Department: ask an expert
Q: The incidence of sudden infant death syndrome (SIDS) has decreased in recent years. What are the current recommendations for new parents and secondary caregivers?
A: Although there has been a strong campaign to educate new parents, key messages about SIDS prevention strategies haven't reached secondary caregivers to the same extent. Given that approximately two-thirds of infants less than age 1 year are in nonparental child care and approximately 20% of all SIDS deaths in the United States take place during care by nonparental caregivers, the education of these caregivers takes on added significance.
According to the National Institute of Child Health and Human Development, SIDS is defined as “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 a review of the clinical history.” Dramatic decreases were seen following implementation of the 1992 American Academy of Pediatrics (AAP) “Back to Sleep” campaign. However, despite the success of this initiative, SIDS remains the most common cause of death in infants beyond the neonatal period.
Key messages for SIDS prevention strategies begin during pregnancy. They include:
* Eliminating maternal smoking. It has been demonstrated that between 23% and 34% of SIDS deaths potentially could have been avoided by preventing intrauterine exposure to smoke. The recommendations not only indicate that pregnant women don't smoke, but also that others don't smoke around women who are pregnant. Even after birth, both mothers and caregivers should be advised against exposing infants to tobacco smoke.
* Positioning. The original “Back to Sleep” campaign promoted nonprone positioning for sleep. New data have shown that side positioning isn't a safe alternative to fully supine positioning because infants can roll over. Furthermore, infants unaccustomed to prone positioning were found to be at particularly high risk (up to 18-fold) when they were placed in the prone position. This emphasizes the importance of having every caregiver place the infant in the supine position on a firm sleep surface for every sleep period.
* Sleep environment. The sleep environment should be kept at a temperature that's comfortable for a lightly clothed adult. Overbundling and covering the infant's face and head should be avoided. Caregivers should be attentive to signs of overheating and act appropriately. The only thing in the crib should be the infant. Loose bedding, pillows, blankets, and toys should be removed from the crib. Head covering involving these items has been implicated in SIDS deaths, both when infants are alone in their cribs and during bed sharing. Sleeping sacks have been suggested as a safe option.
* Eliminating bed sharing. This has been a controversial issue, with supporters citing improved maternal infant bonding and ease for breastfeeding. There's now strong evidence demonstrating that SIDS risk is higher when bed sharing occurs with young infants, when there are multiple bed sharers, when the duration of bed sharing time is longer, when the parent is excessively tired, and when sedating drugs or alcohol are involved. Current policy recommends room sharing but not bed sharing. The most recent policy statement stresses that bed sharing should be avoided for all infants younger than age 3 months. Cobedding or bed sharing should also be avoided with twins and multiples by providing separate sleeping areas.
* Breastfeeding. Recent studies on breastfeeding have shown that it reduces the incidence of SIDS by approximately 50% at all ages throughout infancy. The new AAP policy statement recommends breastfeeding as a SIDS prevention strategy, noting that the protective effect increases with exclusivity.
* Pacifiers. There's support for a protective effect against SIDS from pacifier use, although the mechanism remains unclear. Pacifiers are recommended at times of sleep (nap and bedtime) to reduce SIDS risk in infants during the peak risk age, up to age 1 year. In infants who are breast fed, the use of pacifiers is delayed until breastfeeding has been firmly established.
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Dietz PM, England LJ, Shapiro-Mendoza CK, Tong VT, Farr SL, Callaghan WM. Infant morbidity and mortality attributable to prenatal smoking in the U.S. Am J Prev Med. 2010;39(1):45–52.
Mitchell EA, Blair PS, L'Hoir MP. Should pacifiers be recommended to prevent sudden infant death syndrome? Pediatrics 2006;117(5):1755–1758.
Mitchell EA, Thompson JM, Becroft DM, et al. Head covering and the risk for SIDS: findings from the New Zealand and German SIDS case-control studies. Pediatrics. 2008;121(6):e1478-e1483.
Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128(5):1030–1039.
Vennemann MM, Bajanowski T, Brinkmann B, et al. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics.2009;123(3):e406-e410.
Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pedatr Pathol. 1991;11(5):677–684.