Presentation on theme: "Fern R. Hauck, MD, MS Department of Family Medicine"— Presentation transcript:
1 SIDS and Sleep-related Deaths: Current Statistics, Accomplishments & Challenges Fern R. Hauck, MD, MSDepartment of Family MedicineUniversity of Virginia2009 Health SummitCharlottesville, VAOctober 21, 2009
2 Definitions Sudden and unexpected infant death: (~4,600 /year) Describes all sudden, unexpected deaths regardless of causeSudden infant death syndrome:Cases of SUID that remained unexplained after a complete autopsy and review of the circumstances of death and clinical history (2,230 in 2500, ~50%)Other SUID:Infection, infanticide/intentional suffocation (<5%),inherited disorders of fatty acid metabolism (1%), geneticcardiac channelopathies (5-10%)Suffocation in bed, other suffocation, and “indeterminate” cause are now accounting for a growing proportion of SUID
3 U.S. SIDS Rates,Source: National Center for Health Statistics, CDC3
4 Triple Risk Model for SIDS Filiano JJ and Kinney HC, Biol Neonate, 65: , 1994
5 Established Risk Factors Prone/side sleep positionMaternal smoking during pregnancyMaternal drug use during pregnancyEnvironmental tobacco smokeOverheatingSoft sleep surfaceBed sharingLate or no prenatal careYoung maternal agePrematurity and/or low birth weightMale sexAfrican AmericanNative American
6 Rebreathing TheoryInfants in certain sleep environments are more likely to trap exhaled CO2 around the faceLie prone and near-face-down/face-downSoft beddingTobacco smoke exposureInfants rebreathe exhaled CO2 : CO2 ↑ & O2 ↓Infants die if they cannot arouse/ respond appropriately
8 Proposed Causal Pathway to SIDS Pregnancy related risk factors(low birth weight, smoking)Genetic risk factorsVulnerable infant(impaired autonomic regulationAt risk age groupEnvironmental risk factors(sleep position, bed sharing, thermal stress, head covering, etc.SIDSMitchell EA, Acta Paediatrica, 2009
9 2005 AAP SIDS Task Force Recommendations Back to sleep for every sleepUse a firm sleep surface – a firm mattress is recommendedSoft materials (pillows, quilts, comforters, or sheepskins) should not be placed under a sleeping infant.Keep soft objects and loose bedding out of the sleep area/cribAvoid overheatingAvoid the use of commercial devices marketed to reduce the risk of SIDSDo not use home monitors to prevent SIDS
10 2005 AAP Task Force Recommendations Do not smoke during pregnancyDo not smoke around the babyConsider offering a pacifier at nap time and bedtime throughout the first year of lifeFor breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.
11 2005 SIDS Task Force Recommendations Avoid development of positional plagiocephalyEncourage "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." Upright "cuddle time" should be encouraged.Alter the supine head position during sleep.
12 2005 SIDS Task Force Recommendations A separate but proximate sleeping environment is recommendedThe 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 is recommended. The crib or bassinet should be placed in the parents' bedroom, close to their bed, to allow for more convenient breastfeeding and contact.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 is therefore not recommended.
13 2005 SIDS Task Force Recommendations A separate but proximate sleeping environment is recommendedInfants 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.Infants should not bed share with other children.No one should sleep with an infant on a couch or armchair.
14 Pre-AAP recommendation Post-AAP BTS Campaign (began in 1994) Sleep Position Source: NICHD Household SurveySIDS Rate Source: National Center for Health Statistics, CDC
18 Prone Prevalence Rates among White and Black Infants and SIDS Rates Sources: National Center for Health Statistics, National Infant Sleep Position study
19 Current Issues Racial/ethnic disparities Increasing prone sleeping rates
20 A Quiet Revolt Against the Rules on SIDS By BRIAN BRAIKERPublished: October 18, 2005In homes across the country, parents like Mrs. Stanciu are mounting a minor mutiny against the medical establishment. For more than a decade, doctors have advocated putting babies to bed on their backs as a precaution against sudden infant death syndrome, or SIDS.Increasingly, however, some new parents are finding that the benefits of having babies sleep soundly - more likely when they sleep on their stomachs - outweigh the comparatively tiny risk of SIDS.
