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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 l.jpg

“To Die, To Sleep ...”

A Discussion on SIDS

COL H. Joel Schmidt

Pediatric Pulmonology


Sids outline l.jpg
SIDS - outline

  • ALTE

    • not “near-miss SIDS”

  • SIDS

    • background

    • definition

    • etiology

    • control of breathing

    • epidemiology

    • avoidable risk factors


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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)


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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


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Causes

  • GE Reflux 28%

  • Neurologic problems 12%

  • Infection 6%

  • Upper Airway Obstruction 2%

  • Metabolic problems 2%

  • Cardiac problems 1%

  • Idiopathic 47%


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Work-Up

  • History

  • History

  • History

  • History

  • History

  • History

  • History


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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


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Questionable Risk Group

  • Sib of SIDS

  • moderate ALTE

  • decision based

    • risks, benefits, liabilities, and limitations

    • parent - provider decision


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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


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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


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causes of infant death

<1 year old, 1992


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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


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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


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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


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etiology - focused

  • developing nervous system

  • developing immune system

  • inherited metabolic disease

  • changes in cardiac conduction system

  • changes in respiratory control

  • non-accidental trauma


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Baruch’s Observation

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


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CNS autopsy findings

  • increased gliosis

  • increased brainstem dendritic spine density

  • delayed myelin maturation


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epidemiologic studies

  • NICHD Cooperative Epidemiologic Study of SIDS Risk Factors

  • New Zealand Cot Death Study

  • Avon Infant Mortality Study

  • King County Washington SIDS Study


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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


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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.”


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NICHD SIDS Study - results

maternal factors

  • inadequate prenatal care

  • smoking

  • anemia

  • ISAM

  • VD

  • UTI


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NICHD SIDS Study - results

other factors

  • low birth weight

  • inadequate post-natal care

  • lack of breast feeding

  • GI infections


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NICHD SIDS Study - results

non-factors

  • URI’s

  • apnea of prematurity


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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


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New Zealand Study - results

significant avoidable risks

  • prone sleeping position

  • co-sleeping

  • not breast fed

  • maternal smoking


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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


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Avon Study - results

significant avoidable risks

  • prone sleeping position

  • thermal environment

  • role of infection

  • parental smoking


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avoidable SIDS risk factors

  • prone sleeping position

  • thermal environment

  • parental smoking

  • co-sleeping?


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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


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Infant Sleeping Position and SIDS Rate- Netherlands

1.75

SIDS rate

1.5

1.25

1.0

0.75

0.5

0.25

0


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Infant Sleeping Position and SIDS Rate- Avon England

4.0

SIDS rate

3.4

2.9

2.3

1.7

1.1

0.6

0


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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


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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.”




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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)


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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


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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


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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


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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


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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



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co-sleeping on it.”

  • 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


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co sleeping & SIDS on it.”

  • 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


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co sleeping & SIDS on it.”

  • Questions

    • breastfeeding and co-sleeping relation

    • infant safety (fall)

    • adult sleeping surfaces (waterbed, soft mattress)


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AAP Recommendations: on it.”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.


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AAP Recommendations: on it.”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.


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AAP Recommendations: on it.”revised 12/96

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