EXPERT ANALYSIS FROM AAP 16

SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – At sleep time, infants should share their parents’ bedroom on a separate sleep surface without bed sharing, should be placed on their backs on a firm surface, and should have a sleep area free of blankets and soft objects, according to updated guidelines from the American Academy of Pediatrics aimed at reducing the risk of sudden infant death syndrome (SIDS) and other sleep-related infant deaths.

Drafted by a multidisciplinary task force, the set of 19 evidence-based recommendations largely reiterate messages that the academy has promoted for years such as “back to sleep for every sleep,” according to task force member Fern R. Hauck, MD , the Spencer P. Bass, MD, Twenty-First Century Professor of Family Medicine at the University of Virginia, Charlottesville. They were unveiled in a press briefing at the academy’s annual meeting and simultaneously published ( Pediatrics. 2016;138[5]:e20162938 ).

Progress, but still a ways to go

Education campaigns that convey these and related messages to new parents and other caregivers have led to a more than halving of the rate of SIDS in recent decades. Yet, 3,500 infants are still lost each year to this syndrome and other sleep-related causes of infant death, such as unintentional suffocation, collectively called sudden unexpected infant death (SUID).

The updated recommendations continue to target known risk factors for these deaths, such as inadvertent airway occlusion (they further advise that car seats, strollers, and infant carriers should not be used as regular sleep areas) and overheating (they advise that parents not excessively bundle their infants and to monitor them for signs such as sweating).

New is a recommendation for skin-to-skin care for at least the first hour of life for healthy newborns, as soon as the mother is alert enough to respond to her infant, according to Dr. Hauck. The aims here are to optimize neurodevelopment and promote temperature regulation.

There is no evidence that swaddling reduces the risk of SIDS, but parents can still use this technique if they wish as long as infants are placed on their back and it is discontinued as soon as they start to show signs of rolling over, she said. Evidence is also lacking for new technologies marketed as protective, for example, crib mattresses designed to reduce re-breathing of carbon dioxide should an infant become prone.

Sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%, according to several studies. Bed sharing is not recommended because of the risk of suffocation, strangulation, and entrapment, the policy states.

The updated recommendations should be followed for every sleep and by every caregiver, until the child reaches 1 year of age, Dr. Hauck stressed. “This includes nap time and bedtime sleep, at home, in day care, or in any other locations where the baby is sleeping.”

“We feel that these messages need to start while the mom’s pregnant because some of the decisions that are made that are not always the best decisions, when the mother is exhausted, can occur spur of the moment,” she added. “As pediatricians, you can set up a prebirth visit to start talking about this, and obstetricians should be doing more as well to bring this up during their prenatal visits.”

Other recommendations include offering a pacifier at nap time and bedtime; avoiding smoke exposure during pregnancy and after birth; and avoiding alcohol and illicit drug use during pregnancy and after birth.

Breastfeeding issues

Although breastfeeding protects against SIDS, it can pose some problems for safe sleep practices, acknowledged Lori B. Feldman-Winter, MD, a liaison from the AAP section on breastfeeding to the task force, as well as head of the division of adolescent medicine and professor of pediatrics at Cooper University Health Care in Camden, N.J.

“Given that mothers may fall asleep in bed with their breastfeeding newborns, and many newborns that have died in bed-sharing situations are discovered with their heads covered by bedding, it’s recommended that the bed be modified to remove pillows, soft bedding, loose sheets, blankets, or other bedding, and other objects that may lead to suffocation or overheating,” she explained. “Infants who are brought into bed for feeding should be returned to a separate sleep surface for sleeping.”

Bedside sleepers (also called sidecar sleepers) that attach to the parents’ bed may help facilitate the dual aims of breastfeeding and safe sleep, but they have not been formally studied to assess their impact on SIDS risk.

Raising awareness

“As a father and pediatrician, I want parents to know that their baby is safest following the AAP safe sleep recommendations, and spreading this message has become my life’s mission,” said Dr. Samuel P. Hanke, a pediatric cardiologist at the University of Cincinnati, who knows the heartbreak of SIDS firsthand.

He and his wife lost their son, Charlie, to SIDS, prompting them to found Charlie’s Kids Foundation to promote safe sleep practices. The foundation has published the first children’s bedtime book dedicated to safe sleep, “ Sleep Baby Safe and Snug ” (Cincinnati, Ohio: Blue Manatee Press, 2013), which is based on the AAP recommendations.

“We know practicing safe sleep is hard. We have to be vigilant. We need to start adopting a mentality that safe sleep is not negotiable,” Dr. Hanke asserted. “We cannot emphasize enough that practicing safe sleep for every sleep is as important as buckling your child into a car seat for every drive. And just like car seats, this change won’t occur overnight.”

Federal commitment

Since the 1970s, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) in Bethesda, Md., has been supporting and performing much of the research on which the updated recommendations are based. This research continues to help identify areas where greater efforts are needed, according to acting director Catherine Y. Spong, MD.

“Through our research, we have learned that caregivers are more likely to follow recommendations if they come from multiple sources, particularly from physicians,” she noted. Yet, “many women report that they are not getting advice from their physicians about the ways to reduce the risk of SIDS.”

NICHD also conducts and collaborates on related education campaigns, such as Safe to Sleep , to disseminate messages such as those in the updated AAP recommendations as widely as possible.

“I encourage all physicians, pediatricians, nurses, and other health care and child care providers to lend their authoritative voices to the Safe to Sleep effort,” Dr. Spong said. “Join us all in sharing safe infant sleep recommendations and in supporting parents and caregivers to make informed decisions that will help keep their baby safe during sleep.”

A closer look at setting

Published in conjunction with the guidelines is a study on risk factors that looked at the role of the setting in which sleep-related infant deaths occur ( Pediatrics. 2016 Oct 24:e20161124 ).

The analysis of nearly 12,000 such deaths found that, relative to counterparts who died in their home, infants who died outside of their home were more likely to be in a stroller or car seat at the time (adjusted odds ratio, 2.6) and in other locations, such as on the floor or a futon (1.9), and to have been placed prone (1.1). They were less likely to have been sharing a bed (0.7).

The groups did not differ in terms of whether the infant was sleeping in an adult bed or on a person, on a couch or chair, or with any objects in their sleep environment.

“Caregivers should be educated on the importance of placing infants to sleep supine in cribs/bassinets to protect against sleep-related deaths, both in and out of the home,” conclude the investigators, one of whom disclosed serving as a paid expert witness in cases of sleep-related infant death.

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