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Running head: SIDS IN SAN JOAQUIN COUNTY 1

SIDS in San Joaquin County: Reducing the Incidence through Education

Ashley Holyoak

September 11, 2013

Community Health Nursing

SIDS IN SAN JOAQUIN COUNTY 2

SIDS In San Joaquin County

Sudden infant death syndrome, more commonly referred to as SIDS, is the sudden and

unexplained death of an infant less than one year of age (Centers for Disease Control and

Prevention [CDC], 2013). In order for the death to be classified as SIDS, it must remain

unexplained after a thorough investigation, which includes an autopsy, examination of the death

scene, and review of the infant’s health history. In the United States, SIDS is the leading cause

of death for infants ages one to twelve months old. It is the third overall cause of infant

mortality, after serious birth defects and low birth weight and prematurity (CDC, 2013). This

paper will discuss why SIDS is an important topic related to community health nursing, examine

the current statistics regarding SIDS deaths in San Joaquin County, California, conduct a

literature review to determine best practice in the prevention of SIDS deaths, and then discuss the

recommendation on how the SIDS rates in San Joaquin County can be reduced. San Joaquin

County will see a reduction in SIDS deaths when education is provided to parents in the period

delivery and discharge from the hospital, rather than after they are already home with the baby.

The Issue

Although the United States is one of the wealthiest developed countries in the world, its

infant mortality rates are much higher than other developed countries. According to the United

Stated Department of Health and Human Services, The United States ranked 30th in infant

mortality rates among developed nations in 2005, with a rate of 6.9 deaths per 1,000 live births.

Singapore ranked first, with just 2.1 deaths per 1,000 live births (MacDorman & Mathews,

2009). Although there are many factors that contribute to this high infant mortality rate,

including the high rate of premature births and low birth weight infants, SIDS is a unique cause

in that it effects otherwise healthy babies.

Kristine Warner, 10/16/13,

Would split into 2 sentences for clarity


No superscript in APA


SIDS Risk Factors and Importance to Community Health

Although it has been hypothesized that SIDS may be related to a brainstem abnormality

that negatively affects cardiorespiratory control and arousal during sleep, the cause still remains

unknown (Hockenberry & Wilson, 2013). However, there are several environmental factors that

have been shown to contribute to an infant’s risk of dying from SIDS. These factors, which

include maternal smoking or living in an environment with second hand smoke, cosleeping,

prone sleeping, and having soft bedding and stuffed animals in the crib, make the reduction of

SIDS related deaths an important community health nursing issue because they can be eliminated

through proper maternal and family education.

Maternal smoking has a negative impact on many aspects of fetal and infant health, the

risk of SIDS being one of them. Being exposed to second hand smoke in the home environment

increases an infant’s risk of SIDS 1.9 times over those who are not exposed, and it is estimated

that 12% of SIDS deaths could have been prevented with prenatal maternal smoking cessation

(Hockenberry & Wilson, 2013). Cosleeping, or an infant sleeping with an adult in a noninfant

bed, has been shown to have a correlation with SIDS. It has been recommended that adults do

not share a bed with their infant. This is likely related to the fact that most adult beds are much

softer than the recommendation for infant beds. It has been recommended that infants only sleep

on firm, infant specific mattresses, and that all soft objects, such as pillows, stuffed animals, and

crib bumpers be removed from the crib (Hockenberry & Wilson, 2013). The back to sleep

campaign, which was initiated in 1994 and expanded in 2011, is a very effective public health

campaign that led to a reduction in national SIDS death rates. This national campaign promoted

laying an infant to sleep only in the supine position (Meadows-Oliver & Hendrie, 2013).


SIDS in San Joaquin County

Between 2008 and 2010, there was 32,495 babies born in San Joaquin County. Of these

births, there were 12 reported deaths from SIDS, for a rate of 36.9 per 100,000. This is slightly

higher than the California rate of 35.0 per 100,000 births during the same time period (California

Department of Public Health, 2012). Although this rate may not seem alarming, it is problematic

because SIDS death rates can be reduced through educational campaigns aimed at new parents.

The next section of this paper will examine current research regarding the prevention of SIDS.

