Mixed Credibility of the Revised AAP SIDS Prevention Recommendations

FOR IMMEDIATE RELEASE - October 17, 2005

Washington, DCThe American Academy of Pediatrics (AAP) released revised recommendations for Sudden Infant Death Syndrome (SIDS) prevention last week, one of which provides valuable new information to help parents protect their infant, while others not only lack a solid scientific basis but also entail some risks.

The AAP now recommends that infants sleep in the same room as their parents because this is associated with a reduced risk of SIDS. While studies have consistently found that isolating infants for sleep (in a separate bedroom) is associated with a higher risk of SIDS, this information has not previously been widely disseminated. Sleeping near one’s infant has also been shown to increase maternal responsiveness to the infant’s nighttime physiologic signals and to make it easier for mother to succeed with breastfeeding. Breastfeeding, in turn, is linked to a reduced risk of many acute and chronic illnesses, including a 21% lower all-cause infant mortality rate in an analysis by the National Institutes of Health, and to a reduced risk of SIDS in a number of studies.

Two recommendations in the new AAP statement have stirred particular concern: to give babies pacifiers and to remove the infant from the parental bed prior to sleep. Both recommendations are problematic in a number of ways, including that they lack a clear scientific basis, constrain parental choice, complicate the potentially challenging process of putting infants to sleep, and impair breastfeeding.

Because early pacifier use reduces breastfeeding duration, the AAP SIDS statement recommends waiting until one month of age (to allow breastfeeding to get off to a good start) before starting pacifiers in breastfed infants. Even beyond this period pacifiers entail health risks, however, and may undermine breastfeeding success.

A number of studies (but not all) have found an association between pacifier use and lower rates of SIDS. But these studies cannot determine if the relationship is causal, and therefore whether pacifier use can reduce the risk of SIDS. Nevertheless, even if the oral stimulation of sucking were protective, only those infants lacking the natural source of nighttime suckling, breastfeeding, would be likely to benefit from an artificial pacifier source of such stimulation. Only in such “at risk” groups might it make sense to assume the health risks of pacifier use which include yeast infections, oral malocclusion, and ear infections.

Data are also lacking to justify telling parents whether or not they should sleep with their infants—beyond informing them of the protective effect of sleeping in the same room as their baby. In the best controlled studies, infant safety is not associated with whether the baby sleeps in the parents’ bed per se, but on specific environmental factors that warrant attention whether the baby is in a bed, a crib, or other sleeping surface. For example, SIDS has been associated with prone sleep position, maternal smoking, soft mattresses, and bedding near the baby that could cover the head. Avoidable exceptions in which bedsharing itself has been associated with an increased risk of SIDS include the use of particularly unsafe furniture (e.g., couches, which are associated with a 25-fold increased risk of SIDS) and parent smoking or incapacitation due to alcohol or drug use, or exhaustion.

The United States Breastfeeding Committee recommends caution before advising pacifiers for breastfeeding infants even after one month of age. It also emphasizes the importance of closeness to one’s infant and supports the statement of the Section on Breastfeeding of the AAP that mother and infant sleep in close proximity.

  1. AAP Task Force on Sudden Infant Death Syndrome. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding Sleeping Environment, and New Variables to Consider in Reducing Risk. Pediatrics November 2005; 116(5):1245-1255
  2. American Academy of Pediatrics, Section on Breastfeeding, Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2005; 115(2):496-506
  3. Chen A, Rogan WJ. Breastfeeding and the Risk of Postneonatal Death in the United States. Pediatrics 2004; 113:e435-439
    URL: http://www.pediatrics.org/cgi/content/full/113/5/e435
  4. McKenna JJ, McDade T. Why babies should never sleep alone: A Review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Pediatric Respiratory Reviews 2005; 6:134-152 (available on line at www.sciencedirect.com)
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