Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant under 1 year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history (Willinger et al., 1991).

SIDS is…

• the major cause of death in infants from 1 month to 1 year of age, with most deaths occurring between 2 and 4 months
• sudden and silent–the infant was seemingly healthy
• a death often associated with sleep and with no signs of suffering
• a recognized medical disorder
• determined only after an autopsy, an examination of the death scene, and a review of the infant’s and family’s clinical histories
• a diagnosis of exclusion
• an infant death that leaves unanswered questions, causing intense grief for parents and families

SIDS is not…

• preventable, but the risk can be reduced by placing the baby on his or her back to sleep on a firm surface, by making sure the baby has a smoke-free environment, and by keeping the baby from being overheated
• suffocation
• caused by vomiting and choking or by minor illnesses such as colds or infection
• caused by the diphtheria, pertussis, tetanus (DPT) vaccines or other immunizations
• contagious
• child abuse or neglect
• the cause of every unexpected infant death

What Are the Most Common Characteristics of SIDS?
SIDS is unexpected, usually occurring in healthy-appearing infants under 1 year of age. A SIDS death occurs quickly and usually during sleep. SIDS is rare during the first month of life. Although SIDS can occur in older infants, most SIDS deaths occur by the end of the sixth month, with the greatest number occurring in infants between 2 and 4 months of age (AAP, 2000).

In the United States, more SIDS cases are reported in the fall and winter than in spring or summer. SIDS occurs more often in boys than in girls (approximately a 60- to 40-percent male-to-female ratio). African-American and American-Indian infants are two to three times more likely to die from SIDS as other infants (AAP, 2000; NICHD, 2001). Several Government agencies are intensifying efforts to reach these populations with the latest information about SIDS.

How Many Babies Die from SIDS?
Each year between 1983 and 1992, the average number of reported SIDS deaths ranged from 5,000 to 6,000. Over the past few years, especially since the mid 1990s, the number of SIDS deaths has declined significantly. The National Center for Health Statistics (NCHS) reported that in 2001 in the United States, 2,236 infants under 1 year of age died from SIDS (NCHS, 2003). Still, when considering the number of live births each year, SIDS remains the leading cause of death in the United States among infants between 1 month and 1 year of age and the third leading cause of death overall among infants less than 1 year of age (NCHS, 2003).

Although the overall SIDS rates have declined in all populations throughout the United States, disparities in SIDS rates and prevalence of risk factors remain in certain groups. SIDS rates are highest among African Americans and American Indians and are lowest among Asians and Hispanics (NICHD, 2001).

SIDS Deaths by Race and Hispanic Origin of Mother, 2001*

*Per 100,000 live births by group. Source: NCHS, 2003. Mathews, T.J., Menacker, F., MacDorman, M.F.,. Infant Mortality Statistics from the 2001 Period Linked Birth/Infant Death Data Set. National Vital Statistics Reports; Vol. 52, No. 12. Hyattsville, Maryland: National Center for Health Statistics. September 15, 2003.

How Do Professionals Diagnose a SIDS Death?
By definition, a SIDS diagnosis requires a complete autopsy, a thorough death scene investigation, and a clinical history. A death is diagnosed as SIDS only after all probable alternatives have been eliminated-in other words, SIDS is a diagnosis of “exclusion.” Often, the cause of an infant death can be determined only through a process of collecting information; conducting sometimes complex forensic tests; and by talking with parents, other caregivers, and physicians.

Medical and legal experts rely on three methods to determine a SIDS death:

• a thorough death scene investigation
• autopsy
• review of infant’s and family’s medical records and histories.

When a death is sudden and unexplained, investigators, including medical examiners and coroners, call on forensic experts, who apply their expertise in medicine and the law to help determine a cause of death. SIDS is no exception.

In most cases, the death investigation is led by the medical examiner or coroner for the county, district, or State in which the death occurred. Deaths suspected to be SIDS usually require law enforcement officers to conduct a thorough death scene investigation. The medical examiner/coroner gathers information from the death scene and case histories and presents this information to the pathologist (usually board certified or with credentials in forensic pathology). The pathologist conducts or supervises the autopsy and assesses results of the autopsy, death scene investigation, and case histories to determine whether a SIDS death has occurred. The pathologist issues a SIDS diagnosis when there is no other apparent cause for the infant’s death (Valdes-Dapena, 1995).

A Thorough Death Scene Investigation
Although it may be emotionally painful for the family, a death scene investigation will help shed light on the cause of death by providing a detailed record of the location and circumstances of the death. Therefore, the investigator will attempt to learn as much as possible about the events leading up to the death, even the very moment that the death occurred.

The Centers for Disease Control and Prevention (CDC) have developed guidelines for death scene investigation of a sudden, unexplained infant death (CDC, 1996). Local jurisdictions may use these guidelines or develop their own protocols for investigating sudden unexpected infant death.

Investigators will interview the parent or other individual who was caring for the child at the time of the death, as well as any other family members or adults who were present at the time of the death or before the death occurred. The investigator will ask open-ended, neutral questions such as, “Can you tell me what happened?” “How old was the baby?” “What did the baby weigh?” “What time was the baby put to bed?” “When did the baby fall asleep?” “Who last saw the baby alive?” “Who discovered the baby, and what did that person do?” “What position was the baby in when he/she was found?” “Were there covers over the baby’s head?” “Was CPR attempted?” “Did the baby share a bed with anyone else?” “What was the general health of the baby?” “Had the baby been ill recently?”

