Title: Understanding and managing infant crying: Implications for child maltreatment,swaddling, and sudden infant death
1Safe sleeping practices
- Understanding and managing infant crying
Implications for child maltreatment,swaddling,
and sudden infant death
Dr. Lynne Warda WRHA Injury Prevention
Program Pediatric Emergency Medicine Child
Health Standards Committee (CPSM)
PRESENTATION FOR Injury Prevention
Champions Spring 2015
2Presentation Objectives
- Safe sleep practices
- Normal infant crying patterns
- Management of infant crying
- Safe swaddling
- Benefits and risks of swaddling
- Resources
3Back to Sleep SIDS Trends?
Safe sleep practices
- Declining incidence 1990s-now
- 1.1/1000 live births 1990 0.3/1000 in 1999
- 16-20 cases/year to lt5 cases/year (SIDS)
- Males 60-70
- African American, First Nations 1.5-2X risk
- Age 80 less than 5 months, peak 2-4 months, 3
greater than one year of age - Most apparently healthy prior to death, many with
minor recent illness (GI, resp sx)
4SIDS/SUID Trends - USA
Safe sleep practices
5Recent SIDS/SUID Manitoba Cases
Safe sleep practices
- 3 weeks, sleeping with parent on couch, found
prone - 12 weeks, sleeping with teen mom in foster care,
crib in room - 6 months, adult bed, found on the floor in pile
of clothing - 8 months, sleeping with parents, found wedged
between wall and mattress - 4 months, found between two mattresses on the
floor - 4 months, found in swing with blanket over face
- 11 months, found in stroller under lap tray, no
restraint in use - 4 months, placed prone in playpen
Safe sleep issues? Common themes? Other risks?
Protective factors?
6Prevalence of Sleep Environment Risk Factors for
Sudden Infant Death A Population-Based Study
7Definitions
Safe sleep practices
- SIDS
- SUID
- ALTE
- Entrapment
- Strangulation
- Suffocation
- Choking
- Asphyxia
8Causes of Suffocation
Safe sleep practices
- Types Entrapment, strangulation, suffocation,
aspiration - Crib/bed/furniture entrapment
- Clothing drawstrings, hoods, buttons
- Bedding, piles of clothing, bumper pads
- Pets
- Plastic bags, plastic film
- Aspiration (small parts) toys, coins, food
9Other Causes of Sudden Death
Safe sleep practices
- Child abuse, trauma
- Sepsis/infection/pneumonia
- Seizure
- Dysrhythmia
- Aspiration (GER, other)
- Central causes of apnea
- Upper airway, lower airway causes of apnea
- SIDS, SUID
10Triple-risk model SIDS
Safe sleep practices
- Predisposed infant
- Unstable period of homeostatic control
- Triggering factor(s)
11Risk Factors for Sudden Infant Death
Safe sleep practices
- SIDS risk factors?
- Classic sleep position, smoking, overheating
- SUID risk factors?
- Sleep environment risks
- Suffocation risk factors?
- Bed, bedding, toys/objects, humans, pets
- Entrapment risk factors?
- Bed, furniture
12References/Evidence review
Safe sleep practices
- Joint Statement on Safe Sleep (PHAC 2011)
- SIDS and Other Sleep-Related Infant Deaths
Expansion of Recommendations for a Safe Infant
Sleeping Environment (AAP Oct 2011) - Policy statement
- Technical Report
- WRHA SIDS/SUDS Clinical Practice Guideline
- Research Literature
13The Bottom Line
Safe sleep practices
- Level A recommendations
- Back to sleep for every sleep
- Use a firm sleep surface
- Room-share without bed-sharing
- No soft objects and loose bedding
- Pregnant women should receive regular prenatal
care
14The Bottom Line
Safe sleep practices
- Level A recommendations
- Avoid smoke exposure during pregnancy and after
birth - Avoid alcohol/illicit drug use during pregnancy
and after birth - Breastfeeding is recommended
- Consider offering a pacifier at nap time and
bedtime - Avoid overheating
- Do not use home cardio-respiratory monitors as a
strategy for reducing the risk of SIDS
15Sleep Position
Safe sleep practices
- Supine is the safest position until age 1
- Why? Rebreathing, overheating, suffocation
- Side position is as unsafe as prone (2.0-2.6X)
- Higher risk for infants placed prone who usually
sleep supine (child care, illness) - Hospital preterm infants supine by 32 weeks
- Newborns should be placed supine from birth
- Infants who roll both ways can be left prone
16Sleep Surfaces
Safe sleep practices
- Safety-approved crib, portable crib, playpen or
bassinet - Firm mattress with no gaps
- No drop sides (US, soon Canada?)
