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A Discussion on SIDS
COL H. Joel Schmidt Pediatric Pulmonology
SIDS - outline
near-miss SIDS
SIDS
background definition
etiology
control
ALTE definition
frightening to the observer characterized by some combination of
apnea color
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% - 96% w/o ALTE
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
Home Monitor?
indicated
indicated
decision based
risks,
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
other
birth defects
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
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
Baruchs Observation
If all you have is a hammer, everything looks like a nail.
epidemiologic studies
NICHD Cooperative Epidemiologic Study of SIDS Risk Factors New Zealand Cot Death Study Avon Infant Mortality Study King County Washington SIDS Study
age-matched
living - randomly selected age-matched living - matched for race and low birth weight
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.
covered
485 cot deaths 1800 random controls - matched for post-natal age
pop.
history and conditions collection of bact, and virology specimens 2 controls/death matched for age, Hx, exam, and home
60 50 40 30 20 10 0 1965
1970
1975
1980
1985
1988
1990
SIDS rate
70
1.75
0
1991 1992
SIDS rate
70
4.0
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.
airway obstruction
Pierre
Robin syndrome
& 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
hypothermia no data showing low temp or less insulation are risk factors
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
significant + correlation between parental smoking and SIDS (odds ratio >2) dose effect
ratio for maternal smoking = 1.68 odds ratio for paternal smoking = 1.39 odds ratio if both smoke = 3.46
And this womans son died in the night because she lay on it.
1 Kings 3:19
co-sleeping
same bed rocked or held while sleeping parent & child close enough to hear feel or smell one another pre-industrial societies Far, Near, & Middle East La Leche League
common in:
? fosters development of optimal sleep pattern ? gives infants practice arousing increased in Maori Indians
also highest poverty, drug use, smoking
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.