RECOMMENDATIONS of the American Academy of Pediatrics
recommendations outlined here were developed to reduce the risk
of SIDS in the general population. As it is defined by
epidemiologists, risk refers to the probability that an outcome
will occur given the presence of a particular factor or set of
factors. Scientifically identified associations between risk
factors (eg, socioeconomic characteristics, behaviors, or
environmental exposures) and outcomes such as SIDS do not
necessarily denote causality. Furthermore, the best current
working model of SIDS suggests that more than 1 scenario of
preexisting conditions and initiating events may lead to SIDS.
Therefore, when considering the recommendations in this report,
it is fundamentally misguided to focus on a single risk factor
or to attempt to quantify risk for an individual infant.
Individual medical conditions may warrant a physician to
recommend otherwise after weighing the relative risks and
1. Back to sleep: Infants should be placed for sleep in a
supine position (wholly on the back) for every sleep. Side
sleeping is not as safe as supine sleeping and is not advised.
2. Use a firm sleep surface: Soft materials or objects such as
pillows, quilts, comforters, or sheepskins should not be placed
under a sleeping infant. A firm crib mattress, covered by a
sheet, is the recommended sleeping surface.
Keep soft objects and loose bedding out of the crib: Soft
objects such as pillows, quilts, comforters, sheepskins, stuffed
toys, and other soft objects should be kept out of an infant's
sleeping environment. If bumper pads are used in cribs, they
should be thin, firm, well secured, and not “pillow like.” In
addition, loose bedding such as blankets and sheets may be
hazardous. If blankets are to be used, they should be tucked in
around the crib mattress so that the infant's face is less
likely to become covered by bedding. One strategy is to make up
the bedding so that the infant's feet are able to reach the foot
of the crib (feet to foot), with the blankets tucked in around
the crib mattress and reaching only to the level of the infant's
chest. Another strategy is to use sleep clothing with no other
covering over the infant or infant sleep sacks that are designed
to keep the infant warm without the possible hazard of head
4. Do not smoke during pregnancy: Maternal smoking during
pregnancy has emerged as a major risk factor in almost every
epidemiologic study of SIDS. Smoke in the infant's environment
after birth has emerged as a separate risk factor in a few
studies, although separating this variable from maternal smoking
before birth is problematic. Avoiding an infant's exposure to
second‑hand smoke is advisable for numerous reasons in addition
to SIDS risk.
5. A separate but proximate sleeping environment is
recommended: The risk of SIDS has been shown to be reduced when
the infant sleeps 'in the same room as the mother. A crib,
bassinet, or cradle that conforms to the safety standards of the
Consumer Product Safety Commission and ASTM (formerly the
American Society for Testing and Materials) is recommended. "Cosleepers"
(infant beds that attach to the mother's bed) provide easy
access for the mother to the infant, especially for
breastfeeding, but safety standards for these devices have not
yet been established by the Consumer Product Safety Commission.
Although bed‑sharing rates are increasing in the United States for a
number of reasons, including facilitation of breastfeeding, the
task force concludes that the evidence is growing that bed
sharing, as practiced in the United States and other Western
countries, is more hazardous than the infant sleeping on a
separate sleep surface and, therefore, recommends that infants
not bed share during sleep. Infants may be brought into bed for
nursing or comforting but should be returned to their own crib
or bassinet when the parent is ready to return to sleep. The
infant should not be brought into bed when the parent is
excessively tired or using medications or substances that could
impair his or her alertness. The task force recommends that the
infant's crib or bassinet be placed in the parents' bedroom,
which, when placed close to their bed, will allow for more
convenient breastfeeding and contact. Infants should not bed
share with other children. Because it is very dangerous to sleep
with an infant on a couch or armchair, no one should sleep with
an infant on these surfaces.
6. Consider offering a pacifier at nap time and bedtime:
Although the mechanism is not known, the reduced risk of SIDS
associated with pacifier use during sleep is compelling, and the
evidence that pacifier use inhibits breastfeeding or causes
later dental complications is not. Until evidence dictates
otherwise, the task force recommends use of a pacifier
throughout the first year of life according to the following
The pacifier should be used when placing the
infant down for sleep and not be reinserted once the infant
falls asleep. If the infant refuses the pacifier, he or she
should not be forced to take it.
Pacifiers should not be coated in any sweet
Pacifiers should be cleaned often and replaced
For breastfed infants, delay pacifier introduction
until 1 month of age to ensure that breastfeeding is firmly
overheating: The infant should be lightly clothed for sleep, and
the bedroom temperature should be kept comfortable for a lightly
clothed adult. Overbundling should be avoided, and the infant
should not feel hot to the touch.
commercial devices marketed to reduce the risk of SIDS: Although
various devices have been developed to maintain sleep position
or to reduce the risk of rebreathing, none have been tested
sufficiently to show efficacy or safety.
9. Do not use
home monitors as a strategy to reduce the risk of SIDS:
Electronic respiratory and cardiac monitors are available to
detect cardiorespiratory arrest and may be of value for home
monitoring of selected infants who are deemed to have extreme
cardiorespiratory instability. However, there is no evidence
that use of such home monitors decreases the incidence of SIDS.
Furthermore, there is no evidence that infants at increased risk
of SIDS can be identified by inhospital respiratory or cardiac
10. Avoid development of positional
Encourage "tummy time" when the infant is awake
and observed. This will also enhance motor development.
Avoid having the infant spend excessive time in
car‑seat carriers and "bouncers," in which pressure is applied
to the occiput. Upright "cuddle time" should be encouraged.
Alter the supine head position during sleep.
Techniques for accomplishing this include placing the infant to
sleep with the head to one side for a week and then changing to
the other and periodically changing the orientation of the
infant to outside activity (eg, the door of the room).
Particular care should be taken to implement the
aforementioned recommendations for infants with neurologic
injury or suspected developmental delay.
Consideration should be given to early referral of
infants with plagiocephaly when it is evident that conservative
measures have been ineffective. In some cases, orthotic devices
may help avoid the need for surgery.
11. Continue the Back
to Sleep campaign: Public education should be intensified for
secondary caregivers (child care providers, grandparents, foster
parents, and babysitters). The campaign should continue to have
a special focus on the black and American Indian/Alaska Native
populations. Health care professionals in intensive care
nurseries, as well as those in well‑infant nurseries, should
implement these recommendations well before an anticipated