CHAPTER TWO LITERATURE REVIEW This chapter focused on examining various concepts, theories, and empirical research findings. It included a summary of the existing literature.
2.1 Conceptual Review 2.1.1 Overview of Sudden Infant Death Syndrome (SIDS) Sudden Infant Death Syndrome (SIDS) is a heartbreaking and devastating occurrence that impacts infants. It is the death of an infant below the age of one year. Various definitions of SIDS have been proposed over the years, and constant revisions are being made to accommodate the epidemiologic and pathological features, as well as risk factors. Due to the narrow nature of the initial definition that emerged at the 1969 Second International Conference on Causes of Sudden Death in Infants, the National Institute of Child Health and Human Development convened in 1989 to reexamine the issue. The expert panel agreed upon a new definition of SIDS, stating that it is “the sudden unexpected death of an infant 1 year of age, with the onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including the performance of a complete autopsy and the review of the circumstances of death and the clinical history” (Krous et al., 2004).
The exact cause of SIDS remains unknown, but it is believed to be multifactorial, involving a combination of genetic, environmental, and developmental factors (Hauck et al., 2017).
2.1.2 Epidemiology of SIDS According to the US Centers for Disease Control and Prevention (CDC), the United States had an infant mortality rate of 5.4 deaths per 1,000 live births in 2021, and Sudden Infant Death Syndrome (SIDS) was the third leading cause of infant mortality in the same year. According to figures by the World Health Organisation (WHO), the global average child mortality rate in the year 2000 was 67 per 1,000 live births, with significant improvement from 85 per 1,000 live births in 1990 (Ayoola et al., 2005).
More recently, the Nigeria Demographic and Health Survey published in 2018 also reported that the infant mortality rate stood at 67 deaths per 1,000 live births for the 5-year period preceding the survey. Furthermore, there was a minor decrease in infant mortality, from 75 deaths per 1,000 live births in 2008 to 67 deaths per 1,000 live births in 2018 (Nigeria Demographic and Health Survey, 2018).
2.1.3 History of SIDS Sudden Unexpected Death in Infancy (SUDI) and Sudden Infant Death Syndrome (SIDS) have a long historical presence, as evidenced by a reference in the Old Testament (1 Kings 3) describing a similar incident: 'And this woman's son died in the night because she lay on him' (Edwin & Krous, 2015). In 1969, the term Sudden Infant Death Syndrome (SIDS) was coined to describe unexpected infant deaths that met specific demographic, epidemiologic, and pathologic criteria (Wright, 2017). During the 1940s and 1950s, examinations of infants who died suddenly and unexpectedly uncovered consistent autopsy results, firmly suggesting natural causes. According to Wright (2017), after 1969, cases fitting specific criteria were commonly labelled as Sudden Infant Death Syndrome (SIDS), a term widely accepted by both the public and advocacy organisations.
2.1.4 Risk factors of SIDS Research has shown that certain factors and situations increase the risk for Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths, such as from suffocation (Athanasakis et al., 2011). Some of these risk factors are "modifiable" or changeable—meaning parents and caregivers can take action to lower the risk—while others cannot be changed (Hunt & Hauck FR, 2006).
The modifiable risk factors include prone and side sleeping position, bed sharing, soft bedding, maternal smoking during pregnancy, parental smoking after delivery, and excess thermal insulation from bedding and clothing (Blaset & Wegmann, 2012). Risks that cannot be modified are low socioeconomic class, low birth weight, preterm birth, ethnicity, and high parity and a preceding infectious illness (Mitchell & Krous, 2015).
Sleeping in the prone or side position: This is the most easily modifiable risk factor for SIDS (Stephen et al., 2009). The identification of prone sleeping position as a risk factor of SIDS occurred between the late 1980s and early 1990s (Priyadarshi et al., 2022). In 1992, the American Academy of Pediatrics (AAP) Task force on infants' sleeping position and SIDS advised that all healthy full-term infants should be placed either on their side or on their back while sleeping. This recommendation was followed by major breakthroughs in combating SIDS.
Epidemiological studies conducted in the United Kingdom, New Zealand, Australia, and USA, focusing on factors within the infant sleeping environment that can be altered, discovered a significant link between the prone sleeping position and on the SIDS (Fleming et al., 1996; Mitchell et al., 1997). The reduction in the prevalence of infants sleeping prone following the recommendation to place infants to sleep on their backs (‘Back to Sleep’ or ‘Reduce the Risk’ campaigns) resulted in a dramatic decline in SIDS mortality.
