June 2001 // Volume 39 // Number 3 // Feature Articles // 3FEA8

Previous Article Issue Contents Previous Article

Extending Our Reach: Strategic Opportunities for Cooperative Extension to Promote Infant Health Through Sudden Infant Death Syndrome Preventative Education

Sudden Infant Death Syndrome (SIDS) remains one of the deadliest health risks for infants up to age 1 year, claiming nearly 5,000 lives annually. The number of SIDS cases has decreased in the last decade due to nationwide efforts to educate the public about guidelines for reducing the risk of SIDS; however, evidence indicates that certain segments of the population are failing to implement these guidelines, which include placing infants to sleep on their backs. This article offers specific suggestions on how Extension is ideally suited to influence education, intervention, and public policy efforts aimed at reducing the incidence of SIDS.

Linda A. Jouridine
Assistant Professor and Extension Health Specialist
Internet Address: l-jouridine@tamu.edu

Stephen D. Green
Assistant Professor and Extension Child Development Specialist
Internet Address: s-green@tamu.edu

Texas Agricultural Extension Service
The Texas A&M University System
College Station, Texas


Sudden Infant Death Syndrome (SIDS) remains one of the nation's deadliest health risks for infants up to age 1 year. SIDS, also known as "crib death," is the sudden and unexplained death of an infant under 1 year of age. Nearly 5,000 infants die annually in the United States from SIDS.

According to the American Academy of Pediatrics, SIDS cases have decreased dramatically in the last decade (Pediatrics, 2000). The reduction is due in part to an aggressive "Back to Sleep" nationwide campaign launched in 1994 that encourages parents and child care providers to place children to sleep on their backs. Despite the reduction in SIDS cases, it remains one of the leading causes of infant death in the United States (Matthews, Curtin, & MacDorman, 2000).

While specific guidelines for preventing SIDS are widely available, studies suggest that certain segments of the population are failing to implement these guidelines due to cultural, ethnic, regional, and environmental factors (Gibson, Dembofsky, Rubin, & Greenspan, 2000). Moreover, evidence indicates that even when recommendations for preventing SIDS are practiced by primary care givers, others involved (e.g., relatives, neighbors, nannies, baby sitters) may not be aware of the dangers associated with not following the prescribed guidelines. These include placing children to sleep on their backs, avoiding soft bedding, maintaining a smoke-free environment, breastfeeding, and regular prenatal care (Willinger, Ko, Hoffman, Kessler, & Corwin, 2000).

In a retrospective study of 1,916 SIDS deaths in 11 geographically diverse states, Moon, Patel, and Shaefer (2000) discovered that SIDS deaths are disproportionately higher in child care settings than in the general population. Sixty percent of the reported deaths occurred in family child care homes, which are often unregulated and unmonitored by licensing agencies. Therefore, there is an increased likelihood that providers in informal child care settings will not be familiar with the "Back to Sleep" and other SIDS risk-reduction campaigns (SIDS Alliance, 2000). Given the above facts, it is critically important to think of SIDS as a major public policy issue that needs to be addressed at the local, state, and federal levels.

Extension's rich history of meeting the specific needs of traditionally underserved segments of the population suggests that it is uniquely formed to take on a leadership role in this endeavor. For a number of years, Extension has been committed to improving the quality of child care on a national level through the provision of educational programs and materials that address a wide array of child health and development issues. In addition, the organizational structure of the Cooperative Extension System, which employs qualified specialists, agents, and associates at land-grant institutions in all 50 states, is well suited to reach both rural and urban populations.

This article offers specific suggestions on how Extension can influence education, intervention, and public policy efforts aimed at reducing the incidence of SIDS.

Extension's Role in Reducing SIDS

While it is well documented that the educational campaign to inform the public about SIDS risk-reduction practices has been effective, there have been disturbing trends toward increasing deaths from SIDS in communities where the message is getting lost. Therefore, it is incumbent upon those organizations with the most direct impact on parents and on audiences that reach parents to communicate more effectively about the possibilities of risk for infants. Because Extension's reach often includes partners in the educational process, a concentrated effort could be made to fine-tune the SIDS reduction message beyond the general scope of public service announcements (PSAs) and pamphlets in clinics or physician's offices.

