Sudden Infant Death Syndrome (SIDS)

DEFINITION:

 Sudden infant death syndrome (SIDS) is the sudden and unexplained death of a baby younger than 1 year old.
SIDS is sometimes called crib death. This is because the death may happen when the baby is sleeping in a crib.
SIDS is one of the leading causes of death in babies from ages 1 month to 1 year. It happens most often between
2 and 4 months old. SIDS and other types of sleep-related infant deaths have similar risk factors.
 The term sudden infant death syndrome (SIDS) was first used in 1969 at an international conference on the causes
of sudden death in infants.
 Although the cause is unknown, it appears that SIDS might be associated with defects in the portion of an infant's
brain that controls breathing and arousal from sleep.
 Researchers have discovered some factors that might put babies at extra risk. They've also identified measures
you can take to help protect child from SIDS. Perhaps the most important is placing your baby on his or her back
to sleep.
 Sudden infant death syndrome (SIDS) has caused much grief and anxiety among families for centuries.
 SIDS cannot be explained despite a thorough investigation, including a complete autopsy, examination of the
death scene, and review of the clinical and social history.

CAUSES:

Researchers don't know the exact cause of SIDS. Studies have shown that some babies who die from SIDS have the
following:

 Problems with brain functioning. Some babies have problems with the part of the brain that helps control
breathing and waking during sleep. Babies born with problems in other parts of the brain or body may also be
more likely to die from SIDS.
 Differences in genes. Some genes and the environment may work together to increase the risk for SIDS.
 Problems with heart functioning. Some studies found a link between heart function and SIDS.
 Infection. Some babies who die from SIDS have respiratory infections before death. SIDS happens more often
during the colder months, when respiratory illnesses are more common.

CLINICAL MANIFESTATION:

There are no symptoms or warning signs of SIDS that can be used to prevent it.

The classic presentation of sudden infant death syndrome (SIDS) begins with an infant who is put to bed, typically
after breastfeeding or bottle-feeding. The observations most commonly reported with Brief Resolved Unexplained
Events (BRUEs: formerly Apparent Life-Threatening Events) are as follows:

 Cyanosis. About 50-60% of infants manifests cyanosis.

 Breathing difficulties. Half of the infants who had SIDS experience breathing difficulties before death.
 Abnormal limb movements. Although most of infants are apparently healthy, many parents state that their
babies “were not themselves” in the hours before death.

EPIDEMIOLOGY:

 The current definition of SIDS, developed in 1991, is the sudden death of an infant younger than one year that
remains unexplained after a thorough case investigation, including a complete autopsy, examination of the death
scene, and review of the clinical history.
 Although there has been a dramatic drop in the incidence of deaths during the past 20 years, SIDS is still the
leading cause of death in infants between 7 and 365 days of age.
 Since 1992, SIDS rates have fallen by approximately 58% in the United States.
 In 1992, the incidence of SIDS was 1.2 cases per 1000 live births; in 2004, the incidence had dropped to 0.51.
 In 2004, 2246 deaths were certified as SIDS, accounting for 8% of infant deaths.
 In 2006, the National Center for Health Statistics reported a total of 2323 SIDS deaths nationwide, for an incidence
of 0.54 per 1000 live births.
 In many Asian countries, the current incidence of SIDS is 0.04 per 1000 live births.
 Ninety percent of deaths occur in children younger than 6 months, and 95% of deaths occur in children younger
than 8 months; few occur in children younger than 1 month or older than 8 months.
 Approximately 60-70% of SIDS deaths occur in males.

PATHOPHYSIOLOGY:

