8: Avoiding SIDS and other outcomes

Chapter 8: How can SIDS deaths be avoided?

The following are some suggestions that should greatly improve the chances that a child will advance to a healthy normal life without suffering any harm caused by depleted rebreathing.

This is my list of suggestions. There are many lists available, but these suggestions will reflect my opinions on how to avoid SIDS and other outcomes by avoiding depleted rebreathing through practices followed by parents and caregivers. Each reader should form their own opinions and confirm with their doctor to be assured that their practices are advisable given their situation.

Do I believe that the threat of SIDS can be entirely eliminated? I don’t believe so. However, I do believe that we can get very close to total elimination with a reduction in excess of 95%. Unfortunately there may be times for specific babies whose breathing may be so abnormally shallow, that even if all precautions are taken, they can suffer a SIDS tragedy. At best we can try to identify those infants who are most at risk, identify the situations that put them most at risk, and put in place practices that reduce the risk as much as possible. Just as the Back to Sleep program has had positive results, following other common sense practices can have similar or even better results.

Hopefully you will consider the suggestions here, as well as discover other practices on your own. As a parent, it is important to consider that a parent’s responsibility is not limited to just providing the usual needs of a baby of food, water, nutrition, love, shelter, but must be extended to protecting the infant by assuring that they have a clear and uninterrupted supply of oxygen through the at-risk early months of their lives.

But before I start the list, I wish to remind you of those pre-SIDS indicators that you should be aware of and be watching for:

· A passive and unresponsive baby

· Pink fluid around the nostrils

· Unexpected overheating

· Unexpected high heart rate

Should you ever encounter any of these, you should first make sure that there is nothing preventing them from easily breathing fresh air. If there is pink fluid around the nostrils, and/or they remain passive, I suggest that they immediately be taken to emergency. The suggested treatment would be putting them on an oxygen supply. If you are unable to cool them down, or their heart rate unexpectedly remains high, I would also suggest bringing them to emergency. The problem with this is that if you tell the nurse or doctor at emergency that they are suffering a pre-SIDS condition, they will in all likelihood tell you that there is no such thing as pre-SIDS conditions. This list is the first list of pre-SIDS conditions ever published. If they can’t come up with any other reason for your baby’s condition, you could ask that your infant be put on oxygen for safety reasons. Until a pre-SIDS list of conditions is accepted by the medical profession, and an approved set of complimentary corrective practices be recommended by the medical profession, you are basically on your own. The suggestion that the infant be put on oxygen is just that, a suggestion. I would hope that if this list ever gains acceptance, that a more detailed list of corrective measures be developed that addresses each of the pre-SIDS conditions.

Suggested practices are as follows:

1. Always encourage your child to suck their thumb or use a pacifier until one year of age if possible (some babies reject both thumb sucking and the use of a pacifier). I have placed this first on the list because studies have shown that this generally has been shown to surpass the success of the Back to Sleep program. This behaviour will result in the child having the pacifier and/or their hand in front of their chin, preventing them from facing it directly into the crib mattress. It creates a space so that fresh air can reach their mouth or nose. They are likely to turn their head to either side away from the mattress to enable the practice of thumb sucking or pacifier use. As stated, thumb sucking and pacifier use also forces breathing through the nose which would be more successful at drawing in new fresh air. This practice alone is considered to reduce the risk of SIDS by 90%. Unfortunately, some parents who are trying to produce the best child possible may consider thumb sucking or pacifier use as a flaw and therefore prevent it. Unknowingly, may actually be increasing the risk of harm to the child.

2. The second practice is ensuring that there is air circulation in the crib room (or any room that the early infant might use to sleep). The child's breathing may not be strong enough to discharge their spent air far enough away from their face. Unless there is sufficient air movement in the room, the chance of depleted rebreathing is increased. This can easily be achieved by placing a small silent fan in the room. The fan should not be directed at the crib, but in a direction to cause air to circulate around the room. It can even be placed outside the room (also quieter for the baby) with the airflow directed into the room. Consider a ceiling fan left on the slowest speed, just enough to keep air circulating. Many forced air furnace fans have a permanent low setting that can be applied. Leaving the bedroom window open slightly might also cause some air flow. However, when relying on an open window consider: that there may be no breeze during all or part of the night, that the air flow might get colder resulting in a draft that could possibly cause the child to become ill, or that the open window may introduce allergens into the room which could result in the infant's sinuses becoming blocked.

