Head covering and the risk for SIDS: findings from the New Zealand and German SIDS case-control studies

Infant care practices and parent uptake of safe sleep messages: a cross-sectional survey in Queensland, Australia

Background

Globally, the incidence of sleep-related infant mortality declined dramatically following the first public health campaigns seen internationally in the 1990s to reduce the risks of sudden infant death. However, Australian Sudden Unexpected Death in Infancy (SUDI) rates have plateaued with little change in incidence since 2004 despite two further public health safe sleep campaigns. This study aims to describe contemporary infant care practices employed by families related to the current public health SUDI prevention program.

Methods

A cross-sectional survey of 3341 Queensland primary caregivers with infants approximately 3-months of age was conducted using the Queensland Registry of Births, Deaths and Marriages as a sampling frame. Surveys were returned either via reply-paid mail or online. Questionnaires explored prevalence of infant care practices and awareness of safe sleep recommendations. Univariable analysis was used to generate descriptive statistics for key variables.

Results

Overall, only 13% of families routinely practised all six ‘Safe Sleeping’ program messages. More than one third (1118, 34%) of infants had slept in a non-supine sleep position at some time. Potentially hazardous sleep environments were common, with 38% of infants sleeping with soft items or bulky bedding, or on soft surfaces. Nearly half, for either day- or night-time sleeps, were routinely placed in a sleep environment that was not designed or recommended for safe infant sleep (i.e. a bouncer, pram, beanbag). Most babies (84%) were reportedly smoke free before and after birth. Sleeping in the same room as their caregiver for night-time sleeps was usual practice for 75% of babies. Half (1600, 50%) of all babies shared a sleep surface in the last two-weeks. At 8-weeks, 17% of infants were no longer receiving any breastmilk.

Conclusions

The prevalence rates of infant care practices among this Australian population demonstrate many families continue to employ suboptimal practices despite Australia’s current safe sleep campaign. Strategic approaches together with informed decisions about pertinent messages to feature within future public health campaigns and government policies are required so targeted support can be provided to families with young infants to aid the translation of safe sleep evidence into safe sleeping practices.

T Cells of Infants Are Mature, but Hyporeactive Due to Limited Ca2+ Influx

CD4 T cells in human infants and adults differ in the initiation and strength of their responses. The molecular basis for these differences is not yet understood. To address this the principle key molecular events of TCR- and CD28-induced signaling in naive CD4 T cells, such as Ca²⁺ influx, NFAT expression, phosphorylation and translocation into the nucleus, ERK activation and IL-2 response, were analyzed over at least the first 3 years of life. We report dramatically reduced IL-2 and TNFα responses in naive CD31⁺ T cells during infancy. Looking at the obligatory Ca²⁺ influx required to induce T cell activation and proliferation, we demonstrate characteristic patterns of impairment for each stage of infancy that are partly due to the differential usage of Ca²⁺ stores. Consistent with those findings, translocation of NFATc2 is limited, but still dependent on Ca²⁺ influx as demonstrated by sensitivity to cyclosporin A (CsA) treatment. Thus weak Ca²⁺ influx functions as a catalyst for the implementation of restricted IL-2 response in T cells during infancy. Our studies also define limited mobilization of Ca²⁺ ions as a characteristic property of T cells during infancy. This work adds to our understanding of infants’ poor T cell responsiveness against pathogens.

Scientific consensus forum to review the evidence underpinning the recommendations of the Australian SIDS and Kids Safe Sleeping Health Promotion Programme--October 2010

This paper summarises a 1-day scientific consensus forum that reviewed the evidence underpinning the Australian SIDS and Kids Safe Sleeping Health Promotion Programme. The focus was on each of the potentially modifiable risk factors for sudden unexpected deaths in infancy, including sudden infant death syndrome (SIDS) and fatal sleeping accidents. In particular infant sleeping position, covering of the face, exposure to cigarette smoke, room sharing, unsafe sleeping environments, bed sharing, immunisation, breastfeeding, pacifier use and Indigenous issues were discussed in depth. The participants recommended that future 'Reducing the Risk' campaign messages should focus on back to sleep, face uncovered, avoidance of cigarette smoke before and after birth, safe sleeping environment, room sharing and sleeping baby in own cot.

Implementation of the American Academy of Pediatrics recommendations to reduce sudden infant death syndrome risk in neonatal intensive care units: An evaluation of nursing knowledge and practice

There is a direct relationship between nonsupine sleeping and sudden infant death syndrome (SIDS). Premature infants are at greater risk for SIDS and are often cared for in nonsupine positions during the course of hospitalization. Healthy premature infants should be placed supine for sleep before discharge from the neonatal intensive care unit (NICU), and parents receive specific instruction about infant sleep position and other risk factors for SIDS. Most published literature addressing nursing practices for SIDS reduction reflects practices with the healthy newborn population.

