Sudden Infant Death Syndrome: Facts for NICU Nurses

Sudden Unexpected
Infant Death (SUID):
Facts for NICU Nurses
Christine A. Aris, BSN, RN, NNP, BC
Sherri L. McMullen, PhD, RN, NNP, BC
Bethann M. Lipke, RNC, MS, CNS
Catherine A. Le Mura, RN, MS, NNP, BC
Larry Consenstein, MD
St. Joseph’s Hospital Health Center
Syracuse, New York
With contributions from The Children’s
Hospital at Dartmouth
© copyright 2014
Overall Purpose & Objectives
Purpose: Teach evidence-based practice of SUID risk
reduction strategies in preparation for discharge
Objectives: After viewing the SUID Facts for Nurses
teaching tool the learner will be able to:
Define SUID & SIDS
Identify 2 infant risk factors for SIDS & SUID which are
strongly associated with admission to the NICU
Recognize 2 indications for positioning infants prone in
the NICU
Discuss the impact that nurses have as role models in
the NICU on parent’s practice of SIDS & SUID
reduction strategies after discharge
List 5 risk reduction strategies for SUID as
recommended by the American Academy of Pediatrics
Parent Quote
 “The
hardest thing for us
is that we were not given
the information. You can
only go by what you are
provided with.”
What is a SUID?
Any infant who dies unexpectedly
(Sudden Unexpected Infant Death) –
SUID is a broad term that includes both
explained and unexplained deaths.
We focus on “sleep related” SUID
(i.e. not focused on trauma, drowning,
congenital anomalies, etc).
The Children’s Hospital at Dartmouth
Simple Classification System
Accidental Suffocation
The Children’s Hospital at Dartmouth
What is SIDS?
SIDS is any SUID (i.e. sudden and
unexpected death) that remains
unexplained after:
A complete review of the history
An autopsy
A death scene investigation
Typically, a seemingly healthy infant
is found dead after a sleep period
The Children’s Hospital at Dartmouth
SIDS & explained SUID
share common risk factors
Common risk factors for SIDS and explained
SUID (accidental suffocation and strangulation in
 low socioeconomic status
 smoking
 bed-sharing
 overheating
Specific risk factors for SIDS:
 not breast feeding first 2 weeks of life
 prone sleep position
(Vennemann, Bajonowski, Betterfa-Bahlouol, Suerland, Jorch, Brinkmann, et al, 2007)
When does SIDS & SUID
SIDS is most common in first six months of life.
Peak incidence is between 2 and 4 months.
More SIDS deaths occur in fall & winter months.
 This has diminished since the Back to sleep
 Some hypothesize that the seasonal effect was
due to over bundling and over heating. With the
infant on his or her back and the forehead
exposed, the infant is better able to dissipate
The risk is higher for premature infants.
Populations at risk
SIDS occurs with varying incidence in all
U.S. SIDS incidence in Blacks (113.5 per
100,000) is twice that for Whites (45.5
per 100,000)
Native American infants have higher
incidence for SIDS
SIDS in other countries:
Lowest rates in Asian countries
Higher rates in Maori, Australian, Aboriginine
Maternal risk factors
Young maternal age at first pregnancy
Short inter-pregnancy interval
Low educational level
Poor prenatal care
Cigarette smoking during,after pregnancy
Drug use during pregnancy
Native American and African American
What are the two most significant
risk factors for SIDS?
Prone sleep positioning
 Supine sleep is safest.
• When the frequency of prone decreased from >70%
to ~11.3% in 2002 in the US, SIDS had decreased
by 50-60% by 2001.
• However, the prevalence of prone sleeping increased
to 13% in 2004 and remains stagnant.
 Avoid maternal smoking and exposure to
passive smoking.
Which infants are at
greatest risk?
Neonatal Intensive Care Unit (NICU)
 The lower the gestational age the
higher the risk of SIDS
 The lower the birthweight the higher
the risk of SIDS
A combination of these increases the
risk by more than each factor alone
How big are the risks?
Estimates vary with big risks for small babies
A preterm or low birth weight (LBW) baby
sleeping supine has 2 X more likelihood for SIDS
than a healthy term baby
A preterm infant is:
85 X more likely to die of SIDS sleeping prone
40 X more likely to die of SIDS sleeping on the side
A LBW baby is
83 X more likely to die of SIDS sleeping prone
36 X more likely to die of SIDS sleeping on the side
(Oyen et al. 1997; Fleming & Blair, 2003)
Small babies with big risks
Babies who are “Small at birth”: preterm (<37
weeks) or LBW (< 2500 grams)
A baby who is not “small at birth” is:
2.3 times more likely to die of SIDS sleeping on the
8 times more likely to die of SIDS sleeping prone
A baby who is “small at birth” is:
15 times more likely to die of SIDS sleeping side
>24 times more likely to die of SIDS sleeping prone
(Blair, Ward Platt, Smith, &Fleming, 2006)
NICU Admissions
While we know that preterm infants are at
higher risk for SIDS, full term infants were more
than twice as likely to die of SIDS if they were
admitted to a NICU.
