1. Sudden Infant Death Syndrome (SIDS) Risk Reduction A Continuing Education Curriculum Component for Well Baby Unit Nurses

2. What does Model Behavior mean? Parents tend to copy practices that they observed in hospital settings. As such, nurses should model behavior that reduces an infant’s risk of death. Nursery staff should be more vigilant about endorsing and modeling the supine sleep position and safe sleep guidelines before an anticipated discharge.

3. Training Objectives:  To provide guidelines that will ensure a safe sleep environment for all newborns by implementing the American Academy of Pediatrics’ (AAP) 2005 recommendations regarding safe sleep.  To ensure that all recommendations are modeled for and understood by parents/caregivers with consistent instructions given prior to discharge.

4. What is SIDS? Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant younger than 1 year of age that remains unexplained after a thorough case investigation, including:  Performance of a complete autopsy  Examination of the death scene  Review of the infant’s and family’s clinical histories

5. SIDS is…  The leading cause of death in infants from one month to one year of age.  A sudden and silent medical disorder that can happen to a seemingly healthy infant.  A death often associated with sleep and with little or no signs of suffering.  Determined only after autopsy, an examination of the death scene, and a review of the infant’s and family’s clinical histories.  A diagnosis of exclusion, in which the cause of death can be determined only after ruling out other causes.

6. SIDS is NOT…  Preventable, but the risk can be reduced  Caused by vomiting and/or choking  Caused by DPT vaccine or other immunizations  Contagious  The result of child abuse or neglect  The cause of every unexpected infant death

7. The Triple-Risk Model The most prominent theory regarding SIDS is the Triple Risk Model which requires the convergence of three elements that may lead to the death of an infant from SIDS:  Vulnerable infant (brain abnormality, genetic mutation)  Critical developmental period (rapid growth, changes in homeostasis)  Outside stressor(s) All three elements must be present for sudden infant death to occur. Removing one or more outside stressors can reduce the risk of SIDS.

8. Triple Risk Model Critical Development Period Vulnerable Infant Exogenous Stressors SIDS

9. The Etiology of SIDS Babies who die of SIDS may be born with one or more conditions that make them especially vulnerable to stressors, such as:  Brain abnormalities (e.g., brain stem)  Genetic mutations and polymorphisms (e.g., C4 gene) Stressors include:  Stomach sleep position  Lack of oxygen/excessive carbon dioxide intake  Overheating  Infection  Tobacco smoke

10. The Etiology of SIDS A recent study in the Journal of the American Medical Association (JAMA) provides more conclusive evidence that a significant number of SIDS babies have brain abnormalities. Brain abnormalities identified appear to affect the brainstem's ability to use and recycle serotonin which helps regulate breathing, heart rate, temperature, blood pressure and arousal. While the SIDS cases contained more serotonin using neurons, they appeared to contain fewer receptors for serotonin. Male SIDS infants had fewer serotonin receptors than did either female SIDS infants or control infants.

11. The Etiology of SIDS This research supports a triple risk model: 65 percent of the SIDS cases were sleeping prone or on their side. 23 percent were bedsharing at the time of death. It also indicates the need for continued public health messages on safe sleep.

12. The Epidemiology of SIDS Significant progress has been made:  SIDS deaths have declined more than 50 percent since 1992.  The frequency of stomach sleeping has declined from more than 70 percent in 1990 to 13 percent of U.S. infants in 2003.

13. The Epidemiology of SIDS BUT…  SIDS remains the leading cause of death among U.S. infants between one month and one year of age, and the third leading cause of death overall among infants younger than one year of age.  In 2004, 2,246 infants died of SIDS in the United States which is up from 2,162 infant deaths attributed to SIDS in 2003.  Disparities in SIDS risk factors and rates remain.

14. Understanding SIDS Risk  Stomach sleeping during naps and at night  Soft sleep surfaces and loose bedding  Overheating during sleep  Maternal smoking during pregnancy and smoke in the infant’s environment  Bedsharing with an adult or with other children

15. SIDS Rate and Sleep Position (1988-2003)

16. Unaccustomed Stomach Sleeping Infants who are accustomed to sleeping on their backs, then placed to sleep on their stomachs or sides, are at increased risk of SIDS (7 to 8 times greater than that of an infant always placed to sleep on his/her stomach or side.) (Mitchell and Thach, 1999) This danger is particularly evident in child care settings:  20 percent of SIDS deaths occur while the infant is in child care. (Moon, 2003)  Many child care providers continue to place infants to sleep on their stomachs.