The individual investigating the death will take notes about the appearance of the room where the death occurred; condition and characteristics of the crib or sleeping environment; objects, if any, in the crib; medications at the death scene; and any unusual or dangerous items in the room, such as sharp objects or plastic bags. The investigator may make notes about the behavior of those present at the death scene. The investigator will also photograph the death scene and record the temperature of the room. It is likely that investigators will collect the infant’s bedding (e.g., sheets, blankets, etc.), any objects in the crib (e.g., toys or bottles), or any unusual or dangerous items found near the death scene.

Autopsy
An autopsy provides evidence of the cause of death through microscopic examination of tissue samples and examination of the body and vital organs. An autopsy is particularly important when a SIDS death is suspected because a definitive diagnosis cannot be made without a thorough postmortem examination. It is estimated that in 15 percent of cases suspected to be SIDS, the autopsy identifies another cause of death, such as a disease or genetic disorder, as well as unintentional injury or unnatural death (Valdes-Dapena, 1995). Also, if a cause (or causes) of SIDS is ever to be uncovered, it is likely that the cause will be detected from evidence gathered from a thorough pathological examination.

An autopsy may help parents and other caregivers deal with the death. According to noted authority Marie Valdes-Dapena, M.D., parents whose child has died need to know why the death occurred; they need to be reassured that their baby’s death could neither have been predicted nor prevented (Valdes-Dapena, 1995). Moreover, an autopsy leading to a diagnosis of SIDS will help remove the parents (or caregiver) from potential suspicion of wrongdoing by the legal system and by society in general.

Parents are usually anxious to consult with the pathologist after the autopsy. Discussing the autopsy results often helps most parents accept the reality of their infant’s death. The pathologist reviews the autopsy results, explaining in terms the parents can understand how these findings point to a determination of cause of death. The pathologist should also take the time to answer parents’ questions, responding with “compassion, understanding, and respect for the parents’ dignity and grief” (Valdes-Dapena, 1995).

Review of the Infant’s and Family’s Medical Histories
A comprehensive medical history is essential for a SIDS diagnosis. Along with a death scene investigation and an autopsy, a careful review of the infant’s and family’s history of disease, previous illnesses, accidents, and behaviors often helps to corroborate what is detected from the death scene investigation and the autopsy.

SIDS Deaths Require Special Understanding
Any sudden, unexpected death disturbs the sense of normalcy and security for the victim’s family. These deaths force family members and those around them to confront their own mortality (Corr et al., 1991). This is particularly true in the case of a sudden infant death. Simply put, babies are not supposed to die. Because the death of an infant is a disruption of the natural order, it is especially traumatic for parents, other family members, and friends (Arnold et al., 1997).

Like any sudden death, a SIDS death leaves a family with a sense of shock and loss and an urgent need to understand what happened. Lack of a discernible cause, the suddenness of the death, and possible involvement of law enforcement authorities make a SIDS death even more difficult. A SIDS death also leaves the family with a need for understanding from those close to the family-even the surrounding community.

A SIDS death is as tragic as a death from any readily definable disease or cause. Thus, investigators compiling or reviewing the case histories should be especially sensitive and recognize that the family may view this process as an intrusion, even a violation, of their grief. The interviewer should also be sensitive to the family’s cultural practices and traditions. The interviewer should point out to the family that although obtaining the case histories may be stressful, this information may reveal that the death could not have been prevented, which may provide some solace to a grieving family.

Are There Ways to Reduce the Risk of SIDS?
Currently there is no known way to prevent SIDS, but there are things that parents and caregivers can do to reduce the risk of a SIDS death. For example, researchers now know that the mother’s health and behavior during her pregnancy and the baby’s health before birth seem to influence the occurrence of SIDS.

Scientists also know that certain environmental and behavioral influences (called risk factors) can make an individual more susceptible to disease or ill health. Although risk factors are not necessarily the cause of a condition, by studying risk factors, scientists are able to better understand a disease or condition, which often leads to detecting a cause.

SIDS researchers and clinicians continue to try to identify risk factors that can be modified or controlled to reduce an infant’s risk for SIDS. For example, SIDS experts now know that the baby’s sleep position, exposure to smoke, and becoming overheated while asleep can increase the infant’s risk for SIDS.

Infant Sleep Position
In April 1992, the American Academy of Pediatrics (AAP) Task Force on Infant Sleep Position issued a statement recommending that infants be placed on their backs to sleep to reduce the risk of SIDS. Then, in 1994, the U.S. Public Health Service, AAP, the SIDS Alliance, and the Association of SIDS and Infant Mortality Programs cosponsored the Back to Sleep campaign, a national public service initiative to disseminate AAP’s recommendation that infants be placed on their back to sleep.

Between 1992 and 1998, among U.S. infants, stomach (prone) sleeping decreased from more than 70 percent to approximately 20 percent. During that same time frame, the number of SIDS deaths declined by more than 40 percent (Willinger et al., 1998; AAP, 2000; NICHD, 2001). Not surprisingly, most researchers, policymakers, and SIDS professionals agree that this significant decline occurred largely as a result of changing sleep position (AAP, 2000).

Rates of SIDS are over twice as high among American Indians and African Americans compared with Whites. Prone sleeping was found to be a significant risk factor for SIDS in an African- American urban sample (Hauck et al., 2002). These authors recommend educational outreach to the African-American community.

