Infant Mortality, SIDS, Safe Sleep – PediaCast 302

Dr Jaime Macklin joins Dr Mike in the PediaCast Studio to talk about infant mortality, sudden infant death syndrome and safe sleep. How does Ohio stack up with the rest of the Nation? How does the United States stack up with the rest of the World? And how can we improve our numbers and save lives in the process? Tune in to find out!

Topics

  • Infant Mortality
  • Sudden Infant Death Syndrome (SIDS)
  • Safe Sleep

Guest

Links

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital on Columbus, Ohio. It is Episode 302, for November] 12th, 2014. We're calling this one "Infant Mortality, SIDS, and Safe Sleep".

I want to welcome everyone to the show. We have an important one lined up for you this week. You know, I typically mention this at the end of every program. You know the drill. Be sure to share the show with anyone you know who has children or who takes care of children. And of course, many of you have done just that, and I'm truly thankful for those of you out there who helps spread the news about PediaCast. Today's program is a prime example of why doing this is so important. It's not about the numbers or the downloads or how high our rating goes in iTunes. It's not about getting the show in iHeart Radio, alongside the Big Boy medical programs. It's certainly not about me, and it's not about Nationwide Children's Hospital.

Sure these things are great, but they aren't why we put the show together week in and week out. They're not why you stop by to listen. The goal here truly is to educate moms and dads with evidence-based information you can trust and to, improve the quality of life for children everywhere.

And in that vein, really there's nothing that screams quality of life like being alive. Unfortunately, many babies — to the tune of about 4,000 each year in the United States — don't make it to their first birthday. They die before their family can come along side and celebrate one year of living. What's even more unfortunate, the number doesn't have to be this high. Many baby deaths are preventable, and if this program can help prevent just one baby's death, then it's worth all the work that goes into putting PediaCast together.

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But in order for the show to make a difference, we need more parents listening. And that's where you come in to help spread the word, again, to everyone who has kids or takes care of kids. So as we talk about infant mortality today and SIDS (or Sudden Infant Death Syndrome) and safe sleep, think about all the folk you know who have young babies at home, or those who are pregnant or young couples about to start a family. Get those folks in your mind, write yourself a memo, and send them a text or an email or a Facebook message or a tweet. Or you could do it the old-fashion way and dial up their phone number. Or if you really want to go the old-fashion route, meet them for tea or coffee or lunch or whatever. The point is get together face-to-face and in doing so, fill them in on this particular episode of PediaCast because, again, it is an important one.

Let your child's doctor know about it too. Next time you're in for a visit, whatever the reason – whether it's well checkup or a sick office visit – that way, he or she can also help spread the word and get potentially life-saving information into the hands or ears, as the case maybe, of more moms and dads.

In our usual fashion, I have a great studio guest lined up for you today to help me talk about infant mortality, SIDS, and safe sleep. Dr. Jamie Macklin is a pediatric hospitalist at Nationwide Children's with a particular interest in infant mortality and keeping baby safe, and we'll get her settled in to the studio in a moment.

Before we do, a couple of quick reminders for you. We do have a blog here at Nationwide Children's. We call it 700 Children's and you can find it at 700childrens.org. Some recent topics: "Stuttering: Will My Child Outgrow It?", "Myths About Adult Congenital Heart Disease", "Five Ebola Facts We Want You To Know", "Four Tips to Prevent Your Child From Choking", and then, "Keeping Your Family Safe From Radon".

0:04:04

Here in the Midwest, houses all over the place have basements and radon is a real risk there. When I was in Florida a few years back, living down the southeast. not a lot of basements in Florida because the water table is just right below the surface. And so, the basements would flood, and the concrete slab on top of the ground, you don't have to worry about radon. But here in the Midwest, we do. So if you have a basement at home, you'll definitely want to keep your family safe from radon and you can find out more on the blog at 700childrens.org.

Also, I want to remind you that PediaCast is your show. So if you do have a topic you'd like us to talk about, if you have a question for me, or you want to direct me to a news article or a journal article, it's easy to do, just head over to pediacast.org and click on the Contact link and we'll try to get your question or your topic on the program.

Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals, so if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

All right, let's take a quick break. We'll get Dr. Jamie Macklin settled in to the studio and we'll talk about infant mortality. That's coming up right after this.

[Music]

All right, we are back. Dr. Jamie Macklin is a true jack-of-all-trades. She's double-boarded in adult internal medicine and pediatrics. She serves the Wexner Medical Center at the Ohio State University, in their Division of Hospital Medicine, within the Department of Internal Medicine. She serves Nationwide Children's Hospital as past chief resident and current pediatric hospitalist. She also serves on the faculty of the Ohio State University as an assistant professor of Internal Medicine and Pediatrics.

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She joins us in the PediaCast studio today with her pediatric half firmly in place to talk about three topics that are near and dear to her heart — infant mortality, SIDS and safe sleep. So, please join me with a warm welcome. Dr. Jamie Macklin, thanks for stopping by today.

Dr. Jamie Macklin: Thank you for having me.

Dr. Mike Patrick: We really, really appreciate you coming. Before we begin, you wear many hats. You're an adult doctor and a pediatric specialist. So how did you become interested in the topic of infant mortality.

