Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis

Prävention des plötzlichen Säuglingstods (SIDS, „sudden infant death syndrome“, ICD 10: R95)

Dieser Beitrag fasst die Datenlage zu den wichtigsten Handlungsanweisungen für Eltern bezüglich der Gewährleistung einer sicheren Schlafumgebung für Säuglinge zusammen. Hierzu gehören folgende: 1. Legen Sie Ihr Kind zum Schlafen auf den Rücken; benutzen Sie dabei eine feste und waagerechte Unterlage. 2. Legen Sie Ihr Kind tagsüber, solange es wach ist und Sie es gut beobachten können, regelmäßig für kurze Zeit auch auf den Bauch. 3. Vermeiden Sie Überwärmung: Während der Nacht ist eine Raumtemperatur von 18 °C optimal, anstelle einer Bettdecke empfiehlt sich die Verwendung eines Baby-Schlafsacks in altersentsprechender Größe. 4. Falls Sie keinen Schlafsack verwenden möchten, achten Sie darauf, dass Ihr Kind nicht mit dem Kopf unter die Bettdecke rutschen kann, indem Sie es so ins Bett legen, dass es mit den Füßen am Fußende anstößt. 6. Verzichten Sie auf Kopfkissen, Fellunterlagen, „Nestchen“, gepolsterte Bettumrandungen und größere Kuscheltiere, mit denen sich Ihr Kind überdecken könnte. 7. Wickeln Sie Ihr Kind zum Schlafen nicht fest ein. 8. lassen Sie Ihr Kind bei sich im Zimmer, aber im eigenen Kinderbett schlafen. 9. Achten Sie auf eine rauchfreie Umgebung für Ihr Kind auch schon während der gesamten Schwangerschaft. 10. Stillen Sie im 1. Lebensjahr, möglichst mindestens 4 bis 6 Monate. 11. Bieten Sie Ihrem Kind zum Schlafengehen einen Schnuller an. 12. Diese Empfehlungen gelten auch für die Zeit unmittelbar nach Geburt: Sollte Ihr Kind auf Ihrem Körper liegen, achten Sie darauf, dass es stets freie Atemwege hat.

A ten-year retrospective case review of risk factors associated with sleep-related infant deaths

AIM

The study aimed to identify risk factors associated with sleep-related deaths of infants (0-24 months) in the province of Manitoba, Canada, between January 2009 and December 2018.

METHODS

A systematic retrospective case review of autopsies and administrative records in Manitoba between 2009 and 2018.

RESULTS

A total of 145 infants died in cases where unsafe sleep environments were known to have contributed to or resulted in their death and where no explained medical causes were identified. Where data complete, all infants had at least one known risk factor for sleep-related deaths, and 96% had multiple. The most common risk factors increased over time and included objects in the sleeping environment (90% of cases), not approved sleep surfaces (77%) and bedsharing (50%). Indigenous infants, infants of young mothers and infants in low-income neighbourhoods are overrepresented. Risk factors for Indigenous infants differed from cases involving non-Indigenous infants.

CONCLUSION

A high proportion of sleep-related infant deaths were associated with not approved sleep surfaces and bedsharing, especially for infants under one year. Families in low-income neighbourhoods, Indigenous families and families with young mothers were disproportionately affected by sleep-related infant deaths. There is a need to enhance messaging and smoking cessation messaging in Indigenous communities to prevent sleep-related deaths.

The effect of swaddling on infant sleep and arousal: A systematic review and narrative synthesis

BACKGROUND

Western parents swaddle infants to promote sleep and reduce night-waking, however recent evidence of the effects of swaddling on the sleep of healthy infants has not been systematically reviewed.

OBJECTIVE

To investigate the effect of swaddling on the sleep of infants up to 1 year of age using a narrative synthesis approach.

DATA SOURCES

We systematically searched five academic databases, including the Cochrane trial registry (Pubmed, PsycINFO, Embase, the Cochrane library, and Blackwell Synergy). We manually searched reference lists and citations of included studies and reference lists of existing reviews.