I have placed this practice second because this practice also shows success rates that exceed those of the Back to Sleep campaign. It is quite possible that the combination of pacifier use and air movement almost totally eliminates the need for the Back to Sleep program; however, it is still an important strategy.

3. Always use thin mattress sheets that are fitted tightly over the mattress. Even if a child were to turn face down, these sheets would be less likely to prevent breathing or hold any quantity of CO2 within the fibres.

4. Put your child to bed wearing a properly fitted bodysuit (often called sleepers) that uses snap closures rather than zippers. This clothing would often eliminate the need for blankets which are used to cover the infant and to hold the infant on their backs (as these are a risk in themselves). The importance of snap closures is that the gaps between the snaps allow for some air circulation, reducing the possibility of overheating. However, these sleepers should not be oversized as this may increase the risk that the infant could slip inside the suit, suffering restricted access to fresh air.

5. Follow the “Back to Sleep” Program: When you are putting your child down to sleep (and that means every sleep, including naps), have the child sleep on their back. This ensures that the child's mouth is away from the mattress and high enough to be in the supply of fresh air. This has been a very successful practice which alone has reduced the incidence of SIDS by about 50%.

How you keep them on their back is important. It has been recommended by others to use a thin blanket that is tucked in no higher than the child’s chest, and place them nearer to the foot of the bed. Should the baby move they will likely move away from the blanket, as opposed to moving under the blanket, which could be a problem. However, be very cautious about how tightly the blanket is drawn across the infant’s chest because if it is too tight, it could prevent the child from taking breaths that are sufficiently deep.

Following this Back to Sleep practice is particularly important for those early infants who for some reason reject both the pacifier and thumb sucking.

If the Back to Sleep practice is followed, it is suggested that the child be given a certain amount of tummy time, while they are awake and being supervised. As mentioned, tummy time may help with the physical development of the child, enabling the child to move and protect themselves. It would also help to reduce the flat head problem caused by continually being placed on their backs.

Considering the first four suggestions, I'm not totally convinced that the Back to Sleep methods are necessary at all. Further tests and stats are need to be studied as to whether the Back to Sleep program is necessary at all if the first four recommendations are followed.

6. Related to the second suggestion about air movement, and the fifth concerning the Back to Sleep program, never place any soft and large toys in the child's crib or playpen while they are sleeping. Who can deny a child the comfort of a teddy? However, this should be limited to the times when the child is active and supervised. Once, the child is put down to sleep, the toys should be removed and not just moved to a corner of the crib. These soft toys could easily block breathing should the baby end up with their mouth and nose forced into them, and may hold CO2 within the fibres. They can also block the circulation of fresh air across the crib mattress surface.

7. Related to the second suggestion concerning air movement, remove any bumper guards that are placed around the perimeter of the crib or playpen. These restrict air flow to the child and can act as sides to a container which over time might accumulate CO2, as oxygen is depleted. The infant could accidentally turn their face into the wedge between the side of the bumper and the mattress, severely restricting air flow near their mouth or nose.

8. Again, related to air movement, don’t place the crib or playpen tightly against a wall or in a corner, as this will result in one side of the crib being blocked by a wall, limiting the circulation of fresh air. Ensure that both of the two sides of the crib or playpen are barrier free, so that air can flow easily across the crib. Moving the crib an inch away from the wall probably is enough.

9. Related to air movement and obstructed breathing, never place a child in any form of soft furniture or cushion for the purposes of sleeping. It would be very easy for the child to roll into the middle of the soft furniture, with their mouth and nose pushed into the material. Soft material can not only block breathing but can also accumulate CO2. Also any depression in the bedding could create the condition where a pool of CO2 collects endangering the infant.

10. Related to air movement and restricted breathing, avoid having the baby sleep in the parental bed (this includes having them avoid sleeping with other siblings). Only have them in the parental bed when awake and supervised for play and nurturing. If the early infant is allowed to sleep in the parental bed, it is recommended that the early infant is not placed between the parents. This condition increases the chance that CO2 could accumulate as well as increase the possibility that the child be covered. Also be very careful not to put any unnecessary pressure on the child's chest (like an arm or hand to prevent them from rolling off the bed). This pressure might inhibit the ability of the child to breathe. Be vigilant that there is no bedding which restricts air flow at or near the child's mouth and nose or that might accidentally be moved to that position while the infant or parent is asleep, potentially endangering them.

11. Parents should be very concerned about the presence of pets, mould or any potentially allergic substance in the home for the child's first 12 months. Parents should be very cautious when renting basement apartments as there is an increased risk of mould, as well as generally being poorly ventilated.

