Yesterday we reviewed the American Academy of Pediatrics’ newly updated policy statement, “SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment.” Practically all the suggested guidelines were familiar to parents and pediatricians alike, including putting fully immunized and preferably breastfed infants to sleep on their backs, on a firm sleep surface, without soft objects and loose bedding, in smoke-free, drug-free, and alcohol-free environments. But it was this new recommendation that took so many people, including some pediatricians, by surprise:

It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.

 

The authors used prior studies to explain this recommendation:

There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%. In addition, this arrangement is most likely to prevent suffocation, strangulation, and entrapment that may occur when the infant is sleeping in the adult bed.

 

It goes against what many pediatricians, older parents, and grandmothers have been advising since… well, a long time. But the new recommendation is adament:

The infant’s crib, portable crib, play yard, or bassinet should be placed in the parents’ bedroom until the child’s first birthday. Although there is no specific evidence for moving an infant to his or her own room before 1 year of age, the first 6 months are particularly critical, because the rates of SIDS and other sleep-related deaths, particularly those occurring in bed-sharing situations, are highest in the first 6 months. Placing the crib close to the parents’ bed so that the infant is within view and reach can facilitate feeding, comforting, and monitoring of the infant. Room-sharing reduces SIDS risk and removes the possibility of suffocation, strangulation, and entrapment that may occur when the infant is sleeping in the adult bed.

 

What is being recommended is room sharing, NOT bed sharing, but alone on appropriate firm and uncluttered sleep surfaces designed for infants, like cribs, bassinets, and playards (Pack ‘N Play). Armchairs and sofas are strictly forbidden as a place for infants to sleep:

Couches and armchairs are extremely dangerous places for infants. Sleeping on couches and armchairs places infants at extraordinarily high risk of infant death, including SIDS, suffocation through entrapment or wedging between seat cushions, or overlay if another person is also sharing this surface. Therefore, parents and other caregivers should be especially vigilant as to their wakefulness when feeding infants or lying with infants on these surfaces. Infants should never be placed on a couch or armchair for sleep.

 

Mothers who need to nurse or bottle feed their babies at night should be encouraged to lie in their own beds, without pillows and blankets, for the feeding session. In case sleepiness during nursing ensues, the mother’s bed (free of soft bedding) is a safer location for a baby than feeding in an armchair or on a sofa. Mothers are instructed to put their babies back to sleep in their appropriate sleep areas immediately after the feeding is completed.

Alice Callahan spoke to the guidelines’ authors:

What is new is acknowledgment that tired parents sometimes fall asleep while feeding their babies, and they should plan for that. “We’ve heard stories of parents who take their baby to the couch to feed, because they’re afraid that they’ll fall asleep while feeding on the bed,” said Rachel Moon, professor of pediatrics at University of Virginia School of Medicine and lead author of the policy statement. “Since the couch is a much more dangerous place for this to happen, we wanted to be sure that parents knew this.”

This scenario may be particularly common for breastfeeding mothers. “The process of breastfeeding renders a mom sleepy, physiologically,” said Lori Feldman-Winter, professor of pediatrics at Cooper Medical School and co-author of the AAP policy statement. If a mother thinks she may fall asleep while feeding, “we actually recommend that she feed the baby in the bed, because feeding the baby in a sofa or an armchair is more hazardous” if she falls asleep, Feldman-Winter said.

 

The AAP’s policy statement even addresses a popular trend — twins and multiples sharing the same crib:

The safety and benefits of cobedding for twins and higher-order multiples have not been established. It is prudent to provide separate sleep surfaces and avoid cobedding for twins and higher-order multiples in the hospital and at home.

 

It’s important to state that these sleep recommendations extend to any and every sleep situation an infant encounters — at home, in daycare, at the babysitter’s and grandma’s house — as Alyson Sulaski Wyckoff points out:

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.

 

Like many pediatricians, for the past 26 years I’ve advised that parents put their babies to sleep on their backs, in an uncluttered crib, in their own rooms as soon as mothers and fathers felt comfortable doing so. “The day you come home from the hospital is not too early,” I would say. That advice thankfully never let a parent or a baby down. Even today, parents tell me that my advice was the best I ever gave them because it allowed their babies to learn how to fall asleep — and stay asleep — on their own earlier. Parents also reported to me that they slept better when they put their babies in their own rooms. Alas, I cannot in good conscience continue advising this. The AAP has spoken, the reasoning is clear and evidence-based. It’s time to change my tune. Or retire!

 

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