Implementing the AAP SIDS Prevention Guidelines During Discharge Planning In The NICU

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Implementing the AAP SIDS Prevention Guidelines
During Discharge Planning In The NICU

• Jennifer Sedlmeyer, BSN, RN
• Inova Fairfax Hospital Director of Perinatal
  Outreach

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The Catalyst

• Two years ago, physicians discharging patients
  from the Inova Fairfax Hospital For Children NICU
  identified that infants in the NICU who had grown
  to term corrected gestational age (CGA) were not
  following the AAPs recommendations for infant
  sleep.
• At the time of discharge parents were asking
  inappropriate questions such as, Where can I
  purchase a gel pillow for my baby to use at
  home? and How should I prop up the head of the
  crib at home?

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The Catalyst

• At the same time, a baby who went home from the
  NICU was placed on his abdomen to sleep and died
  of SIDS.
• Mom stated Even though the written instructions
  said to place the baby on his back to sleep, I
  placed the baby how the nurses had placed him, on
  his tummy.

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Taking Action

• A literature review of the current guidelines for
  infant sleep was conducted, focusing on premature
  infants nearing term GCA.
• Experts in the field of SIDS were contacted to
  discuss the AAP recommendations and how they
  pertain to infants born prematurely.
• The most current recommendations and research
  were compiled into a report.

5
The Task Force

• Staff members volunteered for a SIDS Prevention
  Task Force that developed NICU sleeping
  guidelines based on the current recommendations,
  personal experience, standards for supporting
  developmentally appropriate care, and the
  opinions of experts in the field.
• The task force also developed a parent handout to
  explain the transition process for preterm
  infants as they grow closer and closer to term
  CGA.

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Results

• Practices in the NICU significantly improved in
  safety.
• Surveys of NICU Staff found the guidelines to be
  helpful and user-friendly.
• A survey of the NICU Parents showed an increase
  in knowledge and in satisfaction with care.

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• THE LITERATURE REVIEW

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Historical Perspective

• And this child died in the night because she
  over laid it. 1Kings 319-20
• In 1291 a German poster forbid mothers from
  taking their infants under 3 years of age to bed
  with them.
• Late 1800s SIDS was first defined Sudden and
  Unexplained Death in Children

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Definition of SIDS

• The sudden death of an infant under 1 year of
  age, which remains unexplained after
• Thorough case investigation
• Complete autopsy
• Death scene investigation
• Review of the clinical history

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Facts About SIDS

• SIDS is the 3rd leading cause of death in infants
  under 12 months of age.
• 91 of SIDS deaths occur before 6 months of age.
• The peak is between 2-4 months of age.
• African American infants are nearly 2 ½ times
  more likely to die of SIDS than white infants.

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Facts About SIDS

• SIDS is not
• Caused by vomiting and choking
• Caused by immunization
• Contagious
• The result of neglect or child abuse
• Hereditary
• Predictable or preventable

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Which Babies Are at Greatest Risk?

• Infants of mothers with late/no prenatal care
• Infants exposed to nicotine
• Infants with prenatal illicit drug exposure
• Infants of young mothers (under 20)

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Which Babies Are at Greatest Risk?

• Male infants
• Multiples
• African Americans and Native Americans
• Infants who sleep in the prone position
• Infants who sleep on soft bedding
• Overheated infants

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Which Babies Are at Greatest Risk?

• Premature infants and/or low birth weight infants
  (under 1000 grams)
• A recent study showed that premature infants were
  17 times more likely to die of SIDS than term
  infants.

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Some Theories

• Researchers have identified an area of the brain
  that is hypoplastic or absent in SIDS babies
• Medullary arcuate nucleus
• This abnormality may put an infant at risk for
  sudden death during sleep
• This area of the brain regulates autonomic and
  respiratory control during sleep

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Some Theories

• The Atlas-VSC-SIDS Theory
• Suggests misalignment of the spine, caused by
  abnormal positioning in utero or by the birth
  process, can cause the cardiovascular and
  respiratory systems to malfunction, leading to
  sudden death during a vulnerable postnatal
  period.

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Triple Risk Model
Highest risk at 2-4 months
Highest risk for SIDS
1. Critical Stage Of Development
SIDS
2. Vulnerable Infant

3. Exogenous Stressors
External risk factors such as smoking, poor sleep
position, etc.
Arousal response deficit or subtle brainstem
dysfunction
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The Importance of NICU Staff in Stopping SIDS

• A recent national study found that
  recommendations from the neonatal nursery staff
  increased the likelihood of parents following
  through with supine sleeping and other SIDS
  guidelines.

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Behaviors That Should Be Taught To Parents To
Reduce the Risk of SIDS

• Always place your baby on his or her back to
  sleep, even for naps.
• Place your baby on a firm mattress in a
  safety-approved crib or bassinet.
• Remove soft, fluffy bedding and stuffed toys from
  your babys sleep area.
• Make sure your babys head and face remain
  uncovered during sleep.

