FROM THE AMERICAN ACADEMY OF

TECHNICAL REPORT SIDS and Other Sleep-Related Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment

TASK FORCE ON SUDDEN INFANT DEATH SYNDROME KEY WORDS abstract SIDS, sudden infant death, infant mortality, sleep position, - Despite a major decrease in the incidence of sudden infant death syn- sharing, tobacco, pacifier, , , sleep surface drome (SIDS) since the American Academy of Pediatrics (AAP) released ABBREVIATIONS CPSC—Consumer Product Safety Commission its recommendation in 1992 that be placed for sleep in a non- AAP—American Academy of Pediatrics prone position, this decline has plateaued in recent years. Concur- SIDS—sudden infant death syndrome rently, other causes of sudden unexpected infant death occurring dur- SUID—sudden unexpected infant death ICD—International Classification of Diseases ing sleep (sleep-related deaths), including suffocation, asphyxia, and ASSB—accidental suffocation and strangulation in bed entrapment, and ill-defined or unspecified causes of death have in- 5-HT—5-hydroxytryptamine creased in incidence, particularly since the AAP published its last state- OR—odds ratio CI—confidence interval ment on SIDS in 2005. It has become increasingly important to address The guidance in this report does not indicate an exclusive these other causes of sleep-related infant death. Many of the modifi- course of treatment or serve as a standard of medical care. able and nonmodifiable risk factors for SIDS and suffocation are strik- Variations, taking into account individual circumstances, may be ingly similar. The AAP, therefore, is expanding its recommendations appropriate. from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, , room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommenda- tions is discussed in detail in this technical report. The recommenda- tions are published in the accompanying “Policy Statement—Sudden www.pediatrics.org/cgi/doi/10.1542/peds.2011-2285 Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expan- doi:10.1542/peds.2011-2285 sion of Recommendations for a Safe Infant Sleeping Environment,” which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/ All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, peds.2011-2220). Pediatrics 2011;128:e1341–e1367 revised, or retired at or before that time. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). METHODOLOGY Copyright © 2011 by the American Academy of Pediatrics Literature searches using PubMed were conducted for each of the topics in this technical report and concentrated on articles published since 2005 (when the last policy statement1 was published). In addition, to provide additional information regarding sleep-environment haz- ards, a white paper was solicited from the US Consumer Product Safety Commission (CPSC).2 Strength of evidence for recommendations3 was determined by the task force members. Draft versions of the policy statement4 and technical report were submitted to relevant commit- tees and sections of the American Academy of Pediatrics (AAP) for review and comment. After the appropriate revisions were made, a

PEDIATRICS Volume 128, Number 5, November 2011 e1341 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 final version was submitted to the AAP caregiver interviews can provide addi- unknown or unspecified. A death is Executive Committee and Board of Di- tional evidence to assist death certifi- coded as “accidental suffocation and rectors for final approval. ers (ie, medical examiners and coro- strangulation in bed” (ASSB) (ICD-10 ners) in accurately determining the W75) when the terms “asphyxia,” “as- SUDDEN INFANT DEATH SYNDROME cause of death. However, death certifi- phyxiated,” “asphyxiation,” “stran- AND SUDDEN UNEXPECTED INFANT ers represent a diverse group with gled,” “strangulated,” “strangulation,” DEATH: DEFINITIONS AND varying levels of skills and education “suffocated,” or “suffocation” are re- DIAGNOSTIC ISSUES as well as diagnostic preferences. Re- ported, along with the terms “bed” or Sudden Infant Death Syndrome cently, much attention has been fo- “crib.” This code also includes deaths and Sudden Unexpected Infant cused on reporting differences among while sleeping on couches and Death death certifiers. At one extreme, some armchairs. certifiers have abandoned using SIDS Although SIDS was defined somewhat Sudden infant death syndrome (SIDS) as a cause-of-death explanation.7 At loosely until the mid-1980s, there was is a cause assigned to infant deaths the other extreme, some certifiers will minimal change in the incidence of that cannot be explained after a thor- not classify a death as suffocation in SIDS in the United States until the early ough case investigation that includes a the absence of a pathologic marker of 1990s. In 1992, in response to epidemi- scene investigation, autopsy, and re- asphyxia at autopsy (ie, pathologic 5 ologic reports from Europe and Aus- view of the clinical history. Sudden un- findings diagnostic of oronasal occlu- tralia, the AAP recommended that in- expected infant death (SUID), also sion or chest compression8), even with fants be placed for sleep in a nonprone known as sudden unexpected death in strong evidence from the scene inves- position as a strategy for reducing the infancy (SUDI), is a term used to de- tigation that suggests a probable acci- risk of SIDS.9 The “Back to Sleep” cam- scribe any sudden and unexpected dental suffocation. death, whether explained or unex- paign was initiated in 1994 under the plained (including SIDS), that occurs US Trends in SIDS, Other SUIDs, leadership of the National Institute of during infancy. After case investiga- and Postneonatal Mortality Child Health and Human Development tion, SUIDs can be attributed to suffo- To monitor trends in SIDS and other as a joint effort of the Maternal and cation, asphyxia, entrapment, infec- SUIDs nationally, the United States Child Health Bureau of the Health Re- tion, ingestions, metabolic diseases, classifies diseases and injuries ac- sources and Services Administration, and trauma (accidental or nonacci- cording to the International Classifica- the AAP, the SIDS Alliance (now First dental). The distinction between SIDS tion of Diseases (ICD) diagnostic Candle), and the Association of SIDS and other SUIDs, particularly those codes. This classification system is de- and Infant Mortality Programs.10 The that occur during an observed or un- signed to promote national and inter- Eunice Kennedy Shriver National Insti- observed sleep period (sleep-related national comparability in the assign- tute of Child Health and Human Devel- infant deaths), such as accidental suf- ment of cause-of-death determinations; opment began conducting national focation, is challenging and cannot however, this system might not pro- surveys of infant care practices to usually be determined by autopsy vide the optimal precision in classifica- evaluate the implementation of the AAP alone. Scene investigation and review of tion desired by clinicians and re- recommendation. Between 1992 and the clinical history are also required. A searchers. In the United States, the 2001, the SIDS rate declined, and the few deaths that are diagnosed as SIDS National Center for Health Statistics most dramatic declines occurred in are found, after further specialized assigns a SIDS diagnostic code (ICD-10 the years immediately after the first investigations, to be attributable to R95) if the death is classified with ter- nonprone recommendations, consis- metabolic disorders or arrhythmia- minology such as SIDS (including pre- tent with the steady increase in the associated cardiac channelopathies. sumed, probable, or consistent with prevalence of supine sleeping (Fig 1).11 Although standardized guidelines for SIDS), sudden infant death, sudden un- The US SIDS rate declined from 120 conducting thorough case investiga- explained death in infancy, sudden un- deaths per 100 000 live births in 1992 tions have been developed,6 these expected death in infancy, or sudden to 56 deaths per 100 000 live births in guidelines have not been uniformly ad- unexplained infant death on the certi- 2001, representing a decrease of 53% opted across the more than 2000 US fied death certificate. A death will be over 10 years. However, from 2001 to medical examiner and coroner juris- coded as “other ill-defined and unspec- 2006 (the latest year from which data dictions.7 Information from emergency ified causes of mortality” (ICD-10 R99) are available), the rate has remained responders, scene investigators, and if the cause of the death is reported as constant (Fig 1). In 2006, 2327 infants

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180 practices that may reduce the risk of 160 SIDS and other sleep-related infant deaths.1,9 Unfortunately, the ability to 140 measure the prevalence of these other 120 risk factors is limited by lack of data. 100 Death certificates are useful for moni- 80 toring trends in SIDS mortality, but the 60 circumstances and events that lead to death are not captured in vital statis- 40 Deaths per 100 000 births Deaths per 100 tics data.16 The Centers for Disease 20 Control and Prevention recently began 0 to pilot a SUID case registry that will 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 provide supplemental surveillance in- SIDS UNK + ASSB Combined SUID formation about the sleep environ- FIGURE 1 ment at the time of death, infant health Trends in SIDS and other SUID mortality: United States 1990–2006. UNK indicates ill-defined or unspec- ified deaths. history, and the comprehensiveness of the death scene investigation and au- topsy. These factors will better de- died from SIDS. Although SIDS rates Sleep Position scribe the circumstances surrounding have declined by more than 50% since The apparent leveling of the previously SIDS and other sleep-related infant the early 1990s, SIDS remains the declining SIDS rate is occurring coinci- deaths and assist researchers in de- third-leading cause of infant mortality dent with a slowing in the reduction of termining the similarities and differ- and the leading cause of postneonatal the prevalence of prone positioning. ences between these deaths. mortality (28 days to 1 year of age). The prevalence of supine sleep posi- The all-cause postneonatal death rate tioning, as assessed from an ongoing Racial and Ethnic Disparities has followed a trend similar to the national sampling, increased from SIDS mortality rates, similar to other SIDS rate: there was a 29% decline 13% in 1992 to 72% in 2001. From 2001 causes of infant mortality, have nota- from 1992 to 2001 (from 314 to 231 per until 2010, the prevalence of supine ble racial and ethnic disparities (Fig 100 000 live births). From 2001 until sleep positioning has been fairly stag- 2).17 Despite the decline in SIDS in all 11 2006, postneonatal mortality rates nant (prevalence in 2010: 75%). races and ethnicities, the rate of SIDS have also remained fairly unchanged The 1998 and 2005 AAP policy state- in non-Hispanic black (99 per 100 000 (from 231 to 224 per 100 000 live ments and the Back to Sleep campaign live births) and American Indian/ 12 births); the average decline is 3%. not only addressed the importance of Alaska Native (112 per 100 000 live Several recent studies have revealed back sleeping but also provided rec- births) infants was double that of non- that some deaths previously classified ommendations for other infant care Hispanic white infants (55 per 100 000 as SIDS are now being classified as other causes of infant death (eg, acci- dental suffocation and other ill-defined 1996 2006 or unspecified causes).13,14 Since 1999, 203.3 much of the decline in SIDS rates might be explained by increasing rates of 155.3 these other causes of SUID, particu- 119.4 13,15 larly over the years 1999–2001. A 103.8 notable change is in deaths attribut- 78.5 69.4 able to ASSB. Between 1984 and 2004, 54.5 55.6 48.3 ASSB infant mortality rates more than 44.0 22.8 27.0 quadrupled, from 2.8 to 12.5 deaths per 100 000 live births,15 which repre- All race and ethnic Non-Hispanic white Non-Hispanic black American Indian Asian and Hispanic sents 513 infant deaths attributed to origin and Alaska Nave Pacific Islander ASSB in 2004 compared with 103 in FIGURE 2 1984. Comparison of US rates of SIDS according to maternal race and ethnic origin in 1996 and 2006.

