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SIDS is the diagnosis given
for the sudden death of an infant under one year of age that remains
unexplained after a complete investigation, which includes an autopsy,
examination of the death scene (Center for Disease Control and Prevention
guidelines), and review of the symptoms or illnesses the infant
had prior to dying and any other pertinent medical and family history
and a complete death scene investigation. (National Institute of
Child Health and Human Development, Marian Willinger, PhD, 1992)
SIDS is sometimes called "crib death,".
This is a misnomer and a term we are trying to eradicate. According
to the Chicago Infant Mortality Study, the vast majority (75 - 80%)
of babies who die from SIDS in Chicago are not sleeping in cribs.
Cribs do not cause SIDS, in fact, studies show us that the safest
place for baby to sleep is in a safety approved crib that has a
firm, well fitting mattress and a tightly fitted sheet. Other aspects
of an infant's sleep environment have been associated with an infant's
increased risk for SIDS such as the use of soft bedding, like bumper
pads, heavy blankets or quilts, pillows and stuffed animals.
What causes
SIDS?
When is SIDS
most likely to occur?
Is there anything
we can do to prevent SIDS?
What is the
Back to Sleep campaign?
Is the campaign
successful?
Are there any
infants that are more at risk for SIDS?
Are any ethnic
groups more prone to SIDS?
Is SIDS inherited?
I have heard
that the side sleep position is effective against SIDS.
Won't my baby
choke on spit-up or vomit during sleep if placed on its back?
Which babies
should not be placed on their backs to sleep?
Doesn't back
sleeping cause flat heads?
Should infants
ever be placed on their tummies?
What if my
baby cries and cries and won't sleep in the back position?
Could a pacifier
protect a baby against SIDS?
Should sleeping
"wedges" be used for infants?
Are there any
advantages or disadvantages to "shared sleeping" arrangements?
Is there any
research on home monitors?
Does NICHD
recommend the use of monitors to prevent SIDS?
We do not know the cause of Sudden Infant Death Syndrome; however,
we are doing research in many areas. One of the more promising areas
of research is with the brain stem where all autonomic nervous system
functions occur. There is mounting evidence that suggests some SIDS
babies are born with brain abnormalities that make them vulnerable
to sudden death during infancy. Studies of SIDS victims reveal that
many SIDS infants have abnormalities in the "arcuate nucleus,"
a portion of the brain that is involved in control of arousal (breathing
and waking) during sleep. Babies born with defects in other portions
of the brain or body may also be more prone to a sudden death. These
abnormalities may stem from prenatal exposure to a toxic substance,
one being nicotine, or lack of a vital compound in the prenatal
environment, such as sufficient oxygen.
SIDS is the leading cause of death in infants between 28 days to
12 months of age. Most SIDS deaths, approximately 60%, occur when
a baby is between 2 and 4 months of age.. At 6 months of age, 95%
of the babies who are going to die of Sudden Infant Death Syndrome
have already died. After 6 months of age, the risk of SIDS decreases
significantly. Age is adjusted for premature infants. The incidence
of SIDS deaths are higher during the fall and winter, and frequently,
the infant will have a mild upper respiratory or diarrheal illness
preceding the death. Currently, the diagnosis of SIDS is not used
after 1 year of age.
At this time, there is no foolproof way of predicting which
newborns will succumb to SIDS. However, there are a few measures
parents can take to lower the risk of their child dying from SIDS
in order to give their infant the best possible chance to thrive.
We can prevent an accidental suffocation, entrapment
or overlay by following these same safe sleep guidelines.
Back Sleeping - Placing babies
on their backs to sleep for nighttime and naptime, is the single
most important step that parents and other caregivers can take to
reduce the risk of SIDS. Studies have shown that countries where
caregivers have switched from placing babies on their stomachs to
sleep to placing babies on their backs to sleep have reduced their
total SIDS deaths by as much as 70%. 2,000 fewer infants die of
SIDS in the U.S. each year due to this simple measure. Since 1993,
the death rate due to SIDS in Illinois has decreased by 68%! From
2001 to the year 2002, SIDS deaths dropped nationally by 11%!
Smoking - Mothers who smoke during
pregnancy are 3 times more likely to have a baby die from SIDS,
Babies who are exposed to second hand smoke are 1 1⁄2 to 2
times more likely to die from SIDS. Parents should be sure to keep
their babies in a smoke-free environment. Studies have found that
the risk of SIDS rises with each additional smoker in the household,
the numbers of cigarettes smoked per day, and the length of the
infant's exposure to cigarette smoke. Components of smoke, specifically
nicotine, are believed to interfere with an infant's developing
lungs and nervous system, and to disrupt a baby's ability to wake
from sleep. Please note, that smoking in the bathroom with the fan
on does not count as not smoking around the baby and smoking under
the kitchen range hood also does not count as not smoking around
the baby. Smoking in the car, especially with the windows rolled
up is also a very unhealthy environment for the baby.