Blair, P., Ward-Plantt, M., Fleming, P., & CESDI SUDI Research Group Institute of Child Health, UBHT Education
Centre, Bristol BS2 8AE, UK. (2003). Early Human Development, 74, 57-82.
SIDS Etiology
Although there are many theories
about what causes SIDS, the exact
cause of SIDS is still unknown and
may even be multi-factorial
 Much is known about what reduces
the risk
 The most prevalent theory is the
triple risk theory
Triple Risk Model
The Children’s Hospital at Dartmouth
The Triple Risk Model:
The Vulnerable Infant
What makes an infant vulnerable?
 Adverse intrauterine conditions (hypoxia, poor
placental blood flow or maternal smoking may
alter autonomic nervous system)
Medullary region of the brainstem is important
for control of respiration and autonomic
Reflexes that fail to respond to a life
threatening event
Our current hypothesis is that
SIDS results when a vulnerable
infant cannot adequately
defend against an asphyxiating
environment—a level of
asphyxia where most infants
would not die!
The Children’s Hospital at Dartmouth
An Example of SIDS Pathogenesis
The Children’s Hospital at
Adapted from Kinney and
Thach, NEJM, 2009
Common brainstem abnormalities in
SIDS victims
Decreased acetylcholine and glutamate receptor binding
Decreased serotonergic receptor binding in the
serotonergic regions (Panigrahy, A. Filiano, JJ, et al, 2000)
Decreased 5-HT1A receptor binding, increased numbers of
immature 5-HT neurons (Paterson, et al, JAMA, 2006)
Decreased levels of 5-HT and TPH2, the major synthesizing
enzyme for 5-HT (Duncan et al, JAMA, 2010)
Decreased GABAA receptor binding
These metabolic defects are not present in infants dying of
other causes, including chronic hypoxia
(Kinney et al, 1995 and Panigrahy et al, 1997)
Exp Neurol, 2011)
(Broadbelt et al, J Neuropathol
The Children’s Hospital at Dartmouth
Medullary abnormality in the
brainstem impairs function
Arousal to
The Children’s Hospital at Dartmouth
Adapted from Kinney and Thach,
Serotonin 5-HT1A Receptor
Binding decreased in SIDS
Very little 5-HT1A receptor binding
Lots of 5-HT1A receptor binding
Panigraphy et al, J Neuropathol Exp Neurol, 2000
The Children’s Hospital at Dartmouth
Incidence of SIDS in the
 5,000-6,000 deaths per year
 “Back to Sleep” campaign
2001: 2,295 deaths per year
2006: 2,326 deaths per year
 SIDS is still leading cause of infant mortality
beyond the neonatal period.
American Academy of Pediatrics, 2011
Incidence of SUID, SIDS and
ASSB (accidental suffocation or strangulation
in bed)
The Children’s Hospital at Dartmouth
From 1998-2001 the
number of deaths “signed
out” as ASSB and
undetermined increased
This does not
necessarily mean
that the incidences
are changing, only
that the medical
examiners are
assigning the cause
of death differently!
So why the uncertainty?
Many believe this is an example of “DIAGNOSTIC
SHIFT” away from SIDS to “ASPHYXIA”.
Medical examiners are tending to call more deaths
“accidental suffocation” or “undetermined”.
Yet the causative role of asphyxia is based upon the
subjective bias of the scene examiner, as there is
no biomarker or standardized criteria for diagnosing
lethal asphyxia at autopsy.
Often, factors in the environment that suggest
asphyxia/suffocation are well recognized SIDS risk
The Children’s Hospital at Dartmouth
Asphyxia and Suffocation
Asphyxia: situation in which there is a decrease in
oxygen (O2) and an increase in carbon dioxide (CO2)
in the body
Suffocation: a form of asphyxia
Entrapment: when an infant is “trapped” in a situation
that produces asphyxia.
Strangulation: when bed clothes or other material is
wrapped around the neck, blocking the airway causing
Accidental suffocation or strangulation in bed includes
(1) suffocation by bedding, pillow, or waterbed (2)
overlaying the infant while sleeping (3) wedging or
entrapment of an infant between two objects and
The Children’s Hospital at Dartmouth
So…Do we call it SIDS or
Accidental Suffocation?
Probability of death: determined by interaction between infant
vulnerability and asphyxiating environment.
There are degrees of vulnerability and the potential of the environment to
be asphyxiating – i.e. continuum from (none  severe).
Infant vulnerability: related to multiple intrinsic risk factors, many of
which cannot be determined at the time of death.
prematurity, maternal drug use, exposure to intrauterine hypoxia, brainstem
neurotransmitter dysfunction, or a critical period of development.
Asphyxiating environment: can be created by multiple extrinsic risk
factors, which are evaluated by history and the death scene investigation.
soft mattress, soft bedding, pillows, bumper pads, bed sharing, kangaroo
care and prone positioning.
