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How to Write a Research Paper
Writing a research paper is a bit more difficult that a standard high school essay. You need to site sources, use academic data and show scientific examples. Before beginning, you’ll need guidelines for how to write a research paper.
Start the Research Process
Before you begin writing the research paper, you must do your research. It is important that you understand the subject matter, formulate the ideas of your paper, create your thesis statement and learn how to speak about your given topic in an authoritative manner. You’ll be looking through online databases, encyclopedias, almanacs, periodicals, books, newspapers, government publications, reports, guides and scholarly resources. Take notes as you discover new information about your given topic. Also keep track of the references you use so you can build your bibliography later and cite your resources.
Develop Your Thesis Statement
When organizing your research paper, the thesis statement is where you explain to your readers what they can expect, present your claims, answer any questions that you were asked or explain your interpretation of the subject matter you’re researching. Therefore, the thesis statement must be strong and easy to understand. Your thesis statement must also be precise. It should answer the question you were assigned, and there should be an opportunity for your position to be opposed or disputed. The body of your manuscript should support your thesis, and it should be more than a generic fact.
Create an Outline
Many professors require outlines during the research paper writing process. You’ll find that they want outlines set up with a title page, abstract, introduction, research paper body and reference section. The title page is typically made up of the student’s name, the name of the college, the name of the class and the date of the paper. The abstract is a summary of the paper. An introduction typically consists of one or two pages and comments on the subject matter of the research paper. In the body of the research paper, you’ll be breaking it down into materials and methods, results and discussions. Your references are in your bibliography. Use a research paper example to help you with your outline if necessary.
Organize Your Notes
When writing your first draft, you’re going to have to work on organizing your notes first. During this process, you’ll be deciding which references you’ll be putting in your bibliography and which will work best as in-text citations. You’ll be working on this more as you develop your working drafts and look at more white paper examples to help guide you through the process.
Write Your Final Draft
After you’ve written a first and second draft and received corrections from your professor, it’s time to write your final copy. By now, you should have seen an example of a research paper layout and know how to put your paper together. You’ll have your title page, abstract, introduction, thesis statement, in-text citations, footnotes and bibliography complete. Be sure to check with your professor to ensure if you’re writing in APA style, or if you’re using another style guide.
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Sudden infant death syndrome.
Hoon Kim ; Anthony L. Pearson-Shaver .
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Last Update: July 25, 2022 .
- Continuing Education Activity
Sudden infant death syndrome (SIDS) is the abrupt and unexplained death of an infant less than 1-year old. Despite a thorough investigation (a careful review of clinical history, death scene investigation, and a complete autopsy), a cause for the patient's demise is not identified. SIDS is the leading cause of death in the United States in infants one to twelve months of age. This activity reviews the role of the interprofessional team in the evaluation and management of SIDS.
- Review the etiology of SIDS.
- Outline the common historical features associated with SIDS patients.
- Describe the differential diagnosis of the patient with SIDS.
- Introduction
Sudden infant death syndrome (SIDS) is the abrupt and unexplained death of an infant less than 1-year old. Despite investigation (review of clinical history, investigation of the death, and a complete autopsy), no evidence supports a specific single cause of death. [1] SIDS frequently occurs during sleep, and it is the leading cause of death in infants one to twelve months of age in the United States. Due to inconsistencies in the use of SIDS as a diagnostic term, sudden unexpected infant death (SUID) was introduced. SUID includes SIDS, accidental suffocation/asphyxia, and deaths due to uncertain circumstances.
The exact etiology of SIDS is not clear. Studies suggest that SIDS is associated with suboptimal physiologic responses to hypoxemia and hypercarbia and a combination of several intrinsic and extrinsic factors. The most important preventable SIDS risk factor is a supine sleeping position. Acknowledging prone sleeping as a means of preventing SIDS has resulted in advocacy that significantly decreased SIDS deaths. The incidence of SIDS has dramatically reduced in countries that advocate for supine sleeping.
The incidence of SIDS declined by more than 50 percent in the United States after physicians began to promote “On the back to sleep.” After the American Academy of Pediatrics (AAP) issued a recommendation for supine sleeping in 1992, the incidence of SIDS decreased. From 1992 to 2001, the incidence of SIDS deaths declined from 1.2 to 0.56 deaths per 1000 live births. During the reported period, the percentage of infants sleeping in the supine position increased from 13% to 72%.
- Epidemiology
According to the Centers for Disease Control and Prevention (CDC), the incidence of SIDS in 2017 was 35.4 per 100,000 live births in the United States. Prior to the introduction of campaigns to reduce SIDS deaths, death rates were noted to vary significantly between Asian populations, aboriginal people in Australia, the population of the United Kingdom, the population of the United States, and the population of New Zealand. Death rates varied from as low as 0.3 deaths per 1000 live births (among Asian populations in the US and Bangladeshi's in the UK) to 7.4 deaths per 100 live births (in the Maori people in New Zealand). Cultural norms, child-rearing practices, and socioeconomic factors appear to explain the variation. [2] In the United States, CDC reports reflect similar variations among non-Hispanic Black Americans, Native Americans, the non-Hispanic white population, Hispanics, and the Asian population. [3] [4] The peak incidence occurs between 2 and 4 months, and 90 percent of cases occur before six months of age. [5]
Studies suggest that 95% of the SIDS cases were associated with at least one risk factor, and 78% of the cases were associated with at least two risk factors. [6] Several studies identify the prone sleeping position, sleeping on soft surfaces, sleeping with soft objects, co-sleeping with a parent/parents, maternal smoking during pregnancy, maternal age less than 20 years, late/no prenatal care, preterm birth, low birth weight, lack of breastfeeding, and overheating as risk factors in SIDS deaths. [5] Maternal drug use and exposure to smoke from tobacco are associated with a higher incidence of SIDS. Exposure from secondhand smoke is an independent risk factor for SIDS, and the risk increases with an increasing amount of exposure [17]. Although it is not clear that exposure to smoke is a primary cause of SIDS. [7] [8] Exposure to secondhand smoke is an independent risk factor and the risk increases as the amount of exposure to smoke increases. [9] Maternal drug use is associated with a higher incidence of SIDS, although it is not clear whether this is a direct or an indirect effect. [10] [11]
A history of apnea and upper respiratory infection is not SIDS risk factors. Although controversial, studies identify parents sleeping in the same room (in a different bed) breastfeeding, pacifier use, fan use, and immunization as protective factors. [12] [13] [14] [15]
Siblings of SIDS infants have an increased risk of dying as a result of SIDS. Siblings are 5-6 times more likely to die from SIDS than the general population. [16] [17] [7] After investigation, not all sibling deaths can be attributed to SIDS. Sibling deaths were found to be attributable to inborn errors of metabolism, abuse, and malnourishment. Twins have a higher incidence of SIDS, about twice as high as singletons. [8] This association is true for preterm twins, term twins, and twins weighing more than 3kg at birth.
- Pathophysiology
A generally accepted model is a triple-risk model: SIDS occurs in infants with underlying vulnerability who undergo a trigger event at a vulnerable developmental stage. [18]
Underlying Vulnerability
Infants dying as a result of SIDS display suboptimal physiologic regulatory responses. Post-mortem examination of the brainstems of SIDS victims demonstrates abnormalities in serotonergic signaling abnormalities in the arcuate nucleus and tissues that modulate ventilation and blood pressure in response to hypoxia and hypercarbia. [19] [20] Affected infants also show decreased 5-HT 1A receptor binding in the medulla, which influences a broad range of autonomic responses via serotonin signaling. [21] Some authors have identified gene polymorphisms that may predispose to SIDS. [22]
Trigger Event
The exact nature of the trigger is unknown. Studies suggest that the prone positioning predisposes to suffocation, resulting from decreased arousal, the type of bedding material, and overheating. [23] [24] Studies have demonstrated that prone sleeping is associated with longer sleep duration, longer obstructive events, and decreased arousal. [25] Further, the arousal threshold during sleep is higher in infants younger than six months of age. [23] While the data are inconclusive, cardiac dysfunction is suspected of triggering SIDS. Infection is a suspect SIDS trigger as well. Infants dying from SIDS are more likely to be infected by potentially pathogenic organisms on autopsy than infants dying from other non-infectious causes of death. [26]
Vulnerable Developmental Stages
SIDS occurs most frequently between 2 and 4 months of age, a period marked by important changes in the cardiac, ventilatory, and sleep-wake patterns. A nadir in blood pressure, as well as impaired blood pressure responses to cardiovascular challenges induced by the head-tilt challenge, are known to occur during this period. [27] There are great differences in sleep structure and arousal in infants and adults. Rapid maturation in sleep structure occurs in the first six months of life.
- Histopathology
At autopsy, infants who die of SIDS demonstrate multiple external and internal findings insufficient to explain the cause of death. [28] External findings may include frothy, blood-tinged fluid at the nares in an otherwise well-developed infant. Internal observations include subacute inflammation of the upper respiratory tract, pulmonary congestion/edema, intrathoracic petechiae, and persistent hepatic hematopoiesis.
- History and Physical
Commonly, infants dying from SIDS are found dead in the morning. Over 80 percent of SIDS deaths occur between 12 pm to 6 am. Bedding covers the head of a large percentage of infants who die of SIDS. An infant may display blood-tinged fluid at the nares, but the infant appears otherwise intact externally.
SIDS is a diagnosis of exclusion requiring a thorough investigation, including the review of the clinical history, death scene investigation, and a complete autopsy. Recommendations include detailed interviews with caregivers, a review of medical records, reports of the death scene observations, and a complete autopsy within 24 hours of death. Existing internationally standardized protocols for autopsy and national guidelines for the death scene investigation are effective tools to assist with the completion of the investigation. The CDC has established SUID monitoring programs in 22 states and jurisdiction, but no national protocol is available in the United States as state laws govern medicolegal death investigation.
Clinical History
Culturally sensitive professionals may engage in interviews with caretakers, using non-accusatory, open-ended questions that probe the presence of risk factors such as the infant sleeping position, co-sleeping, and medical (and prenatal) history.
An autopsy may identify congenital abnormalities, injuries, infection, or metabolic defects. Autopsy identifies the cause of death in only 15% of suspected SIDS deaths. [28] The autopsy includes external and internal examination, radiologic evaluation, microbiology, toxicology, and laboratory studies. Essential laboratory evaluation incudes: electrolytes, screening for inborn errors of metabolism, and screening for genetic disorders/polymorphisms.
Metabolic Screening
Recommended metabolic labs include plasma acylcarnitine profile, quantitative plasma carnitine levels, quantitative plasma amino acid analysis, qualitative urine organic acid analysis, and plasma lactate and pyruvate. Collect plasma pyruvate in a specimen container with perchlorate.
Death Scene Investigation
First responders should be trained to make visual observations of the environment upon arrival at the scene before beginning to resuscitate the patient. It is important to note: the temperature of the room, the first temperature of the infant, type of ventilation or heating system operating in the home, the location of the infant, the condition and quality of the bed/crib, amount and location of the infant's clothing, the presence or absence of bedding or soft objects in the sleeping environment, the presence or absence of marks on the infant's body, and the reactions of the caretakers. [29]
- Treatment / Management
When an infant's death is suspicious for SIDS, an investigation as outlined above is required. Parents/caregivers should be comforted and educated regarding SIDS. If a genetic cause is found, genetic counseling may be needed. Anticipatory guidance that educates regarding SIDS risks is preventative; however, cardiopulmonary monitoring is not recommended for SIDS prevention. [30]
- Differential Diagnosis
Disorders that mimic SIDS include aspiration, asphyxiation, anaphylaxis, poisoning, fatal child abuse, trauma, hyperthermia, metabolic disorders, cystic fibrosis, hepatitis, pancreatitis, encephalitis, AV malformation with hemorrhage, congenital adrenal hyperplasia, pulmonary hypertension, sickle cell crisis, cardiac disorders including congenital heart disease, subendocardial fibroelastosis and myocarditis, sepsis, and infections including bronchiolitis, pneumonia, tracheobronchitis, pyelonephritis, and enterocolitis with Salmonella, Shigella, or Escherichia Coli. Among these, fatal child abuse and metabolic disease deserve particular attention because they may affect other family members.
Fatal child abuse accounts for 1 to 5% of cases designated as SIDS. [31] [32] The mechanism may be closed head injury (most common), trauma, intentional asphyxia, or poisoning. An autopsy cannot distinguish between accidental asphyxiation, intentional asphyxia, and SIDS. However, the features that suggest fatal child abuse are recurrent episodes of unexplained cyanosis, apnea or ALTE that occurs in the presence of a single caretaker, simultaneous death of twins, previous unexplained death of siblings, previous infant of child death in the presence of a single, and inexplicable death in a child older than six months of age.
The proportion of metabolic diseases was not higher among infants with sudden death compared to the general population. [33] Clinical features suggestive of the metabolic disease include unexpected death in a sibling; a family history of sibling or cousin with BRUE, Reye syndrome, or myopathy; and signs/symptoms prior to death including failure to thrive, vomiting, hypoglycemia, hypotonia, hyperventilation, serious infections, or elevated aminotransferase levels. The metabolic defects may involve the metabolism of fatty acid chains, branched-chain amino acid, urea cycle products, or dysfunction of mitochondria. The most common metabolic conditions causing sudden death are errors in the metabolism of fatty acids (i.e.medium-chain acyl-CoA dehydrogenase -MCAD). [34] [35] A complete autopsy may identify abnormal metabolites. However, an incomplete autopsy may fail to identify subtle findings and classify the deaths as SIDS.
- Pertinent Studies and Ongoing Trials
Studies started to arise as early as the 1960s, suggesting the association between prone positioning and SIDS. Several international studies provided a basis for AAP’s campaign called ‘Back to Sleep.’ [30] National Institute of Child Health and Human Development (NICHD) study of SIDS was a multi-center, case-controlled project that included 10% of live births in the United States in 1988 that provided substantial epidemiological data describing the occurrence of SIDS.
- Deterrence and Patient Education
Medical professionals must be aware of current recommendations for safe sleeping practices and SIDS prevention: do not drink alcohol or use illicit drugs during pregnancy, place the infant on the back to sleep, allow the infant to sleep in his or her own crib in the same room as caregivers, and use a firm and flat surface in a safety-approved crib. Keep soft bedding or objects such as blankets, pillows, bumper pads, or toys out of the sleeping environment. Avoid covering the infant's head and avoid overheating. Avoid second-hand smoke. Smokers should change clothes and wash their hair before coming in contact with the infant. Infants and caregivers benefit from learning to use a pacifier at bedtime - Do Not Prop bottles in the baby's mouth! Breastfeeding and immunizations are beneficial.
Despite a widespread campaign advocating for placing the baby in a supine position for sleep, the adherence to such behavior in the United States peaked at about 80% in 2015. Compliance never reached the targeted level. [36] In a large survey in the United States in 2019, 93% of parents recalled hearing about placing the baby in a supine position to sleep from clinicians, and only 78% of parents reported adhering to the recommendation. [37] Furthermore, parents were less likely to recall hearing about other safe sleeping practices, including avoiding soft objects in the vicinity of the bed (85%), safe sleeping surfaces (84%), and room-sharing without bed-sharing (50%).
- Enhancing Healthcare Team Outcomes
Emergency responders should be trained to observe the scene, document the observations, and provide for the caretakers the emotional support. If the infant is pronounced dead, responders should let families interact with the victim. Due to the sensitive nature of their role, emergency responders should be trained about the grief reactions of the caretakers and beliefs/practices of the families in the communities in which responders serve.
Emergency department (ED) personnel should be supportive to the families, providing appropriate information and emotional support as well. Families should be explained about the rationale for the autopsy and death scene investigation. They should be told when their child will be transported for the autopsy. They should be given enough time with their child in an unhurried and sensitive manner. If the family presents to ED in a private vehicle, ED personnel should call law enforcement so that an officer may secure the area and ensure witnesses. Medicolegal death investigators may be contacted by a medical facility. Before families leave the ED, hospital staff should arrange for families' transportation to home (who are often unable to drive), confirm the contact information, offer a referral to a local SIDS/SUIDS program or other bereavement programs, and provide information about the funeral arrangement and hospital contact number in case families have questions.
It is important for the hospital nursery to follow AAP's recommendations and set up the expectation and role model for mothers.
Hospitals should establish institutional policies on safe sleeping practices for infants.
Despite worldwide campaigns advocating for letting the baby sleep in a supine position in a safe environment, many families still do not adopt safe sleeping practices, due to financial struggles, cultural expectations and norms, lack of knowledge, concern for comfort, and hassles in the efforts. Health professionals should, on the one hand, acknowledge the difficulties in following the recommendations, but, on the other hand, continue to advise for safe sleeping environments for infants.
Large epidemiologic studies have demonstrated that SIDS is associated with many preventable risk factors, of which the most important is prone sleeping. (Level III) Many countries started to campaign for sleeping on the back in a safe environment in the 1990s, and the incidence of SIDS has significantly declined in the 2000s. Regardless, SIDS continues to claim the lives of its victims. The healthcare team should inform parents about safe sleeping practices for an infant and the risk of SIDS in order to reduce the incidence of SIDS.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
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- Cite this Page Kim H, Pearson-Shaver AL. Sudden Infant Death Syndrome. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
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SIDS Counseling
SIDS Counseling Treatment Plan Sudden Infant Death Syndrome: A Treatment Plan The unexpected death of an infant is a heartbreaking tragedy. Sudden infant death syndrome (SIDS) refers to the sudden death of a child which occurs without any known cause. While there are some risk factors for SIDS, little is known about the disorder. Sudden infant death syndrome is the leading cause of infant mortality in the United States (McClain, Arnold, Longchamp, & Shaefer, 2004). Families, who lose a child because of SIDS, require assistance in acknowledging their child's death and expressing grief in a safe and healthy manner. Christian grief counseling provides families affected by SIDS with the support and skills to identify and express their emotions after the sudden death of a child. The purpose of Christian bereavement counseling is to promote the understanding of death and grief and the healthy expression of emotions. A treatment plan for…
(McClain M. Arnold J. Longchamp E. Shaefer J. 2004 Beareavement counseling for sudden infant death syndrome (SIDS) and infant mortality: Core competencies for the health care professional) McClain, M., Arnold, J., LongchampNewman (2006), E., & Shaefer, J. (2004). Beareavement counseling for sudden infant death syndrome (SIDS) and infant mortality: Core competencies for the health care professional. Retrieved April 7, 2011, from http://www.asip1.org/images/BerCouns -- CoreComp.pdf
(Newman W. 2006 Bible teaching about Christian counseling theory and practice) Newman, W. (2006). Bible teaching about Christian counseling theory and practice (Rev. ed.). Tacoma, WA: Newman International LLC.
(Worden J. 2009 Grief counseling and grief therapy: A handbook for the mental health practitioner) Worden, J. (2009). Grief counseling and grief therapy: A handbook for the mental health practitioner (4th ed.). New York, NY: Springer Publishing Company.
SIDS Sudden Infant Death Syndrome
78), or that particulate air pollutants might be a contributing factor in SIDS (Glinianaia, Svetlana V., Rankin, Judith, Bell, Ruth, Pless-Mulloui, Tanja, and Howel, Denise, 2004, p. 1365). However, data that would link either of these things as the specific cause of SIDS is still being researched, and remains inconclusive at this time. Much more study is needed to understand SIDS. Sleep apnea has been the subject of recent research involving SIDS, and while all babies are prone to moments of pausing in their breathing, says, Dr. Robert G. Meny, Maryland's School of Medicine's Sudden Infant Death Institute, "The question is not if -- the question is how much, how often, and how long. I begin to worry especially when I see the pauses for more than 20 seconds (Stehlin, Doris, 1991, p. 16)." In cases where a parent notices prolonged and ongoing apnea, infant apnea monitors have proven successful…
Works Cited
SIDS Prevention the First and
In addition to sleeping the infant on his or her back, CBNR reports that steps must be taken to ensure that the child's respiration and circulation are not constricted in any way. CBNR indicates that "over bundling, and consequently overheating, has been shown to increase SIDS risk. Overheating may disrupt the normal neurological control of sleep and breathing." (p. 1) Research has also increasingly pointed to the surface and surroundings of the inside of the crib as areas where steps can be taken toward prevention. ebMD (2010) indicates that the crib should be free from any loose objects such as toys, stuffed animals, loose pillows, loose blankets or sheets. Essentially, the parent will want to leave nothing in the crib which the infant, while unattended, can use to accidentally smother itself. Additionally, the surface of the best is to be flat and firm. Soft surfaces increase the risk of the…
Works Cited:
American SIDS Institute (ASI). (2010). Reducing the Risk of SIDS. SIDS.org.
Creative Baby Nursery Rooms (CBNR). (2007). SIDS Prevention Advice For New Moms. Creative-baby-nursery-rooms.com.
Sears, W. (2006). SIDS. Ask Dr. Sears.
WebMD. (2010). SIDS Prevention. A Guide to Your Baby's Sleep and Napping.
Preventing SIDS an Overview of the Evidence
Sudden Infant Death Syndrome (SIDS) The causes of Sudden Infant Death Syndrome (SIDS) still remain poorly understood. Although there has been a dramatic decrease in its incidence, it still remains a leading cause of infant death in babies older than 30 days and younger than a year (Carolan, 2015, p.1). SIDS occurs when a previously healthy infant goes to sleep and for no apparent reason dies before waking. One of the most common hypotheses is developmental or that some infants "may experience abnormal or delayed development of specific critical areas of their brain. This could negatively affect the function and connectivity to regions regulating arousal during sleep" (Carolan, 2015, p.2). A lack of neurological response to temporary obstruction of the infant's breathing could cause sudden death. Undiagnosed birth defects or abnormalities (teratogens) may be the cause of at least a small but significant percentage of SIDS cases. "In 15%-25% of…
Carolan, P. (2015). SIDS. Medicine.net. Retrieved from: http://www.medicinenet.com/sids/page2.htm
Downey, G., Silver, R.C., & Wortman, C.B. (1990). Reconsidering the attribution-adjustment
relation following a major negative event: coping with the loss of a child.
Journal of Personality and Social Psychology, 59(5):925-40.