Another recent study of the relationship between infant sleep position and SIDS concluded that infants placed in an unaccustomed prone or side sleeping position are at a higher risk of SIDS (Li et al., 2003). This ethnically diverse, population-based, case-controlled study was conducted in 11 counties in California. The health message from this research is that babies should be on their backs for all sleep, including naps.

Exposure to Smoke
Researchers have concluded that if a mother smokes during or after pregnancy, she is placing her infant at a greater risk for SIDS (AAP, 2000). Some studies suggest that exposure of the newborn to tobacco smoke (whether or not the mother smokes) may be associated with increased risk for SIDS. In a 1997 policy statement, AAP cautioned, “Exposure of children to environmental tobacco smoke is associated with increased rates of lower respiratory illness and increased rates of middle ear effusion, asthma, and SIDS” (AAP 1997).

Overheating
According to AAP (2000), some evidence points to an association of the amount of clothing or blankets on an infant, room temperature, and the time of the year with an increased risk for SIDS. The increased risk associated with overheating is particularly clear when infants are placed on their stomachs (prone).

AAP cautions that the possible relationship between clothing and climate as stand-alone factors (or as a cluster of environmental risk factors) is less clear. Moreover, although the number of recorded SIDS deaths has been higher in the winter months, that increase may be due to the greater frequency of colds, flu, and other infections during the winter.

Infant Bedding
Researchers and consumer safety advocates continue to look for a possible link between SIDS and soft bedding (Scheers, Dayton, and Kemp, 1998). During 2000, seven major retailers joined with the U.S. Consumer Product Safety Commission (CPSC) to kick off a nationwide campaign promoting safe bedding practices for infants. Many retailers are developing public service campaigns to spread this message to parents and other infant caregivers.

The hope is that by circulating this information, infant deaths will be reduced and that those responsible for infant care will receive one consistent message about ensuring a safe sleeping environment for babies.

In recent safety alerts, CPSC has warned parents to guard against unfounded claims from manufacturers of some infant bedding materials that the use of certain products can reduce SIDS. Parents and other caregivers need to be aware that there is no product currently available that can guarantee prevention of a SIDS death.

Other Risk Factors
Although sleep position, smoke exposure, overheating, and infant bedding have been identified as risk factors for SIDS, researchers have identified a number of other factors that may put an infant at increased risk for SIDS.

Infant Care Practices and SIDS Risk Reduction
Several studies have examined various environmental influences or child-rearing practices that may help protect an infant from SIDS (Valdes-Dapena, 1995; Hoffman et al., 1996; NICHD, 2000). It is important to point out, however, that these factors, in and of themselves, are not reliable in predicting how, when, why, or if SIDS will occur.

For example, although researchers conclude that breastfeeding is beneficial, there is no clear-cut link between breastfeeding and reduced risk of SIDS. Other studies have found a lower rate of SIDS among infants who used pacifiers compared with infants who did not use pacifiers. Although results of these studies tend to be consistent, there is still no evidence that pacifier use prevents SIDS (AAP, 2000).

Maternal Risk Factors
Still other risk factors, called maternal risk factors, are associated with how the mother’s behavior and health affect the infant before and after birth.

Maternal risk factors include:

• age less than 20 at first pregnancy
• a short interval between pregnancies
• late or no prenatal care
• smoking during and/or after pregnancy
• placental abnormalities
• low weight gain during pregnancy
• anemia
• alcohol and substance abuse
• history of sexually transmitted disease or urinary tract infection (NICHD, 2001).

How to Lower Your Baby’s Risk of SIDS:

• Back Sleeping and Safe Bedding*
• make sure that everyone who cares for your baby puts the baby on his or her back to sleep
• use a firm, tight-fitting mattress in a crib that meets current safety standards
• remove pillows, quilts, comforters, sheepskins, stuffed toys, and other soft products from the crib
• dress your baby in sleep clothing so that you will not have to use any other covering over the baby
• place your baby so that his or her feet are at the bottom of the crib
• tuck a thin blanket around the bottom of the crib mattress, reaching only as far as the baby’s chest
• make sure the baby’s head remains uncovered during sleep
• keep your baby warm, but not too warm
• make sure that everyone who cares for your baby understands the dangers of soft bedding
• avoid adult beds, waterbeds, sofas, or other soft surfaces for sleep

*from AAP, CPSC, and NICHD AAP: www.aap.org CPSC: www.cpsc.gov NICHD: www.nichd.nih.gov

Current Research Findings and Theories
Most scientists now believe that babies who die of SIDS are born with one or more conditions that make them especially vulnerable to the internal and external stresses that occur in the life of any infant. Currently, many researchers argue that the clue to finding the cause(s) of SIDS lies in a further understanding of the development and functions of the brain and nervous system of SIDS infants.

These scientists theorize that some babies at risk for SIDS have defects in those parts of the nervous system that control breathing and heart rate. Maturation of the brainstem may be delayed in SIDS infants. Myelin, a fatty substance that facilitates nerve signal transmission, appears to develop more slowly in SIDS infants than in other babies.

“The detection of subtle abnormalities in SIDS brains indicates that not all SIDS infants are ‘normal’ despite their lack of clinical abnormalities. The occurrence of brain abnormalities supports the concept that a vulnerable, and not a normal, infant is at risk for SIDS. The idea of a vulnerable infant forms a key part of a triple-risk model for the pathogenesis of SIDS” (Filiano and Kinney, 1994).