The Children’s Hospital at Dartmouth
So…Do we call it SIDS or
Accidental Suffocation?
Interactions can occur anywhere along the continuum:
a normal infant could die in a severely asphyxiating environment
a very vulnerable infant could die in a non-asphyxiating environment.
A medical examiner determines cause of death, based on the death
scene information.
Less deaths are being called “SIDS” and more are “undetermined” or
“accidental suffocation”. In the past, all except obvious cases of
accidental suffocation were called “SIDS”.
This diagnostic shift makes it difficult to track the success of public health
programs such as “back to sleep” or now “safe to sleep”.
Importantly, safe sleep practices that remove the potential for asphyxia,
could reduce deaths for infants that are especially vulnerable.
The Children’s Hospital at Dartmouth
Asphyxia has ALWAYS been
part of SIDS
Most extrinsic risk factors for SIDS are associated
with potentially asphyxiating environments
Prone sleeping
Soft bedding, pillows, bumper pads, etc
Bed sharing
Over bundling
Although it is clear that in some asphyxiating
environments ANY infant would die, in most of these
circumstances infants usually DO NOT DIE!
The Children’s Hospital at Dartmouth
So what have we learned?
• Up to 70% of SIDS infants have abnormalities in
brainstem neurotransmitter systems involved in vital
homeostatic functions
• This may result in: ineffective arousal,
cardiorespiratory and thermal responses to stressors.
The Children’s Hospital at Dartmouth
So what have we learned?
Infants who subsequently die of SIDS have:
blunted arousal responses, decreased heart rate
variability, and episodes of apnea, bradycardia
and tachycardia days to weeks prior to death,
and ineffective gasping shortly before death
evidence for respiratory and autonomic instability
Animal studies have identified abnormalities
resulting from controlled combinations of
neurotransmitter dysfunction and risk factors:
altered sleep and impaired arousal, central
chemosensitivity, and a prolonged laryngeal
The Children’s Hospital at Dartmouth
Low birthweight and early gestation
infants are at the highest risk for SIDS.
These infants are more likely to be placed
side-lying or prone at 2-4 months, during
the peak incidence for SIDS.
Reasons parents place infants to sleep
side or prone:
• Infant’s sleep preference
• Advice from medical professionals
• Observed care in the hospital
Actual death scene
reenactment photographs
Tomorrows Child… CPSC, Detroit, Michigan 2005
Who still needs to be
convinced about the facts?
African American and Native American SIDS
rates have not decreased as much as the
Caucasian population.
These populations may not be receiving the vital
messages of placing their infants on their back
to sleep, avoiding tobacco exposure and cobedding.
Evidence shows that nurses and other health
care professionals are inconsistent with teaching
current recommendations for safe sleep.
Parent Quote
“If a baby is on his back I
thought it was not a
comfortable way to sleep. I
thought he would be nice and
warm on his tummy. It is not
true. If that was told to me I
would have never done that.”
Some nurses may think supine
sleep has risks, but there are …
No significant risks of supine sleep
No increase in apnea
No increase in bradycardia
No increase in problems related
to reflux or aspiration
No difference in total sleep time or
percentage of quiet sleep in prone vs.
supine position
More sleep awakenings which may be
Patient education & safety
Parents need to learn why sleep practices for
sick babies in the NICU differ from safe sleep
at home….
Parents must be cautioned against
continuing these practices at home
Patient safety
• Effective communication is a cornerstone of patient
safety - The Joint Commission
Specific positioning to improve breathing
or promote development in the NICU is
no longer needed at home
Effects of prone during acute illness:
• Improved Oxygenation
Improved lung mechanics
Less ventilation/perfusion mismatching
Higher lung volumes
Decreased energy expenditure
Developmental outcomes
• Muscles develop by pushing when prone or
surrounded by a firm, but cushioned flexible wall
• Prone and side for stress and pain
• Provides comfort and organization
• Low stimuli environment
• Kangaroo holding
• Dark (or cycled lighting > 32 weeks)
Risks of prone increases as preterm
infants mature
Characteristics that potentially increase
vulnerability for SIDS (in preterm infants
sleeping prone at 1-3 months adjusted age):
Heart rate variability
• decreased during quiet sleep
QT intervals
• prolonged during quiet sleep
• fewer arousals, less awakenings
Arousal threshold
• significantly increased stimuli required to arouse
(Ariagno, et al. Pediatrics 2003; Goto et al. Pediatrics 1999; Horn et al. SLEEP, 2002)
Are there exceptions to
‘Back to sleep’
Exceptions for supine sleep are rare, but
include infants for whom risk of death from
complications of gastro-esophageal reflux
is greater than risk of SIDS:
• infants with impaired protective airway
mechanisms, such as those with
laryngeal clefts who have not undergone
anti-reflux surgery
AAP 2011 recommendations
Parent Quote
 “The
main reason parents,
and why I didn’t put my
baby on his back to sleep is
because he would choke.
That is not true. He has the
same reflexes as an adult or
toddler to turn his head.”