Buddhism Compare and Contrast Siddhartha Gautama's Buddha's
uddhism Compare and contrast Siddhartha Gautama's (uddha's) "going forth" into the monastic life with that of Maechi Wabi, based on the reading of "Journey of One uddhist Nun." In his account of the story of uddha, Jonathan Landaw writes "As Siddhartha stood alone in the forest, ready to begin his great adventure, he thought, "From today onwards I am no longer a prince. Therefore, it is not right that I continue to look and dress like one." (Story, p 14). So began Siddhartha's journey of knowledge and enlightenment which would lead him to learning "the way to end all suffering" and becoming a uddha. Like, Siddhartha, the uddhist nun, Maechi Wabi, also began her journey into uddhism from a background that otherwise would not shun, and not expect her to change her way of life so drastically. As a woman, Wabi's decision to become a nun was not initially acceptable…
Bibliography
Brown, S. The Journey of One Buddhist Nun: Even
Against the Wind
State University of New York Press, 2001
Gyatso, T. Dalai Lama My Land and My People
Proj Management 7 2A There Are Several Symptoms
proj Management 7.2a There are several symptoms of cultural communications problems. The first is that Sid did not want to be honest with Judy right away; she had to pry the information out of him. The second is that the hours were way more than was needed. The third is that Randy had added hours to the estimate that Sid had originally provided. The fourth is that Sid indicated that if he failed to meet the target for any reason, there would be neverending negative consequences. The fifth is that Sid is juggling many projects at once -- programming is the sort of work that requires intense concentration on a single task juggling multiple such projects simultaneously is not desirable for programmers. The first step to changing the culture in the department is that the problem needs to be clearly identified so that everybody knows what the current culture is…
Balance Scorecard for Fatura Business Organizations Operate
Balance Scorecard for Fatura Business organizations operate with the sole objective of effectively utilizing the input factors in order to maximize on the output. For this case, output is measured in terms of performance, which, essentially relates to the profits or customer satisfaction. In the industrial age, most managers relied heavily on conventional financial metrics as the only strategic measure to align the activities of the organization to the goals and objectives of the same organization. However, this perspective has gradually shifted in the information age. Balanced scorecard is the most recent strategic tool that most organizations currently use in their planning and management activities. It is crucial as far as the alignment of the business activities to the objectives of the firm, boost both internal and external communications, and assess the organization performance relative to strategic goals. BSC is classified into four quadrants that include customer, financial, internal business…
Kaplan, R.S., & Norton, D.P. (1992). The Balanced Scorecard: Measures That Drive Performance. Retrieved June 18, 2008, from http://library.tmu.edu.tw/news/%5BHarvard%20Business%20Review%20-%20January-February%201992%5D%20-%20Kaplan%20&%20Norton%20-%20The%20Balanced%20Scorecard%20-%20Measures%20That%20Drive%20Pe.pdf
Kaplan, R.S. & Norton, D.P. (2004). Measuring the strategic readiness of intangible assets. Retrieved May 17, 2010, from http://www.cma-slp.com/onlinelibrary/OL_English/Strategy%20Implementation/Management%20Accounting/MeasuringTheStrategicReadinessofIntangibleAssets.pdf
Niven, P. (N.D.) Learning and Growth perspective. EPM Review. Retrieved May 17, 2010, from http://www.epmreview.com/Resources/Articles/Learning-and-Growth-Perspective.html
Gumbus, A. & Johnson, S.D. (2003, July). The balanced scorecard at Futura Industries. Strategic Finance. 85(1). 36-42. Retrieved May 17, 2010, from http://proquest.umi.com/pqdweb?sid=1&vinst=PROD&fmt=6&startpage=-1&clientid=29440&vname=PQD&RQT=309&did=370139621&scaling=FULL&vtype=PQD&rqt=309&TS=1226799369&clientId=29440
Social Psychology Both as an Academic and
Social psychology, both as an academic and a professional practice, is extremely useful for elucidating the phenomenon of high rates of suicide within the military, and within the United States in general. The frequency of the occurrence of suicide within the military is explicitly denoted within Brewin's article (2013), in which there are record rates for suicide in the armed services in 2013 and the "number of military suicides has more than doubled since 2001" (p. 1). Sweeping phenomena such as the high incidence of suicide within a specific population setting validates social psychology as a discipline, since it is apparent that such problems are indicative of social concerns. Such problems will not simply go away, and require psychological means to address this issue. This fact is widely alluded to within the aforementioned article. One of the chief reasons for suicide is the general perception that seeking counseling or psychological…
Brewin, B. (2013). Military suicides are up, despite 900 prevention programs. www.nextgov.com. Retrieved from http://www.nextgov.com/defense/2013/03/military-suicides-are-despite-900-prevention-programs/62019/?oref=ng-skybox
Furuya, S. (2013). Social psychology differs when applied in different cultural contexts.
Furuya, S. (2013). Journal of Experimental Social Psychology: Morality and Group Relations: Possible Bias Part I.
Furuya, S. (2013). Social Psychology View: What ensures that Women are Treated Fairly in Office Settings in the United States?
Infant That Is Under One-Year-Old
For example, when mothers smoke during pregnancy they not only put toxins in their own bodies, but into the bodies of their babies as well. In addition to these toxins, the maternal smoking often deprives the babies of the oxygen that it needs, and this can result in abnormalities that can lead to SIDS. Metabolic disorders are also a consideration for babies that die of SIDS, although this has not been proven (www.nichd.nih.gov,1997). As for treatment or prevention, there is little that can be said. Naturally, there is no treatment for SIDS, since by definition it results in the death of the infant. Prevention is also not something that can be accomplished, since there is no definite way to prevent SIDS. However, there are ways to reduce the risk, such as making sure that the baby sleeps only on its back and not on its stomach, keeping the baby's environment…
Works Cited www.nichd.nih.gov.(1997). Fact Sheet: Sudden Infant Death Syndrome. Retrieved 8 February 2005 at http://www.nichd.nih.gov/publications/pubs/sidsfact.htm .
A www.sidscenter.org.(n.d.). What is SIDS? Retrieved 8 February 2005 at http://www.sidscenter.org/SIDSFACT.HTM .
Adoptive Parents Face When Adopting
Adopting a special needs child also presents strong demands on time and energy that "normal" families do not usually have to deal with. According to Cloud and Townshend (2001) "As a rule, children don't know what they are doing. They have little idea how to handle life so that it works right. That's why God gave them parents - to love them, give them structure and guide them into maturity" (p. 40). Special needs children often require additional nurturing, stricter discipline and setting of limits, and markedly more attention than traditional children. This can sometimes seem overwhelming for the parents, especially if this is there first experience raising a child. Even if there are other siblings, these extra demands can cause great amounts of stress for the entire family system. If the parents are spending too much time dealing with the needs of one child, then the other children may…
Babb, a. & Laws, R. (1997) Adopting and advocating for the special needs child: A guide for parents and professionals, Westport, CT: Bergin & Garvey.
Brodzinsky, D.M., Schecter, D.E., Braff, a.M., & Singer, L.M. (1984). Psychological and academic adjustment in adopted children. Journal of consulting and Clinical Psychology, 52, 582-590
Clinton, T.E. & Sibcy, G. (2006) Loving your child too much: How to keep a close relationship with your child without overindulging, overprotecting, or overcontrolling, Thomas Nelson, Inc.
Cloud, H. & Townshend, J. (2001) Boundaries with kids. Zondervan Publishing
Pharmacologic Treatment of Fear and
e., they became helpless). Furthermore, other behaviors of the dogs were adversely affected (e.g., the dogs appeared apathetic and had poor appetites) (Hitzemann, 2000). In his essay, "Animal Models of Psychiatric Disorders and Their elevance to Alcoholism," Hitzemann (2000) reports that, "Both fear and anxiety are alerting signals that warn the individual against impending danger and enable the individual to take defensive measures. For animals, the distinctions between fear and anxiety are vague" (p. 149). The distinctions between fear and anxiety are clearly irrelevant for humans who encounter such stressed animals, though. According to Hodge and Stull (2000), dog bites cause an average of 17 human deaths, 6,000 hospitalizations, and 330,000 emergency room visits every year in the Untied States and a like number of people probably do not seek treatment or report the incident, but may nevertheless experience psychological trauma, anxiety, and missed work or school. Furthermore, dog bites…
Becker, M.G., Chew, G.L., Correa, J.C., Hoepner, L.A., Jusino, C.M., Kinney, P.L., Miller, R.L., & Perzanowski, M.S. (2003). Distribution and determinants of mouse allergen exposure in low-income New York City apartments. Environmental Health Perspectives, 111(10), 1348.
Boone, J.S., & Tyler, J.W. (2001). Transferable residues from dog fur and plasma cholinesterase inhibition in dogs treated with a flea control dip containing chlorpyrifos. Environmental Health Perspectives, 109(11), 1109.
Chang, Y., Cohen, J.H., Hennon, D.L., LaPorte, R.E., & McMahon, J.E. (1997). Dog bite incidence in the City of Pittsburgh: A capture-recapture approach. American Journal of Public Health, 87(10), 1703-5.
Duke, M.L., & Swain, J.L. (2001). Recommendations for research on ethics in public policy from a public administration perspective: Barking dogs and more. International Journal of Public Administration, 24(1), 125.
Evidence of this can be seen with the company being slow to provide information, on the total amounts of oil that are leaking into the ocean and the various restrictions that they have placed on media coverage. (Lack of Transparency Afflicts Oil Spill Response 2010) This problematic, because when there are restrictions and the company is slow to release information, it appears as if they have something to hide. At which point, the public will become furious with the company, from their perceived unwillingness to cooperate. This could have negative political fallout, as various Congressional Committees and regulators will demand all documents relating to the spill. Once this take place, it sets the stage for an ugly showdown with Congress and the White House. Where, they could seek to force the company to disclose more documents and engage in criminal investigations, as these actions give the appearance that executives are…
'Boards of Directors Need to Oversee Corporate Sustainability more Effectively', 2010, PR Newswire, Available from Proquest. [19 June 2010] http://proquest.umi.com/pqdweb?index=0&did=2054701491&SrchMode=2&sid=4&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1276983049&clientId=45065
'BP Engineer Called Deepwater Horizon Nightmare Well Days Before Blast', 2010, Huffington Post, Available from: [21 June 2010].
'BP Establishes a $20 Billion Claims Fund', 2010, BP, Available from: . [21 June 2010].
'Estimating Cleanup Costs for Oil Spills', 1999, Cutter Information Corporation, Available from: . [19 June 2010].
Starwood Hotel Chain Today Businesses
S.S.. This has resulted in a renewed tourist enthusiasm to visit these countries. The imaging process involved a portrayal of conformity to the European paradigm, a projection of a safe and friendly environment, and the development of niche tourism products to attract visitors. These efforts have culminated in countries such as Hungary and Poland becoming very attractive tourist markets. This creates a favorable climate for hotel chain expansion. In a writing that dates ten years later, Hughes and Allen (2009: 188) also indicate this. Factors in favor of CEE countries and the tourist demand for travel in these countries include their EU membership and associated publicity, as well as the above-mentioned increase of "Europeanness," as opposed to communism, in these countries. Indeed, Hungary and Poland ranked 15th and 17th respectively in the world when surveyed for their international tourist arrivals (Hughes and Allen, 2008). Croatia, Estonia, and Lithuania also showed…
Bartl, H (1999) The hotel market in the former Eastern Bloc -- An overview. Journal of Vacation Marketing, Vol 3, No 4. Internet http://jvm.sagepub.com/content/3/4/341.full.pdf+html Accessed on 06/11/2010.
Chasan, E (2010) Extended Stay accepts Starwood reorganization bid. Reuters, 17 March. Internet http://www.reuters.com/article/idUSN1718200020100317 Accessed on 06/11/2010.
De Lollis, B (2008) CEO Profile: Starwood, Van Paasschen both on the move. USA Today, 23 June. Internet http://www.usatoday.com/money/companies/management/2008-06-22-starwood-ceo-paasschen_N.htm Accessed on 06/11/2010.
Drohan, R and Foley, A (2009) Towards A Resource-Based View Of The Firm Perspective On Enhancing Customer Relationships In The Hotel Industry. Internet http://repository.wit.ie/1381/1/TOWARDS_A_RESOURCE-BASED_VIEW_OF_THE_FIRM_PERSPECTIVE_ON_ENHANCING_CUSTOMER_RELATIONSHIPS_IN_THE_HOTEL_INDUSTRY_-_RIKON_Group.pdf . Accessed on 06/11/2010
Safe Sleep and Sleep Patterns for Children Under 18 Months
Infant Sleep Patterns People sleep nearly one third of their lives and infants sleep significantly more than adults (Franken, Kopp, Landolt, & Luthi, 2009). The function of sleep has hypothesized by different researchers; however, surprisingly there is no general consensus as to what the function and purpose of sleep actually is. It is known that sleep deprivation can have some serious consequences, especially in infants. The reason for this is that growth cycles as well as other developmental and functional processes occur in both the brain and body during sleep (Franken et al., 2009). Since getting adequate sleep is vital in infants it is important to understand their sleeping needs and patterns. In order to understand how to establish safe sleep patterns for children less than 18 months of age is important to understand the stages of sleep, the hypothetical functions of sleep, and the needs of infants regarding sleep…
Carpenter, R., McGarvey, C., Mitchell, E.A., Tappin, D.M., Vennemann, M.M., Smuk, M.,
Carpenter, J.R. (2013). Bedsharing when parents do not smoke: Is there a risk of SIDS?
An individual level analysis of five major case-control studies. British Medical Journal Open, BMJ Open 2013;3:e002299. doi:10.1136/bmjopen-2012-002299
Franken, P., Kopp, C., Landolt, H.P., & Luthi, A. (2009). The functions of sleep. European Journal of Neuroscience, 29(9), 1739-1740.
Patriot Act Throughout American History
The bill before me takes into account of the new realities and dangers posed by modern terrorists. It will help law enforcement to indentify, to dismantle, to disrupt and to punish terrorist before they strike." (Marcovitz, 2008) This is significant because it allows for the effective tracking of suspected terrorists activities. As a result, the overall quality and amount of intelligence gathered will allow law enforcement to determine what is taking place, before a tragedy occurs. A third benefit of the Patriot Act is: it allows for improved coordination. A 2005 study conducted by the Justice Department showed that the Patriot Act helped intelligence / law enforcement officials to identify over 40 different terrorist organizations operating in the United States, they were able to successfully arrest 500 suspected terrorists with ties to different organizations around the world and a total of 57 people were convicted of raising money for terrorist…
Alarm Sounds and CIA Wakes Up in Nightmare Alley. (7 August 1977). NY Times, pg. E1. http://proquest.umi.com.ozone.nsc.nevada.edu:8080/pqdweb?index=0&did=121547567&SrchMode=1&sid=2&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1272749966&clientId=63532
Excerpts from Court Ruling on Justice Departments Broad Powers. (19 November 2002). NY Times., pg. A 19. http://proquest.umi.com.ozone.nsc.nevada.edu:8080/pqdweb?index=3&did=730861052&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1272744494&clientId=63532
Warns of Dangers to Dams in West. (1943). NY Times, pg. 6. http://proquest.umi.com.ozone.nsc.nevada.edu:8080/pqdweb?index=0&did=88542637&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1272747703&clientId=63532
Bhonsle, R. (2007). South Asian Security Trends. New Delhi: Atlantic Publishers.
Geriatric Right to Die the
One solution of this issue can be that the closest most guardians is given the permission and right to take the decision about the life of the patient who is not able to communicate or express his wish. The guardian who should be responsible to take this decision should be the one who will be having direct impact of the death of the patient. Community & Health Care esolution Different communities have varied opinions in regard to right to die for geriatric. Although few of the countries have legalized this matter and have given the right to patient to decide whether he wanted to live more or not, but still there are campaigns in those countries that do not support the way patients should be given death and is also considered another way of committing suicide. Communities think if the right is legalized it will give doctors the right do…
Gastmans C. & Lemiengre. J. (2007). Development and communication of written ethics policies on euthanasia in Catholic hospitals and nursing homes in Belgium (Flanders), Centre for Biomedical Ethics and Law, Faculty of Medicine, Catholic University of Leuven, Belgium. Vol 63, Issue 1. pp 188 to 195, retrieved March 16, 2011 from http://web.ebscohost.com/ehost/detail?sid=06716113-81ca-4db0-a772-51ae3b6dd9ca%40sessionmgr15&vid=1&hid=19&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&an=2009306329
Kenny, R.W. (2007). An effect of communication on medical decision making: answerability, and the medically induced death of Paul Mills., Department of Public Relations, Mount Saint Vincent University. Vol 22, issue 1, pp. 69 -- 78, retrieved March 16, 2011 from http://web.ebscohost.com/ehost/detail?sid=c57afac0-3522-4bc8-8c8e-a0a7732261ee%40sessionmgr15&vid=1&hid=19&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&an=2009640106
Lemiengre K. (2008). How do hospitals deal with euthanasia requests in Flanders (Belgium)? A content analysis of policy documents. Health Promotion/Education, retrieved March 16, 2011 from http://web.ebscohost.com/ehost/detail?sid=37d04412-5a09-4727-92f0-398ccb54533a%40sessionmgr13&vid=1&hid=19&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&an=2009908744
Levett, C. (2011). Dying with dignity -- the case for end of life choices, Australian Nursing Journal, vol. 18, issue 8, pp. 48, retrieved March 16, 2011 from http://web.ebscohost.com/ehost/detail?sid=078d26de-de1f-4206-80ba-d37b9a51f264%40sessionmgr14&vid=1&hid=19&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&an=2010954963
1950s Advertisment One of the
It is also interesting that, somewhat differently from the first advertisement, we are no longer looking for efficiency, productivity increase and lower costs. Since consumerism is the key to this advertisement, the word of order now is spending. This is why this is the "costliest process on Earth." The three advertisement are very interesting, because, despite still reflecting well the period of time in which they were created, they are somewhat different. On one hand, we have a society that stresses the importance of higher productivity rates and lower costs to be able to face the current challenges. On the other hand, we have individuals simply enjoying their existence, despite the existent challenges. ibliography 1. http://proquest.umi.com.ezproxy.fiu.edu/pqdweb?index=3&did=83316914&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1195085617&clientId=20175 2. May Tyler, Elaine. Homeward ound: American Families in the Cold War Era. asic ooks, 1990. Page 91. 3. http://proquest.umi.com.ezproxy.fiu.edu/pqdweb?index=10&did=83316817&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1195087871&clientId=20175 4. http://proquest.umi.com.ezproxy.fiu.edu/pqdweb?index=12&did=83316789&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1195087871&clientId=20175 http://proquest.umi.com.ezproxy.fiu.edu/pqdweb?index=3&did=83316914&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1195085617&clientId=20175 May Tyler, Elaine. Homeward ound: American Families in the Cold War…
1. http://proquest.umi.com.ezproxy.fiu.edu/pqdweb?index=3&did=83316914&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1195085617&clientId=20175
2. May Tyler, Elaine. Homeward Bound: American Families in the Cold War Era. Basic Books, 1990. Page 91.
3. http://proquest.umi.com.ezproxy.fiu.edu/pqdweb?index=10&did=83316817&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1195087871&clientId=20175
4. http://proquest.umi.com.ezproxy.fiu.edu/pqdweb?index=12&did=83316789&SrchMode=1&sid=1&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=HNP&TS=1195087871&clientId=20175
Inclusion of Students Diagnosed With
The academic and behavioral challenges presented by students with EBD affect the nature of their interactions with their teachers. Aggressive behavior patterns increase the likelihood that children will develop negative relationships with their teachers. Indeed, problematic relationships in kindergarten between students with behavior problems and teachers are associated with academic and behavioral problems through eighth grade. Henricsson and ydell (2004) report that poor teacher -- student relationships tend to be stable over time and have a negative effect on school adjustment. These problematic relationships with teachers may contribute to the documented low rates of positive teacher attention, such as academic interactions and teacher praise in classrooms for students with EBD. Teacher -- student interactions in classrooms for students with EBD have been described both in terms of negative reinforcement and as reflecting the transactional nature of social interchanges. Students with and at risk for developing EBD are uniquely influenced by…
Cooley, E, L., Triemer & D.M. (2002, December) Classroom behavior and the ability to decode nonverbal cues in boys with severe emotional disturbance. Journal of social psychology. Vol. 142, Issue 6, 741-751. Retrieved November 19, 2011 from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=8&hid=24&sid=ccc23da9-1464-47f4-b788-49f04f0a8baf%40sessionmgr14
Henricsson, L. & Rydell, A. (2004, April) Elementary scholl children with behavior problems: Teacher-child relationns and elf-perception. A prospective study. Merrill-Palmer Quarterly. Vol. 50, Issue 2, 111-138. Retrieved November 19, 2011 from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=6&hid=24&sid=ccc23da9-1464-47f4-b788-49f04f0a8baf%40sessionmgr14
Lewis, T.J., Jones, S.E.L., Horner, R.H. & Sugai, G. (2010, April - June) School-wide positive behavior support and students with emotional/behavioral disorders: Implications for prevention, identification, and intervention. Exceptionality. Vol. 18, Issue 2, 82-93. Retrieved November 19, 2011, from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=4&hid=24&sid=ccc23da9-1464-47f4-b788-49f04f0a8baf%40sessionmgr14
Solar, E. (2011, September/October). Prove them wrong. Teaching exceptional children. Vol. 44, Issue 1, 40-45. Retrieved November 19, 2011, from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=ccc23da9-1464-47f4-b788-49f04f0a8baf%40sessionmgr14&vid=5&hid=24
Parenting Co-Sleeping Has More Advantage
More Care Giving to Babies: One of the biggest advantages of co sleeping is increase in breast feeding (McKenna, 1994; Richard et al., 1996). This is admitted even by the most conventional American Academy of Pediatrics (AAP) that co-sleeping has the most advantage of breast feeding. According to the research, mothers who co-sleep breast feed an average of twice as long as non-co-sleeping mothers. Moreover, the act of sucking in breast feeding increases oxygen flow, which is useful for both baby's growth and immune functions (McKenna, 1994). In addition, co-sleeping infants also get more notice and protective care. The studies have shown that mothers who co-sleep provides five times the number of care like as adjusting the baby's blanket, stroking or cuddling as compared to those mothers who were non-co sleepers (Mosko, 1997). Long-Term Benefits of Co- Sleeping in Children as adults Higher self-esteem: Those boys who co-slept with their…
La Leche League International, Inc. (1997). The Womanly Art of Breastfeeding. (6th rev. ed.)
Schaumberg, IL: Author
Davies, L. (1995). Babies Co-sleeping with Parents. Midwives: Official Journal of the Royal
Heinig, M.J. (2000). Bed sharing and infant mortality: Guilt by association? Journal of Human
Supplier Service Quality the Importance of Supplier
Supplier Service Quality THE IMPORTNCE OF SUPPLIER SERVICE QULITY Suppliers are an integral part of the value chain as they provide the raw materials, components and parts that are needed to manufacture a finished product. Their strategic value in the value chain has traditionally been obscured because of lower visibility and poor specialization and integration among suppliers. Firms have traditionally put increasing pressure on suppliers to offer supplies at lower prices, frequently switching over to competing suppliers, thereby leading to the erosion of loyalty in the supplies market. On the other hand, newer approaches to supplier-buyer relationships have shed light on the impact of strategic supplier-buyer relationships on reduced time-to-market and enhanced quality for manufacturing firms. The Role of Supplier Service to Business Success With the development of a globalized economy that has made national and geographic boundaries irrelevant for competition, the importance of strategic supplier-buyer relationships has become recognized.…
Ad Straub, "Competence of Maintenance Service Suppliers Servicing End-Consumers," Construction Management & Economics, 28, no. 11 (2010): 1187-1195, 10.1080/01446193.2010.500672. (accessed August 20, 2012).