STUDY SELECTION

Studies of any type, published since 2007, reporting primary data whose subjects were humans up to 12 months of age with outcome measures relating to the impact of swaddling on sleep and arousal.

DATA EXTRACTION

By hand using a customized template. A narrative synthesis is used to present the results.

RESULTS

In total 171 studies were retrieved with 115 studies discarded at title. A further 43 were discarded at abstract, and six were discarded at full text. Two papers were combined as they reported on the same study giving a total of 6 studies that met the inclusion criteria for the review. An evidence hierarchy was used to assess Risk of Bias in the included studies; the results are presented via a narrative synthesis. Swaddling was associated with increased duration of quiet sleep in infants and a significantly reduced number of sleep state changes among infants naïve to the intervention.

LIMITATIONS

The integrity of the intervention (swaddling) including its baseline characteristics, was defined broadly across the included studies limiting the interpretation and transferability of the results of this review.

CONCLUSIONS

Swaddling appears to increase quiet sleep duration in infants and reduces the number of sleep state changes among infants naïve to the intervention. Parents should be made aware that implementing conditions unfavorable to arousability may increase SUDI risk among infant who have not previously been swaddled. This review has relevance for informing future practice recommendations and parent advice as well as in designing future studies.

Cohort profile: National Investigation of Birth Cohort in Korea study 2008 (NICKs-2008)

BACKGROUND

An adequate large-scale pediatric cohort based on nationwide administrative data is lacking in Korea.

PURPOSE

This study established the National Investigation of Birth Cohort in Korea study 2008 (NICKs-2008) based on data from a nationwide population-based health screening program and data on healthcare utilization for children.

METHODS

The NICKs-2008 study consisted of the Korean National Health Insurance System (NHIS) and the National Health Screening Program for Infants and Children (NHSPIC) databases comprising children born in 2008 (n=469,248) and 2009 (n=448,459) in the Republic of Korea. The NHIS database contains data on age, sex, residential area, income, healthcare utilization (International Classification of Diseases-10 codes, procedure codes, and drug classification codes), and healthcare providers. The NHSPIC consists of 7 screening rounds. These screening sessions comprised physical examination, developmental screening (rounds 2-7), a general health questionnaire, and age-specific anticipatory guidance.

RESULTS

During the 10-year follow-up, 2,718 children (0.3%) died, including more boys than girls (hazard ratio, 1.145; P<0.001). A total of 848,048 children participated in at least 1 of the 7 rounds of the NHSPIC, while 96,046 participated in all 7 screening programs. A total of 823 infants (0.1%) weighed less than 1,000 g, 3,177 (0.4%) weighed 1,000-1,499 g, 37,166 (4.4%) weighed 1,500-2,499 g, 773,081 (91.4%) weighed 2,500-4,000 g, and 32,016 (5.1%) weighed over 4,000 g. There were 23,404 premature babies (5.5%) in 2008 compared to 23,368 (5.6%) in 2009. The developmental screening test indicated appropriate development in 95%-98% of children, follow-up requirements for 1%-4% of children, and recommendations for further evaluation for 1% of children.

CONCLUSION

The NICKs-2008, which integrates data from the NHIS and NHSPIC databases, can be used to analyze disease onset prior to hospitalization based on information such as lifestyle, eating habits, and risk factors.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Sudden Infant Death Syndrome: Beyond Risk Factors