12. Going to sleep in all the wrong places: When early infants fall asleep, they don’t wait to be put in their crib. They’ll fall asleep even while eating their supper in their highchair. Parents need to be watchful that they don’t fall asleep anywhere in their home that could potentially compromise their breathing. Notable is deep carpet pile which could not only pose a risk of impairing their breathing, but also hold mould, mildew, and bacteria that might cause an adverse reaction. The motion of a moving vehicle is very conducive to sleep; therefore, be cautious that the infant doesn’t drop down into clothing that blocks breathing.

13. Delay immunizations beyond 12 months only where there is no necessary protection given to the child during the first 12 months by that immunization. Any immunization may temporarily weaken the child as a reaction to the immunization. In consultation with your doctor, delay these for at least 8 months, preferably one year. These immunizations should not be done as a convenience to parents, just getting it done and out of the way. However, flu shots (if the baby is old enough to receive it) or immunizations that are for diseases that are a potential risk to the child during the first year should be taken. Avoiding any disease or illness during the first year may prevent SIDS occurring, as these may weaken the early infant putting them at risk of suffering from depleted rebreathing. If it’s a risk to the child in the first year, get the shot. If it’s not a risk, delay getting the shot. However, if they do get a shot because their doctor has recommended it, watch the child carefully for the first few days after receiving the shot, a time when the child may have a reaction to the drugs and be vulnerable. In my opinion the shots themselves don’t cause SIDS or any other disorders such as Autism. However, a reaction that leads to depleted rebreathing could possibly harm the early infant. Just be doubly sure that the infant’s access to fresh air is not restricted in any way or for any period of time.

14. Keep anyone, especially siblings and other young children, away from the baby, particularly when that person has any contagious illness. Too often, parents are under the misguided opinion that when the flu hits the family, everyone is bound to get it anyway. Therefore there is no point in trying to avoid giving it to the newborn. Some believe that if the child is going to get it anyway, why not get it out of the way sooner. Avoiding contact with someone that is contagious will be hard to practice as it seems that everyone believes they have a right to hold the new baby. However, parents have a duty to protect their newborn child, and that includes avoiding exposure to any flu or virus. It’s not worth the risk. Allowing the child to get the flu in the first year may lead to depleted rebreathing as the infant is in a weakened state, and this could result in a SIDS tragedy.

15. Nurseries, babysitters and home daycare providers are a significant risk. Statistics have shown that as much as 30% of SIDS cases occur when the infant is not in the care of their parents. The education of the providers, the exposure to viruses, and the increased possibility of negligence due to overcrowding, may all have a hand in this statistical fact. As much as we would like to rely on the government for just about everything, when it comes to these providers, it really becomes the duty of the parent to test their qualifications and to detail the care that is expected. Never assume that they know what they are doing, regardless of what they say.

16. There appears to be a competition between parents of newborns to see who can get their child to sleep through the night the soonest. Parents want to fast track having their child sleep through the night uninterrupted. Parents should be cautious that this practice does not lead them to become somewhat negligent. Don’t be in such as rush. I’m not suggesting that a parent check on their child every fifteen minutes, but eight hours is a long time for an early infant to be left unattended. If it is possible I suggest that within the first year (or at least eight months) one of the parents get up to check at regular intervals on the child. These intervals become longer as the infant becomes older, always being vigilant that the child is getting unobstructed fresh air to breathe.

17. Parents need to be aware that baby monitors will not prevent SIDS. They do not monitor the pre-SIDS conditions that I have listed. These monitors only make the parent aware of when the infant is asleep or up and stirring. They may help the parent know when to attend to their child, and when to avoid unnecessary entrance into the infants sleeping room. These devices may help them monitor the child on a regular basis in a safe manner, but they will not avoid SIDS.

18. Hanging cribs that automatically swing should increase the flow of oxygen, however, care must be taken such that the motion does not allow the baby to turn over, resulting with their face being turned down in the bedding. Also care must be taken with the very young, as the curved bedding of these cradles may cause the infants head to be tilted forward into their chest, making it more difficult for their developing lungs to breathe sufficiently.

19. Don’t allow smoking in a house where there is an early infant. I needn’t labour the point here as much has been written already about the significant impact smoking has on SIDS. However, I would like to add that smoking in a car with an early infant should also be avoided. Because of the known dangers of second hand smoke, smoking in the presence of any aged child should also be avoided.

