The Theory of Why Breastfed Babies Have a Lower Incidence of Sids Is

Introduction

Identification of factors that increment run a risk of, or are protective against, sudden babe death syndrome (SIDS) has largely been accomplished through epidemiological case-control studies. Risk factors include side and decumbent positioning, prenatal and postnatal tobacco fume exposure, sleeping on soft or cushioned surfaces (particularly sofas, couches, and armchairs), bed sharing, soft bedding, head roofing and overheating, and prematurity. Protective factors include breastfeeding, pacifier use, and room sharing. In this chapter, we volition discuss the evidence for these hazard and protective factors. We volition besides review the leading theories for SIDS causation including the Triple Risk Hypothesis, rebreathing theory, and scarce arousal and autonomic regulation, and how these theories create a plausible explanation for the risk and protective factors for SIDS identified in instance-control studies.

Risk Factors

Side and prone sleep position

The prone sleep position was noted in multiple example-control studies to exist associated with SIDS (1-6), beginning in 1965 in the United Kingdom (UK) (7). Even before this, in 1944, Abramson reported that prone positioning was institute in 68% of young infants who died of adventitious mechanical suffocation in New York Metropolis (viii). Public health campaigns, which first promoted not-prone positioning in the 1980s so supine placement, only first in the 1990s in many Western countries, take all been associated with a decline in SIDS rates. Subsequent studies have confirmed the association of prone sleep positioning and an increased SIDS run a risk (adjusted odds ratio [aOR] ii.iii-xiii.one) (nine-eleven). Physiologic studies accept demonstrated an association of prone positioning with an increased take chances of hypercapnia and hypoxia (12-14), overheating (fifteen), macerated cerebral oxygenation (16), altered autonomic control (17), and increased arousal thresholds (eighteen).

Subsequent studies accept identified that the run a risk of side sleep positioning is similar to that of prone positioning (aOR 2.0 and 2.6 respectively) (10). Side positioning besides has a college population-attributable take a chance than decumbent positioning (11), likely because many infants who are placed on their side are found prone (10). Placement in, or rolling to, the prone position, particularly when infants are unaccustomed to that position, places infants at extremely high risk of SIDS (aOR 8.vii-45.four) (x, nineteen). Thus all caregivers, including childcare providers, family members, and friends, should place the infant in the supine position for every sleep.

Prenatal and postnatal tobacco smoke, alcohol, and illicit drug exposure

Multiple studies take constitute that both in utero and environmental tobacco smoke exposure increase the risk of SIDS (20-24) in a dose-dependent way (25-27). The strongest gamble occurs with maternal smoking; there is a pocket-sized independent run a risk when fathers fume after the baby'due south nascency (23, 28).

While it is difficult to separate out the effects of in utero and environmental smoke exposure, in utero exposure reduces lung compliance and book, impairs arousal mechanisms, and decreases heart rate variability in response to stress (29, 30), all factors which may negatively impact an infant's ability to respond appropriately to the environment. Researchers have estimated that one-third of SIDS deaths could be prevented if in utero smoke exposure were eliminated (31, 32).

Substance abuse oft involves more than ane substance, and it is difficult to separate each effect from the others or to separate it from smoking. In addition, there are few studies that take examined the clan between substance use and SIDS. In one study of Northern Plains American Indians, periconceptual maternal alcohol consumption was associated with a sixfold increased take chances of SIDS, and binge drinking during the first trimester of pregnancy was associated with an eightfold increase (33). In another study, a maternal alcoholism diagnosis was associated with a sevenfold increased risk (34). Maternal drinking postnatally has also been found to be associated with increased SIDS risk (34, 35), especially when it occurs inside the 24 hours prior to the infant's death. Additionally, although the information for maternal drug use and SIDS are conflicting, overall, maternal prenatal drug employ, specially of opiates, is associated with a ii- to 15-fold increased risk of SIDS (36-38). Thus parents should not smoke during pregnancy, and there should be no smoking around the infant. In addition, booze and illicit drugs should not be consumed during pregnancy. There is also a substantial gamble when smoking or consumption of alcohol or illicit drugs occurs in the context of infant-adult bed sharing (11, 39, forty).

