Chris's Blog

I’ve recently read all of the recent guidelines and studies on SIDS and spoken to several NICU doctors and nurses. Below is a summary of everything useful that I learned. Please also see the reference links for the original source material.

Actionable Takeaways

• • Follow AAP 2016 SIDS recommendation / NIH “Safe to Sleep” Campaign (see below material). [1,2,4,5]
  • No hat on baby while sleeping [2, NICU RN during discharge course]
  • Consider providing a pacifier before sleeping. Even if use of pacifier is short, there seems to be some evidence to show that it helps reduce the risk of SIDS. They are OK with leaving pacifier in the sleep area, but I think it’s probably better to remove it after it falls out of the baby’s mouth. [2]
  • Don’t leave babies sleeping in non-CPSC approved sleep surfaces. In particular, do not leave your baby in a car seat, stroller, swing, infant carrier, or sling. Move them to an approved sleeping surface. [4]
  • Maybe consider increasing room ventilation by leaving a window open or using a fan (though the evidence supporting room ventilation as a means to reduce SIDS risk is weak enough that the AAP does not actually include it in their recommendations) [2].
    • Including use of bedroom heating during last sleep [12]
    • Using a fan [13]
    • Well-ventilated room [14]
  • Recommendation from NICU doctors on intervention if witnessing an episode of sleep apnea, baby not breathing, or other Apparent Life Threatening Event (ALTE is something that is frightening to observer usually involving apnea, color change, marked limpness, choking, etc):
    • NICU RN: Give her some time to self recover, like 10 seconds. Then start stimulating her (rubbing her back, changing her position). If she was feeding take away from breast or bottle and change position. Do not shake baby in attempt to awake.

• NICU Doctor: Same advice as above. On when to start CPR: if skin color changes, or if unresponsive after stimulation. Always start with breaths first, quite often that is enough.

Knowledge Takeaways

• “Sleep apnea”, where the baby stops breathing while sleeping is common, and the babies that experienced it during studies, did not die from it. In the CHIME study, a longitudinal study conducted in early 2000s involving 1,000+ babies and home monitoring devices, they found 41% of all infants experienced at least one sleep apnea event where the infant stops breathing for at least 20 seconds or a heart rate of <80 bpm for more than 5 seconds (for infants <44 weeks) [9]. 10% of all infants had “extreme events” with breathing that stopped for at least 30 seconds.
• There has not been any evidence that “sleep apnea” and ALTE (Apparent Life Threatening Events) are precursors to SIDS. [9]
  • “Premature babies are more likely to experience sleep apnea. Highest rates of extreme events were observed among infants who were 43 or less weeks.”
  • “Peak incidence of SIDS generally occurs at older mean Postconceptional ages (PCA) of 44.2, 46.8, and 52.7 weeks for infants born at 24 to 28, 29 to 32, and 37 weeks, respectively. These differences in timing suggest that extreme events are not likely to be immediate precursors to SIDS, although it does not eliminate the possibility that they are markers of vulnerability. and die of SIDS.”
• There is no solid evidence that SIDS is genetic [2].
• There is no evidence that the use of home monitoring will SIDS.
• My thoughts:
  • SIDS is a collection of different causes of death, often times these deaths are completely unexplained. SIDS risk factors are very similar to suffocation. So all the recommendations that Moon, et al provides “were developed to reduce the risk of SIDS and sleep related suffocation, asphyxia, and entrapment among infants”.
  • There’s an unsettling amount that is unknown about SIDS:
    • It might be issues with the brain stem and autonomous functions that regulate breathing or heart rate.
    • It might be, and often is, related to suffocation where loose clothing, loose bedding, rebreathing, and other factors may lead to death.
    • It might be related to overheating and over-bundling. Some experts hypothesize that it stems from some event or development prior to birth (e.g. women who smoke or drink while pregnant have babies with higher Odds Ratios [OR] for SIDS).
    • It sometimes is environmental (sleeping in same room as parents reduces [OR], exposure to smoke).
    • In some studies, incidents of SIDS was initially misdiagnosed, and it ended up being infanticide or other not actual SIDS causes.
  • Because the causes are varied, there needs to be better segmentation by actual underlying cause, to understand and prevent SIDS. Because it occurs relatively infrequently (91 deaths out of 100,000 births or approximately 0.1%), and because SIDS is often unexplained, it is difficult to segment and analyze the constituent causes. Thus, the SIDS recommendations are generally around preventing suffocation, which has undoubtedly been a leading cause.
  • It’s unsettling to know how little is known, and even more unsettling to know that premature babies are at higher risk of SIDS. [15]

References

What I found most helpful in reviewing the literature was going through the references in the AAP 2016 technical report [2].

1. AAP 2016 SIDS recommendations
2. AAP 2016 Evidence base for the above recommendations (actual facts and research to support recommendations) 
3. [old] AAP 2011 SIDS recommendations: https://timedotcom.files.wordpress.com/2014/11/e1341.full.pdf
4. Article by Rachel Moon (author of above): https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
5. NIH Safe to Sleep two sheeter (their  “Safe to Sleep” campaign is based on American  Academy of Pediatric’s Taskforce on SIDS. Rachel Y. Moon, MD heads the task force
6. 20 page version of above two pager:
7. for parents
8. 20 page version of above two pager, for grandparents
9. Cardiorespiratory Events Recorded on Home Monitors: Comparison of Healthy Infants With Those at Increased Risk for SIDS
10. Apnea, Sudden Infant Death Syndrome, and Home Monitoring (AAP Policy Statement) http://pediatrics.aappublications.org/content/111/4/914
11. https://www.cdc.gov/sids/data.htm
12. https://www.ncbi.nlm.nih.gov/pubmed/7479275
13. https://www.ncbi.nlm.nih.gov/pubmed/18838649
14. https://www.sciencedirect.com/science/article/pii/0277953689900592 (this paper is very old)
15. http://pediatrics.aappublications.org/content/early/2017/06/01/peds.2016-3334 ; https://news.rutgers.edu/news/premature-infants-greater-risk-sids/20170625; https://www.webmd.com/parenting/baby/news/20060207/longer-sids-risk-premature-babies#1

I’ve recently gotten CPR certified, and also even more recently took an infant-specific CPR class. One of the hardest parts of CPR training is getting the correct chest compression pace. Instructors use to say do chest compressions to the beat of Bee Gee’s Staying Alive, which is roughly 100 beats per minute, fairly close to the ideal chest compression per minute pace. However, this is not the correct pace for infants, where pacing should be even faster (somewhere between 100-120, often recommended to be 110). Also, unless you regularly listening to Staying Alive, you probably will misremember the beat. Which is why a fairly inexpensive digital portable metronome is a nice training tool. This one on Amazon sells for less than $10, and remembers the last BPM set (so you could leave it at 110, or whatever bpm of your choosing).