Neonatology, Prematurity, and SIDS

1
Neonatology, Prematurity, and SIDS

• April 2003
• Dr. Kevin Levere
• Preceptor Dr. Jeff Plant

2
Objectives

• An overview of common complaints seen in the ED
  during the neonatal period
• Fever, resuscitation covered previously
• A summary of issues of prematurity that affect
  the ED physician
• A review of SIDS and related issues
• Apnea
• ALTE
• Home monitoring

3
What is a Neonate?

• Birth to 28 days old (or one month)
• Typical vitals for a neonate born at term
• HR 85-205
• RR 30-60
• BP systolic (5thile) 60
• Term gt37, lt42 weeks GA

4
Fetal to Neonatal Transition

• Umbilical ligation initiates dramatic change
• Initial respiration
• Triggered by hypoxia, acidosis, hypercarbia,
  external stimuli
• PVR falls as lungs expand, PaO2 rises and PaCO2
  falls
• SVR increases with loss of the low pressure
  umbilicus
• PFO pressed closed fused closed after months
• PDA (shunted 90 of flow from lungs) functionally
  closes within the first 24hrs fibroses within
  weeks
• Response to rising PaO2 and falling PaCO2
• Cardiovascular adaptation takes months

5
Transition continued

• Rapid fluid shifts, up to 30ml/kg
• Particularly absorbed from lung airspace
• Weight falls up to 10 from birth
• Regains birth weight by 7-10 days
• All these transitions occur more slowly and with
  more difficulty in premature infants

6
Organ immaturity

• CNS
• Poor thermoregulation, immature brainstem
  function, incomplete myelination
• CVS
• Relatively few contractile elements, therefore
  cardiac output especially rate dependent
• Pulmonary
• Ongoing alveolar multiplication (to school age)
  and interstitial development, very compliant
  chest
• Can double adult O2 needs for weight shorter
  interval to desaturation

7
Organ immaturity continued

• GI
• Immature gut motility, liver (drug metabolism)
  low nutrient stores (glycogen, fat)
• GU
• Immature renal function (drug metabolism), poor
  concentrating effect
• Hematology
• Immunologic immaturity physiologic anemia
  typically follows neonatal period
• Skin
• Large SA, thin, lacking subcutaneous depth

8
What is a Preemie?

• Born at lt37 weeks GA
• Not necessarily IUGR/SGA
• LBW lt 2500 gm
• VLBW lt 1500 gm
• ELBW lt 1000 gm
• Prematurity and IUGR both increase neonatal
  morbidity and mortality

9
Causes of Premature Delivery

• Fetal
• Distress, multiple gestation, congenital
  anomalies, hydrops fetalis
• Placental
• Previa, abruption
• Maternal
• Preeclampsia, medical illness, infection, drug
  use, uterine anomalies
• Other
• PROM, iatrogenic, trauma, polyhydramnios

10
Prematurity

• More extreme organ immaturity
• Exposes preemies to specific problems
• Also similar problems as other neonates
• Increased severity or risk
• Even more indistinct presentation
• Increased incidence of congenital anomalies

11
Prematurity to the ED MD

• By 36 weeks GA
• Typically develop adequate suck-swallow ability
  to feed and grow at home
• The majority have outgrown apnea of prematurity
• Thermoregulation is adequate to handle ambient
  temperatures

12
Prematurity to the ED MD

• Significance
• They might be discharged
• YOU might be the next MD to see them

13
Issues down the road

• ICH, PVL, increased HIE
• CP, seizures, developmental delay, hydrocephalus
• CLD, hypoplasia
• Reduced pulmonary reserves, more hypoxia, FTT
• Persistent Fetal Circulation
• Hypoxic-ischemic insults, FTT
• GI incoordination, increased NEC
• Strictures, malabsorption, FTT
• Increased incidence of SIDS

14
Chronic Lung Disease

• Formerly described as BPD
• Defined by O2 required after 36 weeks GA
• Result of RDS (HMD)
• Due to surfactant deficiency
• Complications of HMD
• Mortality
• Much reduced with surfactant
• Iatrogenic subglottic stenosis
• PFC hypoxia and acidosis maintain PDA
• CLD mostly in ventilated and oxygenated infants
• Incidence not changed by surfactant
• Nephrolithiasis sequela of diuretics and TPN

15
More on CLD

• Airway obstruction, hyperactivity and
  hyperinflation may be demonstrated into
  adolescence
• Preterm infants who do not have BPD are likely to
  have pulmonary function at school age that is
  similar to that of healthy term children
• Preterm infants who have BPD are significantly
  more likely to have abnormal pulmonary function
  at 7 years of age
• Gross SJ, et al. Effect of preterm birth on
  pulmonary function at school age a prospective
  controlled study. J Pediatr 1998

