Sudden infant death syndrome (SIDS) is a syndrome marked by the symptoms of sudden and unexplained death of an apparently healthy infant aged one month to one year. The term cot death is often used in the United Kingdom, Australia and New Zealand, while crib death is sometimes used in North America.
SIDS is a diagnosis of exclusion. It can only be applied to an infant whose death is sudden and unexpected, and remains unexplained after the performance of an adequate postmortem investigation including
SIDS is responsible for roughly 1 death per 2,000 births in the U.S. It is responsible for far fewer deaths than congenital disorders and disorders related to short gestation, though it is the leading cause of death in healthy babies after one month of age.
SIDS deaths in the U.S. decreased from 4,895 in 1992 to 2,247 in 2004 . But, during a similar time period, 1989 to 2004, SIDS being listed as the cause of death for sudden infant death (SID) decreased from 80% to 55% . According to Dr. John Kattwinkel, chairman of the Center for Disease Control (CDC) Special Task Force on SIDS "A lot of us are concerned that the rate (of SIDS) isn't decreasing significantly, but that a lot of it is just code shifting” .
In 1992, based upon epidemiological evidence and studies of sleep physiology, the American Academy of Pediatrics began advising parents to place their newborn infants to sleep on their backs (supine position) instead of their stomachs (prone position). This advice is based on the physiological evidence which shows that infants who sleep on their back have lower arousal thresholds and less Slow-Wave Sleep (SWS) compared to infants that sleep on their stomachs. . In human infants sleep develops rapidly during early development. This development includes an increase in non-rapid eye movement sleep (NREM sleep) which is also called Quiet Sleep (QS) during the first 12 months of life in association with a decrease in rapid eye movement sleep (REM sleep) which is also known as Active Sleep (AS) . In addition, slow wave sleep (SWS) which consists of Stage 3 and Stage 4 NREM sleep appears at 2 months of age . and it is theorized that some infants have a brain-stem defect which increases their risk of being unable to arouse from SWS (also called Deep Sleep) and therefore have an increased risk of SIDS due to their increased inability to arouse from SWS . In a currently utilized model that explains the process in which slow wave sleep is involved in memory consolidation the hippocampus acts as a temporary storage facility for new memories which are then transferred to the neocortex during slow wave sleep (SWS) .
A significant way of decreasing slow wave sleep in infants is by changing their sleeping position from their stomach to their back. It has been shown in studies of preterm infants full-term infants , and older infants . , that they have greater time periods of quiet sleep and also decreased time awake when they are positioned to sleep on their stomachs. In both human infants and rats, arousal thresholds have been shown to be at higher levels in the Electroencephalography (EEG) during Slow-wave sleep .
In 1992 , a SIDS risk reduction strategy based upon lowering arousal thresholds during SWS was implemented by the American Academy of Pediatrics (AAP) which began recommending that healthy infants be positioned to sleep on their back (supine position) or side (lateral position), instead of their stomach (prone position), when being placed down for sleep. The AAP’s 1992 recommendations were announced five years after the Netherlands had started it’s infant supine sleep position campaign in 1987 . The Netherlands recommendations were followed by infant supine sleep position campaigns in the United Kingdom, New Zealand, and Australia in 1991, the U.S. and Sweden in 1992, and Canada in 1993 . In 1994 , a number of organizations in the United States combined to further communicate these non-prone sleep position recommendations and this became formally known as the “Back To Sleep” campaign. In 1996 , the AAP further refined its sleep position recommendation by stating that infants should only be placed to sleep in the supine position and not in the prone or lateral positions.
In 1992, the first National Infant Sleep Position (NISP) Household Survey was conducted to determine the usual position in which U.S. mothers placed their babies to sleep: (1) Lateral (side); (2) Prone (stomach); (3) Supine (back); (4) Other; (5) No Usual Position. According to the 1992 NISP survey, 13.0% of U.S. infants were positioned in the supine position for sleep . According to the 2006 NISP survey 75.7% of infants were positioned in the supine position to sleep .
Since 1998 there have been several studies published which report that infants placed to sleep in the supine position lag in motor skills, social skills, and cognitive ability development when compared to infants who sleep in the prone position. In the 1998 article entitled “Effects of Sleep Position on Infant Motor Development.”  by Davis, Moon, Sachs, and Ottolini, the authors state “We found that sleep position significantly impacts early motor development.” The prone (stomach) sleeping infants in this study slept an average of 225.2 hours (8.3%) more in their first 6 months of life than the supine (back) sleeping infants.
