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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Pediatrics
November 8, 2000

News this month
Preventing SIDS at home and at daycare

Two new studies on sudden infant death syndrome (SIDS) demonstrate the progress that is being made in educating the public about prevention measures, but also point out what remains to be done.

The first study in the September issue of Pediatrics reviewed how sleep position and/or sharing a bed with an adult contributed to the deaths of 119 infants in St. Louis from 1994-97. The second surveyed day care centers around Washington, D.C., to see if the centers followed national safe sleeping guidelines designed to reduce the incidence of SIDS. These new studies join a large body of information on SIDS and focus on identifying SIDS risk factors, such as sleeping on the stomach, as well as the difficulty in changing human behavior to reduce the risk of SIDS.

"SIDS remains the leading cause of infant death after the newborn period."

AAP recommendation
In 1992, the American Academy of Pediatrics (AAP) began recommending infants be placed to sleep on their backs (supine position) to reduce the risk of SIDS. The frequency of sleeping on the stomach (prone position) has since dropped from more than 70 percent to less than 20 percent, and the incidence of SIDS has declined 40 percent, according to a March 2000 AAP task force report.

Despite progress, SIDS remains the leading cause of infant death after the newborn period. About 20 percent of all SIDS cases still occur in the childcare setting. While some risk factors, such as maternal smoking, have been known for years, others—such as soft bedding—have only recently been identified. Researchers and physicians hope that continuing education can bring these numbers down even further.

Examining infant deaths
The St. Louis study, led by James Kemp, MD, examined the deaths of 119 infants from both urban and suburban families. They found that:

  • Of the 119 deaths, 66 infants were found sleeping on their stomachs.
  • Twenty-five also had their noses and mouths down and into bedding when found.
  • Another 10 had their heads covered by bedding.
  • Infants were more likely to die when sleeping on something other than a crib; only 29 infants died in cribs or bassinets. Fifty died on adult beds and 19 died on a chair or sofa, most of which had thick cushions. Ten infants became trapped by a bed or other sleep surface.
  • Two deaths in cribs happened when crib rails became loose.
  • Nearly half of the infants (47.1%) died while sharing a sleep surface with one or more bedmates.
Deaths might not have happened if certain high-risk sleep practices had been avoided.

In 84 of the deaths, one or more preventable risk factors was present, suggesting that the deaths might not have happened if certain high-risk sleep practices had been avoided. Only a small minority of infants (8.4%) were found without any risk factors—alone in a crib on their back with a clear airway. And even among these cases, there may have been risk factors that were not identified at the scene.

Day care centers surveyed
In the second study, led by Rachel Y. Moon, MD, 172 day care centers answered a survey about sleep practices and awareness of the national "Back to Sleep" campaign, begun in 1994 to educate the public about SIDS risk factors. In April 1999, 75 percent (129) of centers that responded knew that infants should sleep on their backs, up from 57 percent in 1996. However, infants were placed on their backs exclusively in only 28 percent of centers. Caregivers cited parental preference and confusion about the proper sleep position as reasons for not putting infants on their backs. A high percentage (62%) placed infants on their sides, thinking this preferable to sleeping on the stomach. The researchers acknowledged the percentage of infants sleeping on their stomachs could have been even higher, given that the survey relied on the accuracy and truthfulness of the respondents.


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Eve R. Colosn, MD

Parents are rightfully concerned about SIDS

Talk of Sudden Infant Death Syndrome (SIDS) naturally strikes fear into the hearts of new parents. The goal of any SIDS education campaign isn’t to scare parents and caregivers, but rather share the facts on how SIDS can be prevented. Despite the progress seen in the past eight years, 20 percent of SIDS cases are still happening in the day care setting—which is a lot. We have not seen a dramatic drop in SIDS cases in the African American community. So there is still work to be done to continue the progress already made.

"Despite…progress…, 20 percent of SIDS cases are still happening in the day care setting."

Stomach sleeping not safe
Probably the single greatest risk factor for SIDS is sleep position, which this and other studies have shown. We don’t know for sure why this is, but once again, in the St. Louis study, we see that stomach sleeping is not safe. For parents who tell me that’s the only way their child will go to sleep, I help them explore other options. If mom is exhausted from getting up at night, maybe dad can get up once. Or someone can come in for an hour during the day so mom can rest. The stakes are too high to put a child on the stomach.

When I discuss sleep position with new parents, someone always brings up the notion that a baby will choke if placed on its back. Our research here at Yale has shown that’s the greatest fear, but study after study has shown that this is just not true. In the Yale-New Haven newborn nursery, babies sleep on their backs. Moms who deliver here learn from day one that that is best. And forget trying to prop a baby sleeping on his or her side. There’s too great a potential for the baby to roll over onto the stomach.

“An infant sleeping in an adult bed cannot defend himself if he gets stuck up against the headboard or under a pillow or a comforter or person.”

Pillows, comforters and SIDS
Bed sharing is another issue addressed by the St. Louis study, which is a common practice in many cultures. As a physician, I feel it is important to explain to parents that there may be risks in bed sharing. An infant sleeping in an adult bed cannot defend himself if he gets stuck up against the headboard or under a pillow or a comforter or person. He can’t move his head or his body to get fresh air. The infant eventually removes all the oxygen from the air pocket he is trapped in and can suffocate. This risk is even greater if the adult in the bed has been drinking, using drugs or is a heavy sleeper.

Sometimes infants are placed on a couch or upholstered chair to sleep. Remember that a baby—even a newborn—can wriggle itself into the space where the cushions meet and not be able to breathe. Or the baby can fall off a couch and be injured.

"The safest place for an infant is in a crib or bassinet that meets current consumer protection standards."

The safest place for an infant is in a crib or bassinet that meets current consumer protection standards. The mattress should fit snugly against the sides of the crib and the slats of the crib should be no more than two inches apart. Don’t put a pillow or stuffed animal in with a newborn; they don’t need it and it’s dangerous. You don’t even need bumper pads. Follow the link below for more crib safety tips.

Smoking and SIDS
One thing these two studies did not address was smoking and SIDS. We’ve known for a long time that smoking increases the risk of SIDS, as it does ear infections, respiratory infections and asthma. I encourage women who are smokers to join a smoking cessation program or at the very least don’t smoke in the house. In the long run, it’s better for everyone if they can quit.

Questions to ask about child care
The second study points out the high percentage of SIDS cases at childcare centers. Twenty-eight percent of the centers surveyed were still putting the infants to sleep on their stomachs at least some of the time. What’s even worse is when an infant who is used to sleeping on his back at home is placed on his stomach at day care. Because that child is not used to sleeping on his stomach, the risk of SIDS is increased even further. For parents with infants under a year placed in childcare or left with friends or relatives for the day, insist your child be placed on his or her back to sleep.

Pediatrician Eve R. Colson, MD, is assistant professor of pediatrics and director of the Well Newborn Nursery at Yale-New Haven Children’s Hospital.

 

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