16
A bit on PFC

• Ongoing R-L shunting via PFO and PDA
• Due to PPHN
• Results in cyanosis, respiratory distress
• Causes
• Asphyxia, meconium aspiration, sepsis, HMD,
  hypoglycemia, polycythemia, pulmonary hypoplasia
• Often idiopathic
• Therapy
• O2, correct pH, permissive mild hypercapnia
  inotropes, NO ECMO (needed in 5-10)
• Prognosis
• Related to response of PPHN or associated HIE

17
Delivery Problems

• Meconium aspiration
• Residual lung problems are rare but include
  symptomatic cough, wheezing, and persistent
  hyperinflation for up to 5-10 yr
• Prognosis depends on the extent of CNS injury
  from asphyxia and the presence of associated
  problems such as pulmonary hypertension

18
Delivery Trauma

• Caput succedaneum
• Scalp edema, crosses sutures
• Cephalohematoma
• Subgaleal hematoma
• Fracture of clavicle
• Peripheral nerve injuries
• C5-6 Erb-Duchenne paralysis
• C7-8 Klumpke paralysis
• Prognosis depends on whether neurapraxia or
  neurotmesis
• Facial nerve palsy - hemifacial
• DDx central injury (lower 2/3 of face affected)
  vs agenesis of facial nucleus (Mobius syndrome)
  bilateral effect

19
Millions in Pearls
20
Pass the Clearasil
21
Pustulence
22
Red Herring
23
Spot on
24
Skin problems of no concern

• Milia
• Tiny keratin collections, midline palatal
  occurrences called Epsteins pearls
• Baby acne
• Acne, care of maternal hormones
• Pustular melanosis
• Present at birth, sterile granulocytic
  collections that slough, leaving hyperpigmented
  base
• Erythema toxicum
• Idiopathic onset day 2-3, eosinophilic
  collections on a red base, fade over a week
• Mongolian spot
• Benign patch present from birth, fades over years

25
Hyper Billy

• Alert 5 day old boy
• Jaundiced from 3rd day of life
• Greedy breastfeeding to date
• No perinatal risk factors for infection
• Family Hx negative
• Normal cardiopulmonary exam
• Normal fontanelle and tone, symmetric Moro,
  rooting
• Do you call this an emergency?

26
Hyperbilirubinemia

• Jaundice (aka icterus)
• In neonates at 80-150 micromol/L (60)
• Occurs at low end in preemies, rises slower,
  lasts longer
• Unconjugated bilirubin
• Lipid soluble unbound crosses BBB
• Kernicterus level of risk not strictly known
• Conjugated bilirubin
• Unbound is renally excreted
• Increased if gt20 total bilirubin

27
Approach to Neonatal Jaundice
28
Unconjugated Hyperbilirubinemia

• Hemolytic disease
• Sepsis, UTI
• Hereditary or acquired
• Decreased hepatic conjugation
• Decreased hepatic intake
• Breast milk, hypothyroidism
• Decreased hepatocellular function
• Hepatitis
• Physiologic, Crigler-Najjar, Gilbert
• Enterohepatic recirculation

29
Phototherapy

• Address exacerbating causes
• Empiric levels for phototherapy vs exchange
  transfusion based on risk of kernicterus
• Early signs
• Lethargy, hypotonia, irritability
• Later signs
• Posturing, hypertonicity, seizures

30
Conjugated Hyperbilirubinemia

• Biliary atresia
• Commonest cause of liver failure in pediatrics
• CF
• Bile/mucous plug ("inspissated bile")
• Management
• Disease specific
• No response to phototherapy or exchange
  transfusion

31
Early Anemia (first few days)

• RBC destruction
• Hemolytic
• Immune erythroblastosis fetalis, TORCHS
• RBC loss
• Transplactental
• Hemorrhage vs transfusion
• Hemorrhagic disease early or classic lt 1
  week
• Vitamin K deficiency, intrapartum anticoagulant
  and antiepileptic drug use
• IVH, liver laceration

32
Later Anemia

• Physiologic
• Nadir at 8-12 weeks
• RBC destruction
• Hemolytic
• Immune
• Congenital (RBC membrane or enzyme anomalies,
  Hgb)
• RBC loss
• Iatrogenic
• RBC depressed production rare
• Diamond-Blackfan etc.