The Triple-Risk Model
Pathology studies of SIDS infants support the view that these infants possess underlying vulnerabilities that put them at risk for sudden death, a concept advanced by the triple-risk model in describing the sequence of events leading to the death of an infant. A number of scientists are currently applying this model in their search for a cause(s) of SIDS.

Vulnerable Infant
The first key element of the triple-risk model depicts an infant with an underlying defect or abnormality, which makes the baby vulnerable. In this model, certain pathophysiological factors (e.g., defects in the parts of the brain that control respiration or heart rate, and that occur during early life) explain vulnerability to sudden infant death.

Adapted from Filiano and Kinney 1994.

Critical Developmental Period
The second element in the triple-risk model refers to the infant’s first 6 months of life. During this critical developmental period, rapid growth phases occur and changes in homeostatic controls take place. These changes may be evident (e.g., sleeping and waking patterns), or they may be more subtle (e.g., variations in breathing, heart rate, blood pressure, and body temperature). It may be that some of these changes may temporarily or periodically destabilize the infant’s internal systems.

Outside Stressor(s)
The third element of this model involves outside stressors. These may include environmental factors (e.g., exposure to tobacco smoke, overheating, or prone sleep position) or an upper respiratory infection that most babies can experience and survive, but that an already-vulnerable infant may not be able to overcome. In and of themselves, these stressors do not cause infant deaths, but in a vulnerable infant, “may tip the balance against an infant’s chances of survival” (Filiano and Kinney, 1994).

According to this model, all three elements must interact for a sudden infant death to occur-the baby’s vulnerability is undetected until the infant enters the critical developmental period and is exposed to an outside stressor or stressors.

Brain Abnormalities in SIDS Infants
A team of researchers funded by the National Institute of Child Health and Human Development (NICHD) has discovered that infants who die of SIDS may have abnormalities in several parts of the brainstem. This finding builds on the results of an earlier study that identified abnormalities in the region of the brain known as the arcuate nucleus in babies who died of SIDS.

“These findings show that SIDS infants have a more global biological deficit than we previously believed -one that may originate in fetal life,” explained Marian Willinger, Ph.D., of NICHD’s Pregnancy and Perinatology Branch, in a May 2000 press release. In the NICHD study, SIDS infants were found to have decreased binding of serotonin in the nucleus raphe obscurus, a brain structure linked to the arcuate nucleus, as well as four other brain regions. These areas of the brain are thought to play a crucial role in regulating breathing, heart beat, body temperature, and arousal (Panigrahy et al., 2000).

Back to Sleep Campaign
Since its inception in 1994, the Back to Sleep campaign has focused on heightening awareness among parents, health care providers, and other caregivers about the benefits of putting a baby to sleep on his or her back. Over the course of the campaign, almost 80 million brochures, posters, public service announcements, and informational videos have been distributed. The Back to Sleep campaign continues as a nationwide public health effort, with NICHD having major responsibility for disseminating information and educational materials on this crucial health topic.

Back in 1994 when the Back to Sleep campaign was first initiated, there were almost twice as many SIDS deaths among African-American infants than among White infants. Despite the almost 50 percent drop in the number of SIDS deaths in both groups, a significant disparity still exists (NICHD, 2002). To continue efforts to reach minority and hard-to-reach populations about the importance of placing an infant on its back to sleep, NICHD has partnered with community groups to provide outreach to minority and underserved communities.

SIDS Deaths in Child Care Settings
Twenty percent of SIDS deaths occur in a day care setting (Moon, Patel, and Shaefer, 2000). Although media and mailings have been largely effective in communicating BTS information to many child care centers, nonprone positioning and other risk reduction measures are not universally practiced among child care providers (Moon and Biliter, 2000). To promote these messages in child care settings, the Health Resources and Services Administration’s Maternal and Child Health Bureau is sponsoring the Healthy Child Care America Back to Sleep campaign. The campaign, which was officially launched in January 2003, is a nationwide effort to unite child care, health, and SIDS prevention partners to reduce the risk of deaths in child care settings (AAP, 2003).

Over the past 9 years, the Back to Sleep campaign has been extremely effective in helping reduce the number of SIDS deaths. AAP cautions, however, that while continuing to emphasize the “importance of infant positioning for sleep as an effective modifiable risk factor for SIDS,” it is also important to “focus increased attention on other modifiable environmental factors, to describe complications that may have arisen from modifying risk factors, and to make recommendations about other strategies that may be effective for further reducing the risk of SIDS” (AAP, 2000).

Partners in the Back to Sleep Campaign Outreach to Underserved Populations
Alpha Kappa Alpha Sorority
Chi Eta Phi Sorority
Chicago Department of Public Health
Congress of National Black Churches
District of Columbia Department of Public Health
National Association for the Advancement of Colored People
National Black Child Health Development Institute
National Coalition of 100 Black Women
National Medical Association
National Association of Black Owned Broadcasters
Pampers Parenting Institute
Zeta Phi Beta Sorority
Acknowledgments
Review panel members

Michael Corwin, M.D.
Co-Director
Massachusetts Center for Sudden Infant Death Syndrome

Anne Harvieux, C.I.C.S.W.
Program Administrator
Infant Death Center of Wisconsin

Jeffrey Jentzen, M.D.
Medical Examiner, Milwaukee County, Milwaukee, WI

John Leggatt, M.D.
Deputy Chief Medical Examiner, Milwaukee City, Milwaukee, WI

Mary McClain, R.N., M.S.
Massachusetts Center for Sudden Infant Death Syndrome

Marian Willinger, Ph.D.
Special Assistant for SIDS
National Institute of Child Health and Human Development