PEDIATRICS Volume 128, Number 5, November 2011 e1343 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 1996 2006 44.0

32.4

13.8 12.9

5.4 5.1 3.8 3.9 a a a a

All race and ethnic Non-Hispanic white Non-Hispanic black American Indian and Asian and Pacific Hispanic origin Alaska Nave Islander FIGURE 3 Comparison of US rates of death resulting from ASSB according to maternal race and ethnic origin in 1996 and 2006. a The figure does not meet standards of reliability or precision on the basis of fewer than 20 deaths in the numerator.

1996 2006 64.9

47.3

38.2

24.4 21.1 18.2 18.7 14.8 13.3 12.4

a a

All race and ethnic Non-Hispanic white Non-Hispanic black American Indian and Asian and Pacific Hispanic origin Alaska Nave Islander FIGURE 4 Comparison of US rates of cause ill-defined or unspecified death according to maternal race and ethnic origin in 1996 and 2006. a The figure does not meet standards of reliability or precision on the basis of fewer than 20 deaths in the numerator.

100 White 90 Black live births) in 2005 (Fig 2). SIDS rates cial and ethnic populations might 80 Hispanic 17 70 for Asian/Pacific Islander and Hispanic contribute to these disparities. The Asian 60

placed supine placed 50 infants were nearly half the rate for prevalence of supine positioning in 40 non-Hispanic white infants. Further- 2010 among white infants was 75%, 30 infants 20 more, similar racial and ethnic dispar- compared with 53% among black in- % of 10 ities have been seen with deaths fants (Fig 5). The prevalence of supine 0 199220002010 attributed to both ASSB (Fig 3) and ill- sleep positioning among Hispanic and Year defined or unspecified deaths (Fig 4). Asian infants was 73% and 80%, re- FIGURE 5 Differences in the prevalence of su- spectively.11 Parent--shar- Prevalence of supine sleep positioning accord- 18–20 ing to maternal race and ethnic origin, 1992– pine positioning and other sleep- ing and use of soft bedding are also 2010. Data source: National Infant Sleep Position environment conditions among ra- more common among black families Study.11

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30

23.3 21.9

20 17.6

%

11.6

10 9.1 6.8

3.9 2.2 1.5 0.9 0.6 0.5 0 0–1 1–2 2–3 3–4 4–5 5–6 6–7 7–8 8–9 9–10 10–11 11–12 Age, mo FIGURE 6 Percent distribution of SIDS deaths according to age at death: United States, 2004–2006.

30

24.7

20.3 20

% 14.4 12.9

10 9.0

5.9

3.7 3.7 1.9 1.7 1.1 0.8 0 0–1 1–2 2–3 3–4 4–5 5–6 6–7 7–8 8–9 9–10 10–11 11–12 Age, mo FIGURE 7 Percent distribution of deaths caused by ASSB according to age at death: United States, 2004–2006. than among other racial/ethnic tween 1 and 4 months of age. Although quently in the colder months, and the groups.21,22 Additional work in promot- SIDS was once considered a rare event fewest SIDS deaths occurred in the ing appropriate infant sleep position during the first month of life, in 2004– warmest months.23 In 1992, SIDS rates and sleep-environment conditions is 2006, nearly 10% of cases coded as had an average seasonal change of necessary to resume the previous rate SIDS occurred during the first month. 16.3%, compared with only 7.6% in of decline (observed during the 1990s) SIDS is uncommon after 8 months of 1999,24 which is consistent with re- for SIDS and all-cause postneonatal age (Fig 6).14 A similar age distribution ports from other countries.25 mortality. is seen for ASSB (Fig 7). PATHOPHYSIOLOGY AND GENETICS Age at Death Seasonality of SIDS OF SIDS Ninety percent of SIDS cases occur be- A pattern in seasonality of SIDS is no A working model of SIDS pathogenesis fore an infant reaches the age of 6 longer apparent. SIDS deaths have his- includes a convergence of exogenous months. The rate of SIDS peaks be- torically been observed more fre- triggers or “stressors” (eg, prone

PEDIATRICS Volume 128, Number 5, November 2011 e1345 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 important for sensory integration),29 creased numbers of immature 5-HT and alters fetal autonomic activity and neurons in regions of the brainstem medullary neurotransmitter recep- that are important for autonomic func- tors.30 In human infants, there are tion.41 These findings are not confined strong associations between nicotinic to nuclei containing 5-HT neurons but acetylcholine receptor and serotonin also include relevant projection sites. receptors in the brainstem during de- The most recent study report de- velopment.31 Prenatal exposure to to- scribed in these same regions de- bacco smoke attenuates recovery creased tissue levels of 5-HT and from hypoxia in preterm infants,32 de- tryptophan hydroxylase, the synthe- FIGURE 8 creases heart rate variability in pre- sizing enzyme for serotonin, and no Triple-risk model for SIDS.26 term33 and term34 infants, and abol- evidence of excessive serotonin deg- ishes the normal relationship between radation as assessed by levels of heart rate and gestational age at 5-hydroxyindoleacetic acid (the main sleep position, overbundling, airway birth.33 Moreover, infants of smoking metabolite of serotonin) or ratios of obstruction), a critical period of devel- mothers exhibit impaired arousal pat- 5-hydroxyindoleacetic acid to sero- opment, and dysfunctional and/or im- terns to trigeminal stimulation in pro- tonin.30 A recent article described a mature cardiorespiratory and/or portion to urinary cotinine levels.35 It is significant association between a de- arousal systems (intrinsic vulnerabil- important to note also that prenatal crease in medullary 5-HT receptor ity) that lead to a failure of protective 1A exposure to tobacco smoke alters the immunoreactivity and specific SIDS responses (see Fig 8).26 Convergence normal programming of cardiovascu- risk factors, including tobacco smok- of these factors ultimately results in a lar reflexes such that there is a ing.40 These data confirm results from combination of progressive asphyxia, greater-than-expected increase in earlier studies in humans39,41 and are bradycardia, hypotension, metabolic blood pressure and heart rate in re- also consistent with studies in piglets acidosis, and ineffectual gasping, lead- sponse to breathing 4% carbon dioxide that revealed that postnatal exposure ing to death.27 The mechanisms re- or a 60° head-up tilt.36 These changes to nicotine decreases medullary 5-HT sponsible for dysfunctional cardiore- 1A 42 spiratory and/or arousal protective in autonomic function, arousal, and receptor immunoreactivity. Animal responses remain unclear but might cardiovascular reflexes might all in- studies have revealed that serotoner- be the result of in utero environmental crease an infant’s vulnerability to SIDS. gic neurons located in the medullary conditions and/or genetically deter- Brainstem abnormalities that involve raphe and adjacent paragigantocellu- mined maldevelopment or delay in the medullary serotonergic (5- laris lateralis play important roles in maturation. Infants who die from SIDS hydroxytryptamine [5-HT]) system in many autonomic functions including are more likely to be born at low birth up to 70% of infants who die from SIDS the control of respiration, blood pres- weight or growth restricted, which are the most robust and specific neu- sure, heart rate, thermoregulation, suggests an adverse intrauterine envi- ropathologic findings associated with sleep and arousal, and upper airway ronment. Other adverse in utero envi- SIDS and have been confirmed in sev- patency. Engineered mice with de- ronmental conditions include expo- eral independent data sets and labora- creased numbers of 5-HT neurons and sure to nicotine or other components tories.37–40 This area of the brainstem rats or piglets with decreased activ- of cigarette smoke and alcohol. plays a key role in coordinating many ity secondary to 5-HT1A autoreceptor Recent studies have explored how pre- respiratory, arousal, and autonomic stimulation have diminished ventila- natal exposure to cigarette smoke may functions and, when dysfunctional, tor responses to carbon dioxide, dys- result in an increased risk of SIDS. In might prevent normal protective re- functional heat production and heat- animal models, exposure to cigarette sponses to stressors that commonly loss mechanisms, and altered sleep 43 smoke or nicotine during fetal devel- occur during sleep. Since the Task architecture. These studies linked opment alters the expression of the Force on Sudden Infant Death Syn- SIDS risk factors with possible nicotinic acetylcholine receptor in ar- drome report in 2005, more specific pathophysiology. eas of the brainstem important for au- abnormalities have been described, in- There is no evidence of a strong heri- 28 tonomic function, alters the neuronal cluding decreased 5-HT1A receptor table contribution for SIDS. However, excitability of neurons in the nucleus binding, a relative decrease in binding genetic alterations have been ob- tractus solitarius (a brainstem region to the serotonin transporter, and in- served that may increase the vulnera-

