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For Newborn Infants and Children Through 4 Years of Age

Parents and caregivers need to be advised that they should never—-even for a moment-—leave children alone or in the care of another young child while in bathtubs, pools, spas, or wading pools or near irrigation ditches or other open standing water. They should also be reminded that infant bath seats or supporting rings are not a substitute for adult supervision. [Footnote 11] They should remove all water from containers, such as pails and 5-gallon buckets, immediately after use. To prevent drowning in toilets, young children should not be left alone in the bathroom, and unsupervised access to the bathroom should be prevented.

Whenever infants and toddlers are in or around water, be it at their own home, the home of a neighbor, a party, or elsewhere, a supervising adult should be within an arm’s length providing "touch supervision." The attention of the supervising adult should be focused on the child, and the adult should not be engaged in other distracting activities, such as talking on the telephone, socializing, or tending to household chores.

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To date there have been at least 66 drowning deaths to infants and 37 reports of near drowning incidents. In the first six months of 2000 alone, five babies have died. When CPSC last considered this issue, just 14 children had drowned.

Drownings typically occur when the infant tips over, climbs out of, or slides through the product. In most, but not all cases, the child is left unattended for a brief time by the parent or caregiver.

A recent study conducted by Dr. Clay Mann, Intermountain Injury Control Research Center, found that parents and caregivers of infants that use baby bath seats engage in more risk taking behavior than parents and caretakers not using bath seats. Caregivers using bath seats prepare baths with deeper water and are more likely to leave a child unattended in the bath for conscious, willful reasons (e.g., to perform household chores). There is a false sense of safety that is propagated by having a mechanical aid to "help" to hold a slippery baby upright. This "sense of security" promotes the idea that a child could be left alone in the bath for "just a minute."

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The low socioeconomic parents who participated in this research generally were unaware that injuries are the number one cause of death among children. Furthermore, nearly ¼ of the participants showed an optimism bias, that is, a belief that their child was less likely to be injured than other children.

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Four children can be left longer. Five children can be put in and left for longer (ten, fifteen minutes).

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I want a tub that can hold five children. Yeah, I know there should be some commas in there.

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Many of those risk problems are very preventable, and do not rule out family bed practices.

Even the suffocation by being rolled onto has a preventable factor: not drinking or taking any drugs which can cause drowsiness.

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But even taking in those statistics, one has to consider that many of the suffocation by being rolled onto scenarios may involve SIDS. Of the adult bed scenarios, 108 children died by "co-sleeping" in a seven year period. Compare this to an average of 5,500 children a year dying of SIDS. This means that over the same seven year period, 33,500 children died of SIDS. I suspect that cosleeping will automatically rule out SIDS to investigators, whether it should or not.

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Number one, it does not list the number of infant deaths that occur in cribs during the same period. That should ring some bells right off.

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*all names changed for anonymity's sake.

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We believe most cases of true SIDS to be due to central sleep apnea (the baby's head forgets to breathe, so to speak).

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Background: Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year that remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the scene of death, and review of the clinical history.

Cases failing to meet the standards of this definition, including those without a postmortem investigation, should not be classified as SIDS. Cases that are autopsied and carefully investigated but remain unresolved may be designated as undetermined or unexplained.

References to SIDS exist throughout recorded history. Use of the term SIDS was adopted by an international work group in 1969. The National SIDS Act of 1974 recognized SIDS as a significant public health issue in the United States and provided funding for research and for the establishment of information and counseling programs in each of the 50 states.

SIDS is the single most common cause of death in the postneonatal period, that is, in infants aged 1 month to 1 year. In most series, SIDS accounts for 35-55% of deaths within this time period. SIDS comprises approximately 20-25% of deaths in infancy. Despite intensive study and advances in the understanding of associated factors, the specific cause or causes of SIDS remain unknown.

