Sudden Infant Death Syndrome Betty Connal, RN, MS SIDS Mid-Atlantic

Sudden Infant Death
Betty Connal, RN, MS
SIDS Mid-Atlantic
2700 S. Quincy St. Suite 220
Arlington Va 22206
[email protected]
The sudden death of an infant under
1 year of age, which remains
unexplained after
Thorough case investigation
Complete autopsy
Death scene investigation
Review of the clinical history
Facts About SIDS
SIDS is the leading cause of post neonatal
infant death (AAP, 2000).
About 4500 infants in the US die of sudden
infant death annually, ½ SIDS ½ “other”
8% of all infant deaths are now due to SIDS.
Virginia had 90 SIDS and 13 undetermined
sudden infant deaths in 2005, increased
from 79 SIDS in 2004
Other deaths due to suffocation or
strangulation, infection, anything not expected
Maryland had 64 SIDS deaths in 2004, DC
had 9
Facts About SIDS
No one can tell in
advance which babies
will die – SIDS cannot
be predicted
SIDS babies do not
appear severely ill
Some appear to have
mild URI before
death, but infections
are not found on
SIDS cannot be
Facts About SIDS
91% of SIDS deaths occur before 6
months of age
Peak is between 2-4 months of age
African American infants are nearly 2
½ times more likely to die of SIDS
than white infants. Gene has been
identified in black baby boys.
Facts About SIDS
Almost always occurs when the infant
is asleep
SIDS is not
Caused by immunization
The result of neglect or abuse
Which Babies Are at Greatest
Infants who sleep in the prone
Premature infants and/or low birth
weight infants (under 1000 grams)
Infants who had prenatal nicotine
Infants with prenatal illicit drug
Which Babies Are at Greatest
Infants who sleep on soft bedding
Male infants
African Americans and Native Americans
Infants of mothers with late/no prenatal
Overheated infants
Infant of young mothers (under age 20)
SIDS Statistics
% Babies Sleeping on Stomach
SIDS rate per 1000 live births
SIDS vs.
Triple Risk Model
Highest risk for
Critical period
of development
Some Theories…
Researchers have identified that
serotonin receptors of the brain are
abnormal in SIDS babies
Abnormal response to hypoxia, putting an
infant at risk for sudden death during
This area of the brain regulates
respiration, temperature, blood
pressure, heart rate
Some Theories
Why does the prone position carry such a
high risk for SIDS?
Babies sleeping on their stomachs have lower
blood pressure, higher heart rate and body
This leads us to believe that there is some
degree of vasomotor instability in the prone
Arousal may be diminished in the prone position
More Theories
Babies in a risky environment (soft bedding) may
be rebreathing CO2
Babies who have their heads covered with
blankets, may have a 300% rise in their thermal
resistance, causing a lethal rise in brain
Some babies may die from cardiac arrhythmias –
long QT Syndrome
Recommendation from European Union that all
babies have EKG at about one month. Cost
effective and could save about 250 European
babies’ lives per year
Nicotine Exposure
Nicotine is used in 12.5% of all pregnancies
in the US (DHHS, 2004).
Nicotine is a neuroteratogen
Causing cell damage/deficits in cell number
May shut off the fetal response to hypoxia
before the adult mechanisms can take over
Babies may have a blunted response to hypoxia
Exposure to passive smokers also increases the
risk in a dose-dependent manner (Flemming, et.
al, 2000)
African American Infant
A gap in knowledge about SIDS and SIDS
risk reduction among African American
2/3 of the mothers reported they were
not aware of sleep position
recommendations before their baby died
Rate of SIDS is 3X higher in African
American infants than white infants
Data is from Chicago Infant Mortality study – unpublished as of 7/2001
CPSC Findings
Only 31% of
African American
parents surveyed
put babies on their
Backs to Sleep
80% of all parents
put babies on their
Backs to Sleep
Some 900 deaths a year attributed to
SIDS may be soft bedding deaths
In 30% of these deaths, the infants nose and
mouth were covered in soft bedding
23 soft bedding deaths in Virginia in 2003
Diagnosis subjective
☺ A change in retail practices began in the
spring of 2000
Child Care Providers
About 18% of SIDS babies die
while being cared for by a child
care provider
Statistically, only 9% of SIDS
should occur in child care
Half die in the first week of child
care (Moon, 2000)
Why do so many babies die in
child care?
