We review the history of safe sleep recommendations, risk factors for SIDS, and how to counsel parents about safe sleep. We are joined by Jack Seidel, MD, Professor of Neonatal-Perinatal Medicine at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. Today, we'll be discussing sudden infant death syndrome, or SIDS. We are recording remotely today due to the ongoing COVID pandemic. We are joined remotely by Dr. Jack Seidel, Professor in the UT Southwestern Division of Neonatal-Perinatal Medicine, Medical Director of the Newborn Nursery at UT Southwestern Clements University Hospital, and a primary care pediatrician.
Dr. Jack Seidel:
Hello.
Dr. Neeta Goli:
Dr. Seidel, thanks for joining us today.
Dr. Jack Seidel:
Thank you for having me.
Dr. Neeta Goli:
Sudden infant death syndrome or SIDS is every parent's worst nightmare, an infant dying inexplicably while they are sleeping typically. Could you start by giving us a historical perspective on the incidence of SIDS?
Dr. Jack Seidel:
Well, I think that probably SIDS has been occurring since humans have been on the earth. I can kind of tell you a little bit about the past 35 or so years that I've been in medicine and some of the things that I've seen change that thankfully, have been for the better. One is that we have a lot more information, a lot more data, a lot much more research that is pointing to both the cause of SIDS and the risk of SIDS and things that you can do to help prevent SIDS.
Dr. Jack Seidel:
But one thing that I think has been most dramatic that I've seen is when we switched babies from sleeping typically on their bellies to their back in the kind of mid to late '80s, I think it was. And just about the time that I was in training that was changing because I can remember when I was a pediatric resident, the nurses would get in trouble if they left the baby on their back because back then that was felt, oh, they might spit up or they might aspirate and that was dangerous. And the nurse would get written up if they left the baby on their back.
Dr. Jack Seidel:
And of course, we would caution parents, make sure that your baby always sleeps in their stomach because we don't want them to aspirate. And I can remember being in practice and having a second baby in my office and telling her, "Oh, well now you need to have the baby to sleep on their back." And it's, "What's changed with babies? Because before you told me they need to sleep on their stomach, and now you're telling me they need to sleep on their back." But luckily now everybody pretty much accepts that. And I think that since we've started having babies routinely sleeping on their back, we've seen a significant decrease, and certainly in the United States and the incidence of SIDS, I think by at least 50%.
Dr. Neeta Goli:
What are thought to be some risk factors for SIDS?
Dr. Jack Seidel:
Well, there are a number of risk factors for SIDS. Certainly, teenage moms, moms that are very young, have an increased risk of SIDS, lack of prenatal care, or having no prenatal care increases the risk. Babies that are born with low birth weight or that are born early, premature babies, and maternal drug use. These are all things kind of related to the mom. There are some type of things that have increased the risk slightly with having abruption or premature rupture, some things like that. Also, once they get babies home, sleeping, it's very important that babies sleep on a surface where there's not anything else in the bed, have no bumper pads in the crib, no pillows, no loose blankets, accessories, those type of things. It should be on a firm surface. Bed-sharing or holding the baby while sleeping certainly increase the risk of that baby dying.
Dr. Jack Seidel:
We, unfortunately, that's one that happens not infrequently. And, to me, you talk about the parent's worst nightmare, one of the saddest situations is not when a parent puts a baby in their crib and because of ... For example, let's say that the baby has long QT syndrome and it was not known or something like that, obviously, it's always very sad when the baby dies. But you can imagine how much worse it is if they take the baby to bed with them and they're exhausted and they roll over and next thing you know, they have a dead baby in the bed with them and they actually caused it because they suffocated that baby. To me, that is just incredibly heart-wrenching and something that would be incredibly difficult to get over.
Dr. Jack Seidel:
So bed-sharing is something that I think is very important to speak to parents about and make sure that they do not do that. And I have a lot of conversations about that. And while we're on that topic, I think that it is very important if you have a situation where that is happening, I think it's also very important from a medico-legal standpoint to document that you've had that conversation if you become aware of it.
