Sudden Infant Death Syndrome

STEPHEN M. ADAMS, MD; MATTHEW W. GOOD, MD; and GINA M. DEFRANCO, DO

University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
Sudden infant death syndrome is the leading cause of death among healthy infants, affecting 0.57 per 1,000 live
births. The most easily modifiable ris factor for sudden infant death syndrome is sleeping position. To reduce
the ris of sudden infant death syndrome, parents should be advised to place infants on their bacs to sleep and
avoid e!posing the infant to cigarette smoe. "ther recommendations include use of a firm sleeping surface and
avoidance of sleeping #ith soft ob$ects, bed sharing, and overheating the infant. %acifier use appears to decrease
the ris of sudden infant death syndrome, but should be avoided until one month of age in infants #ho are
breastfed. The occurrence of appar& ent life&threatening events does not increase the ris of sudden infant death
syndrome, and home apnea monitoring does not lo#er the ris of sudden infant death syndrome. Supine
sleeping position has increased the incidence of flattening of the occiput 'deformational plagiocephaly(, but this
condition can be prevented and treated by encour& aging supervised )tummy time,* meaning that #hen a#ae,
infants should spend as much time as possible on their stomachs. +ll apparent deaths from sudden infant death
syndrome should be carefully investigated to e!clude other causes of death, including child abuse. ,amilies #ho
have an infant die from sudden infant death syndrome should be offered emotional support and grief counseling.
'Am Fam Physician. -00./7.'10(0170&172. 3opyright 4 -00. +meri& can +cademy of ,amily %hysicians.(
%atient informa&
tion0 A handout on SIDS,
written ! the author"
o# thi" arti$%e, i" a&ai%'
a%e at h t t ( ) * * ww w . aa # ( .
or+ *a#( *,--.-/0/*
12-' "0.ht3%.
he ter3 "udden in#ant death "!n'
dro3e 4SIDS5 wa" #ir"t u"ed in
0.6. at an internationa% $on#eren$e
on the $au"e" o# "udden death in
in#ant".
0
The $urrent de#inition o# SIDS,
de&e%' o(ed in 0..0, i" the "udden death o#
an in#ant !oun+er than one !ear that
re3ain" une7' (%ained a#ter a thorou+h
$a"e in&e"ti+ation, in$%udin+ a $o3(%ete
auto("!, e7a3ination o# the death "$ene,
and re&iew o# the $%ini$a% hi"tor!. In the
8nited State", SIDS a##e$t" -./2 (er 0,--- %i&e
irth", tota%in+ 3ore than ,,,-- death" (er
!ear. It i" the %eadin+ $au"e o# death a3on+
hea%th! in#ant".
,
5is ,actors
In#ant #a$tor" that ha&e een a""o$iated with
in$rea"ed SIDS ri"9 in$%ude %ow irth
wei+ht, %ow A(+ar "$ore", re$ent &ira%
i%%ne"", Nati&e A3eri$an or A#ri$an
A3eri$an an$e"tr!, and 3a%e "e7.
:
Materna% i""ue" that (redi$t SIDS ri"9
in$%ude %ow "o$ioe$ono3i$ "tatu", "3o9in+,
i%%i$it dru+ u"e, (oor (renata% $are, and
!oun+ a+e.
:
Other #a$tor" re%ated to (oor
"o$ia% and e$ono3i$ "tatu", "u$h a" a
$rowded hou"eho%d, (arenta% une3(%o!3ent,
and "in' +%e (arent "tatu", a%"o in$rea"e the
ri"9 o# SIDS. Pa$i#ier u"e 3a! de$rea"e the
ri"9 o# SIDS,
;
ut "%ee(in+ (o"ition i" the
3o"t ea"i%! 3odi#ia%e ri"9 #a$tor. In#ant"
"hou%d e (%a$ed on their
a$9" to "%ee(; "ide "%ee(in+ i" not re$o3'
3ended.
/
A #ir3 "%ee( "ur#a$e, "u$h a" a
#ir3 $ri 3attre"", "hou%d e u"ed. So#t
o<e$t" and %oo"e eddin+ "hou%d e 9e(t out
o# the $ri.
6
Parent" "hou%d a&oid o&erheatin+
the in#ant durin+ "%ee( 4e.+., 9ee( the roo3
te3(erature $o3#orta%e, do not o&erdre""
the in#ant, u"e a %i+ht %an9et5.
2
Fa$tor" that
are a""o$iated with SIDS are %i"ted in Table
1.
;'6,1'00
The re%ation"hi( etween (rone "%ee(in+
(o"ition and SIDS wa" #ir"t noted in 0.6/,
ut re$o33endation" "u((ortin+ "u(ine
"%ee(in+ were not i""ued unti% the ear%!
0..-".
0,'0;
The =>a$9 to S%ee(? $a3(ai+n
or+ani@ed ! the Nationa% In"titute" o#
Hea%th and the A3eri' $an A$ade3! o#
Pediatri$" 4AAP5 rou+ht aout a de$rea"e
in SIDS $a"e". In "(ite o# re$o33endation",
(rone "%ee(in+ re3ain" a $o33on
(re"u3(ti&e $au"e o# SIDS. Cu%' tura%
(ra$ti$e" re+ardin+ "%ee( (o"ition 3irror
di##eren$e" in SIDS rate" etween ra$e". For
e7a3(%e, in the 8nited State", %a$9 in#ant"
are 3ore %i9e%! to e (%a$ed to "%ee( in the
(rone (o"ition and ha&e hi+her rate" o#
SIDS $o3' (ared with white in#ant", who are
3ore %i9e%! to e (%a$ed to "%ee( in the "u(ine
(o"ition.
