Car Seats, Pacifiers, & Weighted Sleep Sacks: What is "Safe Sleep"?

The research behind the new "safe sleep" guidelines from the American Academy of Pediatrics

Jul 20, 2022

Source: American Academy of Pediatrics

IMPORTANT NOTES: This newsletter includes discussion of infant sleep-related deaths and Sudden Infant Death Syndrome (SIDS). I consulted with board-certified pediatrician and fellow of the American Academy of Pediatrics, Dr. Florencia Segura, in writing this newsletter (for more information on her and the evidence-based information on pediatrics that she shares, check out her Instagram).

First, Some Background Information

The American Academy of Pediatrics (AAP) recently updated their “safe sleep” guidelines. The goal of these guidelines is to provide clear and evidence-based guidance to parents and clinicians in creating the safest sleep environments for infants. Yet, many parents feel that these guidelines fail to recognize the realities of infant sleep and cultural preferences related to sleep. I think how many parents feel can be summed up in a comment I got from one parent on the topic: “Now if someone could just get infants on board with sleeping alone on a hard empty space, we will be all set!”.

So to help you to understand these guidelines and the research behind them, I will first review the changes that have been made by the AAP and then address some of your most common questions on these guidelines. I will also address bedsharing/cosleeping in a separate newsletter since this topic is so complex.

What are the AAP guidelines on “safe sleep” and what has changed?

A quick overview of the most recent AAP guidelines for “safe sleep” are as follows (see here for the full policy statement):

Sleep on a flat, non-inclined surface: The AAP updated their policies from recommending that infants sleep on a “firm sleep surface” to a “firm, flat, non-inclined sleep surface”. This new recommendation means that infants should no longer routinely sleep in car seats (while at home), rockers, swings, inclined strollers, and inclined baby seats when unsupervised. Specifically, any sleep surface with a greater than 10 degree incline is considered unsafe for babies.
Breastfeeding: The AAP continues to emphasize the importance of breastfeeding or feeding an infant human milk in order to prevent SIDS. These updates emphasize that it is particularly important for infants who are premature or low birth weight due to being at higher risk for SIDS.
Sleeping in the parent’s room: The AAP continues to recommend that infants sleep in the parent’s room for ideally 6 months. They previously recommended that parents ideally share their room with their infant for 1 year.
Bedsharing: The AAP continues to recommend that parents avoid sharing a sleep surface with infants. They also state that bedsharing is particularly dangerous under some conditions (including when parents are using medication or alcohol, if anyone in the house is a smoker, in an unsafe sleep environment such as a couch or with soft bedding, when the infant is preterm or low birthweight, and bedsharing with anyone who is not the child’s parent). They also recommend that twins and siblings not share a sleep space.
Bedding: This update adds that weighted blankets, weighted sleep sacks, and other weighted sleep products should not be placed on or near the infant. In addition, they continue to recommend that parents avoid soft bedding, blankets, or anything in the crib with the infant until 12 months.
Pacifiers: The AAP continues to recommend pacifiers and suggests that use of pacifiers be delayed until breastfeeding is “established” (which they now define as having sufficient milk supply, effective latch, and appropriate weight gain).
Hats: This new recommendation states that hats should not be place on infants at any time when indoors except in the first few hours of life and in the NICU.
SIDS monitors: The AAP states that there is no evidence that infant “smart” monitors (such as the Owlet) help to prevent SIDS and should never be used in place of other safe sleep practices.
Tummy time: The AAP continues to recommend tummy time and gave specific recommendations for tummy time, including only doing tummy time while the infant is awake and supervised, starting as soon as the infant is home from the hospital, and gradually increasing the time until they reach at least 15-30 minutes total daily by 7 weeks.

The technical report with links to all of the research can be found here.

It really isn’t safe to sleep in a car seat?!

Source: American Academy of Pediatrics

The AAP updated their recommendations to advise against routinely sleeping on inclined surfaces due to new research suggesting that inclined surfaces may be dangerous for infants. This research finds that inclined surfaces put infants at risk for sliding into a position that could compromise their breathing or rolling onto their side or stomach which increases SIDS risk. Research also suggests that inclined surfaces may not actually help to improve reflux in infants.

For most parents, avoiding sleep in rockers or inclined baby seats is a relatively easy change while avoiding sleep in car seats or inclined strollers seems impossible. I do not know of a single parent who has not let their baby fall asleep in a car seat or stroller and the idea of waking a sleeping baby by transferring them from their car seat or stroller to a crib strikes fear into the heart of even the most confident parent.

