I remember one morning getting a call from the local medical examiner. He was asking for medical history and information on one of my 2-month-old patients. After obtaining proper consent, we spoke at length and learned that my precious little patient had passed. He was wanting to obtain any medical and laboratory information about my patient that might give him a medical cause for his death. I explained to him that the baby’s birth, exams, and newborn screens were normal and that I had no identifiable reason for the cause of his death. He explained that the infant had been sleeping with his parents, and they found him face down, cold, and not breathing. I immediately called his parents and extended my condolences, and after shedding a few tears with the parents, Mom explained that she was nursing with her son in bed and fell asleep. Apparently, as an exhausted nursing mother, she rolled over onto her son, and he apparently suffocated. She was unbelievably brokenhearted… and maybe beyond repair. A day later, I received a call from a CPS worker investigating the case of my patient’s death asking if I had any suspicion of abuse or neglect. I, naturally, conferred the facts that I had no suspicions of abuse or neglect.
Why begin with a tragic story? Quite simply, it is the reality and nightmare of every parent who experiences the loss of an infant from a Sudden Unexpected Infant Death (SUID)-related incident. Only if the event cannot be explained while sleeping does the term Sudden Infant Death Syndrome (SIDS) actually apply. Nevertheless, unexplainable guilt and loss, a coroner investigation, and, to add insult to injury, a CPS investigation all follow these heartbreaking tragedies. Finally, after carrying their baby for nine months, experiencing the pain and joy of birth, dreadfully enduring the greatest turmoil of all… attending a funeral for the love of your life.
I remember another 6-month-old infant in my practice who was cared for by a babysitter. She fed him, and when he fell asleep, she laid him on his side for his nap. Thirty minutes later, she came into the room to find him face down, not breathing, and blue. She rolled him over, began CPR, and called 911. Paramedics arrived, miraculously revived him, and rushed him to the hospital. Thankfully, this baby survived, but he did survive with severe neurological deficits and developmental delays due to the prolonged lack of oxygen to his brain. He is in a wheelchair and non-verbal to this day. Two tragic stories that bring this topic home and make it a priority in the life of any prospective parent.
There are many associations with Sudden Unexplained Infant Death (SUID) events, which may or not be explained at autopsy: infections, central nerve conditions, cardiac conditions, lung conditions, gastrointestinal conditions, endocrine conditions, congenital anomalies, unintentional injuries, and traumatic child abuse are among the explainable causes, while other causes like SIDS, and intentional/unintentional suffocation may not be as readily identifiable at autopsy.1. So, why the cold technical paragraph? Simply, to help ground the reader with the idea that there are both identifiable and unidentifiable causes of Sudden Unexplained Infant Death. Sudden Infant Death Syndrome (SIDS), therefore, is but one explanation of these tragic events.
SIDS is the third leading cause of infant mortality in the United States, accounting for more than 8% of all infant deaths, and it is the most common cause of neonatal mortality, with 40 to 50% of all deaths between the ages of one month and one year of age. In 1992, the annual rate of SIDS was 1.4 per 1,000 live births, roughly 7,000 infants per year. After the “Back-to-Sleep” Campaign began in 1994, the SIDS rate steadily declined to 0.55 per 1,000 live births in 2001, with approximately 2,000 infants per year. In spite of such a dramatic drop in infant mortality by simply having infants simply sleep on their backs, still it is estimated that 11% of infants are still sleeping on their stomachs, and 13% are still sleeping on their sides.2.
Alarmingly, there is evidence that infant deaths once thought to be SIDS-related are now discovered by coroners and medical examiners to be associated with accidental suffocation and strangulation in bed. Stories like those I told above have escalated such that, from 1994 to 2004, there has been a fourfold increase in the rates for accidental suffocation and strangulation in bed with 2.8 to 12.5 deaths per 100,000 live births. These sudden and unexpected deaths have needlessly occurred as a result of an unsafe sleeping environment.3.
With the numerous sources of sudden unexplained infant death, we will focus on the risks and prevention of those deaths occurring with sleep that are largely unexplained (SIDS). Why then has the SIDS rate dropped so dramatically with supine or back sleeping? Science does not have any absolute answers but presents some theories that center around an immature or defective respiratory center in the brain and the concept of infant rebreathing (an extremely oversimplified answer). Nevertheless, coupled with these intrinsic causes, there seem to be extrinsic or environmental factors that contribute to this devastating problem.