0/
%athophysiology
Si+ni#i$ant $ontro&er"! re&o%&e" around
the
(atho(h!"io%o+! o# SIDS. Three $o33on

T

170 American Family Physician ww w . a a # ( .o r + * a # ( Volume 79, Number 1

May 1!, "9
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American Family Physician 666 May 1!, "9

Volume 79, Number 1 ww w . a a # ( .o r + * a # (
a""inet.
in#ant, u"e a %i+ht %an9et5.
in in#ant" who are rea"t#ed.
# $ consistent, good%&uality 'atient%oriented evidence( ) $ inconsistent or limited%&uality 'atient%oriented evidence( C $ consensus, disease%
oriented evidence, usual 'ractice, e*'ert o'inion, or case series. +or information about the ,-.T evidence rating system, go to h t t ' / 00 11 1 . a a f '.
org0af'sort.*ml.
auto("! #indin+" in$%ude un$%otted %ood in the heart,
0
intrathora$i$ (ete$hiae,
06
and #%uid'#i%%ed, hea&ier
or+an",
02
ut the"e #indin+" (ro&ide %itt%e he%( in under'
"tandin+ the #ina% (atho(h!"io%o+! o# SIDS. The now
di"$redited =a(nea theor!? o# SIDS wa" (ro(o"ed in the
0.2-"
01
and %ed to de$ade" o# re"ear$h and the $reation
o# an a(nea 3onitorin+ indu"tr!. Howe&er, in the inde7
$a"e that #ir"t (ro3(ted in&e"ti+ation o# the %in9
etween a(nea and SIDS, the 3other %ater $on#e""ed to
9i%%in+ a%% #i&e o# her $hi%dren.
0.
Current %iterature "u((ort" a tri(%e'ri"9 3ode%,
,-
whi$h
"u++e"t" that SIDS i" the #ina% $o33on (athwa! o# three
$oin$idin+ #a$tor". Thi" 3ode% (ro(o"e" that an in#ant
3u"t #ir"t ha&e an under%!in+ &u%nerai%it! and then e
a""o$iation" and new%! identi#ied ni$otine 3etao%i@in+
+ene" ha&e (ro3(ted a "ear$h #or SIDS $au"a%it!
,1
and
#urther hi+h%i+ht the i3(ortan$e o# "3o9in+ $e""ation
$oun"e%in+ in SIDS (re&ention e##ort". Wo3en "hou%d
not "3o9e durin+ (re+nan$!, and the! "hou%d 9ee( the
in#antA" en&iron3ent "3o9e'#ree.
.
%revention and 3ounseling Issues
The (rin$i(%e" o# "a#e "%ee(in+ (ra$ti$e" #or in#ant"
are
we%% e"ta%i"hed. In a re$ent $a"e "erie", .,., (er$ent
o#
Table 1. Select ,actors +ssociated #ith SIDS
a((ear in a" 3an! a" 0/ (er$ent o# SIDS $a"e".
,/
Fina%%!,
(re' and (o"tnata% e7(o"ure to $i+arette "3o9e ha" een
a 9nown ri"9 #a$tor #or SIDS #or 3ore than :- !ear".
,6
Ni$otine e7(o"ure ha" een $%ear%! %in9ed with SIDS,
a" we%% a" with (re3aturit!, autono3i$ d!"#un$tion,
%ow irth wei+ht, and "(ontaneou" aortion".
,2
The"e
I33uni@ation" u( to date
Pa$i#ier u"e
NOTE) The above odds ratios 1ere derived from different studies of
different 'o'ulations and, therefore, cannot be directly com'ared
1ith each other.
C2 $ confidence interval( ,23, $ sudden infant death syndrome.
2nformation from references 4 through 5, and 6 through 11.
SIDS
"tre""ed ! an e7o+enou" "our$e, "u$h a" (rone "%ee(in+
+actor -dds ratio 79!8 C29
(%a$e3ent. Fina%%!, #or SIDS to o$$ur, the "tre"" 3u"t
o$$ur durin+ a $riti$a% de&e%o(3enta% (eriod, na3e%! in
Increase SIDS ris
>ed "harin+, "3o9in+ 3other
1
0:..- 4../1 to ,-.-.5
the #ir"t !ear o# %i#e. The %a"t two #a$tor" in the tri(%e'
>irth e#ore :2 wee9"A +e"tation
.
00.62 40.1; to 2;.0;5
ri"9 3ode% ha&e een we%% re"ear$hed and de#ined in So#t eddin+ 3ateria%
6
/.0- 4:.0- to 1.:-5
the 3edi$a% %iterature, ut the under%!in+ &u%nerai%it! Prone "%ee(in+ (o"ition 4&er"u" a$95
/
;.., 4:.6, to 6./15
re3ain" to e identi#ied. Prone "%ee(in+ (o"ition 4&er"u" an! ;.:- 4:.:. to /.:.5
Current SIDS re"ear$h to(i$" in$%ude in&e"ti+ation o#
other (o"ition5
/
ion $hanne% anor3a%itie", autono3i$ ner&ou" "!"te3
>ed "harin+, non"3o9in+ 3other
1
,.-. 4-..1 to ;.:.5
di"turan$e", and the e##e$t" o# ni$otine on the de&e%o('
Ci+arette "3o9in+ durin+ (re+nan$!
