Cork doctor: As deaths rise, how can we help prevent cot death?

As a junior doctor in the late 1980s, working in paediatrics, nothing compared to the trauma of a young couple rushing into the Emergency Department with a lifeless baby in their arms. A baby that had been laid in their cot hours earlier, healthy and well, who never woke up again.

The numbers of cases of sudden infant death syndrome (SIDS) in Ireland has “increased significantly”, in recent years according to data from the National Paediatric Mortality Register (NPMR) report.

Exactly why it is happening is not entirely clear. Possibilities include reduced awareness, less adherence to safer sleeping guidelines, or gaps in targeted prevention measures.

Cot death, or SIDS, is the sudden and unexpected death of a baby who seems healthy during sleep. It can happen anywhere a baby is sleeping including a cot, pram, bed, car seat or baby seat. It is one of the main causes of death in babies ages 4 weeks to 12 months. It is most common between 2-4 months but can also happen to older babies.

In the 1980s, when I was an overworked senior house officer in CUH, there were up to 140 SIDS death a year (2.2 per 1,000 live births). In the intervening decades, cases plummeted aligned with risk reduction campaigns.

However, that decline stalled then reversed in 2019. From a low of just 12 deaths (0.2 per 1,000 live births) the figure more than doubled to 25 (0.46 per 1,000 live births) by 2023 – just four years later. The 25 SIDS deaths in 2023 was the highest number recorded since 2008 and repositions SIDS as the leading cause of death in post-neonatal infants - more than one month and less than one year.

“This concerning trend is compounded by a lack of granular information on contributory risk factors such as sleep environment, parental smoking, and social vulnerability,” stated the NPMR report, published in September by the National Office of Clinical Audit.

While the cause of cot death is not known, key factors can be taken to reduce the risk. We also know that it is not caused by vaccines, vomiting, choking or suffocation.

What are the risk factors for SIDS?

Sleeping position: Babies who sleep on their tummies have a higher risk of cot death. The HSE advise it is not safe to place a baby on its side as it may role onto its tummy. Babies should sleep in a cot in the same room as a parent or guardian for at least the first six months. The risk of cot death is higher for babies who sleep in a separate room. Bed sharing increases a risk of suffocation or cot death.

Cot and its contents: The cot should be in good condition with a mattress that is clean, firm and flat with no tears that fits neatly inside the cot. The cot should be clear of all objects to reduce the risk of suffocation, including pillows, cushions, sleep positioners, toys, teddies, and cot bumpers.

Parents and guardians are advised never to fall asleep holding a baby on a sofa, couch, armchair or beanbag as it increases the risk of SIDS. Nor should a baby be left unsupervised in a sitting device like car seats or baby seats. Sleeping in a sitting position can make it more difficult for a baby to breathe.

Sleep temperature: Babies should not be overdressed for sleep. A nappy, vest and babygrow are enough. Ensure the baby sleeps in a comfortable temperature – not too warm or cold - from 16-20C. Never place a baby to sleep next to a radiator, heater, fire or in direct sunlight.

Smoke-free zone: The more people smoke in the home, the higher the risk of SIDS. Nobody should be allowed to smoke in the home, car or in the vicinity of a baby, and babies should not be brought into smoky environments. Babies shouldn’t share a bed with anyone who smokes, even if they never smoke in bed. Smoking in pregnancy also increases the risk of SIDS.

Other ways to reduce the risk of SIDS

Breastfeeding reduces the risk and there is evidence that use of a soother at the start of sleep can reduce the risk of SIDS.

The HSE Child Health is performing a review of SIDS cases from 2002 to 2024. Preliminary findings were recently presented at a National Office of Clinical Audit webinar.

They found SIDS was nearly five times more common in disadvantaged areas compared to affluent areas; eight times more common in emergency accommodation such as homeless or International Protection Accommodation Services compared with national incidence.

This reflects international evidence that socio economic deprivation is a risk factor.

The findings were not explained by documented sleep patterns alone and need to be interpreted with caution due to the small numbers involved. However, in view of the known links between SIDs and factors such as room temperature, smoke free zones, good quality cots and mattresses, the links to social determinants of health are not surprising.

The final review will include recommendations on enhanced and targeted public health communications, training for healthcare professionals, and data reporting. This is likely to include new graphic leaflets that will be translated into key languages.

The historic reductions in SIDS is widely considered to be one of the most successful and impactful public health interventions of the late 20th century. Driven by evidence-based public awareness campaigns – most notably the U.S “Back to Sleep” campaign in the early 1990s - the rate of unexplained infant deaths plummeted by 50-80% across multiple countries, saving tens of thousands of lives.

However, new challenges have emerged in recent years that have caused the rate of progress to stall and even reverse. These gaps in public awareness must be addressed to allow the decline in SIDS cases to continue.

This includes a sharp rise in unsafe sleeping environments including the widespread availability of sleep positioners, soft bedding, bumper pads, soft toys and heavy blankets that conflicts with evidence-based advice.

Sharing a bed with an infant increases the risk of SIDS – particularly if a parent smokes, has consumed alcohol or drugs, or taken medications that induce drowsiness.

Growing evidence suggests targeted awareness programmes directed at people living in emergency accommodation are urgently needed, incorporating digital strategies in key languages to have maximum reach.

Such public health awareness campaigns are required to ensure the spectacular public health achievements over almost four decades in protecting tiny infants from sudden, tragic and unexpected death are not lost.