Recommendations on SIDS Risk Reduction

Disclaimer: Heather Myers RN and Nathan Salomonis PhD are not medical doctors, however, both have extensive biomedical research backgrounds. The recommendations presented here are made based on our personal experience with Sudden Infant Death Syndrome (SIDS) and personal overview of research presented on various websites and biomedical journals. We are not trying to be alarmist, but we feel that the tragic possibility of SIDS is something that is not talked about enough…and therefore the risk-reduction measures that are KNOWN to decrease SIDS incidence are not always followed.  We never thought this could happen to our beautiful, healthy little boy, and we know that that is how most people think about their babies as well…We feel strongly that education and hypervigilance can only benefit new parents who are not presented with a full picture of SIDS. Please see http://www.SIDS.org or http://kidshealth.org/parent/general/sleep/sids.html for the most up-to-date facts on SIDS.

What is SIDS?

SIDS is not clearly defined; it is effectively a non-diagnosis for the sudden and unexplained death of an infant. Although many definitions exist, definitions vary and misdiagnoses are not uncommon [1]. Although new hypotheses have been emerging, the etiology of SIDS is not at all clearly defined. This should be disconcerting to us all, since without any clear way to diagnose the causes of sudden infant death, ALL infants are at risk (although certain risk factors are associated with increased propensity, see below). We mention this to emphasize the importance of donations to SIDS research and increased awareness of SIDS in your community. Although affecting a relatively small percentage of newborns (1 in ~2000), SIDS remains the major cause of death for infants in developed countries.  In the large majority of cases (>80%) [2,3] , SIDS is accompanied by sleeping conditions that are considered to put infants at risk (see Conventional Advice below).  The importance of SIDS education is illustrated by the “back to sleep” campaign, which has resulted in a 50% decrease in SIDS cases [4].

Major Risk factors for SIDS

No risk factors may be present for SIDS to occur and many can be present without it occurring.  Following the risk-reduction strategies listed in the next section, however, are likely to substantially decrease the risk of SIDS (see Wikipedia for more information).

• Teenage pregnancy or premature birth.
• Prenatal or postnatal exposure to cigarette smoke or cocaine.
• Male gender (twice the risk of females).
• African American infants (twice the risk) and American Indian/Alaska Native (three times the risk) [5].
• Babies who sleep on their stomachs; in a bed with other children; in a bed with more than one adult; outside of a clean crib (e.g., on a pillow); in a crib with soft bedding.
• Being born in the winter months.
• Respiratory infection.
• Babies with currently undetermined and determinable (see below) genetic and physiological risk factors.

Conventional SIDS Risk Reduction Guidelines

The below simple suggestions can have a significant impact on SIDS reduction. These should be followed both at home and by daycare providers. These recommendations should be followed religiously. For more information see http://www.nichd.nih.gov/health/topics/Sudden_Infant_Death_Syndrome.cfm.

• Back to sleep (put the baby to sleep on their backs).
• Don't smoke around infants or while pregnant.
• No loose materials in the crib.
• Put infants only on a flat surface in a crib to sleep (no pillows).
• When put to sleep, ensure that the infant is not over-heated.
• During the day, check on a sleeping baby at regular intervals (e.g. every 15 minutes).
• Use of pacifier when putting the baby to sleep (it’s best to introduce the pacifier once breastfeeding has been established…4 weeks or so). Pacifier use can stimulate the baby while sleeping in a manner that is beneficial for SIDS risk reduction.
• Use of a fan in the room can be beneficial to increase air circulation.
• Prevent against early infections. Being sent to a group daycare setting will typically increase the likelihood of infection.
• For long journeys in a car, check frequently on your baby (stop or have a mirror to see the baby).
• Co-sleeping with others, except for the mother, is not recommended.
• Educate your friends and families about SIDS.

Non-Conventional SIDS Risk Reduction Guidelines

This is advice that comes from us, which is not necessarily the view of major SIDS risk reduction organizations.  We believe this advice, while potentially overly strict, can also help to reduce SIDS.

