The Safe to Sleep campaign, formerly known as the Back to Sleep campaign, [1] is an initiative backed by the US National Institute of Child Health and Human Development (NICHD) at the US National Institutes of Health to encourage parents to have their infants sleep on their backs (supine position) to reduce the risk of Sudden Infant Death Syndrome, or SIDS. The target age group of the campaign is 0–1 years of age, because this is when babies are at the greatest risk of experiencing SIDS. [2] Since "Safe to Sleep" was launched in 1994, the incidence of SIDS has declined by more than 50%. [2] However, there has been a rise in infant sleep-related suffocation events. Consequently, the campaign has broadened its goal to focus on safe sleep conditions and further preventative measures.
In 1992, the American Academy of Pediatrics (AAP) recommended that babies sleep on their backs or sides to reduce the risk of SIDS (a revised statement in 1996 retracted the side-sleeping option). NICHD launched the "Back to Sleep" campaign in 1994 to spread the message. [2]
The campaign was successful in significantly reducing the percentage of babies sleeping on their stomachs (prone position). It was found, however, that a significant portion of African-American babies were still sleeping on their stomachs; in 1999, an African-American baby was 2.2 times more likely to die of SIDS than a white baby. Thus, then Secretary of Health and Human Services Donna Shalala and Tipper Gore refocused the "Back to Sleep" campaign on minority babies. [2]
In 1985 Davies reported that in Hong Kong, where the common Chinese habit was for supine infant sleep position (face up), SIDS was a rare problem. [3] In 1987 the Netherlands started a campaign advising parents to place their newborn infants to sleep on their backs (supine position) instead of their stomachs (prone position). [4] This was followed by infant supine sleep position campaigns in the United Kingdom (as "Back to Sleep"), [5] New Zealand, and Australia in 1991, the U.S. and Sweden in 1992, and Canada in 1993. [4] [6]
This advice was based on the epidemiology of SIDS and physiological evidence which showed that infants who sleep on their back have lower arousal thresholds and less slow-wave sleep (SWS) compared to infants who sleep on their stomachs. [7] Thus, these infants are more easily awakened. However, the arousal thresholds have been shown to be higher during SWS causing infants to be less easily awakened. [7]
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). [8] [9] [10] In addition, slow wave sleep (SWS) which consists of stage 3 and stage 4 NREM sleep appears at 2 months of age [11] [12] [13] [14] 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 decreased ability to arouse from SWS. [7]
Studies have shown that preterm infants, [15] [16] full-term infants, [17] [18] and older infants [19] have greater time periods of quiet sleep and also decreased time awake when they are positioned to sleep on their stomachs, meaning these babies are harder to wake when sleeping on their tummy. In both human infants and rats, arousal thresholds have been shown to be at higher levels in the electroencephalography (EEG) during slow-wave sleep. [20] [21] [22]
In 1992 [23] 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. In 1994, [24] 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 [25] 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.
Since the launch of the campaign the incidence of SIDS has declined by more than half, however, 3,400 babies, ages 0–1, die per year from SIDS and sleep-related suffocation events despite the implementation of this campaign. [26] The AAP and further research has shown that there are preventative measures that can be taken to control environmental factors to prevent such adverse events. [27]
Risk factors for SIDS can be divided into three major categories: maternal, infant, and environmental factors. [27] The factors mentioned below are modifiable and preventable to help decrease the occurrence of SIDS and sleep-related suffocation events.
Maternal factors | Infant factors | Environmental factors |
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Several precautions focused on controlling environmental factors can be taken to minimize the risk of SIDS and sleep-related suffocation events. [2] [27] [29] [30] Per the safe to sleep campaign, these preventive measures can be taken to decrease the rate of SIDS and sleep-related suffocation events: [2]
Sudden infant death syndrome (SIDS), sometimes known as cot death, is the sudden unexplained death of a child of less than one year of age. Diagnosis requires that the death remain unexplained even after a thorough autopsy and detailed death scene investigation. SIDS usually occurs during sleep. Typically death occurs between the hours of midnight and 9:00 a.m. There is usually no noise or evidence of struggle. SIDS remains the leading cause of infant mortality in Western countries, constituting half of all post-neonatal deaths.
Brachycephaly is the shape of a skull shorter than average in its species. It is perceived as a cosmetically desirable trait in some domesticated dog and cat breeds, notably the pug and Persian, and can be normal or abnormal in other animal species.
Plagiocephaly, also known as flat head syndrome, is a condition characterized by an asymmetrical distortion of the skull. A mild and widespread form is characterized by a flat spot on the back or one side of the head caused by remaining in a supine position for prolonged periods.
