AAP updates infant sleep guidelines: No bedsharing, flat surfaces only

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(GERMANY OUT) baby is sleeping, (Photo by Wodicka/ullstein bild via Getty Images)

The American Academy of Pediatrics has updated its safe-sleep guidelines for infants, urging parents to make sure their baby sleeps on a flat — not inclined — surface without soft bedding and strongly advises against bedsharing.

The AAP’s first update to its safe infant sleep recommendations since 2016 was just published in the bulletin "Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment."

No co-sleeping

The AAP says the risks of sleep-related infant deaths are up to 67 times higher when infants are sleeping with someone on a couch or soft armchair or cushion. Researchers note the chances of death can be 10 times higher when infants are sleeping with someone who is impaired because of fatigue or use of sedating medications or substances such as alcohol or illicit drugs; or is a smoker.

The AAP also says the risks of sleeping on the same surface with someone else also increase 5-10 times when an infant is under four months of age; is sharing the surface with someone other than a parent; or is a pre-term or low-birthweight, regardless of other factors.

Warning about inclined chairs

The academy also called out the use of inclined chairs such as bouncers and rockers. While most babies don’t spend the night in such devices, they can fall asleep in them during the day — increasing the chance that they roll over or even roll out of them entirely.

Infant sleep products must have a sleep surface angle of 10 degrees or fewer under a new Consumer Product Safety Commission rule that takes effect this month.

"Parents should not use products for sleep that aren’t specifically marketed for sleep," the AAP noted. "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."

Other recommendations to reduce the risk of sleep-related infant death from AAP include:

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 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. Importantly, the use of products claiming to increase sleep safety may provide a false sense of security and complacency for caregivers. Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.
Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of 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. If infants are swaddled, always place them on the back. Weighted swaddles, weighted clothing or weighted objects on or near the baby are not safe and not recommended. 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 the prone position.

"A baby’s death is tragic, heartbreaking and often preventable. If we’ve learned anything, it’s that simple is best: babies should always sleep in a crib or bassinet, on their back, without soft toys, pillows, blankets or other bedding," said Dr. Rachel Moon, professor of pediatrics at the University of Virginia School of Medicine, on the academy’s website.

According to the academy, nearly 3,500 infants die from sleep-related infant deaths a year in the United States. However, the annual number of deaths has remained about the same since 2000 following a substantial decline in deaths in the 1990s, according to the AAP.

AAP’s research shows that sleep-related deaths can occur when an infant with an intrinsic vulnerability to SIDS is placed in an unsafe sleep environment.

"Parents might think that their infant is waking up too much during the night and fear that something is wrong," Moon continued. "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."

The academy has noted that racial and ethnic disparities reflect broader society programs. Researchers cite the rate of sudden unexpected infant deaths (SUIDs) among Black and American Indian/Alaska Native infants was more than double and almost triple, respectively, that of white infants (85 per 100 000 live births) in 2010-2013.

"We know that many parents choose to share a bed with a child, for instance, perhaps to help with breastfeeding or because of a cultural preference or a belief that it is safe," Rebecca Carlin, MD, FAAP, who co-authored the statement and technical report, said.

"The evidence is clear that this significantly raises the risk of a baby’s injury or death, however, and for that reason AAP cannot support bed-sharing under any circumstances," she continued.

This story was reported from Los Angeles.

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