What are the safest sleep arrangements to prevent sudden infant death syndrome (SIDS) in infants, including preterm or low‑birth‑weight newborns?

Safe Sleeping Arrangements to Prevent Sudden Infant Death

The safest sleeping arrangement is room-sharing without bed-sharing: place the infant's crib, bassinet, or play yard in the parents' bedroom on a separate, firm sleep surface until at least 6 months of age, and ideally until the first birthday. 1, 2

Core Sleep Environment Requirements

Sleep Location

• Place the infant's sleep surface in the parents' bedroom close to the parents' bed to reduce SIDS risk by up to 50% while facilitating feeding, comforting, and monitoring 1, 2
• The first 6 months are particularly critical, as SIDS rates and bed-sharing deaths are highest during this period 1
• Use only a crib, portable crib, play yard, or bassinet that meets current safety standards with a firm, flat mattress 2, 3

Sleep Surface Safety

• Keep all soft objects and loose bedding completely out of the sleep area, including pillows, quilts, comforters, sheepskins, blankets, and pillow-like toys 1, 2
• Use infant sleep clothing such as wearable blankets instead of loose blankets to maintain warmth 1
• Do not use bumper pads or similar products that attach to crib slats, as they contribute to suffocation, entrapment, and strangulation deaths 1

Absolute Contraindications for Sleep Location

Never Place Infants to Sleep On:

• Couches or armchairs, which pose extraordinarily high risk of death through suffocation, entrapment, or overlay 1
• Adult beds for routine sleep, as they are not designed for infant safety and increase risks of suffocation, entrapment, and falls 1

High-Risk Bed-Sharing Situations to Avoid Completely

Parents must avoid bed-sharing under these circumstances: 1, 2

• When the infant is younger than 3 months of age, regardless of other factors 1, 2
• With anyone who smokes (even if not smoking in bed) or if the mother smoked during pregnancy 1
• With anyone who is excessively tired or fatigued 1, 2
• With anyone using sedating medications (antidepressants, pain medications) or substances (alcohol, illicit drugs) that impair alertness 1, 2
• With anyone who is not the infant's parent, including other children or nonparental caregivers 1, 2
• On soft surfaces including waterbeds, old mattresses, sofas, or armchairs 1
• With soft bedding accessories such as pillows or blankets present 1

Practical Feeding and Comforting Guidance

• 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
• Parents should be especially vigilant about their wakefulness when feeding infants on couches or armchairs, as these are extremely dangerous if the parent falls asleep 1

Special Populations

Twins and Higher-Order Multiples

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

Preterm and Low Birth Weight Infants

• These infants are at particularly high risk during the first 3 months due to immature motor skills and muscle strength that make it difficult to escape potential threats 1
• The same safe sleep recommendations apply, with heightened vigilance required 1

Important Caveats

Devices promoted to make bed-sharing "safe" (in-bed sleepers) are not recommended, as there is insufficient evidence that they reduce SIDS risk or are safe 1

Bedside sleepers with CPSC standards may be considered, but the task force cannot make a definitive recommendation due to lack of studies examining their association with SIDS or unintentional death 1

Car seats and other sitting devices should not be used for routine sleep at home or in the hospital, as they can potentiate complications and are not designed as sleep surfaces 1