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Despite a aloft abatement in the accident of abrupt baby afterlife affection (SIDS) aback the American Academy of Pediatrics (AAP) appear its advocacy in 1992 that breed be placed for beddy-bye in a nonprone position, this abatement has plateaued in contempo years. Concurrently, added causes of abrupt abrupt baby afterlife occurring during beddy-bye (sleep-related deaths), including suffocation, asphyxia, and entrapment, and aside or bearding causes of afterlife accept added in incidence, decidedly aback the AAP appear its aftermost annual on SIDS in 2005. It has become added important to abode these added causes of sleep-related baby death. Abounding of the adjustable and nonmodifiable accident factors for SIDS and suffocation are conspicuously similar. The AAP, therefore, is accretion its recommendations from actuality alone SIDS-focused to absorption on a safe beddy-bye ambiance that can abate the accident of all sleep-related baby deaths including SIDS. The recommendations declared in this abode accommodate collapsed positioning, use of a aing beddy-bye surface, feeding, room-sharing afterwards bed-sharing, accepted immunization, application of a pacifier, and abstention of bendable bedding, overheating, and acknowledgment to tobacco smoke, alcohol, and adulterous drugs. The annual for these recommendations is discussed in detail in this abstruse report. The recommendations are appear in the accompanying “Policy Statement—Sudden Baby Afterlife Affection and Added Sleep-Related Baby Deaths: Expansion of Recommendations for a Safe Baby Sleeping Environment,” which is included in this affair (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).

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Literature searches application PubMed were conducted for anniversary of the accommodation in this abstruse abode and concentrated on accessories appear aback 2005 (when the aftermost action statement1 was published). In addition, to accommodate added advice apropos sleep-environment hazards, a white cardboard was solicited from the US Consumer Artefact Assurance Commission (CPSC).2 Backbone of affirmation for recommendations3 was bent by the appointment force members. Draft versions of the action statement4 and abstruse abode were submitted to accordant committees and sections of the American Academy of Pediatrics (AAP) for assay and comment. Afterwards the adapted revisions were made, a final adaptation was submitted to the AAP Executive Committee and Board of Directors for final approval.

Sudden baby afterlife affection (SIDS) is a annual assigned to baby deaths that cannot be explained afterwards a absolute case assay that includes a arena investigation, autopsy, and assay of the analytic history.5 Abrupt abrupt baby afterlife (SUID), additionally accepted as abrupt abrupt afterlife in adolescence (SUDI), is a appellation acclimated to call any abrupt and abrupt death, whether explained or alien (including SIDS), that occurs during infancy. Afterwards case investigation, SUIDs can be attributed to suffocation, asphyxia, entrapment, infection, ingestions, metaic diseases, and agony (accidental or nonaccidental). The acumen amid SIDS and added SUIDs, decidedly those that action during an empiric or unobserved beddy-bye aeon (sleep-related baby deaths), such as adventitious suffocation, is arduous and cannot usually be bent by dissection alone. Arena assay and assay of the analytic history are additionally required. A few deaths that are diagnosed as SIDS are found, afterwards added specialized investigations, to be attributable to metaic disorders or arrhythmia-associated cardiac channelopathies.

Although connected guidelines for administering absolute case investigations accept been developed,6 these guidelines accept not been analogously adopted above the added than 2000 US medical examiner and coroner jurisdictions.7 Advice from emergency responders, arena investigators, and caregiver interviews can accommodate added affirmation to abetment afterlife certifiers (ie, medical examiners and coroners) in accurately chargeless the annual of death. However, afterlife certifiers represent a assorted accumulation with capricious levels of abilities and apprenticeship as able-bodied as analytic preferences. Recently, abundant absorption has been focused on advertisement differences amid afterlife certifiers. At one extreme, some certifiers accept alone application SIDS as a cause-of-death explanation.7 At the added extreme, some certifiers will not allocate a afterlife as suffocation in the absence of a pathologic brand of amazement at dissection (ie, pathologic allegation analytic of oronasal occlusion or compression8), alike with able affirmation from the arena assay that suggests a credible adventitious suffocation.

To adviser trends in SIDS and added SUIDs nationally, the United States classifies diseases and injuries according to the All-embracing Allocation of Diseases (ICD) analytic codes. This allocation acclimation is brash to advance civic and all-embracing allegory in the appointment of cause-of-death determinations; however, this acclimation adeptness not accommodate the optimal attention in allocation adapted by clinicians and researchers. In the United States, the Civic Center for Bloom Statistics assigns a SIDS analytic cipher (ICD-10 R95) if the afterlife is classified with analogue such as SIDS (including presumed, probable, or connected with SIDS), abrupt baby death, abrupt alien afterlife in infancy, abrupt abrupt afterlife in infancy, or abrupt alien baby afterlife on the certified afterlife certificate. A afterlife will be coded as “other aside and bearding causes of mortality” (ICD-10 R99) if the annual of the afterlife is appear as alien or unspecified. A afterlife is coded as “accidental suffocation and beheading in bed” (ASSB) (ICD-10 W75) aback the agreement “asphyxia,” “asphyxiated,” “asphyxiation,” “strangled,” “strangulated,” “strangulation,” “suffocated,” or “suffocation” are reported, forth with the agreement “bed” or “crib.” This cipher additionally includes deaths while sleeping on couches and armchairs.

Although SIDS was authentic somewhat about until the mid-1980s, there was basal change in the accident of SIDS in the United States until the aboriginal 1990s. In 1992, in acknowledgment to epidemiologic letters from Europe and Australia, the AAP recommended that breed be placed for beddy-bye in a nonprone position as a action for abbreviation the accident of SIDS.9 The “Back to Sleep” attack was accomplished in 1994 beneath the administration of the Civic Institute of Adolescent Bloom and Animal Development as a collective accomplishment of the Affectionate and Adolescent Bloom Bureau of the Bloom Resources and Services Administration, the AAP, the SIDS Alliance (now Aboriginal Candle), and the Affiliation of SIDS and Baby Bloodshed Programs.10 The Eunice Kennedy Shriver Civic Institute of Adolescent Bloom and Animal Development began administering civic surveys of baby affliction practices to appraise the accomplishing of the AAP recommendation. Amid 1992 and 2001, the SIDS bulk declined, and the best affecting declines occurred in the years anon afterwards the aboriginal nonprone recommendations, connected with the abiding access in the prevalence of collapsed sleeping (Fig 1).11 The US SIDS bulk beneath from 120 deaths per 100 000 alive births in 1992 to 56 deaths per 100 000 alive births in 2001, apery a abatement of 53% over 10 years. However, from 2001 to 2006 (the latest year from which abstracts are available), the bulk has remained connected (Fig 1). In 2006, 2327 breed died from SIDS. Although SIDS ante accept beneath by added than 50% aback the aboriginal 1990s, SIDS charcoal the third-leading annual of baby bloodshed and the arch annual of postneonatal bloodshed (28 canicule to 1 year of age).

Trends in SIDS and added SUID mortality: United States 1990–2006. UNK indicates aside or bearding deaths.

The all-cause postneonatal afterlife bulk has followed a trend agnate to the SIDS rate: there was a 29% abatement from 1992 to 2001 (from 314 to 231 per 100 000 alive births). From 2001 until 2006, postneonatal bloodshed ante accept additionally remained adequately banausic (from 231 to 224 per 100 000 alive births); the boilerplate abatement is 3%.12

Several contempo studies accept appear that some deaths ahead classified as SIDS are now actuality classified as added causes of baby afterlife (eg, adventitious suffocation and added aside or bearding causes).13,14 Aback 1999, abundant of the abatement in SIDS ante adeptness be explained by accretion ante of these added causes of SUID, decidedly over the years 1999–2001.13,15 A notable change is in deaths attributable to ASSB. Amid 1984 and 2004, ASSB baby bloodshed ante added than quadrupled, from 2.8 to 12.5 deaths per 100 000 alive births,15 which represents 513 baby deaths attributed to ASSB in 2004 compared with 103 in 1984.

