There has been a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed down for sleep in a nonprone position. Although the SIDS rate continues to fall, some of the recent decrease of the last several years may be a result of coding shifts to other causes of unexpected infant deaths. Since the AAP published its last statement on SIDS in 2000, several issues have become relevant, including the significant risk of side sleeping position; the AAP no longer recognizes side sleeping as a reasonable alternative to fully supine sleeping. The AAP also stresses the need to avoid redundant soft bedding and soft objects in the infant's sleeping environment, the hazards of adults sleeping with an infant in the same bed, the SIDS risk reduction associated with having infants sleep in the same room as adults and with using pacifiers at the time of sleep, the importance of educating secondary caregivers and neonatology practitioners on the importance of “back to sleep,” and strategies to reduce the incidence of positional plagiocephaly associated with supine positioning. This statement reviews the evidence associated with these and other SIDS-related issues and proposes new recommendations for further reducing SIDS risk.
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November 2005
Comments
Concerns about routine pacifier recommendation
Dear Editor, We are writing in regards to the recent update from the AAP Taskforce on SIDS in the November 2005 issue of Pediatrics.1 We are concerned about the inclusion of a recommendation for routine pacifier use within an AAP policy statement without having further investigating theories behind the potential protective effects and exploring possible negative outcomes of such a broad recommendation.
This recommendation was based primarily on results of a meta-analysis that found a higher risk of SIDS in the babies who did not use a pacifier during the sleep period when they died.2 The authors conclude “The results of our meta-analysis show a strong correlation between giving an infant a pacifier and reducing his or her risk of dying from SIDS”. There were seven studies in this meta-analysis.3-9 One study included infants that did not have an autopsy, which is required for the diagnosis of SIDS according to the AAP Taskforce’s own literature review criteria.2 The large multinational European study of 745 SIDS infants (Carpenter) included infants separately reported in two other cited studies (L’Hoir and Fleming).3,4,6 Risk predictions from multivariate analyses depend upon the variables included. Several of the cited studies did not include important or potential risk predictors such as; co - sleeping, safe sleeping, breastfeeding duration or whether infant was breastfed at the time of death. Since many of the mechanisms hypothesized for pacifier’s risk reduction should also apply to breastfeeding or thumb sucking at the time of SIDS, these variables should have been included in the analyses.
Terms used in the meta-analysis to distinguish routine habitual pacifier use versus the use during the sleep interval when the SIDS baby died are confusing (“usual” and “last sleep” respectively). The Taskforce statement refers to the “last sleep” term without defining it and the figure shown contains only “last sleep” risk information. It is important to distinguish between the two, because their potential protective effects may not be the same. One study found that the routine use of a pacifier actually increased the risk of SIDS.8 They found that the infants who routinely used a pacifier but didn't on the night they died were at the highest risk. Two of the studies didn’t even look at routine use, just “last sleep” use.5,9 Another study showed no difference in routine use between SIDS infants and controls, but confirmed that “last sleep” use may be protective.4 The largest study found that it was only when a routinely used pacifier was also used in the “last sleep” that the protection was significant.6 Despite this, the Taskforce’s recommendation is to offer a pacifier at nap and bedtime, which is promoting routine habitual use. Do we really have enough information to know that this is safe? If we encourage pacifier use in all infants, is it possible that those infants who do not always use their pacifier are at higher risk of SIDS? Should we warn those parents who routinely use pacifiers to be careful to always use it?
There will be a cost to recommending the use of an artificial oral device for non-nutritive sucking even if physicians are able to take the time to explain its use. As the Taskforce recognized, there are few well-designed, randomized studies examining the effect of pacifier use on breastfeeding measures. A recent large international study suggested that pacifier use negatively impacted breastfeeding and that there was a dose response effect. 10 There is evidence that pacifier use is associated with an increased incidence of oral yeast infections, gastrointestinal infections, malocclusion in deciduous dentition, and otitis media.11,12,13 Pacifiers may also be associated with an increased risk of provoking latex allergy symptoms.14,15 In addition, since the U.S. Consumer Product Safety Commission outlined regulations for pacifier manufacture and packaging in 1977, there have been nearly 40 recalls of different pacifier brands; most of which were occurred once after-market testing determined that these pacifiers detached and separated into small pieces posing choking hazards. Although asphyxia from aspiration of a pacifier part is an extremely rare event, this and the other aforementioned problems may reach clinical significance once pacifier use is more frequent.16 No research has been documented on how occasional or habitual pacifier use can impact speech, language, social development or child behavior.
