"All truth passes through 3 phases: First, it is ridiculed. Second, it is violently opposed, and Third, it is accepted as self-evident."
Arthur Schopenhauer, 1788-1860
The goal of this website, www.sids2020.com, is to be part of the international effort to continually decrease the likelihood of infants succumbing to "crib death" or Sudden Infant Death Syndrome (SIDS) by the year 2020 as well as provide 20/20 insight into current knowledge about SIDS. The SIT TO SURVIVE ™ program is part of SIDS 2020 project. The contents of this website and recommendations are based upon the clinical findings and experience of licensed healthcare providers as well as historical precedent in Native American populations (unfortunately the rate of SIDS now in modern Native American populations is several times higher than the average rate in the USA since the introduction of cribs).
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During the last six months of 1981 and 1982, pathologists and county attorneys in Western Nebraska noted that 100% of Sudden Infant Death Syndrome (S.I.D.S.) deaths had a scene investigation revealing all deceased infants were found by their caregivers in the prone position. The pathologists immediately recommended the use of safe infant car seats to decrease the likelihood of the occurence of Sudden Infant Death Syndrome (S.I.D.S.) in Western Nebraska. Safe infant care seats, used at all times and during all circumstances, when infants less than one year old are sleeping prevent the infant from rolling over into the prone position. The SIT TO SURVIVE ™ benefits were apparently understood, in yesteryears, by Native American Indians of many tribes who used papooses and cradle boards that position infants into the reverse Trendelenburg (head higher than torso; stomach contents below the level of the pharynx) position enabling maximal infant airway patency and decreases the likelihood of airway obstruction or irritation by gastric contents or water because the head and upper airways are higher than the stomach in the reverse Trendelenburg position.....gravity helps keep stomach contents in the stomach (and minimal pressure of a full stomach upon the overlying diaphragm...restriction of diaphragm movement may cause hypoxemia) as well as gravity vectors do not allow infants' faces covered with sheets or blankets to completely block the nose and mouth of infants. In the supine position, the head, upper airways and stomach are all on the same level and it is very easy for stomach contents to compromise the very small airways of the infant. Parents are often anxious their infants will choke on their food or stomach contents when their infants are in the "Back to Sleep" supine position (and hence they have their infants sleep prone or face down) or their infants will be uncomfortable in the supine position. Discussions with parents have led the author to believe parents are less worried about uncomfortableness and choking when infants are in the reverse Trendelenburg position.
Navajo Indian infant in reverse Trendelenburg position
Sudden Infant Death Syndrome is the sudden death of an infant under one year of age, which is unexpected by history, and remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and a review of the clinical history, all of which fails to demonstrate an adequate cause of death. Sudden Infant Death Syndrome is virtually unheard of in China. Chinese infants are placed on their backs to sleep. In the late 1980s, clinicians in Britain, New Zealand and other countries suggested that placing infants in a supine position or on their sides decreased the occurence of S.I.D.S. In the mid 1990s, the American Academy of Pediatrics and the U.S. Public Health Service launched the "Back to Sleep" program which revealed a 30% decline in infant deaths due to S.I.D.S. between October, 1993 and October, 1995. In subsequent years, the American Academy of Pediatrics removed its initial recommendations to have infants sleep on their sides because some infants rolled onto their abdomens and were at increased risk for S.I.D.S. Despite persistent efforts, to date, and apparently for no good reason not to, there has been no recommendation for infants positions to be more structured into the reverse Trendeleburg position to decrease the likelihood of S.I.D.S. In the opinion of the author, the BACK TO SLEEP ® program should be modified to include a more stable reverse Trendelenburg position in an infant car seat or other safe recliner.
Apache Indian infants in reverse Trendelenburg positions
Recently, several life threatening respiratory events (alone or in combination) have been postulated to initiate the chain of cataclysmic events resulting in a SIDS death. These events are: (1) rebreathing of exhaled gases that are low in oxygen and high in carbon dioxide content when the infant is in the face down/belly down (prone position) or its face is covered (sheets, blankets, etc.) when the infant is in the face up/lying flat on the back (supine) position, (2) apnea, swallowing and a possible spastic reflex with closure of the larynx ("voice box") due to chemical irritation from water or stomach contents refluxing back into the upper esophagus and into the upper airways. The larynx may reflexly close to protect the lungs from chemical damage and (3) regurgitation of semi-solid food contents from the stomach into the upper airways with physical obstruction of the airways. The SIT TO SURVIVE ™ program is an international effort to have infants less than 12 months of age sleep in infant car seat or other safe recliners that position the infant in the reverse Trendelenburg position with the head higher than the pelvis at an angle of 45 degrees. The program may help to decrease the rate of SIDS as well as help protect infants while they ride in cars or other forms of transportation.The reverse Trendelenburg position optimally opens all human airways, regardless of age, and decreases the likelihood of gastroesophageal reflux or aspiration of gastric contents into the airways.
There appears to be several potential problems associated with simply placing infants in a supine position for sleep. First, due to gravity vectors, the tongue falls backwards and potentially blocks the pharynx and upper airways. Regurgitated gastric contents, water, and ingested food are not as easily expelled and may be aspirated into the lungs due to possible tongue obstruction even when the infant is awake. Second, as infants attain six months of age, infants may easily roll to the prone position. Therefore, despite the partial success of the "Back to Sleep" program, some healthcare providers believe the placing of otherwise healthy infants in a high quality safe infant car seat still has significant advantages because (1) experience has shown that infants who sleep from a young age in infant car seats do not roll to the prone position during sleep even up to one year of age (2) infant car seats position infants not only on their backs but in a reverse Trendelenburg position which better opens their airways, displaces the tongue from the airways, and decreases the likelihood of gastroesophageal reflux or pulmonary aspiration, (3) parents who use infant car seats for infant sleeping are more likely to use infant car seats for infant sleeping in non-home settings and in automobiles while traveling which decreases morbidity and mortality of infants due to motor vehicle accidents, and (4) infant car seats may decrease the potential occurence of severe forms of post-delivery Occipital plagiocephaly ("flat head" ) which occurs in infants who always sleep or placed in the supine position as recommended by the "Back to Sleep" program. When infants are awake, abundant "tummy time" with the infant prone on a caregiver's abdomen helps prevent plagiocephaly.
In plagiocephaly, the skull flattens by one year of age and the infant's posterior head is flat from the nape of the neck to the top of the skull. Infants with plagiocephaly may need to wear a "Dynamic Orthotic Cranioplasty" head band. Plagiocephaly should not be confused with craniosynostosis. The use of completely noncluttered, large SAFE firm bedding in large playpens (no cribs are really needed anywhere at all) as the primary sleeping areas for infants is recommended. The large safe playpens allow ample room for the infant to manuever, on firm bedding, in the unlikely event infants "buck out" of the infant car seats while crying or irritable and decreases the likelihood of the infant becoming wedged between the side of the playpen and the infant car seat. Such wedging has been a cause of death in cribs and bassinets.
Copyright, 1983-2016. Byron L. Barksdale, M.D. All rights reserved worldwide.