Many of these infants are sleeping
Some of these infants are not used
to sleeping on their stomachs
Child care providers don’t know about
back sleeping or don’t believe it works
Parental request
Inexperienced Prone Sleeping
Recent studies suggest that infants
unaccustomed to prone sleeping are at a
greatly increased risk (up to 20 X) for
SIDS when they are placed prone or roll to
prone position during sleep (Mitchell,
1999)(Moon, 2000)
Side sleeping may pose a risk, as the
position is unstable; the infant may role to
A Little History
In the early 1990’s researchers identified the
prone sleep position as a risk factor for SIDS
In 1992 the American Academy of Pediatrics
(AAP) recommended that infants sleep on their
back or side
In 1996, the AAP modified their earlier statement
on sleep position and recommended back sleeping
for all healthy infants
In 2005, AAP made new recommendations to
prevent SIDS
Modifiable Behaviors That
Reduce the Risk of SIDS
Back sleeping – infants who sleep on
their backs are 3 times less likely to die
from SIDS than those who sleep on
their stomachs
They are also less likely to overheat,
rebreathe CO2 and have more arousals
during sleep
Advise parents not to smoke around
their baby
Five A’s of Smoking Cessation
The evidence-based intervention for providers to help their pregnant
smokers quit is based on the following five steps (the "5 As"):
1. ASK – 1 minute: Ask patient about smoking status.
I have NEVER smoked, or have smoked LESS THAN 100 cigarettes in my
I stopped smoking BEFORE I found out I was pregnant, and I am not
smoking now.
I stopped smoking AFTER I found out I was pregnant, and I am not smoking
I smoke some now, but I cut down on the number of cigarettes I smoke
SINCE I found out I was pregnant.
I smoke regularly now, about the same as BEFORE I found out I was
2. ADVISE – 1 minute
Provide clear, strong advice to quit
with personalized messages about the impact of smoking on mother and
Five A’s
3. ASSESS – 1 minute
Assess the willingness of the
patient to make a quit attempt within the next 30 days
4. ASSIST – 3 minutes +
Suggest and encourage the use of problem-solving methods
and skills for cessation.
Provide social support as part of the treatment.
Arrange social support in the smoker’s environment.
Provide pregnancy-specific, self-help smoking cessation
5. ARRANGE – 1 minute + Periodically assess smoking
status and, if she is a continuing smoker, encourage
Modifiable Behaviors That
Reduce the Risk of SIDS
Eliminate soft bedding and blankets
from cribs
Consider using a blanket sleeper or sleepsack
as an alternative to blankets
If using a blanket, use a thin one and tuck it
around the mattress so it reaches only as far
as the baby’s chest
No stuffed animals or pillows in cribs
HALO Sleepsack
Modifiable Behaviors That
Reduce the Risk of SIDS
Remove bumper pads from cribs
Avoid over bundling babies
Make sure pregnant women receive
good prenatal care
Advise caretakers that babies should
sleep on their backs
Safe Sleeping Environment
What About Aspiration?
52% of all parents
surveyed by the CPSC
feared babies would
choke in vomit if
placed on their backs
Babies are NOT more
likely to choke while
sleeping on their
What About Aspiration?
According to the AAP “there is NO
evidence of an increase in aspiration or
increased complaints of vomiting since the
incidence of supine sleeping has increase
dramatically” (AAP, 2000).
There is also some “direct and indirect
evidence that infants who vomit are at
greater risk of choking if they are sleeping
face down” (AAP, 2000).
Plagiocephaly a.k.a Flat Heads
Sleep position and SIDS
There are concerns about head
asymmetries in babies who sleep on their
Encourage parents to give baby
SUPERVISED tummy time when awake
Babies only need to be on their backs for
naptime and night-time sleep
Bed Sharing
Deaths from suffocation have increased as SIDS
deaths decreased
Bed sharing is NOT protective against SIDS
The AAP discourages bed sharing
20% increase in infant deaths when bedsharing especially
if father or sibling in bed
Bed sharing confers a higher risk of SIDS when
Parents smoke and bed share.
