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The End of the SIDS Era: Focus on Safe Sleep

June 21, 2022

In this month’s Pediatrics, the American Academy of Pediatrics (AAP) released a new policy statement “Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment” (10.1542/peds.2022-057990) and its accompanying technical report (10.1542/peds.2022-057991). There are a number of changes in this newest version of the policy, starting with the first major change being the name of the policy. While subtle, the Task Force on Sudden Infant Death Syndrome has removed the term sudden infant death syndrome (or SIDS) from the title and verbiage of the policy – now focusing on “Sleep-Related Deaths.” For those of us who have been involved with Child Fatality Review for the past few decades, this is a welcome change.

As noted in the policy and technical report, SIDS is just one of multiple causes of death for infants who die suddenly and unexpectedly (also known as sudden unexpected infant death (SUID)). Other mechanisms include asphyxiation, strangulation, or “undetermined” (e.g., a child prone sleeping on an adult bed might not have clear evidence of asphyxiation but could have died from either asphyxiation or SIDS). Because the cause of death may overlap 2 viable possibilities, many medical examiners will not make a determination especially if there are other risk factors for suffocation. The bottom line, however, is that “sleep-related deaths” is a much better term that encompasses all of these possible causes of death through a common term.

Preventing sleep-related deaths is everyone’s responsibility. The new policy statement reaffirms the prior recommendations of placing infants to sleep on their own sleep surface (no bed sharing), with a firm mattress, on their back, with nothing else in the crib or bassinette (pillows, blankets, etc.). Pacifiers, breastfeeding, and a smoke-free environment are recommended as well as co-rooming for the first 6 months of life. Changes from the prior policy in 2011 include a specific recommendation against using inclined sleep surfaces (They don’t help reflux and place infants at risk.) and for the acceptable use of temporary “baby boxes” in emergency situations while awaiting an approved crib or pack and play. While acknowledging that some families and breastfeeding advocates want to bed share, the policy explicitly notes that “AAP is unable to recommend bed sharing under any circumstances” and clearly outlines the increased risk of infant death in a variety of bed sharing situations – with the highest risk for bed sharing with caregivers impaired by alcohol or drugs.

Additionally, the new policy statement supports actions that pediatricians can take to promote safe sleep. First is to make sure that physicians and all hospital staff start safe sleep education prenatally and model the safe sleep guidelines in the hospital nursery or NICU, and after discharge. We know that modeling behavior leads to improved compliance with following the guidelines, and patients often do what they see in the hospital after birth. Additionally, pediatricians can help advocate for the media to show safe sleeping positions in advertisements and television shows or movies, and we can support the National Institute of Child Health and Human Development “Safe to Sleep” program and messaging (you can get free materials here). Finally, don’t forget to recommend that babies get plenty of tummy time while awake to help promote motor development.

It’s worth a few minutes of your time to read through both the policy and the supporting technical report so that you are able to effectively counsel families and support safe sleep for all infants.

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