.
,.-: 40.06 to :./;5
in+ rain.
,0
Mu%ti(%e ion $hanne% di"order" that $au"e BT
Parenta% une3(%o!3ent
.
0.2, 40.00 to ,.665
inter&a% (ro%on+ation ha&e een %in9ed to SIDS
,,
and 3a!
Po"tnata% e7(o"ure to $i+arette "3o9e
0-
0.6/ 40.,- to ,.,15
e a #a$tor in / to 0- (er$ent o# SIDS $a"e".
,:
In addition,
Side "%ee(in+ (o"ition 4&er"u" a$95
/
0.:6 40.-: to 0.1-5
de#e$t" in nor3a% arou"a% 3e$hani"3" ha&e %on+ een
5educe SIDS ris
theori@ed to $au"e SIDS,
,;
and +ene 3utation" a##e$t'
00
-./; 4-.:. to -.265
in+ the de&e%o(3ent o# the autono3i$ ner&ou" "!"te3
;
-.:. 4-.:0 to -./-5
S"5T0 789 583"::8;D+TI";S ,"5 %5+3TI38
Clinical recommendation
:vidence
rating .eferences
To redu$e the ri"9 o# "udden in#ant death "!ndro3e, (arent" "hou%d)
P%a$e the in#ant on hi" or her a$9 when "%ee(in+. Side "%ee(in+ (o"ition i" not re$o33ended. A /
8"e a #ir3 "%ee(in+ "ur#a$e #or the in#ant, and 9ee( "o#t o<e$t" and %oo"e eddin+ out o# the $ri or C 6
A&oid o&erheatin+ the in#ant 4e.+., 9ee( the te3(erature o# the roo3 $o3#orta%e, do not o&erdre"" the C 2
Not "3o9e durin+ (re+nan$!, and 3a9e "ure the in#antA" en&iron3ent i" "3o9e'#ree. C .
8"e a "e(arate "%ee(in+ en&iron3ent #or the in#ant that i" near!, idea%%! a a""inet or $ri near the 3otherA"
ed. Do not %et the in#ant "%ee( with other $hi%dren. Do not "%ee( with the in#ant on a $ou$h or ar3$hair.
C 1
Con"ider o##erin+ the in#ant a (a$i#ier at na( or edti3e. Do not u"e a (a$i#ier e#ore one 3onth o# a+e C ;
SIDS SIDS
death" o$$urred in in#ant" who were "%ee(in+ in the
(rone (o"ition, ed "harin+, or "%ee(in+ in a %o$ation
other than a $ri or a""inet.
,.
Patient edu$ation
e##ort" that re$o33ended the "u(ine "%ee(in+ (o"ition
in the 0..-" re"u%ted in a /- to 2- (er$ent de$rea"e in
SIDS rate".
/
<8D S=+5I;>
>ed "harin+ re3ain" a $ontro&er"ia% to(i$ a3on+ hea%th
$are (ro#e""iona%" and #a3i%ie". Po""i%e ene#it" o# ed
"harin+ in$%ude in$rea"ed rea"t#eedin+ rate", (arent'
$hi%d ondin+, and #ewer "%ee( (ro%e3".
:-
The AAP
i""ued a (o%i$! "tate3ent in ,--/ di"$oura+in+ ed "har'
in+, notin+ that a%3o"t one ha%# o# in#ant" who die #ro3
SIDS in the 8nited State" do "o whi%e "%ee(in+ with (ar'
ent".
:0
>ed "harin+ $arrie" a "u"tantia%%! in$rea"ed ri"9
in %owCirth'wei+ht in#ant" and in $hi%dren o# "3o9er"
and (er"on" who u"e i%%i$it dru+" or a%$oho%.
1
Re$ent
ana%!"e" ha&e "u++e"ted that the ri"9" o# ed "harin+ are
i"o%ated to in#ant" !oun+er than #our 3onth", with no
"i+ni#i$ant in$rea"e in ri"9 #or o%der in#ant".
:-,:,
In#ant"
"hou%d "%ee( in a "e(arate, ut (ro7i3a%, "%ee(in+ en&i'
ron3ent, idea%%! in a a""inet or $ri near the 3otherA"
ed. In#ant" "hou%d ne&er "%ee( with other $hi%dren, or
with a (arent on a $ou$h or ar3$hair.
1
D8,"5:+TI";+? %?+>I"38%=+?9
De#or3ationa% (%a+io$e(ha%! i" #%attenin+ o# the o$$i(ut,
whi$h a##e$t" u( to one ha%# o# in#ant" who "%ee( in the
"u(ine (o"ition, and ha" e$o3e 3ore $o33on "in$e the
initiation o# re$o33endation" to (%a$e in#ant" on their
a$9" to "%ee(.
::
To de$rea"e the ri"9 o# "9u%% de#or3itie",
in#ant" "hou%d ha&e "u(er&i"ed =tu33! ti3e,? 3eanin+
that when awa9e, in#ant" "hou%d "(end a" 3u$h ti3e a"
(o""i%e on their "to3a$h". The "ide o# the o$$i(ut that
i" (%a$ed downward durin+ "%ee( a%"o "hou%d e
a%ternated. In#ant" "hou%d not e (%a$ed in $ar "eat"
when the! are not (a""en+er" in a &ehi$%e, and the u"e
o# other de&i$e" that (%a$e (re""ure on the a$9 o# the
head 4e.+., "win+, oun$! "eat5 "hou%d e 3ini3i@ed.