Dr. Jack Seidel:
Overheating, there are some people that really overdress the baby as far as too many outfits or keep it too warm. And certainly, if that baby is sweating, they are too hot and they need to be in a situation where they are not having as much clothing. I cannot think of a time that I've ever had a situation where I felt that the baby was not being kept warm enough. I think that we must have some type of built-in biologic philosophy that we need to keep babies extra warm. So I think that's a lot of the risk factors. But the two risk factors that I think that are most important are one, what we kind of already talked about, making sure that the baby is sleeping on their back. Babies that are not sleeping on their back, whether they're sleeping on their side or whether they're sleeping on their belly, that certainly is a risk factor, and that's a critically important risk factor.
Dr. Jack Seidel:
And then the last risk factor I'll mention that is very important to me personally is cigarette smoking, smoke exposure that is passive. And the reason that that's important to me personally is that in the 30-plus years that I've been in practice, I have had two babies that have died of SIDS, and less than 1% of my patients have a parent that smokes, and yet both of these babies had a parent that smoked. And so when I walk into a hospital room and I see cigarettes, or I walk into the hospital room and I smell smoke, I have the discussion right there. Who smokes? And if it's dad, if it's grandma, whoever it is, we have that conversation. And I document that conversation that I had about the dangers of passive cigarette smoke. And I tell them that obviously, this is a terrific time to stop smoking. This is a terrific time. What more important reason than the health of this beautiful baby than to stop smoking.
Dr. Jack Seidel:
But if I know that that's not going to work and they're refusing, then we talk about how you cannot smoke in the car. You cannot smoke in the home. It doesn't matter if the kid's not in the car at the same time or in the house at the same time. And that if you're going to go outside and smoke, you need to get one of those raincoats like the police wear and wear that, cover up your hair because smoke is not a gas, it is a particulate matter. And that smoke gets in your hair, that gets into your clothes. And if you go inside and you're going to hold that baby, then that baby is inhaling those smoke particles. And I then will tell them, "How do you think I knew that somebody smoked?" And they're like, "Well, ... " I was like, "Because I smell it." And if I'm smelling it, when I walk into this room, that means those smoke particles are going in my nose. And if they're going in my nose, guess who else's nose they're going into?
Dr. Neeta Goli:
So what was the official Back to Sleep campaign in the 1980s? And how did it affect the incidence of SIDS?
Dr. Jack Seidel:
Well, I don't know the exact campaign. I think that the, if I'm recalling correctly, I think the American Academy of Pediatrics and probably some other folks, maybe the CDC came out with that information. And I think it really if I'm remembering correctly and I could be wrong on this, is I think that they started looking at other cultures where babies typically slept on their backs. And they said why did this group of babies have, this cohort has less SIDS than in, for example, the United States? And I think that's what kind of led them to kind of look to see is this really the thing that's making the difference and lo and behold it was. And so how it actually became publicized and so forth, I don't recall.
Dr. Neeta Goli:
And the AAP now also recommends room-sharing, but not bed-sharing with newborns. How has this been shown to affect SIDS rates?
Dr. Jack Seidel:
So, room sharing, I think and it's really interesting is when you say room sharing, it actually is specifically room sharing with an adult or room sharing with a parent. And if the baby or the infant shares a room with another child, you don't seem to have that same reduction in the risk of SIDS as you do if in the same room as an adult. So I think that that's fascinating, and I don't know the reason for that, but is what I have read that that has showed. Now, certainly, we talked about bed-sharing and how that's a no-no and people will come up with these different permutations.
Dr. Jack Seidel:
Well, what's the difference if we have special carrier kind of thing or whatever that we put in the bed with us, but they're in their own box or whatever? And those have not really been shown to be safe, anything that goes actually in the parents' bed, even if it's their own sleeping surface in the bed. So we're talking about like a bassinet or a crib that is next to the parents' bed or to the mother's bed, not part of the parents' bed. But I think that it's very interesting to try to figure out why sleeping in the same room as an adult is protective and not sleeping in the same room as a child is protective, but that's what I've read that the studies have shown.