- Beware playpen bassinets and change tables not
designed for sleep! - Car seats/infant seats/swings are not safe for
routine sleep and require adult supervision
17Bed-sharing
Safe sleep practices
- Adult bed risks related to suffocation,
entrapment between bed/wall/furniture, soft
bedding, pillows, mattress sag, falls - Bed-sharing risks related to overheating,
rebreathing, airway obstruction, head covering,
smoke exposure (all are risk factors for SIDS)
bed-related risks - Recent meta-analysis of 11 studies 2.88?risk
(1.99-4.18) with bedsharing
18Particularly Hazardous
Safe sleep practices
- Stress to parents that they avoid the following
situations at all times - Smokers (one or both parents)(OR 2.3-17.7)
- Age lt 3 months regardless of smoking status (OR
4.7-10.4) - (BWlt2500, GA lt 37 weeks, nonsmokers OR 15.2)
- Waterbeds, sofas, armchairs (OR 5.1-66.9)
- Pillows, blankets (OR 2.8-4.1)
- Multiple bedsharers (OR 5.4)
- Parent has consumed alcohol (OR 1.66)
- Bedsharing with nonparent (OR 5.4)
19Bedding
Safe sleep practices
- Pillows, quilts, comforters, sheepskins
- Increase risk up to 5X regardless of sleep
position - Unsafe under infant
- When loose can cause head-covering
- Risk of suffocation/rebreathing when used to
create barriers to prevent infant from falling - No wedges/positioners, bumper pads
20Room-sharing
Safe sleep practices
- Recommended routine practice
- 50 reduction in SIDS
- Safer than solitary sleeping and bedsharing
- Separate sleep surface
- No smoking in the room
21Smoking
Safe sleep practices
- Maternal smoking accounts for 1/3 SIDS
- LBW, prematurity, decreased infant arousal
- Post-natal parental smoking is associated with a
2.5-5.8 fold increase in SIDS - Risk increases with smokers in the home,
smokers in the same room as the baby,
cigarettes smoked, daily hours baby exposed
22Substance Use/Abuse
Safe sleep practices
- Maternal alcohol use, binge drinking OR 6-8
independent of smoking - In-utero exposure to opiates, cocaine, methadone,
heroin OR 2-3 after controlling for numerous
associated risk factors
23Breastfeeding
Safe sleep practices
- Previous studies not consistent
- Recent meta-analysis of 18 case control studies
OR 0.40 (0.35-0.44) - Exclusive BF more protective OR 0.27 (0.24-0.31)
- Why? More easily aroused from sleep, decreased
respiratory and GI illness - Return infant to crib after feeding
24Pacifier Use
Safe sleep practices
- Protective effect
- Especially when used at time of last sleep
- Two meta-analyses OR 0.39, 0.48
- Why? Lowered arousal thresholds, maintains airway
open in sleep, modifies autonomic control - No significant association with BF duration
- Delay use until BF established
25Overheating
Safe sleep practices
- Definite association with SIDS
- Increased when prone
- Head covering risk overheating, hypoxia,
rebreathing - Some evidence that good room ventilation may
reduce the risk of SIDS
26Key Messages for Parents
Safe sleep practices
- Back to sleep for every sleep
- Alone in a crib or playpen
- No blankets or soft bedding
- Same room as parents (smoke-free room)
- Breastfeed
- Smoking significantly increases the risk of SIDS
- Discuss the risks of bedsharing
27Normal infant crying
28Understanding Normal Crying
Normal infant crying
- Evidence-based international approach
- Normal crying curve
- PURPLE program
- Focus groups, RCTs
- Booklet, DVD
- 10 languages
- www.purplecrying.info
- Video
29Reasons for Crying
Normal infant crying
30Hmmm.what next?
Normal infant crying
- In British Columbia, mothers of newborns who
received PURPLE program materials at public
health home visits showed greater crying
knowledge, shared crying information and
strategies with other caregivers, and were more
likely to walk away during episodes of
inconsolable crying. - What is your approach when supporting mothers of
newborns?
31PURPLE Crying
Management of infant crying
- Some things work some of the time, but nothing
works all of the time - Comforting might involve wrapping your baby in
a blanket, or just holding your baby in your arms
- Carrying includes holding, contact and
closeness - Walking includes all of those as well as
introducing a rhythm to your movements. You may
also want to move your body to the rhythm of the
beats in music while carrying and comforting your
baby - Talking includes adding a human voice, perhaps
saying or singing the same things over and over
to a melody
32Tips for Soothing Crying
Management of infant crying
- Address infant needs (hunger, diaper change,
overheating, overstimulation, fatigue) - Change of position
- Kangaroo care/skin to skin contact
- White noise/vibration (fan, dryer, vacuum, car
ride) - Carrying/closeness
- Do not place the infant on top of a dryer or
washing machine due to the risk of falls
33Swaddling for Crying?
