In its first update in more than five years(!), the American Academy of Pediatrics has revised its safe sleep guidelines for infants.

AAP strongly recommends flat sleeping surfaces for infants, breastfeeding, and advises against bed-sharing and swaddling after three to four months, among other things.

The newly revised recommendations are based on 159 scientific studies to promote safe sleep among babies and apply to children up to one year old.

According to CDC, there are about 3,500 sleep-related deaths among U.S. babies each year, including sudden infant death syndrome (SIDS), accidental suffocation, and other unknown causes. 

“We want to reach new parents, grandparents and other infant caregivers so that everyone is aware about how best to keep their baby safe,” said UVA Health’s Fern Hauck, MD, MS, a member of the AAP’s Task Force on SIDS. 

AAP safe sleep guidelines 2023: Important takeaways

In the 1990s, there were sharp declines in sleep-related deaths following the national “Back to Sleep” campaign. However, the declines have slowed since then—and data from a new Vital Signs report from the U.S. Centers for Disease Control and Prevention shows the risk for babies persists.

Furthermore, families of color are disproportionately impacted. According to an AAP statement released on June 21, 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.

Sleep surfaces

• New safe sleep guidelines: Babies should sleep on a firm, flat sleep surface. According to AAP, “Sleep surfaces with inclines of >10 degrees are unsafe for infant sleep.” Parents are also advised against using devices such as car seats, strollers, swings, infant carriers, and infant slings as routine places to sleep, particularly for infants younger than four months

• What the science says: Sleep surfaces that are inclined more than 10 degrees increase the chances of a baby rolling over onto their stomach or side, which puts them at a higher risk for muscle fatigue and potential suffocation. Sleeping on a soft or fluffy surface is also dangerous for your baby as the soft bedding can come up and around the baby’s nose.
  
  Many parents whose babies struggle with acid reflux resort to inclining the baby or putting a wedge underneath the baby or the mattress in order to help their little ones sleep more comfortably.
  
  “This is not advisable. You do not want to place anything into the crib with the baby,” Dr. Nilong Vyas (MD, Pediatrician), founder of Sleepless at NOLA, says. “A lot of families will roll up blankets or towels, or beddings and place it either under the baby’s neck or head or put them under mattresses or under crib legs.”
  
  Instead, she recommends that “If your newborn is struggling with reflux, it is advisable for you to go talk to a pediatrician and find out about treatment options.”

Swaddling guidelines

• New safe sleep swaddling guidelines: Avoid swaddling after your baby can turn over (which usually occurs at three to four months but may occur earlier). Swaddling increases the risk of suffocation if the infant rolls over onto their tummy or side. Wrapping your baby may help encourage longer sleep stretches, but it’s important to do it safely.

• What the science says: There are conflicting studies regarding the benefits of swaddling. However, there’s no firm evidence to support the claim that it reduces the risk of SIDS. 
  
  Swaddling can also cause your baby to overheat, so make sure to monitor their temperature and keep the room between 68℉ and 72℉ (a fan can help circulate air).

Weighted blankets 

• New safe sleep guidelines: Avoid placing weighted blankets, weighted sleepers, weighted swaddles, or other weighted objects ON or NEAR the sleeping infant.

• What the science says: AAP states that dressing an infant with layers of clothing is preferable to blankets and other coverings to keep the infant warm while reducing the chance of head covering or entrapment that could result from blanket use. Wearable blankets can also be used.

Head coverings

• New safe sleep guidelines: Refrain from putting hats on your infant when indoors except in the first hours of life or in the NICU.

• What the science says:  To avoid overheating, avoid over bundling and covering the baby’s face and head. An increased risk of SIDS is associated with ​excessive clothing or blankets covering an infant.

Bed-sharing

• New safe sleep guidelines: Parents are encouraged to room-share (but not share a bed), ideally for at least six months.

• What the science says: Room-sharing is especially important in the first six months because the rates of sleep-related deaths are highest during this vulnerable time. 
  
  As per AAP, room-sharing decreases the risk of SIDS by as much as 50% and is safer than bed-sharing or when the infant is in a separate room. It allows parents to be close to the baby, which helps facilitate “feeding, comforting, and monitoring of the infant.”
  
  According to Dr. Vyas, “It’s okay to share the bed when nursing or feeding a child, laying flat if mom needs to nurse that way, that’s okay. But after the feeding is done, bring the baby into his or her designated sleep surface.”
  
  We know this is easier said than done when dealing with sleep deprivation. Dr. Vyas suggests that parents set a timer on their phones to alert them when feeding time is over. “It will help kind of to jar you awake a little bit in case you have fallen asleep and put the baby back in the bassinet or crib after feeding,” she says.

Use of bedding

• New safe sleep guidelines: Keep your baby’s sleep area clear of soft objects (like pillows, pillow-like toys, quilts, comforters, mattress toppers, fur-like materials) and loose bedding (like blankets and non-fitted sheets). Avoid crib bumpers.

• What the science says: The aforementioned materials can obstruct a baby’s airway. Bedding in the sleeping environment increases SIDS risk fivefold independent of sleep position. 

Breastfeeding

• New safe sleep guidelines: Breastfeed for the first six months and continue for one year of age (or longer, as mutually desired by the parent and baby). AAP states “Feeding of human milk is recommended because it is associated with a reduced risk of SIDS.”

• What the science says: AAP advises breastfeeding because breast milk boosts a baby’s immune system. Breastfed babies are more easily roused from sleep, reducing their risk of SIDS. As per AAP, “Physiologic sleep studies showed that breastfed infants are more easily aroused from sleep than their formula-fed counterparts.”
  
  Breastfeeding provides the baby with overall immune system benefits attributable to maternal antibodies and micronutrients in human milk.

Pacifiers

• New safe sleep guidelines: Offering a pacifier at nap time and bedtime is recommended to reduce the risk of SIDS.

• What the science says: AAP quotes multiple studies that have reported a protective effect of pacifiers on the incidence of SIDS, with decreased risk of SIDS ranging from 50% to 90%. Although the ‘why’ isn’t yet clear, a possible explanation is that pacifiers help keep the baby’s airway open. 
  
  Also, if your baby is breastfed, delay introducing a pacifier to them until breastfeeding is firmly established (sufficient milk supply; consistent, comfortable, and effective latch for milk transfer, etc.)

Tummy time

• New safe sleep guidelines: Parents are encouraged to place the infant in tummy time while awake and supervised for short periods of time. You can start this soon after hospital discharge and increase your baby’s tummy time incrementally to at least 15 to 30 minutes total daily by seven weeks of age.

• What the science says: Tummy time is good for babies. Babies may develop a flat spot on the back of their head (plagiocephaly) if their head position is not varied when placed for sleep. According to Dr. Vyas, “Tummy time helps strengthen the muscles in the neck and back and will help babies protect their airways when they start to roll.”

Cardiorespiratory monitors

• New safe sleep guidelines: Parents are recommended to not trust home cardiorespiratory monitors and devices as a strategy to reduce the risk of SIDS.

• What the science says: There is no current data to support that existing commercial devices that are designed to monitor infant vital signs reduce the risk of these deaths. Wellness devices don’t save lives. Medical devices do. Therefore, do not rely on these devices. Wearable heart rate and pulse oximetry monitoring devices are considered to be “wellness devices,” which do not meet the FDA criteria for medical devices.
  
  Parents who use these monitors at home for peace of mind are strongly encouraged to still follow safe sleep recommendations. Most importantly keep a physical watch. Nothing like the natural parental instinct to guarantee safety for your baby.