Most pediatricians know what makes a safe sleep environment for babies. But parents still are attracted to elaborate bedding and plush accessories – all the accoutrements experts say have no place in an infant’s crib.

That’s one reason new AAP safe sleep guidelines released today include basic recommendations from the past plus new warnings about increased risk of sudden infant death syndrome (SIDS) from use of soft bedding and the dangers of babies sleeping on couches and armchairs.

Nineteen evidence-based recommendations (see below) aimed at protecting infants up to 1 year of age are featured in SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment, an AAP policy statement and technical report from the Task Force on Sudden Infant Death Syndrome. They are available at http://dx.doi.org/10.1542/peds.2016-2938 and http://dx.doi.org/10.1542/peds.2016-2940 and will be published in the November issue of Pediatrics.

The guidance, updated from 2011, considers data from 63 new studies as well as a recent AAP clinical report on the benefits of skin-to-skin care for newborns (http://bit.ly/2cKSXck).

Safe sleep recommendations include placing infants on their backs to sleep; using a firm sleep surface; room sharing without bed sharing; avoiding exposure to smoke, alcohol and illicit drugs; breastfeeding; routine immunization; and using a pacifier.

SIDS facts

Every year, about 3,500 infants die from sleep-related deaths. Soon after the Back to Sleep campaign debuted in 1994, the SIDS rate declined, but it has leveled off in recent years. Ninety percent of cases occur before an infant turns 6 months of age, with peak incidence between 1 and 4 months. Most parents know the importance of placing babies on their backs to sleep; the focus now is on the total sleep environment.

“I think the back-to-sleep message has gotten out loud and clear,” said Rachel Y. Moon, M.D., FAAP, lead author of the statements and chair of the task force. “When you ask parents, almost every parent knows – whether they are doing it or not is a different thing. We have been less successful at getting people to not sleep with their babies … and much less successful in getting the soft bedding away from babies.”

Dangers not intuitive?

Unfortunately, there is a sense that bed-sharing and soft bedding are protective, Dr. Moon said. “For the soft bedding, everybody thinks if it’s soft, then it can’t hurt the baby. But soft bedding is actually really a problem because it’s so soft they sink into it. People will often use pillows to ‘cushion’ the babies, and babies sink into them. …That’s very dangerous.”

It’s similar with bed-sharing, she said. “Some parents also think if baby is right next to them, they can tell if there is a problem … and protect the baby.”

Other messages

Michael H. Goldstein, M.D., FAAP, a neonatologist and task force member, reminds parents of the “ABCs”: A for the baby sleeping alone, B for back-sleeping and C for sleeping in an uncluttered crib (or play-yard or bassinet). “Outside of these, one of the biggest things I would really like to see people take away from the updated recommendations is that no matter what, babies should never sleep on a couch, especially with another person,” Dr. Goldstein said. Babies can get wedged between the adult and the cushions.

The policy also warns of the dangers of parents falling asleep while feeding the baby, and it provides broad guidelines to minimize risk in that situation. If babies are swaddled, it’s essential to place them on their backs, Dr. Moon said. If placed on their stomachs, they can’t move and have no defense mechanism. When babies look like they are starting to roll, they should no longer be swaddled.

Breastfeeding, along with the use of a pacifier after breastfeeding is established, also is a key recommendation. “We don’t know if people realize that (by breastfeeding) you reduce the risk of SIDS about 50%,” Dr. Goldstein said.

Parents also are advised to be vigilant about environments out of the home. A study in the November issue of Pediatrics found out-of-home settings are more likely to have certain risk factors for sleep-related deaths, including prone placement for sleep and location in a stroller or car seat instead of a crib or bassinet Michael H. Goldstein, M.D., FAAP, a neonatologist and task force member, reminds parents of the “ABCs”: A for the baby sleeping alone, B for back-sleeping and C for sleeping in an uncluttered crib (or play-yard or bassinet). “Outside of these, one of the biggest things I would really like to see people take away from the updated recommendations is that no matter what, babies should never sleep on a couch, especially with another person,” Dr. Goldstein said. Babies can get wedged between the adult and the cushions.

The policy also warns of the dangers of parents falling asleep while feeding the baby, and it provides broad guidelines to minimize risk in that situation. If babies are swaddled, it’s essential to place them on their backs, Dr. Moon said. If placed on their stomachs, they can’t move and have no defense mechanism. When babies look like they are starting to roll, they should no longer be swaddled.

Breastfeeding, along with the use of a pacifier after breastfeeding is established, also is a key recommendation. “We don’t know if people realize that (by breastfeeding) you reduce the risk of SIDS about 50%,” Dr. Goldstein said.

Parents also are advised to be vigilant about environments out of the home. A study in the November issue of Pediatrics found out-of-home settings are more likely to have certain risk factors for sleep-related deaths, including prone placement for sleep and location in a stroller or car seat instead of a crib or bassinet (Kassa H, et al. Pediatrics. 2016;138(5):e20161124, http://dx.doi.org/10.1542/peds.2016-1124). More education is needed for caregivers.

Sometimes caregivers – and others – associate longer sleeping with happier babies and that is another misconception, according to Dr. Moon. It’ s normal and appropriate for newborns to wake up a couple of times during the night, especially if breastfeeding, said Dr. Goldstein.

Families may be confused by the proliferation of “SIDS-prevention-type” products, but no product prevents SIDS.

“What concerns me,” said Dr. Moon, “is that a lot of parents think there is a proactive agency that checks all of these products before they go on the market, like an ‘FDA’ for (SIDS) products. But there isn’t .”

2016 safe sleep recommendations

1. Place infants on their back to sleep (supine) for every sleep period until they are 1 year old. This position does not increase the risk of choking and aspiration.

2. Use a firm sleep surface.

3. Breastfeeding is recommended.

4. Infants should sleep in the parents’ room, close to the parents’ bed but on a separate surface designed for infants, ideally for the first year, but at least for the first six months.

5. Keep soft objects and loose bedding out of the infant’s sleep area.

6. Consider offering a pacifier at naptime and bedtime.

7. Avoid smoke exposure during pregnancy and after birth.

8. Avoid alcohol and illicit drug use during pregnancy and after birth.

9. Avoid overheating and head covering in infants.

10. Pregnant women should obtain regular prenatal care.

11. Infants should be immunized according to the recommended schedule.

12. Avoid using commercial devices that are inconsistent with safe sleep recommendations, such as wedges and positioners.

13. Don’t use home cardiorespiratory monitors as a strategy to reduce SIDS risk.

14. Supervised tummy time while the infant is awake can help development and minimize positional plagiocephaly.

15. There is no evidence to recommend swaddling to reduce the risk of SIDS.

16. Health care professionals and staff in newborn nurseries and neonatal intensive care units as well as child care providers should endorse and model recommendations to reduce SIDS risk.

17. Media and manufacturers should follow safe sleep guidelines in messaging and advertising.

18. Continue the Safe to Sleep campaign, focusing on ways to further reduce sleep-related deaths.

19. Research and surveillance should continue on all risk factors.