SEVEN STEPS TO REDUCE THE RISK OF SIDS

In light of new research, SIDS should no longer be considered a mysterious cloud that hangs over cribs and causes babies to take their last breath. Armed with a new understanding of SIDS, parents can at least do something to reduce their worry and reduce the risk. SIDS seems to be a combination of many factors: immature development of cardiorespiratory control mechanisms, defective arousability from sleep in response to breathing difficulties, medical conditions that compromise breathing, and unsafe sleeping practices. Therefore, this SIDS risk-reduction program is designed to help these factors:

The seven SIDS risk-lowering steps:

1. Give your baby a healthy womb environment.
2. Do not allow smoke around your baby – pre or postnatally.
3. Put your baby to sleep on his back or side, not on his stomach.
4. Breastfeed your baby.
5. Give your baby a safe sleeping environment.
6. Avoid overheating your baby during sleep.
7. Practice the "high-touch" style of attachment parenting.

Medical and family circumstances may prevent you from doing all seven of these risk-lowering practices, but do the best you can.

STEP ONE: GIVE YOUR BABY A HEALTHY WOMB ENVIRONMENT

Prematurity and low birthweight constitute two of the highest risk factors for SIDS. The increased risk and the fact that premature infants show more episodes of irregular breathing and stop-breathing (called apnea) is possibly because the respiratory control center in these infants is immature. Although the SIDS risk in premature babies is higher, the good news is that over 99 percent of premature infants don't die of SIDS and that mothers of premature babies who take good prenatal care of themselves and practice the rest of the SIDS prevention tips mentioned in this section can reduce the risk of losing their baby to SIDS. While prematurity is not always preventable, here are three ways you can increase your chances of giving your baby the best prenatal start.

1. GET GOOD PRENATAL CARE
Babies whose mothers get the least prenatal care have the highest risk of preterm birth, and therefore SIDS. Just as well-baby care is important after birth, periodic checkups during pregnancy give your in-the-womb baby the best chance of a healthy start. During prenatal checkups your healthcare provider will monitor your health, counsel you on nutrition and exercise, check the growth and health of your baby, and offer you advice on creating the healthiest womb environment for your baby.

2. FEED YOUR BABY RIGHT BY FEEDING YOURSELF RIGHT
Good nutrition during pregnancy lowers the risk of SIDS in two ways: it lowers the risk of prematurity, and it prevents anemia. With anemia, there are fewer red blood cells to carry oxygen to the baby. Anything that lowers oxygen to the baby increases the risk of SIDS, probably by harming the development of the baby's respiratory control system in the brain. The risk of SIDS is compounded in an anemic mother who also smokes.

3. GROW YOUR BABY IN A SMOKE-FREE, DRUG-FREE WOMB
Taking illegal drugs and smoking while pregnant increase the risk of SIDS in two ways: First, these harmful habits increase the chances of your baby being born prematurely. Second, these pollutants, primarily by decreasing oxygen supply to developing tissues, can harm baby's brain, specifically the respiratory control center that regulates breathing. The risk of SIDS increases eight times in infants of substance-abusing mothers (abbreviated as ISAM) and as much as twenty times in infants of opiate abusing mothers.

STEP TWO: THANK YOU FOR NOT SMOKING

One of the most significant risk factors for SIDS – and one that mothers can do something about – is smoking when their babies are in the womb or in the same room. Studies show that exposure to cigarette smoking at least doubles the risk of SIDS. The risk of SIDS increases proportionally to the number of cigarettes mother smokes. Heavy maternal smoking (more than twenty cigarettes a day) increases the SIDS risk fivefold. If mother and father smoke, the risk of baby dying of SIDS doubles, compared with maternal smoking alone. Anything that retards infant development, interferes with infant breathing, or lessens maternal sensitivity increases the risk of SIDS.

STEP THREE: PUT BABIES TO SLEEP ON THEIR BACKS, NOT THEIR TUMMIES

Between 1989 and 1993 SIDS researchers in cooperation with the British government launched a "Back to Sleep" campaign, advising parents to put their babies to sleep on their backs rather than their stomachs. A few years after this risk-reduction campaign was launched in England, SIDS rates plummeted throughout the United Kingdom by as much as seventy percent. A similar "Back to Sleep" SIDS-reduction campaign occurred in New Zealand and Australia followed by a fifty percent decrease in national SIDS rates in these two countries. The Netherlands, Sweden, Denmark, Germany, and Ireland saw a similar decrease in SIDS rates following "Back to Sleep" campaigns in these countries. Eight countries doing similar risk-reduction campaigns and all getting similar results. This had to be more than a coincidence. These findings were a breakthrough in SIDS-prevention research – and in SIDS-prevention attitude. Instead of the previous belief – that SIDS was a mysterious and hopeless tragedy – the changing sleep-position advice was finally something practical that professionals could agree upon and parents could do.