Dr. Neeta Goli:
And I haven't read the literature on this in a while, but if I'm remembering correctly, I think it might've had something to do with increased parental sensitivity to infant's noise or to infant's motion. So for example, if there's something out of the ordinary and the parent is used to sleeping with the baby in the same room, they might notice subconsciously that there's something different and the parent might wake up. Again, I haven't read the literature in a while, so I don't remember the exact specifics, but really interesting.
Dr. Jack Seidel:
Well, that brings up ... And I don't know that, but I would guess that that's not the case. And I'll tell you the reason why, is that if we go back to a time where I didn't have any gray hair when I was finishing residency, it was not unusual to send babies home with an apnea monitor or what we called the SIDS monitor. And it was basically something that would detect if the baby stopped breathing. None of this pulse-oximetry or things like that, that is out there now. But it was basically kind of just a cardio apnea monitor. And now, if you ask any recently trained pediatrician, they're like, "What are you talking about? I'd never even heard of such a thing," because we don't use them anymore.
Dr. Jack Seidel:
And the reason we stopped using them is not because they didn't work, because they oftentimes worked just fine. The alarm would go off because of maybe it was no longer breathing. But the problem seemed to be that those babies were unresuscitatable. So the monitor would go off, they go to find the baby, but they could not resuscitate the baby. And so it did not seem that using these monitors was beneficial in the long run, so they stopped being used. So the question really is that, and obviously, the AAP now says, is that there's no evidence to support their use in prevention of SIDS. And they even recommend all these fancy things now, like the socks with a pulse oximeter in them and things like that are also not recommended to be used. So, I'm wondering if the sleeping in the room with the parent ... There's also some information about fans, and do fans actually help to prevent SIDS? And there's limited studies, maybe they do, maybe they don't.
Dr. Jack Seidel:
But it seems like for many babies, not all, but for many babies, they can get into maybe some type of deep state that is very difficult for them to get out of, or maybe a hibernation thing and related to maybe a maturational delay of their neuroregulation. And these are probably babies that have some underlying vulnerability. So maybe it's genetic, and certainly, we do know that there seems to be a strong genetic basis because siblings of children that have had SIDS, of SIDS victims have a significant increase. So if you have a baby that had SIDS and that mom has a subsequent baby, that baby has a much higher risk of having SIDS then just the average risk that you would have.
Dr. Jack Seidel:
So there probably is some type of genetic situation that puts them at a higher risk. And whether that risk is based on positioning, based on airway obstruction, based on something else we don't know about yet, I'm not sure, but certainly, I think that parents that have lost a baby to SIDS and then have another baby, those people are certainly going to be at higher risk. And I think that it's going to be very important to make sure that we do everything we can to minimize risk factors for those babies in particular.
Dr. Neeta Goli:
And can you actually speak to risk based on infants' age? At what age do we see the incidence of SIDS rising or decreasing?
Dr. Jack Seidel:
I think the peak incidence certainly is between two and four months of life. And both babies that I had in my practice that died, both ended up being four months of age. But while your risk decreases through that first year and even later, it doesn't completely go away. And so, it's not like you're completely out of the woods once the baby gets to be say six months. But I think that most of the things that we do to try to minimize risk, I think that certainly, we talk about smoking, sleeping on their back, making sure that those pillows and things like that aren’t in the bed, I think that those are things that are really good to continue at least through the first year of life.
Dr. Neeta Goli:
How do you counsel parents who worry about aspiration risk if babies are sleeping on their back?
Dr. Jack Seidel:
Well, luckily, that is a question that we used to get quite a bit when we were making the change, still sleeping on the back. We don't really get that too often anymore. But I think that we have a lot of science, a lot of data showing that babies are very good at protecting their airway when they are sleeping on their back. Do they still spit up? Yes. Can they choke? Yes. Can they gag? Yes. Are they going to die for it? Almost never. So I think it's good to let them know that it is expected, babies spit up. That's what they do. And they may be messy, but they're very good about protecting their airway when they do.
Dr. Neeta Goli:
And then how do you counsel parents who say their baby will only sleep if they are being held?