More about reflux….
Because of the increased risk of SIDS risk, the
North American Society for Pediatric
Gastroenterology (NASPGHAN) states:
 prone positioning, and elevating head of crib
are no longer recommended treatments, for
mild or moderate reflux in infants less than
one year.
(Vandenplas, Rudolph, DiLorenzo et al, 2009)
Supine sleep position
is safest for reflux…
When positioned prone, a baby could be more
likely to aspirate as gravity allows emesis to flow
down into the trachea.
When supine, the emesis stays in the esophagus
decreasing the risk of aspiration.
(Cote A. Back to sleep…for life, Montreal Children’s Hospital, Montreal, Canada, Copyright 2002)
Keep crib in flat position
Elevation of crib has never been proven
to reduce reflux when infants sleep
supine, but may cause infants to slide
into a position which compromises
AAP 2011 recommendations
Back to sleep: for all healthy
infants, even preterm
There is little evidence to support the perception
that preterm infants actually have more reflux.
Although there are less frequent episodes of
reflux in prone and side position, there are no
benefits that outweigh the risk of death from
Supine sleep does not increase risk of choking
and aspiration, even for infants with reflux.
In fact, in the few cases of infant death from
aspiration, infants were found in the prone
Co-bedding multiples is not
It is the position of the National
Association of Neonatal Nurses (NANN)
that co-bedding cannot be endorsed until
further research is available.
NANN also believes that neonatal units
that choose to implement co-bedding
should do so after developing a clinical
evaluation protocol to be used in
collecting data on the risks and benefits
of practice.
Co-bedding multiples
potentially increases the risks
Many multiples are:
Multiple risks for SIDS
(Hayward, K. MCN 2003;28(4):260-263)
Recent hospital deaths reported
in the US
(1999 to 2013; 9 cases in past 3 years)
All were healthy prior to their deaths and were
successfully breastfed
All were bed sharing
6 received sedating drugs (stated or probable—death
within 24 hours of delivery)
10 reported parental fatigue
3 mothers were obese or had “large breasts”
2 involved bed sharing with multiple adults
6 deaths involved pillows
2 of the mothers smoked
Thach,B. Journal of Perinatology, in press, Nov 2013
The Children’s Hospital at Dartmouth
Public health measures to
prevent SIDS and Suffocation
Have been largely focused on eliminating
potentially asphyxiating environments
Effectiveness does not require a mechanism
For example, we really don’t know why
sleeping on the back reduces the risk for
Does suggest that something is different
about being prone that results in a series of
events culminating in death.
The Children’s Hospital at Dartmouth
Campaign changed from “Back
to Sleep” to “Safe to Sleep”
Focus shifted to safe sleep environment,
building on the success of “Back to sleep”
When the death scene is carefully scrutinized,
asphyxia contributes to the cause of death in
the majority (86%) of SUIDS
Potentially, asphyxia generating conditions in
the sleep environment can increase the risk
for SIDS by 3x
Improving the sleep environment can protect
against SIDS and suffocation, entrapment, and
other accidental deaths
The Children’s Hospital at Dartmouth
“Safe to Sleep” campaign
Consistent with, reinforced, and expanded the
previous recommendations
Easier for parents and providers by providing specific
answers about reflux, crib bumpers, pacifiers, etc.
Detailed, evidence-based answers to encourage
parent compliance.
More emphasis on the role of the health care
provider in modeling safe sleep in the hospital.
Focused on ways to reduce the risk of all sleeprelated infant deaths, including SIDS, suffocation,
and other accidental deaths.
The Children’s Hospital at Dartmouth
There are TWO documents
Policy statement: Summary of recommendations
Technical Report: background literature review and
data analyses (electronic version only)
Some topics are only covered in this report:
Swaddling, toxins and toxic gases and hearing
The Children’s Hospital at Dartmouth
Summary of 2011 AAP
Focus for Safe Infant Sleep
SIDS incidence remains at a plateau
Room sharing is safest, no bed sharing
Always place infants back to sleep until
one year, no side sleeping
Avoid exposure to smoke
Firm bed surface, no soft objects
Place infants to sleep on back in the NICU
as soon as medically stable, by 32 weeks
before they are discharged
Use the back sleep position
every time!
• Babies who usually sleep on their backs, but
who are then placed on their stomachs are
at very high risk for SIDS
• Infants placed either side or prone for sleep
are two times more likely to die of SIDS
• When infants usually sleep on the back,
their risk increases 8.2 times when they are
placed prone.
• The risk increases 6.9 times when placed in
an unaccustomed side sleep position.
(Li, 2003)
Firm sleep surface!
A firm crib mattress, covered by a
fitted sheet is recommended
 Crib, bassinette, or portable crib that
conforms to safety standards
• Consumer Product Safety Commission and
ASTM International
• Make sure product has not been recalled, or
missing hardware
(AAP 2011 recommendations)
Separate but close:
Share the room not the bed
Infants should never bed share or sleep
with adults or other children.