Literature Review

“Risk Factor Changes for Sudden Infant Death Syndrome after Initiation of Back-to-Sleep

Campaign”

In a 2012 research study conducted by Trachtenberg, Haas, Kinney, Stanley, and Krous,

the authors set out to determine why, after a decline with the initiation of the Back to Sleep

(BTS) campaign, the SIDS rate in the United States has hit a plateau. The authors hypothesized

that the profile of infants who die from SIDS has changed since the campaign, meaning that risk

factors other than prone sleeping are contributing to these deaths (Trachtenberg, Haas, Kinney,

Stanley, & Krous, 2012). Risk factors were divided into two categories: intrinsic and extrinsic.

Intrinsic factors included: male gender, prematurity, genetic polymorphisms, and prenatal

exposures to cigarettes and/or alcohol. Extrinsic factors included: prone or side sleep position,

bed sharing, over-bundling, soft bedding, and having the face covered. The authors described

these two groups of factors, along with the critical development period of zero to twelve

postnatal moths, to form the triple-risk model for SIDS (Trachtenberg et al., 2012). This model

works as a Venn diagram, indicating that infants with a risk factor from all three categories have

the highest risk of death from SIDS.


This study examined infant deaths caused by SIDS before and after the BTS campaign,

and found that rates decreased from 1.34 deaths per 1000 births in 1991 to 0.64 per 1000 in 2008

(Trachtenberg et al., 2012). Of the 568 SIDS cases during the period of 1991 to 2008 that were

included in the study, 99% of them were found to have at least one intrinsic or extrinsic risk

factor, 75% had at least one of each, and 57% had at least two extrinsic and one intrinsic risk

factor. This led the authors to conclude that although the proportion of different risk factors has

changed since the BTS campaign, nearly all infants who die of SIDS have at least one risk factor,

while the majority have at least two extrinsic and one intrinsic risk factor (Trachtenberg et al.,

2012).

This study has importance in the effort to reduce SIDS deaths in San Joaquin County

because it helps to identify families who have a greater need for education regarding the risk of

SIDS. This identification should ideally begin in the prenatal period, through interviews at

prenatal appointments. When a woman is found to be expecting a baby with one or more risk

factors, a community health nurse should conduct a home inspection to alert the mother to any

possible extrinsic factors that may be found so that she can eliminate them before the baby is

taken home. Although some of the intrinsic risk factors cannot be modified, such as male gender

and genetic polymorphisms, the rest of the risk factors can be eliminated or at least reduced.

“Pacifier Use and Sids: Evidence for a Consistently Reduced Risk”

The updated guidelines for the BTS campaign indicate that pacifier use has been shown

to have a protective effect against SIDS (Meadows-Oliver & Hendrie, 2013). This study by

Moon, Tanabe, Yang, Young, and Hauck examined the possibility that pacifiers reduce this risk

even when other risk factors are present. Data for this study was gathered from the Chicago

Infant Mortality Study (CIMS), which was initiated to examine the risk factors for SIDS and


eliminate disparities in infant mortality for African American and white babies (Moon, Tanabe,

Yang, Young, & Hauck, 2012). The interest in reducing racial disparities was brought about by

the fact that African American babies are over three times more likely to die of SIDS than white

babies. CIMS included all babies aged one month to one year who died unexpectedly between

November 1993 and April 1996 (Moon et al., 2012).

Soon after each infant’s death, an autopsy and an extensive death scene investigation

were conducted (Moon et al., 2012). The investigation included 400 questions that looked at

events leading up to the death, risk factors, and socioeconomic factors. Two weeks later, another

interview was conducted with the primary caregiver that consisted of 235 questions that focused

on factors such as the infant’s sleep habits, social stressors affecting the family, and access to

health care. After this was completed, a control group was put together which consisted of living

infants who were matched to each infant case based on maternal race and ethnicity, infant age,

and birth weight. They used a multiple conditional logistic regression model to determine the

risk factors for each infant, and then used unconditional logistic regression models to determine

the association of pacifier use at last sleep with specific risk factors for SIDS (Moon et al., 2012).

The study concluded that pacifier use reduced the risk of SIDS by 70%, and was

associated with a reduced risk of death from SIDS with every other risk factor identified (Moon

et al., 2012). Pacifier use was found to have the most significant positive impact on the risk of

SIDS in infants whose mothers were older than 20, married, nonsmokers, received adequate

prenatal care, and breastfed their infants. Pacifiers use was found to also improve outcomes for

infants who sleep in a risky environment, such as in the prone position and with soft bedding

(Moon et al., 2012).


