Episode 153: Sudden Infant Death Syndrome - a podcast by Rio Bravo Family Medicine Residency Program

Episode 153: Sudden Infant Death Syndrome.    

Future doctors Nisha and Afolabi explain the way to prevent sudden infant death syndrome and Dr. Arreaza adds comments about prevention through vaccines.  

Written by Selena Nisha, MS4; and Oluwatoni Afolabi, MS4. Ross University School of Medicine. Comments by Hector Arreaza, MD

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Today, we are going to talk about sudden infant death syndrome, also known by its acronym SIDS. This topic is a heavy one and it may be triggering for some parents or those who may personally know a family member affected by SIDS, so please refrain from listening to this podcast at any point you see fit. 

First and foremost, we tend to hear a lot about SIDS in the news or social media outlets that cover these tragic incidents, but let's define what exactly sudden infant death syndrome is. Sudden Infant Death Syndrome, or SIDS, is the abrupt and unexplained death of an infant <1 year of age. It usually occurs during sleep; it is sometimes referred to as "crib death". According to the CDC, SIDS is the leading cause of death in babies between 1 month and 1 year of age in the United States. 

It occurs mostly between 1-3 months. 

Q: What causes SIDs? 

The exact cause of SIDS is unfortunately unknown. However, there are many studies that have identified several risk factors for SIDS and most of them are definitely preventable. 

• The most important risk factors for SIDS are related to the sleep position and the sleep environment of the baby. Babies placed to sleep on their side or their stomach are at increased risk for SIDs compared to babies placed to sleep on their back. In addition, bed-sharing is also strongly associated with increased risk for SIDs.
• Smoking during pregnancy and postnatal exposure to tobacco. Second-hand smoking exposure is probably the most important risk factor for SIDS.
• Drug use or alcohol use during pregnancy
• Overdressing/overheating the baby
• Babies that are born premature and/or low birth weight
• Late or no prenatal care.

Q: Are there any ethnic or genetic components involved in SIDS? 

• Yes, there are. According to the CDC, African American, American Indian or Native Alaskan babies have a higher risk.
• Surprisingly, some studies have even shown an increase in SIDS in baby boys compared to baby girls and if a baby’s sibling had died of SIDS, that may be linked to a genetic disorder.
• Asian babies are less likely to suffer from SIDS, and African Americans are disproportionally affected by SIDS.

Interesting fact: Several people have been accused of killing their own babies and later forgiven because a diagnosis of SIDS was established after autopsy and extensive investigation. Some examples are: Kathleen Folbigg (Australia), Sally Clark (England), and Angela Cannings (UK).

Q: What are the clinical recommendations to reduce the risk of SIDS that parents and caregivers should be aware of?

• It is important to know that although short episodes of tummy time are beneficial for the baby, we need to be sure to not put the baby to sleep on their belly or side. In fact, the incidence of SIDS has decreased more than 50% in the past 20 years, largely as a result of the “Back to Sleep” campaign in 1992 that recommended that babies be placed on their backs to sleep to reduce the risk of SIDs.
• When choosing a crib and mattress, make sure you pick a crib that is well made and sturdy and a mattress that is firm and flat. It is important for the angle of the mattress to not be higher than 10 degrees. I know that we all love to see fluffy and cute little blankets and toys in the baby’s crib, however, we also need to make sure none of those things are present while the baby is sleeping in order to avoid any chance of suffocation.

Q: A friend of mine who recently had a baby always feels anxious when breastfeeding her baby because she feels that her baby is not getting enough air to breathe in. She actually feels the same way when her baby is using the pacifier too. Is it true that the baby is truly struggling to breathe in these instances? 

• This is a common misconception that many mothers tend to have. Many women genuinely fear that their baby isn’t properly breathing while breastfeeding and are worried that this can increase the risk of SIDS. However, the opposite is actually the truth. Turns out that breastfeeding for 6 months to a year actually decreases the risk of SIDS.
• We know that many parents make use of pacifiers, especially in situations relating to soothing the baby but interestingly enough, pacifiers can decrease the risk of SIDS as well. The only important thing to know about pacifier use is that if the baby does not want the pacifier, please don’t force it. Also, make sure the pacifier does not have any hanging parts to it such as cords or straps and if they are sleeping, be sure to not put the pacifier back in the mouth.

