sids and other sleep-related infant deaths: expansion of

DOI: 10.1542/peds.2011-2285; originally published online October 17, 2011; 2011;128;e1341Pediatrics

Task Force on Sudden Infant Death Syndromefor a Safe Infant Sleeping Environment

SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations

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located on the World Wide Web at: The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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TECHNICAL REPORT

SIDS and Other Sleep-Related Infant Deaths:Expansion of Recommendations for a Safe InfantSleeping Environment

abstractDespite a major decrease in the incidence of sudden infant death syn-drome (SIDS) since the American Academy of Pediatrics (AAP) releasedits recommendation in 1992 that infants be placed for sleep in a non-prone position, this decline has plateaued in recent years. Concur-rently, other causes of sudden unexpected infant death occurring dur-ing sleep (sleep-related deaths), including suffocation, asphyxia, andentrapment, and ill-defined or unspecified causes of death have in-creased in incidence, particularly since the AAP published its last state-ment on SIDS in 2005. It has become increasingly important to addressthese other causes of sleep-related infant death. Many of the modifi-able and nonmodifiable risk factors for SIDS and suffocation are strik-ingly similar. The AAP, therefore, is expanding its recommendationsfrom being only SIDS-focused to focusing on a safe sleep environmentthat can reduce the risk of all sleep-related infant deaths includingSIDS. The recommendations described in this report include supinepositioning, use of a firm sleep surface, breastfeeding, room-sharingwithout bed-sharing, routine immunization, consideration of a pacifier,and avoidance of soft bedding, overheating, and exposure to tobaccosmoke, alcohol, and illicit drugs. The rationale for these recommenda-tions is discussed in detail in this technical report. The recommenda-tions are published in the accompanying “Policy Statement—SuddenInfant Death Syndrome and Other Sleep-Related Infant Deaths: Expan-sion of Recommendations for a Safe Infant Sleeping Environment,”which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220). Pediatrics 2011;128:e1341–e1367

METHODOLOGYLiterature searches using PubMed were conducted for each of thetopics in this technical report and concentrated on articles publishedsince 2005 (when the last policy statement1 was published). In addition,to provide additional information regarding sleep-environment haz-ards, a white paperwas solicited from the US Consumer Product SafetyCommission (CPSC).2 Strength of evidence for recommendations3 wasdetermined by the task force members. Draft versions of the policystatement4 and technical report were submitted to relevant commit-tees and sections of the American Academy of Pediatrics (AAP) forreview and comment. After the appropriate revisions were made, a

TASK FORCE ON SUDDEN INFANT DEATH SYNDROME

KEY WORDSSIDS, sudden infant death, infant mortality, sleep position, bed-sharing, tobacco, pacifier, immunization, bedding, sleep surface

ABBREVIATIONSCPSC—Consumer Product Safety CommissionAAP—American Academy of PediatricsSIDS—sudden infant death syndromeSUID—sudden unexpected infant deathICD—International Classification of DiseasesASSB—accidental suffocation and strangulation in bed5-HT—5-hydroxytryptamineOR—odds ratioCI—confidence interval

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-2285

doi:10.1542/peds.2011-2285

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

FROM THE AMERICAN ACADEMY OF PEDIATRICS

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final version was submitted to the AAPExecutive Committee and Board of Di-rectors for final approval.

SUDDEN INFANT DEATH SYNDROMEAND SUDDEN UNEXPECTED INFANTDEATH: DEFINITIONS ANDDIAGNOSTIC ISSUES

Sudden Infant Death Syndromeand Sudden Unexpected InfantDeath

Sudden infant death syndrome (SIDS)is a cause assigned to infant deathsthat cannot be explained after a thor-ough case investigation that includes ascene investigation, autopsy, and re-view of the clinical history.5 Sudden un-expected infant death (SUID), alsoknown as sudden unexpected death ininfancy (SUDI), is a term used to de-scribe any sudden and unexpecteddeath, whether explained or unex-plained (including SIDS), that occursduring infancy. After case investiga-tion, SUIDs can be attributed to suffo-cation, asphyxia, entrapment, infec-tion, ingestions, metabolic diseases,and trauma (accidental or nonacci-dental). The distinction between SIDSand other SUIDs, particularly thosethat occur during an observed or un-observed sleep period (sleep-relatedinfant deaths), such as accidental suf-focation, is challenging and cannotusually be determined by autopsyalone. Scene investigation and review ofthe clinical history are also required. Afew deaths that are diagnosed as SIDSare found, after further specializedinvestigations, to be attributable tometabolic disorders or arrhythmia-associated cardiac channelopathies.

Although standardized guidelines forconducting thorough case investiga-tions have been developed,6 theseguidelines have not been uniformly ad-opted across the more than 2000 USmedical examiner and coroner juris-dictions.7 Information from emergencyresponders, scene investigators, and

caregiver interviews can provide addi-tional evidence to assist death certifi-ers (ie, medical examiners and coro-ners) in accurately determining thecause of death. However, death certifi-ers represent a diverse group withvarying levels of skills and educationas well as diagnostic preferences. Re-cently, much attention has been fo-cused on reporting differences amongdeath certifiers. At one extreme, somecertifiers have abandoned using SIDSas a cause-of-death explanation.7 Atthe other extreme, some certifiers willnot classify a death as suffocation inthe absence of a pathologic marker ofasphyxia at autopsy (ie, pathologicfindings diagnostic of oronasal occlu-sion or chest compression8), even withstrong evidence from the scene inves-tigation that suggests a probable acci-dental suffocation.

US Trends in SIDS, Other SUIDs,and Postneonatal Mortality

To monitor trends in SIDS and otherSUIDs nationally, the United Statesclassifies diseases and injuries ac-cording to the International Classifica-tion of Diseases (ICD) diagnosticcodes. This classification system is de-signed to promote national and inter-national comparability in the assign-ment of cause-of-death determinations;however, this system might not pro-vide the optimal precision in classifica-tion desired by clinicians and re-searchers. In the United States, theNational Center for Health Statisticsassigns a SIDS diagnostic code (ICD-10R95) if the death is classified with ter-minology such as SIDS (including pre-sumed, probable, or consistent withSIDS), sudden infant death, sudden un-explained death in infancy, sudden un-expected death in infancy, or suddenunexplained infant death on the certi-fied death certificate. A death will becoded as “other ill-defined and unspec-ified causes of mortality” (ICD-10 R99)if the cause of the death is reported as

unknown or unspecified. A death iscoded as “accidental suffocation andstrangulation in bed” (ASSB) (ICD-10W75) when the terms “asphyxia,” “as-phyxiated,” “asphyxiation,” “stran-gled,” “strangulated,” “strangulation,”“suffocated,” or “suffocation” are re-ported, along with the terms “bed” or“crib.” This code also includes deathswhile sleeping on couches andarmchairs.

Although SIDS was defined somewhatloosely until the mid-1980s, there wasminimal change in the incidence ofSIDS in the United States until the early1990s. In 1992, in response to epidemi-ologic reports from Europe and Aus-tralia, the AAP recommended that in-fants be placed for sleep in a nonproneposition as a strategy for reducing therisk of SIDS.9 The “Back to Sleep” cam-paign was initiated in 1994 under theleadership of the National Institute ofChild Health and Human Developmentas a joint effort of the Maternal andChild Health Bureau of the Health Re-sources and Services Administration,the AAP, the SIDS Alliance (now FirstCandle), and the Association of SIDSand Infant Mortality Programs.10 TheEunice Kennedy Shriver National Insti-tute of Child Health and Human Devel-opment began conducting nationalsurveys of infant care practices toevaluate the implementation of the AAPrecommendation. Between 1992 and2001, the SIDS rate declined, and themost dramatic declines occurred inthe years immediately after the firstnonprone recommendations, consis-tent with the steady increase in theprevalence of supine sleeping (Fig 1).11

The US SIDS rate declined from 120deaths per 100 000 live births in 1992to 56 deaths per 100 000 live births in2001, representing a decrease of 53%over 10 years. However, from 2001 to2006 (the latest year from which dataare available), the rate has remainedconstant (Fig 1). In 2006, 2327 infants

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died from SIDS. Although SIDS rateshave declined by more than 50% sincethe early 1990s, SIDS remains thethird-leading cause of infant mortalityand the leading cause of postneonatalmortality (28 days to 1 year of age).

The all-cause postneonatal death ratehas followed a trend similar to theSIDS rate: there was a 29% declinefrom 1992 to 2001 (from 314 to 231 per100 000 live births). From 2001 until2006, postneonatal mortality rateshave also remained fairly unchanged(from 231 to 224 per 100 000 livebirths); the average decline is 3%.12

Several recent studies have revealedthat some deaths previously classifiedas SIDS are now being classified asother causes of infant death (eg, acci-dental suffocation and other ill-definedor unspecified causes).13,14 Since 1999,much of the decline in SIDS ratesmightbe explained by increasing rates ofthese other causes of SUID, particu-larly over the years 1999–2001.13,15 Anotable change is in deaths attribut-able to ASSB. Between 1984 and 2004,ASSB infant mortality rates more thanquadrupled, from 2.8 to 12.5 deathsper 100 000 live births,15 which repre-sents 513 infant deaths attributed toASSB in 2004 compared with 103 in1984.