First, it is important to note that the AAP only recommends that parents avoid letting their baby sleep in the car seat while unsupervised outside of the car and continues to recommend using a car seat in the car, even if that means a baby falls asleep. Research finds that over 90% of infant sleep-related deaths in car seats occurred due to the car seat not being used properly (that is, the infant was not properly strapped into the car seat, the car seat was not the appropriate size, or the car seat was being used outside of the car). In situations where the car seat was used as directed, deaths also occurred due to the car seat being completely covered in a blanket or the infant being left in the car for a prolonged period of time while unsupervised. Most deaths in car seats (52%) and in strollers (74%) occurred in the infant’s home, suggesting these devices may not have been used in the intended way and that the infant may have been unsupervised during sleep.

TRANSLATION: A car seat is the safest place for your infant to be in the car and, as long as it is properly installed, the straps are not too loose, and there is not a blanket over the entire car seat, you should not worry about your infant occasionally falling asleep in a car seat while in the car. To be safe, you may want to try to transfer your baby to the crib when you return home. If you do choose to leave your child sleeping in the car seat, you could supervise them or at the very least leave the straps properly buckled and tight since loose or unbuckled straps often pose a strangulation risk for infants. Similarly, sleeping in inclined strollers may only pose a significant risk when used improperly. To be safe, recline the stroller to flat when your infant falls asleep and supervise them during sleep in an inclined stroller.

Why shouldn’t I use a monitor for SIDS like the Owlet?

One of the new recommendations in this version of the AAP guidelines is that parents should not use a cardiorespiratory or “smart” monitor for their infants (a common example of this is the Owlet). These monitors measure heart rate and oxygen levels in babies with the purpose of preventing sleep-related deaths and putting parents’ minds at ease.

A recent study examined two such monitors on the market (the Owlet monitor and the Baby Vida monitor) and found them to be inconsistent and inaccurate. Specifically, they found that the Owlet monitor typically detected low oxygen levels, yet did not do so consistently and sometimes resulted in false positives. In other words, there were times that the monitor signaled that the baby’s oxygen levels were low when they were actually normal. The Baby Vida monitor was also inaccurate and often indicated that heart rates were abnormally low when they were actually in the normal range. More troubling, the Baby Vida monitor often indicated that oxygen levels were normal when they were abnormally low.

TRANSLATION: Baby monitors for heart rate and oxygen levels may not be an effective way to prevent SIDS. They may result in unnecessary trips to the emergency room and, more importantly, fail to warn parents when their infant is really at risk. They may also make parents more likely to put their infants in unsafe sleeping environments when they put too much faith in these monitors. However, if these monitors give you peace of mind, they are unlikely to be harmful as long as you continue to follow other safe sleep practices.

If pacifiers really help to prevent SIDS, why do I need to wait until breastfeeding is “established”?

Research finds that pacifiers are associated with a reduced risk of SIDS, yet given the quality of the evidence we need further research before we can conclude that pacifiers actually prevent SIDS. So if you want to use a pacifier and they may help to prevent SIDS, why wait until breastfeeding is “established” when it can take months for this happen and may take particularly long for premature and low birthweight infants who are also at higher risk for SIDS and other sleep-related deaths?

Research finds no evidence that pacifiers have any impact on breastfeeding, even if they are used before breastfeeding is “established.” A Cochrane review (the “gold standard” of review articles) from 2016 finds that pacifier use has no impact on breastfeeding success or breastfeeding duration up until 4 months of age, even if pacifier use is started at birth (rather than waiting until breastfeeding is “established” around 4 to 6 weeks). However, it is important to note that this review included only mothers who were highly motivated to breastfeed and had healthy full-term infants. These studies also did not examine whether pacifiers caused any possible breastfeeding difficulties but only looked at breastfeeding success and duration.

TRANSLATION: Pacifier use is unlikely to have a negative impact on breastfeeding success if you are motivated to breastfeed and may prevent SIDS but more research is needed on this topic!

Are weighted sleep sacks actually dangerous?

There is only one study of weighted blankets involving infants. This study included only 16 newborn infants who were weaning from opioid exposure in utero (a common condition called neonatal abstinence syndrome). They found no significant change in respiratory rate or temperature when using the weighted blankets and no safety concerns. They also found reduced heart rate in infants who used the weighted blankets, suggesting that it may help to calm infants.

