This November (2016) the American Academy of Pediatrics published an update of its Policy Statement on recommendations for a safe sleeping environment, whose intent is to reduce the risk of SIDS. The biggest news coming out of this update is the recommendations relating to which room infants should sleep in.
The publication of this Policy Statement gives us all an opportunity to review the basics when it comes to SIDS and what we know can reduce the chance of this horrible catastrophe occurring. So let’s take a look at what SIDS is and what it isn’t, the nature of the evidence for what works to prevent it, and the recommendations.
What is SIDS and what Isn’t It?
All life is sadly at risk for sudden death. Each of us is at risk for this terrible event, but fortunately it is very, very rare.
The same of course is true for infants.
If sudden death occurs before someone turns one and there is no known cause, then this is Sudden Infant Death Syndrome (SIDS).
Both of the elements of this definition are very important to keep in mind, for it to be SIDS, the sudden death cannot happen over age 1.
And, if any known cause is identified, it is not SIDS.
So SIDS is not a sudden death in an older child or adult. It is not a death whose cause is known in an infant. Known causes could include severe prematurity, severe congenital anomalies, or severe infections.
As we learn more about how the body works, and how its workings go wrong, there will be fewer and fewer major events, like sudden death, that cannot have a cause found. Just learning more about what causes what decreases the incidence of SIDS. A new infection discovered, for example, that causes loss of life, will be classified as a case of that infection rather than SIDS if an infant loses life from it, for example.
The fact that at the heart of the definition of SIDS is that we do not know the cause, means that SIDS is not a single disease or problem. If we knew everything about every death, the current cases of SIDS would turn into a large number of known causes.
And, since SIDS is truly a mix of all sorts of causes of death, united only in our inability to explain, it is very, very hard to devise prevention. It is one thing to learn how to prevent a known cause, it is far harder to do so for a mix of unknown causes.
What Do We Know About What Prevents SIDS
Given the understanding that there really is no such thing as one disease called SIDS, that it really is a mixture of unknown causes, one would think there would be no specific step that could be taken to prevent SIDS. After all, actions taken to prevent one specific disease will likely not prevent another unrelated disease.
But fortunately, there are steps that can be taken, and they really do work.
m 1992 to 2001, some steps taken across the US have cut the risk of SIDS down by over 50%!
We don’t know why they work, since by definition all cases of SIDS have unknown causes of death, but they work, so we recommend them.
Again, in the absence of actual knowledge of the cause of SIDS, our search for what works to prevent is forced to look at associations, then try them out.
What does that mean? Well, suppose we just say that tying a red ribbon on the left leg of a baby prevents SIDS. We could look at all cases of SIDS and see how many of those babies wore a red ribbon on the left leg, then look at a bunch of healthy babies who were similar in all ways to those who had SIDS- same range of ages, weights, gender, and many other measures, and see how many of them wear a red ribbon on the left leg.
If all the babies with SIDS had no red ribbon on the left leg, and all the babies without SIDS did wear a red ribbon on the left leg, that would establish an association.
But as anyone reading this scenario would guess, that does not prove cause. It could true that any baby wearing a red ribbon on the left leg does not suddenly pass away before turning 1, but the reason may have nothing to do with red ribbons. Maybe all babies who wear red ribbons do so because they sleep on their backs, and all babies without ribbons sleep on their tummies. The cause would be sleep position, in this example, and the association would be the ribbon.
The only way to know if wearing a red ribbon on the left leg actually causes SIDS, is to take a large enough number of infants, and split them into two comparable groups, and place a red ribbon on their left leg on one of the groups, and not on the other. And then see if that’s the only difference between the groups, does the outcome change.
Back to Sleep
This process is exactly what led to the back to sleep recommendation. It was noticed for many years that infants in China who slept on their back had half the SIDS rate of infants in Europe and America who slept on their stomach. For the longest time, it was assumed the differences reflected local genetic differences. But some years ago, researchers in Australia and New Zealand, in the Eastern Hemisphere, tried taking European infants and placing them on their back to sleep, and in every instance, every village and city that adopted the back position saw their SIDS rate drop in half. The new way spread to Europe and the Americas, and so we now have every baby put to bed on their back, and as noted above, SIDS rates have indeed dropped 50%.