33
Polycythemia

• Hematocrit gt 65
• Placental transfusion at delivery
• Placental insufficiency in utero
• Maternal GDM
• Dehydration
• Idiopathic
• Rehydration
• Partial exchange transfusion

34
Thrombocytopenia

• Increased consumption
• Immune (PLA-1 antibody)
• Sepsis, DIC, TORCHS
• Vasculopathic (hemangiomas)
• Rarely decreased production
• TORCHS
• Rarely loss
• Exchange transfusion

35
Metabolic Emergencies

• Hypoglycemia
• Neonates tolerate lower glucose concentration in
  the first few days
• Nonspecific result of physiologic stress
• Prematurity, sepsis, asphyxia, polycythemia
• Specific result of metabolic disorders
• Galactosemia, glycogen storage disease, AA
  disorders, mitochondrial disease
• Hyperinsulinemia
• GDM mother, Beckwith-Wiedemann Syndrome

36
Hypoglycemia

• Manifestation
• Lethargy, jitteriness, seizure, apnea
• Management
• Acute treatment
• 0.25-0.5 gm/kg, e.g. 2.5-5 ml/kg D10W
• Glucagon 0.025 mg/kg IM (max 1 mg)
• Little role since lack of stores, especially if
  SGA
• Maintenance goal
• 4-6 mg/kg/min (hence D10W, not D5W)
• Address underlying cause

37
Metabolic Emergencies

• Hypocalcemia
• Early (lt72 hours)
• Preemies
• DiGeorge Syndrome
• Infants of GDM mothers
• Birth asphyxia
• Late (end of first week)
• High PO4 containing formulas
• Hypomagnesemia
• Hypoparathyroidism

38
Hypocalcemia

• Manifestation
• Lethargy, jitteriness, seizure, laryngospasm,
  tetany prolonged QTc
• Management
• Acute treatment
• Ca gluconate (10)
• 1-3 ml/kg, 1ml/minute lest bradycardia
• Address underlying cause

39
Metabolic Emergencies

• Hyponatremia and hyperkalemia
• Think congenital adrenal hyperplasia
• Look for female virilization
• Salt-wasting crisis can occur as neonate
• DDx
• Gastroenteritis
• Pyloric stenosis
• Hypochloremic metabolic alkalosis
• /- hyponatremia
• /- hypokalemia

40
CAH

• Management
• ABCDs
• Work-up
• Serum cortisol, aldosterone, 17-OHP
• Glucocorticoid and mineralocorticoid replacement
• 2 mg/m2 Dexamethasone vs 100 mg/m2 Hydrocortisone
• Admit

41
Vomiting

• Causes
• Infection
• Gastroenteritis, NEC, septicemia, meningitis, and
  urinary tract infections
• Milk allergy
• Obstruction (if bile, think volvulus)
• Congenital anomalies (e.g. CDH, malrotation)
• Metabolic
• Adrenal hyperplasia of the salt-losing variety,
  galactosemia, hyperammonemias, organic acidemias
• Increased intracranial pressure

42
Constipation

• 90 pass meconium in the 1st 24hrs of life
• If not, or if constipation during neonatal period
• Hirschsprungs
• CF
• Hypothyroidism
• Anal stenosis

43
Neonatal Seizures

• Atypical manifestation
• Immature cortical organization and myelination
• Focal seizures with general insult
• Electroclinical dissociation common
• Common subtle presentations
• Lip smacking/chewing
• Pedaling
• Eye deviation
• HR changes

44
Perinatal Causes

• HIE
• Hemorrhage
• Intraventricular vs subarachnoid
• Infection
• TORCHS included
• Metabolic
• Hypoglycemia, hypocalcemia, hyponatremia
• Pyridoxine deficiency
• Cerebral malformation
• Trauma
• Drug withdrawal

45
Management

• ABCDs
• FSWU
• CBCd, CS (blood, urine, CSF), CXR
• Metabolic screen
• Blood pH, Ca, PO4, sugar, electrolytes, renal
  function, NH3
• CNS imaging
• Address abnormalities
• Benzodiazepines usually effective
• Phenobarbital, phenytoin second line

46
Lessa G

• 2 week old girl born at term
• Lethargic
• No symptoms
• No signs until Neuro exam
• Babinksi present
• Is this significant?