Dr. Jack Seidel:
Well, I only typically answer that question once every day. But the answer is, is that babies will get used to many different things and they probably prefer to be held while they're sleeping. I might prefer to be held when I am sleeping, but that doesn't mean that I will not sleep if I'm not held. And I think that it's okay to let babies cry a little bit. And actually, what I tell people in my practice is: do not put your baby down in their crib asleep. If you're holding them and they fall asleep, you need to wake them up and then lay them down in the crib. Because what happens is, is that all babies wake frequently when they're sleeping, and they may come to a certain stage of arousal and go back to sleep.
Dr. Jack Seidel:
If they all of a sudden recognize, “hey, I fell asleep, mom was holding me, and now I'm someplace else,” that is going to potentially agitate them and wake them up and they're going to start crying because something has changed. But if they're always used to falling asleep in their crib, and they're awake when they're put down, maybe they're drowsy, maybe you sung them a song, you've done a dance, you read them a book, but you put them down while they're still drowsy, but not completely asleep, that is much better for them to stay asleep and for them to learn to sleep in that situation.
Dr. Neeta Goli:
Other than our safe sleep recommendations, which like we mentioned, include always sleeping on babies back in their crib by themselves, and you mentioned smoking cessation, what else can parents do at home to reduce the risk of SIDS?
Dr. Jack Seidel:
Well, I think that the main things at home that we've talked about. Now, there are some data saying that talking about sleeping in a car seat or sleeping in a swing. And those are questions that I get. And the answer is that babies should only sleep in the car seat when they're in the car. To be perfectly honest, I can tell you, I remember that 30 years ago when my children were young if they had a really bad cold and they were full of snot and couldn't sleep, that I can remember taking the car seat and putting it in our bedroom and having them kind of sleep at an angle upright because it seemed like it helped. Knowing what I know now, I don't think I would recommend doing that.
Dr. Jack Seidel:
So, there were some times that we would sometimes use car seats specifically to have them sleep or swings to have them sleep because, “well, they seem to like that, that seems to work well, and I'm exhausted.” But I think that that's something I would not currently recommend. I think that we talked a little bit about bed-sharing, but kind of an aside with bed-sharing, which is not necessarily SIDS, but certainly can end up with a baby who is injured or dies is parents that are exhausted and holding the baby, and then the parent falls asleep. And, I can tell you that that happens frequently. And thankfully, a lot of times bad things don't happen to the baby, or they wake up startled and don't drop the baby, or they drop the baby from their arms to their lap or something like that.
Dr. Jack Seidel:
But even in the hospital, I think that we have situations that seem like almost every year at our hospital where despite specifically telling parents if you are sleepy, do not hold the baby, they still do it. “Well, the baby was crying and I was exhausted,” and they dropped the baby. So, sleeping, holding the baby on a sofa or a couch, when you're sleepy, if you're tired enough that you need to lay back while you're holding that baby, you need to put the baby down. So I think that's a really important thing to make sure that we communicate to parents.
Dr. Jack Seidel:
The other thing that I'm kind of thinking about that I see even when I make rounds at the hospital is, and I think all of us I've had this happen, you walk in and you see one of those little head pillows, so their head will be nice and round in the baby’s bassinet in the hospital. I will pull that thing out and I will say, "This can never be in the baby's crib again. This may cause your baby to die." And I'll say it just like that. So all these head positioners, those are dangerous. And it's very important for all pediatricians, nurse practitioners, whoever is going to be going in and taking care of babies in the hospital if you see those, this is a great invitation, just like if you see that pack of cigarettes, to educate the parents.
Dr. Neeta Goli:
To end today's episode, what advice do you have for our listeners while they take care of newborns?
Dr. Jack Seidel:
Have fun. Get to know the parents a little bit. I always liked to ask the parents, “what do you do? Where do you live?” And I think that it's great to if you can, to bond with people and depending on even irrespective of what walk of life they come from or what their job is or their socioeconomic situation, I think that thankfully, we're in a situation where the vast majority of the time when we go and see babies, it's a happy time. The parents are happy. There's not too many other situations that patients are in the hospital that they're there for something really great. It's really wonderful. So enjoy that time, share that with the parents and with the family and try to bond with them.
Dr. Neeta Goli:
Dr. Seidel, thank you so much for joining us today.
Dr. Jack Seidel:
Thank you so much for having me.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.