S I D S

Sudden Infant Death Syndrome Reducing the Risk in Childcare

Northeast Wisconsin Technical College

September 2007

This Presentation was developed by NWTC in collaboration with The Infant Death Center of Wisconsin, a program of Childrens Hospital of Wisconsin

Who Should Be Educated About SIDS?

ANYONE WHO HAS ANYTHING TO DO WITH CHILDREN UNDER THE AGE OF ONE YEAR!

Parents, guardians, siblings, grandparents, aunts, uncles, teachers, baby-sitters, pastors, church childcare volunteers, case workers, social workers, home visitors, police, emergency service personal, absolutely EVERY child care provider hired for child care services, and anyone else who touches the lives of children.

Sudden Infant Death Syndrome

SIDS is a term used to describe the sudden, unexplained death of an infant that remains unexplained after a thorough case investigation that includes:

1.A complete autopsy 2.An investigation of the death scene 3.Review of the medical history and file

Cases failing to meet the standards of this definition, including those without autopsies should not be diagnosed as SIDS.

Source: Infant Death Center of Wisconsin

Why Do Emergency Personal Including Police Need to Receive SIDS Training?

1. Observations noted by first responders are important to the determination of cause and manner of death. Knowledge of SIDS assists them in making those observations. Because recent research shows that blood tinged mucus can appear around the mouth and nose. It may appear to be child abuse to police or emergency personnel. Lividity- There will be blood pooling, which will look like bruising on the dependent body part (which is the part the baby was laying on, back, side, or stomach). In combination with blood tinged mucus, it is easy to see how an untrained individual could draw the conclusion of child abuse.

2.

3.

Is SIDS a New Medical Disorder?

No, although extensive research has been conducted over the years, there still are many unanswered questions, about this silent killer. The following slides include recent research facts that are known.

We Know that SIDS is NOT

Hereditary Contagious Caused by choking, vomiting Caused by minor illnesses-colds, ear infections Predictable-there is no warning Child abuse Neglect Anyones fault The cause of every unexpected infant death

There are Many Common Misconceptions about SIDS

Immunization and SIDS-SIDS is not caused by the Diptheria-Pertussis Tetanus (DPT) immunization. The National Institute of Child Health and Human Development (NICHD) published its definitive report on DPT and SIDS in 1987. The data clearly showed that there is no causal relationship between SIDS and the DPT immunization. Aspiration of feeding-Because many SIDS infants have been fed within hours of death, aspiration of milk/formula was suspected. The autopsy examination has shown that any aspirated feeding is related to attempts at resuscitation. Suffocation-Accidental suffocation can occur by entrapment of the head or body in a broken crib; occlusion of the nose and mouth by a thin plastic sheet (e.g. a pillow, waterbed), and the best advice is to avoid them. A sleeping baby should not be restricted by heavy clothing, bulky blankets or tightly tucked in sheets. Apnea monitors-The NICHD stated in a 1987 consensus statement on apnea monitors that there is no evidence to suggest home monitoring can prevent SIDS deaths. Apnea monitors are not recommended for normal healthy infants. Breastfeeding vs. bottle feeding-SIDS cannot be prevented by breast feeding. However, breast feeding is encouraged because breast milk provides natural antibodies to the infants immune system.
Source: Infant Death Center of Wisconsin

Incidence of Infant Mortality for SIDS, Accidents, and Homicide

For every 1 homicide of an infant, there are: almost 4 infant deaths by accident & 12 infant deaths from SIDS

Selected Causes of Infant Death National Data

4500 4000 3500 3000 2500 2000 1500 1000 500 0 1994 1996 1998 2000 2002 2004
Statistics from FBI Uniform Crime Reports and National Center for Injury Prevention

Homicide SIDS Unintentional Injury

Infant Death Center of Wisconsin Referrals for Selected Causes of Death

70 60 50 40 30 20 10 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 SIDS SUDI Unint. Inj Overly Homicide

Mortality Statistics in Wisconsin

African American infant mortality rate is 3 times higher than that of white infants. This is also true for overall infant deaths, regardless of socioeconomic status.