In 1994, the U.S. Public Health Service organized a national "Back to Sleep" campaign, and it paid off. In the past few years, SIDS rates have dropped around 30 to 40 percent in the United States.

HOW BACKSLEEPING HELPS
Why back-sleeping lowers the risk of SIDS is not completely known, yet here are some possibilities.

1. Back-sleeping babies awaken easier. Arousability from sleep in response to a life-threatening event is a healthy, protective mechanism and one that is thought to be diminished in infants at risk of SIDS. Back-sleepers arouse from sleep more easily and sleep less deeply than tummy-sleepers. Mothers have observed, and research has confirmed, that infants sleep more deeply on their tummies. Yet, sleeping more deeply does not mean sleeping more safely.

2. Back-sleeping babies have a lower chance of getting overheated. Overheating, possibly by interfering with the central nervous system control of breathing, is another risk factor for SIDS. Lying on your back leaves your face and internal organs exposed so that they can radiate heat more readily than when sleeping on your tummy. (That's why when your cold, you probably curl up on your front or side to conserve heat.) Also, front- sleeping babies are more likely to slip down under the covers than those sleeping on their backs, another factor that may contribute to overheating, since a baby's prime avenue for heat loss is through their head and face. In the back position, even the baby who slips down underneath the covers would be more likely to throw them off. The contact of a cover with the face is more likely to be noticed and protested by a back-sleeping baby than the contact of the cover with the back of the head would be in a front-sleeping baby.

3. Back-sleeping babies breathe more oxygen. When sleeping face down, a baby may press her head into the mattress or wiggle her face against a soft object. This can form a pocket of air around her face, leaving her to rebreathe her own exhaled air, which has diminished oxygen.

4. Back-sleeping babies are less likely to suffocate. Conventional wisdom has always taught that suffocation is a rare cause of SIDS. Yes, babies are sturdy little persons who, even as newborns, are able to lift their heads and keep their noses clear to breath. The often quoted "study" that even tiny infants have the ability to lift their heads and wiggle their noses clear of obstruction was not really a scientific study; it was more of an observation. Yet, new insights cast doubt on the rareness of suffocation. A growing belief among SIDS researchers is that many babies presumably diagnosed as SIDS may have in reality died from suffocation on soft surfaces

While no one knows exactly why the front-sleeping position is linked to SIDS, the overwhelming number of studies that all come to the same conclusion – back sleeping decreases the risk of SIDS – make it clear that for healthy infants, back-sleeping is safer. Parents should note that there are some medical conditions, such as gastroesophageal reflux or structural abnormalities of the jawbones and airway, in which it is safer for babies to sleep on their tummies rather than on their backs. Be sure to check with your doctor to see whether or not your baby has a medical reason to sleep on his tummy rather than his back.

BABIES WHO SHOULD SLEEP TUMMY DOWN
Be sure to check with your doctor to see if your baby has any medical conditions that necessitate front sleeping. Babies who should sleep prone are the following: • Premature babies with respiratory problems still in the hospital; sleeping on the tummy increases breathing efficiency in prematures with compromised breathing, but not necessarily when their lungs are normal• Babies with small jawbones or other structural abnormalities that may compromise the airway when sleeping on their fronts• Babies who have mucous-producing respiratory infections or profuse drooling associated with teething – if so advised by your doctor• Babies who are extremely restless and settle poorly unless sleeping prone• Babies who suffer from gastroesophageal reflux (GER).

STEP FOUR: BREASTFEED YOUR BABY

Anything that improves the overall health of a baby and sensitivity of its mother should lower the risk of SIDS. In both of these categories, breastfeeding shines. Here's how.

BREASTFEEDING REDUCES THE RISK OF SIDS – THE EVIDENCE
New research is confirming what I have long suspected: SIDS is lower in breastfed infants. A study from New Zealand shows that SIDS was three times higher in babies who were not breastfed. The risk factor for SIDS from not breastfeeding was even higher than from maternal smoking. When I visited New Zealand in 1985 to speak on the subject of SIDS, I spoke with Dr. Shirley Tonkin, a prominent SIDS researcher in that country. She shared with me her belief that SIDS does occur less often in breastfeeding infants. Of the eighty- six babies she studied from 1970 to 1972, all of whom had died of SIDS, only three were breastfed; and this occurred in a country with a particularly high incidence of breastfeeding. Even the large collaborative study of nearly eight hundred SIDS infants performed by the U.S. National Institute of Child Health and Human Development (NICHD) found that SIDS babies were breastfed significantly less often, and if breastfed were weaned earlier. It is interesting that this study did not separate out partial from total breastfeeding, so that a mother who breastfed in any amount was included as a "yes" in the breastfeeding statistics. Undoubtedly, many of these "yes" mothers were combining breastfeeding with formula feeding. I believe that total breastfeeding provides even greater protection against SIDS.

