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Reducing The Risks For SIDS

Some Steps Parents Can Take

Updated AAP recommendations (January 2017)

What is Meant by Risk Factors?

bulletRisk factors by themselves do not cause Sudden Infant Death Syndrome, but can have a negative effect on infant well-being. In fact, as many as two thirds of SIDS victims have no known risk factors, and, most babies with one or more of these risk factors will not become SIDS victims.

bulletTherefore, while doctors are hopeful that following the recommendations we have described may reduce the risk of SIDS, we must understand that following the recommendations faithfully will still not prevent all SIDS deaths. Research must continue if we are to discover how and why SIDS occurs, and expand upon these and other risk factors.

The following recommendations come from, "The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk", AMERICAN ACADEMY OF PEDIATRICS, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome (October 2005). This recommendation can be downloaded as a pdf file here (528k). If you need Acrobat Reader, you can get it here.

Abstract - There has been a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed down for sleep in a nonprone position. Although the SIDS rate continues to fall, some of the recent decrease of the last several years may be a result of coding shifts to other causes of unexpected infant deaths. Since the AAP published its last statement on SIDS in 2000, several issues have become relevant, including the significant risk of side sleeping position; the AAP no longer recognizes side sleeping as a reasonable alternative to fully supine sleeping. The AAP also stresses the need to avoid redundant soft bedding and soft objects in the infant’s sleeping environment, the hazards of adults sleeping with an infant in the same bed, the SIDS risk reduction associated with having infants sleep in the same room as adults and with using pacifiers at the time of sleep, the importance of educating secondary caregivers and neonatology practitioners on the importance of “back to sleep,” and strategies to reduce the incidence of positional plagiocephaly associated with supine positioning. This statement reviews the evidence associated with these and other SIDS related issues and proposes new recommendations for further reducing SIDS risk. Pediatrics 2005;116:1245– 1255;

The recommendations outlined here were developed to reduce the risk of SIDS in the general population. As it is defined by epidemiologists, risk refers to the probability that an outcome will occur given the presence of a particular factor or set of factors. Scientifically identified associations between risk factors (eg, socioeconomic characteristics, behaviors, or environmental exposures) and outcomes such as SIDS do not necessarily denote causality. Furthermore, the best current working model of SIDS suggests that more than 1 scenario of preexisting conditions and initiating events may lead to SIDS. Therefore, when considering the recommendations in this report, it is fundamentally misguided to focus on a single risk factor or to attempt to quantify risk for an individual infant. Individual medical conditions may warrant a physician to recommend otherwise after weighing the relative risks and benefits.

1. Back to sleep: Infants should be placed for sleep in a supine position (wholly on the back) for every sleep. Side sleeping is not as safe as supine sleeping and is not advised.

The side position has in general been considered less effective than supine because it is less stable, and some infants rolling from the side will end up sleeping prone. The only specific and objective data in this regard was reported at the June International Conference by Peter Fleming (Avon, UK). He reported that the relative risk of SIDS when sleeping on the side is double the risk of SIDS when sleeping supine. We do not currently have any data on this question in the U.S.; nevertheless, I am in full agreement that we should recommend only the supine position for sleeping. That is, although side appears to be much better than prone, it is not as effective as supine sleeping. I hope this is helpful.
Carl E. Hunt, M.D.
Toledo/Washington D.C.

2. Use a firm sleep surface: Soft materials or objects such as pillows, quilts, comforters, or sheepskins should not be placed under a sleeping infant. A firm crib mattress, covered by a sheet, is the recommended sleeping surface.

3. Keep soft objects and loose bedding out of the crib: Soft objects such as pillows, quilts, comforters, sheepskins, stuffed toys, and other soft objects should be kept out of an infant’s sleeping environment. If bumper pads are used in cribs, they should be thin, firm, well secured, and not “pillow-like.” In addition, loose bedding such as blankets and sheets may be hazardous. If blankets are to be used, they should be tucked in around the crib mattress so that the infant’s face is less likely to become covered by bedding. One strategy is to make up the bedding so that the infant’s feet are able to reach the foot of the crib (feet to foot), with the blankets tucked in around the crib mattress and reaching only to the level of the infant’s chest. Another strategy is to use sleep clothing with no other covering over the infant or infant sleep sacks that are designed to keep the infant warm without the possible hazard of head covering.