TRANSLATION: There is only one small study of weighted blankets in infants and it did not even examine safety during sleep. Therefore, we need more research before we conclude that weighted blankets and weighted sleep sacks are safe for infant sleep.

Why can’t babies wear hats indoors?

One study found a slight association between wearing hats and SIDS (8% of the infants who died of SIDS were wearing hats while only 5% of infants who did not die from SIDS were wearing hats). Yet, it is unclear from this one study whether hats actually increased the SIDS risk.

TRANSLATION: We do not yet have strong evidence that hats cause SIDS in infants. However, this seems like an easy one to avoid so it may not hurt to remove a hat from your infant before sleep (although it does not seem necessary for an infant to never wear a hat indoors). However, if you put a hat on your infant to sleep in the past, do not feel guilty about this choice!

Is room sharing for 6 months really necessary?

Source: American Academy of Pediatrics

Research has found an association between sharing a room with parents and decreased risk for SIDS (see here, here, here, and here). However, research also finds that room sharing is associated with more infant awakenings, poorer sleep quality in mothers, and shorter stretches of sleep, suggesting that it may be difficult for some parents to continue room sharing for half of a year. However, it is exactly these infant awakenings that may make room sharing protective against SIDS. A leading hypothesis of SIDS is that failure to arouse from sleep makes an infant vulnerable to SIDS. Some risk factors, including sleeping on the stomach and exposure to tobacco smoke, may make infants less likely to arouse to sleep, whereas protective factors, including breastfeeding and room sharing, are associated with being more likely to arouse from sleep and therefore more frequent awakening.

TRANSLATION: Sharing a room with your infant is linked with lower risk for SIDS AND more awakenings at night, and unfortunately it may not be possible to have one without the other. However, sometimes sleep deprivation and unique family factors make this choice impossible and parents should continue to follow other safe sleep guidelines (placing the infants on their back to sleep and away from soft bedding or toys) regardless of whether the infant remains in the parents’ room or not.

I thought a recent study found that an enzyme can predict SIDS so safe sleep measures aren't necessary?

Unfortunately this is not true and the media’s hype of this study has led to a lot of confusion, so let me break down this study for you. This study examined samples from infants who had died of SIDS and found lower levels of an enzyme called Butyrylcholinesterase (BChE) in infants who died of SIDS.

What does this finding mean? First, it is just one study that found an association between SIDS and a particular enzyme but did not show that this enzyme causes SIDS. An association does not allow you to determine cause. For example, eating ice cream may be associated with sunburns, but does that mean that ice cream causes sunburns?!? Of course not… people are just more likely to eat ice cream when it is hot out and also more likely to get a sunburn when it is hot out. Therefore, sunburns are associated with ice cream because both are linked to hot weather.

Source: Harrington, Hafid, & Waters, 2022

In addition, this study only indicated that lower levels of this enzyme increase risk (see graph above), meaning that some infants with low levels may be at risk for SIDS and some may not. Therefore, even if blood tests were regularly conducted to screen for levels of this enzyme, we could not definitively say that a certain level of this enzyme means that you should be on high alert. The advice would still be the same for all parents: practice safe sleep guidelines.

TRANSLATION: We currently have no way of knowing which infants are at high risk for SIDS so it is important for all parents to follow safe sleep guidelines.

When can I relax about all of these restrictions?

The highest risk for SIDS is in the first four months of an infant’s life and 90% percent of SIDS deaths occur before 6 months. The age distribution for accidental suffocation and strangulation in bed is similar. However, SIDS can occur anytime before 12 months and accidental suffocation and strangulation in bed is possible (although unlikely) at any age. After 12 months, infants can have have blankets or small loveys/stuffed animals, yet you still may want to avoid bumpers, bed rails, or anything that can cause entrapment.

OVERALL TRANSLATION

The American Academy of Pediatrics “safe sleep” guidelines help us parents to understand the absolute safest sleep environment for our infants. However, as many of us know, it is often more complicated in the real world and sleep deprivation in parents is also dangerous for infants. Whatever you are considering, discuss your own individual struggles and problems in adhering to these guidelines with your pediatrician. Most pediatricians understand the realities of infant sleep and can help you come up with a plan that will create the safest situation for everyone involved.

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