Sudden infant death syndrome (SIDS) is defined as "the sudden death of an infant under 1 year of age which remains unexplained after thorough investigation including a complete autopsy, death scene investigation, and detailed clinical and pathological review". A significant decrease of SIDS deaths occurred in the last decades in most countries after the beginning of national campaigns, mainly as a consequence of the implementation of risk reduction action mostly concentrating on the improvement of sleep conditions. Nevertheless, infant mortality from SIDS still remains unacceptably high. There is an urgent need to get insight into previously unexplored aspects of the brain system with a special focus on high-risk groups. SIDS pathogenesis is associated with a multifactorial condition that comprehends genetic, environmental and sociocultural factors. Effective prevention of SIDS requires multiple interventions from different fields. Developing brain susceptibility, intrinsic vulnerability and early identification of infants with high risk of SIDS represents a challenge. Progress in SIDS research appears to be fundamental to the ultimate aim of eradicating SIDS deaths. A complex model that combines different risk factor data from biomarkers and omic analysis may represent a tool to identify a SIDS risk profile in newborn settings. If high risk is detected, the infant may be referred for further investigations and follow ups. This review aims to illustrate the most recent discoveries from different fields, analyzing the neuroanatomical, genetic, metabolic, proteomic, environmental and sociocultural aspects related to SIDS.

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.

Sudden infant death syndrome: current perspectives

Despite significant reductions in incidence since the introduction of safe infant sleeping recommendations, sudden infant death syndrome is still the major cause of neonatal death in western countries. In the United States, over 2500 infants die suddenly and unexpectedly each year with nearly 100 deaths annually in Australia. Health professionals play a critical role in advising parents how to sleep their infants safely to minimise the risk of sudden infant death syndrome and sleeping accidents. Infants should be placed supine to sleep in a cot with a firm well-fitting mattress in the parental bedroom with no soft or loose bedding which could obstruct the airway. Exposure to smoking both before and after birth should be minimised. Breastfeeding should be encouraged, as should immunisation. Dummies can be recommended after breastfeeding has been established. This review outlines the evidence behind these recommendations.

Can infant sleeping bags be recommended by medical professionals as protection against sudden infant death syndrome?

Clinical scenario: A mother brought her infant to the hospital with bronchiolitis and incidentally asked if I would recommend the use of infant sleeping bags to protect against Sudden Infant Death Syndrome as several of her friends use them. Structured question: Can infant sleeping bags be recommended by medical professionals as protective against Sudden Infant Death Syndrome? Methods: A literature search was performed. Trials were included if they had an English version available and the papers examined the impact that sleeping bag use had on risk of SIDS or its risk factors. Cochrane Library search found eight trials, two of which were found to meet inclusion criteria. MEDLINE was searched using the search terms ((baby sleeping bag) OR infant sleeping bag) OR cotton sleeping sack. Forty-seven papers were found, two of which were found to meet the inclusion criteria, one of which had already been found in the Cochrane Library search. One further paper was found through searching citations of the papers included. Discussion: Sleeping bags are used in 48-95% of infants in the UK and advocated for by the Lullaby Trust for their safety in the prevention of SIDS. The case control studies included found that sleeping bags are as safe, if not safer than other bedding when examining SIDS as an outcome. For sleeping bags to be safe they must be well made and appropriately used, which includes the correct size, Tog, clothing and other bedding for bedroom temperature.

Variation in Neonate Swaddling Techniques

BACKGROUND

It is common practice for healthcare practitioners to swaddle infants in newborn nursery and neonatal intensive care unit settings. Despite the widespread use of this practice, the American Academy of Pediatrics neither bans nor recommends swaddling. To date, there has been no standard protocol developed for either healthcare professionals or parents to establish optimal swaddling techniques in terms of infant arm positioning, infant leg positioning, and tightness of wrap.

PURPOSE

To evaluate the variability in swaddling techniques used for infants in the newborn nursery and neonatal intensive care unit.

METHODS

Across 2 pediatric hospitals, the swaddling positioning of each open-crib infant in the newborn nursery and neonatal intensive care unit was examined. For each infant, the following data were collected: gender, left and right arm position, left and right leg position, and tightness of wrap.

