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Biomedical subjects

J Golding

Publications and source records attributed to J Golding.

At least 19 recordsLinked to original sources

Nocturnal enuresis: a survey of parental coping strategies at 7 1/2 years.

BACKGROUND: Childhood nocturnal enuresis is a potentially distressing experience. Parents have been found to adopt many approaches designed to help their child become dry at night. This study sought to understand, through a large cohort of children at 7 1/2 years of age, the strategies parents adopt, both during the child's development and currently, to help their child overcome bed-wetting. METHODS: A longitudinal cohort of 13,971 children with expected date of delivery between April 1991-December 1992, in the County of Avon (Bristol) formed the population study group. At 7 1/2 years parents were asked, as part of a regular self-report questionnaire, what methods they had tried or were currently using to help their child stop bed-wetting. Eleven options were supplied. RESULTS: Of 8269 parents responding to the questionnaire, 3376 (40.8%) indicated they had tried at least one of 11 strategies, with restricting night-time fluids and lifting being the predominant methods employed. Amongst strategies employed in the past, lifting and showing displeasure were used significantly more by parents of children with nocturnal enuresis than by those with children dry at 7 1/2 years. However, a greater proportion of parents of dry children encouraged their offspring to toilet more regularly in the daytime than parents of those with nocturnal enuresis or infrequent wetting. In terms of treatment interventions, the enuresis alarm had been employed with 19.2% and medication with 13.1% of those with nocturnal enuresis, although only 31.9% of those with nocturnal enuresis had seen a health worker. The results are discussed in relation to preventative and clinical implications.

Adaptation, Psychological↗

Prevalence of latex allergy in the community at age 7 years.

BACKGROUND: Latex allergy has been highlighted as a problem in children during the last decade based on a number of case series of children with particular problems such as spina bifida. The actual prevalence of latex allergy in the general United Kingdom population is unclear. OBJECTIVE: To estimate the prevalence of childhood latex allergy in the general population. METHODS: The Avon Longitudinal Study of Parents and Children is a geographically based cohort that has been prospectively followed since birth. The children were invited for skin prick testing at 7 years of age. RESULTS: Four subjects out of 1877 tested were sensitized to latex. None had a history of clinical reactions to latex. CONCLUSION: This study suggests that the prevalence of latex sensitization and clinical latex allergy in the general childhood population are very low, 0.2% (95% confidence interval 0.1-0.6%) and 0.0% (0-0.2%), respectively.

Child↗

Relationship between aeroallergen and food allergen sensitization in childhood.

BACKGROUND: Previous studies measuring the prevalence of allergen sensitization have been relatively small and used small numbers of allergens. To effectively evaluate children with atopic disease, we need an accurate knowledge of which allergens are important. OBJECTIVE: To measure the prevalence of sensitization within a large unselected birth cohort, to examine the associations between sensitization to different allergens and determine whether atopy can be defined by a small panel of allergens. METHODS: The Avon Longitudinal Study of Parents and Children is a population-based birth cohort of 13,638 singletons surviving to 4 weeks of age. The cohort was skin tested at 7 years of age to house dust mite (Dermatophagoides pteronyssinus), grass pollens, cat, peanuts, mixed tree nuts and egg and one of three other panels: animal danders, foods or aeroallergens. Sensitization was defined as a weal diameter of > or =3 mm. The strength of associations between sensitization to different allergens was tested by calculating the odds ratio adjusted for sensitization to D. pteronyssinus and grass pollen and gender. RESULTS: Valid data were obtained from 6412 singletons. Sensitization was most common to aeroallergens: grass pollens (8.5%), D. pteronyssinus (7.8%), cat (4.9%), D. farinae (3.6%), dog (2.7%), horse (1.4%), rabbit (1.4%). Of the foods tested, the most common sensitization was to peanut (1.4%) and mixed tree nuts (1.0%). More than 95% of subjects with sensitization to any of the 29 allergens tested were sensitized to one of grass, D. pteronyssinus or cat allergen. There were strong associations of multiple sensitizations both within and between different allergen classes (pollens, animals, foods, peanut and tree nuts). CONCLUSIONS: Seven-year-old children in the UK are primarily sensitized to aeroallergens, but also to peanuts and tree nuts. There are strong associations between sensitization within allergen groups as well as between allergen groups. Further studies are required to observe whether similar associations are seen with clinical allergy to these allergens.