Bedding - Parents should make
sure their baby always sleeps on a firm, flat mattress in a crib
that meets current safety standards. Parents and caregivers should
also avoid using loose, fluffy blankets or coverings and should
not use pillows, sheepskins, bumper pads, positioners, stuffed
animals
or comforters in the babies crib. Consider using a sleeper or other
sleep clothing as an alternative to blankets, with no other covering.
Infants should never be placed to sleep on a waterbed, sofa or
with stuffed toys or pillows. Infants should never sleep in the
adult
bed, whether alone or with parents or siblings. The American adult
bed was never intended for use by an infant. The infant simply
cannot
compete in the adult bed.
Head Covering - Infants do not
need to wear a hat when they are indoors. Make sure your baby's
head and face remain uncovered during sleep. Babies are at an increased
risk for SIDS if their head becomes covered during sleep. Avoid
using a blanket or other covering over your baby's face as a sun
or weather screen, or to block out distractions or sounds while
your baby is sleeping. Bedding that bunches up or contours around
your baby's face can obstruct the mouth and nose, causing potentially
dangerous re-breathing of stale air (carbon dioxide). The only blanket
recommended for use in a crib, is a thin receiving blanket. We also
recommend that when using a thin blanket, you put the baby's feet
to the foot of the crib and tuck the blanket under the mattress
so that the baby cannot pull the blanket over his head.
Bedsharing/Sofa-sharing - In
addition to the recognized hazards presented by pillows and comforters
in the family bed, there are also risks associated with infants
who sleep with parents whose instincts are impaired by exhaustion,
drugs, alcohol use, or who are smokers. There are also dangers connected
with infants sharing a bed with brothers, sisters, or relatives
other than the baby's mother. Sofas and couches are particularly
dangerous environments for shared sleep. Babies are not only at
increased risk for SIDS in the adult bed, they are also 40 times
more likely to die of accidental suffocation, overlay or entrapment.
These deaths are 100% preventable. Bedsharing has not been found
to be protective against SIDS, though studies suggest that room-sharing
may have a protective mechanism. Keeping the baby next to the adult
bed in his/her own safety approved crib or bassinet provides greater
safety for the infant and proximity for parents seeking to facilitate
breastfeeding and share closeness with their baby.
Room Temperature - Babies should
be kept warm, but they should not be allowed to get hot. An overheated
baby is more likely to go into a deeper sleep from which it is more
difficult to arouse. Keep the temperature in the baby's room between
68-72 degrees F, and avoid overdressing the baby. All the baby needs
to wear is as many layers of clothing as you plus one thin layer
for sleeping. If baby has a sweaty head during sleep or upon waking,
they are probably dressed too warmly.
Prenatal Care - Good prenatal
care - including proper nutrition, abstinence from alcohol, drugs,
and smoking, and frequent medical checkups beginning early in pregnancy
- might help prevent a baby from developing an abnormality that
could put him or her at risk for sudden death as well as decrease
the chance of premature birth or low birth weight, both of which
are associated with an increased risk for SIDS.
Regular Health Care - Parents
should take their babies to their health care provider for regular
well baby checkups, and should make sure that their babies receive
their immunizations on schedule. The National Institutes of Health
have turned up no connection between immunizations and SIDS. In
fact, SIDS occurs among infants who never received their shots,
as well as in countries with different immunization schedules.
Child Care - Babies who routinely
sleep on their backs and are unaccustomed to sleeping on their stomachs
are at an 18 times higher risk of SIDS when placed on their tummy
by a well- intentioned but ill-informed relative or caregiver. Infants
who are accustomed to sleeping on their backs who are placed on
their tummy in an adult bed with soft bedding are 21 times more
likely to succumb to SIDS. Studies tell us that a disproportionate
number of SIDS deaths are occurring in family childcare settings.
This is not so surprising when coupled with the fact that half of
family childcare providers are over 50 years of age, have school-aged
or older children, and have not received SIDS risk reduction education.
Be sure to communicate that all babies sleep safest on their backs
to baby sitters, childcare providers, grandparents and everyone
else who cares for your infant. Parents cannot assume that everyone
knows about Back to Sleep and other ways to reduce SIDS risk.