Dr. Jamie Macklin: Actually, it was almost by accident. Two years ago, the Safe Sleep Committee at Nationwide Children's formed, and they needed a physician to serve on the committee. At that time, I had a two-year-old daughter who had just outgrown her infant years a year or two prior. And so, I was vaguely aware of the idea of safe sleep, didn't know much about it. But I was looking for a committee to join, and joined it, and then, quickly became overwhelmed by the problem that's in Ohio and the country as far a perfectly healthy babies that are dying from mostly preventable cause. It's overwhelming.

Dr. Mike Patrick: Absolutely. Let's start with just the definition. What's really meant by the term 'infant mortality'?

Dr. Jamie Macklin: I think the simplest definition for infant mortality is the number of infant deaths in children, ages one year of age or less, divided by the number of live births in any population, a zip code, a county, or a state or what have you. And that is reported in number of 1,000 births. So for example, the United States currently has an infant mortality rate of approximately 6 per 1,000 births.

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Dr. Mike Patrick: Great. So that kind of gives us a reflection of the overall health of community or a state or a region when we look at that kind of number. Then, we can also subdivide infant mortality based on some different categories, like the gestational age of the baby or the age of the parents, or parental age, family income, ethnicity, race, those kinds of things.

Dr. Jamie Macklin: Absolutely, yeah. As you kind of hinted, there's many factors that do affect infant mortality. You touch on prematurity indirectly and that's a big factor on infant mortality — socioeconomic status, race and gender are big ones. Maternal smoking or alcohol use, and then certainly, sleeping conditions that I know will be discussed in safe sleep later.

Dr. Mike Patrick: Yeah. How does the United States, then… You talked about our infant mortality rate in the United States being about 6 deaths per 1,000 live births. And again, these are kids that don't make it to their first birthdays that we're talking about.

Dr. Jamie Macklin: That is correct.

Dr. Mike Patrick: That ends up being 0.6% then of all babies, when we talk about 600,000. How does that stack up to other countries, especially other developed countries around the world?

Dr. Jamie Macklin: Unfortunately, we are really poor. There was actually a really interesting article in the Washington Post that came out the end of September that really highlighted how poor we were. They took somewhere between the most wealthy 25 to 30 countries in the world, and we're somewhere around 27, which means we have about 26-27 countries doing better than we are in infant mortality. Which is sad because we are the wealthiest country in the world.

Dr. Mike Patrick: That's pretty crazy when you think about it.

Dr. Jamie Macklin: It's absolutely crazy.

Dr. Mike Patrick: Now, I had heard and I've not done a ton of research on this, but I had heard that perhaps that number is a bit skewed by how things are defined. For instance, if you have extremely premature babies, is there a point when other countries don't even count that as a live birth?

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Dr. Jamie Macklin: You're absolutely correct. In our country, it's become almost common practice to try to resuscitate babies that are 22 to 23 weeks gestation. A normal gestation is 40 weeks, so babies that are roughly half the gestation. Whereas in other countries, that's not a practice that's normally done. So the semantics kind of account for about 40% of why our mortality rate is reported as high as it is. But that other 60%, that's still our problem, and we can't just wash it away or excuse it by what's called, what's not called.

Dr. Mike Patrick: And so, we're down far enough that even if you took that into account, we still don't make the top ten.

Dr. Jamie Macklin: Oh, yes.

Dr. Mike Patrick: You know, American tends to be competitive, I think. I think we want to crack that, and especially if we're touting one of the best healthcare systems in the world, well then why is infant mortality rate like it is?

Dr. Jamie Macklin: Right. So many factors, lots of factors. We know that breastfeeding reduces infant mortality. Our breastfeeding rates are much lower than some other developed countries. Other countries certainly have better parental leaves after the baby is born. We don't quite have those yet. What are the other high ones«]? Lots of racial and social disparities, those are the big things. If you read this article, they find that wealthy babies in Austria, Finland — other wealthier countries — fared as just well in infant mortality as the wealthy babies in the United States. But if you look at babies that are in poverty in these areas versus babies that are in poverty in the United States, there's a major, major disparity.

Dr. Mike Patrick: Let's talk about Ohio specifically. How does our state stack up to other states in the country?

Dr. Jamie Macklin: Sadly, we are not doing really well as far as overall statistics. We are number, sadly, 50 over 50, as far as African-American infant mortality, meaning we're the absolute worst in the country. We are 44th out of 50 for Caucasian infant mortality. We don't really have numbers for Hispanic infant mortality — I don't have that yet — but, overall in the country, we are 46 out of 50, which means we are the 5th worst state in our country.

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Dr. Mike Patrick: That's not a top ten you want to be in.

Dr. Jamie Macklin: Not at all.

Dr. Mike Patrick: Or the bottom ten, as the case may be. That's really pretty crazy. Why do you think that we're so low when compared to the rest of the United States?

Dr. Jamie Macklin: I think overall, we are just behind. I think other states recognize this was an issue much earlier than we did. We have started; as a state, we've really picked up over the past five years this is a big problem. While we've started the programs and we're working on it, but we're just so far behind.

A key example — and I know it's not a state, as opposed to a city — Harlem, one of the poor areas in New York City, had an infant mortality of approximately 27 per 1,000 way back in 1990. They have a lot of initiatives, a lot of community work, a lot of state work, and now had reduced their infant mortality to 6 per 1,000. But again, this was in the 1990s, and here we are in 2014, and we're just now getting the ball.

