a crib, play yard or bassinet. Naturally, babies will fall asleep while riding in a car but once you arrive at your destination you should move baby onto a flat and firm surface on her back. If you’re on a longer car ride, take breaks and wake baby up to stretch.

Recommendation #5Breastfeed exclusively for approximately 6 months and continuing for 1 year or longer as mutually desired by parent and infant.

Why: Breastfeeding provides an overall built-in immune system for the infant and breastfed babies are more easily aroused from sleep. Providing human milk alone during this time increases the protective immunity effect.

BreastfeedingWhat you need to know: Breastfeeding isn’t always easy and not every mom is successful or chooses to, but even trying for a day will help.  Breastfeeding conversations should begin before baby is born. Look for breastfeeding supports such as family, friends, or co-workers you can ask for advice. See if you can find local lactation support groups and attend one meeting before baby is born to get to know where to go for help if needed. Things to remember: breastfeeding should never hurt or pinch, so if it does, ask for help; the more baby is at the breast the more milk mom will make, and the more baby is breastfed the more protection is provided against SIDS and sleep-related infant death. When you breastfeed your body releases hormones which relax you and make you feel sleepy.  It’s important to stay awake when you’re breastfeeding so sit up in bed, set an alarm or ask someone to help you stay awake.

Recommendation #6Couches and armchairs are extremely dangerous places for infants and should never be used for infant sleep.

Why: Sleeping on a couch, armchair or recliner puts babies at extraordinarily high risk for infant death from SIDS or suffocation due to entrapment (getting tangled up in loose bedding or clothing), getting wedged in cushions or overlay by another person who is sharing this surface.

What you need to know: It’s cozy to cuddle and lay with your baby on a couch or armchair but if you’re tired, put your baby in his crib, bassinet or play yard.  It’s easy for baby to roll off you and get wedged in between the cushions or fall to the floor.  It’s also not safe to let him sleep by himself on a couch or armchair as he can roll over onto the soft surface.

Recommendation #7Keep soft objects, such as pillows, pillow-like toys, quilts, comforters, mattress toppers, fur-like materials, and loose bedding, such as blankets and nonfitted sheets, away from the infant’s sleep area.

Why: Many cases of sleep-related infant death are due to accidental suffocation from pillows, blankets, and stuffed animals near the baby.

What you need to know: It might look cold and uninviting to you, but all your baby needs is a flat, firm mattress with a tight-fitting sheet in a crib, bassinet or play yard with nothing else in the area. Instead of a sheet or blanket, place baby in a swaddle sack or wearable blanket.

Recommendation #8There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. Commercially available swaddle sacks are an acceptable alternative, particularly if the parent or caregiver does not know how to swaddle an infant with a conventional thin blanket. Weighted swaddle clothing or weighted objects within swaddles are not safe and, therefore, not recommended. 

Why: We don’t know that swaddling will prevent SIDS, but it has been shown to calm infants and help them stay sleeping on their backs.  When swaddling your baby with a traditional blanket, his arms can become loose and/or he can roll over, creating the risk of suffocation.

 Break it down: Swaddling is a great way to keep your baby warm and cozy and safer than using a blanket.  Swaddling with a blanket can be tricky and can be dangerous if it becomes loose. Instead, you may use a wearable swaddle, either one with your baby’s arms tucked in or out.

Recommendation #9Offering a pacifier at nap time and bedtime is recommended to reduce the risk of SIDS. 

Why: Although it’s not clear how a pacifier offers this protection, it is believed that it helps keep baby’s airway open and/or that babies wake easier during sleep. 

PacifiersWhat you need to know: There are several things to think about regarding pacifier use. Don’t force your baby to take it; if she refuses just wait until she’s a little older and try again. If it falls out there’s no need to put it back in unless the baby cries for it. To avoid the risk of strangulation, a pacifier should not be attached to baby’s clothing, stuffed toys or around his neck. For breastfed babies, a pacifier should not be offered until breastfeeding has been firmly established and going well. Another value of pacifiers is to sooth a fussy baby.