21 Why do People Choose to Place their Babies Prone? They think that it’s saferConcerns about vomiting or aspiration while supineBaby doesn’t hit or hurt him/herself (startle reflex)They think that the baby is more comfortableSleeps longer, doesn’t easily awake
22 Current Issues Racial/ethnic disparities Increasing prone sleeping ratesIncreasing rates of other sleep-related deathsAccidental suffocationEntrapmentUndeterminedMost (80->90%) of these occur in unsafe sleep environmentsBeddingBed sharing with others
23 Rates of SIDS and SUIDSource: National Center for Health Statistics, CDC, 2009
24 Shhh...My Child Is Sleeping (in My Bed, Um, With Me) By TARA PARKER-POPEPublished: October 23, 2007“Ask parents if they sleep with their kids, and most will say no. But there is evidence that the prevalence of bed sharing is far greater than reported. Many parents are ''closet co-sleepers,'' fearful of disapproval if anyone finds out, notes James J. McKenna, professor of anthropology and director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame.”
26 Bed Sharing Has Become More Popular Renewed popularity of breastfeedingBed sharing all night long has more than doubled in past 10 years from 6% to 13% (Willinger M, 2003, National Infant Sleep Position Survey)More recent study: 1/3 bed share in first 3 months, 27% at 12 months. (Hauck F, 2009, Infant Feeding Practices Study II)Higher numbers in low SES, certain ethnic groups (African Americans, Latinos) - more than 50% may be bed sharing all night long
27 Why Parents Bed Share Space for /availability of crib Convenience FeedingChecking on babyComfortParent sleeps betterBaby sleeps betterBondingSafetyVigilance – can be alert for problemsBelief that “crib death” occurs only in cribs
28 Problems with Bed Sharing OverheatingSoft bedding, pillows, comfortersNo safety standards for adult mattressesRisk of entrapment
29 Infant Bed Sharing and SIDS Risk Earlier studies showed increased risk associated primarily with bed sharing among smoking mothersMore recently, two European studies showed increased risk for younger infants even among non-smoking mothersECAS (Carpenter, 2004) – under 8 weeksScotland (Tappin, 2005) – under 11 weeksGermany (Vennemann, 2005) – risk was independent of age, independent of smokingEngland (Blair, 2009) – bed sharing on bed or couch had almost 3 times higher risk of SIDS; 10 times higher w/ recent drug or alcohol use
30 Infant Bed Sharing and SIDS Risk Other factors that increase risk of bed sharing: multiple bed sharers, bed sharing with other children, parent consumed alcohol or is overtired, infant between both parents, or on couchesReturning the infant to his/her own crib is not associated with increased riskNo studies have ever shown a protective effect of bed sharing on SIDS
32 Infant-Parent Room Sharing and SIDS Risk Room sharing with parents without bed sharing is associated with a lower risk of SIDS than sleeping alone in a separate room or in same room with bed sharingNew Zealand (Mitchell,1995)England (Blair, 1999)ECAS (Carpenter, 2004)Scotland (Tappin, 2005)
33 Other Recommendations Regarding Bed Sharing UK Department of Health: safest place for infants up to 8 months to sleep in a crib in parents’ room. (2004)Canadian Paediatric Society: infants should sleep in cribs for the first year of life, under all circumstances. Parents should be aware that room-sharing is protective against SIDS and is a safer alternative to bed sharing. Hospitals should not allow mothers to sleep in the same bed with their newborns. (2004)Others disagree—believe the evidence is inconclusive, especially for nonsmoking and breastfeeding mothers
34 SummaryWe have accomplished a lot with regard to decreasing rates of SIDSWhen messaging stops, many people perceive SIDS as not an important problemOnly an issue when it’s in the news or always hearing about it – “this must still be a problem”Racial/ethnic disparities continue to be a major concernOther sleep-related deaths are on the rise
35 ImplicationsExpand message from “Back to Sleep” to safe sleep environmentReinforce message wherever and whenever we canMessage needs to be consistentHealth care providers, media, advertisersMessage needs to make sense to parents
36 ImplicationsMessage needs to address parental desire to keep baby safe and keep baby comfortableBack to Sleep needs to address concerns about infant comfort (length of sleep) and vomiting/ aspirationEfforts to encourage room sharing without bed sharing must address parent safety concernsMessage needs to emphasize parent self-efficacyRecommendations need to stress the “preventability” of infant death