Sleep Position

The apparent leveling of the previouslydeclining SIDS rate is occurring coinci-dent with a slowing in the reduction ofthe prevalence of prone positioning.The prevalence of supine sleep posi-tioning, as assessed from an ongoingnational sampling, increased from13% in 1992 to 72% in 2001. From 2001until 2010, the prevalence of supinesleep positioning has been fairly stag-nant (prevalence in 2010: 75%).11

The 1998 and 2005 AAP policy state-ments and the Back to Sleep campaignnot only addressed the importance ofback sleeping but also provided rec-ommendations for other infant care

practices that may reduce the risk ofSIDS and other sleep-related infantdeaths.1,9 Unfortunately, the ability tomeasure the prevalence of these otherrisk factors is limited by lack of data.Death certificates are useful for moni-toring trends in SIDS mortality, but thecircumstances and events that lead todeath are not captured in vital statis-tics data.16 The Centers for DiseaseControl and Prevention recently beganto pilot a SUID case registry that willprovide supplemental surveillance in-formation about the sleep environ-ment at the time of death, infant healthhistory, and the comprehensiveness ofthe death scene investigation and au-topsy. These factors will better de-scribe the circumstances surroundingSIDS and other sleep-related infantdeaths and assist researchers in de-termining the similarities and differ-ences between these deaths.

Racial and Ethnic Disparities

SIDS mortality rates, similar to othercauses of infant mortality, have nota-ble racial and ethnic disparities (Fig2).17 Despite the decline in SIDS in allraces and ethnicities, the rate of SIDSin non-Hispanic black (99 per 100 000live births) and American Indian/Alaska Native (112 per 100 000 livebirths) infants was double that of non-Hispanic white infants (55 per 100 000

0

20

40

60

80

100

120

140

160

180

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Dea

ths

per

100

000

birt

hs

SIDS UNK + ASSB Combined SUID

FIGURE 1Trends in SIDS and other SUIDmortality: United States 1990–2006. UNK indicates ill-defined or unspec-ified deaths.

78.569.4

155.3

203.3

44.0 48.354.5 55.6

103.8119.4

22.8 27.0

All race and ethnic origin

Non-Hispanic white Non-Hispanic black American Indianand Alaska Na�ve

Asian andPacific Islander

Hispanic

1996

2006

FIGURE 2Comparison of US rates of SIDS according to maternal race and ethnic origin in 1996 and 2006.





live births) in 2005 (Fig 2). SIDS ratesfor Asian/Pacific Islander and Hispanicinfants were nearly half the rate fornon-Hispanic white infants. Further-more, similar racial and ethnic dispar-ities have been seen with deathsattributed to both ASSB (Fig 3) and ill-defined or unspecified deaths (Fig 4).Differences in the prevalence of su-pine positioning and other sleep-environment conditions among ra-

cial and ethnic populations mightcontribute to these disparities.17 Theprevalence of supine positioning in2010 among white infants was 75%,compared with 53% among black in-fants (Fig 5). The prevalence of supinesleep positioning among Hispanic andAsian infants was 73% and 80%, re-spectively.11 Parent-infant bed-shar-ing18–20 and use of soft bedding are alsomore common among black families

3.8 3.95.4

13.8 12.9

32.4

44.0

5.1

All race and ethnicorigin

Non-Hispanic white Non-Hispanic black American Indian andAlaska Na�ve

Asian and PacificIslander

Hispanic

19962006

a a a a

FIGURE 3Comparison of US rates of death resulting from ASSB according to maternal race and ethnic origin in 1996 and 2006. a The figure does not meet standardsof reliability or precision on the basis of fewer than 20 deaths in the numerator.

18.214.8

38.2

13.3

24.421.1

47.3

64.9

12.4

18.7

All race and ethnic origin

Non-Hispanic white Non-Hispanic black American Indian andAlaska Na�ve

Asian and PacificIslander

Hispanic

19962006

a a

FIGURE 4Comparison of US rates of cause ill-defined or unspecified death according to maternal race and ethnic origin in 1996 and 2006. a The figure does not meetstandards of reliability or precision on the basis of fewer than 20 deaths in the numerator.

0

10

20

30

40

50

60

70

80

90

100

1992 2000 2010

Year

% o

f inf

ants

pla

ced

supi

ne

White

Black

Hispanic

Asian

FIGURE 5Prevalence of supine sleep positioning accord-ing to maternal race and ethnic origin, 1992–2010. Data source: National Infant Sleep PositionStudy.11



than among other racial/ethnicgroups.21,22 Additional work in promot-ing appropriate infant sleep positionand sleep-environment conditions isnecessary to resume the previous rateof decline (observed during the 1990s)for SIDS and all-cause postneonatalmortality.

Age at Death

Ninety percent of SIDS cases occur be-fore an infant reaches the age of 6months. The rate of SIDS peaks be-

tween 1 and 4 months of age. AlthoughSIDS was once considered a rare eventduring the first month of life, in 2004–2006, nearly 10% of cases coded asSIDS occurred during the first month.SIDS is uncommon after 8 months ofage (Fig 6).14 A similar age distributionis seen for ASSB (Fig 7).

Seasonality of SIDS

A pattern in seasonality of SIDS is nolonger apparent. SIDS deaths have his-torically been observed more fre-

quently in the colder months, and thefewest SIDS deaths occurred in thewarmest months.23 In 1992, SIDS rateshad an average seasonal change of16.3%, compared with only 7.6% in1999,24 which is consistent with re-ports from other countries.25

PATHOPHYSIOLOGY AND GENETICSOF SIDS

A working model of SIDS pathogenesisincludes a convergence of exogenoustriggers or “stressors” (eg, prone

9.1

21.923.3

17.6

11.6

6.8

3.9

2.21.5 0.9 0.6 0.5

0

10

20

30

0–1 1–2 2–3 3–4 4–5 5–6 6–7 7–8 8–9 9–10 10–11 11–12

Age, mo

%

FIGURE 6Percent distribution of SIDS deaths according to age at death: United States, 2004–2006.

14.4

24.7

20.3

12.9

9.0

5.9

3.7 3.7

1.9 1.7 1.1 0.8

0

10

20

30

0–1 1–2 2–3 3–4 4–5 5–6 6–7 7–8 8–9 9–10 10–11 11–12

Age, mo

%

FIGURE 7Percent distribution of deaths caused by ASSB according to age at death: United States, 2004–2006.





sleep position, overbundling, airwayobstruction), a critical period of devel-opment, and dysfunctional and/or im-mature cardiorespiratory and/orarousal systems (intrinsic vulnerabil-ity) that lead to a failure of protectiveresponses (see Fig 8).26 Convergenceof these factors ultimately results in acombination of progressive asphyxia,bradycardia, hypotension, metabolicacidosis, and ineffectual gasping, lead-ing to death.27 The mechanisms re-sponsible for dysfunctional cardiore-spiratory and/or arousal protectiveresponses remain unclear but mightbe the result of in utero environmentalconditions and/or genetically deter-mined maldevelopment or delay inmaturation. Infants who die from SIDSare more likely to be born at low birthweight or growth restricted, whichsuggests an adverse intrauterine envi-ronment. Other adverse in utero envi-ronmental conditions include expo-sure to nicotine or other componentsof cigarette smoke and alcohol.

Recent studies have explored how pre-natal exposure to cigarette smokemayresult in an increased risk of SIDS. Inanimal models, exposure to cigarettesmoke or nicotine during fetal devel-opment alters the expression of thenicotinic acetylcholine receptor in ar-eas of the brainstem important for au-tonomic function,28 alters the neuronalexcitability of neurons in the nucleustractus solitarius (a brainstem region

important for sensory integration),29

and alters fetal autonomic activity andmedullary neurotransmitter recep-tors.30 In human infants, there arestrong associations between nicotinicacetylcholine receptor and serotoninreceptors in the brainstem during de-velopment.31 Prenatal exposure to to-bacco smoke attenuates recoveryfrom hypoxia in preterm infants,32 de-creases heart rate variability in pre-term33 and term34 infants, and abol-ishes the normal relationship betweenheart rate and gestational age atbirth.33 Moreover, infants of smokingmothers exhibit impaired arousal pat-terns to trigeminal stimulation in pro-portion to urinary cotinine levels.35 It isimportant to note also that prenatalexposure to tobacco smoke alters thenormal programming of cardiovascu-lar reflexes such that there is agreater-than-expected increase inblood pressure and heart rate in re-sponse to breathing 4% carbon dioxideor a 60° head-up tilt.36 These changesin autonomic function, arousal, andcardiovascular reflexes might all in-crease an infant’s vulnerability to SIDS.

