Materials this week:
- Case and discussion
- AAP policy guidance on safe infant sleep
- RCT examining sleep outcomes and cortisol for infant sleep problems with interesting science-driven parent perspective of the data on gradual extinction (“cry-it-out”) approach
- Resources on sleep including Seattle Children’s, AAP, and American Psychologist Association pediatric sleep resources (thanks to Dr Julian Davies who shared this from his friend, a pediatric sleep doc’s blog) and great baby sleep resources including videos from the Pediatric Sleep Council.
Take-home points to review on infant sleep:
- Epidemiology of SIDS: Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant less than 1 year of age which remains unexplained after autopsy & review of death. Reducing SIDS through the Back to Sleep campaign has been a great success in pediatrics, as SIDS rates decreased by half since implementation in 1992. It is considered one of the top 7 research achievements in pediatrics. SIDS is uncommon before 1 month of age (~10% of SIDS deaths), peaks between 1 and 6 months of age, and is rare after 8 months.
- What are some risk factors for SIDS? SIDS involves convergence of 3 factors – environmental factors, a critical period of development, and intrinsic vulnerability (i.e., dysfunctional or immature cardiorespiratory systems). Environmental risks include prone sleep position, sleeping on a soft surface, bed sharing, young maternal age, overheating, multiple births, and multiple siblings. Intrinsic vulnerabillity includes preterm birth, low birth weight, male sex, maternal smoking during pregnancy, previous stillbirths, as well as URI infections.
- How should we discuss infant sleep? Our role is to support families with accurate information and explore their beliefs. In a 2012 study, less than half (43.5%) of internet resources contained accurate information about infant sleep. Ask open-ended questions about where baby is sleeping and in what position. Safest sleep for babies is on their backs in their own sleeping unit in the parents’ room without extra blankets or stuffed animals. Co-sleeping/ bed-sharing is the highest cause of death under 3 months- it is especially dangerous if parents smoke or drink alcohol. Review evidence and encourage room-sharing rather than bed sharing.
- What if a baby has difficulty sleeping? There are a number of resources out there and variable recs on strategies: 1) swaddle or not (mostly yes, but not once they are rolling over, so advised to stop before 4 months), 2) swaddle with arms or legs in or not (depends on baby-generally arms in, looser on legs), 3) pacifiers or not & for how long (yes, safe, may help sleep if baby takes one, better to wean early), 4) graduated extinction “cry it out”/”Ferberizing” or not, etc. It’s hard for parents to navigate all of this, so we need to discuss what we think works (based on research, experience, family preferences, etc). Personally I liked reading Dr. Richard Ferber’s actual book Solve Your Child’s Sleep Problems (which covers much more than graduated extinction – see great dialogue where he demystifies some of the interpretations of his work). To assuage parents, there are increasing studies of sleep training demonstrating no discernible adverse effects on babies’ development (and probably the opposite given the benefits!)- see above RCT.
- Refer to specialists when the family/infant are struggling. In Seattle, we are lucky to have some great sleep experts at Seattle Children’s. When all else fails, time is on the side of the parents. Some of the best pediatricians I know who’ve had infants with sleep challenges tried everything without much success until their infant grew and eventually became a good sleeper. There is hope!