Primary prevention
There are several factors that can be modified in the primary prevention of SIDS.[3][7]
Avoidance of antenatal and postnatal smoke exposure
Data suggest that smoking increases the risk of SIDS through central and pulmonary mechanisms.[98][99][100][101] Smoke exposure may account for up to 25% of SIDS deaths, and, given the relatively high prevalence of smoking in pregnancy and the general population, reduction in smoke exposure remains one of the greatest modifiable risk factors for SIDS reduction.[79][102][103]
Parents should avoid smoking during pregnancy and after giving birth.
Practitioners can give advice on smoking cessation programmes during pregnancy and for postnatal carers.
Supine position for sleep
Sleeping an infant in the prone position just once increases the risk for SIDS.[47][48][53]
The risks of sleeping in the prone or side position are similar (odds ratio: 2.6 and 2.0, respectively).[47]
Supine sleeping also reduces SIDS risk compared with side-sleeping.[39][47]
Inclined sleep products in which the infant is at a >10 degree incline are not safe for infant sleep. The inclined baby is more likely to roll to the side or prone. When this occurs, the baby is at higher risk of muscle fatigue and suffocation.[51]
Implementation of programmes aimed at educating infant carers, both in healthcare and at-home environments, to place infants in the supine position compared with the prone position have led to a significant reduction in the incidence of infant deaths from SIDS.[39][47][104][105]
Prospective studies dispute the belief that prone position may be the preferred sleep position for infants with gastro-oesophageal reflux disease (GORD).[106][107] Infants with GORD should be placed supine for sleep unless there is associated absence of protective airway reflexes (i.e., the risk of death from GORD is greater than the risk of SIDS).[54]
Safe sleeping environment
A safe sleeping environment for the infant can be created by using firm mattresses with tightly fitting sheets and avoiding over-bundling, sofas and armchairs, sheepskins, pillows, and comforters.
The infant's head should not be covered during sleep.
Bed-sharing during sleep should also be avoided. It increases the risk of SIDS, particularly for infants <3 months of age, in those who bed-share with a parent who smokes, or has consumed alcohol or drugs (marijuana, opioids, and illicit drugs); in those who bed-share on a surface with pillows and/or blankets; and in those whose carers bed-share with them on a couch rather than a bed.[64][65][66][68][108][109] Parents should, however, be encouraged to sleep in the same room as their infant, but with the infant in a separate crib/bassinet.[9][64][66]
Dummy use during sleep
Encouraging routine use of a dummy during sleep times can be considered. Case-control studies demonstrate that use of a dummy during sleep reduces SIDS risk (odds ratio 0.4).[84][85][86][87] One Cochrane review did not find any randomised controlled trials that support this recommendation.[14] However, randomised controlled trials for SIDS are not done because of ethical concerns; therefore, case-control studies are the best evidence available.
A dummy can be introduced to breastfed infants after breastfeeding has been established, which usually takes 2-3 weeks.[3] There is no impact on breastfeeding duration if a dummy is introduced after breastfeeding is established.[88]
Babies who are not being fed directly on the breast can begin using a dummy at any time after birth.
The mechanism behind the apparent protective effect of dummies is unclear. Infants who die from SIDS seem to have an impaired ability to appropriately arouse from sleep, and so protection from dummy use may be associated with lower arousal thresholds, which have been reported in infants who sleep with a dummy.[110]
Potential adverse associations with routine dummy use include an increased risk of infection, specifically otitis media and dental malocclusions. However, the onset of otitis media risk occurs at 2 to 3 years of age, which does not correlate with the age of peak SIDS incidence (1-3 months). Dental problems tend to resolve on dummy cessation.[111]
Immunisation
There is no causal relationship between immunisations and SIDS. Indeed, they provide a protective effect (odds ratio 0.5) against SIDS.[97] Furthermore, immunisation also reduces the likelihood of contracting diseases known to be associated with sudden death (e.g., pertussis or respiratory syncytial virus, which may present with apnoea alone in an otherwise asymptomatic infant) that may mimic SIDS.
Feeding
Breastfeeding should be encouraged during the first 6 months of life (odds ratio 0.5 to 0.6).[3][82][112][113][114]
Any amount of breastfeeding is protective, with more protection seen with exclusive breastfeeding.[82][83]
In using the above list to counsel mothers and parents regarding risk factors for SIDS, it is important to remember that many risk factors may co-exist within a given household or for a given infant. Recommendations addressing all modifiable risk factors must be provided and reinforced at each visit during infancy. Mobile health interventions such as texts, emails, and educational videos have been shown to improve adherence to infant safe sleep practices compared with control interventions.[115]
Secondary prevention
For parents considering pregnancy again, reassurance is given that the likelihood of another SIDS event is extremely low. Added emphasis on reduction of modifiable risk factors, if present, can be considered, SIDS: safe to sleep campaign Opens in new window although this is balanced with the potential of increasing guilt regarding the initial death if such risk factors were present. Parents should be offered testing for metabolic and genetic conditions that may mimic SIDS.
While parents may look for ways in which to prevent the occurrence of a SIDS event in subsequent children, there is no evidence that home apnea monitoring reduces the risk of SIDS. Consequently, home apnea monitoring should not be routinely offered.[130][131]
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