This is just how we talked about associations and causes above. The difference in SIDS rates between China and America was an association. The actual result of changing face down sleeping to face up sleeping proved that the position was a cause.
Keep in mind, even today, no one knows why sleeping on your back in infancy cuts SIDS rates in half, but it does, so we do.
The AAP Recommendations for Safe Sleep and Less SIDS
The paper lists 15 recommendations, the first 11 actually relate to the premise that if you do them there will be less SIDS. And the last 4 are comments on related SIDS matters. Here is the list, paraphrased for brevity:
- Infants should sleep on their back for the first year of their life, at every sleep.
- Infants should sleep on a firm surface.
- Breast-feeding is preferable to bottle-feeding.
- Infants should sleep in their parents’ room for the first 6 months for sure, 12 months would be best. And, do not have infants sleeping in the same bed as their parents.
- Keep the infant’s bed free of objects, including blankets, animals, bumpers.
- Use a pacifier once nursing is established.
- Avoid all exposure to tobacco smoke.
- Avoid parental exposure to alcohol and/or drugs
- Do not overheat your infant or cover their head.
- Be sure during pregnancy that you receive prenatal care.
- Make sure your infant(s) is fully immunized.
- Avoid commercial devices such as sleeping wedges, they do not prevent SIDS.
- Do not use monitors to try to prevent SIDS, they simply do not work.
- Use tummy time to reduce head flattening in the back, the time needed to achieve this goal is not known.
- Swaddling neither makes SIDS more common nor more infrequent, so it is OK to use.
Of these 15 recommendations, numbers 1, 7, and 8 have the most robust proof that doing these things will drop the chance of SIDS happening.
We just discussed how robust the evidence is that placing your infant on their back to sleep is in reducing the chances of SIDS happening, it is a very real impact because the rates really dropped 50% when it was instituted.
Many, many studies have firmly established that exposure to tobacco smoke sharply increases the incidence of SIDS and reducing the exposure drops that risk.
Use of alcohol and other drugs also has been firmly established as a serious cause of rolling over intoxicated on your infant causing suffocation.
As you can see, the last 4 recommendations do not prevent SIDS, per se, but do offer useful advice about how devices and monitors do not help with preventing SIDS, tummy time can prevent some head flattening that happens if an infant sleeps on their back, and swaddling is fine.
That leaves recommendations 2, 3, 4, 5, 6, 9, 10, and 11 to discuss.
Let’s look at these in several groups:
Prenatal care, Immunizing, Breast Feeding.
My comment on these three recommendations (#3, 10, and 11) is that they are very good ideas. No matter what their role in SIDS prevention, they should be supported, and to the extent they prevent SIDS all the more so. Let’s do them!
Now that leaves recommendations 2, 4, 5, 6, and 9 to discuss.
Bed setting- firm and empty
Two of the remaining recommendations have to do with the bedding environment, number 2 has to do with a firm mattress, and keeping the bed free of objects such as blankets, pillows, bumpers, stuffed animals, and toys.
We support these recommendation, but the evidence to date seems to me to be less than conclusive. To be specific, the association between soft bedding and SIDS, and things in the bed and SIDS is well established, but the causation seems less than established. It remains unclear that actual decreases in SIDS result from keeping stuffed animals out of the crib, or bumpers, or making the mattress firm. Until this question is settled, I see no real cost or down side to following this recommendation, so we fully support it, all the while staying tuned to see if these recommendation withstand the test of time.
That leaves recommendations 4, 6, and 9- room sharing, pacifiers, and overheating
Again, we support this recommendation, though this one too seems established as an association and not yet a cause. So until we learn more, no problem avoiding overheating and keeping your infant’s head uncovered.
Pacifiers are a very interesting phenomenon. As with many other observations, this one too is full of associations but little proof of cause. The association is very clear, in many studies, babies who used a pacifier had a substantially lower risk of SIDS, often a 50% reduction. But the forward power of cause has not been established. That is, if you take a community and change it from a no pacifier to a high pacifier rate of use, and change nothing else, does SIDS actually decrease.
This is once again an instance of why not? If it turns out to help, it is an easy enough step to take, and we support it.