Ram Narasimhan, Sriram Narayanan, and Ravi Srinivasan, "Explicating the Mediating Role of Integrative Supply Management Practices in Strategic Outsourcing: A Case Study Analysis," International Journal of Production Research, 48, no. 2 (2010): 379-404, 10.1080/00207540903174916. (accessed August 20, 2012).
Fred Morgan, "Product liability obligations of component parts suppliers: JPP&M JPP&M JM & PP," Journal of Public Policy & Marketing, 18, no. 2 (1999): 189-96.
Emotional Drivers of Consumer Toward Swarovskis Brand
Emotional Drivers Swarovski The motives behind consumer decisions to purchase luxury brands like Swarovski have been studied in a number of researches. The general findings of these studies have been that these motives are largely emotional, and that they are evolving as the composition of the luxury market segment changes. De Mooij (2005) defines emotion as an "interaction between cognition and physiology." The characteristics of emotion that or of greater concern to luxury brand managers are that emotions are learned and that they vary from culture to culture. The mode of expression of emotion also varies by culture. In capitalistic societies, consumption has evolved into a unique mode of expression of self-satisfaction, self-esteem and self-pleasures. These buying motives shape the perceptions of various brands among consumers, along with brand loyalty and brand image. De Mooij (2005, p. 116) explains luxury brand buying motives in terms of collectivism/individualism and masculinity/feminism. Conformance…
Chevalier, M., & Mazzalovo, G. 2008. Luxury Brand Management. John Wiley & Sons.
De Mooij, M. 2005. Global Marketing and Advertising. Sage Publications, Inc.
Fionda, A.M., & Moore, C.M. 2009. The Anatomy of the Luxury Fashion Brand. Journal of Brand Management, 16(5/6), 347-363. doi.10.1057/bm.2008.45.
Fog, K., Budtz, C., Munch, P., & Blanchette, S. 2010. Storytelling: Branding in Practice. 2nd ed. Springer.
Sexual Liberation in Addition to Sexual Intercourse
Sexual Liberation In addition to sexual intercourse and its variations, sexual liberation refers to the universe of human issues affecting all genders. America was propelled from the sexual enslavement of the 1950's to considerably increased sexual liberation of the 1980's and beyond. Two significant events of the 1960's that contributed to sexual liberation were the FDA approval of The Pill and the birth of the omen's Liberation Movement. Sexual Suppression of the 1950's An examination of liberation should begin with the sexual slavery of the 1950's. By current standards, sexual suppression was a numbing fact of 1950's America, particularly for women. For example, the legendary "Good ife's Guide" (Housekeeping Monthly, 1955) spouts standards that are otherworldly by today's norms. Perhaps its most oppressive statement is "A good wife always knows her place" (Housekeeping Monthly, 1955), though the guide serves up plenty of other now-hilarious goodies. "Assisting" housebound married women in…
Dekkers, O. (1971, December 12). National Women's political caucus. Retrieved on June 15, 2012 from proquest.umi.com Web site: http://proquest.umi.com/pqdweb?index=23&did=659219891&SrchMode=1&sid=4&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1339792329&clientId=14844
Henry, A. (1978, February 28). Reproductive thinking. Retrieved on June 15, 2012 from proquest.umi.com Web site: http://proquest.umi.com/pqdweb?index=2&did=659235281&SrchMode=2&sid=6&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1339792863&clientId=14844
Housekeeping Monthly. (1955, May 13). The Good Wife's Guide. Retrieved on June 15, 2012 from www.democraticunderground.com Web site: http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=105x1067598
Jansen, L. (1979, September 30). National women's political caucus convention. Retrieved on June 15, 2012 from proquest.umi.com Web site: http://proquest.umi.com/pqdweb?index=4&did=659256351&SrchMode=2&sid=4&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1339792068&clientId=14844
Olmec Ancient Civilization
" 4. Social and Political Life There is a general paucity of information about the actual societal and political structure of the Olmec. While there is not much evidence to build a comprehensive picture of the daily and social life of these people, there is enough available data from certain archeological sites to provide some reasonable speculations. One of the assumptions that is derived from the excavation of sites at San Lorenzo and then at La Venta is that the society was very centralized. This in turn has led to the view that the society was highly structured, with a hierarchical basis of order and class stratification. This also implies the existence of a ruling elite and a system of power and control, which was possibly based on religious beliefs. This view of the structure of the society is summarized as follows: "Olmec society was & #8230;highly centralized, with a…
Griffin Gillett G., the Olmec World: Ritual and Rulership,
http://www.tribalarts.com/feature/olmec / (accessed 8 November, 2010).
Jones, David M. Mythology of the Aztecs and Maya, New York: Lorenz, 2007.
Lemonick M.D., Mystery of the Olmec,( Time Magazine, July 1, 1996, Volume 148, No.
Movies Ratings Television Shows Ratings Currently Area
movies atings television shows atings. Cuently aea numbe shows television potaying negative aspects ace, class gende. Fo, show "Family Guy" a show played "pimetime" mateials show "kid-fiendly. Watching Toy Stoy is likely to influence many adults to believe that it would be wong fo them to allow thei childen to view the animated comedy. I believe that it is wong fo the Motion Pictue Association of Ameica film ating system to povide it with a G. ating, taking into account the violent scenes that the animation contains. Andy's next-doo neighbo, Sid, is a hoible peson and he is obsessed with mutilating toys. While it would be pefectly nomal fo childen to occasionally beak toys, an individual who wants to mutilate toys and who ceates mutant toys consequent to doing so is actually deanged. Poviding childen with the image of a deanged individual is pobable to have a negative effect on…
references and profanity, but violence is practically absent and adolescents are shown in ways that are characteristic to teenagers in general.
This film has an inappropriate rating and it should have been provided with an R. rating or even with a PG-13 rating. By labeling it NC-17, the Motion Picture Association of America virtually fails to acknowledge that teenagers are capable of putting across behaviors that are not socially acceptable. The reality is that many teenagers are likely to identify with characters in the film and that the most activities shown are actually perfectly normal for teenagers.
The chart is meant to emphasize the rating that each film should be provided with when concerning particular aspects like violence, sexuality, and drug use:
2 stands for G -- general audience
4 stands for PG -- parental guidance suggested
Sudden Infant Death Syndrome
Sudden Infant Death Syndrome. The articles explore separate studies about the topic. The author of this work discusses various aspects of each article and their merit. There were two sources used to complete this paper. Each year in America thousands of parents walk into their infants room and discover that the child has died from Sudden Infant Death Syndrome. The tragedy shocks and baffles the medical community as it continues to search for answers not only to what causes the syndrome but also what parents can do to reduce the risk of it striking their child. Studies around the globe have been conducted to this end with mixed results. The determination of factors that influence the existence of Sudden Infant Death Syndrome is vital to the ability to stop its occurrence. Study one The first study examined whether the temperament of an infant has a bearing on whether that child…
Temperament ratings do not predict arousability in normal infants and infants at increased risk of sudden infant death syndrome. (Original Articles).
Journal of Developmental & Behavioral Pediatrics; 10/1/2002; Adamson, T. Michael
Cosleeping in young Korean children.
Journal of Developmental & Behavioral Pediatrics; 6/1/2002; Hahn, Hong-Moo
Analyzing State Healthcare Database for Research and Analysis
Healthcare Database for esearch and Analysis South Carolina is amongst states that take part in the Health Cost and Utilization Program (HCUP). Sandra Kelly, the person to contact regarding all matters pertaining to the program is the Operations Manager in the Demographics and Health department. The evenue and Fiscal Affairs of South Carolina under which it operates is situated on 1919, Blanding Street in Colombia, SC 29201. (803) *** is her phone number and (803) *** her fax number. One can also contact her online through Sandra.- --, her official email-id. The data from South Carolina entails stays by inpatients from hospitals offering care for acute health. The data recorded from the hospitals does not cover a whole calendar year as some experience technical defects (SID File Composition - South Carolina, n.d.), while others close at some point in the year. The HCUP is the state's main source of gathering…
Healthcare Cost and Utilization Project (HCUP). (n.d). Retrieved July 10, 2016, from http://www.ahrq.gov/research/data/hcup/index.html
HCUP Partners. (n.d.). Retrieved July 10, 2016, from https://www.hcup-us.ahrq.gov/partners.jsp?SASD
SID File Composition - South Carolina. (n.d.). Retrieved July 10, 2016, from https://www.hcup-us.ahrq.gov/db/state/siddist/siddist_filecompsc.jsp
Gestational Surrogacy Even Though it
A also consider that a proper legislation should protect the surrogate mother, in order to avoid situations in which her rights would not be respected. Therefore, she should be paid her medical expenses and, as a sort of benefit for her act, she should be granted a free medical insurance and the right to free medical analyses. Moreover, the legislation should stipulate that the surrogate mother should be of the same nationality - American in this case - as the future parents, in order to avoid situations as those which occurred in the Indian women case, who have thought to have been abused, a thing they have accepted because of their poor material status. All in all, it seems that gestational surrogacy is not among the best surrogacy practice, and this is because of the ethnic, legal and cultural misunderstandings it might generate. In addition, I consider it should be…
Ciccarrelli, John K., and Janice C. Ciccarrelli. "The Legal Aspects of Parental Rights in Assisted." Journal of Social Issues 61 (2005): 127-137. Tufts Library. 17 Mar. 2007.
Baker, Brenda M. "A Case for Permitting Altruistic Surrogacy." Hypatia. Bloomington 11.2 (1996): 34. Alt-Press Watch. Tufts Library. 17 Mar. 2007. http://proquest.umi.com.ezproxy.library.tufts.edu/pqdweb?did=9766076&sid=1&Fmt=3&clien tId=28972&RQT=309&VName=PQD>.
Ciccarrelli, Janice C., and Linda J. Beckman. "Navigating Rough Waters: an Overview of Psychological Aspects of Surrogacy." Journal of Social Issues 61 (2005): 21-43. Tufts Library. 17 Mar. 2007.
Douglas, Carol Anne. "Women as Wombs." Off Our Backs Jan. 1994: 12. Alt-Press Watch. Tufts Library. 17 Mar. 2007, at http://proquest.umi.com.ezproxy.library.tufts.edu/pqdweb?did=592569041&sid=11&Fmt=3&clientId=28972&RQT=309&VName=PQD .
Tom Sawyer Chapter Exegesis Scene
Fighting fair, Tom still shines despite his aggression, particularly in light of Alfred's cowardly stone throwing when Tom's back is turned. Analysis This first chapter in Tom's adventures is of cleverly constructed form; sharing all key elements needed to know in order to follow the story, identify with the protagonist, despise the multiple antagonists, and fondly recognize the doddering aunt as a 'straight man' to Tom's antics. The reader is immediately engaged in the story because Twain's style opens with dialog - known as a 'hook' in publishing parlance. The reader is instantly curious; why is this person named Tom being so vocally pursued? Who is doing the shouting? Why is this Tom character not responding? The Adventures of Tom Sawyer is a snapshot of reality with which all readers can identify; it is not necessary to live in the backwaters of Mississippi to recognize sincere affection and security, sneaky…
Gw Bush Less Than Six
hen a president of the United States begins incorporating religious rhetoric into his speeches, alarm bells must sound. hen that same president allocates taxpayer monies to religious groups, then citizens should be experiencing widespread panic. Bush's No Child Left Behind Act is no less frightening than the faith-based initiative. Hiding behind good intentions, the No Child Left Behind Act fails to take into account a major factor: reality. Jim Donlevy notes, "It simply is not reasonable to continue to identify thousands of failing schools throughout the United States and then to see through to completion the sanctions written into the Act." The Act includes provisions for annual testing for schools, with progress requirements in core subjects such as English, math and science. "The idea is to be sure that all students are learning at higher standards," (Donlevy). However, the Act demands too much too soon. Forcing some schools to shut…
Anders, Christopher E. 2001. They must remain separate. The World & I. Washington: Jul 2001.Vol.16, Iss. 7; pg. 55 http://proquest.umi.com/pqdweb?did=74767508&sid=1&Fmt=3&clientId=12334&RQT=309&VName=PQD .
Dobbins, James. 2005. Iraq: Winning the Unwinnable War. Foreign Affairs. New York: Jan/Feb 2005.Vol.84, Iss. 1; pg. 16 http://proquest.umi.com/pqdweb?index=7&did=805099671&SrchMode=1&sid=1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1114122900&clientId=12334 .
Donlevy, Jim. 2003. Teachers, Technology and Training: No Child Left Behind: Failing Schools and Future Directions. International Journal of Instructional Media. New York: 2003.Vol.30, Iss. 4; pg. 335, 4 pages http://proquest.umi.com/pqdweb?did=549016431&sid=2&Fmt=3&clientId=12334&RQT=309&VName=PQD .
Patterson, Thomas E. We the People. 5th edition. McGraw-Hill.
T Boone Pickins My Case for Reagan 1984
Boone Pickins, My Case for Reagan (1984) Boone Pickins, "My Case for Reagan" 1984 During the 1980 presidential campaign Republican Ronald Reagan suggested that Americans ask themselves whether or not they better off financially than they were four years earlier, at the beginning of President Jimmy Carter's administration. This became a key issue in the 1984 presidential campaign when President Reagan sought another four years in the hite House. Even though there was a recession during 1982 Reagan won a landslide victory over the Democratic nominee alter Mondale. The economy was a key issue in the 1984 presidential race because the Reagan Administration's policy of cutting taxes and reducing spending on social programs were much more beneficial to some segments of American society than others. Businessman T. Boone Pickins made a case for the reelection of Reagan based on the economic conditions of the time. Pickins argued that more than…
Abramowitz, Alan L., David J. Lanoue and Subha Ramesh. "Economic Conditions, Casual Attributions, and Political Evaluations in the 1984 Presidential Election." Journal of Politics. Vol. 50, Issue 4. November 1988: 848- 863. 7 May 2012.
Kinder, Donald R., Gordon S. Adams and Paul W. Gronke. "Economics and Politics in the 1984 Presidential Election." American Journal of Political Science. Vol. 33, No. 2. May 1989: 491- 515. 7 May 2012.
Pickins, T.B. My Case for Reagan. (1984). 7 May 2012.
Qualls, John H. "Outlook for 1984: Politcal Economicsin an Election Year." Vital Speeches of the Day. Vol. 50, Issue 10. 1 March 1984: 314-317. 7 May 2012.
Educational Philosophies Richard D Mosier
Synthesize traditional and progressive education for today's students. Education digest. Vol. 68, Issue 7, 4-8. etrieved January 17, 2011, from: http://web.ebscohost.com/ehost/detail?hid=12&sid=90682ec6-64e1-4958-adc2-32dc1555fcc4%40sessionmgr13&vid=4&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&an=9317873 Cohen, L.M. & Gelbrich, J. (1999). Philosophical perspectives in education. Oregon State University, School of Education. etrieved January 17, 2011, from: http://oregonstate.edu/instruct/ed416/PP2.html Moser, .D. (1951, July). The educational philopophy of William T. Harris. Peabody Journal of education. Vol. 29, No. 1, 14-33 etrieved January 17, 2011, from http://www. Jstor, org/stable/1489104 Nehring, J.H. (2006, February 1). Progressive vs. traditional: eframing an old debate. Education week. Vol. 25, Issue 21, 32-33. etrieved January 17, 2011, from: http://web.ebscohost.com/ehost/detail?hid=12&sid=90682ec6-64e1-4958-adc2-32dc1555fcc4%40sessionmgr13&vid=4&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&an=19705742 Neil, J. (2005, January). John Dewey: Philosophy of education. Experimental learning. Wilderdom.com. etrieved January 17, 2011, from http://wilderdom.com/experiential/JohnDeweyPhilosophyEducation.html Sternberg, J., & Zhang, L. (2005, Summer). Styles of thinking as a basis of differntiated instruction. Theory into practice, 44(3), 245-253. Lawrence Erlbaum Associates. etrieved January 17, 2011, from: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=4&hid=111&sid=4dc68d17-580a=4983=af18=762283ca50ef%40sessionmgr114
Ackerman, D.B. (2003, March). Synthesize traditional and progressive education for today's students. Education digest. Vol. 68, Issue 7, 4-8. Retrieved January 17, 2011, from: http://web.ebscohost.com/ehost/detail?hid=12&sid=90682ec6-64e1-4958-adc2-32dc1555fcc4%40sessionmgr13&vid=4&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&an=9317873
Cohen, L.M. & Gelbrich, J. (1999). Philosophical perspectives in education. Oregon State University, School of Education. Retrieved January 17, 2011, from: http://oregonstate.edu/instruct/ed416/PP2.html
Moser, R.D. (1951, July). The educational philopophy of William T. Harris. Peabody Journal of education. Vol. 29, No. 1, 14-33 Retrieved January 17, 2011, from http://www. Jstor, org/stable/1489104
Nehring, J.H. (2006, February 1). Progressive vs. traditional: Reframing an old debate. Education week. Vol. 25, Issue 21, 32-33. Retrieved January 17, 2011, from: http://web.ebscohost.com/ehost/detail?hid=12&sid=90682ec6-64e1-4958-adc2-32dc1555fcc4%40sessionmgr13&vid=4&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&an=19705742
New Education the Current Crisis
esearch was the first to feel the effects. The shift in the material base of the university leaves the humanities entirely out in the cold. Corporations don't earmark donations for the humanities because our research culture is both self-contained and absurd. Essentially, we give the copyrights of our scholarly articles and monographs to university presses, and then buy them back, or demand that our libraries buy them back, at exorbitant markups. And then no one reads them. The current tenure system obliges us all to be producers of those things, but there are no consumers." (Donoghue 2008) The idea in education is one of operating as a business. The academic partners within the university setting are essentially in competition with one another for funding and other resources. If the students with stellar marks from certain departments are highly recruited by business and academia, the department is heralded and viewed upon…
Bassett J. 2008. The Future of Humanities Education, or Ahab and His Humanities.. Interdisciplinary Humanities. Retrieved January from: http://web.ebscohost.com.rlib.pace.edu/ehost/pdfviewer/pdfviewer?hid=106&sid=0e20acd8-7fc3-4066-9e72-d2da6278a966%40sessionmgr113&vid=1
Bell D. 2010. Reimaging the Humanities. Proposals for a New Century. Dissent (00129846) Retrieved January from: http://web.ebscohost.com.rlib.pace.edu/ehost/pdfviewer/pdfviewer?hid=106&sid=4f0282e4-a846-49e1-a8af-110652799ccc%40sessionmgr112&vid=1
Pokrovskii N.E., 2007. What Is Happening to Humanities Education? Russian Education & Society. Retrieved January from: http://web.ebscohost.com.rlib.pace.edu/ehost/pdfviewer/pdfviewer?hid=106&sid=44770a98-2f1e-4057-bbef-2bd93b6e1bb0%40sessionmgr110&vid=1
Woodward K. 1980. The Humanities Crisis. Newsweek. Retrieved January from: http://www.lexisnexis.com.rlib.pace.edu/lnacui2api/results/docview/docview.do?docLinkInd=true&risb=21_T10928153278&format=GNBFI&sort=RELEVANCE&startDocNo=1&resultsUrlKey=29_T10928153281&cisb=22_T10928153280&treeMax=true&treeWidth=0&selRCNodeID=9&nodeStateId=411en_US,1&docsInCategory=11&csi=5774&docNo=3
Hurd Undertook in Order to
The tactics that HP adopted were congruent with the company's strategy. HP wanted to continue to thrive as a mass market differentiated player. The firm's industries -- PCs, servers and more -- had become commoditized, but HP realized that its brand still had value as a premium product. Part of that recognition has allowed it to move into China, where no-name brands are common and local brands dominate the market. HP realized that its brand was strong enough to enter that market despite the challenges. HP also realized that the matrix structure was inappropriate for the company. Its businesses rely on innovation and marketing in order for the company to thrive. As a result, the company needs a streamlined organizational structure with direct lines of communication and accountability. This will focus managers on results, including innovation and cost control. The company always had the talent to succeed -- such as…
Burrows, P. (2005). HP Says Goodbye to Drama. Business Week, New York, September 12, 2005, Issue 3950,-Page 83-86 http://proquest.umi.com/pqdweb?index=0&did=893313611&SrchMode=1&sid=16&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1236358670&clientId=29440
Burrows, P. HP's Ultimate Team Player (2006). Business Week. New York: Jan 30, 2006, Issue 3969,-Page 76 http://proquest.umi.com/pqdweb?index=4&did=976455861&SrchMode=1&sid=2&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1241033913&clientId=29440
Einhorn, B., Kharif, O., Roberts, D. (2007). Grudge Match in China; HP and Dell are exporting their rivalry and starting to challenge Lenovo. Business Week. New York. April 2, 2007, Issue 4028,-page 42. http://proquest.umi.com/pqdweb?index=0&did=1246334451&SrchMode=1&sid=17&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1236358771&clientId=29440
Red Tides on the Gulf
brevis blooms are not a new phenomenon, and fish kills that result from red tides caused by K. brevis in the Gulf of Mexico have been described in the scientific literature since 1960 or so and have been reported anecdotally for more than two centuries (Naar et al. 2002). In this regard, Backer and her associates (2005) emphasize that, "The human health effects from consuming shellfish with high concentrations of brevetoxins in their tissues have been well documented. However, there is very little information describing human health effects from environmental exposures. It is ironic that we know the least about the aspects of the Florida red tide problem that poses the greatest public health hazard in terms of number of people affected" (645). Today, K. brevis blooms are monitored closely in order to mitigate the foregoing health hazards that are related to the consumption of shellfish and shellfish harvesting is…
Aguirre, A. Alonso, Richard S. Ostfeld, Gary M. Tabor, Carol House and Mary C. Pearl.
Conservation Medicine: Ecological Health in Practice. New York: Oxford University
Press, 2002.
