Waking up to the danger of SIDS

Guidelines based on epidemiological studies can do much to eliminate the searing family tragedy of Sudden Infant Death Syndrome. However, many parents still don’t follow them.

SIDS 311 (photo credit: Brennan King, Bradenton Herald/MCT)
SIDS 311
(photo credit: Brennan King, Bradenton Herald/MCT)
That early morning on Purim 13 years ago began like any other. The older children were still in bed, but one of the infant twins needed attention. As the girl, Michal, ususally cried, wanting to be fed and diapered urgently, she received the attention first. When, an hour later, the parents got around to the boy, Amit, to their horror they found him dead in his crib.
Celine Michlis and her husband, a religious couple living on a small settlement, heard the ambulance, the urgent movements of the paramedics, the shocked and frantic voices of neighbors, and then the quiet arrival of police investigators. As relatives and neighbors testified that the couple were dedicated parents, the police had no suspicion of foul play and closed the investigation.
Amit had been apparently healthy since his birth – and like the older kids had always slept on his stomach. As the couple did not not suspect anything more than bad luck, they did not even consider approving an infant autopsy.
So they never did know why Amit became a victim of sudden infant death syndrome (SIDS).
In all the years that followed, they regretted not agreeing to the examination and thus not knowing the answer, instead hearing only suppositions. The Michlises had another baby two years ago, but have never gotten over the tragedy.
“Our lives changed,” Celine said at the recent conference of ATID (www.atidbaby.org) – the Jerusalembased voluntary organization for the prevention of, education about and research into SIDS. Working on a shoestring with volunteers at Shaare Zedek Medical Center, where it has a small office and a hotline (02) 666- 6833), ATID was founded by the hospital’s pediatric respiratory expert Dr. Anat Shatz, who knew of the Machlis’s tragedy and asked Celine if – accompanied by her husband, who sat in the audience – she would tell her story to the 400 in the hall. Although she worried that it would be too painful, Celine – a parents’ activist in the 200-member voluntary organization – decided that informing other parents on how to reduce the risk of SIDS was more important, so she nobly agreed to speak.
“A physician from the US had visited us at home and asked why we were putting the twins to sleep on their stomachs. He insisted that the ‘Back to Sleep’ policy – in which an infant from birth to age one is always put to sleep in a supine position on their back – had been proven to reduce the risk of cot death. But we dismissed this, saying we had put the older ones to sleep on their stomachs and they slept well. ‘We know what we’re doing’, we told him. Those words still echo in my mind.”
Shatz, a senior ear-nose-and-throat surgeon at Shaare Zedek, initiated the country’s first-ever international conference on SIDS in 1993. Her interest in the subject began when she conducted research on the upper airways of infants suffering from sleep apnea; the results were that there was no structural difference between them and those without breathing problems, she recalled.
WANTING TO know more, she began to study various aspects of the problem. This led her to establish a unique clinic at Shaare Zedek dealing with babies’ breathing and sleeping problems. Since Shaare Zedek, with over 14,000 deliveries a year, has the busiest obstetrics department in the country, the Jerusalem hospital was a natural spot.
Shatz said that since only a handful of autopsies are performed voluntarily each year (since a 1980 amendment to the Anatomy and Pathology Law made them dependent on parental agreement), it’s impossible to know the cause of unexpected death in infants. It is estimated that of some 75-80 such cases a year, 60 of them are authentic SIDS, which is the leading cause of death from age one month to a year. Although Back to Sleep has been the official Health Ministry policy and well-baby (tipat halav) clinic advice for years, the total number of SIDS victims has shown no significant decline in the past few years. This is due not only to the increasing birth rate, but also because it has been difficult persuading Israeli parents (and even some doctors and nurses) that it must be an iron-clad rule.
PROFESSOR ED Mitchell, an expert in Child Health Research from the University of Auckland in New Zealand who was an invited speaker at the event, said that if strictly adopted, supine sleeping dramatically reduces the prevalence of SIDS. In his own country, only a tiny minority of infants sleep on their stomachs, he said, and crib deaths have significantly declined.
Young adults continue to smoke, and in New Zealand (less so in Israel), many mothers smoke while pregnant.
Those who do quit during gestation may have a partner who smokes heavily; this risk is much smaller than if the fetus is directly exposed, said Mitchell, but environmental smoke remains a significant factor in SIDS. About a third of SIDS in New Zealand is blamed on smoking, he added.
A practice called “bed sharing” is also an important cause, according to epidemiological research. Instead of breastfeeding (or formula feeding) in one’s own bed and then putting the infant to sleep in a nearby cot, too many mothers think it’s more convenient to have the baby sleep in their own bed. This habit is also common among some cultural groups, making it difficult for governments to look “politically incorrect” by telling these parents to stop it.
Bedsharing is a risky practice, said Mitchell, for several reasons. The adult’s mattress is usually too soft, so the child’s airways could close and carbon dioxide can build up and be “rebreathed”; this could happen due to the parent’s sheets and blankets as well. The sleeping (or sleepy) parent could even crush the delicate infant by turning over. Mitchell said the parent can cuddle and feed in the adult bed, but the baby should then be returned to its own crib in the parent’s bedroom, where the child should sleep until the age of at least six months.
