Running Head: FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 1

Risk Factors Associated with Sudden Infant Death Syndrome

Natalie Noday, Selina Nuzzi, Sarah Patrick, Sydney Schisler, Kayleigh Sciulli

Youngstown State University

Abstract

Sudden Infant Death Syndrome (SIDS) is the sudden death of an otherwise healthy infant that

occurs during the first year of life during sleep (Kinney and Thach, 2009). Research findings

identify sex (males), race (African American, American Indian), family history, secondhand

smoke, co-sleeping, and being born to a mother less than twenty years of age as being risk

factors for the development of SIDS. Educating mothers and families of infants on the

prevalence of SIDS is crucial in prevention (Bezerra and Carvalho, 2015). In 1994 the Safe to

Sleep campaign vowed to educate parents, caregivers and healthcare providers; death rates

decreased considerably from 130 (per 1,000 live births) in 1990 to 39.9 in 2013 (Bartlow,

Cartwright, Shefferly, 2016). This research paper examines previous research on SIDS relating to

risk factors associated with the syndrome.

Keywords: sudden infant death syndrome, risk factors, education

Preventive Measures

One of the most essential pieces in identifying the major risk factors associated with

Sudden Infant Death Syndrome is determining the caregiver’s knowledge related to SIDS.

Mothers may be unaware of the key factors that can potentially help reduce their infant’s risk of

exposure. The journal, Risk Factors for Sudden Infant Death Syndrome Among

Northern Plains Indians, explores the relationship between the maternal knowledge and the

risk factors both prenatal and postnatal to target these hazards and decrease the risks throughout

our global populations.

The objective was completed through a population- based case control study of 33 case

SIDS infants to 66 control infants in the following areas: South Dakota, North Dakota, Nebraska,

and Iowa. “SIDS is currently the leading cause of post neonatal mortality” (Iyasu et. al, 2002).

The population was studied by investigating standardized parental interviews, medical records,

autopsy protocols, and reviews of infant deaths. Each participant selected was required to

complete a form with their socio-demographic and socio-economic information to categorize the

sample based on: age, education, family income, number of prenatal consultations, maternal

medical and obstetric history, neonatal history, and a wide range of potential risk factors,

including both fetal and infant exposures. (Iyasu et. al, 2002). A questionnaire then followed,

identifying the mother’s prior knowledge of SIDS. Two living control infants were matched to

each case infant by postnatal age and area of residency. The X2 test and the 2-tailed t test was

utilized to calculate the above information of the different variables in the study. After obtaining
the data needed from the mothers and all the information was collected, the study proved that the

proportions of case and control infants who were placed prone to sleep (15.2% and 13.6%) and

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 4

those who shared a bed with the caregiver (59.4% and 55.4%) were similar in these infant care

practices related to SIDS. However, the mothers who engaged in smoking during pregnancy,

(69.7% and 44.6%) and engaged in drinking alcoholic beverages (72.7% and 45.5%) had a

significant impact on the stress of the baby, increasing it for the risk of SIDS. (Iyasu et. al, 2002).

The research data also shows that factors such as age, 12 years of education or less, and

low family income were identified as risks with a much higher probability of SIDS occurring

related to them. Infants born to mothers who reported 7 prenatal visits or less and relied on the

media for information were also at a much greater risk. Meanwhile, the mothers who were

educated by a health care professional either before or after child birth had a significantly lower

risk of their child suffering from the syndrome. “The mean age at death due to SIDS is only 109

days from birth. This statistic incorporates the fact that 51.5% of those infants were male and

64.7% of them died during either the autumn or winter months” (Iyasu et al., 2002). Infants who

were dressed in 2 or more layers of clothing were also considered to play a role in the risk factors

contributing to SIDS. Among these statistics, the study shows that three of the biggest risk

factors associated with SIDS are teenage pregnancies, late or no-prenatal care, low education

levels, and race; especially among American Indians. It was observed, through the process of

health care education, that the most successful preventive measure is maternal behaviors and

education. Regarding the knowledge of mothers about the adequate care of the infant to reduce

these risks, this study strongly shows that soon to be mothers rely on the utilization of health care
to expand their knowledge on the risks of SIDS. Of the indicators listed above, nearly 89% of

mothers knew about the syndrome and were therefore aware of the risks. Furthermore, as health

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 5

care providers, we must inform our patients of not only the risks of Sudden Infant Death

Syndrome, but also the most common preventive measures to decrease the risk factors

contributing to the syndrome.