Backer, Lorraine C., Barbara Kirkpatrick, Lora E. Fleming, Yung Sung Cheng, Richard Pierce,
Guild of America Wga Strike
As USA Today's Bill Keveney recently noted, "The broadcast networks [are airing] fewer than 20 live-action, 30-minute sitcoms, about half as many as five seasons ago.... No sitcom has finished in the top 10 since 'Everybody Loves aymond' in 2005." (Dumenco 2007, NP) This may lead some to conclude that the writer's strike will actually have less of an effect on the industry than expected, because so much of their work has been replaced by primetime reality television offerings and therefore when they are not working there is always something else to watch. Again, this remains to be seen, as there are still many diehard fans who would rather continue to watch sitcoms and television news broadcasts, though trends show that even these venues are dying off as more and more people seek their news from the ala cart news offerings of the internet. In short it can be argued…
Cooper, M. (2001, April 2). Residual Anger: Hollywood Unions on the Brink.
The Nation, 272, 22.
Dumenco, S. Cheap laughs take bite out of network comedy's bottom line. (November, 12, 2007) Advertising Age, 78, 45 NP Retrieved from Database Business Search Premier:
http://web.ebscohost.com/ehost/detail?vid=6&hid=3&sid=64d87508-2933-42ac-8c2c-f76a37955c7f%40sessionmgr8
Hour vs 8-Hour Work Shifts the Effect
Hour vs. 8-Hour Work Shifts The Effect of 12 Hour vs. 8-Hour Work Shifts on Health Care in Intensive Care Units Critical care areas, such as intensive care units (ICUs), may be very demanding and challenging places to work. ICU's are typically populated by very highly dependent patients. This work requires an increased staff to patient ratio, entails periods of high activity, the use of advanced equipment, and the need for multiple and significant decision-making situations. Since the late 1980s, the conventional shift work pattern of 8 hours has been increasingly re-engineered into the 12-hour shift pattern meaning nurses work longer, but fewer shifts. esearch has been conducted on 12-hour shifts for nurses since this practice began, however consensus on the effects of this practice on healthcare and the individuals involved is still highly contentious and problematic. Discussion In general terms, the best kind of shift system to promote maximum…
McGettrick, K.S. & O'Neill, M.A. (2006, July/August). Critical care nurses -- perceptions of 12-h shifts. Nursing in critical care. Vol. 11, Issue 4, 188-197. Retrieved July 14, 2011 from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=8e2c823c-2c9e-4b7c-999f-909aed15af3c%40sessionmgr10&vid=4&hid=12
Richardson, A., Turnock, C., Harris, l., Finley, A., & Carson, S. (2007, November). A study examining the impact of 12-hour shifts on critical care staff. Journal of nursing management, Vol. 15, Issue 8, 838-846. Retrieved July 14, 2011 from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&hid=126&sid=e34a1818-19dd-4758-b9a4-5fdc6712a718%40sessionmgr115
Rossen, B.R. & Fegan, M.A. (2009, Jan/Feb). Eight or twelve-hour shifts: What nursing students prefer. Nursing Education perspectives, Vol. 30, Issue 1, 40-43. Retrieved July 14, 2011 from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&hid=122&sid=3ac0d29b-956b-4220-9fe9-3da93dec099b%40sessionmgr113
Laptop Implementation Program - Action Plan Ideal
Laptop Implementation Program - Action Plan Ideal Classroom The ideal school in the modern era of global education evokes dynamic and progressive thought to what exactly enables a student population to excel and succeed in life's endeavors. Truly, this is central to any discussion regarding educational reformation via school and classroom development. The critical component to these decisions is inherent to the leadership at the school to understand that, according to Cause & Chen, "the children's active use of technology in making decisions, technology resources in writing and drawing, and logical thinking programs to solve problems and illustrate ideas." (Cause, Chen, 2010) The ideal school will therefore target the way young children learn and teach accordingly. According to Cause & Chen, an appropriate method to educate the young is to "offer pictures and sounds to support the natural ways that young children learn." (Cause, Chen, 2010) The importance of vision…
Katie Ash. (2010, March). Building on a Decade of 1-to-1 Lessons: Sustaining a laptop program at a middle school in Michigan requires a wireless vision and parent purchasing power.. Education Week, 29(26), 12, 14, 15. Retrieved December 20, 2010, from Research Library. (Document ID: 2030552671).
Cause, L., & Chen, D.. (2010). A Tablet Computer for Young Children? Exploring Its Viability for Early Childhood Education. Journal of Research on Technology in Education, 43(1), 75-98. Retrieved December 20, 2010, from Research Library. (Document ID: 2134707481).
Dawson, K., Cavanaugh, C., & Ritzhaupt, A.. (2008). Florida's EETT Leveraging Laptops Initiative and Its Impact on Teaching Practices. Journal of Research on Technology in Education, 41(2), 143-159. Retrieved December 20, 2010, from Research Library. (Document ID: 1609084841).
Chris Kieffer. (15 September). Tupelo hopes to expand school laptop use. McClatchy - Tribune Business News,***[insert pages]***. Retrieved December 20, 2010, from ABI/INFORM Dateline. (Document ID: 1859409821).
Continental Airline Has Evolved as
Continental recovered from each event in good time and generated overall benefits worth tens of millions of dollars. ("Continental Airlines wins INFOMS best practices award," 2002, website) The company has managed against great odds to continue to serve customers, some would say even more effectively than previous to the 2001 disaster, even recently expanding services. (FACTS: A Quarterly Digest of Interesting Information from Continental Airlines 4th Quarter 2004) Though, in the past the Continental has made significant contributions to charities and needy organizations, at this time of economic hardship within the aviation industry in general the company has suspended accepting applications for sponsorships they hope to resume in the near future. ("Continental Airlines: Community Service" website) the historical commitment to community service and customer relationships shows the marketing tactics of Continental Airlines to be some of the best in the world, and current conservation shows the companies ability to weather…
Continental Airlines wins INFORMS best practices award," 2002, website) http://www.eurekalert.org/pub_releases/2002-05/ifor-caw052302.php
Continental Airlines: Community Service" http://www.continental.com/company/profile/community.asp?SID=CCDB
1 CF7D48546C68E6E7C6F95C28895
Continental Airlines / Travel Center / Make Reservations" http://www.continental.com/resmgt/pmakereservations.asp?SID=CCDB1CF7D48546C68E6E7C6F95C28895
E-Business Model
eBusiness Websites and eBusiness Models: A Comparison of Three Organizations The features and functions of a website are a reflection of the purpose of that website. In turn, this is a function of the business model. This will now be shown by comparing the websites of three companies: eBay, Lands' End, and Ecolab. For each website, the target audience will be described, the website will be described, and the features of the website will be linked to the business model. The eBay website is an online bidding site, where the general public can bid to purchase items from sellers. These sellers can either be other members of the general public or can also be retailers. The eBay website has two target audiences. Firstly, there are the consumers bidding on items to purchase them. Secondly, there are the sellers, with eBay needing to attract sellers so that consumers can find items…
Campanelli, M. (2005). Sharing the Wealth: Want to Get a Piece of the eBay Pie? Joining its Affiliate Program can be a Good Way to do Just That. Retrieved May 30, 2005, from Entrepreneur. Web site: http://www.entrepreneur.com/article/0,4621,319519,00.html
eBay. (2005). The Company. Retrieved May 30, 2005, from eBay. Web site: http://pages.eBay.com/abouteBay/thecompany/companyoverview.html
Ecolab. (2005). Company Profile. Retrieved May 30, 2005, from Ecolab. Web site: http://www.ecolab.com/companyprofile/
Lands' End. (2005). About Lands' End. Retrieved May 30, 2005, from Lands' End. Web site: http://www.landsend.com/cd/fp/help/0,,1_36877_36883_37027____, [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] @ [email protected] & sid=6114120827695142630
Income Gap Hurricane Katrina Stuck
For instance we can take the examples of African-Americans, the events and issues show that some ethnic groups had to struggle hard to stay ahead in the social fabric of American society. Conclusion The living conditions of poor and middle segment of the society are main indicators of the health of economy and income distribution. While in developing nations the plight of the poor and even middle segments of society is well-known. Developed nation like United States have not been associated with poverty and the poor treatment of certain segments of society. Recent event have made people argue that over the years issues of poverty and unequal income distribution have hit America in a big way. These issues now can not be brushed under the carpet as the issues are being debated at all forums. People have accepted the grim fact that Income gap exists in American Society and these…
Dovring, F. Inequality: The Political Economy of Income Distribution. Praeger Publishers. New York. 1991.
Kristof. N. The Larger Shame. New York Times. Sep 6,2005 http://cygnus.lcc.edu:2051/pqdweb?did=892078491&sid=2&Fmt=3&clientId=9230&RQT=309&VName=PQD
Ryscavage, P. Sharpe. Income Inequality in America: An Analysis of Trends M.E. Sharpe. New York, 1999.
Scott, J. & Leonhardt, D. Class in America: Shadowy Lines That Still Divide; CLASS MATTERS. New York Times. May 15, 2005. http://cygnus.lcc.edu:2051/pqdweb?did=839712251&sid=8&Fmt=3&clientId=9230&RQT=309&VName=PQD
Microeconomics Over the Last Few Years it
Microeconomics Over the last few years, it is evident that the airline industry in the U.S. has been experiencing long standing as well as novel challenges (The American Antitrust Institute, 2012). These includes the increase in the price of fuel, slowing demand for air travel and pressures to expand globally. Consolidation among various airlines across the country is the most common remedy that most of the airline firms are applying. In April 2012, the U.S. Airways made an announcement to move and take over the American Airlines. American airline is the fourth largest airline in the United States while U.S. Airways is the fifth (Plane Buzz, 2013). This merger, therefore, will make the U.S. Airways- American the largest in the United States with a combined share of more than 21% (The American Antitrust Institute, 2012). The merger is worth 11 billion U.S. dollars and will turn America into the largest…
Carlton, D.W., Landes, W.M. & Posner, R.A 1980 'Benefits and Costs of airline mergers, The
Bell Journal of Economics, Vol. 11, No. 1, pp. 65-83
Retrieved from http://www.jstor.org/discover/10.2307/3003401?uid=2134&uid=2&suid=70&uid=4&sid=21101927848577
Raper, K.C, Love, A.H. & Shumway, R.C 2007, Distinguishing the Source of Market Power, American Journal of Agricultural Economics, Vol. 89, No. 1 (Feb., 2007), pp. 78-90 Retrieved from http://www.jstor.org/discover/10.2307/4123564?uid=3738336&uid=2&uid=4&sid=21101942783417
Marketing Forces and Diversification
Marketing Forces and Diversification As American society becomes increasingly ethnically diverse through immigration, relocation, birth rates and other factors, our hospitals must hone their sensitivity to resulting changes in community health needs. In addition, rigorous competition among hospitals requires sensitive, targeted marketing strategies attractive to diverse populations. An excellent example of responsive marketing and health care is given in Noonan's and Savolaine's article. The intelligence and success of the subject community hospital's approach shows that at least a hybrid of its approach should be followed in marketing to and serving a hospital's community. Analysis with Noonan and Savolaine Article as the Focus Thoughts about the Market Orientation of the Community Hospital Focusing on Noonan and Savolaine article's examination of marketing obstetrical services in a diverse Midwestern market, the community hospital showed considerable wisdom in closely examining its prospective patient population by reviewing discharge data for obstetrical patients and asking doctors…
Anonymous. (2011, February 16). Nationwide, interactive community need maps guide community health planning. Retrieved on May 28, 2012 from Proquest.umi.com Web site: http://proquest.umi.com/pqdweb?index=1&did=2268066501&SrchMode=2&sid=3&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1338218546&clientId=14844
Eastaugh, S.R. (2008, May 15). Diversification in the hospital industry. Retrieved on May 28, 2012 from Proquest.umi.com Web site: http://proquest.umi.com/pqdweb?index=0&sid=4&srchmode=2&vinst=PROD&fmt=6&startpage=-1&clientid=14844&vname=PQD&RQT=309&did=1502831361&scaling=FULL&ts=1338218925&vtype=PQD&rqt=309&TS=1338218931&clientId=14844
Noonan, M.D., & Savolaine, R. (2001). A neighborhood of nations. Retrieved on May 28, 2012 from Proquest.umi.com Web site: http://proquest.umi.com/pqdweb?index=5&sid=2&srchmode=2&vinst=PROD&fmt=6&startpage=-1&clientid=14844&vname=PQD&RQT=309&did=93247294&scaling=FULL&ts=1338218230&vtype=PQD&rqt=309&TS=1338218258&clientId=14844
Maryland Schools and NCLB
No Child Left ehind Letter of Transmittal Impact of NCL on Maryland School Systems Request for specified action Federal and State Restructuring Options Maryland State School Improvement Grant udget Application, Allowable and Non-Allowable Expenditures No Child Left ehind (NCL) is the re-embodiment of President Lyndon Johnson's Elementary and Secondary Education Act of 1965 (ESEA). The primary purpose was to raise the standard of education and bridge educational boundaries. NEA certainly supports these aims and works solely in order to provide children equally standardized public schools. The paper discuses impact of NCL on Maryland schools and what effect the state takeover had on the schools present in the district. Several recommendations and strategies are discussed in order to improve the management of the schools and a detailed request to Mr. Delaney has also been made in the paper to further improve and implement the strategies for the improvement of the schools.…
Dee, T.D., Jacob, B., Hoxby, C., & Ladd, H. (2013). The Impact of No Child Left Behind on Students, Teachers and Schools. U.S.: Brookings Institution Press. Retrieved from: http://faculty.smu.edu/millimet/classes/eco4361/readings/dee%20et%20al%202010.pdf
Editorial Projects in Education Research Center. (2011, Septmber 19). Retrieved from Education Week: http://www.edweek.org/ew/issues/no-child-left-behind/
Ellis, C.R. (2007). No Child Left Behind -- A Critical Analysis. Excelsior. Retrieved from: http://eds.b.ebscohost.com.vlib.excelsior.edu/eds/detail/detail?sid=13942473-32f0-4108-a965-c3a784d24d3d%40sessionmgr112&vid=0&hid=102&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d
Issues and Actions: No Child Left Behind Act. (2011). Retrieved from National Education Association: http://www.nea.org/home/NoChildLeftBehindAct.html
Media's Stereotyical Portrayal of Blacks
But Martin Lawrence bugs out his eyes a little and he's a coon. It makes no sense.'7 The defense seems somewhat warranted. After all, if all characters in the sitcom Martin were white, and acted the same way, such behavior would be attributed to the standard stupidity showcased on television. Much like the quote earlier about sitcoms and stereotypes leveling things, television in general fails to showcase the brightest and most sublime of human endeavors. Lawrence is not alone in criticisms aimed at contemporary black actors. In her essay, "Stereotypes of History: Reconstructing Truth and the Black Mammy," Jennifer Kowalski claims, "actors such as Martin Lawrence, Eddie Murphy, and Tyler Perry, have once again recycled the first existence of the Mammy/Aunt Jemima character." The "mammy" stereotype is "represented as full-figured women with strong and defensive attitudes, especially toward men who may bring harm to their loved ones." Lawrence recently starred…
Aristotle. "Poetics." The Norton Anthology of Theory and Criticism. Ed. Vincent B.
Leitch. New York. W.W. Norton and Company, 2001, 90-117.
"Blackboard Jungle Fever." Martin. By John Bowman. Martin Lawrence, Tisha
Campbell-Martin, Carl Anthony Payne II, Thomas Mikal Ford. The WB. January
Federal Deficit and Entitlement Programs
" What this shows is how the current financial crisis / recession have placed a drag on both programs that are facing severe challenges from the large numbers of uninsured. Where, the lack of health insurance is indirectly forcing people to turn to both programs, once their condition becomes so severe that it can no longer be ignored. At which point, the costs increase to treat these people which causes the overall levels of the national debt to increase. However, the current recession is also having a direct impact on both entitlement programs. This is because a large number of aby oomers are approaching retirement age, which means that many will often look to both programs as way to supplement their income and health insurance. Then, when you combine this with the fact that the current recession is causing incomes to decline and health insurance premiums to increase, means that…
Annuity. 2010. Free Dictionary. Online. Available from the Internet, http://www.thefreedictionary.com/annuity , accessed 7 May 2010.
Estimating the Number of Uninsured. 2009. Medical News Today. Online. Available from the Internet, http://www.medicalnewstoday.com/articles/161577.php , accessed 7 May 2010.
Life Expectancy. 2004. Office of National Statistics. Online. Available from the Internet, http://www.statistics.gov.uk/cci/nugget.asp?id=881 , accessed 7 May 2010.
Senate Lifts Debt Ceiling by $1.2 Trillion. Fox News. Online. Available from Internet, http://www.foxnews.com/politics/2010/01/28/senate-lifts-federal-debt-ceiling-trillion/ , accessed 7 May 2010.
Waves in the Mass Immigration
For instance, most illegal immigrants earn a living that is below the poverty threshold. Towns and cities can enforce legal policy created due to the economic incentive of protecting local schools and hospitals from financial ruin. Therefore, if there is a large population of illegal immigrants living in a town/city and are below a minimal level of income, the most effective policy is to build additional schools and hospitals designed to cater specifically to these populations. The idea is to create facilities where illegal immigrants can learn and understand how to become an assimilated immigrant into American life. Additionally, these facilities will house programs that enable immigrants to become American citizens through the legal process of obtaining citizenship. The creation of additional schools and hospitals will increase jobs in the community, which can be funded in part through a number of federal programs that provide direct and indirect monetary resources…
Joch. (2010). "Immigration in the United States." New Presence: The Prague Journal of Central European Affairs. July 1, 2010. Retrieved from: http://web.ebscohost.com.rlib.pace.edu/ehost/pdfviewer/pdfviewer?hid=7&sid=79b0dbd3-39a3-42cd-9251-b89bc3234568%40sessionmgr13&vid=1
Independent Review. January 1, 2010. Retrieved from: http://web.ebscohost.com.rlib.pace.edu/ehost/pdfviewer/pdfviewer?hid=7&sid=9e5d9f48-ef82-40e2-b0da-de96f7c9b839%40sessionmgr15&vid=1
Independent Review. 2010
National Council for Accreditation of
It is felt that this action will enhance the value of institutional accreditation and help to better prepare teachers for the reality of the classroom. orks Cited Duncan, Arne. "Secretary Arne Duncan's Remarks to National Council for Accreditation of Teacher Education." U.S. Department of Education. November 16, 2010. ED.gov. 13 December 2010. "Professional Standards for the Accreditation of Teacher Preperation Institutions." NCATE. (February 2008). 12 December 2010. Sawchuk, Stephen. "Merger lies ahead for Accrediting Bodies of Teacher Preparation." Education eek. Vol. 30, Issue 10. November 3, 2010. 13 December 2010. Starnes, Bobby Ann, Jon Saderholm and Althea ebb. "A Community of Teachers." Phi Delta Kappan. Vol. 92, Issue 2 (October 2010): 14-18. 13 December 2010. ise, Arthur E. "National Council for Acceditation of Teacher Education." Gale Encyclopedia of Teacher Education. (2002) in Answers.com 10 December 2010.
Duncan, Arne. "Secretary Arne Duncan's Remarks to National Council for Accreditation of Teacher Education." U.S. Department of Education. November 16, 2010. ED.gov. 13 December 2010. http://www.ed.gov/news/speeches/secretary-arne-duncans-remarks-national-council-accreditation-teacher-education >
"Professional Standards for the Accreditation of Teacher Preperation Institutions." NCATE. (February 2008). 12 December 2010.
Sawchuk, Stephen. "Merger lies ahead for Accrediting Bodies of Teacher Preparation." Education Week. Vol. 30, Issue 10. November 3, 2010. 13 December 2010.
Starnes, Bobby Ann, Jon Saderholm and Althea Webb. "A Community of Teachers." Phi Delta Kappan. Vol. 92, Issue 2 (October 2010): 14-18. 13 December 2010.
Identity in the Professor's Daughter
She was greatly disturbed by the hite Buffalo deer hunting party because she identified and sympathised with the deer. Unlike the rash temper Bernard Jr. displayed in times of conflict, Meteke was almost silent in her pain and anguish, to the point that her husband begged her to talk to him, resorting to offers for tea, food, and foot massages to ease her tensions and cheer her (Raboteau, Professor's 72). Professor Lester was fairly clueless about what ailed her, as she chose to steer around his questioning rather than answer him directly. One evening in bed she turned away from him, and when he asked why she seemed upset she responded "I'm tired," rather than confiding in him her fear for the dear (Raboteau, Professor's 83). The reader saw very little of who Meteke was before she married Professor Lester, so her identity was only really articulated in her response…
Bardelson, Susanne, and Jackie Gropman. "The Professor's Daughter: A Novel." School
Library Journal Sep 2005: 244-245. Academic Search Premier. 2010. EBSCO
Industries Inc. 4 Dec. 2010
Horseshoe Crabs According to the
In insects, the anterior portion of the heart, located in the abdomen, is extended into a tube, the aorta, which directs the blood forward as it goes out into the body cavity. Arthropods have a well-developed, mesodermal, ventral, solid nerve cord and well-developed sense organs. The body feature from which the phylum takes its name is the jointed appendages, which include antennae and mouthparts as well as walking legs. Arthropods early ancestors had a number of body segments, each with a pair of jointed appendages and looked similar to a centipede. From there, some of these segments became fused to form a head and some of the appendages became modified to form mouthparts or antennae. Early on, there was an evolutionary split which led to the various modern subphyla and classes. Currently, three living subphyla are recognized, with trilobites representing an extinct fourth subphylum (Carter, 1997). Horseshoe Crabs belong to…
Carter, J.S. (1997). Phylum Arhropoda. UC Clermont College Biology Home Page. Retrieved September 14, 2010, from http://biology.clc.uc.edu/courses/bio106/arthrpod.htm
NAI. (1999, February). Horseshoe crabs. National geographic, Vol. 195, Issue 2. Retrieved September 14, 2010, from http://web.ebscohost.com/ehost/detail?vid=7&hid=7&sid=69110e3d-d254-4915-a7c7-bed5e36affaf%40sessionmgr12&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=1440406
NAI. (2009, December 1). Horseshoe crab. Columbia electronic encyclopedia, 6th Edition . Retrieved September 14, 2010, from http://web.ebscohost.com/ehost/detail?vid=4&hid=7&sid=2bdf4e92-2120-48e7-9941-1005ce6b0446%40sessionmgr14&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=39012259
Wal-Mart's Mission and Vision Take
Many other stakeholders are simply not addressed in al-Mart's mission or vision at all. The environment is not addressed. The company's stakeholders in China are not addressed, although the firm's strong relationship with the Chinese government must place that government as a major stakeholder in al-Mart's enterprise. Although al-Mart does have stores in China, it is not nearly the factor for Chinese consumers as it is for American ones, although it is a net creator of manufacturing jobs rather than a net destroyer of them in that country. al-Mart's vision is that from giving the consumers want they want -- and assuming that low prices is what they want -- that the needs of other stakeholders will be met. The company certainly has its mission set to consumers as one stakeholder group. Indeed, for direct employees of al-Mart its mission functions well also, as the company now employs two million…
WalMartStores.com, various pages. (2010). Retrieved June 23, 2010 from http://walmartstores.com/AboutUs/8123.aspx
Bianco, a.(2007). Wal-Mart's Midlife Crisis; Declining growth, increasing competition, and not an easy fix in site. Business Week. New York, April 30, 2007, Issue 4032,-page 46. http://proquest.umi.com/pqdweb?index=2&did=1260663161&SrchMode=1&sid=5&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1236357424&clientId=29440
Bianco, a., Zellner, W., Brady, D., France, M., France, M., Lowry, T., Byrnes, N., & Zegel. S. (2003). IS WAL-MART TOO POWERFUL? Low prices are great. But Wal-Mart's dominance creates problems -- for suppliers, workers, communities, and even American culture. Business Week. New York: Oct 6, 2003., Iss. 3852; pg. 100
Raising a Sensory Smart Child
" Does the child show impulsiveness, or have problems transitioning from one activity to another activity, or seem rigid and inflexible at times? Moreover, are there signs of carelessness or clumsiness -- and is the child uncomfortable while involved with group situations? All of these behaviors in this paragraph are signs that SI dysfunction may be part of the problem, the authors assert. And there are several more that the authors point to -- including when a kid has a big problem handling frustration, when he can't smoothly transition from an active state to a "calm, rested state" -- but just because one or more of these behaviors are apparent that doesn't automatically mean the child has SI dysfunction. "Lots of kids show these signs for lots of reasons," the authors explain. And some of the behaviors are quite "appropriate at certain ages" because "most toddlers are pretty impulsive" (note…
Biel, Lindsey, and Peske, Nancy K. (2005). Raising a Sensory Smart Child: The
Definitive Handbook for Helping Your Child With Sensory Processing Issues.
