Training Objectives• To understand the current

recommendations on infant safe sleep practices

• To understand the barriers to following safe sleep recommendations

• To learn techniques for how to work effectively with parents to increase safety

Top Three Causes of Infant Deaths, Florida 2003 Deaths per 10,000 Live Births

Data Source: Florida Vital Statistics Annual Report, 2003

13.66

4.33

36.89

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

Perinatal Conditions Congential Anomalies SIDS

Deaths per 10,000 Live Births

Definition of Sudden Infant Death Syndrome

“The sudden and unexpected death of an infant under one year of age, with the onset of the lethal episode apparently occurring during sleep, that remains unexplained after a thorough investigation including performance of a complete autopsy, review of the circumstances of death and the clinical history.”

Facts about SIDS

• Leading cause of infant deaths from 28 days to 1 year.

• 85% of all sudden and unexpected infant deaths between the age of 1 month and 1 year are due to SIDS.

• Highest incidence occurs between 2 to 4 months.

• 90% of SIDS occur from 1 to 6 months of age.

• Higher incidence among male infants.

Maternal Risk Factors

• Smoking during and after pregnancy

• Maternal age < 20 years

• Poor prenatal care• Low weight gain• Anemia• Use of alcohol or drugs• History of STDs or UTIs

Infant Risk Factors

• Male

• Low birthweight

• Premature

• African-American

• Native American

• Exposed to tobacco and drugs

FL SIDS Rates and Deaths by Race and Hispanic Ethnicity, 2003 Data Source: FL DOH Vital Statistics

(Number of Deaths are in Parentheses)

23.56 (13)

64.96 (30)

47.11 (49)

43.35 (92)

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

All Races White, Non-Hispanic Black, Non-Hispanic Hispanic

Rate per 100,000 Births

(age – vulnerability)2-4 months - 75%4-6 months - 15%

External Stress Factors (Modifiable)

–temperature–swaddling–bedding–sleep position–smoking–drug use–minor respiratory symptoms

–poverty–limited prenatal care–season

SIDS

Vulnerable Infant

Critical Development

Period

ExternalStressFactors

Triple Risk SIDS Theory

Chemical receptors that respond to low blood oxygen or high blood carbon dioxide may not function normally

This could lead to respiratory failure and death in certain circumstances

Prematurity, exposure to cigarette smoke and other risk factors may operate by contributing to this abnormal function

Current Theories Based on Recent Research

Cerebral Cortex

Brain Stem

Environmental Risk Factors

Prone sleeping(sleeping face

down)Is estimated to

account for 40-80% of SIDS cases

Source: Nursing Research Mar/Apr 2004

Tummy sleepers are 5 to 7 times at greater risk of dying of SIDS thanback sleepers.

Back sleepers who nap on their tummies face an 19-fold risk of SIDS.

Source: Mitchell and Thach, Arch Pediatr Adol Med, 1999

Side Sleepers Have a Two-Fold Greater Risk of SIDS.

Florida 2002 PRAMS: Infant Sleeping Position by Maternal Race

50.8

20.5 20.1

60.6

16.218.7

34.9

24.125.3

46.5

25.2

18.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Back Side Stomach

Percent

All Races White (Non-Hispanic) Black (Non-Hispanic) Hispanic

Environmental Risk Factors

Overheating

Exposure to tobacco smoke increases the risk of SIDS

Sleeping in Adult Beds Can Result in:

Entrapment/wedging Overlying Suffocation from

Bedding Strangulation

Comparison of Risk for Suffocation in Adult Bed and Sofa/Chair

• For infants younger than 8 months, risk of dying in a crib was 0.63 deaths per 100,000 infants

• Risk of dying in adult bed was 25.5 deaths per 100,000 infants

Source: Scheers, et. al., “Where Should Infants Sleep? A Comparison of Risk for Suffocation of Infants Sleeping in Cribs, Adult Beds, and other Sleeping Locations,” Pediatrics Vol. 112 No. 4 October 2003

The Incidence of Bed-sharingIt’s on the Rise

The incidence of bed-sharing has increased from 5.5% in 1993 to 12.8% in 2000.

Source: Archives of Pediatrics and Adolescent Medicine, January 2003

Source: National Infant Sleep Position Study

What are the Reasons Given for Bedsharing ?

1. No crib2. Easier to breastfeed at night3. To avoid crib death4. Family tradition5. To spend quality time6. Too tired to get up7. To keep baby warm8. Baby sleeps better

98.0

80.0

74.0

77.0

72.0

61.0 57.0

49.5 46.646.2

43.3

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Florida SIDS Rate per 100,000 Live Births1993-2003

Cause of Death: SIDS and Suffocation in Bed A Comparison of Florida Infant Death Rates (per 100,000 live births)

1995-2003

4.777.39 8.32

11.25 10.15 10.78

20.89 19.46

24.97

46.2143.35

74.2677.11

72.28

60.85

56.86

49.5046.65

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

1995 1996 1997 1998 1999 2000 2001 2002 2003

Dea

ths

per 1

00,0

00 L

ive

Birt

hs

Suffocation in Bed Death Rate FL SIDS Death Rate

Total Postneonatal Death Rate (per 1,000 Live Births)

Rate Per 1,000

FloridaCHARTS.com is provided by the Florida Department of Health, Office of Planning, Evaluation and Data Analysis, (850) 245-4009

Data Source: Florida Department of Health, Office of Vital Statistics.