Campaigns promoting supine sleep have effectively decreased sudden infant death syndrome (SIDS) worldwide, as is shown by proper documentation in 13 countries (Hauck & Tanabe, 2008). The reduction in SIDS cases was "fairly immediate and in proportion to the population uptake of supine sleep following the public health messages" (Hauck & Tanabe, 2008).
Prone position was also demonstrated to reduce cardiac output, mean arterial pressure, oxygen saturation, minute ventilation, and arousal responses to various stimuli (Yiallourou et al., 2008). Similarly, Horne et al reported that even in healthy infants,"the prone position significantly impairs arousal from both active sleep and quiet sleep." This decreased arousability from sleep was not accompanied by any changes in cardiorespiratory variables or body temperature that were clinically significant. However, it still sheds light on the role of prone sleeping as a major risk factor for SIDS (Horne et al., 2001).
The 2016 guidelines from the American Academy of Pediatrics (AAP) advise placing infants on their back for sleep at all times until they reach one year of age, as recommended by all caregivers (Moon & TASK FORCE ON SUDDEN INFANT DEATH SYNDROME, 2016).
Bedsharing: Recent research indicates that bed-sharing elevates the risk of SIDS in younger infants, even in households with nonsmokers (Carpenter et al., 2004). This suggests that all types of bed-sharing should be discouraged for these infants. A study by Tappin et al in 2005 led to the conclusion that "bedsharing is associated with an increased risk of SIDS for infants <11 weeks of age." They discouraged couch sharing for sleep at any age. Worthy of note is that temporary bed‐sharing poses no risk when the infant is placed back in their own (separate) cot during sleep (McGarvey et al., 2005).
Prematurity or low birth weight: Preterm infants have an increased risk of SIDS and the rate of sudden unexpected death in preterm infants is at least double that of term infants (Mitchell et al., 2020). Although there has been a significant decrease in SIDS cases since 1987, the risk of SIDS remains high among premature infants (Malloy, 2013). Mitchell et al reported that "there is a greater prevalence of some risk factors for Sudden Infant Death Syndrome in preterm infants compared to term infants with medical complexity."
Excess thermal insulation (bedding and clothing): Various studies have shown that Sudden Infant Death Syndrome may be closely associated with excessive insulation, resulting in thermal stress to the infant (Williams et al, 1996; Ponsonby et al, 1992). This can be caused by bedding and clothing used to provide warmth. Williams et al reported that excessive thermal insulation, beyond what was necessary to maintain the lower critical temperature, elevated the risk of SIDS primarily in infants placed in the prone sleep position. Furthermore, it was stated that "overheating and prone sleeping position are independently associated with an increased risk of the sudden infant death syndrome" (Ponsonby et al., 1992).
Maternal smoking during pregnancy: For both SIDS and SUIDS, maternal smoking is a modifiable risk factor, as they are more frequently observed in infants of mothers who smoke (Bednarczuk et al., 2020). In New Zealand, a survey revealed that smoking in pregnancy and/or bed sharing were the key risk factors for SUID regardless of ethnicity (MacFarlane et al., 2018). Furthermore, a dose-dependent relationship exists, meaning that there is a correlation where the risk of sudden death rises as daily maternal cigarette consumption increases (Mitchell & Milerad, 2006). On examining the pathological and physiological effects of tobacco, Mitchell and Milerad (2006) reported that the predominant effect from maternal smoking stems from in utero exposure of the foetus to smoke. If a causal link between smoking and SIDS is assumed, roughly one-third of SIDS deaths could have potentially been averted by preventing in utero exposure to maternal smoking (Mitchell & Milerad, 2006).
Maternal use of alcohol: Infants exposed to both alcohol and cigarettes throughout pregnancy, especially beyond the first trimester, face a significantly greater risk for SIDS compared to those unexposed or exposed to alcohol or cigarettes separately. The risk is also higher when mothers reported quitting early in pregnancy (Elliott et al., 2020).
Studies of maternal alcohol use during pregnancy have found that risk for SIDS is six times higher with periconceptional use and eight times higher with binge drinking in the first trimester (Iyasu et al., 2003). Furthermore, there risk is four times as high with drinking beyond the first trimester (Elliott et al., 2020) and a "seven-fold increased risk when mothers had a diagnosis of alcoholism during pregnancy" (O'Leary et al., 2013; Hauck & Blackstone, 2022).