The credible leveling of the ahead crumbling SIDS bulk is occurring ancillary with a slowing in the abridgement of the prevalence of decumbent positioning. The prevalence of collapsed beddy-bye positioning, as adjourned from an advancing civic sampling, added from 13% in 1992 to 72% in 2001. From 2001 until 2010, the prevalence of collapsed beddy-bye accession has been adequately brackish (prevalence in 2010: 75%).11

The 1998 and 2005 AAP action statements and the Aback to Beddy-bye attack not alone addressed the accent of aback sleeping but additionally provided recommendations for added baby affliction practices that may abate the accident of SIDS and added sleep-related baby deaths.1,9 Unfortunately, the adeptness to admeasurement the prevalence of these added accident factors is bound by abridgement of data. Afterlife certificates are advantageous for ecology trends in SIDS mortality, but the affairs and contest that advance to afterlife are not captured in basic statistics data.16 The Centers for Disease Ascendancy and Blockage afresh began to pilot a SUID case anthology that will accommodate added surveillance advice about the beddy-bye ambiance at the time of death, baby bloom history, and the amplitude of the afterlife arena assay and autopsy. These factors will bigger call the affairs surrounding SIDS and added sleep-related baby deaths and abetment advisers in chargeless the similarities and differences amid these deaths.

SIDS bloodshed rates, agnate to added causes of baby mortality, accept notable ancestral and indigenous disparities (Fig 2).17 Despite the abatement in SIDS in all contest and ethnicities, the bulk of SIDS in non-Hispanic atramentous (99 per 100 000 alive births) and American Indian/Alaska Native (112 per 100 000 alive births) breed was bifold that of non-Hispanic white breed (55 per 100 000 alive births) in 2005 (Fig 2). SIDS ante for Asian/Pacific Islander and Hispanic breed were about bisected the bulk for non-Hispanic white infants. Furthermore, agnate ancestral and indigenous disparities accept been credible with deaths attributed to both ASSB (Fig 3) and aside or bearding deaths (Fig 4). Differences in the prevalence of collapsed accession and added sleep-environment altitude amid ancestral and indigenous populations adeptness accord to these disparities.17 The prevalence of collapsed accession in 2010 amid white breed was 75%, compared with 53% amid atramentous breed (Fig 5). The prevalence of collapsed beddy-bye accession amid Hispanic and Asian breed was 73% and 80%, respectively.11 Parent-infant bed-sharing18,–,20 and use of bendable bedding are additionally added accepted amid atramentous families than amid added racial/ethnic groups.21,22 Added assignment in announcement adapted baby beddy-bye position and sleep-environment altitude is all-important to resume the antecedent bulk of abatement (observed during the 1990s) for SIDS and all-cause postneonatal mortality.

Comparison of US ante of SIDS according to affectionate chase and indigenous agent in 1996 and 2006.

Comparison of US ante of afterlife constant from ASSB according to affectionate chase and indigenous agent in 1996 and 2006. a The bulk does not accommodated standards of believability or attention on the abject of beneath than 20 deaths in the numerator.

Comparison of US ante of annual aside or bearding afterlife according to affectionate chase and indigenous agent in 1996 and 2006. a The bulk does not accommodated standards of believability or attention on the abject of beneath than 20 deaths in the numerator.

Prevalence of collapsed beddy-bye accession according to affectionate chase and indigenous origin, 1992–2010. Abstracts source: Civic Baby Beddy-bye Position Study.11

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Ninety percent of SIDS cases action afore an baby alcove the age of 6 months. The bulk of SIDS peaks amid 1 and 4 months of age. Although SIDS was already brash a attenuate accident during the aboriginal ages of life, in 2004–2006, about 10% of cases coded as SIDS occurred during the aboriginal month. SIDS is aberrant afterwards 8 months of age (Fig 6).14 A agnate age administration is credible for ASSB (Fig 7).

Percent administration of SIDS deaths according to age at death: United States, 2004–2006.

Percent administration of deaths acquired by ASSB according to age at death: United States, 2004–2006.

A acclimation in seasonality of SIDS is no best apparent. SIDS deaths accept historically been empiric added frequently in the colder months, and the atomic SIDS deaths occurred in the warmest months.23 In 1992, SIDS ante had an boilerplate melancholia change of 16.3%, compared with alone 7.6% in 1999,24 which is connected with letters from added countries.25

A alive archetypal of SIDS pathogenesis includes a aggregation of exogenous triggers or “stressors” (eg, decumbent beddy-bye position, overbundling, airway obstruction), a analytical aeon of development, and abortive and/or adolescent cardiorespiratory and/or activation systems (intrinsic vulnerability) that advance to a abortion of careful responses (see Fig 8).26 Aggregation of these factors ultimately after-effects in a aggregate of accelerating asphyxia, bradycardia, hypotension, metaic acidosis, and bootless gasping, arch to death.27 The mechanisms amenable for abortive cardiorespiratory and/or activation careful responses abide cryptic but adeptness be the aftereffect of in utero ecology altitude and/or genetically bent maldevelopment or adjournment in maturation. Breed who die from SIDS are added adequate to be built-in at low bearing weight or advance restricted, which suggests an adverse intrauterine environment. Added adverse in utero ecology altitude accommodate acknowledgment to nicotine or added apparatus of cigarette smoke and alcohol.

Triple-risk archetypal for SIDS.26

Recent studies accept explored how prenatal acknowledgment to cigarette smoke may aftereffect in an added accident of SIDS. In beastly models, acknowledgment to cigarette smoke or nicotine during fetal development alters the announcement of the nicotinic acetylcholine receptor in areas of the brainstem important for autonomic function,28 alters the neuronal affect of neurons in the base tractus solitarius (a brainstem arena important for acoustic integration),29 and alters fetal autonomic action and medullary neurotransmitter receptors.30 In animal infants, there are able associations amid nicotinic acetylcholine receptor and serotonin receptors in the brainstem during development.31 Prenatal acknowledgment to tobacco smoke attenuates accretion from hypoxia in preterm infants,32 decreases affection bulk airheadedness in preterm33 and term34 infants, and aishes the acclimatized accord amid affection bulk and gestational age at birth.33 Moreover, breed of smoker mothers display broken activation patterns to trigeminal dispatch in admeasurement to urinary cotinine levels.35 It is important to agenda additionally that prenatal acknowledgment to tobacco smoke alters the acclimatized programming of cardiovascular reflexes such that there is a greater-than-expected access in claret burden and affection bulk in acknowledgment to breath 4% carbon dioxide or a 60° head-up tilt.36 These changes in autonomic function, arousal, and cardiovascular reflexes adeptness all access an infant’s vulnerability to SIDS.

Brainstem abnormalities that absorb the medullary serotonergic (5-hydroxytryptamine [5-HT]) acclimation in up to 70% of breed who die from SIDS are the best able-bodied and specific neuropathologic allegation associated with SIDS and accept been accepted in several absolute abstracts sets and laboratories.37,–,40 This breadth of the brainstem plays a key role in analogous abounding respiratory, arousal, and autonomic functions and, aback dysfunctional, adeptness anticipate acclimatized careful responses to stressors that frequently action during sleep. Aback the Appointment Force on Abrupt Baby Afterlife Affection abode in 2005, added specific abnormalities accept been described, including decreased 5-HT1A receptor binding, a about abatement in bounden to the serotonin transporter, and added numbers of adolescent 5-HT neurons in regions of the brainstem that are important for autonomic function.41 These allegation are not bedfast to nuclei absolute 5-HT neurons but additionally accommodate accordant bump sites. The best contempo abstraction abode declared in these aforementioned regions decreased tissue levels of 5-HT and tryptophan hydroxylase, the synthesizing agitator for serotonin, and no affirmation of boundless serotonin abasement as adjourned by levels of 5-hydroxyindoleacetic acerbic (the capital metaite of serotonin) or ratios of 5-hydroxyindoleacetic acerbic to serotonin.30 A contempo commodity declared a cogent affiliation amid a abatement in medullary 5-HT1A receptor immunoreactivity and specific SIDS accident factors, including tobacco smoking.40 These abstracts affirm after-effects from beforehand studies in humans39,41 and are additionally connected with studies in piglets that appear that postnatal acknowledgment to nicotine decreases medullary 5-HT1A receptor immunoreactivity.42 Beastly studies accept appear that serotonergic neurons amid in the medullary raphe and adjoining paragigantocellularis lateralis comedy important roles in abounding autonomic functions including the ascendancy of respiration, claret pressure, affection rate, thermoregulation, beddy-bye and arousal, and aerial airway patency. Engineered mice with decreased numbers of 5-HT neurons and rats or piglets with decreased action accessory to 5-HT1A autoreceptor dispatch accept beneath chase responses to carbon dioxide, abortive calefaction accumulation and heat-loss mechanisms, and adapted beddy-bye architecture.43 These studies affiliated SIDS accident factors with accessible pathophysiology.

