The sudden and unexpected death of a previously well infant is a tragedy known since biblical times. Commonly referred to as ‘cot or crib death’ or in the scientific literature as the sudden infant death syndrome (SIDS), Beckwith defined it in 1969 as "the death of an infant or young child, which is unexpected by history and in whom a thorough necroscopy examination fails to reveal an adequate cause of death".
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The classical belief was that these deaths were due to overlaying or suffocation - in fact the official title for the condition in the USA until the early 1950’s was ‘accidental mechanical suffocation’.
We now know that this view is incorrect. In the developed world SIDS is the commonest cause of death in infants between one week and one year of age. It occurs in all countries and socio-economic groups, but rates vary widely, from well below one, to over six per thousand live births.
A careful autopsy will fail to demonstrate an adequate cause of death in the majority of infants. Many infants who die suddenly and unexpectedly, however, show changes indicative of a mild, “non-lethal” respiratory or bowel infection. In a minority frank pathology will be found, such as pneumonia or meningitis, intracranial trauma or significant cardiac anomaly. In these cases death may indeed have been totally sudden and unexpected, but more often there have been prior symptoms which have not been recognised by the mother or caretaker.
Can cot death be prevented?
“Put your baby on the back to sleep”. The prone (face down) sleeping position should be avoided; from birth infants should be put to sleep on their sides or back, unless there are specific indications against this. Sleeping on their backs appears to be preferable to side sleeping, because of the greater likelihood of the infant rolling face down when on the side.
“Make sure your baby’s head remains uncovered during sleep and avoid overheating and tight wrapping”.
“Keep your baby smoke free – before birth and after”. Mothers should be warned of the dangers of smoking and drug taking.
“Cover the mattress with polythene sheeting”. Many new mattresses are fitted with such covering; used mattresses should be wrapped in a sheet of thick polythene (125 microns) which is folded and taped underneath. The evidence for toxic gases is still incomplete, but the practice has been shown to be safe, and is recommended in the UK and New Zealand. The best underblanket to use on a wrapped mattress is fleecy cotton.
"You should sleep in the same room as your baby". To lessen the risk of cot death it may be safer for the infant to sleep in the parent’s room. “For babies to endure increasingly long periods of solitude after birth is biologically unreasonable”.
It would also seem entirely reasonable biologically for the young infant to sleep in close proximity to its mother, and perhaps this is actually protective. The evidence suggests that there may be potential benefits to bed sharing which cannot be overlooked. This aspect requires further study in communities where co-sleeping is common.
“Near miss” episodes
Brief spells of stopping breathing or a few seconds of ineffectual breathing due to airway closure are commonly seen in normal infants during sleep. More prolonged attacks, and especially those associated with pallor, blueness or a long recovery period are more important. With increased public awareness, such “acute life-threatening events” - ALTE's - have become a common problem for paediatricians, but the great majority of such reported episodes are benign and simply represent normal sleep pauses or brief choking spells. It should be stressed that in the majority of cot deaths there is NO antecedent history of such events. Nevertheless any such episode MUST be fully investigated by an expert; in particular an electrocardiograph must be performed to rule out a conduction disorder of the heart, such as the “long QT” syndrome.
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