Running Head: Back to Sleep 1

Back to Sleep: Strategies to prevent Sudden Infant Death Syndrome

Kelsey Baker, Sarah Marlinski, Sandra Sterchi, Morgan Sodeman

1 April 2016

Youngstown State University

Abstract
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Sudden Infant Death Syndrome, also known as SIDS, is one of the leading causes of

death in infants up to one year of age. Several risk factors have been known to contribute to

increased likeliness of sudden infant mortality. Although there has been an increase in SIDS

research and information sources for parents, many teachings are undermined by conflicting

information and incompliance due to poor modeling in hospital settings. A literature review was

conducted to evaluate what factors decrease the likeliness of SIDS. Primary areas of concern

were sleeping environment, environmental factors, and parental education and compliance.

Environmental factors that decrease the likeliness of SIDS include non-smoking households and

avoiding overheated environments and co-sleeping. Parents should avoid falling asleep while

holding infants. Pacifiers and breastfeeding are highly encouraged. Its crucial items are

removed from cribs, including bumpers, loose blankets, diapers, and stuffed animals. Soft

surfaces are proven unsafe. Infants should sleep on firm surfaces. The crucial teaching period for

SIDS prevention begins in the hospital. Poor modeling in hospital practice includes elevating the

head of the bed, nesting, and using positioning devices. Nurses need to be well informed of safe

sleep techniques and implement a variety of teaching strategies. Effective teaching methods

include posters of infant positioning, power points, videos and demonstration of safe sleep

techniques. Teachings should be evaluated with parent questionnaires. Safe sleep techniques

should be taught and modeled consistently in nursing practice. Providing safe sleep

environments and monitoring environmental factors will decrease the occurrence of SIDS.

Introduction
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According to the National Institutes of Health, Sudden death of an infant or young child,

which is unexpected by history, and in which a thorough postmortem examination fails to

demonstrate an adequate cause of death (Carol & Wood, 2012). SIDS occurs in infants, children

up to 1 year old. SIDS is a leading cause of infant death, specifically in infants that are no longer

in the neonatal period of development. The CDC also recorded that SIDS is the third leading

cause of infant mortality in the U.S. (Sudden Unexpected Infant Death).

Several risk factors for SIDS are unable to be controlled or manipulated, including male

gender, African American or Indian Race, prematurity and low birth weight. Attention has been

brought to controllable factors that can be modified to reduce the risk. Parents should avoid co-

sleeping, extra items in the crib, overheated environments, and smoking just to name a few.

Parental compliance for SIDS prevention continues to be an issue. Often, its due to either

a lack of thorough parental teaching, or miscommunication about how unsafe some sleep

practices truly are to infants. Co-sleeping continues to occur in many households across the U.S.

cribs continue to have multiple unnecessary items due to convenience or an attempt to promote

infant comfort. Although these practices may appear to provide additional comfort for infants,

they are very risky and pose a great threat.

SIDS rates still remain high in the U.S. despite campaign efforts such as Safe to Sleep

and In 2010, the rate for infant mortality in the U.S. was 6.1 per 1,000 live births (Rowe, et al.,

2015). In order to decrease the risk of SIDS, hospitals are implementing safety awareness

programs that are focusing on the education and compliance of safe sleep techniques and

preventative measures. Hospitals are the primary source of safe sleep information and education,

therefore it is important they are providing credible and up to date information to parents.

Review of Literature
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In this review, six studies were included that describe and explain risk factors for SIDS,

preventative measures, teaching methods, and the importance of appropriate role modeling from

the hospital staff. All articles are peer-reviewed and excerpted from medical and pediatric

journals.

Risk Factors
Several articles have listed major risk factors that are contributing to infant mortality

related to SIDs. As previously mentioned, there are unmodifiable risk factors for sudden infant

death syndrome. Related intrinsic factors include male gender, African American or Indian race,

prematurity and low birth weight. Maternal factors include young age, tobacco and drug use, low

socioeconomic background, limited education and insufficient prenatal care.

Extrinsic factors contribute to the majority of risk factors related to SIDS. According to

Hitchcock (2012); Carroll and Wood (2012); Mason, Ahlers-Schmidt, & Schunn (2013); and

Rowe et al. (2015), extrinsic factors for SIDS include infant sleep position, soft bedding, co-

sleeping and crib safety. According to research, sleeping in the prone position, or on the side

significantly increases the risk for SIDS. Therefore, the safest sleep position for infants is on

their back or in the supine position. Since the removal of soft bedding in infants cribs has been

encouraged, the incidence of SIDS cases has decreased.