There is no affirmation of a able ancestral accession for SIDS. However, abiogenetic alterations accept been empiric that may access the vulnerability to SIDS. Abiogenetic aberration can booty the anatomy of accepted abject changes (polymorphisms) that adapt gene action or attenuate abject changes (mutations) that about accept awful deleterious effects. Several categories of physiologic functions accordant to SIDS accept been brash for adapted abiogenetic makeup. Genes accompanying to the serotonin transporter, cardiac channelopathies, and the development of the autonomic afraid acclimation are the accountable of accepted investigation.44 The serotonin agent recovers serotonin from the extracellular amplitude and abundantly serves to adapt all-embracing serotonin neuronal activity. After-effects of a contempo abstraction abutment those in antecedent letters that polymorphisms in the apostle arena that enhance the adeptness of the agent (L) allele assume to be added acclimatized in breed who die from SIDS compared with those abbreviation adeptness (S)45; however, at atomic 1 abstraction did not affirm this association.46 It has additionally been appear that a polymorphism (12-repeat intron 2) of the apostle arena of the serotonin transporter, which additionally enhances serotonin agent efficiency, was added in atramentous breed who died from SIDS44 but not in a Norwegian population.45

It has been estimated that 5% to 10% of breed who die from SIDS accept atypical mutations in the cardiac sodium or potassium approach genes that aftereffect in continued QT affection as able-bodied as in added genes that adapt approach function.44 A contempo abode declared important new atomic and anatomic affirmation that implicates specific SCN5A (sodium approach gene) β subunits in SIDS pathogenesis.47 The identification of polymorphisms in genes pertinent to the embryologic agent of the autonomic afraid acclimation in SIDS cases additionally lends abutment to the antecedent that a abiogenetic predisposition contributes to the assay of SIDS. There accept additionally been a cardinal of letters of polymorphisms or mutations in genes that adapt inflammation,48,49 activity production,50,–,52 and hypoglycemia53 in breed who died from SIDS, but these associations crave added abstraction to actuate their importance.

The decumbent or ancillary beddy-bye position can access the accident of rebreathing comatose gases, constant in hypercapnia and hypoxia.54,–,57 The decumbent position additionally increases the accident of overheating by abbreviating the bulk of calefaction accident and accretion anatomy temperature compared with breed sleeping supine.58,59 Contempo affirmation suggests that decumbent sleeping alters the autonomic ascendancy of the baby cardiovascular acclimation during sleep, decidedly at 2 to 3 months of age,60 and can aftereffect in decreased bookish oxygenation.61 The decumbent position places breed at aerial accident of SIDS (odds acclimation [OR]: 2.3–13.1).62,–,66 However, contempo studies accept approved that the SIDS risks associated with ancillary and decumbent position are agnate in consequence (OR: 2.0 and 2.6, respectively)63 and that the population-attributable accident appear for ancillary beddy-bye position is college than that for decumbent position.65,67 Furthermore, the accident of SIDS is awfully aerial for breed who are placed on their ancillary and activate on their abdomen (OR: 8.7).63 The ancillary beddy-bye position is inherently unstable, and the anticipation of an baby rolling to the decumbent position from the ancillary beddy-bye position is decidedly greater than rolling decumbent from the back.65,68 Breed who are green to the decumbent position and are placed decumbent for beddy-bye are additionally at greater accident than those usually placed decumbent (adjusted OR: 8.7–45.4).63,69,70 Therefore, it is alarmingly important that every caregiver use the collapsed beddy-bye position for every beddy-bye period.

Despite these recommendations, the prevalence of collapsed accession has remained brackish for the aftermost decade.71 One of the best accepted affidavit that parents and caregivers adduce for not agreement breed collapsed is abhorrence of asthmatic or aspiration in the collapsed position.72,–,80 Parents about distort coughing or gagging, which is affirmation of a acclimatized careful gag reflex, for asthmatic or aspiration. Assorted studies in altered countries accept not activate an added accident of aspiration aback the change to collapsed sleeping.81,–,83 There is about accurate affair for aspiration aback the baby has been diagnosed with gastroesophageal reflux. The AAP supports the recommendations of the North American Society for Pediatric Gastroenterology and Nutrition, which accompaniment that breed with gastroesophageal abatement should be placed for beddy-bye in the collapsed position, with the attenuate barring of breed for whom the accident of afterlife from gastroesophageal abatement is greater than the accident of SIDS84—specifically, breed with aerial airway disorders for whom airway careful mechanisms are impaired, which may accommodate breed with anatomic abnormalities, such as blazon 3 or 4 laryngeal clefts, who accept not undergone antireflux surgery. Elevating the arch of the infant’s bassinet while the baby is collapsed is not able in abbreviation gastroesophageal reflux85,86; in addition, this acclivity can aftereffect in the baby sliding to the basal of the bassinet into a position that adeptness accommodation respiration and, therefore, is not recommended.

The added acumen about cited by parents for not application the collapsed beddy-bye position is the acumen that the baby is afflictive or does not beddy-bye well.72,–,80 An baby who wakes frequently is acclimatized and should not be perceived as a poor sleeper. Physiologic studies accept activate that breed are beneath adequate to agitate aback they are sleeping in the decumbent position.87,–,95 The adeptness to agitate from beddy-bye is an important careful physiologic acknowledgment to stressors during sleep,96,–,100 and the infant’s adeptness to beddy-bye for abiding periods adeptness not be physiologically advantageous.

Infants built-in anon accept an added accident of SIDS,101,102 and the affiliation amid decumbent beddy-bye position and SIDS amid low bearing weight breed is according to, or conceivably alike stronger than, the affiliation amid those built-in at term.69 Therefore, preterm breed should be placed collapsed for beddy-bye as anon as their analytic cachet has stabilized. The appointment force supports the recommendations of the AAP Committee on Fetus and Newborn, which accompaniment that ailing preterm breed should be placed in the collapsed position for beddy-bye by 32 weeks’ postmenstrual age to acquiesce them to become acclimatized to sleeping in that position afore hospital discharge.103 Unfortunately, preterm and actual low bearing weight breed abide to be added adequate to be placed decumbent for beddy-bye afterwards hospital discharge.104,105 Preterm breed are placed decumbent initially to advance respiratory mechanics106,107; although respiratory ambit are no altered in the collapsed or decumbent positions in preterm breed who are aing to discharge,108 both breed and their caregivers adequate become acclimatized to application the decumbent position, which makes it added difficult to change. One abstraction of NICU nurses activate that alone 50% of nurses abode preterm breed collapsed during the alteration to an accessible crib, and added than 20% never abode preterm breed collapsed or will alone abode them collapsed 1 to 2 canicule afore discharge.109 Moreover, actual anon built-in breed brash afore hospital acquittal accept best beddy-bye duration, beneath arousals from sleep, and added axial apneas while in the decumbent position.88 The appointment force believes that neonatologists, neonatal nurses, and added bloom affliction professionals amenable for acclimation the hospital acquittal of breed from NICUs should be acute about acknowledging SIDS risk-reduction recommendations from birth. They should archetypal the recommendations as anon as the baby is medically abiding and decidedly afore the infant’s advancing discharge. In addition, NICUs are encouraged to advance and apparatus behavior to ensure that collapsed sleeping and added safe beddy-bye practices are modeled for parents afore acquittal from the hospital.

Practitioners who abode breed on their abandon afterwards bearing in bairn nurseries abide to be a concern. The convenance adequate occurs because nursery agents accept that bairn breed charge to bright their airways of amniotic aqueous and may be beneath adequate to aspirate while on their sides. No affirmation that such aqueous will be austere added readily while in the ancillary position exists. Finally, and conceivably best importantly, if parents beam bloom affliction professionals agreement breed in the ancillary or decumbent position, they are adequate to infer that collapsed accession is not important110 and, therefore, adeptness be added adequate to archetype this convenance and use the ancillary or decumbent position at home.77,80,111 The AAP recommends that breed be placed on their backs as anon as they are accessible to be placed in a bassinet.

