Parents’ Nightmare
Sudden Infant Deaths During Sleep Decreasing, But Risk Remains High
Sudden infant death syndrome (SIDS) involves the mysterious deaths of infants less than 1 year old who appear to be healthy but die in their sleep. Fewer and fewer babies are dying from SIDS thanks to public education with a simple but urgent message: Babies should go to sleep facing up.
But SIDS still stalks infants born to poor families and those in certain ethnic groups—and rates remain relatively high for all infants who come into the world early, suggesting special cautions for “preemies.”
So just how important is all of this? It’s vital: SIDS is the leading cause of infant deaths in the United States.
SIDS rates in this country have gone down more than 50 percent in recent years, according to the Centers for Disease Control and Prevention, in large part because of a public education campaign called “Back to Sleep,” sponsored by the federal government and private groups.
When research started linking sleep position to infant deaths in the early 1990s (the mechanism remains unknown), alarmed parents and officials began the campaign. An ongoing effort, “Back to Sleep” promotes infants sleeping face up to anybody who might care for a baby, including grandparents and neighborhood babysitters.
The “Back to Sleep” campaign caused a sharp drop in SIDS deaths all across the United States, according to a 2005 study conducted by Kate Pickett of University of York in England and her colleagues at the University of Chicago. However, the study also found that white babies benefited the most from this drop.
Although SIDS rates for African Americans have also dramatically declined, they’re still more than twice as high as the rates for white babies, and the SIDS death rate for Native American Indian infants is three and a half times higher. In addition, Pickett’s work showed that these differences, called “health disparities,” have only gotten worse under the “Back to Sleep” program—with one exception. Her study, published in the American Journal of Public Health last November, found that babies in Hispanic families, rich and poor alike, have lower rates of SIDS than any other group.
Across all ethnic groups, mothers with more education (a quick indicator of social class) adapted more quickly to the SIDS sleep suggestions, and fewer of their babies died. In other words, despite the “Back to Sleep” campaign, “social class inequalities in SIDS have grown,” according to Pickett’s study. Pickett surmised that two interlocking factors may be the culprits: Poor and poorly educated moms are simply less likely to get good information, and they’re also less likely to be able to follow it.
The Children’s National Medical Center in Washington, D.C., has established a number of primary care clinics called Children’s Health Centers (CHC) that provide SIDS education services throughout the city and serve people of diverse income levels and ethnic backgrounds. CHC has care sites in the Anacostia, Adams Morgan and Shaw neighborhoods. The program offers SIDS information, for example, to low-income pregnant women and mothers and encourages the involvement of community and religious organizations interested in SIDS education. CHC will also provide classes and peer training for groups interested in community outreach as well as educational materials.
“It’s important to go out where people are,” instead of waiting for them to come to you, explained Rosalind Oden, health educator in the CHC-SIDS program. Oden stressed the importance of peer training. She works, for instance, with the grandparents who provide child care information to members of the younger generation and have a strong influence in the African American community. “If your grandmother tells you to take care of a baby a certain way, that’s the way you do it,” she said.
A similarly practical approach is being taken in Maryland, according to Dr. Maureen Edwards, medical director of the Maryland Center for Maternal and Child Health in Baltimore who coordinates the state’s SIDS programs. “Baltimore City, which has high numbers of low-income mothers, is very pro-active in its SIDS outreach,” said Edwards, who noted that the city’s SIDS program is providing safe cribs to low-income families who need them and is distributing little “ABC” stickers to new moms: “Alone on my Back in a Crib.”
Maryland also offers grief counseling to parents who have lost a child to SIDS and review programs throughout the state to help distinguish SIDS deaths from deaths caused by child abuse. These efforts are run by the Center for Infant and Child Loss at the University of Maryland.
In addition to ethnic disparities, babies born prematurely are at higher risk for SIDS, as are all infants of lower birth weight, and both types of infants remain at risk for SIDS for a longer length of time than other infants, according to a January study published in the Annals of Epidemiology.
Although most babies who die from SIDS are younger than three months, premature infants can still be in danger when they’re older—up to six months of age. The study also found that babies who were small for their age were 1.7 times more likely to fall victim to SIDS. The researchers said they had no explanation for this increased risk.