4. Do not smoke during pregnancy: Maternal smoking during pregnancy has emerged as a major risk factor in almost every epidemiologic study of SIDS. Smoke in the infant’s environment after birth has emerged as a separate risk factor in a few studies, although separating this variable from maternal smoking before birth is problematic. Avoiding an infant’s exposure to second- hand smoke is advisable for numerous reasons in addition to SIDS risk.

5. A separate but proximate sleeping environment is recommended: The risk of SIDS has been shown to be reduced when the infant sleeps in the same room as the mother. A crib, bassinet, or cradle that conforms to the safety standards of the Consumer Product Safety Commission and ASTM (formerly the American Society for Testing and Materials) is recommended. “Co-sleepers” (infant beds that attach to the mother’s bed) provide easy access for the mother to the infant, especially for breastfeeding, but safety standards for these devices have not yet been established by the Consumer Product Safety Commission. Although bed-sharing rates are increasing in the United States for a number of reasons, including facilitation of breastfeeding, the task force concludes that the evidence is growing that bed sharing, as practiced in the United States and other Western countries, is more hazardous than the infant sleeping on a separate sleep surface and, therefore, recommends that infants not bed share during sleep. Infants may be brought into bed for nursing or comforting but should be returned to their own crib or bassinet when the parent is ready to return to sleep. The infant should not be brought into bed when the parent is excessively tired or using medications or substances that could impair his or her alertness. The task force recommends that the infant’s crib or bassinet be placed in the parents’ bedroom, which, when placed close to their bed, will allow for more convenient breastfeeding and contact. Infants should not bed share with other children. Because it is very dangerous to sleep with an infant on a couch or armchair, no one should sleep with an infant on these surfaces.

6. Consider offering a pacifier at nap time and bedtime: Although the mechanism is not known, the reduced risk of SIDS associated with pacifier use during sleep is compelling, and the evidence that pacifier use inhibits breastfeeding or causes later dental complications is not. Until evidence dictates otherwise, the task force recommends use of a pacifier throughout the first year of life according to the following procedures:

• The pacifier should be used when placing the infant down for sleep and not be reinserted once the infant falls asleep. If the infant refuses the pacifier, he or she should not be forced to take it.

• Pacifiers should not be coated in any sweet solution.

• Pacifiers should be cleaned often and replaced regularly.

• For breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.

7. Avoid overheating: The infant should be lightly clothed for sleep, and the bedroom temperature should be kept comfortable for a lightly clothed adult. Overbundling should be avoided, and the infant should not feel hot to the touch.

8. Avoid commercial devices marketed to reduce the risk of SIDS: Although various devices have been developed to maintain sleep position or to reduce the risk of rebreathing, none have been tested sufficiently to show efficacy or safety.

9. Do not use home monitors as a strategy to reduce the risk of SIDS: Electronic respiratory and cardiac monitors are available to detect cardiorespiratory arrest and may be of value for home monitoring of selected infants who are deemed to have extreme cardiorespiratory instability. However, there is no evidence that use of such home monitors decreases the incidence of SIDS. Furthermore, there is no evidence that infants at increased risk of SIDS can be identified by inhospital respiratory or cardiac monitoring.

10. Avoid development of positional plagiocephaly:

• Encourage “tummy time” when the infant is awake and observed. This will also enhance motor development.

• Avoid having the infant spend excessive time in car-seat carriers and “bouncers,” in which pressure is applied to the occupant. Upright “cuddle time” should be encouraged.

• Alter the supine head position during sleep. Techniques for accomplishing this include placing the infant to sleep with the head to one side for a week and then changing to the other and periodically changing the orientation of the infant to outside activity (eg, the door of the room).

• Particular care should be taken to implement the aforementioned recommendations for infants with neurologic injury or suspected developmental delay.

• Consideration should be given to early referral of infants with plagiocephaly when it is evident that conservative measures have been ineffective. In some cases, orthotic devices may help avoid the need for surgery.

11. Continue the Back to Sleep campaign: Public education should be intensified for secondary care- givers (child care providers, grandparents, foster parents, and babysitters). The campaign should continue to have a special focus on the black and American Indian/Alaska Native populations. Health care professionals in intensive care nurseries, as well as those in well-infant nurseries, should implement these recommendations well before an anticipated discharge.

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