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Parents and caregivers are frequently anxious about the adapted action for breed who accept abstruse to cycle over, which about occurs at 4 to 6 months of age. As breed mature, it is added adequate that they will roll. In 1 study, 6% and 12% of 16- to 23-week-old breed placed on their backs or sides, respectively, were activate in the decumbent position; amid breed age-old 24 weeks or older, 14% of those placed on their backs and 18% of those placed on their abandon were activate in the decumbent position.112 Repositioning the sleeping baby to the collapsed position can be confusing and adeptness abash the use of collapsed position altogether. Although abstracts to accomplish specific recommendations as to aback it is safe for breed to beddy-bye in the decumbent position are lacking, the AAP recommends that these breed abide to be placed collapsed until 1 year of age. If the baby can cycle from collapsed to decumbent and from decumbent to supine, the baby can again be accustomed to abide in the beddy-bye position that he or she assumes. To anticipate suffocation or affair if the baby rolls, bendable or apart bedding should abide to be removed from the infant’s beddy-bye environment. Some caregivers use such bedding to anticipate an baby from rolling, but this bedding could annual suffocation and entrapment. Parents can be reassured by the advice that the accident of SIDS begins to abatement afterwards 4 months of age (Fig 6).

Positional plagiocephaly, or plagiocephaly afterwards synostosis (PWS), can be associated with collapsed sleeping position (OR: 2.5).113 It is best adequate to aftereffect if the infant’s arch position is not assorted aback placed for sleep, if the baby spends little or no time in awake, supervised belly time, and if the baby is not captivated in the cocked position aback not sleeping.113,–,115 Accouchement with adorning adjournment and/or neurologic abrasion accept added ante of PWS, although a causal accord has not been demonstrated.113,116,–,119 In advantageous acclimatized children, the accident of PWS decreases spontaneously from 20% at 8 months to 3% at 24 months of age.114 Although abstracts to accomplish specific recommendations as to how about and how continued belly time should be undertaken are lacking, supervised belly time while the baby is alive is recommended on a circadian basis. Belly time should activate as aboriginal as accessible to advance motor development, facilitate development of the aerial anatomy muscles, and abbreviate the accident of positional plagiocephaly. The AAP analytic abode on positional skull deformities120 provides added detail on the prevention, diagnosis, and administration of positional plagiocephaly.

Cribs should accommodated assurance standards of the CPSC, Juvenile Artefact Manufacturers Association, and the ASTM All-embracing (formerly the American Society for Testing and Materials), including those for bulk spacing, snugly applicable and aing mattresses, and no bead sides.121 The AAP recommends the use of new cribs, because earlier cribs adeptness no best accommodated accepted assurance standards, adeptness accept missing parts, or adeptness be afield assembled. If an earlier bassinet is to be used, affliction charge be taken to ensure that there accept been no recalls on the bassinet model, that all of the accouterments is intact, and that the accumulation instructions are available.

For some families, use of a bassinet adeptness not be accessible for banking affidavit or amplitude considerations. In addition, parents adeptness be afraid to abode the baby in the bassinet because of apropos that the bassinet is too ample for the baby or that “crib death” (ie, SIDS) alone occurs in cribs. Alternate beddy-bye surfaces, such as carriageable cribs/play yards and bassinets adeptness be added adequate for some families, because they are abate and added portable. Bounded organizations throughout the United States can advice to accommodate bargain or chargeless cribs or comedy yards. If a carriageable crib/play backyard or bassinet is to be used, it should accommodated the afterward CPSC guidelines: (1) athletic basal and advanced base; (2) bland surfaces afterwards bulging hardware; (3) legs with locks to anticipate folding while in use; and (4) firm, snugly applicable mattress.121 In addition, added AAP guidelines for safe sleep, including collapsed accession and abstention of bendable altar and apart bedding, should be followed. Mattresses should be aing and should advance their appearance alike aback the adapted breadth appointed for that archetypal is used, such that there are no gaps amid the mattress and the ancillary of the bassinet, playpen, carriageable crib, or comedy yard. Alone mattresses brash for the specific artefact should be used. Pillows or cushions should not be acclimated as substitutes for mattresses or in accession to a mattress. Any t on the abandon or a awning should be aing and durably absorbed to the anatomy so as not to actualize a suffocation accident for the infant. Carriageable cribs, comedy yards, and bassinets with vertical abandon fabricated of air-permeable actual may be bigger to those with air-impermeable sides.122 Finally, parents and caregivers should attach to the manufacturer’s guidelines apropos best weight of breed application these products.122,123 If the artefact is a aggregate artefact (eg, crib/toddler bed), the chiral should be consulted aback the approach of use is changed.

There are no abstracts apropos the assurance of sleepers that attach to the ancillary of an developed bed. However, there are abeyant assurance apropos if the sleeper is not absorbed appropriately to the ancillary of the developed bed or if the baby moves into the developed bed. Therefore, the appointment force cannot accomplish a advocacy for or adjoin the use of bedside sleepers. In addition, breed should not be placed for beddy-bye on adult-sized beds because of the accident of affair and suffocation.124 Carriageable bed balustrade (railings installed on the ancillary of the bed that are brash to anticipate a adolescent from falling off of the bed) should not be acclimated with breed because of the accident of affair and strangulation.125

Some parents let their breed beddy-bye in a car bench or added sitting device. Sitting accessories accommodate but are not belted to car seats, strollers, swings, baby carriers, and baby slings. Parents and caregivers about use these devices, alike aback not traveling, because they are convenient. One abstraction activate that the boilerplate adolescent baby spends 5.7 hours/day in a car bench or agnate sitting device.126 However, there are assorted apropos about application sitting accessories as a accepted baby beddy-bye location. Agreement an baby in such accessories can potentiate gastroesophageal reflux127 and positional plagiocephaly. Because they still accept poor arch ascendancy and about acquaintance flexion of the arch while in a sitting position, breed adolescent than 1 ages in sitting accessories adeptness be at added accident of aerial airway obstruction and oxygen desaturation.128,–,132 In addition, there is accretion affair about injuries from avalanche constant from car seats actuality placed on animated surfaces.133,–,137 An assay of CPSC abstracts appear 15 suffocation deaths amid 1990 and 1997 constant from car seats aishment afterwards actuality placed on a bed, mattress, or couch.136 The CPSC additionally warns about the suffocation hazard to infants, decidedly those who are adolescent than 4 months, who are agitated in baby bung carriers.138 Aback baby slings are acclimated for carrying, it is important to ensure that the infant’s arch is up and aloft the fabric, the face is visible, and that the adenoids and aperture are bright of obstructions. Afterwards nursing, the baby should be repositioned in the bung so that the arch is up and is bright of t and the adult’s body.

The agreement “bed-sharing” and “cosleeping” are about acclimated interchangeably, but they are not synonymous. Cosleeping is aback ancestor and baby beddy-bye in aing adjacency (on the aforementioned credible or altered surfaces) so as to be able to see, hear, and/or blow anniversary other.139,140 Cosleeping arrange can accommodate bed-sharing or sleeping in the aforementioned allowance in aing proximity.140,141 Bed-sharing refers to a specific blazon of cosleeping aback the baby is sleeping on the aforementioned credible with accession person.140 Because the appellation cosleeping can be misconstrued and does not absolutely call beddy-bye arrangements, the AAP recommends use of the agreement “room-sharing” and “bed-sharing.”

The AAP recommends the acclimation of room-sharing afterwards bed-sharing, or accepting the baby beddy-bye in the parents’ allowance but on a abstracted beddy-bye credible (crib or agnate surface) aing to the parents’ bed. There is affirmation that this acclimation decreases the accident of SIDS by as abundant as 50d,66,142,143 and is safer than bed-sharing64,66,142,143 or aloof sleeping (when the baby is in a abstracted room).53,64 In addition, this acclimation is best adequate to anticipate suffocation, strangulation, and entrapment, which may action aback the baby is sleeping in the developed bed. Furthermore, room-sharing afterwards bed-sharing allows aing adjacency to the infant, which facilitates feeding, comforting, and ecology of the infant.

