Practice Guidelines

SIDS and Safe Sleeping Environments for Infants: AAP Updates Recommendations


Am Fam Physician. 2017 Jun 15;95(12):806-807.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• For the first six to 12 months of life, infants should sleep in the same room as the parents, on a separate surface near the bed.

• To avoid overheating, infants should be dressed properly for the sleep environment.

• Breastfeeding is associated with a lower risk of SIDS, and infants should be breastfed exclusively for the first six months unless contraindicated.

• Use of commercial devices that are inconsistent with safe sleep recommendations should be avoided.

From the AFP Editors

Sudden and unexpected deaths that occur in infancy are called sudden unexpected infant death (SUID) or sudden unexpected death in infancy (SUDI). These types of death can be caused by suffocation, asphyxia, entrapment, infection, ingestions, metabolic diseases, arrhythmia-associated cardiac channelopathies, or trauma. If no cause can be determined, the death is attributed to sudden infant death syndrome (SIDS), which is a subcategory of SUID and difficult to distinguish from SUIDs. A conclusive diagnosis often cannot be made via autopsy. The American Academy of Pediatrics (AAP) updated its recommendations to reduce the risk of SIDS and suffocation, asphyxia, and entrapment associated with sleep, focusing on SUIDs that transpire during sleep in infants one year or younger.


Grades for these recommendations are based on the Strength-of-Recommendation Taxonomy. Level A recommendations are based on good-quality patient-oriented evidence. Level B is based on inconsistent or limited-quality patient-oriented evidence. Level C is based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series. No randomized controlled trials exist on SIDS or other deaths associated with sleep; therefore, case-control studies are considered standard evidence.


For the first six to 12 months of life, infants should sleep in the same room as the parents, on a separate surface near the bed. This has a greater likelihood of preventing suffocation, strangulation, or entrapment that can occur when an infant shares a bed with the parents. The sleep surface should be specifically designed for infants, be firm (e.g., crib mattress placed in a crib or bassinet), and meet applicable safety standards. A soft sleeping surface (e.g., memory foam) can increase the risk of rebreathing or suffocation. Only a fitted sheet should be placed on the sleeping surface; other bedding (e.g., pillows, nonfitted sheets) and soft objects (e.g., toys) should be kept away from the sleep area.

When sleeping, infants should always be placed fully on their backs. Placing an infant on his or her side is not safe and not recommended. A pacifier should be offered, but if it falls out after the infant is asleep, it does not need to be placed back in the infant's mouth. If the pacifier is refused, it should not be forced, but can be offered again in the future. The pacifier should not be placed around the infant's neck or attached to clothing, soft toys, or blankets.

To avoid overheating, infants should be dressed properly for the sleep environment. Caregivers should not dress the infant in more than one layer more than an adult would wear, nor should they cover the infant's face or head. Care should be taken to assess for signs of overheating (e.g., sweating). Home cardiorespiratory monitors should not be used to lower the risk of SIDS.

Pregnant women should routinely receive prenatal care. Breastfeeding is associated with a lower risk of SIDs, and infants should be breastfed exclusively for the first six months unless contraindicated. Immunization may provide some protection from SIDS; therefore, infants should receive vaccinations recommended by the AAP and the Centers for Disease Control and Prevention.

Exposing the infant to smoke should be avoided, including during pregnancy, because it is a risk factor for SIDS. Alcohol consumption and illicit drug use are also risk factors and should be avoided during and after pregnancy. There is a greater risk of SIDS when parents share a bed with an infant after using alcohol or drugs.

Health care and child care staff should promote and follow recommendations for reducing the risk of SIDS. Safe sleep practices should be screened for and recommended by health care professionals during all visits in the first year of the infant's life. All health care professionals should receive education on safe infant sleep practices, and should in turn screen for safe sleep protocols and make recommendations to caregivers at every visit. Hospital policies should align with current sleeping recommendations, and infant sleeping surfaces in hospitals should meet appropriate safety standards. Persons providing child care services should be required by their state regulatory agency to receive safe sleep education, follow safe sleep protocols, and have written policies in place, if possible.

“Safe to Sleep” should continue to be promoted, with physicians actively participating, and should focus on situations that increase the risk of SIDS and on ways to decrease the incidence of bed sharing and exposure to tobacco smoke, as well as ways to increase breastfeeding. Public education should be aimed at caregivers (e.g., parents, grandparents, babysitters). To incorporate new products and reach new parents, this campaign and its messages should be reassessed at least every five years and revised, if needed.


Use of commercial devices (e.g., wedges, positioners) that are inconsistent with safe sleep recommendations should be avoided. It is recommended that when awake, the infant should have tummy time supervised by a caregiver, which can help with his or her development and decrease the occurrence of positional plagiocephaly. No evidence regarding the frequency and duration exists; however, other guidelines indicate that some tummy time can help minimize occiput flattening and aid in the infant's development.


Although no data exist on the use of swaddling for lowering the risk of SIDS, caregivers should be aware that there is increased risk of death if the infant is placed on or rolls onto his or her stomach; therefore, infants should always be placed on their backs if swaddled, and swaddling should be discontinued once an infant tries to roll.

Guideline source: American Academy of Pediatrics

Evidence rating system used? Yes

Literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? Yes

Published source: Pediatrics. November 2016;138(5):e20162938

Available at:

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



Copyright © 2017 by the American Academy of Family Physicians.
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