On$e de#or3ationa% (%a+io$e(ha%! ha" de&e%o(ed,
(arent" "hou%d a&oid (%a$in+ the #%attened "ide o# the
o$$i(ut down on the 3attre"" durin+ "%ee( ti3e".
Ph!"i$a% thera(! i" he%(#u% i# torti$o%%i" i" (re"ent. A
neuro"ur+i$a% e&a%uation 3a! e indi$ated in rare $a"e"
when the "9u%% de#or3it! doe" not i3(ro&e with $han+e"
in head (o"itionin+.
::
I::@;IA+TI";S
In#ant" who do not re$ei&e i33uni@ation" 3a! e at
+reater ri"9 o# SIDS.
00
So3e, ut not a%%, $a"e'$ontro%
"tudie" #ound a %ower rate o# SIDS a3on+ a((ro(ri'
ate%! i33uni@ed $hi%dren $o3(ared with $hi%dren with
in$o3(%ete i33uni@ation". Howe&er, the a((arent (ro'
te$ti&e e##e$t o# i33uni@ation" a+ain"t SIDS 3a! in
(art e e$au"e o# the re%ation"hi( etween in$o3(%ete
i33uni@ation and %ower "o$ioe$ono3i$ "tatu" and other
ri"9 #a$tor" #or SIDS.
00
"T=85 T"%I3S
A hi"tor! o# one or 3ore a(nei$ e(i"ode" doe" not
in$rea"e the ri"9 o# SIDS, and the u"e o# ho3e a(nea
3onitor" doe" not %ower the ri"9 o# SIDS.
:;
Pa$i#ier u"e
a((ear" to de$rea"e the ri"9 o# SIDS, and the ,--/ AAP
(o"ition "tate3ent on SIDS (re&ention "u++e"t" o##er'
in+ the in#ant a (a$i#ier at na( or edti3e.
2
Howe&er, the
(otentia% SIDS ri"9 redu$tion #ro3 (a$i#ier u"e 3u"t e
wei+hed a+ain"t the (o""ii%it! that ear%! (a$i#ier u"e 3a!
"horten the duration o# rea"t#eedin+.
:/
8"e o# a (a$i#ier
"hou%d e de%a!ed unti% one 3onth o# a+e in in#ant" who
are rea"t#ed.
;
+pparent ?ife&Threatening
8vents
A((arent %i#e'threatenin+ e&ent" 4ADTE"5 are a(nei$
e(i"ode" a""o$iated with $han+e" in "9in $o%or 4e.+.,
$!a' no"i", (a%%or, er!the3a5, $han+e" in 3u"$%e tone,
and $ho9in+ or +a"(in+. Co33on dia+no"e" and
e&a%ua' tion o# in#ant" with ADTE" are %i"ted in Table
".
:6
ADTE" are re%ati&e%! $o33on, o$$urrin+ in
a((ro7i3ate%! one in ;-- in#ant".
:2
In the (a"t, ADTE"
were re#erred to a" =near'3i"" SIDS,? ut thi"
$hara$teri@ation doe" not a((ear to e a$$urate. The
edu$ation $a3(ai+n" that ha&e redu$ed the in$iden$e o#
SIDS ha&e not a##e$ted the rate o# ADTE", and the on%!
i3(ortant SIDS ri"9 #a$tor that i" a""o$iated with ADTE"
i" 3aterna% "3o9in+ durin+ (re+' nan$!.
:2
Ri"9 #a$tor"
#or ADTE" 4in order o# 3o"t to %ea"t i3(ortant5 in$%ude
hi"tor! o# a(nea, $!ano"i", or (a%%or; #eedin+ di##i$u%tie";
"in+%e (arenthood; #a3i%! hi"tor! o# in#ant death; and
"3o9in+ durin+ (re+nan$!.
:1
An etio%o+! #or ADTE" i" deter3ined in on%! one ha%#
o# $a"e".
:2
Ga"trointe"tina% etio%o+ie" 4u"ua%%! +a"tro'
e"o(ha+ea% re#%u75 a$$ount #or 3o"t $a"e" in whi$h a
$au"e i" identi#ied. Re"(irator! in#e$tion" are another
i3(ortant $au"e. Cardia$ di"order", "u$h a" &a%&u%ar
di"ea"e, arrh!th3ia, and $ardio3!o(ath!, are re"(on'
"i%e #or a 3inorit! o# $a"e". Neuro%o+i$ $au"e", "u$h a"
3a%i+nan$!, "tru$tura% anor3a%itie" o# the rain, and
"ei@ure", are un$o33on, ut "hou%d e $on"idered. The
hi"tor! and (h!"i$a% e7a3ination are the 3o"t i3(ortant
#a$tor" in deter3inin+ an etio%o+!.
:.
In a $a"e "erie"
o#
,;: (atient" ad3itted to a "in+%e a$ade3i$ 3edi$a% $en'
ter, #ewer than 6 (er$ent o# a%% te"t" ordered were u"e#u%
in 3a9in+ the dia+no"i".
:.
