SIDS and Sleep-related Deaths:

Current Statistics, Accomplishments &

ChallengesFern R. Hauck, MD, MSFern R. Hauck, MD, MSDepartment of Family Department of Family

MedicineMedicineUniversity of VirginiaUniversity of Virginia

2009 Health SummitCharlottesville, VAOctober 21, 2009

DefinitionsDefinitions

Sudden and unexpected infant death: (~4,600 Sudden and unexpected infant death: (~4,600 /year)/year) Describes all sudden, unexpected deaths regardless of Describes all sudden, unexpected deaths regardless of

causecause Sudden infant death syndrome:Sudden infant death syndrome:

Cases of SUID that remained unexplained after a Cases of SUID that remained unexplained after a complete autopsy and review of the circumstances of complete autopsy and review of the circumstances of death and clinical history (2,230 in 2500, ~50%)death and clinical history (2,230 in 2500, ~50%)

Other SUID: Other SUID: Infection, infanticide/intentional suffocation (<5%), Infection, infanticide/intentional suffocation (<5%), inherited disorders of fatty acid metabolism (1%), geneticinherited disorders of fatty acid metabolism (1%), geneticcardiac channelopathies (5-10%)cardiac channelopathies (5-10%) Suffocation in bed, other suffocation, and Suffocation in bed, other suffocation, and

“indeterminate” cause are now accounting for a “indeterminate” cause are now accounting for a growing proportion of SUID growing proportion of SUID

U.S. SIDS Rates, 1990-U.S. SIDS Rates, 1990-20052005

0

0.5

1

1.5

2

2.5

3

3.519

90

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Dea

ths/

1000

live

birth

s

WhiteBlackAIHispanicTOTAL

Source: National Center for Health Statistics, CDC

Triple Risk Model for SIDSTriple Risk Model for SIDS

Critical developmental period-baby’s age: Highest risk at 2-4 months of age

Stressful environment: stomach sleeping, smoke exposure, blankets or soft items

Vulnerable baby: Brainstem dysfunction, arousal defect, genetic susceptibility

SIDS

Filiano JJ and Kinney HC, Biol Neonate, 65:194-197, 1994

Established Risk FactorsEstablished Risk Factors

Prone/side sleep Prone/side sleep positionposition

Maternal smoking Maternal smoking during pregnancyduring pregnancy

Maternal drug use Maternal drug use during pregnancyduring pregnancy

Environmental Environmental tobacco smoketobacco smoke

OverheatingOverheating

Soft sleep surfaceSoft sleep surface Bed sharingBed sharing Late or no prenatal Late or no prenatal

carecare Young maternal ageYoung maternal age Prematurity and/or Prematurity and/or

low birth weightlow birth weight Male sexMale sex African AmericanAfrican American Native AmericanNative American

Rebreathing TheoryRebreathing Theory

Infants in certain sleep environments are Infants in certain sleep environments are more likely to trap exhaled COmore likely to trap exhaled CO22 around the around the faceface Lie prone and near-face-down/face-downLie prone and near-face-down/face-down Soft beddingSoft bedding Tobacco smoke exposureTobacco smoke exposure

Infants rebreathe exhaled COInfants rebreathe exhaled CO2 2 : CO: CO2 2 ↑ & O↑ & O2 2

↓↓ Infants die if they cannot arouse/ respond Infants die if they cannot arouse/ respond

appropriatelyappropriately

Kinney HC, Thach BT. NEJM 2009;361:795-805.

Proposed Causal Pathway to SIDS

Genetic risk factors

Pregnancy related risk factors

(low birth weight, smoking)Vulnerable infant

(impaired autonomic regulation

At risk age group

Environmental risk factors(sleep position, bed sharing, thermal stress, head

covering, etc.

SIDSMitchell EA, Acta Paediatrica, 2009

2005 AAP SIDS Task Force 2005 AAP SIDS Task Force RecommendationsRecommendations

Back to sleep for every sleepBack to sleep for every sleep Use a firm sleep surface – a firm mattress is Use a firm sleep surface – a firm mattress is

recommendedrecommended Soft materials (pillows, quilts, comforters, or Soft materials (pillows, quilts, comforters, or

sheepskins) should not be placed under a sleeping sheepskins) should not be placed under a sleeping infant. infant.