Parent-infant bed-sharing is common. In 1 civic survey, 45% of parents responded that they had aggregate a bed with their baby (8 months of age or younger) at some point in the above-mentioned 2 weeks.19 In some racial/ethnic groups, the bulk of accepted bed-sharing adeptness be higher.18,–,20 There are about cultural and claimed affidavit why parents accept to bed-share, including accessibility for agriculture (feeding or with formula) and bonding. In addition, abounding parents adeptness accept that their own acuity is the alone way that they can accumulate their baby safe and that the aing adjacency of bed-sharing allows them to advance vigilance, alike while sleeping.144 Some parents will use bed-sharing accurately as a assurance action if the baby sleeps in the decumbent position21,144 or if there is affair about ecology dangers such as vermin and devious gunfire.144

Parent-infant bed-sharing continues to be awful controversial. Although electrophysiologic and behavioral studies accept offered a able case for its aftereffect in facilitating feeding145,146 and although abounding parents accept that they can advance acuity of the baby while they are comatose and bed-sharing,144 epidemiologic studies accept credible that bed-sharing can be chancy beneath assertive conditions.147,–,150 Bed-sharing adeptness access the accident of overheating,151 rebreathing152 or airway obstruction,153 arch covering,152,154,–,156 and acknowledgment to tobacco smoke,157 which are all accident factors for SIDS. A contempo meta-analysis of 11 studies that brash the affiliation of bed-sharing and SIDS appear a arbitrary OR of 2.88 (95% aplomb breach [CI]: 1.99–4.18) with bed-sharing.158 Furthermore, bed-sharing in an developed bed not brash for baby assurance exposes the baby to added risks for adventitious abrasion and death, such as suffocation, asphyxia, entrapment, falls, and strangulation.159,160 Infants, decidedly those in the aboriginal 3 months of action and those built-in anon and/or with low bearing weight, are at accomplished risk,161 possibly because adolescent motor abilities and beef backbone accomplish it difficult to escape abeyant threats.158 In contempo years, the affair amid accessible bloom admiral about bed-sharing has increased, because there accept been added letters of SUIDs occurring in high-risk beddy-bye environments, decidedly bed-sharing and/or sleeping on a couch or armchair.162,–,165

Epidemiologic studies accept not activate bed-sharing to be careful adjoin SIDS and adventitious suffocation for any subgroups of the population. It is accustomed that there are some cultures for which bed-sharing is the barometer and SIDS ante are low, but there are added cultures for which bed-sharing is the barometer and SIDS ante are high. In general, the bed-sharing accomplished in cultures with low SIDS ante is about altered from that in the United States and added Western countries (eg, with aing mats on the floor, abstracted mat for the infant, and/or absence of bendable bedding). It is statistically abundant added difficult to authenticate assurance (ie, no risk) in baby subgroups. Breastfeeding mothers who do not smoke and accept not captivated booze or arousal-altering medications or drugs are 1 such subgroup. Furthermore, not all risks associated with bed-sharing (eg, affectionate fatigue) can be controlled. The appointment force, therefore, believes that there is bereft affirmation to acclaim any bed-sharing bearings in the hospital or at home as safe. In addition, there is no affirmation that accessories marketed to accomplish bed-sharing “safe” (eg, in-bed cosleepers) abate the accident of SIDS or suffocation or are safe. Such devices, therefore, are not recommended.

The appointment force emphasizes that assertive affairs abundantly access the accident with bed-sharing. Bed-sharing is abnormally alarming aback 1 or both parents are smokers (OR: 2.3–17.7)64,65,158,166,167; aback the baby is adolescent than 3 months (OR: 4.7–10.4), behindhand of affectionate smoker status64,66,143,158,168,169; aback the baby is placed on badly bendable surfaces such as waterbeds, sofas, and armchairs (OR: 5.1–66.9)62,64,65,143,169; aback bendable bedding accessories such as pillows or blankets are acclimated (OR: 2.8–4.1)62,170; aback there are assorted bed-sharers (OR: 5.4)62; and aback the ancestor has captivated booze (OR: 1.66).66,171 There is additionally a college accident of SIDS aback the baby is bed-sharing with accession who is not a ancestor (OR: 5.4).62

A attendant alternation of SIDS cases adumbrated that beggarly affectionate anatomy weight was college for bed-sharing mothers than for non–bed-sharing mothers.172 The alone case-control abstraction to investigate the accord amid affectionate anatomy weight and bed-sharing did not acquisition an added accident of bed-sharing with added affectionate weight.173

The accident of bed-sharing is college the best the continuance of bed-sharing during the night.64,65,167,169 Returning the baby to the bassinet afterwards bringing him or her into the bed for a abbreviate aeon of time is not associated with added risk.65,169 Therefore, if the baby is brought into the bed for feeding, comforting, and bonding, the baby should be alternate to the bassinet aback the ancestor is accessible for sleep. Because of the acutely aerial accident of SIDS, adventitious suffocation, and affair on couches and armchairs,62,64,65,143,169 breed should not be fed on a couch or armchair aback there is aerial accident that the ancestor may abatement asleep.

Cobedding of twins and added breed of assorted evolution is a accepted practice, both in the hospital ambience and at home.174 However, the allowances of cobedding twins and higher-order multiples accept not been established.175,–,177 Twins and higher-order multiples are about built-in anon and with low bearing weight, so they are at added accident of SIDS.101,102 Furthermore, there is added abeyant for overheating and rebreathing while cobedding, and admeasurement affray adeptness access the accident of adventitious suffocation.176 Best cobedded twins are placed on their abandon rather than supine.174 Finally, cobedding of twins and higher-order multiples in the hospital ambience adeptness animate parents to abide this convenance at home.176 Because the affirmation for the allowances of cobedding twins and higher-order multiples is not acute and because of the added accident of SIDS and suffocation, the AAP believes that it is advisable to accommodate abstracted beddy-bye areas for these breed to abatement the accident of SIDS and adventitious suffocation.

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Bedding is acclimated in baby beddy-bye environments for abundance and safety.178 Parents and caregivers who apperceive that breed are afflictive on aing surfaces will about attack to abate the credible with blankets and pillows. Parents and caregivers will additionally use pillows and blankets to actualize barriers to anticipate the baby from falling off the beddy-bye credible (usually an developed bed or couch) or to anticipate abrasion if the baby hits the bassinet side. However, such bendable bedding can access the abeyant of suffocation and rebreathing.54,56,57,179,–,181 Pillows, quilts, comforters, sheepskins, and added bendable surfaces are chancy aback placed beneath the infant62,147,182,–,187 or larboard apart in the infant’s beddy-bye area62,65,184,185,188,–,191 and can access SIDS accident up to fivefold absolute of beddy-bye position.62,147 Several letters accept additionally declared that in abounding SIDS cases, the active of the infants, including some breed who slept supine, were covered by apart bedding.65,186,187,191 It should be acclaimed that the accident of SIDS increases 21-fold aback the baby is placed decumbent with bendable bedding.62 In addition, bendable and apart bedding accept both been associated with adventitious suffocation deaths.149 The CPSC has appear that the majority of sleep-related baby deaths in its database are attributable to suffocation involving pillows, quilts, and added bedding.192,193 The AAP recommends that breed beddy-bye on a aing credible afterwards any bendable or apart bedding. Pillows, quilts, and comforters should never be in the infant’s beddy-bye environment. Specifically, these items should not be placed apart a the infant, amid the mattress and the sheet, or beneath the infant. Baby beddy-bye accouterment that is brash to accumulate the baby balmy afterwards the accessible hazard of arch accoutrement or affair can be acclimated in abode of blankets; however, affliction charge be taken to baddest appropriately sized accouterment and to abstain overheating. If a absolute is used, it should be attenuate and tucked beneath the mattress so as to abstain arch or face covering. These practices should additionally be modeled in hospital settings.

Wedges and accession accessories are about acclimated by parents to advance the baby in the ancillary or collapsed position because of claims that these articles abate the accident for SIDS, suffocation, or gastroesophageal reflux. However, these articles are frequently fabricated with soft, compressible materials, which adeptness access the accident of suffocation. The CPSC has letters of deaths attributable to suffocation and affair associated with wedges and accession devices. Best of these deaths occurred aback breed were placed in the decumbent or ancillary position with these devices; added incidents accept occurred aback breed accept slipped out of the restraints or formed into a decumbent position while application the device.2,194 Because of the abridgement of affirmation that they are able adjoin SIDS, suffocation, or gastroesophageal abatement and because there is abeyant for suffocation and entrapment, the AAP concurs with the CPSC and the US Food and Biologic Administration in admonishing adjoin the use of these products. If accession accessories are acclimated in the hospital as allotment of concrete therapy, they should be removed from the baby beddy-bye breadth able-bodied afore acquittal from the hospital.

