Sudden Infant Death (SIDS) SLIDE 1 Infant asleep lying on her back. SLIDE 2 Training Objectives: To understand the current recommendations on infant safe sleep practices To understand the barriers to following safe sleep recommendations To learn techniques for how to work effectively with parents to increase safety. SLIDE 3 Explanation of chart: Top Three Causes of INfant Deaths, Florida 2003. Number 1 is perinatal conditions, congentital anormalities is second, and SIDS is the third cause of infant death in Florida. SLIDE 4 Definition of Sudden Infant Death Syndrome “The sudden and unexpected death of an infant under one year of age, with the onset of the lethal episode apparently occurring during sleep, that remains unexplained after a thorough investigation including performance of a complete autopsy, review of the circumstances of death and the clinical history.” An expert panel of pediatric and forensic pathologists and pediatricians developed a new general definitions of SIDS. This group then proposed a stratification of cases based upon the information gathered which would be more inclusive and would provide better opportunities to evaluate new theories. This new definition would include those infants found face down or in shared sleeping situations because neither of these would automatically exclude SIDS. Prone position was considered as a risk factor for SIDS but not necessarily a cause of suffocation unless specific circumstances could be demonstrated. The problems that result from prone sleeping such as rebreathing of carbon dioxide, overheating, upper airway obstruction, etc. Are most likely problems only among infants with underlying susceptibilities. SLIDE 5 Facts about SIDS Leading cause of infant deaths from 28 days to 1 year. 85% of all sudden and unexpected infant deaths between the age of 1 month and 1 year are due to SIDS. Highest incidence occurs between 2 to 4 months. 90% of SIDS occur from 1 to 6 months of age. Higher incidence among male infants. When a baby seems to be healthy, but dies usually while sleeping, for no other reason, it is called Sudden Infant Death Syndrome (SIDS). SIDS is sometimes called "crib death". No one can predict which babies will die from SIDS. There is no known way to prevent SIDS but there are ways to reduce the risk of dying from SIDS. There is no known medical certainty about what causes SIDS but there are some theories about what may be happening They do know that babies who die of SIDS: Do Not cry out Do Not suffocate or choke Do Not suffer SLIDE 6 Maternal Risk Factors Smoking during and after pregnancy Maternal age < 20 years Poor prenatal care Low weight gain Anemia Use of alcohol or drugs History of STDs or UTIs Researchers now know that the mother’s health and behavior during her pregnancy and the baby’s health before birth seem to influence the occurrence of SIDS but don’t necessarily predict how, when, why or IF SIDS will occur. These behaviors are associated with prematurity and low birth weight. An example of research that links alcohol use to SIDS deaths is the Aberdeen Indian Study found that binge drinking (5 or more drinks at a time) during the first trimester made it 8x more likely an infant would die of SIDS. Drinking during the first trimester and three months prior to conception are associated with a 6 fold increase in SIDS. Picture of the side silhoutte of a pregnant woman. SLIDE 7 Infant Risk Factors: Male Low birthweight Premature African-American Native American Exposed to tobacco and drugs 2.5 times higher in African-American infants than white. 3 times higher in some Native American communities Cartoon picture of an infant on his back holding his toes. SLIDE 8 Chart of Florida SIDS rates and deaths by race and hispanic ethnicity, 2003. Black, non hispanic infants had the highest rate of death, 64.96 per 100,000 births. We also know that we continue to have a disparity in the number of white deaths and black infant deaths. African-American babies are nearly twice as likely to die from SIDS as white babies. 50% of black babies are still sleeping on their stomachs and African-American are twice as likely to bed share. SLIDE 9 Triple Risk SIDS Theory: External Stress Factors (Modifiable) temperature swaddling bedding sleep position smoking drug use minor respiratory symptoms poverty limited prenatal care season Picture of three circles that overlap. The first circle is, "vulnerable infant", the second circle is, "critical development period", and the third circle is, "external stress factor". The factor that is overlapping all three circles is "SIDS". Triple Risk SIDS Theory is that the Vulnerable Infant is one with an intrinsic developmental defect that is undetectable. The Critical Development Period coincides with a period of rapid growth and development of the brain during the first six months of life This time period accounts for 90% of all SIDS deaths.  Second, the baby must be passing through the stage of development when the autonomic nervous system control is relatively unstable and easily threatened by outside “stressors”. 90% of SIDS deaths occur during this period between two and six months of age. The third and currently the only modifiable area is the Exogenous Stressors or environmental factors, such as sleeping on the stomach, loose bedding or inappropriate sleep surfaces. The bottom line is that researchers believe that no single risk factor is likely to cause a SIDS death. Rather, the convergence of several risk factors combined may contribute to cause an infant to die of SIDS. At this time we know of no specific cause or causes of SIDS. But, it is much more complicated than that. Third, a group of environmental factors must be present; perhaps prone sleeping, overheating, having the baby’s head covered and exposure to smoke. In the triple risk model, SIDS occurs only if all three conditions come together on the wrong night or day; a vulnerable infant during that peak developmental stage is exposed to an environmental factor that he, because of his particular vulnerability, is unable to recover from. (age – vulnerability) 2-4 months - 75% 4-6 months - 15% SLIDE 10 Current Theories Based on Recent Research: Chemical receptors that respond to low blood oxygen or high blood carbon dioxide may not function normally This could lead to respiratory failure and death in certain circumstances Prematurity, exposure to cigarette smoke and other risk factors may operate by contributing to this abnormal function Picture of a cross section of the brain with arrows pointing to the cerebral cortex and the brain stem. SLIDE 11 Environmental Risk Factors: Prone sleeping (sleeping face down) Is estimated to account for 40-80% of SIDS cases (Source: Nursing Research Mar/Apr 2004) One of the biggest risk factors for SIDS is prone sleeping or sleeping on the stomach. Babies sleep differently on their backs than they do on their stomachs. When infants sleep on their stomachs they are less reactive to noise, sudden decreases in blood pressure