e1346 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 FROM THE AMERICAN ACADEMY OF PEDIATRICS bility to SIDS. Genetic variation can also been a number of reports of poly- greater risk than those usually placed take the form of common base morphisms or mutations in genes that prone (adjusted OR: 8.7–45.4).63,69,70 changes (polymorphisms) that alter regulate inflammation,48,49 energy pro- Therefore, it is critically important that gene function or rare base changes duction,50–52 and hypoglycemia53 in in- every caregiver use the supine sleep (mutations) that often have highly del- fants who died from SIDS, but these position for every sleep period. eterious effects. Several categories of associations require more study to de- Despite these recommendations, the physiologic functions relevant to SIDS termine their importance. prevalence of supine positioning has have been examined for altered ge- remained stagnant for the last de- ISSUES RELATED TO SLEEP netic makeup. Genes related to the se- cade.71 One of the most common rea- POSITION rotonin transporter, cardiac channelo- sons that parents and caregivers cite pathies, and the development of The Supine Sleep Position Is for not placing infants supine is fear of the autonomic nervous system are the Recommended for Infants to choking or aspiration in the supine po- subject of current investigation.44 The Reduce the Risk of SIDS; Side sition.72–80 Parents often misconstrue serotonin transporter recovers sero- Sleeping Is Not Safe and Is Not coughing or gagging, which is evi- tonin from the extracellular space and Advised dence of a normal protective gag re- largely serves to regulate overall sero- The prone or side sleep position can flex, for choking or aspiration. Multiple tonin neuronal activity. Results of a re- increase the risk of rebreathing ex- studies in different countries have not cent study support those in previous pired gases, resulting in hypercapnia found an increased incidence of aspi- reports that polymorphisms in the and hypoxia.54–57 The prone position ration since the change to supine promoter region that enhance the effi- 81–83 also increases the risk of overheating sleeping. There is often particular cacy of the transporter (L) allele seem by decreasing the rate of heat loss and concern for aspiration when the infant to be more prevalent in infants who die increasing body temperature com- has been diagnosed with gastroesoph- from SIDS compared with those reduc- pared with infants sleeping supine.58,59 ageal reflux. The AAP supports the rec- ing efficacy (S)45; however, at least 1 Recent evidence suggests that prone ommendations of the North American study did not confirm this associa- sleeping alters the autonomic control Society for Pediatric Gastroenterology tion.46 It has also been reported that a of the infant cardiovascular system and Nutrition, which state that infants polymorphism (12-repeat intron 2) of during sleep, particularly at 2 to 3 with gastroesophageal reflux should the promoter region of the serotonin months of age,60 and can result in de- be placed for sleep in the supine posi- transporter, which also enhances se- creased cerebral oxygenation.61 The tion, with the rare exception of infants rotonin transporter efficiency, was in- prone position places infants at high for whom the risk of death from gas- creased in black infants who died risk of SIDS (odds ratio [OR]: 2.3– troesophageal reflux is greater than from SIDS44 but not in a Norwegian 84 13.1).62–66 However, recent studies the risk of SIDS —specifically, infants 45 population. have demonstrated that the SIDS risks with upper airway disorders for whom It has been estimated that 5% to 10% of associated with side and prone posi- airway protective mechanisms are im- infants who die from SIDS have novel tion are similar in magnitude (OR: 2.0 paired, which may include infants with mutations in the cardiac sodium or po- and 2.6, respectively)63 and that the anatomic abnormalities, such as type tassium channel genes that result in population-attributable risk reported 3 or 4 laryngeal clefts, who have not long QT syndrome as well as in other for side sleep position is higher than undergone antireflux surgery. Elevat- genes that regulate channel function.44 that for prone position.65,67 Further- ing the head of the infant’s crib while A recent report described important more, the risk of SIDS is exceptionally the infant is supine is not effective in new molecular and functional evi- high for infants who are placed on reducing gastroesophageal reflux85,86; dence that implicates specific SCN5A their side and found on their stomach in addition, this elevation can result in (sodium channel gene) ␤ subunits in (OR: 8.7).63 The side sleep position is the infant sliding to the foot of the crib SIDS pathogenesis.47 The identification inherently unstable, and the probabil- into a position that might compromise of polymorphisms in genes pertinent ity of an infant rolling to the prone po- respiration and, therefore, is not to the embryologic origin of the auto- sition from the side sleep position is recommended. nomic nervous system in SIDS cases significantly greater than rolling prone The other reason often cited by par- also lends support to the hypothesis from the back.65,68 Infants who are un- ents for not using the supine sleep po- that a genetic predisposition contrib- accustomed to the prone position and sition is the perception that the infant utes to the etiology of SIDS. There have are placed prone for sleep are also at is uncomfortable or does not sleep

PEDIATRICS Volume 128, Number 5, November 2011 e1347 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 well.72–80 An infant who wakes fre- and more than 20% never place pre- soon as they are ready to be placed in a quently is normal and should not be term infants supine or will only place . perceived as a poor sleeper. Physio- them supine 1 to 2 days before dis- logic studies have found that infants charge.109 Moreover, very prema- Once an Infant Can Roll From the are less likely to arouse when they are turely born infants studied before Supine to Prone and From the sleeping in the prone position.87–95 The hospital discharge have longer sleep Prone to Supine Position, the ability to arouse from sleep is an im- duration, fewer arousals from sleep, Infant Can Be Allowed to Remain in portant protective physiologic re- and increased central apneas while the Sleep Position That He or She sponse to stressors during sleep,96–100 in the prone position.88 The task Assumes and the infant’s ability to sleep for sus- force believes that neonatologists, Parents and caregivers are fre- tained periods might not be physiolog- neonatal nurses, and other health quently concerned about the appro- ically advantageous. care professionals responsible for priate strategy for infants who have organizing the hospital discharge of Preterm Infants Should Be Placed learned to roll over, which generally infants from NICUs should be vigilant Supine as Soon as Possible occurs at 4 to 6 months of age. As about endorsing SIDS risk-reduction infants mature, it is more likely that Infants born prematurely have an in- recommendations from birth. They 101,102 they will roll. In 1 study, 6% and 12% creased risk of SIDS, and the as- should model the recommendations of 16- to 23-week-old infants placed sociation between prone sleep posi- as soon as the infant is medically sta- on their backs or sides, respectively, tion and SIDS among low ble and significantly before the in- were found in the prone position; infants is equal to, or perhaps even fant’s anticipated discharge. In addi- among infants aged 24 weeks or stronger than, the association tion, NICUs are encouraged to 69 among those born at term. There- develop and implement policies to older, 14% of those placed on their fore, preterm infants should be ensure that supine sleeping and backs and 18% of those placed on placed supine for sleep as soon as other safe sleep practices are mod- their sides were found in the prone 112 their clinical status has stabilized. eled for parents before discharge position. Repositioning the sleep- The task force supports the recom- from the hospital. ing infant to the supine position can mendations of the AAP Committee on be disruptive and might discourage Fetus and Newborn, which state that Newborn Infants Should Be Placed the use of supine position altogether. hospitalized preterm infants should Supine Within the First Few Hours Although data to make specific rec- be placed in the supine position for After Birth ommendations as to when it is safe sleep by 32 weeks’ postmenstrual for infants to sleep in the prone po- age to allow them to become accus- Practitioners who place infants on their sides after birth in newborn sition are lacking, the AAP recom- tomed to sleeping in that position be- mends that these infants continue to 103 nurseries continue to be a concern. fore hospital discharge. Unfortu- be placed supine until 1 year of age. nately, preterm and very low birth The practice likely occurs because If the infant can roll from supine to weight infants continue to be more nursery staff believe that newborn in- prone and from prone to supine, the likely to be placed prone for sleep fants need to clear their airways of am- infant can then be allowed to remain after hospital discharge.104,105 Pre- niotic fluid and may be less likely to in the sleep position that he or she term infants are placed prone ini- aspirate while on their sides. No evi- assumes. To prevent suffocation or tially to improve respiratory me- dence that such fluid will be cleared chanics106,107; although respiratory more readily while in the side position entrapment if the infant rolls, soft or parameters are no different in the exists. Finally, and perhaps most im- loose bedding should continue to be supine or prone positions in preterm portantly, if parents observe health removed from the infant’s sleep en- infants who are close to discharge,108 care professionals placing infants in vironment. Some caregivers use both infants and their caregivers the side or prone position, they are such bedding to prevent an infant likely become accustomed to using likely to infer that supine positioning is from rolling, but this bedding could the prone position, which makes it not important110 and, therefore, might cause suffocation and entrapment. more difficult to change. One study of be more likely to copy this practice and Parents can be reassured by the in- NICU nurses found that only 50% of use the side or prone position at formation that the incidence of SIDS nurses place preterm infants supine home.77,80,111 The AAP recommends that begins to decline after 4 months of during the transition to an open crib, infants be placed on their backs as age (Fig 6).

