Preventing sudden unexpected death in infancy - information for health practitioners

Preventing sudden unexpected death in infancy
Information for health practitioner

Date of publication: April 2008

Information for parents and caregivers
Background information for health practitioners
Dummies (pacifiers)
Advice regarding use of dummies to reduce SUDI/SIDS risk
Baby Friendly Hospital Initiative
References

The Ministry of Health and the Child and Youth Mortality Review Committee have reviewed the current Ministry of Health recommendations for preventing Sudden Unexpected Death in Infancy (SUDI).

Health practitioners are in a strong position to educate, promote and influence safe sleeping practices for infants. This leaflet is intended for health practitioners who work with parents. It provides background information about the current recommendations and discusses the recently raised issue of dummy (pacifier) use as a potential method of reducing SUDI risk.

Parents and caregivers can reduce the risk of SUDI. The actions they can take are outlined below.

Information for parents and caregivers

Following the advice given here can help reduce the risk of SUDI.
Sudden unexpected death in infancy (SUDI) used to be called SIDS or cot death.

No smoking during pregnancy

Smoking during pregnancy is an important cause of SUDI because smoking damages babies before they are born. It is important to stop smoking as soon as possible after a pregnancy has been confirmed. Many women find that it is easier to give up smoking when they are pregnant. A midwife or health practitioner can help pregnant women and other household members who smoke quit smoking. A phone call to Quitline (0800 778 778) can help people to stop smoking.

Sleeping position – Back to sleep

Put babies down to sleep on their backs. Babies who sleep on their backs are less likely to get their faces accidentally covered by sheets or bedding.

Sleeping environment

Room sharing
The recommended sleeping environment is having baby sleeping in a cot or basinette near the parents’ bed.
Babies who sleep in the same room as parents for the first six months are at lower risk of SUDI.

Co-sleeping
Co-sleeping (a parent who sleeps with their baby in bed) is dangerous when:

the baby’s mother has smoked during pregnancy
the adult in bed with the baby has been drinking, or taking drugs or medicines that might reduce their awareness of the baby
the co-sleeping adult is excessively tired.

There is also a small increase in the risk of SUDI from co-sleeping for babies less than three months old, whether or not the mother smoked during pregnancy.

Breastfeeding – ‘Breast is best’

Breastfeeding has many benefits for mothers and babies. Breastfeeding helps to keep babies healthy and well.

Background information

SUDI means a sudden and unexpected infant death. A thorough clinical history, a review of details of the circumstances of death, and an adequate post-mortem examination may provide a contributory or causative diagnosis. The term SUDI is now often used instead of Sudden Infant Death Syndrome (SIDS) because some coroners prefer to use the term ‘undetermined’ for a death previously considered to be SIDS. This change is causing diagnostic shift in the mortality data. The terms SUDI and SIDS are both used in this document to show the transitional nature of the terminology.

The recognition of high rates of sudden unexplained infant deaths towards the end of the 1980s resulted in large-scale case control studies worldwide. The 1987–1990 New Zealand cot death study aimed to identify risk factors related to particular infant care practices¹. Avoiding the prone sleep position for infants, maternal smoking in pregnancy and not breastfeeding were identified as important prevention factors, and led to a successful New Zealand intervention programme. The study found Māori infants had a 3.8 times higher risk of dying than non-Māori infants. Maternal smoking accounted for 50 percent of the higher rate, and bed sharing another 22 percent. They were both considered modifiable factors.

Since 1990, there has been a worldwide reduction in the incidence of SUDI/SIDS. ‘Back to Sleep’ campaigns were undertaken in many countries, and the resulting reductions in incidence of SUDI/SIDS have shown that the infant’s sleep environment strongly influences the risk of SUDI/SIDS².

The European Concerted Action on SUDI/SIDS (ECAS) study combined data from 20 regions in Europe and identified avoidable risk factors such as infant sleeping position, type of bedding used and sleeping arrangements³. The main risk factors were largely independent. For example, a prone sleeping position was found to carry highly significant risks of SUDI (odds ratio 13.1 [CI 8.51–20.2]). If the mother smoked, there was significant risk associated with bed sharing, especially during the first two weeks of life. The odds ratios for bed sharing when the mother smoked were 27 [13.3–54.9], compared with 2.4 [1.2–4.6] for non-smoking mothers. The bed sharing risk decreased with infant age and was not significant for non-smoking mothers after babies were three months old.

