News & Events

NANN 2007: The Sudden Infant Death Rate: How Low Can It Go?

Posted to the Web: Thursday, January 10 , 2008
Laura A. Stokowski, RN, MS

Sudden Infant Death Syndrome (SIDS)SIDS, or sudden infant death syndrome, has been called an "extraordinarily complex" problem, a statement that researchers and clinicians would not argue with.[1] We are extremely fortunate that despite not having a clear understanding of all factors contributing to SIDS, we have learned how to lower the risk, and it doesn't involve expensive medications, diagnostic testing, monitors, or surgical procedures. How low the SIDS rate can go with simple risk-reduction strategies won't be known until we, the healthcare providers, fully exploit the knowledge we hold today.

Debbie G. Thompson, MS, RN, PNP-BC, Children's Medical Center, Dallas, Texas, shared a heartbreaking story.[2] A young father was lying on the sofa, with his 2-month-old baby boy lying prone on his chest. Both fell asleep. When the father awoke from his nap, the baby was dead. A collective sadness was expressed in reaction to this story; every parent in the audience thinking, in horror: I've done that! I've napped with my baby like that!

Told as part of her presentation, "Optimizing Outcome: Prevention Strategies for SIDS and Shaken Baby Syndrome,"[2] Thompson's intent was not to shock or distress. This story reminds us that there is much we still do not know about the mystery that is SIDS or what separates one seemingly healthy baby from another. The official definition is of little help: "the sudden death of an infant less than one year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history."[3] In short, it is a diagnosis of exclusion.[4]

Thompson reported that there has been a 53% decline in the SIDS rate over the past 10 years, believed to be primarily related to the nationwide "Back to Sleep" campaign. Between 2000 and 2500 infant deaths each year in the United States are classified as SIDS,[5] still the third leading cause of infant mortality. Before 1992, 5000 to 6000 infant deaths each year were attributed to SIDS. In recent years, the rate of decline in annual SIDS deaths has slowed, and a racial disparity in the occurrence of SIDS persists.[4]

Infants at Highest Risk

The most recent research into the pathophysiology of SIDS indicates that SIDS is a multifactorial condition, with contributions from genetic, environmental, and behavioral/sociocultural factors.[4] Epidemiologic studies to date have identified the following risk factors for SIDS: Male (3:2 ratio) Prone and side sleeping positions
Sleeping on soft surfaces
Overheating
Preterm or low birthweight
African-American or American Indian/Alaskan Native heritage
Maternal smoking during pregnancy
Environmental tobacco smoke
Young maternal age
Late or no prenatal care

Current thoughts about the cause of SIDS center on the interrelated rebreathing and impaired arousal theories. When an infant sleeps face down (prone) or on soft bedding, exhaled carbon dioxide becomes trapped around the face and is then inhaled again by the infant, leading to hypercarbia and hypoxia.[4] If the infant has an impaired arousal response, this can lead to death.[6]

Myths and Misunderstandings

Nurses are probably in the most powerful position to teach risk reduction, correct misconceptions, and counter myths about SIDS.[1] Prevention strategies concentrate on both the modifiable risk factors for SIDS (sleeping surfaces, overheating, tobacco) and on known protective factors (supine sleep, pacifier use, room-sharing but not bed-sharing). However, awareness of these evidence-based approaches doesn't necessarily imply compliance with them.[1] Prone-sleeping prevalence rates remain greater than 10%.[7] Even those who should know better -- the nurses -- can nonverbally sabotage the family's adoption of risk-reduction strategies.

Choking

In spite of the dramatic fall in the SIDS rate attributed to supine sleeping, some nurses still resist putting babies on their backs for sleep, a holdover from the days when nurses were taught that babies would choke or aspirate if they spit up while sleeping supine. Recent evidence has dispelled this myth,[8] but the stumbling block persists, resulting in failure to teach or model safe sleeping strategies to some new parents.[9,10]

Deeper Sleep and Comfort

Parents and nurses alike often perceive that babies are more comfortable, less fussy, and sleep better and longer when they are prone. This might be true, but the irony is that it could be the easier arousability in the absence of very deep sleep that protects the infant from SIDS. Most babies will adapt to back sleeping if it is used early and consistently.

Positional Plagiocephaly (Flattened Skulls)

Flat spots on a baby's skull from spending too much time in a single position are a possibility but not a certainty. Periodic changing of sleeping head position, spending time holding the infant upright when the baby is not sleeping, avoiding the overuse of infant seats and swings, and supervised tummy time are suggested actions to prevent plagiocephaly.[1] Once again, education and guidance are the keys to prevention.