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Supervised, Awake Tummy Time on cribs might no longer meet current with vertical sides made of a Daily Basis Can Promote Motor safety standards, might have missing air-permeable material may be prefer- Development and Minimize the parts, or might be incorrectly assem- able to those with air-impermeable Risk of Positional Plagiocephaly bled. If an older crib is to be used, care sides.122 Finally, parents and caregiv- Positional plagiocephaly, or plagio- must be taken to ensure that there ers should adhere to the manufactur- cephaly without synostosis (PWS), can have been no recalls on the crib model, er’s guidelines regarding maximum be associated with supine sleeping po- that all of the hardware is intact, and weight of infants using these prod- sition (OR: 2.5).113 It is most likely to that the assembly instructions are ucts.122,123 If the product is a combina- result if the infant’s head position is available. tion product (eg, crib/), the not varied when placed for sleep, if the For some families, use of a crib might manual should be consulted when the infant spends little or no time in not be possible for financial reasons mode of use is changed. awake, supervised tummy time, and if or space considerations. In addition, There are no data regarding the safety the infant is not held in the upright po- parents might be reluctant to place the of sleepers that attach to the side of an sition when not sleeping.113–115 Chil- infant in the crib because of concerns adult bed. However, there are potential dren with developmental delay and/or that the crib is too large for the infant safety concerns if the sleeper is not neurologic injury have increased rates or that “crib death” (ie, SIDS) only oc- attached properly to the side of the of PWS, although a causal relationship curs in cribs. Alternate sleep surfaces, adult bed or if the infant moves into the has not been demonstrated.113,116–119 In such as portable cribs/play yards and adult bed. Therefore, the task force healthy normal children, the incidence bassinets might be more acceptable cannot make a recommendation for or of PWS decreases spontaneously from for some families, because they are against the use of bedside sleepers. In 20% at 8 months to 3% at 24 months of smaller and more portable. Local orga- addition, infants should not be placed 114 age. Although data to make specific nizations throughout the United States for sleep on adult-sized beds because recommendations as to how often and can help to provide low-cost or free of the risk of entrapment and suffoca- how long tummy time should be under- cribs or play yards. If a portable crib/ tion.124 Portable bed rails (railings in- taken are lacking, supervised tummy play yard or bassinet is to be used, it stalled on the side of the bed that are time while the infant is awake is rec- should meet the following CPSC guide- intended to prevent a child from falling ommended on a daily basis. Tummy lines: (1) sturdy bottom and wide base; off of the bed) should not be used with time should begin as early as possible (2) smooth surfaces without protrud- infants because of the risk of entrap- to promote motor development, facili- ing hardware; (3) legs with locks to ment and strangulation.125 tate development of the upper body prevent folding while in use; and (4) muscles, and minimize the risk of po- firm, snugly fitting .121 In addi- Car Seats and Other Sitting sitional plagiocephaly. The AAP clinical tion, other AAP guidelines for safe Devices Are not Recommended for report on positional skull deformi- sleep, including supine positioning Routine Sleep at Home or in the ties120 provides additional detail on the and avoidance of soft objects and Hospital, Particularly for Young prevention, diagnosis, and manage- loose bedding, should be followed. Infants ment of positional plagiocephaly. should be firm and should Some parents let their infants sleep in SLEEP SURFACES maintain their shape even when the fit- a car seat or other sitting device. Sit- ted sheet designated for that model is ting devices include but are not re- Infants Should Sleep in a Safety- used, such that there are no gaps be- stricted to car seats, strollers, swings, Approved Crib, Portable Crib, Play tween the mattress and the side of the infant carriers, and infant slings. Par- Yard, or Bassinet bassinet, , portable crib, or ents and caregivers often use these Cribs should meet safety standards of play yard. Only mattresses designed devices, even when not traveling, be- the CPSC, Juvenile Product Manufac- for the specific product should be cause they are convenient. One study turers Association, and the ASTM Inter- used. or should not found that the average young infant national (formerly the American Soci- be used as substitutes for mattresses spends 5.7 hours/day in a car seat or ety for Testing and Materials), or in addition to a mattress. Any fabric similar sitting device.126 However, including those for slat spacing, snugly on the sides or a canopy should be taut there are multiple concerns about us- fitting and firm mattresses, and no and firmly attached to the frame so as ing sitting devices as a usual infant drop sides.121 The AAP recommends not to create a suffocation risk for the sleep location. Placing an infant in the use of new cribs, because older infant. Portable cribs, play yards, and such devices can potentiate gastro-

PEDIATRICS Volume 128, Number 5, November 2011 e1349 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 esophageal reflux127 and positional the AAP recommends use of the terms in facilitating breastfeeding145,146 and plagiocephaly. Because they still have “room-sharing” and “bed-sharing.” although many parents believe that poor head control and often experi- The AAP recommends the arrange- they can maintain vigilance of the in- ence flexion of the head while in a sit- ment of room-sharing without bed- fant while they are asleep and bed- 144 ting position, infants younger than 1 sharing, or having the infant sleep in sharing, epidemiologic studies have month in sitting devices might be at the parents’ room but on a separate shown that bed-sharing can be hazard- 147–150 increased risk of upper airway obstruc- sleep surface (crib or similar surface) ous under certain conditions. tion and oxygen desaturation.128–132 In ad- close to the parents’ bed. There is evi- Bed-sharing might increase the risk of 151 152 dition, there is increasing concern dence that this arrangement de- overheating, rebreathing or air- 153 about injuries from falls resulting creases the risk of SIDS by as much as way obstruction, head cover- 152,154–156 from car seats being placed on ele- 50%64,66,142,143 and is safer than bed- ing, and exposure to tobacco 157 vated surfaces.133–137 An analysis of sharing64,66,142,143 or solitary sleeping smoke, which are all risk factors for CPSC data revealed 15 suffocation (when the infant is in a separate SIDS. A recent meta-analysis of 11 stud- deaths between 1990 and 1997 result- room).53,64 In addition, this arrange- ies that investigated the association of ing from car seats overturning after ment is most likely to prevent suffoca- bed-sharing and SIDS revealed a sum- mary OR of 2.88 (95% confidence inter- being placed on a bed, mattress, or tion, strangulation, and entrapment, val [CI]: 1.99–4.18) with bed- couch.136 The CPSC also warns about which may occur when the infant is sharing.158 Furthermore, bed-sharing the suffocation hazard to infants, par- sleeping in the adult bed. Furthermore, in an adult bed not designed for infant ticularly those who are younger than 4 room-sharing without bed-sharing al- safety exposes the infant to additional months, who are carried in infant sling lows close proximity to the infant, risks for accidental injury and death, carriers.138 When infant slings are which facilitates feeding, comforting, such as suffocation, asphyxia, entrap- used for carrying, it is important to en- and monitoring of the infant. ment, falls, and strangulation.159,160 In- sure that the infant’s head is up and Parent-infant bed-sharing is common. fants, particularly those in the first 3 above the fabric, the face is visible, and In 1 national survey, 45% of parents months of life and those born prema- that the nose and mouth are clear of responded that they had shared a bed turely and/or with low birth weight, obstructions. After nursing, the infant with their infant (8 months of age or are at highest risk,161 possibly because should be repositioned in the sling so younger) at some point in the preced- immature motor skills and muscle 19 that the head is up and is clear of fab- ing 2 weeks. In some racial/ethnic strength make it difficult to escape po- ric and the adult’s body. groups, the rate of routine bed-sharing tential threats.158 In recent years, the 18–20 might be higher. There are often concern among public health officials BED-SHARING cultural and personal reasons why about bed-sharing has increased, be- parents choose to bed-share, includ- Room-Sharing Without Bed-Sharing cause there have been increased re- ing convenience for feeding (breast- Is Recommended ports of SUIDs occurring in high-risk feeding or with formula) and bonding. sleep environments, particularly bed- The terms “bed-sharing” and “cosleep- In addition, many parents might be- sharing and/or sleeping on a couch or ing” are often used interchangeably, lieve that their own vigilance is the only armchair.162–165 but they are not synonymous. Cosleep- way that they can keep their infant safe ing is when parent and infant sleep in and that the close proximity of bed- There Is Insufficient Evidence to close proximity (on the same surface sharing allows them to maintain vigi- Recommend Any Bed-Sharing or different surfaces) so as to be able lance, even while sleeping.144 Some Situation in the Hospital or at to see, hear, and/or touch each parents will use bed-sharing specifi- Home as Safe; Devices Promoted other.139,140 Cosleeping arrangements cally as a safety strategy if the infant to Make Bed-Sharing “Safe” Are can include bed-sharing or sleeping in sleeps in the prone position21,144 or if Not Recommended the same room in close proximity.140,141 there is concern about environmental Epidemiologic studies have not found Bed-sharing refers to a specific type of dangers such as vermin and stray bed-sharing to be protective against cosleeping when the infant is sleeping gunfire.144 SIDS and accidental suffocation for any on the same surface with another per- Parent-infant bed-sharing continues to subgroups of the population. It is ac- son.140 Because the term cosleeping be highly controversial. Although elec- knowledged that there are some cul- can be misconstrued and does not pre- trophysiologic and behavioral studies tures for which bed-sharing is the cisely describe sleep arrangements, have offered a strong case for its effect norm and SIDS rates are low, but there

