by Donna Walls RN, BSN, ICCE, IBCLC

October is Sudden Infant Death Syndrome (SIDS) Awareness month and a time to take a fresh look at how we can educate parents and caregivers on reducing the risk of SIDS. According to the Center for Disease Control and Prevention (CDC), about 3,500 infants died in the United States in 2014 of Sudden Unexplained Infant Death. (SUID). SIDS is the sudden death of an infant less than 1 year old that cannot be explained after a thorough investigation that includes a complete autopsy, examination of the death scene, and a review of the medical history. This is the most commonly occurring unexplained death of infants Another definition to be aware of is Accidental Suffocation and Strangulation in Bed (ASSB) which is the sudden death of an infant less than 1 year of age that can happen because of:

• Suffocation by soft bedding such as when a pillow or covers an infant’s nose and mouth.
• Overlay, or when another person rolls on top of or against the infant.
• Wedging or entrapment which is when an infant is wedged between two objects such as a mattress and wall, bed frame, or furniture.
• Strangulation which can happen when an infant’s head and neck get caught between crib railings.

The original Back to Sleep campaign has been updated by the CDC and the National Institutes of Health to become the Safe to Sleep campaign. The campaign works hand in hand with The National Action Partnership to Promote Safe Sleep (NAPPSS) and other organizations to bring awareness to and provide education on SIDS and ASSB prevention. Current research supports the following recommendation for SIDS risk reduction:

• Always place babies on their backs when putting them to sleep for naps and at night.
• Use a firm sleep surface, such as a mattress in a safety-approved crib, covered by a fitted sheet.
• Share your room with your baby, not your bed. Your baby should not sleep in an adult bed, on a couch, or on a chair alone, with you, or with anyone else.
• Keep soft objects, such as pillows and loose bedding, out of your baby’s sleep area.
• The risk of SIDS is even greater when a baby shares a bed with a smoker. To reduce risk, do not smoke during pregnancy, and do not smoke or allow smoking around your baby.

Absent from many of the messages is encouraging mothers to breastfeed, which confers a 50% risk reduction of SIDS, and an even stronger protection if the mother is exclusively breastfeeding. Recognizing that the sleep separately message can be confusing or difficult for breastfeeding mothers, the United States Breastfeeding Committee and NAPPSS worked with the American Academy of Pediatrics to develop a more “breastfeeding friendly” safe sleep message. On October 24, 2016 the American Academy of Pediatrics announced their Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. The following recommendations were given supporting the updated policy:

1. Breastfeeding is recommended to reduce the risk of SIDS and to enhance the health and well-being of the infant and the mother. The AAP recommends exclusive breastfeeding for 6 months (no formula, nutritional liquids or solid foods). Newer research demonstrates that exclusive breastfeeding can reduce the risk of SIDS by as much as 70%.
2. Skin to skin care is recommended for all mothers and newborns, regardless of feeding or delivery method for at least an hour after birth
3. Room-sharing with the infant on a separate sleep surface is recommended. Keep infants in close proximity to parents for the first 6 to 12 months of life.
4. The AAP recognizes that parents may fall asleep in bed after or during feeding their infant, so remove pillows, loose blankets, loose sheets and move the bed away from walls to prevent entrapment, and follow remainder of safe sleep recommendations.
5. Avoid nighttime feeding on couches and arm chairs which are not considered safe sleep surfaces at any time for infants.
6. It is important that anyone who cares for the infant puts the baby to sleep on their baby on the back. Prone sleeping (sleeping on the stomach) increases the risk of rebreathing the same air that is under the baby’s face which can increase the levels of carbon dioxide in their blood, not enough oxygen in their blood which can be potentially fatal.
7. Creating a safe sleep surface. Recommendations from the National Action Partnership to Promote Safe Sleep (in partnership with the AAP) recommends to: “Use a firm sleep surface, such as a mattress in a safety-approved crib covered by a fitted sheet, to reduce the risk of SIDS and other sleep-related causes of infant death. Firm sleep surfaces with no other bedding or soft objects. Nothing soft such as pillows etc. should be placed under the baby. Appropriate surfaces can include safety approved cribs, bassinets, and portable play areas. Safety approved cribs are those that have been manufactured and sold since the requirements went into effect on June 28, 2011. They have been designed to have the spaces between the bars too small for a baby’s head to get through and get stuck. Standards for other safety approved spaces such as bassinets, portable play areas and side cars (attachment to an adult bed that provides a separate, but close safe space) have also been developed by the U.S. Consumer Product Safety Commission, the agency that tracks accidents and deaths with products and helps keep babies safe from products that can be harmful or cause accidents. For information on safety standards for sleep products , contact the Consumer Product Safety Commission at 1-800-638-2772 or https://www.cpsc.gov.”
8. Avoid smoking, alcohol, and drugs during pregnancy and after birth.
9. Avoid devices marketed to reduce risk of SIDS such as monitors, wedges, devices or specific mattresses.
10. Swaddling does not reduce the risk of SIDS and in some cases may increase the risk for overheating and SIDs.
11. Consider offering a pacifier at nap or bed time, after breastfeeding is firmly established (no specified time frame). If the baby is not breastfed, then a pacifier can be introduced as soon as the family desires.
12. Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly.

Teaching points for prenatal or postpartum education on safe sleep include:

• Exclusive breastfeeding significantly reduces the risk of SIDS.
• Newborns and new parents sleep better when in close proximity.
• Always place infants on their back for any sleep.
• Do not allow any smoking in the home. Encourage and provide information to help women stop smoking during pregnancy.
• Swaddling has not been shown to reduce the risk of and may increase the risk of overheating and SIDS. Avoid swaddling during times of sleep.
• Do not use couches or chairs for nighttime feedings.
• Do not co-sleep if either parent smokes or is using alcohol or drugs which can alter responding to the baby.
• All surfaces that an infant might be sleeping on needs to be safe. This includes cribs, cots, playpens, and the parental bed (if the mother falls asleep while feeding). A safe sleep surface includes:
  • Firm mattress
  • Well-fitting sheet
  • No blankets or pillows
  • No bumper pads
  • Use only equipment designated and approved for infant sleep
  • No surface that can entrap an infant
  • No toys or pets sharing the same sleep surface
  • Avoid swaddling or clothing that can cause overheating

ICEA recently updated our Position Paper on Safe Sleep which is available on our web site.

References

https://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938 Centers for Disease Control and Prevention . (2015). Sudden unexpected infant death. Retrieved August 20, 2015, from https://www.cdc.gov/sids/aboutsuidandsids https://awhonn.files.wordpress.com/2015/10/tips-for-nurses-teaching-safe-sleep-in-the-hospital-setting.pdf Pease AS, Fleming PJ, Hauck FR, et al. Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics. 2016-05-09 00:05:32 2016. McKenna JJ, Gettler LT. There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping. Acta Paediatr. Aug 21 2015 Carpenter R, McGarvey C, Mitchell EA, et al. Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies. BMJ Open. January 1, 2013 2013;3(5)