Air Pollution↗

Frequent use of chemical household products is associated with persistent wheezing in pre-school age children.

BACKGROUND: In the UK and other developed countries the prevalence of asthma symptoms has increased in recent years. This is likely to be the result of increased exposure to environmental factors. A study was undertaken to investigate the association between maternal use of chemical based products in the prenatal period and patterns of wheeze in early childhood. METHODS: In the population based Avon Longitudinal Study of Parents and Children (ALSPAC), the frequency of use of 11 chemical based domestic products was determined from questionnaires completed by women during pregnancy and a total chemical burden (TCB) score was derived. Four mutually exclusive wheezing patterns were defined for the period from birth to 42 months based on parental questionnaire responses (never wheezed, transient early wheeze, persistent wheeze, and late onset wheeze). Multinomial logistic regression models were used to assess the relationship between these wheezing outcomes and TCB exposure while accounting for numerous potential confounding variables. Complete data for analysis was available for 7019 of 13, 971 (50%) children. RESULTS: The mean (SD) TCB score was 9.4 (4.1), range 0-30. Increased use of domestic chemical based products was associated with persistent wheezing during early childhood (adjusted odds ratio (OR) per unit increase of TCB 1.06 (95% confidence interval (CI) 1.03 to 1.09)) but not with transient early wheeze or late onset wheeze. Children whose mothers had high TCB scores (>90th centile) were more than twice as likely to wheeze persistently throughout early childhood than children whose mothers had a low TCB score (<10th centile) (adjusted OR 2.3 (95% CI 1.2 to 4.4)). CONCLUSION: These findings suggest that frequent use of chemical based products in the prenatal period is associated with persistent wheezing in young children. Follow up of this cohort is underway to determine whether TCB is associated with wheezing, asthma, and atopy at later stages in childhood.

Body Burden↗

Early experiences and their relationship to maternal eating disorder symptoms, both lifetime and during pregnancy.

BACKGROUND: There is some evidence that early sexual abuse is an aetiological factor for eating disorder. However, there is sparse information from large-scale, non-clinical studies. AIMS: This study was designed to explore which early experiences, recalled during pregnancy, were associated with both lifetime and antenatal eating disorder symptoms in a community sample. METHOD: Univariate and multivariate analyses were conducted of data from questionnaires administered during pregnancy to a community sample of pregnant women. RESULTS: Recall of parental mental health problems and of early unwanted sexual experiences were independently associated with both lifetime eating problems, laxative use and vomiting during pregnancy, and marked concern during pregnancy over shape and weight. CONCLUSIONS: There are public health implications for these results. Eating disorders in mothers represent a risk for child development. It may be important to enquire during pregnancy about a history of eating problems and to provide the opportunity for early experiences to be discussed.

Adolescent↗

Medication use during pregnancy: data from the Avon Longitudinal Study of Parents and Children.

OBJECTIVE: To present data on the self-reported use of all types of medicinal products collected during pregnancy in a large cohort in southwest England. METHODS: Pregnant women with a delivery date during 1991-1992 and forming part of the prospective, population-based Avon Longitudinal Study of Parents and Children (ALSPAC) were sent up to four self-completion postal questionnaires during pregnancy. Text data collected from the questions on drug usage were coded using an ALSPAC drug dictionary based on the World Health Organization Drug Dictionary. RESULTS: At least one antenatal self-completion questionnaire was completed for 14,119 pregnancies, and 11,545 women completed all four. The data included prescription, over-the-counter, herbal and homeopathic products as well as iron, vitamins and other supplements. Only 7.6% did not report use of any medicinal product throughout their entire pregnancy. The remaining 92.4% used at least one product at some stage. After exclusion of iron, folate, vitamins, supplements, herbal and homeopathic products and skin emollients, 83% of those completing all questionnaires had used conventional therapeutic drugs. Analgesics were reported by approximately one-third of women at each stage during pregnancy, and paracetamol was the most frequently reported substance. Iron preparations were reported by 33% of the full cohort, at some stage, and folate by 21.9%. Use of anti-anaemic products increased during pregnancy with the greatest incidence at 32 weeks. Other vitamins and supplements were taken by 17.4% at some stage. Use of vitamins decreased throughout pregnancy from 9.6% in early pregnancy to 5% at 32 weeks. Antacids were reported by 23% at 32 weeks. The reported incidence of antibiotic use decreased slightly during pregnancy from 8% early on to 5.8% at 32 weeks; amoxicillin was the most frequently reported antibacterial. CONCLUSION: Use of medicinal products was high during pregnancy in the ALSPAC cohort. This finding is consistent with data from recent publications.

