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A national model of care service for professionals dealing with sudden infant death.

Sudden Infant Death Syndrome (SIDS) is any death occurring in an infant or young child which is unexpected by history and in which a thorough post mortem examination fails to demonstrate an adequate cause of death. The National Sudden Infant Death Register collects information on all sudden unexpected deaths in infants and young children occurring in Ireland. In this study, a comparison was made between parent's experience of professional services in the aftermath of their child's death both before and after the implementation of a National Model of Care for professionals in 1995. In addition, a random sample of 105 professionals were surveyed about their knowledge of the Model of Care services. Results were grouped according to the parental experience of the emergency services, the hospital services, the community services and the bereavement support services offered to parents. Prior to the implementation of the Model of Care Service (MOC) (1992-1994), 14 per cent of families stated that they did not find the Gardai helpful. After the Model of Care, only 7 per cent of parents expressed such dissatisfaction. Prior to the MOC, only 3 per cent of Gardai provided families with an information booklet on sudden infant death but afterwards, 23 per cent of Gardai did so. After the MOC families were more likely to have been given the opportunity to hold their infant, were given more privacy and were offered more keepsakes of their infant. Only 46 per cent of families were offered momentos of their baby prior to the MOC as compared to 84 per cent after the implementation of the MOC. They were also more likely to perceive the ancillary services such as the Gardai in a more positive light, where 22 per cent of Gardai offered the family the ISIDA support booklet compared to a previous 3 per cent. Over 50 per cent of parents were provided with a special room in the hospital following the MOC as opposed to a previous 48 per cent. Twenty-one per cent of parents prior to the MOC described the conditions in the hospital as awful, poor or fair, however 31 per cent of parents stated this after the MOC. While there have been improvements in certain areas, there still remains considerable variation in the quality of service provided to all parents. Specifically, we need to address the fact that 16 per cent of parents still report a difficulty in obtaining post-mortem information. Almost 40 per cent said they had little input into how their child was dressed or laid out at this highly emotive time. Over one-third of parents stated they were concerned about how few of their primary health providers, namely general practitioners and public health nurses called to visit them in the aftermath of this tragic event.

Delivery of Health Care↗

Magnesium deficiency promotes muscle weakness, contributing to the risk of sudden infant death (SIDS) in infants sleeping prone.

A review was published (1991) of 19 retrospective case-control studies that had investigated the relationship between prone sleeping position (on the stomach) and the sudden infant death syndrome (SIDS). These studies, which had been conducted between 1965 and 1990 in New Zealand, Australia, England, France and the Netherlands, showed an overall higher rate of SIDS in infants who usually slept prone. In those countries, vigorous community intervention to change babies' sleep position away from the prone has resulted in marked declines of 50 per cent or more in the rate of SIDS. Such encouraging reports from many countries prompted the American Academy of Pediatrics to recommend that infants be placed to sleep on their backs to reduce the risk of SIDS. This was followed by a successful campaign in the United States between mid-1994 and 1998. Despite the decreased incidence, SIDS remains the leading cause of death in infants 1 month to 1 year of age of industrialized nations of the world. Studies have been conducted in human infants, mechanical models and animal models to learn the role of risk factors in prone sleeping infants. Soft bedding, thermal stress and biologic risk factors such as impaired ventilatory and arousal responsiveness are among many factors that have been investigated. Hunt states that there is not a single unifying factor that explains increased SIDS in prone sleeping infants. Two major studies conducted in the 1970s showed: (1) muscle weakness in the upper half of the body in infants who subsequently died of SIDS, and (2) shoulder hypotonia in near-miss for SIDS infants. An infant sleeping face-down in the prone position could be jeopardized if he lacked the muscle strength to shift his position or turn his head to rescue himself from a life-threatening situation. In contrast, recent studies in neonates sleeping in the prone position report that normal infants can spontaneously arouse and turn their heads. Some data support the hypothesis that magnesium deficiency contributes to SIDS. Muscle strength is seriously impaired in the young magnesium deficient subject, while magnesium rapidly reverses muscle weakness. In rats, marginal deprivation in dietary magnesium reduces exercise capacity, an early effect of magnesium deficiency which is preventable by consuming magnesium-enriched mineral water. It is concluded that magnesium deficiency is at least one major unifying factor that explains increased SIDS in prone sleeping infants.