For Additional Information on SIDS and Infant Death, and for a List of State SIDS Coordinators, Please Contact:

National SIDS/Infant Death Resource Center (NSIDRC)
8280 Greensboro Drive
Suite 300
McLean, VA 22102
Phone: (866) 866-7437, (703) 821-8955
Fax: (703) 821-2098
E-mail: sids@circlesolutions.com
www.sidscenter.org

Other SIDS Resources
American Academy of Pediatrics (AAP)
The best way to contact the AAP is to access the Academy’s Web site: www.aap.org. To locate news releases and policy statements, search the site using “SIDS” as keyword.

Association of SIDS and Infant Mortality Programs (ASIP)
c/o Marie Chandick, ASIP President
New York State Center for Sudden Infant Death
School of Social Welfare/Stony Brook University
Stony Brook, NY 11794-8232
Phone: (631) 444-3690
Fax: (631) 444-6475
E-mail: marie.chandick@stonybrook.edu
www.asip1.org

C.J. Foundation for SIDS
Barry Bornstein, Executive Director
The Don Imus-WFAN Pediatric Center
Hackensack University Medical Center
30 Prospect Avenue
Hackensack, NJ 07601
Phone: (201) 996-5111, 1-888-8CJ-SIDS
Fax: (201) 996-5326
E-mail: barrycjf@aol.com
www.cjsids.com

First Candle/SIDS Alliance
1314 Bedford Avenue
Suite 210
Baltimore, MD 21208
Phone: (800) 221-7437, (410) 653-8226
Fax: (410) 653-8709
E-mail: info@sidsalliance.org
www.sidsalliance.org

National Center for Cultural Competence (NCCC)
SIDS/ID Component
Georgetown University Center for Child and Human Development
3307 M Street NW
Suite 401
Washington, DC 20007-3935
Phone: (800) 788-2066, (202) 687-5387
Fax: (202) 687-8899
E-mail: cultural@georgetown.edu
www.georgetown.edu/research/gucdc/nccc

National SIDS and Infant Death Program Support Center
Kathleen Graham, Director
1314 Bedford Avenue
Suite 210
Baltimore, MD 21208
Phone: (410) 415-6628, (800) 638-7437
Fax: (410) 415-5093
E-mail: kgrahamsids@yahoo.com
www.sids-id-psc.org

National SIDS and Infant Death Project IMPACT
8280 Greensboro Drive
Suite 300
McLean, VA 22102
Phone: (703) 902-1260, (800) 930-7437
Fax: (703) 902-1320
E-mail: lcooper@sidsprojectimpact.com
www.sidsprojectimpact.com

U.S. Consumer Product Safety Commission
4330 East-West Highway
Bethesda, MD 20814-4408
Phone: (800) 638-2772
(Consumer Hotline: Call toll-free to obtain product safety information and to report unsafe products.)
Fax: (301) 504-0124
E-mail: info@cpsc.gov
www.cpsc.gov

Contact Information for the Back to Sleep Campaign
The National Institute of Child Health and Human Development
Back to Sleep Campaign
31 Center Drive, Room 2A32
Bethesda, MD 20892-2425
Public Information: (301) 496-5133
Fax: (301) 496-7101
www.nichd.nih.gov
To order campaign materials, call toll-free: 1-800-505-CRIB

References
American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. “Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position.” Pediatrics 2000 March; 105 (No.3):650-6.

American Academy of Pediatrics, Healthy Child Care Back to Sleep Campaign, 2003. www.healthychildcare.org.

Arnold, J., McClain, M.E., and Shaefer, S.J.M. “Reaching Out to the Family of a SIDS Baby.” In: Woods, J.R., and Woods, J.L.E. (Eds.). Loss During Pregnancy or in the Newborn Period: Principles of Care with Clinical Cases and Analysis. Pitman (NJ): Jannetti Publications, Inc., 1997.

Centers for Disease Control and Prevention. “Guidelines for Death Scene Investigation of Sudden, Unexplained Infant Deaths: Recommendations of the Interagency Panel on Sudden Infant Death Syndrome.” Morbidity and Mortality Weekly Report 1996; 45 (No. RR-10).

Corr, C.A., Fuller, H., Barnickol, C.A., and Corr, D.M. (Eds.). Sudden Infant Death Syndrome: Who Can Help and How. New York: Springer Publishing Co., 1991.

Filiano, J.J., and Kinney, H.C. “A Perspective on Neuropathologic Findings in Infants of the Sudden Infant Death Syndrome: The Triple Risk Model.” Biology of the Neonate 1994; 65(3-4):194-7.

Hauck, F.R., Moore, C.M., Herman, S.M., Donovan, M., Kalelkar, M., Christoffel, K.K., Hoffman, H.J., and Rowley, D. “The Contribution of Prone Sleeping Position to the Racial Disparity in Sudden Infant Death Syndrome: The Chicago Infant Mortality Study.” Pediatrics 2002 Oct; 110(4):772-80.

Hauck, F.R., Herman, S.M., Donovan, M., Iyasu, S., Moore, C.M., Donoghue, E., Kirschner, R.H., and Willinger, M. “Sleep Environment and the Risk of Sudden Infant Death Syndrome in an Urban Population: The Chicago Infant Mortality Study.” Pediatrics 2003; 111(5), 1207-1214.