Native American infant mortality rate is double that of white infants.

Latino infant mortality rate is 1.5 times that of white infants.

WI INFANT MORTALITY IN SELECT POPULATIONS

25 20
18.6 17.9 18.3 17.9 14.9 13.4 11.7 10.8 10.2 10.8 10.3 11 9.6 10.7 9 7.7 5.7 8.9 5.6 4.7 7 5.7 6.6 5.5 6.9 5.3 7.5 6.5 5.6 11 10.7 10 16.9 15.3 15 19.2

18.7

18.3

15 10 5 0

14.4

9.2 6.5

8.8 6.2 5.9 5.5 5.6

5.07 4.52

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

White

Black

Hispanic

American Indian

American Indian data is based on Five Year Moving Average Rates.

NATIONAL AND WISCONSIN SIDS RATES

1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0
19 90
1.7 1.47 1.3 1.3

1.36 1.2

1.35 1.17 1.19 1.03 0.87 0.74 0.69 0.67 0.67 1.25 1.09 0.904 0.8 0.669 0.669 1.04 0.77 0.671 0.529 0.55 0.48 0.486 0.512 0.52

19 91

19 92

19 93

19 94

19 95

19 96

19 97

19 98

19 99

20 00

20 01

20 02

20 03

20 04

WI SIDS Rate

National SIDS Rate

20 05

Incidence Rate Nationally

Nationally about 0.5 babies out of 1000 die of SIDS each year.

Source: Infant Death Center of Wisconsin

Approximately 2000 infants die of SIDS every year in the United States. Source: Infant Death Center of Wisconsin In the State of Wisconsin, about 0.52 of 1000 babies die of SIDS each year (WI Deaths 2000). In the United States, approximately 20.4 % of SIDS deaths occurred in regulated child care (1995-1997).
60% in family child care 20% in child care centers 20% in relative care

Source: American Academy of Pediatrics

Non-Parental Childcare
Two-thirds of US infants younger than 1 year are in non-parental childcare.

Approximately 1/3 of SIDS related deaths in childcare occur in the first week. One half of these on the first day. Something intrinsic to child care? NO

Unaccustomed tummy sleeping? YES

A California study found that infants who were usually placed supine but were placed on their sides or prone for the last sleep were at very high risk of SIDS, which emphasizes the importance of every caregiver using the back to sleep position during every sleep period, particularly when the infants accustomed position is supine.

Source: National Institute of Health and Human Development

Troubling
In another finding, children placed prone (on their stomachs) by caretakers, more than half were usually put to sleep on their backs by their parents.

This is called unaccustomed tummy sleeping. Why do you think caretakers would do this?

Source: Dr. Rachel Moon Pediatrician at Childrens National Medical Center in Washington, D.C.

Unaccustomed Tummy Sleeping

Unaccustomed tummy sleep places infants at extremely high risk for SIDS. The risk is almost 20 times the risk of always supine sleepers. Part of the risk may be because babies who do not typically sleep on their tummies develop upper body strength later than babies who do typically sleep on their tummies. If these infants are placed on their tummies and they get into a suffocating or low-oxygen situation, they cannot lift or move their heads to get out of that situation. Research has shown that many of the unaccustomed prone sleepers were placed on their tummies by nonparental caregivers (eg, grandparents, babysitters, child care providers).
Mitchell EA, Thach BT, Thompson JM, Williams S. Changing infants sleep position increases risk of sudden infant death syndrome. Arch Pediatr Adolesc Med. 1999;153:11361141

Why Would Child Care Providers Use Tummy Sleeping Methods?

