How to Prevent SIDS

It was a Sunday night in June 2007, in Ho-Ho-Kus, New Jersey. Lisa DeMarco finished nursing 3-week-old Andrew and went to bed. At 10 p.m., her husband, Frank, tried to give Andrew a bottle of pumped breast milk, as had been their custom. But Andrew was uncharacteristically fussy and didn't take it until 1 a.m. On most nights, Frank would then place him in his bassinet in the master bedroom. But this evening, saddened by news that his grandmother had died and trying to calm the baby, Frank fell asleep on the couch holding Andrew against his chest.

The next thing anyone remembers, it was 5 a.m. Lisa ran down the stairs because Andrew hadn't woken up for his 4 a.m. meal. Frank was screaming that Andrew felt lifeless and cold. Lisa immediately began giving Andrew CPR and paramedics arrived within minutes, but it was too late: The baby was a victim of sudden infant death syndrome.

Between 1984 and 2004, the rate of SIDS, the diagnosis given when a healthy child suddenly dies before his first birthday, dropped from one in 700 babies to one in 1,800. This was mainly the result of an American Academy of Pediatrics (AAP) campaign urging parents to put infants to sleep on their back. A small number of babies are thought to be unable to arouse from sleep normally and become deprived of oxygen when they rebreathe too much carbon dioxide. This is more likely when babies sleep on their stomach and exhaled carbon dioxide gets trapped near their face, so experts recommend that they sleep face up.

However, new figures from the Centers for Disease Control and Prevention (CDC) show that the SIDS rate has remained fairly stable in the last few years. Even more worrisome, the number of infant deaths attributable to accidental suffocation and strangulation in bed (when something is found over the baby's face or around his neck) tripled between 1996 and 2004. The result of these combined trends: Babies are dying unexpectedly in their sleep at a rate similar to that of 1998.

Experts aren't certain whether strangulation and suffocation are actually more common now; it's possible that local examiners investigating the deaths are simply more willing to use those labels than SIDS. "Years ago, there was a movement away from putting 'strangulation' and 'suffocation' on a death certificate, because it could be seen as blaming the parent, but that stigma seems to be fading because people are starting to realize that there are other potential causes," says John Kattwinkel, M.D., professor of neonatology at the University of Virginia, in Charlottesville, and chair of the AAP Task Force on SIDS.

Still, some SIDS researchers are convinced that the recent rise is real, and they attribute it to the fact that more parents are now sleeping with their baby. The CDC report found that more than half of the deaths for which sleeping location was noted involved a form of cosleeping, says Carrie Shapiro-Mendoza, Ph.D., lead epidemiologist in the CDC's division of reproductive health. Bedsharing increases the chance that a parent could accidentally smother a child, and an adult bed is also filled with pillows, sheets, and blankets that pose a danger.

Frank didn't intend to sleep with his baby, but for many parents, bedsharing has become a way of life. In 1993, 6 percent of U.S. infants under 8 months usually shared an adult bed. That rate more than doubled by 2000, according to a report from the National Institutes of Health. And a recent study in Pediatrics found that a third of families share their bed with their baby -- at least sometimes -- for the first three months, and 27 percent continue for a year. "Bedsharing is more popular because breastfeeding rates are up, and many breastfeeding mothers advocate it. Formula-feeding parents also like the convenience," says study author Fern Hauck, M.D., associate professor of family medicine and public health sciences at the University of Virginia School of Medicine and an AAP SIDS Task Force member.

Studies have proven that babies are safest in their own sleeping space -- be it a crib, a bassinet, or a cosleeper attached to the side of the parents' bed. That's why the AAP Task Force on SIDS recently reaffirmed its 2005 policy statement, which advises against bedsharing and offers other safety precautions. "At this point, most parents know they need to put their baby on his back. Now we need to focus their attention on other risk factors too," Dr. Kattwinkel says. If all parents stuck to these recommendations during their baby's first year, and especially the first six months, the peak time for SIDS, strangulation, and suffocation, many more babies could be saved. This isn't just wishful thinking. Dr. Hauck's recent study comparing death rates in developed countries found that in ones like the Netherlands, where parents closely obey SIDS guidelines, sudden infant deaths have practically disappeared. In contrast, the rate in the U.S. remains one of the highest in the world. That's why it's crucial to follow safe-sleeping rules from the moment your baby is born.

You should always lay your baby down to sleep on his back, even when he naps. (Until 2005, the AAP recommended either the back or the side, but babies who were put down on their side often rolled onto their tummy; young babies can't roll over from their back.) Some parents resist because they fear flathead syndrome, but that's largely preventable. Just give your baby plenty of tummy time during waking hours, and alternate the direction you turn his face when you put him to sleep on his back. Others worry that babies on their back could more easily choke if they vomit. This is a myth, Dr. Hauck insists: Infants will automatically swallow or cough up any fluids.

Some doctors still recommend putting babies to sleep on their stomach in certain cases because it might help with reflux or gas, but this practice may be dangerous, as Karen Garni, of Westport, Connecticut, discovered. When using medication, changing formulas, and elevating the head of the crib mattress didn't stop her 2-month-old son, Spencer, from screaming all night, Garni asked her doctor for additional suggestions. "He said that even though it was a SIDS risk, putting him on his abdomen would help him -- and us -- get the sleep we needed," she recalls. It worked, and for the next two months Spencer slept much better. But then one night Karen went to check on him and found that he was blue. "I immediately called 911, and the EMTs tried to revive him, but he was already gone," she says.

