AAP Releases New Guidelines and Provides Recommendations for Safe Bed-Sharing

bed-share.jpgSleep for both new parents and the newborn is a big topic of discussion during pregnancy and certainly in childbirth classes.  Few new families are fully prepared for the impact of the needs of a newborn and understanding how adequate sleep for everyone can be accomplished safely.  Some childbirth educators may have been torn between strictly covering the recommendations of the American Academy of Pediatrics and also sharing information on safe bed-sharing. Educators are aware that, for many reasons, families may choose to bed-share with their young infant.  I covered this topic in a recent post - "Safe Bed-Sharing: Do Childbirth Educators Have a Responsibility to Cover This Topic?"

Today the American Academy of Pediatrics released a new policy statement titled "SIDS and Other Sleep Related Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment."  This updated guideline has been well received because for the first time, the AAP has acknowledged that parents are likely to fall asleep when breastfeeding their babies, and it is recommended that they should plan for this situation. Falling asleep with a baby on a couch or in a recliner is more dangerous than falling asleep in bed after breastfeeding when plans are made for this bed-sharing situation.

3500 babies die every year from sleep related infant deaths. Approximately 1500 of those deads can be attributed to SIDS. That includes including sudden infant death syndrome (SIDS), ill-defined deaths and accidental suffocation and strangulation in bed. The number of deaths decreased in the 1990s when the orginal "Back to Sleep" campaign was released in 1994.  This campaign is now known as the Safe to Sleep campaign.  The overall death rate attributable to sleep-related infant deaths has remained consistent and has not continued to decline. Despite the decline since the 1990s, SIDS is the leading cause of death in infants who are between 28 days to 1 year old.

Sudden unexpected infant death (SUID), also known as sudden unexpected death in infancy, or SUDI, is a term used to describe any sudden and unexpected death, whether explained or unexplained that occur during the first year of life.  SUID can be attributed to suffocation, asphyxia, entrapment, infection, ingestions, metabolic diseases, arrhythmia-associated cardiac channelopathies, and trauma (unintentional or nonaccidental). SIDS is a subcategory of SUID and is a cause assigned to infant deaths that cannot be explained after a thorough case investigation, including a scene investigation, autopsy, and review of the clinical history.  SIDS peaks between 1 month and 4 months of age. The AAP acknowledged that SIDS and SUID mortality rates, like other causes of infant mortality, have notable and persistent racial and ethnic disparities.  Infants of color are more likely to to be affected.

Recently, there has been more research into which infants might be predisposed to SIDS and there are ndications that some infants might be more at risk.  The paper states: "A working model of SIDS pathogenesis includes a convergence of exogenous triggers or “stressors” (eg, prone sleep position, overbundling, airway obstruction), a critical period of development, and dysfunctional and/or immature cardiorespiratory and/or arousal systems (intrinsic vulnerability) that lead to a failure of protective responses.  The convergence of these factors may ultimately result in a combination of progressive asphyxia, bradycardia, hypotension, metabolic acidosis, and ineffectual gasping, leading to death. Thus, death may occur as a result of the interaction between a vulnerable infant and a potentially asphyxiating and/or overheating sleep environment...Infants who die of SIDS are more likely to have been born preterm and/or were growth restricted, which suggests a suboptimal intrauterine environment. Other adverse in utero environmental conditions include exposure to nicotine or other components of cigarette smoke and alcohol."

Each of the recommendations and strength of evidence for each recommendation are published in the updated guidelines. While I have summarized them here, please refer to the original document linked above for detailed information.

AAP Recommended Guidelines

Infant Sleep Position

  • To reduce the risk of SIDS, infants should be placed for sleep in the supine position (wholly on the back) for every sleep period by every caregiver until 1 year of age. Side sleeping is not safe and is not advised.
  • The supine sleep position does not increase the risk of choking and aspiration in infants, even in those with gastroesophageal reflux.
  • Preterm infants should be placed supine as soon as possible.
  • As stated in the AAP clinical report, “skin-to-skin care is recommended for all mothers and newborns, regardless of feeding or delivery method, immediately following birth (as soon as the mother is medically stable, awake, and able to respond to her newborn), and to continue for at least an hour.”130 Thereafter, or when the mother needs to sleep or take care of other needs, infants should be placed supine in a bassinet.
  • Once an infant can roll from supine to prone and from prone to supine, the infant may remain in the sleep position that he or she assumes.