Adolescent↗

Strategies to prevent eclampsia in a developing country: I. Reorganization of maternity services.

OBJECTIVE: To determine whether changes in primary and secondary care service delivery could prevent antenatal eclampsia. METHOD: One intervention (St. Catherine) and two control (St. Ann, Manchester) parishes were chosen. The health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions for referring patients to a high-risk antenatal clinic or to hospital. Guidelines were provided to high-risk clinics and the antenatal ward for appropriate treatment of hypertension and preeclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored before and during the intervention and compared with control parishes (no intervention). Each eclampsia case was investigated to identify inadequacies in the system. RESULTS: The process resulted in better identification of women at risk. Antenatal eclampsia incidence dropped dramatically as care improved. Compared with control areas, by completion of the study, the rate was significantly lower than at the start: OR 0.19 (95% CI: 0.13-0.27; p<0.001 trend). Antenatal admissions for hypertensive disorders declined significantly, and the number of bed days halved. CONCLUSION: Reorganization of maternal care can have major public health benefits and cost savings; however, women need to be alerted to recognise and act upon signs of impending eclampsia.

Adolescent↗

Strategies to prevent eclampsia in a developing country: II. Use of a maternal pictorial card.

OBJECTIVE: To assess the efficacy and acceptability of a patient-held pictorial card aimed at raising awareness and appropriate health seeking behavior in response to prodromal symptoms of imminent eclampsia. METHOD: Pictorial cards (and posters) were issued to antenatal clinics and used to focus instruction and advice to pregnant women. Mothers were surveyed before and after the cards were introduced to assess maternal likelihood of seeking care if edema was seen, and of attending hospital if so advised. We monitored the eclampsia rate. Health workers were interviewed 6 months after cards and posters were issued to determine the acceptability of using the cards as part of routine antenatal care. RESULTS: The card was seen as widely acceptable by health professionals, and increased their own awareness of the prodromal symptoms of eclampsia and their discussion of these symptoms with antenatal mothers. Mothers' awareness and response to symptoms improved significantly and there was a marked drop in eclampsia incidence. Suggested improvements to the card were made by mothers and health workers. CONCLUSION: The cost of providing a card for every pregnant mother is likely to be offset by health service delivery savings.

Adult↗

Association of parental eczema, hayfever, and asthma with atopic dermatitis in infancy: birth cohort study.

OBJECTIVE: To evaluate the association of parental history of atopic disease with childhood atopic dermatitis, and to examine the relative strength of associations with maternal and paternal disease. DESIGN: Mothers were recruited to the Avon longitudinal study of parents and children (ALSPAC) from the eighth week of pregnancy. Before parturition, both parents were asked, separately, to report their lifetime history of eczema, asthma, and hayfever. Parents reported symptoms of atopic dermatitis in their children at ages 6, 18, 30, and 42 months. RESULTS: Of 8530 children with complete information on rash at ages 6, 18, 30, and 42 months, 7969 had complete information on maternal atopic disease and 5658 on maternal and paternal atopic disease. There was a strong association between parental eczema and childhood atopic dermatitis: odds ratio 1.69 (95% confidence interval, 1.47 to 1.95) for maternal eczema only, 1.74 (1.44 to 2.09) for paternal eczema only, and 2.72 (2.09 to 3.53) for eczema in both parents. Associations with parental asthma or hayfever were attenuated after controlling for parental eczema. There was no evidence that associations with maternal atopy were stronger than with paternal. CONCLUSIONS: Associations between parents' atopic disease and the risk of atopic dermatitis in offspring vary according to the type of atopic disease in the parents, but not according to parental sex. These results are at variance with previous studies reporting stronger associations with maternal than paternal atopy, and suggest that there is no "parent-of-origin" effect in atopic dermatitis. Parental eczema may be a better marker than parental asthma/hayfever in predisposing to childhood eczema.