Although the data that the researchers used for this study was gathered between 1993 and

1996, it is still relevant today, as CIMS was the largest population-based study ever conducted

on risk factors for SIDS (Moon et al., 2012). Although it is generalizable to the general

population, it is especially generalizable to high risk populations, as it was this group that was

mainly used as the subjects in the study (Moon et al., 2012). While the mechanism by which

pacifier use protects infant from SIDS is still not known, it is an important recommendation to

make to parents, because it will potentially protect their infant from harm.

“The Physician’s Role in Reducing SIDS”

In order to properly educate parents regarding ways to prevent their baby’s risk of SIDS,

physician need to play an active role in providing them with proper information. A group of

researchers conducted a study that began in 2002 to determine how much education physicians

were providing to their patients, and how accurate this information was (Eron, Dygert, Squillace,

Webster, Andrianos, Crockett, & Consenstein, 2011). They began the cross-sectional survey of

pediatricians, family practitioners, and obstetrician-gynecologists (OB-GYNs) in four central

New York counties in 2002, and added practitioners from 12 upstate New York counties in 2004.

The results from both groups were merged. Three page questionnaires were sent to 912

practitioners, which consisted of true-false, multiple choice, and open ended answer questions.

The survey included sections on demographics, knowledge of SIDS and risk factors, individual

practices and methods regarding educating parents about SIDS, sources of information on SIDS,

and interest in further education on SIDS (Eron, et al., 2011).

Of the 912 practitioners whom were sent questionnaires, 214 responded (Eron et al.,

2011). Of these, 85 were pediatricians, 68 were family practitioners, and 60 were OB-GYNs.

Of the 7 questions used to assess knowledge about SIDS, approximately half of the respondents


answered 6 or 7 correctly. However, 88.8% did not know that SIDS most commonly occurs

between the ages of 2 and 4 months, and 27% were unable to identify the supine position as the

safest infant sleeping position. 97.6% of respondents agreed that it is important to discuss SIDS

risk factors and strategies to reduces these factors with all parents of children 12 months of age

and younger. However, only 70% reported that they or someone in their office actually discuss

these matters with their patients on a regular basis, and only 41% regularly provide written

material about SIDS (Eron et al., 2011).

It is very alarming to learn that so many physicians who provide care to infants do not

know these important facts about SIDS. If they are not able to provide accurate information to

parents, the parents will not be able to apply risk reduction techniques to keep their infant safe.

Education needs to begin at the source, thus, physicians and their staff need to be aware of

proper facts regarding SIDS and SIDS prevention. Until this happens, it will present a barrier to

parental education and infant safety.

“Changing Hospital Newborn Nursery Practice: Results from a Statewide ‘‘Back to Sleep’’

Nurses Training Program”

Physicians are not the only healthcare providers that need to be knowledgeable about

SIDS risk reduction factors. Nurses have the most direct contact with mothers and infants in

perinatal care, and therefore need to be able to provide teaching to parents regarding reducing

their infants risk for SIDS. A 2008 article studied the efficacy of a nurse education program on

“Back to Sleep” at several Missouri hospitals.

The hospitals provided evidence based training regarding the “Back to Sleep” campaign

and concerns that may be expressed while working in the hospital nursery to their nursing staffs

(Price, Hillman, Gardner, Schenk, & Warren, 2008). The nurses were able to choose if they


would prefer direct, in person training or computer based training. The researchers provided a

pre- and post-test to all participants. The pre-test found that the nurses surveyed reported placing

newborns to sleep supine 68% of the time, prone 3% of the time, and on their side 29% of the

time. The majority of the respondents (92%) agreed that their habits of placing an infant to sleep

were likely to be emulated by the parents after they got home (Price et al., 2008).

The post-survey, which was completed by 295 of the participants, found that after the

training 98% of the nurses put infants in the newborn nursery to sleep only on their back, and

98% also reported recommending the back to sleep position to new parents (Price et al., 2008).

The study determined that using evidenced based practice to teach healthcare providers is an

excellent way to increase best practice behaviors. In addition, offering the nurses the option of

either in-person or online teaching methods was effective because it gave them the opportunity to

use whichever method best fit their learning style.

“Assessing Knowledge of SIDS Among African American Women in Mississippi”

Before teaching individuals about a certain subject, it is important to discover what they

already know about that subject. A study conducted by Northington, Graham, Winters, and

Fletcher assessed the knowledge of African American women living in two Mississippi

communities, one urban and one rural, on the topic of SIDS. After assessing the current

knowledge within the group, the authors hoped to gain insight on ways to improve education

about SIDS (Northington, Graham, Winters, & Fletcher, 2011).

