Preventing SIDS: Are Programs Making a Difference

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Preventing SIDSAre Programs Making a Difference
5th Annual Primary Care and Prevention Conference

• Lynette Wilson-Phillips, M.D., F.A.A.P.
• Pediatrician
• Decatur Pediatric Group, P.A.

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Topics of Discussion

• Review SIDS Epidemiology, Risk Factors
• American Academy of Pediatrics Recommendations to
  Reduce SIDS
• Opportunities as a PCP to advise parents on the
  prevention of SIDS
• Georgia Infant Safe Sleep Campaign

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SIDS Definition

• The sudden death of an infant under one year of
  age which remains unexplained after a thorough
  case investigation, including a
• Complete autopsy
• Death scene investigation
• Review of the clinical history

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Epidemiology

• Despite recent decreases in the incidence of
  SIDS, it is still responsible for more infant
  deaths between the ages of 1 month and 1 year
  than any other cause.
• SIDS rate 1994 1.03/1,000
• SIDS rate 1998 0.67/1,000
• SIDS rate 2003 0.52/1,000
• Decrease in SIDS rate appears to be leveling off

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SIDS Epidemiology

• Incidence is rare during the 1st month
• 1-3 under 1 month
• Peak incidence 2-4 months of age
• 95 of infants dying of SIDS will have done so by
  6 months of age
• African Americans and American Indians have
  consistently higher rates, 2 to 3 times the
  national average

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Infant Mortality RateU.S. and Georgia 1990-2002
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AAP SIDS Statement 1996

• Healthy term infants should sleep wholly on
  their back as the safest sleep position.

"Positioning and SIDS Update, Pediatrics, Vol.
98, No. 6, December 1996
In Australia and England, premature and LBW
babies are not discharged until they have been
sleeping on their backs for at least 5 days, and
parents trained in using this position after the
routine of rotating position in the NICU. No baby
should leave the hospital before back sleeping
has been firmly established to reduce risk and
train parents for home care.
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Risk Factors

• African Americans (2x greater risk)
• American Indians (more than 2x greater risk)
• Babies who sleep on their tummies (5x greater
  risk)
• Babies put on their tummies to sleep who usually
  sleep on their backs (1820x greater risk)
• Babies who sleep with others (risk varies)
• Babies that are overheated (risk varies)
• Babies placed in an unsafe sleep space
• Babies that sleep on a soft surface are 5-6X more
  likely to die than those placed on a firm sleep
  surface.

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Maternal Risk Factors

• Young maternal age at 1st pregnancy
• Short inter-pregnancy interval
• Low education level
• Poor prenatal care
• Cigarette smoking during, and after pregnancy
• Drug use during the pregnancy

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Infant Risk Factors for SIDS

• Low birth-weight
• Prematurity
• Risk increases with decreasing gestational age
  and birth-weight

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Preterm Birth and Low Birth Weight Infants

• Preterm and low birth weight infants are at
  increased risk for SIDS
• NICHD 1985

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Incidence of preterm and LBW infants in the U.S.

• Between 1981-2002
• Preterm births have increased 29
• LBW births have increased 15

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Preterm and LBW Infants

• 65 decrease in infant mortality since 1970
• Large reduction in neonatal mortality
• Congenital anomalies-Folic acid, ECMO
• Respiratory Distress Syndrome-Surfactant
• Significant improvements in survival of preterm
  and LBW infants-HFVO, etc.
• 50 reduction in SIDS

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Modifiable Risk Factors

• Prone Sleeping
• Soft Sleep Surfaces and Loose Bedding
• Overheating
• Smoking
• Bed Sharing

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Modifiable Risk Factors

• PRONE SLEEPING
• Major risk factor for SIDS
• odds ratios ranging from 1.7 to 12.9
• Plausibility of such a relationship
• countries with campaigns to reduce the prevalence
  of prone sleeping have had dramatic decreases in
  their SIDS rates
• Cultures in which prone sleeping is rare have low
  SIDS rates

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Prone Sleeping

• Despite the effort to educate the public about
  the risk of prone sleeping
• 20 of U.S. infants continue to sleep prone
• black infants are twice as likely to be placed
  prone
• 20 of caregivers switch from placing infants in
  the nonprone to prone position between 1-3 months
  of age