Q: After listening to all of these recommendations, it seems like the baby should be sleeping with the parents in the first year of life just to be sure nothing happens to them. This way, the parents will be able to jump into action as quickly as possible because they will be right next to the baby. As safe as this sounds to me, is co-sleeping even recommended?

• It may seem like a good idea in retrospect however studies have shown that co-sleeping in an adult bed can actually increase the chances for SIDS. Although there may be many reasons as to why parents choose to have their baby in bed with them, we need to try to refrain from co-sleeping with the baby. It is definitely okay to have them sleep in the same room as you, but make sure they are in a bassinet or someplace nearby instead of sleeping in your actual bed. There are risks involved that you may not think can occur but certainly have in past cases such as accidentally rolling over on your baby or the baby may become trapped between the headboards if there is empty space present.

Q: These are some excellent recommendations and very helpful tips that parents will be able to utilize when prepping for the baby and after the baby arrives. Luckily, we have many well-known baby cameras and devices that can also be put into place to ensure that the baby is safe. Do you think this is enough to be reassured? 

• There are many baby monitors and devices on the market currently that claim to help reduce the risk of SIDS. While that may seem true, I would argue that nothing is more reliable than utilizing the safe sleep practices we mention here today as no device or monitor can do the same.

Q: Who can parents talk to if they aren’t sure that what they are doing is right or if they need more help in figuring out ways to practice safe sleep? 

• This is what your well-baby visits are for. Parents can always verbalize their worries or questions to their pediatricians during the visits. As important as it is for doctors to make sure that the babies are developing well, it is also their job to make sure your questions and concerns are taken care of.

Q: How exactly is the diagnosis of SIDs made, especially since many of these risk factors seem majorly accidental?

• It is important to note that there is no specific diagnostic test for SIDs. The diagnosis of SIDs is made only when all other causes have been ruled out following a thorough clinical history, death scene investigation, and autopsy. It is a postmortem diagnosis.
• Clinical history is gathering all information about the infant which includes certain lab work or other studies that may have been abnormal during their life. As we have mentioned, it is very important to rule out all the other possible causes of death before making a SIDS diagnosis.
• Not only is the clinical history important, but the death scene is also crucial to making a diagnosis as well. Some may think that just by looking at the scene you will be able to figure out exactly how the death occurred. But that is not always the case. There are certain parameters officers and investigators have to follow prior to coming to a conclusion. For instance, some may use a doll to demonstrate the position of the baby in certain instances where the baby may have been in a crib that was not well made or if they were wedged between objects.
• Other things to ask would be when the baby was awake and when they went to sleep, where they were found, what time they were found. If they happen to be found in a bed, it is important to ask how many people were on the bed sleeping with the baby and how firm or soft the actual mattress was that the baby was sleeping on. Other things to observe are what type of bedding did the crib or bed have and what clothes the baby had on.

Q: There were so many factors to consider after death. Selena, what would the autopsy show at this point that would lead to SIDS being the cause of death?

• First, we have to make sure there is no evidence of trauma or anything that points to abuse externally. Some external findings for SIDS could be fluid in the nose that is tinged with blood or it may even look frothy. The infant itself should look well-developed. Internal findings could be upper respiratory tract inflammation, congestion or pulmonary edema, petechiae in the intrathoracic region or hepatic hematopoiesis that is persistent. After hearing about all this, if I ever have my own baby, I would feel so afraid to leave them with anyone but me.
• Please don’t feel this way. This information is not meant to scare you. There are many caregivers and family that have a ton of love for the baby and would be more than happy to take care of them. I would say to set boundaries and ask questions about how your baby will be cared for when you are not around. This will bring you lots of ease that your baby is in safe hands. Sometimes it is very important to remind our family or caregivers the proper safe sleep practices, especially if it has been a while since they’ve been around a baby.

Q: How can boundaries be set in a way that doesn’t seem offensive? What are some questions parents can ask or what can they do before leaving their baby in the care of someone else? 

• Encourage parents to not feel afraid to ask questions. That is the best thing you can actually do to ensure your needs are being met for safe sleep. Let me give you some examples of questions to ask that will be direct, but in no way will it seem offensive.