New York: Penguin Books.
Planning by 2012 Starbucks' Chairman
Finally, increasing repeat business through expanded customer loyalty efforts would help to increase sales. Threats abound. A longer than expected recession could lead to more sagging demand for premium-priced coffee. An ongoing recession will also continue to make it difficult for Starbucks to impose additional price increases at a time when U.S. operating margins are falling because of increased labor and utility costs and increasing coffee prices (MCRoskey, 2008). Dunkin' Donuts and McDonald's are fierce competitors at lower-price points and could always scale up to offer more premium-based products. The company's international expansion plan is extraordinarily aggressive and customers may find that it has failed to meet their cultural expectations for cafes and coffee. This expansion is coming at a time when the company is experiencing problems in its established global markets. Continued growth could further erode the company's brand image and lead to commoditization that threatens the company's ability…
Helm, B. (2007, April 9). Saving Starbuck's Soul: Chairman Howard Schultz is on a mission to take the company back to its roots! Oh, yeah-- he also wants to triple sales in five years. Business Week, 4029, p. 56. http://proquest.umi.com/pqdweb?index=2&did=1252343951&SrchMod e=2&sid=12&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1235501315&c lientId=29440
McRoskey, R. (2008, August 19). Starbucks: Big investors' divorce grounds. Business Week. http://proquest.umi.com/pqdweb?index=0&did=1534482941&SrchMode =2&sid=13&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=123
Rae, J. (2006, November 27). The importance of great customer experiences. Business Week, 4011, p. 32.
Criminal Justice Walpole State Prison
There should be a manual override system in place in regards to the cell doors. This would allow those in charge to manually lock down all cells to help make sure that no other ones opened on their own. Providing training to all staff ahead of time so that they are enabled to handle any such situation that might arise is critical. Every staff member should know what they are supposed to do and when they are supposed to do it, if an emergency situation should arise. Training and practice drills should be conducted ahead of time so that everyone is one the same page. Because human lives are at stake every effort should be made to make sure that the best possible plan is developed and available. The security threat plan should be reviewed an updated on a regular basis. This will help to ensure that any changes that…
MCI - Cedar Junction. (2009). Retrieved September 29, 2009, from Mass.gov Web site:
http://www.mass.gov/?pageID=eopsterminal&L=4&L0=Home&L1=Law+Enforcement+
%26+Criminal+Justice&L2=Prisons&L3=State+Correctional+Facilities&sid=Eeops&b=t erminalcontent&f=doc_facility_mcicedarjunction&csid=Eeops
Ranalli, Ralph. (2005). Havoc created in jail cells. Retrieved October 1, 2009, from Boston.com
Charles Lindblom Pendleton Herring the
242). This approach to decision making in public administration was thought to result in improved policies since the approach was well suited to the pluralist environment in which these decisions were being made and provided opportunities for alternative views to be advanced. The incremental model as "took into account the limitations of human cognitive capacities and the costs of acquiring information" (Utter & Lockhart, 2002, p. 242). Lindblom, C.E. (1959, Spring). The science of 'muddling through.' Public dministration Review, 19, 79-88 in Stevens at 15. Stevens, J.B. (1993). The economics of collective choice. Boulder, CO: Westview Press. Utter, G.H. & Lockhart, C. (2002). merican political scientists: dictionary. Westport, CT: Greenwood Press. Unit II ssessment. Question 1: Marble cake federalism Question 2: Congressional Budget Office Question 3: Municipal Question 4: Pluralism and Calvinism Question 5: Federal system of government Question 6: "Why can't the citizens of the states just keep their…
According to Hanson (1998), "Adherents to picket fence federalism contend that the most important components of the federal system are the various functional bureaucracies, not the national, state, or local governments" (p. 24). From this perspective, the "pickets" of the governmental fence (e.g., the national, state, and local governments) are frequently too fragmented to provide the level of coordination needed to effect meaningful action at the local level (Hanson, 1998). A good example of how this approach has been used in New Brunswick, New Jersey is the implementation of so-called "Special Improvement Districts" (also known as Business Improvement Districts) that are described by the municipality as being "Self-help ventures organized by property owners and local governments to identify and develop defined areas of cities where a more successful and profitable business climate is needed" (Special improvement districts, 2009, p. 1). These districts, which are referred to by the acronym "SID," are managed by private agents who coordinates commercial promotional activities, as well as identifying opportunities for improving the security and maintenance services for existing businesses in their districts (Special improvement districts, 2009). According to the city's official Web site at http://www.newbrunswick.com , "The law permits property owners and businesses in the specified district to organize and assess themselves to pay for the services that they determine. SIDs provide specialized services to advance business revitalization in downtowns. These services are designed to complement rather than replace municipal government services" (Special improvement districts, 2009, p. 3).
Hanson, R.L. (1998). Governing partners: State-local relations in the United States. Boulder,
CO: Westview Press.
Study Skills and Why They
This also refers to the false impression that cramming is a successful learning technique. As this study notes; "…it is much better to create an interval between the times you study an item" ( Glenn, 2007, p. 2). Similarly, a study entitled Smart way to study (2009) also emphasizes that intervals between study session have been shown to improve retention and understanding of the material. This method also means that information is retained and can be utilized in a more interactive manner by the student. 3. Tips to improve study skills Study preparations are an important part of developing useful and long-term study skills. As has been referred to, the organization and management of the correct study skills that are appropriate to each individual's predilections is an important aspect that should be borne in mind in the development of successful learning skills. This also includes significant aspects, such as choosing…
Fleming G. Would Group Study Improve Your Grades? College Professors Think So!
Retrieved July 16, 2009, from http://homeworktips.about.com/od/homeworkhelp/a/study.htm
Larson, S. (2005). Teaching for Transformation in Today's Challenging Youth.
Reclaiming Children and Youth, 14(1), 27+. Retrieved July 12, 2009, from Questia database:
Nontraditional Student Experience Serving the
Compare the costs of different programs. There is a wide variety, and costs are not always related to quality." can say from my own personal experience, education has gained more emphasis than actual work experience. Now, more and more, employers are asking for formal degrees before looking at someone's accomplishments and expertise. Therefore, working people may not prosper without a degree. Online education provides an option to get a degree that might not otherwise be available. I am suffering from the same problems that prevent most people from obtaining a degree and I am taking online classes from home. It is allowing me to fulfill my parental obligations and to continue my education while I am working in a way that is more flexible and affordable than traditional classrooms. While these offer many benefits over online courses, I do not need these at my current stage in life. eferences Berkson,…
Berkson, Jennie. "Learning Online." The Writer. May 2005. Boston: Vol. 118, Iss. 5; pg. 23, 3 pages Retrieved from ProQuest on May 23, 2008, Document ID: 825769111
http://proquest.umi.com.proxy.devry.edu/pqdweb?did=825769111&sid=2&Fmt=4&clientId=44941&RQT=309&VName=PQD
Fretty, Peter. "Career Track," PM Network. September 2006. Drexel Hill: Vol. 20, Iss. 9; pg. C16
Ingle, Henry T. "Distance Learning/Technology." The Hispanic Outlook in Higher Education. 8 May 2006. Paramus: Vol. 16, Iss. 15; pg. 33
Home Industry There Are a
The house would still be capable of customization but would not necessarily have to be. This could lead to more profitability to the builders and a less likely chance of sloppy workmanship. The home building industry has the opportunity to show that it can react to adversity and with the situation as it currently stands, builders may have the desire to lower expenses, while not cutting corners, as much as possible. The home building industry, therefore, seems to be one that can provide the economy with a boost when it is needed, with a foundation at all times and with overall growth that can lead to a robust job market, growth in the GDP and financial independence for those builders that are willing to commit to the hard work necessary to succeed. There are relatively few industries that provide individuals with that type of opportunity and even fewer industries that…
Bogoslaw, D. (2007) Homebuilders in a Hole, Business Week Online, pg 15 Accessed Sept 24, 2007 at http://web.ebscohost.com/ehost/detail?vid=6&hid=2&sid=486e70e9-8320-4156-9bd0-750d6c9d32d0%40sessionmgr2
Fed's Calming Outlook Bucks up Stocks, (2007) USA Today, Money Section, pg 1B
Patterson, R. (2005) Home Sour Home, Mother Jones, Vol. 30, Issue 4, Accessed September 26, 2007 from Academic Search Premier
Stovall, S. (2004) Homebuilders: A Slump After the Jump, BusinessWeekOnline, Accessed Sept. 25, 2007 at
Death Penalty Annotated Bibliography
Death Penalty+ Annotated Bibliography It has been theorized and even proven that many laws that are in place in America are the product of JudeoChristian religious beliefs, practices and writings, that have over the years been toned down to better meet the needs and standards of the U.S. society. here is a clear sense that some penalties for breaking the law have little if any effect on crime committed in the future, i.e. act as deterrents to crime and penalties for crime range from paying small fines to capital punishment. Opponents of capital punishment have always claimed that it does not deter crime while proponents have claimed that it does. Opponents have also claimed that the death penalty is a violation of the 8th amendment, cruel and unusual punishment and that it does not belong in any civilized society. Proponents on the other hand state that it is important to…
Tonry's book is a detailed and comprehensive look at racial disparity in the U.S. legal system. The work is troubling but based on serious inquiry and serious thought. In the work he discusses how many experts have convened over the years to determine that there is no reason to believe that capital punishment is more of a deterrent to violent crime that life sentences and yet the U.S. government is still alone among all Western nations to retain its legality.
Zimring, F.E. (2003) The contradictions of American capital punishment. New York, NY: Oxford University Press.
Zimring's book is a fascinating discussion about the history of capital punishment in the U.S. with comprehensive look at the ebb and flow of the laws that entrench it and the many theories and contradictions that are embedded in it. He is also very effective at providing a relatively balanced look at just why in a social, political and legal sense that capital punishment exists today and especially at the manner in which it is applied, including an extensive look at why the appeals process is so vast and strict. His thesis is basically that the process is so "moral" and "ethical" because it is the stop gap effort of the nation to come to terms with why the death penalty is still on the books at all.
International Relations Theory and United Nations Peace
International elations Theory and United Nations Peace: International elations (I) field normally focuses on the study of how various state systems can be made to work more efficiently to improve the power of law, maintain order, manage interstate affairs peacefully, and lessen prospects of war. The word relation in this field is used to denote the inclusion of more than political affairs to aspects like conflict and peace. International relations field is closely linked administratively to political science departments (O'Connor, 2010). Actually, the field of international relations traces its origin from various subfields including international law, diplomatic history, and international economics. While it's still early to consider international relations as a sovereign field of study, it has broken from the analytical procedures of economics and law as well as the ongoing process of breaking from political science. Consequently, this field has become an important facet because of the conceptualizations of…
References:
Ahmed, S. Keating P. & Solinas, U (2007), 'Shaping the Future of UN Peace Operations: is there
A Doctrine In the House?' Cambridge Review of International Affairs, vol. 20, no. 1, pp. 11-28, viewed 26 November 2011,
Cristol, J (n.d.), International Relations Theory, Oxford Bibliographies Online, viewed 26
November 2011,
Persuasive Against Smoking
If a driver ignored a road sign that said "Danger: Bridge Out!" and proceeded along the street, he would be labeled as an idiot by his community. If a fence had a sign on it that read, "arning: Vicious Dogs" and some adventure-seeking teens climbed that fence, no one would be surprised when they had their legs torn off by a pack of pit bulls. However, every single year 400,000 Americans die[1] from ignoring one of the most infamous warnings: The Surgeon General's warning on cigarette packages. Smoking cigarettes may seem to be a part of the definition of being an American-- everyone from the street punk rebels to the successful big business CEOs are automatically visualized with a cigarette or fat Cuban cigar hanging from their mouths. These smokers see themselves as a better person for the momentary pleasure they receive from these tobacco products, but fail to realize…
Works Cited.
The American Cancer Society. Who Is At Risk? "Tobacco and Cancer." 2001.
The American Heart Association. Publications and Resources. "Tobacco Smoke."
California Department of Health Services. Youth Media Network. "Effects of Secondhand Smoke." November 2001.
Emphysema Foundation For Our Right to Survive. Medical Info Pages. "About Smoking With Emphysema." January 2002.
SIDS Counseling Treatment Plan Sudden Infant Death Syndrome: A Treatment Plan The unexpected death of an infant is a heartbreaking tragedy. Sudden infant death syndrome (SIDS) refers to the…
78), or that particulate air pollutants might be a contributing factor in SIDS (Glinianaia, Svetlana V., Rankin, Judith, Bell, Ruth, Pless-Mulloui, Tanja, and Howel, Denise, 2004, p. 1365). However,…
Professional Writing
In addition to sleeping the infant on his or her back, CBNR reports that steps must be taken to ensure that the child's respiration and circulation are not constricted…
Health - Nursing
Sudden Infant Death Syndrome (SIDS) The causes of Sudden Infant Death Syndrome (SIDS) still remain poorly understood. Although there has been a dramatic decrease in its incidence, it still…
Mythology - Religion
uddhism Compare and contrast Siddhartha Gautama's (uddha's) "going forth" into the monastic life with that of Maechi Wabi, based on the reading of "Journey of One uddhist Nun." In…
Communication
proj Management 7.2a There are several symptoms of cultural communications problems. The first is that Sid did not want to be honest with Judy right away; she had to…
Balance Scorecard for Fatura Business organizations operate with the sole objective of effectively utilizing the input factors in order to maximize on the output. For this case, output is…
Social psychology, both as an academic and a professional practice, is extremely useful for elucidating the phenomenon of high rates of suicide within the military, and within the United…
For example, when mothers smoke during pregnancy they not only put toxins in their own bodies, but into the bodies of their babies as well. In addition to these…
Research Paper
Adopting a special needs child also presents strong demands on time and energy that "normal" families do not usually have to deal with. According to Cloud and Townshend (2001)…
e., they became helpless). Furthermore, other behaviors of the dogs were adversely affected (e.g., the dogs appeared apathetic and had poor appetites) (Hitzemann, 2000). In his essay, "Animal Models…
Research Proposal
Communication - Journalism
Evidence of this can be seen with the company being slow to provide information, on the total amounts of oil that are leaking into the ocean and the various…
S.S.. This has resulted in a renewed tourist enthusiasm to visit these countries. The imaging process involved a portrayal of conformity to the European paradigm, a projection of a…
Infant Sleep Patterns People sleep nearly one third of their lives and infants sleep significantly more than adults (Franken, Kopp, Landolt, & Luthi, 2009). The function of sleep has…
The bill before me takes into account of the new realities and dangers posed by modern terrorists. It will help law enforcement to indentify, to dismantle, to disrupt and…
One solution of this issue can be that the closest most guardians is given the permission and right to take the decision about the life of the patient who…
Business - Advertising
It is also interesting that, somewhat differently from the first advertisement, we are no longer looking for efficiency, productivity increase and lower costs. Since consumerism is the key to…
The academic and behavioral challenges presented by students with EBD affect the nature of their interactions with their teachers. Aggressive behavior patterns increase the likelihood that children will develop…
More Care Giving to Babies: One of the biggest advantages of co sleeping is increase in breast feeding (McKenna, 1994; Richard et al., 1996). This is admitted even by…
Supplier Service Quality THE IMPORTNCE OF SUPPLIER SERVICE QULITY Suppliers are an integral part of the value chain as they provide the raw materials, components and parts that are…
Literature Review
Emotional Drivers Swarovski The motives behind consumer decisions to purchase luxury brands like Swarovski have been studied in a number of researches. The general findings of these studies have…
Sports - Women
Sexual Liberation In addition to sexual intercourse and its variations, sexual liberation refers to the universe of human issues affecting all genders. America was propelled from the sexual enslavement…
Drama - World
" 4. Social and Political Life There is a general paucity of information about the actual societal and political structure of the Olmec. While there is not much evidence…
movies atings television shows atings. Cuently aea numbe shows television potaying negative aspects ace, class gende. Fo, show "Family Guy" a show played "pimetime" mateials show "kid-fiendly. Watching Toy…
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Perspective article, the science (or nonscience) of research into sudden infant death syndrome (sids).
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
This Viewpoint paper presents a timely and constructive critique of mainstream SIDS research. It is concerning that twenty-first century medical science has not provided an answer to the tragic enigma of SIDS. The paper helps explain why this is so and illustrates possible shortcomings in the investigation of Sudden Infant Death Syndrome/Sudden Unexplained Infant Death (SIDS/SUID) by mainstream researchers. Mainstream findings are often based on questionable and dogmatic assumptions that return to founding notions such as the Triple Risk Hypothesis and the contention that the mechanisms underlying SIDS/SUID are heterogeneous in nature. The paper illustrates how the pathological findings in SIDS have been under-investigated (or ignored) and that key epidemiological risk factors have slipped from memory. This apparent amnesia has resulted in failure to use these established SIDS facts to substantiate the significance of various neuropathological, neurochemical, or other research findings. These unsupported findings and their derivative hypotheses are therefore ill-founded and lack scientific rigor.
Conclusion: The deficits of SIDS “science” revealed in this paper explain why the SIDS enigma has not yet been solved. To make progress in understanding SIDS, it is important that researchers, as scientists, uphold standards of research. Encouragement for new directions of research is offered.
Introduction
Over the past 30 years, as a Sudden Infant Death Syndrome (SIDS)/Sudden Unexplained Infant Death (SUID) researcher, the author has followed mainstream's progress and has realized that mainstream approaches to the problem are flawed at a fundamental level. To address this, leading peer-reviewed publications were reviewed using PubMed and Google Scholar (search terms: “Sudden Infant Death Syndrome,” “SIDS”) to provide evidence as to why the SIDS enigma remains unexplained. Where possible, papers cited were selected on the basis of the senior author having published a minimum of 10 papers on the subject and that the papers concerned the prevailing hypotheses on SIDS. While this paper is a critique of mainstream research, its aim, through the arguments herein put, is to encourage SIDS researchers to reconsider their hypotheses in the hope of yielding improved research outcomes.
There are not many issues in medical science that lack explanation. It could be argued that current mainstream SIDS research remains at a stage not dissimilar to that of peptic ulceration in the pre- Helicobacter era. To achieve an understanding of a condition, respect must be paid to the essential elements of the condition: these elements include the epidemiology (e.g., risk factors), the pathology (including the laboratory findings), and the physiological findings. Based on these, a case definition is developed. The definition of SIDS has undergone several iterations ( 1 – 3 ). The often-used San Diego definition ( 3 ) states “the sudden and unexpected death of an infant under 1 year of age, with the onset of the lethal episode, apparently occurring during sleep, that remains unexplained after a thorough investigation including a performance of a complete autopsy, and review of the circumstances of death and the clinical history.” The definition is unhelpful in that its usefulness is limited to being exclusive. However, this definition, in extended form, is more helpful than previous ones, as it provides categories based on some pathological findings. All definitions could be misleading in relation to the reference to sleep . This allusion has led many researchers to explore physiological events during infant sleep, and such work has extended to investigate arousal mechanisms ( 4 , 5 ). With very few exceptions, the results of these investigations do not refer to epidemiological risk factors or the gross pathological findings of SIDS. Therefore, these findings are unsupported in obvious ways. Death during sleep is not a prerequisite for diagnosing SIDS/SUID: cases occur in awake infants ( 6 ), although the San Diego definition ( 3 ) with its “ during sleep” restriction would exclude these cases. Such restriction is only academic, as proof of being asleep cannot be ascertained. Additionally, it is known that SIDS occurs at all times of the day, suggesting that an infant could have been awake. Most SIDS cases occur between midnight and 0600 h ( 7 ).
A more recent development regarding the SIDS definition deemed as a new classification of SUID has surfaced, which is heavily weighted toward asphyxia as the underlying event ( 8 ). The study re-examined cases originally designated SIDS; a panel of reviewers ascertained that asphyxia potentially contributed to death in 40–59% of the cases based on a potentially risky sleeping environment. The authors “ suggest that SIDS not be used if a potential (but not necessarily proven) other cause of death exists .” This should raise many questions: no mention in this article of extrathoracic petechial hemorrhages was made. Such a pathological finding would raise suspicion and strongly indicate an asphyxial mode of death. Other risk factors, such as prone sleeping and features of infection, were not examined, nor were the ages of cases reported; asphyxia appears to be uncommon in older cases than the peak age (2–4 months) of SIDS. In a similar study, Garstang et al. ( 9 ) found that only 14% of SUID could be reclassified as caused by asphyxia, which puts the findings of Randall et al. under further question.
