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					“To Die, To Sleep ...”
 A Discussion on SIDS

             COL H. Joel Schmidt
           Pediatric Pulmonology
SIDS - outline
      ALTE
        not   “near-miss SIDS”
      SIDS
        background
        definition
        etiology
        controlof breathing
        epidemiology
        avoidable risk factors
ALTE definition
 frightening to the observer
 characterized by some combination of
     apnea
     colorchange
     marked change in muscle tone
     choking
     gagging

   (involves vigorous stimulation or
    resuscitation)
Factoids
 prevalence from 0.05% to 6.0%
 most with ALTE do not die of SIDS
     combinedprevalence of SIDS among other
     family members of infants w/ ALTE = 11%
   most with SIDS have never had ALTE
     73   - 96% w/o ALTE
 median age at presentation = 2 months
 slight male predominance
Causes
 GE Reflux                28%
 Neurologic problems      12%
 Infection                 6%
 Upper Airway Obstruction  2%
 Metabolic problems        2%
 Cardiac problems          1%
 Idiopathic               47%
Work-Up
 History
 History
 History
 History
 History
 History
 History
Home Monitor?
   1986 NIH Consensus Conference on
    Infantile Apnea and Home Monitoring
     definitely   indicated
       – severe ALTE
       – tracheostomy <18 months old
       – ISAM‟s
       – twin of SIDS victim
     not   indicated
       – normal infant
       – asymptomatic premature infant
Questionable Risk Group
 Sib of SIDS
 moderate ALTE


   decision based
           benefits, liabilities, and limitations
     risks,
     parent - provider decision
Monitor Requirements
 home telephone
 basic infant CPR instruction for all
  caregivers
 use and trouble shooting of monitor for
  all caregivers
 24‟ medical and technical back-up
SIDS background
 decreasing infant mortality this century
 one category of infant death not
  decreasing
 1969 - “SIDS” title given
 Steinschneider A: Prolonged apnea and
  the sudden infant death syndrome.
  Pediatrics 1972; 50 (4): 646.
 1991 - definition expanded by NICHD
causes of infant death
                                     <1 year old, 1992
           maternal
         complications   RDS
                                prematurity




                                         birth defects
      other




                               Unknown
definition of SIDS
 sudden death of an infant under 1 year
 old that can not be explained despite:
  autopsy within 24‟ incl. skeletal survey, tox
   and metabolic screens
  prompt examination of the death scene
   including interviews of household
   members by knowledgeable indevidual
  review of the clinical history from
   caretaker, key medical providers and
   medical records
AAP Addition to Evaluation
   Exam of the dead infant at a hospital
    ED by a child maltreatment specialist
     1-5%  of SIDS may be infanticide
     clues to infanticide
       – > 6 months old
       – previous unexpected or unexplained sib death
       – simultaneous death of twins
etiology - broad
 no common etiology- multifactorial
 final common pathway may be:
     failure to arouse to cope w/ homeostatic
      challenge
     abnormal development of the control of
      cardiorespiratory systems
     maldevelopment of fetal to newborn
      transition mechanism
etiology - focused
 developing nervous system
 developing immune system
 inherited metabolic disease
 changes in cardiac conduction system
 changes in respiratory control
 non-accidental trauma
Baruch‟s Observation
  “If all you have is a hammer,
   everything looks like a nail.”
CNS autopsy findings
 increased gliosis
 increased brainstem dendritic spine
  density
 delayed myelin maturation
epidemiologic studies
 NICHD Cooperative Epidemiologic
  Study of SIDS Risk Factors
 New Zealand Cot Death Study
 Avon Infant Mortality Study
 King County Washington SIDS Study
NICHD SIDS Study
 Oct „78 - Dec '79
 multicenter, population based, case
  controlled
 838 SIDS
 1676 controls
     age-matched  living - randomly selected
     age-matched living - matched for race and
      low birth weight
NICHD Study - conclusion
   “None of the risk factors documented
    are of sufficient strength to enable
    identification of SIDS infants prior to
    their death. Instead a descriptive
    profile has emerged that associates
    several maternal, neonatal, and
    postnatal factors with increased SIDS
    risk.”
NICHD SIDS Study - results
maternal factors
 inadequate prenatal care
 smoking
 anemia
 ISAM
 VD
 UTI
NICHD SIDS Study - results
other factors
 low birth weight
 inadequate post-natal care
 lack of breast feeding
 GI infections
NICHD SIDS Study - results
non-factors
 URI‟s
 apnea of prematurity
New Zealand Cot Death Study
 1987 - 1990
 multicenter, prospective, case-
  controlled
     covered   78% of all births
 485 cot deaths
 1800 random controls - matched for
  post-natal age
New Zealand Study - results
significant avoidable risks
 prone sleeping position
 co-sleeping
 not breast fed
 maternal smoking
Avon Infant Mortality Study
 1984 - 1992
 Avon County in SW England
     pop. 940,000 with 13,000 births/year
     1 coroner, 1 Peds Path, 3 OB units

   all unexpected deaths
     detailed history and conditions
     collection of bact, and virology specimens
     2 controls/death matched for age, Hx,
      exam, and home
Avon Study - results
significant avoidable risks
 prone sleeping position
 thermal environment
 role of infection
 parental smoking
avoidable SIDS risk factors
 prone sleeping position
 thermal environment
 parental smoking
 co-sleeping?
studies of infant sleep position
   > 20 retrospective studies
     odds  ratio 1.9 - 12.7
     ? recall bias