The journal, Nurses’ Knowledge and Adherence to Sudden Infant Death

Syndrome Prevention Guidelines has been objected to determine the nurses’ knowledge

on preventive measures to educate patients and caregivers on how to care for an infant postnatal

to reduce the risks of SIDS throughout the first year of life. “Adherence to the standard

guidelines set by The American Academy of Pediatrics may be limited in the hospital setting,

but must be accomplished in one way or the other” (Bartlow et al, 2016). An observational,

quantitative, and descriptive study was conducted on two well- baby postpartum nurseries at

hospitals located in Washington, D.C. Direct observations were performed on a population of 66

infants, with the main focus of monitoring their sleep position and crib environment.

It has been established that there is a relationship between both infant positioning and

sleep environment related to the risk of SIDS. According to the article, “the AAP prevention

guidelines have been published indicating that the prone position is a significant risk factor in

SIDS” (Bartlow et al, 2016). In order to decrease these risks and provide preventable guidelines,

it is crucial to educate soon to be mothers on the correct sleeping position of the infant early in

the process of motherhood. Research shows that “SIDS death rates have decreased considerably,

from 130.5 (per 1,000 births) in 1990 to 39.9 in 2013 due to the correct positioning, while SIDS

continues to be the leading cause of death in infants aged 1 to 12 months” (Bartlow et al, 2016).
Therefore, education is a significant protocol in identifying these potential risk factors and can

make the difference in many cases between life and death.

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 6

Nurses’ knowledge on the unit were also evaluated utilizing a 17- questionnaire. Of the

observed sleeping positions, 69.7% of nurses failed the expected guidelines for infant

positioning, crib environment, or both. Although, 95% of the nurses on the unit did correctly

identify the correct sleeping position of the infant (which is published to be “supine”). In regard

to patient education, the study shows that 89% of the responding nurses encourage parents to use

the supine sleeping position at home and 79% of the nurses reported this in their discharge

teaching. It is also important to take into consideration the number of objects in the crib and the

type of soft objects that may cause bodily harm or injury to the infant, such as: blankets, towels,

gloves, onesies, loose diapers, etc. Through different hospital policies, research, and clinical

evidence- based practice, the observations prove that there is still a high risk of SIDS due to the

lack of education provided to the caregiver of the patient (Bartlow et al, 2016). This research

shows that to expand the knowledge of our global populations, role modeling of infant care by

nurses and other providers of the health care team impact mothers around the world to ensure

protection and safety upon the infant’s discharge home.

Adolescent Mothers

Among the many risk factors for sudden infant death syndrome, maternal age is a major

contributor. Adolescent mothers (less than 20 years old) are a group whom are at increased risk

for SIDS. The journal, Knowledge, Attitudes, and Risk for Sudden Unexpected

Infant Death in Children of Adolescent Mothers: A Qualitative Study,

investigates why SIDS targets this population. The study used seven focus group that included 43
adolescent mothers of children less than a year old (Caraballo et al., 2016). Adolescent mothers

were recruited from daycare

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 7

centers throughout Colorado. Surveying was conducted using open-ended questions exploring

mothers’ knowledge and current practices regarding infant sleeping.

Participants were asked to share how they acquired parenting information. Several

mothers obtained information from internet and books; however, the majority of participants

expressed learning about SIDS most often from a nurse, physician, or teacher. When dealt with

contraindicating parenting information, almost all participants said they were more likely to take

their own mother’s parenting advice (Caraballo et al., 2016). Moreover, all 43 mothers felt their

motherly instinct surpassed any source of parenting recommendations.

Despite being informed the risks associated with SIDS, bed sharing, and using soft

bedding and/or loose blankets, almost all adolescent mothers reported doing so on a daily basis.

Reasons for noncompliance included beliefs that the baby slept better in bed with them, felt bed

sharing was safer and easier compared to a separate bed space, and believed their baby needed a

blanket to keep them warmer (Caraballo et al., 2016). Decision making was highly influenced by

participants’ own mothers.

After conducting the study, it was determined these participants had good awareness of

safe sleep recommendations, but almost all of these mothers violated these. New approaches to

further the education on SIDS in regards to adolescent mothers should include educating the

grandmothers since they have a strong influence on adolescent parenting. Improving education

of nurses and promoting public service announcements targeting adolescent mothers may help to

decrease the risk of SIDS substantially among this high-risk population (Caraballo et al., 2016).
RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 8

Adolescent Mothers of Hispanic Ethnicity

According to Sleep Behaviors of Infants and Young Children, infants are at

increased risk for SIDS and sleep-related deaths if they are born from teenage mothers of

Hispanic ethnicity. In this study, 55 Hispanic adolescent mothers were surveyed in Travis

County, Texas regarding their sleep practices for their infants. Participants were recruited for a

cross-sectional phone survey from five high schools. The survey included 58 closed and open-

ended questions that placed emphasis on demographics, acculturation, and infant sleep practices

(Duzinski et al., 2013).