and to touch. They lose heat less effectively in this position. They experience a reduction in heart rate control, have less movement, are in a deeper sleep. They don’t waken as easily. This is very significant because infants who sleep in the prone position (on their stomach) may be rebreathing air which is high in carbon dioxide and low in oxygen, which can be deadly. In this position infants cannot respond as effectively if their air supply is cut off. Sleep is less deep in the supine position and the heart activity is more responsive compared to prone sleeping. Sleep is lighter and the infants are potentially much more responsive to an challenge that might threaten them. When an infant can awaken from sleep, the body has the most potent reflexes to deal with any threat to their system. Cartoon picture of an infant sleeping face down. SLIDE 12 Tummy sleepers are 5 to 7 times at greater risk of dying of SIDS than back sleepers. Back sleepers who nap on their tummies face an 19-fold risk of SIDS. (Source: Mitchell and Thach, Arch Pediatr Adol Med, 1999). Tummy sleepers at Greatest Risk The latest research in the U.S. indicates that tummy sleepers are 5 to 7 times at greater risk of dying of SIDS than back sleepers. Back sleepers who nap on their tummies (Unaccustomed Prone) face an 19.3-fold risk of SIDS, according to research by Bradley T. Thach, Washington University, St. Louis. (*Mitchell and Thach, Arch Pediatr Adol Med, 1999) Secondary caregivers may change the position Less ability to lift head when prone Later development of upper body strength Back sleepers might be more vulnerable on their stomachs because they lack experience in that position. 30 % of caretakers, after being vigilant with newborns, switch babies to tummy sleeping at 2 to 4 months old- the peak risk period for SIDS. Some parents are cautious for night sleeping but are lax for naps. Babies die of SIDS 2 to 3 times more frequently in daycare homes and centers than researchers would expect, given the time they spend there. (Rachel Moon, George Washington University) Supine position – refers to being placed on the back Prone position – refers to being place on the stomach Unaccustomed prone – refers to a normal back sleeper being placed on the stomach. SLIDE 13 Side Sleepers Have a Two-Fold Greater Risk of SIDS. Side Sleepers at Greater Risk An NICHD study conducted in CA. by Kaiser Permanente found that infants last placed to sleep on their sides were twice as likely to die of SIDS than infants last placed on their backs. In addition, the risk significantly increased if infants turned from their sides to their stomach during sleep. Stomach sleeping and side sleeping are more common among babies born extremely premature, even though they face a much higher risk of SIDS than larger babies. Very small, premature babies are often put to sleep on their stomachs in the NICU, where they can be closely monitored. Such infants often have lung problems and doctors believe they can breathe easier on their stomachs. Doctors should, but often don’t, switch premature babies to back sleeping toward the end of their hospital stays. Parents who see their hospitalized babies on their stomachs may assume that is the correct position at home. Parents need to be directed to put their babies to sleep on their backs by their physician. Picture of an infant in a hospital bassinet sleeping face down. SLIDE 14 Chart of the Florida 2002 PRAMS Data: Infants Sleeping Position by Maternal Race PRAMS stands for Pregnancy Risk Assessment Monitoring System and is a telephone survey that is sent out to women several months after they have given birth. According to the latest survey results less than 50% of hispanic and African American moms are putting babies to sleep on their backs. The total for all racial groups is just above 52%. This tells us that there is still considerable work to be done to get the word out about safe sleep. What are some of the reasons why people are not following the safe sleep recommendations? SLIDE 15 Environmental Risk Factors Overheating An infant retains more body heat when he is on his stomach because the main source of heat loss in the baby’s head and particularly the face. Babies do not wake up as easily when they are hot. Therefore they may be less able to wake up and protect themselves from things that might happen to them during sleep. Also being too hot causes the infant’s heart, lung and sweat glands to work harder to cool down. Studies have shown that an infant frequently has it’s head covered when bedsharing, as well as the heat source provided by the mother’s body under shared blankets. Caricature of a swaddled infant. SLIDE 16 Exposure to tobacco smoke increases the risk of SIDS Smoking remains the single most important preventable cause of poor birth outcome According to Susan Fisher of the University of California at San Francisco, tobacco use is responsible for 19,000 to 141,000 abortions, 32,000 to 61,000 low birth weight infants, 14,000 to 26,000 infants who require admission to neonatal intensive care units and 1,900 to 4,800 infant deaths. She has been conducting research on the effects of maternal smoking on placental development. She found that maternal smoking harms the growth of the placenta even before it harms the growth of the baby. She uncovered a domino effect in which the damaged placenta does not support normal development of the baby in the womb. Other recent research has shown that smoking during pregnancy causes damage to the airways of the unborn child. A team of researchers in the UK discovered that airflow through the breathing tubes was on average 20% lower in babies born to women who smoked during pregnancy and that the effect persisted for at least the first 18 months of life. “Assessment of airway function in premature babies allowed the researchers to deduce that these differences in airway function were present up to 2 months before the babies were supposed to be born. Nicotine can affect the development of the lung and brain of the fetus. There is also evidence that smoking alters cardiovascular responses in infants. The risk of SIDS is 3 times higher for mothers who smoke while pregnant. After pregnancy, the risk rises, depending on the number of smokers in the household and the number of cigarettes smoked by each person. Research suggests the risk of a SIDS death is 2-3 times higher for babies living in smokers’ households. Cartoon pictures of a pipe, cigarette, and a cigar. SLIDE 17 Sleeping in Adult Beds Can Result in: Entrapment/wedging Overlying Suffocation from Bedding Strangulation Adult beds are not designed for babies. Babies can suffocate in bedding such as pillows, comforters, blankets, etc. They can also become trapped between the mattress and the headboard or the mattress and the wall. Babies can fall out of adult beds and be injured. Babies can be suffocated by another person in the bed. It can happen even if the adult is not on top of the baby. Babies have suffocated who were simply up