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Behaviors That Should Be Taught To Parents To
Reduce the Risk of SIDS

• Do not allow smoking around your baby.
• Do not let your baby get too warm during sleep.
• Talk to childcare providers, grandparents,
  babysitters and all caregivers about SIDS risk.

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Always place your baby on his or her back to
sleep, even for naps.

• The American Academy of Pediatrics has
  recommended since 1992 that infants be placed to
  sleep on their backs to reduce the risk of sudden
  infant death syndrome (SIDS).
• Infants who sleep on their backs are 3 times less
  likely to die from SIDS than those who sleep on
  their stomachs.

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Always place your baby on his or her back to
sleep, even for naps.

• Side sleeping
• While better than prone sleeping, it still has
  twice the risk of SIDS as back sleeping.
• Stomach sleeping
• Babies sleeping on their stomachs have lower
  blood pressure, higher heart rate and higher body
  temperature.
• Arousal may be diminished in the prone position
• These babies are also more likely to overheat
  to rebreathe CO2.

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The Back To Sleep Program

• Since 1994, when the Back To Sleep advisory was
  first announced, the rate of SIDS deaths in the
  U.S. has dropped by 50.
• When babies all slept on their stomachs, there
  were approximately 5000-6000 deaths per year.
• There were just over 2,000 deaths due to SIDS in
  2003.

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What About Aspiration?

• According to the AAP there is NO evidence of an
  increase in aspiration or increased complaints of
  vomiting since the incidence of supine sleeping
  has increased dramatically (AAP, 2000).
• There is also some direct and indirect evidence
  that infants who vomit are at greater risk of
  choking if they are sleeping face down (AAP,
  2000).

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Place your baby on a firm mattress in a
safety-approved crib or bassinet

• Never place babies to sleep on a waterbed, sofa,
  or cushions.
• A safe crib is in good repair with a firm
  mattress and the slats are 2 3/8 apart (close
  enough so that a soda pop can cannot fit between
  them).

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What About Bed Sharing?

• NOT protective against SIDS
• The AAP discourages bed sharing
• Bed sharing does become unsafe and confers a
  higher risk of SIDS when
• Parents smoke and bed share
• Parents are exhausted or under the influence of
  alcohol or drugs.
• Encourage rooming in rather than bed sharing.

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Remove soft, fluffy bedding and stuffed toys from
your babys sleep area.

• Eliminate soft bedding such as quilts or pillows
  from cribs.
• If using a blanket, use a thin one and tuck it
  around the mattress so it reaches only as far as
  the babys chest.
• Remove bumper pads from cribs.
• Remove wedges from cribs.
• Do not place stuffed animals or toys inside the
  sleeping area.
• Make certain crib sheets fit well.

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Make sure your babys head and face remain
uncovered during sleep.

• Avoid using a blanket or other coverings over
  your baby's face as a sun or weather screen.
• Do not swaddle the babys head.
• Consider using a sleep sack
• as an alternative to a blanket.

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Do not let your baby get too warm during sleep.

• Keep the temperature in the baby's room at a
  level that feels comfortable.
• Room temperature should be about 70 degrees.
• Dress a baby in as much or as little as an adult
  would wear.
• Remember to remove hats and heavy outerwear when
  indoors during the cold weather months.
• Limit layers of clothes and blankets in warmer
  weather.

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Do not allow smoking around your baby.

• Nicotine is a neuroteratogen
• Causes cell damage
• May shut off the fetal response to hypoxia
• May disrupt the rhythmic organization of
  autonomic function (Zeskind, 2000)
• Babies whose mothers smoke have 3X the risk of
  SIDS as babies born to non-smoking mothers.
• Exposure to other passive smokers increases the
  risk in a dose-dependent manner (Flemming, et.
  al, 2000).

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Talk to childcare providers, grandparents,
babysitters and all caregivers about SIDS risk.

• About 20 of the babies that die of SIDS each
  year die while being cared for by someone other
  than their parents.
• Half of these children die in their first week of
  day care.
• Babies unaccustomed to sleeping on their stomachs
  are at significantly increased risk.
• Parents should tell caretakers that they want the
  baby to sleep on his/ her back, even at nap time.

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Safe Sleeping

• Ideally this is how an infant under 1 year of age
  should sleep
• He is on a firm, flat mattress in a crib that
  meets safety standards.
• There are no quilts, pillows or toys in the crib.
  
• The baby is placed with his feet at the foot of
  the crib.
• The blanket being used is thin and it is tucked
  around the crib mattress, reaching only as far as
  the baby's chest.

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Modeling Proper Behaviors In The NICU

• Research shows that parents model behaviors seen
  in the hospital.
• Stomach sleeping in the hospital stomach
  sleeping at home
• Same is true for nesting, bundling with multiple
  blankets, stuffed animals in the bed and placing
  the head of the bed up

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Modeling Proper Behaviors In The NICU

• In the study that showed premature infants were
  17 times more likely to die of SIDS than term
  infants, much of the risk was attributed to poor
  behaviors learned in the nursery.

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• What do parents see in the NICU?