This study involved holding six focus groups within the selected Mississippi

communities, which would be led by an African American professor at a local nursing school

(Northington et al., 2011). There were 29 participants from the urban community who ranged in

age from 14 to 40. All of them had at least one child less than 18 months of age. There were 28


rural participants, ranging in age from 18 to 30. All of the participants had at least heard the

term SIDS, or “crib death,” but their sources of information were inconsistent. Most of the

participants indicated that they did not receive any education about SIDS during their pregnancy,

and most of them expressed that at the time of hospital discharge the only information regarding

SIDS that they were given was to put their baby in the supine position to sleep (Northington et

al., 2011).

A number of barriers to education were identified during this study. First, the women

expressed a lack of trust within the community (Northington et al., 2011). They felt that the

information would be the most well received coming from a community member with whom the

mothers could relate. They indicated that they would feel most comfortable being taught in a

familiar setting, such as in a church, community gathering place, or public assistance office. In

addition, the women expressed a discontent with the tone in which the information was being

presented to them. They stated that they would prefer the material be presented in a more

positive manner, and focus on positive outcomes rather than negative (Northington et al., 2011).

Although there may be issues with generalizability because this was such a small study

conducted on such a specific population, it can still be of use when developing suggestions for

reducing the incidence of SIDS in San Joaquin County. If healthcare providers want women to

truly learn and absorb information about SIDS prevention, it needs to be presented to them in a

manner that is both understandable and engaging. It should be done in terms that are

understandable to the average woman, and presented in a positive manner by someone with

whom they feel comfortable.

“Usage and Impact of an Online Education Tool for Preventing Sudden Unexpected Death

in Infancy”


In order for a community health initiative to be effective, it needs to be successful in

reaching as many members of its target population as possible. In the case of SIDS education,

the target population should be at minimum expectant parents and those with an infant under 12

months of age, but ideally could include all adults of child bearing age. A study conducted in

New Zealand between November 2009 and December 2011 looked at the efficacy of an online

education tool to teach the population about SIDS.

A 24 slide presentation targeted at healthcare providers was developed, and modified to

include a voice over that explained the slides in everyday language to increase its appeal to the

average person (Cowan, Pease, & Bennett, 2013). This online education tool aimed to extend

the reach of face-to-face educational sessions and increase access of rural and after-hours

participants. Developing an education tool that is applicable to both healthcare providers and the

general public is useful because it can help assure that there is a standard of quality for

information that providers are giving to their patients, and help produce continuity of information

from provider to provider.

At the end of the online session, participant were asked to rate how much they felt their

confidence for discussing safe sleeping habits with others had increased, on a scale of 1-9.

68.7% of participants rated their confidence of a 7 or above. Those who spent a longer time on

the site tended to rate their confidence as being higher than those who spent less time on the site

(Cowan et al., 2013).

Online education sessions can be an excellent way to reach a larger portion of a

campaign’s target population. They allow individuals to access educational materials on their

own time and at their own pace, and also allow them to go back and review material that they

were not comfortable with after reading it the first time. As long as the material is presented in a


user-friendly manner and uses terms understood by the average adult, online education can be a

very effective tool in reducing the incidence of SIDS.

Recommendations for Reducing the Incidence of SIDS in San Joaquin County

The single most effective tool that can be used to reduce the incidence of SIDS in San

Joaquin County is education. Not only education of parents, but education of healthcare

providers, especially nurses. As determined in the study by Eron et al., physicians are not always

providing consistent and accurate information about SIDS to their patients (Eron et al., 2011).

Providing inaccurate education to parents is worthless and can even be detrimental to the health

of their infant.

The article by Price et al. found that nurses are very likely to place newborns to sleep

only in the supine position and to teach parents to do the same after they receive evidence based

education on the subject (Price et al., 2008). Because nurses provide the majority of education to

new parents in the hospital, ensuring that perinatal nurses stay up to date on facts and

recommendations regarding SIDS needs to be a top priority. Developing continuing education

curriculum about SIDS and requiring these nurses to take refresher courses every year would be

an effective way to make sure perinatal nurses stay current on the issue.