Polystyrene bead filled pillows were among the first soft sleep surfaces as contributing

to the deaths of young infants and, consequently, were removed from the market.

Subsequent studies identified other soft surfaces such as pillows, quilts, comforters, sheep

skins, and porous mattresses as a significant risk factor, particularly when placed under

the sleeping infant (Carol and Wood, 2012).

Approximately one-sixth of infants who died from SIDS were found sleeping with an

adult. Many parents believe that co-sleeping is a way of keeping their infant near and safe, but
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room sharing is recommended over bed sharing. Meta-analysis proved that bed sharing strongly

increases the risk for SIDS, and that ratio is even greater with parents who smoke. For the same

reason, eliminating unnecessary items such as stuffed animals, blankets, and crib bumpers is

recommended as a safe sleep guideline.

In addition, environmental factors play a key role in the risk for SIDS. Its important that

the sleeping environment is warm enough that the infant is comfortable. However, its also

crucial the infants environment does not become too hot. The infant can be overheated with too

many clothes. A onesie or warm outfit without extra layers in a warm bedroom is sufficient

enough. Overheated environments and extra clothing layers increase the risk of SIDS.

Drug and tobacco use also contribute to the incidence of SIDS. According to Carol and

Wood (2012), postnatal smoking was an independent risk factor for SIDS, with an odds ratio of

2.5 if only one of the parents smoked. This ratio increased significantly to 5.77 if both parents

smoked. This study also proved that infants who carry a specific polymorphism of a gene are

more at risk for SIDS if they are imposed to cigarette smoke. That is because this polymorphism

decreases the infants ability to metabolize nicotine.

A study conducted on the potential mechanisms of failure in sudden infant death

syndrome (Harper and Kinney, 2010), showed that prenatal exposure to nicotine, alcohol,

cocaine or heroin alters developmental processes, increasing the risk for SIDS. They believe this

is because there is interference of vital cardiac or breathing systems. Although its difficult to

pinpoint clear physiologic causes of SIDS, many studies are investigating failure of the cardiac

and respiratory systems in rare times of crises while infants sleep. The majority of infants studied

showed abnormalities in 5-HT function in the medulla oblongata. The medullary 5-HT system is

responsible for maintenance of many homeostatic functions, including upper airway control,
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ventilation, and thermoregulation. Nicotine can interfere with 5-HT neurotransmitter

components, causing reduced 5-HT receptor binding. Infants who were exposed to nicotine

during the prenatal period have a decreased ability to maintain homeostasis in respiratory crises.

Pacifi ers
Pacifiers provide infants with a source of comfort. They also help strengthen the oral

muscles infants need to begin babbling, and eventually talking. Many infants enjoy going to

sleep with pacifiers, and according to some studies, they will be safer according to Moon and

others (2012). The effects of pacifier use and SIDS rates were examined in a correlational study.

The researchers also took into consideration other factors such as maternal age, maternal level of

education, whether mothers smoked during their pregnancy, race, bed sharing, and bed

environment. Based on the data from the Chicago Infant Mortality Study, pacifier use reduced

the risk of SIDS by approximately 70%. Pacifier use also notably decreased the risk of SIDS in

adverse sleep conditions, including sleeping in the prone or side position, bed sharing, and when

soft bedding was used. Results were significant since this study involved a population at high

risk for SIDS based on demographic variables.

Breastfeeding
Breastfeeding is highly encouraged for many reasons. It provides a bonding experience

for mothers and their babies, provides the best source of passive immunity, and is important for

growth and development. Among the many benefits of breastfeeding, there has been significant

evidence indicating it decreasing the risk of SIDS. In a Meta-analysis conducted by Hauck and

others, eighteen case-control studies were analyzed. Breastfeeding took place for varying periods

of time. Based on analysis, breast-feeding to any extent and of any duration is protective against

SIDS (Hauck et al., 2011, pg. 3). It is highly encouraged by researchers that exclusive
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breastfeeding is given for at least four to six months and breast-feeding continues the first year of

life.

