UNDERSTANDING AND MANAGING INFANT CRYING: IMPLICATIONS FOR CHILD MALTREATMENT,SWADDLING, AND SUDDEN...

UNDERSTANDING AND MANAGING INFANT CRYING: IMPLICATIONS FOR CHILD MALTREATMENT,SWADDLING, AND SUDDEN INFANT DEATH

SAFE SLEEPING PRACTICES

Dr. Lynne WardaWRHA Injury Prevention ProgramPediatric Emergency Medicine Child Health Standards Committee (CPSM)

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PRESENTATION FOR:

Injury Prevention Champions

Spring 2015

1. Safe sleep practices2. Normal infant crying patterns3. Management of infant crying4. Safe swaddling5. Benefits and risks of swaddling6. Resources

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Presentation Objectives

BACK TO SLEEP SIDS TRENDS?

• Declining incidence 1990s-now• 1.1/1000 live births 1990 – 0.3/1000 in 1999• 16-20 cases/year to <5 cases/year (SIDS)

• Males 60-70%• African American, First Nations 1.5-2X risk• Age: 80% less than 5 months, peak 2-4 months, 3% greater

than one year of age• Most apparently healthy prior to death, many with minor

recent illness (GI, resp sx)

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Safe sleep practices

SIDS/SUID TRENDS - USA

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RECENT SIDS/SUID MANITOBA CASES• 3 weeks, sleeping with parent on couch, found prone• 12 weeks, sleeping with teen mom in foster care, crib in

room• 6 months, adult bed, found on the floor in pile of clothing• 8 months, sleeping with parents, found wedged between

wall and mattress• 4 months, found between two mattresses on the floor• 4 months, found in swing with blanket over face• 11 months, found in stroller under lap tray, no restraint in

use• 4 months, placed prone in playpenSafe sleep issues? Common themes? Other risks? Protective factors?

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PREVALENCE OF SLEEP ENVIRONMENT RISK FACTORS FOR SUDDEN INFANT DEATH:

A POPULATION-BASED STUDY

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DEFINITIONS• SIDS• SUID• ALTE• Entrapment• Strangulation• Suffocation• Choking• Asphyxia

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CAUSES OF SUFFOCATION

• Types: Entrapment, strangulation, suffocation, aspiration• Crib/bed/furniture entrapment• Clothing: drawstrings, hoods, buttons• Bedding, piles of clothing, bumper pads• Pets• Plastic bags, plastic film• Aspiration (small parts): toys, coins, food

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OTHER CAUSES OF SUDDEN DEATH

• Child abuse, trauma• Sepsis/infection/pneumonia• Seizure• Dysrhythmia• Aspiration (GER, other)• Central causes of apnea• Upper airway, lower airway causes of apnea• SIDS, SUID

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TRIPLE-RISK MODEL: SIDS• Predisposed infant• Unstable period of

homeostatic control• Triggering factor(s)

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RISK FACTORS FOR SUDDEN INFANT DEATH

• SIDS risk factors?• Classic: sleep position, smoking, overheating

• SUID risk factors?• Sleep environment risks

• Suffocation risk factors?• Bed, bedding, toys/objects, humans, pets

• Entrapment risk factors?• Bed, furniture

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REFERENCES/EVIDENCE REVIEW

• Joint Statement on Safe Sleep (PHAC 2011)• SIDS and Other Sleep-Related Infant Deaths:

Expansion of Recommendations for a Safe Infant Sleeping Environment (AAP Oct 2011)• Policy statement• Technical Report

• WRHA SIDS/SUDS Clinical Practice Guideline• Research Literature

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THE BOTTOM LINE…

Level A recommendations

• Back to sleep for every sleep• Use a firm sleep surface• Room-share without bed-sharing• No soft objects and loose bedding• Pregnant women should receive regular prenatal care

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THE BOTTOM LINE…

Level A recommendations

• Avoid smoke exposure during pregnancy and after birth• Avoid alcohol/illicit drug use during pregnancy and after

birth• Breastfeeding is recommended• Consider offering a pacifier at nap time and bedtime• Avoid overheating• Do not use home cardio-respiratory monitors as a strategy

for reducing the risk of SIDS

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SLEEP POSITION

• Supine is the safest position until age 1 • Why? Rebreathing, overheating, suffocation• Side position is as unsafe as prone (2.0-2.6X)• Higher risk for infants placed prone who usually

sleep supine (child care, illness)• Hospital: preterm infants supine by 32 weeks• Newborns should be placed supine from birth• Infants who roll both ways can be left prone