Studies demonstrate that infants are most vulnerable directly following the days that mark the end of maternity leave for the mother, and if they are African-American, low-income, cared for by an influential family member, and/or cared for by someone with no formal training in infant health and development. Many nationally recognized programs developed by Extension serve these populations through a variety of economic, nutrition, health and safety, family-life, and 4-H programs. The following recommendations are proposed with these audiences in mind.

Incorporate the SIDS Risk Reduction Message into Existing Programming

Rather than expending the effort to create a separate and distinct program that focuses exclusively on SIDS, one alternative strategy is to incorporate SIDS information into already existing educational trainings and materials. As previously stated, Extension programming covers a broad spectrum of subject matter related to child health and human development. The SIDS risk-reduction message can easily be incorporated into parenting workshops/trainings, maternal health and safety programs, and child care provider trainings.

Two examples illustrate this point. First, research suggests that breastfeeding infants can possibly reduce the risk of SIDS (Gordon, Saadi, MacKenzie, Molony, James, Weir, Busuttil, & Blackwell, 1999; McKenna, Mosko, & Richard, 1997). With this information in mind, Extension faculty can emphasize the importance of breastfeeding in parenting education and maternal health programs.

Second, studies also indicate that certain environmental hazards, such as exposure to tobacco smoke, can increase the risk of SIDS (Andres & Day, 2000; Dybing & Sanner, 1999; Wisborg, Kesmodel, Henriksen, Olsen, & Secher, 2000). Extension educators addressing environmental health issues can appropriately integrate this information into their curricula so that parents and child care providers understand the potential danger of exposing children to tobacco smoke.

Contact Qualified Agencies for SIDS Public Awareness Campaign Materials

SIDS public awareness campaign materials, such as camera-ready news releases, posters, videos, PSAs, and support group information, are readily available to agency representatives. The key point in this recommendation is that Extension faculty are very familiar with "best practices" associated with the acquisition and dissemination of information.

While not unique to Extension, collaboration with other organizations to reach a common goal is a hallmark of the Cooperative Extension Service. Moreover, county Extension faculty traditionally have access to the local leadership, which provides an avenue to promote public awareness campaigns. Materials from such campaigns can be modified by trained Extension personnel to fit the needs of a particular audience.

Involve the Local Media

Certain segments of the Extension audience may be difficult to reach with national media campaigns. This may be particularly true for rural audiences who, for various reasons, are unable or unwilling to access national media markets. In such cases, local media outlets (e.g., radio, television, newspapers) may provide a better avenue for reaching these audiences with educational information regarding SIDS.

Newspaper advertisements, television spots, and radio announcements can be used to advertise future trainings and workshops or to simply provide direct information to consumers about SIDS. Tapping into local media markets may be especially important for reaching informal child care providers, such as relatives, neighbors, friends, and family day home operators who may be unaware of the factors that place infants at a greater risk for SIDS.

Provide an Opportunity for People to Discuss Fears and Concerns

Recent studies suggest that a significant percentage of parents and child care providers are aware of the "Back to Sleep" guidelines; however, there is a reluctance on the part of some parents and providers to follow the recommendations (Gibson et al., 2000; Willinger, Ko, Hoffman, Kessler, & Corwin, 2000). Prior to 1992, when the American Academy of Pediatrics issued their statement encouraging parents and caregivers to place children to sleep on their backs, many parents were informed that placing children to sleep on their stomachs was a safe practice. One of the greatest fears expressed by many parents and caregivers is the possibility that infants will asphyxiate on their own vomit if placed on their backs while sleeping. It has also been discovered in interviews with parents and child care providers that many place their children on their stomachs simply because it is perceived to be a more comfortable position for the infant (Gibson et al., 2000).

A related, yet more difficult issue to contend with is the cultural and traditional factors that influence parents' and caregivers' decisions to not follow the suggested guidelines for reducing the risk of SIDS. For example, some family members are very reluctant to go against the practices of their extended family. It may be perceived as disrespectful to contradict the advice of an esteemed relative who may be providing primary care for the family member's children.

One recommendation for Extension educators who address the issue of SIDS is that they involve pediatricians and physicians in their programming efforts. A pediatrician could be invited to talk about proper sleep positions and other SIDS risk factors, as well as field questions from the audience regarding their fears and concerns.

