“To Die, To Sleep...” A Discussion on SIDS COL H. Joel Schmidt Pediatric Pulmonology.
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Transcript of “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 control of breathing epidemiology avoidable risk factors
ALTE definition
frightening to the observer characterized by some combination of
apnea color change 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
combined prevalence 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%
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 risks, benefits, liabilities, and
limitations 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
Unknown
other
maternal complications RDS
prematurity
birth defects
<1 year old, 1992
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
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
other factors low birth weight inadequate post-natal care lack of breast feeding GI infections
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 15 SIDS, 116 controls odds ratio 3.92 x’s higher
2 intervention studies 1 U.S. study
Infant Sleeping Position and SIDS Rate- Netherlands
0
10
20
30
40
50
60
70
% in
fan
ts
1965 1970 1975 1980 1985 1988 1990
prone sleep
SIDS rate
0
0.25
0.5
0.75
1.0
1.25
1.5
1.75
SID
S r
ate
Infant Sleeping Position and SIDS Rate- Avon England
1987 1988 1989 1990 1991 19920
10
20
30
40
50
60
70
% in
fan
ts
1987 1988 1989 1990 1991 1992
prone sleep
SIDS rate
0
0.6
1.1
1.7
2.3
2.9
3.4
4.0
SID
S r
ate
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
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 mean ambient temp was 1.5
oC >
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
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.