Adult↗

Maternal fish intake in late pregnancy and the frequency of low birth weight and intrauterine growth retardation in a cohort of British infants.

OBJECTIVE: To investigate the relation between maternal fish intake in late pregnancy and the frequency of low birth weight and intrauterine growth retardation (IUGR). PARTICIPANTS: 11 585 pregnant women in south west England. METHODS: Information on fish intake was obtained from a food frequency questionnaire sent to the women at 32 weeks' gestation, and used to calculate n-3 fatty acid (n-3FA) intake from fish. IUGR was defined as a birth weight for gestational age and sex below the 10th centile. Confounding variables considered included maternal age, height, weight, education, parity, smoking and drinking in pregnancy, and whether the mother was living with a partner. Only singleton, liveborn infants were included. MAIN RESULTS: Mean daily intakes of fish and n-3FAs were 32.8 g and 0.147 g respectively. In unadjusted analyses there were positive associations between mean birth weight and fish intake or n-3FA intake, but these disappeared on adjustment for potential confounders. The frequency of IUGR decreased with increasing fish intake-the OR (95%CI) of IUGR in those eating no fish was 1.85 (1.44 to 2.38) compared with those in the highest fish intake group. On adjustment this relation was attenuated (adjusted OR 1.37 (1.02 to 1.84)), but the decline in the frequency of IUGR with increasing fish intake remained statistically significant. No relation was observed between mean gestation and fish or n-3FA intake. CONCLUSIONS: These results lend some support to the hypothesis that raising fish or n3-FA intake during pregnancy may increase fetal growth rate. However, they provide no evidence that increasing fish consumption is associated with an increase in mean gestation.

Analysis of Variance↗

A prospective study of the prevalence and incidence of atopic dermatitis in children aged 0-42 months.

BACKGROUND: There is strong evidence that the incidence and prevalence of atopic diseases is increasing. However, estimates of the prevalence of atopic dermatitis (AD) have varied greatly in the U.K. and most parts of the developed world. OBJECTIVES: The aim of the study was to estimate the prevalence and incidence of AD between the ages of 0 and 42 months in children born in the 1990s in a defined population in the U.K. DESIGN: We used data from the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC), a large population-based study in the U.K. that enrolled all pregnant mothers who were resident in Avon and had their delivery date falling between 1 April 1991 and 31 December 1992. Since then ALSPAC has collected a wide range of data from the newborns and their parents. Data reported here were collected at 6, 18, 30 and 42 months using parental reports in a postal questionnaire. Of the 14 009 children originally enrolled 8530 provided information on AD in each of the four follow-up questionnaires. We defined AD as a report of rash in at least two of the four questionnaires. Incidence risk was defined as the percentage of new cases of AD between follow-up questionnaires, out of the total number of children whose parents had not reported that they had AD by the time of the previous follow-up. RESULTS: Period prevalence of 21.0%, 25.6%, 23.2% and 19.9% were observed at ages 0-6, 6-18, 18-30 and 30-42 months, respectively. The corresponding incidence risks were 21.0%, 11.2% and 3.8%, at 0-6, 6-18 and 18-30 months, respectively. There were no gender differences in either the incidence or prevalence of the disease. CONCLUSIONS: Results from this large, prospective study are consistent with recent reports of increased incidence and prevalence of AD. Health planners can use our estimates of incidence and prevalence to project the number of children likely to suffer from AD during infancy and early childhood, and thus to determine the human and financial resources required.

Age Distribution↗

Hygiene levels in a contemporary population cohort are associated with wheezing and atopic eczema in preschool infants.