In the 1998 article entitled “Does the Supine Sleeping Position Have Any Adverse Effects on the Child? II. Development in the First 18 Months” by Dewey, Fleming, Golding, and the ALSPAC Study Team the objective of the study was “To assess whether the recommendations that infants sleep supine could have adverse consequences on their motor and mental development.” They utilized the Denver Developmental Screening Test (DDST) and studied infants at 6 and 18 months. According to the study, at 6 months of age, the infants who were placed to sleep in the prone position had statistically significant higher social skills scores, gross motor scores, and total development scores than those infants who were put to sleep in the supine position. In addition, the total development scores of prone sleeping infants were still higher than supine sleeping infants at 18 months of age but were no longer statistically significant. In the 2005 article entitled “Influence of supine sleep positioning on early motor milestone acquisition” by Majnemer and Barr they utilized the Alberta Infant Motor Scale Scores (AIMS Scores) to analyze the impact of infant sleep position. They reported that “Typically developing infants who were sleep-positioned in supine had delayed motor development by age 6 months, and this was significantly associated with limited exposure to awake prone positioning.” But, the authors also note that awake prone (stomach) positioning is associated with prone (stomach) sleeping. No studies have been conducted which compare supine sleeping infants who have regular awake prone positioning (tummy time) to prone sleeping infants who have regular awake prone positioning (tummy time).
Placing infants on their stomachs while they are awake (tummy time) has been recommended to offset the motor skills delays associated with the back sleep position but positioning the infant on their stomach while awake will not impact the amount of slow wave sleep [39-43] since tummy time only occurs when an infant is awake.
Some conditions that may be undiagnosed and thus result in a diagnosis of SIDS include
Very little is certain about the possible causes of SIDS, and there is no proven method for prevention. Although studies have identified risk factors for SIDS, such as putting infants to bed on their stomachs, there has been little understanding of the syndrome's biological cause or causes. The frequency of SIDS appears to be a strong function of infant sex and the age, ethnicity, and the education and socio-economic status of the parents.
According to a study published in October 2007 in the Journal of the American Medical Association, babies who die of SIDS have abnormalities in the part of the brain called the medulla oblongata which helps control functions like breathing, blood pressure and arousal. Researchers examined the brains of 31 babies who had died of SIDS and 10 who had died from other causes. It was discovered that the medulla oblongata had neurons that released a chemical called serotonin. The number of these neurons was greater than normal in 55% of the brains of the babies who had died of SIDS. They also found that babies had fewer receptors for serotonin and that abnormalities in the brain stem appear to affect the ability to use and recycle serotonin, which is responsible for regulating mood as well as vital body functions. According to the National Institutes of Health, which funded the study, the new finding is the strongest evidence to date suggesting that innate differences in a specific part of the brain may place some at increased risk of dying from SIDS.
In a British study released May 29 2008 researchers discovered that the common bacterial infections Staphylococcus aureus (staph) and Escherichia coli (E. coli) appear to be the cause of some cases of Sudden Infant Death Syndrome. Both the "staph" and E. coli bacteria had a greater presence in the unexplained deaths of infants. SIDS cases peak between eight and ten weeks after birth, which is also the time frame in which the antibodies that were passed along from mother to child are starting to disappear and babies have not yet made their own antibodies.
Listed below are several factors associated with increased probability of the syndrome based on information available prior to this recent study.
Though SIDS cannot be prevented, parents of infants are encouraged to take several precautions in order to reduce the likelihood of SIDS.
Among the theories supporting the Back to Sleep recommendation is the idea that small infants with little or no control of their heads may, while face down, inhale their exhaled breath (high in carbon dioxide) or smother themselves on their bedding—the brain-stem anomaly research (above) suggests that babies with that particular genetic makeup do not react "normally" by moving away from the pooled CO2, and thus smother. Another theory is that babies sleep more soundly when placed on their stomachs, and are unable to rouse themselves when they have an incidence of sleep apnea, which is thought to be common in infants.
Arguments against infant back-sleeping include concerns that an infant could choke on fluids it brings up. Hospital staff commonly place newborns on their side, although they advise parents to place their infants on their backs after going home from the hospital.
Other concerns raised about the Back to Sleep Campaign have included the possible increase the risk of positional facial and head deformities (see positional plagiocephaly), possible interference with development of good sleep habits (which in turn may have other bad effects), and possible interference with motor skills development (as infants delay attempts to lift their heads, crawl, etc.).
A controversial approach to lowering SIDS rates is limiting co-sleeping. A 2005 policy statement by the American Academy of Pediatrics on sleep environment and the risk of SIDS condemned all co-sleeping and bedsharing as unsafe.