The authors of the NICHD study concluded that SIDS rates were higher in formula-fed infants even after correcting for other factors, such as socioeconomic status. They also concluded that breastfeeding was protective against respiratory and gastrointestinal infections, two factors that have been implicated in increasing the risk of SIDS. SIDS infants between two and eleven months of age showed increased upper respiratory infections within two weeks prior to death if they had never been breastfed. Another important finding in this study was that 74 percent of Caucasian and 86 percent of African-American infants who died of SIDS were mostly, or only, fed artificial baby milk (formula). The researchers in this study concluded that infants who were never breastfed had two to three times a greater risk of SIDS.

Even though statisticians have tried to separate the effects of breastfeeding from other maternal factors, (and some researchers, such as those performing the NICHD study, "corrected" for these factors) a definite separation of factors is nearly impossible. A Copenhagen study showed that SIDS infants were more likely to be formula-fed or breastfed for a shorter period of time than other infants. These authors concluded, however, that differences in breastfeeding between SIDS cases and controls merely reflected other features that were associated with SIDS, particularly socioeconomic factors and maternal smoking. But recent data from one of the largest and most reputable SIDS studies, the previously cited Avon Project in England, shows that SIDS is lower in breastfeeding infants, even after correcting for educational and other socioeconomic factors. According to Dr. Fleming, the more the Avon study progressed, the more it became evident that the incidence of SIDS is lower among infants of breastfeeding mothers. They concluded that breastfeeding is second only to back position as a protective factor against SIDS.

The Avon researchers feel that one of the reasons SIDS was lower in breastfeeding infants was that breastfeeding mothers, due to their higher educational level, were more likely to be informed about, and follow, the advice of the overall SIDS reduction campaign. A breastfeeding mother is usually one who takes good prenatal care of herself, and therefore her baby; she is unlikely to smoke prenatally or postnatally, and if she does, she is more likely to quit when pregnant; and she tends to sleep with her baby and wear her baby a lot in a baby sling—all factors which I believe also lower the risk of SIDS. Because there are so many other parenting factors that play a part in affecting the SIDS rate, let's rely on our innate common sense, as did the writers of the Declaration of Independence when they drafted the words "We hold these Truths to be self-evident." The authors did not say "And we are going to try these Truths out until they can be proven by a double-blind controlled study and replicated by three different researchers." Breastfeeding matters. Experiments, experience, and common sense tell us that.

STEP FIVE: GIVE YOUR BABY A SAFE SLEEPING ENVIRONMENT

Because SIDS occurs during sleep, most of the SIDS prevention program focuses on providing a safe sleeping environment.

STEP SIX: KEEP BABY'S BEDROOM TEMPERATURE RIGHT

Keep your baby comfortably warm, but not too warm. Overbundling, and consequently overheating, has been shown to increase the risk of SIDS. Overheating may disrupt the normal neurological control of sleep and breathing. The respiratory control center in the brain is affected by abnormal changes in temperature, and SIDS researchers believe that overheating may cause respiratory control centers in some babies to fail.

FIVE WAYS TO KEEP BABY'S TEMPERATURE RIGHT
1. Uncover baby's head. Because the head and face are an infant's main source of heat release, it's important not to cover your baby's head. The environment around baby's head seems to be the most important for maintaining a safe body temperature. Baby's head is responsible for around 40 percent of the body's heat production and as much as 85 percent of the body's heat loss. This is why hospital nurses cover the head of a newly born baby, especially a premature infant. Note, however, that they remove the "ski cap" as soon as the preterm baby gains weight and has a stable body temperature. Covering the head of a newborn is sometimes healthful, but covering the head of a three-month-old may be harmful. Covering the head of an infant may cause a rise in brain temperature without a noticeable rise in body temperature, and the baby's respiratory control center may be affected by this overheating.

