Understanding and managing infant crying: Implications for child maltreatment,swaddling, and sudden infant death

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Safe sleeping practices

• Understanding and managing infant crying
  Implications for child maltreatment,swaddling,
  and sudden infant death

Dr. Lynne Warda WRHA Injury Prevention
Program Pediatric Emergency Medicine Child
Health Standards Committee (CPSM)
PRESENTATION FOR Injury Prevention
Champions Spring 2015
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Presentation Objectives

• Safe sleep practices
• Normal infant crying patterns
• Management of infant crying
• Safe swaddling
• Benefits and risks of swaddling
• Resources

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Back to Sleep SIDS Trends?
Safe sleep practices

• Declining incidence 1990s-now
• 1.1/1000 live births 1990 0.3/1000 in 1999
• 16-20 cases/year to lt5 cases/year (SIDS)
• Males 60-70
• African American, First Nations 1.5-2X risk
• Age 80 less than 5 months, peak 2-4 months, 3
  greater than one year of age
• Most apparently healthy prior to death, many with
  minor recent illness (GI, resp sx)

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SIDS/SUID Trends - USA
Safe sleep practices
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Recent SIDS/SUID Manitoba Cases
Safe sleep practices

• 3 weeks, sleeping with parent on couch, found
  prone
• 12 weeks, sleeping with teen mom in foster care,
  crib in room
• 6 months, adult bed, found on the floor in pile
  of clothing
• 8 months, sleeping with parents, found wedged
  between wall and mattress
• 4 months, found between two mattresses on the
  floor
• 4 months, found in swing with blanket over face
• 11 months, found in stroller under lap tray, no
  restraint in use
• 4 months, placed prone in playpen

Safe sleep issues? Common themes? Other risks?
Protective factors?
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Prevalence of Sleep Environment Risk Factors for
Sudden Infant Death A Population-Based Study
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Definitions
Safe sleep practices

• SIDS
• SUID
• ALTE
• Entrapment
• Strangulation
• Suffocation
• Choking
• Asphyxia

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Causes of Suffocation
Safe sleep practices

• Types Entrapment, strangulation, suffocation,
  aspiration
• Crib/bed/furniture entrapment
• Clothing drawstrings, hoods, buttons
• Bedding, piles of clothing, bumper pads
• Pets
• Plastic bags, plastic film
• Aspiration (small parts) toys, coins, food

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Other Causes of Sudden Death
Safe sleep practices

• Child abuse, trauma
• Sepsis/infection/pneumonia
• Seizure
• Dysrhythmia
• Aspiration (GER, other)
• Central causes of apnea
• Upper airway, lower airway causes of apnea
• SIDS, SUID

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Triple-risk model SIDS
Safe sleep practices

• Predisposed infant
• Unstable period of homeostatic control
• Triggering factor(s)

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Risk Factors for Sudden Infant Death
Safe sleep practices

• SIDS risk factors?
• Classic sleep position, smoking, overheating
• SUID risk factors?
• Sleep environment risks
• Suffocation risk factors?
• Bed, bedding, toys/objects, humans, pets
• Entrapment risk factors?
• Bed, furniture

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References/Evidence review
Safe sleep practices

• Joint Statement on Safe Sleep (PHAC 2011)
• SIDS and Other Sleep-Related Infant Deaths
  Expansion of Recommendations for a Safe Infant
  Sleeping Environment (AAP Oct 2011)
• Policy statement
• Technical Report
• WRHA SIDS/SUDS Clinical Practice Guideline
• Research Literature

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The Bottom Line
Safe sleep practices

• Level A recommendations
• Back to sleep for every sleep
• Use a firm sleep surface
• Room-share without bed-sharing
• No soft objects and loose bedding
• Pregnant women should receive regular prenatal
  care

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The Bottom Line
Safe sleep practices

• Level A recommendations
• Avoid smoke exposure during pregnancy and after
  birth
• Avoid alcohol/illicit drug use during pregnancy
  and after birth
• Breastfeeding is recommended
• Consider offering a pacifier at nap time and
  bedtime
• Avoid overheating
• Do not use home cardio-respiratory monitors as a
  strategy for reducing the risk of SIDS

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Sleep Position
Safe sleep practices

• Supine is the safest position until age 1
• Why? Rebreathing, overheating, suffocation
• Side position is as unsafe as prone (2.0-2.6X)
• Higher risk for infants placed prone who usually
  sleep supine (child care, illness)
• Hospital preterm infants supine by 32 weeks
• Newborns should be placed supine from birth
• Infants who roll both ways can be left prone

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Sleep Surfaces
Safe sleep practices

• Safety-approved crib, portable crib, playpen or
  bassinet
• Firm mattress with no gaps
• No drop sides (US, soon Canada?)
• Beware playpen bassinets and change tables not
  designed for sleep!
• Car seats/infant seats/swings are not safe for
  routine sleep and require adult supervision

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Bed-sharing
Safe sleep practices