Brainstem abnormalities that involvethe medullary serotonergic (5-hydroxytryptamine [5-HT]) system inup to 70% of infants who die from SIDSare the most robust and specific neu-ropathologic findings associated withSIDS and have been confirmed in sev-eral independent data sets and labora-tories.37–40 This area of the brainstemplays a key role in coordinating manyrespiratory, arousal, and autonomicfunctions and, when dysfunctional,might prevent normal protective re-sponses to stressors that commonlyoccur during sleep. Since the TaskForce on Sudden Infant Death Syn-drome report in 2005, more specificabnormalities have been described, in-cluding decreased 5-HT1A receptorbinding, a relative decrease in bindingto the serotonin transporter, and in-

creased numbers of immature 5-HTneurons in regions of the brainstemthat are important for autonomic func-tion.41 These findings are not confinedto nuclei containing 5-HT neurons butalso include relevant projection sites.The most recent study report de-scribed in these same regions de-creased tissue levels of 5-HT andtryptophan hydroxylase, the synthe-sizing enzyme for serotonin, and noevidence of excessive serotonin deg-radation as assessed by levels of5-hydroxyindoleacetic acid (the mainmetabolite of serotonin) or ratios of5-hydroxyindoleacetic acid to sero-tonin.30 A recent article described asignificant association between a de-crease in medullary 5-HT1A receptorimmunoreactivity and specific SIDSrisk factors, including tobacco smok-ing.40 These data confirm results fromearlier studies in humans39,41 and arealso consistent with studies in pigletsthat revealed that postnatal exposureto nicotine decreasesmedullary 5-HT1Areceptor immunoreactivity.42 Animalstudies have revealed that serotoner-gic neurons located in the medullaryraphe and adjacent paragigantocellu-laris lateralis play important roles inmany autonomic functions includingthe control of respiration, blood pres-sure, heart rate, thermoregulation,sleep and arousal, and upper airwaypatency. Engineered mice with de-creased numbers of 5-HT neurons andrats or piglets with decreased activ-ity secondary to 5-HT1A autoreceptorstimulation have diminished ventila-tor responses to carbon dioxide, dys-functional heat production and heat-loss mechanisms, and altered sleeparchitecture.43 These studies linkedSIDS risk factors with possiblepathophysiology.

There is no evidence of a strong heri-table contribution for SIDS. However,genetic alterations have been ob-served that may increase the vulnera-

FIGURE 8Triple-risk model for SIDS.26



bility to SIDS. Genetic variation cantake the form of common basechanges (polymorphisms) that altergene function or rare base changes(mutations) that often have highly del-eterious effects. Several categories ofphysiologic functions relevant to SIDShave been examined for altered ge-netic makeup. Genes related to the se-rotonin transporter, cardiac channelo-pathies, and the development ofthe autonomic nervous system are thesubject of current investigation.44 Theserotonin transporter recovers sero-tonin from the extracellular space andlargely serves to regulate overall sero-tonin neuronal activity. Results of a re-cent study support those in previousreports that polymorphisms in thepromoter region that enhance the effi-cacy of the transporter (L) allele seemto bemore prevalent in infants who diefrom SIDS compared with those reduc-ing efficacy (S)45; however, at least 1study did not confirm this associa-tion.46 It has also been reported that apolymorphism (12-repeat intron 2) ofthe promoter region of the serotonintransporter, which also enhances se-rotonin transporter efficiency, was in-creased in black infants who diedfrom SIDS44 but not in a Norwegianpopulation.45

It has been estimated that 5% to 10% ofinfants who die from SIDS have novelmutations in the cardiac sodium or po-tassium channel genes that result inlong QT syndrome as well as in othergenes that regulate channel function.44

A recent report described importantnew molecular and functional evi-dence that implicates specific SCN5A(sodium channel gene) � subunits inSIDS pathogenesis.47 The identificationof polymorphisms in genes pertinentto the embryologic origin of the auto-nomic nervous system in SIDS casesalso lends support to the hypothesisthat a genetic predisposition contrib-utes to the etiology of SIDS. There have

also been a number of reports of poly-morphisms or mutations in genes thatregulate inflammation,48,49 energy pro-duction,50–52 and hypoglycemia53 in in-fants who died from SIDS, but theseassociations require more study to de-termine their importance.

ISSUES RELATED TO SLEEPPOSITION

The Supine Sleep Position IsRecommended for Infants toReduce the Risk of SIDS; SideSleeping Is Not Safe and Is NotAdvised

The prone or side sleep position canincrease the risk of rebreathing ex-pired gases, resulting in hypercapniaand hypoxia.54–57 The prone positionalso increases the risk of overheatingby decreasing the rate of heat loss andincreasing body temperature com-pared with infants sleeping supine.58,59

Recent evidence suggests that pronesleeping alters the autonomic controlof the infant cardiovascular systemduring sleep, particularly at 2 to 3months of age,60 and can result in de-creased cerebral oxygenation.61 Theprone position places infants at highrisk of SIDS (odds ratio [OR]: 2.3–13.1).62–66 However, recent studieshave demonstrated that the SIDS risksassociated with side and prone posi-tion are similar in magnitude (OR: 2.0and 2.6, respectively)63 and that thepopulation-attributable risk reportedfor side sleep position is higher thanthat for prone position.65,67 Further-more, the risk of SIDS is exceptionallyhigh for infants who are placed ontheir side and found on their stomach(OR: 8.7).63 The side sleep position isinherently unstable, and the probabil-ity of an infant rolling to the prone po-sition from the side sleep position issignificantly greater than rolling pronefrom the back.65,68 Infants who are un-accustomed to the prone position andare placed prone for sleep are also at

greater risk than those usually placedprone (adjusted OR: 8.7–45.4).63,69,70

Therefore, it is critically important thatevery caregiver use the supine sleepposition for every sleep period.

Despite these recommendations, theprevalence of supine positioning hasremained stagnant for the last de-cade.71 One of the most common rea-sons that parents and caregivers citefor not placing infants supine is fear ofchoking or aspiration in the supine po-sition.72–80 Parents often misconstruecoughing or gagging, which is evi-dence of a normal protective gag re-flex, for choking or aspiration. Multiplestudies in different countries have notfound an increased incidence of aspi-ration since the change to supinesleeping.81–83 There is often particularconcern for aspiration when the infanthas been diagnosed with gastroesoph-ageal reflux. The AAP supports the rec-ommendations of the North AmericanSociety for Pediatric Gastroenterologyand Nutrition, which state that infantswith gastroesophageal reflux shouldbe placed for sleep in the supine posi-tion, with the rare exception of infantsfor whom the risk of death from gas-troesophageal reflux is greater thanthe risk of SIDS84—specifically, infantswith upper airway disorders for whomairway protective mechanisms are im-paired, which may include infants withanatomic abnormalities, such as type3 or 4 laryngeal clefts, who have notundergone antireflux surgery. Elevat-ing the head of the infant’s crib whilethe infant is supine is not effective inreducing gastroesophageal reflux85,86;in addition, this elevation can result inthe infant sliding to the foot of the cribinto a position that might compromiserespiration and, therefore, is notrecommended.

The other reason often cited by par-ents for not using the supine sleep po-sition is the perception that the infantis uncomfortable or does not sleep





well.72–80 An infant who wakes fre-quently is normal and should not beperceived as a poor sleeper. Physio-logic studies have found that infantsare less likely to arouse when they aresleeping in the prone position.87–95 Theability to arouse from sleep is an im-portant protective physiologic re-sponse to stressors during sleep,96–100

and the infant’s ability to sleep for sus-tained periods might not be physiolog-ically advantageous.

Preterm Infants Should Be PlacedSupine as Soon as Possible

Infants born prematurely have an in-creased risk of SIDS,101,102 and the as-sociation between prone sleep posi-tion and SIDS among low birth weightinfants is equal to, or perhaps evenstronger than, the associationamong those born at term.69 There-fore, preterm infants should beplaced supine for sleep as soon astheir clinical status has stabilized.The task force supports the recom-mendations of the AAP Committee onFetus and Newborn, which state thathospitalized preterm infants shouldbe placed in the supine position forsleep by 32 weeks’ postmenstrualage to allow them to become accus-tomed to sleeping in that position be-fore hospital discharge.103 Unfortu-nately, preterm and very low birthweight infants continue to be morelikely to be placed prone for sleepafter hospital discharge.104,105 Pre-term infants are placed prone ini-tially to improve respiratory me-chanics106,107; although respiratoryparameters are no different in thesupine or prone positions in preterminfants who are close to discharge,108

both infants and their caregiverslikely become accustomed to usingthe prone position, which makes itmore difficult to change. One study ofNICU nurses found that only 50% ofnurses place preterm infants supineduring the transition to an open crib,

and more than 20% never place pre-term infants supine or will only placethem supine 1 to 2 days before dis-charge.109 Moreover, very prema-turely born infants studied beforehospital discharge have longer sleepduration, fewer arousals from sleep,and increased central apneas whilein the prone position.88 The taskforce believes that neonatologists,neonatal nurses, and other healthcare professionals responsible fororganizing the hospital discharge ofinfants from NICUs should be vigilantabout endorsing SIDS risk-reductionrecommendations from birth. Theyshould model the recommendationsas soon as the infant is medically sta-ble and significantly before the in-fant’s anticipated discharge. In addi-tion, NICUs are encouraged todevelop and implement policies toensure that supine sleeping andother safe sleep practices are mod-eled for parents before dischargefrom the hospital.

Newborn Infants Should Be PlacedSupine Within the First Few HoursAfter Birth

Practitioners who place infants ontheir sides after birth in newbornnurseries continue to be a concern.The practice likely occurs becausenursery staff believe that newborn in-fants need to clear their airways of am-niotic fluid and may be less likely toaspirate while on their sides. No evi-dence that such fluid will be clearedmore readily while in the side positionexists. Finally, and perhaps most im-portantly, if parents observe healthcare professionals placing infants inthe side or prone position, they arelikely to infer that supine positioning isnot important110 and, therefore, mightbemore likely to copy this practice anduse the side or prone position athome.77,80,111 The AAP recommends thatinfants be placed on their backs as

soon as they are ready to be placed in abassinet.