One should never sleep on a couch or
armchair with infant.
Placing cribs or bassinets in parents’
bedroom has been shown to reduce SIDS
Infants should never sleep on adult beds
because of risk of entrapment and
(AAP 2011 recommendations)
Bed-Sharing Risks….
Bed sharing:
 Increased from 5.5 to 12.8% between 19932000
• 3 times in U.S. Asian population
• 4 times in U.S. African Americans
 Promoted by breast feeding advocates
Bed sharing risks are associated with:
 Maternal cigarette smoke
 Recent maternal alcohol consumption.
 Covering by quilt or comforter.
 Parental tiredness.
 Sleeping with other children.
Breastfeeding & Safe Sleep
• Breast feeding is associated with a reduced
risk of SIDS
• Safe practice- infants may be brought to
bed to breastfeed or comfort and returned
to their own crib when parents are ready to
• However, this not recommended for parents
that are excessively tired or using
medications or substances that may impair
(AAP 2011 recommendations)
Pacifiers to reduce SIDS
The mechanism is unknown, however
pacifier use is strongly associated with
reducing the risk for SIDS.
Protection lasts during sleep, even if
pacifier falls out of the infant’s mouth.
(AAP 2011 recommendations)
AAP infant sleep policy
use of pacifiers (2011)
Mechanism is unclear, but studies show
protective effect of pacifiers
• Do not reinsert once the infant falls asleep.
• Don’t force baby to take it, try to offer
pacifier when infant is a little older
• Do not attach to clothing or stuffed toys, or
hang around neck
• Clean pacifier and replace often
• For breast fed infants, wait 3-4 weeks
before introducing
Avoid overheating!
Dress appropriate for environment
 No more than one layer than adult
would wear to comfortably sleep
 Blanket sleep sacks, correctly sized
 Avoid over bundling or covering face
and head
 Signs of overheating: infant’s chest
feeling hot to touch or sweating
(AAP 2011 recommendations)
Back to Sleep,
but prone for play!
 Too much supine positioning can cause:
Positional deformities
Diaper rash, eczema, cradle cap
Mild delay in developmental milestones
not significant by 18 months
gross motor skills, upper body tone
Ways to reduce potential harmful effects:
“Tummy Time” while awake and observed
Avoid excess time in infant seats
Change position in crib so infant will orient
toward activity outside of room (e.g. door)
Home monitors and
commercial sleep devices
Home monitors have not been found to reduce
the incidence of SIDS
Avoid commercial devices marketed to reduce
SIDS by maintaining sleep position or prevent
• None are sufficiently tested for safety or
effectively reducing SIDS or suffocation
(AAP 2011 recommendations)
Car seats, swings, boppies and infant
seats are not for sleeping
When returning home from travel and infant is
asleep in the car seat, transfer the infant to a crib.
Boppie pillows are sometimes used to help support
the infant during breastfeeding. Infants should not
be placed on boppies for sleep.
Swings are appropriate for play, but when it is time
for sleep transfer the infant to a crib.
Car seats, swings and infant seats should never be
placed on elevated surfaces, including counters,
beds, and cribs.
The Children’s Hospital at Dartmouth
Swaddling and Sleep Sacks
The risks of swaddling are uncertain and therefore
the AAP did not make any firm recommendations
Swaddling not done correctly clearly increases the
risk for strangulation
We recommend that after “safe sleep” is
implemented, swaddling be replaced by sleep sacks
for normal nursing care.
We are further recommending sleep sacks rather
than swaddling for home care.
The Children’s Hospital at Dartmouth
What you do will make a
Parents copy at home what is
demonstrated in the hospital
Stable preterm infants should be placed supine
for sleep by 32 weeks.
Demonstrate proper practice
No stuffed animals in crib
No blankets over crib
Avoid over bundling, quilts and comforters
Tummy time when awake and observed
Nurse as Educator
The Joint Commission
• Delineates nursing standards for patient
• Expects evidence that patients and significant
others understand what they have been taught
State Nurse Practice Acts (NPAs)
• Nursing scope of practice includes teaching!
• Nurses are expected to provide instruction to
maintain optimal levels of wellness, prevent
disease, manage illness, and develop skills to give
supportive care to family members.
(Bastable 2003 Nurse as Educator- Principles of Teaching and Learning for
Nursing Practice)
Nurse’s discharge instructions
will save lives
Discourage parents from placing their baby to
sleep in the prone or side lying position
Teach parents to place their baby on his or her
back to sleep for the first year. Parents should
require anyone who cares for their baby to do
However, once the child can roll over, there is no need
to keep flipping him or her over onto their back
Teach parents about risk reduction measures
protect infant from any smoke exposure
no soft bedding or co-bedding
avoid overdressing/overheating
Seeing is Believing!
Parents need to see their baby sleeping safely on
his or her back before discharge
Best practice in the NICU
before going home!