One more word on pacifiers, there is much discussion on their impact on nursing. I find that pacifiers, at least in the limited experience of our practice, have impact at all on nursing. Babies who latch on well and nurse well do so whether a pacifier is used or not, and babies who struggle do so again whether a pacifier is in use or not. Many official agencies, such as the World Health Organization, advise strongly against pacifier use in the first days of life for fear use of a pacifier will discourage a newborn from initiating nursing. We find just to the contrary, many newborns start right off with a fierce instinct to suck all day and night and without a pacifier, that constant sucking chews up Mom’s nipples which really does make nursing miserable.
That leaves one more recommendation, perhaps the one with the most questions, and clearly the newest one, #4, all about sharing rooms and beds.
The last recommendation, recommendation #4 states very clearly that infants should sleep in their parent’s room and should be in their own bed.
Once again this recommendation results from observed associations, but causation is not established.
Again, that means a far greater proportion of infants experiencing SIDS had the observed experience than infants who did not experience SIDS.
Let’s first take a long at sharing beds.
One item that stands out from the studies of bed sharing is the sofa. In some studies, infants who slept on a sofa with an adult had a staggering 49 fold (!) increase in their risk of SIDS or suffocation. This is enough for us to strongly urge all families to never sleep on a sofa with their infant.
But it gets more complicated when it comes to sharing a bed with your Mom or Dad. Clearly, many studies reveal that if the parents are smoking, drinking, or using drugs, the risk of suffocation and SIDS goes up, and dramatically. But interestingly, in a number of studies if an infant sleeps with Mom or Dad, and Mom and Dad neither smoke, drink, or get high, the risk of SIDS does not rise. One study from England, looking at SIDS events across a sample of 17 million population, found that overall the risk of SIDS goes up about 10-fold for all infants, but that risk goes away after 14 weeks of age, and goes away all together if the parents neither smoke, drink, or use drugs. A similar result was found in a review of 20 European centers. These two papers are the 2 of the four cited to support recommendation #4 in the AAP Policy Statement. One paper, the only other recent study cited for recommendation #4, was from Scotland, and it found the risk of SIDS increased for infants in parent’s bed even if the mother nursed and did not smoke.
Again, these are all association studies, no one has found that a group of infants consigned to no sleeping in parent’s bed actually experienced a reduction in the number of SIDS cases. This can be done, as noted, it has been seen with the intervention of putting infants to sleep on their backs, it cut SIDS numbers in half.
But it has not been tried with having infants only sleep out of their parent’s bed.
I spend some time on this point, because this recommendation begins to interfere with family life more than the recommendation to use a firm mattress, not cover an infant’s head, or use a pacifier. Infants have been sleeping with Mom and Dad for a very long time, perhaps since humanity first evolved. To tell families they may no longer do this, or that it is in fact dangerous, is a major life-changing intervention for many families.
Out conclusion is cautious. So many studies find the risk of sleeping together is minimized by not smoking, drinking, or getting high. And, no studies have shown taking such a step can be assured to reduce the number of tragic SIDS events. Putting that all together, we support further research on this subject.
In the meantime we urge all families to never sleep with their infant even after a glass of wine and never ever after smoking. If infants sleep with parents, it should be on firm mattresses with nothing to cover the infant’s head or face, sleeping on their back.
Sharing a Room
Perhaps the most powerful of these recommendations has to do with sleeping in a room together. The recommendation cites 4 references for this point, and 3 are current articles, each of which have been noted above. The fourth is an out of print book for which I have no comment.
When it comes to sleeping in the same room, the two of the three cited articles looked at the trends associated with sleeping in the same room, and both presented a simple association. Infants sleeping in the parent’s room had fewer cases of SIDS than those who slept in a separate room. In one study the risk went up 10 times, in another 26 times, Both papers stated the reason for this association was completely unknown.
This is the most recent of the cited SIDS observations, we actually know very little about it, beyond that the risk was observed.
It is on the basis of these observations that the AAP Policy Statement makes a clear recommendation that infants sleep in their parent’s room, in a separate bed, for sure for 6 months, preferably for the first 12.
Our view on this last recommendation under consideration is in line with questions raised by The New York Times (http://www.nytimes.com/2016/11/06/upshot/should-your-baby-really-sleep-in-the-same-room-as-you.html?_r=0)
The Times review of this recommendation clearly takes note of the weakness of an association, versus the strength of evidence that an action clearly causes an outcome. But the Times also notes that the cited studies collected data on SIDS when SIDS was far more frequent, it simply is less common now. We don’t know, but the question is raised as to whether having your own bedroom might have less impact today in a time when SIDS is rarer.