RESULTS

In total, 132 swaddle observations were recorded. There was significant variability in swaddling positioning of arms and legs. The most common combination of arm/leg positioning was "mixed arm positioning" and "both legs flexed" (25.0% of all observations). In 9.1% of cases, tightness of wrap around chest was "tight," and in 30.3% of cases, tightness of wrap around legs was "tight."

IMPLICATIONS FOR PRACTICE

There was a large variability in swaddling positioning of both arms and legs. For such a widespread practice, the lack of medical guidelines results in inconsistent, and potentially harmful, positioning. Parents and healthcare professionals would benefit from specific, research-driven guidelines regarding proper swaddling techniques.

IMPLICATIONS FOR RESEARCH

Different variations on swaddling should be evaluated for consideration of best practice swaddling.

Sudden Infant Death Syndrome: A Review

Sudden infant death syndrome (SIDS) is the sudden unexpected death of an apparently healthy infant younger than age 12 months whose cause of death remains unknown despite a thorough death scene investigation, a review of the clinical history, and an autopsy. Despite the huge achievement of the Back to Sleep program, SIDS remains one of the leading causes of infant death in the United States. In recent years, the SIDS rate has remained stationary despite major public health efforts aimed at high-risk groups to improve sleep environment and strategies. This review focuses on SIDS epidemiology, pathogenesis and risk factors, the American Academy of Pediatrics recommendations on safe infant sleeping environment, and the US Centers for Disease Control and Prevention's multistate registry to improve knowledge on SIDS, evaluate trends, and analyze circumstances and events surrounding SIDS cases. [Pediatr Ann. 2018;47(3):e118-e123.].

Cardiovascular autonomic dysfunction in sudden infant death syndrome

A failure of cardiorespiratory control mechanisms, together with an impaired arousal response from sleep, are believed to play an important role in the final event of sudden infant death syndrome (SIDS). The 'triple risk model' describes SIDS as an event that results from the intersection of three overlapping factors: (1) a vulnerable infant, (2) a critical developmental period in homeostatic control and (3) an exogenous stressor. In an attempt to understand how the triple risk hypothesis is related to infant cardiorespiratory physiology, many researchers have examined how the known risk and protective factors for SIDS alter infant cardiovascular control during sleep. This review discusses the association between the three components of the triple risk hypothesis and major risk factors for SIDS, such as prone sleeping, maternal smoking, together with three "protective" factors, and cardiovascular control during sleep in infants, and discusses their potential involvement in SIDS.

Predictors of Maternal Trust in Doctors About Advice on Infant Care Practices: The SAFE Study

OBJECTIVE

To determine predictors of maternal trust in doctors about advice on infant care practices.

METHODS

Using probability sampling methods, we recruited mothers from 32 US maternity hospitals. Mothers completed a survey 2 to 6 months postpartum that included questions about maternal trust in doctors regarding 6 infant care practices and physician characteristics (doctor asked mother's opinion, doctor is qualified, infant sees 1 main doctor who is/is not of the same ethnicity/race). Prevalence estimates and 95% confidence intervals were calculated for maternal trust in physician advice for each infant care practice. Multivariate logistic regression was used to calculate the independent association of maternal and physician characteristics and trust for each infant care practice, controlling for sociodemographic characteristics.

RESULTS

Of the 3983 mothers enrolled from January 2011 to March 2014, 3297 (83%) completed the follow-up survey. Maternal trust in the doctor varied according to infant care practice with highest trust for vaccination (89%) and lowest trust for pacifier use (56%). In the adjusted analyses, for all infant care practices, mothers were more likely to trust their doctors if they reported that the doctors were qualified (adjusted odds ratio [AOR], >3.0 for all practices) or if the doctor had asked their opinion (AOR, 1.76-2.43). For mothers who reported seeing 1 main doctor, white mothers were more likely to trust physicians for almost all infant care practices if they reported the doctor was the same race (AOR, 1.54-2.19).

CONCLUSIONS

Physician characteristics and ways of communication were significantly associated with maternal trust in doctors about advice on infant care practices.

ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.