too close to the adult’s body which then cut off the air supply. Cartoon picture of an adult bed. SLIDE 18 Comparison of Risk for Suffocation in Adult Bed and Sofa/Chair: For infants younger than 8 months, risk of dying in a crib was 0.63 deaths per 100,000 infants Risk of dying in adult bed was 25.5 deaths per 100,000 infants (Source: Scheers, et. al., “Where Should Infants Sleep? A Comparison of Risk for Suffocation of Infants Sleeping in Cribs, Adult Beds, and other Sleeping Locations,” Pediatrics Vol. 112 No. 4 October 2003.) Scheers, et. al conducted an analysis of sleep practices of 348 infants whose deaths were identified as suffocation in cribs and adult beds. The suffocation patterns found were: Entrapment/wedging: body caught between 2 products or between components of a single product Overlying: narrative reported diagnosis of overlay or head/body reportedly covered by all or part of another person’s body Respiration compromised by bedding: face and or head covered by pillows, comforters, blankets or sheets The primary suffocation patterns association with adult beds was entrapment. When overlying deaths were reported, it was because someone found the infant covered by an adult or child. The primary suffocation patterns associated with deaths on sofas or chairs were entrapment and overlying. 60.6% of the deaths on sofas or chairs classified as nonspecific suffocation, also reported the infant was sharing the sofa or chair with another person. Study found the risk for suffocation in adult beds was 40 times higher than the risk for suffocation in cribs. SLIDE 19 The Incidence of Bed-sharing - It’s on the Rise The incidence of bed-sharing has increased from 5.5% in 1993 to 12.8% in 2000. (Source: Archives of Pediatrics and Adolescent Medicine, January 2003.) In many cultures, sleeping with baby is the norm. The US is the only country that emphasizes babies sleeping in their own beds in their own rooms. The May 2005 edition of Parenting Magazine reported on a recent internet poll where 68,000 people responded to the question “Do you think babies should sleep in their parent’s bed? 30% said YESAccording to research by James McKenna, while sleeping together mothers and babies are extraordinarily in sync. The movements and breathing of one partner, mother or baby, affect the other. Co-sleeping results in more attention by the mothers. Women who sleep with their babies have a longer duration of breastfeeding so some lactation consultants have actually promoted bed sharing for that reason. I suspect there may be a difference between those mothers who are very committed to breastfeeding and co-sleeping and started out doing this and those mothers who take their babies to bed because they (mothers) are too tired to get up with them or are trying to get the baby to go to sleep. These mothers would not be accustomed to having the baby in bed and might be less likely to wake up in their body was too close to the baby. Picture of a Mother and an infant sleeping in an adult bed together. SLIDE 20 What are the Reasons Given for Bedsharing ? 1. No crib 2. Easier to breastfeed at night 3. To avoid crib death 4. Family tradition 5. To spend quality time 6. Too tired to get up 7. To keep baby warm 8. Baby sleeps better SLIDE 21 Bar graph on Florida SIDS Rates per 100,000 Live Births from 1993 to 2003 This graph further illustrates the declining SIDS rates in Florida. The number of SIDS deaths has declined considerably since the American Academy of Pediatrics recommended babies be placed on their backs to sleep. This decline is also represented in this graph. The lack of decline in the post neonatal mortality rate from 1999-2001 suggest that reclassification of SIDS cases is now occurring. While the number of SIDS deaths is declining, the number of infant deaths due to suffocation in bed is increasing from 22 in 2000 to 43 in 2001. There appears to be a shift in diagnosis occurring due to more detailed information about the circumstances of deaths and relevant sleep practices. Accidental suffocation or positional asphyxia is a preventable cause of death but is difficult to distinguish from SIDS because post mortem findings may be similar and the age of peak risk overlaps between the two. The diagnosis often depends on an estimation of whether or not a normal infant would have been physically capable of escaping the constraints of the entrapment. This is often a subjective assessment. SLIDE 22 Bar graph on Cause of Death: SIDS and Suffocation in Bed A Comparison of Florida Infant Death Rates per 100,000 live births from 1995-2003. Between 1992 and 1999 the total SIDS rate in the US dropped from 1.2 per thousand live births to 0.67 (44% decrease). Much of this decline has been attributed to the back to sleep campaign and the decline in prone sleeping. Increasingly, the reliability of SIDS certification is being questioned. The SIDS rate dropped at an average annual rate of 8.6% while other causes of infant death have been increasing. Suffocation in bed increased at an average rate of 11.2%. Between 1999 and 2001 there was no significant change in the post-neonatal mortality rate but the SIDS rate has continue to decline. During this period, deaths attributed to known or unspecified cause has increased significantly. Bass et al conducted death scene investigations in 26 consecutive cases brought to the ED in which the presumptive diagnosis was SIDS. They found that 6 were accidental and 18 had causes of death other than SIDS. Their primary conclusion was than many sudden infant deaths have a definable cause that can be revealed by careful investigation of the death scene. SLIDE 23 Total Postneonatal Death Rate (per 1,000 Live Births) Deaths occurring 28 to 364 days from birth. SUSAN TO EXPLAIN**** (FloridaCHARTS.com is provided by the Florida Department of Health, Office of Planning, Evaluation and Data Analysis, (850) 245-4009.) Data Source: Florida Department of Health, Office of Vital Statistics. SLIDE 24 PANHANDLE FIMR STUDY OF SLEEPING INFANT DEATHS from 1994-2003: Our data sources such as FIMR show that we have a significant number of deaths due to unsafe sleep practices. 