American Academy of Pediatrics 2022 Updated Guidelines on Reducing Infant Deaths in the Sleep Environment
by Anne Eglash MD, IBCLC, FABM
First, a little history. In 1994, the US National Institutes of Health promoted the first Back to Sleep Campaign after the AAP recommended that infants be placed in a non-prone sleeping position to reduce sudden infant death syndrome (SIDS). The campaign was successful, with a marked decline in SIDS cases. In 2016, the AAP refined their recommendations to address, among other issues, how to manage breastfeeding in the middle of the night. They suggested that a tired parent breastfeed in the parent’s bed rather than on a couch or recliner. If the parent falls asleep during breastfeeding, they should return the infant to their separate sleep surface after awakening. The AAP reiterated that breastfeeding protects from SIDS and explained that SIDS is a syndrome within a category of Sudden Unexpected Infant Deaths (SUID). SUID also includes accidental events such as roll-overs, infants falling out of bed, etc.
After 2016, La Leche League International and the Academy of Breastfeeding Medicine outlined evidence that SUIDS is highly unlikely among breastfeeding dyads in low risk situations, and reframed the discussion on bed sharing using a risk reduction approach.
Fast forward to 2022, with the AAP presenting clarifications and new definitions. The National Association of Medical Examiners prefers the term ‘unexplained sudden death in infancy’ rather than SIDS and the 2022 AAP policy uses the term ‘sleep-related death’ rather than SUIDS. A triple risk model has been embraced to conceptualize the complexity of sleep-related deaths. This model theorizes that SIDS occurs among infants with an intrinsic vulnerability, exposed to an exogenous trigger event such as an unsafe sleep environment, during a critical developmental period.
The term ‘co-sleeping’ has been retired (good night!), as it is not specific. Replacement terms are ‘room sharing’, ‘bed-sharing’ or ‘sleep-surface sharing’.
For the sake of keeping this essay short, let’s get to the question. I encourage you to read the full policy at some point.
- Sleep-related deaths continue to decline each year.
- Sleep-related deaths in the USA are more common among non-Hispanic black and American Indian/Alaska Native infants.
- The AAP 2022 guidelines are based on randomized-controlled trials.
- Human milk feeding, not just breastfeeding, is considered protective from unexplained sudden death in infancy.
- Back sleeping (supine) is recommended for all infants. Side sleeping is not considered safe.
- Prone positioning (on the stomach) is considered unsafe, even for infants with gastroesophageal reflux.
- Infants who turn over onto their tummies during sleep should be turned to their backs during the night.
- Room-sharing is recommended for at least the first 6 months, and there is no evidence for when it is safe to move an infant to another room before age 1.
- Breastfed infants should be offered a pacifier after breastfeeding is well established.
- Sleeping at an incline more than 10 degrees is considered unsafe.
- Sleeping in a swing or car seat is considered unsafe.
- Alternative sleep surfaces, such as in-bed sleepers, baby nests or pods, need to meet the federal safety standards set by the Consumer Product Safety Commission to be considered safe sleep locations.
- Wearable blankets are considered appropriate to keep the infant warm.
- It is advised to avoid hats on infants indoors except in the NICU or in the first few hours of life.
- Swaddling should be 100% avoided.
- Tummy time is recommended for at least 15-30 minutes a day by 7 weeks of age.
See the Answer
Each year in the United States, 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Classification of Diseases, 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths has remained stagnant since 2000, and disparities persist. The triple risk model proposes 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. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined 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. New recommendations are presented regarding noninclined 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 to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is also included. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report.
The incidence of infant sleep-related deaths has not changed since 2000, likely because most deaths occur in poor and marginalized families. The policy states that research on health care delivery system inequalities and the impact of structural racism and implicit bias as they pertain to health care delivery are needed to help reduce sleep-related deaths.
These guidelines are NOT based on randomized controlled trials since we cannot randomly assign patients to prone or side sleeping.
Once infants can roll both ways, they can be allowed to stay in the sleep position they assume. Swaddling is not considered contraindicated but should stop when infants can roll onto their stomachs, and the swaddling should not involve the hip regions.
The 2022 AAP sleep guidelines, for the most part, clarify several aspects that were somewhat vague in their 2016 statement, which is helpful. I didn’t include any questions about avoiding parental use of substances such as tobacco, opiates, cannabis, alcohol, etc, although the statement is clear that exposure to substances during pregnancy and postpartum increases the risk of infant sleep-related death.
The policy emphasizes that any human milk feeding is protective from infant sleep-related death. This protection is dose related, increasing with a greater % of human milk in the diet, and for longer periods of breastfeeding or human milk feeding.
The statement did not discuss risk reduction. They outline the degree of risk with various behaviors, such as 10x risk of sleep-related death if the infant sleeps with a current smoker, and a 5x-10x increased risk if bed-sharing occurs with anyone who is not the infant’s parent.
We know that some families have only 1 sleep surface, and/or they don’t have resources for a safe infant sleep surface. The policy didn’t address how to have risk-reduction conversations with these families, nor does the policy have a list of available resources, yet these families are at highest risk for infant-related death! This seems ironic given their attention to addressing social and economic factors such as homelessness, unemployment, and domestic violence.
Interestingly, the policy emphasizes the need to only use infant sleep products or surfaces that are approved by the US Consumer Product Safety Commission (CSPI). In searching this website, I was unable to find information on Baby Nests or the SNOO. The information on toddler beds was last reviewed in 2011, and the links for the information on Play Yards were broken.
In summary, this policy is fitting for middle- and upper-class Caucasian families, and I believe it needs to be rewritten using a lens of health inequity. In addition, we need accurate and timely resources on sleep products.