Pediatric Guidelines Urge Flat Surface for Sleeping BabiesJune 23, 2022
Caregivers should continue putting infants to sleep in a supine position, according to updated pediatric guidelines that make the additional recommendation to make sure the sleeping surface is fully firm and flat — meaning no inclined sleepers, couches, or armchairs.
Recent research shows that infants on an incline are more likely to slide down and obstruct their airway, and roll onto the side or into prone position.
In contrast, a firm, flat surface for sleeping does not increase the risk of choking or aspiration, even if coughing and gagging in this setting is sometimes mistaken for choking, according to the latest guidance on safe sleep for babies from the American Academy of Pediatrics (AAP).
Published in Pediatrics, the recommendations are otherwise mostly unchanged since the AAP last updated them in 2016, Rebecca Carlin, MD, a coauthor of the guidelines, told MedPage Today. “Babies should be placed on their backs, on a firm surface that meets federal safety standards, with nothing but the baby in the space,” she emphasized.
There should be no other objects on the flat surface in order to reduce the risk of suffocation or entrapment, the AAP group says.
Manufacturers like Fisher-Price have recalled millions of inclined sleepers because of infant deaths. Just in May this year, the Safe Sleep for Babies Act of 2021 banning crib bumpers and inclined sleepers became law.
The AAP’s insistence on a flat sleeping surface for babies follows years of warnings that babies sleeping prone or on their sides are at increased risk of rebreathing expired gases, potentially leading to hypoxia and hypercapnia, as well as overheating.
Carlin’s group stated that older infants able to roll between supine and prone positions can be allowed to sleep in whatever position they assume. They should always be placed supine for the first year, even if they change position on their own. Data to make specific recommendations as to when it is safe for infants to sleep in the prone position are lacking, however.
Other recommendations from the AAP group encourage human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier to reduce risk of sudden infant death syndrome (SIDS). There is no evidence that swaddling reduces these mysterious deaths, on the other hand.
The risk of SIDS begins to decline after 4 months of age and is attributed to different mechanisms at different ages. It may be related to underdevelopment of cardiorespiratory response, autonomic response, or impaired arousal in an unsafe sleeping environment. Recently, one study generated much interest in its finding that low butyrylcholinesterase activity appeared to be a marker for SIDS.
SIDS is also more common in infants that were born premature, suggesting the role of a poor intrauterine environment.
AAP guideline authors noted that there are approximately 3,500 sleep-related infant deaths every year in the U.S. caused by suffocation, strangulation, and other ill-defined deaths. A decline in these deaths in the 1990s was followed by stagnant rates since the 2000s.
SIDS cases have also been on the decline, with 75% fewer cases in 2019 than the early 1990s. However, some causes of death previously deemed SIDS have been reclassified upon more rigorous death investigation, which may partially explain the decline.
Nationwide, sudden infant deaths, both explained and unexplained, continue to disproportionately affect non-Hispanic Black, American Indian, and Alaska Native infants, according to Carlin and colleagues.
The updated AAP guidelines were based on a review of 159 studies published since 2015.
Guideline authors had no disclosures.