Lack of awareness Misconceptions about risk of sleep position
25% of licensed child care providers say they never heard of the relationship between SIDS and sleep position. Supine and aspiration, choking. There is plenty of data to show that back sleeping babies are not more likely to choke or aspirate. Healthy babies will not choke if they spit up. Belief that tummy sleeping improves infant comfort and that babies will sleep more deeply. This actually can be dangerous, as they do not arouse when they are in a life-threatening situation. Lack of information Lack of education-We need to make sure that providers have the information they need and support necessary to enable them to talk to parents about this important issue and to refuse to perform what might be a life-threatening practice.
Source: American Academy of Pediatrics

Parental preference

Caregivers Might Have These Misconceptions

Babies Do Not Sleep As Long On Their Backs-Babies can be taught to
sleep on their backs at a very early age and will get used to this sleep position. It is safer than tummy sleeping. flat. This is generally temporary and as babies grow and become more active, their skulls will round out. Supervised tummy time and holding awake babies helps alleviate pressure on the back of the head.

Flat Heads-Constant pressure can cause the babys head to be less rounded and

Developmental Lag- Some parents and providers are concerned about the

slight developmental lag in rolling over or sitting up that has been reported in the literature and media among babies who sleep on their backs. This delay is still within the normal range for development. Tummy time helps babies to become more active and strengthen muscles that enable them to roll over or sit up.
on their backs their arms may flail. This startle response may actually be a protective response for the baby, prompting an exchange of fresh air or a slight arousal from deep sleep. their side or stomach more comfortable and this influences how they decide to place baby for sleeping.

Startle Response- Some babies flinch or jerk in their sleep and if they sleep

Parent Preferences-Some parents and child care providers find sleeping on

There is a Higher Incidence of SIDS in Males

Male infants are slightly more susceptible to SIDS than females. However, this also is true for most diseases affecting infants and children.

Source: Infant Death Center of Wisconsin

90 % of SIDS Deaths Occur before the Age of 6 Months. 10% occur between 6 and 12 months of age.

The Incidence of SIDS Peaks Between 2-4 Months.

Source: Infant Death Center of Wisconsin

SIDS is a silent death. In those cases which have been observed, the infants do not cry and there is no struggle. SIDS almost always occurs during a sleep period
Source: Infant Death Center of Wisconsin

40% of SIDS Victims Have or Recently Had a Mild Upper Respiratory Infection

The Time of Year can be a Factor SIDS and the Heating Season
Historically, the SIDS statistics always have shown a
distinct seasonality, with higher rates recorded during winter months. A significant decrease has been observed in the seasonal association of SIDS as the stomach sleep position has decreased and SIDS rates have declined.
Source: Infant Death Center of Wisconsin

SIDS Occurs in Families of All Economic and Social Levels

Source: Infant Death Center of Wisconsin

Characteristics of SIDS Victim

Appears to be a healthy baby Frequently found sleeping on stomach (prone position) No other health conditions identified that would result in death Blood tinged mucous around mouth and nose Silent-No outcry Lividity discoloration due to pooling of blood

Deaths in Child Care in WI

25 20 15 10 5 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

SIDS Rate and Sleep Position, 1985-99 (Deaths per 1,000 Live Births)
1.5
1.41 1.41 1.37 1.4 1.39

100
1.3 1.3 1.2 1.17 1.03 70 0.87 0.74 0.77 0.72 39 28 0.67 74 78 81 85
Percent Back and Side Sleeping

SIDS Rate

54

50

0.5

0
1985 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Year

A Number of Factors Seem to Put a Baby at a Higher Risk for SIDS

RISK FACTORS

THESE ARE NOT CAUSES!

What about the Risk Factors?

It is important to note that risk factors (associations) are not causes. Half of all SIDS cases do not have or are not exposed to any known identified risk factors. These risk factors are not unique to SIDS, but are present in other infant deaths. SIDS cases have declined 50% following the recommendation that infants should be placed to sleep on their backs.

The Risk Factors Appear in Higher Numbers for Babies than for the General Population
For instance, if a mom smokes during pregnancy, the baby is three times (3X) more likely to die of SIDS. If there is smoking in the house, the baby is twice (2X) as likely to die of SIDS.