• Adult bed risks related to suffocation,
  entrapment between bed/wall/furniture, soft
  bedding, pillows, mattress sag, falls
• Bed-sharing risks related to overheating,
  rebreathing, airway obstruction, head covering,
  smoke exposure (all are risk factors for SIDS)
  bed-related risks
• Recent meta-analysis of 11 studies 2.88?risk
  (1.99-4.18) with bedsharing

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Particularly Hazardous
Safe sleep practices

• Stress to parents that they avoid the following
  situations at all times
• Smokers (one or both parents)(OR 2.3-17.7)
• Age lt 3 months regardless of smoking status (OR
  4.7-10.4)
• (BWlt2500, GA lt 37 weeks, nonsmokers OR 15.2)
• Waterbeds, sofas, armchairs (OR 5.1-66.9)
• Pillows, blankets (OR 2.8-4.1)
• Multiple bedsharers (OR 5.4)
• Parent has consumed alcohol (OR 1.66)
• Bedsharing with nonparent (OR 5.4)

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Bedding
Safe sleep practices

• Pillows, quilts, comforters, sheepskins
• Increase risk up to 5X regardless of sleep
  position
• Unsafe under infant
• When loose can cause head-covering
• Risk of suffocation/rebreathing when used to
  create barriers to prevent infant from falling
• No wedges/positioners, bumper pads

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Room-sharing
Safe sleep practices

• Recommended routine practice
• 50 reduction in SIDS
• Safer than solitary sleeping and bedsharing
• Separate sleep surface
• No smoking in the room

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Smoking
Safe sleep practices

• Maternal smoking accounts for 1/3 SIDS
• LBW, prematurity, decreased infant arousal
• Post-natal parental smoking is associated with a
  2.5-5.8 fold increase in SIDS
• Risk increases with smokers in the home,
  smokers in the same room as the baby,
  cigarettes smoked, daily hours baby exposed

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Substance Use/Abuse
Safe sleep practices

• Maternal alcohol use, binge drinking OR 6-8
  independent of smoking
• In-utero exposure to opiates, cocaine, methadone,
  heroin OR 2-3 after controlling for numerous
  associated risk factors

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Breastfeeding
Safe sleep practices

• Previous studies not consistent
• Recent meta-analysis of 18 case control studies
  OR 0.40 (0.35-0.44)
• Exclusive BF more protective OR 0.27 (0.24-0.31)
• Why? More easily aroused from sleep, decreased
  respiratory and GI illness
• Return infant to crib after feeding

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Pacifier Use
Safe sleep practices

• Protective effect
• Especially when used at time of last sleep
• Two meta-analyses OR 0.39, 0.48
• Why? Lowered arousal thresholds, maintains airway
  open in sleep, modifies autonomic control
• No significant association with BF duration
• Delay use until BF established

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Overheating
Safe sleep practices

• Definite association with SIDS
• Increased when prone
• Head covering risk overheating, hypoxia,
  rebreathing
• Some evidence that good room ventilation may
  reduce the risk of SIDS

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Key Messages for Parents
Safe sleep practices

• Back to sleep for every sleep
• Alone in a crib or playpen
• No blankets or soft bedding
• Same room as parents (smoke-free room)
• Breastfeed
• Smoking significantly increases the risk of SIDS
• Discuss the risks of bedsharing

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Normal infant crying
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Understanding Normal Crying
Normal infant crying

• Evidence-based international approach
• Normal crying curve
• PURPLE program
• Focus groups, RCTs
• Booklet, DVD
• 10 languages
• www.purplecrying.info
• Video

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Reasons for Crying
Normal infant crying
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Hmmm.what next?
Normal infant crying

• In British Columbia, mothers of newborns who
  received PURPLE program materials at public
  health home visits showed greater crying
  knowledge, shared crying information and
  strategies with other caregivers, and were more
  likely to walk away during episodes of
  inconsolable crying.
• What is your approach when supporting mothers of
  newborns?

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PURPLE Crying
Management of infant crying

• Some things work some of the time, but nothing
  works all of the time
• Comforting might involve wrapping your baby in
  a blanket, or just holding your baby in your arms
  
• Carrying includes holding, contact and
  closeness
• Walking includes all of those as well as
  introducing a rhythm to your movements. You may
  also want to move your body to the rhythm of the
  beats in music while carrying and comforting your
  baby
• Talking includes adding a human voice, perhaps
  saying or singing the same things over and over
  to a melody

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Tips for Soothing Crying
Management of infant crying

• Address infant needs (hunger, diaper change,
  overheating, overstimulation, fatigue)
• Change of position
• Kangaroo care/skin to skin contact
• White noise/vibration (fan, dryer, vacuum, car
  ride)
• Carrying/closeness
• Do not place the infant on top of a dryer or
  washing machine due to the risk of falls

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Swaddling for Crying?
Management of infant crying

• Several studies have documented reduced crying
  hours with routine and ? stimuli
• Sleep, feed, cuddle, alone time in playpen, to
  his/her crib awake but sleepy when showing signs
  of fatigue
• Reduce noise from radio, television, or noisy
  toys, and baby gyms, if the child is less than 3
  months old.
• Avoid using bouncy chair (except for feeding) for
  an infant that cries excessively. Never use on
  elevated surfaces!
• Avoid continuous entertainment, visits, outings
• Swaddling did not ADD significant benefit to this
  routine after the first 3 days. Try this first!

