Despite decreased rates in the past decade, sudden infant death syndrome (SIDS) continues to be the leading cause of infant deaths in the United States after the neonatal period.¹ In October 2005, the American Academy of Pediatrics (AAP) released updated recommendations on SIDS risk reduction, reiterating several of its earlier risk-reduction measures (Table 1).² In this issue of American Family Physician, Dr. Schnitzer discusses these recommendations in her article on unintentional childhood injuries.³

The evidence continues to support the protective role of placing infants on their backs to sleep; side sleeping is not advised because it confers a greater risk than supine sleeping. A firm crib mattress is the recommended sleeping surface. Soft objects and loose bedding should be kept out of the crib. Overheating of infants should be avoided. The infant’s environment should be smoke-free during pregnancy and after birth.²

In light of new evidence, the AAP has provided new recommendations for infant-parent bed sharing and the use of pacifiers. The AAP now recommends a separate but proximal sleeping environment for infants (i.e., infants should not sleep in the same bed as their parents). However, proponents of breastfeeding argue that bed sharing facilitates optimal breastfeeding and reinforces mother-infant bonding.⁴ Many public health groups, including the AAP’s task force on SIDS, have taken a moderate position by recognizing that although bed sharing may have benefits such as facilitating breastfeeding, there is no evidence that this practice reduces the risk of SIDS. In fact, some studies suggest that bed sharing under certain conditions actually may increase SIDS risk.⁴ Studies suggest that the risk is greatest for infants younger than 11 weeks, regardless of whether the parents smoke.⁵

Advocates argue that there is no evidence of increased SIDS risk after 11 weeks of age. In addition, the overall risk of death probably is greater than the risk of SIDS, considering other sudden infant deaths that occur in adult beds, such as death by suffocation.⁶ Advocates of bed sharing recommend strict practices such as sleeping on a thin floor mat with no pillows or blankets.⁷ Such practices, however, may be virtually impossible to implement. Therefore, bed sharing, as commonly practiced, should not be recommended, especially before 11 weeks of age. There is strong scientific evidence that bed sharing by mothers who smoke significantly increases the risk of SIDS throughout infancy, as does sleeping with an infant on a couch or armchair and allowing infants to sleep with other children. Nonetheless, there is growing evidence that room sharing without bed sharing is associated with a reduced risk of SIDS.^2,5 The AAP recommends placing the crib or bassinet near the mother’s bed to facilitate breastfeeding and contact. “Co-sleepers,” infant beds that attach to the mother’s bed, also may be a good solution, but safety standards for these devices have not been established.

The AAP also updated its recommendations on pacifier use. The group recommends that caregivers consider offering a pacifier at naptime and bedtime. Several studies have shown that pacifier use has a protective effect on the incidence of SIDS, especially when used at the time of last sleep.⁸ Controversy exists primarily because of concern about breastfeeding, leading some groups to recommend pacifier use in bottle-fed infants only.⁹ Decreased breastfeeding duration has been associated with pacifier use in observational studies; however, results of well-designed, randomized controlled trials have found that pacifiers do not affect breastfeeding duration, especially if pacifiers are introduced after breastfeeding is well established.¹⁰ Until evidence dictates otherwise, the AAP recommends the use of pacifiers when placing infants to sleep for the first year of life, but delaying this practice until one month of age in breastfed infants.

Family physicians are uniquely positioned to inform patients about SIDS and the current evidence on risk-reduction measures. This discussion should be started during pregnancy and continued immediately after birth and during each well-child examination, especially in the first six months of age, when SIDS risk is highest. However, there is still work to be done. In a study published in 2002, only one third of family physicians surveyed in North Carolina and the Washington, D.C., metropolitan area knew that the supine position was the recommended position for sleep; two thirds of pediatricians knew the correct position.¹¹ Furthermore, only one half of family physicians routinely counseled parents about SIDS risk reduction. Thus, family physicians should become familiar with the new recommendations and consider how their practices might be affected. They also should consider their own biases so that they may objectively inform parents. Although it is ultimately up to parents to determine their infant care practices, we must provide the most up-to-date information to help them make informed decisions.