From Research to Practice: International Trends, Maternal Substance Use, and Pacifiers

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From Research to Practice International Trends,
Maternal Substance Use, and Pacifiers

• Fern R. Hauck, MD, MS
• University of Virginia
• 1 Department of Family Medicine
• 2 Department of Public Health Sciences

2008 ASIP National Conference September 19, 2008
Dearborn, MI
                                                  
                
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International Trends in SIDS With Kawai
Tanabe, MPH

• Objectives
• To compare international data on SIDS and
  postneonatal infant mortality rates to examine
  trends after campaigns to reduce SIDS risk were
  implemented
• To discuss possible reasons for differences

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Methods

• National SIDS and postneonatal mortality rates
  were collected from
• Websites from national vital statistics centers
• Published reports
• Correspondence with SIDS researchers and program
  personnel

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Results Trends in Postneonatal Mortality and
SIDS rates, 1990 2005 (1)
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Results Trends in Postneonatal Mortality and
SIDS rates, 1990 2005 (2)
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Results Trends in Postneonatal Mortality and
SIDS rates, 1990 2005 (3)
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Conclusions

• Campaigns were successful in reducing the
  incidence of SIDS, but stabilization of rates is
  cause for concern
• Diagnostic shift for classification of sudden
  unexpected infant death (SUID) is occurring in
  some countries
• Several factors contribute to variability in
  rates across countries, including differences in
  
• Definition
• Diagnostic methods and classification
• Risk factor profiles

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Recommendations (1)

• Standardize definitions of SIDS to ensure
  validity of research data and comparability of
  data
• Standardize criteria for classification of SUID
• Standardize content and use of death scene
  investigation and autopsy protocols in cases of
  SUID
• Expand SIDS risk reduction education to include
  all modifiable factors, with emphasis on
  high-risk communities and settings

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Recommendations (2)

• Evaluate the effects of these interventions on
  reducing SIDS and SUID
• Establish a streamlined and accessible system for
  international surveillance
• Continue research that investigates the
  underlying pathophysiological cause(s) of SIDS
  to help reach the goal of eliminating SIDS

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Maternal Substance Use and SIDS With Mark
Smolkin, MS

• Context
• Sudden infant death syndrome (SIDS) is the
  leading cause of death among infants 1 month 1
  year of age
• African American infants are twice as likely to
  die as white infants
• Maternal smoking in pregnancy is a major risk
  factor for SIDS
• Little is known about racial differences in
  smoking as a risk factor
• Little is known about illegal drug use as a risk
  factor, independent of smoking

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Objectives

• To determine
• 1. If maternal prenatal smoking is a risk factor
  for SIDS among African Americans
• 2. If maternal prenatal drug use contributes to
  the excess risk of SIDS among African Americans,
  and
• 3. If this is independent of smoking.

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Chicago Infant Mortality Study - Methods

• Design
• Case-control, infants matched on age, birth
  weight, and race
• Case Ascertainment and Eligibility
• Cases identified through Cook County Medical
  Examiner, November 1993 - April 1996
• Chicago residents only
• Infants under 1 year of age who died with a final
  diagnosis of SIDS
• Controls
• Randomly selected from birth certificates, using
  matching criteria
• Invited to participate, small incentive

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Data Collection

• CASES
• Autopsy, death scene investigation, and review of
  the infants medical history to determine cause
  of death
• Follow-up home interview and mailed survey to
  assess additional environmental and social
  factors
• Medical records of mother (labor and delivery)
  and newborn
• CONTROLS
• Home interview, mailed survey and review of
  medical records of mother and infant
• IRB approval for study from all participating
  hospitals

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Results Descriptive Characteristics of SIDS
Cases and Controls (N 260 pairs)

• Demographic Characteristics Cases ()
  Controls ()
• Birth weight lt 1,500 g 4 1
• 1,500 - 2,499 g 24 26
• 2,500 g 72 73
• Race African American 75 75
• Hispanic 13 13
• White, non-Hispanic 12 12
• Gender Male 57 51
• Female 43 49

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Descriptive Characteristics of SIDS Cases and
Controls (2)

• Demographic Cases Controls
  P-values
• Characteristics
• Infants age in days (S.D.) 89 (57) 86
  (57) NS
• (at death/interview)
• Mothers age in years (S.D.) 23.2 (5.4) 24.8
  (6.5) 0.001
• (this birth)

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Maternal Prenatal Smoking by Race
Difference between black and white SIDS cases P
0.003
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Maternal Prenatal Drug Use by Race
Difference between black and white SIDS cases P
lt 0.001
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Drugs Used by Mothers
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Maternal Prenatal Smoking and SIDS Risk among
African American Infants