Sleeping a baby on his or her back can result in flattening of the occipital area of the skull. The terms flat head syndrome or positional plagiocephaly both describe this condition. Mild flattening of the back of a baby's head does not cause problems for the baby. Some babies however, especially those who may have tightness of one of their neck muscles, may prefer to hold their head in one position. This can lead to flattening of one side of the head. This flattening can be prevented in most cases by alternating the baby's head position when they are put to sleep on their backs and by giving the baby plenty of ‘tummy time’ when they are awake. Occasionally the baby develops a preferred head position while sleeping and parents may need to get advice from a physiotherapist or a paediatrician.

Bed sharing and co-sleeping

Bed sharing is when a baby is brought into an adult bed for feeding or settling without the intention of sleeping.
Co-sleeping is where a adult and baby sleep together in bed.

Mothers and babies sleeping in close proximity is a widespread historical and cultural practice, and has been shown to improve breastfeeding outcomes. Bed sharing is advocated for promoting breastfeeding⁴. There is substantial evidence that breastfeeding promotes an infant’s health and wellbeing, and it is strongly recommended. Bed sharing is fine for breastfeeding and cuddles, but babies should be in their own bed when parents go to sleep, preferably in a cot or bassinette beside the parents’ bed until the baby is six months’ old.

Dummies (pacifiers)

Literature about dummies shows that this is a complex and often controversial topic of research. In 1979, Cozzi et al claimed that dummies might protect against SUDI/SIDS⁵. Support for this hypothesis was first reported by Mitchell et al in 1993⁶. Since then, there have been other studies that have supported this observation, although evidence is lacking for a biological underlying mechanism and, outside this field, dummy use has mainly been associated with detrimental effects⁷. A recent meta analysis to identify whether dummies reduce the risk of SUDI/SIDS showed a strong correlation between giving an infant a dummy when placing them to sleep and reducing their risk of dying from SUDI/SIDS⁸. The results indicate that the effect is strongest when the dummy is given at the infant’s night-time sleep. These results were all part of larger studies examining potential risk and protective factors for SUDI/SIDS. A California study⁹ that interviewed the mothers of 185 infants who were victims of SUDI/SIDS and 312 randomly selected controls identified that after adjusting for known risk factors, the use of a dummy during sleep was associated with a 90 percent reduced risk of SUDI/SIDS, compared with infants who did not use a dummy. The study also suggested that using a dummy may reduce the impact of other risk factors, especially those related to other adverse sleep conditions.

How dummies may reduce the risk of SUDI/SIDS is unknown, but there are several hypotheses. These include avoidance of the prone position, protecting the oropharyngeal airway, reducing the gastro-oesophageal reflux through non-nutritive sucking, and lowering the arousal threshold.

Concerns about recommending dummies have focused on breastfeeding, otitis media and other infections, and dental malocclusion.

More research is needed to understand what may influence the use and non-use of dummies, including parenting behaviours and infant factors. Ongoing monitoring of SUDI/SIDS rates using population-based infant mortality statistics, as well as infants’ dummy use, will be needed to help evaluate the impact of this practice.

Breastfeeding and dummies
Professor Ed Mitchell has recently published a review article⁷ in which he notes that observational studies have shown a clear relationship between frequent or continuous dummy use and a reduction in breastfeeding. In one study, introducing a dummy after one month of age was not detrimental to breastfeeding duration.

Dummy use has also been associated with a significantly higher risk of infective symptoms. There is a 1.2 to 2 times increased risk of otitis media associated with dummy use. Although some dental malocclusions, notably cross bite, have more commonly been found among dummy users than non-users, the differences generally disappear after cessation of dummy use.

The American Academy of Pediatric Task Force¹⁰ recommends using a pacifier (dummy) to reduce SUDI/SIDS risk throughout the first year of life as follows.

