This morning, the American Academy of Pediatrics (AAP) released a new set of safe sleep guidelines—the biggest update since 2011. Many of the recommendations are more of the same advice we’ve heard previously—don’t use bumper pads or blankets, always put baby to sleep on her back, don’t bed-share—but some of the new safe sleep guidelines are going to be harder for many parents to incorporate into their routines.
The 20-page policy statement tackles the topic of SIDS and safe sleep more thoroughly than ever before, using lots of different meta-analyses and studies. We spoke with co-author Lori Winter-Feldman, who is a professor of paediatrics, a practicing paediatrician in Camden, New Jersey, and a member of the Task Force on Sudden Infant Death Syndrome, to help guide us through what we found most surprising in the AAP report. Here's what we learned.
Parents should room-share for an entire year. The AAP is still adamantly against bed-sharing (sometimes called co-sleeping) for safety reasons, but, they say, we should be room-sharing for at least six months, and, optimally, a full year. Here’s the exact wording: “It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface. The infant’s crib, portable crib, play yard or bassinet should be placed in the parents’ bedroom ideally for the first year of life, but at least for the first six months.”
Yup, we know, this sounds extra cautious—and downright impractical for many parents. (It would make sleep training nearly impossible, for one.) But, says the AAP, room-sharing arrangements “decrease the risk of SIDS by as much as 50 per cent, and is safer than bed-sharing or solitary sleeping (when the infant is in a separate room).”
I was happy to room-share for the first few months of motherhood. I wanted my helpless, teeny little bundle of baby squish as close by as possible, pretty much at all times. But there was no way we could fit a full-sized crib into our bedroom. When our baby outgrew the bassinet at four months, we moved him to his crib in the nursery a few feet down the hall and used a video monitor to take a peek whenever he fussed. I didn’t love shuffling down the hall for middle-of-the-night nursing sessions, but eventually we both seemed to sleep more soundly in separate rooms, anyhow. In my case, the only way we would have been able to sleep in the same room for a full year is if I set up a twin mattress on the floor of the nursery.
With this new safe sleep guideline, parents are being told they definitely shouldn’t bed-share, but they really should room-share—a tricky balance to strike, and a complex message for paediatricians to communicate.
“We understand that this is going to be frustrating to parents—we get that,” says Feldman-Winter. But she says discussing the health risks, and any challenges you are having when it comes to following safe sleep guidelines, should be part of the conversation with your doctor.
Bed-sharing is still dangerous, even with no risk factors. The research shows that bed-sharing is particularly risky if your baby is younger than four months, if she was born pre-term or with a low birth weight, if you or your partner are smokers, if you or your partner has consumed alcohol, if you are not exclusively breastfeeding, if you smoked during pregnancy, and for certain ethnic and cultural backgrounds (specifically, Native Americans and African-Americans). This leads some parents to reason that if they don’t have any of the other risk factors, bed-sharing might be safer for them.
“Mothers do this intuitively: ‘If I’m reducing the risk here and here—I don’t smoke, for instance, and I’m breastfeeding, or I’m not one of the higher-risk groups, then maybe it’s OK?’” says Feldman-Winter. “We have a mathematical term for that: risk stratification.” So the task force tried to re-examine populations with no other risk factors, using existing studies and data. They still found that bed-sharing with babies under four months puts them at five times greater risk for SIDS or suffocation. The risk increases with every hour you bed-share, too—which means that bed-sharing only in the early morning, after that last sleepy, 5 a.m. “snooze-button” feed, is safer than bed-sharing all night long.
Meanwhile, nursing moms know that bed-sharing often makes breastfeeding easier (and therefore you're more likely to stick with it), and breastfeeding protects against SIDS. It’s a confusing jumble of conflicting evidence.
If you’re still going to bed-share against medical advice, make sure you remove all blankets, pillows and comforters from the shared flat sleep surface, says Winter-Feldman. “It’s still not safe, but it’s better than not following the recommendations at all.”
Do your best to return the baby to a bassinet or crib after feeding, but if you do doze off while nursing, you and your baby are better off in a bed than on a couch or rocking chair. “Couches and armchairs are extremely dangerous places for infants,” write the report authors. If you know this is happening a lot, make sure you’re doing feeds in a bed, and not on an armchair or on a couch.