Windows of Opportunity: Set the Right Example

A one-shot approach, where safe sleep and SIDS prevention recommendations are verbally reviewed just before hospital discharge, is unsatisfactory. First, it is difficult for new parents to retain all of the information presented to them during the postpartum hospitalization. Second, many parents, after leaving the hospital, will be more likely to follow the advice of trusted friends and family members, even when this advice contradicts what they were told in the hospital.[5] This is particularly true in certain cultures whose time-honored beliefs in prone sleeping, bed-sharing, or overwrapping newborn infants are likely to take precedence as soon as the infant is brought home.[1] Nurses must take advantage of each opportunity to identify infants at risk and reinforce safe sleep principles by setting the right example and consistently demonstrating safe sleep position and proper use of clothing and blankets at every opportunity.[1]

Prenatal or Preconception Care

In an ideal world, providers would see all women for preconception care, providing an opportunity to counsel them about risks for SIDS, especially those related to tobacco exposure. A woman who is pregnant or intends to become pregnant needs to know that exposing her fetus to tobacco doubles the chances of her baby dying of SIDS,[4] regardless of whether she smokes in the home or car after the baby is born. Prenatal visits and classes are also good times to introduce the concepts of safe sleeping environments as parents prepare for the birth of their baby. Expectant parents can be advised to save their money by not purchasing crib quilts, sheepskins, pillows, bumper pads, soft crib toys, or products that claim to reduce the risk of SIDS.[1]

Birth Hospitalization

The most critical time period for nurses to influence parents' behaviors is the first 24 to 48 hours after the baby's birth.[1] All parents should be educated or re-educated about safe sleeping before discharge from the hospital, and, whenever possible, other family members such as grandparents should be included in this teaching. Parents who may have had a baby a few years earlier when side sleeping was still being taught as a reasonable alternative must now be warned that studies show that side sleeping position carries the same risk of SIDS as does prone sleeping. Advise parents to keep the baby's crib in the same room where they sleep and to give the baby a pacifier for sleep. Breastfeeding mothers can introduce the pacifier at 2-3 weeks of age, when breastfeeding is well established.

Neonatal Intensive Care Unit (NICU)

Although preterm birth is a risk factor for SIDS,[11] a stay in the NICU offers many more opportunities to educate parents about risk reduction. A recent study, however, found that a disturbingly low 52% of NICU nurses routinely taught parents to use only the supine sleep position for their babies at home.[10] It is common to care for preterm infants in the prone position early in their hospitalization when respiratory problems predominate. As soon as respiratory problems resolve, infants should be placed on their backs, well before discharge so that both infant and parents can become accustomed to the supine sleeping position. Nesting and positioning devices used to enhance the development of smaller babies must be removed from the sleep environment well before discharge.

Primary Care/Well-Baby Visits

Because the incidence of SIDS peaks at 2-3 months of age, and the risk continues almost throughout the first year, safe sleeping recommendations should be reinforced during well-baby and all other visits to primary healthcare providers. Many mothers return to work just prior to the peak age for SIDS, leaving their infants with family or nonfamily caretakers. Research shows that grandparents and child care workers are among those likely to be unfamiliar with safe sleep recommendations and to place infants prone to sleep, a very dangerous practice.

The risk of SIDS in an infant unaccustomed to prone sleeping who is placed prone to sleep is even higher than the risk of SIDS with full-time prone sleeping.[12] Thus, the question to ask at well-child or sick-child visits is not just, "Do you place your baby on his/her back to sleep?" but also, "Have you instructed your family, babysitters, and other caretakers to place your baby only on his/her back to sleep?"

Furthermore, of particular importance to primary care practitioners, research shows that about a third of parents who start out placing their babies supine for sleep switch to the prone position by 3 months of age.[7] Practitioners must continue to assess the risks for SIDS present in the home and counsel parents accordingly.

Primary care practitioners should also remind parents about supervised awake "tummy time," which can be gradually increased as the baby gains head and neck control. Breastfeeding mothers can be instructed that if breastfeeding is well-established, they can introduce a pacifier for sleep as recommended by the American Academy of Pediatrics.

Let's Get Educated

Nurses who care for newborns at any stage from birth through 1 year of age should take advantage of a highly recommended, free continuing education (CE) program, Curriculum for Nurses: Continuing Education Program on SIDS Risk Reduction offered through the National Institute for Child Health and Human Development (NICHD). The NICHD and its partners in the Back to Sleep campaign worked with national nursing organizations to design this CE program about reducing the risk of SIDS. Nurses can receive CE credit by completing the module themselves, or an instructor can lead a group of nurses through the module to receive CE credit. The module is approved for 1.1 hours of CE credit from the Maryland Nurses Association. The module includes information about SIDS, SIDS risk, risk-reduction strategies, challenges to risk reduction, communicating about risk reduction, and the unique role nurses can play in helping families reduce the risk of SIDS. Multiple copies are available free from the NICHD.