Task Force on Sudden Infant Death Syndrome

Pediatrics 2005;116:1245 1255

Dr Abid Ali Rizvi Maternity Hospital, Kuwait

Definition- SIDS
The sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.

Sudden Unexpected Death of an Infant

SUID is any infant death that is unexpected and initially unexplained. Frequently, a cause of death is determined after a thorough investigation and autopsy. The deaths that remain unexplained are defined as SIDS. Therefore, SIDS is a type of Sudden Unexpected Infant Death.

SIDS - Age Spectrum

Rare in first mo of life to a peak in 2 - 3 mo & then Diagnosis after 1 yr age is invalid

Between 1992 and 2004

SIDS /1000 live births
1992: 2004: 1.20 0.56

Prone Sleeping:
1992: 70% 2004: 13% [Prone sleeping means sleeping on tummy]

Seasonality
Historically, SIDS occur more frequently in the colder months.

ing Winter-Summer Incidence Difference: 1992 16.3% 1999 7.6%

Independent Risk Factors

Prone [on tummy] sleep position, Sleeping on a soft surface, Maternal smoking during pregnancy, Overheating, Late or no prenatal care, Young maternal age, Preterm birth and/or Low Birth Weight, Male gender, Black /American Indian/Alaska Native.

RECOMMENDATIONS

Back to sleep
Infants should be placed for sleep in a supine position (wholly on the back) for every sleep.

Side
Side sleep position is unstable.
The probability of an infant rolling to the prone from the side sleep position is significantly greater than rolling to prone from the back.

 If the side position is used, keep the dependent arm forward to lessen the likelihood of the infant rolling to the prone position.

SIDS Risks :

Adjusted Odds Ratio

2.0 2.6
Similar

Side position Prone position Placed on the Side & found on the Stomach

8.7

V. High

Finally
Side sleeping is not as safe as supine sleeping and is not advised.

Bedding
A strong interaction was found between prone sleep position and soft bedding surface, with an adjusted OR of 21.0, indicating that these 2 factors together are very hazardous. A firm crib mattress, covered by a sheet, is the recommended sleeping surface.

Keep any soft material or objects AWAY from sleep area:

Pillows Quilts Comforters Sheepskins Stuffed toys

If bumper pads are used in cribs, they should be thin, firm, well secured, and not pillow-like.

 Loose bedding such as blankets and sheets may cause suffocation by accidentally covering the head. If blankets are to be used, then make sure: Infant's feet reaches the foot end of the crib. Blankets tucked in around the crib mattress; Reaching only to the level of the infant's chest.

Dress the infant with adequately warm sleep suit so that no extra sheet is needed for covering.

Room Sharing & Bed Sharing

 The risk of SIDS has been shown to be reduced when the infant sleeps in the same room as the mother. Infant should not be sharing bed with: Parents Other Caregivers Siblings Pets

It is very dangerous to sleep with an infant on a couch or armchair.

 Risk is significant when the bed sharing occurs for > 1 hr or for the whole night. Infants may be brought into bed for nursing or comforting but should be returned to their own crib when the parents want to sleep. Returning the infant to crib is not associated with risk.

The infant should not be brought into bed when the parent is:
Excessively tired Intoxicated

Breast feeding
Longer Breastfeeding is associated with a risk for death after age of 1 month. Factors associated with breastfeeding, rather than breastfeeding itself, are protective. Task Force believes that the evidence is insufficient to recommend breastfeeding as a stand alone strategy to reduce SIDS .

Controversy: Bed Sharing & Breast Feeding

Origin of supine sleep position of a human infant is traced to its role in facilitating the night-time breast feeding in context to mother& baby co-sleeping. [natural selection & survival of the fittest].

This slide content is not in AAP policy paper.

Bed Sharing & Breast Feeding

Arousals Stage 1-2 (light) sleep Stage 3-4 (deep) sleep Breast Feeding X 2-3 Crying Non-breast feeding interventions Sensitivity to mother Sleep duration
This slide content is not in AAP policy paper.

Can mothers elect bed sharing ?

Sofa / couch Soft Mattress Cigarettes Alcohol Drugs Exhaustion Bottle-fed baby [arousal] Father

Is breast feeding involved?

Sensitivity to movements/ arousal / positioning is altogether different from a mother-baby pair on bottle feeding.

This slide content is not in AAP policy paper.

Maternal smoking during pregnancy

Passive (2nd hand) Smoke

SIDS risk is 2.5 times

 There is compelling evidence for the reduced risk of SIDS associated with pacifier use during sleep time. Mechanism is unknown. ? ed threshold of arousal in case of hypoxia

The pacifier should be used when placing the infant down for sleep and not be reinserted once the infant falls asleep. If the infant refuses the pacifier, he or she should not be forced to take it. Pacifiers should not be coated in any sweet solution. Pacifiers should be cleaned often and replaced regularly. For breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.

Possible Deleterious Effects of Pacifier Use:

Reduced breastfeeding duration:
Recently disproved by well designed studies.

Dental malocclusions:
Generally disappears after cessation of pacifier use.

 EAR Infections:
risk is 1.2- to 2 folds. But relatively less in < 6 mo age group. However, pacifier use, once established, may persist beyond 6 mo age, thus ing the risk.

GIT infections. Candida oral colonization.

Secondary Caregivers
20% to 28% of day care centers are unaware / misinformed, & continue to place infants prone for sleep. Unaccustomed prone sleep position in a baby increases the risk of SIDS by as much as 18-fold.

Heat
Avoid Overheating & Over-bundling. The infant should be lightly clothed for sleep. Bedroom temperature should be kept comfortable for a lightly clothed adult.

Commercial Products
Claiming to SIDS by:
maintaining sleep position re-breathing Improving air circulation in crib

Efficacy or Safety not proved.

Cardio-Respiratory Monitoring.
Do not use home monitors as a strategy to reduce the risk of SIDS. No evidence that use of these gadgets the incidence of SIDS.
Alarm sounds if baby stops breathing!

 Cardio-respiratory / apnea monitors may be of value for home monitoring of selected unstable infants. No evidence that infants at risk of SIDS can be identified by in-hospital or cardiorespiratory monitoring.

Avoid development of positional plagiocephaly

Encourage "tummy time" when the infant is awake and under observation. This will also enhance motor development. Upright "cuddle time" should be encouraged.

 Alter every week the supine head position during sleep. Periodically changing the orientation of the infant to outside activity (e.g., door/ window). Particular care should be taken to implement the above recommendations for infants with neurological injury or suspected developmental delay. Early referral for plagiocephaly if conservative measures have been ineffective. Orthotic devices (SURGERY SPARING) Surgery.

Education
Continue the Back to Sleep campaign Public education should be intensified for: child care providers Grandparents foster parents baby sitters SCU/ PNW, should implement these recommendations well before an anticipated discharge from hospitals.

When considering the recommendations in this report, it is fundamentally misguided to focus on a single risk factor or to attempt to quantify risk for an individual infant. Individual medical conditions may warrant a physician to recommend otherwise after weighing the relative risks and benefits. Risk factors by themselves do not cause SIDS, but can have a negative effect on infants wellbeing. In fact, as many as two thirds of SIDS victims have no known risk factors. Most babies with one or more of these risk factors will not become SIDS victims. Following these recommendations faithfully will still not prevent all SIDS deaths.