2. Put baby to sleep on side or back. When baby sleeps on her stomach (prone) with her cheek and abdominal organs against the bedding, these prime areas of heat release are covered, thus conserving heat. So the phrase "prone to get hot" appears to have a physiological basis. When a baby is sleeping on her side, more heat-releasing areas are exposed, and sleeping on the back releases the most heat. Also, a prone-sleeping baby is more likely to slide her head under the covers and not protest having her head covered; the baby sleeping on her back or side is likely to protest if her head becomes covered, because her face is more sensitive than the back of the head.

3. Don't bundle up a sick baby. Parents often tend to overwrap sick babies, as if extra bundling were a part of extra nurturing. This is one of the instances where social customs and baby's basic physiology don't agree. Sick babies are likely to have a fever and when you cover a hot body, it becomes hotter. A mother may feel, "If I don't bundle her well she'll catch cold." Baby already has a cold. Studies show that in the first three months of life a baby's metabolic rate either decreases or it does not change during a respiratory infection. For infants older than three months of age, the metabolic rate tends to increase with an infection. Thus infants older than three months of age (the age at highest risk of SIDS) respond to upper respiratory tract infections by conserving heat. This biologic quirk may further increase the baby's risk of being overheated when sick, and overwrapping a baby with a respiratory infection piles one risk factor on top of another. Observers have also suggested that, paradoxically, the infant's sleeping room may be warmer in the winter time than it is in the summer, so that the risk of overheating is greater in the winter; researchers have also observed that babies dying of SIDS were more likely to be overwrapped than appropriately wrapped if they had been ill.

Dress a sick baby as you would yourself. When it's warm outside or your body is hot, you dress more lightly. During an illness, parents tend to overwrap babies when it's cold outside, even though the temperature of the baby's room is comfortably toasty. Be especially sensible about bundling sick babies for sleep. Don't overcompensate by overinsulating when it's cold outside.

4. Don't overheat the room where baby sleeps. Central heating may not be the most comfortable, or the safest, for sleeping babies. SIDS death-scene investigators sometimes notice an overheated room where the central heating has been left on all night.

As a general guide, a sleeping environment temperature of around 20 degrees celsius is preferable. Preterm infants or newborns weighing less than eight pounds may require a temperature a few degrees higher. Healthy, term newborns weighing more than eight pounds usually have sufficient body fat and mature enough temperature-regulating mechanisms to allow them to sleep comfortably in a room temperature that you find comfortable.

Recent research has also supported what grandmothers have always claimed—that if babies get cold, they catch a cold. The cooler the sleeping environment, the more likely babies are to get respiratory infections. Yet babies who are overheated have an increased risk of SIDS. In this study, the fewest respiratory infections occurred in bedroom temperatures around 68 degrees Fahrenheit (20 degrees Celsius)

Consider humidity levels, too. Besides insuring a safe sleeping temperature for baby, pay attention to the relative humidity in baby's room. Best humidity is around 60 to 70 percent. Less humidity may dry out a baby's breathing passages, making his nose stuffy and thickening the mucous in his airways. High humidity, on the other hand, favors the growth of respiratory allergens and may peel off the paint or wallpaper in older houses. As you might expect, most central heating is not friendly to breathing passages, because the air is either too dry or full of allergens. We have come up with a healthier alternative: Turn the central heating down or off during the night and turn on a warm-mist vaporizer in baby's room. (Because steam kills bacteria, it is healthier than cool mist.) This inexpensive steam producer (available at pharmacies and department stores for around ten dollars at this writing) provides two benefits: It increases the humidity in the room and it warms the room. From high school physics you know that when steam condenses, it releases heat. That's how the vaporizer warms the room. As a precaution, don't let the humidity get so high or the room so hot that the paint or wallpaper begins to peel off, or mold begins to grow.

Be especially vigilant about bedroom temperature when traveling. Electric baseboard heaters, such as those typically found in ski chalets and motels, have a particularly drying effect on the air. It's worth taking along a warm-mist vaporizer or buying one locally. Except in extremely cold weather, a warm-mist vaporizer will keep a draftless motel-size bedroom comfortably and safely warm with the heater turned off.

5. Dress baby for safe and comfortable sleeping. Consider three things when dressing your baby for sleep: comfort, warmth, and safety. What style and fabric are most comfortable to your baby is a matter of observation. It won't take you long to figure out whether your baby sleeps better in footed sleepers or loose, tie-at-the-bottom "sacques." Learning how to dress your baby appropriately is really only a matter of common sense and getting a feel for your individual baby. Also, an appropriately clothed baby is more likely to reward you with a longer night's sleep. Overheated infants tend to be more restless. As a general guide, dress and cover your infant in as much, or as little, clothing and blankets as you would put on yourself. Then, let your hands be a thermostat. Feel your baby's head or the back of her neck. If these areas feel too hot, baby is sweating, or her hair is damp, remove one layer. If baby feels cold, add a layer. In general, it's safer to adjust baby's sleeping temperature by changing clothes than by piling on more blankets. Baby's hands and feet are not accurate indicators of body temperature, since in most babies, these parts are usually cooler than the rest of the body.