Supine sleep position
Wearable blanket or
swaddle below nipple line
Be careful not to do
anything in the ICN
that you don’t want
parents doing at
No loose bedding or soft toys in crib
Flat crib position
Convert “Back to Sleep” to “Safe Sleep”
campaign to reduce ALL sleep-related
Provide public education for all who care for infants
(parents, child care providers, grandparents, foster
parents, babysitters and expectant families),
including strategies for:
Overcoming barriers to behavior change
Increasing breastfeeding while decreasing unsafe
Eliminating tobacco smoke exposure
Continue to have a special focus on cultures and
ethnic groups with the highest incidence of SIDS and
accidental suffocation.
Introduce recommendations before pregnancy and
ideally in secondary school curricula to both males
and females.
The Children’s Hospital at Dartmouth
Stick to the facts
Stay current!
Be a safe sleep champion
 Remember: parents place infants in
positions recommended and
modeled by medical and nursing
 Provide educational materials
The Children’s Hospital at Dartmouth
We endorse
use of this
national poster
in your
institution to
promote safe
sleep for
Nursing research findings….
514 surveys were sent to NICU nurses in 9 institutions
and 252 (49%) responded. Only half instructed parents
to place infants on the back to sleep as illustrated in the
chart below:
Discharge Instructions Given to Parents
Always place infant to sleep on back
Back or side for sleep
Whatever position the infant is most comfortable
Side with positioning r olls
(Aris et al. Advances in Neonatal Care 2006)
More evidence of “unsafe”
hospital safe sleep practice
1080 surveys sent to nurses in 19 institutions in 2 Mid
Atlantic states; 430 (40%) responded.
85% identified AAP SIDS reduction strategies
Regardless of nursing and neonatal experience, or
education level: 50% position preterm infants supine when
weaned to an open crib, 15% wait one to only a few days
before discharge, and 6% never do so.
45.5% use positioning aids/rolls in infants cribs
Common reasons for side and prone positioning
 Fear of aspiration (29%)
 Infant comfort (28%)
 Infant safety (20%)
(Grazel, Phalen. Gibbons, & Polomano, 2010)
Nurses hold the key to
saving lives!
Nursing is key to getting accurate
information to parents. Use evidence
based practice, not opinion or traditional
Nurses are essential role models for
Nurses are in a powerful position to make
a difference.
Parent Quote
“ I talked to a lot of doctors and asked
them why they don’t tell parents
about SIDS. They say they don’t
want to scare mothers. They don’t
want them to think their baby is
going to die from SIDS. I say, I
would rather be scared for a year
than to be sad for the rest of my life
because my baby died.”
1. Adams, M.M., Kugener, B., Mirmiran, M., & Ariagno, R.L. (1998). Survey of sleeping position after
hospital discharge in healthy preterm infants. Journal of Perinatology, 18 (3), 168-172.
2. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome (2005).The changing
concept of sudden infant death syndrome: Diagnostic coding shifts,
regarding the sleeping environment, and new
variables to consider in reducing risk.
Pediatrics, 116(5), 1245-1255.
3. American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome.
(2000). Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping
Environment and Sleep Position. Pediatrics, 105 (3), 650-656.
4. American Academy of Pediatrics (2011). SIDS and other sleep-related infant deaths: Expansion of
recommendations for a safe sleeping environment. Pediatrics, e000. Retrieved from
5. Ariagno, R.L., Mirmiran, M., Adams, M.M., Saporito, A.G., Dubin, A.M., & Baldwin, R.B. (2003). Effect
of position on sleep, heart rate variability, and QT interval in preterm infants at 1 and 3 months’
corrected age. Pediatrics, 111 (3), 622-625.
6. Aris, C., Stevens, T., Le Mura, C. Lipke, B., McMullen, S., Cote-Arsenault, D., Consenstein, L (2006).
NICU nurses knowledge and discharge teaching related to infant sleep position and risk of SIDS.
Advances in Neonatal Care, 6, 281-294.
7. Bastable, S. B. (2003). Nurse as Educator- Principles of Teaching and Learning for Nursing Practice, 2nd
ed. Sudbury, Mass. Jones & Bartlett Publishers.
8. Bhat, R.Y., Leipala, J.A., Singh, N.R., Rafferty, G.F., Hannam, S., & Greenough, A. (2003). Effect of
posture on oxygenation, lung volume, and respiratory mechanics in premature infants studied before
discharge. Pediatrics, 112 (1), 29-32.
9. Bhat, R.Y., Leipala, J.A., Rafferty, G.F., Hannam, S., & Greenough, A. (2003). Survey of sleeping position
recommendations for prematurely born infants on neonatal intensive care unit discharge. European
Journal of Pediatrics, 162 (6), 426-427.
10. Blair, P., Ward-Plantt, M., Fleming, P., & CESDI SUDI Research Group Institute of Child Health, UBHT
Education Centre, Bristol BS2 8AE, UK. (2003). Sleeping position amongst preterm infants after
discharge: are we getting the message across? Early Human Development, 74, 57-82.
