A proud parent frequently slips into the room where his or her new baby is sleeping...just to make sure everything is all right. Imagine the parent’s horror when things are not all right.
Several thousand parents each year are devastated by the sudden loss of an infant through crib death or SIDS. SIDS is an acronym for sudden infant death syndrome, officially defined by the American Academy of Pediatrics (AAP) as “the sudden death of an infant under one year of age, which remains unexplained after a thorough case investigation.”
Doctors still don’t know for sure what causes a healthy baby to die suddenly during sleep, but they believe they are on the way toward prevention. Based on epidemiological reports from Europe and Australia, the AAP in 1992 recommended that parents avoid laying their infants down for sleep in a prone position (stomach down). The Back to Sleep campaign, initiated under the leadership of the National Institute of Child Health and Human Development, followed in 1994 as a way of reducing the incidence of SIDS.
Since 1992, the rate of SIDS in the United States declined significantly–from 1.20 deaths per one thousand live births to .57 deaths per one thousand live births in 2002.
From 1999 to 2001, several other causes of sudden unexpected infant death increased–suggesting that some of the decreased incidence of SIDS during this period may be attributed to changing definitions and classification of death. There is no question, however, that the true SIDS rate has been declining significantly and that the “Back to Sleep” campaign has played a role.
According to national surveys, only 13 percent of American babies were sleeping regularly on their stomachs in 2004, compared to 70 percent in 1992.
The American Academy of Pediatrics issued updated guidelines in November, 2005, refining their previous recommendations and adding new ones. News reports have focused on the additions to the guidelines–both of which are somewhat controversial. The most important feature–sleep position–remains the same, however, and deserves primary emphasis.
Side Position Also Risky
The original recommendation in 1992, was that parents avoid the prone or face down position. Since then, fairly strong evidence has emerged linking the side as well as the prone position to an increased risk. A baby is also more likely to roll onto his stomach from a side as opposed to a back down position. As a result, the 2005 recommendation leaves no room for doubt: to lower the risk of SIDS, babies should be put to sleep on their backs.
Two thirds of American babies under one year of age spend significant time in child care situations–in an organized day care center or with a nanny or baby-sitter. Even workers in licensed child care settings may not be aware of the importance of sleeping position.
An infant who is accustomed to sleeping on her back at home is particularly vulnerable if placed on her stomach by another care giver. In fact, the risk is increased 18-fold in such situations.
Other risk factors that have been identified–sleeping on a soft surface, maternal smoking during pregnancy and overheating are covered in the guidelines. Incidence of SIDS is high among pre-term and low-birth-weight babies, children of young mothers and those who get late or no prenatal care.
BEDDING: Children who die of crib death are frequently found either with their face down or with the nose and mouth completely covered by bedding. Aside from sleeping position, studies have linked SIDS to the use of soft bedding or pillows. Reports from Australia and New Zealand found that infants dying of SIDS were often found lying on sheepskins or soft crib mattresses filled with bark from the ti tree and other natural fibers.
All soft objects and loose blankets should be kept out of the crib, and bumper pads, if they are used, should be thin, firm and well secured.
One strategy is to use a sleep sack or clothing warm enough that no blankets are needed. It’s important, however, to avoid over-dressing the child or overheating the room.
BED SHARING: Many American couples–either because of cultural traditions or personal preference–choose to share their bed with their young child for at least part of the night. And there are benefits in terms of parent-infant bonding and the encouragement of breast feeding.
While epidemiological studies indicate that bed sharing can be hazardous for the child, critics say that most of these cases involve unsafe sleeping conditions–with a parent who has consumed alcohol or sedating drugs, is a smoker or is over-tired or careless–rather than bed sharing. Some cultures that practice bed sharing have a relatively low incidence of SIDS.
Two recent European studies, however, found an elevated risk for very young children even in beds with non-smoking mothers.
An adult sleeping with an infant on a couch is a very high risk situation and should be strictly avoided. The safest sleep environment, according to the guidelines, is for the baby to sleep in a crib in the parents’ room.
PACIFIERS: A recent meta-analysis of seven case control studies found a lower risk of SIDS in children using pacifiers, and this finding is reflected in the 2005 guidelines: “Consider offering a pacifier at nap time and bed time.” The pacifier should not be forced upon the child, however, and it should not be reinserted once the child falls asleep.
Those who question this recommendation are concerned primarily that such a practice could result in reduced breast feeding–which is in itself a health risk for both mother and child. Carefully designed, controlled studies, however, found no link between pacifiers and reduced breast feeding. For breast fed babies, it’s recommended that the pacifier not be introduced until after the first month or until breast feeding is firmly established.
Commercial devices and home monitors are not recommended in the 2005 guidelines since there’s no firm evidence supporting their effectiveness.
With increased back sleeping, an abnormally high number of infants have developed what is known as positional plagiocephaly–a flattened back of the head. This can be avoided by letting the child have “tummy time” while awake and being observed. Most important, of course, is cuddle time; eye contact and a smile are certain signs that your child is well and happy.
Tana N Kaefer, PharmD