• Prenatal Unadjusted Adjusted OR
• Characteristics OR (95 CI) OR (95 CI)
• Any smoking 4.4 (2.7-7.4) 4.2 (2.2-8.1)
• Amount
• lt ½ ppd 3.8 (2.0-7.1) 3.2 (1.5-6.7)
• ½-lt1 ppd 4.3 (2.1-9.0) 5.5 (2.1-14.3)
• gt1 ppd 6.4 (2.0-20.4) 8.7 (1.8-42.8)
• 95 confidence interval, based on Wald
  estimates
• Adjusted for maternal age, marital status,
  prenatal care Kessner Index, education, sleep
  position, bed sharing

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Maternal Prenatal Drug Use and SIDS Risk among
African American Infants

• Prenatal Unadjusted Adjusted OR
• Characteristics OR (95 CI) OR (95 CI)
• Any drug use 6.2 (3.3-11.7) 5.7 (2.6-12.8)
• Kind of drug
• Cocaine 6.9 (3.3-14.4) 6.5 (2.6-16.2)
• Marijuana 3.5 (1.7-7.1) 3.2 (1.3-7.7)
• Heroin 5.8 (2.0-16.6) 4.7 (1.2-17.7)
• 95 confidence interval, based on Wald
  estimates
• Adjusted for maternal age, marital status,
  prenatal care Kessner Index, education, sleep
  position, bed sharing

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Maternal Drug Use and SIDS Risk among African
American Infants Adjusted for Smoking and Alcohol
Use in Pregnancy

• Prenatal Adjusted OR Adjusted OR
• Characteristics OR (95 CI) OR (95 CI)
• Any drug use 3.3 (1.7-8.2) 4.0 (1.6-10.0)
• Kind of drug
• Cocaine 3.5 (1.3-9.3) 4.5 (1.6-12.8)
• Marijuana 2.2 (0.9-5.7) 2.2 (0.8-6.2)
• Heroin 2.6 (0.5-12.2) 3.7 (0.8-17.1)
• Adjusted for maternal age, marital status,
  prenatal care Kessner Index, education, sleep
  position, bed sharing, and prenatal smoking
• Adjusted for maternal age, marital status,
  prenatal care Kessner Index, education, sleep
  position, bed sharing, and prenatal alcohol use

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Conclusions

• Maternal cigarette and drug use during pregnancy
  are strongly associated with SIDS risk among
  African Americans.
• There is a dose response associated with smoking
  and SIDS risk.
• Cocaine use is associated with SIDS risk
  independent of smoking.

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Conclusions (2)

• Higher prevalence of these behaviors among
  mothers of African-American infants who died from
  SIDS may account in part for the racial disparity
  in SIDS rates.
• Clinicians and clinics caring for pregnant women
  should routinely ask about smoking and drug use
  (and alcohol use) among their patients.
• The health care providers need to offer
  interventions that will benefit the patients own
  health and reduce the risk of SIDS among their
  infants.

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Pacifiers and SIDS With Lanre Omojokun, MD and
Mir Siadaty, MD, MS

• Numerous studies have demonstrated an
  association between SIDS and pacifier use.

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Usual Pacifier Use and SIDS Risk
Hauck FR, Omojokun OO, Siadaty MS. Pediatrics
2005116(5) . Available at www.pediatrics.org/cg
i/content/full/116/5/e716
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Last/Referent Sleep and SIDS Risk
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Other Studies Not Included in Meta-Analysis Last
Sleep Pacifier Use

• California aOR 0.08, 95 CI 0.03-0.21
• (Li DK, et al, 2005)
• Germany aOR 0.39, 95 CI 0.25-0.59
• (Vennemann MM, et al, 2005)
• Meta-Analysis
• -Pooled OR from 8 studies 0.48 (95 CI 0.430.54)
  
• (Mitchell EA, et al, 2006)

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Possible Mechanisms to Explain Apparent
Protective Effect

• Focus on arousal, airway patency, and sleep
  position
• Franco et al decreased arousal threshold
  (increased arousal) in infants who usually used a
  pacifier also cardiac autonomic control affected
  
• Pacifiers dislodge within 15 minutes (Weiss and
  Kerbl) to 1 hour (Franco et al) of sleep
• Dislodgement might contribute to more sleep
  disruption and easier arousability. This may
  explain why usual use not as protective as last
  sleep use.

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Other Benefits of Pacifiers

• Management of discomfort (reduction of crying
  during painful procedures)
• Preterm infants reduced length of hospital stay,
  no adverse outcomes (review of 19 studies)

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American Academy of PediatricsRecommendations
Regarding Pacifiers

• Consider offering a pacifier at nap time and
  bedtime.
• For breastfed infants, delay pacifier
  introduction until 1 month of age to ensure that
  breastfeeding is firmly established.
• American Academy of Pediatrics, Task Force on
  Sudden Infant Death Syndrome. Pediatrics.
  2005116 1245-1255.

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Conclusions

• Pacifiers are associated with reduced risk of
  SIDS.
• Recommend that infants be offered a pacifier when
  put down for sleep.
• Delay pacifier use until breastfeeding is firmly
  established.

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