Dr. Mike Patrick: Just in case folks are, especially those who live in Ohio, maybe like, "Really? Are we really that low?" I'm going to put a link in the Show Notes. It's to the Henry J. Kaiser Family Foundation. They have a nicely done graphic that really shows where the different states are, and you can see for yourself that, really, we are that low in our infant mortality right now.

Dr. Jamie Macklin: We're really, truly that bad.

Dr. Mike Patrick: I guess it's kind of close to about a 8.

Dr. Jamie Macklin: Yeah, 7 1/2 and 8, somewhere right around there. Again, oppose to the 6 of the rest of the country.

Dr. Mike Patrick: Absolutely. I did look up some other countries as well to sort of see, and that puts us pretty… If you put Ohio and compared it to other developed countries around the world, we're really way down there.

Dr. Jamie Macklin: Yes, we are.

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Dr. Mike Patrick: OK, so we need more education. We need more access to health care. There's a lot things that we can do that you have mentioned to improved infant mortality. I guess, for starters, what can healthcare providers to improve infant mortality in the United States and in Ohio?

Dr. Jamie Macklin: We know that two major causes of infant mortality are prematurity, especially in the first months of life, and then sleep-related deaths, which makes up the bulk of infant mortality for the rest of that first year of life. So healthcare providers can really focus their efforts on encouraging prenatal care. If you have a doctor of a mom or a woman who's planning on getting pregnant really kind of stressing go get a doctor early, start taking your vitamins and if you're an obstetrician obviously encouraging repeat visits often. Healthcare providers in general can increase breastfeeding, because we know that breastfeeding reduces infant mortality.

Healthcare providers can also educate about and can mimic appropriate sleeping conditions. If you have a baby admitted to a hospital setting, the healthcare providers, the nurses, and other people that are involved in the care of the baby ca demonstrate appropriate sleeping conditions, so that we have these babies who are going home and being put in the appropriate areas for sleep without extra things in the crib, which I know we'll get to, but can model what that's supposed to look like.

Dr. Mike Patrick: That's a great point. If you can show parents, "Hey, this is how you should be doing it at home." And I suspect that you get a lot of pushback on some of those things from families who come in, like "No, no. We've been fine. We've got older kids at home. They made it through these types of sleeping conditions."

Dr. Jamie Macklin: Right. And that's a big pushback, not only for parents but also from healthcare providers especially those older ones who raised children before the recommendations came out, and their babies turn out fine. And yes, babies turn out find except when they don't, and if it's your baby, it doesn't really matter what all the other babies did.

Dr. Mike Patrick: Yeah, statistics doesn't mean anything when… For each child, it's either a 100% or 0%. I've worked in the emergency department before when a dead baby's come in that mom rolled over on. They were sleeping together on the couch. You see that , and it just really changes your feelings on that.

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Dr. Jamie Macklin: Yeah, when that happens, the numbers don't matter. It's all about that baby.

Dr. Mike Patrick: What then can parents and caregivers do to improve infant mortality in the United States? We can say we got this advanced healthcare system, but it's really what mom and dad are doing at home that can make the biggest difference.

Dr. Jamie Macklin: As we mentioned going from a prematurity standpoint, obviously moms can seek prenatal care early. They can avoid cigarette smoking throughout their pregnancy and afterwards, something like alcohol use and illicit drugs. Moms can breastfeed, and family should be supportive of that mom who is choosing to breastfeed because we know that lowers infant mortality. And then, they can practice appropriate safe sleep practices.

Dr. Mike Patrick: I do want to point out that it's really important that you do see your doctor at those regular scheduled intervals for well checkups or health maintenance visits at two weeks of age, or whenever the delivery room folks — when the baby's born — tell you to see your regular doctor — at 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months. It's a safety net to be able to look at a child's growth and development and to make sure that things are going as we would predict that they would go, so that we can catch kids if they're at risk for something that could end up taking their life.

Dr. Jamie Macklin: I agree, and you bring up an important point with the scheduled well-child check. And while those well-child checks in the first year involve vaccinations and while certainly we know that their vaccinations are fun, it hurts the baby so forth, we know that vaccines have been linked to decrease infant mortality. So that is something else that parents can do, is seek the appropriate medical care for their babies.

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Dr. Mike Patrick: Yup, absolutely. I want to put a plugin for one of my past podcast, Episode 241. Dr. Sarah Denny joined me for that one. It's called "Parenting 101: Baby Basics", and we covered lots of safety topics. And I'll put a link in the Show Notes for this Episode 302, so people can find it easily. But just in terms of injury prevention and child-proofing your home, we went into a lot of that. We did talk about safe sleep, and we're going to talk about safe sleep in much more detail today than in that particular one.

So let's do that. First, I guess, most people associate unsafe sleep with SIDS, because it seems Sudden Infant Death Syndrome occurs when children are sleeping for the most part. Let's define that first. What exactly is SIDS?