Although the most recent statement from the American Academy of Pediatrics says that “SIDS continues to be a phenomenon of unknown cause,” members of a research team that includes Jan-Marino Ramirez of the University of Chicago hypothesize that they may have part of the answer. The researchers, whose study was published in the Journal of Neuroscience last March, argue that brain levels of serotonin and the breathing mechanism known as “gasping” might not be working properly in infants who die from SIDS.
People gasp when their bodies aren’t getting enough air and they lack oxygen, a condition called “hypoxia.” When the body senses this deprivation, an internal alarm should go off, Ramirez explained. The hypoxia alarm creates deep, sharp breathing called gasping and normal oxygen levels come back. With a sleeping infant, the child wakes up. Gasping also alerts the baby and the parents that something is wrong.
But sometimes this alarm doesn’t go off. “We suggest that these children do not arouse—that is, they are not aware that their brain is getting increasingly more hypoxic,” Ramirez told The Washington Diplomat by e-mail. “These children do not struggle or fight the hypoxic conditions. They just stop breathing. They don’t show the normal responses that characterize smothering or suffocating…. The normal child would arouse, gasp and struggle to fight the hypoxic conditions, and this is missing in SIDS.”
So what has gone wrong? Special clusters of respiratory neurons in the brain and the brain chemical serotonin are keys to this alarm system, according to the researchers. Serotonin is implicated in mood disorders, and antidepressant medicines such as Prozac can increase its levels when the chemical is too low. Serotonin also works with the respiratory neurons to trigger gasping, Ramirez found. Low levels of serotonin can weaken or turn off the gasping mechanism so sleeping babies who lack oxygen don’t gasp and don’t wake up when they need to.
But sleeping on their backs can help protect these vulnerable infants. For example, a new study led by British researcher Anne Greenough found that premature babies who slept face up had more arousals or partial wakeups each hour than babies who slept face down. They woke up more often for deeper breathing and had fewer breathing problems.
There may be other causes of SIDS beyond breathing problems, Ramirez cautioned, noting that a small number of children may have problems regulating their heart beats and that further research is needed to develop new ways to prevent SIDS.
Carolyn Cosmos is a contributing writer for The Washington Diplomat.
Ten Tips to Sleep More Soundly
The following are guidelines from the American Academy of Pediatrics and the National Institutes of Health on ways to prevent Sudden Infant Death Syndrome:
• Always place your baby on his or her back to sleep, both for naps and at night.
• Place your baby on a firm sleep surface, such as a safety-approved crib mattress covered by a fitted sheet. Never place your baby to sleep on pillows, quilts, sheepskins or other soft surfaces.
• Keep soft objects and loose bedding out of your baby’s sleep area. Don’t use pillows, blankets, quilts, sheepskins and pillow-like crib bumpers in your baby’s sleep area, and keep any other items away from your baby’s face.
• Keep your baby’s sleep area close to, but separate from, where you and others sleep. Your baby should not sleep in a bed or on a couch or armchair with adults or other children, but he or she can sleep in the same room. If you bring the baby into bed with you to breastfeed, put the baby back in a separate sleep area when finished—a bassinet, crib, cradle or an infant bed that attaches to an adult bed.
• Think about using a clean, dry pacifier when placing the infant down to sleep, but don’t force the baby to take it. (If you are breastfeeding, wait until your child is one month old or is accustomed to breastfeeding before using a pacifier. Pacifier use may decrease SIDS risk, studies show.)
• Don’t cover your baby with extra blankets in the winter.
• Do not let your baby overheat during sleep. Dress your baby in light sleep clothes, and keep the room at a temperature that is comfortable for an adult.
• Don’t smoke before or after the birth of your baby, and don’t let others smoke around your baby. Cigarette smoke increases SIDS risk.
• Avoid products that claim to reduce the risk of SIDS because most have not been tested. Do not use home monitors to reduce the risk. There is no proof that monitors help.
• Reduce the chance that flat spots will develop on your baby’s head by providing “tummy time” when your baby is awake and someone is watching.
— Carolyn Cosmos
