pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

SIDS, “Back To Sleep” and Bed Sharing

Nearly ten years is enough time that some of you may not remember when our best advice was to always put a baby to bed facing downward so that he wouldn’t choke if he “upchucked” a bit. Things change and to me that was a big one. I almost felt like I needed to phone everyone I had ever given that advice to and issue a retraction because the advice is now completely the opposite.

It was back then that researchers were, after a very long and difficult effort, able to link some of the very rare (but devastating) SIDS deaths to sleeping face down and a build up of carbon dioxide in some infants. The widely publicized “back to sleep” program (i.e. put them on their back to go to sleep – get it?) was VERY effective. BUT it’s as if some people have forgotten about everything else.

You probably know that SIDS is defined as the sudden unexpected death during sleep of an infant younger than 1 year which remains unexplained after a thorough investigation, including a complete autopsy and review of the circumstances of death and the clinical history. You may not be aware that its incidence has been cut in half in the past fifteen or so years.

A study was done to check up on the results of the back-to-sleep program and found that the percentage of infants who died of SIDS, and who were found to have been sleeping prone, decreased from 84% in 1991-93 to 48% in ’98-’08. That was WAY more impact than when we discovered that feeding infants honey was also a link which only brought the incidence down to about one infant in every thousand.

infant sleeping - back to sleep programThe Back To Sleep campaign led to a more than 50% drop in SIDS in the 10 years after its implementation; however, the incidence has now plateaued and still remains the leading cause of post-neonatal infant mortality in the United States – 0.53/1000 infants.

That’s because there isn’t ONLY one cause of SIDS. There are apparently many AND there are also several predisposing factors as well and the point of me writing this article is to point out that just because one of the causes gets some well deserved press WE CAN’T FORGET WHAT WE ALREADY HAVE LEARNED. The same study that showed us the benefit of back-to-sleep showed some equally disturbing news.

Bed-sharing nearly doubled (19% to 38%) and the prematurity rate increased also from 20 to 29% of births. Especially in infants younger than two months, sleeping with another person is a HUGE risk – not worth taking. The study that I’m referencing in the journal Pediatrics (see below) discovered that the percentage of infants who had died of SIDS and were found in an adult bed was 45%, up from 23% before the back-to-sleep program.

The risk factors and apparent predisposing factors for SIDS are divided into two groups: Intrinsic and Extrinsic. The Intrinsic are: being male, black, born at less than 37 weeks gestation (premature) and having a mother who either drank alcohol or smoked while she was pregnant.

The Extrinsic risk factors are: sleeping in the prone/side position; head being covered; sleeping on an adult mattress couch or playpen; having soft bedding; bed-sharing; and having an upper respiratory tract infection. Not any one of these is the single cause. It is what is called multi-factorial.

It is known that the more of them you have, the higher the risk of SIDS. Obviously, even though these are the correlations which are noted, there are some that you can do nothing about. The others, however, we can’t forget about.

Just as important as sleeping on your back for an infant is NOT sleeping with a parent or on soft, poofy bedding or having your head covered or any one of the other things listed.

The San Diego Medical Examiner’s Office records of infant deaths between 1991 and 2008 were examined and found to reveal that 60% of all unexpected infant deaths were attributed to SIDS (568). The records showed that almost 60% of infants who died of SIDS had at least one intrinsic and two extrinsic factors; so, there is still plenty of room for improvement.

“Although SIDS is a disease, and these risk factors are not causative of SIDS in and of themselves, risk reduction campaigns that emphasize the importance of avoiding multiple and simultaneous SIDS risks are essential,” is what the authors of the study say – who can possibly disagree?

[Pediatrics. 2012;129:630-638]

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