Maintaining safe sleep environments

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On October 24, 2016, the American Academy of Pediatrics (AAP) released new guidelines to help support safe infant sleeping environments. While Sudden Unexpected Infant Death (SUID) statistics continue to reflect a decline, approximately 3500 infants die annually in the United States from sleep-related infant death.


There are three categories of SUID:


    Sudden Infant Death Syndrome (SIDS)

    The sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and a review of the clinical history.
    • About 1,500 infants died of SIDS in 2014.
    • SIDS is the leading cause of death in infants 1 to 12 months old.

    Unknown Cause

    The sudden death of an infant less than 1 year old that remains undetermined because one or more parts of the investigation were not completed.

    Accidental Suffocation and Strangulation in Bed

    The sudden death of an infant less than 1 year of age that can happen because of:
    • Suffocation by soft bedding - for example, when a pillow or waterbed covers an infant's nose and mouth.
      • Overlay—when another person rolls on top of or against the infant while sleeping.
      • Wedging or entrapment—when an infant is wedged between two objects such as a mattress and wall, bed frame, or furniture.
      • Strangulation—for example, when an infant’s head and neck become caught between crib railings.

American Academy of Pediatrics Guidelines

One of the guidelines provided by the AAP has a direct impact on child care providers.  Recommendation #16 states, health care professionals, staff in newborn nurseries and NICUs, and child care providers should endorse and model the SIDS risk-reduction recommendations from birth. This recommendation highlights that all state regulatory agencies should require that child care providers receive education on safe infant sleep and implement safe sleep practices.  It further outlines that it is preferable that they have written policies.

How would you rate your center’s compliance with the new AAP guidelines?


The additional guidelines are as follows:

  1. Place infants on their back to sleep (supine) for every sleep period until they are 1 year old. This position does not increase the risk of choking and aspiration.
  2. Use a firm sleep surface.
  3. Breastfeeding is recommended.
  4. Infants should sleep in the parents’ room, close to the parents’ bed but on a separate surface designed for infants, ideally for the first year, but at least for the first six months.
  5. Keep soft objects and loose bedding out of the infant’s sleep area.
  6. Consider offering a pacifier at naptime and bedtime.
  7. Avoid smoke exposure during pregnancy and after birth.
  8. Avoid alcohol and illicit drug use during pregnancy and after birth.
  9. Avoid overheating and head covering in infants.
  10. Pregnant women should obtain regular prenatal care.
  11. Infants should be immunized according to the recommended schedule.
  12. Avoid using commercial devices that are inconsistent with safe sleep recommendations, such as wedges and positioners.
  13. Don’t use home cardiorespiratory monitors as a strategy to reduce SIDS risk. 
  14. Supervised tummy time while the infant is awake can help development and minimize positional plagiocephaly. (Plagiocephaly is often referred to as flat head syndrome. It is a condition that causes a baby’s head to have a flat spot.) 
  15. There is no evidence to recommend swaddling to reduce the risk of SIDS.
  16. Healthcare professionals and staff in newborn nurseries and neonatal intensive care units, as well as child care providers, should endorse and model recommendations to reduce SIDS risk.
  17. Media and manufacturers should follow safe sleep guidelines in messaging and advertising.
  18. Continue the Safe to Sleep campaign, focusing on ways to further reduce sleep-related deaths.
  19. Research and surveillance should continue on all risk factors.

You can further review the American Academy of Pediatrics SUID guidelines by visiting the sids.org website.

To aid in your public education efforts, the National Institute of Health - Safe to Sleep campaign - provides a number of resources child care providers can use to aid their public education efforts. 

Overall, while SUID statistics continue to reflect a decline; it is important for child care providers maintain vigilant in their efforts to reduce the likelihood of SUID.


Additional strategies that can help support a safe sleeping environment include:

  • Maintaining supervision by sight and sound at all times.
  • Continue to educate yourself and your staff on strategies to reduce SUID events.
  • Frequently inspect cribs and always file product registration cards with the manufacturer to ensure you are made aware of any product recalls.
  • Avoid putting children to sleep with teething necklaces and pacifier straps that may become a potential strangulation hazard while a child sleeps.

Get tips on conducting Crib inspections through Markel’s risk management library.


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