AAP issues update: SIDS and infant sleep positioning

Today the American Academy of Pediatrics (AAP) issued a new update to their infant sleep positioning recommendation to prevent Sudden Infant Death Syndrome (SIDS.)

The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleep Environment, and New Variables to Consider in Reducing Risk
www.aap.org...

"Despite major decreases in the incidence of Sudden Infant Death Syndrome (SIDS) over the past decade, SIDS is still responsible for more infant deaths beyond the newborn period in the United States than any other cause of death during infancy. In an updated policy statement on “The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk,” the American Academy of Pediatrics (AAP) addresses several issues that have become relevant since they last published a statement in 2000"

Changes and clarification from their 2000 directive include as a few examples:

From side sleeping being markedly safer than tummy sleeping to - "The AAP no longer recognizes side sleeping as a reasonable alternative to fully supine (lying on back) sleeping... Every caregiver should use the back sleep position during every sleep period."

From co-sleeping being hazardous under certain conditions to - "Bed sharing is not recommended during sleep."

And a new additional endorsement that - "Research now indicates an association between pacifier use and a reduced risk of SIDS, which is why the revised statement recommends the use of pacifiers at nap time and bedtime throughout the first year of life."


These more stringent guidelines come five months after the publishing of a study on statistics of SIDS deaths that determine no decrease in overall infant deaths - just a shifting in assignation of cause of death.

Changes in the classification of sudden unexpected infant deaths: United States, 1992-2001
www.ncbi.nlm.nih.gov...

"The failure of the overall postneonatal mortality rate to decline in the face of a declining SIDS rate in 1999-2001 raises the question of whether the falling SIDS rate is a result of changes in certifier practices such that deaths that in previous years might have been certified as SIDS are now certified to other non-SIDS causes. The observation that the increase in the rates of non-SIDS causes of sudden unexpected infant death could account for >90% of the drop in the SIDS rates suggests that a change in classification may be occurring."

Disturbingly, one of the study authors reveals a nuanced observation in an interview for a news article that the community of coroners, etc. may feel bullied or either pressure themselves to not certify infant deaths to be a result of SIDS now. In addition, a new requirement of health authorities mandates that they must conduct an investigation of every suspected SIDS deaths; this means that many times additional information comes to light that leads them to another cause of death (i.e. suffocation.) Also, this new investigation requirement dictates that when and investigation isn't conducted, a cause of death of "unknown" must be assigned.

U.S. Study: Recent decline in SIDS deaths illusory
www.healthsentinel.com...

""There's been this general feeling out in the community of pathologists and people who certify deaths (of) reticence to assign SIDS as the cause of death," study author Dr. Michael Malloy of the University of Texas Medical Branch in Galveston said in a telephone interview. "

"Health authorities now require a death scene investigation prior to certifying SIDS as a cause of death. Such information can yield clues to whether pillows, blankets or loose bedding might have led to suffocation. If no investigation is done, then the cause of death is usually listed as unknown. "

Even the support group First Candle/SIDS Alliance recognizes a need to apply some standardization to determining SIDS (from news article already linked above

""We've definitely come a long way and we don't want to see this classification issue undo the recommendations and their effectiveness," said Laura Reno of the SIDS support group First Candle/SIDS Alliance. She said her group is working with health experts to improve consistency in applying the SIDS classification to deaths. "

Increasingly, studies are beginning to challenge current SIDS statistics (abstracts follow):

A Reassessment of the SIDS Back to Sleep Campaign
www.thescientificworld.co.uk...
"The principal argument that initiated the BTSC (Back to Sleep Campaign) and that continues to justify its existence is the observed parallel declines in the number of infants placed in the prone sleeping position and the number of reported SIDS deaths. We are compelled to challenge both the implied causal relationship between these observations and the SIDS mortality statistics themselves."

How reliable are SIDS rates?
www.ncbi.nlm.nih.gov...
"This report shows how varying the criteria for a diagnosis of SIDS significantly alters the SIDS rate in Ireland."

Investigation into sudden infant deaths and unascertained infant deaths in England and Wales, 1995-2003
www.ncbi.nlm.nih.gov...
"It concludes that changes in certification practices surrounding sudden infant deaths and unascertained deaths suggest that it is becoming more difficult to distinguish between these two causes of death."


I have more thoughts later on the impact of alleged inaccurate SIDS statistics, but would appreciate any dialogue or comments from anyone interested so far.