Keep soft objects and loose bedding out of the Keep soft objects and loose bedding out of the sleep area/cribsleep area/crib

Avoid overheatingAvoid overheating Avoid the use of commercial devices marketed to Avoid the use of commercial devices marketed to

reduce the risk of SIDSreduce the risk of SIDS Do not use home monitors to prevent SIDS Do not use home monitors to prevent SIDS

2005 AAP Task Force 2005 AAP Task Force Recommendations Recommendations

Do not smoke during pregnancyDo not smoke during pregnancy Do not smoke around the babyDo not smoke around the baby Consider offering a pacifier at nap time Consider offering a pacifier at nap time

and bedtime throughout the first year of and bedtime throughout the first year of life life

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

2005 SIDS Task Force 2005 SIDS Task Force RecommendationsRecommendations

Avoid development of Avoid development of positional plagiocephalypositional plagiocephaly Encourage "tummy time" Encourage "tummy time"

when the infant is awake when the infant is awake and observed. This will also and observed. This will also enhance motor enhance motor development. development.

Avoid having the infant Avoid having the infant spend excessive time in car-spend excessive time in car-seat carriers and seat carriers and "bouncers." Upright "cuddle "bouncers." Upright "cuddle time" should be encouraged. time" should be encouraged.

Alter the supine head Alter the supine head position during sleep. position during sleep.

2005 SIDS Task Force 2005 SIDS Task Force RecommendationsRecommendations

A separate but proximate sleeping environment is A separate but proximate sleeping environment is recommendedrecommended

The risk of SIDS has been shown to be reduced The risk of SIDS has been shown to be reduced when the infant sleeps in the same room as the when the infant sleeps in the same room as the mother. mother.

A crib, bassinet, or cradle that conforms to the A crib, bassinet, or cradle that conforms to the safety standards is recommended. The crib or safety standards is recommended. The crib or bassinet should be placed in the parents' bassinet should be placed in the parents' bedroom, close to their bed, to allow for more bedroom, close to their bed, to allow for more convenient breastfeeding and contact. convenient breastfeeding and contact.

Bed sharing, as practiced in the United States Bed sharing, as practiced in the United States and other Western countries, is more hazardous and other Western countries, is more hazardous than the infant sleeping on a separate sleep than the infant sleeping on a separate sleep surface and is therefore not recommended. surface and is therefore not recommended.

2005 SIDS Task Force 2005 SIDS Task Force RecommendationsRecommendations

A separate but proximate sleeping environment is A separate but proximate sleeping environment is recommendedrecommended

Infants may be brought into bed for nursing or Infants may be brought into bed for nursing or comforting but should be returned to their own comforting but should be returned to their own crib or bassinet when the parent is ready to crib or bassinet when the parent is ready to return to sleep. return to sleep.

The infant should not be brought into bed when The infant should not be brought into bed when the parent is excessively tired or using the parent is excessively tired or using medications or substances that could impair his medications or substances that could impair his or her alertness. or her alertness.

Infants should not bed share with other children. Infants should not bed share with other children. No one should sleep with an infant on a couch or No one should sleep with an infant on a couch or

armchair.armchair.

SIDS Rate and Sleep Position, 1988-2005(Deaths per 1,000 Live Births)

1.4 1.39

1.3 1.3

1.2 1.17

1.03

0.87

0.74 0.720.67

0.620.56 0.57

0.53 0.55 0.54

0.77

72.270.1

53.1

35.338.6

26.9

1317

55.7

64.466.6

71.6 71.172.8

0

0.5

1

1.5

Year

SID

S R

ate

0

50

100

Perc

en

t B

ack S

leep

ing

Pre-AAP recommendation Post-AAP BTS Campaign (began in 1994)

Sleep Position Source: NICHD Household Survey SIDS Rate Source: National Center for Health Statistics, CDC

Sleep Position Sleep Position PrevalencePrevalence

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

1992

1994

1996

1998

2000

2002

2004

2006

2008

Side

Prone

Supine

NISP data, 2008

Lives SavedLives Saved

0

1000

2000

3000

4000

5000

6000

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Deaths

Lives saved since 1994

Total lives saved since 1994: 23,665

Total lives saved since 1999: 15,476

Current IssuesCurrent Issues

1.1. Racial/ethnic disparitiesRacial/ethnic disparities

Prone Prevalence Rates among Prone Prevalence Rates among White and Black Infants and White and Black Infants and

SIDS RatesSIDS Rates

Sources: National Center for Health Statistics, National Infant Sleep Position study

0

10

20

30

40

50

60

70

80

90

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Per

cen

t P

ron

e

0

0.5

1

1.5

2

2.5

Dea

ths/

1000

LB

Prone-B Prone-NB SIDS-B SIDS-NB

Current IssuesCurrent Issues

1.1. Racial/ethnic disparitiesRacial/ethnic disparities

2.2. Increasing prone sleeping ratesIncreasing prone sleeping rates

A Quiet Revolt Against the Rules on SIDS

     By BRIAN BRAIKERPublished: October 18, 2005

In 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.