While there are many instances during a pregnancy that parents can be educated about

risk factors for SIDS, the time between delivery and discharge from the hospital is the focus of

this plan. At this time, nurses will be able to use all three learning styles: visual, verbal, and

kinesthetic. Along with providing verbal information, nurses should provide parents with

brochures that they can read in the hospital and again at home, as people do not absorb all the

information presented when they read it for the first time. According to the study by

Northington et al., women prefer educational brochures that focus on positive outcomes rather


than negative, and explain things using words that they can understand, rather than medical

jargon (Northington et al., 2011). Short, to the point instructional videos make an effective

supplement to verbal teaching. In addition, the parents should be provided with a link to re-

watch the video online after they return home, and the website should reinforce teaching that

they were provided with in the hospital. The nurse can teach to the kinesthetic learning style by

demonstrating to parents how to properly swaddle their baby and put them in the bassinet on

their back, and then have the parents repeat the action in front of the nurse. As evidenced by the

article by Price et al., parents are more likely to put the newborn to sleep in the supine position

when they see the nurses do it in the hospital, so nurses need to always place the newborn in the

supine position every time they are in the bassinet.

The literature review that was conducted demonstrated that there although are a number

of intrinsic and extrinsic risk factors for SIDS, unexpected infant death is largely preventable. It

has been determined that education on risk factor reduction is the most effective prevention

method. While this education should touch on all risk factors, it should especially emphasize

supine sleeping and avoidance of exposure to second hand smoke, as these factors have the

largest influence on negative infant outcomes. Further research on effective teaching methods

for parents of different ages, ethnicities, and education levels would be helpful in individualizing

teaching plans to make them more effective for each individual patient. San Joaquin County

currently has a SIDS death rate just slightly higher than the state of California as a whole. With

proper parental education between delivery and discharge from the hospital, San Joaquin County

will see a reduction in this preventable cause of infant mortality.


References

California Department of Public Health. (2012). Number of SIDS deaths, total number of live

births, and SIDS death rate by county. Retrieved from:

http://www.cdph.ca.gov/programs/SIDS/Documents/MO-SIDS-SIDSByCounty-07-09-

08-10.pdf

Centers for Disease Control and Prevention. (2013). Sudden unexpected infant death (SUID).

Retrieved from: http://www.cdc.gov/sids/

Cowan, S., Pease, A., & Bennett, S. (2013). Usage and impact of an online education tool for

preventing sudden unexpected death in infancy. Journal of Paediatrics and Child Health,

49, 228-232. DOI:10.1111/jpc.12128

Eron, N.B., Dygert, K.M., Squillace, C., Webster, N.J., Andrianos, A., Crockett, E.G., &

Consenstein, L. (2011). The physician’s role in reducing SIDS. Health Promotion

Practice, 12(3), 370-378. DOI: 10.1177/1524839909341033

Hockenberry, M.J. & Wilson, D. (2013). Wong’s essentials of pediatric nursing. St. Louis, MO:

Elsevier.

MacDorman, M. F. & Mathews, T.J. (2009). Behind international rankings of infant mortality:

How the United States compares with Europe. NCHS Data Brief, 23, 1-8.

Meadows-Oliver, M. & Hendrie, J. (2013). Expanded back to sleep guidelines. Pediatric

Nursing, 39(1), 40-49.

Moon, R.Y., Tanabe, K.O., Yang, D.C., Young, H.A., & Hauck, F.R. (2012). Pacifier use and

SIDS: Evidence for a consistently reduced risk. Maternal Child Health Journal, 16, 609–

614. DOI 10.1007/s10995-011-0793-x

Northington, L., Graham, J., Winters, K., & Fletcher, A. (2011). Assessing knowledge of sudden


Same here


Capitalize after colon


infant death syndrome among African American women in two Mississippi communities.

Journal of Cultural Diversity, 18(3), 95-100.

Price, S.K., Hillman, L., Gardner, P., Schenk, K., & Warren, C. (2008). Changing hospital

newborn nursery practice: Results from a statewide ‘‘back to sleep’’ nurses training

program. Maternal Child Health Journal, 12, 363-371. DOI 10.1007/s10995-007-0243-y

Trachtenberg, F.L., Haas E.A., Kinney, H.C., Stanley, C., & Krous, H.F. (2012). Risk factor

changes for sudden infant death syndrome after initiation of back-to-sleep campaign.

Pediatrics, 129, 630-638. doi: 10.1542/peds.2011-1419.


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