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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 control of breathing epidemiology avoidable risk factors. ALTE definition. frightening to the observer

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to die to sleep

“To Die, To Sleep ...”

A Discussion on SIDS

COL H. Joel Schmidt

Pediatric Pulmonology

sids outline
SIDS - outline
  • ALTE
    • not “near-miss SIDS”
  • SIDS
    • background
    • definition
    • etiology
    • control of breathing
    • epidemiology
    • avoidable risk factors
alte definition
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
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
Causes
  • GE Reflux 28%
  • Neurologic problems 12%
  • Infection 6%
  • Upper Airway Obstruction 2%
  • Metabolic problems 2%
  • Cardiac problems 1%
  • Idiopathic 47%
work up
Work-Up
  • History
  • History
  • History
  • History
  • History
  • History
  • History
home monitor
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
Questionable Risk Group
  • Sib of SIDS
  • moderate ALTE
  • decision based
    • risks, benefits, liabilities, and limitations
    • parent - provider decision
monitor requirements
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
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
causes of infant death

<1 year old, 1992

definition of sids
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
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
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
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
Baruch’s Observation

“If all you have is a hammer, everything looks like a nail.”

cns autopsy findings
CNS autopsy findings
  • increased gliosis
  • increased brainstem dendritic spine density
  • delayed myelin maturation
epidemiologic studies
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
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
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
NICHD SIDS Study - results

maternal factors

  • inadequate prenatal care
  • smoking
  • anemia
  • ISAM
  • VD
  • UTI
nichd sids study results24
NICHD SIDS Study - results

other factors

  • low birth weight
  • inadequate post-natal care
  • lack of breast feeding
  • GI infections
nichd sids study results25
NICHD SIDS Study - results

non-factors

  • URI’s
  • apnea of prematurity
new zealand cot death study
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
New Zealand Study - results

significant avoidable risks

  • prone sleeping position
  • co-sleeping
  • not breast fed
  • maternal smoking
avon infant mortality study
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
Avon Study - results

significant avoidable risks

  • prone sleeping position
  • thermal environment
  • role of infection
  • parental smoking
avoidable sids risk factors
avoidable SIDS risk factors
  • prone sleeping position
  • thermal environment
  • parental smoking
  • co-sleeping?
studies of infant sleep position
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
Infant Sleeping Position and SIDS Rate- Netherlands

1.75

SIDS rate

1.5

1.25

1.0

0.75

0.5

0.25

0

infant sleeping position and sids rate king county washington
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 washington35
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.”

adverse effects of supine sleep
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
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
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 studies41
thermal environment - studies

Tasmania (28 SIDS c/w 54 controls)

  • mean insulation for SIDS was 1.3 tog > controls
  • mean ambient temp was 1.5oC > controls
  • SIDS more likely to have home heating
thermal environment pathophysiologic mechanisms
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
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
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
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 sids47
co sleeping & SIDS
  • Questions
    • breastfeeding and co-sleeping relation
    • infant safety (fall)
    • adult sleeping surfaces (waterbed, soft mattress)
aap recommendations revised 12 96
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 9649
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 9650
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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