Endorsing Safe Sleep Measures

It is important for health care professionals in the hospital setting to model safe sleep

practices to positively influence caregivers and teach good habits to practice when discharged

home. According to Hitchcock (2012), nurses and medical staff are displaying mixed behaviors

regarding safe sleep which is sending mixed messages to the parents. Safe sleep

recommendations have been inconsistently adopted by medical and nursing staff. Hospitals

began noticing that safe sleeps measures were not being implemented in the hospital setting,

resulting in poor nurse to parent modeling. For example, nurses were placing the newborns on

their stomachs, allowing large stuffed animals and multiple blankets in the infants cribs. These

actions by nurses and hospital staff are adding confusion and undermining the safe sleep

measures being taught to parents.

To improve the safe sleep model nurses recommended using educational tools for the

parents while in the hospital setting prior to discharge. In previous years, the safe sleep

recommendations werent being taught until the patient was being discharged. Hospitals are now

trying to enforce the education and recommendations earlier to allow more time for the parents

to learn and ask questions. For instance, safe sleep videos were provided, and the parents were

required to watch this video within the first 24 hours after the baby was born. Additionally, a

poster is being displayed in each postpartum room showing an infant sleeping in a crib supine

with no additional items. Nurses are also asked to discuss the posters with the caregivers during

their stay and answer any questions that the parents may have. If the nurse walks into the

patients room and the infant or sleep environment was found unsafe, the nurse was instructed to

use this opportunity as a teaching moment and instruct and reinforce the importance of safe
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sleep. The hospital setting provides a vital opportunity for nurses and medical staff to model

proper safe sleep techniques and risk-reduction behaviors. The hospital may be the primary

source of teaching and information that caregivers receive and it is crucial that it is promoted and

implemented accurately.

Conclusion

After the review of several articles, it was clear that rates of SIDS can be greatly reduced

by implementing safety precautions, providing ample sleep environments, and stressing the

importance of carrying out safe sleep practices by parents and nurses. By modifying risk factors

such as sleep position, co-sleeping, and removing unnecessary items in the crib, infant mortality

rates decrease significantly. Smoking in the households of infants is highly discouraged, as well

as the use of any other drugs. Breast-feeding provides many benefits and improves the chances

infants wont become a victim of SIDS. Adopting safe sleep measures and enforcing protocols in

the hospital setting promotes important practices among nursing staff and patient families.

Educating families about SIDS safe sleep protocols and reinforcing the importance of safe sleep

through demonstration and visual learning materials is most effective. These expert teaching

methods not only help families to learn important home care practices, but reinforce their

knowledge to ensure they are carried out throughout the infants life. Through all of these factors

and techniques, the rates of SIDS can be considerably decreased.

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References

Carroll, R. & Wood, J. N. (2012). Sudden Unexpected Infant Death: A Compassionate Forensic

Approach to Care. Clinical Pediatric Emergency Medicine, 13(3), 239-248.

doi:10.1016/j.cpem.2012.06.011

Hauck, F., Thompson, J., Tanabe, K., Moon, R. & Vennemann, M. (2011). Breastfeeding and

reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics, 128(1). doi:

10.1542/peds.2010-3000

Harper, R. & Kinney, H. (2010). Potential mechanisms of failure in the sudden infant death

syndrome. Social Sciences and Medicine, 6(1), 39-47.

doi: 10.2174/157339610791317214.

Hitchcock, S. (2012). Endorsing Safe Infant Sleep. A Call to Action, 16(5), 388-396.

doi: 10.1111/j.1751-486X.2012.01762.x

Mason, B., Ahlers-Schmidt, C. R., & Schunn, C. (2013). Improving safe sleep environments for

well newborns in the hospital setting. Clinical Pediatrics, 52(10).

doi: 10.1177/0009922813495954

Moon, R., Tanabe, K., Yang, D., Young, H. & Hauck, F. (2012). Pacifier use and sids: evidence

for a consistently reduced risk. Maternal Child Health Journal, 16(1), 609-614.

doi:10.1007/s10995-011-0793-x

Rowe, A. D., Sisterhen, L. L., Mallard, E., Borecky, B., Schmid, B., Rettiganti, M., & Luo, C.

(2015). Integrating safe sleep practices into a pediatric hospital: Outcomes of a quality
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improvement project. Journal of Pediatric Nursing, 31(2).

DOI:10.1016/j.pedn.2015.10.015