The Importance of Autopsy Findings
In understanding the fundamental facts about SIDS, the shortcomings of mainstream SIDS/SUID research will become obvious. The current dogma purports that the gross pathology of SIDS is unremarkable ( 10 ). This is fundamentally erroneous. As with the investigation of adult deaths the autopsy remains the mainstay for proper diagnosis ( 11 ). The same applies to the investigation of SIDS. Standardized autopsy protocols go some way in improving the investigation of sudden deaths but these, unfortunately, are not universally applied. In regard to SIDS, where autopsies have been conducted by pediatric pathologists, it is remarkable that the pathological findings ( 12 , 13 ) are very consistent and can be applied to approximately 90% of cases. The gross findings include
• Intrathoracic petechial hemorrhages in and on the thymus, epicardium, and visceral pleura/lungs.
• Heavy fluid-laden lungs with early subtle acute inflammatory changes.
• Heavier than normal thymus ( 13 , 14 ), brain ( 13 – 21 ) and liver ( 13 , 22 , 23 ).
• Liquid blood in the chambers of the heart ( 12 ).
• Empty bladder ( 12 ).
• Raised core temperature ( 24 ).
The autopsy extends to histopathological findings and laboratory findings. These are discussed below.
Laboratory Data
As part of the autopsy investigation, laboratory findings can also provide clues to underlying pathogenetic mechanisms in SIDS/SUID. These include increased tissue proinflammatory cytokines IFN-alpha, TNF and IL-6 ( 25 – 30 ), including increased IL-6 in cerebrospinal fluid and vitreous in the eye ( 26 , 31 ). Raised serum fibrin degradation products (FDPs, D-dimer) ( 32 ) provide another clue, as does lower than normal serum melatonin ( 33 ). Infection and sepsis stimulate the release of serotonin, increasing serum levels of this related hormone ( 34 ). Histopathological findings also support the infection model. These include low-grade lung inflammation ( 35 ) and/or myocardial inflammation ( 35 ) and changes typical of haematogenous shock ( 36 ) and shock-like diaphragmatic muscular degeneration ( 37 , 38 ). Neuropathological features that could reflect shock include neuronal apoptosis ( 39 ) and microglial activation ( 40 ). Microbiological investigation reveals detection of bacterial toxins in SIDS tissues ( 41 , 42 ), isolation of bacterial pathogens (e.g., Staphylococcus aureus and Escherichia coli ) from normally sterile sites ( 43 , 44 ), and despite these clues, infection and sepsis have not been widely examined in relation to most aspects of SIDS research and despite the findings of those proposing the Infection Model of SIDS ( 25 – 32 , 35 , 41 – 49 ).
While serotonin has been a major focus of SIDS research, the work has lacked meaningful results because there has been no or minimal supporting epidemiological or clinicopathological correlation ( 50 ). Without this, interpretation of results is impossible. In regard to serotonin levels, these are confusing; for example, some studies show raised blood levels ( 50 ), while brainstem levels of tryptophan hydroxylase and serotonin receptor binding were found to be lowered ( 51 ). This seems counterintuitive. Moreover, important correlations with SIDS risk factors could not be found in these publications.
Physiological Clues
Also important are clinicophysiological findings ( 52 ): computer memory monitored babies have been recorded as apparent SIDS/SUID deaths. These recordings demonstrated bradycardia followed by asystole. Gasping respirations and cessation of breathing followed the cardiological events and suggest that the cause lies within the heart rather than respiratory control. Prone sleeping has been assumed to be related to asphyxia, but its likely real reason for increased SIDS risk has been overlooked (vide infra) .
Triple Risk Hypothesis
In fashioning a research direction, a number of models incorporating known risk factors have been proposed and refined ( 53 – 55 ). These eventuated in the SIDS “triple risk” model ( 56 , 57 ). It supposes that the risk of SIDS is increased when a vulnerable infant is exposed to environmental stressors. The three components of the model are (1) a critical developmental period in homeostatic control (from 1 to 6 months, especially 2–4 months, the “SIDS peak”); (2) exposure to stressors (overheating, infection), and (3) underlying susceptibilities (age, sex, race, etc.) ( 57 ). The model has since been modified, but its essence remains much the same ( 57 ). Guntheroth and Spiers ( 57 ) concluded after analyzing in detail the series of hypotheses… “ The advantage of any of the triple risk hypotheses in understanding SIDS has not been demonstrated.” This warning has not been heeded, and researchers still use the triple risk hypothesis as a platform upon which they base their research. More recently, Spinelli et al. ( 58 ) errantly continue the notion of its usefulness: the authors state that it… “ assists in helping to conceptualize SIDS” and “ continues to provide an extremely useful framework to guide current and future research.” Of additional concern is the emphasis of the triple risk hypothesis on homeostatic control . This has been misleading and requires new thinking.
In seeking a homeostatic control answer, researchers tried to link apparent abnormalities in the brainstems of SIDS cases ( 59 , 60 ). They found that 40–50% of SIDS babies' brainstems appeared abnormal. Some controls had similar abnormalities.
This led a quest for a common underlying pathogenetic mechanism and advanced the theory of failure in homeostatic control (breathing and/or cardiac arrhythmia) to be central to SIDS. This approach has yet to provide a definitive answer despite concerted efforts. This focus on homeostatic control has generally ignored [with a few exceptions ( 39 )] the key clinicopathological and epidemiological findings herein set out. The physiological monitoring information clearly relates to cardiac control ( 52 ). Investigation into the heart (and potential underlying mechanisms, e.g., sepsis) is therefore appropriate. Continuation of respiratory control research without physiological evidence of an abnormality in respiratory control would deem this line of research fruitless. Evidence of chronic hypoxia in some SIDS cases ( 11 , 61 ) may have led researchers to explore a respiratory-based paradigm; however, data pertaining to “chronic hypoxia” are contradictory ( 62 ) and place this paradigm on shaky ground. Consideration of and active research into other possible causes of hypoxia (sepsis being one) ( 62 , 63 ) has not occurred.
Infection and Epidemiology
Several authors have hypothesized that SIDS could be caused by a dual infection with a respiratory virus and toxigenic bacteria ( 22 , 41 – 49 ).
The epidemiology and gross pathology of SIDS clearly demonstrate evidence for respiratory viral infection, which could possibly act as a SIDS trigger ( 48 ). In many studies, more than 75% of SIDS babies featured recent or active respiratory tract infections ( 64 , 65 ).
In matched case-control studies, living babies showed rates of infection similar to those of SIDS and reflected the epidemiology extant at the time. Numerous studies [reviewed by Prandota et al. ( 66 )] have attempted to demonstrate a link between respiratory infection and SIDS. These studies naturally were unable to show a difference in viral infection [and lung pathology ( 67 )] between SIDS and controls. However, the results of the study by Bajanowski et al. ( 68 ) favored the hypothesis that respiratory viral infection could act as a trigger in SIDS. Despite the positive findings of Bajanowski et al. ( 68 ) researchers tended to discount the possible role of infection in SIDS. Regrettably, this attitude has largely continued to this day, despite all the established infection-related epidemiological features listed below:
• seasonality (the winter peak) ( 47 , 69 )
• a pronounced association with epidemic viral diseases, including influenza A ( 70 , 71 )
• Acute illness (e.g., URTI/otitis media) with symptoms present at the time of death but are not significant as a cause of death ( 72 ). Susceptibility to infection could be influenced by genetic make-up (vide infra)
• male sex ( 73 )
• Low socioeconomic status ( 74 ), as measured by deprivation indices, overcrowding, maternal age and maternal education, etc.
• sleeping on contaminated surfaces (the parental or other shared bed ( 75 ), used mattress ( 76 ), or sofa ( 77 )
• high birth order wherein older siblings bring viral infection home ( 78 )
• prematurity/preterm birth ( 79 )
• smoke exposure ( 80 )
• lack of breastfeeding ( 81 )
• waning maternal transplacental IgG ( 82 )
• Overcrowding, low socioeconomic status ( 74 , 83 )
• Prone sleep position (the effect of this appears only to operate when there is a coincident infection) ( 84 – 86 ) (vide infra) .
Prone Sleep Position and Infection
The above features uphold the infection model for SIDS. Interaction between viral respiratory tract infection, prone sleeping and secondary nasopharyngeal bacterial flora changes leading to fatal sepsis provides a simple and plausible mechanism ( 48 , 49 ).
The role of infection in SIDS has been previously addressed ( 45 , 46 ) and remains salient. As suggested above, the mechanism underlying SIDS/SUDI could involve an abnormal response to viral respiratory infection at a time a bacterially colonized infant becomes challenged by a bacterial toxin. An experimental model for SIDS was suggested by Nobel Laureate Peter Doherty and his colleagues: mice exposed to a virus and challenged with a staphylococcal enterotoxin died of hematogenous shock when dually exposed. Mice did not die when exposed to the single agents ( 87 ).
Except for several research groups ( 41 , 42 , 45 , 48 , 49 , 82 , 88 – 94 ), support for a role of infection has been largely unexplored by mainstream SIDS researchers. The Tasmanian SIDS Study of Ponsonby et al. ( 84 ) unaccountably failed to reawaken interest in infection. The study was able to reveal the plausibly true nature and effect of prone sleep position and showed that the risk of SIDS was increased 10-fold if a baby slept prone when it had features of a concurrent upper respiratory tract or other viral-like illness . In addition, the risk of prone sleeping was hardly affected if infants were apparently infection-free. The Nordic Epidemiological Study ( 85 , 86 ) confirmed the Tasmanian findings and showed an even higher risk (29-fold) of prone-plus-infection . Mainstream SIDS researchers have failed to acknowledge or appreciate this important finding: a nearly two-decade blind spot that may have kept a solution to the SIDS problem in the dark.
Studies featuring epidemiological, sociological and pregnancy risk factors for the prone sleeping position in SIDS often showed a relationship to winter seasonality ( 95 , 96 ). It is surprising that these studies overlooked the obvious connection with infection. However, other studies had no trouble making the connection ( 96 ). It is of value to quote from the latter study by Froggatt et al. ( 97 ) “Any orthodox interpretation of our results must ascribe some role to infection, mainly respiratory infection. The greatest incidence is in Belfast among the lowest socioeconomic groups and the most crowded houses, in the coldest months, with serial correlation between SUD frequency and documented major virus epidemics, and with “season”/“city” contingency. Cases in Belfast in the winter being disproportionately prevalent;” ( 97 ).
The sleeping position of babies is featured in numerous recent and current SIDS research papers. Researchers have posited (without providing supportive evidence) that prone sleep position has a causal relationship with mortality ( 98 ). Such uncorroborated statements are not scientifically acceptable and have until now remained unaddressed. SIDS occurs in supine and side sleeping infants.
Heterogeneous Pathogenesis vs. Single Mode of Death
Another aspect of SIDS research is the dogma promoting the notion of a heterogeneous pathogenetic process. As indicated above, the Triple Risk Hypothesis ( 56 – 58 ) has led the approach to the SIDS problem. The hypothesis' ( 56 – 58 ) focuses on homeostatic control , and the generally accepted abiding notion that SIDS has a heterogeneous pathogenesis deserves further consideration. This question has been put forth in previous publications: ( 23 , 45 , 46 ) why do ~90% of SIDS cases have very similar gross pathological findings? The consistent finding of intrathoracic petechiae involving the thymus, pleura and heart, the unclotted/liquid heart chamber blood, the congested lungs (usually with low-grade inflammatory changes), the empty bladder, the raised core temperature, and the characteristic organ weight findings (a large thymus, brain and liver) ( 46 ) make this collective pathology an important phenomenon that could not plausibly be a coincidence. On balance of probability, heterogeneous pathogenesis would imply a panoply of various pathological findings and therefore several implied modes of death. Similar pathological findings in any collection of SIDS/SUID babies logically point to a single mortal process. Other or absent pathological findings (not conforming to the classical gross pathology of SIDS), which could include cases resulting from genetic mutations resulting in cardiac arrhythmia, etc. would be candidates for the remaining ~10% of cases that do not conform to the classical gross pathology of SIDS/SUID. The pathological picture in SIDS should be a guide for future research efforts.
Other Unanswered Questions
These have been discussed in detail previously ( 99 ) and deserve brief revisiting. The almost universal finding of intrathoracic petechiae in SIDS stands out as a poorly investigated phenomenon. To date, there have been no transmission electron microscopy or other relevant studies to help ascertain the nature of the vasculopathy. Studies using asphyxiated animals did not provide convincing answers ( 99 ). Another almost universal finding is liquid/unclotted blood in SIDS cases. Nevertheless, only one study has investigated this ( 32 ) and revealed increased D-dimer (FDPs), strongly suggesting coagulopathy; infection is a possible primary underlying mechanism. The review by Blackwell et al. ( 89 ) provides a comprehensive overview of key findings and risk factors and how they act through inflammatory responses and their genetic control. A number of genetic polymorphisms have been shown to be related to infection and inflammatory responses, which could help explain the increased susceptibility in SIDS babies. As indicated above, ethnicity (e.g., Australian Aboriginals and Indigenous North Americans) and male sex provide evidence of increased susceptibility and, obviously, both infer a genetic link; however, these effects can be complicated by socioeconomic and other factors (e.g., smoking) ( 89 ). The finding of cardiac ion channel mutations in a small proportion of SIDS cases remains unresolved as to whether death is with or due to the genetic mutation ( 100 ).
The consistently observed organ weight changes (heavy thymus, brain and liver) in SIDS deserve fulsome investigation. Thymic enlargement suggests some perturbation of innate or adaptive immune responses wherein infection deserves special attention ( 22 , 23 ).
New tools for investigation of SIDS such as the liquid biopsy, utilizing the science of proteomics to seek new molecular biomarkers may provide interesting results.
SIDS research appears to have lost its way because researchers appear to have forgotten or overlooked the epidemiological risk factors and clinical pathology because these are essential pointers to the underlying cause of SIDS/SUID. It is hoped that this article is seen as a constructive critique that highlights these neglected areas and provides encouragement for fresh thinking and therefore influence future SIDS research toward a more productive course and outcome. A recently published and easily tested novel hypothesis may provide new insights into the SIDS problem for it upholds all the epidemiological features of SIDS and is consistent with the clinicopathology of the syndrome ( 101 ).
Data Availability Statement
The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.
Author Contributions
PG as the sole author, is responsible for all aspects of this paper (including conception, literature review, writing all drafts, and final version) and approved the article for publication and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Conflict of Interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's Note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Abbreviations
SIDS, sudden infant death syndrome; SUID, sudden unexplained infant death; SUDI, sudden unexplained death in infancy; IFN, interferon; IL-6, interleukin-6; FDP, fibrin degradation products.
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Keywords: Sudden Infant Death Syndrome, SIDS, Sudden Unexplained Infant Death, SUID, pathology, epidemiology, physiology
Citation: Goldwater PN (2022) The Science (or Nonscience) of Research Into Sudden Infant Death Syndrome (SIDS). Front. Pediatr. 10:865051. doi: 10.3389/fped.2022.865051
Received: 29 January 2022; Accepted: 03 March 2022; Published: 15 April 2022.
Reviewed by:
Copyright © 2022 Goldwater. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Paul Nathan Goldwater, pgoldwater@gmail.com
This article is part of the Research Topic
Insights in Pediatric Infectious Diseases: 2021
Sudden Infant Death Syndrome Essay
Introduction, the global trends of sids, risk factors, addressing and preventing sids, the role of community health nurses, conclusion, recommendation, and evaluation.
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Healthcare is an essential requirement for adults and infants. Due to the various factors that children are exposed to in the process of their development, it is critical for parents and caregivers to ensure that children are provided with all the necessities that will enhance their overall health status.
Despite the measures that have been put in place to realize this goal, children are still susceptible to various diseases, some of which might be fatal. Pneumonia, malaria, cholera, typhoid, and HIV are examples of fatal diseases that can have profound effects on the health of children.
Sudden infant death syndrome (SIDS) is a condition that causes sudden death to a child. Despite the fact that this condition can affect children of all ages, its effect is mainly felt on children who are under the age of one year. However, unlike other diseases, SIDS is a condition that cannot be detected on the medical history of the victim (Dick, 2009).
Consequently, the cause of death cannot be ascertained even after conducting a thorough forensic autopsy on the body of the victim or investigating the crime scene. In most cases, SIDS causes death when a child is sleeping. It is due to this fact that the condition is referred to as the crib death disease.
Despite the fact that it has been virtually impossible to tie a given factor as the cause of SIDS, information gathered from recent studies has revealed that the sleeping position of children might be a relevant risk factor (Dick, 2009).
For instance, the study that was conducted by the American Academy of Pediatrics revealed that putting a baby to sleep on the supine position greatly reduced the occurrence of SIDS (Dick, 2009). The results of this study led to the development of the Back to Sleep campaign that was launched in the USA, the UK, New Zealand, and Australia.
This movement was an educational campaign that aimed at increasing the awareness of SIDS and empowering individuals to take precautionary measures that resulted in the reduction of the occurrence of SIDS. The campaign was successful since it led to a decline of death as a result of SIDS to around 66% in New Zealand alone (Dick, 2009).
Despite the success of this program, the incidences of SIDS are still high in some nations across the globe. Particularly, the incidence of SIDS in developing nations is very high.
These nations are characterized by high levels of poverty, poor healthcare services, and the lack of post-natal education that would empower parents to provide the best conditions for the growth of their children. These factors are responsible for the high rates of infant mortality in developing nations.
This paper will therefore focus on the impact of SIDS in developing nations, its trends, and the actions that have been taken to put this condition under control. Finally, the paper will come up with recommendations that should be applied in order to reduce the incidences of death from SIDS in developing states.
The trends of SIDS in the world vary from nation to nation. However, developing nations exhibit high death as compared to developed states. From the surveys that have been conducted, Japan is the nation that has the lowest rates of deaths in developed states by recording an astonishing rate of 0.09/1000 deaths.
On the other hand, New Zealand is the developed state that has the highest death rate as a result of SIDS (0.08/1000). The United States of America has been placed at the intermediate level after having a death rate of 0.57/1000.
In the nations where SIDS studies have been carried out, it has been identified that the rates of death from this condition highly depend on various factors. For instance, the rate of SIDS varies greatly across racial and ethnic lines. In the United States for instance, the rate of SIDS in African Americans and Hispanics is almost two times that of Native Americans.
Consequently, the rate of SIDS is higher among the members of the mixed race in Cape Town, South Africa. In New Zealand and Australia, the Maoris and Aboriginals exhibit the highest rates of SIDS respectively in these nations (Dick, 2009).
From these trends therefore, it is evident that the way of life plays a significant role in determining the occurrence of SIDS. Thus, poor living conditions have a direct relationship with SIDS.
Prior to the 1990s, not a lot of research on SIDS had been conducted in the world. This fact therefore played a significant role in the high rates of infant mortality that was being experienced in the world. In Africa, the infant mortality rate during the early 1990s was around 112/1000 children (Vanderford, 2009).
Despite the fact this rate was relatively low in developed nations, SIDS was one of the leading causes of infant mortality. These trends played a significant role in the increased number of studies that focused on factors that caused infant mortality.
Particularly, several studies were conducted on SIDS. Most of these studies focused on the incidences of SIDS, factors that are responsible for the condition, and the possible measures that could be put in place to reduce the incidence of the condition.
The information gathered from these studies led to the development of campaigns and education initiatives that led to an increase in the awareness of the condition. Most of these campaigns and initiatives were successful since they led to an overall decline in the number of deaths as a result of SIDS.
According to the study conducted by Vanderford (2009), the period between 1999 and 2005 saw a drastic decline in SIDS related cases in nations such as the United States of America, England, South Africa, Nigeria, Australia, and New Zealand.
For instance, Argentina recorded a decline of 40% in SIDS during this period while Ireland recorded a decline of 83%. However, Mage (2004) came up with the diagnostic shift argument that he used to explain the drastic decline in SIDS related cases.
According to this argument, the drastic decline in SIDS since 1999 can be attributed to the shift in diagnosis from SIDS to other related cases such as accidental suffocation or indeterminate causes. The diagnostic shift argument can thus be used to explain the static trend in SIDS that has been experienced since the year 2000.
However, it is evident that individuals all around the world have become more aware about the condition. Thus, these individuals take necessary measures to that have greatly reduced the incidence of SIDS. Despite this fact however, the incidences of SIDS in developing nations are fairly high.
In Nigeria for instance, only a limited number of studies have been conducted. This factor therefore explains why the level of awareness in these nations is very low hence resulting in high deaths.
Several risk factors have been involved with SIDS. Most of these factors however, have been linked to the standards of living. Many of these factors have been linked to the socioeconomic status of individuals, families, and states.
In the United States for instance, it is assumed that White Americans have a higher income as compared to African Americans and Hispanics.
White Americans therefore tend to have a better quality of life which in turn reduces the risk associated with SIDS as compared to African Americans and Hispanics. The same trend is exhibited all across the globe with the risk being even higher in developing nations.
Social class is thus a critical factor that determines the incidence of SIDS in a given nation. Developing nations are characterized with low incomes and low levels of GDP. These factors have a direct correlation with SIDS. According to a study that was conducted by Dick (2009), the level of SIDS was higher by 62% in families where the father had no income.
In such a situation, there are high chances that a child will be exposed to situations that will greatly increase the incidence of SIDS. This trend was also experienced across ethnic lines. In South Africa for instance, the rate of SIDS was slightly higher in families that had a mixed ancestry as compared to Dutch families.
Socioeconomic factors play a significant role in determining a number of factors that increase the prevalence levels of SIDS. Due to low income levels, there are high chances that a mother will not take considerable measures during pregnancy to enhance her health and the health of her baby.
The lack of proper prenatal care, poor eating habits, and exposure of extreme environmental condition usually have detrimental effects on the unborn baby. For instance, such a baby might be underweight during birth.
In Nigeria, the rate of SIDS in children who are born weighing between 1.0-1.5 kg is 15.89/1000 as compared to the rate of 2.91/1000 on children who are born weighing between 3.5-4.0 kg (Dick, 2009). A low weight during birth is an indicator of poor health of a baby. Thus, such a child will be prone to a lot of diseases including SIDS.
Consequently, the children who are exposed to extreme environmental conditions exhibit higher rates of SIDS as compared to those children who are exposed to conducive environmental condition. Air pollution and tobacco smoke are examples of factors that can result into SIDS.
Thus, a child who is exposed to tobacco smoke either from his parents or the people who are immediately around him/her will stand a high chance of becoming susceptible to SIDS. On the other hand, there are minimal chances of a child who is living in a properly aerated environment that is free from air pollution to become susceptible to SIDS.
SIDS usually occurs when a child is sleeping. Therefore, the sleeping environment of a child is a key determinant of this condition. The sleeping position of a child is thus a critical factor. From the studies that have been conducted, it has been identified that most children who succumb to SIDS were sleeping on their stomachs.
These incidences have been particularly high in developing nations due to lack of awareness about the importance of sleeping positions. Consequently, due to economic constraints and social practices, children in less developed nations tend to share beds either with their parents or with other siblings.