RISK FACTORS in Pregnancy

*Low birth weight (less than 5 pounds)

*Premature (less than 37 weeks)

*Maternal smoking during pregnancy *Multiple births (twins, triplets)

*Maternal age younger than 18 years

*Less than 18 months between births *Mother with little to no prenatal care

*Maternal substance abuse moms who use drugs during pregnancy

Sources: American Academy of Pediatrics and Infant Death Center of Wisconsin

RISK FACTOR Babies Placed to Sleep on their Stomachs

(Prone Position)

RISK FACTOR
Co-Sleeping or Bed Sharing
While bed sharing between infants and adults is highly controversial, the American Academy of Pediatrics reports that it can be hazardous under certain conditions. Several case studies of accidental suffocation or death from undetermined cause, suggests that bed sharing is hazardous. Adults, children, or siblings should avoid bed sharing with an infant.

We Do Not Know What Causes SIDS

It is believed that this defect occurs as the babys brain is maturing and the sensors that are responsible for giving information to the brain do not send the information.

Because of these malfunctions, the basic system that maintains that automatic functioning does not work correctly when stressed. The stressor might be sleep position, a cold, or a soft sleep surface.

We Do not Know What Causes SIDS

Research has studied the part of the brain that controls breathing, waking, blood pressure, heart rate and temperature control. These are functions that the body normally controls automatically.

The predominant hypothesis regarding SIDS is that certain infants for reasons yet to be determined, may have a maldevelopment or delay in maturation of the brainstem neural network that is responsible for arousal and affects the physiologic responses to lifethreatening challenges during sleep. This functional birth defect begins before the baby is born.
Source: The American Academy of Pediatrics

Critical Periods of Development

Weeks gestation from LMP
Most Susceptible Time For Maj or Malformation

6
Heart

10

11

12

Central Nervous NervousSystem System Central

Arms Eyes Eyes Legs Legs Teeth Palate

External External genitalia genitalia

Ear Ear Mean Entry i nto Pre natal Care

Missed Period

From Karla Damus, March of Dimes grant presentation

First 6 months of life. Rapid growth and development of brain. 90% of deaths occur in this period.
Critical Development Period

SIDS
Vulnerable Infant Exogenous Stressors

undetectable defect.

Infant with

Sleeping on stomach, loose bedding, inappropriate sleep surfaces, smoke, etc.

Triple Risk Model

Source: American Academy of Pediatrics

Triple Risk Model

Research has led to the development of a Triple Risk Model A functional Birth Defect that may cause death when you have a:
1. Vulnerable Infant There are different ways an infant can become
vulnerable. There may be an underlying defect-respiratory, heart rate, or homeostatic controls. When moms smoke, use drugs, or get little or late prenatal care the infants growth in the womb can be affected also.

2. 3.

Critical Development Period after birth-often in the period 2-4

months after birth. 90% of SIDS deaths occur in this time frame.

A Stressor is Present (Exogenous) Could be stomach sleeping, a

soft sleep surface, a cold, or upper respiratory infection. This is the only currently modifiable area and one in which you can make a

difference.

Risk factors alone do not cause SIDS. Most babies with one or more of the above risk factors do no succumb to SIDS.

When These 3 Factors Come Together it Provides a Potential SIDS Event

Do Not let that happen!

Other Risk Reduction Methods

Get early and regular prenatal care. Breastfeeding is recommended. Educate parents. Do not allow babies to share a crib, even if they are siblings or twins. Ask parents to provide a sleeper garment. Dress the baby in it for sleep instead of covering him with a blanket or comforter. Make the families you serve aware of the steps you take to reduce the risk of SIDS while caring for their children.

Avoid Overheating
At an early age, babies are unable to regulate their own body temperature. Over time their ability to regulate body temperature and other internal comfort controls increases. Becoming too hot can diminish the babys ability to maintain its core body temperature.

Signs that the baby is too hot include sweating, damp hair, flushed cheeks, heat rash, and breathing rapidly.
Use a temperature that is comfortable for adults in the babys room. Room temperature should be set from 68F to 72F.

Smoking
Do not smoke! Provide a smoke-free environment for babies in your care. Recent research indicates that the risk of SIDS doubles among babies exposed only after birth to cigarette smoke and triples for those exposed both during pregnancy and after birth.