1. Ask what sleeping arrangements they have for your child in their home. There is no harm in providing your own if you feel that the arrangements are not safe.
2. If the baby happens to fall asleep in things like a car seat or bouncer, ask them what they would do upon seeing that.
3. Be sure to ask in what position they put the baby to sleep and remind them that babies should only be sleeping on their backs. Ask them where tummy time will be taking place and make sure to see the location yourself.

Since we can’t control the people who are around or go into the caregivers' house, it is crucial to ask if anyone who tends to smoke tobacco or use vaping products will be in the vicinity of the baby. This is especially important to ask as many people may not consider this to be harmful to the baby, but even secondhand smoke increases the risk for SIDS greatly. 

Q: How to approach parents affected by SIDS?

• These families are truly living their worst nightmare. It is a situation that you or I cannot even fathom being in. It is very heartbreaking for all those involved especially since the deceased is such a young baby that had more life to live. First and foremost, it is very important that the parents have a good support system.
• Be sure to show compassion and empathy. This goes a very long way. Simple things such as saying, “I am here for you”, “I am so sorry for your loss”, “I can’t even imagine what you’re going through”, “please, let me know if there is anything I can help you with during this time”, or “I am here if you need to talk” will allow the parents to feel supported and their emotions to feel validated. Just being there is a huge step in the right direction to help a family who is processing all of this trauma and tragedy.

SIDS is definitely a traumatic event in a family. Let’s not forget about vaccinations to reduce the risk of SIDS. I’m glad that the incidence has been decreasing in the last decades thanks to research. Let’s wrap up this episode.

Vaccines: The CDC recently recommended RSV vaccination to all pregnant women between 32 through 36 weeks of pregnancy from September through January.

The diagnosis of SIDS requires the exclusion of other causes of death, including investigation of the death scene and autopsy.

Prevention is key. The most evidence-based preventive measures are back sleeping, pacifier use, breastfeeding, and proper bedding, and avoid co-sleeping. 

If you made it to the end of this episode, I really hope you can take some of these tips and recommendations and apply them to your practice and share this useful information to your patients who are family planning or those with infants. We know it is such a difficult topic to bring up to patients but it is very important to let them know how to prevent SIDS and the unfortunate consequences that can come out of not practicing safe sleep. 

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Conclusion: Now we conclude episode number 153, “Sudden Infant Death Syndrome.” Future Doctors Nisha and Afolabi explained how to prevent SIDS. Evidence supports some preventive measures such as: avoiding second-hand smoke exposure, avoiding co-sleeping, and avoiding overdressing and overheating of the baby. The preferred sleeping position for babies is on their backs. Dr. Arreaza also emphasized the prevention of SIDS by giving appropriate vaccinations to infants. Dr. Schlaerth highlighted the importance of proper beds and bedding for babies. Remember to recommend parents use a firm mattress for cribs and avoid blankets, stuffed animals, or any other items on babies’ beds that could cause accidental suffocation.

This week we thank Hector Arreaza, Selena Nisha, Toni Afolabi, and Katherine Schlaerth. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

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3. Mitchell EA, Ford RP, Stewart AW, et al. Smoking and the sudden infant death syndrome. Pediatrics. 1993;91(5):893-896. https://pubmed.ncbi.nlm.nih.gov/8474808/
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5. Bass M, Kravath RE, Glass L. Death-scene investigation in sudden infant death. N Engl J Med. 1986;315(2):100-105. doi:10.1056/NEJM198607103150206. https://pubmed.ncbi.nlm.nih.gov/3724796/
6. Berry PJ. Pathological findings in SIDS. J Clin Pathol. 1992;45(11 Suppl):11-16. https://pubmed.ncbi.nlm.nih.gov/1474151/
7. Moon RY, et al. Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. Sleep-related infant deaths: Updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics. 2022; doi:10.1542/peds.2022-057990. https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022?autologincheck=redirected
8. Safe Sleep NC. (2019, September 13). Talking to Families about Safe Sleep - Safe Sleep NC. https://safesleepnc.org/healthcare-providers/talking-to-families-about-safe-sleep/
9. Royalty-free music used for this episode: Latin Chill, downloaded on July 20, 2023, from https://www.videvo.net/.

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