Dr. Jamie Macklin: SIDS is Sudden Infant Death Syndrome. It is a part of sleep-related deaths. So before I get too much more into that definition, I will say that the latest AAP or American Academy of Pediatrics recommendation really were expanded a few years ago to involve prevention for all sleep-related deaths. SIDS, by definition, is an unexplained death after an autopsy, a coroner's report, an investigation of the sleep environment was obtained, the coroner still says, "We don't know what caused this." So therefore, it is SIDS. It is unexplained.

We know there are many more sleep-related deaths that are explained. You mentioned the moms rolling over on the babies, babies that are in bed with parents that have a blanket put over them by accident, or rolling to a pillow or go on a crib with a stuffed animal who then falls on the baby's face. There's so many other, again, explained deaths that we know that we can prevent.

Dr. Mike Patrick: One of the statistics that I'd come across was in the US, again, there's about 4,000 cases of sudden unexpected infant death each year. After investigation, about a quarter of them were ruled as accidental suffocation and strangulation in bed. That is totally preventable.

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Dr. Jamie Macklin: Absolutely, 100% preventable.

Dr. Mike Patrick: But if you can't figure out after an investigation, there's no obvious cause of death, that's when we would call it SIDS.

Dr. Jamie Macklin: That is absolutely correct.

Dr. Mike Patrick: We do have some great resources there, too. And in the Show Notes, I'm going to put those. There's one, it's a collaborative effort between the CDC (Centers for Disease Control and Prevention) and the National Institutes of Health or NIH. They've kind of put their resources together to come up with the whole SIDS Resource. And I'll put a link to that in the Show Notes.

And then, the American Academy of Pediatrics, they actually have a site called Preventing SIDS and Other Sleep-Related Infant Deaths, and that's more research-oriented. And then, healthychildren.org, which is also from the American Academy of Pediatrics. This one's more consumer-friendly, and it's called Reducing The Risks of SIDS, and I'm going to put the links for all those things in the Show Notes over at pediacast.org for this episode which is 302.

But let's kind of move away from SIDS for a moment and talk about safe sleep in babies. What are the rules for safe sleep?

Dr. Jamie Macklin: So the rules of safe sleep in babies can really be distilled down to three letters: ABC. A stands for Alone, meaning the baby should sleep alone, either on a crib or a Pack 'n Play, or a bassinet or something approved for baby sleep. Again, alone.

B stands for Back. I don't think this is new to anyone. Babies should be put on their back for every sleep whether that's nap time or nighttime. The back-to-sleep campaign came in the 90s and we're doing pretty well with that one. So, the back.

The C is Crib. So, again, this is what your crib should look like. The crib should be completely empty. And when I say crib, it's crib, Pack 'n Play, bassinette, so forth. That means no stuffed animals. No blankets, no toys, no pillows, no bumpers, no anything, because all of those represent suffocation or asphyxia arrest to the baby. So alone, on the back, in an empty crib.

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Dr. Mike Patrick: This is difficult. I think where we do run into some pushback on this is grandparents. When grandparents come over and they want to buy things, and this is the way that the sleep environment should be. But parents, really, you got to take your stand on this.

Dr. Jamie Macklin: Absolutely, absolutely. Again, as we mentioned before, "This was the way it always was and my kid did fine, so your kid will do fine, too." We hear that a lot. But again, these recommendations were made on numerous studies and we know it's not just the safest thing for the baby.

Dr. Mike Patrick: What about products that claim to reduce the risk of SIDS, so things like wedges and positioners. You go to the baby store, and down the aisle, there's going to be products that claim that they help prevent SIDS. Are those safe?

Dr. Jamie Macklin: Those claims are not scientifically based. So, no, I would save money and spend it on other things. But no, wedges, sleep-related like nap nannies was a big thing a few years ago. Those have not been shown to reduce sleep-related deaths. You mentioned retail aisle bumpers. Crib bumpers are a big thing. And we've actually have kids in the hospital who have rolled in the crib bumpers and suffered brain injury from lack of oxygen from one of those. They're actually outlawed from being sold in the state of Maryland and the city of Chicago. We've love to work on that for Ohio.

Those are a big thing. Again, we tell parents, save your money on the crib bumpers. Spend it on a baby sitter and a nice dinner for you guys once the baby is born.

Dr. Mike Patrick: Talking about the products that claim to reduce the risk of SIDS like wedges and positioners. That's also the position of the American Academy of Pediatrics, not to use those things. So it's not just you or I sitting in the studio talking about it. We really have the weigh of the American Academy of Pediatrics say no, don't do this things.

Dr. Jamie Macklin: That is correct.

Dr. Mike Patrick: Then, also, slats on the crib. You want those to be pretty narrow so a kid couldn't get body parts between them. So it can become an issue if there's an old crib that's been in the family. So great-grandma use it and handed it down and handed it down. You really want to make sure that it meets current recommendations.

0:24:19

Dr. Jamie Macklin: Absolutely. That's a big thing whenever we have families using old cribs. We worry they don't make the safety specifications. The slat should be no more than a dollar apart, and that's kind of how you know. Actually, back in the olden days, the slats were further apart and that's why bumpers were made in the first place, so babies wouldn't get their head stuck between the slats. Now that those slats are not quite as far apart, the bumpers aren't needed anymore.

Dr. Mike Patrick: Then, you want the sleeping surface to be firm as well.

Dr. Jamie Macklin: Correct. Firm mattress with a fitted sheet.