RISK FACTOR Safe Sleep Environment

The American Academy of Pediatrics suggests that the majority of infants dying prone were on sheepskins, soft crib mattresses, and pillows. Soft surfaces have also been implicated in infant deaths occurring on adult beds.

Cribs Not Meeting Safety Standards The crib should be safety approved. The firm mattress should be a snug fit for the crib, portable crib, or playpen. Avoid Chairs, Sofas, And Water Beds In family child care home settings, it is not uncommon to find babies sleeping on a variety of surfaces. Chairs, sofas, waterbeds, cushions and standard or adult beds are NOT safe sleep surfaces because babies can fall or become entrapped in crevices in the furniture or between cushions. Excess Bedding Excess bedding and fluffy blankets, comforters, and pillows can impair the babys ability to breathe if these items cover the face. Toys and stuffed animals as well as bumper pads and wedges should not be placed in the crib. (American Academy of Pediatrics)

Lets Reduce the Risk for SIDS

(American Academy of Pediatrics)

Use a Pacifier: Recent

research has shown that pacifiers can significantly reduce a babys risk for SIDS.

Experts Recommend

providing your baby with a pacifier EVERY time they are placed down to sleep. While the exact safety mechanism is not yet known, there are many possibilities for this finding. (SIDS Alliance)

It has been suggested that the presence of a pacifier in the mouth may discourage babies from turning over onto their faces during sleep.

Pacifier Finding Possibilities

Moving or turning may dislodge the pacifier, which may have the effect of encouraging babies to stay on their backs. Another theory suggests that pacifier use might help to keep the tongue positioned forward, keeping the airways open.

It has also been hypothesized that pacifier use may quiet a restless infant, who might otherwise move more aggressively around the crib.
On the other hand, pacifiers may stimulate the upper airway muscles and saliva production, possibly triggering brain activity and ability to arouse from sleep. Increased arousability is seen in infants who usually sleep with a pacifier, even if the pacifier is not being used.

SIDS Alliance 2006

This is Riker. Riker is wearing a sleep garment rather than blankets.

He is placed on his back without any stuffed animals, blankets, or quilts.

He will be comfortable without an extra blanket. Please Note: Bumper pads are NOT recommended by AAP. Even though Bumper Pads are well secured, they still pose a risk for this 4 month old infant.

SAFE vs. UNSAFE

In this photograph, there are three things that promote a safe sleep environment and two things that are risks promoting an unsafe environment. Can you pick them out?
SAFE 1.Sleep Sack rather than blankets.

2.Tight sheet on firm surface.

3.Infant placed Back to Sleep. UNSAFE 1.Pillow like bumper pads. 2.Wedge under infant.

Risk Factors
There are several things that pose risk factors here.

Can you name them?

Thats Right; This Crib Poses Several Risks.

1. 2. Infant laying in the prone position Stuffed animals in crib

3.
4.

Bumper pads
Blanket

THIS IS AN UNSAFE SLEEP ENVIRONMENT WITH MANY RISK FACTORS FOR SUDDEN INFANT DEATH SYNDROME.

This is a picture from the Consumer Product Safety Commission that shows how a baby should be placed in a crib when put to sleep at night or for a nap.

Surfaces
Place the Baby on a Firm Mattress and REMOVE: all pillows quilts comforters bumper pads sheepskins stuffed toys and other soft items from the crib Do NOT Place the Baby to Sleep on a: waterbed sofa chair soft mattress Pillow or pillow top mattress sleeping bag or any other soft surface

Discussion with Parents

Have a discussion with parents about sleep position policies.
If they are insistent about tummy sleeping, use a brochure and/or let them know what you have learned about SIDS and that you cannot intentionally put a child a risk. Discuss medical waiver and implications.

Forms
Check with your state licensor about an enrollment form that helps to protect you. There is a section for parents to request sleeping positions-Remember, this also protects parents!
Some caregivers and centers will not accept a baby that must be laid in a prone (tummy) position.