Pathophysiology: SIDS likely represents an intersection of factors, including a vulnerable infant possessing intrinsic abnormalities in cardiorespiratory control, a critical period of development of homeostatic control mechanisms, and exogenous stressors. See "Triple risk model" in Causes.
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Mortality/Morbidity:

Following careful analysis of information obtained from the complete postmortem evaluation, including death scene and historical information, SIDS predominates as the single leading cause of unexpected deaths in infancy; however, alternative diagnoses are identified in as many as 15-25% of sudden unexpected deaths in infancy (SUDIs).
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With a change to supine sleep for infants, cigarette smoke exposure has emerged as one of the most important potentially modifiable risk factors associated with SIDS. Studies examining maternal smoking and SIDS conducted following back to sleep campaigns demonstrated that infants of mothers who smoke have a nearly 5-fold elevated risk of SIDS compared to infants of mothers who do not smoke. The adverse effects of maternal smoking are generally believed to stem principally from in utero exposure of the fetus. Despite emphasis in back to sleep campaigns on the avoidance of cigarette smoke exposure (prenatal and postnatal), little change in the rates of maternal smoking during pregnancy has occurred in most countries.

The contributions of other infant care practices to SIDS risk remain less well defined. Pacifier (dummy) use, infant bundling, and temperature regulation are examples. Recent studies from overseas centers have indicated that pacifier use may reduce the risk of SIDS. Several population-based studies have shown lower rates of pacifier use by SIDS infants compared to control subjects, suggesting a protective effect. The pathophysiologic advantages conferred by pacifier use remain unknown at this time. Advice in campaigns to reduce risk has also focused on avoidance of overbundling infants during sleep. This advice appears to be more important for prone-sleeping infants and perhaps less of a factor for infants sleeping supine.
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Causes:
The triple risk model

The cause or causes of SIDS are likely to be multifactorial. The triple risk model proposed by Filiano and Kinney suggests that SIDS represents an intersection of factors, including a vulnerable infant possessing intrinsic abnormalities in cardiorespiratory control, a critical period of development of homeostatic control mechanisms, and exogenous stressors.

Death occurs when vulnerable infants are subjected to stressors at times when normal defense mechanisms may be structurally, functionally, and/or developmentally deficient.

This model allows for the possibility of multiple potential stressors and for heterogeneity in underlying vulnerabilities manifesting as SUDI.

Neuropathology and SIDS
The vulnerable infant
A number of structural and functional nerve cell abnormalities have been described in infants with SIDS. Evidence suggesting delayed development of the brain stem has been demonstrated in 2 studies in which elevated dendritic spine counts were noted among victims of SIDS. Reductions in the degree of myelination of specific brain regions of infants with SIDS provide further evidence of defective neuronal development.

Several studies have demonstrated neurotransmitter abnormalities in infants with SIDS. Ozawa et al noted that differences in CNS dopamine beta-hydroxylase and tryosine hydroxylase have been shown in infants with SIDS compared to control infants. Abnormalities in adrenergic pathways related to cardiorespiratory control within the medulla and pons also have been identified.

Some infants with SIDS have been noted to have fewer acetylcholine-binding (muscarinic) receptors within the arcuate nucleus. This nerve cell complex, which resides within the ventral surface of the medulla, is thought to be critical to the integration of cardiorespiratory and arousal responses. In a subset of infants with SIDS, the arcuate nucleus was noted to be structurally deficient. Reduced kainate binding has also been noted within the arcuate nucleus of victims of SIDS.
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Establishing the diagnosis of SIDS
An infant who is discovered lifeless may be transported by the family or by 911 first response personnel to the nearest hospital emergency department. In a growing number of cases, when signs of death are obvious, the infant's death may be declared at the scene by first responders. Local medical examiner or coroner protocol should be followed in either instance. In many jurisdictions, specific infant death investigation guidelines exist and should be followed by prehospital or emergency department staff when an infant death has occurred. National guidelines for infant death investigation, including death scene evaluation, have been developed and are useful to those responsible for establishing the cause and manner of death.

As its definition suggests, the process of establishing a diagnosis of SIDS is driven by excluding recognizable causes of SUDI. The necessary data set includes information obtained from the scene of death, infant and family medical and social history, and autopsy examination. Guidelines for the autopsy examination, including gross and microscopic dissections, and the role of toxicologic, microbiologic, radiographic, and other special procedures are detailed elsewhere.

