Editorials
New Recommendations to Reduce the Risk of SIDS: What Should We Advise Parents?
This article exemplifies the 2006 AAFP Annual
Clinical Focus on caring for children and adolescents.
See related article on page 1864.
Despite decreased rates in the past decade, sudden infant death syndrome (SIDS) continues to be the leading cause of infant deaths in the United States after the neonatal period.1 In October 2005, the American Academy of Pediatrics (AAP) released updated recommendations on SIDS risk reduction, reiterating several of its earlier risk-reduction measures (Table 1).2 In this issue of American Family Physician, Dr. Schnitzer discusses these recommendations in her article on unintentional childhood injuries.3
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TABLE 1 AAP Recommendations for SIDS Risk Reduction |
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Place infant on his or her back to sleep. Side sleeping is not advised. Use a firm sleep surface (e.g., a firm crib mattress), and keep soft objects and loose bedding out of the crib. Avoid overheating infants during sleep. Keep the room temperature comfortable, do not overdress the infant, and use a light blanket or sleep sack. Do not smoke during pregnancy. Keep the infant's environment smoke-free. Use a separate but proximal sleeping environment, ideally with the infant in a bassinet or crib near the mother's bed. Do not sleep with an infant on a couch or armchair, and do not allow the infant to sleep with other children. Consider offering a pacifier at naptime and bedtime. Delay its use until one month of age in breastfed infants. |
| AAP = American Academy of Pediatrics; SIDS = sudden infant death syndrome. Information from reference 2. |
The evidence continues to support the protective role of placing infants on their backs to sleep; side sleeping is not advised because it confers a greater risk than supine sleeping. A firm crib mattress is the recommended sleeping surface. Soft objects and loose bedding should be kept out of the crib. Overheating of infants should be avoided. The infant's environment should be smoke-free during pregnancy and after birth.2
In light of new evidence, the AAP has provided new recommendations for infant-parent bed sharing and the use of pacifiers. The AAP now recommends a separate but proximal sleeping environment for infants (i.e., infants should not sleep in the same bed as their parents). However, proponents of breastfeeding argue that bed sharing facilitates optimal breastfeeding and reinforces mother-infant bonding.4 Many public health groups, including the AAP's task force on SIDS, have taken a moderate position by recognizing that although bed sharing may have benefits such as facilitating breastfeeding, there is no evidence that this practice reduces the risk of SIDS. In fact, some studies suggest that bed sharing under certain conditions actually may increase SIDS risk.4 Studies suggest that the risk is greatest for infants younger than 11 weeks, regardless of whether the parents smoke.5
Advocates argue that there is no evidence of increased SIDS risk after 11 weeks of age. In addition, the overall risk of death probably is greater than the risk of SIDS, considering other sudden infant deaths that occur in adult beds, such as death by suffocation.6 Advocates of bed sharing recommend strict practices such as sleeping on a thin floor mat with no pillows or blankets.7 Such practices, however, may be virtually impossible to implement. Therefore, bed sharing, as commonly practiced, should not be recommended, especially before 11 weeks of age. There is strong scientific evidence that bed sharing by mothers who smoke significantly increases the risk of SIDS throughout infancy, as does sleeping with an infant on a couch or armchair and allowing infants to sleep with other children. Nonetheless, there is growing evidence that room sharing without bed sharing is associated with a reduced risk of SIDS.2,5 The AAP recommends placing the crib or bassinet near the mother's bed to facilitate breastfeeding and contact. "Co-sleepers," infant beds that attach to the mother's bed, also may be a good solution, but safety standards for these devices have not been established.
The AAP also updated its recommendations on pacifier use. The group recommends that caregivers consider offering a pacifier at naptime and bedtime. Several studies have shown that pacifier use has a protective effect on the incidence of SIDS, especially when used at the time of last sleep.8 Controversy exists primarily because of concern about breastfeeding, leading some groups to recommend pacifier use in bottle-fed infants only.9 Decreased breastfeeding duration has been associated with pacifier use in observational studies; however, results of well-designed, randomized controlled trials have found that pacifiers do not affect breastfeeding duration, especially if pacifiers are introduced after breastfeeding is well established.10 Until evidence dictates otherwise, the AAP recommends the use of pacifiers when placing infants to sleep for the first year of life, but delaying this practice until one month of age in breastfed infants.
Family physicians are uniquely positioned to inform patients about SIDS and the current evidence on risk-reduction measures. This discussion should be started during pregnancy and continued immediately after birth and during each well-child examination, especially in the first six months of age, when SIDS risk is highest. However, there is still work to be done. In a study published in 2002, only one third of family physicians surveyed in North Carolina and the Washington, D.C., metropolitan area knew that the supine position was the recommended position for sleep; two thirds of pediatricians knew the correct position.11 Furthermore, only one half of family physicians routinely counseled parents about SIDS risk reduction. Thus, family physicians should become familiar with the new recommendations and consider how their practices might be affected. They also should consider their own biases so that they may objectively inform parents. Although it is ultimately up to parents to determine their infant care practices, we must provide the most up-to-date information to help them make informed decisions.
Address correspondence to Shahrzad Saririan, M.D., at shahrzad_saririan@medprodoctors.com. Reprints are not available from the authors.
