Recent Changes to the American Academy of Pediatrics (AAP) Safe Sleep Recommendations

Safe infant sleep information has always been important to us here at The Sleep Store. The American Academy of Pediatrics (AAP) recently issued its 2022 recommendations for safer infant sleep, titled ‘Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment’. So we wanted to share our thoughts on the recommendations and note any changes for you.  

The AAP last updated their recommendations in 2016, over 5 years ago. In addition the US Government passed the Safe Sleep Act in May 2022, banning inclined sleep products (over 10 degrees) and padded cot bumpers (Mesh cot liners are specifically excluded).

Below is a summary of the latest guidelines and how that relates to us here in New Zealand and Australia. We will also be updating our sleep articles with the latest advice over the coming months, so please bear with us as we update our hundreds of articles and use this article as your main Sleep Store guide to what constitutes the most up to date safe sleep information.

1. Sleep surface - Use a firm, flat, non inclined sleep surface
2. Breastfeeding - Recommended to breastfeed exclusive for approximately 6 months and continue until 1 year of age or longer as mutually desired.
3. Sleep location - It is recommended that babies sleep in the parents room, ideally for at least the first 6 months.
4. Soft bedding - It is recommended that weighted blankets, weighted sleepers, weighted swaddles or other weighted objects not be placed on or near the baby.
5. Swaddling - stop swaddling when baby shows signs of rolling
   

Some of the above points you may already be familiar with as they are consistent with current safe sleep advice in New Zealand. We’ll also discuss the main changes and how these relate to the Sleep Advice articles we have and the products we sell.

Using a bassinet or cot which has specifically been designed for infants is the safest option for your baby. It should have a firm, flat, non-inclined sleep surface. New Zealand banned bassinets and sleep products with greater than 7 degrees with a Dangerous Goods Notice in 2020, while the APP guidelines recommend not having an incline over 10 degrees. Note that the US Government has also now banned sleep products with incline over 10 degrees under the Safe Sleep Act 2022.

However beyond the Dangerous Good Notice, did you know, in New Zealand there are no safety standards for bassinets or “nests”? It’s up to the consumer to be aware of how to choose a safe first bed for a baby. At The Sleep Store we choose bassinets, co-sleepers & moses baskets that meet either the UK or US safety standards.

We do not sell (and never have sold) the padded nests or pods that have a soft base and sides. All our sleep products have a firm, flat surface including the Purflo Sleep Tight Baby Bed, which is safe for unsupervised overnight sleep for babies. While it looks a bit like a nest, it is totally consistent with safe sleep advice and is tested accordingly. We also do not sell any recliners, swings or loungers that are not permitted to be marketed for sleep if they have an incline over 7 degrees in NZ, even though lots of parents use them for sleep.

Safety standards in New Zealand are currently limited to the AS/NZS 2172:2013 Safety Standard for Household Cots. Any cot you buy in NZ must meet the mandatory standard. The NZ Cot Standard still allows drop sided cots, which many countries overseas have banned due to entrapment injuries. The Sleep Store only recommends and sells cots with fixed sides as these are the safest now and over time. The AAP recommendations do not refer to Drop-Side cots (cribs) as they were banned in the US in 2011 after multiple recalls and over 30 deaths in the decade before. They recommend choosing a cot that is safety-approved and meets the safety of the standards of the CPSC.

In terms of the actual sleep surface, choose a new mattress that has been independently tested to the NZ voluntary mattress firmness standard like ours have. Here’s how you can test the firmness of your baby’s mattress if you already own one or are not sure if it’s been tested. Your mattress should not leave a dip where baby’s head has been.

The AAP goes on to state “Products that do not meet the federal safety standard are likely not safe for infant sleep, and their use is not recommended.”

For NZ families with specific cultural needs & practices, where babies would traditionally sleep in the parents bed, the Pepi Pod or Wahakura is a safe way to keep your baby close to you. Your baby has their own sleep space with a firm, flat surface which can be kept clear of loose blankets and bedding. The Pepi Pod is placed in the middle of the parents bed, high up towards the head of the bed.

AAP recommends breastfeeding exclusively for the first 6 months of life and continuing to breastfeed until 1 year or older because it is associated with a reduced risk of SIDS. This is consistent with current advice in NZ.

AAP has updated its recommendation for infants to sleep close to the parents bed, but on a separate sleep surface designed for babies for at least 6 months. This is a change from previously which recommended babies sleep in the same room for their first year of life.

There are a number of considerations when choosing your baby's first bed and one of these is the amount of space you have. If you are short on space there are a number of bassinet and co-sleeper options which are small enough to fit close to your bed. These tend to be much smaller than a cot and will usually last the baby for 3-4 months, when they would likely outgrow it and need to move to a cot. At this point you could move the cot into your bedroom to keep the baby close, but in their own safe sleep space.

