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 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 SUID EXPLAINED UNEXPLAINED Trauma SIDS Drowning Known Diagnosis Undetermined 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 bed-ASSB): 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 occur? 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 campaign. 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 heat. The risk is higher for premature infants. Populations at risk SIDS occurs with varying incidence in all cultures 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 ethnicity 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. Smoking Avoid maternal smoking and exposure to passive smoking. Which infants are at greatest risk? Neonatal Intensive Care Unit (NICU) admission 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 side 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 function 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 Dartmouth 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 hypoxia The Children’s Hospital at Dartmouth Adapted from Kinney and Thach, 2009 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 U.S. 1983-1992: 5,000-6,000 deaths per year 1994: “Back to Sleep” campaign 2001: 2,295 deaths per year 2006: 2,326 deaths per year 2011: 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 BTS SUID SIDS UNK + ASSB From 1998-2001 the number of deaths “signed out” as ASSB and undetermined increased dramatically 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 factors. 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 asphyxia. 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 strangulation 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 chemoreflex. The Children’s Hospital at Dartmouth HIGH ALERT! 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 protective 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 Awakenings • fewer arousals, less awakenings Arousal threshold • significantly increased stimuli required to arouse infant (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 respiration 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 SIDS. 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 position. Co-bedding multiples is not recommended 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: Premature IUGR LBW Re-breathing + Hyperthermia _________________________________________ 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 SIDS • 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 screens 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 suffocation (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 sleep • However, this not recommended for parents that are excessively tired or using medications or substances that may impair alertness. (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 re-breathing • 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 difference! 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 education • 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 likewise 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 home No loose bedding or soft toys in crib Flat crib position Firm mattress Convert “Back to Sleep” to “Safe Sleep” campaign to reduce ALL sleep-related deaths 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 sleep 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 professionals Provide educational materials The Children’s Hospital at Dartmouth We endorse use of this national poster in your institution to promote safe sleep for parents http://www.cpsc.gov/en/Safety-Education/Neighborhood-Safety-Network/Posters/Bare-is-Best/ 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 1% 9% 52% 38% Always place infant to sleep on back Back or side for sleep Whatever position the infant is most comfortable in 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 practice. Nurses are essential role models for parents. 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. 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