Management of infant crying
- Several studies have documented reduced crying
hours with routine and ? stimuli - Sleep, feed, cuddle, alone time in playpen, to
his/her crib awake but sleepy when showing signs
of fatigue - Reduce noise from radio, television, or noisy
toys, and baby gyms, if the child is less than 3
months old. - Avoid using bouncy chair (except for feeding) for
an infant that cries excessively. Never use on
elevated surfaces! - Avoid continuous entertainment, visits, outings
- Swaddling did not ADD significant benefit to this
routine after the first 3 days. Try this first!
34Benefits
Benefits and risks of swaddling
- Pain relief positive impact on behavioural
and/or physiological pain indicators - Weighing showed reduced physiological distress,
improved motor organization and more effective
self-regulatory ability when weighed - Excessive crying Soothes excessive crying
- PURPLE program
- Regularity and uniformity approach
- Happiest Baby Method
- Sleep infants sleep longer
35Risks
Benefits and risks of swaddling
- Maternal-infant bonding a reduction in the
mothers responsiveness and involvement with the
infant - Breastfeeding skin-to-skin contact is not
possible with swaddling - Respiratory infections a study of 186 infants in
Turkey and China concluded that infants routinely
swaddled had a 4-fold greater likelihood of
developing pneumonia and other upper respiratory
infections compared to those not swaddled - Developmental Dysplasia of the Hips (DDH)
greater risk of hip dysplasia for infants who are
tightly swaddled, restricting hip flexion and
abduction - SIDS/SUID/Suffocation Studies show that infants
who were swaddled have a higher risk for SIDS
36Swaddling and Infant Death
Benefits and risks of swaddling
- Manitoba cases (sling, swaddling, blankets)
- 2013 CASE EXAMPLE
- A newborn who was being carried in an infant
sling-style carrier inside the mother's
clothing/coat was found unresponsive and did not
respond to resuscitation - Though not exactly swaddling, it is related, and
a similar mechanism to both SIDS/SUID and
swaddling/suffocation
37Swaddling and Infant Death
Benefits and risks of swaddling
- Journal of Pediatrics 20141641152-6 case
series infant deaths and injuries - New Zealand Cot Death study
- Netherlands sleep sack case control study
- Ponsonby (CC) 12X risk
- Blair (CC) 30X risk
38Swaddling for Warmth
Benefits and risks of swaddling
- The Winnipeg Liveability bylaw residential
temperatures must be no less than 18C between
11pm and 7am, and no less than 21C between 7am
and 11pm. - Sleep in the warmest room, away from windows,
drafts, and exterior walls. Infants should not
sleep next to a radiator, heater or
fireplace/woodstove, given the risk of
overheating. Do not use a hot water bottle or an
electric blanket. - Use a fleece or flannel fitted crib sheet.
- Dress in undershirt and fleece sleeper with feet
/- hat. - May use a small fleece blanket tucked in.
39Swaddling Tips
Benefits and risks of swaddling
- Not recommended as routine practice
- May be used to convert prone sleeper to supine
- Always lay supine, not side or prone
- No head covering
- Swaddle to allow hip flexion/abduction,
breathing. - Ensure infant will not escape the swaddle
- Stop swaddling when the infant can roll over
- Use light receiving blanket (may need two)
40Summary
Benefits and risks of swaddling
- Does not reduce the risk of SIDS
- increased risk if swaddled and prone
- May be used as a strategy to soothe/calm
- Tight swaddling overheating, increases
respiratory rate, adversely affects respiration - Loose swaddling risk of head covering
- Any swaddling may reduce sleep arousal,
particularly if unaccustomed to swaddling
41Sleep sacks and swaddlers
42Sleep Sacks and Swaddlers
- CONSIDERATIONS
- Follow manufacturers instructions age, weight,
length - Fabric meets Canadian sleepwear flammability
guidelines - No drawstrings or cords at neck. No ribbons,
cords, or tight elastic that could cause
strangulation or constrict a limb or digit. No
small parts that could cause a choking hazard
43Sleep Sacks and Swaddlers
- CONSIDERATIONS
- Must fit snugly around upper body and neck to not
cover mouth and nose, and infant cannot wiggle
inside the sack, under the collar - Should not be tight around the chest. No
restrictions at the hip, so that the hips can
flex comfortably - Caution the parent regarding overheating, and
always dress lightly under the sack and/or
swaddler
44SIDS and Kids Safe Sleeping app
Resources
- App provides information on how to sleep baby
safely and reduce the risk of sudden unexpected
death in infants and fatal sleeping accidents - It also includes valuable information on Tummy
Time and Safe Wrapping
45Safe Sleeping Posterhttp//www.sidsandkids.or
g
Resources
46Safe Sleep For your baby brochurehttp//www.pha
c-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood
-enfance_0-2/sids/pdf/sleep-sommeil-eng.pdf
Resources
47Questions?