However, some data has suggested that almost all SIDS deaths in adult beds occur when other prevention methods, such as placing infants on their backs, are not used. Co-sleeping studied in the West has been present mostly in poorer families where other risk factors are present,. while co-sleeping in other cultures such as in China is more prevalent and is done in combination with practices such as sleeping children on their back, correlating with a significantly lower rate of SIDS than the West.. There are also evolutionary theories as to why co-sleeping would be healthier for infants than sleeping alone. Further studies have suggested that factors associated with safe co-sleeping such as enhanced infant arousals are responsible for a positive contribution to SIDS prevention.
The maternal pregnancy smoking rate decreased by 38% between 1990-2002 .
To prevent SIDS, many families use firm mattresses with tight-fitting sheets in cribs or bassinets. The families do not allow pillows, stuffed animals, or fluffy bedding in the cribs. In cold weather, the families dress the infants warmly in well-fitted clothing..''
Infants' blankets should also not be placed over their heads. It has been recommended that the infants are only covered up to their chest with their arms exposed. This will help eliminate the chances of the infant moving the blanket over their head.
Bumper pads may be a contributing factor in SIDS deaths and should be removed. Health Canada, the Canadian government's health department, issued an advisory recommending against the use of bumper pads, stating:
The presence of bumper pads in a crib may also be a contributing factor for Sudden Infant Death Syndrome (SIDS). These products may reduce the flow of oxygen rich air to the infant in the crib. Furthermore, proposed theories indicate that the rebreathing of carbon dioxide plays a role in the occurrence of SIDS.
A number of theoretical causes have been proposed as a trigger for SIDS, but many of them are unproven or have not been thoroughly studied and peer-reviewed.
According to a 1993 article in Journal of Orthomolecular Medicine, Australian medical doctor Archie Kalokerinos performed research showing that high doses of vitamin C eliminates SIDS. As SIDS was shown to be caused solely by vitamin deficiency, the article stated that it was no longer a syndrome, and that the proper disease name is now SID. As of January 2007, the Journal of Orthomolecular Medicine was not included among journals selected by the U.S. National Library of Medicine for inclusion in their Medline database.
In 1989, a controversial piece of research by UK Scientist Barry Richardson claimed that all cot deaths were the result of toxic nerve gases being produced through the action of fungus in mattresses on compounds of phosphorus, arsenic and antimony. These chemicals are frequently used to make mattresses fire-retardant.
A major plank in this explanation is the widely-observed phenomenon that the risk of cot death rises from one sibling to the next. Richardson claims that the cause is that parents are more likely to buy new bedding for their first child, and to re-use that bedding for later children. The more frequently used the bedding is, the more chance there will be that fungus has become resident in the material; thus, a higher chance of cot death. A paper by Peter Fleming and Peter Blair references evidence from other studies that both supports and refutes the increasing occurrence of SIDS with mattress sharing and suggests that this is still inconclusive.
In 1994, the New Zealand government, under the advice of Dr. Jim Sprott, issued advice recommending new parents to either buy bedding free of the toxic compounds or to wrap the mattresses in a barrier film to prevent the escape of the gases. Dr. Sprott claims that no case of cot death has ever been traced back to a properly manufactured or wrapped mattress
However, a final report of The Expert Group to Investigate Cot Death Theories: Toxic Gas Hypothesis, published in May 1998, concluded that "there was no evidence to substantiate the toxic gas hypothesis that antimony- and phosphorus-containing compounds used as fire retardants in PVC and other cot mattress materials are a cause of SIDS. Neither was there any evidence to believe that these chemicals could pose any other health risk to infants. The report also states that "in normal cot-like conditions it is not possible to generate toxic gas from antimony in mattresses" and "babies have also been found to die on wrapped mattresses." Dr. Sprott's website, however, claims that the study does not actually refute his theory:
Contrary to media publicity, the 1998 UK Limerick Report did not disprove the toxic gas theory—as a highly qualified environmental scientist has stated in the New Zealand Medical Journal. In fact, the Limerick Committee's experiments proved the fungal generation of toxic gases (forms of stibine and arsine) from cot mattress materials.
In February 2000 Dr Peter Fleming (a co-author of the Limerick Report and principal author of the UK CESDI Report) conceded that the claim that three babies in the United Kingdom had died of cot death on polythene-covered mattresses could not be substantiated.
There is ongoing research in the pediatric/neonatal community that has begun to associate apnea-like breathing cessations in animal models with unusual neural architecture or signal transduction in central pattern generator circuits including the pre-Bötzinger complex. It is possible that irregularities in neurotransmitter release (such as GABA, adenosine, and NMDA) or deficiencies in their associated receptors (including both GABAA, GABAB subtypes and NMDA-glutamate receptors) are linked to incomplete prenatal development as is evident in pre-term infants.
Genetic factors are also being studied with several rat and mouse knockouts.