PURPOSE

To examine and describe NICU nurses' knowledge of SIDS risk-reduction measures, modeling of safe infant sleep interventions prior to discharge, and inclusion of SIDS risk reduction in parent education.

SUBJECTS

Convenience sample of nurses practicing in level II and III NICUs located in 2 Middle Atlantic States.

DESIGN AND METHODS

A prospective survey design was used for the study. The 14-item questionnaire was developed by a team of neonatal clinical experts and distributed via site coordinators to nurses in 19 NICUs.

PRINCIPAL RESULTS

A total of 1080 surveys were distributed and 430 (40%) NICU nurses completed the survey. The majority of nurses (85%) identified the American Academy of Pediatrics SIDS risk-reduction strategies for safe sleep. The investigators found that age, years of nursing and neonatal nursing experience, and educational preparation did not significantly contribute to the practice of "supine-only" position for sleep for infants in NICUs. The study revealed that nurses frequently position healthy preterm infants supine for sleep when weaned to an open crib (50%). Others wait one to a few days before discharge (15%) and some never position supine for sleep (6%). Stuffed toys are removed from cribs 90.5% of the time. For term infants without major medical complications, 45.5% of surveyed nurses continued to use positioning aids/rolls in infants' cribs. The most common reasons nurses cited to position preterm infants side-lying or prone in a crib were fear of aspiration (29%), infant comfort (28%), and infant safety (20%). NICU nurses educated parents about SIDS and reduction strategies, using various media. At discharge, 73% of the nurses verbally communicated with parents, 53% provided printed literature, and 14% used audiovisual aids with parents.

CONCLUSIONS

NICU nurses are in influential positions to educate parents and model SIDS risk-reduction strategies. This study supports other published research that points to inconsistencies in nursing practice regarding implementation of methods to reduce the risk of SIDS.

Evaluation of the thermal insulation of clothing of infants sleeping outdoors in Northern winter

It is a common practice in Northern countries that children aged about 2 weeks to 2 years take their daytime sleep outdoors in prams in winter. The aim was to evaluate the thermal insulation of clothing of infants sleeping outdoors in winter. Clothing data of infants aged 3.5 months was collected, and sleep duration, skin and microclimate temperatures, humidity inside middle wear, air temperature and velocity of the outdoor environment were recorded during sleep taken outdoors (n = 34) and indoors (n = 33) in families' homes. The insulation of clothing ensembles was measured by using a baby-size thermal manikin, and the values were used for defining clothing insulation of the observed infants. Required clothing insulation for each condition was estimated according to ISO 11079. Clothing insulation did not correlate with ambient air temperature. The observed and required insulation of the study group was equal at about -5 °C, but overdressing existed in warmer and deficiency in thermal insulation in colder temperatures (r (s) 0.739, p < 0.001). However, even at -5 °C a slow cooling (ca. 0.012 °C/min) of mean skin temperature (T (sk)) was observed. When the difference between observed and required insulation increased, the cooling rate of T (sk) increased linearly (r (s) 0.605, p < 0.001) and the infants slept for a shorter period (r (s) 0.524, p = 0.001). The results of this study show the difficulty of adjusting systematically the optimal thermal insulation for outdoor sleeping infants during northern winter. Therefore, the necessity for guidelines is obvious. The study provides information for adequate cold protection of infants sleeping in cold conditions.

The German case-control scene investigation study on SIDS: epidemiological approach and main results

The present study, which was part of the German SIDS Study (GeSID), enrolled sudden infant death syndrome (SIDS) cases and population controls and obtained objective scene data via specifically trained observers shortly after discovery of each dead infant. Infants who had died suddenly and unexpectedly at ages between 8 and 365 days were enrolled in five regions of Germany between November 1998 and October 2001. Shortly after discovery of each dead infant, a specially trained doctor of legal medicine visited the bereaved family at home. Data were obtained by measurements and observations. Dead infants underwent a standardised autopsy, additional information being obtained by standardised parent interviews. Investigation of the sleep environment and wake-up scene in matched controls followed the same protocol. A total of 52 SIDS cases and 154 controls were enrolled, 58% were boys, and median age of cases vs. controls was 126 vs. 129 days. Risk factors in the sleeping environment were pillow use (adjusted OR 4.3; 95%CI 1.6-11.6), heavy duvets (OR 4.4; 1.5-13.3), soft underlay (OR 3.0; 1.1-8.7), face covered by bedding (OR 15.8; 2.5-102.1) and entire body covered by bedding (OR 35.5; 5.5-228.3). Using a standardised protocol, including objective measurements of the sleep environment and a case-control design, this study was able to confirm many risk factors for SIDS.