Maternal risk factors for their infants having SIDS are: smoking, alcohol use, drug use, nutritional deficiency, inadequate prenatal care, low socioeconomic status, younger age, single marital status, shorter interpregnancy interval, intrauterine hypoxia, and fetal growth restriction. Infant risk factors for SIDS have been identified as: age of the infant (peaking at 2 to 4 months of age), male gender, minority ethnicity, growth failure, not breastfeeding, no pacifier, prematurity, tummy (prone) or side sleeping, recent febrile illness, inadequate immunizations, both pre- and postnatal smoking exposure, soft sleeping surface, soft bedding, bed sharing with infant (co-sleeping), overheating, colder season, and no central heating.4.
As a result of the risk factors and the information above, the AAP has revised its Back to Sleep policy statement in 2016. Recommendations made for infant sleeping are very practical and easily implemented:
- Back to sleep for every sleep. Not side… not stomach… ever. Contrary to some’s belief, infants sleeping supine (back) are not at higher risk of choking, aspiration, or pneumonia. If infants are rolling both ways, they do not need to be constantly repositioned.
- Use a firm surface to sleep on. To clarify, the surface should not conform to the infant’s head or body. Cribs, bassinets, and portable cribs are fine as long as they are approved by the Consumer Product Safety Commission (CPSC). Bedside sleepers are an option. However, in-bed sleepers have not been thoroughly evaluated by the CPSC and cannot be recommended.
- Absolutely no soft materials, such as pillows, quilts, comforters, sheepskins, or bumpers should be in cribs.
- Infants should not be placed for sleep on parental or sibling beds because of risk of entrapment and strangulation.
- Infants should sleep in an area free of hazards, such as dangling cords, wires, and window-covering cords as they may be a strangulating risk.
- Avoid the use of sitting devices, such as car seats, strollers, swings, infant carriers, and slings for routine sleeping especially in infants less than 4 months.
- Breastfeed if possible.
- Infants sleep in their parents’ room in proximity to the parents for at least the first six months… but NOT in the parents’ bed! Infants who are nursed in bed should be returned to their own crib or bassinet immediately after feeding.
- No sleeping on couches or armchairs. They are an extraordinarily high SIDS hazard.
- Absolutely no bed sharing (co-sleeping) infants with parents, siblings, or among twins.
- Consider offering a pacifier with sleeping. If the infant spits it out, there is no need to reinsert the pacifier. For breastfed infants, one may delay pacifier use until breastfeeding is established.
- Avoid objects such as toys, stuffed animals, and other items that might be a choking/smothering hazard.
- Avoid smoking during pregnancy and after birth.
- Avoid alcohol and illicit drug use during pregnancy and after birth.
- Avoid overheating and over-bundling in infants. Infants should be dressed for the environment with no more than one layer than an adult would wear to be comfortable. Definitely avoid covering the face and head while sleeping.
- Pregnant women should have regular prenatal care.
- Infants should be immunized in accordance with the CDC and ACIP guidelines.
- Avoid the use of commercial devices that are inconsistent with safe sleep recommendations such as wedges and positioners.
- Do not use cardiopulmonary monitors as a strategy to reduce SIDS risk. These monitors have NOT been shown to reduce SIDS.
- Supervised wake and tummy time is recommended to minimize cranial molding and aid in infant development. Infants must be awake and supervised anytime they are on their tummy (prone).5.
Sudden Infant Death Syndrome is not something we like to talk about, think about, or even whisper about in the shadows. For any parent, it is an inexplicable nightmare that few parents face, but if they do, it will completely alter their remaining lives. Nevertheless, making a few easily implemented lifestyle changes and following the AAP Recommendations, parents can likely prevent or at least minimize the risk of SIDS for their infants. Hopefully, one day, with advancing science and interventions, SIDS will be nothing but a distant nightmare of the past.
- Nelson’s Textbook of Pediatrics 20th Edition, Robert Kliegmen MD, Bonita Stanton MD, Joseph St Geme MD, Nina Schor MD, Sudden Infant Death Syndrome, Ch. 375. pp. 1999 – 2008.
- SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics, November 2016, 138 (5) e20162938.
By Ike Pauli, M.D.