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Prone Sleeping

• Evidence that infants who are accustomed to
  sleeping supine are at particularly high risk for
  SIDS when they are then placed in a prone
  position
• babies normally placed on their backs to sleep
  are 20 times more likely to die of SIDS when
  switched to their stomachs
• possibly because upper body strength is less
  developed

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Back to Sleep.Prone to Play

• Developmental considerations
• Upper body tone
• Gross motor skills
• Morbidities of supine positioning
• Developmental delay, positional deformities
• Diaper rash, eczema, cradle cap

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It is developmentally important for infants to
have tummy time.
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Prone Sleeping in Day Care Settings

• SIDS in Child Care Settings
• Pediatr. vol.106 No 2 August 2000
• Studied 1,916 SIDS deaths in 11 states
• found a rate in day care much higher than
  expected. Expected rate to be about 7 but found
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• especially troubling was a finding of children
  placed on their stomachs by caretakers, more than
  half were usually put to sleep on their backs by
  their parents

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Prone Sleeping in Day Care Settings-continued

• About a third of the SIDS deaths took place
  during the 1st week in child care
• 60 of SIDS deaths happened in day care homes,
  which tend to be unlicensed and run by older women

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SIDS in NICU Graduates

• Reasons why parents place infants to sleep
  non-supine
• Infants sleep preference
• Advice from medical professional
• Hospital practice
• (Vernacchio L. et al, Pediatrics 2003, 111
  (3) 633-40.)

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Hospital Practice continued

• Mothers of prone sleeping infants cited advice
  from medical professionals or nursery practice as
  the 10 reason
• Mothers of non-prone (side) sleeping infants
  cited advice from medical professionals as the
  most influential reason

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Hospital Practice continued

• Conclusions
• VLBW infants who are at the highest risk for SIDS
  are more likely to be placed prone than larger
  infants
• Prone sleeping increased significantly at 3
  months from 15.5 at 1 month to 26.8 at 3 months
• Brenner JAMA 1998280341-346
• The most important determinant of early
  intentions of the mother was observation of sleep
  position in the hospital

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Back to Sleep Good Advice for Parents but Not
for Hospitals?

• Pediatrics Vol. 107 No. 3 March 2001
• 1997 the position statement of the SIDS Global
  Strategy Task Force indicated that health care
  professionals having contact with newborn infants
  in hospital settings should establish, before
  discharge, the same safe sleeping practices they
  desire the family to use after discharge.

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Back to Sleep Good Advice for Parents but Not
for Hospitals?

• Surveyed personnel in all of Iowas maternity
  hospitals about sleep position used
• received 100 response from the 94 hospitals
• Purpose of the study was to learn why nurses in
  Iowa hospitals used the side position in
  preference to the supine position

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Results of Survey

• 85 (89.5) were using back or side in the
  hospital
• 86 (90.5) informed parents that placing an
  infant on his/her side to sleep was acceptable at
  home

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Federal Brochure

• June 1992 The Academy recommends that healthy
  infants, when being put down for sleep, be
  positioned on their side or back.
• December 1996 Healthy term infants should sleep
  wholly on their back as the safest sleep
  position.
• New data suggest that the supine position
  confers the lowest risk however, the side
  position is still significantly safer than the
  prone position.
• 1998 preemies as well as term infants should be
  placed on their backs when sleeping

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Modifiable Risk Factors

• Prone Sleeping
• Soft Sleep Surfaces and Loose Bedding
• Overheating
• Smoking
• Bed Sharing

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Soft Sleep Surfaces and Loose Bedding

• Polystyrene bead-filled pillows -1st soft
  sleeping surface identified
• Additional studies have identified others
• pillows, quilts, comforters, sheepskins, and
  porous mattresses
• reports that in a significant of SIDS cases the
  heads of the infant (including those supine) were
  covered by loose bedding

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Soft Sleep Surfaces and Loose Bedding-continued

• 85 of African-American parents say they keep
  quilts and comforters in their babys crib
• 67 of white parents keep these products in the
  crib

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Modifiable Risk Factors

• Prone Sleeping
• Soft Sleep Surfaces and Loose Bedding
• Overheating
• Smoking
• Bed Sharing

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Overheating

• SIDS statistics have always shown a distinct
  seasonality, with higher rates during winter
  months
• thought to reflect increased infections
• As prone sleeping has increased, the seasonal
  variation of SIDS has decreased
• may be more environmental factors such as
  blankets, quilts, etc.