87% (46/53) of cases had one or more documented “sleep risk factors”: Placed on adult bed (50%) Placed on sofa, chair, pillow of lap (22%) Positioned on stomach (55%) Slept on or near questionable bedding (74%) Slept with other family members (56%) Exposed to second-hand smoke (30%) SLIDE 25 AAP Recommendation for SIDS Risk Reduction: A separate but proximate sleeping environment is recommended Room sharing allows mother and child to remain close at night. The baby can hear and smell the mother which helps to regulate the baby emotionally. It can make breast feeding easier. There is nothing dangerous about breast feeding in bed but when it is time to go to sleep, the baby can be put in a safe environment for sleep. This allows both mother and baby to sufficient rest. While bed sharing has not been shown to be protective against SIDS, room sharing has been shown to be of some benefit. Cartoon pictures of a crib and an adult bed. SLIDE 26 What Are The Barriers To Following Safe Sleep Recommendations? Cartoon picture of a worksite barrier. SLIDE 27 What Are The Barriers To Following Safe Sleep Recommendations? National annual telephone survey or 1000 households: African American. Hispanic, Asian and American Indian parents of 2 and 4 month olds. The purpose of the study was to find out how parents of color learned about infant sleep position recommendations, what practices they use for positioning their infants and how they felt about the current recommendations. Found that African-Americans were most likely to use prone position. Higher rates were found in inner-city parents. In 1992 82% of African-American mothers placed their infants prone. This decline to 43% in 1995 and 1996. Cartoon picture of a woman on the phone while working on a laptop computer. SLIDE 28 Findings from Focus Groups with Caregivers Caregivers reported concerns about: Safety – choking Comfort – believed child more comfortable on stomach Advice – trusted family members and their own instincts over health professionals. 2003-2004 focus groups with primarily African American caregivers to find out what caregivers think and why they think they way they do. Purpose: To identify themes and specific language that inner city primarily African-American caregivers use to explain how they make decisions related to sleep position and to identify barriers to adherence to back to sleep recommendations. 9 focus groups were held between October and November 2003. There were 49 group participants 92% were women 16% were grandmothers 86% were Black SLIDE 29 Findings from Focus Groups with Caregivers Caregivers lacked knowledge about: What causes SIDS The dangers of soft bedding Why back sleeping is important. Some still believed SIDS happens in a crib so avoided placing child to sleep in a crib. Some doubted existence of SIDS. They felt that some babies just die. “You have to educate us. Don’t just say put baby on his back. Tell us why.” Confusion about which advice to follow since it has changed. Caregivers need help coping with the fact that infants don’t sleep for as long and as deeply on their backs. SLIDE 30 Why are Parents Still Putting Babies to Sleep on Their Stomachs? 1. Baby sleeps better on stomach 2. Baby cries if put down on his back 3. Baby will choke 4. Baby can breathe easier 4. Advice from grandmother 5. Previous experience 6. Doctor said it was ok. The West Palm Beach health Department asked their home visiting staff to complete a survey asking what reasons parents were giving for not putting their babies on their backs. Cartoon picture of a father putting baby to sleep on his stomach. SLIDE 31 SIDS and the Child Care Setting Research (Moon, Pediatrics 2000) indicates: 20.4% of all SIDS deaths occur in the childcare setting (1995-1997); of these deaths, 60% occur in Family Child Care homes 20% occur in child care centers 20% occur with a babysitter, nanny,relative’s home 1/3 die in the first week in child care; 1/2 of these die on the first day 9.4%-40.2% of SIDS deaths occur while infants are in the care of someone other than the parents. 59.5% of infants found on stomach were usually back sleepers Infants tend to be Caucasian, with older, more educated parents. Dr. Moon’s research indicates that 20.4% of SIDS deaths are occurring in childcare centers. This is more than double what we would expect from the number of infants in child care. This has become the newest risk factor for SIDS; infants who are by other measures considered low risk now become high risk because of child care. So the question emerges: Why is the SIDS rate abnormally high in childcare settings? Is there something intrinsic to child care?? Unaccustomed prone sleeping -- when a baby that is normally placed on its back to sleep by the primary caregiver is placed on the stomach to sleep. SLIDE 32 Why Do Child Care Providers Place Babies Prone? Lack of awareness 25% of licensed CCC have never heard of the relationship between SIDS and sleep position Misconceptions about risks of sleep position Supine and aspiration, choking Emphasis on infant comfort Parental preference Lack of information Lack of empowerment The Back to Sleep campaign has been successful in getting the back sleeping SIDS risk reduction message out to parents and other primary caregivers, but has fallen short in getting the message and training out to childcare providers. Unaccustomed prone sleeping is a contributing factor to the high rate of SIDS in childcare settings. Dr. Moon surveyed childcare providers to gain some insight as to why they were placing infants to sleep on their tummies. Her findings indicated that 25% of licensed child care providers had not heard about the importance of back sleeping to reducing SIDS risk. Her results also indicate that there are many misconceptions and myths regarding SIDS that need to be addressed. There is no scientific evidence that infants aspirate and choke if they spit up or vomit when in the supine position. We need to educate and train child care providers in safe sleep practices. SLIDE 33 Preemies No Longer Exempted Based on all available data, we now recommend that all full-term and preterm infants in the NICU without upper airway obstruction be placed in the supine position for sleeping as soon as ready for oral feedings.(Dr. Carl Hunt) Preemies No Longer Exempted The initial focus of the various “Back to sleep” campaigns was for full-term infants in the home environment, but back sleeping appears to be as safe in preterm infants as in term infants, and preterm infants have been included in those home recommendations since 1996. It is common to utilize the supine position in acutely ill infants, but tummy or side sleeping has generally been the routine sleep position as infants improve. Based on all available data, we now recommend that all full-term and preterm infants in the NICU without upper airway obstruction be placed in the supine position for sleeping as soon as ready for oral feedings. As in the newborn nursery, this will also provide opportunities to demonstrate safe bedding & blankets. These recommendations for the final phase of newborn hospital care will provide an opportunity for the hospital care team to model recommended sleep position (on the back or supine) and safe bedding and blankets. This early modeling should lead to further decreases in prone and side sleeping rates at home without incurring any risk to full-term or preterm infants approaching discharge from the nursery or NICU.” Picture of a premature infant in an incubator with all the tubes and wires attached. SLIDE 34 American Journal of Maternal Child Nursing Bar graph showing sleep positions for infants. Majority of infants placed on side (55%), while prone sleeping (16%), and supine sleeping (29%). This research article surveyed 103 nurses. 