Dr. Mike Patrick: So no pillows, no soft, anything that they could get their head, that they could potentially suffocate in.

Dr. Jamie Macklin: Absolutely.

Dr. Mike Patrick: Now here's one that I always get to ask when I was in private practice. So, you put the kid in bed on their back, what do you do every time they turn over? Do you flip them back on their back?

Dr. Jamie Macklin: No. Thankfully, you don't have to do that. Go get yourself some sleep instead. Once babies are old enough to roll, we know that they have the muscle control to start protecting their airway and to get their heads in appropriate position to where they're not going to suffocate on the mattress or sheet. So, the general rule is once the baby rolls, let them roll. It's OK.

Dr. Mike Patrick: I'd still put them down on their back, but if they roll over, don't keep flipping them.

Dr. Jamie Macklin: That's absolutely correct. And that's also a good reminder, to keep all the stuff out of the crib. Because if a baby can roll, if there's an empty crib, they're not going to roll in anything and it's not a problem. But if they can roll and they roll into a teddy bear next to them, that can be a huge issue.

Dr. Mike Patrick: Now, what about bundling them or… There's another word I'm…

Dr. Jamie Macklin: Swaddling?

Dr. Mike Patrick: Swaddling, that was the word I was looking for. What about baby swaddling? When you wrap them like a burrito in a blanket, is that safe?

Dr. Jamie Macklin: So the American Academy of Pediatrics has taken a pretty neutral stance on this as this point in time. It is certainly safer than having a loose blanket in the crib because — as we discussed that — that can get over the baby's face and then cause a suffocation risk. If a baby is to be swaddled, they should only be swaddled up to the shoulder area right about here. They should not go any higher to the chin or the face, and the swaddle should be loose enough to wear. Mom or dad should be able to get two fingers into the swaddle between the blanket and the chest. If it's more restricted than that, then we worry about can the baby breathe appropriately.

0:26:35

The other big issue with swaddling is you want to make sure the legs can move rather freely. In the swaddle, if legs are too constricted and the baby can't move, you worry about dysplasia or improper growth of the hips.

Dr. Mike Patrick: And this is really something that you should only do during the first couple of months. Once a kid is really able to move around, we don't want them swaddled.

Dr. Jamie Macklin: Yeah, once a baby can roll, you don't want them constricted in any way. You want free movement.

Dr. Mike Patrick: And then, there's also this issue of whether a baby gets too hot at night. And so, sometimes, I think the house is cold in the winter time, but it is possible to overdo things, and to have your kids in too warm a clothes.

Dr. Jamie Macklin: Absolutely. And we know that overbundling or over-heating can be one of the risk factors for SIDS as well.

A general rule of thumb is that babies should be in only one extra layer of clothing than the parents. So for example, if mom is wearing a t-shirt and a pair of light cotton pants to bed, maybe baby can wear a long-sleeve t-shirt or something else. The baby should not be in three or four layers of clothing if the parents are not. One extra layer is the key.

Dr. Mike Patrick: OK, so whatever the parents and comfortable in, it's probably OK for the baby as well, maybe the addition of one more layer.

Dr. Jamie Macklin: That's correct. That should be it.

Dr. Mike Patrick: But no more layers after that.

Dr. Jamie Macklin: No more.

Dr. Mike Patrick: And then, so you got baby in their own crib with nothing in it and they're on their back. Should they be in the same room as the parent? Or is the baby monitor OK? What do you think about that?

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Dr. Jamie Macklin: We know — or the American Academy of Pediatrics recommends that the baby should room-share for the first several months of life. Room-sharing has actually been shown to greatly decrease the risk of sleep-related death because mom and dad are right next to the baby on a separate sleep surface, but they can be there to attend to the baby if the baby is having a kind of distress whatsoever. They can hear the baby and respond right there.

So room sharing is wonderful, yes. Bedsharing, however, is not. So wonderful that we discussed that.

Dr. Mike Patrick: Absolutely. One of the things I wanted to bring up with sleep — and speaking of monitors — is that some babies go home with an apnea monitor or cardiorespiratory monitor, but these rules are still important is still important even if your baby is on a monitor.

Dr. Jamie Macklin: Absolutely. These rules absolutely still apply. And we know that, certainly , some of the most fragile premature babies can be an increased risk of sleep-related deaths, so all of these apply even if the baby's on a monitor.

Dr. Mike Patrick: So parents shouldn't think, "Well, if my baby's on a monitor, then when the monitor goes off, then I would be able to intervene." The cardiorespiratory monitors do not reduce the risk of SIDS.

Dr. Jamie Macklin: That is correct.

Dr. Mike Patrick: They may reduce the risk of apnea, of prematurity, but they're not going to reduce SIDS. I think that's an important thing for parents to keep in mind.

Dr. Jamie Macklin: Yeah, there's a lot of monitors. If you go on Amazon.com or anything like that, you can find a number of things. But again, they're not scientifically proven to reduce sleep-related deaths or SIDS.

Dr. Mike Patrick: Yeah. Great. Again, I don't want to beat this under the ground, but it's just so important. Babies need to be in their own crib. Nothing else in the crib at all with them. Just dressed like the parents dressed, basically. No pillows, no blankets, no stuff animals, nothing in there. In the same room as the parent is wonderful.