11. Bullock, L.,Mickey, K., Green, J., Heine, A. (2004). Are Nurses Acting as Role Models for the Prevention
of SIDS? American Journal of Maternal Child Nursing, 29 (3), 172-177.
12. Blair, P.S, Ward Platt, M., Smith, I.J., Fleming, P.J., (2006). Sudden infant death syndrome and sleeping
position in pre-term and low birth weight infants: an opportunity for targeted intervention. Arch Dis
Child, 91, 101-106 doi:10.1136/adc.2004.070391.
13. Center for Disease Control (2006). Notice to readers: Release of sudden unexplained infant death
investigation reporting form. Retrieved May 7, 2008 from
14. Center for Disease Control SUID line graph. Retrieved from the CDC website on 5/14/13 @ (
15. Dimitriou, G., Greenough, A., Pink, L., McGhee, A., Hickey, A., & Rafferty, G.F. (2002). Effect of
posture on oxygenation and respiratory muscle strength in convalescent infants. Archives of Disease
in Childhood, 86(3), F147-F150.
16. Fleming, P.J., & Blair, P.S. (2003). Sudden unexpected deaths after discharge from the neonatal intensive
care unit. Seminars in Neonatology, 8, 159-167 Gibson, E., Dembofsky, C.A., Rubin, S., &
Greenspan, J.S. (2000). Infant sleep position practices 2 years into the “back to sleep” campaign.
Clinical Pediatrics, 39 (5), 285-289.
17. Gleeson, M. (2003). Development of Infant Mucosal Immunity in Relation to Vulnerability to Infections,
from SIDS International Conference Booklet in Edmonton, Alberta, Canada, July 2-6, 67-117-118.
18. Goto, K., Mirmiran, M., Adams, M.M., Longford, R.V., Baldwin, R.B., Boeddiker, M.A., & Ariagno,
R.L. (1999). More awakenings and heart rate variability during supine sleep in preterm infants.
Pediatrics, 103 (3), 603-609.
19. Grazel, R., Phalon, A, Gibbons, & Polomano, R.C. (2010). Implementation of th eAmerican Academy od
Pediatrics recommendations to reduce sudden infant death syndrome risk in neonatal intensive care
units: an evaluation of nursing knowledge and practice. Advances in Neonatal Care, 10, 332-42.
20. Harper, Ronald (2003). Brain mechanisms that compensate for cardiovascular collapse, from SIDS
International Conference Booklet in Edmonton, Alberta, Canada, July 2-6, 37-38, 104-105.
21. Hayward K. (2003). Co bedding of twins: a natural extension of the socialization process? MCN, 28:260263.
22 . Hein, H.A. & Pettit, S.F. (2001). Back to sleep: Good advice for parents but not for hospitals? Pediatrics,
107 (3), 537-53
23. Horne RS, Bandopadhayay P, Vitkovic J, Cranage SM, Adamson TM. Effects of age and sleeping
position on arousal from sleep in preterm infants. Sleep 2002;25:746-750.
24. Hunt, C.E. (1997). Expanded “back-to-sleep” recommendations: Hospital-based safe sleeping practices.
Journal of Sudden Infant Death Syndrome and Infant Mortality, 2 (4), 223-224.
25. Hunt, C.E., Lesko, S.M., Vezina, R.M., McCoy, R., Corwin, M.J., Mandell, F., Willinger, M Hoffman,
H.J., & Mitchell, A.A. (2003). Infant sleep position and associated health outcomes. Archives of
Pediatric Adolescent Medicine, 157, 469-474
26. Hunt, C.E., Gene-Environment Interactions: Implications for Sudden Infant Death Syndrome, from the
SIDS International Conference Booklet in Edmonton, Alberta, Canada, July 2-6,47-49.
27. Iyasu, S., Randall, L.L., Welty, T.K., Hsia, J., Kinney, H.C., Mandell, F., McClain, M., Randall, B.,
Habbe, D., Wilson, H., & Willinger, M. (2002). Risk factors for sudden infant death syndrome among
Northern Plains Indians. JAMA, 288 (21), 2717-2723.
28. Jones, M., & McMurray, J.L. (2003). The other side of “Back to Sleep”. Neonatal Network, 22 (4), 4953
29. Keene, D.J., Wimmer Jr., J.E., & Mathew, O.P. (2000). Does supine positioning increase apnea,
bradycardia, and desaturation in preterm infants? Journal of Perinatology, 1, 17-20.
30. Kinney, H.C., Filiano, J.J., Sleeper, L.A., Mandell, F., Valdes-Dapena, M., & White, W.F. (1995).
Decreased muscarinic receptor binding in the arcuate nucleus in SIDS. Science, 269, 1446-1450.
31. Lesko, S.M., Corwin, M.J., Vezina, R.M., Hunt, C.E., Mandell, F., McClain, M., Heeren, T., Mitchell,
A.A. (1998). Changes in sleep position during infancy: A prospective longitudinal assessment. JAMA,
280 (4), 336-340.
