By Dr. Miriam O. Laker-Oketta
Recently, after seeing a photo of a baby sleeping on its tummy on an advertisement of a daycare center, I wrote to them advising that a baby should not be put to sleep on its tummy. The response from the daycare centre was, “There is nothing wrong with babies sleeping on their tummies.” I was enraged and explained to them the dangers of infants lying on their tummies.
I know you are wondering why I was enraged at such a ‘normal’ thing. The answer is Sudden Infant Death Syndrome (SIDS). SIDS, Sudden infant death syndrome, is the name given to sudden death occurring to an infant (child under one year) who was previously known to be completely well. SIDS is the commonest cause of death in babies under one year in the western world with most cases happening in children under 6 months old.
In Africa, it accounts for a smaller proportion of infant death not because it is rare but because there are other conditions – malaria, pneumonia, diarrhea and dehydration, and malnutrition, that kill more children in this age group than SIDS but, that does not mean that we do not have SIDS. In Uganda, for example, it is estimated that over 52,000 babies die from SIDS every year. Unfortunately, many people in our setting do not believe the danger that SIDS poses. Parents of infants commonly say, “Those are problems of the western world. Why is it that we did not hear about SIDS during the time of our great grandparents?”
To answer this, first, we know how high infant mortality was in the past and continues to be in our setting, some of these are undoubtedly due to SIDS. Unfortunately, unlike in the western world where all deaths, including deaths of infants at home, are documented often with a post mortem, most deaths in Africa, especially those occurring out of hospital are not documented. When infants die at home; it is usually not considered a police case and the babies are buried with neither documentation nor postmortem. As a result, the number of infants with SIDS in Africa can only be estimated.
What causes SIDS?
Although the actual cause of SIDS is not known, extensive review of thousands of SIDS infants by postmortem, interview of caretakers present at the time of death and investigation of the scene of death have identified certain factors that keep recurring in most cases. Here are possible biological explanations for their association with SIDS: Placing babies to sleep on their tummies. This is the most implicated. Most babies who died from SIDS were reported to have been put to sleep on their tummies. When this was established, it gave rise to the “back to sleep” crusade among pediatricians. It dictates that ALL BABIES MUST BE PUT TO SLEEP LYING ON THEIR BACKS. Not on their sides or on their tummies. The tummy sleeping position increases the risk for SIDS due to: Rebreathing asphyxia (suffocation from breathing in exhaled carbon dioxide):
When a baby is facedown, air movement around the mouth may be impaired. This can cause the baby to re-breathe carbon dioxide that the baby has just exhaled. Soft bedding and gas-trapping objects, such as blankets, comforters, water beds, and soft mattresses are other types of sleep surfaces that may impair normal air movement around the baby’s mouth and nose when positioned facedown. Since babies have weak control over the neck muscles, they will often not be able to turn their heads to a better ventilated posture. Tummy time is good for babies but must only be done when baby is awake and in the presence of an adult who is actively engaging the baby.
Co-sleeping (sharing a bed with mother, another adult, or child). It could cause suffocation when the multiple beddings or the other person on the bed accidentally obstructs the child’s breathing by lying too close or on the child. The risk of SIDS is higher when the beddings consist of any of the following: soft mattress, bedsheets, blanket, duvets, pillows. The rural African mother’s bed is typically a firm pallet which could be a thin mattress, palm leaf or papyrus reed mat with none or a single item of clothing or basic thin mattress for covering the baby.
Overdressing, using excessive coverings, or increasing the air temperature may lead to an increased metabolic rate in these infants and eventual loss of breathing control. It is not clear, though, whether it is the overheating that independently increases the risk of SIDS of the use of more clothing, shawls or blankets that may act as objects obstructing the airway.
Smoking. Infants frequently exposed to secondary smoke and those whose mothers smoked while pregnant have a higher risk of SIDS. Nicotine affects lung development of a baby in the womb and secondary smoke exposure increases the risk of lung complications.
Alcohol. Maternal alcohol consumption in pregnancy also affects lung development of babies in the womb so that the infant’s lungs cannot function efficiently.
Caffeine use. Heavy use of caffeine in pregnancy (4 cups of coffee a day or 10 cups of tea of cola drinks per day) is associated with SIDS. Infants exposed to heavy amounts of caffeine while still in the womb are born with defects in the part of the brain concerned with breathing.
Prematurity and low birth weight. One out of every five babies who die of SIDS is a baby born before 37 weeks of gestation (premature). Low birth weight babies (less than 2.5kg at birth) also have an increased risk of SIDS. However, this risk is still strongly associated with putting them to sleep on their tummies. The possible biological explanation for this is that these babies may have poorer neck control than mature babies born with normal birth weight and are more likely to suffer rebreathing asphyxia.
Research shows that multiple births increase the risk of SIDS. It could be because multiple birth babies are often premature or have lower birth weight than singletons (babies born alone). It could, also, be because most multiple birth babies are usually put to sleep together in the same cot so that the movement of one may accidentally suffocate another, or one may be too close to the edge of the crib and turn and suffocate on the bumpers and other beddings.
Other factors associated with SIDS include undiagnosed under development of lungs or the breathing center in the brain so that the baby brains may not be able to detect when it is not receiving sufficient oxygen and thus the child dies. Parents and caregivers can take the following remedies to reduce the risk of SIDS and other sleep-related infant deaths:
• Place your baby on its back for all sleep times for naps and at night.
• Use a firm sleep surface covered by a fitted sheet which will not crumple up and whose edges will not come loose.
• Have the baby share your room, not your bed. Your baby should not sleep in an adult bed, on a couch, or on a chair alone, with you, or with anyone else.
• Keep soft objects, such as pillows, loose bedding, cot bumper, toys out of your baby’s sleep area.
• Do not smoke during pregnancy and do not smoke or allow smoking around your baby.
• Cut caffeine intake during pregnancy.
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