The role of the Extension educator could be to facilitate this discussion. In a study that analyzed data from the National Infant Sleep Position Study, Willinger et al. (2000) discovered that the strongest influence on parents' and caregivers' choice to place children to sleep on their backs was physician recommendation. Allowing parents and child care providers to discuss their fears and concerns with well respected professionals may motivate parents to adopt SIDS risk-reduction practices.

General Recommendations for SIDS Education, Intervention, and Policy

Expand the Use of Information Technologies

Cooperative Extension is an organization with rich expertise in the field of technology and the incorporation of newer and improved technologies into existing programming efforts. In the new millennium, the competitive edge will be derived from the ability to make previously inaccessible information, accessible and user friendly. A myriad of excellent Web sites already exists with reliable maternal and child health, parenting, and infant and child care information. State and county administrative offices can provide links to these credible SIDS sites through their existing Extension homepages. This information should be made available to the general public through a variety of downloadable formats (e.g., PDF, Word, WordPerfect).

In some unique instances, it may be more feasible to use the technology of distance education. For instance, Extension could host a video satellite conference in conjunction with academic units/departments whose faculty have expertise in infant and child health and safety. While Internet usage is expanding rapidly, there remain audiences who do not have ready access to computers and the Internet. One solution is to make SIDS information available on compact disks and videos for use at local libraries, clinics, and county offices. (For a list of juried Web sites on this topic see the Appendix.)

Broaden 4-H Programs to Include SIDS Teaching and Learning Opportunities

The 4-H program is undoubtedly the largest organization geared toward youth leadership of its kind. A number of quality programs have been developed within this organization to help America's youth develop into healthy and productive citizens. One program offered by a number of states focuses on training youth to become babysitters. While variations in programming and curriculum can be found from state to state, most emphasize a basic set of child care provider skills. Programs such as these can be easily modified to include important information about SIDS and strategies for reducing the incidence in child care settings.

Incorporate Technical Subject Matter on SIDS into Volunteer Training

The success of Extension's Master Volunteer Programs is well documented. These award-winning programs have allowed millions to gain valuable knowledge in areas such as parenting, gardening, agriculture, money management, and food preservation. A unique feature of Extension is the ability to incorporate technical subject matter into a user-friendly curriculum designed to train people with various skill levels to teach others.

SIDS prevention education requires the learner to grasp knowledge of very specific risk-reduction practices. Volunteers could be aptly trained to disseminate information on the modifiable risk factors for SIDS, as well as to respond to questions and concerns raised about the AAP guidelines. The use of volunteers expands Extension's outreach capabilities by recruiting volunteers from populations that we are attempting to serve.

Target New Audiences

Research on SIDS prevention has provided tremendous insight into the influential roles of policy makers, pediatricians, nurses, grandparents, and/or influential family members on the caregivers' decision to follow the recommended guidelines regarding SIDS risk-reduction practices (Carroll & Siska, 1998). New audiences for Extension, such as those mentioned above, include those who might not appreciate the value of their influence on parents and child care providers' health and safety practices. Educational messages by Extension faculty should be designed to reach those with a possible role, no matter how small, in an infant's care.

This observation brings to light the awesome responsibility of the entire community in ensuring the health and safety of America's children. Focusing on influential individuals within local communities fits well with Extension's commitment to leadership and community development.

Modify National Initiatives to Include SIDS Education

The model for a national initiative to promote SIDS awareness and prevention among our nation's citizens exists through the Children, Youth, and Families at Risk (CYFAR) Initiative. Extension's response to the problems plaguing the healthy development and basic needs of children has been addressed by the marshalling of resources from land-grant institutions to support collaborations with organizations that cater to limited resource audiences.

The vision statement from the goals and philosophy of CYFAR states that it is committed "to a future where all children and youth live in families and communities which promote their positive development." The message of SIDS prevention is one that does not require an additional line-item budget or a request for funding. It is merely one that requires thoughtful and careful support to include SIDS awareness as a part of the national agenda for Cooperative State Research, Education, and Extension Service (CSREES) through USDA support.

Recognize and Promote SIDS as a Public Policy Issue

Policy decisions at the local, state, and federal levels can have a major influence on the lives of families. As an organization interested in the well-being of children and families, Extension has an opportunity to play a part in promoting infant health by educating policy makers about the scope and impact of SIDS on communities across the nation. Policies pertaining to child care and child health issues are of continuing interest to those directly responsible for constructing such policies. Extension's presence at the local, state, and federal levels makes it ideally suited to become actively involved in the dialog about policies that potentially lead to better outcomes for families.


