Reducing Infant Death in the Sleep Environment

Back to Sleep for Every Sleep

• The infant should be placed flat on the back to sleep for every sleep until the child reaches 1 year of age.
• The supine sleep position on a flat, firm, non-inclined surface does not increase the risk of aspiration and choking in infants, including infants with gastroesophageal reflux (GER).
• Hospitalized preterm infants should be placed supine as soon as the infant is clinically stable.

Back to Sleep for Every Sleep

• It is not recommended to elevate the head or to use positional therapy, such as lateral and prone positioning, to treat symptoms of GER disease in sleeping infants.
• Head elevation is not recommended in infants receiving nasogastric or orogastric feeds.
• Head elevation could cause the infant to slide into a position that increases risk of respiratory compromise, or it could lead to rolling onto the side or prone which increases risk for suffocation.

Back to Sleep for Every Sleep

• During birth hospitalization, healthy newborn infants should be placed supine on a flat, firm, non-inclined surface for every sleep when not practicing skin-to-skin care or being held by an awake and alert individual.

Back to Sleep for Every Sleep

• Infants who can roll should still be placed to sleep supine until 1 year of age but are allowed to remain in the sleep position that they assume.
• The sleep environment should have only a fitted sheet and be clear of everything, to reduce the risk of rolling into soft bedding or other materials.

Firm, Flat, Non-inclined Sleep Surface

• Use of a firm, flat, non-inclined sleep surface covered by a fitted sheet without other bedding or soft objects can reduce the risk of suffocation or wedging/entrapment.

• Sleep surfaces with inclines of more than 10 degrees are unsafe for infant sleep and nothing should be placed under or over the mattress to elevate the infant off the mattress.

Firm, Flat, Non-inclined Sleep Surface

• Mattresses designed for the specific product must be used. Pillows, cushions, and mattress toppers should not be used in the infant's sleeping area.

• Soft, adjustable, or memory foam mattresses should not be used as a sleep surface.

• A crib, bassinet, portable crib, or play yard that is approved by the Consumer Product Safety Commission (CPSC) safety standards is recommended.

Firm, Flat, Non-inclined Sleep Surface

• Cribs with missing hardware, missing instructions, or broken components should not be used.

• Adult-sized beds and mattresses have been shown to increase risk of entrapment and suffocation in infants.

• Sitting devices, such as car seats, strollers, swings, infant carriers, and infant slings, should not be used for routine sleep. Do not leave infants unattended in sitting devices, and do not leave infants in car seats or other sitting devices with the straps unbuckled or partially unbuckled.

Firm, Flat, Non-inclined Sleep Surface

• When infant slings and cloth carriers are used for carrying, ensure the infant's head is up and above the fabric and that the nose and mouth are clear of obstructions.

• In an emergency, such as personal or regional disasters, an alternative sleep device with a firm, flat, non-inclined sleep surface (such as a box, basket, or dresser drawer) with thin, firm padding may be used temporarily until a CPSC-approved surface is available.

Breastfeeding

• Breastfeeding is associated with a reduced risk of Sudden Infant Death Syndrome (SIDS), and it is recommended unless contraindicated or the parent is unable to do so.

• Exclusive breastfeeding is recommended for the first 6 months, with a continuation of human milk feeding for at least 1 year.

Breastfeeding

• Emphasize benefits of human milk and provide more support and assistance to families of preterm and low birth-weight infants, as these infants are at an increased risk of dying from SIDS.

• Maintain culturally appropriate, respectful, and nonjudgmental communication when discussing feeding practices.

Room Sharing without Bed Sharing

• Infants should sleep in the parents' room, close to the parents' bed, but on a separate sleep surface for at least the first 6 months, as it decreases the risk of SIDS by as much as 50%.
• Bed sharing is not recommended under any circumstances.
• There are no recommendations for or against the use of bed sharing devices designed to make bed sharing “safe.”

• Couches and armchairs should never be used for infant sleep.

• It is recommended that twins and higher-order multiples be provided separate sleep surfaces; co-bedding should be avoided.

Soft Objects and Loose Bedding

• Soft objects (pillows, quilts, comforters, mattress toppers, plush or stuffed toys) and loose bedding (blankets and nonfitted sheets) should not be placed in the infant's sleep area, as these increase the risk of SIDS, suffocation, entrapment/wedging, and strangulation.

• Weighted blankets, weighted sleepers, weighted swaddles, or other weighted objects should not be used on a sleeping infant.

Soft Objects and Loose Bedding

• Dress the infant in layers of clothing or use a wearable blanket to keep the infant warm while sleeping rather than using blankets or other coverings.

• Bumper pads or products that attach to crib slats or sides are not recommended.

Pacifier Use

• Pacifier use during naps and nighttime sleep is recommended to reduce the risk of SIDS.
• Once the infant falls asleep, the pacifier does not need to be reinserted, and infants who refuse a pacifier should not be forced to take it.
• Pacifiers should not be hung around an infant's neck or attached to clothing when an infant is placed to sleep.
• Objects (blankets or plush stuffed toys) should not be attached to pacifiers.

Pacifier Use

• Delay introducing a pacifier to breastfed infants until breastfeeding is firmly established (sufficient milk supply; consistent, comfortable, and effective latch for milk transfer; appropriate infant weight gain).

Smoke and Nicotine Exposure

• Avoid smoke and nicotine exposure during pregnancy and after birth.

• Pregnant individuals should not smoke during pregnancy or after the infant's birth, and other people should not smoke near pregnant individuals or infants.

Alcohol and Drug Use

• Prenatal and postnatal exposure to alcohol, marijuana, opioids, and illicit drug use places the infant at increased risk of SIDS and is not recommended.

Overheating

• It is important to avoid overheating and head covering in infants.

• Infants should not be over-bundled and should wear no more than one layer more than an adult would wear to be comfortable in that environment.

• Assess for signs of overheating (sweating, flushed skin, chest feeling hot to touch).

Prenatal Care

• Pregnant individuals should obtain regular prenatal care and follow guidelines for the frequency of prenatal visits.

Immunizations

• Infants should be immunized in accordance with guidelines from the American Academy of Pediatrics and Centers for Disease Control and Prevention.

Commercial Devices

• There is no evidence that commercial devices reduce risk of sleep-related infant deaths, and such devices should not be used if there is inconsistency with safe sleep recommendations.

Home Cardiorespiratory Monitors

• There is no evidence that the use of home cardiorespiratory monitors reduces the risk of sleep-related infant deaths, and they should not be used as a strategy to reduce the risk of SIDS.

Tummy Time

• Supervised, awake tummy time is recommended for short periods beginning shortly after hospital discharge and increasing slowly to at least 15 to 30 minutes total daily by 7 weeks of age.
• Tummy time reduces the development of positional plagiocephaly.

Swaddling

• Swaddling is not recommended to reduce the risk of SIDS.

• If infants are swaddled, they should always be placed on their back.

• Swaddling should be snug around the chest but allows sufficient room at the hips and knees to reduce risk of developing hip dysplasia.

• When an infant is showing signs of attempting to roll (around 3 to 4 months), swaddling is no longer appropriate.