The worst day of my pediatric career. The emergency room called to notify me they had just attempted to resuscitate my 3-week old patient and were sorry to report they were unsuccessful. The cause of death was presumed to be SIDS. I drove to the ER to attempt to comfort the grief-stricken parents. They were devastated and heartbroken from losing the most precious thing in their life. The pain was so deep because the love was so great. How could this happen? Their child was perfect and was doing so well. Years of planning, effort, and resources ended tragically in the desolation of their shared dreams together.
We don’t want to think about it. Who has a child and wants to contemplate Sudden Infant Death Syndrome (SIDS)? What a horrible thought! Approximately one in 2000 babies will succumb to this awful disease in the United States each year. And as advanced as medical knowledge is we still don’t know why.
The only perfect prevention of SIDS is to not have children. The risk of SIDS is about seven times higher than dying in an auto accident in Utah. In parenting, just as in driving, we only have influence and not control. If we fret too much about merging on the highway we may freeze up, slam on the brakes and cause an accident. Likewise, if the stress and anxiety about SIDS consume us, we become more sleep-deprived and may do things that make matters worse.
Let me give you an example. Your one-day-old newborn is in the hospital nursery and starts to choke. What happens? It becomes a five-alarm fire. The nurse rushes over, quickly suctions out the nose and mouth, puts the baby on a monitor, and gives some blow-by oxygen and gentle stimulation. The baby improves and then the nurse puts a feeding tube down the mouth into the stomach and informs you she sucked out 2 ounces of thick secretions. Thank goodness you were in the hospital to avert tragedy but how do you deal with this when you go home tomorrow with your newborn?
This scenario creates great anxiety in parents. What happens the next time she chokes? How do you sleep while listening for every squeak foreboding the next episode? It’s now 2:00 am and time to breastfeed. You are exhausted and bring your infant to bed with you. It’s impossible to stay awake and you fall asleep and spend the rest of the night with your newborn next to you. The risk of SIDS just doubled.
Influence, not control. Let’s put on our seat belts, put down the phone, obey traffic rules and drive with enjoyment. There is a long list of do’s and don’ts, based on research, to influence the prevention of SIDS. You should know them and they should be a habit. I will list them at the end of the Blog but I would like to make special mention of a few.
- Sleeping on the back is the most important prevention for Sudden Infant Death Syndrome. Babies should sleep on a firm mattress without soft items nearby that can obstruct the airway. The side sleeping position has been shown to be safer than sleeping on the abdomen but not as safe as sleeping on the back. Although unclear, abdomen sleeping likely increases the risk of SIDS because the baby’s face presses into bedding which causes suffocation. If babies are old enough (around six months) to roll over onto their abdomens after falling asleep, you do not need to worry about continually repositioning them on their backs. Likely, if a child is strong enough to roll over, they are also strong enough to reposition their heads to avoid suffocation. Sleeping on the back does not increase the risk of choking on vomit.
- Reflux does not increase the risk of SIDS in an otherwise healthy baby. If your child has a neurologic or muscular disease, abnormal facial structure or any airway abnormalities we may have other issues to consider. Nurses in the hospital react dramatically to choking episodes and do more than you can do at home because it’s their job to assure your baby has normal airway protective mechanisms. Once that is established you can rest assured that choking won’t be harmful. Signs of abnormal airway protection the nurses watch for and you should too are the following: babies should never lose consciousness while choking, babies should not hold their breath longer than 15 seconds, the skin around the mouth may turn a bluish shade but the lips and tongue should not appear blue, babies should feed normally without persistent choking and gagging during feeding. If you have any concerns about your baby’s ability to protect his airway please let one of our doctors know. In a healthy baby, sleeping flat on the back is the most important SIDS prevention method! Spitting up doesn’t change that. If the choking infant with normal airway protection ability in the above scenario had received no intervention she would have done just fine. Newborns have very strong airway protection mechanisms to guard secretions against entering the windpipe. When your baby arches her back and has a wide-eyed panicked look, gagging and holding her breath, she is showing how strong she is. She is demonstrating that she knows how to hold her breath and protect her airway until the spit-up episode is over so that she inhales air instead of inhaling spit-up. When babies spit secretions to the back of their mouths they choke, cough, gag, shut their vocal cords, stop breathing for 5 -15 seconds, turn blue around their mouths, swallow, then breath and do just fine. The best management of choking episodes is to place the infant tummy down in an inclined position such as over your shoulder. This will allow gravity to assist in clearing secretions from the airway and minimize further reflux. Keep the airway in a neutral position with a chin at a 90-degree angle from the neck.
- Parenting a newborn means sleep deprivation and exhaustion for you. Have a nighttime system to keep your infant from sleeping with you. Use a bassinet with a firm flat mattress next to your bed. Get up and sit in a not so comfortable chair to breastfeed or have a significant other keep watches to put your newborn back in the bassinet when she starts to fall asleep. (The significant other may be more tired than you.)