Soft or cushioned sleep surfaces (including sofas, couches, armchairs)

A house sleep surface, such every bit a tight-plumbing equipment mattress in an infant cot (known in some countries as "cribs"), bassinet, play yard, or portable crib, is the safest sleep surface. Sofas, couches, and armchairs are specially dangerous sleep surfaces; compared with a crib mattress, these surfaces confer up to 67 times higher risk of infant expiry (41-43). A contempo written report in the United states (United states of america) found that deaths on sofas comprised 12.9% of all infant sleep-related deaths in 2004-12, including SIDS, adventitious suffocation, and ill-divers deaths (44). Parents should exist counseled about the take chances of placing the baby for sleep, or falling asleep with an infant, on a sofa, burrow, or similarly cushioned surface.

Infants are also often placed to slumber in car seats, strollers, swings, baby carriers, and slings, ofttimes because the baby volition fall comatose more chop-chop or because of the belief that sleeping in a sitting position will convalesce gastroesophageal reflux. However, sitting in a car seat or similar sitting device exacerbates gastroesophageal reflux (45) and is thus not recommended for that purpose. Additionally, immature infants may not have adequate caput command to support their airway when sleeping in such sitting devices, and sleeping in these devices may pb to accidental death (46). Slings are of particular business concern in this regard, and infants who are carried in slings should have their heads visible and exterior of the sling to minimize the take chances of suffocation (47).

Bed sharing

Bed sharing is defined as the babe sleeping on the same surface as another person. The practice of bed sharing is common in many cultures and facilitates breastfeeding (48, 49), which is known to be a protective factor against SIDS (50). However, in case-command studies, bed sharing has been associated with an increased risk of SIDS (39, 41), and information technology is believed that soft mattresses, other soft bedding, the risk of overheating, and the take a chance of overlay contribute to this increased hazard.

It is clear that there is increased risk of babe decease when bed sharing occurs when i or both parents are smokers (even if they do non fume in the bed), when there was maternal smoking during pregnancy, when the adult bed sharer has drunk alcohol or taken arousal-altering medications or drugs, when the bed sharing takes identify on a couch or sofa, when in that location is soft bedding, when bed sharing lasts for the entire night, and when the infant is <11 weeks of age (eleven, 39, 40). Indeed, bed sharing was found in ane U.s.a. analysis of infant deaths to be the most of import risk factor for death for infants <4 months of age (51).

However, at that place is controversy about bed sharing for infants who are breastfed and whose parents are non-smokers and have non consumed alcohol, medications, or illicit drugs. Case-control studies accept had alien conclusions. An individual-level assay of 19 studies from nine datasets in the Great britain, Europe, Australia, and New Zealand, with i,472 SIDS cases and four,679 controls, found that bed sharing for these low-take a chance infants was associated with a fivefold increased hazard of SIDS in the first 3 months of life (aOR 5.1, 95% CI: 2.3-eleven.4) and an eightfold increased take chances in the start two weeks of life (aOR eight.3, 95% CI: 3.7-18.half dozen) (52). In this written report, there was no increased risk of SIDS if the bed-sharing infant was >three months old. However, this written report has been criticized for the large amount of imputed missing data on parental booze and drug utilize (53). Some other assay of data from two English studies, with 400 SIDS infants and 1,386 controls, establish that, although bed sharing with a smoker or an developed who had recently consumed >2 units of booze was associated with an increased risk of SIDS, infants younger than 98 days of age who bed shared with an developed who was a non-smoker and did not recently consume alcohol were not at increased hazard for SIDS (OR i.6, 95%: CI 0.96-two.vii) (43). Both of these studies are limited past small sample size in the subanalyses (54).

Recommendations regarding bed sharing differ. In kingdom of the netherlands, parents are advised not to bed share if the baby is <3 months sometime. In the US, parents are brash to avert bed sharing for the first twelvemonth but instead to have the infant sleep on a separate sleep surface shut to the parents' bed (55). Because in that location is no increased SIDS chance if bed sharing does non last the unabridged night (eleven), parents are encouraged to bring the babe to the bed for feeding and comforting, and then to return the infant to his/her ain sleep space when the parent is ready to go to sleep. Other countries, including Australia and the UK, recommend against bed sharing, specially when the parent is a smoker or has consumed alcohol, drugs, or arousal-altering medication (56, 57).