Sharing of beds increases the occurrence of SIDS. Despite the fact that the mechanisms behind bed sharing and SIDS are unclear, possible causes of death include accidental suffocation and position accidental asphyxiation (Mage, 2004).
It is thus advised that children sleep in their own cribs but in the same room with adults. Other causes of death include excessive use of beddings and soft materials, stuffed animals such as dolls, and the presence of soft surfaces in the sleeping area.
Other than socioeconomic factors, biological factors also play a significant role in deterring the occurrence of SIDS. Breastfeeding is an important post natal practice that mothers are encouraged to engage in. A mother’s milk contains the essential nutrients that are important in the process of growth and development in a child.
Therefore, the children who do not breastfeed do not get the necessary nutrients that will protect them from infections and diseases. Thus, the level of SIDS in children who are not breastfed is relatively higher as compared to the children who are breastfed.
Children who are born prematurely also stand a high chance of becoming victims of SIDS. The defensive mechanisms of a child who is born prematurely are relatively lower as compared to that of a child who is born maturely. Thus, a premature baby will stand a high chance of succumbing to SIDS due to his/her weak defensive mechanism.
The age of a child also determines the prevalence levels of SIDS. From the studies that have been conducted, it has emerged that children who are between 2-4 months stand a high chance of succumbing to SIDS as compared to newborns and children who are almost 12 months.
Research has also revealed that male children have a 50% chance of becoming SIDS victims as compared to female children. Consequently, anaemia increases the risk of a child succumbing to SIDS. However, it is difficult for doctors to diagnose this condition since anaemia tests need to be conducted on the blood cells of an individual who is alive.
Other conditions that might result to SIDS include pulmonary haemorrhage, virus infections, bacterial infections, and influenza. Infanticide also plays a significant role in SIDS cases.
Numerous cases have been reported where a mother kills a child immediately after birth or after some time. In some societies, female children are always killed after birth due to the preference for male children.
In addressing this phenomenon, many governments across the world have come up with several policies that aim at reducing the incidence of SIDS within their nations.
Despite the fact that the policies that have been developed vary from one nation to another, most of the nations across the globe have developed the policies that enhance pre-natal and post-natal care.
SIDS is a condition that mainly affects children who are under one year old. In this age bracket, the level of healthcare offered to such a child before and after birth is essential. With effective pre-natal and post-natal exercises, mothers will be able to enhance their health and diet during pregnancy.
This will increase the chances of giving birth to a healthy baby who is not susceptible to opportunistic diseases. Consequently, through post-natal care, the health of the new born baby will be monitored through frequent clinic visits.
If a child is diagnosed with any health complications, preventive measures will be taken early enough before becoming fatal. Consequently, a child will be immunized against various diseases that are known to affect the health of children hence leading to death.
Through research, several practices have been developed to prevent SIDS. These practices aim at reducing the risk at which children might be involved in during their process of growth and development.
Putting a baby to sleep on his/her back is one of the most effective measures that can be used to reduce the occurrence of SIDS (Mage, 2004). Initially, it was advised that a baby should be put to sleep on the side. However, this position is risky since a baby can roll over and put his/her face in the mattress.
This will in turn lead to chocking hence leading to the death of the baby. This realization led to the development of the Back to Sleep campaign that drastically reduced the rates of SIDS in developing nations by about 66%.
This campaign aimed at creating the awareness regarding to SIDS and the importance of putting a baby to sleep on his/her back. This campaign targeted parents, grandparents, siblings, nannies, and any other individual who might be taking care of a baby.
The message of this campaign was simple; ensure that a baby sleeps on his/her back at all times. This includes during the day, at night, and after meals. However, there were concerns regarding chocking from fluids or saliva when a baby is sleeping in this position.
To overcome this shortcoming, this strategy advocated that a baby’s head should be elevated during sleep. In such a position, a child can easily swallow or drool any fluids that come out of his/her mouth.
Consequently, it is advised that children should sleep on a hardened surface. For instance, the use of a safety approved mattress is highly recommended. Despite the fact that this mattress might be stiff, it is very comfortable for a child.
Parents should also avoid putting additional materials such as extra blankets, stuffed animals, pillows and crib bumpers in the sleeping area of children. These materials might result in the suffocation of a child leading to his/her death.
Another measure that can be taken to reduce the incidence of SIDS is to ensure that a child sleeps close to an adult but not in the same bed. However, a mother can share the bed with a child for feeding and breastfeeding purposes after which, the child should be taken back to his/her own crib.
This practice is essential as it reduces the risk of another individual suffocating a child during sleep. Breastfeeding is also encouraged especially during the first six months after birth. Despite the fact that the effects of breastfeeding with regards to SIDS are not quite known, it is believed that it reduces the risk factors and infections that might result to SIDS.
A child should also be immunized against various diseases and kept away from extreme temperatures. Smoking during pregnancy or around the baby should also be discouraged.
Community health nurses (CHN) play a significant role in fighting against SIDS. CHNs are the direct care providers within a given community. It is thus their role to ensure that members of a given community are provided with the best healthcare services.
In this respect, CHNs should utilize their knowledge, skills, and expertise to ensure that they provide their clients with the best health services.
Consequently, the actions of CHNs should be guided by the codes of ethics and standards. For instance, CHNs are not supposed to discriminate their patients on the grounds of race, religion, or economic success (Vanderford, 2009).
CHNs also act as the health educators within a given community. It is thus their role to decimate the knowledge and information that they have with regards to SIDS to community members.
To achieve this goal, CHNs usually organize seminars, workshops, and short courses that aim at creating SIDS awareness to the members of the public. This information is essential as it empowers the members of the public to put in place measures that will reduce the occurrence of SIDS.
Finally, CHNs act as the health counselors and advisors within a given community. It is their role to advise the members of the public on the best health practices that they can use to prevent SIDS. Examples of such practices include breastfeeding, proper sleeping strategies, the impacts of smoking, and so on.
CHNs also counsel the parents, friends, and relatives of individuals who have lost a child as a result of SIDS. This will encourage such individuals to have the motivation to move on with their lives and take proper care of their other children.
As it has been stated, different nations put in place different measures to prevent the occurrence of SIDS. As a result, the budgetary considerations vary depending on the nature of the project, its incidence, and the expected outcomes.
Despite this fact, a lot of money has been used in research and project implementation all around the world. These initiatives have however been successful in reducing the levels of SIDS all around the world.
SIDS is one of the leading factors that cause death of children who are less than one year old. Due to this fact, therefore, several measures have been put in place to put this condition under control.
Therefore, to ensure that this condition is put under control, I would advocate for increased research to ensure that the specific causal factors of SIDS are determined. This will ensure that the condition can be controlled more effectively.
Consequently, I will advocate for increased education as a means of empowering the public on the condition. With relevant knowledge and skills, members of the public will be in a position to implement effectively and efficiently preventive measures that will ultimately reduce the occurrence of SIDS.
To determine the effectiveness of these recommendations, I will monitor the number of studies that have been taken on this topic and the number of SIDS project all around the world. Research in this topic is essential since it will increase the knowledge that professionals have on the topic.
As a result, better measures will be put in place to the condition under control. Furthermore, I will monitor the trends in SIDS statistic to determine whether the numbers of fatalities are increasing or reducing.
An increase in the number of fatalities as a result of SIDS is an indicator that the measures that have been put in place to control the condition are not working.
On the other hand, a decline in the number of deaths as a result of this condition is an indicator of the effectiveness of the measures that have been put in place. Therefore, it will be the objective of the measures that have been put in place to ensure that a decline in death rates is realized.
Dick, A. (2009). Incidence of SIDS in Infants. Acta Paediatr, 98(11), 1768–75.
Mage, D. (2004). Trends of SIDS in the 21 st Century. JSTOR, 1(2), 1210–5.
Vanderford, J. (2009). Physiological factors that affect Health in Children. Arch Pediatr Adolesc Med, 163(5), 490-1.
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Volume 21 Supplement 1
Defined preventive interventions for children under five years of age: evidence summaries for primary health care in the WHO European region
- Open Access
- Published: 08 September 2021
Sudden infant death syndrome prevention
- Sophie Jullien ORCID: orcid.org/0000-0001-5587-626X 1
BMC Pediatrics volume 21 , Article number: 320 ( 2021 ) Cite this article
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We looked at existing recommendations and supporting evidence for successful strategies to prevent the sudden infant death syndrome (SIDS).
We conducted a literature search up to the 14th of December 2020 by using key terms and manual search in selected sources. We summarized the recommendations and the strength of the recommendation when and as reported by the authors. We summarized the main findings of systematic reviews with the certainty of the evidence as reported.
Current evidence supports statistical associations between risk factors and SIDS, but there is globally limited evidence by controlled studies assessing the effect of the social promotion strategies to prevent SIDS through knowledge, attitude and practices, due to obvious ethical reasons. A dramatic decline in SIDS incidence has been observed in many countries after the introduction of “Back to Sleep” campaigns for prevention of SIDS. All infants should be placed to sleep in a safe environment including supine position, a firm surface, no soft objects and loose bedding, no head covering, no overheating, and room-sharing without bed-sharing. Breastfeeding on demand and the use of pacifier during sleep time protect against SIDS and should be recommended. Parents should be advised against the use of tobacco, alcohol and illicit drugs during gestation and after birth.
Introduction
The World Health Organization (WHO) European Region is developing a new pocket book for primary health care for children and adolescents in Europe. This article is part of a series of reviews, which aim to summarize the existing recommendations and the most recent evidence on preventive interventions applied to children under 5 years of age to inform the WHO editorial group to make recommendations for health promotion in primary health care. In this article, we looked at existing recommendations and supporting evidence for successful strategies to prevent the sudden infant death syndrome (SIDS).
What is the sudden infant death syndrome?
SIDS is ‘the sudden death on an infant under one 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’ [ 1 ]. The sudden unexpected infant death (SUID) or sudden unexpected death in infancy is a broader term referring to ‘a sudden and unexpected death, whether explained or unexplained, occurring during infancy’ and includes the SIDS and other sleep-related infant death such as ill-defined death and accidental suffocation and strangulation in bed [ 2 ]. Therefore, for any SUID, when the cause of death after case investigation is not attributed to any explained cause such as suffocation, asphyxia, infection or metabolic diseases, the case is classified as SIDS, which is an ultimate diagnosis reached by exclusion.
Although defined by an unexplained origin, several risk factors have been associated with the incidence of SIDS. Despite the success of several preventive campaigns started in the 1990’s targeting modifiable risk factors related with the SIDS, it remains a leading cause of infant mortality in high-income countries. The rate of SIDS was estimated at 19.8 per 100,000 live births among 14 European countries between 2005 and 2015, ranging from 1.4 to 29.2 between countries [ 3 ]. It is therefore imperative to identify and assess the effective strategies to prevent SIDS.
Key questions
Which are the most important risk factors associated with the SIDS?
Which are the successful strategies to prevent SIDS?
Search methods and selected manuscripts
We described the search methods, data collection and data synthesis in the second paper of this supplement (Jullien S, Huss G, Weige R. Supporting recommendations for childhood preventive interventions for primary health care: elaboration of evidence synthesis and lessons learnt. BMC Pediatr. 2021. https://doi.org/10.1186/s12887-021-02638-8 ).
We conducted the search up to the 14th of December 2020, by manual search and by using the search terms “sudden death”, “unexpected death”, “sudden infant death syndrome”, and “SIDS”. We found a bulletin from the WHO with a short comment on the topic. No document was identified from the US Preventive Services Task Force (USPSTF) website, but we found their position published through the American Academy of Pediatrics (AAP), in a manuscript that was first published in 2011, with updated recommendations in 2016 [ 2 ]. The recommendations from the PrevInfad workgroup (Spanish Association of Primary Care Pediatrics) were also published in 2016, together with their supportive document [ 4 ]. The Centers of Disease Control and Prevention (CDC) supports the AAP recommendations and summarize them in their website [ 5 , 6 ]. We found 72, 36, 18, and 10 documents by using the search terms cited above, respectively, in the National Institute for Health and Care Excellence (NICE) official website. Out of them, we retrieved two NICE guidelines that addressed SIDS, but recommendations were from a single guideline [ 7 ]. The search in the Cochrane library returned 17 reviews and no protocols. By screening the titles and abstracts, we included one systematic review [ 8 ].
All the included manuscripts for revision in this article are displayed in Table 1 .
Existing recommendations
Both the WHO and CDC promote the AAP recommendations. In the NICE guideline ‘Postnatal care up to 8 weeks after birth’ the recommendations provided are as follows [ 7 ]:
“Recognise that co-sleeping can be intentional or unintentional. Discuss this with parents and carers and inform them that there is an association between co- sleeping (parents or carers sleeping on a bed or sofa or chair with an infant) and SIDS.”
“Inform parents and carers that the association between co-sleeping (sleeping on a bed or sofa or chair with an infant) and SIDS is likely to be greater when they, or their partner, smoke.”
“Inform parents and carers that the association between co-sleeping (sleeping on a bed or sofa or chair with an infant) and SIDS may be greater with parental or carer recent alcohol consumption, or parental or carer drug use, or low birthweight or premature infants.”
The AAP and the PrevInfad documents, published the same year, provide a list of very similar recommendations that we summarized together with the strength of each recommendation (as per their authors) in Table 2 . Many of the modifiable and non-modifiable risk factors identified for SIDS are very similar to those for other sleep-related infant deaths such as suffocation or asphyxia. In their document, the AAP provides recommendations for a safe sleep environment with the aim of reducing all sleep-related infant deaths [ 2 ]. Recommendations related to sleeping environment apply to infants up to 12 months of age.
Existing evidence
With the aim to analyse preventive measures to reduce SIDS, factors that increase or decrease the risk of SIDS have been identified. However, the identification of statistical associations between risk factors and SIDS does not prove a causal link or mechanistic explanation. The different institutions developed their recommendations based on these statistical associations together with the assessment of other factors such as the balance between potential benefit from reducing the risk and any harm derived from the preventive strategy. Although the evidence exposed below show the association between identified risk factors and SIDS, there is limited evidence assessing the effect of the recommendations through knowledge, attitude, and practices, with the exception of the sleep position [ 4 , 11 ].
We mainly retrieved the evidence from the two supportive documents developed for the PrevInfad and AAP recommendations [ 2 , 4 , 10 ]. Therefore, the references cited below were used in these documents and do not correspond with an additional literature review conducted by the authors of this summary document. As already indicated by the AAP, there are no randomized controlled trials (RCTs) with regard to SIDS and other sleep-related deaths. Evidence mainly derives from case-control studies and national pre and post intervention data. Currently, it is very unlikely that any clinical trial will be initiated to assess effectiveness of known risk factors due to obvious ethical reasons. The only Cochrane review identified aimed to assess the use of infant pacifiers for reduction of SIDS but no RCT addressing the topic was found. We summarize below the evidence supporting the recommendations addressing the most relevant or controversial risk factors.
Modifying behaviours and care related to the sleeping environment and nutrition
Supine position for sleeping, recommendations.
“Avoid prone sleeping position in infants less than 6 months old. Sleeping in supine decubitus position is the safest and clearly preferable to lateral decubitus. Only in a specific medical indication (severe gastroesophageal reflux, active respiratory illness in preterm infants and certain upper way malformations) can prone decubitus be recommended.” ( Grade A recommendation ) [ 4 ].
“To reduce the risk of SIDS, infants should be placed for sleep in the supine position (wholly on the back) for every sleep period by every caregiver until 1 year of age. Side sleeping is not safe and is not advised.” ( Grade A recommendation ) [ 2 ].
This is the main modifiable risk factor identified for SIDS. Consistent findings across the world and decreasing trend on the incidence of SIDS in countries that have implemented the ‘Back to Sleep’ recommendations support the hypothesis that the supine position for sleep protects against SIDS [ 4 ]. Indeed, case-control studies, conducted in Europe and the United States indicate that the prone position during sleep increases the risk of SIDS as compared to supine position with adjusted odds ratio (AOR) ranging from 2.3 and 13.1 [ 12 , 13 , 14 , 15 , 16 ]. Similarly, the lateral side has been associated with increased risk of SIDS when compared to supine position, with AOR ranging from 1.31 to 2 [ 13 , 14 , 15 ]. These five case-control studies were conducted in the US [ 12 , 13 , 16 ], the UK [ 14 ] and in 20 regions of Europe [ 15 ] from 1992 and 2000, including 1432 SIDS cases and 3905 matched controls. In addition, countries with preventive campaigns for avoiding prone position in infants during sleep that have been successful for reducing the prevalence of infants sleeping in such position have estimated a 30 to 50% decrease in the mortality associated to SIDS [ 4 ].
Supine position does not increase the risk of choking and aspiration [ 2 , 4 ]. Only infants with certain upper airway disorders such as type 3 or 4 laryngeal clefts in which the risk of death from gastroesophageal reflux disease may outweigh the risk of SIDS can be considered to be placed in prone position during sleep [ 2 ].
Supervised awake tummy time
“When awake, infants can be placed in prone position with supervision.” (Recommended but not graded) [ 4 ].
“Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly.” ( Grade B recommendation ) [ 2 ].
Sustained supine position combined with restricted motor abilities lead to postural plagiocephaly [ 4 ]. In addition, prone position facilitates the development of the upper shoulder girdle strength [ 2 ]. Therefore, although there is no data to support this recommendation and to establish the frequency and duration of it, experts recommend “a certain amount of prone positioning, or ‘tummy time,’ while the infant is awake and being observed” [ 17 ].
Firm surface for sleeping
“Firm surfaces should always be used: the mattresses must be firm and maintain their shape even when covered with the sheets, so that there are no gaps left between the mattress and the crib railing. Adjustable sheets and specific bedding should be used.” [ 4 ].
“Infants should be placed on a firm sleep surface (eg, mattress in a safety-approved crib) covered by a fitted sheet with no other bedding or soft objects to reduce the risk of SIDS and suffocation.” ( Grade A recommendation ) [ 2 ].
Soft sleep surface has consistently been reported as a risk factor for SIDS. A case-control study conducted in the US among 260 SIDS cases and 260 matched living controls, showed an association between soft sleep surface and a higher risk of SIDS (AOR 5.1 [95% CI: 2.9 to 9.2]) [ 12 ]. The risk was significantly higher when prone position and soft sleep surface were combined (AOR 21.0 [95% CI: 7.8 to 56.2]) [ 12 ]. Soft mattresses could create a pocket around the infant within which the CO2 dispersal is limited, increasing the risk of rebreathing or suffocation in infants placed in prone position [ 2 , 18 ].
Soft objects and loose bedding away from the sleep area
“Other loose accessories such as blankets, quilts and pillows, cushions, soft objects and neck pendants” should be kept away from the infant’s sleep area [ 4 ].
“Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and strangulation.” [ 2 ].
Several publications pointed out that soft objects (pillows, pillow-like toys, quilts, comforters, sheepskins) and loose bedding (blankets, nonfitted sheets) can cause the obstruction of an infant’s external airways, leading to an increased risk of suffocation, rebreathing, and SIDS [ 2 , 10 ]. In an already mentioned study, the use of pillow and covering the head or face with bedding were associated to an increased risk of SIDS (AOR 3.1 [95% CI 1.6 to 5.8] and AOR 2.5 [95% CI 1.2 to 5.2]) [ 12 ]. A higher risk was found when the use of pillow was combined with prone position (AOR 11.8 [95% CI 4.0 to 34.4]) [ 12 ]. In another study conducted in the US among 206 SIDS cases showed that the use of comforters (AOR 2.46) and pillows (AOR 3.31) increased the risk of death (95% CI not provided, but p ≤ 0.05 for both comparisons) [ 19 ]. Other studies reported that infants victim of SIDS were found in supine position with their head covered by loose bedding.
Avoid overheating and head covering
“Avoid overheating and avoid the head to be covered while sleeping” “The recommendation to prevent the head from covering is to put the infant at the foot of the bed and the blanket up to the chest.” ( Grade I recommendation ) [ 4 ].
“Avoid overheating and head covering in infants.” “In general, infants should be dressed appropriately for the environment, with no greater than 1 layer more than an adult would wear to be comfortable in that environment.” ( Grade A recommendation ) [ 2 ].
Overheating has been identified as a risk factor for SIDS, especially when the head is covered. Both the AAP and PrevInfad have stated that several studies had shown that overheating (including external temperature and the child’s clothes) was associated with an increased risk of SIDS, but that it was difficult to provide any specific room temperature recommendation as the definition of overheating varies across studies [ 2 , 4 ]. When looking at the ‘several studies’ mentioned above, we found no references from PrevInfad, and four references cited in the AAP document. Three manuscripts are case-control studies published between 1990 and 2002 that showed an increased risk of SIDS when infants were heavily wrapped, when the heating was on all night, or when the infants slept with two or more layers of clothing, showing a small effect or a broad confidence interval [ 20 , 21 , 22 ]. The fourth study analysed data from one of the three cited case control by the same first author, and a prospective cohort, to emphasize the increased risk of SIDS when the prone position is associated with other risk factors including overheating [ 23 ]. To avoid overheat, several strategies have been put in place. PrevInfad recommends a temperature of 20 to 22 °C and to avoid excessive clothing, especially if the infant has fever. AAP recommends that ‘in general, infants should be dressed appropriately for the environment, with no greater than one layer more than an adult would wear to be comfortable in that environment’ and that ‘parents and caregivers should evaluate the infant for signs of overheating, such as sweating or the infant’s chest feeling hot to the touch’. Both identities agree that ‘there is currently insufficient evidence to recommend the use of a fan as a SIDS risk-reduction strategy’.
A systematic review including 10 case-control studies conducted between 1958 and 2003 found that the prevalence of head covering was higher in SIDS cases (24.6% [95% CI 22.3 to 27.1%]) than in controls (3.2% [95% CI 2.7 to 3.8%]) [ 24 ]. The AOR was 16.9 (95% CI 12.6 to 22.7) and the risk associated to SIDS was consistently significant across studies. The review did not establish a causal mechanism between head covering and SIDS, but the authors concluded that head covering is a major modifiable risk factor associated with SIDS. With a potential high attributable risk of 27.1% and the ease of adopting this measure with low cost and no adverse effect, avoiding head covering was adopted as a recommendation to decrease deaths related to SIDS [ 25 ]. As a strategy to avoid head covering, a ‘Feet to foot’ campaign was initiated, which recommends placing the baby at the foot of the cot. However, this strategy was established following common sense, but there is no evidence showing that this measure does reduce head covering and has any impact on SIDS.
Overall, it seems that there is low quality evidence regarding overheating and head covering and that current strategies are based on common sense that have not been proved to reduce SIDS.
Room-sharing with the infant on a separate sleep surface
“The crib in the parents’ bedroom is the safest place.” ( Grade B recommendation ) [ 4 ].
