Reducing SIDS

Reducing Sleep-related Deaths in Infants

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The American Academy of Pediatrics (AAP) has just issued a new policy statement aimed at reducing all sleep-related deaths in infants, including Sudden Infant Death Syndrome (SIDS).[1] In 1992, the AAP issued recommendations that all babies should sleep on their backs; although deaths from SIDS have declined by more than 50% since the early 1990s, SIDS remains the third-leading cause of infant mortality and the leading cause of postneonatal mortality (28 days to 1 year of age).[2] Of note is the fact that sleep-related deaths from other causes, including suffocation, entrapment, and asphyxia, have increased.[1]

The new policy statement was released at the AAP National Conference on October 18, 2011.

The policy statement and technical report provide global recommendations for education and safety related to reducing risk factors for SIDS and other sleep-related deaths. The first recommendation regarding sleeping position is not new, but has been reinforced in the new technical report.

Babies should sleep in the supine position, not in the prone or side position. Recent evidence suggests that prone sleeping alters the autonomic control of the infant cardiovascular system, particularly at 2 to 3 months of age, and can result in decreased oxygenation to the brain.[3] Other data also suggest that side sleeping confers a similar risk of SIDS and that the population-attributable risk reported for side sleep position is higher than that for prone position.[4]

However, once infants are able to roll from supine to prone and prone to supine, they should be allowed to remain in the sleep position that they assume. Repositioning the sleeping infant to the supine position can be disruptive and can discourage infants from assuming the supine position altogether. Infants begin to roll over on their own at about 4 to 6 months—the age at which the incidence of SIDS begins to decline.

The guideline also reinforces that infants should sleep only in a safety-approved crib, portable crib, play yard, or bassinet; that car seats and other sitting devices are not recommended for routine sleep; and that room sharing—as opposed to bed sharing—is safe. The authors emphasize the lack of evidence to recommend that bed sharing protects against SIDS.

Three important additions to the new policy statement include:

  1. Breastfeeding. Breastfeeding is recommended, as newer research suggests that it has a protective role against SIDS,[5] although most of the research does not distinguish between breastfeeding and expressed human milk. This protective effect may be due to the fact that breastfed infants are more arousable from sleep than formula-fed infants or because the nutrients in breast milk confer an enhanced immunity to infections associated with an increased risk of SIDS. Moms should also consider offering a pacifier at naptime and bedtime, which might maintain airway patency during sleep.[6]
  2.  Immunizations. The incidence of SIDS peaks during the time babies receive their first sets of immunizations. While earlier data suggested an association between the administration of diphtheria-tetanus-pertussis (DTaP) and SIDS,[7] a 2003 review produced by the Institute of Medicine concluded that there was no relationship between exposure to multiple vaccinations and SIDS.[8] Although subsequent studies have shown that vaccines may protect against SIDS by up to 50%, this could be related to confounding factors such as socioeconomic status or the maternal, birth, and infant histories.[9]
  3.  Bumper pads. These should not be used in cribs. There is no evidence that bumper pads prevent injuries, and there is a potential risk of suffocation, strangulation, or entrapment.

The report also includes the following recommendations:

  • Keep soft objects or loose bedding out of the crib. This includes pillows, blankets, and bumper pads.
  • Wedges and positioners should not be used.
  • Pregnant woman should receive regular prenatal care.
  • Don’t smoke during pregnancy or after birth.
  • Avoid covering the infant’s head or overheating.
  • Do not use home monitors or commercial devices marketed to reduce the risk of SIDS.
  • Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly.


Jill Shuman, MS, ELS
Published October 25, 2011


  1. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 2011;October 17 [pub online before print]. doi: 10.1542/peds.2011-2285.
  2. U.S. Department of Health and Human Services, Centers of Disease Control and Prevention, National Center for Health Statistics, Office of Analysis and Epidemiology, Division of Vital Statistics. Compressed mortality data: underlying cause-of-death for 1979 –1998 with ICD 9 codes; and Mortality for 1999 –2007 with ICD 10 codes. Centers for Disease Control and Prevention Website. Accessed October 18, 2011.
  3. Wong FY, Witcombe NB, Yiallourou SR, et al. Cerebral oxygenation is depressed during sleep in healthy term infants when they sleep prone. Pediatrics. 2011;127(3)e558-e565.
  4. Fleming PJ, Blair PS, Bacon C, et al. Environment of infants during sleep and risk of the sudden infant death syndrome: results of 1993–5 case-control study for confidential inquiry into stillbirths and deaths in infancy. Confidential Enquiry into Stillbirths and Deaths Regional Coordinators and Researchers. BMJ. 1996;313(7051):191-195.
  5. Ip S, Chung M, Raman G, et al. A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. Breastfeed Med. 2009;4(Suppl 1):S17-S30.
  6. Franco P, Chabanski S, Scaillet S, et al. Pacifier use modifies infant’s cardiac autonomic controls during sleep. Early Hum Dev. 2004;77(1-2):99-108.
  7. Bernier RH, Frank JA Jr, Dondero TJ Jr, Turner P. Diphtheria-tetanus toxoids-pertussis vaccination and sudden infant deaths in Tennessee. J Pediatr. 1982;101(3):419-421.
  8. Immunization Safety Review Committee. In: Stratton K, Almario DA, Wizemann TM, McCormick MC, eds. Immunization Safety Review: Vaccinations and Sudden Unexpected Death in Infancy. Washington, DC: National Academies Press; 2003.
  9. Vennemann MM, Höffgen M, Bajanowski T, et al. Do immunisations reduce the risk for SIDS? A meta-analysis. Vaccine. 2007;25(26):4875-4879.