Adolescent students who came from two first-generation, foreign-born parents were more

likely to report bed sharing with the infant; however, were more likely to keep their infant’s sleep

space clear of blankets and stuffed animals. On the other hand, participants with two United

States-born parents were not as likely to co-sleep. Recent U.S. residency of Hispanic

immigration are shown to have lower rates of SIDS and sleep-related injury compared to United

States-born Hispanics (Duzinski et al., 2013). Low English fluency also increases the risk for

sleep-related death and/or injuries among the Hispanic population.

Hispanic teen mothers require appropriate safe sleep recommendations by nurses,

physicians, and educators in regards to their culture and language. Education that focuses solely

on the adolescent mother may be ineffective since this study has shown co-sleeping and non-

supine sleep positioning is an acculturated practice if the infant is from foreign-born

and prone sleep positioning for the baby (Duzinski et al., 2013). Safe sleep recommendations for

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 9

Hispanic teen mothers should include all family members, with emphasize on the grandparents,

to ensure family-wide understanding to safe sleep practices (Duzinski et al., 2013).

Caregivers

When taking into consideration risk factors for sudden infant death syndrome, there are

many important points to consider. While mothers may be the primary caregiver, many do have

occupations and commitments in their lives that lead them to seek help at times when caring for

their child. According to caregiveraction.org, the average child spends approximately 20 hours a

week in the hands of a caregiver. These mothers assume their children are being safely cared for

whether at daycare or in their own homes. Sudden infant death syndrome has decreased over the

last 20 years as our mothers are well educated at the hospital before going home with their newly

born infant (Byington et al., 2011). However, we know that children don’t always spend all day

with their mothers. This poses the question, how educated are our caregivers on caring for our

children? Do they get the education mothers receive before taking home an infant? How

important and effective is education to caregivers on preventing sudden infant death syndrome?

The Journal of Extension, Teaching Child Care Providers to Reduce the Risk

of SIDS

(Sudden Infant Death Syndrome) looked into the teaching of child care providers to

reduce the risk of Sudden infant death syndrome. Based on the number of hours infants spend a

week in child care, about 7% of SIDS death should occur during this type of care. However, they
found the SIDS death rate in this type of care to be much higher at 20% (Byington et al., 2011).

The purpose of the study was to gain knowledge on how knowledgeable caregivers really are on

sudden infant death syndrome and safety related to it. In the study, a pre-questionnaire test was

conducted to gather demographic information and to assess knowledge and behavior associated

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 10

with SIDS. The study then gave child care training to participants and in turn conducted a post-

questionnaire to evaluate how effective the training was on educating caregivers about SIDS.

The participants of this study were 297 child care providers in 14 different communities.

Approximately 65% of the participants were Caucasian, with the next highest being 16%

Hispanic/Latino (Byington et al., 2011). The pre-questionnaire indicated that caregivers lack the

correct information regarding SIDS prevention. An example in the study showed that 79% of the

participants believed there is an increase in choking problems when infants sleep on their backs.

Many also believe SIDS is caused by suffocation and immunizations. The pre-questionnaire,

however, did show some strengths. Many participants were well informed and knew that soft

mattresses were unsafe for infants to sleep on and that the crib should be free of all toys and

extra bedding. Before the training took place, the caregivers were to indicate how they currently

place infants to sleep. 46% stated that they placed infants to sleep on their stomach some or all of

the time (Byington et al., 2011).

Following the training given to the caregivers, a post-questionnaire was distributed.

Before the training the average knowledge level on SIDS was 4.32, based on a t-test. After, the

average knowledge level on SIDS was 9.04. This shows a significant increase after the training

was provided. Overall, the post-questionnaire showed significant results. The education was very
effective on teaching caregivers about the safe way infants should sleep and the risk factors

associated with SIDS. After the education on SIDS, 98% of the participants reported that in the

future they would place infants on their backs to sleep. (Byington et al., 2011).

