SIDS and Other Sleep-Related Infant Deaths: Expansion of ...

1 DOI: ; originally published online October 17, 2011; 2011;128;e1341 PediatricsTask Force on sudden Infant death Syndromefor a Safe Infant Sleeping EnvironmentSIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations on the World Wide Web at: The online version of this article, along with updated information and services, is of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: , Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly by guest on January 11, from TECHNICAL REPORTSIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe InfantSleeping EnvironmentabstractDespite a major decrease in the incidence of sudden Infant death syn-drome (SIDS) since the American Academy of Pediatrics (AAP) releasedits recommendation in 1992 that infants be placed for sleep in a non-prone position, this decline has plateaued in recent years.

2 Concur-rently, Other causes of sudden unexpected Infant death occurring dur-ing sleep ( Sleep-Related deaths), including suffocation, asphyxia, andentrapment, and ill-defined or unspecified causes of death have in-creased in incidence, particularly since the AAP published its last state-ment on SIDS in 2005. It has become increasingly important to addressthese Other causes of Sleep-Related Infant death . Many of the modifi-able and nonmodifiable risk factors for SIDS and suffocation are strik-ingly similar. The AAP, therefore, is expanding its recommendationsfrom being only SIDS-focused to focusing on a safe sleep environmentthat can reduce the risk of all Sleep-Related Infant deaths includingSIDS. The recommendations described in this report include supinepositioning, use of a firm sleep surface, breastfeeding, room-sharingwithout bed-sharing, routine immunization, consideration of a pacifier,and avoidance of soft bedding, overheating, and exposure to tobaccosmoke, alcohol, and illicit drugs.

3 The rationale for these recommenda-tions is discussed in detail in this technical report. The recommenda-tions are published in the accompanying Policy Statement SuddenInfant death syndrome and Other Sleep-Related Infant Deaths: Expan-sion of Recommendations for a Safe Infant Sleeping Environment, which is included in this issue ( ).Pediatrics2011;128:e1341 e1367 METHODOLOGYL iterature searches using PubMed were conducted for each of thetopics in this technical report and concentrated on articles publishedsince 2005 (when the last policy statement1was published). In addition,to provide additional information regarding sleep-environment haz-ards, a white paper was solicited from the US Consumer Product SafetyCommission (CPSC).2 Strength of evidence for recommendations3wasdetermined by the task force members.

4 Draft versions of the policystatement4and technical report were submitted to relevant commit-tees and sections of the American Academy of Pediatrics (AAP) forreview and comment. After the appropriate revisions were made, aTASK FORCE ON sudden Infant death SYNDROMEKEY WORDSSIDS, sudden Infant death , Infant mortality, sleep position, bed-sharing, tobacco, pacifier, immunization, bedding, sleep surfaceABBREVIATIONSCPSC Consumer Product Safety CommissionAAP American Academy of PediatricsSIDS sudden Infant death syndromeSUID sudden unexpected Infant deathICD International Classification of DiseasesASSB accidental suffocation and strangulation in bed5-HT 5-hydroxytryptamineOR odds ratioCI confidence intervalThe guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical , taking into account individual circumstances.

5 May technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).Copyright 2011 by the American Academy of PediatricsFROM THE AMERICAN ACADEMY OF PEDIATRICSPEDIATRICS Volume 128, Number 5, November 2011e1341 by guest on January 11, from final version was submitted to the AAPE xecutive Committee and Board of Di-rectors for final Infant death SYNDROMEAND sudden UNEXPECTED INFANTDEATH: DEFINITIONS ANDDIAGNOSTIC ISSUESS udden Infant death Syndromeand sudden Unexpected InfantDeathSudden Infant death syndrome (SIDS)is a cause assigned to Infant deathsthat cannot be explained after a thor-ough case investigation that includes ascene investigation, autopsy, and re-view of the clinical un-expected Infant death (SUID), alsoknown as sudden unexpected death ininfancy (SUDI), is a term used to de-scribe any sudden and unexpecteddeath, whether explained or unex-plained (including SIDS), that occursduring infancy.