The on%! te"t" #ound to e o#
&a%ue in dete$tin+ $au"e" o# ADTE" that were not e&ident
Table -. 3ommon Diagnoses and 8valuation of Infants
%resenting #ith an +pparent ?ife&Threatening 8vent
SIDS
,
u
A
n
A
(
d
thorou+h death "$ene
e&a%uation and a
$o3(%ete auto("!, with
a radio+ra(hi$
"9e%eta% "ur&e! and
to7i$o%o+!
Arrh!th
3ia
4e.+.,
%on+
BT
"!ndro3
e5
>ron$hio%
iti",
(ertu""i",
or
re"(ira
tor!
"!n$!ti
a% &iru"
E%e$tro$ardio+ra(h!
Che"t radio+ra(h!;
(u%"e o7i3etr!;
re"(irator!
"!n$!tia% &iru" or
(ertu""i" $u%ture
"tudie". E&a%uation
o# the death "$ene
"hou%d in$%ude
notation o# the
in#antA" (o"ition,
ed' din+, t!(e o#
ed or $ri, od!
te3(erature,
(re"en$e or a"en$e
o# ri+or 3orti",
roo3
Cho9in+ e(i"ode
>ariu3'$ontra"t u((er
+a"trointe"tina% "erie"
or
+a"t
ri$
(H
(ro
e;
o"
er&a
tion
te3(erature, t!(e o#
heatin+ or $oo%in+
u"ed,
and $are+i&er
re"(on"e.
Ga"tro
e"o(h
a+ea%
re
#%
u
7
di
"
e
a
"
e
>ariu3'$ontra"t
u((er
+a"trointe"tina%
"erie"
or +a"tri$ (H
(roe;
radioi"oto(e 3i%9
"$an
Intentiona%
"u##o$ation i"
di##i$u%t to di"'
In#e$tion or "e("i" >%ood +a"
ana%!"i"
; %ood
%a$tate
or
i$aro
nate
%e&e%;
C>C;
$he"t
radio+r
a(h!;
%u3ar
(un$tur
e with
$erero
"(ina%
#%uid
ana%!"i"
; "eru3
e%e$tro%
!te";
urina%!"i
" with
$u%ture
tin+ui"h #ro3 SIDS,
and the in$iden$e
o#
in#anti$ide a3on+
death" %ae%ed a"
SIDS i" e"ti3ated to
e 0 to / (er$ent.
;-
S3a%% "tud' ie" o#
$hi%dren with
re$urrent ADTE"
"howed
Dower
re"(ir
ator!
tra
$t
in#
e$
tio
n
C
>
C;
$h
e"t
ra
di
o+
ra
(h
!
a hi+h in$iden$e
o# Mun$hau"en
"!ndro3e
Nona$$identa% trau3a Di%ated
#undu"$o
(i$ e7a3ination;
non$ontra"t $o3(uted
to3o+ra(h! o# the
he
ad;
ra
di
o+
ra
(h
i$
"9
e%e
ta%
"ur
&e
!;
uri
ne
to7
i$o
%o
+!;
&id
eo
"ur
&ei
%%a
n$
e
Sei
@u
re
di"
or
de
r
>r
ain
i3
a+i
n+
;
C>
C;
e%e
$tr
oe
n$
e(
ha%
o+
ra
(h
!;
3et
urin
4$a%$
&ide
C)
C
$
co
m
'le
te
bl
oo
d
co
un
t.
#d
a'
te
d
1i
th
'e
rm
issi
on
from
;ar
ren
<,
)iagi
oli +,
=am
ilton
#,
,mit
h
>C.
:val
uati
on
of
a''a
rent
life%
thre
aten
ing
even
ts in
infa
nts.
?+>2
N@s
Clini
cal
2n&u
iries.
A A3
Fa3
Ph!"i
'
$ian.
"
7(75
719/1
"!.
! (ro7!. Fa$tor" that rai"e
the (o""ii%'
it! o# intentiona% "u##o$ation
are a hi"tor! o# ADTE" o$$urrin+
with a %one $areta9er, death o#
in#ant" o%der than "i7 3onth",
hi"' tor! o# une7(%ained death o#
"i%in+", "i3u%' taneou" death o#
twin", a (re&iou" death o# a
$hi%d under the $are o# the
"a3e (er"on, or e&iden$e o#
(re&iou" (u%3onar!
he3or' rha+e" at
auto("!.
;-
%ost&SIDS
Support and
3ounseling
Fa3i%ie" who ha&e
had an in#ant die
#ro3
#ro3 the hi"tor! and
(h!"i$a% e7a3ination were
te"tin+ #or +a"troe"o(ha+ea%
re#%u7, urina%!"i",
neuroi3a+in+, $he"t
radio+ra(h!, and white %ood
$e%% $ount.
:.
Diffe
renti
al
Diag
nosis
of
SIDS
Other $au"e" o# death,
"u$h a" in#e$tion,
e%e$tro%!te anor3a%itie",
inorn error" o#
3etao%i"3, and $hi%d
au"e, 3u"t e e%i3inated
e#ore a death $an e attri'
uted to SIDS 7Table B
;-
9.
In&e"ti+ation o# a (otentia%
SIDS
Table 6.
Differential
Diagnosis of
Sudden Infant
Death Syndrome
A"(iration, a"(h!7iation, or
drownin+
Cardia$ di"ea"e 4e.+.,
arrh!th3ia, "tru$tura%
anor3a%itie"5
E%e$tro%!te
anor3a%itie" or
deh!dration
Inorn error" o# 3etao%i"3
In#e$tion
4e.+.,
3enin+iti",
"e("i",
(neu3onia
5 Poi"onin+
Trau3a
2nformation from reference 4.