Policy
Develop a policy on Back Sleep position for indicating all healthy babies will be placed on their backs to sleep unless a medical condition requires a different sleep position. In the case where a medical condition requires non-supine sleeping, a physician needs to sign off. It should not be a parents choice.

The Legal Side

Do everything in your environment that you can to prevent SIDS. (All mentioned previously). Abide by the recent law enacted requiring childcare provider SIDS Educationincluding volunteers. Childcare providers who do not follow current recommendations for infant sleep position and bedding may be sued if an infant dies while in their care. Litigation could include: wrongful death, loss to society, a breach of contract between caregiver and parents, and neglect.

Develop a Plan
Develop a plan if a child stops breathing. What will you do? Who will take care of other children? How will this be handled with parents and the other childrens parents? Have a plan in place. Review the plan with all staff periodically. Practice rescue breathing and choke-saving skills for infants in a first aid course as required by licensing.

What if a SIDS Event Occurs?

(Know What to Expect)
Since SIDS is a diagnosis of exclusion, all other possible causes of death must be ruled out before a SIDS diagnosis is applied. In order for this to happen, the following will occur.
There will be an investigation Several people will ask for the same information so they can help Law enforcement will probably arrive first and they will Note babys health, behavior, etc. Take photos Limit disturbance of the area Licensing agency Questions about licensing regulations SIDS death not a cause for revoking a license Coroner/medical examiner Conducts autopsy Determines circumstances of death

Take Classes
Take advantage of classes on emergency procedures, first aid, and risk reduction such as this course. If a child in your care becomes unresponsive do the following:

Call 911. Get help to care for the other children. Call the childs parents or emergency contact. Call the parents of the other children. Do not disturb the scene. Notify your licensor and your insurance agency.

Learn CPR
Learn CPRCardio Pulmonary Resuscitation
Remember, we do not know it is SIDS until after the autopsy.

Play Time
To keep a crib safe, remove all stuffed animals and other soft items from the crib and have toys available for tummy time play. The American Academy of Pediatrics recommends,

Tummy to Play and Back to Sleep.

It is important for an infants development to have supervised tummy time. This is supervised playtime with the child while he or she is positioned on the tummy. By incorporating tummy time every day, we are able to address some of the barriers to placing babies to sleep on their backs, such as flat head and the ability to roll over and sit up. By making sure that babies have supervised tummy time, you are promoting healthy physical development, the opportunity to learn to lift and turn their heads and exercise their bodies, and time to strengthen the neck, arm, and shoulder muscles. This will help to ensure that the baby will reach its developmental milestones of rolling over and sitting up at the recommended time. Remember, by placing babies on their backs to sleep, you are reducing the risk of SIDS. * Dont worry, back sleeping is comfortable and does not require any special equipment. Wedges to keep babies in place are not necessary and are not recommended, unless specified by a physician.
Click here to download the brochure from the American Academy of Pediatrics on Tummy to Play and Back to Sleep.

If you must use a blanket

Place the baby with his feet at the foot of the crib; bring a thin blanket up only as far as his chest; and tuck the blanket firmly under the crib mattress.

Back to Sleep
ALWAYS place a baby on his back to sleep. If he falls asleep while playing on his stomach, turn him over on his back to sleep.

Photo from http://www.keepkidshealthy.com/welcome/safety/back_to_sleep.html#Babies

Sudden Infant Death Syndrome Has Been Reduced by Approximately 50% Since the Back To Sleep Campaign Started.

Do your part in reducing the risk!

Click below to download the brochures.

Child Care Providers Guide to Safe Sleep Parents Guide to Safe Sleep

Resources
Following are some links for families and those impacted by infant death: Infant Death Center of Wisconsin A Place to Remember Bereavement Publishing, Inc. Children's Hospital of Wisconsin Bereavement Program C J Foundation for SIDS The Compassionate Friends National SIDS Resource Center SIDS Network, Inc. Crisis, Grief, & Healing March of Dimes American Academy of Pediatrics The National SIDS/Infant Death Center First Candle - Helping Babies Survive and Thrive National Institute of Child Health & Human Development

COPYRIGHT 2001 by Northeast Wisconsin Technical College