Sudden Infant Death Syndrome Guidelines

Updated: May 16, 2022
  • Author: Lynn Barkley Burnett, MD, EdD, JD; Chief Editor: Kirsten A Bechtel, MD  more...
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Guidelines Summary

2016 American Academy of Pediatrics Updated Recommendations for a Safe Sleeping Environment

In 2016, the American Academy of Pediatrics released guidelines on sudden infant death syndrome that included the following recommendations [119, 120] :

  • AAP recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, the use of a firm sleep surface, room-sharing without bed-sharing, and the avoidance of soft bedding and overheating.

  • Additional recommendations for SIDS reduction include the avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier.

  • New evidence is presented for skin-to-skin care for newborn infants, use of bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 mo of age.

  • Offer a pacifier at nap time and at bedtime. Studies show these can reduce the risk for SIDS.

  • Infants should be immunized in accordance with AAP and CDC recommendations.

  • Provide supervised, awake tummy time daily to facilitate development.

  • Remove infants from car seats, strollers, swings, infant carriers, and infant slings, if they fall asleep in them, to reduce the risk for gastroesophageal reflux and positional plagiocephaly.

  • Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.

2013 Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society (HRS/EHRA/APHRS) Guidelines

In its 2013 expert consensus statement on inherited primary arrhythmia syndromes, the Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society (HRS/EHRA/APHRS) recommended that an unexplained sudden death occurring in a child younger than 1 year with negative pathological and toxicological assessment be called “sudden unexplained death in infancy” (SUDI). Additional recommendations are summarized below. [121]


  • Personal/family history and circumstances of the sudden death, along with blood and/or tissue for molecular autopsy should be collected in all cases of SUDI (Class I)
  • An arrhythmia syndrome focused molecular autopsy/postmortem genetic testing can be useful (Class IIa)
  • Considered assessment by an expert cardiac pathologist to rule out the presence of microscopic indicators of structural heart when a diagnosis of SUDI is made at autopsy. (Class IIb)

Follow-up Screening of First-degree relatives

  • First-degree relatives should undergo genetic testing whenever a pathogenic mutation in a gene associated with increased risk of sudden death is identified by molecular autopsy. Obligate carriers should be prioritized.
  • First-degree relatives with a family history of inherited heart disease should be evaluated with resting ECG and exercise stress testing. Additional tests as indicated can be useful. Those with a history of arrhythmias or syncope should be prioritized.(Class IIa)
  • Follow-up clinical assessment in young family members with a family history of inherited heart disease or other sudden unexplained death syndrome (SUDS) or SUDI death who may manifest symptoms and/or signs of the disease at an older age and in all family members whenever additional SUDS or SUDI events occur. (Class IIa)
  • Consider evaluation of first-degree relatives with resting ECG and exercise stress testing.(Class IIb)

2006 Policy on Distinguishing Sudden Infant Death Syndrome from Child Abuse Fatalities

In its 2006 Policy on Distinguishing Sudden Infant Death Syndrome from Child Abuse Fatalities, the Committee on Child Abuse and Neglect of the American Academy of Pediatrics (AAP) states that the death of an infant may be attributed to sudden infant death syndrome (SIDS) when all of the following are true [122] :

  • A complete autopsy is performed, including cranium and cranial contents, and autopsy findings are compatible with SIDS

  • No gross or microscopic evidence of trauma or significant disease process is present

  • No evidence of trauma exists on skeletal survey

  • Other causes of death are adequately ruled out, including meningitis, sepsis, aspiration, pneumonia, myocarditis, abdominal trauma, dehydration, fluid and electrolyte imbalance, significant congenital lesions, inborn metabolic disorders, carbon monoxide asphyxia, drowning, and burns

  • No evidence of current alcohol, drug, or toxic exposure is present

  • Thorough death scene investigation and review of the clinical history are negative

Circumstances could indicate the possibility of intentional suffocation include:

  • Recurrent cyanosis, apnea, or ALTEs occurring only while in the care of the same person;

  • Age at death older than 6 months;

  • Previous unexpected or unexplained deaths of 1 or more siblings;

  • Simultaneous or nearly simultaneous death of twins

  • Previous death of infants under the care of the same unrelated person 

  • Evidence of previous pulmonary hemorrhage (such as marked siderophages in the lung).

2016 AAP Clinical Practice Guideline on Brief Unexplained Events in Infants

In 2016, the American Academy of Pediatrics (AAP) released a new clinical practice guideline that recommended the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). The authors define BRUE as an event observed in infants younger than 1 year during which an observer reports a sudden, brief (less than one minute), but then resolved episode including at least one of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in muscle tone (hyper- or hypotonia); or altered responsiveness. The guidelines also add that a BRUE is diagnosed only when there is no explanation for a qualifying event after completion of a thorough history and physical examination. Infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or, (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered.  This clinical practice guideline is structured to promote a patient- and family-centered approach to care, reduce unnecessary and potentially costly medical interventions, improve patient outcomes, and enhance efforts at future research. [123, 124]

Forensic Investigation and Autopsy

National guidelines for infant death investigation have been developed by the US Centers for Disease Control and Prevention (CDC) and endorsed by the National Sheriffs’ Association, the National Association of Medical Examiners, the International Coroners and Medical Examiners Association, and the American Board of Medicolegal Death Investigators. The Sudden Unexplained Death in Infancy Investigation and Reporting Form (SUIDIRF) is a reporting inventory that standardizes information collected at the scene of death. The form contains 25 questions that medical examiners and coroners should ask before beginning an autopsy. [1]

The following information is collected on the SUIDIRF:

  • Investigation data.
  • Witness interview.
  • Infant’s medical history.
  • Infant’s dietary history.
  • Pregnancy history.
  • Incident scene investigation.
  • Investigation summary.
  • Investigation diagrams.
  • Summary for pathologist.


Since 1996, the American Academy of Pediatrics (AAP) has recommended infants be placed in the supine position for sleep. [61]  In 2011, the AAP issued a policy statement expanding its recommendations to ensure a safe sleeping environment for infants and to further reduce the risk for sudden infant death syndrome (SIDS). [125]  

Other key recommendations are:

  • Breastfeeding is recommended
  • Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep.

  • The baby should sleep in the same room as the parents, but not in the same bed (room sharing without bed sharing).

  • Keep soft objects or loose bedding out of the crib.

  • Wedges and positioners should not be used.

  • Offer a pacifier at nap time and bedtime.

  • Avoid covering the infant's head or overheating.

  • Do not use home monitors or commercial devices marketed to reduce the risk for SIDS.

  • Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads).

  • Avoid alcohol, illicit drug use and smoke exposure during pregnancy and after birth

  • Infants should be immunized in accordance with recommendations of the AAP and Centers for Disease Control and Prevention