Humans↗

Sudden infant death syndrome: can gastroesophageal reflux cause sudden infant death?

Although gastric contents in the airways and lungs of sudden infant death syndrome (SIDS) victims is commonly found during postmortem examination, its significance as a sole or contributory cause of death has long been controversial. Currently, most authorities view such aspiration as resulting from "agonal" processes and, therefore, irrelevant to cause of death. Recent clinical and experimental evidence indicates that infants who are near death because of a variety of conditions, frequently "autoresuscitate," which produces rapid and complete recovery. In animal models, aspiration of water or saline into the airways has been shown to prevent autoresuscitation. In light of these findings, aspiration of gastric contents should be reconsidered as a contributory cause of many SIDS deaths.

Forensic Medicine↗

The seasonal distribution of infant deaths by age: a comparison of sudden infant death syndrome and other causes of death.

OBJECTIVE: To examine the possibility that among deaths in infancy the increase in the winter/summer ratio with increasing age is not peculiar to sudden infant death syndrome (SIDS). METHODOLOGY: Details of the winter (December-February)/summer (June-August) ratio among deaths in neonates (< 28 days) and post neonates dying in the United States of America between 1979 and 1990 were abstracted from published statistics. The primary causes of death were classified according to the ninth Revision of the International Classification of Diseases. RESULTS: For every non-traumatic cause of death including SIDS, the winter/summer ratio was higher among postneonates than neonates. This was not seen for deaths due to trauma. Cases of SIDS and deaths due to infection had the highest ratios in both age categories. Causes of death occurring predominantly in the neonatal period (e.g. anencephaly) had the lowest overall ratios. CONCLUSIONS: Neither the greater number of SIDS cases in the winter, nor the increasing winter/summer ratio with increasing age is unique to SIDS.

Age Distribution↗

Pneumographic studies: predictors of future apnoeas but not sudden infant death in asymptomatic infants.

Pneumograms were performed on 401 asymptomatic infants: 322 siblings, 15 cousins and 24 twins of sudden infant death syndrome (SIDS) victims; 14 siblings of near-miss SIDS victims, and 26 infants of anxious parents. The infants of anxious parents had significantly fewer abnormalities than siblings of SIDS victims. In 222 infants subsequently monitored at home, the pneumogram as a predictor of future apnoea had a sensitivity rate of 97.5% and a specificity rate of 72% (P less than 0.001). Infants who were to experience future apnoeas had a significantly higher percentage of time in periodic breathing and a higher density of apnoeas in their original pneumograms. However, the abnormal pneumogram did not predict SIDS, because the eight infants who died all had normal pneumograms.

Apnea↗

Astrocytes in the hypoglossal nuclei of sudden infant death syndrome (SIDS) infants: a quantitative study.

It has been suggested that brain stem hypoxia or ischaemia underlies the sudden infant death syndrome (SIDS), but previous reports of astrocytosis in the brain stems of SIDS infants have been contradictory. A volumetric quantitative technique was, therefore, developed to compare astrocyte numbers and sizes in the hypoglossal nuclei of SIDS and control infants. In 12 SIDS and eight control infants, serial sagittal sections were taken through the hypoglossal nucleus and every tenth section was stained for glial fibrillary acidic protein. Astrocytes were counted in the central 4% of a grid stepped throughout the hypoglossal nucleus, and the heights of 100 astrocyte nuclei were measured with a microcator. Astrocyte number, corrected for section thickness and nuclear height, was divided by the volume of the hypoglossal nucleus to calculate astrocyte density. Numbers of astrocytes did not differ significantly between SIDS (mean number 44729, SD 12096) and control (mean number 46562, SD 11060) infants. Astrocyte nuclear height did not differ significantly between groups (SIDS: mean height 3.98 microns, SD 0.22; control: mean height 3.84 microns, SD 0.31). Astrocyte density was similar in SIDS (mean density 24378 astrocytes/mm3, SD 6155) and control (mean density 23978 astrocytes/mm3, SD 4031) infants. No quantitative evidence of astrocytosis was found in the hypoglossal nuclei of SIDS infants. This implies that SIDS infants die without previous episodes of hypoxia/ischaemia severe enough to damage the brain stem.