REFERENCES
1. Arias E, MacDorman MF, Strobino DM, Guyer B. Annual summary of vital statistics-2002. Pediatrics 2003;112:1215-30.
2. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 2005;116:1245-55.
3. Schnitzer PG. Prevention of unintentional childhood injuries. Am Fam Physician 2006;74:1864-69, 1870.
4. Thach BT. Where should baby be put back to sleep? J Pediatr 2005;147:6-7.
5. Tappin DM, Ecob R, Brooke H. Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-control study. J Pediatr 2005;147:32-7.
6. Scheers NJ, Rutherford GW, Kemp JS. Where should infants sleep? A comparison of risk for suffocation of sleeping in cribs, adult beds, and other sleeping locations. Pediatrics 2003;112:883-9.
7. Mckenna J. Consumer safety group warns of new lethal danger to babies: are warning labels for mommy next? Accessed August 29, 2006, at: http://www.redflagsweekly.com/features/2002_sept09_2.html.
8. Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics 2005; 116:e716-23.
9. L'Hoir MP, Engelberts AC, van Well GT, Damste PH, Idema NK, Westers P, et al. Dummy use, thumb sucking, mouth breathing and cot death. Eur J Pediatr 1999;158:896-901.
10. Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003;111:511-8.
11. Moon RY, Gingras JL, Erwin R. Physicians beliefs and practices regarding SIDS and SIDS risk reduction. Clin Pediatr 2002;41:391-5.
Improving Practice Guidelines in AFP
See related article on page 1967.
The care that patients receive too often depends on where they live, their race, or their physician. Large variations have been found in rates of hysterectomy, mammography, A1C testing, hip replacement, spinal surgery, and hospital admission that cannot be explained by differences in age or other demographic factors.1-3 Decisions often are driven by geographic factors, local opinion leaders, reimbursement, and local customary practices. In addition, we are increasingly recognizing that errors of omission and commission are too common in our health care system.4 With an increasing number of tests, drugs, and treatments to juggle for each patient, relying on the memory of individual physicians to make the best possible decisions is no longer adequate. Meanwhile, Americans spent $6,102 per person on health care in 2004-approximately twice as much as Denmark, Canada, Austria, the Netherlands, and Sweden-yet had a lower life expectancy at birth than persons in all of those countries.5
Practice guidelines have been proposed as a solution to inappropriate variations in care, medical errors, high costs, and poor-quality health care. The airline industry has dramatically reduced its error rate (as measured by major crashes) by requiring checklists, standard protocols, and the aviation equivalent of practice guidelines to be used by pilots, who initially were as reluctant as physicians to adopt such procedures. Would you be comfortable getting on a plane if it was left to the pilot's memory and discretion to check the engines and flaps, and to make sure the plane had enough fuel?
Nevertheless, guidelines sometimes are criticized by those who call them "cookbook medicine" and decry their perceived interference with "the art of medicine." Sometimes this criticism is based on false notions of what is correct; these ideas often are formed on the basis of faulty evidence or are contradicted by recent research literature. Sometimes the criticism is based on a lack of understanding of what makes a well-designed guideline. On the other hand, sometimes the criticism is valid; a guideline that is too rigid, that is not based on a careful review of the evidence, or that fails to communicate clearly and effectively is unlikely to improve the quality of care, and it may even worsen it.
What makes a well-designed guideline? The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information-"best" implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and "available" implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence6) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.7
This month in American Family Physician, we will begin giving you more information about the practice guidelines that we summarize.8 We will tell you in an easy-to-read box who created the guideline; where you can find it online; whether the authors performed a comprehensive, well-described search of the literature; whether they rated the strength of clinical recommendations; and whether there were any potential conflicts of interest. We think this will make it easier for you to choose the best guidelines for your practice.
editor's note: Dr. Ebell is deputy editor for evidence-based medicine for American Family Physician. Dr. Siwek is editor of AFP.
Address correspondence to Mark H. Ebell, M.D., M.S., at ebell@msu.edu. Reprints are not available from the authors.
REFERENCES
1. Wennberg JE, Gittelsohn A. Health care delivery in Maine I: patterns of use of common surgical procedures. J Maine Med Assoc 1975; 66:123-30, 149.
2. Baicker K, Chandra A, Skinner JS, Wennberg JE. Who you are and where you live: how race and geography affect the treatment of Medicare beneficiaries. Health Aff (Millwood) 2004;(suppl Web exclusive):VAR33-44.
3. Wennberg JE. Dealing with medical practice variations: a proposal for action. Health Aff (Millwood) 1984;3:6-32.
4. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 2000.
5. Organisation for Economic Co-operation and Development. OECD health data 2006: statistics and indicators for 30 countries. Accessed November 2, 2006, at: http://www.oecd.org/health/healthdata.
6. American Society of Health-System Pharmacists. Most clinical practice guideline authors receive drug industry support. Accessed November 2, 2006, at: http://www.ashp.org/news/ShowArticle.cfm?id=2838.
7. Abramson J, Starfield B. The effect of conflict of interest on biomedical research and clinical practice guidelines: can we trust the evidence in evidence-based medicine? J Am Board Fam Pract 2005;18:414-8.
8. Graham L. CDC releases guidelines on improving preconception health care. Am Fam Physician 2006;74:1967-8,1970.
| Copyright © 2006 by the American
Academy of Family Physicians. |