Recommendation #10It is recommended that pregnant people obtain regular prenatal care.

Why: Prenatal care provides the opportunity for physicians and other health care providers to watch over mother and baby’s health and to talk with the future parents about safe sleep practices, breastfeeding and to manage high risk behaviors, such as smoking.

What you need to know: Starting your prenatal visits as soon as possible is important to track your baby’s development and reduce the risk of complications. Doulas are a wonderful resource to have during and after pregnancy to support mom. Don’t hesitate to contact your OB/GYN or doula if you have a question, concern, or something feels different.

Recommendation #11Avoid smoke and nicotine exposure during pregnancy and after birth.

Why: Smoking, including vaping, increases the risk of babies being born premature and low birth weight, which are both risk factors for SIDS.

No smokingWhat you need to know: While you might not smoke around the baby, there’s also the issue of “third-hand smoke” which is smoke that sticks to fabric in furniture, clothing and car seats.  Ask anyone who smokes in your home to do it outside and to change their jacket or shirt before coming into the house.

Recommendation #12Avoid alcohol, marijuana, opioids, and illicit drug use during pregnancy and after birth. 

Why: Alcohol and illicit drugs increases the risk of babies being born premature and low birth weight, which are both risk factors for SIDS. 

What you need to know: It is also helpful for you to know that over-the-counter medications (allergy and cold medications) that can cause drowsiness and dull arousal should not be used when caring for infants.

Recommendation #13Avoid overheating and head covering in infants. 

Why: Excessive clothing or blankets covering an infant, and the room temperature, are associated with an increased SIDS risk. In general, dress infants appropriately for the environment. 

What you need to know: You might worry about your baby being warm and cozy but really, he only has to have one more layer than you would wear.  Hats and any other head covering should be removed before placing your baby down to sleep. A wearable blankets or layering baby’s clothes is the best way to keep your baby warm and eliminate the risks that traditional blankets create from potentially covering his head or his becoming trapped in it.

Recommendation #14Avoid the use of commercial devices that claim to reduce the risk of SIDS or other sleep-related deaths.

Why: “Commercial devices” can mean wearable monitors or other devices that are said to promote health. There is no evidence that any of these devices reduce the risk of sleep-related deaths and, important, using products claiming to increase sleep safety may create a false sense of security that could result in reducing infant safe sleep practices. Do not use home cardiorespiratory monitors (devices that monitor baby’s heart rate and oxygen levels) as a strategy to reduce the risk of SIDS, because there is no evidence that they do.

Break it down: If you have been sent home from the hospital with an apnea monitor then it should be used but if your doctor has not prescribed one there is no need for one. The best way to prevent sleep-related deaths is to always lay your baby down in a safe sleep area – on his back, on a firm, flat surface in a crib, bassinet or play yard with no pillows, blankets, stuffed animals, or fluffy bumpers in the area.

Recommendation #15Babies should receive routine immunizations.

Why: The evidence continues to show that there is no cause-and-effect relationship between immunization & SIDS. Research does suggest that vaccination may have a protective effect against SIDS.

Break it down: You’ll see comments on social media and may hear from some people that vaccines cause SIDS.  It is possible that because the time at which babies receive vaccinations happens to be at the peak time for SIDS this contributes to the myth that vaccines cause SIDS.

Recommendation #16Parents are encouraged to place the infant in tummy time while awake and supervised for short periods of time beginning soon after hospital discharge, increasing incrementally to at least 15 to 30 minutes total daily by 7 weeks of age.

Why: Babies placed only on their backs when awake will be delayed in building muscles in their neck, arms, and shoulders. They may also develop a flat spot (plagiocephaly) on the back of the baby’s head.

Break it down: Supervised tummy time is an opportunity to nurture and bond with your baby. It will help get them rocking, scooting, and crawling. Items used for tummy time, however, such as toys, should not be used for sleeping.

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