S
I
D
S
"
h
o
u
%
d

e
t
r
e
a
t
e
d
w
it
h
$
o
3
(
a
"
"
i
o
n
a
n
d
e
3
(
a
t
h
!
.
T
h
e
!
"
h
o
u
%
d

e
"
u
(
(
o
r
t
e
d
t
h
r
o
u
+
h
t
h
e
(
r
o
$
e
"
"
o
#
t
h
e
d
e
a
t
h
i
n
&
e
"
ti
+
a
ti
o
n
a
n
d
+
u
i
d
e
d
t
h
r
o
u
+
h
(ro%e3", "u$h a" endin+
%a$tation and #unera%
(%annin+. Grie# $oun' "e%in+
and re#erra% to a SIDS
"u((ort +rou( "hou%d e
o##ered. Parent" "hou%d e
$oun"e%ed that the ri"9 o#
#uture $hi%dren d!in+ #ro3
SIDS i" not in$rea"ed.
;-
T
h
e

+
u
t
h
o
r
s
STEPHEN M. ADAMS, MD, i" an
a""o$iate (ro#e""or and the (ro+ra3
dire$' tor o# the De(art3ent o#
Fa3i%! Medi$ine at the 8ni&er"it! o#
Tenne""ee Co%%e+e o# Medi$ine
Chattanoo+a. He re$ei&ed hi"
3edi$a% de+ree #ro3 the 8ni&er"it!
o# Tenne""ee Co%%e+e o# Medi$ine,
Me3(hi", and $o3(%eted a #a3i%!
3edi$ine re"iden$! at the Hunt"&i%%e
Re+iona% Medi$a% Ca3(u" o# the
8ni&er"it! o# A%aa3a S$hoo% o#
Medi$ine.
MATTHEW W. GOOD, MD, FAAP, i"
an a""i"tant (ro#e""or in the De(art'
3ent o# Pediatri$" and a (ediatri$
ho"(ita%i"t at the 8ni&er"it! o#
Tenne"' "ee Co%%e+e o# Medi$ine
Chattanoo+a. He re$ei&ed hi"
3edi$a% de+ree #ro3 the Medi$a%
Co%%e+e o# Eir+inia, Ri$h3ond, and
$o3(%eted a (ediat' ri$ re"iden$! at
E3or! 8ni&er"it!, At%anta, Ga.
GINA M. DEFRANCO, DO, i" an
a""i"tant (ro#e""or in the
De(art3ent o# Fa3i%! Medi$ine at the
8ni&er"it! o# Tenne""ee Co%%e+e o#
Medi$ine Chat' tanoo+a. She
re$ei&ed her de+ree in o"teo(athi$
3edi$ine #ro3 Fan"a" Cit! 4Mo.5
8ni&er"it! o# Medi$ine and
>io"$ien$e", and $o3(%eted a #a3' i%!
3edi$ine re"iden$! at the 8ni&er"it!
o# Tenne""ee Co%%e+e o# Medi$ine
Chattanoo+a.
999 American Family
Physician
ww w . a a # ( .o r + * a # ( Volume 79, Number 1

May 1!,
"9
SIDS
#ddress corres'ondence to ,te'hen M. #dams, M3, 11 :. Third
,t., Chattanooga, TN B74B 7e%mail/ ste'hen. a d a m s C e r l a n g e r .o r g 9.
.e'rints are not available from the authors.
Author di"$%o"ure) Nothin+ to di"$%o"e.
58,858;38S
0. >er+3an A>, >e$9with G>, Ra! CG, Feiter MD, ed". ,udden 2nfant
3eath ,yndrome/ >roceedings of the ,econd 2nternational
Conference on Causes of ,udden 3eath in 2nfants. Seatt%e, Wa"h.)
8ni&er"it! o# Wa"h' in+ton Pre""; 0.2-.
,. Wi%%in+er M, Ga3e" DS, Cat@ C. De#inin+ the "udden in#ant death "!n'
dro3e 4SIDS5) de%ieration" o# an e7(ert (ane% $on&ened ! the Nationa%
In"titute o# Chi%d Hea%th and Hu3an De&e%o(3ent. >ediatr >athol.
0..0;004/5)622'61;.
:. Nae!e RD, Dadi" >, Dra+e GS. Sudden in#ant death "!ndro3e. A (ro"(e$'
ti&e "tud!. #m < 3is Child. 0.26;0:- 4005)0,-2'0,0-.
;. Hau$9 FR, O3o<o9un OO, Siadat! MS. Do (a$i#ier" redu$e the ri"9 o#
"ud' den in#ant death "!ndro3eH A 3eta'ana%!"i". >ediatrics.
,--/;006 4/5) e206'e2,:.
/. Gi%ert R, Sa%anti G, Harden M, See S. In#ant "%ee(in+ (o"ition and the
"udden in#ant death "!ndro3e) "!"te3ati$ re&iew o# o"er&ationa%
"tudie" and hi"tori$a% re&iew o# re$o33endation" #ro3 0.;- to ,--,.
2nt < :'idemiol. ,--/;:; 4;5)12;'112.