- The American Academy of Pediatrics (AAP) recommends using a pacifier at bedtime but not until 3 to 4 weeks of age and mentions not needing to replace it if the pacifier falls out. Does this make sense to anyone? Let me explain. SIDS studies are generally retrospective, not prospective. This means that researchers study the conditions surrounding SIDS deaths. Pacifiers turn up in these studies as being protective but we can’t do a prospective study and give them to half the infants in the country and not the other half and see who lives and who doesn’t. Researchers and SIDS scientists don’t know why pacifiers might be protective. Some infants won’t ever take them and you can’t spend your life fretting about it. The recommendation of 3-4 weeks is to avoid disrupting breastfeeding and probably because this is when SIDS risks increase. The pacifier should be used when placing the infant down for sleep and not be reinserted if the pacifier falls out of the mouth after the infant falls asleep. If the infant refused 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. Breastfeeding is protective against SIDS and many other illnesses (see my last blog). When breastfeeding is well established, start offering a pacifier at bedtime. Daytime pacifier use hasn’t been shown to help, so use it then for comfort and teaching your baby to take a pacifier if you desire. Don’t worry about putting it back in if it falls out, and if your baby refuses the pacifier don’t stress. Remember influence, not control.
- Heart rhythm problems. There are some heart rhythm issues that are hereditary and there are no formal screening programs in the US to detect them. Long QT syndrome, for example, may affect as many as 1 in 2,500 people. The best we have right now is to know something about your family history of SIDS and heart arrhythmias in young people. Please let us know if you have a history of any of these. An EKG to screen your child may be warranted if there is a history of heart issues.
- Monitors are not recommended by the AAP to prevent SIDS because they haven’t been proven to work. They stress people out and can create the exhaustion I warned about. Nevertheless, they haven’t been shown not to work either, and some studies monitoring lots of babies have shown lower than expected SIDS rates on monitored babies. It’s a decision you and your physician can make together in high-risk situations. The equipment needs to be sophisticated and state-of-the-art. Putting a microphone by your baby and a speaker by your ear will do nothing more than make you more tired. Crib death is generally a silent event.
Here is the list of dos and don’ts. Follow them as best you can, but please try to enjoy your newborn. Babies grow up so fast.
- Put baby to sleep only flat on his back. This includes naps. Some babies have to get used to this position. Start when you first place him down to sleep in the hospital. He’ll get used to it.
- Don’t put your baby to sleep on his side or abdomen even for a short time. The side position is not as safe as the back position.
- Use a separate but proximate sleeping environment. The risk of SIDS has been shown to be reduced when the infant sleeps in the same room as the mother. Sleeping in his own bassinet next to you is ideal for the first several months.
- Do not allow your baby to sleep with you or anyone else even for a short time.
- Use a firm mattress covered with a fitted sheet. No car seats, swings, or strollers. No gadgets or wedges or positioners or fancy infant bed co-sleepers.
- Do not place your baby on your bed to sleep – ever!
- Avoid any cords near the sleeping area. Also, avoid attachments on the pacifier.
- No pillows/stuffed animals/quilts/comforters/loose bedding or other soft items.
- No bumper pads. The mattress should fit firmly against the bassinet or crib sides.
- No cigarette smoke. Not during pregnancy, not in the house, not in the sleep room. No second and smoke on clothing, etc.
- Breastfeed. (See my last blog)
- Use a pacifier at the initiation of sleep at night and for naps. Don’t reinsert if it falls out. Wait until after 4 weeks of age for breastfed infants.
- Avoid overheating. There are no temperature or clothing/bedding recommendations. Just go by the layers of clothing and blankets that help you feel comfortable, and then no more than one extra layer for baby. The bedroom temperature should be kept comfortable for a lightly clothed adult.
- Consider using a warm infant sleeper or pajama so that blankets aren’t needed. If blankets are used, they should be tucked in around the crib mattress so that the infant’s face is less likely to become covered by the bedding with the blankets tucked in around the crib mattress and reaching only to the level of the infant’s chest.
- Know something about your family history of diseases that might affect your baby, especially SIDS, other sudden unexplained death, and heart rhythm problems in young people.
- Consider learning infant CPR. Hospitals offer courses. The greatest benefit is knowing how to assess babies so you can feel more comfortable that your infant is ok.
Here are some references for further education:
This is an excellent video at the AAP’s website healthychildren .org. There is one error demonstrated by going into repositioning your baby if they change from the back position. This is not necessary. Once your child is old enough and strong enough to move by themselves out of the back position it does not pose an increased risk for SIDS. You can read about this on page 1348 of the technical report. Focus on how you lay your baby down. Don’t exhaust yourself with repeat checks at night for repositioning.
This healthy children’s website has many good sleep articles.
This is the AAP policy statement with the associated technical report referencing the studies behind the recommendations.
SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment
Accompanying Technical report
John Bennett M.D. FAAP
Canyon View Pediatrics