Again, our own view is that this recommendation asks many parents to do something fairly radical in the US- have all infants sleep every night in their parent’s room for at least 6 months, without evidence that this will definitely drop the risk of SIDS.
So our advice is to have your infant sleep in your bedroom for at least the first 6 months, and if possible, a year, but know that it is very likely fine to have them sleep in their own room, we simply don’t have enough proof to say it is not OK at this time.
- SIDS is a true tragedy, one of the great fears of all of us parents.
- Strangely enough, there is no actual disease or condition known as SIDS. SIDS is defined by any sudden death whose cause cannot be found, occurring in the first year of life. As a result, infants suffering this tragedy likely have a wide variety of conditions and causes for the sudden death.
- Also, as we learn what causes sudden death, the number of SIDS cases will decrease. Once we know the cause in each instance, SIDS will be no more.
- Since SIDS is actually a collection of events, there is no way to determine one action to keep all of these events from happening. That leaves us all looking for actions that can reliably reduce the risk, even across a wide variety of causes.
- The search for actions to take to lower the risk of SIDS nearly always starts with looking for associations. Associations are relatively easy to find. If you compare two reasonably similar groups of infants, one who have passed from SIDS and one group that has not, then you can ask, how do they differ. Any event in which they differ a lot is an .
- A cause is much harder to prove. Many, many associations turn out not to be causes. An event is a cause only if eliminating the event results in and actual drop in the incidence of SIDS in the community.
- The American Academy of Pediatrics regularly updates its recommendations to parents to help them take steps to prevent SIDS, the most recent update was published just this month, November, 2016. This update contains 15 recommendations which are all listed above.
- Of those 15 recommendations, 3 are very well established as actually dropping the rate of SIDS in communities around the world. They are
- Always put your infant to sleep on their back, through the first year of life, always. This action has eliminated 50% of all SIDS death when done.
- The recommendation to never smoke around an infant also has clear proof that it prevents SIDS, with special note that smoking when sleeping in the same bed accounts for much of the risk of SIDS when sharing a bed with an infant.
- The recommendation to never drink or do drugs around an infant also has clear proof that it prevents SIDS, with special note that drinking or using drugs when sleeping in the same bed accounts for much of the risk of SIDS when sharing a bed with an infant.
- Many of the recommendations have little to do with reducing the risk of SIDS but rather offer useful advice about how devices and monitors do not help with preventing SIDS, tummy time can prevent some head flattening that happens if an infant sleeps on their back, and swaddling is fine.
- All of the remaining recommendations rest on the finding of strong associations with these events, but no proof of cause. It appears that following these recommendations may reduce the risk of SIDS, but we are not sure of that at this time. When it comes to breast feeding, using a pacifier, getting prenatal care, getting the infant immunized, avoiding overheating, using a firm bed surface free of objects and blankets and bumpers and pillows, we fully support following the recommendations, even if in time some of them turn out not to actually reduce the risk of SIDS. Until we know for sure, these associations may turn out to be important, and there is no very good reason not to follow them.
- The same could be said for the last remaining recommendation we comment on, namely, to have your infant sleep in the same room but not bed as you for at least the first 6 months, preferably the first year. The association with SIDS is strong, babies sleeping on other rooms had 10-28 times greater rates of SIDS, but there are relatively new observations, there simply is no information that proves or disproves this is actually a cause of SIDS, is available. Our stance on room sharing is that it is very reasonable to observe this recommendation, but the proof is weak enough, and the intervention so large for many families, that more information is reasonably required before families feel forced to comply with this one.
- On bed sharing, sleeping with an infant is very dangerous on a sofa, so don’t. SIDS rates go up if you sleep with an infant if you smoke or drink, so don’t. If you don’t smoke, drink, or get high, the increased risk of SIDS from sleeping in bed together drops, often to as low as not sleeping together at all. So, if all other recommendations are being observed, sleeping together in the same bed with your baby should be safe.
Once again, SIDS is a terrible, terrible tragedy. As a conglomeration of all the unknown causes of such a sudden and horrible loss, it has no one solution,
The AAP recommendations will help further reduce the risk of SIDS, just placing your infant on their back to sleep has eliminated half of all SIDS!
May such an event never happen again!
To your health,
Dr. Arthur Lavin