e1350 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 FROM THE AMERICAN ACADEMY OF PEDIATRICS are other cultures for which bed- 1.66).66,171 There is also a higher risk of multiples are often born prematurely sharing is the norm and SIDS rates are SIDS when the infant is bed-sharing and with low birth weight, so they are high. In general, the bed-sharing prac- with someone who is not a parent (OR: at increased risk of SIDS.101,102 Further- ticed in cultures with low SIDS rates is 5.4).62 more, there is increased potential for often different from that in the United A retrospective series of SIDS cases in- overheating and rebreathing while States and other Western countries dicated that mean maternal body cobedding, and size discordance might (eg, with firm mats on the floor, sepa- weight was higher for bed-sharing increase the risk of accidental suffoca- 176 rate mat for the infant, and/or absence mothers than for non–bed-sharing tion. Most cobedded twins are of soft bedding). It is statistically much mothers.172 The only case-control study placed on their sides rather than su- more difficult to demonstrate safety to investigate the relationship be- pine.174 Finally, cobedding of twins and (ie, no risk) in small subgroups. tween maternal body weight and bed- higher-order multiples in the hospital Breastfeeding mothers who do not sharing did not find an increased risk setting might encourage parents to smoke and have not consumed alcohol of bed-sharing with increased mater- continue this practice at home.176 Be- or arousal-altering medications or nal weight.173 cause the evidence for the benefits of drugs are 1 such subgroup. Further- cobedding twins and higher-order more, not all risks associated with Infants May Be Brought Into the multiples is not compelling and be- bed-sharing (eg, parental fatigue) can Bed for Feeding or Comforting but cause of the increased risk of SIDS and be controlled. The task force, there- Should Be Returned to Their Own suffocation, the AAP believes that it is fore, believes that there is insufficient Crib or Bassinet When the Parent prudent to provide separate sleep ar- evidence to recommend any bed- Is Ready to Return to Sleep eas for these infants to decrease the sharing situation in the hospital or at risk of SIDS and accidental suffocation. home as safe. In addition, there is no The risk of bed-sharing is higher the evidence that devices marketed to longer the duration of bed-sharing BEDDING 64,65,167,169 make bed-sharing “safe” (eg, in-bed during the night. Returning Pillows, , , cosleepers) reduce the risk of SIDS or the infant to the crib after bringing him Sheepskins, and Other Soft suffocation or are safe. Such devices, or her into the bed for a short period of Surfaces Are Hazardous When therefore, are not recommended. time is not associated with increased risk.65,169 Therefore, if the infant is Placed Under the Infant or Loose There Are Specific Circumstances brought into the bed for feeding, com- in the Sleep Environment in Which Bed-Sharing Is forting, and bonding, the infant should Bedding is used in infant sleep environ- Particularly Hazardous, and It be returned to the crib when the par- ments for comfort and safety.178 Par- Should Be Stressed to Parents ent is ready for sleep. Because of the ents and caregivers who perceive that That They Avoid the Following extremely high risk of SIDS, accidental infants are uncomfortable on firm sur- Situations at All Times suffocation, and entrapment on faces will often attempt to soften the 62,64,65,143,169 The task force emphasizes that certain couches and armchairs, in- surface with and pillows. Par- circumstances greatly increase the fants should not be fed on a couch or ents and caregivers will also use pil- risk with bed-sharing. Bed-sharing is armchair when there is high risk that lows and blankets to create barriers to especially dangerous when 1 or both the parent may fall asleep. prevent the infant from falling off the parents are smokers (OR: 2.3– sleep surface (usually an adult bed or 17.7)64,65,158,166,167; when the infant is It Is Prudent to Provide Separate couch) or to prevent injury if the infant younger than 3 months (OR: 4.7–10.4), Sleep Areas and Avoid Cobedding hits the crib side. However, such soft regardless of parental smoking sta- for Twins and Higher-Order bedding can increase the potential of tus64,66,143,158,168,169; when the infant is Multiples in the Hospital and at suffocation and rebreathing.54,56,57,179–181 placed on excessively soft surfaces Home Pillows, quilts, comforters, sheep- such as , sofas, and arm- Cobedding of twins and other infants skins, and other soft surfaces are haz- chairs (OR: 5.1–66.9)62,64,65,143,169; when of multiple gestation is a frequent ardous when placed under the in- soft bedding accessories such as pil- practice, both in the hospital setting fant62,147,182–187 or left loose in the lows or blankets are used (OR: 2.8– and at home.174 However, the benefits infant’s sleep area62,65,184,185,188–191 and 4.1)62,170; when there are multiple bed- of cobedding twins and higher-order can increase SIDS risk up to fivefold sharers (OR: 5.4)62; and when the multiples have not been estab- independent of sleep position.62,147 Sev- parent has consumed alcohol (OR: lished.175–177 Twins and higher-order eral reports have also described that

PEDIATRICS Volume 128, Number 5, November 2011 e1351 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 in many SIDS cases, the heads of the devices; other incidents have occurred cluded that the potential benefits of infants, including some infants who when infants have slipped out of the preventing minor injury with bumper slept supine, were covered by loose restraints or rolled into a prone posi- pad use were far outweighed by the bedding.65,186,187,191 It should be noted tion while using the device.2,194 Be- risk of serious injury such as suffoca- that the risk of SIDS increases 21-fold cause of the lack of evidence that they tion or strangulation.197 In addition, when the infant is placed prone with are effective against SIDS, suffocation, most bumper pads obscure infant and soft bedding.62 In addition, soft and or gastroesophageal reflux and be- parent visibility, which might increase loose bedding have both been associ- cause there is potential for suffocation parental anxiety.195 There are other ated with accidental suffocation and entrapment, the AAP concurs with products that attach to crib sides or deaths.149 The CPSC has reported that the CPSC and the US Food and Drug crib slats that claim to protect infants the majority of sleep-related infant Administration in warning against the from injury. However, there are no deaths in its database are attributable use of these products. If positioning published data that support these to suffocation involving pillows, quilts, devices are used in the hospital as part claims. Because of the potential for and extra bedding.192,193 The AAP rec- of physical therapy, they should be re- suffocation, entrapment, and strangu- ommends that infants sleep on a firm moved from the infant sleep area well lation and lack of evidence to support surface without any soft or loose bed- before discharge from the hospital. that bumper pads or similar products ding. Pillows, quilts, and comforters that attach to crib slats or sides pre- should never be in the infant’s sleep Bumper Pads and Similar Products vent injury in young infants, the AAP environment. Specifically, these items Are not Recommended does not recommend their use. should not be placed loose near the Bumper pads and similar products infant, between the mattress and the that attach to crib slats or sides are PRENATAL AND POSTNATAL sheet, or under the infant. Infant sleep frequently used with the thought of EXPOSURES (INCLUDING SMOKING clothing that is designed to keep the protecting infants from injury. Initially, AND ALCOHOL) infant warm without the possible haz- bumper pads were developed to pre- Pregnant Women Should Seek and ard of head covering or entrapment vent head entrapment between crib Obtain Regular Prenatal Care can be used in place of blankets; how- slats.195 However, newer crib stan- ever, care must be taken to select ap- dards that require crib slat spacing to There is substantial epidemiologic evi- propriately sized clothing and to avoid be less than 23⁄8 inches have obviated dence that links a lower risk of SIDS for overheating. If a is used, it the need for crib bumpers. In addition, infants whose mothers obtain regular should be thin and tucked under the infant deaths have occurred because prenatal care.198–200 Women should mattress so as to avoid head or face of bumper pads. A recent report by seek prenatal care early in the preg- covering. These practices should also Thach et al,196 who used CPSC data, nancy and continue to obtain regular be modeled in hospital settings. found that deaths attributed to bum- prenatal care during the entire per pads were from 3 mechanisms: (1) pregnancy. Wedges and Positioning Devices suffocation against soft, -like Are not Recommended bumper pads; (2) entrapment between Smoking During Pregnancy, in the Wedges and positioning devices are of- the mattress or crib and firm bumper Pregnant Woman’s Environment, ten used by parents to maintain the pads; and (3) strangulation from bum- and in the Infant’s Environment infant in the side or supine position be- per pad ties. However, the CPSC be- Should Be Avoided cause of claims that these products re- lieves that there were other confound- Maternal smoking during pregnancy is duce the risk for SIDS, suffocation, or ing factors, such as the presence of a major risk factor in almost every ep- gastroesophageal reflux. However, pillows and/or blankets, that might idemiologic study of SIDS.201–204 Smoke these products are frequently made have contributed to many of the deaths in the infant’s environment after birth with soft, compressible materials, in this report.2 Thach et al196 also ana- is a separate major risk factor in a few which might increase the risk of suffo- lyzed crib injuries that might have studies,202,205 although separating this cation. The CPSC has reports of deaths been prevented by bumper pad use variable from maternal smoking be- attributable to suffocation and entrap- and concluded that the use of bumper fore birth is problematic. Thirdhand ment associated with wedges and po- pads only prevents minor injuries. A smoke refers to residual contamina- sitioning devices. Most of these deaths more recent study of crib injuries that tion from tobacco smoke after the cig- occurred when infants were placed in used data from the CPSC National Elec- arette has been extinguished206; there the prone or side position with these tronic Injury Surveillance System con- is no research to date on the signifi-

