Fern Hauck, MD, MS
It's great news that sudden infant death syndrome (SIDS), also known as "crib death," has become less common in the past decade as more parents than ever are placing their infants on their back to sleep. The incidence in SIDS in the U.S. has declined from 1.2 per 1,000 live births to 0.5 per 1,000. In other words, it occurs in about 1 out of every 2,000 infants born. But, despite the Back to Sleep campaign, which emphasizes back sleeping position for infants and other recommendations to create a safe sleep environment, over 2000 infants die tragically each year in the U.S. from SIDS. Since SIDS rates in many other countries are lower than those in the U.S, we need to do more to achieve lower numbers here, too.
Researchers still do not know the exact cause of SIDS, but it is believed to be related to a central nervous system abnormality where infants, who appear normal and healthy, don't arouse properly during sleep when faced with a challenge, such as a blocked air passageway. Even without knowing the exact cause of SIDS, we have learned a great deal from research studying the relationship between various environmental risk factors and SIDS. The biggest gains in SIDS reductions have resulted from applying the findings from epidemiologic studies to educating families and other infant caregivers, as well as health professionals.
The American Academy of Pediatrics (AAP) recently released updated guidelines for SIDS risk reduction. Despite earlier reductions in SIDS, in the past few years the SIDS rates have changed little. Therefore, the AAP Task Force on SIDS felt it important to address other practices that may hold potential for further SIDS reductions. One of these is infant pacifier use.
Several studies have examined the relationship between pacifier use and SIDS. The majority found that infants who used a pacifier had a lower risk of SIDS compared with infants who did not use a pacifier, particularly when used at the time of last sleep. Based on seven studies that examined infant pacifier use when going to sleep, there is a 60% reduction in SIDS risk when infants go to sleep using a pacifier. This benefit was found for both breastfeeding and non-breastfeeding infants. The mechanism for this apparent protective effect is still unknown. Several mechanisms have been proposed, including the possibility that pacifiers help infants to arouse more easily during sleep.
The recently released guidelines from the AAP for pacifier use states: Consider offering a pacifier at nap time and bedtime. Until evidence dictates otherwise, the task force recommends use of a pacifier throughout the first year of life according to the following procedures:
• The pacifier should be used when placing the infant down for sleep and not be reinserted once the infant falls asleep. If the infant refuses the pacifier, he or she should not be forced to take it.
• Pacifiers should not be coated in any sweet solution.
• Pacifiers should be cleaned often and replaced regularly.
• For breastfed infants, delay pacifier introduction until one month of age to ensure that breastfeeding is firmly established.
The AAP recommendations have been controversial. Most of the criticism has been voiced by organizations and individuals concerned that pacifier use will interfere with breastfeeding. The task force reported that although many studies have shown a relationship between pacifier use and decreased breastfeeding duration, well-designed randomized controlled clinical trials did not show that pacifiers caused shortened breastfeeding duration. Since one study showed a small deleterious effect on breastfeeding when the pacifier was introduced in the first week of life, the task force recommends waiting a month before offering a pacifier to breastfed infants. Many nurseries in the U.S. provide a pacifier immediately after birth, so be sure to put it away for a month if you are nursing your baby.
Parents may find that depending on whom they talk to, advice regarding pacifiers may differ. For infants who are not breastfeeding, using a pacifier offers clear advantages with few disadvantages. For breastfed infants, to ensure breastfeeding success, always offer the breast first and use the pacifier sparingly, primarily at naptime and bedtime. Babies can be weaned from pacifiers at about one year of age, when SIDS is less likely to occur.
Don't forget that there are other very important things that mothers can do to reduce their infants' risk of SIDS: always place their babies on their backs to sleep; don't smoke during pregnancy or around the baby; use a firm mattress; and place their babies to sleep in a crib or bassinet in their room. Be sure these recommendations are followed by all caregivers, at daycare as well as at home.
Fern R. Hauck, M.D., M.S. is Associate Professor of Family Medicine and Public Health Sciences at the University of Virginia School of Medicine in Charlottesville, Virginia. Her research focuses on sudden unexpected infant death, including Sudden Infant Death Syndrome (SIDS). She is principal investigator of a large case-control study of infant mortality in Chicago to examine risk factors for SIDS and other unexpected infant deaths; analysis is ongoing. Related projects include examination of SIDS trends internationally, bedsharing practices cross culturally, and examination of new risk factors and preventive measures for SIDS, with particular attention to pacifier use. Dr. Hauck is a member of the American Academy of Pediatrics Task Force on SIDS. She is also the mother of twins.
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