6 After case investiga-tion, SUIDs can be attributed to suffo-cation, asphyxia, entrapment, infec-tion, ingestions, metabolic diseases,and trauma (accidental or nonacci-dental). The distinction between SIDSand Other SUIDs, particularly thosethat occur during an observed or un-observed sleep period (sleep-relatedinfant deaths), such as accidental suf-focation, is challenging and cannotusually be determined by autopsyalone. Scene investigation and review ofthe clinical history are also required. Afew deaths that are diagnosed as SIDSare found, after further specializedinvestigations, to be attributable tometabolic disorders or arrhythmia-associated cardiac standardized guidelines forconducting thorough case investiga-tions have been developed,6theseguidelines have not been uniformly ad-opted across the more than 2000 USmedical examiner and coroner from emergencyresponders, scene investigators, andcaregiver interviews can provide addi-tional evidence to assist death certifi-ers (ie, medical examiners and coro-ners) in accurately determining thecause of death .

7 However, death certifi-ers represent a diverse group withvarying levels of skills and educationas well as diagnostic preferences. Re-cently, much attention has been fo-cused on reporting differences amongdeath certifiers. At one extreme, somecertifiers have abandoned using SIDSas a cause-of- death Other extreme, some certifiers willnot classify a death as suffocation inthe absence of a pathologic marker ofasphyxia at autopsy (ie, pathologicfindings diagnostic of oronasal occlu-sion or chest compression8), even withstrong evidence from the scene inves-tigation that suggests a probable acci-dental Trends in SIDS, Other SUIDs,and Postneonatal MortalityTo monitor trends in SIDS and otherSUIDs nationally, the United Statesclassifies diseases and injuries ac-cording to theInternational Classifica-tion of Diseases(ICD) diagnosticcodes.

8 This classification system is de-signed to promote national and inter-national comparability in theassign-ment of cause-of- death determinations;however, this system might not pro-vide the optimal precision in classifica-tion desired by clinicians and re-searchers. In the United States, theNational Center for Health Statisticsassigns a SIDS diagnostic code (ICD-10R95) if the death is classified with ter-minology such as SIDS (including pre-sumed, probable, or consistent withSIDS), sudden Infant death , sudden un-explained death in infancy, sudden un-expected death in infancy, or suddenunexplained Infant death on the certi-fied death certificate. A death will becoded as Other ill-defined and unspec-ified causes of mortality (ICD-10 R99)if the cause of the death is reported asunknown or unspecified.

9 A death iscoded as accidental suffocation andstrangulation in bed (ASSB) (ICD-10W75) when the terms asphyxia, as-phyxiated, asphyxiation, stran-gled, strangulated, strangulation, suffocated, or suffocation are re-ported, along with the terms bed or crib. This code also includes deathswhile sleeping on couches SIDS was defined somewhatloosely until the mid-1980s, there wasminimal change in the incidence ofSIDS in the United States until the early1990s. In 1992, in response to epidemi-ologic reports from Europe and Aus-tralia, the AAP recommended that in-fants be placed for sleep in a nonproneposition as a strategy for reducing therisk of Back to Sleep cam-paign was initiated in 1994 under theleadership of the National Institute ofChild Health and Human Developmentas a joint effort of the Maternal andChild Health Bureau of the Health Re-sources and Services Administration,the AAP, the SIDS Alliance (now FirstCandle), and the Association of SIDSand Infant Mortality Kennedy Shriver National Insti-tute of Child Health and Human Devel-opment began conducting nationalsurveys of Infant care practices toevaluate the implementation of the AAPrecommendation.

10 Between 1992 and2001, the SIDS rate declined, and themost dramatic declines occurred inthe years immediately after the firstnonprone recommendations, consis-tent with the steady increase in theprevalence of supine sleeping (Fig 1).11 The US SIDS rate declined from 120deaths per 100 000 live births in 1992to 56 deaths per 100 000 live births in2001, representing a decrease of 53%over 10 years. However, from 2001 to2006 (the latest year from which dataare available), the rate has remainedconstant (Fig 1). In 2006, 2327 infantse1342 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on January 11, from died from SIDS. Although SIDS rateshave declined by more than 50% sincethe early 1990s, SIDS remains thethird-leading cause of Infant mortalityand the leading cause of postneonatalmortality (28 days to 1 year of age).