As a new parent there are few things you will focus on more than your baby’s sleep, or lack there of. Luckily the long hours and little sleep I received during my residency prepared me for being the parent of a newborn, but it was still difficult. I remember the sleepless nights, the frequent waking up to feed, and the role designated to me by my wife: “the baby getter.” When my son was born there was little research on safe infant sleep, so at night we placed him in his crib in his own room to sleep. When he woke to eat I would get up to bring him into our room so my wife could breastfeed. More than a decade later there’s a significant body of research on safe infant sleep, and as you likely heard last week the American Academy of Pediatrics (AAP) updated it’s Safe Sleep Policy Statement. If we’d had the new guidelines when my son was born, it may have afforded me a few extra minutes of sleep by having him sleep in our room.
If you only saw the headlines about the AAP’s revised policy you may have walked away with a misunderstanding about what the policy actually says, especially if you just looked at the images posted on most media sites, they demonstrated exactly what not to do to keep your baby safe. So what does the policy really say? Is it time to forgo any and all parental freedom and have your snorting baby sleep in your room for a year?
There are very few significant changes to the 2016 Safe Sleep Policy Statement compared to the 2011 statement. This is because the research over the last five years reaffirms that the best way to reduce the risk of SIDS or other sleep related deaths, is to place your baby to sleep on a firm mattress, on their back, in a crib, bassinette, or pack-n-play. What is different about the 2016 guidance is the acknowledgement that exhausted and overwhelmed parents can unintentionally practice unsafe sleep habits and they need support to avoid those hazards.
Before we talk about accidental unsafe sleep, let’s review what the new policy says and why.
The policy highlights maternal and caregiver factors that can begin prior to delivery. Not only should parents not smoke after delivery, but expectant moms should avoid all tobacco smoke while pregnant. Smoking during pregnancy can lead to infants having decreased sleep arousal and post-natal smoking likely contributes to up to 30% of SIDS deaths. In addition to smoking, the AAP recommends that mothers abstain from alcohol and illicit drug use during pregnancy, and all caregivers avoid alcohol and illicit drug use after a baby is born especially in combination with bed-sharing which greatly increases the risk of SIDS.
The 2016 policy reaffirms that infants should be placed on their backs (also known as supine) to sleep. Research has shown that infants placed on their sides or stomachs (also known as prone) have greater than an eight-fold increase in dying of SIDS. Parents often worry that placing children on their backs to sleep will increase their baby’s risk of choking or aspiration, but the research shows there’s no increased risk, even in infants with Gastroesophageal Reflux.
Additionally, once an infant can roll, parents do not have to wake up and put their infants back onto a supine position, as the muscles needed to roll are also the ones a baby needs to be able to move it’s head and neck if something is blocking it’s airway.
Bedding is a major hazard that can block an infant’s airway. The 2016 Safe Sleep Policy reaffirms that infants should be placed to sleep on a firm mattress (CPSC approved) covered in a fitted sheet. That’s it. That’s all. Nothing else. No bumpers, no blankets, no nursing or other pillows, no stuffed animals. Nothing. Boring. Simple.
Again the AAP calls on a complete ban on bumper pads, including those that are marketed as “breathable”. Since their introduction crib bumpers have been responsible for 77 infant suffocations in America and numerous other injuries resulting from partial suffocation. As of now, Maryland remains the only state that has actually acted on this recommendation.
Parents should also be aware that car seats, swings, strollers and slings are not safe sleep surfaces and babies should be removed from them when feasible after they fall asleep (yes, when you get out of the car you can’t leave the baby in the car seat for the next 3 hours).
What has garnered the most media coverage was the AAP’s recommendations about sleep location. As I mentioned before the policy recommends co-rooming for at least 6 months, but preferably a full year. This is associated with a 50% reduction in the risk of SIDS. While this recommendation is identical to what is stated in the 2011 policy the 2016 policy used bold font to call out the recommendation, which is likely why the media latched onto it.
The AAP reaffirmed that infants should NOT sleep in an adult bed, a couch, an arm chair or with another child or animal. Couches are particularly dangerous because infants can become easily wedged between an adult and the back of a couch, or roll into the back of the couch because of the downward angle. What’s new in this policy is the simple recognition that exhausted parents feeding infants in the middle of the night can fall asleep during or after feeding the baby and unintentionally cause an unsafe sleep environment. To this end, the policy statement notes that the ideal situation is for infants to be returned to their own sleep environment when the parent is ready to go back to sleep. If this is not possible (or you think there is a good chance you will fall asleep with the infant) the recommendation is to feed the infant in the adult bed but remove “pillows, sheets, blankets, or any other items that could obstruct infant breathing or cause overheating.”
It’s important to be clear, that the policy does NOT recommend bed sharing and reaffirms that bed sharing increases an infant’s risk of SIDS. The policy recommends that in a situation where an unsafe sleep environment is likely to occur due to the parent’s exhaustion that parents attempt to make the environment less hazardous.
Finally, with regard to co-bedding, there are two more important points. First, there is insufficient evidence about the safety of all the new in-bed sleepers – they just haven’t been around long enough. And second, there are times when co-bedding should be completely avoided: when parents smoke (or mom smoked in pregnancy), when a parent is on illicit drugs or alcohol when the infant is under 4 months old, premature or low birth weight infants, waterbeds (or other soft bedding/surfaces), multiple bed-sharers, and non-parents.
The policy again reinforces the recommendations that babies do not need to be on external need any sort of commercial device that says it prevents SIDS. These are sometimes sold as pads that go under the crib sheet, as a onesie or a sock that monitor’s the child’s breathing and heart rate, or are sold as foam wedges or “positioners”. These devices can actually pose a danger to infants and they don’t decrease the incidence of SIDS. The use of positioners, wedges and other monitors have been associated with reports of death and may give parents a false sense of security they should not have. Additionally, the recommendations about using a pacifier remains as “consider” using one at the time of sleep and naps (but don’t wake up and put it back in every time it falls out).
The final group of recommendations is our of most parents’ control, its for the media, doctors and hospitals. The AAP urges media and advertisers to use safe sleep images in their messaging. This is something that was missed when many media outlets reported on this story. The AAP requests media outlets review the Cribs for Kids media guide before putting out an image of a sleeping baby. The AAP encourages hospitals and doctors to counsel parents about the safe sleep recommendations and to model the recommendations from birth. This includes turning premature infants onto their backs as soon as feasible in the NICU. Interestingly, most AAP policy statements are almost entirely proscriptive to doctors, yet this is the only recommendation that directly targets them in the safe sleep policy. And with good reason – prior research has shown that parents can change their behavior when a comprehensive nursery safe sleep program is implemented.
Overall, the vast majority of recommendations were in the previous policy from 2011 and reinforce the core recommendation that maintaining a clear airway for the infant while sleeping is the most beneficial approach to reducing the risk of a SUID. As more information is learned (yes, there was a recommendation for more research….) from the national CDC SUID database, my prediction is that we will end up with a very small number of SIDS cases (infants in safe sleep positions) and better data about the risks to infants who are in unsafe sleep environments.