Back to Sleep is aptly named for its main recommendation to place
all healthy infants on their backs to sleep for nighttime and naptime
to reduce the risk of SIDS. The National Institute of Child Health
and Human Development (NICHD) leads the campaign, along with the
Maternal and Child Health Bureau and other Federal agencies such
as the Centers for Disease Control and the Census Bureau. The American
Academy of Pediatrics (AAP) is the major private sponsor, along
with the SIDS of Illinois and the Association of SIDS and Infant
Mortality Programs. Based on a recommendation made by the AAP in
1992, the campaign was launched in 1994 with an effort to reach
every newborn nursery in the country. In March 1997, Tipper Gore
became national campaign spokesperson.
This campaign has been increasingly successful in reaching parents
and other caregivers of infants. We have seen a change from 70%
of babies placed on their stomachs to sleep in 1992 to only 21%
in 1998. In Spring of 1999, NICHD phone surveys in Cook County indicated
only 11% of infants were routinely being placed on their stomachs
to sleep. The death rate from SIDS declined nationally by 42% between
1992 and 1998, the first significant decrease in SIDS deaths in
the U.S. In Illinois, the death rate due to SIDS has dropped by
68% in the last 10 years.
Yes, infants in the following categories are at a statistically
higher risk for SIDS:
- Infants who are placed on their tummies to sleep.
- Infants who sleep in the adult bed, or couch.
- Infants who sleep with a lot of soft bedding
- Infants born to mothers who smoked during their pregnancy or
were exposed to second hand smoke while in utero or after birth.
- Infants born to mothers with little or no prenatal care.
- Infants born to mothers who are less than 20 years of age at
the time of their first pregnancy.
- Infants born to mothers with too short an interval between
pregnancies
- Premature (less than 37 weeks gestation) or low birth weight
(less than 5.5 lbs.) babies and multiples (twins triplets, etc.)
- There is a higher incidence of SIDS in boys than in girls.
Illinois' African American infants are more than six times more
likely to die of SIDS than Caucasian infants. In the City of Chicago
and African American infant is more than 13 times more likely to
die. The national average for SIDS in the African American community
is 2.5 times higher than in the Caucasian community. The Back to
Sleep campaign is being stepped up, with a special effort to get
the message out to these and other previously underserved populations
with the help of community, civic and religious groups.
There may be something that genetically predisposes an infant to
higher SIDS risk. Metabolic disorders, which can be inherited,
have,
at times, been mistaken for SIDS. One such disorder, medium chain
acylCoA dehydrogenase deficiency (MCAD), prevents an infant
from
properly processing fatty acids. A build up of these acid metabolites
could eventually lead to a rapid and fatal disruption in breathing
and heart functioning. All babies born in Illinois hospitals are
given Expanded Newborn Screening since July, 2002. In the first
year of this expanded screening, we have saved approximately 1
baby per day. Metabolic disorders can be treated (although not
cured)
if they are found within the first few days of life. If the baby
is born outside of Illinois, parents can request screening from
their pediatrician.
In 1992, the American Academy of Pediatrics
(AAP) recommended both the side and the back sleeping position
to
reduce the risk of SIDS. In 1996, however, after reviewing data
from various new studies, they revised their recommendation to
back
sleeping as the best position for infants. These reports indicated
that the risk for SIDS is greater for babies placed on their sides
versus those placed on their backs, perhaps because babies placed
on their sides have a higher likelihood of spontaneously turning
onto their tummies. Since 2000, the AAP has made the Standard of
Care back sleeping only. Side sleeping is not recommended. Wedges
and other positioners are not recommended. These are made of foam
and are too soft to be around baby.
Many parents place babies on their stomachs to sleep because they
mistakenly think it prevents them from choking on spit-up or vomit
during sleep. But studies in countries where there has been a switch
from babies sleeping predominantly on their stomachs to sleeping
wholey on their backs have not found any evidence of increased
incidence of aspiration, pneumonia, choking, or other problems.
In addition,
the AAP has reviewed all the scientific literature and found that
there is no additional risk of choking on vomit when babies sleep
on their backs. Babies are actually less likely to vomit when placed
on their back in part because we traditionally put babies to sleep
with full tummies. The pressure of the mattress against babies
full tummy makes them more likely to spit up. If your baby has
Reflux or spits up frequently, consult your pediatrician.
All babies should be placed on their backs
to sleep unless otherwise instructed by the baby's doctor. In some
instances, a doctor may recommend that a baby be placed on their
stomachs to sleep if they have certain upper airway disorders. A
baby who has Gastro-esophageal reflux does not automatically indicate
that the baby should tummy sleep. Make sure you check with your
physician if you are unsure.