Once an Infant Can Roll From theSupine to Prone and From theProne to Supine Position, theInfant Can Be Allowed to Remain inthe Sleep Position That He or SheAssumes

Parents and caregivers are fre-quently concerned about the appro-priate strategy for infants who havelearned to roll over, which generallyoccurs at 4 to 6 months of age. Asinfants mature, it is more likely thatthey will roll. In 1 study, 6% and 12%of 16- to 23-week-old infants placedon their backs or sides, respectively,were found in the prone position;among infants aged 24 weeks orolder, 14% of those placed on theirbacks and 18% of those placed ontheir sides were found in the proneposition.112 Repositioning the sleep-ing infant to the supine position canbe disruptive and might discouragethe use of supine position altogether.Although data to make specific rec-ommendations as to when it is safefor infants to sleep in the prone po-sition are lacking, the AAP recom-mends that these infants continue tobe placed supine until 1 year of age.If the infant can roll from supine toprone and from prone to supine, theinfant can then be allowed to remainin the sleep position that he or sheassumes. To prevent suffocation orentrapment if the infant rolls, soft orloose bedding should continue to beremoved from the infant’s sleep en-vironment. Some caregivers usesuch bedding to prevent an infantfrom rolling, but this bedding couldcause suffocation and entrapment.Parents can be reassured by the in-formation that the incidence of SIDSbegins to decline after 4 months ofage (Fig 6).



Supervised, Awake Tummy Time ona Daily Basis Can Promote MotorDevelopment and Minimize theRisk of Positional Plagiocephaly

Positional plagiocephaly, or plagio-cephaly without synostosis (PWS), canbe associated with supine sleeping po-sition (OR: 2.5).113 It is most likely toresult if the infant’s head position isnot varied when placed for sleep, if theinfant spends little or no time inawake, supervised tummy time, and ifthe infant is not held in the upright po-sition when not sleeping.113–115 Chil-dren with developmental delay and/orneurologic injury have increased ratesof PWS, although a causal relationshiphas not been demonstrated.113,116–119 Inhealthy normal children, the incidenceof PWS decreases spontaneously from20% at 8 months to 3% at 24 months ofage.114 Although data to make specificrecommendations as to how often andhow long tummy time should be under-taken are lacking, supervised tummytime while the infant is awake is rec-ommended on a daily basis. Tummytime should begin as early as possibleto promote motor development, facili-tate development of the upper bodymuscles, and minimize the risk of po-sitional plagiocephaly. The AAP clinicalreport on positional skull deformi-ties120 provides additional detail on theprevention, diagnosis, and manage-ment of positional plagiocephaly.

SLEEP SURFACES

Infants Should Sleep in a Safety-Approved Crib, Portable Crib, PlayYard, or Bassinet

Cribs should meet safety standards ofthe CPSC, Juvenile Product Manufac-turers Association, and the ASTM Inter-national (formerly the American Soci-ety for Testing and Materials),including those for slat spacing, snuglyfitting and firm mattresses, and nodrop sides.121 The AAP recommendsthe use of new cribs, because older

cribs might no longer meet currentsafety standards, might have missingparts, or might be incorrectly assem-bled. If an older crib is to be used, caremust be taken to ensure that therehave been no recalls on the cribmodel,that all of the hardware is intact, andthat the assembly instructions areavailable.

For some families, use of a crib mightnot be possible for financial reasonsor space considerations. In addition,parentsmight be reluctant to place theinfant in the crib because of concernsthat the crib is too large for the infantor that “crib death” (ie, SIDS) only oc-curs in cribs. Alternate sleep surfaces,such as portable cribs/play yards andbassinets might be more acceptablefor some families, because they aresmaller andmore portable. Local orga-nizations throughout the United Statescan help to provide low-cost or freecribs or play yards. If a portable crib/play yard or bassinet is to be used, itshould meet the following CPSC guide-lines: (1) sturdy bottom and wide base;(2) smooth surfaces without protrud-ing hardware; (3) legs with locks toprevent folding while in use; and (4)firm, snugly fitting mattress.121 In addi-tion, other AAP guidelines for safesleep, including supine positioningand avoidance of soft objects andloose bedding, should be followed.Mattresses should be firm and shouldmaintain their shape even when the fit-ted sheet designated for that model isused, such that there are no gaps be-tween the mattress and the side of thebassinet, playpen, portable crib, orplay yard. Only mattresses designedfor the specific product should beused. Pillows or cushions should notbe used as substitutes for mattressesor in addition to a mattress. Any fabricon the sides or a canopy should be tautand firmly attached to the frame so asnot to create a suffocation risk for theinfant. Portable cribs, play yards, and

bassinets with vertical sides made ofair-permeable material may be prefer-able to those with air-impermeablesides.122 Finally, parents and caregiv-ers should adhere to the manufactur-er’s guidelines regarding maximumweight of infants using these prod-ucts.122,123 If the product is a combina-tion product (eg, crib/toddler bed), themanual should be consulted when themode of use is changed.

There are no data regarding the safetyof sleepers that attach to the side of anadult bed. However, there are potentialsafety concerns if the sleeper is notattached properly to the side of theadult bed or if the infantmoves into theadult bed. Therefore, the task forcecannot make a recommendation for oragainst the use of bedside sleepers. Inaddition, infants should not be placedfor sleep on adult-sized beds becauseof the risk of entrapment and suffoca-tion.124 Portable bed rails (railings in-stalled on the side of the bed that areintended to prevent a child from fallingoff of the bed) should not be used withinfants because of the risk of entrap-ment and strangulation.125

Car Seats and Other SittingDevices Are not Recommended forRoutine Sleep at Home or in theHospital, Particularly for YoungInfants

Some parents let their infants sleep ina car seat or other sitting device. Sit-ting devices include but are not re-stricted to car seats, strollers, swings,infant carriers, and infant slings. Par-ents and caregivers often use thesedevices, even when not traveling, be-cause they are convenient. One studyfound that the average young infantspends 5.7 hours/day in a car seat orsimilar sitting device.126 However,there are multiple concerns about us-ing sitting devices as a usual infantsleep location. Placing an infant insuch devices can potentiate gastro-





esophageal reflux127 and positionalplagiocephaly. Because they still havepoor head control and often experi-ence flexion of the head while in a sit-ting position, infants younger than 1month in sitting devices might be atincreased risk of upper airway obstruc-tion and oxygen desaturation.128–132 In ad-dition, there is increasing concernabout injuries from falls resultingfrom car seats being placed on ele-vated surfaces.133–137 An analysis ofCPSC data revealed 15 suffocationdeaths between 1990 and 1997 result-ing from car seats overturning afterbeing placed on a bed, mattress, orcouch.136 The CPSC also warns aboutthe suffocation hazard to infants, par-ticularly those who are younger than 4months, who are carried in infant slingcarriers.138 When infant slings areused for carrying, it is important to en-sure that the infant’s head is up andabove the fabric, the face is visible, andthat the nose and mouth are clear ofobstructions. After nursing, the infantshould be repositioned in the sling sothat the head is up and is clear of fab-ric and the adult’s body.

BED-SHARING

Room-Sharing Without Bed-SharingIs Recommended

The terms “bed-sharing” and “cosleep-ing” are often used interchangeably,but they are not synonymous. Cosleep-ing is when parent and infant sleep inclose proximity (on the same surfaceor different surfaces) so as to be ableto see, hear, and/or touch eachother.139,140 Cosleeping arrangementscan include bed-sharing or sleeping inthe same room in close proximity.140,141

Bed-sharing refers to a specific type ofcosleeping when the infant is sleepingon the same surface with another per-son.140 Because the term cosleepingcan bemisconstrued and does not pre-cisely describe sleep arrangements,

the AAP recommends use of the terms“room-sharing” and “bed-sharing.”

The AAP recommends the arrange-ment of room-sharing without bed-sharing, or having the infant sleep inthe parents’ room but on a separatesleep surface (crib or similar surface)close to the parents’ bed. There is evi-dence that this arrangement de-creases the risk of SIDS by as much as50%64,66,142,143 and is safer than bed-sharing64,66,142,143 or solitary sleeping(when the infant is in a separateroom).53,64 In addition, this arrange-ment is most likely to prevent suffoca-tion, strangulation, and entrapment,which may occur when the infant issleeping in the adult bed. Furthermore,room-sharing without bed-sharing al-lows close proximity to the infant,which facilitates feeding, comforting,and monitoring of the infant.