Dr. Jamie Macklin: Is ideal.

Dr. Mike Patrick: That's it, , and on their back on a firm surface.

Dr. Jamie Macklin: That's correct.

Dr. Mike Patrick: I can't tell you how many times that, even today, when I work in the emergency when parents say, "Well, we're sleeping in bed together." I just hear that all the time. So I think it's just something that, really, we need to educate parents. Parents need to take it seriously, and take a stand when grandmas and aunts and uncles tell them to do something differently.

Dr. Jamie Macklin: Absolutely.

0:30:15

Dr. Mike Patrick: Then, some sort of non-sleep recommendations for preventing SIDS. We talked about some of those. Breastfeed as long as you possibly can. Go to all your well checkups. Get your immunizations. Keep babies away from smokers and places where people smoke.

But then, back to sleep, tummy-time is OK when babies are awake and you are awake supervising them.

Dr. Jamie Macklin: Tummy time is actually great because it helps to build those neck muscles and helps those developmental skills, the rolling, that we want babies to do. So, certainly, whenever mom or dad is awake and baby's awake, tummy time is wonderful.

Dr. Mike Patrick: And this is where you got to get off the screens to a degree and get down and play with your kids.

Dr. Jamie Macklin: Absolutely. It can be a wonderful bonding experience for parents, grandparents, and baby. It also helps prevent something called positional plagiocephaly. A lot of parents are worried that their babies are going to have "funny-shaped heads", and appropriate tummy time when awake can actually prevent that.

Dr. Mike Patrick: And that happens when kids are on their back too much, and then they get flat on the back. Then, there's a controversy whether helmets help or don't help, or whether it get better on its own. We won't go there.

Dr. Jamie Macklin: Sure.

[Laughter]

Dr. Mike Patrick: What about pacifiers at night? Are those OK?

Dr. Jamie Macklin: Those are OK, and pacifiers have actually been shown to decrease the risk of SIDS. So we do recommend pacifiers if the baby will take them. We would encourage moms that are breastfeeding to maybe hold off on the pacifiers until about the first or three or four weeks, just so breastfeeding is established by that point. But after that, yes, a baby can be put to bed with a clean pacifier. If the pacifier falls out, that's OK. You don't need to keep resticking it back in. Just look at the benefits.

Dr. Mike Patrick: But bottles with fluid in it, whether it be milk formula, breast milk in the bottle, water even. You don't need any fluid in the bed.

0:32:03

Dr. Jamie Macklin: You don't need. No. That's certainly doesn't have the same protective value, and it shouldn't be there.

Dr. Mike Patrick: Great. I'm going to put a link in the Show Notes. We have an entire safe sleep resource page from Nationwide Children's Hospital, and it covers sleep position, creating a safe place to sleep, making a safe home environment, SIDS information, information on tummy time, swaddling rules. There's videos and helping hints and links to tons of other resources and some infographics as well. So I'll put all of the links. So people, just go to pediacast.org, find the Show Notes for Episode 302, and we'll have links to everything that we need for that.

Now, what about the toddler years? Are there some safe sleep rules for toddlers?

Dr. Jamie Macklin: Actually, the American Academy of Pediatric recommendations only go up to 12 months of age. After that, we know healthy toddlers above one year of age to protect their airways. You know, if they get a blanket over them, their face, they don't like it, they kick it off. They throw it off. They can roll. They can stand up in their crib. They can do all kinds of things.

So we really do have the same recommendations. So I tell parents, "If you've been waiting a year to get a stuff animal or grandma made you blanket and you want it in the crib, now is the time." Certainly, we recommend, if it's amenable to both mom and baby, continue breastfeeding because there's many benefits beyond that first year of life. We recommend continued well-child checks and vaccines and avoiding smoke exposure, just like we would in the infant years. But as far as the ABCs, that kind of goes away at least for right now.

Dr. Mike Patrick: What about when toddlers start getting up at night? And then, you're worried that they'll roam in the house or they're going fall down the stairs, or they're going to things that they shouldn't. How can parents keep their toddler safe from the habit of roaming?

Dr. Jamie Macklin: Obviously keeping him in a crib as long it's possible. Certainly, for every toddler, that's different. But having them in the crib — again, a safety approved crib that doesn't have the drop rails so that the toddler can't get out as easily will help. Once the toddler gets to be two-and-a-half, three years old, it probably gets a little bit harder, but adding things like door alarms or a number of things can kind of help out. It might be time for the toddler to get their own bed, so at least if they are getting out, they're not trying to climb a crib and fall. A toddler that might not be appropriate then.

0:34:24

Dr. Mike Patrick: And parents, if the child has their own room, sort of make that whole room a crib.

Dr. Jamie Macklin: Sure.

Dr. Mike Patrick: So you have a baby gate and that room is absolutely safe. But if they're climbing over the gate, then you may need to close doors and, like you said, set door alarms. And certainly, folks can talk to their regular doctor about this because the recommendations may vary depending on what the kids do without.

Dr. Jamie Macklin: Yeah, absolutely.

Dr. Mike Patrick: And then, co-sleeping, does there become a time when you think co-sleeping is safe once kids get to be toddlers.

