aap revises sids prevention recommendations

444 AWHONN Lifelines Volume 9 Issue 6

In the NHS, 5,145 cases of type 2 diabetes

were diagnosed between 1986 and 2002, and in

the NHS II, 1,132 cases were diagnosed

between 1989 and 2001. In analyses restricted

to women who reported a birth in the past 15

years and controlled for current body mass

index and other relevant risk factors for type 2

diabetes, there was a 15 percent reduced risk of

diabetes in the NHS and 14 percent reduced

risk in the NHS II per additional year of

breastfeeding. Among women who reported

their last birth more than 15 years ago, there

was no association between duration of lacta-

tion and type 2 diabetes in the NHS II and a

substantially reduced association in the NHS.

“In conclusion, increased duration of breast-

feeding was associated with reduced risk of

type 2 diabetes in 2 large cohorts of women.

Together with clinical evidence of improved

glucose homeostasis [equilibrium] in lactating

women, these data suggest that lactation may

reduce the risk of type 2 diabetes in young and

middle-aged women. Further clinical studies

are needed to confirm this finding and to elu-

cidate the physiologic mechanisms for an

inverse association between duration of breast-

feeding and risk of type 2 diabetes,” the authors

wrote (JAMA 2005;294:2601-2610).

AAP Revises SIDS PreventionRecommendations

Despite major decreases in the incidence

of sudden infant death syndrome (SIDS)

during the past decade, SIDS is still responsible

for more infant deaths beyond the newborn

period in the U.S. than any other cause of

death during infancy. In an updated policy

statement, “The Changing Concept of Sudden

Infant Death Syndrome: Diagnostic Coding

Shifts, Controversies Regarding the Sleeping

Environment, and New Variables to Consider

in Reducing Risk,” the American Academy of

Pediatrics (AAP) addresses several issues that

have become relevant since they last published

a statement in 2000.

The AAP no longer recognizes side sleeping

as a reasonable alternative to fully supine (lying

on back) sleeping. Studies have found that the

side sleep position is unstable and increases the

chances of the infant rolling onto his or her

stomach. Every caregiver should use the back

sleep position during every sleep period.

Bed sharing is not recommended during

sleep. Infants may be brought into bed for

nursing or comforting, but should be returned

to their own crib or bassinet when the parent is

ready to return to sleep. However, there is

growing evidence that room sharing (infant

sleeping in a crib in parent’s bedroom) is asso-

ciated with a reduced risk of SIDS. The AAP

recommends a separate but proximate sleeping

environment.

Research now indicates an association

between pacifier use and a reduced risk of

SIDS, which is why the revised statement rec-

ommends the use of pacifiers at nap time and

bedtime throughout the first year of life. The

evidence that pacifier use inhibits breastfeeding

or causes later dental complications is not

compelling enough to discredit the recommen-

dation. However, it is recommended that paci-

fier introduction for breastfed infants be

delayed until one month of age to ensure that

breastfeeding is firmly established. In addition,

if the infant refuses the pacifier, it should not

be forced. There is a slight increased risk of ear

infections associated with pacifier use, but the

incidence of ear infection is generally lower in

the first year of life, especially the first six

months, when the risk of SIDS is the highest.

The following have been consistently identi-

fied as risk factors for SIDS: prone (lying on

stomach) sleep position, sleeping on a soft sur-

face, maternal smoking during pregnancy,

overheating, late or no prenatal care, young

maternal age, pre-term birth and/or low birth

weight, and male gender. Consistently higher

rates of SIDS are found in black and American

Indian/Alaska Native children at two to three

times the national average.

The policy recommendations include:

• Back to sleep: Infants should be placed for

sleep in a supine (wholly on back) position

for every sleep

• Use a firm sleep surface: A firm crib

mattress, covered by a sheet, is the

recommended sleeping surfaceCarolyn Davis Cockey,

MLS, is executive editor

of AWHONN Lifelines

in New Castle, CO.

• Keep soft objects and loose bedding

out of the crib: Pillows, quilts,

comforters, sheepskins, stuffed toys

and other soft objects should be kept

out of an infant’s sleeping

environment

• Do not smoke during pregnancy:

Also avoiding an infant’s exposure to

second-hand smoke is advisable for

numerous reasons in addition to

SIDS risk

• A separate but proximate sleeping

environment is recommended such

as a separate crib in the parent’s

bedroom. Bed sharing during sleep

is not recommended

• Consider offering a pacifier at nap

time and bedtime: The pacifier

should be used when placing infant

down for sleep and not be reinserted

once the infant falls asleep

• Avoid overheating: The infant

should be lightly clothed for sleep,

and the bedroom temperature

should be kept comfortable for a

lightly clothed adult

• Avoid commercial devices marketed

to reduce the risk of SIDS: Although

various devices have been developed

to maintain sleep position or reduce

the risk of rebreathing, none has

been tested sufficiently to show

efficacy or safety

• Do not use home monitors as a

strategy to reduce the risk of SIDS:

There is no evidence that use of such

home monitors decreases the risk of

SIDS

• Avoid development of positional

plagiocephaly (flat back of head):

Encourage “tummy time.” Avoid

having the infant spend excessive

time in car-seat carriers and

“bouncers.” Place the infant to sleep

with the head to one side for a week

and then changing to the other

• Ensure that others caring for the

infant (child care provider, relative,

friend, babysitter) are aware of these

recommendations

December 2005 | January 2006 AWHONN Lifelines 445

9/11 Panel CallsFor DNA-BasedIdentificationAfter MassDisasters

Only days after the

Sept. 11, 2001,

attacks on the World

Trade Center, the National

Institutes of Justice con-

vened a panel of experts to

develop a process to iden-

tify victims using DNA

collected at the site of the

tragedy. Now, in an article

published in the journal

Science, the panel reports

that DNA-based efforts led

to the identification of more than one-quarter of those reported missing.

The article also makes recommendations to improve DNA identification in

the event of future terrorist attacks or mass disasters.

In their Science paper, panel members report that they have been able to

identify about 850 of the 2,749 people reported missing after the World

Trade Center attacks based solely on DNA results. In conjunction with New

York City’s chief medical examiner, the panel has determined that no fur-

ther identifications can be made at this time using the DNA samples

collected.

The Kinship and Data Analysis Panel (KADAP) included two senior

investigators from the National Human Genome Research Institute, part of

the National Institutes of Health (NIH). Leslie G. Biesecker, MD, a medical

geneticist and the first author of the paper, provided expert advice about

kinship analysis, communicating relevant information about genetic testing

to the families, and human subject issues. Joan E. Bailey-Wilson, PhD, a sta-

tistical geneticist, furnished the team with the statistical expertise necessary

to reduce the risk of misidentifications.

“This effort presented the group with some overwhelming challenges in

the face of such an unprecedented tragedy, but they came together at this

time of national crisis and developed a process that provided better results

than many would have expected. We owe them a debt of gratitude for pro-

viding the scientific expertise and compassion needed to help families and

friends identify their loved ones,” said NIH Director Elias A. Zerhouni, MD.

KADAP was organized and funded by the National Institute of Justice, an

agency of the U.S. Department of Justice, based on a request from New York

City’s chief medical examiner. The New York State Police Forensics Identifi-

cation Center was responsible for analyzing any reference DNA samples, and

several private laboratories tested samples from the World Trade Center site.

The final identifications were made by the Office of Chief Medical Examiner

of New York City. The panel included experts in forensics, bioinformatics,

molecular and medical genetics and statistical and population genetics.