6. Hau$9 FR, Her3an SM, Dono&an M, et a%. S%ee( en&iron3ent and the
ri"9 o# "udden in#ant death "!ndro3e in an uran (o(u%ation) the Chi'
$a+o In#ant Morta%it! Stud!. >ediatrics. ,--:;0004/ (t ,5)0,-2'0,0;.
2. A3eri$an A$ade3! o# Pediatri$" Ta"9 For$e on Sudden In#ant Death
S!n' dro3e. The $han+in+ $on$e(t o# "udden in#ant death "!ndro3e)
dia+no"ti$ $odin+ "hi#t", $ontro&er"ie" re+ardin+ the "%ee(in+
en&iron3ent, and new &aria%e" to $on"ider in redu$in+ ri"9. >ediatrics.
,--/;0064/5)0,;/'0,//.
1. M$Gar&e! C, M$Donne%% M, Ha3i%ton F, OARe+an M, Matthew" T. An
1 !ear "tud! o# ri"9 #a$tor" #or SIDS) ed'"harin+ &er"u" non'ed'
"harin+. #rch 3is Child. ,--6;.04;5):01':,:.
.. Dea$h CE, >%air PS, F%e3in+ PG, et a%. E(ide3io%o+! o# SIDS and
e7(%ained "udden in#ant death". CESDI S8DI Re"ear$h Grou(.
>ediatrics. 0...;0-; 4;5)e;:.
0-. Mit$he%% EA, Ford RP, Stewart AW, et a%. S3o9in+ and the "udden in#ant
death "!ndro3e. >ediatrics. 0..:;.04/5)1.:'1.6.
00. Eenne3ann MM, HI##+en M, >a<anow"9i T, Hen"e HW, Mit$he%%
EA. Do i33uni"ation" redu$e the ri"9 #or SIDSH A 3eta'ana%!"i".
Vaccine. ,--2;,/4,65);12/';12..
0,. Mit$he%% EA, S$ra++ R, Stewart AW, et a%. Re"u%t" #ro3 the #ir"t !ear o#
the New Jea%and $ot death "tud!. N D Med <. 0..0;0-; 4.-65)20'26.
0:. >%air PS, Sideotha3 P, >err! PG, E&an" M, F%e3in+ PG. Ma<or
e(ide3io' %o+i$a% $han+e" in "uddent in#ant death "!ndro3e) a ,-'
!ear (o(u%a' tion'a"ed "tud! in the 8F. Eancet. ,--6;:624./-25):0;'
:0..
0;. A3eri$an A$ade3! o# Pediatri$" Ta"9 For$e on In#ant Po"itionin+
and
SIDS) Po"itionin+ and SIDS K(u%i"hed $orre$tion a((ear" in >ediatrics.
0..,;.- 4, (t 05),6;L. >ediatrics. 0..,;1. 46 (t 05)00,-'00,6.
0/. Co%"on ER, De&en"on S, R!in D, et a%. >arrier" to #o%%owin+ the "u(ine
"%ee( re$o33endation a3on+ 3other" at #our $enter" #or the Wo3en,
In#ant", and Chi%dren Pro+ra3. >ediatrics. ,--6;001 4,5)e,;:'e,/-.
06. Haa" GE, Ta!%or GA, >er+3an A>, et a%. Re%ation"hi( etween e(ide3io'
%o+i$ ri"9 #a$tor" and $%ini$o(atho%o+i$ #indin+" in "udden in#ant death
"!ndro3e. >ediatrics. 0..:;.0405)0-6'00,.
02. Sieert GR, Haa" GE. Or+an wei+ht" in "udden in#ant death "!ndro3e.
>ediatr >athol. 0..;;0; 465).2:'.1/.
01. Stein"$hneider A. Pro%on+ed a(nea and the "udden in#ant death
"!ndro3e)
$%ini$a% and %aorator! o"er&ation". >ediatrics. 0.2,;/- 4;5)6;6'6/;.
0.. Fir"t3an R, Ta%an G. The 3eath of 2nnocents. New Mor9, NM)
>anta3
>oo9", 0..2.
101010 American Family
Physician
ww w . a a # ( .o r + * a # ( Volume 79, Number 1

May 1!,
"9
SIDS
,-. Fi%iano GG, Finne! HC. A (er"(e$ti&e on neuro(atho%o+i$ #indin+" in &i$'
ti3" o# the "udden in#ant death "!ndro3e) the tri(%e'ri"9 3ode%. )iol
Neonate. 0..;;6/4:';5)0.;'0.2.
,0. Wee"e'Ma!er DE, A$9er3an MG, Mara@ita MD, >err!'Fra&i" EM. Sudden
in#ant death "!ndro3e) re&iew o# i3(%i$ated +eneti$ #a$tor". #m < Med
Fenet #. ,--2;0;:A415)220'211.
,,. P%ant DD, >ower" PN, Diu B, et a%. A $o33on $ardia$ "odiu3
$han' ne% &ariant a""o$iated with "udden in#ant death in A#ri$an
A3eri$an", SCN/A S00-:M. < Clin 2nvest. ,--6;006 4,5);:-';:/.
,:. Wan+ DW, De"ai RR, Crotti D, et a%. Cardia$ "odiu3 $hanne% d!"#un$tion
in "udden in#ant death "!ndro3e. Circulation. ,--2;00/4:5):61':26.
,;. Hunt CE, >roui%%ette RT. Sudden in#ant death "!ndro3e) 0.12 (er"(e$'
ti&e. < >ediatr. 0.12;00- 4/5)66.'621.