Soft bedding

The presence of soft bedding, including pillows, blankets, sheepskins, bumper pads, and positioners, in the baby sleep surroundings has been shown to increase the risk for infant death fivefold, contained of the sleep position, and 21-fold when the babe is in the prone slumber position (9). In addition, the The states Consumer Product Safety Commission has reported an increased risk of accidental suffocation and asphyxial deaths associated with soft bedding utilize (58). Soft bedding increases the risk of overheating and head covering, both of which have been associated with increased SIDS risk. Finally, in an assay of US child deaths, the presence of soft bedding in the baby sleep environment was reported to be the most important hazard factor for sudden and unexpected death in infants four months and older (51).

Infants are safest when they exercise not sleep with blankets (53, 59). If parents are concerned that their infant will become cold, an infant sleeping bag, sleeping sack, or wearable blanket is recommended as an alternative to blankets. A condom infant sleeping bag is one in which the infant cannot slip inside the bag and the head cannot become covered. One Dutch study found that the odds ratio for a sleeping pocketbook was 0.30 (95% CI: 0.13-0.67); withal, when adjusted for confounders, the odds ratio was no longer statistically significant (aOR 0.73 (95% CI: 0.29-6.43)) (threescore). Cot bumpers and similar products that attach to the cot sides are not recommended because of the hazard of entrapment between the mattress or cot and the bumper, the gamble of suffocation against the bumper, and the take a chance of strangulation with bumper pad ties (61, 62).

Head covering and overheating

In one instance-control study, 24.half-dozen% of SIDS victims had their heads covered by bedding, compared with three.ii% of control infants during last sleep (63). Duvets, blankets, and quilts should be avoided in the baby sleep environs, as they may cover the infant'due south caput or confront and obstruct breathing (11, 63).

Prematurity

Infants who are built-in preterm or with low birth weight are at fourfold risk of SIDS, compared to full term, normal birth weight infants (64, 65). Despite overall declines in SIDS rates, the rates amid infants born preterm or with depression birth weight all the same remain higher (66). Much of this may exist due to an immature autonomic system, with impaired arousal mechanisms and an increased risk for hypercarbia. The increased SIDS risk does not announced to be related to apnea of prematurity, as there is no evidence that these episodes of apnea precede SIDS deaths (67). The increased risk of SIDS, all the same, may also be related to decumbent sleep positioning. Preterm infants are at equal or increased SIDS risk when placed prone (68). Further, they are more likely to be placed prone after hospital discharge, presumably because they were placed prone in the neonatal intensive care unit of measurement as a means to improve ventilatory status while requiring mechanical ventilation (69). It is therefore recommended that preterm infants be placed supine as soon as they are clinically stable, so that they and their parents can get accustomed to the supine position before the infant is discharged to home. The American Academy of Pediatrics recommends that this transition to the supine position occur past 32 weeks post-menstrual age (70).

Protective Factors

Breastfeeding

Multiple studies have demonstrated that breastfeeding provides protection against SIDS (50). Studies do non distinguish between directly breastfeeding and feeding with expressed breast milk. A meta-analysis of 18 case-control studies plant that any breastfeeding was protective, simply that the protective consequence increased with increased duration and exclusivity of breastfeeding (l). A contempo private-level analysis of eight instance-command studies in the US, Europe, Australia, and New Zealand institute that two months of breastfeeding was required before a protective outcome against SIDS was seen, and that this protective event is seen with any amount of breastfeeding, regardless of exclusivity (seventy). Parents are encouraged to feed the baby with breast milk every bit much and for equally long equally possible.

Dummy (pacifier) employ

Several case-control studies and meta-analyses take plant a potent protective outcome with dummy (also known every bit pacifier) employ (71-73). Although the mechanism of protection is yet unclear, proposed mechanisms include increased arousability and improved autonomic control (74). Others note that non-nutritive sucking of the pacifier may alter the upper airway diameter (75). All the same, it should be noted that the protective outcome of dummy use is seen if the dummy is used when the infant is falling asleep, even though the dummy often falls out of the mouth soon later on the onset of sleep (76, 77). Because the mechanism by which dummy use confers protection is still unclear, some experts are reluctant to recommend dummy use every bit a SIDS run a risk reduction strategy. However, in some countries, such as the Us, dummy use is promoted every bit a risk reduction strategy. Considering in that location is some concern that dummy use may interfere with breastfeeding initiation, introduction of a dummy for infants who are directly breastfed should be delayed until breastfeeding has been well established. In infants who are fed with formula or expressed breast milk, a dummy can exist introduced at whatever time. If the dummy is non accepted past the infant, it should not be forced.