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SLEEP SURFACES

• Safety-approved crib, portable crib, playpen or bassinet• Firm mattress with no gaps• No drop sides (US, soon Canada?)• Beware playpen bassinets and change tables –

not designed for sleep!• Car seats/infant seats/swings are not safe for

routine sleep and require adult supervision

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BED-SHARING

• Adult bed: risks related to suffocation, entrapment between bed/wall/furniture, soft bedding, pillows, mattress sag, falls• Bed-sharing: risks related to overheating,

rebreathing, airway obstruction, head covering, smoke exposure (all are risk factors for SIDS) + bed-related risks• Recent meta-analysis of 11 studies: 2.88risk

(1.99-4.18) with bedsharing

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PARTICULARLY HAZARDOUS…

• “Stress to parents that they avoid the following situations at all times”• Smokers (one or both parents)(OR 2.3-17.7)• Age < 3 months regardless of smoking status (OR 4.7-

10.4)• (BW<2500, GA < 37 weeks, nonsmokers OR 15.2)• Waterbeds, sofas, armchairs (OR 5.1-66.9)• Pillows, blankets (OR 2.8-4.1)• Multiple bedsharers (OR 5.4)• Parent has consumed alcohol (OR 1.66)• Bedsharing with nonparent (OR 5.4)

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BEDDING

• Pillows, quilts, comforters, sheepskins• Increase risk up to 5X regardless of sleep position• Unsafe under infant• When loose can cause head-covering• Risk of suffocation/rebreathing when used to

create barriers to prevent infant from falling• No wedges/positioners, bumper pads

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ROOM-SHARING

• Recommended routine practice• 50% reduction in SIDS• Safer than solitary sleeping and bedsharing• Separate sleep surface• No smoking in the room

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SMOKING• Maternal smoking accounts for 1/3 SIDS• LBW, prematurity, decreased infant arousal• Post-natal parental smoking is associated with a

2.5-5.8 fold increase in SIDS• Risk increases with # smokers in the home,

smokers in the same room as the baby, # cigarettes smoked, daily hours baby exposed

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SUBSTANCE USE/ABUSE

• Maternal alcohol use, binge drinking: OR 6-8 independent of smoking• In-utero exposure to opiates, cocaine,

methadone, heroin: OR 2-3 after controlling for numerous associated risk factors

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BREASTFEEDING

• Previous studies not consistent• Recent meta-analysis of 18 case control studies:

OR 0.40 (0.35-0.44)• Exclusive BF more protective: OR 0.27 (0.24-0.31)• Why? More easily aroused from sleep, decreased

respiratory and GI illness• Return infant to crib after feeding

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PACIFIER USE

• Protective effect• Especially when used at time of last sleep• Two meta-analyses: OR 0.39, 0.48• Why? Lowered arousal thresholds, maintains

airway open in sleep, modifies autonomic control• No significant association with BF duration• Delay use until BF established

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OVERHEATING

• Definite association with SIDS• Increased when prone• Head covering risk: overheating, hypoxia,

rebreathing• Some evidence that good room ventilation may

reduce the risk of SIDS

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KEY MESSAGES FOR PARENTS

• Back to sleep for every sleep• Alone in a crib or playpen• No blankets or soft bedding• Same room as parents (smoke-free room)• Breastfeed• Smoking significantly increases the risk of SIDS• Discuss the risks of bedsharing

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Normal infant crying

UNDERSTANDING NORMAL CRYING• Evidence-based international approach• Normal crying curve• PURPLE program• Focus groups, RCTs• Booklet, DVD• 10 languages• www.purplecrying.info•Video

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http://www.purplecrying.info/

http://purplecrying.info/what-is-the-period-of-purple-crying.php

REASONS FOR CRYING

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HMMM….WHAT NEXT?

In British Columbia, mothers of newborns who received PURPLE program materials at public health home visits showed greater crying knowledge, shared crying information and strategies with other caregivers, and were more likely to walk away during episodes of inconsolable crying.

What is your approach when supporting mothers of newborns?

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PURPLE CRYING• Some things work some of the time, but nothing

works all of the time• “Comforting” might involve wrapping your baby in a

blanket, or just holding your baby in your arms • “Carrying” includes holding, contact and closeness • “Walking” includes all of those as well as introducing

a rhythm to your movements. You may also want to move your body to the rhythm of the beats in music while carrying and comforting your baby

• “Talking” includes adding a human voice, perhaps saying or singing the same things over and over to a melody

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Management of infant crying

TIPS FOR SOOTHING CRYING

• Address infant needs (hunger, diaper change, overheating, overstimulation, fatigue)• Change of position• Kangaroo care/skin to skin contact• White noise/vibration (fan, dryer, vacuum, car

ride)• Carrying/closeness• Do not place the infant on top of a dryer or

washing machine due to the risk of falls

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SWADDLING FOR CRYING?

• Several studies have documented reduced crying hours with routine and stimuli• Sleep, feed, cuddle, alone time in playpen, to his/her

crib awake but sleepy when showing signs of fatigue• Reduce noise from radio, television, or noisy toys,

and baby gyms, if the child is less than 3 months old.