Sleep Surfaces

  • Infants should be placed on a firm sleep surface (eg, a mattress in a safety-approved crib) covered by a fitted sheet with no other bedding or soft objects to reduce the risk of SIDS and suffocation.
  • A crib, bassinet, portable crib, or play yard that conforms to the safety standards of the Consumer Product Safety Commission (CPSC) is recommended.
  • Sitting devices, such as car seats, strollers, swings, infant carriers, and infant slings, are not recommended for routine sleep in the hospital or at home, particularly for young infants.

Breastfeeding

  • Breastfeeding is associated with a reduced risk of SIDS. The protective effect of breastfeeding increases with exclusivity. Furthermore, any breastfeeding is more protective against SIDS than no breastfeeding.

Infant Sleep Location

  • It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface. The infant’s crib, portable crib, play yard, or bassinet should be placed in the parents’ bedroom, ideally for the first year of life, but at least for the first 6 months.
  • There is insufficient evidence to recommend for or against the use of devices promoted to make bed-sharing “safe.”
  • Infants who are brought into the bed for feeding or comforting should be returned to their own crib or bassinet when the parent is ready to return to sleep.
  • Couches and armchairs are extremely dangerous places for infants.
  • Guidance for parents who fall asleep while feeding their infant. (I have included the new info below!)

"The safest place for an infant to sleep is on a separate sleep surface designed for infants close to the parent’s bed. However, the AAP acknowledges that parents frequently fall asleep while feeding the infant. Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep.87,89,90,173,200,207 It is important to note that a large percentage of infants who die of SIDS are found with their head covered by bedding.186 Therefore, there should be no pillows, sheets, blankets, or any other items in the bed that could obstruct infant breathing87,182 or cause overheating.208211 Parents should follow safe sleep recommendations outlined elsewhere in this statement. Because there is evidence that the risk of bed-sharing is higher with longer duration, if the parent falls asleep while feeding the infant in bed the infant should be placed back on a separate sleep surface as soon as the parent awakens.89,90,206,207

There are specific circumstances that, in case-control studies and case series, have been shown to substantially increase the risk of SIDS or unintentional injury or death while bed-sharing, and these should be avoided at all times.

The task force emphasizes that certain circumstances greatly increase the risk of bed-sharing for both breastfed and formula-fed infants. Bed-sharing is especially dangerous in the following circumstances, and these should be avoided at all times:

  • when one or both parents are smokers, even if they are not smoking in bed 

  • when the mother smoked during pregnancy

  • when the infant is younger than 4 months of age, regardless of parental smoking status

  • when the infant is born preterm and/or with low birth weight

  • when the infant is bed-sharing on excessively soft or small surfaces, such as waterbeds, sofas, and armchairs

  • when soft bedding accessories such as pillows or blankets are used

  • when there are multiple bed-sharers

  • when the parent has consumed alcohol and/or illicit or sedating drugs

  • when the infant is bed-sharing with someone who is not a parent

A retrospective series of SIDS cases reported that mean maternal body weight was higher for bed-sharing mothers than for non–bed-sharing mothers.  The only case-control study to investigate the relationship between maternal body weight and bed-sharing did not find an increased risk of bed-sharing with increased maternal weight."

  • The safety and benefits of cobedding twins and higher-order multiples have not been established. It is prudent to provide separate sleep areas and avoid cobedding (sleeping on the same sleep surface) for twins and higher-order multiples in the hospital and at home.

Use of Bedding

  • Keep soft objects, such as pillows, pillow-like toys, quilts, comforters, sheepskins, and loose bedding, such as blankets and nonfitted sheets, away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and strangulation.
  • Bumper pads are not recommended; they have been implicated in deaths attributable to suffocation, entrapment, and strangulation and, with new safety standards for crib slats, are not necessary for safety against head entrapment.

Pacifier Use

  • Consider offering a pacifier at naptime and bedtime. (After one month of age and breatsfeeding is well established.)
  • There is insufficient evidence that finger sucking is protective against SIDS.

Prenatal and Postnatal Exposures (Including Smoking and Alcohol) 

  • Pregnant women should obtain regular prenatal care.
  • Smoking during pregnancy, in the pregnant woman’s environment, and in the infant’s environment should be avoided.
  • Avoid alcohol and illicit drug use during pregnancy and after the infant’s birth.

Overheating, Fans and Room Ventilation

  • Avoid overheating and head covering in infants.