,/. Wee"e'Ma!er DE, >err!'Fra&i" EM, Jhou D, et a%. Sudden in#ant death
"!ndro3e) $a"e'$ontro% #reNuen$! di##eren$e" at +ene" (ertinent to
ear%! autono3i$ ner&ou" "!"te3 e3r!o%o+i$ de&e%o(3ent. >ediatr .es.
,--;;/6 4:5):.0':./.
,6. >er+3an A>, Wie"ner DA. Re%ation"hi( o# (a""i&e $i+arette'"3o9in+ to
"udden in#ant death "!ndro3e. >ediatrics. 0.26;/1 4/5)66/'661.
,2. Fran$o P, S@%iwow"9i H, Dra3ai7 M, Fahn A. De$rea"ed autono3i$
re"(on"e" to o"tru$ti&e "%ee( e&ent" in #uture &i$ti3" o# "udden in#ant
death "!ndro3e. >ediatr .es. 0...;;6 405)::':..
,1. Rand CM, Wee"e'Ma!er DE, Maher >S, Jhou D, Mara@ita MD, >err!'
Fra&i" EM. Ni$otine 3etao%i@in+ +ene" GSTT0 and CMP0A0 in "udden
in#ant death "!ndro3e. #m < Med Fenet #. ,--6;0;- 40:5)0;;2'0;/,.
,.. A%e7ander RT, Radi"$h D. Sudden in#ant death "!ndro3e ri"9
#a$tor" with re+ard" to "%ee( (o"ition, "%ee( "ur#a$e, and $o'"%ee(in+. <
+orensic ,ci. ,--/;/- 405)0;2'0/0.
:-. Hor"%e! T, C%i##ord T, >arrow3an N, et a%. >ene#it" and har3"
a""o$i' ated with the (ra$ti$e o# ed "harin+) a "!"te3ati$ re&iew. #rch
>ediatr #dolesc Med. ,--2;0604:5),:2',;/.
:0. A3eri$an A$ade3! o# Pediatri$" Ta"9 For$e on Sudden In#ant Death S!n'
dro3e. The $han+in+ $on$e(t o# "udden in#ant death "!ndro3e)
dia+no"ti$ $odin+ "hi#t", $ontro&er"ie" re+ardin+ the "%ee(in+
en&iron3ent, and new &aria%e" to $on"ider in redu$in+ ri"9. >ediatrics.
,--/;0064/5)0,;/'0,//.
:,. Ru!" GH, de Gon+e GA, >rand R, En+e%ert" AC, Se33e9rot >A. >ed'
"harin+ in the #ir"t #our 3onth" o# %i#e) a ri"9 #a$tor #or "udden in#ant
death. #cta >ediatr. ,--2;.6 40-5)0:..'0;-:.
::. Per"in+ G, Ga3e" H, Swan"on G, Fattwin9e% G, #or the A3eri$an A$ade3!
o# Pediatri$" Co33ittee on Pra$ti$e and A3u%ator! Medi$ine, Se$'
tion on P%a"ti$ Sur+er! and Se$tion on Neuro%o+i$a% Sur+er!. Pre&ention
and 3ana+e3ent o# (o"itiona% "9u%% de#or3itie" in in#ant".
>ediatrics.
,--:;00,40 (t 05)0..',-,.
:;. Co33ittee on Fetu" and Neworn. A3eri$an A$ade3! o# Pediatri$".
A(nea, "udden in#ant death "!ndro3e, and ho3e 3onitorin+. >ediat%
rics. ,--:;0004; (t 05).0;'.02.
:/. S$hwart@ RH, Guthrie FD. In#ant (a$i#ier") an o&er&iew. Clin >ediatr
7>hila9. ,--1;;24;5):,2'::0.
:6. Warren G, >ia+io%i F, Ha3i%ton A, S3ith PC. E&a%uation o# a((arent %i#e'
threatenin+ e&ent" in in#ant". KFPINA" C%ini$a% InNuirie".L #m +am >hysi%
cian. ,--2;26 405)0,;'0,6.
:2. Fie$h%'Foh%endor#er 8, Ho# D, Pe+%ow 8P, et a%. E(ide3io%o+! o#
a((ar' ent %i#e threatenin+ e&ent". #rch 3is Child. ,--/;.- 4:5),.2'
:--.
:1. Edner A, Wennor+ M, A%3 >, Da+er$rant@ H. Wh! do ADTE in#ant" not
die in SIDSH #cta >aediatr. ,--2;.6 4,5)0.0'0.;.
:.. >rand DA, A%t3an RD, Purti%% F, Edward" FS. Mie%d o# dia+no"ti$ te"tin+
in in#ant" who ha&e had an a((arent %i#e'threatenin+ e&ent K(u%i"hed
$orre$tion a((ear" in >ediatrics. ,--/;006 4:5)1-,'1-:L.
>ediatrics.
,--/;00/4;5)11/'1.:.
;-. A3eri$an A$ade3! o# Pediatri$", H!3e% FP, #or the Co33ittee on Chi%d
Au"e and Ne+%e$t, and Nationa% A""o$iation o# Medi$a% E7a3iner".
Di"tin+ui"hin+ "udden in#ant death "!ndro3e #ro3 $hi%d au"e #ata%i'
tie". >ediatrics. ,--6;001 405);,0';,2.