Deaths occurring 28 to 364 days from birth.

PANHANDLE FIMR STUDY OF SLEEPING INFANT DEATHS from 1994-2003

87% (46/53) of cases had one or more documented “sleep risk factors”: Placed on adult bed (50%)Placed on sofa, chair, pillow of lap (22%)Positioned on stomach (55%)Slept on or near questionable bedding (74%)Slept with other family members (56%)Exposed to second-hand smoke (30%)

A separate but proximate sleeping environment is recommended

AAP Recommendation for SIDS Risk Reduction

What Are The Barriers To Following Safe Sleep Recommendations?

National Infant Sleep Position Study

• National annual telephone survey or 1000 households

• African American. Hispanic, Asian and American Indian parents of 2 and 4 month olds

Findings from Focus Groups with Caregivers

Caregivers reported concerns about:

Safety – choking

Comfort – believed child more comfortable on stomach

Advice – trusted family members and their own instincts over health

professionals

Findings from Focus Groups with Caregivers

Caregivers lacked knowledge about:

What causes SIDS

The dangers of soft bedding

Why back sleeping is important

Why are Parents Still Putting Babies

to Sleep on Their Stomachs?

1. Baby sleeps better on stomach

2. Baby cries if put down on his back

3. Baby will choke

4. Baby can breathe easier

5. Advice from grandmother

6. Previous experience

7. Doctor said it was ok

Preemies No Longer Exempted

Based on all available data, we now recommend that all full-term and preterm infants in the NICU without upper airway obstruction be placed in the supine position for sleeping as soon as ready for oral feedings.

Dr. Carl Hunt

American Journal of Maternal Child Nursing

• 55% Side• 16% Prone• 29 % Supine

0

20

40

60

80

100

Position

Prone Side Supine

Nov/Dec 1999, Infant Sleep Positioning: Nursing Practice and Knowledge, Peek Hershberger, Kuehn and Levett

Tasks of Falling Asleep

1. Regulating sleep-wake cycles2. Internalizing daily routines and schedules3. Transitioning from active and quiet alert

states to sleep4. Screening out noise to fall asleep5. Self calming when awakened in the night6. Feeling attached to caregivers while feeling

secure in separating from them to sleep

Source: Pediatric Disorders of Regulation in Affect and Behavior. De Gangi. 2000

Sleep Problems

• Difficulty initiating (settling into sleep)

• Difficulty maintaining sleep (waking up during the night with difficulty returning to sleep

Source: Diagnostic Classification 0-3

Causes of sleep problems

• Medical Problems

• Regulatory Disorders

• Attachment Disorders

• Poor Sleep Hygiene

Medical Problems Which Interfere With Sleep

1. Obstructive sleep apnea syndrome (OSAS)

2. Respiratory conditions, e.g. asthma, CF

3. Food allergies4. Ear infections

What Is Self Regulation?

“The mastery of tasks that were accomplished by the mother’s body or in concert with the mother’s body when the child was in the womb, but must now be accomplished by the child’s body and through signaling needs to responsive adults.”

Source: From Neurons to Neighborhoods, 2000.

Developmental Milestones of Self Regulation In Infancy

• Regulation of arousal and sleep-wake cycles

• Responsive interactions with others

• Attempts to influence others

• Begins to anticipate and participate in simple routines

Source: Bronson, Martha. (2000). Self Regulation in Early Childhood. New York: Guilford Press.

Role of Adults in Infant Self Regulation

• Being sensitive to infant signals and “state”

• Being responsive to infant’s signals• Engaging in warm positive interactions• Participating in predictable sequences of

caregiving, social and play routines that the infant can learn and participate in

Source: Bronson, Martha. (2000). Self Regulation in Early Childhood. New York: Guilford Press.

Sleep Problems Occur in Children with Regulatory Disorders

• HypersensitiveOver-reactive to touch or soundDifficulty settling or getting

comfortable

• Motorically DisorganizedCraves vestibular stimulation Can only fall asleep with

movement or vibration

Disorders of Attachment in Infancy Can Affect Self Regulation

1. Constitutional vulnerabilities in the infant

2. Emotional liabilities in the parents

3. Poorness of fitSource: Infant and Toddler Mental Health, edited by J. Martin Maldonado-Duran, M.D.

Newborns of Depressed Mothers

• Are less active

• Are more irritable

• Show fewer positive expressions

• Have disturbed sleep

patterns

• Have increased stress hormones

Source: “Breaking the Cycle of Depression” American Psychological Association

Poor Sleep Hygiene

• Feeding a baby every time it cries

• Parent soothing vs. self soothing

How Can We Help Parents to Implement Safe Sleeping Recommendations?