Hoffman, H.J., Damus, K., Hillman, L., and Krongrad, E. “Risk Factors for SIDS. Results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study.” In: Schwartz, P.J., Southall, D.P., and Valdes-Dapena, M. (Eds). The Sudden Infant Death Syndrome: Cardiac and Respiratory Mechanisms and Interventions. New York: New York Academy of Sciences, 1988.

Hoffman, H.J., Willinger, M., Gloeckner, C., Wu, K-T., and Hillman, L.S. “Risk Factors by Race/Ethnicity in the National Institute of Child Health and Human Development (NICHD) SIDS Cooperative Epidemiological Study.” Paper presented at the Fourth SIDS International Conference, June 23-26, 1996.

Li, D.K., Petitti, D.B., Willinger, M., McMahon, R., Odouli, R., Vu, H., and Hoffman, H.J. “Infant Sleeping Position and the Risk of Sudden Infant Death Syndrome in California, 1997-2000.” American Journal of Epidemiology 2003 March 1; 157(5):446-55.

Mathews, T.J., Menacker, F., and MacDorman, M.F. “Infant Mortality Statistics from the 2001 Period Linked Birth/Infant Death Data Set.” National Vital Statistics Reports September 15, 2003; 52(2).

Moon, R.Y., and Biliter, W.M. “Infant Sleep Position Policies in Licensed Child Care Centers after Back to Sleep Campaign.” Pediatrics 2000; 106:576-580.

Moon, R.Y., Patel, K.M., and Shaefer, S.J.M. “Sudden Infant Death Syndrome (SIDS) in Child Care Settings.” Pediatrics 2000; 106 (2) 295-300.

National Institute of Child Health and Human Development, National Institutes of Health. From Cells to Selves. Targeting Sudden Infant Death Syndrome (SIDS): A Strategic Plan. Bethesda (MD): National Institute of Child Health and Human Development, 2001.

National Institute of Child Health and Human Development, National Institutes of Health. NICHD-funded Researchers Uncover Abnormal Brain Pathways in SIDS Victims. News Release. Rockville (MD): May 14, 2000.

National Institute of Child Health and Human Development, National Institutes of Health, Public Information and Communications Branch. Sudden Infant Death Syndrome. Bethesda (MD): National Institute of Child Health and Human Development, 1997.

Panigrahy, A., Filiano, J., Sleeper, L.A., Mandell, F., Valdes-Dapena, M., et al. “Decreased Serotonergic Receptor Binding in Rhombic Lip-Derived Regions of the Medulla Oblongata in the Sudden Infant Death Syndrome.” Journal of Neuropathology and Experimental Neurology 2000 May; 59(5): 377-84.

Scheers, N.J., Dayton, C.M. Kemp, J.S. “Sudden Infant Death with External Airways Covered.” Archives of Pediatric Adolescent Medicine 1998; 152:540-547.

U.S. Consumer Product Safety Commission, Office of Information and Public Affairs. Recommendations Revised to Prevent Infant Deaths from Soft Bedding. News Release #99-091. Washington, DC. April 8, 1999.

U.S. Consumer Product Safety Commission, Office of Information and Public Affairs. Retailers Join CPSC in Promoting Safe Bedding Practices for Babies-Each Year 900 SIDS Deaths May be Caused by Soft Bedding. News Release #00-078. Washington, DC. March 14, 2000.

Willinger, M., Hoffman, H.J., Wu, K-T., et al. “Factors Associated with the Transition to Nonprone Sleep Positions of Infants in the United States: The National Infant Sleep Position Study.” Journal of the American Medical Association 1998; 280:329-335.

Willinger, M., James, L.S., and Catz, C. “Defining the Sudden Infant Death Syndrome (SIDS): Deliberations of an Expert Panel Convened by the National Institute of Child Health and Human Development.” Pediatric Pathology September-October 1991; 11(5): 677-84.

Valdes-Dapena, M. “The Postmortem Examination.” Pediatric Annals 1995 July; 24(7): 365-372.

by Cori Young

A growing body of scientific evidence shows that the way babies are cared for by their mothers will determine not only their emotional development, but the biological development of the child’s brain and central nervous system as well. The nature of love, and how the capacity to love develops, has become the subject of scientific study over the last decade. New data is emerging from a multitude of disciplines including neurology, psychology, biology, ethology, anthropology and neurocardiology. Something scientific disciplines find in common when putting love under the microscope is that in addition to shaping the brains of infants, mother’s love acts as a template for love itself and has far reaching effects on her child’s ability to love throughout life.

To mothers holding their newborn babies it will come as little surprise that the ‘decade of the brain’ has lead science to the wisdom of the mother’s heart.

According to Alan Schore, assistant clinical professor in the department of psychiatry and biobehavioral sciences at UCLA School of Medicine, a major conclusion of the last decade of developmental neuroscience research is that the infant brain is designed to be molded by the environment it encounters.1 In other words, babies are born with a certain set of genetics, but they must be activated by early experience and interaction. Schore believes the most crucial component of these earliest interactions is the primary caregiver – the mother. “The child’s first relationship, the one with the mother, acts as a template, as it permanently molds the individual’s capacities to enter into all later emotional relationships.” Others agree. The first months of an infant’s life constitute what is known as a critical period – a time when events are imprinted in the nervous system.