Co-sleeping means baby in same room as parents,
not same bed. Co-sleeping is safest for baby
NO SMOKING! Or drinking, or drugs
Bed Sharing
There are also hazards in adult beds
and some risk of overlay deaths in
certain situations:
People using drugs or alcohol while bed
If the baby slips under the covers,
under pillows, becomes trapped between
the mattress and bed frame, is rolled on,
or becomes overheated
AAP Guidelines 2005
Infants should be put to sleep on
their backs every time
Use a firm crib mattress and a snug
fitting crib sheet
Keep soft objects and loose bedding
out of the crib. No pillows, quilts,
comforters, sheepskins or stuffed
AAP 2005
Do not smoke during pregnancy and avoid
exposing babies to second hand smoke
Offer the baby a pacifier at nap time and
bedtime. Do not reinsert the pacifier once
the baby falls asleep. Pacifier use should
begin once breast feeding is well
established, and it needs to be consistent
Infants should be lightly clothed for sleep.
Bedroom temperature should be
comfortable for a lightly clothed adult.
AAP 2005
Avoid commercial devices marketed
to reduce the risk of SIDS, like
wedges and positioners. None has
been shown to be safe or effective.
Parents should not share their bed
with the baby during sleep
Home monitors do not reduce the risk
of SIDS.
Positioning Device
Do not use. Unnecessary and may be
AAP 2005
Avoid positional plagiocephaly (flat
heads) by encouraging “tummy time”
Babies should not spend excessive
time in car seat carriers and
SIDS in Your Practice?
Provide parents with names and numbers of
support groups in the area
Have someone review the autopsy with the
parents – if they desire
Don’t be afraid to say the baby’s name
Expect these parents to need extra
support upon birth of subsequent children
Considerations for Subsequent
Expanded newborn screening
Virginia tests for 29 disorders as of
March 2006
Testing for long QT syndrome
No smoking and safe sleep
Monitors for preemies with apnea or
for parents’ peace of mind
Expanded Newborn Screening
Virginia tests for 29 disorders
Pediatrix screening
55 disorders for
45 disorders for
Mayo medical
35 disorders for $50
ask for supplemental
newborn screen, MML
test # 82594
55 disorders for
Baylor medical center
over 30 disorders for
Reduce The Risk
Back is best—in baby’s own crib
Advise pregnant women not to smoke
Learn Five A’s Method
Advise parents to avoid second hand smoke
exposure around baby
Remove soft bedding from crib
Avoid overheating baby
Give baby supervised tummy time when
Kylie’s Playground
Step 1: Baby
is placed on
back to sleep
when in open
crib or one
week prior to
going home.
Step 2: Do not
bundle baby
while asleep or
keep the room too
warm The best
temperature is
65-71 degrees.
Do not put loose
bedding, bumper
pads or stuffed
toys in the crib.
Step 3: Baby can
be on tummy for
playtime while
always being
Step 4:
Parents need
to tell all
that baby
sleeps on
back only.
Step 5:
Home should
be smoke
SIDS Mid-Atlantic 703-933-9100
New Logo for Brisan
American Academy of Pediatrics Task Force on Infant Sleep Position
and Sudden Infant Death Syndrome. (2000). Changing concepts of sudden
infant death syndrome: implications for infant sleeping environment and
sleep position. [on-line]. Pediatrics, 105, (3), 650-656.
Hudson Mohawk SIDS Affiliate. (1998). Reducing the risk of SIDS:
what public health nurses need to know.
Kemp, J. S. & Thach, B. T. (1995). Quantifying the potential of infant
bedding to limit CO2 dispersal and factors affecting rebreathing in
bedding. American Physiological Society, 740-745.
Lockridge, T., Taqino, L. T., Knight, A., (1999). Back to Sleep:Is there
room in that crib for both AAP recommendations and developmentally
supportive care? Neonatal Network, 18 (5), 29-31.
Moon, R., (2000). Answering medical questions about SIDS.
Presented at the National SIDS Alliance Conference, Salt Lake City, Utah.
Willinger, M., Ko, C. W., Hoffman, H. J., Kessler, R. C., Corwin, M. J.
(2000) Factors Associated with caregivers’ choice of infant sleep position,
1994-1998. JAMA, 283 (16), 2135-2142.
Zeskind, P. S., (2000). Maternal cigarette-use during pregnancy
disrupts rhythmic activity in fetal autonomic regulation. Presented at the
National SIDS Alliance Conference, Salt Lake City, Utah