As a doula, one of our biggest roles is to empower clients through education. It is important we provide evidenced based information in accordance with current professional guidelines. This is for client safety, as well as our own liability as professionals. The new AAP sleep guidelines are important for us to be aware of.
Regardless of our personal beliefs, experience, etc., as doulas or parents, we must always provide our clients with current evidence.
The new guidelines are not drastically different from before. However, they highlight the importance of not using unapproved safe sleep devices. Ads bombard parents with the latest baby gear promising a good night’s sleep. Appropriate organizations have not approved these devices which remain unsafe.
The new AAP sleep guidelines help parents make informed choices about buying safe baby gear. We live in a time where many parents face constant ads for trendy products. The AAP has updated guidelines to combat these trends and reduce the risk of sleep accidents and potentially SIDS.
What is Safe Sleep?
As humans, a birthing person and their baby are wired to be close to each other. This is especially true for breastfeeding pairs. However, our modern furniture, lack of support (leading to exhaustion), baby gear, etc., can make infant sleep dangerous when certain guidelines are not followed.
At the basics of safe sleep, many organizations simplify by recommending sleep ABC:
- Alone – baby should not share a sleep surface with anyone, including no animals, and no items.
- Back – Baby should always be on their back to sleep. If baby rolls on their own, that is fine, but caregivers should place baby back down when putting in crib.
- Crib – Baby should sleep in a safe crib or bassinet.
Certainly, there are more guidelines, but the ABC was designed to be simple to remember. That said, it does not address the many commercialized products, what parents should do if they are afraid of falling asleep while feeding, etc.
In the US, there are about 3,500 infants who die annually from sleep related deaths. Research indicates that these deaths can occur when an infant with an intrinsic vulnerability to SIDS is placed in an unsafe sleep situation.
The annual number of sleep-related deaths has unfortunately remained the same since 2000. Prior to that, there was a substantial drop in deaths in the 1990s following a national education campaign to place babies to sleep on their backs.
We know safe sleep can save lives. We have clear evidence on how to reduce risks. As doulas, it is important we share this information with our clients. While overall risk remains low, it is still important to reduce preventable deaths.
What Are The New AAP Safe Sleep Guidelines?
For the first time in five years, the AAP has released new guidelines. The biggest changes are around commercialized products following multiple recalls. Devices such as Rock n Plays, bouncy seats, etc., can increase the risk of positional asphyxiation and sleep related death. This can occur even when a parent is close.
Items such as weighted sleep sacks, plush newborn loungers, and other devices make the rounds on social media ads, in popular magazines, and on store shelves. Despite the good marketing campaigns, they remain unsafe for infant sleep.
Desperately fatigued parents often purchase these products hoping to get a better night’s sleep. And while some items provide that, it can come at a very dangerous cost. Babies naturally rouse easily, an inherent instinct which reduces their risk of SIDS.
The AAP Safe Sleep Guidelines include:
- Only use firm, flat non inclined surfaces which at minimum follow the CPSC 2021 rule that any infant sleep product follow federal guidelines for cribs, bassinets, pack n plays, etc. No items not marketed for sleep should be used for infant sleep.
- Breastfeeding reduces the risk of sleep-related infant deaths, and while any human milk feeding is more protective than none, 2 months of feeding at least partial human milk feeding has been demonstrated to significantly lower the risk of sleep-related deaths. The AAP recommends exclusive human milk feeding to 6 months, with continuation of human milk feeding for 1 year or longer as mutually desired by parent and infant.
- Babies should sleep in the same room as parents – though not in the same bed – preferably for at least 6 months.
- Parents and infants should avoid exposure to nicotine, alcohol, illicit drugs.
- Infants should follow routine vaccination schedules
- Consider pacifier use which is associated with a reduced risk
- Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of positional plagiocephaly. Parents are encouraged to place the infant in tummy time while awake and supervised for short periods of time beginning soon after hospital discharge, increasing incrementally to at least 15 to 30 minutes total daily by 7 weeks of age. (Note – by a couple of months many other sources suggest a minimum of ninety cumulative minutes per day to aid in muscle development and mastering gross motor skills).