“Recommend against co-sleeping if father or mother are tobacco smokers, have drunk alcohol, anxiolytic, antidepressant or hypnotic drugs have been used and in case of extreme exhaustion. Co-sleeping is advised against also in sofas, armchairs or any other place but the bed.” ( Grade B recommendation ) [ 4 ].
“Inform parents that there is not enough evidence to recommend against bed-sharing when infants are breastfed and there are no other risk factors” ( Grade I recommendation ) [ 4 ].
“It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.” ( Grade A recommendation ) [ 2 ].
“Infants should never be placed on a couch or armchair for sleep.” [ 2 ].
Co-sleeping and bed-sharing do not mean the same. The term co-sleeping refers to parents and infant sleeping in close proximity, which can be bed-sharing (sleeping on the same surface) or sleeping in the same room in close proximity on separate surfaces [ 10 ]. Room-sharing has been shown to reduce the risk of SIDS by as much as 50% [ 2 , 4 ]. However, bed-sharing between parents and infant remains highly controversial. While bed-sharing has been associated with an increased risk of SIDS, bed-sharing has also been assessed to improve attachment and breastfeeding, considered as a protecting factor to SIDS (see below).
A meta-analysis published in 2012 and including 11 studies conducted between 1987 and 2006 looked at the association between bed-sharing and SIDS. Authors found an increased risk of SIDS among those bed-sharing with an odds ratio (OR) of 2.89 (95% CI: 1.99 to 4.18) and an increased risk among smoking mothers (OR 6.27 [95% CI 3.94 to 9.99]; 4 studies) [ 26 ]. Carpenter et al. pooled data from five case-control studies including Scotland, Germany, Ireland, other European countries, and New Zealand to look at the same association of bed-sharing and the risk of SIDS, among breastfed infants with non-smoking parents and with no maternal use of alcohol or drugs, with no other associated risk factors [ 27 ]. They found an increased risk of SIDS among infants with bed-sharing versus room sharing with an AOR of 2.7 (95% CI 1.4 to 5.3) and a higher risk in infants less than 3 months (AOR 5.1 [95% CI 2.3 to 11.4]).
Blair et al. had opposite findings when assessing the same association of bed sharing with SIDS among infants without other risk factors from two different case-control studies conducted between 1993 and 2006 in the UK [ 28 ]. They found no association between bed sharing and SIDS globally (OR 1.1 [IC 95% 0.6 to 2]) and among infants under 3 months of age (OR 1.6 [95% CI 0.96 to 2.7]). Among infants above 3 months of age, authors found bed sharing to be protector for SIDS, with an OR of 0.1 (95% CI 0.01 to 0.5). These findings were independent of whether the infant was breastfed or not. When looking at this association in presence of parents who consumed tobacco or alcohol, they found similar findings to Carpenter.
Facing these contradicting findings and recommendations between Carpenter et al. and Blair et al., the US task force requested an independent review of both manuscripts, reported by the AAP. They concluded that both studies have strengths and weaknesses, and that both studies lacked power to examine the association in subgroups of children (under or above 3 months of age). “Clearly, these data do not support a definitive conclusion that bed-sharing in the youngest age group is safe, even under less hazardous circumstances.” [ 10 ].
In summary, there is a lack of evidence to determine the balance between harm and benefits of bed-sharing among infants without other risk factors associated (parental use of tobacco or alcohol), taking breastfeeding into consideration. Accordingly, in case of breastfed infants with no other risk factors, PrevInfad recommends to inform parents that there is not enough evidence to recommend against bed-sharing ( Grade I recommendation ) [ 4 ]. However, there are specific circumstances that have been shown to substantially increase the risk of SIDS, independently to the form of feeding and that should be avoided. Those are summarized by the AAP as follows, and are in agreement with the PrevInfad and NICE recommendations [ 4 , 7 , 10 ]: “when one or both parents are smokers, even if they are not smoking in bed (OR 2.3 to 21.6); when the mother smoked during pregnancy; when the infant is younger than four months of age, regardless of parental smoking status (OR 4.7 to 10.4); when the infant is born preterm and/or with low birth weight; when the infant is bed-sharing on excessively soft or small surfaces, such as waterbeds, sofas and armchairs (OR 5.1 to 66.9); when soft bedding accessories such as pillows or blankets are used (OR 2.8 to 4.1); when there are multiple bed sharers (OR 5.4); when the parent has consumed alcohol (OR 1.66 to 89.7) and/or illicit or sedating drugs; and when the infant is bed-sharing with someone who is not a parent (OR.5.4).”
Consider offering a pacifier at naptime and bedtime
“Not rejecting the use of a pacifier during sleeping time in the first year of life seems to be a cautious measure.” ( Grade B recommendation ) [ 4 ].
“Consider offering a pacifier at naptime and bedtime” ( Grade A recommendation ) [ 2 ].
“Offer a pacifier to the infant when put to sleep in supine position, and do not reinsert it once the infant is asleep. If the infant refuses the pacifier, do not force him or her to use it.” [ 2 , 4 ].
“For breastfed infants, pacifier introduction should be delayed until breastfeeding is firmly established” [ 2 ] or until the infant is 1 month of age [ 4 ].
Although the mechanism is unclear, the use of pacifier during the sleep has a protective effect on SIDS [ 2 , 4 ]. A Cochrane review was published in 2017, after the development of both the PrevInfad and the AAP recommendations [ 8 ]. The aim of this review was to evaluate the use of infant pacifiers versus no pacifiers during sleep in reducing the risk of SIDS. However, the review authors found no randomized controlled trials addressing this topic.
Recommendations are mainly based on findings from another systematic review that was conducted by Hauck et al. and included case control studies published between 1993 and 2004 [ 29 ]. A protector effect of pacifier was shown for usual pacifier use (AOR 0.71 [95% CI 0.59 to 0.85]; 4 studies) and for use of pacifier in the last sleep (AOR 0.39 [95% CI 0.31 to 0.50]; 7 studies). Authors also estimated the number needed to treat as 2733 (95% CI 2416 to 3334), meaning that one SIDS death could be prevented for every 2733 infants using a pacifier during the sleep.
Pacifier can be introduced as soon as desired after birth in not breastfed infants, but it is recommended to delay its introduction in breastfed infants until breastfeeding is well established [ 2 , 4 ]. There is however a lack of evidence to confirm the belief that the use of pacifier interferes with breastfeeding [ 4 ].
Breastfeeding on demand
“Recommend breast-feeding on demand.” ( Grade A recommendation ) [ 4 ].
“Unless contraindicated, mothers should breastfeed exclusively or feed with expressed milk (i.e., not offer any formula or other nonhuman milk- based supplements) for 6 months, in alignment with recommendations of the AAP” ( Grade A recommendation ) [ 2 ].
Breastfeeding is a clear protective factor for SIDS. Exclusive breastfeeding is recommended for the first 6 months of life, in line with global recommendations [ 30 ]. A systematic review included 18 case control studies (published between 1976 and 2009) for meta-analysis [ 31 ]. The univariate analysis showed a protector effect of any breastfeeding (any amount for any duration) versus no breastfeeding (OR 0.40 [95% CI 0.35 to 0.44]; 18 studies), which was maintained with multivariate analysis from seven of the included studies (AOR 0.55 [95% CI 0.44 to 0.69]; 7 studies). The protective effect was higher in infants who were exclusively breastfed for any duration in univariate analysis (OR 0.27 [95% CI 0.24 to 0.31]; 8 studies), with no data provided in the included studies allowing multivariate analysis [ 31 ].
Counselling to modify beneficial behaviours and care related to maternal factors
Regular prenatal care.
“Recommend appropriated control of pregnancy and perinatal period.” ( Grade B recommendation ) [ 4 ].
“Pregnant women should obtain regular prenatal care” ( Grade A recommendation ) [ 2 ].
This recommendation is mainly based on the findings of a case control study nested in a large cohort of all live births in the US between 1995 and 1998, which aimed to identify maternal and obstetric risk factors for SIDS [ 32 ]. From 12,404 cases (SIDS) and 49,616 controls, authors found an increased risk for SIDS when there was no prenatal care (OR 1.70 [95% CI 1.44 to 2.0]).
Avoid smoke exposure during pregnancy and after birth
“Recommend against tobacco smoking to parents, especially to the mother during pregnancy, although also after delivery. Don’t allow anybody smoking in the infants’ presence.” ( Grade A recommendation ) [ 4 ].
“Smoking during pregnancy, in the pregnant woman’s environment, and in the infant’s environment should be avoided.” ( Grade A recommendation ) [ 2 ].
Maternal smoking is an independent risk factor for SIDS. This association has been found independently for both maternal smoking during pregnancy and after birth, from several studies [ 2 , 4 ]. The large case-control nested study mentioned above for prenatal care, also associated maternal smoking during pregnancy with an increased risk of SIDS (OR 3.19 [95% CI 3.03 to 3.37]) [ 32 ]. Several studies have confirmed the association between foetal nicotine exposure and neuropathological and neurochemical anomalies. These anomalies are translated into dysregulation of the autonomic nervous system, prompting disruption of ventilation and cardiac rhythm control, leading to sudden and unexpected death [ 33 ]. In addition, it is also well known that smoke exposure is associated with an increased risk of preterm birth and low birth weight, which are both identified risks for SIDS [ 2 ].
Regarding exposure to smoke in any circumstances such as in the same house or car, 13 studies found that the maternal or paternal habit of smoking after birth increased the risk of SIDS 2.31 times (95% CI 2.02 to 2.59%) [ 4 ]. The association between smoke exposure and SIDS is dose dependent. The risk increases substantially when there is bed sharing between the infant and the smoker, even if the adult does not smoke in bed [ 10 ].
Avoid alcohol and illicit drug use during pregnancy and after birth
“Avoid the prenatal and postnatal use of alcohol and illegal drugs.” ( Grade B recommendation ) [ 4 ].
“Avoid alcohol and illicit drug use during pregnancy and after the infant’s birth.” ( Grade A recommendation ) [ 2 ].
The use of alcohol or illicit drugs during prenatal (periconceptional and gestational) and postnatal periods has been associated with increased risk of SIDS [ 2 , 4 ]. Similarly to smokers, the risk increases when alcohol or drug user share the bed with the infant [ 2 , 4 ].
Summary of findings
Current evidence supports statistical associations between risk factors and SIDS, but there is globally limited evidence by controlled studies assessing the effect of the social promotion strategies to prevent SIDS through knowledge, attitude and practices, due to obvious ethical reasons.
A dramatic decline in SIDS incidence has been observed in many countries after the introduction of “Back to Sleep” campaigns for prevention of SIDS.
All infants should be placed to sleep in a safe environment including supine position, a firm surface, no soft objects and loose bedding, no head covering, no overheating, and room-sharing without bed-sharing.
Breastfeeding on demand and the use of pacifier during sleep time protect against SIDS and should be recommended.
Parents should be advised against the use of tobacco, alcohol and illicit drugs during gestation and after birth.
The American Academy of Pediatrics recommendations updated in 2016 are the most comprehensive resume about SIDS prevention.
Availability of data and materials
Not applicable.
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I am very grateful to María Jesús Esparza, Laura Reali, and Gottfried Huss for carefully reviewing and providing valuable feedback for each article. I am also grateful to Ralf Weigel and Gottfried Huss for proofreading the final version of this document.
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This article has been published as part of BMC Pediatrics Volume 21, Supplement 1 2021: Defined preventive interventions for children under five years of age: evidence summaries for primary health care in the WHO European region. The full contents of the supplement are available at https://bmcpediatrics.biomedcentral.com/articles/supplements/volume-21-supplement-1 .
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- Sudden infant death syndrome
- Breastfeeding
STEPHEN M. ADAMS, MD, MATTHEW W. GOOD, MD, AND GINA M. DEFRANCO, DO
Am Fam Physician. 2009;79(10):870-874
A more recent article on this topic is available .
Patient information: See related handout on SIDS , written by the authors of this article.
Author disclosure: Nothing to disclose.
Sudden infant death syndrome is the leading cause of death among healthy infants, affecting 0.57 per 1,000 live births. The most easily modifiable risk factor for sudden infant death syndrome is sleeping position. To reduce the risk of sudden infant death syndrome, parents should be advised to place infants on their backs to sleep and avoid exposing the infant to cigarette smoke. Other recommendations include use of a firm sleeping surface and avoidance of sleeping with soft objects, bed sharing, and overheating the infant. Pacifier use appears to decrease the risk of sudden infant death syndrome, but should be avoided until one month of age in infants who are breastfed. The occurrence of apparent life-threatening events does not increase the risk of sudden infant death syndrome, and home apnea monitoring does not lower the risk of sudden infant death syndrome. Supine sleeping position has increased the incidence of flattening of the occiput (deformational plagiocephaly), but this condition can be prevented and treated by encouraging supervised “tummy time,” meaning that when awake, infants should spend as much time as possible on their stomachs. All apparent deaths from sudden infant death syndrome should be carefully investigated to exclude other causes of death, including child abuse. Families who have an infant die from sudden infant death syndrome should be offered emotional support and grief counseling.
The term sudden infant death syndrome (SIDS) was first used in 1969 at an international conference on the causes of sudden death in infants. 1 The current definition of SIDS, developed in 1991, is the sudden death of an infant younger than one year that remains unexplained after a thorough case investigation, including a complete autopsy, examination of the death scene, and review of the clinical history. In the United States, SIDS affects 0.57 per 1,000 live births, totaling more than 2,200 deaths per year. It is the leading cause of death among healthy infants. 2
Risk Factors
Infant factors that have been associated with increased SIDS risk include low birth weight, low Apgar scores, recent viral illness, Native American or African American ancestry, and male sex. 3 Maternal issues that predict SIDS risk include low socioeconomic status, smoking, illicit drug use, poor prenatal care, and young age. 3 Other factors related to poor social and economic status, such as a crowded household, parental unemployment, and single parent status, also increase the risk of SIDS. Pacifier use may decrease the risk of SIDS, 4 but sleeping position is the most easily modifiable risk factor. Infants should be placed on their backs to sleep; side sleeping is not recommended. 5 A firm sleep surface, such as a firm crib mattress, should be used. Soft objects and loose bedding should be kept out of the crib. 6 Parents should avoid overheating the infant during sleep (e.g., keep the room temperature comfortable, do not overdress the infant, use a light blanket). 7 Factors that are associated with SIDS are listed in Table 1 . 4 – 6 , 8 – 11
The relationship between prone sleeping position and SIDS was first noted in 1965, but recommendations supporting supine sleeping were not issued until the early 1990s. 12 - 14 The “Back to Sleep” campaign organized by the National Institutes of Health and the American Academy of Pediatrics (AAP) brought about a decrease in SIDS cases. In spite of recommendations, prone sleeping remains a common presumptive cause of SIDS. Cultural practices regarding sleep position mirror differences in SIDS rates between races. For example, in the United States, black infants are more likely to be placed to sleep in the prone position and have higher rates of SIDS compared with white infants, who are more likely to be placed to sleep in the supine position. 15
Pathophysiology
Significant controversy revolves around the pathophysiology of SIDS. Three common autopsy findings include unclotted blood in the heart, 1 intrathoracic petechiae, 16 and fluid-filled, heavier organs, 17 but these findings provide little help in understanding the final pathophysiology of SIDS. The now discredited “apnea theory” of SIDS was proposed in the 1970s 18 and led to decades of research and the creation of an apnea monitoring industry. However, in the index case that first prompted investigation of the link between apnea and SIDS, the mother later confessed to killing all five of her children. 19
Current literature supports a triple-risk model, 20 which suggests that SIDS is the final common pathway of three coinciding factors. This model proposes that an infant must first have an underlying vulnerability and then be stressed by an exogenous source, such as prone sleeping placement. Finally, for SIDS to occur, the stress must occur during a critical developmental period, namely in the first year of life. The last two factors in the triple-risk model have been well researched and defined in the medical literature, but the underlying vulnerability remains to be identified.
Current SIDS research topics include investigation of ion channel abnormalities, autonomic nervous system disturbances, and the effects of nicotine on the developing brain. 21 Multiple ion channel disorders that cause QT interval prolongation have been linked to SIDS 22 and may be a factor in 5 to 10 percent of SIDS cases. 23 In addition, defects in normal arousal mechanisms have long been theorized to cause SIDS, 24 and gene mutations affecting the development of the autonomic nervous system appear in as many as 15 percent of SIDS cases. 25 Finally, pre- and postnatal exposure to cigarette smoke has been a known risk factor for SIDS for more than 30 years. 26 Nicotine exposure has been clearly linked with SIDS, as well as with prematurity, autonomic dysfunction, low birth weight, and spontaneous abortions. 27 These associations and newly identified nicotine metabolizing genes have prompted a search for SIDS causality 28 and further highlight the importance of smoking cessation counseling in SIDS prevention efforts. Women should not smoke during pregnancy, and they should keep the infant's environment smoke-free. 9
Prevention and Counseling Issues
The principles of safe sleeping practices for infants are well established. In a recent case series, 92.2 percent of deaths occurred in infants who were sleeping in the prone position, bed sharing, or sleeping in a location other than a crib or bassinet. 29 Patient education efforts that recommended the supine sleeping position in the 1990s resulted in a 50 to 70 percent decrease in SIDS rates. 5
BED SHARING
Bed sharing remains a controversial topic among health care professionals and families. Possible benefits of bed sharing include increased breastfeeding rates, parent-child bonding, and fewer sleep problems. 30 The AAP issued a policy statement in 2005 discouraging bed sharing, noting that almost one half of infants who die from SIDS in the United States do so while sleeping with parents. 31 Bed sharing carries a substantially increased risk in low–birth-weight infants and in children of smokers and persons who use illicit drugs or alcohol. 8 Recent analyses have suggested that the risks of bed sharing are isolated to infants younger than four months, with no significant increase in risk for older infants. 30 , 32 Infants should sleep in a separate, but proximal, sleeping environment, ideally in a bassinet or crib near the mother's bed. Infants should never sleep with other children, or with a parent on a couch or armchair. 8
DEFORMATIONAL PLAGIOCEPHALY
Deformational plagiocephaly is flattening of the occiput, which affects up to one half of infants who sleep in the supine position, and has become more common since the initiation of recommendations to place infants on their backs to sleep. 33 To decrease the risk of skull deformities, infants should have supervised “tummy time,” meaning that when awake, infants should spend as much time as possible on their stomachs. The side of the occiput that is placed downward during sleep also should be alternated. Infants should not be placed in car seats when they are not passengers in a vehicle, and the use of other devices that place pressure on the back of the head (e.g., swing, bouncy seat) should be minimized. Once deformational plagiocephaly has developed, parents should avoid placing the flattened side of the occiput down on the mattress during sleep times. Physical therapy is helpful if torticollis is present. A neurosurgical evaluation may be indicated in rare cases when the skull deformity does not improve with changes in head positioning. 33
IMMUNIZATIONS
Infants who do not receive immunizations may be at greater risk of SIDS. 11 Some, but not all, case-control studies found a lower rate of SIDS among appropriately immunized children compared with children with incomplete immunizations. However, the apparent protective effect of immunizations against SIDS may in part be because of the relationship between incomplete immunization and lower socioeconomic status and other risk factors for SIDS. 11
OTHER TOPICS
A history of one or more apneic episodes does not increase the risk of SIDS, and the use of home apnea monitors does not lower the risk of SIDS. 34 Pacifier use appears to decrease the risk of SIDS, and the 1995 AAP position statement on SIDS prevention suggests offering the infant a pacifier at nap or bedtime. 7 However, the potential SIDS risk reduction from pacifier use must be weighed against the possibility that early pacifier use may shorten the duration of breastfeeding. 35 Use of a pacifier should be delayed until one month of age in infants who are breastfed. 4
Apparent Life-Threatening Events
Apparent life-threatening events (ALTEs) are apneic episodes associated with changes in skin color (e.g., cyanosis, pallor, erythema), changes in muscle tone, and choking or gasping. Common diagnoses and evaluation of infants with ALTEs are listed in Table 2 . 36 ALTEs are relatively common, occurring in approximately one in 400 infants. 37 In the past, ALTEs were referred to as “near-miss SIDS,” but this characterization does not appear to be accurate. The education campaigns that have reduced the incidence of SIDS have not affected the rate of ALTEs, and the only important SIDS risk factor that is associated with ALTEs is maternal smoking during pregnancy. 37 Risk factors for ALTEs (in order of most to least important) include history of apnea, cyanosis, or pallor; feeding difficulties; single parenthood; family history of infant death; and smoking during pregnancy. 38
An etiology for ALTEs is determined in only one half of cases. 37 Gastrointestinal etiologies (usually gastro-esophageal reflux) account for most cases in which a cause is identified. Respiratory infections are another important cause. Cardiac disorders, such as valvular disease, arrhythmia, and cardiomyopathy, are responsible for a minority of cases. Neurologic causes, such as malignancy, structural abnormalities of the brain, and seizures, are uncommon, but should be considered. The history and physical examination are the most important factors in determining an etiology. 39 In a case series of 243 patients admitted to a single academic medical center, fewer than 6 percent of all tests ordered were useful in making the diagnosis. 39 The only tests found to be of value in detecting causes of ALTEs that were not evident from the history and physical examination were testing for gastroesophageal reflux, urinalysis, neuroimaging, chest radiography, and white blood cell count. 39
Differential Diagnosis of SIDS
Other causes of death, such as infection, electrolyte abnormalities, inborn errors of metabolism, and child abuse, must be eliminated before a death can be attributed to SIDS ( Table 3 40 ) . Investigation of a potential SIDS death should include a thorough death scene evaluation and a complete autopsy, with a radiographic skeletal survey and toxicology studies. Evaluation of the death scene should include notation of the infant's position, bedding, type of bed or crib, body temperature, presence or absence of rigor mortis, room temperature, type of heating or cooling used, and caregiver response.
Intentional suffocation is difficult to distinguish from SIDS, and the incidence of infanticide among deaths labeled as SIDS is estimated to be 1 to 5 percent. 40 Small studies of children with recurrent ALTEs showed a high incidence of Munchausen syndrome by proxy. Factors that raise the possibility of intentional suffocation are a history of ALTEs occurring with a lone caretaker, death of infants older than six months, history of unexplained death of siblings, simultaneous death of twins, a previous death of a child under the care of the same person, or evidence of previous pulmonary hemorrhages at autopsy. 40
Post-SIDS Support and Counseling
Families who have had an infant die from SIDS should be treated with compassion and empathy. They should be supported through the process of the death investigation and guided through problems, such as ending lactation and funeral planning. Grief counseling and referral to a SIDS support group should be offered. Parents should be counseled that the risk of future children dying from SIDS is not increased. 40
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