For the first time in five years, The American Academy of Pediatrics (AAP) has released updated recommendations regarding infant sleep. The 2022 safe sleep guidelines are based on an evidence review from nearly 160 scientific studies since 2015 and are aimed at preventing sudden infant death syndrome (SIDS), which is the cause of death of approximately 3,500 infants in the U.S. every year.
In many cases, these deaths may be preventable with safe sleep practices. First Candle, a nonprofit organization dedicated to reducing SIDS and sudden unexplained infant death syndrome (SUIDS), states that 79% of SIDS deaths are due to babies sleeping in an adult bed or in a crib/bassinet with pillows, blankets, stuffed animals, crib bumpers or loose clothing.
Though SIDS-related deaths decreased dramatically after the Back to Sleep campaign was introduced in the 1990s, they have remained relatively unchanged since the 2000s.
But there has been a recent push to address risk factors. The Safe Sleep for Babies Act signed into law this year outlaws the manufacture and sale of crib bumpers and inclined sleepers that have been linked to dangerous sleep practices.
Researchers may have recently identified a biomarker that could help predict which infants are at higher risk for SIDS, but safe sleep practices are still critically necessary to help reduce risk for all babies. Here’s what you need to know about the AAP’s new evidence-based recommendations for safe infant sleep.
Infant sleep position
AAP recommendation: Babies should be placed on their back for every sleep by every caregiver until they reach 1 year of age. Babies should not be placed on their side or tummy for sleep, even for short naps.
What you need to know: When babies sleep on their stomach, it means their airway is not able to be as open as when they sleep on their backs. Sleeping on their side means it’s easier for babies to roll onto their stomach. Stomach sleeping can also raise body temperature and cause them to overheat.
For parents and caregivers worried about baby choking on spit-up, it’s actually safer to have baby sleep on their back than on their side or stomach. “When a baby is on his back and spits up, he can turn his head left to right to clear his airway, but if he’s on his stomach, he can only turn his head into the mattress. Also, when he’s on his back, gravity will pull the spit-up down and back into his food pipe [esophagus] rather than his windpipe [trachea],” notes First Candle.
AAP recommendation: Baby should sleep in a crib, bassinet, portable crib or play yard on a flat, non-inclined sleep surface with a firm, tightly fitting mattress. The mattress should be covered by a fitted sheet with no other bedding or soft objects.
What you need to know: Recent studies have shown that sleep surfaces inclined beyond 10 degrees are unsafe for infant sleep, as they might encourage infants to roll over to their tummy, even if they haven’t before.
The Consumer Product Safety Commission (CPSC) also recently passed a rule that any infant sleep product must meet strict federal safety standards, so look for a sleeping surface that’s certified by CPSC. Any in-bed sleepers, inclined sleep products, baby nests, pods and hammocks are not recommended, and mattresses should be firm, not soft. “A great way to test if a surface is too soft is to press your hand down and then lift it up. If your hand leaves an indentation, it’s too soft,” states First Candle.
AAP recommendation: Infants should sleep in the parents’ room, close to the parents’ bed but on a separate surface designed for infants, ideally for at least the first six months.
What you need to know: Room-sharing—without bed-sharing—drastically reduces the risk of SIDS. Because 90% of SIDS cases occur before a baby reaches 6 months, AAP has shortened the recommended period of room sharing to the time when SIDS risk is highest (recommendations used to state for up to 12 months). SIDS risk peaks between 1 and 4 months of age and is uncommon after 8 months of age, states AAP.
Bed-sharing or co-sleeping
AAP recommendation: Although AAP cannot recommend bed-sharing based on the evidence, the organization also respects that many parents choose to bed-share routinely for a variety of reasons, including making breastfeeding easier and cultural preferences.
What you need to know: The evidence shows that co-sleeping or bed-sharing may increase the risk of SIDS, but If bed-sharing is important to you, have a conversation with your child’s pediatrician first to ensure you’re bed-sharing in the safest possible way.
Lots of families still opt to co-sleep: Data from The Centers for Disease Control and Prevention (CDC) found that 61.4% of families reported infant bed sharing.
“Parents are exhausted and while they may know the guidelines are against adult bed sharing, it happens, often for practicality while the mother is breastfeeding, and she may fall asleep. For others it’s due to socioeconomic factors, cultural beliefs, traditions, or personal choice,” says First Candle CEO Alison Jacobson, a SIDS mother who lost her son in 1997.
To reduce SIDS risk factors when bed-sharing, AAP recommends babies should never co-sleep with someone who is using medications or substances that may impair their ability to arouse, or with someone who is a current smoker.
Because the risk can be up to 67 times greater, AAP strongly recommends not placing infants for sleep (by themselves or with another person) on a couch, sofa or armchair, or on a waterbed or old mattress, and removing any blankets, pillows or soft bedding from nearby babies’ head or face. If babies were born pre-term or with a low birth weight, co-sleeping increases their risk of SIDS.
The risk of SIDS from co-sleeping is also higher for babies who were born full-term but are less than 4 months of age. After 4 months, their risk decreases.
“It feels as if keeping your baby right next to you is the safest spot to protect him/her and to bond, but even the tiniest baby can 'root and scoot' up towards a pillow, under a blanket, into your chest or roll over onto your soft mattress or into the corner between the wall and your bed,” notes First Candle.
Bedding and weighted blankets
AAP recommendation: Do not place any soft objects, including pillows, blankets or bumper pads, in the infant’s sleep environment.