I can understand some of the misdiagnoses, as SIDS is generally a diagnosis of exclusion (and even then, it's the collective umbrella for myriad conditions leading up to the same thing - a death which can't really be explained by any other condition). Confusing the issue: In the US, autopsies for suspected SIDS cases are not mandatory in every state, leaving more room for assumption and ambiguity.

Then we have articles such as this one , which asks the question:

It is also important to enlarge the debate of the cause of death in infants with cardiovascular malformations. Should they be included in borderline SIDS?

Looking forward to reading more from you

Thank you for your reply!

My concerns about the Back to Sleep campaign are two-fold; one, how can it be claimed that placing babies to sleep supine prevents SIDS cases when not only is there no standardization of what falls under the SIDS umbrella, but there also appears to be no statistical decrease in infant deaths overall anyway regardless of designation of cause of death? Personally, I was caught off-guard by the SIDS statistical analysis study results that I referenced in the thread-opener. I wonder if subsequent studies will confirm those conclusions. And two, are there any undesireable effects of supine sleeping? An example of one, is that the Back to Sleep campaign has caused an epidemic of deformational plagiocephaly (misshaped skull,) which the AAP acknowledges.

Prevention and Management of Positional Skull Deformities in Infants
aappolicy.aappublications.org...;112/1/199?fulltext=plagiocephaly&searchid=QID_NOT_SET

"Over the past several years, pediatricians have seen an increase in the number of children with cranial asymmetry, particularly unilateral flattening of the occiput. This increase likely is attributable to parents following the American Academy of Pediatrics "Back to Sleep" positioning recommendations aimed at decreasing the risk of sudden infant death syndrome."


Emerging research not yet addressed by the AAP shows that deformational plagiocephaly is now associated with higher risks of certain health issues and subtle learning difficulties, and not merely the "cosmetic issue" once thought. Some of the study abstracts, all of which have been published only in the last few years are:

Auditory ERPs reveal brain dysfunction in infants with plagiocephaly
www.ncbi.nlm.nih.gov...
"In the current study we demonstrated, for the first time, that the central sound processing, as reflected by ERPs, is affected in children with plagiocephaly."

Anthropometric analysis of mandibular asymmetry in infants with deformational posterior plagiocephaly
www.ncbi.nlm.nih.gov...
" This study supports the clinical observation that the mandibular asymmetry in deformational posterior plagiocephaly is secondary to rotation of the cranial base and anterior displacement of the temporomandibular joint (quantified by anterior auricular position) and not the result of primary mandibular deformity"

Long-Term Developmental Outcomes in Patients With Deformational Plagiocephaly
pediatrics.aappublications.org...
"Infants with deformational plagiocephaly comprise a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years"

Neurodevelopment in children with single-suture craniosynostosis and plagiocephaly without synostosis.
www.ncbi.nlm.nih.gov...
"...0 percent of the subjects in the group with plagiocephaly without synostosis were accelerated, 67 percent were normal, 20 percent had mild delay, and 13 percent had significant delay"

Ophthalmologic findings in patients with nonsyndromic plagiocephaly
www.ncbi.nlm.nih.gov...
"The prevalence of astigmatism in patients with nonsyndromic craniosynostotic plagiocephaly appears to be greater than in the general population..."

The Relationship Between Craniofacial Morphology and Obstructive Sleep Apnea in Whites and in African-Americans
ajrccm.atsjournals.org...
"Thus, brachycephaly is associated with an increased AHI in the white population but not in African-American population. "

Visual Field Testing in Deformational Plagiocephaly
www.aans.org...
"Our study demonstrates a notable incidence of visual field constriction in patients with PP. In addidition, patients with PP may have delayed progression of visual field development. Our data sheds doubt on the concept that PP is a benign entity with no neurologic sequelae and requires treatment for cosmetic purposes only."

Visual field defects in deformational posterior plagiocephaly
www.ncbi.nlm.nih.gov...
"Deformational posterior plagiocephaly may affect visual field development but neither the laterality nor the severity of skull deformity is predictive of the severity of visual field defects."

Isn't it a bad idea to have a baby sleep on it's back for the simple reason that if it spits up or vomits in the middle of the night it could drown or choke on it's on vomit? Seems a bit distressing to me to tell anyone to have their babies sleep on their backs!

Besides...it appears SIDS is caused by vaccinations anyway!