97% of the nurses were aware of the AAP supine sleep recommendation, only 67% agreed with it. The chart refers to observed infant positioning in a newborn nursery where n=206. The study found that nurses also fear infants will aspirate if placed on their backs. A Missouri study of hospital nurses working with health newborns found that 51% felt that sleep position was no associated with SIDS or were unsure is sleep position was associated. It also showed that over 1/3 of these nurses continued to used the lateral position for newborns in the first 24 hours of life and after that time period as well. Health care professionals and physicians recommendations can greatly influence parent’s decision. Even if parent’s are told about back to sleep, they tend to follow position that they observed their infant to be in while in the hospital. It is important that parents are educated about sleep position before birth and then observe nurse using the supine position while in the hospital. SLIDE 35 Tasks of Falling Asleep 1. Regulating sleep-wake cycles 2. Internalizing daily routines and schedules 3. Transitioning from active and quiet alert states to sleep 4. Screening out noise to fall asleep 5. Self calming when awakened in the night 6. Feeling attached to caregivers while feeling secure in separating from them to sleep (Source: Pediatric Disorders of Regulation in Affect and Behavior. De Gangi. 2000). ng any risk to full-term or preterm infants approaching discharge from the nursery or NICU.” Picture of an infant sucking her thumb while sleeping on her back. SLIDE 36 Sleep Problems 1. Difficulty initiating (settling into sleep) 2. Difficulty maintaining sleep (waking up during the night with difficulty returning to sleep. (Source: Diagnostic Classification 0-3) When children have problems sleeping, parents are more likely to engage in unsafe sleep practices, such as stomach sleeping or bed sharing, in order to get the child to go to sleep. Picture of a crying baby with a baby blanket on her head. SLIDE 37 Causes of sleep problems: Medical Problems Regulatory Disorders Attachment Disorders Poor Sleep Hygiene SLIDE 38 Medical Problems Which Interfere With Sleep: 1. Obstructive sleep apnea syndrome (OSAS) 2. Respiratory conditions, e.g. asthma, CF 3. Food allergies 4. Ear infections SLIDE 39 What Is Self Regulation? “The mastery of tasks that were accomplished by the mother’s body or in concert with the mother’s body when the child was in the womb, but must now be accomplished by the child’s body and through signaling needs to responsive adults.” (Source: From Neurons to Neighborhoods, 2000.) During the first three months of life the baby’s behavior and physiology shift from intrauterine to extra-uterine regulation. These tasks include everything from maintaining a normal body temperature to orchestrating physiology and behavior to conform to the day-night rhythms, to learning to soothe and settle once basic needs are met. Self regulation includes the ability to be soothed when upset, gradual acquisition of predictable sleep/wake cycle and tolerance of a range of sensory stimulation. Regulation in early development is deeply embedded in the child’s relations with others. Parents are acting as extensions of their internal regulatory systems. The first step for parents in the earliest days of a child’s life is to establish regulatory connections with them and then gradually shift the responsibility of regulation over to them in the day to day domains of sleeping, waking and soothing. When infants have regulatory problems such as excessive crying or irregular sleeping, the problem often lies not with the infant but in the transactions between the infant and the caregivers. SLIDE 40 Developmental Milestones of Self Regulation In Infancy Regulation of arousal and sleep-wake cycles Responsive interactions with others Attempts to influence others Begins to anticipate and participate in simple routines (Source: Bronson, Martha. (2000). Self Regulation in Early Childhood. New York: Guilford Press.) Stanley Greenspan states that “self regulation is reflected in the infant’s ability to calm down and take an interest in the world.” The infant learns to regulate himself by taking in and processing information, leading to increased independence in state regulation, sleep and attentiveness. When babies can maintain a quiet alert state they can begin to form attachments. SLIDE 41 Role of Adults in Infant Self Regulation Being sensitive to infant signals and “state” Being responsive to infant’s signals Engaging in warm positive interactions Participating in predictable sequences of caregiving, social and play routines that the infant can learn and participate in (Source: Bronson, Martha. (2000). Self Regulation in Early Childhood. New York: Guilford Press.) The development of emotional self regulation is affected by the quality of the environment as well as the care the child receives. The adult needs to provide an environment that contains a reasonable amount of order and routine that the infant can recognize and anticipate and provide alternating periods of stimulation and quiet that assist the child in regulating around and sleep-wake cycles. If parents over stimulate a baby, all the baby’s energy goes to protecting itself rather than to learning and brain development. Responding quickly and sensitively to baby’s cries helps the baby’s brain to develop patterns – baby learns there is regularity in his world. Parent needs to read their baby’s cues and signals for how much stimulation they can handle, when they seem to get hungry and sleepy and support their early attempts at self regulation. Regular predictable patterns in the environment as well as responsive care help children to develop emotional control. They may be less frantic when hungry, tired or otherwise upset when they learn predictable routines and that their signals will summon help. SLIDE 42 Sleep Problems Occur in Children with Regulatory Disorders Hypersensitive Over-reactive to touch or sound Difficulty settling or getting comfortable Motorically Disorganized Craves vestibular stimulation Can only fall asleep with movement or vibration. A baby who is sensory sensitive will react to many things in everyday life. This child will be easily upset (irritable, often crying) and cannot soothe himself readily (finds it difficult to return to sleep). He will be light sleeper, being easily awakened by sound or light, will turn to look at movement or sounds, may only settle into one or two outfits, be very picky about the sheets, etc. Babies who are sensation seeking will crave movement and roughhousing. They may rock when sitting. Picture of a young toddler crying. SLIDE 43 Disorders of Attachment in Infancy Can Affect Self Regulation Constitutional vulnerabilities in the infant Emotional liabilities in the parents Poorness of fit (Source: Infant and Toddler Mental Health, edited by J. Martin Maldonado-Duran, M.D.) The security of the child’s attachment to caregivers and the quality of care provided affect the child’s capacity of emotional self regulation and behavioral