20. Be careful not to tighten car seat belts (and baby seats) too tightly, or to let clothing get pushed in front of their mouths, as can happen with these belts. Pay particular attention when the clothing is over-sized.

21. The recommendations that I have made here are more focussed on the relationship of depleted rebreathing and SIDS. It is recommended that you browse the internet for other recommendations that may have not been included here.

What society can do to reduce SIDS

The above recommendations are focussed on what a parent or caregiver could do to avoid SIDS or exceptionalities. The following are those that society can do as a whole. Some of these have already been adopted in some jurisdictions.

22. Governments must provide generous support to enable mothers, whether they be married or not, to stay home and provide their child with the best care possible for the first year of the child's life. Unfortunately, to promote married and supported relationships, single parents are often given minimal support. Unmarried mothers should be given generous support, because there is a significant increase in SIDS cases for single parents. This support should help the mother or father stay at home to care for the child, rather than provide support for nursery or daycare, as attendance at daycare or nursery has shown to increase the child's risk of suffering a SIDS death, and by my suggestion an increased risk of disabilities.

23. Postnatal care should include home visits for up to one year by a qualified postnatal nurse who can ensure that ideal conditions are present in the home and that the parent’s practices lead to the best health of the child. There has been shown to be an increased risk of SIDS for mothers who have had little or no pre or postnatal care or education. This is particularly needed for single and/or young mothers. New mothers needn't face this new experience alone and without necessary advice.

24. Where a qualified postnatal nurse is unavailable, there might be established a service group which comprises of experienced mothers who visit and support new mothers. This would be an opportunity to network and pass down experience, as well as safe and healthy parenting skills. Young mothers in the past were able to rely on a large family base for support, but that rarely exists today. A new mother should never feel alone and guessing as to what is the right thing to do.

25. Considering support for new mothers, government should consider putting in place a toll free telephone number that connects to a postnatal nurse who can give free advice 24/7.

26. At the high school level an education program should be put into effect (I’m thinking mandatory), teaching young potential parents about how to care for very young babies. There is an increased risk of SIDS for young mothers, most likely due to limited prenatal and postnatal care and education.

27. Governments should have very strict standards considering the qualifications of daycare centres and nurseries. With regards to the issues I have brought forward here, are these facilities aware of the risk of SIDS through depleted rebreathing, air movement, pacifier use, tight bindings, the Back to Sleep program, etc? Considering that the early infant will be exposed to many more infants and toddlers, has the newborn had a flu shot, or have the others including staff had their flu shot?

28. Governments should enact laws to protect newborns:

a. Make it illegal to take drugs (including alcohol) while pregnant.

b. Make it illegal to smoke while pregnant.

c. Make it illegal to smoke in a house or car with a child who is less than five years of age.

There are probably many other laws that could be put into effect. Don’t think that just because they would be hard (or impossible) to enforce that they shouldn’t be considered. These laws would put significant social (peer) pressure on parents to follow as these behaviours become the norm.


The following is an acronym for a suggested short set of practices that could possibly significantly reduce the risk of SIDS more than that achieved by having the infants sleep on their backs (supine). However, only follow these practices after full consultation with your doctor. These practices may be an effective alternative to the Back to Sleep program, although most parents would wish to follow both. Others may disagree. However, understand that no program can entirely eliminate the risk of SIDS.

· P: Pacifiers. Always encourage the use of pacifiers or thumb sucking during the first year.

· A: Air movement. Always ensure that there is sufficient and continuous air movement in the baby’s room and that there are no obstructions that could restrict this air flow, such as bumper pads. This includes removing any soft toy or bedding that could hold carbon dioxide in its fibres. Moving the crib slightly away from the wall or corner.

· T: Tightly fitted bed sheet. Use tightly fitted thin bed sheets so that these cannot curl up to block breathing or hold carbon dioxide.

· S: Snap fitted bodysuits (sleepers). Dress early infants with properly fitted (loose enough for air movement within the suit, but not oversized such that the baby’s head could slip inside the suit) bodysuits that use snap closures. These are an alternative to other bedding that could pose a risk to the infant.

What parents can do to reduce possibility of SIDS or other outcomes before and during pregnancy

These are a few suggestions that parents should take before and during pregnancy.

  1. Avoid smoking, alcohol, and any illegal drugs, before and during pregnancy.
  2. Check with your doctors whether any medications you are taking have any impact on your pregnancy.
  3. Never sleep with your head and breathing restricted by being under the covers. Don't deliberately subject yourself and your fetus to depleted rebreathing.

Barry Stanley