Information for Family Doctors and Health Visitors

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Definition of Cot Death

A Cot death is the sudden unexpected death of a baby who was previously well or suffering from an apparently minor ailment such as a cold or a gastric upset. If, after a thorough police investigation and post mortem examination, no adequate cause of death is found the death will be certified in one of the following ways: Sudden Infant Death Syndrome, Sudden Unexpected Death in Infancy, Unascertained or Undetermined. Different pathologists use different terminology but all such deaths are eventually classified in the annual Report of the Registrar General as Sudden Infant Death Syndrome (SIDS).

In the UK the term Cot Death is almost always used by the general public for sudden unexplained infant deaths and we have followed this practice for the purposes of this leaflet.

Incidence

During the last decade there has been a dramatic decrease in the incidence of Cot Death, from a rate of 2.5 per 1,000 livebirths in 1989 to a current rate of around 0.6 per 1,000 livebirths. Despite this decline Cot Death still accounts for the deaths of more children over one week of age than any other single cause.

A visit from the GP as soon possible after the death is greatly appreciated. He/she should avoid prescribing unnecessary sedation as this tends to delay the normal grief process and necessary expression of feelings. Parents may regret at a later point their inability to be fully involved. Short acting hypnotics to assist sleep may sometimes be appropriate. If the mother was breastfeeding, she will need advice on coping with continued lactation.

If the death is that of a twin, the remaining twin should be carefully checked and an apnoea monitor is often issued if the parents wish this. In most areas the baby is admitted to hospital for observation.

A visit from the Health Visitor soon after the death is also very important. He/she can check that the family has received a copy of the leaflet “Information for Bereaved Parents” (available from the Scottish Cot Death Trust), which will explain the legal procedures which follow a sudden death. Reassurance should be given to the parents that these procedures are routine and do not indicate that the family is under suspicion of wrongdoing. It is important to ensure that any hospital appointments for the baby have been cancelled and that, if the mother still has to attend for post-natal check-up, arrangement are made to ensure the minimum distress. The maternity unit where the baby was born should also be informed.

Parents often do not know what to tell their children. Research has shown that it is best to tell the truth – to explain that the baby has died and will not be coming back. Even if children are too young to understand the concept of the permanence of death, use of the proper words at this stage is important. Children may think that the baby’s death was their fault or be frightened to go to sleep. They need to be reassured that no-one is to blame and that Cot Death only happens to small babies. They also need reassurance that their parents, despite their grief, still love them.

It is now considered important that siblings should be given the chance to attend the funeral service, to say good-bye. Since parents may be too preoccupied with their own grief to cope with them, it is advisable to have another adult whom the children know and like to help look after them at the service.

Siblings often show regressive and difficult behaviour in the days after the baby’s death. This can be immensely stressful for the emotionally exhausted parents. They need reassurance that such behaviour is normal and that their own feelings of irritation are also normal.

The strong feeling of guilt experienced by parents needs to be alleviated. With present day knowledge no-one can either predict or prevent these tragic deaths and this should be clearly stated and emphasised.

In each Health Board Area there is a consultant paediatrician with a special interest in Cot Death who is willing to see parents and to discuss the post mortem results. Parents may ask about the risk of recurrence. There are no reliable statistics on this but the chances of another Cot Death in the family is very rare (perhaps 4-5 times the population rate of 0.6 per 1,000 livebirths) and should not deter families from having another child.

The parents’ initial state of shock and numbness may help them through the first few days or even weeks and they may give the impression that they are coping very well when, in fact, they may not have yet begun to face the reality of their baby’s death. This state is usually followed by a period of great anguish. Parents are often very frightened by their grief reactions. They describe difficulty in sleeping, nightmares, imagining hearing and seeing their baby, pain in the chest and arms, strong positive or negative sexual feelings, nausea and feelings of panic, fear and isolation. They need reassurance that all these are normal symptoms of grieving and that they will, in time, pass.

There may be loss of appetite, heavy drinking or smoking and some parents may have thoughts of suicide.

Frequently parents find that they cannot talk to each other about the baby and this is where a supportive GP and/or Health Visitor can be very helpful, giving an opportunity to the parents to talk separately about their feelings. Fathers, in particular, may bottle up emotions unless they are encouraged to express them.

As the grieving process continues depression often occurs, leaving the parents with feelings of tiredness, failure and worthlessness. Recovery comes very gradually, although there will still be painful anniversaries to cope with and the loss will always be there.

If and when the parents decide to have another baby there will understandably be increased anxiety and lack of self-confidence. Extra visits from the Health Visitor are often very much appreciated, as is easy access to the family doctor for what may appear to be minor concerns. Many parents value the provision of an apnoea monitor from the maternity unit and this is available at no cost, along with training in resuscitation techniques and follow-up from a consultant paediatrician.