There is some suggestion that the incidence of babies developing
flat spots may have increased with back sleeping. This is almost
always a benign condition, which will disappear within several months
after the baby has begun to sit up. Flat spots can be avoided by
altering the back sleeping head position, such as turning the head
to one side for a week or so and then changing to the other. Reversing
the head-to-toe axis in the crib so the baby's head can continually
face outside activity (e.g., the door to the room) helps maintain
this position.
Remember to limit the amount of time each day
that a baby spends in his or her car seat. Car seats were designed
to keep baby safe in a car accident. However, now that car seats
disconnect from the car and can be carried, many babies spend hours
each day in the seat. Carry your baby in your arms whenever possible.
A certain amount of "tummy time" while the infant is awake
and being observed is recommended for motor development of the upper
body. In addition, supervised awake time on the stomach may help
prevent flat spots from developing on the back of the baby's head.
Babies typically begin to roll to their tummies at around 4-5 months
of age. When the baby can roll alone, it is important to know that
this is normal growth and development. It is not necessary to keep
"flipping" the baby on to their backs. The most important
thing to remember is that when the baby begins to roll, that they
have a safe sleep area free from soft bedding or other obstructions.
A good rule to remember is "Back to Sleep - Tummy to Play".
Positional preference appears to be a learned behavior among infants
from birth to 4 to 6 months of age. Infants who start out sleeping
on their backs from day one should become accustomed most readily
to the back sleeping position. Swaddling the baby from the nipple
line (under the arm pits) down for a few days, will help baby become
accustomed to the back sleeping position. Once the baby can kick
out of the swaddle, is should be discontinued so that there is no
danger of the baby kicking the blanket over his/her head and face.
There have been a few studies done on the relationship between SIDS
and pacifiers. In each case, it appears that the use pacifiers is
associated with a decreased risk of SIDS. There are many possibilities
for this finding. Some researchers have suggested that a pacifier
may prevent the infant's tongue from falling back into the throat
causing the air passage to seal. Others have theorized that pacifiers
encourage swallowing and therefore stimulate the muscular development
of upper airways; or that pacifier use prevents an infant from turning
into a directly prone position. Until further studies explain the
relationship between pacifier use in infants and SIDS, the Back
to Sleep campaign does not make a recommendation for or against
their use. Parents and child care providers are, however, to be
discouraged from taking a pacifier away from a baby who seems to
need or want one.
The American Academy of Pediatrics and SIDS of Illinois have stated
that devices designed to maintain sleep position are not recommended
since they have not been sufficiently tested for their safety and
none have been shown to be effective at reducing the risk of SIDS.
They may actually be dangerous in the infants sleep area. Remember
that the baby needs to have a safe sleep environment in which to
roll.
There are no scientific studies demonstrating that bedsharing reduces
SIDS. Conversely, there are a number of studies suggesting that
bedsharing, under certain conditions, may actually increase the
risk of SIDS, suffocation, overlay and accidental death. There is
no basis at this time for encouraging bedsharing as a strategy to
reduce SIDS risk. However, studies indicate that room-sharing -
keeping the baby alongside the adult bed in his own crib or bassinet
- may be protective against SIDS.
Among the many avenues of research initiated by the NICHD, infant
monitoring was thoroughly investigated by NICHD-funded researchers.
In the 1970's and early 1980's, it was thought that monitoring had
promise in identifying infants at risk for SIDS and signaling caregivers
when infants have life-threatening events that may proceed to SIDS.
In September of 1986, the NICHD held a consensus conference titled,
"Infantile Apnea and Home Monitoring." After examining
all available research, the consensus panel determined that cardiorespiratory
monitoring is effective only in managing apnea. For the normal newborn,
the risks, disadvantages, and costs of monitoring outweigh the potential
of identifying infants at risk for SIDS.
Although some electronic home monitors detect and sound an alarm
when a baby stops breathing, there is no evidence that such monitors
prevent SIDS. The monitors also pose several disadvantages, including
frequent false alarms, restricted mobility of both infant and parents,
and the risk of electrical injury to young children. A panel of
experts convened by the National Institutes of Health recommended
that home monitors not be used for babies who do not have an increased
risk of sudden unexpected death. However, the monitors may be recommended
in some cases in which infants have experienced one or more severe
episodes during which they stopped breathing and required resuscitation
or stimulation, if the baby is premature and has symptomatic apnea,
or if the baby has a medical condition such as central hypoventilation.
If an incident has occurred or if an infant is on a monitor, parents
need to know how to properly use and maintain the device, as well
as how to resuscitate their baby if the alarm sounds.
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