e1352 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 FROM THE AMERICAN ACADEMY OF PEDIATRICS cance of thirdhand smoke with re- ciation of maternal alcohol drinking in BREASTFEEDING gards to SIDS risk. Smoke exposure ad- the 3 months before or during preg- Breastfeeding Is Recommended versely affects infant arousal207–213;in nancy was of borderline significance addition, smoke exposure increases on univariate analysis but was not sig- Earlier epidemiologic studies were not risk of and low birth nificant when prenatal smoking and consistent in demonstrating a protec- weight, both of which are risk factors case-versus-control status were in the tive effect of breastfeeding on SIDS*; for SIDS. The effect of tobacco smoke model.39 However, this study had lim- some studies found a protective ef- 67,239,240 exposure on SIDS risk is dose- ited power for multivariate analysis fect, and others did not.† Be- dependent. Aside from sleep position, because of its small sample size. One cause many of the case-control studies smoke exposure is the largest con- study found an association of SIDS with demonstrated a protective effect of tributing risk factor for SIDS.149 It is heavy alcohol consumption in the 2 breastfeeding against SIDS in univari- ate analysis but not when confounding estimated that one-third of SIDS days before the death.220 Although factors were taken into ac- deaths could be prevented if all ma- some studies have found a particularly count,62,184,198,231,238 these results sug- ternal smoking during pregnancy strong association when alcohol con- gested that factors associated with were eliminated.214,215 The AAP sup- sumption occurs in combination with breastfeeding, rather than breastfeed- ports the elimination of all tobacco bed-sharing,64–66,221 other studies ing itself, are protective. However, smoke exposure, both prenatally and have not found interaction between newer published reports support the environmentally.216,217 bed-sharing and alcohol to be protective role of breastfeeding on significant.167,222 Avoid Alcohol and Illicit Drug Use SIDS when taking into account poten- Studies investigating the relationship 243–245 During Pregnancy and After the tial confounding factors. Studies of illicit drug use and SIDS have fo- Infant’s Birth do not distinguish between nursing cused on specific drugs or illicit drug and expressed human milk. In the Several studies have specifically inves- use in general. In utero exposure to Agency for Healthcare Research and tigated the association of SIDS with opiates (primarily methadone and her- Quality’s “Evidence Report on Breast- prenatal and postnatal exposure to al- oin) has been shown in retrospective feeding in Developed Countries,”243 cohol or illicit drug use, although sub- studies to be associated with an in- multiple outcomes, including SIDS, stance abuse often involves more than creased risk of SIDS.223,224 With the ex- were examined. Six studies were in- 1 substance and it is difficult to sepa- ception of 1 study that did not show cluded in the SIDS-breastfeeding meta- rate these variables from each other increased risk,225 population-based analysis, and in both unadjusted and and from smoking. However, 1 study of studies have generally shown an in- adjusted analysis, ever breastfeeding Northern Plains American Indians creased risk with in utero cocaine ex- was associated with a lower risk of found that periconceptional maternal posure.226–228 However, these studies SIDS (summary OR: 0.41 [95% CI: 0.28– alcohol use (adjusted OR: 6.2 [95% CI: did not control for confounding fac- 0.58]; adjusted summary OR: 0.64 [95% 1.6–23.3]) and maternal first- tors. A prospective cohort study found CI: 0.51–0.81]). The German Study of trimester binge drinking (adjusted OR: the SIDS rate to be significantly in- Sudden Infant Death, the largest and 8.2 [95% CI: 1.9–35.3])218 were associ- creased for infants exposed in utero to most recent case-control study of ated with increased SIDS risk indepen- methadone (OR: 3.6 [95% CI: 2.5–5.1]), SIDS, found that exclusive breastfeed- dent of prenatal cigarette smoking ex- heroin (OR: 2.3 [95% CI: 1.3–4.0]), ing at 1 month of age halved the risk of posure. Another study from Denmark, methadone and heroin (OR: 3.2 [95% CI: SIDS (adjusted OR: 0.48 [95% CI: 0.28– which was based on prospective data 1.2–8.6]), and cocaine (OR: 1.6 [95% CI: 0.82]). At all ages, control infants were about maternal alcohol use, also found 1.2–2.2]), even after controlling for breastfed at higher rates than SIDS vic- a significant relationship between ma- race/ethnicity, maternal age, parity, tims, and the protective effect of par- ternal binge drinking and postneona- birth weight, year of birth, and mater- tial or exclusive breastfeeding re- 219 tal infant mortality, including SIDS. nal smoking.229 In addition, a meta- mained statistically significant after Postmortem studies of Northern analysis of studies that investigated an adjustment for confounders.244 A re- Plains American Indian infants re- association between in utero cocaine cent meta-analysis that included 18 vealed that prenatal cigarette smoking exposure and SIDS found an increased case-control studies revealed an un- was significantly associated with de- risk of SIDS to be associated with pre- adjusted summary OR for any breast- creased serotonin receptor binding in natal exposure to cocaine and illicit *Refs 62, 65, 67, 184, 198, and 231–239. the brainstem. In this study, the asso- drugs in general.230 †Refs 62, 184, 198, 231, 238, 241, and 242.

PEDIATRICS Volume 128, Number 5, November 2011 e1353 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 Study or Subgroup log[] SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI Fleming et al65 (1996) 0.058269 0.317657 12.6% 1.06 [0.57–1.98] Hauck et al62 (2003) -0.91629 0.319582 12.4% 0.40 [0.21–0.75] Klonoff-Cohen and Edelstein222 (1995) -0.89159812 0.3346305 11.4% 0.41 [0.21–0.79] Mitchell25 (1997) -0.07257 0.420337 7.2% 0.93 [0.41–2.12] Ponsonby et al235 (1995) -0.15082 0.401245 7.9% 0.86 [0.39–1.89] Vennemann et al244 (2009) -0.84397 0.239354 22.2% 0.43 [0.27–0.69] Wennergren et al240 (1997) -0.693147 0.21979 26.3% 0.50 [0.33–0.77]