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Modifiable Risk Factors

• Prone Sleeping
• Soft Sleep Surfaces and Loose Bedding
• Overheating
• Smoking
• Bed Sharing

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Smoking

• Virtually every study ever done has shown
  maternal smoking during pregnancy as a major risk
  factor for SIDS
• Smoke in the infants environment after birth has
  emerged as a separate risk factor
• paternal smoking
• grandparents smoking

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Smoking

• Both human and animal data support the notion
  that a number of respiratory responses are
  altered by nicotine
• Animal studies have identified the involvement of
  carotid chemoreceptors and their central
  processing in these mechanisms
• Poor growth and altered ventilatory and arousal
  responses have been observed in infants of
  smoking mothers suggesting an increased
  vulnerability in these infants
• Spectral analyses of heart rates have revealed
  differences during REM sleep among infants of
  smoking mothers and their non-smoking controls

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Smoking

• Children who died from SIDS had higher
  concentrations of nicotine in their lungs than
  control children
• These results further support the relationship
  between environmental tobacco smoke and the risk
  of SIDS

McMartin 2002
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Modifiable Risk Factors

• Prone Sleeping
• Soft Sleep Surfaces and Loose Bedding
• Overheating
• Smoking
• Bed Sharing

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Bed Sharing

• Controversial Practice that is becoming
  increasingly popular
• Opposed by the US Consumer Product Safety
  Commission (CPSC) and the AAP

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Recommendations to Reduce the Incidence of SIDS

• AAP Task Force on Infant Sleep Position and
  Sudden Infant Death Syndrome

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SIDS Reduction

• 1) Infants should be placed for sleep in a
  nonprone position. Supine confers the lowest risk
  and is preferred
• if side positioning is used, caretakers should be
  advised to bring the dependent arm forward to
  lessen the likelihood of the infant rolling to
  the prone position

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SIDS Reduction

• 2) A crib that conforms to the safety standards
  of the Consumer Product Safety Commission is
  recommended for infants.
• Sleep surfaces designed for adults are not
  adequate

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SIDS Reduction

• 3) Infants should not be put to sleep on
  waterbeds, sofas, soft mattresses, or other soft
  surfaces

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SIDS Reduction

• 4) Avoid soft materials in the infants sleeping
  environment
• pillows, quilts, comforters, or sheepskins should
  not be placed under a sleeping infant
• loose bedding, such as blankets and sheets should
  be tucked in around the crib mattress so the
  infants face is less likely to become covered by
  bedding
• use sleep clothing with no other covering over
  the infant

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SIDS Reduction

• 5) Bed sharing or co-sleeping may be hazardous
  under certain conditions
• as an alternative, place infants crib near bed
• adults (other than the parents), children, or
  other siblings should avoid bed-sharing with the
  infant
• parents who choose to bed share should not smoke
  or use substances such as alcohol or drugs that
  may impair arousal

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SIDS Reduction

• 6) Overheating should be avoided
• child should be lightly clothed and room set at a
  temperature for a lightly clothed adult

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SIDS Reduction

• 7) Tummy time while the child is awake
  and observed is needed for developmental reasons
  and to help prevent flat spots on the
  occiput--positional plagiocephaly.

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SIDS Reduction

• 8) Devices to maintain sleep position are
  NOT recommended
• 9) Home monitors have not been proven to reduce
  the incidence of SIDS
• no studies done!

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Opportunities as a PCP to advise parents on the
prevention of SIDS
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Initial Newborn Hospital Visit

• Cribs/Bassinets
• Sleep Supporters
• Position Position Position
• Advise Grandparents and Father of Baby

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Initial Office Visit

• Breast feeding
• Several retrospective studies support but
  prospective cohort studies failed to show an
  association
• Pacifier use
• Consistent association between lower incidence of
  SIDS and pacifier use

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Programs and Services

• Infant Safety Injury Prevention Education
• SIDS Risk Reduction Education
• Grief Support for families experiencing
  miscarriage, stillbirth and infant death
• Professional Training Programs
• Kidz Books Programs
• Crib for Kids Project
• Monthly research and program updates for
  professionals

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Georgia Infant Safe SleepCampaign

• Sponsored by

678-342-3360 www.sidsga.org gasids_at_mindspring.com