   1 prospective study in high risk infants
     15SIDS, 116 controls
     odds ratio 3.92 x‟s higher

 2 intervention studies
 1 U.S. study
Infant Sleeping Position and SIDS Rate
- Netherlands

              70                                                      1.75




                                                                             SIDS rate
  % infants




                          prone sleep
              60                                                      1.5
                          SIDS rate
              50                                                      1.25
              40                                                      1.0
              30                                                      0.75
              20                                                      0.5
              10                                                      0.25
              0                                                       0
                   1965     1970   1975   1980   1985   1988   1990
Infant Sleeping Position and SIDS Rate
- Avon England

             70                                                4.0




                                                                     SIDS rate
 % infants




             60                               prone sleep      3.4
             50                               SIDS rate        2.9
             40                                                2.3
             30                                                1.7
             20                                                1.1
             10                                                0.6
              0                                                0
                  1987   1988   1989   1990     1991    1992
Infant Sleeping Position and SIDS Rate
- King County Washington

 population based, case-controlled study
 Nov. 1992 - Oct. 1994
 47 SIDS, 142 matched controls
 57.4% of SIDS cases usually slept prone
  vs./ 24.6% of controls
 adjusted odds ratio = 3.12
Infant Sleeping Position and SIDS Rate
- King County Washington

Conclusion:
“Prone sleep position was significantly
 associated with an increased risk of
 SIDS among a group of American
 infants.”
US SIDS Rate 1991 - „99
  year   % prone   rate   deaths
   „91             1.30   5349
   „92     70      1.20   4891
   „93     59      1.17   4669
   „94     43      1.03   4073
   „95     29      0.87   3396
   „99             0.68   2648
US SIDS Rate 1980 - „99
 1.6
 1.4
 1.2
  1
 0.8
 0.6
 0.4
 0.2
  0
       '80   '82   '84   '86   '88   '90   '92   '94   '96   '98
adverse effects of supine sleep
   airway obstruction
     Pierre   Robin syndrome
 RDS
 choking/aspiration not a problem
     Czech & Hong Kong data
     Netherlands interventional study data
     750 newborn deaths reviewed
       – only lethal episodes of aspiration occurred in
         neurologically impaired (all were prone)
thermal environment
   well known association of SIDS & cold
     suggests hypothermia
     no data showing low temp or less
      insulation are risk factors
   2 controlled studies investigating tog
     Avon
     Tasmania
thermal environment - studies
Avon (risk increases 1.14/tog if > 8 tog)
 SIDS slightly more heavily wrapped
 SIDS more likely have heating left on
 25% SIDS found with head covered (no
  controls)
 >10 tog + URI increased odds ratio to
  51.5
thermal environment - studies
Tasmania (28 SIDS c/w 54 controls)
 mean insulation for SIDS was 1.3 tog >
  controls
                             o
 mean ambient temp was 1.5 C >
  controls
 SIDS more likely to have home heating
thermal environment
- pathophysiologic mechanisms
   birth to 3 months
       metabolic rate increases by 50%
       SQ fat increases
       peripheral vasomotor control becomes more
        effective
   > 3 mo. metabolic rate markedly increases
    with virus
   < 3 mo. metabolic rate decreases or remains
    the same with virus
   increased temp causes hypoventilation
smoking & SIDS
   prospective cohort studies
     highly significant + correlation between
      parental smoking and SIDS (odds ratio >2)
     dose effect

   retrospective case controls
     odds ratio for maternal smoking = 1.68
     odds ratio for paternal smoking = 1.39
     odds ratio if both smoke = 3.46
 “And this woman‟s son died in
the night because she lay on it.”
                    1 Kings 3:19
co-sleeping
   infants and children sleeping in contact or
    close proximity to their parents
       same bed
       rocked or held while sleeping
       parent & child close enough to hear feel or smell
        one another
   common in:
       pre-industrial societies
       Far, Near, & Middle East
       La Leche League
   discouraged in Euro./Western society
co sleeping & SIDS
   sleep data demonstrate overlapping, partner
    induced arousals
       ? fosters development of optimal sleep pattern
       ? gives infants practice arousing
   New Zealand cot death study
       increased in Maori Indians
         – also highest poverty, drug use, smoking
   ?evolved with & to offset neurologic
    immaturity
co sleeping & SIDS
   Questions
     breastfeeding   and co-sleeping relation
     infant safety (fall)
     adult sleeping surfaces (waterbed, soft
      mattress)
AAP Recommendations:
revised 12/96

   Placing infants to sleep supine carries
    the lowest risk of SIDS and is preferred.
    However, a side position carries a
    significantly lower risk than a prone
    position. If a side position is used, place
    the lower arm forward to reduce the
    risk of the infant rolling onto his or her
    stomach.
AAP Recommendations:
revised 12/96

 Soft surfaces and gas trapping objects
  should be avoided in the crib or other
  sleeping surfaces. In particular, pillows
  or quilts should not be placed beneath a
  sleeping infant.
 The recommendations are for healthy
  infants only. Some medical problems
  may prompt a pediatrician to
  recommend prone sleep.
AAP Recommendations:
revised 12/96

   The recommendations are for sleeping
    babies. Some “tummy time” while the
    baby is awake and observed is
    recommended.

				
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