Following careful analysis of information obtained from the complete postmortem evaluation, including death scene and historical information, SIDS predominates as the single leading cause of death among unexpected deaths in infancy; however, alternative diagnoses are identified in as many as 15-25% of SUDIs. The principal non-SIDS categories of SUDI include infectious diseases, metabolic abnormalities, environmental factors, and structural (congenital) cardiac, respiratory, and CNS lesions.

Apparent life-threatening events and SIDS
An apparent life-threatening event (ALTE) is defined as an episode that is frightening to the observer and is characterized by some combination of apnea (central or obstructive), change in muscle tone (usually diminished), and choking or gagging. In some cases, the observer fears that the infant has died. Previously used terminology such as near-miss SIDS or aborted crib death should be abandoned because their use implies a possibly misleading close association between this type of spell and SIDS.

The estimated frequency of ALTEs among healthy term infants is 1-3%. A relationship between SIDS and ALTE is suggested by the observation that the risk of subsequent death among infants experiencing an ALTE is 1-2%. The risk of mortality increases to 4% among infants whose ALTE is associated with respiratory syncytial virus (RSV) infection. The risk of subsequent death increases to 8-10% for infants who experience ALTE during sleep or require some form of CPR. Among infants with SIDS, only 5% have a history of an ALTE preceding the death.

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SIDS is a specific medical diagnosis, and it is a diagnosis of exclusion. In the lay press, SIDS and SUDI may be conflated, and there may be an incorrectly assumed relationship between each and ALTEs. There is some relationship, but it is at an almost negligible level.

I don't know enough of the details of your family's case to give you a specific answer, but you have my sympathy regardless.

[ December 25, 2004, 12:24 AM: Message edited by: Sara Sasse ]

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Briefly, obstructive sleep apnea is due to a structural fault of the airway system, and this should be replicable on autopsy.

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That was what I was wondering, and it makes sense.

Next question. So what about infants dying from obstructive sleep apnea? Do we know statistics on that?

Sara, thank you for digging up all this info. You're terrific!

Edit: I went to the emedicine site and looked up OSA for children, and there wasn't any surprising information there - um, that which I understood, anyway. So thank you for the original link. I guess I'm just getting morbid and paranoid because OSA is such a problem in our family. Sheesh.

[ December 25, 2004, 12:33 AM: Message edited by: quidscribis ]

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Yes, you can decrease the risk, and you can decrease it to a potentially acceptable level of risk. Still, it is worth noting that the risk is still there, and taking that risk -- if one choses -- with one's eyes open.

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"Our newborn was on a monitor and slept in a cradle next to our bed. One night I heard her gasping. I know baby noises, and these weren't normal noises. As soon as I picked her up and put her next to me in bed, she breathed regularly. My pediatrician told me I was just a nervous mother. If her breathing didn't wake her up, it wasn't a problem. He told me it was my problem, and if I moved her out of our room I wouldn't hear her. I kept badgering pediatricians to study her and indeed they found she had apnea eighteen percent of the time. When she slept with me I noticed a difference. She breathed with me. My doctor still thought I was a nervous

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In 1992 we set up equipment in our bedroom to study eight-week-old Lauren's breathing while she slept in two different arrangements. One night Lauren and Martha slept together in the same bed, as they were used to doing. The next night, Lauren slept alone in our bed and Martha slept in an adjacent room. Lauren was wired (see figure) to a computer that recorded her electrocardiogram, her breathing movements, the airflow from her nose, and her blood oxygen level. The instrumentation was painless and didn't appear to disturb her sleep. Martha nursed Lauren down to sleep in both arrangements and sensitively responded to her during the nighttime as needed. (The equipment was designed to detect only Lauren's physiologic changes during sleep. The equipment did not pick up Martha's signals.) Martha nursed Lauren down to sleep in both arrangements and sensitively responded to Lauren's nighttime needs. A technician and I observed and recorded the information. The data was analyzed by computer and interpreted by a pediatric pulmonologist who was "blind" to the situation—that is, he didn't know whether the data he was analyzing came from the shared-sleeping or the solo-sleeping arrangement.