Screen Women for Depression

DEPRESSED MOTHERS ARE

• Less likely to breastfeed

• Less likely to use “back to sleep” position

• Less likely to take child for recommended preventive care and immunizations

• More likely to use corporal punishment Source: “Maternal Depressive Symptoms and Infant Health Care Practices Among Low Income Women” Chung,

et. al., Pediatrics Vol. 113 No.6 June 2004

Do you now, or have you ever had, problems with depression?

YES20.8%

NO79.2%

Florida Healthy Start Prenatal Screen2003 - 2004

Give Back to Sleep Recommendations During Postpartum Hospital Stay

• Ask about SIDS knowledge• Ask what recommendations they have heard• Ask if they know why side is not

recommended• Ask if they are worried about choking• Ask what they think about the

recommendations• Ask if they have questions

Inform all Caregivers

Make certain that all caregivers know to put baby on its back to sleep

Provide Additional Education On:

1. Why back sleeping is important2. The advantages of back sleeping3. How infants sleep4. The risks associated with bed sharing5. Strategies to help infants learn to sleep

on their own6. Benefits of breastfeeding7. Sensitive caregiving

Babies Do Cry More When on Their Backs

Sleep is lighter.They awaken more

easily.

These things help protect infants from SIDS.

Babies Who Sleep on their Backs

• Swallow more often

• Have fewer ear infections at 3 and 6 months

• Have less stuffy noses at six months

Source: Carl Hunt, M.D., et. al. Arch Pediatr

Adolesc Med. 2003;157:469-474.

Infant Sleep

REM (Rapid Eye Movement) Sleep:

• Activated brain state• Dream like sleep• Eyes move under lids• Heart rate and breathing patterns

are rapid• Small body jerks, facial grimaces, twitching

Infant Sleep

NREM (Non REM) Sleep:

• Heart rate and breathing are slow and regular• Sleeper looks restful• Quiet sleep

Parental Behaviors That Help to Regulate Infant Sleep/Wake Cycles

• “Kangaroo Care”

• Breastfeeding

• Swift, consistent response to crying from birth to four months

• Play games such as Peek-a-boo to help with separation

BABYWEARING• Reminds baby of the motion and

balance enjoyed in the womb

• Stimulates baby’s vestibular system which has a regulatory effect

• Carried babies show a heightened level of quiet alertness

• Source: www.asksrsears.com

Breastfeeding Aids Sleep

Calming Strategies for Fussy Babies

• Swaddling• Shhhh Source: Harvey Karp, M.D.

• Rhythmic, repetitive sounds• Comfort sucking (fingers, fist, pacifier)• Massage

Source: Charles E. Schaefer, Ph.D.

AAP Recommendation for SIDS Risk Reduction

Consider offering a pacifier at bed and nap time

Source: Dr. Rachel Moon, M.D., Children’s National Medical Center, Washington, D.C. March 2005

Routines Help to Regulate Arousal

• Predictable and consistent nap and bedtime routines

• Quiet hour before bedtime

• Bed time ritual

• Place baby in the crib drowsy but still awake

• Help child attach to a security object

• Make middle of the night feedings brief and boring

Techniques for Helping Infants Transition into Sleep State

Stay Asleep Techniques

• Quiet, dark room

• Temperature around 70 degrees

• Repetitive, monotonous sounds

• Transitional object in the crib

Promote Parental Sensitivity

• Recognizing infant’s ability to signal needs

• Accurately reading and interpreting cues

• Responding appropriately

• Responding consistently and predictably

Source: Infants, Toddlers and Families: A Framework for Support and Intervention, Erickson and Kurz-Riemer, 1999

Indications of Parental Insensitivity

• Persistent failure to respond to infant cries and other bids for attention

• Inconsistent patterns of responding

• Intrusiveness

Source: Infants, Toddlers and Families, Erickson and Kurz-Riemer, 1999

Behaviors to Observe

• Eye contact between mother and infant• Holding patterns of mother• Mutual touching of mother and infant• Talking and other communication patterns• Responsivity and reciprocity• Sensitivity of both mother and infant to each

other

Source: Joy Osofsky, Ph.D., Harris Institute of Infant Mental Health, LSUHSC, New Orleans, La., 2005

Promote Maternal Role Attachment during Pregnancy

• Relationship between mother and child begins before birth.

• Development of an internal working model of the baby to be influences mother’s later relationship with her baby

THE END

From the Florida Department of Health

• Infant, Maternal and Reproductive HealthField Staff Trainings 2007

• Visit: http://www.doh.state.fl.us/family/mch/training/sids/sids.html