 Significant controversy revolves around the pathophysiology of SIDS. Three common autopsy findings include
unclotted blood in the heart, intrathoracic petechiae, and fluid-filled, heavier organs, but these findings provide
little help in understanding the final pathophysiology of SIDS.
  The now discredited “apnea theory” of SIDS was proposed in the 1970s and led to decades of research and the
creation of an apnea monitoring industry. However, in the index case that first prompted investigation of the link
between apnea and SIDS, the mother later confessed to killing all five of her children.
 Current literature supports a triple-risk model, which suggests that SIDS is the final common pathway of three
coinciding factors. This model proposes that an infant must first have an underlying vulnerability and then be
stressed by an exogenous source, such as prone sleeping placement. Finally, for SIDS to occur, the stress must
occur during a critical developmental period, namely in the first year of life. The last two factors in the triple-risk
model have been well researched and defined in the medical literature, but the underlying vulnerability remains
to be identified.
 Current SIDS research topics include investigation of ion channel abnormalities, autonomic nervous system
disturbances, and the effects of nicotine on the developing brain.
o Multiple ion channel disorders that cause QT interval prolongation have been linked to SIDS and may be a
factor in 5 to 10 percent of SIDS cases.
 Although both prolongation of the QT interval (long QT syndrome [LQTS]) and shortening of the QT
interval (short QT syndrome [SQTS]) are associated with increased risk of cardiac arrhythmia and sudden
death, it is QT prolongation that has received the greatest attention in SIDS. Clinically, these
dysrhythmias may present as syncope, seizures, or sudden cardiac death. According to conservative
estimates, 30-35% of infants who subsequently die of SIDS have prolongation of the QT interval in the
first week of life.
o In addition, defects in normal arousal mechanisms have long been theorized to cause SIDS.
o Gene mutations affecting the development of the autonomic nervous system appear in as many as 15
percent of SIDS cases.
 Although multiple hypotheses have been proposed as the pathophysiologic mechanisms responsible for SIDS,
none have been proven.
 Other evidence also implicates hypoxia (acute and chronic) in SIDS; hypoxanthine, a marker of tissue hypoxia, is
elevated in the vitreous humor of patients who die of SIDS as compared with control subjects who die suddenly.
 Alveolar hypoxia stimulates pulmonary vasoconstriction and, eventually, pulmonary vascular smooth muscle
cell hyperplasia.
 Muscularity of the pulmonary vasculature causes pulmonary vasoconstriction, increased right ventricular
afterload, and heart failure with more tissue hypoxia.
 Another significant autopsy finding is pleural petechiae, whose formation reflects acute hypoxia in a
physiologically intact infant.

CONTRIBUTING FACTORS:

A combination of physical and sleep environmental factors can make an infant more vulnerable to SIDS. These factors
vary from child to child.

Physical Factors associated with SIDS include:

 Brain Defects. Some infants are born with problems that make them more likely to die of SIDS. In many of these
babies, the portion of the brain that controls breathing and arousal from sleep hasn't matured enough to work
properly.
 Low Birth Weight. Premature birth or being part of a multiple birth increases the likelihood that a baby's brain
hasn't matured completely, so he or she has less control over such automatic processes as breathing and heart
rate. Low birth weight, whether resulting from premature birth or from other causes, is associated with a
maturational delay in the ability to turn the head to the face-down position.
 Respiratory Infection. Many infants who died of SIDS had recently had a cold, which might contribute to breathing
problems. At the time of death, 30-50% of otherwise healthy infants have an acute infection, such as
gastroenteritis, otitis media, or, in particular, upper respiratory tract infection (URTI); infantile botulism may be
the cause of 5-10% of sudden infant deaths.
 Apnea. Regurgitation of gastric contents with acidic pH can cause reflexive apnea with resultant hypoxia.
 Breastfeeding. A study from New Zealand suggests that infants who are not breastfed are at increased risk for
SIDS.

Sleep Environmental Factors

The items in a baby's crib and his or her sleeping position can combine with a baby's physical problems to increase the
risk of SIDS. Examples include:

 Sleeping on the stomach or side. Babies placed in these positions to sleep might have more difficulty breathing
than those placed on their backs.
 Sleeping on a soft surface. Lying face down on a fluffy comforter, a soft mattress or a waterbed can block an
infant's airway.
 Sharing a bed. While the risk of SIDS is lowered if an infant sleeps in the same room as his or her parents, the
risk increases if the baby sleeps in the same bed with parents, siblings or pets.
 Overheating. Being too warm while sleeping can increase a baby's risk of SIDS.
RISK FACTORS:

The most easily modifiable risk factor for sudden infant death syndrome is sleeping position.

The occurrence of apparent life-threatening events does not increase the risk of sudden infant death syndrome, and home
apnea monitoring does not lower the risk of sudden infant death syndrome.

Supine sleeping position has increased the incidence of flattening of the occiput (deformational plagiocephaly), but this
condition can be prevented and treated by encouraging supervised “tummy time,” meaning that when awake, infants
should spend as much time as possible on their stomachs.

All apparent deaths from sudden infant death syndrome should be carefully investigated to exclude other causes of death,
including child abuse.

Infant Factors that have been associated with increased SIDS risk include:

 Low APGAR scores

 Recent viral illness
 Sex. Boys are slightly more likely to die of SIDS.
 Age. Infants are most vulnerable between the second and fourth months of life.
 Race. Native American or African American ancestry
 Family history. Babies who've had siblings or cousins die of SIDS are at higher risk of SIDS.
 Secondhand smoke. Babies who live with smokers have a higher risk of SIDS.
 Being premature. Both being born early and having a low birth weight increase your baby's chances of SIDS.