Astrocytes↗

Incidence of sudden infant death syndrome in infants with sickle cell trait.

The significantly higher incidence of both sickle cell trait (SCT) and sudden infant death syndrome (SIDS) in the black population suggests that SCT and SIDS may be epidemiologically related. To study this possibility, we identified, for the period of February 1990 to February 1992, all infants with SCT born in Los Angeles County whose disease was diagnosed through the California Newborn Screening Program. We matched these infants with all confirmed cases of SIDS in Los Angeles County from February 1990 to March 1993. Three cases of SCT among 589 infants confirmed to have had SIDS were identified. The incidence of SIDS was 1.25/1000 live births for the general population versus 0.58/1000 cases for the SCT group. This finding remained unchanged when rates were adjusted for ethnicity. We conclude that infants born with SCT are not at increased risk of dying of SIDS.

Black People↗

A critical comparison of the history of sudden-death infants and infants hospitalised for near-miss for SIDS.

To determine whether significant historical differences distinguish the near-miss for Sudden Infant Death from the infants who died of SIDS, we analysed the histories and clinical data from two groups of infants seen in our University Hospital and from collaborative research group. The data were obtained with the use of a standardised questionnaire and consultation of all available medical data. Sixty-five infants were identified as near-miss for SIDS after they had suffered a severe cardiorespiratory incident during sleep for which no cause could be found despite a complete medical examination. After an autopsy had failed to reveal a cause for the unexpected death 95 cases of SIDS were retained in the study. A series of 353 variables were collected from the parents, the gynaecologists, neonatologists and attending physicians. After statistical analysis, only 15 of the 353 items studied significantly differentiated between the two groups. A step-wise discriminant analysis performed on these items led to the identification of six independent variables: the time of the incident; the circumstances leading to the observation of the child; the child's sleep position; previous minor intestinal problems; the size of the family and the mother's coffee consumption. Most variables indicate that the near-miss infants were discovered and rescued earlier than the infants who died. No other historical information appeared significantly to differentiate between the two groups of infants. These data need confirmation from a prospective epidemiological survey.

Family Characteristics↗

Sudden infant death syndrome in infants of substance-abusing mothers.

A population-based study was performed to determine whether substance abuse during the perinatal period may be a risk factor for sudden infant death syndrome (SIDS). The incidence of SIDS was studied in 2143 infants of substance-abusing mothers (ISAM) born in Los Angeles County during 1986 and 1987 who were reported to the Los Angeles County Department of Health Services because of a history of drug exposure or positive urine test results in the mother, infant, or both. By comparing the ISAM birth reports with records of autopsy-proven SIDS in Los Angeles County, we found 19 SIDS cases in the population of 2143 ISAM, a SIDS rate of 8.87 cases per 1000 ISAM (95% confidence interval 5.3 to 13.8). This was significantly higher than the SIDS rate for the non-ISAM general population: 396 SIDS deaths among 325,372 live births, an incidence rate of 1.22 cases per 1000 births, p less than 0.00001. The age of ISAM at death was 99 +/- 63 (mean +/- SD) days compared with 91 +/- 52 days for the non-ISAM population (not significant). The incidence of SIDS was significantly greater in male infants, during the winter months, in black infants, and in non-Hispanic white infants in the non-ISAM population. Such differences were not observed in the ISAM group. A greater incidence of symptomatic apnea was reported before SIDS for the ISAM than for the non-ISAM population (22% vs 5.4%, p = 0.022). We conclude that ISAM have a higher incidence of SIDS than the non-ISAM general population. However, it was not possible to separate maternal substance abuse from other confounding variables that may also have had an impact on SIDS risk in the ISAM group.