control When caregivers do not make verbal or physical contact and respond to the infant’s signals OR when they respond unpredictably, the child’s early attempts to interact with the environment and find patterns and meaning will be delayed or impaired. Attachment problems can be caused by the three things above. Constitutional vulnerabilities may include regulatory disorders or a difficult temperment which makes them fussy and difficult to console. Premature or medically fragile infants often have regulatory challenges. These infants are much less adept in organizing rhythms of sleep, waking and feeding. They are more unpredictable, fussier, make less eye contact, smile less, vocalize less, show resistance to being cuddled or be sensitive to stimulation. and to show less positive affect which makes it more difficult for parents to read their cues and respond in a sensitive manner. These infants are challenging to care for and parents don’t always understand the meaning of a child’s responses and then respond inappropriately, leading to a vicious cycle. Emotional liabilities: Depression, personality disorders, PTSD can cause parents to misperceive or misreact to their infant’s behavior. They may attribute intentions or motivations that are developmentally inappropriate or inaccurate. Ghosts in the nursery – where the baby’s behavior is distorted by the parent’s prior experiences. Poorness of fit where the parent has one style and the baby another. SLIDE 44 Newborns of Depressed Mothers Are less active Are more irritable Show fewer positive expressions Have disturbed sleep patterns Have increased stress hormones (Source: “Breaking the Cycle of Depression” American Psychological Association). Picture of a smiling nurse holding a new born infant. SLIDE 45 Poor Sleep Hygiene Feeding a baby every time it cries Parent soothing vs. self soothing Sleep hygiene refers to the habits children develop, often with the help of caregivers, for falling and staying asleep. Feeding a baby every time it cries leads to grazing where the infant will only eat small amounts every hour or so. This will result in frequent night wakening. Frequent feedings will also cause the child to wake up because of a soaked diaper. The way a baby goes to sleep at night is the way a baby expects to go back to sleep when she awakens. Babies who are rocked to sleep or nursed to sleep do not learn to comfort themselves and require the presence of the parent in order to go back to sleep. There are two schools of thought on what is the best way to get children back to sleep – parent soothing or teaching the child to self soothe. But there are other things parents can do to set the stage for sleep and help their child transition into sleep. Picture of a Mother trying to soothe her crying infant. SLIDE 46 How Can We Help Parents to Implement Safe Sleeping Recommendations? Three cartoon picture of Mothers holding an infant. SLIDE 47 Screen Women for Depression Cartoon picture of a woman holding the bridge of nose while a tear falls from her eye. SLIDE 48 DEPRESSED MOTHERS ARE It is critically important to screen for depression because it has been shown that depressed mothers . . . . Less likely to breastfeed Less likely to use “back to sleep” position Less likely to take child for recommended preventive care and immunizations More likely to use corporal punishment (Source: “Maternal Depressive Symptoms and Infant Health Care Practices Among Low Income Women” Chung, et. al., Pediatrics Vol. 113 No.6 June 2004). SLIDE 49 Florida Healthy Start Prenatal Screen 2003 - 2004 Do you now, or have you ever had, problems with depression? According to our healthy start screening data, almost 21% of women screened said they have had problems with depression. Screening should begin in the interconceptional period and be completed again during pregnancy and in the post partun period. In a study of 774 African-American women, nearly one half of them (48%) had depressive symptoms during their pregnancy or in the year after the birth of their child. Findings from the Early head Start Research and Evaluation project found that at enrollment when one quarter of the mothers were pregnant and all children were under one year of age, nearly half of mothers reported depressive symptoms. One third of mothers of one years old and one third of mothers of three year olds were depressed. Pediatricians can play an important role in detecting signs of maternal depression. In a study of mothers in a large pediatric care practice at the University of Rochester Medical Center they found that 27% of the mothers who completed the EPDS form had high depressive symptoms. SLIDE 50 Joke- do we need? SLIDE 51 We need to do more than just give out brochures. The brochure provides a starting point but there is much additional information that parents need which is not included in the brochure. Brochure picturing two infants sleeping on their backs in cribs,the brochure is called, "All babies need a safe place to sleep". SLIDE 52 Give Back to Sleep Recommendations During Postpartum Hospital Stay Ask about SIDS knowledge Ask what recommendations they have heard Ask if they know why side is not recommended Ask if they are worried about choking Ask what they think about the recommendations Ask if they have questions Cartoon picture of a doctor holding an infant. SLIDE 53 Inform all Caregivers Make certain that all caregivers know to put baby on its back to sleep. Babies that are accustomed to sleeping on their backs and then placed on their stomachs are at a much higher risk of dying from SIDS. Babies who are used to sleeping on their backs at home are 20 times more likely to die of SIDS when placed on their stomachs.This unaccustomed stomach sleeping may explain the high rate of SIDS in day care settings.It is extremely important for day care providers and other caregivers to put babies to sleep on their backs. Advise parents to discuss back sleeping with daycare providers, relatives and babysitters – everyone who takes care of their baby. Cartoon picture of a grangmother touching an infant that is crying while lying in a crib on his back. SLIDE 54 Provide Additional Education On: Why back sleeping is important The advantages of back sleeping How infants sleep The risks associated with bed sharing Strategies to help infants learn to sleep on their own Benefits of breastfeeding Sensitive caregiving SLIDE 55 Babies Do Cry More When on Their Backs Sleep is lighter. They awaken more easily. These things help protect infants from SIDS. Babies do tend to cry more when they are on their backs. For many hard to soothe babies, placing them on their stomachs may have a calming effect and help them to fall asleep. They also tend to sleep longer and more soundly. But as we have already seen, that is not necessarily a good thing for young babies. Arousability from sleep is a protective mechanism. Waking up easily is a good thing for babies but not necessarily welcomed by parents who are tired and exhausted. Help parents to understand that back sleeping is a learned behavior and not to give up. Cartoon picture of a crying baby. SLIDE 56 Babies Who Sleep on their Backs Swallow more often Have fewer ear infections at 3 and 6 months Have less stuffy noses at six months (Source: Carl Hunt, M.D., et. al. Arch Pediatr Adolesc Med. 2003;157:469-474.) Babies who sleep on their backs have a heightened swallow reflex which helps keep their airway clear and well as clears their Eustachian tubes. Carl Hunt conducted a study of 3733 U.S. infants whose mothers reported that their infants always placed them in the same position to sleep. When the infants were 1, 3 and 6 months old, the researchers asked them whether their infants had fever, cough, wheezing, stuffy nose trouble breathing, trouble sleeping and vomiting. Alex N, Thompson JM, Becroft DM, Mitchell EA. Pulmonary aspiration of gastric contents and the sudden infant death syndrome. J Paediatr Child Health. 