MATERNAL RISK FACTORS:

During pregnancy, the mother also affects her baby's risk of SIDS, especially if she:

 Is younger than 20. High risk pregnancy

 Maternal smoking. Cigarette smoking during pregnancy is highly significant as a risk factor in the pathogenesis of
SIDS. The pre- and postnatal exposure to cigarette smoke has been a known risk factor for SIDS for more than 30
years. Nicotine exposure has been clearly linked with SIDS, as well as with prematurity, autonomic dysfunction,
low birth weight, and spontaneous abortions.
 Uses drugs or alcohol. Substance abuse
 Has inadequate prenatal care
 Low socioeconomic status
 A crowded household
 parental unemployment
 Single parent status, also increase the risk of SIDS

Why Is Stomach Sleeping Dangerous?

 SIDS is more likely among babies placed on their stomachs to sleep than among those sleeping on their backs.
Babies also should not be placed on their sides to sleep. A baby can easily roll from a side position onto the belly
during sleep.
 Some researchers believe that stomach sleeping may block the airway and hurt breathing. Stomach sleeping can
increase "rebreathing" — when a baby breathes in his or her own exhaled air — particularly if the infant is sleeping
on a soft mattress or with bedding, stuffed toys, or a pillow near the face. As the baby rebreathes exhaled air, the
oxygen level in the body drops and the level of carbon dioxide rises.
 Infants who die from SIDS may have a problem with the part of the brain that helps control breathing and waking
during sleep. If a baby is breathing stale air and not getting enough oxygen, the brain usually triggers the baby to
wake up and cry to get more oxygen. If the brain is not picking up this signal, oxygen levels will continue to fall.

DEFORMATIONAL PLAGIOCEPHALY

 Deformational plagiocephaly is flattening of the occiput, which affects up to one half of infants who sleep in the
supine position, and has become more common since the initiation of recommendations to place infants on
their backs to sleep.
 To decrease the risk of skull deformities, infants should have supervised “tummy time,” meaning that when
awake, infants should spend as much time as possible on their stomachs. The side of the occiput that is placed
downward during sleep also should be alternated. Infants should not be placed in car seats when they are not
passengers in a vehicle, and the use of other devices that place pressure on the back of the head (e.g., swing,
bouncy seat) should be minimized.
 Once deformational plagiocephaly has developed, parents should avoid placing the flattened side of the occiput
down on the mattress during sleep times. Physical therapy is helpful if torticollis is present. A neurosurgical
evaluation may be indicated in rare cases when the skull deformity does not improve with changes in head
positioning.

ASSESSMENT & DIAGNOSTIC FINDINGS:

  A diagnosis of sudden infant death syndrome (SIDS) is established by excluding recognizable causes of sudden
unexplained infant death (SUID).
o Laboratory studies. For a living patient, initial laboratory studies include a complete blood count (CBC),
electrolyte concentrations, and urinalysis.
o Radiography and computed tomography scans. Radiographs and computed tomography (CT) scans of the
skull may be indicated if abuse is suspected or if signs of increased intracranial pressure are present.
o Histology. In a series of 800 consecutive cases of SUID, [113] 6% of the infants had a neuropathologic cause
of death; almost all had clinical histories or gross brain findings at autopsy suggesting the cause of death.

MEDICAL MANAGEMENT:

The following measures are done for an infant who experiences SIDS or almost falls victim to it:

 Emergency care. For the infant found in cardiorespiratory arrest, the first priority is life support via attention to
the ABCs (Airway, Breathing, Circulation) and other medical interventions as appropriate; in the absence of
postmortem lividity or other signs of obvious death, infants must be transported to the hospital to ensure full
resuscitative attempts.
 Management of apnea. All infants presenting with nontrivial apnea or apparent life-threatening event (ALTEs)
associated with cyanosis or alterations in mental status or tone should be admitted.
 After death. If the infant is pronounced dead, inform the family in a quiet environment. Refer to the child by
name, not as “the baby”; detailing resuscitative efforts before telling the parents of the death is not helpful and
may engender parents’ resentment; specifically and directly, tell parents that their child has died; use of words
such as “dead” or “died” avoids the confusion that may result from gentler terms.

PREVENTION:

 Get early and regular prenatal care.