Parent-infant bed-sharing is common.In 1 national survey, 45% of parentsresponded that they had shared a bedwith their infant (8 months of age oryounger) at some point in the preced-ing 2 weeks.19 In some racial/ethnicgroups, the rate of routine bed-sharingmight be higher.18–20 There are oftencultural and personal reasons whyparents choose to bed-share, includ-ing convenience for feeding (breast-feeding or with formula) and bonding.In addition, many parents might be-lieve that their own vigilance is the onlyway that they can keep their infant safeand that the close proximity of bed-sharing allows them to maintain vigi-lance, even while sleeping.144 Someparents will use bed-sharing specifi-cally as a safety strategy if the infantsleeps in the prone position21,144 or ifthere is concern about environmentaldangers such as vermin and straygunfire.144

Parent-infant bed-sharing continues tobe highly controversial. Although elec-trophysiologic and behavioral studieshave offered a strong case for its effect

in facilitating breastfeeding145,146 andalthough many parents believe thatthey can maintain vigilance of the in-fant while they are asleep and bed-sharing,144 epidemiologic studies haveshown that bed-sharing can be hazard-ous under certain conditions.147–150

Bed-sharing might increase the risk ofoverheating,151 rebreathing152 or air-way obstruction,153 head cover-ing,152,154–156 and exposure to tobaccosmoke,157 which are all risk factors forSIDS. A recentmeta-analysis of 11 stud-ies that investigated the association ofbed-sharing and SIDS revealed a sum-mary OR of 2.88 (95% confidence inter-val [CI]: 1.99–4.18) with bed-sharing.158 Furthermore, bed-sharingin an adult bed not designed for infantsafety exposes the infant to additionalrisks for accidental injury and death,such as suffocation, asphyxia, entrap-ment, falls, and strangulation.159,160 In-fants, particularly those in the first 3months of life and those born prema-turely and/or with low birth weight,are at highest risk,161 possibly becauseimmature motor skills and musclestrength make it difficult to escape po-tential threats.158 In recent years, theconcern among public health officialsabout bed-sharing has increased, be-cause there have been increased re-ports of SUIDs occurring in high-risksleep environments, particularly bed-sharing and/or sleeping on a couch orarmchair.162–165

There Is Insufficient Evidence toRecommend Any Bed-SharingSituation in the Hospital or atHome as Safe; Devices Promotedto Make Bed-Sharing “Safe” AreNot Recommended

Epidemiologic studies have not foundbed-sharing to be protective againstSIDS and accidental suffocation for anysubgroups of the population. It is ac-knowledged that there are some cul-tures for which bed-sharing is thenorm and SIDS rates are low, but there



are other cultures for which bed-sharing is the norm and SIDS rates arehigh. In general, the bed-sharing prac-ticed in cultures with low SIDS rates isoften different from that in the UnitedStates and other Western countries(eg, with firm mats on the floor, sepa-ratemat for the infant, and/or absenceof soft bedding). It is statistically muchmore difficult to demonstrate safety(ie, no risk) in small subgroups.Breastfeeding mothers who do notsmoke and have not consumed alcoholor arousal-altering medications ordrugs are 1 such subgroup. Further-more, not all risks associated withbed-sharing (eg, parental fatigue) canbe controlled. The task force, there-fore, believes that there is insufficientevidence to recommend any bed-sharing situation in the hospital or athome as safe. In addition, there is noevidence that devices marketed tomake bed-sharing “safe” (eg, in-bedcosleepers) reduce the risk of SIDS orsuffocation or are safe. Such devices,therefore, are not recommended.

There Are Specific Circumstancesin Which Bed-Sharing IsParticularly Hazardous, and ItShould Be Stressed to ParentsThat They Avoid the FollowingSituations at All Times

The task force emphasizes that certaincircumstances greatly increase therisk with bed-sharing. Bed-sharing isespecially dangerous when 1 or bothparents are smokers (OR: 2.3–17.7)64,65,158,166,167; when the infant isyounger than 3 months (OR: 4.7–10.4),regardless of parental smoking sta-tus64,66,143,158,168,169; when the infant isplaced on excessively soft surfacessuch as waterbeds, sofas, and arm-chairs (OR: 5.1–66.9)62,64,65,143,169; whensoft bedding accessories such as pil-lows or blankets are used (OR: 2.8–4.1)62,170; when there are multiple bed-sharers (OR: 5.4)62; and when theparent has consumed alcohol (OR:

1.66).66,171 There is also a higher risk ofSIDS when the infant is bed-sharingwith someone who is not a parent (OR:5.4).62

A retrospective series of SIDS cases in-dicated that mean maternal bodyweight was higher for bed-sharingmothers than for non–bed-sharingmothers.172 The only case-control studyto investigate the relationship be-tween maternal body weight and bed-sharing did not find an increased riskof bed-sharing with increased mater-nal weight.173

Infants May Be Brought Into theBed for Feeding or Comforting butShould Be Returned to Their OwnCrib or Bassinet When the ParentIs Ready to Return to Sleep

The risk of bed-sharing is higher thelonger the duration of bed-sharingduring the night.64,65,167,169 Returningthe infant to the crib after bringing himor her into the bed for a short period oftime is not associated with increasedrisk.65,169 Therefore, if the infant isbrought into the bed for feeding, com-forting, and bonding, the infant shouldbe returned to the crib when the par-ent is ready for sleep. Because of theextremely high risk of SIDS, accidentalsuffocation, and entrapment oncouches and armchairs,62,64,65,143,169 in-fants should not be fed on a couch orarmchair when there is high risk thatthe parent may fall asleep.

It Is Prudent to Provide SeparateSleep Areas and Avoid Cobeddingfor Twins and Higher-OrderMultiples in the Hospital and atHome

Cobedding of twins and other infantsof multiple gestation is a frequentpractice, both in the hospital settingand at home.174 However, the benefitsof cobedding twins and higher-ordermultiples have not been estab-lished.175–177 Twins and higher-order

multiples are often born prematurelyand with low birth weight, so they areat increased risk of SIDS.101,102 Further-more, there is increased potential foroverheating and rebreathing whilecobedding, and size discordancemightincrease the risk of accidental suffoca-tion.176 Most cobedded twins areplaced on their sides rather than su-pine.174 Finally, cobedding of twins andhigher-order multiples in the hospitalsetting might encourage parents tocontinue this practice at home.176 Be-cause the evidence for the benefits ofcobedding twins and higher-ordermultiples is not compelling and be-cause of the increased risk of SIDS andsuffocation, the AAP believes that it isprudent to provide separate sleep ar-eas for these infants to decrease therisk of SIDS and accidental suffocation.

BEDDING

Pillows, Quilts, Comforters,Sheepskins, and Other SoftSurfaces Are Hazardous WhenPlaced Under the Infant or Loosein the Sleep Environment

Bedding is used in infant sleep environ-ments for comfort and safety.178 Par-ents and caregivers who perceive thatinfants are uncomfortable on firm sur-faces will often attempt to soften thesurface with blankets and pillows. Par-ents and caregivers will also use pil-lows and blankets to create barriers toprevent the infant from falling off thesleep surface (usually an adult bed orcouch) or to prevent injury if the infanthits the crib side. However, such softbedding can increase the potential ofsuffocation and rebreathing.54,56,57,179–181

Pillows, quilts, comforters, sheep-skins, and other soft surfaces are haz-ardous when placed under the in-fant62,147,182–187 or left loose in theinfant’s sleep area62,65,184,185,188–191 andcan increase SIDS risk up to fivefoldindependent of sleep position.62,147 Sev-eral reports have also described that





in many SIDS cases, the heads of theinfants, including some infants whoslept supine, were covered by loosebedding.65,186,187,191 It should be notedthat the risk of SIDS increases 21-foldwhen the infant is placed prone withsoft bedding.62 In addition, soft andloose bedding have both been associ-ated with accidental suffocationdeaths.149 The CPSC has reported thatthe majority of sleep-related infantdeaths in its database are attributableto suffocation involving pillows, quilts,and extra bedding.192,193 The AAP rec-ommends that infants sleep on a firmsurface without any soft or loose bed-ding. Pillows, quilts, and comfortersshould never be in the infant’s sleepenvironment. Specifically, these itemsshould not be placed loose near theinfant, between the mattress and thesheet, or under the infant. Infant sleepclothing that is designed to keep theinfant warm without the possible haz-ard of head covering or entrapmentcan be used in place of blankets; how-ever, care must be taken to select ap-propriately sized clothing and to avoidoverheating. If a blanket is used, itshould be thin and tucked under themattress so as to avoid head or facecovering. These practices should alsobe modeled in hospital settings.

Wedges and Positioning DevicesAre not Recommended

Wedges and positioning devices are of-ten used by parents to maintain theinfant in the side or supine position be-cause of claims that these products re-duce the risk for SIDS, suffocation, orgastroesophageal reflux. However,these products are frequently madewith soft, compressible materials,which might increase the risk of suffo-cation. The CPSC has reports of deathsattributable to suffocation and entrap-ment associated with wedges and po-sitioning devices. Most of these deathsoccurred when infants were placed inthe prone or side position with these

devices; other incidents have occurredwhen infants have slipped out of therestraints or rolled into a prone posi-tion while using the device.2,194 Be-cause of the lack of evidence that theyare effective against SIDS, suffocation,or gastroesophageal reflux and be-cause there is potential for suffocationand entrapment, the AAP concurs withthe CPSC and the US Food and DrugAdministration in warning against theuse of these products. If positioningdevices are used in the hospital as partof physical therapy, they should be re-moved from the infant sleep area wellbefore discharge from the hospital.

Bumper Pads and Similar ProductsAre not Recommended

Bumper pads and similar productsthat attach to crib slats or sides arefrequently used with the thought ofprotecting infants from injury. Initially,bumper pads were developed to pre-vent head entrapment between cribslats.195 However, newer crib stan-dards that require crib slat spacing tobe less than 23⁄8 inches have obviatedthe need for crib bumpers. In addition,infant deaths have occurred becauseof bumper pads. A recent report byThach et al,196 who used CPSC data,found that deaths attributed to bum-per pads were from 3mechanisms: (1)suffocation against soft, pillow-likebumper pads; (2) entrapment betweenthe mattress or crib and firm bumperpads; and (3) strangulation from bum-per pad ties. However, the CPSC be-lieves that there were other confound-ing factors, such as the presence ofpillows and/or blankets, that mighthave contributed tomany of the deathsin this report.2 Thach et al196 also ana-lyzed crib injuries that might havebeen prevented by bumper pad useand concluded that the use of bumperpads only prevents minor injuries. Amore recent study of crib injuries thatused data from the CPSC National Elec-tronic Injury Surveillance System con-

cluded that the potential benefits ofpreventing minor injury with bumperpad use were far outweighed by therisk of serious injury such as suffoca-tion or strangulation.197 In addition,most bumper pads obscure infant andparent visibility, which might increaseparental anxiety.195 There are otherproducts that attach to crib sides orcrib slats that claim to protect infantsfrom injury. However, there are nopublished data that support theseclaims. Because of the potential forsuffocation, entrapment, and strangu-lation and lack of evidence to supportthat bumper pads or similar productsthat attach to crib slats or sides pre-vent injury in young infants, the AAPdoes not recommend their use.

