SIDS: A Parent's Worst Nightmare

By Dr. Todd Huffman, for the Eugene Register-Guard, October 2008

It’s a parent’s worst nightmare. A seemingly healthy baby is put down for a nap or for the night. The child is assumed well and in a protected environment. The caregiver feels secure, their world is in order.

Then, suddenly, everything has been turned upside down. The baby is found dead, the cause a total mystery. Often, the infant is fed normally just before being placed in bed. No outcry is heard, and the infant has been found in the position he or she was placed.

Sudden infant death syndrome (SIDS) is the biggest killer of babies over one month old in the rich world. Most sudden infant deaths occur at home, forcing parents and siblings to witness and live with the memory of a terrible tragedy, and scenes of intense confusion. Parents who are innocent of blame in their child’s death often feel responsible nonetheless, and torture themselves imagining ways in which they might have contributed to or prevented the tragedy.

Despite decades of extensive research, our understanding of the causes of SIDS remains incomplete, though SIDS is known as a phenomenon of multiple causes. While dramatic reductions in the numbers of deaths have been achieved over the past fifteen years, SIDS is still responsible for more infant deaths in the United States than any other cause of death during infancy beyond the first month.

We know what SIDS is not. It is not caused by contagious disease, or by immunizations. Neither is it the result of accidental or intentional suffocation, vomiting or choking, or child abuse. It cannot be predicted by “near-SIDS” events, what doctors call “apparent life-threatening events.”

Doctors define SIDS as the sudden death of a previously healthy infant under one year of age that remains unexplained after a thorough case investigation, including examination of the death scene, a review of the child’s medical history, and performance of a complete autopsy that includes X-rays and a wide range of laboratory tests.

It is a diagnosis of exclusion; heart conditions, infections, aspiration, metabolic disorders, toxin or drug exposure, suffocation, and trauma all must have been excluded in order for doctors to assign SIDS as the cause of death.

Nine in ten SIDS deaths occur in the first 6 months of life, most often between 2 and 4 months. It is rare in the first month of life, for reasons not yet fully understood.

SIDS occurs at higher rates in African-Americans, Alaska natives, and in some American Indian populations. It also occurs more often in male babies, and in babies who were premature, or were of low birth weight.

SIDS is more likely to strike babies of young mothers, mothers who received late or no prenatal care, and, most significantly, mothers who smoked during pregnancy or afterwards. Infants whose mothers smoke during or after pregnancy are 6 times more likely to die of SIDS than infants of non-smoking mothers. The more an infant is exposed to smoke, the higher the risk.

Other known risk factors include: the prone sleep position (“tummy sleeping”), sleeping on a soft surface, and overheating. Finally, bed sharing has been proven to increase the risk of SIDS, primarily in babies whose mothers smoke, or drink or use illicit substances or prescription medications that impair her ability to awaken.

The risk of SIDS is also increased if the parent bed has an improper mattress, unsafe bedding, or has gaps between the mattress and the headboard, footboard, or wall.

Bed-sharing can also be hazardous if the mother is obese, leading to accidental suffocation of the infant, or if there are multiple bed-sharers. The highest risks to the infant occur when adults sleep with an infant on a couch or in an armchair.

Prone, or tummy, sleeping is the most important modifiable risk factor for SIDS, increasing the risk 10 to 15 times. Since 1994, the SIDS rate in the United States has fallen by more than half, thanks to the national Back To Sleep public awareness campaign launched that year by the American Academy of Pediatrics. Today more than 80 percent of infants are now placed on their backs to sleep.

Yet too many caregivers, especially child care providers and relatives, are still placing infants to sleep on their tummy. In fact, 20 percent of all SIDS deaths occur when the infant is in the care of a non-parental caregiver, and this number has held constant over the past decade.

Safe sleep helps reduce SIDS. There are some simple actions every parent, child care provider, relative, and babysitter can take to lower the risk.

Put babies on their backs to sleep every time, even for short daytime naps. While safer than tummy sleeping, side sleeping is nevertheless too risky, as babies can easily roll onto the tummy. Tummy time is okay when the baby is awake.

Because babies can easily overheat, avoid wrapping the baby with lots of blankets and clothes, and keep the room temperature between 68 and 72 degrees. In the winter, use a blanket sleeper rather than adding layers of blankets for warmth.

Babies’ breathing systems are not grown up yet. Babies can be smothered easily. Keep soft blankets, quilts, comforters, soft toys, stuffed animals, and pillows away from babies’ sleeping space. Don’t put the baby to sleep on soft surfaces such as a couch, waterbed, pillow-top mattress, egg-crate mattress, or beanbag chair. Put the baby to sleep only on a firm mattress with a fitted sheet.

While co-sleeping can be made safe, a separate but nearby sleeping place is safest. Select a crib, bassinet, or cradle that conforms to the “CPSC” recommendations. If bumper pads are used, they should be thin, firm, well-secured, and not “pillow-like”. Devices intended to keep babies on their back or side are not recommended.

Consider offering a pacifier at nap time and bedtime once successful breast feeding is established. Pacifiers reduce the risk of SIDS as much as threefold. And, finally, create a smoke-free zone for a pregnant woman and baby.

Removing risk factors decreases but does not eliminate the risk of SIDS. The syndrome can strike infants who do not have any risk factors, including those who sleep on their back. Nevertheless, adopting these safe sleep practices dramatically reduces the risk. For more information, check out the Healthy Babies, Healthy Communities initiative, at www.lanecounty.org/prevention.