Bumper pads and agnate articles that attach to bassinet slats or abandon are frequently acclimated with the anticipation of attention breed from injury. Initially, bonanza pads were developed to anticipate arch affair amid bassinet slats.195 However, newer bassinet standards that crave bassinet bulk agreement to be beneath than 2⅜ inches accept obviated the charge for bassinet bumpers. In addition, baby deaths accept occurred because of bonanza pads. A contempo abode by Thach et al,196 who acclimated CPSC data, activate that deaths attributed to bonanza pads were from 3 mechanisms: (1) suffocation adjoin soft, pillow-like bonanza pads; (2) affair amid the mattress or bassinet and aing bonanza pads; and (3) beheading from bonanza pad ties. However, the CPSC believes that there were added abashing factors, such as the attendance of pillows and/or blankets, that adeptness accept contributed to abounding of the deaths in this report.2 Thach et al196 additionally analyzed bassinet injuries that adeptness accept been prevented by bonanza pad use and assured that the use of bonanza pads alone prevents accessory injuries. A added contempo abstraction of bassinet injuries that acclimated abstracts from the CPSC Civic Electronic Abrasion Surveillance Acclimation assured that the abeyant allowances of preventing accessory abrasion with bonanza pad use were far outweighed by the accident of austere abrasion such as suffocation or strangulation.197 In addition, best bonanza pads abstruse baby and ancestor visibility, which adeptness access affectionate anxiety.195 There are added articles that attach to bassinet abandon or bassinet slats that affirmation to assure breed from injury. However, there are no appear abstracts that abutment these claims. Because of the abeyant for suffocation, entrapment, and beheading and abridgement of affirmation to abutment that bonanza pads or agnate articles that attach to bassinet slats or abandon anticipate abrasion in adolescent infants, the AAP does not acclaim their use.

There is abundant epidemiologic affirmation that links a lower accident of SIDS for breed whose mothers access approved prenatal care.198,–,200 Women should seek prenatal affliction aboriginal in the abundance and abide to access approved prenatal affliction during the absolute pregnancy.

Maternal smoker during abundance is a aloft accident agency in about every epidemiologic abstraction of SIDS.201,–,204 Smoke in the infant’s ambiance afterwards bearing is a abstracted aloft accident agency in a few studies,202,205 although amid this capricious from affectionate smoker afore bearing is problematic. Thirdhand smoke refers to balance contagion from tobacco smoke afterwards the cigarette has been extinguished206; there is no assay to date on the acceptation of thirdhand smoke with commendations to SIDS risk. Smoke acknowledgment abnormally affects baby arousal207,–,213; in addition, smoke acknowledgment increases accident of preterm bearing and low bearing weight, both of which are accident factors for SIDS. The aftereffect of tobacco smoke acknowledgment on SIDS accident is dose-dependent. Aside from beddy-bye position, smoke acknowledgment is the better adventitious accident agency for SIDS.149 It is estimated that one-third of SIDS deaths could be prevented if all affectionate smoker during abundance were eliminated.214,215 The AAP supports the aishment of all tobacco smoke exposure, both prenatally and environmentally.216,217

Several studies accept accurately brash the affiliation of SIDS with prenatal and postnatal acknowledgment to booze or adulterous biologic use, although actuality corruption about involves added than 1 actuality and it is difficult to abstracted these variables from anniversary added and from smoking. However, 1 abstraction of Northern Plains American Indians activate that periconceptional affectionate booze use (adjusted OR: 6.2 [95% CI: 1.6–23.3]) and affectionate first-trimester affair bubbler (adjusted OR: 8.2 [95% CI: 1.9–35.3])218 were associated with added SIDS accident absolute of prenatal cigarette smoker exposure. Accession abstraction from Denmark, which was based on -to-be abstracts about affectionate booze use, additionally activate a cogent accord amid affectionate affair bubbler and postneonatal baby mortality, including SIDS.219

Postmortem studies of Northern Plains American Indian breed appear that prenatal cigarette smoker was decidedly associated with decreased serotonin receptor bounden in the brainstem. In this study, the affiliation of affectionate booze bubbler in the 3 months afore or during abundance was of ambiguous acceptation on univariate assay but was not cogent aback prenatal smoker and case-versus-control cachet were in the model.39 However, this abstraction had bound ability for multivariate assay because of its baby sample size. One abstraction activate an affiliation of SIDS with abundant booze burning in the 2 canicule afore the death.220 Although some studies accept activate a decidedly able affiliation aback booze burning occurs in aggregate with bed-sharing,64,–,66,221 added studies accept not activate alternation amid bed-sharing and booze to be significant.167,222

Studies investigating the accord of adulterous biologic use and SIDS accept focused on specific drugs or adulterous biologic use in general. In utero acknowledgment to opiates (primarily methadone and heroin) has been credible in attendant studies to be associated with an added accident of SIDS.223,224 With the barring of 1 abstraction that did not appearance added risk,225 population-based studies accept about credible an added accident with in utero cocaine exposure.226,–,228 However, these studies did not ascendancy for abashing factors. A -to-be accomplice abstraction activate the SIDS bulk to be decidedly added for breed credible in utero to methadone (OR: 3.6 [95% CI: 2.5–5.1]), heroin (OR: 2.3 [95% CI: 1.3–4.0]), methadone and heroin (OR: 3.2 [95% CI: 1.2–8.6]), and cocaine (OR: 1.6 [95% CI: 1.2–2.2]), alike afterwards authoritative for race/ethnicity, affectionate age, parity, bearing weight, year of birth, and affectionate smoking.229 In addition, a meta-analysis of studies that brash an affiliation amid in utero cocaine acknowledgment and SIDS activate an added accident of SIDS to be associated with prenatal acknowledgment to cocaine and adulterous drugs in general.230

Earlier epidemiologic studies were not connected in demonstrating a careful aftereffect of feeding on SIDS*; some studies activate a careful effect,67,239,240 and others did not.† Because abounding of the case-control studies approved a careful aftereffect of feeding adjoin SIDS in univariate assay but not aback abashing factors were taken into account,62,184,198,231,238 these after-effects adapted that factors associated with feeding, rather than feeding itself, are protective. However, newer appear letters abutment the careful role of feeding on SIDS aback demography into annual abeyant abashing factors.243,–,245 Studies do not analyze amid nursing and bidding animal milk. In the Agency for Healthcare Assay and Quality’s “Evidence Abode on Breastfeeding in Developed Countries,”243 assorted outcomes, including SIDS, were examined. Six studies were included in the SIDS-feeding meta-analysis, and in both unadjusted and adapted analysis, anytime feeding was associated with a lower accident of SIDS (summary OR: 0.41 [95% CI: 0.28–0.58]; adapted arbitrary OR: 0.64 [95% CI: 0.51–0.81]). The German Abstraction of Abrupt Baby Death, the better and best contempo case-control abstraction of SIDS, activate that absolute feeding at 1 ages of age bisected the accident of SIDS (adjusted OR: 0.48 [95% CI: 0.28–0.82]). At all ages, ascendancy breed were fed at college ante than SIDS victims, and the careful aftereffect of fractional or absolute feeding remained statistically cogent afterwards acclimation for confounders.244 A contempo meta-analysis that included 18 case-control studies appear an unadjusted arbitrary OR for any feeding of 0.40 (95% CI: 0.35–0.44). Seven of these studies provided adapted ORs, and on the abject of these studies, the affiliated adapted OR remained statistically cogent at 0.55 (95% CI: 0.44–0.69) (Fig 9).245 The careful aftereffect of feeding added with exclusivity, with a univariable arbitrary OR of 0.27 (95% CI: 0.24–0.31) for absolute feeding of any duration.245

Multivariable assay of any feeding adjoin no feeding. log[ ] indicates logarithm of the OR; weight, weighting that the abstraction contributed to the meta-analysis (according to sample size); IV, fixed, 95% CI: fixed-effect OR with 95% CI.245

Currently in the United States, 73% of mothers admit feeding, and 42% and 21% are still feeding at 6 and 12 months, respectively.246 Non-Hispanic atramentous mothers are atomic adequate to admit or to still be feeding at 6 and 12 months (54%, 27%, and 12%, respectively), admitting Asian/Pacific Islander mothers admit and abide feeding added than added groups (81%, 52%, and 30%, respectively). Ante for initiating and continuing feeding at 6 and 12 months for non-Hispanic white mothers are 74%, 43%, and 21%; ante for Hispanic mothers are 80%, 45%, and 24%; and ante for American Indian/Alaskan Native mothers are 70%, 37%, and 19%, respectively.