MITCHELL, WHOSE winter season in New Zealand is in June, July and August, noted that SIDS deaths used to be highest then, but after the Back to Sleep campaign, this peak nearly disappeared,. Still, if babies are put to sleep in a prone position, they remain at risk – mostly between 10 p.m. and 7:30 a.m.
Prof. Yona Amitai, a pediatrician and former head of the Health Ministry’s department of maternal, child and adolescent health, discussed environmental factors in crib death. “Babies breathe more rapidly than adults or older children, so if they inhale something harmful such as chemicals, they can be in bigger danger.
Remember that babies usually spend their first months in their (or a babyminder’s) home. So the quality of air is very important, and there is a difference between indoors and outdoors.”
In developing countries, wood- or kerosene-burning stoves and fireplaces can produce toxic fumes, but one needn’t live in a poor country to be in danger. It’s fashionable in rich countries, and even in some places in Israel, to have fireplaces for heating or esthetics.
“Never leave a car running in the attached garage,” Amitai added. “Deodorizers, glues, paints, thinners, biological pollutants and formaldehyde [from certain furniture, like that of MDF] can affect infant’s breathing and trigger SIDS. Wall-to-wall carpets, or any carpets in a baby’s sleep area are not recommended.” Instead of chemical deodorizers, air can be cleaned with ionizers, for example. Dust mites, animal dander, molds, pollen and humidifiers with standing water can also be a factor in SIDS.
Dr. Ronit Lubetzky of Tel Aviv Sourasky Medical Center said data had convinced her that breastfeeding cuts SIDS risks. Large, serious meta analyses published in major journals have concluded that breastfeeding strengthens the immune system and allows infants to wake up more easily, thus reducing the danger of too-deep sleep. Thus SIDS’ reduction campaigns should endorse breastfeeding, she said. A soon-to-be-published study by Prof. Fern Hauck of the University of Virginia at Charlottesville examined 18 separate studies by meta analysis and came to the firm conclusion that breastfeeding from birth significantly reduces the risk of crib death.
Hauck, who was the other foreign speaker at the conference, discussed SIDS guidelines of the American Academy of Pediatrics’ Task Force, of which she is a member. The task force periodically reassesses and updates them. They were updated a couple of years ago, she said, and this is due again by the end of the year.
Some parents are deterred by needless concern that supine sleep causes the baby’s head to flatten at the back.
But healthy babies are never left with a permanent indentation; they bounce back. Tummy time, she added, is recommended when infants are alert and exercise their necks when they are in a prone position – but this is prohibited during sleep. Hauck, who noticed stuffed sponge-and-cloth “crib bumpers” on a baby bed on commercial display outside the hall, said from the stage that these should not be used to protect heads from bumping into crib sides. This, she said, is because they can lead to smothering. Commercial apnea alarms should also not be purchased or borrowed for use under baby mattresses because they have not been shown to reduce SIDS while significantly raising false alarms. But Hauck said baby pacifiers in tiny mouths during sleep on one’s back are recommended to reduce SIDS’ risk, but only after a month in breastfed babies, after nursing habits are well established.
THE UNIVERSITY of Virginia expert said she had spoken during her visit to Israel physicians who always put their babies to sleep prone despite all the evidence. “There are highly educated people who still think this. Yes, there are societal pressures and parental stresses, but I urge them to examine the evidence.”
The nature of the prone position, that makes sleeping deeper than the supine position, is problematic, said Hauck. Such babies don’t wake up so easily; parents appreciate that, so they get more of a rest, but in apnea, babies can die because the position does not easily trigger waking up, she said. As newborns prefer sleeping on their stomachs for this reason, if they get used to it after a few days or weeks, they won’t want the supine position at all.
So don’t get them habituated, Hauck urged.
American couples are much more likely to observe Back-to-Sleep rules than their Israeli parents, as only 10% of babies up to their first birthday sleep prone (this doubles for the African American population). According to Dr. Lisa Rubin, Amitai’s successor at the Health Ministry who presented a detailed PowerPoint presentation, only about 42% of Israeli infants sleep supine on a regular basis. Too many mothers still smoke.
More SIDS deaths occur in the winter months, and there is an increased risk when mothers have little education.
First children are at higher risk than babies born after them, and baby girls are at higher risk in the Arab Israeli population, she said – compared to a higher risk among male babies in the Jewish sector.
Prof. Michael Schimmel, head of Shaare Zedek’s neonatology unit, said the premature babies he and his staff treat have the highest SIDS risks of all newborns.
“This year, we had 490 low- or very-low-birth-weight preemies born at less than 37 weeks.” More awareness of the importance of the supine position – as soon as neonatal monitor equipment allows – is needed, said Schimmel, who noted that he himself had for some time been unaware of its importance. “Perhaps there is less stimulation of the breathing mechanism, more immaturity of the lungs or less muscle strength, less cerebral oxygenization – but it is clear.”
Doctors at the all-day conference seemed in unanimous agreement with Mitchell’s conclusion: “If we apply what we know, we can eliminate SIDS.”