Beep-beep-beep-beep
It’s around 5am in the pediatric emergency department when the high-pitched tone of our call-ahead radio chimes four times. A hush falls over the normally chaotic room. I reach for the radio to hear the report from EMS, giving them my identifier: “Children’s Physician 236. Go ahead.”
“Physician 236, how do you copy?” says the first responder on a static-filled line.
“Loud and clear, please go ahead.”
“Yeah, I’ve got a three-month-old infant in full cardiac arrest found in an adult bed this morning. CPR ongoing, we’re about four minutes out from your facility.”
My stomach drops and a lump forms in my throat. Sudden Infant Death Syndrome, or SIDS, is the patient case that I find most emotionally difficult in my job as a pediatric emergency medicine doctor. I’ll have to tell parents that their infant has died this morning. In cases like these, we don't know the cause of death other than that it occurs suddenly during the infant’s sleep. It’s unimaginably devastating.
Let me be clear – no individual is to blame for SIDS. Families do their absolute best to protect and love their children. No one is more heartbroken over the death of an infant than his or her parents. SIDS can happen no matter the infant's sleeping environment, even if the parents are doing everything “right,” and that's what makes this condition so deeply tragic and difficult to talk about.
Why does SIDS happen and what can we do to prevent it?
The medical literature has attempted to make sense of this challenging condition over the years and the current understanding is that SIDS occurs when a vulnerable infant in a critical developmental period is exposed to an external stressor.
- Vulnerable infant: genetic factors and immature relationship between the heart, lungs, and sleep/waking systems.
- Critical developmental period: SIDS can occur at up to one year of age, with most cases occurring at age one to four months and 90% of cases occurring by six months.
- External stressor: unsafe sleeping environment.
Parents can't control or change the first two factors (genetics, anatomy/physiology, and age) but they should feel empowered with knowledge and evidence-based recommendations about what makes a safe sleep environment. The American Academy of Pediatrics (AAP) recommends a safe sleep environment to reduce the risk of all sleep-related deaths.
What is safe sleep?
It’s as easy as ABC. Put simply, the infant should be sleeping Alone, on their Back, and in the Crib (or bassinet).
Alone
- Infants should sleep alone, not in a shared bed or with an adult on a couch, armchair, or cushion.
- Risk of infant death is more than 10 times higher for infants who share a bed with someone who is fatigued, has been drinking alcohol, or has been using marijuana or other drugs that make it harder for the adult to wake up.
- Room sharing, not bed sharing, can be protective. In fact, room sharing can decrease the risk of SIDS by as much as 50%. That’s why the AAP recommends infants sleep in a bassinet in their parents’ room for the first six months of life. If this isn’t feasible, using a baby monitor is a reasonable alternative.
- There should not be anything besides the infant in the crib.
- Soft objects and loose bedding such as pillows, blankets, sheets, bumper pads, and toys increase the infant’s risk of suffocation and strangulation.
Back
- Infants who sleep on their backs are much less likely to die in their sleep than infants who sleep on their stomachs or sides.
- The AAP's Back to Sleep campaign in the 1990s led to the largest decline of SIDS in decades.
Crib
- Infants should sleep on a firm, flat surface: for example, in a crib with a tightly fitting mattress covered by a fitted sheet and no other objects.
- Sleeping on an incline or on a soft mattress that can indent can cause a higher risk of suffocation.
- If your infant falls asleep in a car seat, stroller, swing, or carrier move them to a firm, flat sleep surface as soon as you can.
- When an infant's head tilts forward and their chin rests on their chest or straps, this can impact their airway and ability to breathe effectively.
Additional ways to decrease the risk of SIDS:
- Breastfeed.
- Use a pacifier at naps and bedtime.
- Avoid smoking during pregnancy and avoid second-hand smoke before and after the infant's birth.
- Once the infant can roll, stop swaddling and free their arms in a sleep sack instead.
- Prevent overheating and overbundling; infants only need one more layer of clothing than adults do to stay warm. Hats aren't needed indoors.
SIDS can feel unpredictable and terrifying, but knowledge is power. We can’t change biology but we can follow safe sleep guidelines to decrease the risk, because every infant deserve a safe night’s sleep.
Reference:
Moon RY, Carlin RF, Hand I; AAP Task Force on Sudden Infant Death; AAP Committee on Fetus and Newborn. Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics. 2022;150(1):e2022057991