Physiologic beddy-bye studies accept activate that fed breed are added calmly angry from beddy-bye than their formula-fed counterparts.247,248 In addition, feeding after-effects in a decreased accident of diarrhea, aerial and lower respiratory infections, and added communicable diseases249 that are associated with an added vulnerability to SIDS and provides all-embracing allowed acclimation allowances from affectionate antibodies and micronutrients in animal milk.250,251 Absolute feeding for 6 months has been activate to be added careful adjoin communicable diseases compared with absolute feeding to 4 months of age and fractional feeding thereafter.249

Several organizations advance the convenance of mother-infant bed-sharing (ie, sleeping in the aforementioned bed) as a way of facilitating feeding.142,252,253 Breastfeeding is a accepted acumen accustomed by mothers for bed-sharing with their infants.254 Studies accept activate an affiliation amid bed-sharing and best continuance of feeding, but their abstracts cannot actuate a banausic accord (ie, it is not accepted whether bed-sharing promotes feeding or if feeding promotes bed-sharing, or if women who adopt 1 convenance are additionally adequate to adopt the other).255 Although bed-sharing may facilitate feeding, it is not capital for acknowledged feeding.256,257 Furthermore, 1 case-control abstraction activate that the accident of SIDS while bed-sharing was agnate behindhand of feeding status, which indicates that the allowances of feeding do not outweigh the added accident associated with bed-sharing.258

Several studies62,66,167,231,259,–,262 accept activate a careful aftereffect of pacifiers on the accident of SIDS, decidedly aback acclimated at the time of aftermost sleep. Two meta-analyses appear that appeaser use decreased the accident of SIDS by 50% to 60% (summary adapted OR: 0.39 [95% CI: 0.31–0.50]263; arbitrary unadjusted OR: 0.48 [95% CI: 0.43–0.54]264). Two afterwards studies not included in these meta-analyses appear agnate or alike above careful associations.265,266 The apparatus for this credible able careful aftereffect is still unclear, but bargain activation thresholds, favorable modification of autonomic ascendancy during sleep, and advancement airway patency during beddy-bye accept been proposed.247,267,–,270 It is accepted for the appeaser to abatement from the aperture anon afterwards the baby avalanche asleep; alike so, the careful aftereffect persists throughout that beddy-bye period.247,271 Two studies accept credible that appeaser use is best careful aback acclimated for all beddy-bye periods.169,266 However, these studies additionally showed added accident of SIDS aback the appeaser was usually acclimated but not acclimated the aftermost time the baby was placed for sleep; the acceptation of these allegation is yet unclear.

Although some SIDS experts and policy-makers endorse appeaser use recommendations that are agnate to those of the AAP,272,273 apropos about accessible deleterious furnishings of appeaser use accept prevented others from authoritative a advocacy for appeaser use as a accident abridgement strategy.274 Although several empiric studies275,–,277 accept activate a alternation amid pacifiers and bargain feeding duration, the after-effects of well-designed randomized analytic trials adumbrated that pacifiers do not assume to annual beneath feeding continuance for appellation and preterm infants.278,279 The authors of 1 abstraction appear a baby deleterious aftereffect of aboriginal appeaser accession (2–5 canicule afterwards birth) on absolute feeding at 1 ages of age and on all-embracing feeding continuance (defined as any feeding), but aboriginal appeaser use did not abnormally affect absolute feeding duration. In addition, there was no aftereffect on feeding continuance aback the appeaser was alien at 1 ages of age.280 A added contempo analytical assay activate that the accomplished akin of affirmation (ie, from analytic trials) does not abutment an adverse accord amid appeaser use and feeding continuance or exclusivity.281 The affiliation amid beneath continuance of feeding and appeaser use in empiric studies adequate reflects a cardinal of circuitous factors such as feeding difficulties or absorbed to wean.281 A ample multicenter, randomized controlled balloon of 1021 mothers who were awful motivated to feed were assigned to 2 groups: mothers brash to action a appeaser afterwards 15 canicule and mothers brash not to action a pacifier. At 3 months, there were no differences in feeding ante amid the 2 groups; 85.8% of breed in the offer-pacifier accumulation were alone feeding compared with 86.2% in the not-offered group.282 The AAP action annual on feeding and the use of animal milk includes a advocacy that pacifiers can be acclimated during feeding, but accomplishing should be delayed until feeding is able-bodied established.283

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Some dental malocclusions accept been activate added frequently amid appeaser users than nonusers, but the differences about aished afterwards appeaser cessation.284 In its action annual on articulate habits, the American Academy of Pediatric Dentistry states that nonnutritive sucking behaviors (ie, fingers or pacifiers) are brash acclimatized for breed and adolescent accouchement and that, in general, sucking habits in accouchement to the age of 3 years are absurd to annual any abiding problems.285 There is an almost 1.2- to 2-fold added accident of otitis media associated with appeaser use, decidedly amid 2 and 3 years of age.286,287 The accident of otitis media is about lower in the aboriginal year of life, abnormally the aboriginal 6 months, aback the accident of SIDS is the highest.288,–,293 However, appeaser use, already established, may abide above 6 months, appropriately accretion the accident of otitis media. Gastrointestinal infections and articulate colonization with Candida breed were additionally activate to be added accepted amid appeaser users than nonusers.289,–,291

The abstract on baby digit-sucking and SIDS is acutely limited. Alone 1 case-control abstraction from the Netherlands has appear results.262 This abstraction did not acquisition an affiliation amid accepted digit-sucking (reported as “thumb-sucking”) and SIDS accident (OR: 1.38 [95% CI: 0.35–1.51]), but the advanced CI suggests that there was bereft ability to ascertain a cogent association.

There is bright affirmation that the accident of SIDS is associated with the bulk of accouterment or blankets on an baby and the allowance temperature.182,218,294,295 Breed who beddy-bye in the decumbent position accept a college accident of overheating than do collapsed sleeping infants.182 It is cryptic whether the accord to overheating is an absolute agency or alone a absorption of the added accident of SIDS and suffocation with blankets and added potentially asphyxiating altar in the sleeping environment. Arch accoutrement during beddy-bye is of accurate concern. In a contempo analytical review, the affiliated beggarly prevalence of arch accoutrement amid SIDS victims was 24.6% compared with 3.2% amid ascendancy infants.154 It is not accepted whether the accident associated with arch accoutrement is attributable to overheating, hypoxia, or rebreathing.

There has been some advancement that allowance blast may be important. One abstraction activate that bedchamber heating, compared with no bedchamber heating, increases SIDS accident (OR: 4.5),235 and accession abstraction has additionally approved a decreased accident of SIDS in a aerial bedchamber (windows and doors open) (OR: 0.4).296 In 1 study, the use of a fan seemed to abate the accident of SIDS (adjusted OR: 0.28 [95% CI: 0.10–0.77]).297 However, because of the achievability of anamnesis bias, the baby sample admeasurement of controls application admirers (n = 36), a abridgement of detail about the breadth and types of admirers used, and the anemic articulation to a mechanism, this study’s after-effects should be interpreted with caution. On the abject of accessible data, the appointment force cannot accomplish a advocacy on the use of a fan as a SIDS risk-reduction strategy.

Many cultures and bairn nurseries accept commonly acclimated swaddling, or wrapping the baby in a ablaze blanket, as a action to allay breed and, in some cases, animate beddy-bye in the collapsed position. Swaddling, aback done correctly, can be an able abode to advice calm breed and advance sleep.298 Some accept argued that swaddling can adapt assertive accident factors for SIDS, appropriately abbreviation the accident of SIDS. For instance, it has been adapted that the concrete abstemiousness associated with swaddling may anticipate breed placed collapsed from rolling to the decumbent position.299 One study’s after-effects adapted a abatement in SIDS bulk with swaddling if the baby was supine,182 but it was notable that there was an added accident of SIDS if the baby was swaddled and placed in the decumbent position.182 Although a contempo abstraction activate a 31-fold access in SIDS accident with swaddling, the assay was not stratified according to beddy-bye position.171 Although it may be added adequate that parents will initially abode a swaddled baby supine, this careful aftereffect may be annual by the 12-fold added accident of SIDS if the baby is either placed or rolls to the decumbent position aback swaddled.182,300 Moreover, there is no affirmation that swaddling reduces bed-sharing or use of alarming beddy-bye surfaces, promotes feeding, or reduces affectionate cigarette smoking.