Total (95% CI) 100.0% 0.55 [0.44–0.69] Heterogeneity: χ² = 10.08, df = 6 (P = .12); I² = 40% 0.01 0.1 1 10 100 Test for overall effect: z = 5.28 (P < .00001) Favors breastfeeding Favors not breastfeeding FIGURE 9 Multivariable analysis of any breastfeeding versus no breastfeeding. log[ ] indicates logarithm of the OR; weight, weighting that the study contributed to the meta-analysis (according to sample size); IV, fixed, 95% CI: fixed-effect OR with 95% CI.245 feeding of 0.40 (95% CI: 0.35–0.44). other infectious diseases249 that are study found that the risk of SIDS while Seven of these studies provided ad- associated with an increased vulnera- bed-sharing was similar regardless of justed ORs, and on the basis of these bility to SIDS and provides overall im- breastfeeding status, which indicates studies, the pooled adjusted OR re- mune system benefits from maternal that the benefits of breastfeeding do mained statistically significant at antibodies and micronutrients in hu- not outweigh the increased risk asso- 0.55 (95% CI: 0.44–0.69) (Fig 9).245 The man milk.250,251 Exclusive breastfeeding ciated with bed-sharing.258 protective effect of breastfeeding in- for 6 months has been found to be creased with exclusivity, with a uni- more protective against infectious dis- PACIFIER USE variable summary OR of 0.27 (95% CI: eases compared with exclusive breast- Consider Offering a Pacifier at Nap 0.24–0.31) for exclusive breastfeeding feeding to 4 months of age and partial Time And Bedtime of any duration.245 breastfeeding thereafter.249 Several studies62,66,167,231,259–262 have Currently in the United States, 73% of found a protective effect of pacifiers If a Breastfeeding Mother Brings mothers initiate breastfeeding, and on the incidence of SIDS, particularly the Infant Into the Adult Bed for 42% and 21% are still breastfeeding at when used at the time of last sleep. Nursing, the Infant Should Be 6 and 12 months, respectively.246 Non- Two meta-analyses revealed that paci- Returned to a Separate Sleep Hispanic black mothers are least likely fier use decreased the risk of SIDS by Surface When the Mother Is Ready to initiate or to still be breastfeeding at 50% to 60% (summary adjusted OR: for Sleep 6 and 12 months (54%, 27%, and 12%, 0.39 [95% CI: 0.31–0.50]263; summary respectively), whereas Asian/Pacific Several organizations promote the unadjusted OR: 0.48 [95% CI: 0.43– Islander mothers initiate and continue practice of mother-infant bed-sharing 0.54]264). Two later studies not in- breastfeeding more than other groups (ie, sleeping in the same bed) as a way cluded in these meta-analyses re- (81%, 52%, and 30%, respectively). of facilitating breastfeeding.142,252,253 ported equivalent or even larger Rates for initiating and continuing Breastfeeding is a common reason protective associations.265,266 The breastfeeding at 6 and 12 months for given by mothers for bed-sharing with mechanism for this apparent strong non-Hispanic white mothers are 74%, their infants.254 Studies have found an protective effect is still unclear, but 43%, and 21%; rates for Hispanic moth- association between bed-sharing and lowered arousal thresholds, favorable ers are 80%, 45%, and 24%; and rates longer duration of breastfeeding, but modification of autonomic control dur- for American Indian/Alaskan Native their data cannot determine a tempo- ing sleep, and maintaining airway pa- mothers are 70%, 37%, and 19%, ral relationship (ie, it is not known tency during sleep have been pro- respectively. whether bed-sharing promotes posed.247,267–270 It is common for the Physiologic sleep studies have found breastfeeding or if breastfeeding pro- pacifier to fall from the mouth soon that breastfed infants are more easily motes bed-sharing, or if women who after the infant falls asleep; even so, aroused from sleep than their prefer 1 practice are also likely to pre- the protective effect persists through- formula-fed counterparts.247,248 In addi- fer the other).255 Although bed-sharing out that sleep period.247,271 Two studies tion, breastfeeding results in a de- may facilitate breastfeeding, it is not have shown that pacifier use is most creased incidence of diarrhea, upper essential for successful breastfeed- protective when used for all sleep pe- and lower respiratory infections, and ing.256,257 Furthermore, 1 case-control riods.169,266 However, these studies also

e1354 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 FROM THE AMERICAN ACADEMY OF PEDIATRICS showed increased risk of SIDS when months, there were no differences in power to detect a significant the pacifier was usually used but not breastfeeding rates between the 2 association. used the last time the infant was groups; 85.8% of infants in the offer- placed for sleep; the significance of pacifier group were exclusively breast- OVERHEATING, FANS, AND ROOM these findings is yet unclear. feeding compared with 86.2% in the VENTILATION Although some SIDS experts and not-offered group.282 The AAP policy Avoid Overheating and Head policy-makers endorse pacifier use statement on breastfeeding and the Covering in Infants use of human milk includes a recom- recommendations that are similar to There is clear evidence that the risk of 272,273 mendation that pacifiers can be used those of the AAP, concerns about SIDS is associated with the amount of possible deleterious effects of pacifier during breastfeeding, but implementa- clothing or blankets on an infant and use have prevented others from mak- tion should be delayed until breast- the room temperature.182,218,294,295 In- 283 ing a recommendation for pacifier use feeding is well established. fants who sleep in the prone position as a risk reduction strategy.274 Al- Some dental malocclusions have been have a higher risk of overheating than though several observational stud- found more commonly among pacifier do supine sleeping infants.182 It is un- ies275–277 have found a correlation users than nonusers, but the differ- clear whether the relationship to over- between pacifiers and reduced ences generally disappeared after heating is an independent factor or breastfeeding duration, the results of pacifier cessation.284 In its policy state- merely a reflection of the increased well-designed randomized clinical tri- ment on oral habits, the American risk of SIDS and suffocation with blan- als indicated that pacifiers do not Academy of Pediatric Dentistry states kets and other potentially asphyxiating seem to cause shortened breastfeed- that nonnutritive sucking behaviors objects in the sleeping environment. ing duration for term and preterm in- (ie, fingers or pacifiers) are consid- Head covering during sleep is of par- 278,279 fants. The authors of 1 study re- ered normal for infants and young chil- ticular concern. In a recent systematic ported a small deleterious effect of dren and that, in general, sucking hab- review, the pooled mean prevalence of early pacifier introduction (2–5 days its in children to the age of 3 years are head covering among SIDS victims was after birth) on exclusive breastfeeding unlikely to cause any long-term prob- 24.6% compared with 3.2% among con- 154 at 1 month of age and on overall lems.285 There is an approximate 1.2- to trol infants. It is not known whether breastfeeding duration (defined as 2-fold increased risk of otitis media as- the risk associated with head covering any breastfeeding), but early pacifier is attributable to overheating, hypoxia, sociated with pacifier use, particularly use did not adversely affect exclusive or rebreathing. between 2 and 3 years of age.286,287 The breastfeeding duration. In addition, incidence of otitis media is generally There has been some suggestion that there was no effect on breastfeeding lower in the first year of life, especially room ventilation may be important. duration when the pacifier was intro- the first 6 months, when the risk of One study found that bedroom heating, duced at 1 month of age.280 A more re- SIDS is the highest.288–293 However, pac- compared with no bedroom heating, cent systematic review found that the 235 ifier use, once established, may persist increases SIDS risk (OR: 4.5), and an- highest level of evidence (ie, from clin- beyond 6 months, thus increasing the other study has also demonstrated a ical trials) does not support an ad- risk of otitis media. Gastrointestinal in- decreased risk of SIDS in a well- verse relationship between pacifier fections and oral colonization with ventilated bedroom (windows and use and breastfeeding duration or ex- doors open) (OR: 0.4).296 In 1 study, Candida species were also found to be clusivity.281 The association between the use of a fan seemed to reduce the more common among pacifier users shortened duration of breastfeeding risk of SIDS (adjusted OR: 0.28 [95% than nonusers.289–291 and pacifier use in observational stud- CI: 0.10–0.77]).297 However, because ies likely reflects a number of complex The literature on infant digit-sucking of the possibility of recall bias, the factors such as breastfeeding difficul- and SIDS is extremely limited. Only 1 small sample size of controls using ties or intent to wean.281 A large multi- case-control study from the Nether- fans (n ϭ 36), a lack of detail about center, randomized controlled trial of lands has reported results.262 This the location and types of fans used, 1021 mothers who were highly moti- study did not find an association be- and the weak link to a mechanism, vated to breastfeed were assigned to 2 tween usual digit-sucking (reported as this study’s results should be inter- groups: mothers advised to offer a “thumb-sucking”) and SIDS risk (OR: preted with caution. On the basis of pacifier after 15 days and mothers ad- 1.38 [95% CI: 0.35–1.51]), but the wide available data, the task force cannot vised not to offer a pacifier. At 3 CI suggests that there was insufficient make a recommendation on the use