17. Reducing SIDS Risk: Back to Sleep  Back sleeping is the single most effective action that caregivers can take to lower a baby’s risk of SIDS.  Stomach sleeping carries between 1.7 and 12.9 times the risk of SIDS as back sleeping.

18. Reducing SIDS Risk: Back to Sleep Stomach sleeping may increase the risk of SIDS by:  Increasing the probability that babies re-breathe expired breath  Causing upper-airway obstruction  Interfering with body heat dissipation Babies who sleep on their stomachs are less reactive to noise, experience sudden decreases in blood pressure and heart rate control and experience less movement, higher arousal thresholds and longer periods of deep sleep.

19. SIDS Risk Reduction Recommendations  Always place the baby on his or her back to sleep for naps and at night.  Place the baby to sleep on a firm sleep surface, such as on a safety-approved crib mattress, covered by a fitted sheet.  Keep soft objects, toys and loose bedding out of the baby’s sleep area.  Do not allow smoking around the baby.

20. SIDS Risk Reduction Recommendations  Keep the baby’s sleep area close to, but separate from, where parents sleep.  Consider using a clean, dry pacifier when placing the baby down to sleep.  Do not let the baby overheat during sleep.  Avoid products that claim to reduce the risk of SIDS.

21. SIDS Risk Reduction Recommendations  Do not use home monitors to reduce the risk of SIDS.  Reduce the chance that flat spots will develop on the baby’s head (“Tummy Time”).  Talk about SIDS to child care providers, grandparents, babysitters and everyone who cares for the baby.

22. Challenges to Back Sleeping  Fear of aspiration or choking  Comfort of the infant  Concern about a flattened skull  Advice from others

23. Fear of Aspiration “Data show no evidence of an increased risk of death from aspiration as a result of the ‘Back to Sleep’ program.” —Trends in Postneonatal Aspiration Deaths and Reclassification of Sudden Infant Death Syndrome: Impact of the ‘Back to Sleep’ Program, Michael H. Malloy, M.D., M.S., Pediatrics, Vol. 109, No. 4, April 2002, pp. 661–665.

24. Trachea Esophagus In the supine position, the trachea lies on top of the esophagus. Anything regurgitated or refluxed from the esophagus has to go against gravity to be aspirated into the trachea.

25. Conversely, when a baby is in the prone position, anything regurgitated or reflux will pool at the opening of the trachea. This makes it much easier for the baby to aspirate. Trachea Esophagus

26. Comfort of the Infant Babies sleeping on their backs do not sleep as deeply as those who lie on their stomachs. Babies sleeping on their stomachs sleep more deeply:  Less reactive to noise  Experience less movement  And less easily aroused than back sleepers  All place infant at higher risk of SIDS Babies get used to back sleep position over time. Products to keep infants sleeping on their backs are NOT recommended since they have not been tested for safety.

27. “Tummy Time” Flattened Skull Persistent flat spots on infant’s head is known as plagiocephaly.  Repeated time in one position can lead to positional plagiocephaly.  Data suggests number of babies with positional plagiocephaly has increased with the ‘Back to Sleep’ campaign. Daily ‘Tummy Time’ while awake and supervised helps reduce flat spots.

28. Advice From Others  Parents are influenced by their relatives.  Parents need to be prepared to counter contrary advice they receive from others.  Parents also must be prepared to insist on consistent use of back sleeping position when others care for the infant. (grand parents, babysitters, child care providers, family members)

29. AAP Sleep Environment Recommendations  A separate but proximate sleeping environment is recommended.  The risk of SIDS is reduced when infant sleeps in the same room with the mother.  A crib which meets safety standards is recommended.

30. Bedsharing & Crib Safety Roomsharing is preferred to bedsharing.  Placing an infant in a crib next to a parent’s bed is a safe way for a parent to sleep next to an infant.

31. Bedsharing & Breastfeeding “There is no basis at this time for encouraging bedsharing as a strategy to reduce SIDS risk.” -- American Academy of Pediatrics, August 1997 Tell parents that they may bring the baby in bed for breastfeeding and bonding. Once the feeding is complete, the safest place for baby is in his/her own separate sleep area which is firm, and has no blankets or sheets which can block the breathing or airway of the baby.