Dr. Jamie Macklin: So, it could safer. Once they are toddlers again, we know that they have the capacity to protect their airway, kick off the blankets, do what have you. So if we have parents that wanted to bedshare… Again, I'm going to assume you're talking about bedshare.

Dr. Mike Patrick: Yes. Yeah.

Dr. Jamie Macklin: Then yes, that would be safer in the toddler years and would be in the infant years.

Dr. Mike Patrick: Yeah. Again though, parents and families can… Everyone's got what sort of works for them as long as it's safe.

Dr. Jamie Macklin: That is correct.

Dr. Mike Patrick: But I know in our house, our rule used to be — when our kids were littler — you can sleep with us but you're going to sleep on the floor next to the bed, not in the bed. And I guess, if you set some boundaries right from the beginning, that's going to get easier.

On the other hand, you may have a single mom, and the bed sharing, there is a social band that's happening there; and so each family's going to be a little bit different.

Dr. Jamie Macklin: Absolutely. As long as parents established boundaries early or lack of boundaries, whatever works for that family, again, as long as it's after 12months of age, 1 year of age, whatever works for that family.

0:36:00

Dr. Mike Patrick: What are some hot topics in infant mortality and safe sleep research? Is there anything going on there?

Dr. Jamie Macklin: As far as safe sleep research, the big thing right now is SIDS. Again, that's a portion of the sleep-related deaths and we certainly know that a lot of the deaths related to suffocation, the strangulation, asphyxia, so forth. But then, there is the SIDS, which is the unexplained part. And we're trying to wrap our brains around what causes that.

Right now, the current theory is something called the triple risk theory. We know that babies are more prone to SIDS between two and four months of age. We think that there is something related to some kind of brain stem dysfunction at this point, but we don't know exactly what. There is gene testing involved in these babies that have died of SIDS. We're trying to figure out. Certainly, most babies go between two to four months of age. What makes those babies that die more prone to dying of SIDS?

We know that the babies three months of age, some of them do have these unsafe sleep exposures. They're put on their stomach. They have blankets, so forth. And those babies don't die, yet some of them do. So what it is different about the babies who do. So that's the big hot topic in safe sleep research right now.

Dr. Mike Patrick: I think parents need to understand that sometimes this is going to happen and we don't know why, and they shouldn't feel guilty.

Dr. Jamie Macklin: No.

Dr. Mike Patrick: If you really tried to make a safe sleep environment and your baby still dies from SIDS, it's not your fault.

Dr. Jamie Macklin: No, it is absolutely not. We have several, several well-meaning parents every year who have done all the "right things". They followed the ABCs to a T. They breastfeed. They didn't smoke. They took all their prenatal care and yet their baby died. It's horrible, but it's not their fault.

Dr. Mike Patrick: We certainly want to encourage — not encourage — we want parents to follow these safe sleep guidelines. But there are going to be some that slip through, and once a baby has passed, you can't bring the baby back. Certainly, we want education but we also want compassion on the parents, even when it was maybe their fault.

0:38:15

Dr. Jamie Macklin: Absolutely.

Dr. Mike Patrick: Don't live with that guilt, please.

Dr. Jamie Macklin: No, absolutely. I think the guilt is going to be worse than any kind of… That's the "punishment" right there. No, parents should never be made to be guilty.

Dr. Mike Patrick: Yeah, I agree. So what is Nationwide Children's Hospital doing to improve infant mortality and promote safe sleep?

Dr. Jamie Macklin: Nationwide Children's has been a part of the Franklin County Safe Sleep Task Force since its very beginning in 2003. They've work locally to kind of work education for day care providers, hospitals, both birth hospitals and our hospital, offices throughout the area to try to educate people about sleep-related deaths and infant mortality.

More recently, the Greater Columbus Infant Mortality Task Force was formed a couple of years ago, and they partnered with Nationwide Children's Hospital to do the same message. We've been involved, as part of quality improvement project with Nationwide Children's over the past two years, to get a lot of education out to parents, healthcare providers in the hospital, and then to work on modeling again that safe sleep behavior in the hospital. That's also been spread to the birth hospitals as well.

Dr. Mike Patrick: And we're doing PediaCast.

Dr. Jamie Macklin: And we are. Here we are.

Dr. Mike Patrick: On safe sleep and SIDS to try to get the word out, and we really again encourage parents to share this particular episode with everyone they know that has babies or who'll soon have babies at home.

Dr. Jamie Macklin: Sure. You mentioned the 700 Children's Blog as well. There had been a couple of posts to the past year written about safe sleep and the ABCs, and what have you, so parents can check that out as well.

Dr. Mike Patrick: I think one of the things we talked about with preventing SIDS and improving infant mortality is just access to healthcare, and I think in this community — in Nationwide Children's — our tag line used to be "For Every Child, For Every Reason". Now, it's "When Your Child Needs A Hospital, Everything Matters." But really still, with that every child, we want to make sure that they do have access to healthcare.

0:40:10

One of the ways that's easy for parents to get in touch, I'm going to give a phone number but we'll also have this in the Show Notes, it was area code 614-722-KIDS as our physician referral for primary care. Regardless of where you live in Central Ohio, regardless of what insurance you have or if you don't have insurance at all, they would be able to get you in touch with a primary care provider that would be able to see your kids and social workers that could help you apply for any kind assistance that you may need from a financial standpoint. The hospital still works with folks in the finance department to come up with payment plans to figure out what you… I mean the primary thing is we want to get kids taken care of.

