What are the recommended sleep practices to prevent Sudden Infant Death Syndrome (SIDS)?

Safe Sleep Practices to Prevent SIDS

Infants must sleep on their back on a firm, flat surface in the parents' room (but not in the parents' bed) for at least the first 6 months and ideally the entire first year of life. 1, 2, 3

Sleep Position

• Place infants supine (on their back) for every sleep until 1 year of age, as this position confers the lowest risk of SIDS compared to side or prone positioning. 2
• Side sleeping is unsafe and carries significantly higher risk than supine positioning—it should never be used. 2
• The supine position does not increase choking or aspiration risk, even in infants with gastroesophageal reflux, because infants have protective airway mechanisms. 2

Sleep Location: Room-Sharing Without Bed-Sharing

The infant's crib, portable crib, play yard, or bassinet must be placed in the parents' bedroom close to the parents' bed. 1, 2, 3

• Room-sharing without bed-sharing decreases SIDS risk by as much as 50%. 1, 3
• This arrangement should continue ideally for the first year of life, but at least for the first 6 months, which are the most critical period when SIDS rates are highest. 1, 3
• Room-sharing facilitates feeding, comforting, and monitoring while removing the possibility of suffocation, strangulation, and entrapment that may occur in the adult bed. 1, 3

Sleep Surface Requirements

• Use only a firm sleep surface (mattress in a safety-approved crib) covered by a fitted sheet with no other bedding or soft objects. 1
• The surface must maintain its shape and not indent or conform to the infant's head when placed on it. 1
• Soft mattresses, including memory foam, can create pockets that increase rebreathing or suffocation risk if the infant rolls prone. 1
• Use only cribs, bassinets, portable cribs, or play yards that conform to Consumer Product Safety Commission standards, including slat spacing less than 2-3/8 inches. 1

Absolute Bed-Sharing Prohibitions

Parents must avoid bed-sharing in these high-risk situations at all times: 1, 3

• When the infant is younger than 3 months, regardless of parental smoking status 1, 3
• With a current smoker (even if not smoking in bed) or if the mother smoked during pregnancy 1, 3
• With someone who is excessively tired 1, 3
• With someone using medications (antidepressants, pain medications) or substances (alcohol, illicit drugs) that impair alertness or ability to arouse 1, 3
• With anyone who is not the infant's parent, including other children 1
• With multiple persons 1
• On soft surfaces such as waterbeds, old mattresses, sofas, couches, or armchairs 1
• On surfaces with soft bedding accessories such as pillows or blankets 1

Critical Caveat About Couches and Armchairs

Infants should never be placed on a couch or armchair for sleep under any circumstances. 1 Sleeping on couches and armchairs places infants at extraordinarily high risk of death through SIDS, suffocation, entrapment between cushions, or overlay. 1 Parents must be especially vigilant about their wakefulness when feeding infants on these surfaces. 1

Safe Sleep Environment

Remove all soft objects and loose bedding from the infant's sleep area. 1, 2

• Keep out pillows, pillow-like toys, quilts, comforters, sheepskins, blankets, and nonfitted sheets, as these can obstruct the infant's nose and mouth. 1
• Use infant sleep clothing such as wearable blankets instead of loose blankets to keep the infant warm. 1
• Do not use bumper pads or similar products that attach to crib slats, as they contribute to deaths from suffocation, entrapment, and strangulation and are unnecessary with modern crib safety standards. 1
• Keep the sleep area free of dangling cords, electric wires, and window-covering cords that present strangulation risk. 2

Feeding and Comforting Practices

• Infants may be brought into the parental bed for feeding or comforting but must be returned to their own crib or bassinet when the parent is ready to return to sleep. 1, 2, 3
• This is a critical distinction—temporary bed contact for feeding is acceptable, but the infant cannot remain in the adult bed for sleep. 1

Special Considerations for Multiples

• Provide separate sleep surfaces and avoid co-bedding for twins and higher-order multiples both in the hospital and at home. 1, 2, 3
• The safety and benefits of co-bedding for multiples have not been established. 1

Temperature Regulation

• Dress infants appropriately for the environment with no more than 1 layer more than an adult would wear to be comfortable. 1
• Evaluate the infant for signs of overheating such as sweating or chest feeling hot to the touch. 1
• Avoid overbundling and covering of the face and head. 1

Additional Protective Measures

• Offer a pacifier at nap time and bedtime after breastfeeding is established (usually 3-4 weeks for breastfed infants), as pacifiers have a protective effect against SIDS even if they fall out during sleep. 1
• Avoid all smoke exposure during pregnancy and after birth, as maternal smoking during pregnancy and environmental smoke are major SIDS risk factors. 1
• Avoid alcohol and illicit drug use during pregnancy and after birth, as these significantly increase SIDS risk, especially when combined with bed-sharing. 1, 3
• Breastfeed exclusively or feed with expressed milk for 6 months, as breastfeeding is associated with reduced SIDS risk, with the protective effect increasing with exclusivity. 1, 3

Devices and Products

The American Academy of Pediatrics cannot make recommendations for or against bedside sleepers or in-bed sleepers because no studies have examined their association with SIDS or unintentional injury and death. 1 There is no evidence that devices promoted to make bed-sharing "safe" actually reduce SIDS or suffocation risk. 1