32. Pacifiers & SIDS Risk Reduction  In 2005, the American Academy of Pediatrics’ (AAP) Task Force on Sudden Infant Death Syndrome published their revised risk reduction recommendations including the use of a pacifier.  In 2005, a meta-analysis of the published research evaluating the strength of evidence on the use of pacifiers as a protective measure against SIDS was published showing that there is a strong correlation between pacifier use and a reduced risk of SIDS.

33. AAP Pacifier Recommendations  Offer a pacifier at nap time and bedtime.  Do not force an infant to use a pacifier.  Do not reinsert a pacifier after the infant falls asleep.  Pacifiers should not be coated in any sweet solutions.  For breastfed babies, the pacifier should be delayed until 1 month of age to ensure that breastfeeding is firmly established.

34. Pacifier Theories Although the physiologic mechanism to explain the protective nature of pacifiers against SIDS remains unclear, there are several major categories of theories. These include:  Infant sleep position: A pacifier may discourage an infant from turning to the stomach position while sleeping.  Infant arousal during sleep: Research on infant arousal and pacifier use shows that pacifier users have lower auditory thresholds than non-pacifier users  Airway and/or respiration effects: Pacifier use may make it easier to for infants to keep their airways free. Pacifier use also changes infant tongue position.  Unknown variable: Pacifier use may also be a marker for some undiscovered variable such as the mother’s behavior or an infant characteristic.

35. Concerns About Pacifier Usage Nurses may be reluctant to recommend pacifiers due to past research that indicated that pacifier use:  Increases dental problems  Reduces the rate of breastfeeding and duration of breastfeeding  Increases the risk of acute otitis media

36. Pacifiers and Teeth According to The American Academy of Pediatric Dentists (AAPD):  All types of nonnutritive (NNS) sucking impact teeth in the same way but pacifiers are an easier habit to break compared to finger or thumb sucking.  NNS is not a problem for teeth unless it continues after the child’s permanent teeth have come in.

37. Pacifiers & Breastfeeding  In randomized studies – the gold standard - pacifier use had no impact on prevalence or duration of breastfeeding at 6-months.  Early weaning and use of a pacifier was found to be a marker of breastfeeding difficulties, not the cause.

38. Pacifiers & Preterm Infants  Studies of pacifier usage by preterm infants is associated with shorter hospital stays.  A randomized controlled trial found no impact on breastfeeding by preterm infants who used a pacifier.

39. Pacifiers & Acute Otitis Media  While research studies have shown that pacifier use is associated with acute otitis media (AOM), it is important to consider that the incidence of AOM is low during the first 6-months of life when the risk of SIDS is highest.  Supine sleep position has also been found to be protective against AOM.

40. What Can Nurses Do? “Nurses and other professionals in WBUs and NICUs should implement SIDS risk reduction recommendations well before discharge.” -- American Academy of Pediatrics (2005)

41. “Parents tend to copy practices that they observe in hospital settings.”

42. Well Baby Nurseries  Nurses are aware of the supine position recommendation.  Nurses believe the supine position to have the lowest risk of SIDS.

43. Knowledge vs. Practice In a 1999 American Academy of Pediatrics study:  97 percent of nurses reported awareness of back sleeping recommendation  67 percent followed the recommendation  The majority cited “experience” or “the potential adverse consequences of the back position” as their reason for disregarding the recommendation

44. Observed Infant Sleep Position in the Newborn Nursery

45. Knowledge vs. Practice In a 2004 survey:  96 percent of nurses reported awareness of back sleeping recommendation.  75 percent reported using either side position or a mixture of side and back positioning.  Most nurses thought side sleeping was still acceptable. Nursery staff do not uniformly recommend back sleeping position.

46. Why do newborn nursery staff choose the specific infant sleep positions?

47. Side Position Nurses can use the side position immediately following delivery to assist the baby in clearing amniotic fluids. Once the infant has cleared all fluids (usually within a few hours of birth) they should then be placed to sleep on their backs to sleep. Side sleeping is not advised as normal practice.

48. Nurses as Role Models Nurses can model SIDS risk-reduction techniques to ensure that families know how to reduce SIDS risk. Nurses who placed infants to sleep on their backs during the postpartum hospital stay changed parents’ behaviors significantly. The most critical opportunity during which nurses can influence parents’ behavior is during the 24 to 48 hours following delivery.

49. Modeling Demonstrate to parents the correct position to place their infants to sleep.

50. Spreading the Message Studies indicate that nursery staff do not uniformly recommend the back sleeping position to parents. Training nursery staff to emphasize back sleeping education with parents does change parent behavior.