Immunizations

  • Infants should be immunized in accordance with AAP and Centers for Disease Control and Prevention recommendations.

Commercial Devices

  • Avoid the use of commercial devices that are inconsistent with safe sleep recommendations.

Home Monitors, SIDS, and Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events)

  • There is no evidence that apparent life-threatening events are precursors to SIDS. Furthermore, infant home cardiorespiratory monitors should not be used as a strategy to reduce the risk of SIDS.
Tummy Time
  • Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly.

Swaddling

  • There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. Infants who are swaddled have an increased risk of death if they are placed in or roll to the prone position. If swaddling is used, infants should always be placed on the back. When an infant exhibits signs of attempting to roll, swaddling should no longer be used.

Potential Toxicants

  • There is no evidence substantiating a causal relationship between various toxicants to SIDS.

Hearing Screens

  • Current data do not support the use of newborn hearing screens as screening tests for SIDS

Educational Interventions

  • Educational and intervention campaigns are often effective in altering practice.

Media Messages

  • Media and manufacturers should follow safe sleep guidelines in their messaging and advertising.

I feel that childbirth educators can now discuss bed-sharing (which I always did) with a bit more confidence and acknowledge that the AAP recognizes it can happen, and wants families to know how to do it safely.   A big step in the right direction in my opinion. Estimates are that 60% of families bed-share at some point after having a baby.  They need to kow how to do it safely.

Here are some other Science & Sensibility posts that also discuss this topic.

Expert Opinion

kendall-tackett 2014-small.jpgI asked Science & Sensibility contributor and maternal infant health expert Kathleen Kendall Tackett PhD, IBCLC, FAPA her thoughts after she initially looked at the new guidelines released yesterday.  Dr, Kendall Tackett commented, "First, the statement specifically pulls out breastfeeding as something that lowers the risk of SIDS, which it does (by 50% according to Vennemann's study). But they don't acknowledge the oft-repeated finding that bed-sharing increases exclusive breastfeeding rates. In fact, "any" pattern of bed-sharing increases breastfeeding duration. So it's hard to have one without the other.

Second, they acknowledge, for the first time, that parents do fall asleep while feeding their babies and it will often be in bed. This is the first time for that particular statement. In the 2011 statement, they warned parents about not feeding babies on couches or recliners as this really increases SIDS. That was what a lot of parents were doing so they would not be "bed-sharing." In 2011, they said to feed babies in bed, but put them in their own space for sleep. The 2011 statement didn't acknowledge that parents fall asleep. The 2016 statement does acknowledge that, but still goes on to point out all the times when bed-sharing is not safe. They only had one study that said that bedsharing is not safe before 4 months even for breastfeeding babies. Actually, the studies say 12 weeks or younger (which is 3 months, not 4). Then after that, NO increase in risk. 

So for exclusively breastfeeding, non-impaired mothers, I think we are moving in the right direction. At least they are acknowledging that bed-sharing does happen and here's how to make it safer. But the current statement doesn't differ all that much from the 2011 statement in terms of other key recommendations."

Conclusion

I invite you to read the entire AAP updated guidelines and share your thoughts here in the comments section,  Did they go too far or not far enough?  Are you happy with the content of this document?  Will you change what you discuss in class and with your families?   Let me know below.

Photo credit: https://www.isisonline.org.uk/image-archive/images/image-17/

References

SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment, Rachel Y. Moon, TASK FORCE ON SUDDEN INFANT DEATH SYNDROME, 
3 Comments

Image credit

October 27, 2016 02:35 AM by Cassandra Yuill

Hi there - thank you for a great article! I work out at the Parent-Infant Sleep Lab/Infant Sleep Information Source, who created the image used above. It's amazing to see an image from the archive being used in exactly the way we intended. Do you mind adding a credit to image with a link to the archive? (https://www.isisonline.org.uk/image-archive/images/image-17/) We would greatly appreciate it, since it will help us get the word out about it! 

Cassandra

Credit for photo

October 27, 2016 10:54 AM by Sharon Muza

Changing that now! My mistake.  In fact, I did a whole post on that respository!  It is so appreciated.

Thank you!

November 6, 2016 01:52 AM by Maura Shirey

This was a hot topic at group class this weekend and I was so happy to be able to share this thorough article with attendees.  Thank you for this great info and expert opinion on what can be a scary, emotional and stressful topic for many.  

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