Why do People Choose to Place Why do People Choose to Place their Babies Prone?their Babies Prone?

They think that it’s saferThey think that it’s safer Concerns about vomiting or Concerns about vomiting or

aspiration while supineaspiration while supine Baby doesn’t hit or hurt him/herself Baby doesn’t hit or hurt him/herself

(startle reflex)(startle reflex) They think that the baby is They think that the baby is

more comfortablemore comfortable Sleeps longer, doesn’t easily awakeSleeps longer, doesn’t easily awake

Current IssuesCurrent Issues

1.1. Racial/ethnic disparitiesRacial/ethnic disparities

2.2. Increasing prone sleeping ratesIncreasing prone sleeping rates

3.3. Increasing rates of other sleep-Increasing rates of other sleep-related deathsrelated deaths

Accidental suffocationAccidental suffocation EntrapmentEntrapment UndeterminedUndetermined Most (80->90%) of these occur in unsafe Most (80->90%) of these occur in unsafe

sleep environmentssleep environments BeddingBedding Bed sharing with othersBed sharing with others

Rates of SIDS and SUIDRates of SIDS and SUID

00.20.40.60.8

11.21.41.6

Year

Dea

ths/

1000

LB

SUID

Postneonatal SIDS

Source: National Center for Health Statistics, CDC, 2009

By TARA PARKER-POPE Published: October 23, 2007

Shhh...My Child Is Sleeping (in My Bed, Um, With Me)

“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.”

Copyright ©2008 American Academy of Pediatrics

Hauck, FR et al. Pediatrics 2008;122:660-666

International Trends in PNM and SIDS rates: 1990-2005

Bed Sharing Has Become More Bed Sharing Has Become More PopularPopular

Renewed popularity of breastfeedingRenewed popularity of breastfeeding Bed sharing all night long has more than Bed sharing all night long has more than

doubled in past 10 years from 6% to 13% doubled in past 10 years from 6% to 13% (Willinger M, 2003, National Infant Sleep Position Survey)(Willinger M, 2003, National Infant Sleep Position Survey)

More recent study: 1/3 bed share in first 3 More recent study: 1/3 bed share in first 3 months, 27% at 12 months. months, 27% at 12 months. (Hauck F, 2009, (Hauck F, 2009, Infant Feeding Practices Study II) Infant Feeding Practices Study II)

Higher numbers in low SES, certain Higher numbers in low SES, certain ethnic groups (African Americans, ethnic groups (African Americans, Latinos) - more than 50% may be bed Latinos) - more than 50% may be bed sharing all night longsharing all night long

Why Parents Bed ShareWhy Parents Bed Share Space for /availability of cribSpace for /availability of crib ConvenienceConvenience

FeedingFeeding Checking on babyChecking on baby

ComfortComfort Parent sleeps betterParent sleeps better Baby sleeps betterBaby sleeps better BondingBonding

SafetySafety Vigilance – can be alert for problemsVigilance – can be alert for problems Belief that “crib death” occurs only in cribsBelief that “crib death” occurs only in cribs

Problems with Bed SharingProblems with Bed Sharing

OverheatingOverheating Soft bedding, pillows, comfortersSoft bedding, pillows, comforters No safety standards for adult No safety standards for adult

mattressesmattresses Risk of entrapmentRisk of entrapment

Infant Bed Sharing and Infant Bed Sharing and SIDS RiskSIDS Risk

Earlier studies showed increased risk associated Earlier studies showed increased risk associated primarily with bed sharing among smoking mothersprimarily with bed sharing among smoking mothers

More recently, two European studies showed More recently, two European studies showed increased risk for younger infants even among non-increased risk for younger infants even among non-smoking motherssmoking mothers ECAS (Carpenter, 2004) – under 8 weeksECAS (Carpenter, 2004) – under 8 weeks Scotland (Tappin, 2005) – under 11 weeksScotland (Tappin, 2005) – under 11 weeks

