New guidelines say babies should sleep flat and alone to prevent infant death

• The American Academy of Pediatrics updated its infant sleep guidance for the first time since 2016.
• To avoid sleep-related deaths, infants should sleep flat and not wear hats indoors, they said.

Babies should sleep flat, and alone, the American Academy of Pediatrics has said in its first update to guidance on preventing sleep-related deaths in six years.

The guidance comes weeks after President Joe Biden signed the Safe Sleep for Babies Act into law, banning the manufacture and sale of crib bumpers or inclined sleepers for infants.

Previously, in 2016, the AAP simply stated babies should sleep on a firm surface. Now, the leading authority on pediatrics in the US emphasizes evidence showing the importance of the surface also being flat and not on an incline, and strengthened its warning against bed-sharing.

The lead author of the guidance said that, in turn, means sleeping without toys and bedding.

Infants can die during their sleep from sudden infant death syndrome (SIDS), and accidental suffocation or strangulation in bed. Roughly 3,500 infants die each year from sleep-related deaths, according to the AAP.

The latest AAP recommendations are effective from Tuesday and apply to infants younger than one year old.

How to know if a surface is firm and flat

Rachel Moon, the lead author of the guidelines and a professor of pediatrics at the University of Virginia School of Medicine, said in a statement that infant deaths are often preventable. "If we've learned anything, it's that simple is best," Moon said.

The updated guidance also includes new advice against placing weighted objects or clothing, including blankets, sleepers or swaddles on or near the sleeping baby.

First Candle, a nonprofit that aims to avoid sleep-related infant deaths, says on its website that parents can test if a surface is adequately firm by pressing a hand down and then lifting it up. "If your hand leaves an indentation, it's too soft," it says.

There may be times when a parent does not have access to a perfectly firm, flat surface, the AAP acknowledged. "In an emergency, an alternative device with a firm, flat, noninclined surface (eg, box, basket, or dresser drawer) with thin, firm padding may be used temporarily," the AAP said.

Infants should always sleep alone

According to the AAP's latest advice, bed-sharing should be avoided in any circumstance.

There are certain situations that are more dangerous than others, though. For example, sharing a bed with a smoker or someone with impaired alertness because they have taken medication or drank alcohol increases an infant's risk of dying in their sleep 10-fold, the AAP said.

Sharing the same room was recommended for the first year of life but at least the first six months, but is now advisable "ideally for at least the first 6 months" of life. The AAP also strengthened its recommendations against using home cardiorespiratory monitors to try to prevent SIDS.

Most babies don't need to wear hats indoors

The latest guidance features new advice on overheating and head coverings, advising against infants wearing hats indoors because it is not clear they prevent hypothermia.

Hats are now only recommended during the first hours of life or in intensive care.

'Tummy time' should happen when the baby is awake

The guidance now actively promotes human breast milk feeding for up to a year because it is associated with a reduced risk of SIDS.

It also provides a new step-wise approach to "tummy time" where the baby is in a prone position, whereas the 2016 guidance did not carry specific recommendations as to how often or how long it should happen.

The AAP now recommends having tummy time while the newborn is awake from as soon as they are discharged from hospital, and then increasing incrementally to at least 15–30 minutes each day by seven weeks of age.

Moon said: "When parents have questions about their infant's sleep, they should always ask their pediatrician for guidance."