• Avoid using bouncy chair (except for feeding) for an infant that cries excessively. Never use on elevated surfaces!

• Avoid continuous entertainment, visits, outings• Swaddling did not ADD significant benefit to this

routine after the first 3 days. Try this first!

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BENEFITS• Pain relief: positive impact on behavioural

and/or physiological pain indicators• Weighing: showed reduced physiological

distress, improved motor organization and more effective self-regulatory ability when weighed• Excessive crying: Soothes excessive crying• PURPLE program• Regularity and uniformity approach• Happiest Baby Method

• Sleep: infants sleep longer

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Benefits and risks of swaddling

RISKS• Maternal-infant bonding: a reduction in the mother’s

responsiveness and involvement with the infant• Breastfeeding: skin-to-skin contact is not possible with

swaddling• Respiratory infections: a study of 186 infants in Turkey

and China concluded that infants routinely swaddled had a 4-fold greater likelihood of developing pneumonia and other upper respiratory infections compared to those not swaddled

• Developmental Dysplasia of the Hips (DDH): greater risk of hip dysplasia for infants who are tightly swaddled, restricting hip flexion and abduction

• SIDS/SUID/Suffocation: Studies show that infants who were swaddled have a higher risk for SIDS

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SWADDLING AND INFANT DEATH

• Manitoba cases (sling, swaddling, blankets)

2013 CASE EXAMPLE• A newborn who was being carried in an infant sling-style

carrier inside the mother's clothing/coat was found unresponsive and did not respond to resuscitation

• Though not exactly swaddling, it is related, and a similar mechanism to both SIDS/SUID and swaddling/suffocation

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SWADDLING AND INFANT DEATH

• Journal of Pediatrics 2014;164:1152-6 case series: infant deaths and injuries• New Zealand Cot Death study• Netherlands sleep sack case control study• Ponsonby (CC): 12X risk• Blair (CC): 30X risk

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SWADDLING FOR WARMTH• The Winnipeg Liveability bylaw: residential temperatures

must be no less than 18°C between 11pm and 7am, and no less than 21°C between 7am and 11pm.

• Sleep in the warmest room, away from windows, drafts, and exterior walls. Infants should not sleep next to a radiator, heater or fireplace/woodstove, given the risk of overheating. Do not use a hot water bottle or an electric blanket.

• Use a fleece or flannel fitted crib sheet.• Dress in undershirt and fleece sleeper with feet +/- hat.• May use a small fleece blanket tucked in.

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SWADDLING TIPS

• Not recommended as routine practice• May be used to convert prone sleeper to supine• Always lay supine, not side or prone• No head covering• Swaddle to allow hip flexion/abduction, breathing.• Ensure infant will not escape the swaddle• Stop swaddling when the infant can roll over• Use light receiving blanket (may need two)

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SUMMARY

• Does not reduce the risk of SIDS• ++ increased risk if swaddled and prone• May be used as a strategy to soothe/calm• Tight swaddling: overheating, increases

respiratory rate, adversely affects respiration• Loose swaddling: risk of head covering• Any swaddling may reduce sleep arousal,

particularly if unaccustomed to swaddling

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Sleep sacks and swaddlers

CONSIDERATIONS•Follow manufacturer’s instructions: age, weight, length•Fabric meets Canadian sleepwear flammability guidelines •No drawstrings or cords at neck. No ribbons, cords, or tight elastic that could cause strangulation or constrict a limb or digit. No small parts that could cause a choking hazard

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Sleep Sacks and Swaddlers

CONSIDERATIONS•Must fit snugly around upper body and neck to not cover mouth and nose, and infant cannot wiggle inside the sack, under the collar •Should not be tight around the chest. No restrictions at the hip, so that the hips can flex comfortably•Caution the parent regarding overheating, and always dress lightly under the sack and/or swaddler

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Sleep Sacks and Swaddlers

SIDS AND KIDS SAFE SLEEPING APP• App provides information on how to sleep baby safely and

reduce the risk of sudden unexpected death in infants and fatal sleeping accidents

• It also includes valuable information on Tummy Time and Safe Wrapping

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Resources

SAFE SLEEPING POSTER

HTTP://WWW.SIDSANDKIDS.ORG

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Resources

SAFE SLEEP FOR YOUR BABY BROCHUREHTTP://WWW.PHAC-ASPC.GC.CA/HP-PS/DCA-DEA/STAGES-ETAPES/CHILDHOOD-ENFANCE_0-2/

SIDS/PDF/SLEEP-SOMMEIL-ENG.PDF

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Resources

QUESTIONS?47

UNDERSTANDING AND MANAGING INFANT CRYING: IMPLICATIONS FOR CHILD MALTREATMENT,SWADDLING, AND SUDDEN...

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