Germany (Vennemann, 2005) – risk was independent Germany (Vennemann, 2005) – risk was independent of age, independent of smokingof age, independent of smoking

England (Blair, 2009) – bed sharing on bed or couch England (Blair, 2009) – bed sharing on bed or couch had almost 3 times higher risk of SIDS; 10 times had almost 3 times higher risk of SIDS; 10 times higher w/ recent drug or alcohol use higher w/ recent drug or alcohol use

Infant Bed Sharing and Infant Bed Sharing and SIDS Risk SIDS Risk

Other factors that increase risk of bed Other factors that increase risk of bed sharing: multiple bed sharers, bed sharing sharing: multiple bed sharers, bed sharing with other children, parent consumed with other children, parent consumed alcohol or is overtired, infant between both alcohol or is overtired, infant between both parents, or on couches parents, or on couches

Returning the infant to his/her own crib is Returning the infant to his/her own crib is not associated with increased risk not associated with increased risk

No studies have ever shown a protective No studies have ever shown a protective effect of bed sharing on SIDSeffect of bed sharing on SIDS

Not a safe sleeping arrangement!

Infant-Parent Room Sharing and Infant-Parent Room Sharing and SIDS RiskSIDS Risk

Room sharing Room sharing with parentswith parents without without bed sharing is associated with a bed sharing is associated with a lower risk of SIDS than sleeping lower risk of SIDS than sleeping alone in a separate room or in same alone in a separate room or in same room with bed sharingroom with bed sharing New Zealand (Mitchell,1995)New Zealand (Mitchell,1995) England (Blair, 1999) England (Blair, 1999) ECAS (Carpenter, 2004)ECAS (Carpenter, 2004) Scotland (Tappin, 2005)Scotland (Tappin, 2005)

Other Recommendations Other Recommendations Regarding Regarding

Bed SharingBed Sharing UK Department of Health: safest place for UK Department of Health: safest place for

infants up to 8 months to sleep in a crib in infants up to 8 months to sleep in a crib in parents’ room. (2004)parents’ room. (2004)

Canadian Paediatric Society: infants Canadian Paediatric Society: infants should sleep in cribs for the first year of should sleep in cribs for the first year of life, under all circumstances. Parents life, under all circumstances. Parents should be aware that room-sharing is should be aware that room-sharing is protective against SIDS and is a safer protective against SIDS and is a safer alternative to bed sharing. Hospitals alternative to bed sharing. Hospitals should not allow mothers to sleep in the should not allow mothers to sleep in the same bed with their newborns. (2004) same bed with their newborns. (2004)

Others disagree—believe the evidence is Others disagree—believe the evidence is

inconclusive, especially for nonsmoking inconclusive, especially for nonsmoking and breastfeeding mothersand breastfeeding mothers

SummarySummary

We have accomplished a lot with regard We have accomplished a lot with regard to decreasing rates of SIDS to decreasing rates of SIDS

When messaging stops, many people When messaging stops, many people perceive SIDS as not an important perceive SIDS as not an important problemproblem Only an issue when it’s in the news or always Only an issue when it’s in the news or always

hearing about it – “this must still be a problem”hearing about it – “this must still be a problem” Racial/ethnic disparities continue to be a Racial/ethnic disparities continue to be a

major concernmajor concern Other sleep-related deaths are on the riseOther sleep-related deaths are on the rise

ImplicationsImplications

Expand message from “Back to Sleep” Expand message from “Back to Sleep” to safe sleep environmentto safe sleep environment

Reinforce message wherever and Reinforce message wherever and whenever we canwhenever we can

Message needs to be consistentMessage needs to be consistent Health care providers, media, advertisersHealth care providers, media, advertisers

Message needs to make sense to Message needs to make sense to parentsparents

ImplicationsImplications

Message needs to address parental Message needs to address parental desire to keep baby safe and keep desire to keep baby safe and keep baby comfortablebaby comfortable Back to Sleep needs to address concerns Back to Sleep needs to address concerns

about infant comfort (length of sleep) and about infant comfort (length of sleep) and vomiting/ aspirationvomiting/ aspiration

Efforts to encourage room sharing without bed Efforts to encourage room sharing without bed sharing must address parent safety concernssharing must address parent safety concerns

Message needs to emphasize parent Message needs to emphasize parent self-efficacyself-efficacy Recommendations need to stress the Recommendations need to stress the

“preventability” of infant death“preventability” of infant death

Thank youThank you