While significant progress has been made in reducing the overall death rate from SIDS, it remains one of the leading causes of infant mortality in the United States. Based on large-scale studies conducted across the nation, it appears that certain segments of the population are failing to implement the recommended AAP guidelines regarding SIDS risk-reduction practices. Some populations are simply unaware of the guidelines, while others chose to ignore them because of cultural and traditional factors.

Whatever rationale is given for not implementing the guidelines, it is clear that increased efforts are needed to educate parents and child care providers on the dangers of not following the suggested practices. It should be made clear, however, that the intended audiences for SIDS risk-reduction activities are parents and providers with healthy infants whose doctors have not provided special medical recommendations (Lockridge, Taquino, & Knight, 1999). In some cases, physicians have offered alternative advice regarding sleep positions due to certain childhood illnesses and life-threatening conditions.

This article offers specific suggestions on how Extension can influence education, intervention, and public policy efforts aimed at reducing the incidence of SIDS. Based on its unique organization and history of providing high-quality, research-based information to consumers throughout the world, the Cooperative Extension Service is well suited to be a leader in the fight against SIDS.


Andres, R.L. & Day, M.C. (2000). Perinatal complications associated with maternal tobacco use. Semin Neonatol, 5, 231-241.

Carroll, J.L. & Siska, E.S. (1998). SIDS: Counseling parents to reduce the risk. Am Fam Physician, 58, 52.

Dybing, E., & Sanner, T. (1999). Passive smoking, sudden infant death syndrome (SIDS) and childhood infections. Hum Exp Toxicol, 18, 202-205.

Gibson E., Dembofsky C.A., Rubin S., & Greenspan J.S. (2000). Infant sleep position practices 2 years into the "back to sleep" campaign. Clin Pediatr (Phila), 39, 285-289.

Gordon, A.E., Saadi, A.T., MacKenzie, D.A., Molony, N., James, V.S., Weir, D.M., Busuttil, A., & Blackwell, C.C. (1999). The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): III. Detection of IgA antibodies in human milk that bind to bacterial toxins implicated in SIDS. FEMS Immunol Med Microbiol, 25, 175-182.

Lockridge, T., Taquino, L.T., & Knight, A. (1999). Back to sleep: Is there room in that crib for both AAP recommendations and developmentally supportive care? Neonatal Netw, 18, 29-33.

Matthews, T.J., Curtin, S.C., & MacDorman, M.F. (2000). Infant mortality statistics from the 1998 period linked birth/infant death data set. Natl Vital Stat Rep, 48, 1-25.

McKenna, J.J., Mosko, S.S., & Richard, C.A. (1997). Bedsharing promotes breastfeeding. Pediatrics, 100, 214-219.

Moon, R.Y., Patel, K.M., & Shaefer, S.J. (2000). Sudden infant death syndrome in child care settings. Pediatrics, 106, 295-300.

Pediatrics (2000). Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. American Academy of Pediatrics. Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics, 105, 650-656.

SIDS Alliance (2000). Disproportionately high rate of SIDS in family child care settings reported. Media Advisory, August 7, 2000 [)n-line]. Available: http://www.sidsalliance.org/

Willinger, M., Ko, C.W., Hoffman, H.J., Kessler, R.C., & Corwin, M.J. (2000). Factors associated with caregivers' choice of infant sleep position, 1994-1998: The national infant sleep position study. JAMA, 283, 2135-2142.

Wisborg, K., Kesmodel, U., Henriksen, T.B., Olsen, S.G., & Secher, N.J. (2000). A prospective study of smoking during pregnancy and SIDS. Arch Dis Child, 83, 203-206.

Appendix: Juried Web Sites with SIDS Information

American Academy of Pediatrics. www.aap.org

American SIDS Institute. www.sids.org

Association of SIDS and Infant Mortality Programs. www.asip1.org

Maternal and Child Health Bureau. www.mchb.hrsa.gov

National Institute of Child Health & Human Development. www.nichd.nih.gov

National SIDS and Infant Death Program Support Center. www.sids-id-psc.org

National Sudden Infant Death Syndrome Resource Center. www.circsol.com/SIDS

SIDS Alliance. www.sidsalliance.org

SIDS Network. www.sids-network.org