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Benefits
Benefits and risks of swaddling

• Pain relief positive impact on behavioural
  and/or physiological pain indicators
• Weighing showed reduced physiological distress,
  improved motor organization and more effective
  self-regulatory ability when weighed
• Excessive crying Soothes excessive crying
• PURPLE program
• Regularity and uniformity approach
• Happiest Baby Method
• Sleep infants sleep longer

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Risks
Benefits and risks of swaddling

• Maternal-infant bonding a reduction in the
  mothers responsiveness and involvement with the
  infant
• Breastfeeding skin-to-skin contact is not
  possible with swaddling
• Respiratory infections a study of 186 infants in
  Turkey and China concluded that infants routinely
  swaddled had a 4-fold greater likelihood of
  developing pneumonia and other upper respiratory
  infections compared to those not swaddled
• Developmental Dysplasia of the Hips (DDH)
  greater risk of hip dysplasia for infants who are
  tightly swaddled, restricting hip flexion and
  abduction
• SIDS/SUID/Suffocation Studies show that infants
  who were swaddled have a higher risk for SIDS

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Swaddling and Infant Death
Benefits and risks of swaddling

• Manitoba cases (sling, swaddling, blankets)
• 2013 CASE EXAMPLE
• A newborn who was being carried in an infant
  sling-style carrier inside the mother's
  clothing/coat was found unresponsive and did not
  respond to resuscitation
• Though not exactly swaddling, it is related, and
  a similar mechanism to both SIDS/SUID and
  swaddling/suffocation

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Swaddling and Infant Death
Benefits and risks of swaddling

• Journal of Pediatrics 20141641152-6 case
  series infant deaths and injuries
• New Zealand Cot Death study
• Netherlands sleep sack case control study
• Ponsonby (CC) 12X risk
• Blair (CC) 30X risk

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Swaddling for Warmth
Benefits and risks of swaddling

• The Winnipeg Liveability bylaw residential
  temperatures must be no less than 18C between
  11pm and 7am, and no less than 21C between 7am
  and 11pm.  
• Sleep in the warmest room, away from windows,
  drafts, and exterior walls. Infants should not
  sleep next to a radiator, heater or
  fireplace/woodstove, given the risk of
  overheating. Do not use a hot water bottle or an
  electric blanket.
• Use a fleece or flannel fitted crib sheet.
• Dress in undershirt and fleece sleeper with feet
  /- hat.
• May use a small fleece blanket tucked in.

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Swaddling Tips
Benefits and risks of swaddling

• Not recommended as routine practice
• May be used to convert prone sleeper to supine
• Always lay supine, not side or prone
• No head covering
• Swaddle to allow hip flexion/abduction,
  breathing.
• Ensure infant will not escape the swaddle
• Stop swaddling when the infant can roll over
• Use light receiving blanket (may need two)

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Summary
Benefits and risks of swaddling

• Does not reduce the risk of SIDS
• increased risk if swaddled and prone
• May be used as a strategy to soothe/calm
• Tight swaddling overheating, increases
  respiratory rate, adversely affects respiration
• Loose swaddling risk of head covering
• Any swaddling may reduce sleep arousal,
  particularly if unaccustomed to swaddling

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Sleep sacks and swaddlers
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Sleep Sacks and Swaddlers

• CONSIDERATIONS
• Follow manufacturers instructions age, weight,
  length
• Fabric meets Canadian sleepwear flammability
  guidelines
• No drawstrings or cords at neck. No ribbons,
  cords, or tight elastic that could cause
  strangulation or constrict a limb or digit. No
  small parts that could cause a choking hazard

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Sleep Sacks and Swaddlers

• CONSIDERATIONS
• Must fit snugly around upper body and neck to not
  cover mouth and nose, and infant cannot wiggle
  inside the sack, under the collar
• Should not be tight around the chest. No
  restrictions at the hip, so that the hips can
  flex comfortably
• Caution the parent regarding overheating, and
  always dress lightly under the sack and/or
  swaddler

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SIDS and Kids Safe Sleeping app
Resources

• App provides information on how to sleep baby
  safely and reduce the risk of sudden unexpected
  death in infants and fatal sleeping accidents
• It also includes valuable information on Tummy
  Time and Safe Wrapping

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Safe Sleeping Posterhttp//www.sidsandkids.or
g
Resources
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Safe Sleep For your baby brochurehttp//www.pha
c-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood
-enfance_0-2/sids/pdf/sleep-sommeil-eng.pdf
Resources

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Questions?