Bedsharing. The AAP recognises that accidental bedsharing can occur when parents fall asleep whilst feeding their baby, particularly when tired or the babies are colicky. But let's face it, what parent isn’t tired?!  

So, whilst bed sharing isn’t recommended by AAP or us, there are ways you can make bed sharing safer. We recommend you prepare safe sleep spaces in advance to ensure your baby has all their sleeps safely.   For example, if you’re feeding your baby in the lounge, have a moses basket or sleep tight baby bed near your feeding chair, so if you’re feeling like you might nod off, you can place the baby in their own sleeping space to ensure they’re as safe as they can be. Sleeping with baby on a sofa or chair is the most dangerous sleeping option.

Even if you’re not intending to bedshare, we strongly recommend you take the time to make your bed as safe as possible in case of accidental bed-sharing.Making a few simple changes to your sleep environment can make it all the more safer should you accidentally fall asleep while doing a night feed. Remove any mattress toppers to ensure your mattress is firm, make sure you have a firm mattress, ensure pillows and loose bedding is moved away from baby and ensure baby can’t fall and become entrapped between the wall and the bed.

“The AAP understands and respects that many parents choose to routinely bed share for a variety of reasons, including facilitation of breastfeeding, cultural preferences, and belief that it is better and safer for their infant. However, based on the evidence, we are unable to recommend bed sharing under any circumstances. Having the infant close by their bedside in a crib or bassinet will allow parents to feed, comfort, and respond to their infant’s needs.“ Bedsharing can increase the baseline risk of SUDI by between 2 and 10 times depending on other risk factors such as bed-sharing with someone impared by their alertness or bed sharing on a soft surface such as the couch or armchair.

The AAP recommends that weighted sleepers, weighted swaddles or other weighted objects not be used and that dressing the baby with layers of clothing is preferable to blankets and other coverings to keep the baby warm. Wearable Blankets (or Sleeping Bags) can also be worn.

The Sleep Store offers a wide range of baby swaddles, including fitted and traditional wrap styles. You can rest assured, knowing that none of the swaddles we sell are weighted. They are also hip-healthy and available in different weights depending on the season. Read more about overheating here.

Not all parents will choose to swaddle their baby, so we also offer a wide range of sleeping bags which are suitable for newborns. When you choose the right size for your baby they won’t ride up over the baby's head and you can rest assured that they’ll stay warm and cosy as they won’t be able to kick off their blankets, which can also become a suffocation hazard. We recommend natural fibre sleepwear for its breathability as very little babies often aren’t able to regulate their temperature.

As stated earlier, the AAP states that weighted swaddles (along with weight blankets & weighted sleeping bags) are not safe and therefore not recommended.  

The recommendations from the AAP state that “there is no evidence with regard to risk of SIDS related to the arms being swaddled in or out. Parents can decide on an individual basis whether to swaddle and whether the arms are swaddled in or out, depending on the behavioural and developmental needs of the infant” However they do also comment that “there is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS”.

So there is no evidence to show that the practise of swaddling is unsafe provided these safety recommendations are always followed:

• Always place baby on their back to sleep
• Stop swaddling as soon as baby if showing signs of rolling (see below)
• If using a blanket with a swaddle, ensure the blanket is tucked in tight and not above the baby’s chest.
• Do not swaddle if you are bedsharing.

The AAP recommends that swaddling be stopped when an infant shows signs of attempting to roll which is usually around 3-4 months. Not all babies attempt to roll at the same time, so there are some signs to look for, including if the baby is:

• Rolling to their shoulders or side
• Lifting its head & shoulders more during tummy time
• Kicking their legs and scooting in a circle when on their back

Here in New Zealand, the Ministry of Health gives some general swaddling advice and how to keep swaddling safe:

• Sleep baby on their back
• Use a lightweight wrap
• Ensure the wrap is not to tight or too loose
• Ensure baby is only swaddled when sleep in their own bed
• Once baby tries to roll over then stop swaddling or swaddle with arms free

(Baby sleep and settling | Ministry of Health NZ)

The AAP advises that media and manufacturers follow safe sleep guidelines in their messaging and media to promote safe sleep practices as the social norm. This includes:

• Not showing babies sleeping on their tummies
• Not showing images of babies sleeping in hats
• Not showing images of babies sleeping in dangerous positions (such as the sofa) or in an adult bed alone
• A completely clear cot (eg, no loose bedding, toys etc)

We completely agree with this philosophy and you’ll notice that none of our own The Sleep Store images show sleeping babies with hats or headbands, no tummy sleeping babies and always a clear cot or bassinet. We educate our suppliers on this as much as possible as well and we often reshoot product photography so that it doesn’t show babies in unsafe situations. Some may consider it cute to see gorgeous wee babies asleep all swaddled with a headband and a soft toys or pillows nearby, but it simply isn’t safe and we don’t want to share those images.