During birth, if the infant's head is traumatically turned side to side, upper cervical spinal injury can result. Difficulty breathing is a classic sign of upper spinal cord and brain-stem injury. When infants with undiagnosed upper cervical spinal cord injury are continually placed on their stomach for sleep, they are forced to turn their head to the side to breathe. This is hypothesised to aggravate and prolong the spinal cord injury sustained during birth, preventing proper healing and ultimately leading to fatal breathing difficulty.
The study which indicated that there was a relationship between fewer serotonin binding sites and SIDS noted that the boys "had significantly fewer serotonin binding sites than girls".
The misdiagnosis of infanticide as SIDS "happens all over," Ms. Talan, a medical reporter at Newsday, said. "A lot of doctors and police don't know how to handle it. They don't take it as seriously as they should." As a result of the book's revelations, people are starting to scrutinize possible cases of this "perfect crime," which involves no physical evidence and no witnesses.
British former pediatrician Roy Meadow believes that many cases diagnosed as SIDS are really the result of child abuse on the part of a parent displaying Munchausen Syndrome by Proxy (a condition which he was first to describe, in 1977). During the 1990s and early 2000s, a number of mothers of multiple apparent SIDS victims were convicted of murder, to varying degrees on the basis of Meadow's opinion. In 2003 a number of high-profile acquittals brought Meadow's theories into disrepute. Several hundred murder convictions were reviewed, leading to several high-profile cases being re-opened and convictions overturned.
The Royal Statistical Society issued a media release refuting the expert testimony in one UK case in which the conviction was subsequently overturned.
A 2005 study by researchers at the University of California, San Diego found that "SIDS may be related to high levels of acute outdoor NO2 exposure during the last day of life. While nitrogen dioxide (NO2) exposure may be one of many possible risk factors, it is not considered causal, and the report cautioned that further studies were needed to replicate the result.
According to the CDC's page on SIDS and vaccines:
According to a 1998 study by British researchers that compared back sleeping infants to stomach sleeping infants there were developmental differences at 6 months of age between the two groups. At 6 months of age the stomach sleeping infants had higher gross motor scores, social skills scores, and total development skills scores than the back sleeping infants. The differences were apparent at the 5% statistical significant level. But, at 18 months the differences were no longer apparent. The researchers deemed the lower development scores of back sleeping infants at 6 months of age to be transient and stated that they do not believe the back sleeping recommendations should be changed. Other scientists have stated that the conclusion that the negative effects of back sleep at 18 months of age is transient is based upon very little evidence and that no long-term randomized trials have been completed.
Other side effects of the back sleeping position include increased rates of shoulder retraction, positional plagiocephaly, and positional torticollis. Some scientists dispute that plagiocephaly is a negative side effect. Dr. Peter Fleming, who is co-author of the study that deemed delays at 6 months of age to be transient, has stated that he does not think plagiocephaly is a negative side effect of back sleep. In an interview with the Guardian Dr. Fleming stated "I do not think it is a medical problem—it is more of a cosmetic one. Mothers may feel it is a syndrome and a problem when it really is nonsense. A research study on children with plagiocephaly found that 26% had mild to severe psychomotor delay. This study also showed that 10% of infants with plagiocephaly had mild to severe mental development delay.
Because of the delays caused by back sleep some medical professionals have suggested that the "normal" ages at which children had previously attained developmental milestones should be pushed back. This would enable medical professionals to consider "normal" children who previously were considered developmentally delayed.
Additional studies have found the following negative conditions that the back sleep position has been reported to be associated with are: Increase in Sleep Apnea, Decrease in Sleep Duration, Strabismus, Social Skills Delays, deformational plagiocephaly, and Temporomandibular Jaw Difficulties. In addition, the following are symptoms that are associated with sleep apnea: growth abnormalities, failure to thrive syndrome in infants, neurocognitive abnormalities, daytime sleepiness, emotional problems, decrease in memory, decrease in learning, and a delay in nonverbal skills. The conditions associated with deformational plagiocephaly include visual impairments, cerebral dysfunction, delays in psychomotor development and decreases in mental functioning. The conditions associated with Gross Motor Milestone Delays include speech and language disorders. In addition, it has been hypothesized that delays in motor skills can have a negative impact on the development of social skills. In addition, other studies have reported that the prone position prevents subluxation of the hips, increases psychomotor development, prevents scoliosis, lessens the risk of gastroesophageal reflux, decreases infant screaming periods, causes less fatigue in infants, and increases the relief of infant colic. In addition, prior to the “Back to Sleep” campaign many babies self-treated their own torticollis by turning their heads from one side to the other while sleeping in the prone position. Supine sleeping infants cannot self-treat their own torticollis.