Dr. Jamie Macklin: Absolutely.

Dr. Mike Patrick: I think that's another big thing that Nationwide Children's is doing to improve infant mortality, just to access to healthcare for all kids.

Anything else? Any other issues on infant mortality, SIDS or safe sleep that we should be talking about. Do we cover it all?

Dr. Jamie Macklin: I think we hit the high points. Again, the ABCs are the big thing.

Dr. Mike Patrick: Let me remind folks again with the links. I'm going to put another plug-in for PediaCast 241. It was our "Parenting 101; Baby Basics". It was truly a monster of a show. Again, Dr. Sarah Denny joined me. We talked about breastfeeding, formula feeding, solid food, vitamins, fluorides, spit-ups, growth, developmental milestones, developmental delay, early intervention. We talked pee, poop, sleep, crying-it-out, colic, immunizations, home safety, car safety, bath safety, sleep safety, child abuse prevention, all in that one big episode. Again, that was Episode 241. So that one, definitely if you know anyone who's new parent, point him in the direction or soon to be new parent, be sure to point him in the direction of that episode.

0:42:01

And then, the Nationwide Children's Safe Sleep Resource page, again, loaded with information and we'll put a link to that as I mentioned in the Show Notes. And then, SIDS information from the CDC and NIH, "Preventing SIDS And Other Sleep-Related Infant Deaths" from the AAP, both one that's research-oriented and another one that's more consumer-friendly that's easy for moms and dads to understand. And then, infant mortality by US State. The Henry J. Kaiser Family Foundation, if you like to see how your state — because we have listeners in all 50 states — if you want to see how your state fares compared to the rest of the country, be sure to check out that link. Then, the 614-722-KIDS is the local phone number to get connected with the pediatrician from Nationwide Children's Hospital.

All right, we really appreciate you stopping by. The holiday season is fast approaching, regardless of what folks celebrate. It's the time for giving gifts. One of the things that I'm really passionate about is families doing stuff together and sort of turning off the screens, and playing some old fashion games. Any ideas on what a good gift for your family? What's a good gift that folks should be thinking about?

While you're thinking about it, I'll go first. We've been playing a lot of Canasta. And my grandma used to play Canasta with my grandma when I was little. My wife, I taught her, although she would claim that I make up rules as I go along because there's so many of them. But our kids, we've been playing Canasta, and playing cards is a great way to be around the table. You can talk and interact with one another. I would encourage people, a simple gift this holiday season is a Canasta. What say you?

[Laughter]

Dr. Jamie Macklin: Well, I have a four-year-old at home, so my life is currently involved with Candy Land and Snakes and Ladders. We play that about non-stop every day.

Dr. Mike Patrick: Those are both great gifts.

Dr. Jamie Macklin: I think those are perennial favorites.

Dr. Mike Patrick: Yeah. I remember when, for both of those games — everyone was excited — there was a computer version of it, or you can play those on iPads.

Dr. Jamie Macklin: It's not the same.

Dr. Mike Patrick: No, it's not the same at all.

0:44:04

Dr. Jamie Macklin: It's not the same, no.

Dr. Mike Patrick: Get the actual board game.

Dr. Jamie Macklin: Right.

Dr. Mike Patrick: Yup, absolutely.

All right, we really appreciate you stopping by.

Dr. Jamie Macklin: Wonderful. Thank you very much for having me. It's been a pleasure.

Dr. Mike Patrick: Let's take a quick break, and we'll be back and wrap up the show, right after this.

[Music]

Dr. Mike Patrick: All right, we are back with just enough time to say goodbye. Want to thank everyone for taking a part of your day and making PediaCast a part of it. Thanks to all my listeners out there. Also thanks to Dr. Jamie Macklin, pediatric hospitalist here at Nationwide Children's Hospital. Really appreciate her stopping by and talking about infant mortality, SIDS and safe sleep with us.

That does wrap up our time together. PediaCast is a production of Nationwide Children's Hospital. Don't forget, PediaCast and our single-topic program, PediaBytes, are both available on iHeart Radio Talk which you'll find on the Web at iHeart.com and the iHeart Radio app for mobile devices.

Our show archive, which includes over 300 programs, as well as our Show Notes, transcripts, terms of use, and contact page are available at our landing site, which is pediacast.org.

We're also on iTunes, under the Kids and Family Section of their podcast directory. You'll find PediaCast on Stitcher, TuneIn, Downcast, iCatcher, Pod Bay and most other podcasting apps for iPhone and Android.

We're also on Facebook, Twitter, Google+, and Pinterest. Of course, we really appreciate you connecting with us there, and sharing, retweeting, and re-pinning all of our posts so you can help spread the word about the show.

We also appreciate you talking us up with your family, friends, neighbors and co-workers, anyone with kids, or anyone who takes care of children. In the case of this episode, if you have babies at home or you know someone who has babies or they're soon to be parents, make sure you let them know about this program. It's really important, and you could save a baby's life by doing that.

0:46:12

As always, be sure to tell your child's doctor about the show. Posters are available under the Resources tab at pediacast.org.

Until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long, everybody.

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.e you next time on PediaCast.

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