“Hugs and kisses during these critical periods make those neurons grow and connect properly with other neurons.” Says Dr. Arthur Janov, in his book Biology of Love. “You can kiss that brain into maturity.”

Hormones, The Language of Love
In his beautiful book, The Scientification of Love, French obstetrician Michel Odent explains how Oxytocin, a hormone released by the pituitary gland stimulates the release of chemical messengers in the heart. Oxytocin, which is essential during birth, stimulating contractions, and during lactation, stimulating the ‘milk ejection reflex’, is also involved in other ‘loving behaviors’. “It is noticeable that whatever the facet of love we consider, oxytocin is involved.’ Says Odent. “During intercourse both partners – female and male – release oxytocin.” One study even shows that the simple act of sharing a meal with other people increases our levels of this ‘love hormone’.2

The altruistic oxytocin is part of a complex hormonal balance. A sudden release of Oxytocin creates an urge toward loving which can be directed in different ways depending on the presence of other hormones, which is why there are different types of love. For example, with a high level of prolactin, a well-known mothering hormone, the urge to love is directed toward babies.

While Oxytocin is an altruistic hormone and prolactin a mothering hormone, endorphins represent our ‘reward system’. “Each time we mammals do something that benefits the survival of the species, we are rewarded by the secretion of these morphine-like substances.” Says Odent.

During birth there is also an increase in the level of endorphins in the fetus so that in the moments following birth both mother and baby are under the effects of opiates. The role of these hormones is to encourage dependency, which ensures a strong attachment between mother and infant. In situations of failed affectional bonding between mother and baby there will be a deficiency of the appropriate hormones, which could leave a child susceptible to substance abuse in later life as the system continually attempts to right itself.3 You can say no to drugs, but not to neurobiology. Human brains have evolved from earlier mammals. The first portion of our brain that evolved on top of its reptilian heritage is the limbic system, the seat of emotion. It is this portion of the brain that permits mothers and their babies to bond. Mothers and babies are hardwired for the experience of togetherness. The habits of breastfeeding, co-sleeping, and babywearing practiced by the majority of! mothers in non-industrialized cultures, and more and more in our own, facilitate two of the main components needed for optimal mother/child bonding: proximity and touch.

PROXIMITY, Between Mammals, the Nature of Love is Heart to Heart
In many ways it’s obvious why a helpless newborn would require continuous close proximity to a caregiver; they’re helpless and unable to provide for themselves. But science is unveiling other less obvious benefits of holding baby close. Mother/child bonding isn’t just for brains, but is also an affair of the heart. In his 1992 work, Evolution’s End, Joseph Chilton Pearce describes the dual role of the heart cell, saying that it not only contracts and expands rhythmically to pump blood, it communicates with its fellow cells. “If you isolate a cell from the heart, keep it alive and examine it through a microscope, you will see it lose it’s synchronous rhythm and begin to fibrillate until it dies. If you put another isolated heart cell on that microscopic slide it will also fibrillate . If you move the two cells within a certain proximity, however , they synchronize and beat in unison.” Perhaps this is why most mothers instinctively place their babies to their left breast, keep! ing those hearts in proximity. The heart produces the hormone, ANF that dramatically affects every major system of the body. “All evidence indicates that the mother’s developed heart stimulates the newborn heart, thereby activating a dialogue between the infant’s brain-mind and heart.” says Pearce who believes this heart to heart communication activates intelligences in the mother also. “On holding her infant in the left-breast position with its corresponding heart contact, a major block of dormant intelligences is activated in the mother, causing precise shifts of brain function and permanent behavior changes.” In this beautiful dynamic the infant’s system is activated by being held closely; and this proximity also stimulates a new intelligence in the mother, which helps her to respond to and nurture her infant. Pretty nifty plan – and another good reason to aim for a natural birth. If nature is handing out intelligence to help us in our role as mothers we want to be awake ! and alert!

Touch
“The easiest and quickest way to induce depression and alienation in an infant or child is not to touch it, hold it, or carry it on your body.” – James W. Prescott, PhD

Research in neuroscience has shown that touch is necessary for human development and that a lack of touch damages not only individuals, but our whole society. Human touch and love is essential to health. A lack of stimulus and touch very early on causes the stress hormone, cortisol to be released which creates a toxic brain environment and can damage certain brain structures. According to James W. Prescott, PhD, of the Institute of Humanistic Science, and former research scientist at the National Institute of Child Health and Human Development, sensory deprivation results in behavioral abnormalities such as depression, impulse dyscontrol, violence, substance abuse, and in impaired immunological functioning in mother deprived infants.4 For over a million years babies have enjoyed almost constant in-arms contact with their mothers or other caregivers, usually members of an extended family, receiving constant touch for the first year or so of life. “In nature’s nativity scene, ! mother’s arms have always been baby’s bed, breakfast, transportation, even entertainment, and, for most of the world’s babies, they still are.” says developmental psychologist, Sharon Heller in, The Vital Touch: How Intimate Contact With Your Baby Leads to Happier, Healthier Development.5

To babies,touch = love and fully loved babies develop healthy brains. During the critical period of development following birth the infant brain is undergoing a massive growth of neural connections. Synaptic connections in the cortex continue to proliferate for about two years, when they peak. During this period one of the most crucial things to survival and healthy development is touch. All mammal mothers seem to know this instinctively, and, if allowed to bond successfully with their babies they will provide continuous loving touch.