PEDIATRICS Volume 128, Number 5, November 2011 e1355 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 of a fan as a SIDS risk-reduction consequences. For example, it can when swaddled. Thus, although swad- strategy. cause an increase in respiratory dling clearly promotes sleep and de- rate,301 and tight swaddling can reduce creases the number of awakenings, SWADDLING the infant’s functional residual lung the effects on arousability to an exter- 299,302,303 Although Swaddling May Be Used capacity. Tight swaddling can nal stimulus remain unclear. There is as a Strategy to Calm the Infant also exacerbate hip dysplasia if the accumulating evidence, however, that and Encourage Use of Supine hips are kept in extension and adduc- there are only minimal effects of rou- Position, There Is Not Enough tion.304–307 This is particularly impor- tine swaddling on arousal. In addition, Evidence to Recommend It as a tant, because some have advocated there have been no studies investigat- Strategy for Reducing the Risk of that the calming effects of swaddling ing the effects of swaddling on arousal SIDS are related to the “tightness” of the to more relevant stimuli such as hyp- swaddling. In contrast, “loose” or in- oxia or hypercapnia. Many cultures and newborn nurseries correctly applied swaddling could re- In summary, it is recognized that swad- have traditionally used swaddling, or sult in head covering and, in some dling is one of many child care prac- wrapping the infant in a light blanket, cases, strangulation if the blankets be- tices that can be used to calm infants as a strategy to soothe infants and, in come loose in the bed. Swaddling may and promote sleep. However, there is some cases, encourage sleep in the su- also possibly increase the risk of over- insufficient evidence to recommend pine position. Swaddling, when done heating in some situations, especially routine swaddling as a strategy for re- correctly, can be an effective tech- when the head is covered or the infant ducing the incidence of SIDS. More- nique to help calm infants and pro- has an infection.308,309 However, a re- over, as many have advocated, swad- mote sleep.298 Some have argued that dling must be correctly applied to swaddling can alter certain risk fac- cent study found no increase in ab- avoid possible hazards such as hip tors for SIDS, thus reducing the risk of dominal skin temperature when in- dysplasia, head covering, and strangu- SIDS. For instance, it has been sug- fants were swaddled in a light cotton 302 lation. It is important to note that gested that the physical restraint as- blanket from the shoulders down. swaddling does not reduce the neces- sociated with swaddling may prevent Impaired arousal has often been pos- sity to follow recommended safe sleep infants placed supine from rolling to tulated as a mechanism that contrib- practices. the prone position.299 One study’s re- utes to SIDS, and several studies have sults suggested a decrease in SIDS investigated the relationship between AND SIDS rate with swaddling if the infant was swaddling, arousal, and sleep patterns supine,182 but it was notable that there in infants. Physiologic studies have Infants Should Be Immunized in was an increased risk of SIDS if the demonstrated that, in general, swad- Accordance With infant was swaddled and placed in the dling decreases startling,301 increases Recommendations of the AAP and prone position.182 Although a recent sleep duration, and decreases sponta- Centers for Disease Control and study found a 31-fold increase in SIDS neous awakenings.310 Swaddling also Prevention risk with swaddling, the analysis was decreases arousability (ie, increases The incidence of SIDS peaks at a time not stratified according to sleep posi- cortical arousal thresholds) to a nasal when infants are receiving numerous tion.171 Although it may be more likely pulsatile air-jet stimulus, especially in immunizations. Case reports of a clus- that parents will initially place a swad- infants who are easily arousable when ter of deaths shortly after immuniza- dled infant supine, this protective ef- not swaddled but less so in infants who tion with diphtheria-tetanus-pertussis fect may be offset by the 12-fold in- have high arousal thresholds when not in the late 1970s created concern of a creased risk of SIDS if the infant is swaddled.301 One study found de- possible causal relationship between either placed or rolls to the prone po- creased arousability in infants at 3 vaccinations and SIDS.312–315 Case- 182,300 sition when swaddled. Moreover, months of age who were not usually control studies were performed to there is no evidence that swaddling re- swaddled and then were swaddled but evaluate this temporal association. duces bed-sharing or use of unsafe found no effect on arousability in rou- Four of the 6 studies found no relation- sleep surfaces, promotes breastfeed- tinely swaddled infants.301 In contrast, ship between diphtheria-tetanus- ing, or reduces maternal cigarette another group of investigators showed pertussis vaccination and subsequent smoking. decreased arousal thresholds310 and SIDS,316–319 and results of the other 2 There is some evidence that swaddling increases in autonomic (subcortical) studies suggested a temporal relation- might cause detrimental physiologic responses311 to an auditory stimulus ship but only in specific subgroup anal-

e1356 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 FROM THE AMERICAN ACADEMY OF PEDIATRICS ysis.320,321 In 2003, the Institute of Medi- egy for preventing SIDS.329 However, sequently died from SIDS did not fail cine of the National Academy of there is no evidence that home moni- their hearing tests but, compared with Sciences reviewed available data and tors are effective for this purpose.330–333 controls, showed a decreased signal- concluded that “[t]he evidence favors The task force concurs with the AAP to-noise ratio score in the right ear rejection of a causal relationship be- Committee on Fetus and Newborn, only (at frequencies of 2000, 3000, and tween exposure to multiple vaccina- which has recommended that infant 4000 Hz). Methodologic concerns have tions and SIDS.”322 Additional subse- home monitoring not be used as a been raised about the validity of the quent large population case-control strategy to prevent SIDS, although it study methods used in this study,344,345 trials consistently have found vaccines can be useful for some infants who and these results have not been sub- to be protective against SIDS323–325; have had an apparent life-threatening stantiated by others. A larger but non– however, confounding factors (social, event.334 peer-reviewed report of hearing maternal, birth, and infant medical his- POTENTIAL TOXICANTS AND SIDS screening data in Michigan revealed tory) might account for this protective no relationship between hearing 326 effect. It also has been theorized that There Is no Evidence Linking screening test results and SIDS the decreased SIDS rate immediately Various Toxicants to SIDS cases.346 Until additional data are avail- after vaccination was attributable to Many theories link various toxicants able, hearing screening should not be infants being healthier at time of im- and SIDS. Currently, no studies have considered as a valid screening tool munization, or “the healthy vaccinee substantiated a causal relationship for determining which infants might effect.”327 Recent illness would both between metals, such as silver, cad- be at subsequent risk of SIDS. Further- place infants at higher risk of SIDS and mium, cobalt, lead, or mercury, and more, an increased risk of SIDS should make them more likely to have immu- SIDS.335–337 Although an ecological not be inferred from an abnormal nizations deferred.328 study found correlation of the maxi- hearing screen result. Recent studies have attempted to mal recorded nitrate levels of drink- control for confounding by social, ing water with local SIDS rates in EDUCATIONAL INTERVENTIONS maternal, birth, and infant medical Sweden,338 no case-control study has Educational and Intervention history.323,325,328 In a meta-analysis, demonstrated a relationship be- 328 Campaigns Are Often Effective in Vennemann et al found a multivar- tween nitrates in drinking water and Altering Practice iate summary OR for immunizations SIDS. Furthermore, an expert group and SIDS to be 0.54 (95% CI: 0.39– in the United Kingdom analyzed data Intervention campaigns for SIDS 0.76), which indicates that the risk of pertaining to a hypothesis that SIDS have been extremely effective, espe- SIDS is halved by immunization. The is related to toxic gases, such as an- cially with regard to avoidance of evidence continues to show no timony, phosphorus, or arsenic, be- prone positioning.347 Furthermore, causal relationship between immu- ing released from mattresses339,340 there is evidence that primary care– nizations and SIDS and suggests that and found the toxic-gas hypothesis to based educational interventions, vaccination may have a protective ef- be unsubstantiated.341 Finally, 2 case- particularly those that address care- fect against SIDS. control studies found that wrapping giver concerns and misconceptions mattresses in plastic to reduce toxic about safe sleep recommendations, HOME MONITORS, SIDS, AND gas emission did not protect against can be effective in altering practice. APPARENT LIFE-THREATENING SIDS.191,342 For instance, addressing concerns EVENTS about infant comfort, choking, and HEARING SCREENS There Is no Evidence That aspiration while the infant is sleep- Apparent Life-Threatening Events Newborn Hearing Screens Should ing prone is helpful.348,349 Similar in- Are Precursors to SIDS, and Infant Not Be Used as a Screening Test terventions for improving behavior Home Monitors Should Not Be for SIDS of medical and nursing staff and Used as a Strategy for Preventing A single, small, retrospective case- child care providers have shown that SIDS control study examined the use of new- these professionals have similar For many years it was believed that ap- born transient evoked otoacoustic concerns about the supine sleep po- parent life-threatening events were emission hearing screening tests as a sition.350–353 Primary care providers the predecessors of SIDS, and home tool for identifying infants at subse- should be encouraged to develop qual- apnea monitors were used as a strat- quent risk of SIDS.343 Infants who sub- ity improvement initiatives to improve

PEDIATRICS Volume 128, Number 5, November 2011 e1357 Downloaded from www.aappublications.org/news at Arkansas Children's Hospital on January 16, 2020 adherence with safe sleep recommen- and media messages have been quite Robert A. Darnall, MD dations among their patients. influential in decisions regarding Michael H. Goodstein, MD Fern R. Hauck, MD, MS sleep position.77,80 Media and advertis- MEDIA MESSAGES ing messages contrary to safe sleep CONSULTANTS recommendations may create misin- Media and Manufacturers Should Marian Willinger, PhD – Eunice Kennedy formation about safe sleep practices. Shriver National Institute for Child Health Follow Safe Sleep Guidelines in Safe sleep messages should be re- and Human Development Their Messaging and Advertising Carrie K. Shapiro-Mendoza, PhD, MPH – viewed, revised, and reissued at least Centers for Disease Control and Prevention A recent study found that, in maga- every 5 years to address the next gen- zines targeted toward childbearing eration of new parents and products STAFF women, more than one-third of pic- on the market. James Couto, MA tures of sleeping infants and two- thirds of pictures of infant sleep envi- RECOMMENDATIONS ACKNOWLEDGMENTS ronments portrayed unsafe sleep The AAP’s recommendations for a safe The task force acknowledges the con- positions and sleep environments.354 infant sleeping environment to reduce tributions provided by others to the Media exposures (including movie, the risk of both SIDS and other sleep- collection and interpretation of data television, magazines, newspapers, related infant deaths are specified in examined in preparation of this report. and Web sites), manufacturer adver- the accompanying policy statement.4 The task force is particularly grateful tisements, and store displays affect in- LEAD AUTHOR for the report submitted by Dr Suad dividual behavior by influencing be- Rachel Y. Moon, MD Wanna-Nakamura (CPSC) and for the liefs and attitudes. Frequent exposure TASK FORCE ON SUDDEN INFANT assistance of Sarah McKinnon, PhD, to health-related media messages can DEATH SYNDROME, 2010–2011 MPH, and Cristina Rodriguez-Hart, affect individual health decisions,355,356 Rachel Y. Moon, MD, Chairperson MPH, with the statistics and graphs. REFERENCES

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