 Back to Sleep. Place your baby to sleep on his or her back, rather than on the stomach or side, every time you —
or anyone else — put the baby to sleep for the first year of life. This isn't necessary when your baby's awake or
able to roll over both ways without help.
 Don't assume that others will place your baby to sleep in the correct position — insist on it. Advise sitters and
child care providers not to use the stomach position to calm an upset baby.
 Keep the crib as bare as possible. Use a firm mattress and avoid placing your baby on thick, fluffy padding, such
as lambskin or a thick quilt. Don't leave pillows, fluffy toys or stuffed animals in the crib. These can interfere with
breathing if your baby's face presses against them.
 Don't overheat your baby. To keep your baby warm, try a sleep sack or other sleep clothing that doesn't require
additional covers. Don't cover your baby's head.
 Have your baby sleep in in your room. Ideally, your baby should sleep in your room with you, but alone in a crib,
bassinet or other structure designed for infant sleep, for at least six months, and, if possible, up to a year. Bed
sharing carries a substantially increased risk in low–birth-weight infants and in children of smokers and persons
who use illicit drugs or alcohol. Infants should never sleep with other children, or with a parent on a couch or
armchair.
 Adult beds aren't safe for infants. A baby can become trapped and suffocate between the headboard slats, the
space between the mattress and the bed frame, or the space between the mattress and the wall. A baby can also
suffocate if a sleeping parent accidentally rolls over and covers the baby's nose and mouth.
 Breast-feed your baby, if possible. Breast-feeding for at least six months lowers the risk of SIDS.
 Don't use baby monitors and other commercial devices that claim to reduce the risk of SIDS. The American
Academy of Pediatrics discourages the use of monitors and other devices because of ineffectiveness and safety
issues.
 Offer a pacifier. Sucking on a pacifier without a strap or string at naptime and bedtime might reduce the risk
of SIDS. One caveat — if you're breast-feeding, wait to offer a pacifier until your baby is 3 to 4 weeks old and
you've settled into a nursing routine. However, the potential SIDS risk reduction from pacifier use must be weighed
against the possibility that early pacifier use may shorten the duration of breastfeeding. Use of a pacifier should
be delayed until one month of age in infants who are breastfed
 Immunize your baby. There's no evidence that routine immunizations increase SIDS risk. Some evidence indicates
immunizations can help prevent SIDS. Infants who do not receive immunizations may be at greater risk of SIDS.
Some, but not all, case-control studies found a lower rate of SIDS among appropriately immunized children
compared with children with incomplete immunizations. However, the apparent protective effect of
immunizations against SIDS may in part be because of the relationship between incomplete immunization and
lower socioeconomic status and other risk factors for SIDS.
 Don't smoke during pregnancy or after birth. Infants of moms who smoked during pregnancy are more at risk
for SIDS than those whose mothers were smoke-free; exposure to secondhand smoke also raises a baby's risk,
and that risk is very high if a parent who smokes shares the bed with a baby.
 Do not use alcohol or drugs during pregnancy or after birth. Parents who drink or use drugs should not share a
bed with their infant.
NURSING MANAGEMENT:

 The effects of SIDS on caregivers and families are devastating.

NURSING ASSESSMENT:

Assessment of a child before an incidence of SIDS include:

 Physical Examination. It is not uncommon for the infant to have been recently examined by a physician and
found to be in excellent health.

NURSING DIAGNOSIS: (CASE TO CASE BASIS)

Based on the assessment data, the major nursing diagnoses for a child with SIDS are:

 Dysfunctional grieving related to sudden, unpredictable death of the infant.

 Interrupted family processes related to grieving.

NURSING CARE PLANNING:

The major nursing care planning goals for the family are:

 Family caregivers will seek appropriate support persons for assistance.

 Family caregivers will use available support systems to assist in coping with fear.
 Family caregivers will share feelings about the event.
 Family caregivers will verbalize measures to prevent SIDS.

NURSING INTERVENTIONS:

 Grief is coupled with guilt, even though SIDS cannot be predicted; disbelief, hostility, and anger are common
reactions.
 Allow expression of feelings. The immediate reaction of the staff should be to allow the family to express their
grief, encouraging them to say goodbye to their infant, and providing a quiet, private place for them to do so.
 Appropriate referrals. Referrals should be made to the local chapter of the National SIDS Foundation immediately;
Sudden Infant Death Alliance is another resource for help.
 Encourage use of community resources. In some states, specially trained community health nurses who are
knowledgeable about SIDS are available; these nurses are prepared to help families and can provide written
materials, as well as information, guidance, and support in the family’s home.
 Monitoring subsequent infants. Caregivers are particularly concerned about subsequent infants; recent studies
have indicated that the risk for these infants for the first few months of life to help reduce the family’s stress;
monitoring is usually maintained until the new infant is past the age of the SIDS infant’s death.

NURSING EVALUATION:

Goals are met as evidenced by:

 Family caregivers sought appropriate support persons for assistance.

 Family caregivers used available support systems to assist in coping with fear.
 Family caregivers shared feelings about the event.
 Family caregivers verbalized measures to prevent SIDS.

REFERENCES:

https://www.aafp.org/afp/2009/0515/p870.html

https://www.stanfordchildrens.org/en/topic/default?id=sudden-infant-death-syndrome-sids-90-P02412

https://www.mayoclinic.org/diseases-conditions/sudden-infant-death-syndrome/symptoms-causes/syc-20352800

https://kidshealth.org/en/parents/sids.html