• If possible, delay group day care until after 5 months. SIDS risk is increased in babies 2-4 months. This corresponds with the peak time of many potential stressors (infection and possibly weakened immune system). Group daycare is a new environment for your infant with increased risk of early infection and distinct diurnal patterns from those employed at home.  If multiple daycare providers exist, there may not be common adherence to the same protocols, such as sleep positioning. Infants put to sleep on their stomach are at greater risk in the day than at night [6]. We believe, based on a high rate of occurrence of SIDS in day care, that early day care presents an increased risk during the initial adjustment phase; however, this is based on a collection of many individual reports. Further supporting evidence is required for more concrete associations.
• Consider not starting your infant at daycare during the winter months. The winter months have the most prevalent incidence of SIDS and infections.
• If using a daycare, do not assume the daycare you are using is intimately familiar with the above guidelines! Make sure that they can repeat back to you each of these rules. Don't be timid! If you feel your daycare is deviating from these rules, feel empowered to confront them or remove your child immediately. Don’t assume that the daycare will follow these directions, even if they have had hundreds of infants and many accreditations. Shop around for a daycare you are comfortable with and with whom you can communicate effectively. Ensure that all daycare personnel are CPR certified.
• Ensure that all daycare providers follow the same protocol that you use at home. Clarify with them that they are doing the same thing (e.g. use of pacifier, swaddling, back to sleep, crib sleep only, checking on the baby at least 15 minute intervals and no loose items or bumpers in crib). Even if there is one primary daycare person for your child, at some point, other providers will take care of your child. It is important for you to clarify the rules with everyone, one-on-one. Many parents are timid confronting daycare providers, especially if English is not their first language, but remember that they are entrusted with your most precious possession, thus, do and say what you need to.
• Although there is no convincing data to support a link between vaccinations and SIDS, spacing out vaccinations is a personal choice, so don't be bullied into making a decision you are not comfortable with by anyone.
• Use a pacifier when putting a baby in the backseat of a car alone for lengthy journeys.
• When nursing, continue to take a multivitamin and eat healthy.
• If you have any questions, email a local SIDS support organization (e.g., First Candle).
• REMEMBER… No matter how vigilant you are, in many cases biological factors may override any external factors, making SIDS unpreventable. We hope with all of our hearts that you do not have to experience this firsthand but know that if you do, please seek out help immediately. SIDS will likely be the most difficult experience of your life and you will need support. Daycare providers experiencing SIDS firsthand also require grief support and counseling, just as you would since they love and care for your baby. No one wants to hurt your baby and even if you want to assign blame, in nearly all cases there is no blame to be given out.

Hypotheses on the Causes of SIDS

Several hypotheses now exist to suggest that the probability of SIDS is increased by both genetic and environmental factors. The most well held theory is that three risk factors must be present in nearly all SIDS cases (triple risk hypothesis). These include; 1) an existing intrinsic biological risk factor, 2) vulnerable age and 3) external stressor present while sleeping [3].

Environmental factors include those listed above (e.g., altered sleep positioning, a big change in the baby’s schedule/environment, infection, smoking, improper ventilation), which are considered stressors to your infant. Although we still have a poor understanding of the biological risk factors, the most prominent are; 1) mis-expression of serotonin receptors and altered distribution of serotonin secreting neurons in the infant brain stem [3], 2) cardiac ventricular arrhythmia and 3) mutations in essential metabolic genes. By assuming all infants have one or more of these risk factors, we can decrease the incidence of SIDS by making sure to reduce the environmental risk factors your infant is exposed to.

Altered distribution of serotonin neurons and receptors appears to have the strongest association with SIDS.  It is hypothesized that a lack of serotonin receptivity in the brain stem in infants may increase the risk of SIDS when challenged by a sleeping position that increases the amount of inhaled carbon dioxide [3]. The brain stem controls breathing and cardiac function and thus can result in death when the wrong signals are sent or not sent at all.  Males are more likely to have these changes as opposed to females.  It is not known how or why these changes occur and it is currently not known how to detect these changes in advance of death. This area is likely where the most research needs to be done in the coming years, in order to understand why these changes happen and how we might be able to easily test for susceptibility in infants. These serotonin abnormalities are thought to be transient and children with them are expected to be fine if they make it out of the critical SIDS susceptibility time period (under one year of age) without experiencing an external SIDS stressor.

Unlike the above serotonin defects, SIDS resulting from a cardiovascular or metabolic predisposition may be detectable using tests provided by your pediatrician or a specialist. Up to 15% of SIDS cases appear to be correlated with mutations in genes, which predispose the infant to cardiac ventricular arrhythmias that can cause sudden death [7]. A cardiologist can diagnose this syndrome, known as long QT syndrome.  Another syndrome that results in a small percentage of SIDS death are mutations that occur in essential metabolic genes, such as MCAD [7].  Many of these mutations can be tested for through your pediatrician or genetic counselor on your infant.

Please feel free to email us, even if you just want to chat about any of this or if you have suggested changes.

References

1. Bowman L, Hargrove T (2007) Exposing Sudden Infant Death In America. Scripps Howard News Service. http://dailycamera.com/news/2007/oct/08/saving-babies-exposing-sudden-infant-death-in/.
2. Alexander RT, Radisch D (2005) Sudden infant death syndrome risk factors with regards to sleep position, sleep surface, and co-sleeping. J Forensic Sci 50: 147-151.
3. Paterson DS, Trachtenberg FL, Thompson EG, Belliveau RA, Beggs AH, et al. (2006) Multiple serotonergic brainstem abnormalities in sudden infant death syndrome. Jama 296: 2124-2132.
4. http://www.sids.org/nannualrates.htm U.S. Annual SIDS Rate per 1000 Live Births
5. http://www.nichd.nih.gov/health/topics/Sudden_Infant_Death_Syndrome.cfm Sudden Infant Death Syndrome (SIDS). National Institute of Child Health and Human Development.
6. Mitchell EA, Bajanowski T, Brinkmann B, Jorch G, Stewart AW, et al. (2008) Prone sleeping position increases the risk of SIDS in the day more than at night. Acta Paediatr 97: 584-589.
7. Opdal SH, Rognum TO (2004) The sudden infant death syndrome gene: does it exist? Pediatrics 114: e506-512.