PRENATAL AND POSTNATALEXPOSURES (INCLUDING SMOKINGAND ALCOHOL)

Pregnant Women Should Seek andObtain Regular Prenatal Care

There is substantial epidemiologic evi-dence that links a lower risk of SIDS forinfants whose mothers obtain regularprenatal care.198–200 Women shouldseek prenatal care early in the preg-nancy and continue to obtain regularprenatal care during the entirepregnancy.

Smoking During Pregnancy, in thePregnant Woman’s Environment,and in the Infant’s EnvironmentShould Be Avoided

Maternal smoking during pregnancy isa major risk factor in almost every ep-idemiologic study of SIDS.201–204 Smokein the infant’s environment after birthis a separate major risk factor in a fewstudies,202,205 although separating thisvariable from maternal smoking be-fore birth is problematic. Thirdhandsmoke refers to residual contamina-tion from tobacco smoke after the cig-arette has been extinguished206; thereis no research to date on the signifi-



cance of thirdhand smoke with re-gards to SIDS risk. Smoke exposure ad-versely affects infant arousal207–213; inaddition, smoke exposure increasesrisk of preterm birth and low birthweight, both of which are risk factorsfor SIDS. The effect of tobacco smokeexposure on SIDS risk is dose-dependent. Aside from sleep position,smoke exposure is the largest con-tributing risk factor for SIDS.149 It isestimated that one-third of SIDSdeaths could be prevented if all ma-ternal smoking during pregnancywere eliminated.214,215 The AAP sup-ports the elimination of all tobaccosmoke exposure, both prenatally andenvironmentally.216,217

Avoid Alcohol and Illicit Drug UseDuring Pregnancy and After theInfant’s Birth

Several studies have specifically inves-tigated the association of SIDS withprenatal and postnatal exposure to al-cohol or illicit drug use, although sub-stance abuse often involves more than1 substance and it is difficult to sepa-rate these variables from each otherand from smoking. However, 1 study ofNorthern Plains American Indiansfound that periconceptional maternalalcohol use (adjusted OR: 6.2 [95% CI:1.6–23.3]) and maternal first-trimester binge drinking (adjusted OR:8.2 [95% CI: 1.9–35.3])218 were associ-ated with increased SIDS risk indepen-dent of prenatal cigarette smoking ex-posure. Another study from Denmark,which was based on prospective dataaboutmaternal alcohol use, also founda significant relationship between ma-ternal binge drinking and postneona-tal infant mortality, including SIDS.219

Postmortem studies of NorthernPlains American Indian infants re-vealed that prenatal cigarette smokingwas significantly associated with de-creased serotonin receptor binding inthe brainstem. In this study, the asso-

ciation of maternal alcohol drinking inthe 3 months before or during preg-nancy was of borderline significanceon univariate analysis but was not sig-nificant when prenatal smoking andcase-versus-control status were in themodel.39 However, this study had lim-ited power for multivariate analysisbecause of its small sample size. Onestudy found an association of SIDSwithheavy alcohol consumption in the 2days before the death.220 Althoughsome studies have found a particularlystrong association when alcohol con-sumption occurs in combination withbed-sharing,64–66,221 other studieshave not found interaction betweenbed-sharing and alcohol to besignificant.167,222

Studies investigating the relationshipof illicit drug use and SIDS have fo-cused on specific drugs or illicit druguse in general. In utero exposure toopiates (primarilymethadone and her-oin) has been shown in retrospectivestudies to be associated with an in-creased risk of SIDS.223,224 With the ex-ception of 1 study that did not showincreased risk,225 population-basedstudies have generally shown an in-creased risk with in utero cocaine ex-posure.226–228 However, these studiesdid not control for confounding fac-tors. A prospective cohort study foundthe SIDS rate to be significantly in-creased for infants exposed in utero tomethadone (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]), even after controlling forrace/ethnicity, maternal age, parity,birth weight, year of birth, and mater-nal smoking.229 In addition, a meta-analysis of studies that investigated anassociation between in utero cocaineexposure and SIDS found an increasedrisk of SIDS to be associated with pre-natal exposure to cocaine and illicitdrugs in general.230

BREASTFEEDING

Breastfeeding Is Recommended

Earlier epidemiologic studies were notconsistent in demonstrating a protec-tive effect of breastfeeding on SIDS*;some studies found a protective ef-fect,67,239,240 and others did not.† Be-causemany of the case-control studiesdemonstrated a protective effect ofbreastfeeding against SIDS in univari-ate analysis but not when confoundingfactors were taken into ac-count,62,184,198,231,238 these results sug-gested that factors associated withbreastfeeding, rather than breastfeed-ing itself, are protective. However,newer published reports support theprotective role of breastfeeding onSIDS when taking into account poten-tial confounding factors.243–245 Studiesdo not distinguish between nursingand expressed human milk. In theAgency for Healthcare Research andQuality’s “Evidence Report on Breast-feeding in Developed Countries,”243

multiple outcomes, including SIDS,were examined. Six studies were in-cluded in the SIDS-breastfeedingmeta-analysis, and in both unadjusted andadjusted analysis, ever breastfeedingwas associated with a lower risk ofSIDS (summary OR: 0.41 [95% CI: 0.28–0.58]; adjusted summary OR: 0.64 [95%CI: 0.51–0.81]). The German Study ofSudden Infant Death, the largest andmost recent case-control study ofSIDS, found that exclusive breastfeed-ing at 1 month of age halved the risk ofSIDS (adjusted OR: 0.48 [95% CI: 0.28–0.82]). At all ages, control infants werebreastfed at higher rates than SIDS vic-tims, and the protective effect of par-tial or exclusive breastfeeding re-mained statistically significant afteradjustment for confounders.244 A re-cent meta-analysis that included 18case-control studies revealed an un-adjusted summary OR for any breast-

*Refs 62, 65, 67, 184, 198, and 231–239.†Refs 62, 184, 198, 231, 238, 241, and 242.





feeding of 0.40 (95% CI: 0.35– 0.44).Seven of these studies provided ad-justed ORs, and on the basis of thesestudies, the pooled adjusted OR re-mained statistically significant at0.55 (95% CI: 0.44 – 0.69) (Fig 9).245 Theprotective effect of breastfeeding in-creased with exclusivity, with a uni-variable summary OR of 0.27 (95% CI:0.24–0.31) for exclusive breastfeedingof any duration.245

Currently in the United States, 73% ofmothers initiate breastfeeding, and42% and 21% are still breastfeeding at6 and 12 months, respectively.246 Non-Hispanic black mothers are least likelyto initiate or to still be breastfeeding at6 and 12 months (54%, 27%, and 12%,respectively), whereas Asian/PacificIslander mothers initiate and continuebreastfeeding more than other groups(81%, 52%, and 30%, respectively).Rates for initiating and continuingbreastfeeding at 6 and 12 months fornon-Hispanic white mothers are 74%,43%, and 21%; rates for Hispanicmoth-ers are 80%, 45%, and 24%; and ratesfor American Indian/Alaskan Nativemothers are 70%, 37%, and 19%,respectively.

Physiologic sleep studies have foundthat breastfed infants are more easilyaroused from sleep than theirformula-fed counterparts.247,248 In addi-tion, breastfeeding results in a de-creased incidence of diarrhea, upperand lower respiratory infections, and

other infectious diseases249 that areassociated with an increased vulnera-bility to SIDS and provides overall im-mune system benefits from maternalantibodies and micronutrients in hu-manmilk.250,251 Exclusive breastfeedingfor 6 months has been found to bemore protective against infectious dis-eases comparedwith exclusive breast-feeding to 4 months of age and partialbreastfeeding thereafter.249

If a Breastfeeding Mother Bringsthe Infant Into the Adult Bed forNursing, the Infant Should BeReturned to a Separate SleepSurface When the Mother Is Readyfor Sleep

Several organizations promote thepractice of mother-infant bed-sharing(ie, sleeping in the same bed) as a wayof facilitating breastfeeding.142,252,253

Breastfeeding is a common reasongiven by mothers for bed-sharing withtheir infants.254 Studies have found anassociation between bed-sharing andlonger duration of breastfeeding, buttheir data cannot determine a tempo-ral relationship (ie, it is not knownwhether bed-sharing promotesbreastfeeding or if breastfeeding pro-motes bed-sharing, or if women whoprefer 1 practice are also likely to pre-fer the other).255 Although bed-sharingmay facilitate breastfeeding, it is notessential for successful breastfeed-ing.256,257 Furthermore, 1 case-control

study found that the risk of SIDS whilebed-sharing was similar regardless ofbreastfeeding status, which indicatesthat the benefits of breastfeeding donot outweigh the increased risk asso-ciated with bed-sharing.258