Age Factors↗

Epidemiological comparisons of sudden infant death syndrome with infant apnoea.

A unique opportunity to study proven infant apnoea (PIA) and Sudden Infant Death Syndrome (SIDS) occurrences epidemiologically in 12 Counties in north-western Washington State during the same time period during which 180,017 live births were recorded revealed markedly dissimilar distribution patterns. The overall incidence of SIDS exceeded that of PIA by a factor of 3. Five PIA babies subsequently succumbed to SIDS. Statistical analysis reveals that these five events cannot be explained as random coincidences; they represent 3% of 163 PIA cases but only 1% of 503 SIDS occurrences. Infant apnoea is an infrequent precursor of SIDS. These results do not support the view that SIDS and infant apnoea are related conditions caused by a common underlying disorder. Aetiological models other than infant apnoea must be devised if the momentum of SIDS research is to be sustained.

Adult↗

[Repetition of sudden infant death].

Sudden infant death syndrome is the most common cause of death in the age group one month - one year. The article reviews a ten-year survey from Western Norway. Among 131 cases, there were six where a previous sibling had had the same diagnosis. Nevertheless, risk of repetition of sudden infant death syndrome is considered to be low.

Humans↗

[Bacterial toxins as cause of sudden infant death (author's transl)].

At post-mortems held on cot-death infants, the cause of death can be established as a variety of pathological changes. Inflammationin the region of the respiratory tract, in particular in the lungs;infections of the gastrointestinal tract; otitis media; shift of electrolytes-recently also the so-called yellow fat ect., can in association with the data on the anamnesis in many cases, through the assumption of bacterio-enterotoxin poisoning, which takes a different course in infants, to that in older children or adults, be traced back to a common origin. Extensive inquiries before the post-mortem, are as much indispensable prerequisites forthe clarification of the cause of sudden death as are the actual post-mortem and the ensuing investigations which must be carried out in the same way.

Bacterial Infections↗

Sudden infant death syndrome in infants of cocaine using mothers.

A study of Sudden Infant Death Syndrome (SIDS) with maternal cocaine exposure was undertaken using the perinatal medical records at the University of Miami/Jackson Memorial Medical Center and case files of the Metropolitan Dade County Medical Examiner Department, Miami, Florida USA from 1988-1992. 78 SIDS cases were analysed. 18 infants were classified as cocaine-exposed SIDS infants with positive history of maternal cocaine abuse and/or positive urine toxicology; 50 infants were classified as cocaine-negative SIDS infants without the history and with negative toxicology. The incidence of SIDS among cocaine-exposed infants was estimated to be higher than that of cocaine-negative infants overall (p < 0.025), but statistical significance between the groups was not confirmed when controlled for ethnicity. No significant differences of birth weight, estimated gestational age, body and brain weights were observed at autopsy between the two groups. Cocaine-exposed SIDS cases included 6 infants born small for gestational age (p < 0.05). 10 of 18 cocaine-exposed SIDS infants had a positive result for urine toxicology at birth and died younger aged than cocaine-negative infants (p < 0.05). Toxicology tests of the specimens obtained from cadavers were all negative for cocaine metabolites.

Journal Article↗

Hypercapnea and hypoxia challenge tests in infants at risk for sudden infant death syndrome.

Infants who have almost died of sudden infant death syndrome (SIDS) and infants who are siblings of SIDS victims constitute groups at increased risk for SIDS. Management dilemmas are common among physicians caring for these infants. To assess the usefulness of hypoxia (17% oxygen) and hypercapnea (3% carbon dioxide) challenge tests as predictors of outcome, we reviewed the records of 102 infants who underwent these tests. During hypoxia tests, we found that periodic breathing and respiratory pauses frequently developed among the infants in these high-risk groups, but also developed among control infants. During hypercapnea testing, some infants failed to increase their minute ventilation (usually measured by volume of breath X breaths per minute), but control infants showed this poor response just as often as high-risk infants. Our findings suggest that hypoxia and hypercapnea stress tests are of limited usefulness in planning management of infants at risk for SIDS.

Humans↗