Consider these tips and precautions:

• Sleepers with feet are the most practical. Even if baby kicks off his blankets, you can be sure he has on one layer of warmth. A minor drawback to sleepers is that it's harder to get a good fit in a one-piece garment, but still, they don't need to fit perfectly. Buy them loose, since they are quickly outgrown.
• Most of our babies seemed more comfortable (and had fewer irritating rashes) in cotton sleepwear, which absorbs moisture and "breathes," allowing air to circulate freely. Since cotton sleepwear allows for the release of body heat, it lessens the chance of baby becoming overheated. Flame-retardant cotton sleepwear is now available, yet it may be more difficult to find than cotton sleepers made of polyester.
• Sleepwear should be loose-fitting enough to allow baby to move freely, yet snug enough to stay on.
• Leave baby's head uncovered, unless baby is less than eight pounds and the room is very cold.
• For crib sleepers, use a single, porous blanket. Avoid heavy comforters that don't "breathe." To keep baby from sliding under the covers, tuck the portion of the covers beneath baby's feet in tighter, or place baby so his feet touch the lower end of the crib. Tuck the blanket in snugly beneath each side of the crib mattress; yet don't fit the blanket so tightly as to restrict baby's freedom of movement.
• If you swaddle your baby, swaddle her safely. Experiment with different ways of wrapping your baby at bedtime. In the first couple months, some babies like to "sleep tight," securely swaddled in cotton baby blankets. After the first few months, some infants like to "sleep loose," and settle better in loose coverings that allow them more freedom of movement. Both experience and research have shown that swaddled newborns sleep longer, especially newborns that startle themselves by their random, jerky movements. Swaddling contains these babies. But the recent publicity about overwrapping and overheating increasing the risk of SIDS may scare some parents away from the time-honored custom of swaddling. If your baby seems more comfortable and sleeps better swaddled, then swaddle without worry. Recent studies have shown that safe swaddling does not overheat babies.
  If you swaddle, be sure to place your baby to sleep on his side or back, and leave his head uncovered. If you swaddle your baby "burrito-style" (tucking each arm in the blanket and folding arms across the baby's chest) be sure not to place your baby prone, since he will not have the use of his arms to help him adjust the position of his face against the mattress. After the first month or two, many babies settle better in loose, sacque-like sleepwear that allows them freedom of movement.
• Avoid dangling strings or ties on baby's sleepwear (and your sleepwear as well). Remove any attached objects (decorative buttons, for example, or bows that could come untied) that might cause strangulation or choking.
• If you change baby's sleeping arrangement, change her sleepwear appropriately. For example, if you dress baby for sleeping in a crib in her own room and then take her into your bed after the first waking, consider the increased warmth baby may get sleeping next to you.

While overheating is a risk factor for SIDS, you don't have to become thermal engineers in order to get the temperature of baby's sleeping environment perfect. Babies are sturdy little persons with efficient temperature-regulating systems. If you use common sense and the above sleep-dressing suggestions, there is little risk of overinsulating your baby. In fact, under laboratory-controlled conditions, studies that compared usual night-dressing practices with ideal wrapping showed that 95 percent of mothers intuitively wrapped their babies correctly, so that their infants were able to maintain normal body temperature while sleeping.

STEP SEVEN: PRACTICE ATTACHMENT PARENTING

The biggest breakthrough in SIDS risk-reduction is the discovery that parenting practices can influence SIDS rates. A dramatic testimony to this change occurred in New Zealand, a country noted for its high SIDS rates and respected for the validity of its SIDS statistics. Following a national SIDS intervention program that discouraged front sleeping and maternal smoking, and encouraged breastfeeding and safe-sleeping practices, SIDS rates plummeted from 6.3 per thousand in 1979 through 1984 to 1.3 per thousand in 1990—a whopping 80 percent reduction.

These groundbreaking findings are a wake-up call to SIDS writers who cling to the conventional thinking that SIDS is a non-preventable tragedy. While the non- preventability of SIDS is still a popular and emotionally correct belief, in light of recent research this concept is no longer scientifically correct. In the final step of this risk-reduction program, I propose that an overall style of caregiving called attachment parenting will further reduce the risk of SIDS.