Touch deprivation in infant monkeys is so traumatic their whole system goes haywire, with an increase of stress hormones, increased heart rate, compromised immune system and sleep disturbances.6

With only 25% of our adult brain size, we are the least mature at birth of any mammal. Anthropologist, Ashley Montagu concluded that given our upright position and large brains, human infants are born prematurely while our heads can still fit through the birth canal, and that brain development must therefore extend into postnatal life. He believed the human gestation period to actually be eighteen months long – nine in the womb and another nine outside it, and that touch is absolutely vital to this time of “exterogestation.”7

Newborns are born expecting to be held, handled, cuddled, rubbed, kissed, and maybe even licked! All mammals lick their newborns vigorously, off and on, during the first hours and days after birth in order to activate their sensory nerve endings, which are involved in motor movements, spatial, and visual orientation. These nerve endings cannot be activated until after birth due to the insulation of the watery womb environment and the coating of vernix casseus on the baby’s skin.

Recall Dr. Janov’s claim that you can kiss a brain into maturity. Janov believes that very early touch is central to developing a healthy brain. “Irrespective of the neurojuices involved, it is clear that lack of love changes the chemicals in the brain and can eventually change the structure of that brain.”

Breastfeeding: Liquid Love
Breastfeeding neatly brings together nourishment for baby with the need for closeness shared by mother and child; and is another crucial way that mother’s love helps shape baby’s brain. Research shows that breastmilk is the perfect “brain food”, essential for normal brain development, particularly, those brain processes associated with depression, violence, and social and sexual behaviors.8

Mother’s milk, a living liquid, contains just the right amount of fatty acids, lactose, water, and amino acids for human digestion, brain development, and growth. It also contains many immunities a baby needs in early life while her own immune system is maturing. One more instance of mother extending her own power, (love) to her developing child.

Limbic Regulation: The Loop of Love
Another key to understanding how a mother’s love shapes the emerging capacities of her infant is what doctors Thomas Lewis, Fari Amini, and Richard Lannon , authors of A General Theory of Love, call limbic regulation; a mutually synchronizing hormonal exchange between mother and child which serves to regulate vital rhythms.

Human physiology, they say, does not direct all of its own functions; it is interdependent. It must be steadied by the physical presence of another to maintain both physical and emotional health. “Limbic regulation mandates interdependence for social mammals of all ages.” says Lewis, “But young mammals are in special need of it’s guidance: their neural systems are not only immature but also growing and changing. One of the physiologic processes that limbic regulation directs, in other words, is the development of the brain itself – and that means attachment determines the ultimate nature of a child’s mind.” A baby’s physiology is maximally open-loop: without limbic regulation, vital rhythms collapse posing great danger, even death.

The regulatory information required by infants can alter hormone levels, cardiovascular function, sleep rhythms, immune function, and more. Lewis, et al contend that , the steady piston of mother’s heart along with the regularity of her breathing coordinate the ebb and flow of an infant’s young internal rhythms. They believe sleep to be an intricate brain rhythm which the neurally immature infant must first borrow from parents. “Although it sounds outlandish to some American ears, exposure to parents can keep a sleeping baby alive.”

The Myth of Independence
This interdependence mandated by limbic regulation is vital during infancy, but it’s also something we need throughout the rest of childhood and on into adulthood. In many ways, humans cannot be stable on their own-we require others to survive. Recall that our nervous systems are not self-contained; they link with those of the people close to us in a silent rhythm that helps regulate our physiology. This is not a popular notion in a culture that values independence over interdependence. However, as a society that cherishes individual freedoms more than any other, we must respect the process whereby autonomy develops.

Children require ongoing neural synchrony from parents in order for their natural capacity for self-directedness to emerge. A mother’s love is a continuous shaping force throughout childhood and requires an adequate stage of dependency. The work of Mary Ainsworth has shown that maternal responsiveness and close bodily contact lead to the unfolding of self-reliance and self confidence.9 Because our culture does not sufficiently value interpersonal relationships, the mother/child bond is not recognized and supported as it could be.

The ability of a mother to read the emotional state of her child is older than our own species, and is essential to our survival, health and happiness. We are reminded of this each time a hurt child changes from sad/scared/angry to peaceful in our loving embrace. Warm human contact generates the internal release of opiates, making mother’s love a powerful anodyne. Even teenagers who sometimes behave as if they are ’so over’ the need for a mother’s affection must be kept in the limbic loop. Children at this age might be at special risk for falling through the emotional cracks. If they don’t get the emotional regulation that family relationships are designed to provide, their hungry brains may seek ineffectual substitutes like drugs and alcohol.

Children left too long under the electronic stewardship of television, video games, etc., are not receiving the steady limbic connection with a resonant parent. Without this a child cannot internalize emotional balance properly.

Our hearts and brains are hardwired for love, and from infancy to old age our health and happiness depend on receiving it.

As the research keeps coming in and we gain a gradually expanding vision of how mother love shapes our species, we see an obvious need to take steps to protect and provide for the mother/child bond. We can take heart knowing that all the while we carry in our genes over a million years of evolutionary refinements equipping us for our role as mothers. The answers sought by science beat steadily within our own hearts.

About The Author
Cori Young has been researching human development for nearly a decade, and is currently working on a book about birth and bonding. She is also an herbalist, and publisher of www.HerbalRemediesInfo.com
cori@herbalremediesinfo.com