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AAP recommendations peds_2022057990
AAP recommendations peds_2022057990
Each year in the United States, 3500 infants die of sleep-related infant abstract
deaths, including sudden infant death syndrome (SIDS) (International a
Department of Pediatrics, University of Virginia School of Medicine,
Classification of Diseases, 10th Revision [ICD-10] R95), ill-defined deaths Charlottesville, Virginia; bDepartment of Pediatrics, Division of Pediatric
Critical Care and Hospital Medicine, Columbia University Irving Medical
(ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 Center, NewYork-Presbyterian Hospital, New York, New York, New York;
W75). After a substantial decline in sleep-related deaths in the 1990s, the and cDepartment of Pediatrics, SUNY-Downstate College of Medicine, NYC
Health 1 Hospitals jKings County, Brooklyn, New York
overall death rate attributable to sleep-related infant deaths has remained
stagnant since 2000, and disparities persist. The triple risk model Drs Moon, Carlin, and Hand approved the final manuscript as
submitted and agree to be accountable for all aspects of the work.
proposes that SIDS occurs when an infant with intrinsic vulnerability
This document is copyrighted and is property of the American
(often manifested by impaired arousal, cardiorespiratory, and/or Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy of
autonomic responses) undergoes an exogenous trigger event (eg, Pediatrics. Any conflicts have been resolved through a process
exposure to an unsafe sleeping environment) during a critical approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
developmental period. The American Academy of Pediatrics recommends involvement in the development of the content of this publication.
a safe sleep environment to reduce the risk of all sleep-related deaths. Policy statements from the American Academy of Pediatrics benefit
from expertise and resources of liaisons and internal (AAP) and
This includes supine positioning; use of a firm, noninclined sleep surface; external reviewers. However, policy statements from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
room sharing without bed sharing; and avoidance of soft bedding and organizations or government agencies that they represent. The
overheating. Additional recommendations for SIDS risk reduction include guidance in this statement does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
human milk feeding; avoidance of exposure to nicotine, alcohol, into account individual circumstances, may be appropriate.
marijuana, opioids, and illicit drugs; routine immunization; and use of a All policy statements from the American Academy of Pediatrics
pacifier. New recommendations are presented regarding noninclined automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
sleep surfaces, short-term emergency sleep locations, use of cardboard DOI: https://doi.org/10.1542/peds.2022-057990
boxes as a sleep location, bed sharing, substance use, home Address correspondence to Rachel Y. Moon, MD, FAAP. E-mail:
cardiorespiratory monitors, and tummy time. Additional information to rymoon@virginia.edu
assist parents, physicians, and nonphysician clinicians in assessing the PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
risk of specific bed-sharing situations is also included. The Copyright © 2022 by the American Academy of Pediatrics
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BACKGROUND technical report) will use the term identification of a single cause of
Sudden unexpected infant death sleep-related death (infants implied) death challenging.
(SUID) is a term used to describe to encompass unexplained sudden
any sudden and unexpected death, death in infancy/SIDS and accidental Rates of sleep-related death, like
deaths explained by a physical other causes of infant mortality,
whether explained or unexplained,
hazard in the sleep environment, have notable and persistent racial
occurring during infancy (Table 1).
except where reference is made to and ethnic disparities,6 reflecting
After case investigation, it may be
published data that used a specific broader racial and ethnic societal
determined that an unexpected
inequities. Mortality rates for non-
death was caused by a specific terminology and definition.
Hispanic Black and American
unnatural or natural etiology, such
The pathophysiology of sleep- Indian/Alaska Native infants have
as suffocation, mechanical asphyxia,
related deaths is complex and decreased more slowly than rates
entrapment, infection, ingestions,
multifactorial, with the triple-risk for other infants. Differences in the
metabolic diseases, arrhythmia-
model being the most widely prevalence of supine positioning and
associated cardiac channelopathies,
other sleep environment conditions
or trauma (unintentional or accepted conceptual framework.
among different racial and ethnic
nonaccidental). Unexplained sudden This model proposes that SIDS
populations may contribute to these
death in infancy (also known as occurs when an infant with intrinsic
disparities.7 Factors that result in
sudden infant death syndrome vulnerability (often manifested by
the marginalization of infants and
[SIDS]) is a subcategory of SUID and impaired arousal, cardiorespiratory,
their families, including low
is a cause assigned to infant deaths and/or autonomic responses)
socioeconomic status or low
that cannot be explained after a undergoes an exogenous trigger
socioeconomic position,
thorough case investigation, event (such as exposure to an unemployment, housing instability,
including a scene investigation, unsafe sleeping environment) during and domestic violence, are highly
autopsy, and review of the clinical a critical developmental period.5 correlated with race/ethnicity in the
history.1–3 Unexplained sudden Although research supports various United States,8 and are also
death in infancy, and not SIDS, is the intrinsic anatomic, physiologic, and associated with both higher risk of
terminology preferred by the genetic vulnerabilities in some sleep-related deaths9 and increased
National Association of Medical infants, improved death prevalence of known risk factors for
Examiners.3,4 Because nearly all of investigation and systematic reviews these deaths.10 Addressing the
the deaths discussed in this policy of case series have revealed often- potential impact of structural
statement occur during infant sleep modifiable exogenous stressors. The racism; recognizing the lack of
or in a sleep environment, this multifactorial nature of many sleep- access to economic, social, and
statement (and the accompanying related deaths can make educational resources as a risk
the accompanying technical report, sleep by every caregiver until the aspiration19,20 (see Fig 1 and
“Evidence Base for 2022 Updated child reaches 1 year of age.14–18 video [https://www.youtube.
Recommendations for a Safe Infant Side sleeping is not safe and is com/watch?v=zm0YQbAsDnk],
Sleeping Environment to Reduce the not advised.15,17 both of which may be helpful
Risk of Sleep-Related Infant a. The supine sleep position on a in educating parents and care-
Deaths”.13 flat, noninclined surface does givers). The American Acade-
not increase the risk of my of Pediatrics (AAP)
RECOMMENDATIONS TO REDUCE THE choking and aspiration in concurs with the North Ameri-
RISK OF SLEEP-RELATED INFANT infants and is recommended can Society for Pediatric Gas-
DEATHS
for every sleep, even for troenterology and Nutrition
1. Back to sleep for every sleep. To infants with gastroesophageal that “ … no position other than
reduce the risk of sleep-related reflux (GER). The infant supine position is recom-
death, it is recommended that airway anatomy and mended for infants because of
infants be placed for sleep in a protective mechanisms (eg, the risk of SIDS.” Further, “the
supine (back) position for every gag reflex) protect against working group recommends
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