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The head of the bed is up. The baby is nested
with a stuffed animal and quilt in the bed. She
is in the side sleeping position.
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The baby is sleeping prone with multiple layers
of soft bedding.
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There is a covering over the babys face and
there are multiple objects in the sleeping area.
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The baby is nested and is in the side sleeping
position with his face against the soft bedding.
40
There is a heavy, non-secured covering over the
babys face and the head of the bed is elevated.
This is a baby who never had issues with emesis
or reflux.
41
This babys bedding is covering her mouth and
nares. She had 6 blankets in the crib.
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• Learning from Our Mistakes
• And Taking Action

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What We Learned

• Neonatal hospital staff can unwittingly be poor
  role models.
• Prone positioning, elaborate nesting and the use
  of soft bedding or gel pillows may be quite safe
  within the confines of the critical care setting
  but are potentially lethal at home.

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Taking Action

• Staff members were asked to volunteer for a SIDS
  Prevention Task Force.
• The multidisciplinary task force met weekly to
  discuss the current recommendations for
  preventing SIDS and how we could better
  incorporate them in to our NICU.
• The goal of the task force was that all infants
  would be following the AAPs recommendations for
  sleep before their date of discharge.

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The Guidelines

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The Task Force

• The task force developed these guidelines based
  on the current recommendations, personal
  experience, standards for supporting
  developmentally appropriate care, and the
  opinions of experts in the field.
• The task force agreed that guidelines would be
  more effective than a policy, recognizing that
  there will always be variations from the norm in
  our patient population.
• The guidelines are divided into 3 categories
  babies less than 32 weeks CGA and/or lt1500 grams,
  babies between 32 and 35 weeks CGA and/or gt1500
  grams, and babies over 35 weeks CGA.

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Changing Our Practice

• Sleep position and conditions should be adjusted
  to follow the AAP guidelines as soon as the baby
  is physiologically and developmentally ready.
• If a baby is expected to follow any guidelines
  for sleeping other than the AAP SIDS Prevention
  Recommendations, they should have specific
  written instructions and the physician should
  discuss the alternate interventions with the
  family.

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Sharing Our Wisdom

• The task force also developed a parent handout to
  explain the transition process for preterm
  infants as they grow closer and closer to term
  CGA
• If a patient is getting ready to go home and
  staff is unable to follow the SIDS prevention
  guidelines, an explain of why alternate practices
  may be acceptable in the hospital setting but not
  at home is given.
• No more waiting until the day of discharge to
  review the SIDS Prevention Recommendations!

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What We Learned

• There is room for both Developmentally Supportive
  Care and SIDS Prevention Recommendations in the
  NICU.
• We need to carefully consider each childs
  changing clinical status, gestational maturity
  and individual readiness for supine sleeping with
  minimal bedding.
• The ultimate goal is to help high-risk babies
  become healthy babies

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Remember, You Can Make A Difference!

• Be aware of the risk of SIDS for our vulnerable
  patients as they transition to home.
• Use your influence as healthcare professionals,
  through education and modeling, to minimize the
  risk!

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For More Information

• The National Institute of Child Health and Human
  Development
• www.nichd.nih.gov, Back to Sleep
• SIDS Mid-Atlantic
• 703-933-9100
• www.sidsma.org

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For More Information

• American Academy of Pediatrics
• www.aap.org
• Association of SIDS and Infant Mortality Programs
• www.asip1.org

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For More Information

• National SIDS Resource Center
• www.sidscenter.org
• SIDS Alliance
• www.sidsalliance.org

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References

• American Academy of Pediatrics Task Force on
  Infant Sleep Position and Sudden Infant Death
  Syndrome. (2000). Changing concepts of sudden
  infant death syndrome implications for infant
  sleeping environment and sleep position.
  on-line. Pediatrics, 105, (3), 650-656.
• Hudson Mohawk SIDS Affiliate. (1998). Reducing
  the risk of SIDS what public health nurses need
  to know.
• Kemp, J. S. Thach, B. T. (1995). Quantifying
  the potential of infant bedding to limit CO2
  dispersal and factors affecting rebreathing in
  bedding. American Physiological Society,
  740-745.
• Lockridge, T., Taqino, L. T., Knight, A.,
  (1999). Back to SleepIs there room in that crib
  for both AAP recommendations and developmentally
  supportive care? Neonatal Network, 18 (5), 29-31.

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References

• Moon, R., (2000). Answering medical questions
  about SIDS. Presented at the National SIDS
  Alliance Conference, Salt Lake City,
  Utah. Willinger, M., Ko, C. W., Hoffman, H. J.,
  Kessler, R. C., Corwin, M. J. (2000) Factors
  Associated with caregivers choice of infant
  sleep position, 1994-1998. JAMA, 283 (16),
  2135-2142. Zeskind, P. S., (2000). Maternal
  cigarette-use during pregnancy disrupts rhythmic
  activity in fetal autonomic regulation.
  Presented at the National SIDS Alliance
  Conference, Salt Lake City, Utah