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SIDS - “To Die To Sleep.” A Discussion on SIDS COL H...

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Unformatted text preview: “To Die, To Sleep ...” A Discussion on SIDS COL H. Joel Schmidt Pediatric Pulmonology SIDS - outline s ALTE ® not “near­miss SIDS” s SIDS ® background ® definition ® etiology ® control of breathing ® epidemiology ® avoidable risk factors ALTE definition frightening to the observer s characterized by some combination of s ® apnea ® color change ® marked change in muscle tone ® choking ® gagging s (involves vigorous stimulation or resuscitation) Factoids prevalence from 0.05% to 6.0% s most with ALTE do not die of SIDS s ® combined prevalence of SIDS among other family members of infants w/ ALTE = 11% s most with SIDS have never had ALTE ® 73 ­ 96% w/o ALTE median age at presentation = 2 months s slight male predominance s Causes GE Reflux s Neurologic problems s Infection 6% s Upper Airway Obstruction s Metabolic problems 2% s Cardiac problems s Idiopathic s 28% 12% 2% 1% 47% Work-Up History s History s His ry to s History s History s History s History s Home Monitor? s 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 s moderate ALTE s s decision based ® risks, benefits, liabilities, and limitations ® parent ­ provider decision Monitor Requirements home telephone s basic infant CPR instruction for all caregivers s use and trouble shooting of monitor for all caregivers s 24’ medical and technical back­up s SIDS background decreasing infant mortality this century s one category of infant death not decreasing s 1969 ­ “SIDS” title given s Steinschneider A: Prolonged apnea and the sudden infant death syndrome. Pediatrics 1972; 50 (4): 646. s 1991 ­ definition expanded by NICHD s causes of infant death maternal complications <1 year old, 1992 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 s Exam of the dead infant at a hospital ED by a child maltreatment specialist ® 1­5% 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 s final common pathway may be: s ® 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 s developing immune system s inherited metabolic disease s changes in cardiac conduction system s changes in respiratory control s non­accidental trauma s Baruch’s Observation “If all you have is a hammer, everything looks like a nail.” CNS autopsy findings increased gliosis s increased brainstem dendritic spine density s delayed myelin maturation s epidemiologic studies NICHD Cooperative Epidemiologic Study of SIDS Risk Factors s New Zealand Cot Death Study s Avon Infant Mortality Study s King County Washington SIDS Study s NICHD SIDS Study Oct ‘78 ­ Dec '79 s multicenter, population based, case controlled s 838 SIDS s 1676 controls s ® age­matched living ­ randomly selected ® age­matched living ­ matched for race and low birth weight NICHD Study - conclusion s “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 s inadequate prenatal care s smoking s anemia s ISAM s VD s UTI NICHD SIDS Study - results other factors s low birth weight s inadequate post­natal care s lack of breast feeding s GI infections NICHD SIDS Study - results non­factors s URI’s s apnea of prematurity New Zealand Cot Death Study 1987 ­ 1990 s multicenter, prospective, case­controlled s ® covered 78% of all births 485 cot deaths s 1800 random controls ­ matched for post­ natal age s New Zealand Study - results significant avoidable risks s prone sleeping position s co­sleeping s not breast fed s maternal smoking Avon Infant Mortality Study 1984 ­ 1992 s Avon County in SW England s ® pop. 940,000 with 13,000 births/year ® 1 coroner, 1 Peds Path, 3 OB units s 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 s prone sleeping position s thermal environment s role of infection s parental smoking avoidable SIDS risk factors prone sleeping position s thermal environment s parental smoking s co­sleeping? s studies of infant sleep position s > 20 retrospective studies ® odds ratio 1.9 ­ 12.7 ® ? recall bias s 1 prospective study in high risk infants ® 15 SIDS, 116 controls ® odds ratio 3.92 x’s higher 2 intervention studies s 1 U.S. study s % infants 70 1.75 prone sleep SIDS rate 60 50 1.5 1.25 40 1.0 30 0.75 20 0.5 10 0.25 0 1965 1970 1975 1980 1985 1988 1990 0 SIDS rate Infant Sleeping Position and SIDS Rate - Netherlands 70 4.0 60 prone sleep SIDS rate 50 3.4 2.9 40 2.3 30 1.7 20 1.1 10 0.6 0 0 1987 1988 1989 1990 1991 1992 SIDS rate % infants Infant Sleeping Position and SIDS Rate - Avon England Infant Sleeping Position and SIDS Rate - King County Washington population based, case­controlled study s Nov. 1992 ­ Oct. 1994 s 47 SIDS, 142 matched controls s 57.4% of SIDS cases usually slept prone vs./ 24.6% of controls s adjusted odds ratio = 3.12 s 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 rate d eaths ‘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 % prone 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 s airway obstruction ® Pierre Robin syndrome RDS s choking/aspiration not a problem s ® 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 s well known association of SIDS & cold ® suggests hypothermia ® no data showing low temp or less insulation are risk factors s 2 controlled studies investigating tog ® Avon ® Tasmania thermal environment - studies Avon (risk increases 1.14/tog if > 8 tog) s SIDS slightly more heavily wrapped s SIDS more likely have heating left on s 25% SIDS found with head covered (no controls) s >10 tog + URI increased odds ratio to 51.5 thermal environment - studies Tasmania (28 SIDS c/w 54 controls) s mean insulation for SIDS was 1.3 tog > controls o mean ambient temp was 1.5 C > controls s SIDS more likely to have home heating s thermal environment - pathophysiologic mechanisms s birth to 3 months metabolic rate increases by 50% ® SQ fat increases ® peripheral vasomotor control becomes more effective ® s s s > 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 s prospective cohort studies ® highly significant + correlation between parental smoking and SIDS (odds ratio >2) ® dose effect s 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 s 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 ® s common in: pre­industrial societies ® Far, Near, & Middle East ® La Leche League ® s discouraged in Euro./Western society co sleeping & SIDS s sleep data demonstrate overlapping, partner induced arousals ? fosters development of optimal sleep pattern ® ? gives infants practice arousing ® s New Zealand cot death study ® increased in Maori Indians – also highest poverty, drug use, smoking s ?evolved with & to offset neurologic immaturity co sleeping & SIDS s Questions ® breastfeeding and co­sleeping relation ® infant safety (fall) ® adult sleeping surfaces (waterbed, soft mattress) AAP Recommendations: revised 12/96 s 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. s The recommendations are for healthy infants only. Some medical problems may prompt a pediatrician to recommend prone sleep. s AAP Recommendations: revised 12/96 s The recommendations are for sleeping babies. Some “tummy time” while the baby is awake and observed is recommended. ...
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