The unexpected death of an infant during sleep is still a challenge to our knowledge andpractice. The international scientific communityhas advanced a lot in the knowledge of itsmechanisms and the risk factors that should beavoided. However, after the major reduction inmortality rates following the first preventioncampaigns in the 1990s, no significant changeshave been observed since approximately2000. There has only been a mild reduction inthe number of cases diagnosed with suddenunexpected infant death, together with aslight increase in the number of suffocation orstrangulation diagnoses.¹

Although it could be said that records are deficient, that diagnoses are inaccurate, that thesetting of death is not thoroughly studied, andthat autopsies are uncommon, such shortcomingshave existed for many years, with subtledistinctions, and affect the accuracy of beforeand after values.

The triple-risk model, although not perfect like any simplified concept, allows for a schematicapproach to the problem and its current situation.

What do we know so far?

1. A vulnerable child exposed to anenvironmental risk factor during their firstyear of life may die during sleep due to afailure in the microarousal mechanism in thecase of asphyxia.

2. A vulnerable child is defined as a child withpoor intrauterine growth and development, with immature neurological connectionsin relation to the response to asphyxia. This is the case of children with chronicintrauterine hypoxia due to hypertension, placental insufficiency, exposure to tobacco, alcohol or illegal drugs, stress or a poorlycontrolled pregnancy, and also children withgenetic causes involving neurotransmissionmechanisms.

3. During the first year of life, neurodevelopmentand growth occur very fast, making theimportance of breastfeeding, health checkups, and a complete immunization schedulenoteworthy.

4. Risk factors include a prone sleeping position, the presence of loose or soft objects next to thechild, overheating, and exposure to tobacco, alcohol, and illegal drugs.

5. Some recommendations to reduce such riskshave been considered controversial, such aspacifier use, co-sleeping, sleep positioners ordevices for their use in the parents' bed.²

From theory to practice

The first question is why, although we are aware of this information, we have not been ableto reduce the mortality rate in recent years.

More controls are required during pregnancy so that children are born with fewervulnerabilities. However, in reality, an increasehas been observed in teenage pregnancy, drug, tobacco and alcohol use among youngwomen, the number of people in unfavorablesocioeconomic conditions, medically-assistedfertilization procedures for women with problemsto conceive and maintain a pregnancy, and manyother current realities that affect the differentstages of pregnancy.

Any effort made in favor of children's growth and development during their first year of life isnot only beneficial in relation to safe sleep butalso provides an opportunity for a healthy life, forexample, promoting and protecting breastfeeding, facilitating access to a complete immunizationschedule for all children, ensuring well-child carevisits and adequate disease control.³

Risk factors entail a problem, or rather, several problems. One is uncertainty. It is not alwayspossible to identify a vulnerable child. A healthy, term newborn infant may be vulnerable due togenetic causes, such as neurotransmitter synthesis, release or reuptake deficiency. For this reason, therecommendations on safe sleep are the same forall children.

Another aspect is the lack of knowledge among the health care team members. At thematernity ward, there are usually only a fewvulnerable children among normal newborninfants, but at the neonatal intensive care unit, practically every child is vulnerable.

Children born prematurely, with a low birth weight, with intrauterine growth restriction, genetic disorders or severe neonatal conditionsare clearly vulnerable. The families of thesechildren should receive training to providethem with a safe sleep environment, amongother aspects. This is the role of the healthcare team. Nurses spend a lot of time with thefamilies during hospitalization; they are the direct caregivers of newborn infants and become undisputed role models for parents. However, while some health care providers are unaware ofsafe sleep recommendations, others know thembut fail to implement them.⁴ The same thing couldbe said about the families.⁵

At this point, we need to question ourselves about what we could do in response to thesesituations.

The Global Action and Prioritisation of Sudden Infant Death (GAPS) project was aninternational consensus process set up in 2015 todefine research development priorities in orderto reduce the rate of sudden unexpected deathsin infancy.⁶

After three discussion panels, it was concluded that the following is necessary:

1. To better understand the biologicalmechanisms underlying sudden unexpectedinfant death and how environmental factorsinteract with such mechanisms at differentages and stages of maturation.

2. To ensure best practice data collection, management, and sharing.

3. To better identify the most vulnerablepopulations and have a more effectivecommunication of risks to the extent thatsocial and cultural factors affect the familychoice in sleep practices.

The American Academy of Pediatrics updated its recommendations for a safe sleep environmentin 2016 to include new evidence on skin-to-skincare for newborn infants, bedside and in-bedsleepers, sleeping on couches/armchairs andin sitting devices, and use of soft bedding after4 months of age.

Consistent with the new trends on how these recommendations should be conveyed, theemphasis was placed on encouraging an openand nonjudgmental conversation with familiesabout their sleep practices. The specific situationsof each family call for a customized message thatweighs the relative risks and benefits.⁷

We are now leaving behind an outright message and entering the process of shareddecision making, taking into considerationscientific evidence in a personal and familysetting that encompasses social, financial, andcultural aspects.⁸

All these aspects influence how each family looks after their children. Rigid mandates leadto a rift. An open communication consideringthe particular family's beliefs and conditions willallow to suggest the best way to reduce the riskwithin the scope of their possibilities.

Without a doubt, this is more time-consuming but the best possible way forward.