PACIFIER USE

Consider Offering a Pacifier at NapTime And Bedtime

Several studies62,66,167,231,259–262 havefound a protective effect of pacifierson the incidence of SIDS, particularlywhen used at the time of last sleep.Two meta-analyses revealed that paci-fier use decreased the risk of SIDS by50% to 60% (summary adjusted OR:0.39 [95% CI: 0.31–0.50]263; summaryunadjusted OR: 0.48 [95% CI: 0.43–0.54]264). Two later studies not in-cluded in these meta-analyses re-ported equivalent or even largerprotective associations.265,266 Themechanism for this apparent strongprotective effect is still unclear, butlowered arousal thresholds, favorablemodification of autonomic control dur-ing sleep, and maintaining airway pa-tency during sleep have been pro-posed.247,267–270 It is common for thepacifier to fall from the mouth soonafter the infant falls asleep; even so,the protective effect persists through-out that sleep period.247,271 Two studieshave shown that pacifier use is mostprotective when used for all sleep pe-riods.169,266 However, these studies also

Study or SubgroupFleming et al65 (1996)Hauck et al62 (2003)Klonoff-Cohen and Edelstein222 (1995)Mitchell25 (1997)Ponsonby et al235 (1995)Vennemann et al244 (2009)Wennergren et al240 (1997)

Total (95% CI)Heterogeneity: χ² = 10.08, df = 6 (P = .12); I² = 40%Test for overall effect: z = 5.28 (P < .00001)

log[]0.058269-0.91629

-0.89159812-0.07257-0.15082-0.84397

-0.693147

SE0.3176570.319582

0.33463050.4203370.4012450.2393540.21979

Weight12.6%12.4%11.4%7.2%7.9%

22.2%26.3%

100.0%

IV, Fixed, 95% CI1.06 [0.57–1.98]0.40 [0.21–0.75]0.41 [0.21–0.79]0.93 [0.41–2.12]0.86 [0.39–1.89]0.43 [0.27–0.69]0.50 [0.33–0.77]

0.55 [0.44–0.69]

IV, Fixed, 95% CI

0.01 0.1 1 10 100Favors breastfeeding Favors not breastfeeding

FIGURE 9Multivariable analysis of any breastfeeding versus no breastfeeding. log[ ] indicates logarithm of the OR; weight, weighting that the study contributed to themeta-analysis (according to sample size); IV, fixed, 95% CI: fixed-effect OR with 95% CI.245



showed increased risk of SIDS whenthe pacifier was usually used but notused the last time the infant wasplaced for sleep; the significance ofthese findings is yet unclear.

Although some SIDS experts andpolicy-makers endorse pacifier userecommendations that are similar tothose of the AAP,272,273 concerns aboutpossible deleterious effects of pacifieruse have prevented others from mak-ing a recommendation for pacifier useas a risk reduction strategy.274 Al-though several observational stud-ies275–277 have found a correlationbetween pacifiers and reducedbreastfeeding duration, the results ofwell-designed randomized clinical tri-als indicated that pacifiers do notseem to cause shortened breastfeed-ing duration for term and preterm in-fants.278,279 The authors of 1 study re-ported a small deleterious effect ofearly pacifier introduction (2–5 daysafter birth) on exclusive breastfeedingat 1 month of age and on overallbreastfeeding duration (defined asany breastfeeding), but early pacifieruse did not adversely affect exclusivebreastfeeding duration. In addition,there was no effect on breastfeedingduration when the pacifier was intro-duced at 1 month of age.280 A more re-cent systematic review found that thehighest level of evidence (ie, from clin-ical trials) does not support an ad-verse relationship between pacifieruse and breastfeeding duration or ex-clusivity.281 The association betweenshortened duration of breastfeedingand pacifier use in observational stud-ies likely reflects a number of complexfactors such as breastfeeding difficul-ties or intent to wean.281 A large multi-center, randomized controlled trial of1021 mothers who were highly moti-vated to breastfeed were assigned to 2groups: mothers advised to offer apacifier after 15 days and mothers ad-vised not to offer a pacifier. At 3

months, there were no differences inbreastfeeding rates between the 2groups; 85.8% of infants in the offer-pacifier groupwere exclusively breast-feeding compared with 86.2% in thenot-offered group.282 The AAP policystatement on breastfeeding and theuse of human milk includes a recom-mendation that pacifiers can be usedduring breastfeeding, but implementa-tion should be delayed until breast-feeding is well established.283

Some dental malocclusions have beenfound more commonly among pacifierusers than nonusers, but the differ-ences generally disappeared afterpacifier cessation.284 In its policy state-ment on oral habits, the AmericanAcademy of Pediatric Dentistry statesthat nonnutritive sucking behaviors(ie, fingers or pacifiers) are consid-ered normal for infants and young chil-dren and that, in general, sucking hab-its in children to the age of 3 years areunlikely to cause any long-term prob-lems.285 There is an approximate 1.2- to2-fold increased risk of otitis media as-sociated with pacifier use, particularlybetween 2 and 3 years of age.286,287 Theincidence of otitis media is generallylower in the first year of life, especiallythe first 6 months, when the risk ofSIDS is the highest.288–293 However, pac-ifier use, once established,may persistbeyond 6 months, thus increasing therisk of otitis media. Gastrointestinal in-fections and oral colonization withCandida species were also found to bemore common among pacifier usersthan nonusers.289–291

The literature on infant digit-suckingand SIDS is extremely limited. Only 1case-control study from the Nether-lands has reported results.262 Thisstudy did not find an association be-tween usual digit-sucking (reported as“thumb-sucking”) and SIDS risk (OR:1.38 [95% CI: 0.35–1.51]), but the wideCI suggests that there was insufficient

power to detect a significantassociation.

OVERHEATING, FANS, AND ROOMVENTILATION

Avoid Overheating and HeadCovering in Infants

There is clear evidence that the risk ofSIDS is associated with the amount ofclothing or blankets on an infant andthe room temperature.182,218,294,295 In-fants who sleep in the prone positionhave a higher risk of overheating thando supine sleeping infants.182 It is un-clear whether the relationship to over-heating is an independent factor ormerely a reflection of the increasedrisk of SIDS and suffocation with blan-kets and other potentially asphyxiatingobjects in the sleeping environment.Head covering during sleep is of par-ticular concern. In a recent systematicreview, the pooled mean prevalence ofhead covering among SIDS victims was24.6% comparedwith 3.2% among con-trol infants.154 It is not known whetherthe risk associated with head coveringis attributable to overheating, hypoxia,or rebreathing.

There has been some suggestion thatroom ventilation may be important.One study found that bedroom heating,compared with no bedroom heating,increases SIDS risk (OR: 4.5),235 and an-other study has also demonstrated adecreased risk of SIDS in a well-ventilated bedroom (windows anddoors open) (OR: 0.4).296 In 1 study,the use of a fan seemed to reduce therisk of SIDS (adjusted OR: 0.28 [95%CI: 0.10 – 0.77]).297 However, becauseof the possibility of recall bias, thesmall sample size of controls usingfans (n � 36), a lack of detail aboutthe location and types of fans used,and the weak link to a mechanism,this study’s results should be inter-preted with caution. On the basis ofavailable data, the task force cannotmake a recommendation on the use





of a fan as a SIDS risk-reductionstrategy.

SWADDLING

Although Swaddling May Be Usedas a Strategy to Calm the Infantand Encourage Use of SupinePosition, There Is Not EnoughEvidence to Recommend It as aStrategy for Reducing the Risk ofSIDS

Many cultures and newborn nurserieshave traditionally used swaddling, orwrapping the infant in a light blanket,as a strategy to soothe infants and, insome cases, encourage sleep in the su-pine position. Swaddling, when donecorrectly, can be an effective tech-nique to help calm infants and pro-mote sleep.298 Some have argued thatswaddling can alter certain risk fac-tors for SIDS, thus reducing the risk ofSIDS. For instance, it has been sug-gested that the physical restraint as-sociated with swaddling may preventinfants placed supine from rolling tothe prone position.299 One study’s re-sults suggested a decrease in SIDSrate with swaddling if the infant wassupine,182 but it was notable that therewas an increased risk of SIDS if theinfant was swaddled and placed in theprone position.182 Although a recentstudy found a 31-fold increase in SIDSrisk with swaddling, the analysis wasnot stratified according to sleep posi-tion.171 Although it may be more likelythat parents will initially place a swad-dled infant supine, this protective ef-fect may be offset by the 12-fold in-creased risk of SIDS if the infant iseither placed or rolls to the prone po-sition when swaddled.182,300 Moreover,there is no evidence that swaddling re-duces bed-sharing or use of unsafesleep surfaces, promotes breastfeed-ing, or reduces maternal cigarettesmoking.