Our study revealed that Lauren breathed better when sleeping next to Martha than when sleeping alone. Her breathing and her heart rate were more regular during shared sleep, and there were fewer "dips," low points in respiration and blood oxygen from stop-breathing episodes. On the night Lauren slept with Martha, there were no dips in her blood oxygen. On the night Lauren slept alone, there were 132 dips. The results were similar in a second infant, whose parents generously allowed us into their bedroom. We studied Lauren and the other infant again at five months. As expected, the physiological differences between shared and solo sleep were less pronounced at five months than at two months.

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Mother fills in a missing ingredient. In the early months, much of a baby's night is spent in active sleep— the state in which babies are most easily aroused. As we discussed previously, this state may "protect" the infant against stop-breathing episodes. From one to six months, the time of primary concern about SIDS, the percentage of active sleep decreases, and quiet, or deeper, sleep increases. More deep sleep means that babies start to sleep through the night. That's the good news. The concern, however, is that as baby learns to sleep deeper, it is more difficult for him to arouse when there is an apnea episode, and the risk of SIDS increases. By six months, the baby's cardiopulmonary regulating system has matured enough that the breathing centers in the brain are better able to restart breathing, even in deep sleep. But there is a vulnerable period between one and six months when the sleep is deepening, yet the compensatory mechanisms are not yet mature. During the time baby is at risk, mother fills in. In fact, mother sleeps like a baby until the baby is mature enough to sleep like an adult. That warm body next to baby acts as a breathing pacemaker, sort of reminding baby to breathe, until the baby's self-start mechanisms can handle the job on their own. (See Sleep Safety)

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Co-sleeping promotes physiological regulation.

The proximity of the parent may help the infant’s immature nervous system learn to self-regulate during sleep (Farooqi, 1994; Mitchell, 1997; Mosko, 1996; Nelson, 1996; Skragg, 1996). It may also help prevent SIDS by preventing the infant from entering into sleep states that are too deep. In addition, the parents’ own breathing may help the infant to "remember" to breathe (McKenna, 1990; Mosko, 1996; Richard, 1998).

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The recent Consumer Product Safety Commission (CPSC) finding that adult beds are inherently hazardous is both misleading and inaccurate. Parents should know that this recent campaign is sponsored and financed by the Juvenile Product Manufacturing Association (i.e. crib manufacturers), an organization that has everything to gain from parents choosing to buy cribs.

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Developmental Psychobiology. 2002 Jan;40(1):14-22.
The sleep of co-sleeping infants when they are not co-sleeping: evidence that co-sleeping is stressful.
Hunsley M, Thoman EB.

Co-sleeping proponents consider the practice to be "natural" and a potential protection against sudden infant death syndrome (SIDS); others consider the practice of an infant sleeping in the parents' bed for prolonged periods at night to place an infant at risk for harm or death. For this study, co-sleeping was investigated from a different perspective, that is, as a significant early experience to investigate as it may have implications for the infant's development. The sleep of 101 normal, full-term infants was recorded nonintrusively in the home for 24 hr periods when they were 5 weeks and 6 months old. Infants were assigned to three groups: short-term co-sleepers, long-term co-sleepers, and non-co-sleepers. Their sleep states and wakefulness were compared at the two ages and over age. At 5 weeks and 6 months, the long-term co-sleeping infants differed significantly from the non-co-sleepers on a number of measures: At 5 weeks, they showed more quiet sleep and longer bouts of quiet sleep; and at 6 months, they also showed less active sleep, fewer arousals in active sleep, and less wakefulness. Each of these differences indicates a markedly lower arousal level in the long-term co-sleeping infants. This sleep pattern has been repeatedly found to be an indicator of stress. We infer that a major source of stress for these infants is the experience of sleep disturbance documented for infants when they were co-sleeping. Based on extensive evidence for long-term effects of early stress, we conclude that co-sleeping should have significant implications for infants' neurobehavioral development. [italics added]

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Experts have indicated that "overlying" is a notoriously difficult diagnosis to prove and there is tremendous variation how the term is used across the country. In addition, infants who are found in cribs are much more likely to receive a diagnosis of SIDS. It is nearly impossible, they say, to determine the exact cause of death without a full medical investigation.

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