- Evidence does not suggest swaddling reduces the risk of SIDS. If an infant is swaddled, they must always be placed on their back to sleep. Swaddling should cease when baby shows signs of rolling, which is about 8 weeks to 4 months of age.
Be Wary of Commercial Products
- Sitting devices, such as bouncy seats, car seats, swings, etc., should not be used for routine in home sleep, especially for infants under 4 months of age.
- Avoid using commercialized (non-medical) devices which claim to reduce the risk of SIDS or cardiopulmonary events. If an infant requires monitoring, a physician will prescribe an approved medical grade device. These devices can lead to complacency regarding safe sleep by providing a false sense of security.
- Weighted swaddles, weighted clothing, or weighted objects on or near the baby are not safe and not recommended.
To review the AAP Safe Sleep guidelines directly from their site, alongside more evidence visit the AAP website.
Is Bedsharing Safe?
As doulas, many of us may find ourselves in more natural parenting circles. It is not uncommon for many to be adamant about safe ways to co-sleep or bedshare. As professional doulas, however, it is vital we follow all current guidelines for our own safety and of course that of our clients.
If you are based in the US, it is important you share these current guidelines with your clients. If you are a postpartum doula and you are on shift, it is important you follow these guidelines even if the parents make other decisions when you are not there.
While some places, such as The Mother Baby Sleep Lab at Notre Dame, have evidence related to bedsharing, we must be careful of what we say to our clients.
We can provide them with that information. UNICEF UK also has guidelines for professionals regarding bedsharing. Reading it can be very helpful in understanding how to discuss bedsharing with parents.
Per the new guidelines, study authors note:
“It’s essential for families and pediatricians to partner with each other, to build trust and have thoughtful conversations about how to keep children safe by lowering risks,” said Rebecca Carlin, MD, FAAP, who co-authored the statement and technical report. “We know that many parents choose to share a bed with a child, for instance, to help with breastfeeding or because of a cultural preference or a belief that it is safe.
“The evidence is clear that this significantly raises the risk of a baby’s injury or death, however, and for that reason AAP cannot support bed-sharing under any circumstances.”
“The risks of sleep-related infant deaths are up to sixty-seven times higher when sleeping with someone on a couch or soft armchair or cushion; and ten times higher when sleeping with someone who is impaired because of fatigue or use of sedating medications or substances such as alcohol or illicit drugs; or is a smoker. Risks of sleeping on the same surface with someone else also increase 5-10 times when an infant is under four months of age; is sharing the surface with someone other than a parent; or is a pre-term or low birthweight, regardless of other factors.”
While the AAP does not recommend bedsharing, you can share resources. Things such as the Mother Baby Sleep Lab and UNICEF UK. This allows parents to make informed decisions. As doulas, we must remember guidelines are for protection. Guidelines protect the most babies regardless of demographics, feeding methods, etc.
As professionals, it is imperative that we provide evidenced based information and empower parents to make informed decisions.
Author: Aliza Juliette Bancoff
Aliza Juliette Bancoff is a well-known doula and doula trainer who has been providing doula services to families for over a decade. She is the founder of Main Line Doulas, a doula group providing doula support in the great Philadelphia area for the last decade, the International Doula Institute, which provides online doula training and lactation training and certification programs and the International Breastfeeding Institute which provides lactation training and certification. She is the co-founder of United Birth, a company devoted to increasing access to doulas across the country to make the perinatal time safer both physically and emotionally. “Every birthing person deserves access to quality doula support. And we are working to make that a reality across the country. The work we are doing to get doulas to every birthing person will decrease the black infant and maternal mortality rate significantly by 2030.” Says Bancoff. Aliza is known for her compassionate and empowering approach to doula work, and she has been featured in numerous media outlets, including United Nations Maternal Health Report, Parent Magazine, CafeMom, theBump and many more. Aliza's journey into doula work began when she gave birth to her first child and felt a strong calling...