Pacifiers should be used when putting infants down for sleep and should not be reinserted once the infant falls asleep.
If the infant refuses the pacifier, he/she should not be forced to take it.
pacifiers should not be coated in any sweet solution.
They should be cleaned often and replaced regularly.
For breastfed infants, delay introduction until one month of age to ensure breastfeeding is established.

At this stage, the Ministry of Health and Child and Youth Mortality Review Committee do not recommend dummy use in infants, although it seems appropriate to stop actively discouraging their use. Any possible reduction in SUDI/SIDS needs to be balanced against the established risks, especially the reduction of breastfeeding duration, with the attendant reduction in health benefits to the infant.

If breastfeeding mothers want to give their baby a dummy advise them to offer it only after breastfeeding is well established.

Advice regarding use of dummies to reduce SUDI/SIDS risk

The Ministry of Health and the Child and Youth Mortality Review Committee do not recommend the routine use of dummies for all babies.

If an infant is already being bottle fed, it is reasonable to discuss the use of dummies with the parents, especially if SUDI risk factors are present.
For mothers breastfeeding their infants, there is a need to discuss the benefits of breastfeeding and risks of dummy use.

If breastfeeding mothers want to give their baby a dummy, it is best to recommend waiting until breastfeeding is well established.

Baby Friendly Hospital Initiative
In New Zealand, the Ministry of Health expects every facility providing maternity services and care for newborn infants to become ‘Baby Friendly’, which means that they should practise the Ten Steps to Successful Breastfeeding¹¹ .

The ten steps to successful breastfeeding are:

Have a written breastfeeding policy that is routinely communicated to all health care staff.
Train all health care staff in skills necessary to implement this policy.
Inform all pregnant women about the benefits and management of breastfeeding.
Help mothers initiate breastfeeding within half an hour of birth.
Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.
Give newborn infants no food or drink other than breast milk, unless medically indicated.
Practise rooming-in – that is, allow mothers and infants to remain together – 24 hours a day.
Encourage breastfeeding on demand.
Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

References

Mitchell E.A., Taylor B.J., Ford R.P.K. et al.. Four Modifiable and Other Major Risk Factors for Cot Death: The New Zealand study. J Pediatr Child Health. 1992; 28 (suppl): 53–58.
Li D.K., Petitti D.B., Willinger M. et al.. Infant Sleeping Position and the Risk of Sudden Infant Death Syndrome in California, 1997-2000. Am J Epidemiol. 2003; 157: 446–455.
Carpenter R.G., Irgens L.M. et al.. Sudden Unexplained Infant Death in 20 Regions of Europe: Case control study. Lancet. 2004; 363:185–191.
The Baby Friendly Initiative: www.babyfriendly.org.uk/sharing/bedleaflet.pdf (last accessed March 2007).
Cozzi F., Albani R., Cardi E.. A Common Pathophysiology for Sudden Cot Death and Sleep Apnoea: “The vacuum glossoptisis syndrome”. Med Hypothesis. 1979; 5: 328–338.
Mitchell E.A., Taylor B.J., Ford R.P. et al.. Dummies and the Sudden Infant Death Syndrome. Arch Dis Child 1993; 68: 501–504.
Mitchell E.A., Blair P.S., Hoir M.P.L.. Should Pacifiers be recommended to Prevent Sudden Infant Death Syndrome? Pediatrics 2006; 117: 1755–1758.
Hauck F.R., Omojokun O.O., Siadaty M.S.. Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A meta-analysis. Pediatrics. 2005; Nov 116(5): e716-723.
Li D.K., Willinger M et al.. Use of a Dummy (Pacifier) During Sleep and Risk of Sudden Infant Death Syndrome (SIDS): Population based case – control study. BMJ. 2006; 332:18-22.
American Academy of Pediatrics Policy Statement.. The changing concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. Pediatrics. 2005; Nov 116(5):1245–1255.
Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A joint WHO/UNICEF statement published by the World Health Organization.

This brochure is available to download in PDF format from the Child, Youth and Mortality Review Committee website (www.cymrc.health.govt.nz)