What parents need to know: Babies shouldn’t be placed to sleep on top of or underneath any type of bedding other than a fitted sheet. If you’re worried that your infant might be cold, add layers of clothing, but not blankets, states AAP.
Wearable blankets or sleep sacks may be used, but the AAP recommends against using any weighted objects, such as weighted blankets, weighted sleep sacks or weighted swaddles on or near a sleeping infant.
Sleeping in car seats
AAP recommendation: Car seats, strollers, swings, infant carriers and infant slings are not recommended for routine sleep, particularly for infants younger than 4 months. When infants fall asleep in a car seat or other sitting device, remove them from the seat and move them to a crib as soon as is safe and practical.
What parents need to know: When infants fall asleep in a seated position, they may inadvertently obstruct their own airway as they relax their heads and their chin falls onto their chest. Babies may of course fall asleep in a car seat when driving in a car, but once you arrive, move baby out of the car seat and onto a firm, flat surface and on their back, recommends First Candle. “If you’re on a longer car ride, take breaks and wake baby up to stretch.”
It’s also unsafe to leave an infant unattended in a car seat, or to leave an infant in a car seat with the straps unbuckled or partially buckled, notes AAP, due to a risk of strangulation. And when using a baby carrier or infant sling, make sure your infant's head is up and above the fabric and their face is visible.
AAP recommendation: Breastfeed exclusively for approximately 6 months and continuing for 1 year or longer as mutually desired by parent and infant.
What parents need to know: Breastfeeding is associated with a lower risk of SIDS as it provides an immune system boost for babies, and because breastfed babies are more easily woken up from sleep, notes First Candle. Even breastfeeding for any amount of time can reduce SIDS risk. AAP also says benefits can be conferred from breast milk regardless of whether it comes from breast or is pumped and fed from a bottle. Feeding with breast milk also can help to offset SIDS risks in babies born pre-term or at a lower birth weight, who may be at a naturally higher risk.
Overheating and hats
AAP recommendation: Avoid overheating and head covering in infants.
What parents need to know: Because head-covering and overbundling with excessive clothing/blankets can be associated with an increased risk of SIDS, AAP does not recommend babies wear hats indoors outside of the NICU or beyond the first few hours after birth.
A warmer room temperature can also be tied to SIDS risk. AAP doesn’t recommend a specific room temperature, but does suggest that parents dress infants appropriately for the environment, with no more than one layer more than an adult would be comfortable wearing. To check for signs of overheating, look for flushed skin, sweating, or the infant’s chest feeling hot to the touch.
AAP recommendation: There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS.
What parents need to know: If a swaddled infant is placed on their back but rolls to their tummy, there is a high risk for death, notes AAP. Swaddled infants should always be placed on their back, but when an infant starts to show signs of attempting to roll, swaddling should no longer be used.
Swaddling has been shown to calm infants and help them stay sleeping on their backs, notes First Candle, but swaddling with a blanket may be dangerous if it loosens. Try a wearable swaddle, with one arm untucked.
AAP recommendation: Offering a pacifier at nap time and bedtime is recommended to reduce the risk of SIDS.
What parents need to know: Multiple studies have shown that offering a pacifier for every sleep can reduce the risk of SIDS by 50% to 90%. The reasons why are still unclear—but it may be due to increased control over waking and better airway opening. If the pacifier falls out of the baby’s mouth during sleep, there’s no need to reinsert it, says the AAP.
They also recommend waiting to introduce a pacifier until breastfeeding is firmly established, defined as having sufficient milk supply, an effective latch and appropriate infant weight gain.
AAP recommendation: Avoid the use of commercial devices that claim to reduce the risk of SIDS or other sleep-related deaths.
What parents need to know: The AAP warns parents and caregivers to be particularly wary of devices that claim to reduce the risk of SIDS. “There is no evidence that any of these devices reduce the risk of these deaths,” the organization states. Certain sleep positioners, mattresses and wearable monitors are considered “wellness devices” and not “medical devices” by the FDA, and aren’t held to the same regulatory requirements as medical devices.
They may give a false sense of security or signal a false alarm because they’re not calibrated to be as accurate as a medical device. “Do not use home cardiorespiratory monitors (devices that monitor baby’s heart rate and oxygen levels) as a strategy to reduce the risk of SIDS, because there is no evidence that they do,” states First Candle.
AAP recommendation: Supervised tummy time should start soon after hospital discharge and increase slowly to at least 15-30 minutes total daily by 7 weeks of age.
What parents need to know: When awake, babies should be placed on their tummies to help build muscles in their neck, arms and shoulders. Placing babies only on their back while awake could also lead to the development of a flat spot on the back of their head. “Items used for tummy time, however, such as toys, should not be used for sleeping,” notes First Candle.
AAP also recommends that parents and caregivers avoid smoke and nicotine exposure both during pregnancy and after birth, along with alcohol and other substances. Additionally, they note that pregnant people should keep up with regular prenatal care and that infants should receive their childhood vaccines in accordance with AAP and CDC recommendations. For the full list of AAP’s updated guidelines, find the complete recommendations here.
A note from Motherly
These guidelines may seem like a lot to remember, but the most important thing to keep in mind? Putting your baby to sleep on their back on a firm, flat surface—every time. The guidelines are meant to serve as steps to take to keep your baby safe. If you have any concerns or questions, reach out to your child’s pediatrician.