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 11

Caregivers: A More Recent Study

As stated by An analysis of attitude toward infant sleep safety and SIDS

risk reduction behavior among caregivers of newborns and infants, active

caregiver education may result in more effective demonstration of safe sleep and SIDS risk

reduction behavior. This study explored attitudes toward safe infant sleeping and SIDS among

caregivers of newborns and infants. Participants in this study were 121 caregivers of newborns at

Staten Island University Hospital in the year of 2015 (Varghese et al., 2015). These participants

completed a questionnaire designed to investigate attitudes towards safe sleep and SIDS risk

reduction behavior. 93% of the participants were between the ages of 18-40. Disclosed was 80%

Caucasian and 20% ethnicity reported being from a minority group. 61% reported having at least

some college education with 39% completing high school or less. During this study, level of

education was noted when reviewing the answers given. Interestingly, caregivers with less

formal education worried more so about their infant choking while in the supine position

(Varghese et al., 2015). The questionnaire given was based on the Likert scale ranging from 1 to

5. A score of 4 or 5 indicating agree or strongly agree. The mean for caregivers who agreed with

back to sleep was 4.26. The mean for no soft items in the crib was 4.26 as well.
 This study gives a great insight when comparing my previous article with this current

one. Within a 4-year span, caregivers seem to have increased their knowledge, beliefs, and

education on safe sleeping regarding SIDS. This comparison allows us to acknowledge that

education has been effective on back to sleep for infants. Comparing these two studies also leads

researchers to believe that more caregivers are aware of the risk factors and causes related to

SIDS. (Varghese et al., 2015).

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 12

Co-sleeping

There are many risk factors that increase the occurrence of Sudden Infant Death

Syndrome. A major risk factor is infant and parent co-sleeping, also referred to as bed sharing.

According to a research article written by a group of authors who researched Sudden Infant

Death Syndrome, “Bed sharing was defined as the practice of sharing a sleep surface between

adults and young children” (Vennemann et al., 2012, p. 44).

An article written by Trina C. Salm Ward titled Reasons for Mother-Infant Bed-

Sharing: A Systematic Narrative Synthesis of the Literature and Implications

for Future Research Ward researches articles about co-sleeping to help understand why

parents co-sleep and some of the factors that influence co-sleeping. During her research, she

concluded that co-sleeping in any place that is not meant for protection increases the risk of

Sudden Infant Death Syndrome. She also found in her research that co-sleeping leads to factors

that contribute to SIDS like overheating of the infant and interference of the infant’s airway

(Ward, 2014, p. 675). Found in

this research article it was concluded that in all the research done by Ward there were ten

common reasons found for reasons mothers co-sleep. These ten reasons included breastfeeding,
comfort for mother or infant, better sleep for infant/parent, monitoring, bonding and attachment,

environmental reasons, crying, cultural/family traditions, disagreement with danger, maternal

instinct, and ambivalence about the decision to co-sleep. Breastfeeding was determined to be the

number one reason for co-sleeping between mothers and infants. Mothers reported the main

reason for doing this was to help with infant feedings (Ward, 2014, p. 677). Mothers also

reported feeling more emotionally stable and better attachment with their infants when co-

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 13

sleeping. It was reported that mothers felt they could watch their infant better when they shared a

bed with them and could better detect if anything was wrong with the infant (Ward, 2014, p.

682). Some mothers reported not having some of the things to take care of infants such as a crib

or warm environment as their reason for co-sleeping. Culture and tradition influences co-

sleeping because of how the mother was raised or what she had been routinely exposed to (Ward,

2014, p. 682). According to this research article each reason for co-sleeping depended on things

such as where the study took place and to population that was researched in each study. This

helped lead to the conclusion that SIDS education should be based on individuals instead of

generalized so more specific education can be given depending on what risk factors are present

(Ward, 2014, p. 686).

Another study done on co-sleeping done by a group of authors called Bed Sharing

and the Risk of Sudden Infant Death Syndrome: Can We Resolve the Debate?

looked into the proof of SIDS related deaths and co-sleeping. Some of the areas the study

focused on was co-sleeping and

Smoking was shown to increase the risk of SIDS even more when associated with co-sleeping.

According to this study with SIDS, “the risk was 10 times higher in infants <12 weeks old, and

the risk for infants ≥12 weeks old was not elevated” (Vennemann et al., 2012, p. 46). This was

supported by the evidence that infants that were older in age were more likely to be able to wake

up themselves and their parents and get out of a situation in which they might become trapped

while co-sleeping. It was also shown that co-sleeping increased body temperature which could be

dangerous for younger infants (Vennemann et al., 2012, p. 46). Infants who did not usually co-

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 14

sleep had an increase risk of SIDS compared to those infants who co-sleep on a regular basis.

