Sudden Infant Death Syndrome (SIDS) Nursing Care Management

SIDS is the sudden, unexplained death of a seemingly healthy infant during sleep. You cannot predict it and you cannot reverse it once it happens, so the nursing work splits two ways: prevention through caregiver teaching (back to sleep, no soft bedding, no maternal smoking) and bereavement support for a family that just lost a healthy baby with no warning.

What is Sudden Infant Death Syndrome?

SIDS is death in an infant younger than 12 months that occurs suddenly, unexpectedly, and without obvious cause. It cannot be explained despite a thorough investigation, including a complete autopsy, examination of the death scene, and review of the clinical and social history. It is commonly called "crib death."

Pathophysiology

Multiple hypotheses exist; none are proven. Both prolongation of the QT interval (long QT syndrome, LQTS) and shortening of the QT interval (short QT syndrome, SQTS) raise the risk of cardiac arrhythmia and sudden death, but QT prolongation has drawn the most attention in SIDS. Clinically these dysrhythmias may present as syncope, seizures, or sudden cardiac death. By conservative estimates, 30 to 35% of infants who later die of SIDS have QT prolongation in the first week of life. Hypoxia is also implicated: hypoxanthine, a marker of tissue hypoxia, is elevated in the vitreous humor of SIDS infants compared with controls who die suddenly. Alveolar hypoxia stimulates pulmonary vasoconstriction and, eventually, pulmonary vascular smooth muscle hyperplasia; the increased muscularity drives pulmonary vasoconstriction, raises right ventricular afterload, and produces heart failure with more tissue hypoxia. Pleural petechiae are another significant autopsy finding, reflecting acute hypoxia in a physiologically intact infant.

Statistics and Incidences

A leading cause of infant mortality worldwide, SIDS claims an estimated 2,500 lives annually in the United States. Despite a dramatic drop over the past 20 years, it remains the leading cause of death in infants between 7 and 365 days of age. Since 1992, US rates have fallen by approximately 58%. In 1992 the incidence was 1.2 cases per 1000 live births; by 2004 it had dropped to 0.51. In 2004, 2246 deaths were certified as SIDS, 8% of infant deaths. In 2006 the National Center for Health Statistics reported 2323 SIDS deaths nationwide, an incidence of 0.54 per 1000 live births. In many Asian countries the current incidence is 0.04 per 1000 live births. Ninety percent of deaths occur in infants younger than 6 months and 95% in infants younger than 8 months; few occur younger than 1 month or older than 8 months. About 60 to 70% of SIDS deaths occur in males.

Contributing Factors

No single cause has been identified. Several risk factors recur. Low birth weight, from prematurity or other causes, is associated with a maturational delay in the ability to turn the head out of the face-down position. Regurgitation of acidic gastric contents can trigger reflexive apnea with hypoxia. At the time of death, 30 to 50% of otherwise healthy infants have an acute infection such as gastroenteritis, otitis media, or, in particular, upper respiratory tract infection (URTI); infantile botulism may cause 5 to 10% of sudden infant deaths. A New Zealand study suggests infants who are not breastfed are at increased risk. Cigarette smoking during pregnancy is a highly significant risk factor. Per Gilbert-Barness et al, unequivocal evidence indicates that a substantial number of SIDS deaths (by some estimates as many as 73.7%) can be prevented by avoiding the prone sleeping position, particularly on soft bedding.

Clinical Manifestations

The classic presentation begins with an infant put to bed, typically after breastfeeding or bottle-feeding. The observations most commonly reported with Brief Resolved Unexplained Events (BRUEs, formerly Apparent Life-Threatening Events) are cyanosis in about 50 to 60% of infants, breathing difficulties before death in half of infants, and abnormal limb movements. Most infants appear healthy, though many parents report their babies "were not themselves" in the hours before death.

Assessment and Diagnostic Findings

SIDS is a diagnosis of exclusion, established by ruling out recognizable causes of sudden unexplained infant death (SUID). For a living patient, initial labs include a complete blood count (CBC), electrolyte concentrations, and urinalysis. Skull radiographs and CT may be indicated if abuse is suspected or signs of increased intracranial pressure are present. In a series of 800 consecutive SUID cases, 6% of infants had a neuropathologic cause of death; almost all had clinical histories or gross brain findings at autopsy suggesting the cause.

Medical Management

For the infant found in cardiorespiratory arrest, the first priority is life support via the ABCs (Airway, Breathing, Circulation) plus other interventions as appropriate; absent postmortem lividity or other obvious signs of death, infants are transported to the hospital for full resuscitative attempts. Admit all infants presenting with nontrivial apnea or an apparent life-threatening event (ALTE) associated with cyanosis or altered mental status or tone. If the infant is pronounced dead, inform the family in a quiet environment, refer to the child by name rather than "the baby," and tell parents specifically and directly that their child has died. Detailing resuscitative efforts before delivering the news is not helpful and may breed resentment; using "dead" or "died" avoids the confusion that gentler terms create.

Nursing Management

Nursing Assessment

It is not uncommon for the infant to have been recently examined by a physician and found to be in excellent health.

Nursing Diagnoses

Based on assessment data, the major nursing diagnoses are:

• Dysfunctional grieving related to sudden, unpredictable death of the infant.
• Interrupted family processes related to grieving.

Nursing Care Planning and Goals

The major goals are that family caregivers seek appropriate support persons, use available support systems to cope with fear, share feelings about the event, and verbalize measures to prevent SIDS.

Nursing Interventions

Grief is coupled with guilt even though SIDS cannot be predicted; disbelief, hostility, and anger are common. Allow the family to express their grief, encourage them to say goodbye to their infant, and give them a quiet, private place to do so. Refer to the local chapter of the National SIDS Foundation immediately; the Sudden Infant Death Alliance is another resource. In some states, community health nurses trained in SIDS can support families in the home with written materials, guidance, and information. Caregivers are particularly anxious about subsequent infants; home monitoring of the next infant is usually maintained until that infant is past the age at which the SIDS infant died, which helps reduce the family's stress.

Evaluation

Goals are met when family caregivers sought appropriate support persons, used available support systems to cope with fear, shared feelings about the event, and verbalized measures to prevent SIDS.

Documentation Guidelines

Document the availability and use of support systems and community resources, the plan of care, the teaching plan, attainment or progress toward outcomes, and deviations from normal parenting expectations.