Shaken baby syndrome (SBS), also known as abusive head trauma (AHT), is a medical condition in children younger than five years old, generally caused by blunt trauma, vigorous shaking, or a combination of both. SBS is the leading cause of fatal head injuries in children under two, with a risk of death of about 25%. The most common symptoms include retinal bleeds, multiple fractures of the long bones, and subdural hematomas.
The American Academy of Pediatrics (AAP) is the largest professional association of pediatricians in the United States. It is headquartered in Itasca, Illinois, and maintains an office in Washington, D.C. The AAP has published hundreds of policy statements, ranging from advocacy issues to practice recommendations.
Co-sleeping or bed sharing is a practice in which babies and young children sleep close to one or both parents, as opposed to in a separate room. Co-sleeping individuals sleep in sensory proximity to one another, where the individual senses the presence of others. This sensory proximity can either be triggered by touch, smell, taste, or noise. Therefore, the individuals can be a few centimeters away or on the other side of the room and still have an effect on the other. It is standard practice in many parts of the world, and is practiced by a significant minority in countries where cribs are also used.
A pacifier is a rubber, plastic, or silicone nipple substitute given to an infant or toddler to suckle upon between feedings to quiet its distress by satisfying the need to suck when it does not need to eat. Pacifiers normally have three parts: an elongated teat, a handle, and a mouth shield which prevents the child from swallowing or choking on it.
An infant bed is a small bed especially for infants and very young children. Infant beds are a historically recent development intended to contain a child capable of standing. The cage-like design of infant beds restricts the child to the bed. Between one and two years of age, children are able to climb out and are moved to a toddler bed to prevent an injurious fall while escaping the bed.
Swaddling is an ancient practice of wrapping infants in blankets or similar cloths so that movement of the limbs is tightly restricted. Swaddling bands were often used to further restrict the infant. Swaddling fell out of favour in the 17th century.
The supine position means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic and pericardial regions; as well as the head, neck and extremities.
Tummy time is a colloquialism for placing infants in the prone position while awake and supervised, to encourage development of the neck and trunk muscles and prevent skull deformations.
Breastfeeding difficulties refers to problems that arise from breastfeeding, the feeding of an infant or young child with milk from a woman's breasts. Although babies have a sucking reflex that enables them to suck and swallow milk, and human breast milk is usually the best source of nourishment for human infants, there are circumstances under which breastfeeding can be problematic, or even in rare instances, contraindicated.
Tobacco smoking during pregnancy causes many detrimental effects on health and reproduction, in addition to the general health effects of tobacco. A number of studies have shown that tobacco use is a significant factor in miscarriages among pregnant smokers, and that it contributes to a number of other threats to the health of the foetus.
The sleeping position is the body configuration assumed by a person during or prior to sleeping. It has been shown to have health implications, particularly for babies.
Sleep training is a set of parental intervention techniques with the end goal of increasing nightly sleep in infants and young children, addressing “sleep concerns”, and decreasing nightime signalling. Although the diagnostic criteria for sleep issues in infants is rare and limited, sleep training is usually approached by parent(s) or caregivers self identifying supposed sleep issues.
Sudden unexplained death in childhood (SUDC) is the death of a child over the age of 12 months which remains unexplained after a thorough investigation and autopsy. There has not been enough research to identify risk factors, common characteristics, or prevention strategies for SUDC.
A bedside sleeper, also referred to as a sidecar sleeper or bedside bassinet, is a bassinet or baby cot that attaches to the parents' bed, allowing newborns to sleep next to their parents safely. This is a form of safe co-sleeping, and has little risks associated with sudden infant death syndrome, unlike bedsharing. Bedside sleepers are a component of rooming-in, a practice followed in hospitals to keep the baby by the mother's bed, giving her time to establish a stronger bond with her baby.
Infant and toddler safety are those actions and modifications put into place to keep babies and toddlers safe from accidental injury and death. Many accidents, injuries and deaths are preventable.
Gerhard Jorch is a German pediatrician. He is Professor for general pediatrics and neonatology at the Otto-von-Guericke University of Magdeburg and director of the University children's hospital.
Infant sleep is an act of sleeping by an infant or a newborn. It differs significantly from sleep during adulthood. Unlike in adults, sleep early in infancy initially does not follow a circadian rhythm. Infant sleep also appears to have two main modes - active, associated with movement, and quiet, associated with stillness - exhibiting distinct neurological firing patterns. Sleep duration is also shorter. As the infant ages, sleep begins to follow a Circadian rhythm and sleep duration increases. Infants nap frequently. Infants are also particularly vulnerable during sleep; they are prone to suffocation and SIDS. As a result, "safe" sleep techniques have been the subject of several public health campaigns. Infant sleep practices vary widely between cultures and over history; historically infants would sleep on the ground with their parents. In many modern cultures, infants sleep in a variety of types of infant beds or share a bed with parents. Infant sleep disturbance is common, and even normal infant sleep patterns can cause considerable disruption to parents' sleep.
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