2005 Aug;41(8):428-31. Department of Paediatrics, University of Auckland, Auckland, New Zealand. Objective: To determine ante-mortem and post-mortem risk factors for the finding of gastric contents in pulmonary airways (aspiration of gastric contents) at post-mortem examination in the sudden infant death syndrome (SIDS). Methods: There were 217 post-neonatal deaths in the Auckland region of the New Zealand Cot Death Study. No deaths were certified as due to aspiration of gastric contents. There were 138 SIDS cases. The parents of 110 (80%) of these cases were interviewed. Histological sections from the periphery of the lungs in 99 of the 110 cases were reviewed for evidence of aspiration of gastric contents. A wide range of variables were analyzed in SIDS cases with and without aspiration to determine risk factors. Results: Aspiration of gastric contents was identified in 37 (37%) of SIDS cases. Aspiration was of mild-to-moderate degree and in no case was severe and a potential cause of death. Finding infants on their backs at death (P = 0.024) and conducting the post-mortem on the day after the death or subsequently (P = 0.033) were statistically significant variables linked to identification of aspiration. Position placed to sleep, symptoms of gastro-oesophageal reflux and other variables were not related to aspiration. Conclusions: The only determinants for aspiration of gastric contents identified were agonal or post-mortem events, supporting the contention that aspiration has limited relevance to the mechanism of SIDS. Back sleeping babies also have a lower chance of getting overheated because their heads and faces are not covered. The prime avenue for heat loss is through the head and face. Picture of a Mother and an infant lying on a changing table before a diaper change. SLIDE 57 Infant Sleep REM (Rapid Eye Movement) Sleep: Activated brain state Dream like sleep Eyes move under lids Heart rate and breathing patterns are rapid Small body jerks, facial grimaces, twitching When parents see this sleep state they may feel their infant is not comfortable and is not getting enough rest. Need to explain that full term infants spend 50% of their sleeping time in REM sleep and 50% in NREM. SLIDE 58 Infant Sleep NREM (Non REM) Sleep: Heart rate and breathing are slow and regular Sleeper looks restful Quiet sleep SLIDE 59 Parental Behaviors That Help to Regulate Infant Sleep/Wake Cycles Kangaroo Care” Kangaroo care – skin to skin contact with a caregiver helps to regulate the infants temperature and heart rate. Touch makes babies feel more regulated. The baby uses this sensory information to become clamed and soothed. Breastfeeding - Breastfeeding has a claming effect on babies. The harmony between a breastfeeding mother and her suckling infant has on organizing effect on the baby’s sleep-wake cycle. When parents respond quickly to babies cries, baby’s brain begins to develop patterns and will learn to be comforted more easily. Hold or comfort baby for all fussy crying during the early months. Gently rocking and cuddling are helpful. Don’t use feeding as a pacifier. For every feeding, there should be four or five times that the baby is held and snuggled without nursing Swift, consistent response to crying from birth to four months Play games such as Peek-a-boo to help with separation SLIDE 60 BABYWEARING Reminds baby of the motion and balance enjoyed in the womb Stimulates baby’s vestibular system which has a regulatory effect Carried babies show a heightened level of quiet alertness (Source: www.asksrsears.com) Carried babies seem to fuss less. One theory is that “baby wearing” extends the womb experience which helps to organize the baby’s bio-rhythms so that they are more regulated. Dr. Sears www.askdrsears.com/html/5/t051300.asp Motion calms babies. When infants are in the quiet alert state, they are able to learn from their environment. Babies who are carried in cloth carriers or baby slings for several hours a day settle better at night. Studies have shown that cloth carriers helped to calm and quiet newborns which gave mothers a feeling of competency. They also helped fathers to feel more comfortable and successful. Studies have also shown that mothers who used cloth carriers were more sensitive to their babies cues and the babies developed a more secure attachment. Source: “Does Infant Carrying Promote Attachment?” Anisfeld, et.al., Child Development, 1990, 61, 1617-1627. SLIDE 61 Breastfeeding Aids Sleep Studies by the National Institute of Child Health and Human Development show that babies who died of SIDS were less likely to be breast-fed. Breastfeeding prevents gastrointestinal and respiratory illness, infections and provides immunologic protection. A study published in the Archives of Diseases in Childhood in January 2004 found that infants who are breast-fed are more easily aroused. A study reported in Pediatrics 2004; 113:e435-3439 compared 1204 cases of infant deaths with 7740 infants who were still alive at 1 year and found that 53% of control infants were ever breastfed compared with 38% of those who died. While not demonstrating causality, it may mean that breastfeeding represents a package of skills, abilities and emotional attachments that make families whose infants survive. Breast feeding also helps mom cope better with stress. Picture of an infant breatfeeding. SLIDE 62 Calming Strategies for Fussy Babies Swaddling Shhhh Source: Harvey Karp, M.D. Rhythmic, repetitive sounds Comfort sucking (fingers, fist, pacifier) Massage (Source: Charles E. Schaefer, Ph.D.) Swaddling can restore a safe feeling and prevents arms and legs from flailing about which can be startling and unsettling to newborns. A recent study of 16 infants aged 6-16 weeks found that swaddled babies sleep longer and are less likely to wake up spontaneously. The researchers found swaddling increases a baby’s total amount of sleep as well as NREM or light sleep compared to when they were not swaddled. Swaddling may also be protective against SIDS because it prevents infants from rolling onto their