“Sitting devices” should not be used for routine sleep. I'll be honest: strapping my baby into his swing for 90-minute morning nap was often the only way I got a shower in while on maternity leave. But the AAP is now warning against babies sleeping in what it calls "sitting devices," such as swings, strollers, bouncer chairs or car seats. This includes both naps and nighttime sleep. What's the problem with these devices? The AAP warns that the average baby spends 5.7 hours a day in a car seat or similar sitting device, which can cause flat head (positional plagiocephaly). What's more, babies under four months have poor head control in a sitting position; their heads can fall forward and cause positional asphyxiation (upper airway obstruction and oxygen desaturation). “Instead, parents should transfer a sleeping baby to a flat, safe sleep surface (a crib or bassinet) as soon as possible," says Feldman-Winter. This is easier said than done, obviously. “I know the Rock ‘n Plays are wildly popular,” she says, “but we do consider those sleep environments hazardous unless someone is monitoring the baby closely."
Offer a pacifier at naptime and bedtime. Once a steady breastfeeding relationship has been established, research shows that babies who sleep while sucking on a soother have a significantly decreased risk of SIDS—anywhere from 50 per cent to 90 per cent. Experts call this “the protective effect of pacifiers.” You might have heard of nipple confusion, or worry that allowing a pacifier creates a bad habit or hard-to-phase-out sleep crutch that will persist into toddlerhood. But the AAP reassures parents that “in general, sucking habits in children to the age of three years are unlikely to cause any long-term problems.” The report does, however, warn against letting babies sleep or nap with a pacifier clip attached to their clothing (it’s a strangulation risk) and states that sleeping, unmonitored infants should not use pacifiers with “objects such as stuffed toys” attached to them. (The popular WubbaNub binkies would fall into this risky category.)
Elevating the head of the crib mattress or otherwise keeping your baby more upright will not reduce reflux. This report looked at all the available evidence and found that, contrary to popular belief, putting babies to sleep flat on their backs does not increase the risk of choking and aspiration, even in those with gastroesophageal reflux (a more severe condition than the occasional newborn spit-up). Furthermore, “elevating the head of the infant’s crib is not effective in reducing reflux," says the AAP. "It may result in the infant sliding to the foot of the crib into a position that may compromise respiration and therefore is not recommended.” The risk of SIDS outweighs the benefits of allowing your baby to sleep on his stomach or side. Sadly, the experts don’t provide better advice for what to do with a baby who seems to be screaming in pain from reflux. Feldman-Winter theorizes that infants with reflux are calmer when they’re held in a vertical position not because their head is elevated, but because the cuddling and attention from a caregiver is soothing.
Safe sleep starts on the maternity ward and in the NICU. Often, parents see their brand new baby in the hospital bassinet and the nurses have placed them to sleep on their sides or stomachs. This leads them to assume that if the hospital did it, then it must be OK. The AAP wants to spread the message that there's no evidence that fluid (amniotic fluid or spit-up) will be cleared more readily while in the side position.
Swaddling does not reduce SIDS. There is no evidence, says the AAP, that swaddling protects babies from SIDS. In fact, babies have an increased risk of death if they are swaddled and then roll onto their tummies. Never place a swaddled baby to sleep on her stomach. If your infant “exhibits signs of attempting to roll, swaddling should no longer be used.” The doctors also found no conclusive relationship between SIDS and babies who were swaddled with their arms in, or with their arms out. This doesn’t mean you shouldn’t swaddle—it can be a great way to encourage sleep and calm your baby. Just make sure she’s always swaddled on her back.
In-bed sleepers are still a question mark. Studies on the safety of in-bed sleepers are underway, but the results aren't in yet, so the AAP's safe sleep guidelines don’t recommend for or against them. There are no Consumer Product Safety Commission safety standards for in-bed sleepers, either, which should be worrisome for parents using products like the DockaTot, By Your Side co-sleepers, or Snuggle Nests. Research is ongoing.
Frequent wake-ups keep your baby safe. The updated safe sleep guidelines reiterate the importance of always putting babies on their backs (not their side or tummies). "My baby wakes up a lot unless she's on her stomach!” you say? We hear you. But the experts believe that’s actually a good thing. “An infant who wakes frequently is normal and should not be perceived as a poor sleeper,” write the AAP authors. In fact, frequent “arousal” is the best way to protect against SIDS. “Physiologic studies show that infants are less likely to arouse when they are sleeping in the prone [on] position. The ability to sleep arouse from sleep is an important protective physiologic response to stressors during sleep, and the infant's ability to sleep for sustained periods may not be physiologically advantageous.” This is not exactly what exhausted parents want to hear, though.
Dr. Feldman-Winter is aware that a lot of these safe sleep guidelines aren't easy to follow, but doing your best to adhere to the latest recommendations is extremely important for ensuring a safe infant sleeping environment. “We know it’s not easy—that’s why we want to have these conversations about reducing risk. The best we can do is to get folks moving along the pathway to change," she says. "And fortunately, SIDS is a rare event.”