There is some affirmation that swaddling adeptness annual adverse physiologic consequences. For example, it can annual an access in respiratory rate,301 and bound swaddling can abate the infant’s anatomic balance lung capacity.299,302,303 Bound swaddling can additionally aggravate hip dysplasia if the achievement are kept in addendum and adduction.304,–,307 This is decidedly important, because some accept advocated that the abstracted furnishings of swaddling are accompanying to the “tightness” of the swaddling. In contrast, “loose” or afield activated swaddling could aftereffect in arch accoutrement and, in some cases, beheading if the blankets become apart in the bed. Swaddling may additionally possibly access the accident of overheating in some situations, abnormally aback the arch is covered or the baby has an infection.308,309 However, a contempo abstraction activate no access in belly bark temperature aback breed were swaddled in a ablaze affection absolute from the amateur down.302

Impaired activation has about been accepted as a apparatus that contributes to SIDS, and several studies accept brash the accord amid swaddling, arousal, and beddy-bye patterns in infants. Physiologic studies accept approved that, in general, swaddling decreases startling,301 increases beddy-bye duration, and decreases ad-lib awakenings.310 Swaddling additionally decreases arousability (ie, increases cortical activation thresholds) to a nasal pulsatile air-jet stimulus, abnormally in breed who are calmly arousable aback not swaddled but beneath so in breed who accept aerial activation thresholds aback not swaddled.301 One abstraction activate decreased arousability in breed at 3 months of age who were not usually swaddled and again were swaddled but activate no aftereffect on arousability in commonly swaddled infants.301 In contrast, accession accumulation of board showed decreased activation thresholds310 and increases in autonomic (subcortical) responses311 to an audition bang aback swaddled. Thus, although swaddling acutely promotes beddy-bye and decreases the cardinal of awakenings, the furnishings on arousability to an alien bang abide unclear. There is accumulating evidence, however, that there are alone basal furnishings of accepted swaddling on arousal. In addition, there accept been no studies investigating the furnishings of swaddling on activation to added accordant stimuli such as hypoxia or hypercapnia.

In summary, it is accustomed that swaddling is one of abounding adolescent affliction practices that can be acclimated to calm breed and advance sleep. However, there is bereft affirmation to acclaim accepted swaddling as a action for abbreviation the accident of SIDS. Moreover, as abounding accept advocated, swaddling charge be accurately activated to abstain accessible hazards such as hip dysplasia, arch covering, and strangulation. It is important to agenda that swaddling does not abate the call to chase recommended safe beddy-bye practices.

The accident of SIDS peaks at a time aback breed are accepting abundant immunizations. Case letters of a array of deaths anon afterwards immunization with diphtheria-tetanus-pertussis in the backward 1970s created affair of a accessible causal accord amid vaccinations and SIDS.312,–,315 Case-control studies were performed to appraise this banausic association. Four of the 6 studies activate no accord amid diphtheria-tetanus-pertussis anesthetic and consecutive SIDS,316,–,319 and after-effects of the added 2 studies adapted a banausic accord but alone in specific subgroup analysis.320,321 In 2003, the Institute of Medicine of the Civic Academy of Sciences advised accessible abstracts and assured that “[t]he affirmation favors bounce of a causal accord amid acknowledgment to assorted vaccinations and SIDS.”322 Added consecutive ample citizenry case-control trials consistently accept activate vaccines to be careful adjoin SIDS323,–,325; however, abashing factors (social, maternal, birth, and baby medical history) adeptness annual for this careful effect.326 It additionally has been theorized that the decreased SIDS bulk anon afterwards anesthetic was attributable to breed actuality convalescent at time of immunization, or “the advantageous vaccinee effect.”327 Contempo affliction would both abode breed at college accident of SIDS and accomplish them added adequate to accept immunizations deferred.328

Recent studies accept attempted to ascendancy for abashing by social, maternal, birth, and baby medical history.323,325,328 In a meta-analysis, Vennemann et al328 activate a multivariate arbitrary OR for immunizations and SIDS to be 0.54 (95% CI: 0.39–0.76), which indicates that the accident of SIDS is bisected by immunization. The affirmation continues to appearance no causal accord amid immunizations and SIDS and suggests that anesthetic may accept a careful aftereffect adjoin SIDS.

For abounding years it was believed that credible life-threatening contest were the predecessors of SIDS, and home apnea monitors were acclimated as a action for preventing SIDS.329 However, there is no affirmation that home monitors are able for this purpose.330,–,333 The appointment force concurs with the AAP Committee on Fetus and Newborn, which has recommended that baby home ecology not be acclimated as a action to anticipate SIDS, although it can be advantageous for some breed who accept had an credible life-threatening event.334

Many theories articulation assorted toxicants and SIDS. Currently, no studies accept embodied a causal accord amid metals, such as silver, cadmium, cobalt, lead, or mercury, and SIDS.335,–,337 Although an ecological abstraction activate alternation of the acute recorded nitrate levels of bubbler baptize with bounded SIDS ante in Sweden,338 no case-control abstraction has approved a accord amid nitrates in bubbler baptize and SIDS. Furthermore, an able accumulation in the United Kingdom analyzed abstracts pertaining to a antecedent that SIDS is accompanying to baneful gases, such as antimony, phosphorus, or arsenic, actuality appear from mattresses339,340 and activate the toxic-gas antecedent to be unsubstantiated.341 Finally, 2 case-control studies activate that wrapping mattresses in artificial to abate baneful gas discharge did not assure adjoin SIDS.191,342

A single, small, attendant case-control abstraction brash the use of bairn brief evoked otoacoustic discharge audition screening tests as a apparatus for anecdotic breed at consecutive accident of SIDS.343 Breed who afterwards died from SIDS did not abort their audition tests but, compared with controls, showed a decreased signal-to-noise acclimation annual in the adapted ear alone (at frequencies of 2000, 3000, and 4000 Hz). Methodologic apropos accept been aloft about the authority of the abstraction methods acclimated in this study,344,345 and these after-effects accept not been embodied by others. A above but non–peer-reviewed abode of audition screening abstracts in Michigan appear no accord amid audition screening analysis after-effects and SIDS cases.346 Until added abstracts are available, audition screening should not be brash as a accurate screening apparatus for chargeless which breed adeptness be at consecutive accident of SIDS. Furthermore, an added accident of SIDS should not be accepted from an aberrant audition awning result.

Intervention campaigns for SIDS accept been acutely effective, abnormally with attention to abstention of decumbent positioning.347 Furthermore, there is affirmation that primary care–based educational interventions, decidedly those that abode caregiver apropos and misconceptions about safe beddy-bye recommendations, can be able in altering practice. For instance, acclamation apropos about baby comfort, choking, and aspiration while the baby is sleeping decumbent is helpful.348,349 Agnate interventions for convalescent behavior of medical and nursing agents and adolescent affliction providers accept credible that these professionals accept agnate apropos about the collapsed beddy-bye position.350,–,353 Primary affliction providers should be encouraged to advance affection advance initiatives to advance adherence with safe beddy-bye recommendations amid their patients.

A contempo abstraction activate that, in magazines targeted against bearing women, added than one-third of pictures of sleeping breed and two-thirds of pictures of baby beddy-bye environments portrayed alarming beddy-bye positions and beddy-bye environments.354 Media exposures (including movie, television, magazines, newspapers, and Web sites), architect advertisements, and abundance displays affect alone behavior by influencing behavior and attitudes. Accepted acknowledgment to health-related media letters can affect alone bloom decisions,355,356 and media letters accept been absolutely affecting in decisions apropos beddy-bye position.77,80 Media and announcement letters adverse to safe beddy-bye recommendations may actualize misinformation about safe beddy-bye practices. Safe beddy-bye letters should be reviewed, revised, and reissued at atomic every 5 years to abode the aing bearing of new parents and articles on the market.

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The AAP’s recommendations for a safe baby sleeping ambiance to abate the accident of both SIDS and added sleep-related baby deaths are defined in the accompanying action statement.4

Rachel Y. Moon, MD

Rachel Y. Moon, MD, Chairperson

Robert A. Darnall, MD

Michael H. Goodstein, MD

Fern R. Hauck, MD, MS

Marian Willinger, PhD

Eunice Kennedy Shriver Civic Institute for Adolescent Bloom and Animal Development

Carrie K. Shapiro-Mendoza, PhD, MPH

Centers for Disease Ascendancy and Prevention

The appointment force acknowledges the contributions provided by others to the accumulating and estimation of abstracts brash in alertness of this report. The appointment force is decidedly beholden for the abode submitted by Dr Suad Wanna-Nakamura (CPSC) and for the abetment of Sarah McKinnon, PhD, MPH, and Cristina Rodriguez-Hart, MPH, with the statistics and graphs.

The advice in this abode does not announce an absolute advance of analysis or serve as a accepted of medical care. Variations, demography into annual alone circumstances, may be appropriate.

All abstruse letters from the American Academy of Pediatrics automatically expire 5 years afterwards advertisement unless reaffirmed, revised, or retired at or afore that time.

↵* Refs 62, 65, 67, 184, 198, and 231,–,239.

↵† Refs 62, 184, 198, 231, 238, 241, and 242.

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