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## Complete Summary

#### GUIDELINE TITLE

The changing concept of sudden infant death syndrome: diagnostic coding
shifts, controversies regarding the sleeping environment, and new
variables to consider in reducing risk.

#### BIBLIOGRAPHIC SOURCE(S)

American Academy of Pediatrics Task Force on Sudden Infant Death
Syndrome. The changing concept of sudden infant death syndrome:
diagnostic coding shifts, controversies regarding the sleeping
environment, and new variables to consider in reducing risk.
Pediatrics 2005 Nov;116(5):1245-55. \[137 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16216901)

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: American Academy of
Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death
Syndrome. Changing concepts of sudden infant death syndrome:
implications for infant sleeping environment and sleep position.
American Academy of Pediatrics. Task Force on Infant Sleep Position and
Sudden Infant Death Syndrome. Pediatrics 2000 Mar;105(3 Pt 1):650-6.
\[120 references\]

All policy statements from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Sudden infant death syndrome (SIDS \[also called crib or cot death\])

#### GUIDELINE CATEGORY

Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To endorse elements from the previous statement on sudden infant death
syndrome (SIDS) from the American Academy of Pediatrics that have not
changed, to include information about recent research, and to present
updated recommendations based on current evidence

#### TARGET POPULATION

Infants under 1 year of age, especially infants between 2 and 4 months
old

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Placing infant to sleep in a supine position (i.e., wholly on the
    back)

2.  Use of safe bedding practices (crib that conforms to safety
    standards, use of firm sleep surface, avoidance of soft materials,
    objects, and loose bedding in the infant\'s sleep environment)

3.  Use of proximate but separate sleeping environment

4.  Avoidance of overheating

5.  Consideration of use of a pacifier for sleep and nap times

6.  Avoidance of plagiocephaly (use of prone positioning when awake
    \[tummy time\], altering supine head position during sleep,
    avoidance of excessive time in car seat carrier and \"bouncers\")

7.  Promotion of smoking cessation during pregnancy and the prevention
    of exposure of the infant to second hand smoke

8.  Use of electronic respiratory and cardiac monitors only for infants
    with extreme cardiorespiratory instability

9.  Continuation and expansion of campaigns (e.g., Back to Sleep) to
    promote safe sleeping practices and to reduce potentially modifiable
    risk factors for sudden infant death syndrome (with special focus on
    black, American Indian/Alaska Native populations)

The use of devices to maintain sleep position and reduce risk of
rebreathing and the use of electronic respiratory and cardiac monitors
(except in infants with extreme cardiorespiratory instability) were
considered, but not recommended.

#### MAJOR OUTCOMES CONSIDERED

Incidence of sudden infant death syndrome

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

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.

3.  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 covering.

4.  Do not smoke during pregnancy: Maternal smoking during pregnancy has
    emerged as a major risk factor in almost every epidemiologic study
    of sudden infant death syndrome (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 procedures:

    -   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 solution.

    -   Pacifiers should be cleaned often and replaced regularly.

    -   For breastfed infants, delay pacifier introduction until 1 month
        of age to ensure that breastfeeding is firmly established.

7.  Avoid 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.

8.  Avoid 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
    in-hospital respiratory or cardiac monitoring.

10. Avoid development of positional plagiocephaly:

    -   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 (e.g., 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 care-givers (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
    discharge.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Prevention of sudden infant death syndrome

#### POTENTIAL HARMS

Pacifier use may be associated with an increased risk of otitis media,
gastrointestinal infections, and oral colonization with Candida species.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The recommendations outlined here were developed to reduce the risk of
sudden infant death syndrome (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
(e.g., 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 benefits.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Academy of Pediatrics Task Force on Sudden Infant Death
Syndrome. The changing concept of sudden infant death syndrome:
diagnostic coding shifts, controversies regarding the sleeping
environment, and new variables to consider in reducing risk.
Pediatrics 2005 Nov;116(5):1245-55. \[137 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16216901)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 Mar (revised 2005 Nov)

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Task Force on Sudden Infant Death Syndrome

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force on Sudden Infant Death Syndrome, 2005-2006*: John
Kattwinkel, MD, *Chairperson*; Fern R. Hauck, MD, MS; Maurice E. Keenan,
MD; Michael Malloy, MD, MS; Rachel Y. Moon, MD

*Consultant*: Marian Willinger, PhD

*Staff*: James Couto

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### ENDORSER(S)

Association of SIDS and Infant Mortality Programs - Professional
Association\
National Institute of Child Health and Human Development - Federal
Government Agency \[U.S.\]\
SIDS Alliance - Professional Association

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: American Academy of
Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death
Syndrome. Changing concepts of sudden infant death syndrome:
implications for infant sleeping environment and sleep position.
American Academy of Pediatrics. Task Force on Infant Sleep Position and
Sudden Infant Death Syndrome. Pediatrics 2000 Mar;105(3 Pt 1):650-6.
\[120 references\]

All policy statements from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Policy Web
site](http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/5/1245).

Print copies: Available from AAP, 141 Northwest Point Blvd., P.O. Box
927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Do pacifiers reduce the risk of sudden infant death syndrome? A
    meta-analysis. American Academy of Pediatrics. Pediatrics 2005
    Nov;116(5):e716-23.

Electronic copies: Available from the [*[Pediatrics]{.underline}* Web
site](http://pediatrics.aappublications.org/cgi/content/full/peds.2004-2631v1).

Print copies: Available from AAP, 141 Northwest Point Blvd., P.O. Box
927, Elk Grove Village, IL 60009-0927.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on September 17, 2001. The
information was verified by the guideline developer as of December 5,
2001. This NGC summary was updated by ECRI on November 15, 2005. The
updated information was verified by the guideline developer on November
29, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest
Point Blvd, Elk Grove Village, IL 60007.

### DISCLAIMER

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Date Modified: 11/3/2008