An unfortunate outcome is that we have already seen an increase in pacifiers brought in to our newborn unit, even though the Taskforce recommended not initiating pacifier use for the first 4 weeks in breastfeeding babies. It will be important to track changes in breastfeeding rates and complications related to increased pacifier use following the new AAP recommendations.
As pediatricians, it is our responsibility to provide families with anticipatory guidance that is safe, evidence-based, developmentally and culturally appropriate. Currently 14% of parents in the US are not placing their child supine to sleep. This figure may be even higher in certain minority groups. This most important message has not been accepted by all parents. A recent article in the New York Times (“A quiet revolt against the rules on SIDS”) reports the same trend.17 We feel that the taskforce missed the opportunity to further strengthen the “Back to Sleep” message and provide risk-based recommendations by branching out into less well-founded territory.
1. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleep environment, and new variables to consider in reducing risk. Pediatrics. 2005;116:1245-1255 2. Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics. 2005;116:e716 3. L’Hoir MP, Engleberts AC, van Well GTJ, Damste PH, Idema NK, Westers P, Mellenbergh GJ, Wolters WHG, Huber J. Dummy use, thumb sucking, mouth breathing and cot death. Eur J Pediatr. 1999;158:896-901 4. Fleming PJ, Blair PS, Pollard K, et al. Pacifier use and sudden infant death syndrome: results from the CESDI/SUDI case control study. Arch Dis Child. 1999;81:112-116 5. Tappan D, Brooke H, Ecob R, Gibson A. Used infant mattresses and sudden infant death syndrome in Scotland: case-control study. BMJ. 2002;325:1007-1009 6. Carpenter RG, Irgens LM, Blair PS, England PD, Fleming P, Huber J, Jorch G, Schreuder P. Sudden unexplained infant death in 20 regions in Europe: case control study. Lancet. 2004;363:185-191 7. Mitchell EA, Taylor BJ, Ford RPK, Stewart AW, Becroft DMO, Thompson JMD, Scragg R, Hassall IB, Barry DMJ, Allen EM, Roberts AP. Dummies and the sudden infant death syndrome. Arch Dis Child. 1993;68:501-504 8. McGarvey C, McDonnell M, Chong A, O’Regan M, Matthews T. Factors relating to the infant’s last sleep environment in sudden infant death syndrome in the Republic of Ireland. Arch Dis Child. 2003;88:1058-1064 9. Hauck FR, Herman SM, Donovan M, Iyasu S, Merrick Moore C, Donoghue E, Kirschner, RH, Willinger M. Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago infant mortality study. Pediatrics. 2003;111:1207-1214 10. Nelson EAS, Yu LM, Williams S, et al. International child care practices study: breastfeeding and pacifier use. J Human Lactation. 1995;21:289-295 11. Darwazeh AM, al Bashir, A. Oral candidal flora in healthy infants. Journal of oral pathology & medicine. 1995;24:361-364 12. North K, Fleming P, Golding J. Pacifier use and morbidity in the first six months of life. Pediatrics. 1999;103:e34 13. Niemela M, Uhari M, Mottonen M. A pacifier increases the risk of recurrent acute otitis media in children in day care centers. Pediatrics. 1995;96:884-888 14. Freishtat RJ, Goepp JG. Episodic stridor with latex nipple use in a 2 - month-old infant. Annals of emergency medicine. 2002;39:441-443 15. Kimata H. Latex allergy in infants younger than 1 year. Clinical and experimental allergy. 2004;34:1910-1915 16. Wehner F, Martin DD, Wehner HD. Asphyxia due to pacifiers-case report and review of the literature. Forensic science international. 2004;141:73- 75 17. A quiet revolt against the rules on SIDS. The New York Times. Oct 18,2005
Conflict of Interest:
None declared