Sleep Safety for Infants

Recommendations for safe and healthful sleep hygiene for infants comes from the American Academy of Pediatrics (AAP). Approximately 3,500 infants die from sleep-related infant deaths annually in the United States. Research indicates that sleep-related death can occur when an infant with an intrinsic vulnerability to sudden infant death syndrome (SIDS) is placed in an unsafe sleep environment.

The AAP emphasizes the need for infants to sleep on their backs on flat non-inclined surfaces without soft bedding and to avoid bed-sharing with adults. Sharing a bed with a child significantly raises the risk of a baby’s injury or death. The AAP also promotes human milk feeding, tummy time for infants, and does not recommend home cardiorespiratory monitors to prevent sudden infant death syndrome.
For babies up to one year to reduce the risk of sleep-related infant death AAP recommends:

  • Avoid baby products that aren't consistent with safe sleep recommendations. The baby should sleep on a firm, flat non-inclined surface that, at a minimum, adheres to the June 2021 Consumer Product Safety Commission’s (CPSC) rule that any infant sleep product must meet existing federal safety standards for cribs, bassinets, play yards, and bedside sleepers. Parents should not use products for sleep that aren’t specifically marketed for sleep. This is especially true for products that claim to reduce the risk of SIDS or other sleep-related infant deaths. There's no evidence that this is true. If you're not sure about a specific product, check the CPSC website.
  • Keep soft objects & loose bedding out of your baby's sleep area. These objects can increase your baby's risk of entrapment, suffocation, or strangulation. This includes pillows and pillow-like toys, quilts, comforters, mattress toppers, non-fitted sheets, blankets, toys, bumper pads, or related products that attach to crib slats or sides. A loose blanket, including a swaddling blanket that comes unwrapped, could cover your baby's face, and increase the risk of suffocation.
  • Sharing a bed with a child significantly raises the risk of a baby’s injury or death, and for that reason AAP does not support bed-sharing under any circumstances. Co-bedding of twins and higher order multiples is not recommended.
  • If you're worried about your baby getting cold, you can dress them in layers of clothing or use a wearable blanket. In general, you should dress your baby in only one layer more than you're wearing. Infant sleep clothing, such as layers of clothing or a wearable blanket or sleep sack, is preferred over blankets and other coverings to keep a baby warm. A safe sleep space for infants should stay free of any loose bedding or soft objects. However, as with regular blanket swaddling, the use of wearable blankets or sleep sacks that compress the arms, chest and body should stop once a baby shows signs of starting to roll over. Sleep sacks that do not swaddle and allow the baby to move freely can be used as long as you want.
  • Overheating can increase the risk of SIDS. Your baby only needs one more layer than you would wear in the same environment to be comfortable. Check your baby for signs of overheating such as sweating, a hot chest or flushed skin. Swaddling can increase the chance a baby will overheat. To avoid overheating it is also advisable not to place hats on infants when indoors except in the first hours of life.
  • Don't use weighted blankets, sleepers, swaddles or other weighted objects on or near your baby.
  • If your baby falls asleep in a car seat, stroller, swing, infant carrier or sling, you should move them to a firm sleep surface on their back as soon as possible.
  • Some babies will roll onto their stomachs. You should always place your baby to sleep on their back. But if they're comfortable rolling both ways (back to tummy, tummy to back), then you don't need to keep turning your baby to their back again. Be sure that there are no blankets, pillows, stuffed toys or bumper pads in your baby's bed.
  • 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 infants younger than 4 months.
  • Breastfeeding reduces the risk of sleep-related infant deaths, and while any human milk feeding is more protective than none, 2 months of feeding at least partial human milk feeding has been demonstrated to significantly lower the risk of sleep-related deaths. The AAP recommends exclusive human milk feeding to 6 months, with continuation of human milk feeding for 1 year or longer as mutually desired by parent and infant.
  • AAP recommends that parents sleep in the same room – but not in the same bed as a baby, preferably for at least the first six months.
  • Avoid parent and infant exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs.
  • Make sure the baby receives routine immunizations.
  • Pacifier use is associated with reducing risk.
  • Avoid the use of cardiorespiratory monitors or other commercial devices that claim to reduce the risk of SIDS or other sleep-related deaths. There is no evidence that any of these devices reduce the risk of these deaths––they may provide a false sense of security and complacency for caregivers.
  • Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of a flat spot on one side of the head or the whole back of the head (positional plagiocephaly). Parents 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.
  • There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. Parents should know that there are some risks to swaddling. Swaddling may decrease a baby's arousal, so that it's harder for them to wake up. That is why swaddling can seem so attractive to new, sleep-deprived parents—the baby sleeps longer and doesn't wake up as easily. Decreased arousal can be a problem and may be one of the main reasons that babies die of SIDS. A newborn can be swaddled correctly and placed on their back in his crib at home, and it can help comfort and soothe them to sleep. When the child is older, in a new environment, with a different caregiver, if they are learning to roll or perhaps haven't been swaddled before, swaddling becomes more challenging and risky.
  • If infants are swaddled, make sure that your baby is always on their back when swaddled. The swaddle should not be too tight or make it hard for your baby to breathe or move their hips. Studies have found that straightening and tightly wrapping a baby's legs can lead to hip dislocation. “Hip-healthy swaddling" allows the baby's legs to bend up and out.
  • If babies are swaddled, they should be placed only on their back and monitored so they don't roll over. When an infant exhibits signs of attempting to roll (which usually occurs at 3 to 4 months but may occur earlier), swaddling is no longer appropriate, as it could increase the risk of suffocation if the swaddled infant rolls to a face down (prone) position.
  • Weighted swaddles, weighted clothing or weighted objects on or near the baby are not safe and not recommended.

According to Dr. Rachel Moon, a pediatrician and chair of AAP’s task force on SIDS, “Parents might think that their infant is waking up too much during the night and fear that something is wrong. But babies by their nature wake up frequently during the night. Although this can be understandably frustrating for parents who are exhausted and losing out on their own sleep, babies have to wake to feed every 2-3 hours, so this is normal and healthy, and should be expected. When parents have questions about their infant’s sleep, they should always ask their pediatrician for guidance.”

Don't hesitate to talk with your pediatrician if you have any questions or concerns about the safety of your baby's sleep environment.

For details see the  AAP policy statement, “Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment,” and a technical report that provides the evidence base for updated recommendations, which apply to children up to 1 year old.

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