sids and sleep-related deaths: current statistics, accomplishments & challenges fern r. hauck,...
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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