You should skip all soft objects and loose bedding -- including bumpers, quilts, pillows, and toys -- in the crib for the entire first year. That's a hard one for many parents, says pediatrician James Schmidt, M.D., cofounder of Child Safety House Calls, in Virginia Beach, Virginia. "I call it the baby-shower effect. You get this cute quilt, and it's painful to learn you can't use it," he says. Dr. Schmidt tells parents to hang the quilt on the nursery wall instead. If you want to protect your child from the crib bars, it's okay to use mesh bumpers with breathable holes. Also, don't let your baby sleep in a hammock or another device that has a pillowy part near her head.

Smoking during pregnancy is one of the biggest risk factors for SIDS. Experts believe it might lead to a brain defect that makes an infant vulnerable. It's great if you stopped smoking for the whole nine months you were expecting -- but don't light up now. Secondhand smoke has also been shown to increase risk.

Especially when you're breastfeeding, it can seem much easier to let your baby lie next to you. But the evidence shows that if you and your baby fall asleep after feeding, he'll be at increased risk of both SIDS and suffocation. That's why the AAP discourages sleeping with your baby during the whole first year. Studies have shown that factors like medication, drug use, and smoking play a role in bedsharing deaths, but experts don't know to what degree they're to blame. Until studies offer proof, don't assume that cosleeping can be done safely. "It's unwise for any mother to sleep with her baby, but it's even more dangerous if you've been drinking or taking medication, are obese (and could more easily smother your baby), or have a child who's already at an increased risk of SIDS because you smoke," cautions AAPSIDS Task Force member Maurice Keenan, M.D., assistant professor of pediatrics at Harvard Medical School, in Boston.

Out of your bed doesn't mean out of your room. Although researchers aren't sure why, they have found that a baby's risk of SIDS drops by a third when the mom is nearby, at least during the first 6 months. Place a bassinet, cradle, or crib adjacent to your bed -- or use a "cosleeper" that attaches to the side of your bed. Nurse your baby in bed only if you're sure you can remain alert to put her back afterward.

When babies use a pacifier (and sleep on their back) their risk of SIDS plunges by two thirds compared with babies who sleep without a pacifier, says Dr. Keenan. One possible reason it's effective: Babies who suck a Binky don't sleep as deeply. Don't force your baby to take one if he refuses, and there's no need to reinsert it if it falls out.

When the AAP Task Force wrote its report in 2005, it concluded that there wasn't enough evidence to say that breastfeeding reduced the risk of SIDS. But research in the last few years has confirmed that nursing does offer protection. Most recently, a German study found that exclusively breastfed babies are only half as likely to die and that even partial nursing is beneficial. It may be that breastfeeding, like using a pacifier, keeps babies from sleeping too deeply. "Breast milk has anti-inflammatory effects as well, and this may be protective," Dr. Hauck says.

When a baby who has died from SIDS is discovered, her temperature is often extremely high. Cases in the U.S. also peak in winter, when infants are likely to be overdressed. This has led scientists to believe that overheating may affect babies' arousal mechanisms. Keep the room around 68?F, a temperature at which you're comfortable when dressed in light clothes Dr. Schmidt advises. Worried she'll be cold? Try a sleep sack, a blanket that zips around her body but leaves her arms and head exposed.

It's also a good idea to turn on a fan. A study at Kaiser Permanente in Oakland, California, found that babies who slept in a room with a fan had more than a 70 percent reduced risk of SIDS. It's likely that the airflow keeps carbon dioxide from building up around a baby's face, but a fan also keeps the room cooler, says study coauthor De-Kun Li, M.D., Ph.D.

Studies have shown that unless your baby has a diagnosed cardiac or respiratory illness, using an electronic breathing monitor that sounds an alarm if your baby stops breathing doesn't help -- and it may give you a misguided sense of security. The false alarms will only make you anxious, warns Dr. Schmidt. Devices marketed to reduce carbon-dioxide rebreathing, such as crib mattresses with built-in fans, are also not proven to be effective. And avoid wedge-shaped sleep positioners that claim to keep your baby face up. "He can slide off and suffocate against it," says Dr. Schmidt.

Tragically, 20 percent of SIDS deaths occur in day care or when a baby is being watched by someone other than his parents. That's why it's crucial that his caregivers take safe-sleep measures. In fact, a baby who usually sleeps on his back and is suddenly put on his abdomen is at an even higher risk of SIDS, Dr. Keenan says. "These 'unaccustomed tummy sleepers' simply can't handle the higher level of carbon dioxide they're exposed to in this position," he explains. Make sure that anyone who cares for your baby, even just once, follows the rules.

The cause of SIDS has long been a mystery, but researchers at Children's Hospital Boston are unraveling the clues. In the past few years, they've discovered that many SIDS victims have a defect in the part of the brain that controls the chemical serotonin. (Yes, the same serotonin that regulates mood.) In a healthy baby, it helps coordinate breathing, keeps temperature steady, and sends out a wake-up alert when it detects trouble. Babies at risk of SIDS have too few serotonin receptors and too little of a protein that controls the chemical's level in the brain, explains David Paterson, Ph.D., associate director of the hospital's Laboratory for SIDS Research. As the baby grows, it can overcome these problems, which explains why SIDS is no longer a danger after age 1. Dr. Paterson and his colleagues are trying to find a way to detect which infants are born with this defect and, ultimately, how to cure it.

Originally published in the January 2010 issue of Parents magazine.