Introduction

The sudden and unexpected death of an infant less than one year is termed sudden unexpected infant death (SUID).   There are two common causes for SUID one is termed Sudden Infant Death Syndrome (SIDS) which is the unexplainable death that typically occurs in healthy infants under the age of one year old.  The second cause is what is called accidental suffocation and strangulation in bed (ASSB).

Currently, the cause of SIDS is unknown, some believe it is a result of a defect in the infant’s brain where the brain doesn’t properly control breathing and arousal from sleep.  Others say that SIDS is no longer a mystery, but is a result of an unsafe sleeping environment.  Even though there is no clear known reason for SUID and no way to eliminate SIDS, there are a lot of preventative steps that can be taken to lower the risk.

Given these tragic and alarming infant deaths, it has become important for the public at large to understand what can be done to prevent these infant mortalities.   Most infant sleep-related deaths are considered avoidable.   New parents must learn how to create a safe sleep environment for their new infant by following key safe sleep practice recommendations outlined by the American Academy of Pediatrics (AAP).

Before an infant’s first birthday SUID is the leading cause of death.   AAP has made several recommendations, but some of the recommendations have caused heated debate.  Some of those issues are breastfeeding, sleeping with your baby and giving babies Vaccinations.

The nursing profession is at the forefront of teaching new parents about the recommendations from the AAP.  Nurses need to be a role model for every new parent that they come in contact with.  Nurses are on the frontline in preventing these newborn deaths. We need to make sure we give parents safe sleep recommendations and teach them how to prevent SUID.  Nurses have the ethical challenge to teach parents the sleep recommendations and at the same time respecting the new parents’ rights.

Selected in-depth focus

The AAP which is a physician-directed organization has defined several recommendations for infant sleep.  The AAP has recommended a safe sleep environment that includes placing the infant on a firm surface on their back.  Keep the bed free from soft bedding and other items such as soft toys.  For the first 6 months of the infant’s life, they should sleep in the same bedroom as the parents, but in a separate bed.  The infant should also not be exposed to any drugs or alcohol.  Breastfeeding is also suggested to help reduce SIDS and providing a pacifier when the child goes to sleep.

New parents need to understand what actions they can take to minimize the possibility of SIDS.  This information can be learned online, from your family doctor, or  the nursing department.  The best way for a family to learn how to prevent SIDS is when a family observes a registered nurse demonstrating safe sleep recommendations in the hospital.   That family is more likely to follow the recommended safe sleep practices at home.  Let’s look at each of the main AAP recommendations.

The first recommendation is to not place your infant on their stomach when they sleep.  It is recommended to place the infant on their back because the infant will have more access to fresh air and will be less likely to overheat.  Also placing the infant on their side increases the chances of SIDS because the infant can roll over on their stomach much easier.  Once the child reaches a certain age, they will be able to roll over on their own, but the risk of SIDS is greatly reduced as the child can control their breathing.

Keep the bed free from soft bedding.  Any type of soft bedding, blankets, pillows, comforters, and stuffed toys can hamper your child’s breathing, so it is best to not put anything in the crib until the child’s first birthday.  To keep your infant warm, you can swaddle them in a blanket or bed bag.  Always use proper swaddling techniques.  Swaddling can help the infant sleep better on their back and feel more secure.  Swaddling has been used for thousands of years, but the “use of tight, traditional swaddling practices, which tended to immobilize infants in a mummy-like configuration, decreased dramatically in the Western world in the 18th century after being widely condemned by the medical establishment” (Nelson, 2017).

Infants should sleep in the same room as their parents.  The parent should make arrangements for the baby to sleep in the same room for the first 6 months to 1 year.  There are several benefits to this arrangement, including the ability to easily monitor the baby, provide comfort to the infant and reduce the risk of suffocation. Even though the infant is in the same room, they should have their own bed, such as a crib or bassinet, with a firm mattress.

Infants should be breastfed.  Research shows that infants that are breastfed, tend to be more easily aroused from sleep than those that are formula-fed (Moon, 2016).   Mothers who breastfeed typically don’t smoke, so there is less chance of the infant be exposed to second-hand smoke.  It is recommended that if you are tired and you need to breastfeed the baby, then lie in your bed and not on a couch or other cushioned chair.  Breastfeeding also will be of great health benefit to the infant, such as a stronger immune system which can reduce infections and other types of diseases.  This reduction in infection and disease helps to reduce the risk of SIDS.

Give your baby a pacifier when they go to sleep has been shown to reduce the risk of SIDS.  The reason is currently unknown, but it might have to do with the pacifier holding the tongue away from the airway.