51. Encouraging Parents to Take Action Conditions for “learning through observation:”  Attention. Parents must be paying attention.  Retention. Imagery and language are important. Consistently model the behavior of placing infants to sleep on their backs.

52. Encouraging Parents to Take Action  Reproduction. Patients must model the behavior nurses demonstrate. Provide opportunities for parents to practice placing the baby to sleep on his or her back. Help parents learn to communicate to others why back sleeping is safest (e.g., role play).  Motivation. Provide convincing arguments. Demonstrate how easy it is to do. Reinforce that parents are doing what is best. Provide ongoing encouragement and praise.

53. Parent Education Infant care often has its roots in tradition and experience. More than 15 percent of African American infants are placed to sleep on their stomachs.  Back sleeping may be most important message. Infants in American Indian/Alaska Native families are more likely to be overdressed for sleep.  Avoiding overheating may be most important message.

54. Parent Education: Back to Sleep  Demonstrate to parents placing the baby on his or her back to sleep for naps and at night.  Stress the need to place the baby to sleep on a firm sleep surface covered by a fitted sheet.

55. Bedsharing & Crib Safety Inform parents/caregivers to place their infant to sleep in a crib or bassinet that meets the U.S. Consumer Product Safety Commission’s safety standards.

56. Bedsharing Parent Education  Stress to parent/caregiver that interactions with the infant at home need to occur under safe conditions when both are awake and alert.  Discuss how bed- extenders and small cribs near the adult bed to facilitate breastfeeding should be addressed.

57. Bedsharing and Breastfeeding Parent Education  Inform parents/caregivers about the multiple dangers of an infant sleeping in an adult bed prior to discharge.  Clearly point out the extreme danger of bedsharing on couches and with other children.  Discuss breastfeeding and returning the infant to a proximate, safe sleeping area and surface.

58. Breastfeeding Parent Education and Support Discuss feeding options with parents. Proactively encourage and assist mothers in efforts to breastfeed. Weigh the baby before and after feedings to help the mother build her confidence. Provide the mother with resources for ongoing support once she leaves the hospital. Provide her with ointment for sore nipples or cool clothes for engorgement. Offer breast pumps.

59. Bedding/Soft Materials Parent Education  Ask parents/caregivers to compare the normal temperature of their home with that of the WBU and figure out with you how to adjust the home environment or the infant’s clothing.  Ask parents/caregivers to look for signs of overheating such as fever and sweating and signs of being cold such as cold hands and skin mottling.

60. Bedding/Soft Materials Parent Education  Encourage parents/caregivers to consider using a wearable blanket or dressing the infant in layers as an alternative to loose blankets.  Show parents/caregivers, using the bassinet, that no loose or soft items are to be in the crib or bassinet with the infant.

61. Swaddling/ Bundling Policy  Encourage parents/caregivers to speak with their physician about swaddling.  Nurses may need to demonstrate swaddling.  Blankets used for swaddling should come no higher than the infant’s chest.

62. Smoking Parent Education  Make parents/caregivers aware of the dangers of anyone smoking around the infant.  Strongly warn parents/caregiver that bedsharing may be more dangerous if the mother smokes.  Encourage parents/caregivers to stop smoking and create a smoke-free environment for the infant.

63. Pacifier Use Parent Education  Suggest to parents that they consider offering a pacifier at nap time and bedtime.  Discuss waiting one month before offering a pacifier to a breastfeeding baby.  Explain that the risk of SIDS is very low during the first month and it is important to ensure that the baby is nursing well before introducing a pacifier.

64. Pacifier Use Parent Education  Tell parents not to use a pacifier as a substitute for nursing or feeding.  Pacifiers should be offered after a feeding or when a baby is put down to sleep.  Tell parents not to put a pacifier back in a baby’s mouth if it falls out after he or she falls asleep.  Explain that babies who use a pacifier at nap and nighttime are protected, even if the pacifier falls out of their mouth after they fall asleep.

65. Parent Education Summary 1.Ask about how and where the baby will be sleeping. 2.Provide SIDS risk reduction educational materials. 3.Guide parents in modifying the crib and home environment.

66. Resources National Institute of Child Health and Human Development, Back to Sleep Campaign 1-800-505-CRIB www.nichd.nih.gov/SIDS First Candle/SIDS Alliance, National SIDS and Infant Death Program Support Center 1-800-221-SIDS www.firstcandle.org

67. Hospital Onesies

68. Resource Tools