There is some evidence that swaddlingmight cause detrimental physiologic

consequences. For example, it cancause an increase in respiratoryrate,301 and tight swaddling can reducethe infant’s functional residual lungcapacity.299,302,303 Tight swaddling canalso exacerbate hip dysplasia if thehips are kept in extension and adduc-tion.304–307 This is particularly impor-tant, because some have advocatedthat the calming effects of swaddlingare related to the “tightness” of theswaddling. In contrast, “loose” or in-correctly applied swaddling could re-sult in head covering and, in somecases, strangulation if the blankets be-come loose in the bed. Swaddling mayalso possibly increase the risk of over-heating in some situations, especiallywhen the head is covered or the infanthas an infection.308,309 However, a re-cent study found no increase in ab-dominal skin temperature when in-fants were swaddled in a light cottonblanket from the shoulders down.302

Impaired arousal has often been pos-tulated as a mechanism that contrib-utes to SIDS, and several studies haveinvestigated the relationship betweenswaddling, arousal, and sleep patternsin infants. Physiologic studies havedemonstrated that, in general, swad-dling decreases startling,301 increasessleep duration, and decreases sponta-neous awakenings.310 Swaddling alsodecreases arousability (ie, increasescortical arousal thresholds) to a nasalpulsatile air-jet stimulus, especially ininfants who are easily arousable whennot swaddled but less so in infantswhohave high arousal thresholds when notswaddled.301 One study found de-creased arousability in infants at 3months of age who were not usuallyswaddled and then were swaddled butfound no effect on arousability in rou-tinely swaddled infants.301 In contrast,another group of investigators showeddecreased arousal thresholds310 andincreases in autonomic (subcortical)responses311 to an auditory stimulus

when swaddled. Thus, although swad-dling clearly promotes sleep and de-creases the number of awakenings,the effects on arousability to an exter-nal stimulus remain unclear. There isaccumulating evidence, however, thatthere are only minimal effects of rou-tine swaddling on arousal. In addition,there have been no studies investigat-ing the effects of swaddling on arousalto more relevant stimuli such as hyp-oxia or hypercapnia.

In summary, it is recognized that swad-dling is one of many child care prac-tices that can be used to calm infantsand promote sleep. However, there isinsufficient evidence to recommendroutine swaddling as a strategy for re-ducing the incidence of SIDS. More-over, as many have advocated, swad-dling must be correctly applied toavoid possible hazards such as hipdysplasia, head covering, and strangu-lation. It is important to note thatswaddling does not reduce the neces-sity to follow recommended safe sleeppractices.

IMMUNIZATIONS AND SIDS

Infants Should Be Immunized inAccordance WithRecommendations of the AAP andCenters for Disease Control andPrevention

The incidence of SIDS peaks at a timewhen infants are receiving numerousimmunizations. Case reports of a clus-ter of deaths shortly after immuniza-tion with diphtheria-tetanus-pertussisin the late 1970s created concern of apossible causal relationship betweenvaccinations and SIDS.312–315 Case-control studies were performed toevaluate this temporal association.Four of the 6 studies found no relation-ship between diphtheria-tetanus-pertussis vaccination and subsequentSIDS,316–319 and results of the other 2studies suggested a temporal relation-ship but only in specific subgroup anal-



ysis.320,321 In 2003, the Institute of Medi-cine of the National Academy ofSciences reviewed available data andconcluded that “[t]he evidence favorsrejection of a causal relationship be-tween exposure to multiple vaccina-tions and SIDS.”322 Additional subse-quent large population case-controltrials consistently have found vaccinesto be protective against SIDS323–325;however, confounding factors (social,maternal, birth, and infantmedical his-tory) might account for this protectiveeffect.326 It also has been theorized thatthe decreased SIDS rate immediatelyafter vaccination was attributable toinfants being healthier at time of im-munization, or “the healthy vaccineeeffect.”327 Recent illness would bothplace infants at higher risk of SIDS andmake them more likely to have immu-nizations deferred.328

Recent studies have attempted tocontrol for confounding by social,maternal, birth, and infant medicalhistory.323,325,328 In a meta-analysis,Vennemann et al328 found a multivar-iate summary OR for immunizationsand SIDS to be 0.54 (95% CI: 0.39 –0.76), which indicates that the risk ofSIDS is halved by immunization. Theevidence continues to show nocausal relationship between immu-nizations and SIDS and suggests thatvaccination may have a protective ef-fect against SIDS.

HOME MONITORS, SIDS, ANDAPPARENT LIFE-THREATENINGEVENTS

There Is no Evidence ThatApparent Life-Threatening EventsAre Precursors to SIDS, and InfantHome Monitors Should Not BeUsed as a Strategy for PreventingSIDS

For many years it was believed that ap-parent life-threatening events werethe predecessors of SIDS, and homeapnea monitors were used as a strat-

egy for preventing SIDS.329 However,there is no evidence that home moni-tors are effective for this purpose.330–333

The task force concurs with the AAPCommittee on Fetus and Newborn,which has recommended that infanthome monitoring not be used as astrategy to prevent SIDS, although itcan be useful for some infants whohave had an apparent life-threateningevent.334

POTENTIAL TOXICANTS AND SIDS

There Is no Evidence LinkingVarious Toxicants to SIDS

Many theories link various toxicantsand SIDS. Currently, no studies havesubstantiated a causal relationshipbetween metals, such as silver, cad-mium, cobalt, lead, or mercury, andSIDS.335–337 Although an ecologicalstudy found correlation of the maxi-mal recorded nitrate levels of drink-ing water with local SIDS rates inSweden,338 no case-control study hasdemonstrated a relationship be-tween nitrates in drinking water andSIDS. Furthermore, an expert groupin the United Kingdom analyzed datapertaining to a hypothesis that SIDSis related to toxic gases, such as an-timony, phosphorus, or arsenic, be-ing released from mattresses339,340

and found the toxic-gas hypothesis tobe unsubstantiated.341 Finally, 2 case-control studies found that wrappingmattresses in plastic to reduce toxicgas emission did not protect againstSIDS.191,342

HEARING SCREENS

Newborn Hearing Screens ShouldNot Be Used as a Screening Testfor SIDS

A single, small, retrospective case-control study examined the use of new-born transient evoked otoacousticemission hearing screening tests as atool for identifying infants at subse-quent risk of SIDS.343 Infants who sub-

sequently died from SIDS did not failtheir hearing tests but, compared withcontrols, showed a decreased signal-to-noise ratio score in the right earonly (at frequencies of 2000, 3000, and4000 Hz). Methodologic concerns havebeen raised about the validity of thestudy methods used in this study,344,345

and these results have not been sub-stantiated by others. A larger but non–peer-reviewed report of hearingscreening data in Michigan revealedno relationship between hearingscreening test results and SIDScases.346 Until additional data are avail-able, hearing screening should not beconsidered as a valid screening toolfor determining which infants mightbe at subsequent risk of SIDS. Further-more, an increased risk of SIDS shouldnot be inferred from an abnormalhearing screen result.

EDUCATIONAL INTERVENTIONS

Educational and InterventionCampaigns Are Often Effective inAltering Practice

Intervention campaigns for SIDShave been extremely effective, espe-cially with regard to avoidance ofprone positioning.347 Furthermore,there is evidence that primary care–based educational interventions,particularly those that address care-giver concerns and misconceptionsabout safe sleep recommendations,can be effective in altering practice.For instance, addressing concernsabout infant comfort, choking, andaspiration while the infant is sleep-ing prone is helpful.348,349 Similar in-terventions for improving behaviorof medical and nursing staff andchild care providers have shown thatthese professionals have similarconcerns about the supine sleep po-sition.350–353 Primary care providersshould be encouraged to develop qual-ity improvement initiatives to improve





adherence with safe sleep recommen-dations among their patients.

MEDIA MESSAGES

Media and Manufacturers ShouldFollow Safe Sleep Guidelines inTheir Messaging and Advertising

A recent study found that, in maga-zines targeted toward childbearingwomen, more than one-third of pic-tures of sleeping infants and two-thirds of pictures of infant sleep envi-ronments portrayed unsafe sleeppositions and sleep environments.354

Media exposures (including movie,television, magazines, newspapers,and Web sites), manufacturer adver-tisements, and store displays affect in-dividual behavior by influencing be-liefs and attitudes. Frequent exposureto health-related media messages canaffect individual health decisions,355,356

and media messages have been quiteinfluential in decisions regardingsleep position.77,80 Media and advertis-ing messages contrary to safe sleeprecommendations may create misin-formation about safe sleep practices.Safe sleep messages should be re-viewed, revised, and reissued at leastevery 5 years to address the next gen-eration of new parents and productson the market.

RECOMMENDATIONS

The AAP’s recommendations for a safeinfant sleeping environment to reducethe risk of both SIDS and other sleep-related infant deaths are specified inthe accompanying policy statement.4

LEAD AUTHORRachel Y. Moon, MD

TASK FORCE ON SUDDEN INFANTDEATH SYNDROME, 2010–2011Rachel Y. Moon, MD, Chairperson

Robert A. Darnall, MDMichael H. Goodstein, MDFern R. Hauck, MD, MS

CONSULTANTSMarian Willinger, PhD – Eunice KennedyShriver National Institute for Child Healthand Human DevelopmentCarrie K. Shapiro-Mendoza, PhD, MPH –Centers for Disease Control and Prevention

STAFFJames Couto, MA

ACKNOWLEDGMENTSThe task force acknowledges the con-tributions provided by others to thecollection and interpretation of dataexamined in preparation of this report.The task force is particularly gratefulfor the report submitted by Dr SuadWanna-Nakamura (CPSC) and for theassistance of Sarah McKinnon, PhD,MPH, and Cristina Rodriguez-Hart,MPH, with the statistics and graphs.

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DOI: 10.1542/peds.2011-2285; originally published online October 17, 2011; 2011;128;e1341Pediatrics

Task Force on Sudden Infant Death Syndromefor a Safe Infant Sleeping Environment

SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations

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