Nurses are expected to provide instruction to maintain optimal levels of wellness, prevent disease, manage illness, and develop skills to give supportive care to family members. It is important that when the infant is discharged from the hospital that the nurse instructs parents to not place their baby in the prone or side-lying position.  The nurse should also teach parents to place their babies on his or her back to sleep for the first year. Parents should require anyone who cares for their baby to do likewise.  However, once the child can roll over, there is no need to keep flipping him or her over onto their back.  The nurse should also instruct them about risk reduction, measures including no soft bedding or co-bedding, avoid overdressing/overheating, and protecting the infant from any smoke exposure.

Ethical Issues

Maintaining patient safety is one of the most important components of nursing practice. The nurse’s main job is to advocate for and protects the rights, health, and safety of the patient.   Some of the recommendations from the AAP for the parents to follow to lower the risks for SIDS can cause ethical issues.  One of the recommendations is to have a separate bed for an infant but in the same room.  This can cause issues with a lot of cultures and families because of the belief that it is important. Many of the world’s mothers wouldn’t dream of placing a baby or young child in a separate bed.   According to the new AAP recommendations, a separate but nearby sleep location for the infant is now endorsed in place of bed sharing.  This policy has created a lot of controversies, but the evidence shows that potential risks can be reduced by not sharing the same bed, versus what culture demands.

When it comes to breastfeeding, every new mother has to make a decision based on her ability and personal beliefs.  The decision to either breastfeed or formula feed can make a difference in the reduction of SIDS in newborn infants.  Infants that have been breastfed tend to awake easier and have better health due to a stronger immune system.  The AAP recommendation for breastfeeding to help prevent SIDS can cause controversy, with new mothers who don’t necessarily believe in breastfeeding because of culture and other factors.  The other side of the coin is the fact that breastfeeding evidence shows that it can lower the risk of SIDS.

Conclusion

Currently, there are close to 3500 sudden unexplained infant deaths per year in the US.  Even though the cause of SIDS is mainly unknown, there are several steps that can be taken to lessen the risk.

Nurses hold the key to saving lives!  Nurses are the key to getting accurate information to parents and educating them on safe sleep practices.  Nurses are essential role models for parents and they need to demonstrate to the parents the proper and right way to put an infant to sleep.  Nurses are in a powerful position to make a difference and help to reduce the SIDS tragedy.  The nurse can be at the forefront of teaching each new parent to follow the AAP guidelines for “Safe Sleep”.

Maintaining patient safety is one of the most critical ethical components that a nurse follows.  Helping to teach and train new parents on the AAP recommendations around new infant’s safe sleep to help reduce the risk of SIDS.  Some of the AAP recommendations can cause ethical issues around such topics as breastfeeding, sharing the same room versus the same bed.  These issues need to be discussed with the new parents, so they can understand the importance and the rationale behind each AAP recommendation.

References

• Moon, R. Y. (2016). SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment.
  
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• Naugler, M. R., & Dicarlo, K. (2018). Barriers to and Interventions that Increase Nurses’ and Parents’ Compliance With Safe Sleep Recommendations for Preterm Infants. Nursing for Womens Health, 22(1), 24–39. doi: 10.1016/j.nwh.2017.12.009
• Nelson, A. M. (2017). Risks and Benefits of Swaddling Healthy Infants. MCN, The American Journal of Maternal/Child Nursing, 42(4), 216–225. doi: 10.1097/nmc.0000000000000344
• Newberry, J. A. (2019). Creating a Safe Sleep Environment for the Infant: What the Pediatric Nurse Needs to Know. Journal of Pediatric Nursing, 44, 119–122. doi: 10.1016/j.pedn.2018.12.001
• Ricci, S. S., Kyle, T., & Carman, S. (2017). Maternity and pediatric nursing. Philadelphia: Wolters Kluwer.

Although concerns have been voiced about the potential impact of this policy on breastfeeding, a recent article in the Journal of Human Lactation recognized the intent of the policy and noted that lactation consultants should determine how best to provide support to women as they follow these guidelines.40 While infants may be brought into the parent’s bed for comfort or to support breast-feeding, they should be returned to a separate sleep surface (eg, a crib, bassinet, or cradle that meets the Consumer Product Safety Commission standards) when the parent returns to sleep. Infants should not share their bed with a sibling or other child. Nurses should review hospital policies concerning cobedding of multiples, as this practice provides a contradictory model. However, sleeping in the same room as the parent is recommended as data support the risk-lowering benefit of room sharing.