What You Should Know About the New Safe Sleeping Guidelines from AAP

Early this week, the American Academy of Pediatrics (AAP) released new guidelines for safe infant sleeping practices as part of their ongoing efforts to reduce the rate of infant death like SIDS and other sleep-related infant deaths. Up until this point, the AAP has maintained guidelines that show parents how they can make sleep safer for their child, but has never acknowledged that many (if not most) sleep-deprived new parents commonly fall asleep while feeding their child.

Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), and our fellow expert blogger at Science & Sensibility, provides a helpful summary of the guidelines, and explains why the revised information is beneficial:

"This updated guideline has been well received because for the first time, the AAP has acknowledged that parents are likely to fall asleep when breastfeeding their babies, and it is recommended that they should plan for this situation. Falling asleep with a baby on a couch or in a recliner is more dangerous than falling asleep in bed after breastfeeding when plans are made for this bed-sharing situation."

In the new statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," the Task Force on Sudden Infant Death Syndrome advises the following, which includes new information on how to safely fall asleep while feeding your infant:

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%.^6,8,41,42 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.

1. The infant's crib, portable crib, play yard, or bassinet should be placed in the parents' bedroom until the child's first birthday. Although there is no specific evidence for moving an infant to his or her own room before 1 year of age, the first 6 months are particularly critical, because the rates of SIDS and other sleep-related deaths, particularly those occurring in bed-sharing situations, are highest in the first 6 months. 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.

2. There is insufficient evidence to recommend for or against the use of devices promoted to make bed-sharing 'safe.' There is no evidence that these devices reduce the risk of SIDS or suffocation or are safe. Some products designed for in-bed use (in-bed sleepers) are currently under study but results are not yet available. Bedside sleepers, which attach to the side of the parental bed and for which the CPSC has published standards,²² may be considered by some parents as an option. There are no CPSC safety standards for in-bed sleepers. The task force cannot make a recommendation for or against the use of either bedside sleepers or in-bed sleepers, because there have been no studies examining the association between these products and SIDS or unintentional injury and death, including suffocation.

3. Infants who are brought into the bed for feeding or comforting should be returned to their own crib or bassinet when the parent is ready to return to sleep.^7,43

4. 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,^4,6,7,42,43 suffocation through entrapment or wedging between seat cushions, or overlay if another person is also sharing this surface.⁴⁴ 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.

5. The safest place for an infant to sleep is on a separate sleep surface designed for infants close to the parents' bed. However, the AAP acknowledges that parents frequently fall asleep while feeding the infant. Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep. It is important to note that a large percentage of infants who die of SIDS are found with their head covered by bedding. Therefore, no pillows, sheets, blankets, or any other items that could obstruct infant breathing or cause overheating should be in the bed. Parents should also follow safe sleep recommendations outlined elsewhere in this statement. Because there is evidence that the risk of bed-sharing is higher with longer duration, if the parent falls asleep while feeding the infant in bed, the infant should be placed back on a separate sleep surface as soon as the parent awakens.

6. There are specific circumstances that, in case-control studies and case series, have been shown to substantially increase the risk of SIDS or unintentional injury or death while bed-sharing, and these should be avoided at all times:

7. Bed-sharing with a term normal-weight infant younger than 4 months^{6,8,42,43,45,46} and infants born preterm and/or with low birth weight,⁴⁷ regardless of parental smoking status. Even for breastfed infants, there is an increased risk of SIDS when bed-sharing if younger than 4 months.⁴⁸ This appears to be a particularly vulnerable time, so if parents choose to feed their infants younger than 4 months in bed, they should be especially vigilant to not fall asleep.

   1. Bed-sharing with a current smoker (even if he or she does not smoke in bed) or if the mother smoked during pregnancy.^6,7,46,49,50

   2. Bed-sharing with someone who is impaired in his or her alertness or ability to arouse because of fatigue or use of sedating medications (eg, certain antidepressants, pain medications) or substances (eg, alcohol, illicit drugs).^8,48,51,52

   3. Bed-sharing with anyone who is not the infant's parent, including nonparental caregivers and other children.⁴

   4. Bed-sharing on a soft surface, such as a waterbed, old mattress, sofa, couch, or armchair.^4,6,7,42,43

   5. Bed-sharing with soft bedding accessories, such as pillows or blankets.^4,53

8. The safety and benefits of cobedding for twins and higher-order multiples have not been established. It is prudent to provide separate sleep surfaces and avoid cobedding for twins and higher-order multiples in the hospital and at home.⁵⁴

I encourage you to take a close look at the complete list of guidelines, as well as the parent and caregiver-friendly resource site, Safe to Sleep. While these revised guidelines are a step in the right direction, more work is needed to provide parents with information on safe co-sleeping and to acknowledge that bed-sharing helps parents breastfeed children longer. Lamaze blog contributor and maternal infant health expert Kathleen Kendall Tackett PhD, IBCLC, FAPA, weighs in with her review:

"First, the statement specifically pulls out breastfeeding as something that lowers the risk of SIDS, which it does (by 50% according to Vennemann's study). But they don't acknowledge the oft-repeated finding that bed-sharing increases exclusive breastfeeding rates. In fact, 'any' pattern of bed-sharing increases breastfeeding duration. So it's hard to have one without the other.

For exclusively breastfeeding, non-impaired mothers, I think we are moving in the right direction. At least they are acknowledging that bed-sharing does happen and here's how to make it safer. But the current statement doesn't differ all that much from the 2011 statement in terms of other key recommendations."

How do you approach safe sleep with your child? What worries you most? What makes you feel encouraged?