Also infants who co-sleep on a surface other than a bed such as a couch were associated with and

increased risk of SIDS (Vennermann et al., 2012, p.46). Overall the conclusion of all the research

was that all studies showed an increased risk of SIDS in infants and parents who co-sleep,

especially when associated with risk factors that increase the occurrence of SIDS. The

occurrence SIDS was shown to increase even more when co-sleeping was associated with

smoking and infants under the age of twelve weeks (Vennemann et al., 2012, p. 47).

Education

Sudden Infant Death Syndrome (SIDS) is the unexpected death of a child less than one

year of age which occurs during sleep (Bezerra 2015; Carvalho 2015). In the city of Recife,

Brazil 202 mothers were interviewed over the course of May 2011 and October 2012 to better

understand the relationship between maternal knowledge and SIDS prevalence. The descriptive,
cross-sectional and quantitative study was implemented in a clinic at the Federal University of

Pernamabuco where infants received their first checkup after discharge from the hospital

(Bezerra 2015; Carvalho 2015).

Out of the 202 mothers that were a part of the study, 80% were 20 years of age or older,

75% had eight or more years of schooling, and 52% had an income that was above minimum

wage. After gathering the mother’s knowledge of SIDS, 29% identified supine as the position for

a preventative measure; however only 15% had heard of SIDS. (Bezerra 2015; Carvalho 2015).

When asked about where they gathered their main source of information, only 25% said that

health care professionals gave them knowledge of the syndrome (Bezerra 2015; Carvalho 2015).

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 15

“Among risk factors for SIDS, teenage pregnancy and mothers with low education levels

contribute to the prevalence of the choice for prone position as the most comfortable for the

child, which is very alarming as the occurrence of SIDS is associated with that position”

(Bezerra 2015; Carvalho 2015). The major limitation of the study was generalizing results since

the sample came from a clinic which not all groups may have access to.

In Conclusion, reinforcing preventative measures in education of SIDS is crucial so those

in charge of children understand the risk factors and correct sleeping position. The study was

geared toward improving health services to newborns and families which supports education as a

major component in SIDs prevention (Bezerra 2015; Carvalho 2015).

Sleep positions

SIDS is defined as sudden death of a seemingly healthy infant during sleep (Kinney

2009; Thach 2009). Infants that sleep in the prone position are more than three times as likely to
develop SIDS. Prone position sleeping is thought to trigger infant death because of airway

compression and rebreathing exhaled gases (Kinney 2009; Thach 2009). Campaigns that have

advocated for a supine sleeping position have decreased the rate of SIDS by more than 50%

(Kinney 2009; Thach 2009).

Extrinsic and Intrinsic risk factors for SIDS have been identified. Extrinsic risk factors

are those that are physical in nature such as sleeping prone, clothes covering the infants head,

and bed sharing. Intrinsic risk factors include developmental factors (prematurity), genetic

factors (familial SIDS), male sex, and belonging to a minority group (Kinney 2009; Thach

2009). “Current evidence suggests that SIDS involves convergence of stressors that probably

results in the asphyxia of a vulnerable infant who has defective cardiorespiratory or arousal

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 16

defense systems during a critical developmental period when immature defense mechanisms are

not fully integrated” (Kinney 2009; Thach 2009). SIDS research has been geared towards the

brain stem of an infant because it’s the neural network that mediates respiration, autonomic

function, sleep, and arousal. Nearly half of infants with SIDS have an abnormality in the

medullary 5-hydroxytryptamine system which controls response to ventilation and arousal from

sleep among others. Risk reduction for SIDS is characterized by placing infants on a firm

mattress in a supine position, in a shared room, but in a separate bed (Kinney 2009; Thach 2009).

The ABCs of infant sleep support risk reduction; Alone, Back, Crib.

Conclusion

In conclusion, the exact cause of Sudden Infant Death Syndrome remains unknown. However,

the research provided supports that this syndrome is multifactorial in nature due to the many risk

factors that can increase an infant’s risk of mortality related to SIDS. The studies also prove that
preventive measures initiated by nurses and other members of the health care team and families

strongly impact a child’s exposure. It is important as future health care providers to continue

expanding our own knowledge on this syndrome to educate and spread awareness to caregivers

of infants.

RISK FACTORS ASSOCIATED WITH SUDDEN INFANT DEATH SYNDROME 17

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