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To Die, To Sleep ...

A Discussion on SIDS
COL H. Joel Schmidt Pediatric Pulmonology

SIDS - outline

ALTE (Apparent Life-Threatening Event)


near-miss SIDS

background definition


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)

prevalence from 0.05% to 6.0% most with ALTE do not die of SIDS


prevalence of SIDS among other family members of infants w/ ALTE = 11% - 96% w/o ALTE

most with SIDS have never had ALTE


median age at presentation = 2 months slight male predominance

GE Reflux 28% Neurologic problems 12% Infection 6% Upper Airway Obstruction 2% Metabolic problems 2% Cardiac problems 1% Idiopathic 47%

History History History History

History History History

Home Monitor?

1986 NIH Consensus Conference on Infantile Apnea and Home Monitoring



severe ALTE tracheostomy <18 months old twin of SIDS victim



normal infant asymptomatic premature infant

Questionable Risk Group

Sib of SIDS moderate ALTE

decision based

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

<1 year old, 1992
maternal complications RDS prematurity


birth defects


definition of SIDS
sudden death of an infant under 1 year old that can not be explained despite:

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


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:


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.

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


Oct 78 - Dec '79 multicenter, population based, case controlled 838 SIDS 1676 controls


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

maternal factors inadequate prenatal care smoking anemia VD UTI

NICHD SIDS Study - results

other factors low birth weight inadequate post-natal care lack of breast feeding GI infections

NICHD SIDS Study - results

non-factors URIs apnea of prematurity

New Zealand Cot Death Study

1987 - 1990 multicenter, prospective, casecontrolled


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


940,000 with 13,000 births/year 1 coroner, 1 Peds Path, 3 OB units

all unexpected deaths


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


ratio 1.9 - 12.7 ? recall bias

1 prospective study in high risk infants


SIDS, 116 controls odds ratio 3.92 xs higher

2 intervention studies 1 U.S. study

Infant Sleeping Position and SIDS Rate - Netherlands

% infants

60 50 40 30 20 10 0 1965

prone sleep SIDS rate

1.5 1.25 1.0 0.75 0.5 0.25







SIDS rate



Infant Sleeping Position and SIDS Rate - Avon England

% infants

60 50 40 30 20 10 0 1987 1988 1989 1990

prone sleep SIDS rate

3.4 2.9 2.3 1.7 1.1 0.6

1991 1992

SIDS rate



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 91 92 93 94 95 99 70 59 43 29 % prone rate 1.30 1.20 1.17 1.03 0.87 0.68 deaths 5349 4891 4669 4073 3396 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

airway obstruction

Robin syndrome

RDS choking/aspiration not a problem


& 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


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 o mean ambient temp was 1.5 C > 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


significant + correlation between parental smoking and SIDS (odds ratio >2) dose effect

retrospective case controls


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


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 pre-industrial societies Far, Near, & Middle East La Leche League

common in:

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 increased in Maori Indians
also highest poverty, drug use, smoking

New Zealand cot death study

?evolved with & to offset neurologic immaturity

co sleeping & SIDS


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.