BACKGROUND: The hygiene hypothesis states that insufficient exposure to certain infectious agents during childhood increases the risk of developing asthma and atopic diseases. Improvements in hygiene levels may be partly responsible for this decline in exposure. AIMS: To assess whether hygiene levels in infancy are associated with wheeze and/or atopic eczema, independent of a number of possible confounding factors. METHODS: Data were gathered from the Avon Longitudinal Study of Parents and Children (ALSPAC). Parental self completion questionnaires provided symptom data on infant wheeze and atopic eczema at 0-6 months and 30-42 months, respectively. A simple hygiene score was derived using questionnaire responses at 15 months, which ranged from least hygienic to most hygienic. Multivariable logistic regression models analysed the effect of hygiene scores on health outcomes, while adjusting for a number of important confounding variables. RESULTS: Increasing hygiene scores were independently associated with wheezing (OR = 1.04; 95% CI: 1.00 to 1.08) and atopic eczema (OR = 1.04; 95% CI: 1.01 to 1.07) between 30 and 42 months, but not in the first six months. The odds ratio was higher for atopic eczema if the rash was reported to have become sore and oozy (OR = 1.09; 95% CI: 1.02 to 1.16). CONCLUSIONS: High levels of hygiene at 15 months of age were independently associated with wheeze and atopic eczema reported between 30 and 42 months, and there was an increased risk for children with more severe eczema during this period. The importance of hygiene in public health should not be dismissed; however, the creation of a sterile environment through excessive cleanliness may potentially be harmful to the immune system.

Child, Preschool↗

Factors associated with different hygiene practices in the homes of 15 month old infants.

BACKGROUND: Improved hygiene in Westernised regions of the world may be partly responsible for the increased prevalence of diseases of the immune system, such as asthma and atopy. There is a paucity of data on cleanliness norms in young children in the UK and there has been no attempt to identify factors that influence the adoption of particular hygiene practices in the home. AIMS: To examine levels of hygiene in a contemporary cohort of children and identify social and lifestyle factors influencing hygiene practices in the home. METHODS: The sample under study are participants in the Avon Longitudinal Study of Parents and Children (ALSPAC). Parental self completion questionnaires provided data on hygiene levels in children at 15 months of age, and a hygiene score was derived from these responses. Multivariable logistic regression models investigated associations between high hygiene scores (top quintile) and a number of perinatal, maternal, social, and environmental factors. RESULTS: Maternal smoking during pregnancy, low maternal educational achievement, and living in local authority housing were factors independently associated with high hygiene scores, as was increased use of chemical household products. High hygiene scores were inversely related to living in damp housing and attendance at day care. There were no gender or ethnic differences in hygiene score. CONCLUSION: Important data on cleanliness norms for infants have been presented. The adoption of hygiene practices is influenced to some degree by social, lifestyle, and environmental factors-with higher hygiene scores occurring in more socially disadvantaged groups. Increased use of chemical household products in the more socially disadvantaged groups within ALSPAC has emerged as an important confounder in any study of hygiene and ill health.

Animals↗

Reduced birth weight in boys with hypospadias: an index of androgen dysfunction?

Anthropometric birth measurements analysed for 51 boys with hypospadias identified in a prospective cohort study showed significant reductions in mean values for birth weight, length, and head circumference compared with controls. The absence of the usual sex dimorphism for these variables suggests that the results represent a marker of fetal androgen dysfunction in this subgroup of infants.

Androgens↗

Paracetamol use in pregnancy and wheezing in early childhood.

BACKGROUND: We recently reported links between frequent paracetamol (acetaminophen) use and wheezing and asthma in adults and children, but data are lacking on possible effects of prenatal exposure on wheezing in early childhood. METHODS: In the population based Avon Longitudinal Study of Parents and Children (ALSPAC) women were asked twice during pregnancy (at 18-20 weeks and 32 weeks) about their usage of paracetamol and aspirin. Six months after birth, and at yearly intervals thereafter, mothers were asked about wheezing and eczema symptoms in their child. The effects of paracetamol and aspirin use in pregnancy on the risk in the offspring of wheezing at 30-42 months (n=9,400) and eczema at 18-30 months (n=10,216) and on their risk of different wheezing patterns (defined by presence or absence of wheezing at <6 months and at 30-42 months) were examined. RESULTS: Paracetamol was taken frequently (most days/daily) by only 1% of women. After controlling for potential confounders, frequent paracetamol use in late pregnancy (20-32 weeks), but not in early pregnancy (<18-20 weeks), was associated with an increased risk of wheezing in the offspring at 30-42 months (adjusted odds ratio (OR) compared with no use 2.10 (95% CI 1.30 to 3.41); p=0.003), particularly if wheezing started before 6 months (OR 2.34 (95% CI 1.24 to 4.40); p=0.008). Assuming a causal relation, only about 1% of wheezing at 30-42 months was attributable to this exposure. Frequent paracetamol use in pregnancy was not associated with an increased risk of eczema. Frequent aspirin use in pregnancy was associated with an increased risk of wheezing only at <6 months. CONCLUSIONS: Frequent use of paracetamol in late pregnancy may increase the risk of wheezing in the offspring, although such an effect could explain only about 1% of the population prevalence of wheezing in early childhood.

