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Sudden Infant Death Syndrome

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Sudden Infant Death Syndrome, Crib Death, SIDS

  • See Also
  1. Apparent Life-Threatening Events In Children (ALTE)
  • Epidemiology
  1. Incidence: 0.57 per 1000 live births
  2. Responsible for 1400 to 2200 deaths per year in the United States
    1. Accounts for slighly less than half the number of unexpected infant deaths in the U.S.
  3. Ages affected: 1 to 6 months (peaks at ages 1-4 months)
  4. Males are more likely to die of SIDS (RR 1.2)
  5. SIDS occurs most often between midnight and 8 am
  • Pathophysiology
  1. Triple-Risk Model (SIDS is final common pathway of 3 contributing factors)
    1. Underlying Vulnerability (e.g. Prolonged QT, Autonomic Dysfunction)
    2. Exogenous Stress (e.g. prone position, smoke exposure)
    3. Stress occurs during critical time in development (age <1 year old)
  • Risk Factors
  • Ordered by Level of Risk
  1. Major Risk Factors
    1. Bed Sharing with smoking mother (OR 13.90)
    2. Gestational age <37 weeks (OR 11.67)
    3. Bed Sharing with infant <12 weeks old (OR 10.37)
    4. Soft bedding material (OR 5.10)
    5. Prone sleeping position (OR 4.30)
    6. Low brth weight <2500 g (OR 3.3)
    7. Bed Sharing with non-smoking mother (OR 2.09)
    8. Mother smoked during pregnancy (OR 2.06)
  2. Other Risk Factors
    1. Side sleeping position (OR 1.9)
    2. Smoke exposure as infant (OR 1.65)
    3. Sleeping in a Car Seat or stroller (OR 1.5)
  3. Protective Factors
    1. Up-to-date Immunizations
    2. Pacifier use during sleep (not attached)
    3. Breast Feeding
  4. References
    1. Adams (2009) Am Fam Physician 79(10): 870-4 [PubMed]
  • Risk Factors
  • Ordered by Category
  1. Infant Factors (Non-Modifiable)
    1. Preterm Birth (Gestational age <37 weeks)
    2. Low birth weight <2500 g
    3. Family History of previous SIDS deaths
  2. Sleep Environment
    1. Bed Sharing (Co-Sleeping) prior to 4 months of age (especially with smoking mother)
    2. Prone sleeping position (also side sleeping to lesser extent)
    3. Soft sleep surface (pillows, bedding)
  3. Substance Use by Parents
    1. Parental Smoking (associated with 61% of SIDS deaths)
    2. Maternal Alcohol Abuse (associated with 16% of SIDS deaths)
    3. Maternal Drug Abuse
  4. Socioeconomic Factors
    1. Teenage parents
    2. Minimal Prenatal Care
  • History
  • By coroner or medical provider
  1. Reporting demographics
    1. Time infant was last normal
    2. Name of person who found the infant
  2. Infant status when found
    1. Respiratory status of infant when found (i.e. breathing or apneic)
    2. Sleep environment and surface on which the infant was found
    3. Items present around the infant when found (e.g. blankets)
    4. Position of infant when found (e.g. prone)
  3. Contributing factors
    1. Co-Sleeping
    2. Recent illness
  • Diagnosis
  • Autopsy
  1. Assess for other possible cause
    1. Requires a full medical examiner evaluation into unexpected infant death
    2. SIDS is a diagnosis of exclusion after other causes have been evaluated
  2. Findings consistent with SIDS
    1. Intrathoracic Petechiae
    2. Mild respiratory tract congestion
    3. Brainstem gliosis
    4. Extramedullary hematopoiesis
  • Differential Diagnosis
  1. Apparent Life-Threatening Events In Children (ALTE or BRUE) or
    1. ALTE (or BRUE) events are not related to SIDS and are not a risk for SIDS
  2. Anoxia (Aspiration, Asphyxiation, Drowning)
  3. Cardiac Arrhythmia or Congenital Heart Defect
  4. Dehydration
  5. Inborn Errors of Metabolism
  6. Overwhelming infection (e.g. Neonatal Sepsis, Pneumonia)
  7. Poisoning
  8. Trauma (including Non-accidental Trauma)
  9. Hyperthermia
  • Management
  • Emergency Department
  1. Avoid cleaning baby post-Resuscitation
  2. Evaluate neck flexibility on intubation (stiff or flexible)
    1. Stiffness may suggest longer duration since time of death
    2. Rigor mortis cannot otherwise be determined in infants due to lack of musculature
  3. Describe secretions found in the airway
    1. Do not clear the suction canister of secretions until examined by coroner
  4. Toxicology Screening
    1. May be performed during Resuscitation
    2. Coroner will perform if not already done
  5. Imaging
    1. Skeletal Survey is typically performed by coroner (multiple views, without limitations of Radiation Exposure)
  • Management
  • Family Support
  1. Counseling services
  • Resources
  1. American SIDS Institute
    1. https://sids.org/
  • Prevention
  1. Avoid Bed Sharing (especially prior to 4 months of age)
    1. Bed Sharing is most dangerous on soft surface, substance use (e.g. Alcohol, Tobacco), age <12 weeks
    2. Room sharing for first 6 months, however, is recommended (may reduce SIDS risk 50%)
  2. Infants should sleep in their own bassinet or crib
    1. See Crib Safety
    2. Firm sleep surface
    3. No pillows, comforters, toys or bedding
      1. Layers of clothing (or wearable blankets) may be used instead
      2. Avoid hats after the first day of life (may increase risk of SIDS)
    4. Swaddling (snugly wrapped blanket) is considered safe until infant shows signs of rolling over (3-4 months)
      1. Swaddling can result in suffocation if infant rolls
    5. Avoid sleeping in a Car Seat or stroller (or other inclined device)
  3. Child should sleep in supine position (Back to sleep campaign)
    1. Practice prevention of Deformational Plagiocephaly (related to supine sleeping)
      1. Supervised prone position while infant is awake starting at 2 weeks of age
      2. Gradually advance supervised prone position to 15-30 minutes/day (at age 2 months)
      3. Limit time that infants are in Car Seats or strollers
    2. Gross Motor Delays may occur due to supine positioning, but resolve by 18 months old
    3. Back to sleep campaign started in 1992 and reduced SIDS Incidence by 39%
  4. Pacifier Use
    1. Pacifiers use during sleep reduces SIDS risk even if expelled during sleep
    2. Do not attach Pacifier to any clothing or string
  5. Tobacco Cessation for parents (prior to pregnancy or prenatally is best)
  6. Keep Immunizations up-to-date
  7. Infant monitors are not recommended by AAP (not effective in preventing SIDS)
    1. Many OTC commercial cardiorespiratory monitors are directly marketed to parents
    2. Home monitors are expensive, inaccurate and offer false reassurance
  8. Breast Feeding substantially reduces SIDS Risk (OR 0.27)
    1. Hauck (2011) Pediatrics 128(1): 103-10 [PubMed]
  • References
  1. Bertone and Spangler in Herbert (2013) EM:Rap 13(11): 8-9
  2. Merenstein (1994) Handbook Pediatrics, Lange
  3. (1996) BMJ 313:191 [PubMed]
  4. (1996) BMJ 313:195 [PubMed]
  5. Adams (2015) Am Fam Physician 91(11): 778-83 [PubMed]
  6. Adams (2009) Am Fam Physician 79(10): 870-4 [PubMed]
  7. Alexander (2005) J Forensic Sci 50(1): 147-51 [PubMed]
  8. Darrow (2025) Am Fam Physician 111(2): 164-70 [PubMed]