2.1.5 Maternal Awareness of SIDS Maternal awareness of SIDS refers to the knowledge and understanding that mothers have about the risk factors, prevention measures, and warning signs of SIDS. The level of maternal awareness of SIDS has been found to be an important determinant of the incidence of SIDS (Alzahrani et al., 2020).
Several studies have investigated the level of maternal awareness of SIDS, and the results have been mixed (Pease et al., 2018; Rai et al., 2019; Alanezi et al., 2023). While SIDS impacts infants across different social backgrounds, it is consistently observed that lower socioeconomic status, younger maternal age, insufficient prenatal care, and lower maternal education levels are factors linked to an elevated risk of SIDS (Oliveira & Amorim, 2018; Mohamed et al., 2021). Thus, it has become increasingly relevant to study maternal awareness on SIDS and the factors associated with it.
2.1.6 Factors Affecting Maternal Awareness of SIDS These factors can be broadly categorised into three groups: demographic characteristics, cultural beliefs, and access to health information and resources.
Demographic characteristics: Several demographic characteristics have been found to influence maternal awareness of SIDS. For example, maternal age, education level, and occupation have been found to be positively associated with maternal awareness of SIDS (Alzahrani et al., 2019). Mothers who are younger, less educated, and unemployed or underemployed are less likely to be aware of SIDS and its risk factors (Getahun et al., 2004). Other demographic factors, such as maternal race, marital status, and parity, have been found to have inconsistent effects on maternal awareness of SIDS (Moon et al., 2007; Ansa et al., 2012; Beal and Ralston, 2015).
Cultural beliefs: Cultural beliefs have also been found to influence maternal awareness of SIDS. This includes beliefs about the causes of SIDS, the appropriate sleeping position for babies and co-sleeping. In some cultures, SIDS is attributed to supernatural causes such as curses, evil spirits, or bad luck (Ikenna, 2015). A retrospective study conducted by Ugiagbe and Osifo (2009) in Benin reported that in the local culture, infant death was considered a punishment for past wrongdoings. Autopsies are vital for the identification of SIDS cases. However, Nigerians are not entirely receptive to postmortem examinations (Ikenna, 2015). A study by Oluwasola et al. (2009) aimed at assessing factors influencing acceptance of autopsy at Ibadan, discovered that Christians were about six times more likely to agree to autopsies compared to Muslims, affecting parental decisions to decline postmortem analysis.
In some cultures, placing babies on their back to sleep is not the norm, and it may be considered unnatural or uncomfortable for the baby. This belief may prevent mothers from adopting the recommended sleep position for their babies, which increases the risk of SIDS. Co-sleeping, or bed-sharing, is a common practice in some cultures. However, bed-sharing has been identified as a risk factor for SIDS. In cultures where bed-sharing is the norm, mothers may not be aware of the risks associated with this practice and may not take preventive measures.
It is important to understand the cultural beliefs and practices that influence maternal awareness of SIDS in order to develop effective interventions that can improve maternal awareness and prevent SIDS.
Access to health information and resources Mothers who receive information about SIDS from multiple sources, such as healthcare professionals, family members, and media, are more likely to have a higher level of awareness of SIDS (). Access to health information and resources is also an important factor in maternal awareness of SIDS. Studies have found that mothers who receive prenatal care, attend parenting classes, and have access to healthcare professionals are more likely to be aware of SIDS and its risk factors (Vennemann et al., 2008; Ansa et al., 2012; Beal and Ralston, 2015). Additionally, mothers who receive information about SIDS from multiple sources, such as healthcare professionals, family members, and media, are more likely to have a higher level of awareness of SIDS (Moon et al., 2007; Patra et al., 2017).
2.4 Prevention measures for SIDS
Several prevention measures have been recommended to reduce the risk of SIDS. These measures include: Placing babies on their back to sleep, using a firm and flat sleep surface for the baby, avoiding bed-sharing with the baby, keeping the baby's sleep area free of soft objects and loose bedding, offering a pacifier at naptime and bedtime, avoiding overheating the baby, encouraging breastfeeding and avoiding exposure to smoke during pregnancy and after birth.
These prevention measures have been found to be effective in reducing the incidence of SIDS (Hauck et al., 2017). However, the adoption of these measures by mothers depends on their level of awareness of SIDS and their cultural beliefs (Hauck et al., 2017; Patra et al., 2017).
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