Acetaminophen↗

Cohort study of depressed mood during pregnancy and after childbirth.

OBJECTIVE: To follow mothers' mood through pregnancy and after childbirth and compare reported symptoms of depression at each stage. DESIGN: Longitudinal cohort study. SETTING: Avon. PARTICIPANTS: Pregnant women resident within Avon with an expected date of delivery between 1 April 1991 and 31 December 1992. MAIN OUTCOME MEASURES: Symptom scores from the Edinburgh postnatal depression scale at 18 and 32 weeks of pregnancy and 8 weeks and 8 months postpartum. Proportion of women above a threshold indicating probable depressive disorder. RESULTS: Depression scores were higher at 32 weeks of pregnancy than 8 weeks postpartum (difference in means 0.88, 95% confidence interval 0.79 to 0.97). There was no difference in the distribution of total scores or scores for individual items at the four time points. 1222 (13.5%) women scored above threshold for probable depression at 32 weeks of pregnancy, 821 (9.1%) at 8 weeks postpartum, and 147 (1.6%) throughout. More mothers moved above the threshold for depression between 18 weeks and 32 weeks of pregnancy than between 32 weeks of pregnancy and 8 weeks postpartum. CONCLUSIONS: Symptoms of depression are not more common or severe after childbirth than during pregnancy. Research and clinical efforts need to be moved towards understanding, recognising, and treating antenatal depression.

Depression↗

Fluorometric and mass spectrometric analysis of nonenzymatic glycosylated albumin.

Albumin is the major transport protein in blood and intramolecular movement contributes to this function. Nonenzymatic glycosylation (NEG) of albumin occurs in diabetes and, in this study, fluorometric methods were used to determine the effect of increasing levels of NEG upon intramolecular movement in human serum albumin. Low levels of NEG significantly reduced and left-shifted Trp fluorescence, reduced quenching by acrylamide and inhibited penetration of bis-ANS, while these changes became only modestly more pronounced at higher levels of NEG. Mass spectrometry of tryptic and CNBr NEG-HSA fragments identified potential glycosylation sites and demonstrated only late glycosylation of the C- and N-terminal regions of the protein. Similar changes in diabetes may contribute to altered transport function in these patients.

Acrylamide↗

The UK accelerated immunisation programme and sudden unexpected death in infancy: case-control study.

OBJECTIVES: To investigate whether the accelerated immunisation programme in the United Kingdom is associated, after adjustment for potential confounding, with the sudden infant death syndrome. DESIGN: Population based case-control study, February 1993 to March 1996. Parental interviews were conducted for each death and for four controls matched for age, locality, and time of sleep. Immunisation status was taken from records held by the parents. SETTING: Five regions in England with a combined population of over 17 million. SUBJECTS: Immunisation details were available for 93% (303/325) of infants whose deaths were attributed to the sudden infant death syndrome (SIDS); 90% (65/72) of infants with explained sudden deaths; and 95% (1515/1588) of controls. RESULTS: After all potential confounding factors were controlled for, immunisation uptake was strongly associated with a lower risk of SIDS (odds ratio 0.45 (95% confidence interval 0.24 to 0.85)). This difference became non-significant (0.67 (0.31 to 1.43)) after further adjustment for other factors specific to the infant's sleeping environment. Similar proportions of SIDS deaths and reference sleeps (corresponding to the time of day during which the index baby had died) among the controls occurred within 48 hours of the last vaccination (5% (7/149) v 5% (41/822)) and within two weeks (21% (31/149) v 27% (224/822)). No longer term temporal association with immunisation was found (P=0.78). Of the SIDS infants who died within two weeks of vaccination, 16% (5/31) had signs and symptoms of illness that suggested that medical contact was required, compared with 26% (16/61) of the non-immunised SIDS infants of similar age. The findings for the infants who died suddenly and unexpectedly but of explained causes mirrored those for SIDS infants. CONCLUSIONS: Immunisation does not lead to sudden unexpected death in infancy, and the direction of the relation is towards protection rather than risk.

Age Factors↗