Room sharing

The safest identify in which an baby can sleep is in the parental bedroom, on a separate sleep surface; this reduces the gamble of SIDS past as much as 50% (39, 41, 42, 78, 79). Infants who have died of SIDS while sleeping in a separate room are more likely to have been plant with their heads covered by bedding and to have rolled into the prone position if they had been placed on their sides for sleep (80). It is recommended that the infant sleep surface be placed close to the parents' bed, to allow for easy monitoring and feeding. Room sharing, without bed sharing, is recommended for the first 6-12 months of life (55, 56, 57, 81, 82).

Theories

At that place have been multiple theories over the years regarding the etiology and mechanisms of SIDS. This may be partly because the successes in reducing the SIDS rates have come from epidemiological studies. Thus there has been considerable research into the underlying mechanisms that may underpin the risk factors identified in these epidemiological studies.

For many years, it was believed that apneic events, including credible life-threatening events, were precursors to SIDS. Home apnea monitors were often prescribed for these infants as a means to prevent SIDS. However, subsequent research constitute that apparent life-threatening events and apnea did not predict SIDS. Indeed, the increment in the use of apnea monitors beginning in the 1970s did not correlate with a decline in the SIDS rate (67).

Because many deaths occurred in cribs, much attention has been paid to sleep surfaces. I theory has attributed SIDS to toxic gases and has proposed that gases such as antimony, arsenic, or phosphorus can be released from infant mattresses (in particular, old mattresses) and cause toxicity when inhaled. However, no data support this theory. In addition, case-command studies accept found no benefit to wrapping mattresses in plastic to reduce toxic gas emission (83, 84).

Some other theory that focuses on the infant slumber environment proposed that, in specific situations, infants may rebreathe exhaled carbon dioxide. Relevant situations include when the infant is prone and/or when the infant'due south face is close to bedding. It is theorized that, in these conditions, a "pocket" of exhaled carbon dioxide collects around the babe'south face, and the baby, rather than inhaling oxygen, inhales the exhaled carbon dioxide. The infant thus becomes increasingly hypercarbic and eventually succumbs to decease if there is no stimulus that interrupts the rebreathing (85, 86). It has been suggested that the rebreathing theory could explain some of the risk posed by soft bedding and prone sleeping. Withal, at that place are no physiologic data from infants who died for which evidence supporting rebreathing has been documented.

In recent years, there has been growing consensus among scientists that SIDS is multifactorial in origin. The Triple Run a risk Hypothesis (87) (Figure 10.1) proposes that when a vulnerable babe, such every bit one born preterm or one exposed to maternal smoking, is at a critical but unstable developmental menstruum in homeostatic control and is exposed to an exogenous stressor, such equally existence placed prone to sleep, and then SIDS may occur. The model proposes that infants will die of SIDS but if all three factors are present, and that the vulnerability lies fallow until they enter the critical developmental period and are exposed to an exogenous stressor. SIDS unremarkably occurs during sleep, and the summit incidence is betwixt 2-4 months of age, when sleep patterns are chop-chop maturing. The final pathway to SIDS is widely believed to involve immature cardiorespiratory command, in conjunction with a failure of arousal from sleep (86, 88, 89). Support for this hypothesis comes from numerous physiological studies showing that the major adventure factors for SIDS (prone sleeping, maternal smoking, prematurity, head roofing) have significant effects on blood pressure level, heart rate, and their control (90), and as well impair arousal from sleep (91).

Figure ten.one:

Triple Hazard Hypothesis. (Adapted by the National Institutes of Health with permission from (87).).

Conclusions

Epidemiological case-command studies have been disquisitional in identifying factors that are associated with an increased or decreased run a risk of SIDS. Equally such, swell strides accept been made in our understanding of the adventure and protective factors for SIDS based on epidemiologic research, leading to educational interventions that have resulted in dramatic declines in SIDS rates. Theories regarding the pathophysiology of SIDS are myriad, but they all rely upon understanding the mechanisms by which these factors increase or subtract SIDS take chances. However, further research — peculiarly on the physiological mechanisms that contribute to or cause SIDS — is essential to achieving the reduction of SIDS rates to lowest levels possible.

Acknowledgements

The authors give thanks their families for their continuous support.

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