32. Li, DK, Pettiti, DB, Willinger, M., McMahon, R., Oduli, R., Vu, H. et al. (2003). Infant sleeping position
and the risk of sudden infant death syndrome in California, 1997-2000. American Journal of
Epidemiology, 157 (5), 446-455.
33. Lockridge, T., Taquino,L.T., & Knight, A. (1999). Back to sleep: Is there room in that crib for both AAP
recommendations and developmentally supportive care? Neonatal Network, 18 (5), 29-31.
34. Malloy, M.H., editorial. (1998). Effectively delivering the message on infant sleep position. JAMA, 280
(4), 373-374.
35. Malloy, M.H., & MacDorman, M. (2005). Changes in the classification of sudden unexpected infant
deaths: United States, 1992-2001. Pediatrics, 155, 1247-1253.
36. Moon, R.Y. & Oden, R.P. (2003). Back to sleep: Can we influence child care providers? Pediatrics, 112
(4), 878-882.
37. Morris, J.A., The common bacterial toxin hypothesis for SIDS, from the SIDS International Conference
Booklet in Edmonton, Alberta, Canada, July 3-6, 69-70, 118.
38. Narita, N., Narita, M., Takashimas, S., Nakayama, M., Nagai, T., & Okado, N. (2001). Serotonin
transporter gene variation is a risk factor for SIDS in the Japanese population. Pediatrics,107 (4), 690692.
39. National Association of Neonatal Nurses (NANN). (2001). Cobedding of twins or higher multiples.
Position statement 3038. web site:
40. New York State Center for Sudden Infant Death. (n.d.) SIDS Risk Reduction: Self Study Module.
41. Oyen et al. (1997). Combined effects of sleeping position and prenatal risk factors in sudden infant
death syndrome: The Nordic Epidemiological SIDS Study. Pediatrics, 100 (4), 613-621.
42. Panigraphy et al. (1997). Decreased kainate receptor binding in the arcuate nucleus of the SIDS. Journal
of Neuropathology and Experimental Neurology,56 (11), 1256-1261.
43. Peeke K, Hershberger M, Kuehn D, Levett J. (1999) Infant sleep position: nursing practice and
knowledge. MCN, 24:301-304
44. Poets CF. Gastroesophageal reflux: a critical review of its role in preterm infants. (2004) (Electronic
article) Pediatrics, 113:pp.e128-e132
45. Pastore, G., Guala, A., Zaffaroni, M, &Bona, G. (2003). Back to sleep: Risk factors for SIDS as targets for
public health campaigns. The Journal of Pediatrics, 109(4), 453-454.
46. Pollack, H., Frohna, J. (2002). Infant Sleep Placement After the Back to Sleep Campaign. Pediatrics,
109(4), 608-614.
47. Peeke, K., Hershberger, M., Kuehn, D., & Levett, J. (1999). Infant sleep position: Nursing practice and
knowledge. MCN, 24 (6), 301-304.
48. Rudolph et al. (2001). Guidelines for evaluation and treatment of gastroesophageal reflux in infants and
children: Recommendations of the North American Society of Pediatric Gastroenterology and Nutrition.
Journal of Pediatric Gastroenterology and Nutrition, 32 (2), S1-S31.
49. Sahni, R., Schulze, K.F., Kashyap, S., Ohira-Kist, K., Myers, M.M., & Fifer, W.P. (1999). Body position,
sleep states, and cardiorespiratory activity in developing low birth weight infants. Early Human , 54, 197206.
50. Shapiro-Mendoza, C.K., Kimball, M., Tomashek, K.M., Anderson, R.N., & Blanding, S. (2009). US
mortality trends attributable to accidental suffocation and strangulation in bed from1994 through 2004:
Are rates increasing? Pediatrics, 123, 533-539.
51. SIDS facts. (n.d.). Retrieved September 16, 2004, from
52. Vandenplas, Y., Rudolph, C.D., Di Lorenzo, C. et al. (2009). Pediatric gastroesophageal reflux clinical
practice guidelines:Joint recommendations of the North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (ESPGHAN). J Pediatri Gastroenterol Nutr, 49, 498-547.
53. Vernacchio et al. (2003). Sleep position of low birth weight infants. Pediatrics,111(3), 633-40.
54. Vennemann, M., Bajanowski, T., Betterfa-Bahloul, T., Sauerland, C., Jorch, G., Brinkmann, B., &
Mitchell, E.A. (2007). Do risk factors differ between explained sudden unexpected death in infancy and
sudden infant death syndrome? Archives in Disease in Childhood, 92,133-136.
55. Willinger, M.Ko, C., Hoffman, H., Kessler, R., & Corwin. (2000). Factors associated with caregivers
choice of infant sleep position, 1994-1998: The National Infant Sleep Position Study. JAMA, 283 (16),
56. Willinger, M. Catz, L.S. (1991). Defining the sudden infant death syndrome (SIDS): deliberations of an
expert panel convened by the National Institute of Child Health and Human development. Pediatr Pathol.,
11, 677-684.

similar documents