stomachs. According to Dr. Karp the sound of calm and tranquility is the loud shushing sound of the uterine and placental blood blow. The sound inside the uterus is loud, constant and rhythmic. Other soothing sounds that remind them of things they heard in the womb are sounds of the ocean or a waterfall, the hum of the washer or dryer, hum of a vacuum cleaner or the sound of a heartbeat. Babies have a strong sucking urge not related to desire for food. Stroking the infant’s skin can calm baby and help her to sleep better. SLIDE 63 AAP Recommendation for SIDS Risk Reduction Consider offering a pacifier at bed and nap time. Studies consistently demonstrate a protective effect of pacifiers on SIDS. According to current data, the use of pacifiers appears to halve the risk. A variety of mechanisms by which pacifiers protect against SIDS have been proposed. It has been suggested that the presence of a pacifier in the mouth may discourage babies from turning over onto their faces during sleep. Another theory is that the pacifier might help keep the tongue position forward, keeping the airways open. Some scientists speculate that sucking on a pacifier will be more likely to keep his or her nose free of bedding in order to breathe. A pacifier would help to quiet an infant who might otherwise move around the crib and end up underneath bedding. Pacifiers could stimulate the upper airway muscles and saliva production, possibly triggering brain activity and ability to rouse from sleep. The down side of pacifiers is that they have been associated with increased ear infections, dental malocclusion and shortened duration of breastfeeding. The recommendation for breastfeeding infants is to delay pacifier introduction until one month of age to assure establishment of breastfeeding, (Source: Dr. Rachel Moon, M.D., Children’s National medical Center, Washington, D.C. March 2005). SLIDE 64 Routines Help to Regulate Arousal Predictable and consistent nap and bedtime routines Quiet hour before bedtime Bed time ritual Routines help to regulate arousal by providing appropriate stimulation when the child is awake and soothing routines that precede periods of sleep. a bit to help baby practice some self regulatory skill. “The more structured and predictable the external world, the more ordered the internal world.” Pat Blackwell, Ph.D. Babies who have consistent nap routines during the day sleep longer stretches at night. But Don’t let the baby sleep for more than 3 consecutive hours during the day. Familiar bed time rituals set up baby for sleep. Warm bath, soothing massage, stories, rocking, lullabies, nursing let baby know that sleep is expected to follow. Infants who go to bed earlier at night (between 6 and 7) gradually develop longer initial periods of uninterrupted sleep. Some parents have trouble doing this because they feel guilty that they haven’t seen their child all day while they have been an work. Keeping an infant up late does not result in the infant sleeping later in the morning. Close up picture of an infant sleepiing on her back. SLIDE 65 Techniques for Helping Infants Transition into Sleep State Place baby in the crib drowsy but still awake Help child attach to a security object Make middle of the night feedings brief and boring When the baby starts to act sleepy, place her in her crib. The baby’s last memory before going to sleep should be of the crib, not of the breast or bottle. If she is fussy, rock her until she settles down and is almost asleep but not asleep. If she learns how to put herself back to sleep, she will not cry after normal awakenings. Babies wake up at least briefly 1-3 times a night, on average after 4-6 hours of sleep. Breastfeeding advocates disagree with putting a child into bed drowsy but awake. They feel children are biologically programmed to fall asleep while nursing. The disadvantage is that the breast becomes the baby’s security object and the child does not learn to comfort herself and fall asleep without the breast. Cartoon picture of an infant on her back crying. SLIDE 66 Stay Asleep Techniques: Quiet, dark room Temperature around 70 degrees Repetitive, monotonous sounds Transitional object in the crib SLIDE 67 Promote Parental Sensitivity Recognizing infant’s ability to signal needs Accurately reading and interpreting cues Responding appropriately Responding consistently and predictably (Source: Infants, Toddlers and Families: A Framework for Support and Intervention, Erickson and Kurz-Riemer, 1999). Sensitive care in the early months of life is one of the most powerful predictors of the quality of the child’s attachment. Rather than providing developmental guidance based on what a baby should be doing week to week, we should be focusing on the relationship between the parent and the baby. Picture of a baby looking at and touching her Fathers face. SLIDE 68 Indications of Parental Insensitivity Persistent failure to respond to infant cries and other bids for attention Inconsistent patterns of responding Intrusiveness (Source: Infants, Toddlers and Families, Erickson and Kurz-Riemer, 1999). Not attending to the child’s bid for comfort or stimulation. Interactions are driven by the adult’s agenda rather that what is in the best interest of the child. Inconsistent patterns result in the child not knowing what to expect. Intrusiveness is a failure to respect the child’s signals Insensitivity may result from inaccurate knowledge or erroneous beliefs about child development, stress and exhaustion that interfere with the parent from being able to respond appropriately to the infant’s cues or emotional issues that prevent the parent from being emotionally available to the child. SLIDE 69 Behaviors to Observe: Eye contact between mother and infant Holding patterns of mother Mutual touching of mother and infant Talking and other communication patterns Responsivity and reciprocity Sensitivity of both mother and infant to each other (Source: Joy Osofsky, Ph.D., Harris Institute of Infant Mental Health, LSUHSC, New Orleans, La., 2005). SLIDE 70 Questionairre on baby/parent relationship SUSAN***** SLIDE 71 Promote Maternal Role Attachment during Pregnancy: Relationship between mother and child begins before birth. Development of an internal working model of the baby to be influences mother’s later relationship with her baby. Best way to prevent insensitive care giving is to start during pregnancy. The Parent-Child Communication Coaching Program is a pregnancy intervention with maternal tasks of: Recognizing the fetus Gaining support for the fetus within the family Exploring the maternal role. The intervention was designed to be carried out by home visitors to address the maternal-infant attachment process. Women can practice the role of mother by fantasizing what her baby will be like and what kind of mother she will be and what behaviors she will need to develop. cartoon cross sectional view of a fetus in a pregnant woman. SLIDE 72 The End Picture of a healthy, happy bay on her back kicking her feet.