To test the hypothesis that the profile of sudden infant death syndrome (SIDS) changed after the Back-to-Sleep (BTS) campaign initiation, document prevalence and patterns of multiple risks, and determine the age profile of risk factors.
The San Diego SIDS/Sudden Unexplained Death in Childhood Research Project recorded risk factors for 568 SIDS deaths from 1991 to 2008 based upon standardized death scene investigations and autopsies. Risks were divided into intrinsic (eg, male gender) and extrinsic (eg, prone sleep).
Between 1991–1993 and 1996–2008, the percentage of SIDS infants found prone decreased from 84.0% to 48.5% (P < .001), bed-sharing increased from 19.2% to 37.9% (P < .001), especially among infants <2 months (29.0% vs 63.8%), prematurity rate increased from 20.0% to 29.0% (P = .05), whereas symptoms of upper respiratory tract infection decreased from 46.6% to 24.8% (P < .001). Ninety-nine percent of SIDS infants had at least 1 risk factor, 57% had at least 2 extrinsic and 1 intrinsic risk factor, and only 5% had no extrinsic risk. The average number of risks per SIDS infant did not change after initiation of the BTS campaign.
SIDS infants in the BTS era show more variation in risk factors. There was a consistently high prevalence of both intrinsic and especially extrinsic risks both before and during the Back-to-Sleep era. Risk reduction campaigns emphasizing the importance of avoiding multiple and simultaneous SIDS risks are essential to prevent SIDS, including among infants who may already be vulnerable.
Comments
Bed-sharing is bad-sharing
We read with interest the article by Trachtenberg et al(1) on the modification of risk factors for sudden infant death syndrome (SIDS) after the initiation of the US Back-to-Sleep (BTS) campaign. Their study confirms an impressive decline of SIDS rate in San Diego County (from 65 to 25 cases/year) allowed by the full establishment of the BTS principle. The results of the analysis of risk factors in SIDS infants prompted us to some considerations. Bed-sharing is the most prevalent modifiable risk factor among SIDS infants in the BTS era, as present in almost 40% of cases. Moreover, 45% of SIDS infants died in adult beds. Despite the American Academy of Pediatrics advises against bed-sharing,(2) this practice remains worryingly popular.(3,4) Bed-sharing is generally associated with infant feeding on demand. Unfortunately, the impact of different habits of feeding has not been investigated by the Authors. Breastfeeding on demand, however, a practice currently recommended by experts and pediatric society, is naturally associated with nocturnal feeding and bed-sharing. Both the administration of nocturnal feeds and bed-sharing are commonly maintained when the infant will shift from breast to bottle feeding. As a consequence, it appears that the strong association between bed-sharing and SIDS risk may be an additional argument against a large consensus favourishing the practice of breastfeeding on demand. Substantial considerations, derived from physiological and behavioral observations,(5) are in agreement.
References
1. Trachtenberg FL, Haas EA, Kinney HC, Stanley C, Krous HF. Risk factor changes for sudden infant death syndrome after initiation of back- to-sleep campaign. Pediatrics. 2012;129 (4):630-638.
2. 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 sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116 (5):1245- 1255.
3. Hauck FR, Signore C, Fein SB, Raju TN. Infant sleeping arrangements and practices during the first year of life. Pediatrics. 2008;122 Suppl 2:S113-120.
4. Blair PS, Heron J, Fleming PJ. Relationship between bed sharing and breastfeeding: longitudinal, population-based analysis. Pediatrics. 2010;126(5): 1119-1126.
5. Walshaw CA. Are we getting the best from breastfeeding? Acta Paediatr. 2010;99(9):1292-1297.
Conflict of Interest:
None declared