47
Lethargy

• Top of differential?
• Infection
• Neurologic injury or anomaly
• Metabolic disorder

48
The Misfits

• TTrauma/non accidental trauma
• HHeart disease (congenital)/Hypovolemia
• EElectrolyte disturbances
• MMetabolic disturbances
• IInborn errors of metabolism
• SSepsis
• FFormula dilution or over concentration
• IIntestinal catastrophes
• TToxins (home remedies)
• SSeizures/CNS abnormalities

49
Lethargy

• Critically ill until proven otherwise
• ABCDs
• FSWU
• CBCd, CS (blood, urine, CSF), CXR
• Metabolic screen
• Blood pH, Ca, PO4, sugar, electrolytes, renal
  function, NH3

50
Last etiology to R/O Sepsis

• Treatment of sepsis empiric
• GBS, E.coli, Listeria
• Staph, Strep
• Amp and Gent vs Amp and Cefotax
• TORCH
• Treatment not always possible
• Avoidance sometimes is

51
Irritability

• Think pain
• Surgical problems
• Trauma
• Similar DDx to lethargy
• The Misfits
• A bit young for colic, needs an explanation

52
Respiratory distress

• Tachypnea
• Increased work of breathing
• Grunting
• Auto-PEEP, suggests primary pulmonary problem
• Can be due to systemic problem (e.g. infection)
• Tachycardia
• Cyanosis

53

• Etiology
• Pulmonary
• Hypoxia, aspiration, pneumothorax, CDH
• Cardiovascular
• CHF (CHD, dysrhythmia), anemia
• Infection
• Pneumonia, bronchiolitis, sepsis
• Metabolic
• Hypoglycemia, hypocalcemia, hypothyroidism,
  acidosis

54
Cyanosis

• Manifest when gt5 gm/dL deoxyHgb
• Normal Hgb 13-20
• Peripheral
• Acrocyanosis, perioral
• Common, can reflect vasomotor instability
• Cool ambient temperature, shock, CHF
• Central
• Mucous membrane, trunk, and extremity involvement
• Etiology typically cardiac or pulmonary,
  occasionally hypoventilation
• Hyperoxia test
• PaO2 lt100 in FiO2 100 suggests R-L shunt or
  mixing CHD

55

• Cyanotic heart diseases
• Not all present with CHF
• Key diseases
• Tetralogy Of Fallot
• Transposition of the Great Arteries
• Tricuspid atresia
• Total Anomalous Pulmonay Venous Return
• Truncus arteriosus
• Hypoplastic Left Heart
• Pulmonary atresia
• Ebsteins Anomaly

56

• Management of cyanotic CHD
• ABCDs
• ECG, CXR, et al. labs
• Hyperoxic test
• PGE1 0.05-0.1 mcg/kg/min
• Maintain or reopen PDA
• Pulmonary and systemic vasodilator
• Side effects of note seizure, hypotension,
  apnea, fever

57
Apnea

• Definition of Apnea
• Respiratory pause
• gt20 seconds OR
• Associated bradycardia, cyanosis, pallor, or
  hypotonia
• Hypoxia, hypercarbia
• Risk of cor pulmonale, hypertension, FTT
• CNS effects not clear

58
Apnea

• Apnea of Prematurity
• Obstructive (with inspiratory effort)
• Central (without inspiratory effort)
• Mixed
• Diagnosis of exclusion
• lt 30 weeks GA 80
• 30 - 31 weeks GA 50
• 32 - 33 weeks GA 14
• 34 - 35 weeks GA 7

59
Apnea

• Apnea of prematurity
• Management if several a day, or severe
• Trial of xanthines
• Doxapram infusion
• CPAP
• Ventilation

60
ALTE

• Definition
• an episode that is frightening to the observer
  and is characterized by some combination of
  apnea, color change, change in muscle tone,
  choking, or gagging.
• NIH concensus group, Pediatrics 1987
• NOT near-miss SIDS

61
ALTE

• Incidence unknown
• Heterogeneity of definitions, causes
• Most occur with infant awake
• Etiology
• As many as 30-50 of ALTEs idiopathic
• Aka Apnea of Infancy

62
Causes of ALTE, As and Bs

• Digestive
• GER, esophagitis, aspiration, BM, perforation,
  malformation
• Neurologic
• Seizure, ICH, HIE, malformation, hydrocephalus,
  hyperthermia, hypothermia, immaturity of
  respiratory center, sleep state
• Infection
• Sepsis, meningitis, pneumonia, bronchiolitis,
  pertussis, NEC, UTI
• Respiratory
• Airway anomaly, pneumothorax, laryngospasm,
  alveolar hypoventilation
• Cardiovascular
• CHD, arrhythmia, anemia, CHF, shock, PFC,
  vasovagal
• Metabolic
• Hypoglycemia, hypocalcemia, hyponatremia,
  hypernatremia, acidosis, food intolerance, inborn
  errors
• Miscellaneous
• Trauma (NAT), Munchausen by proxy, drugs

63
Alan B. Tse

• 4 week old ex34 week preemie
• Home one day, presents with apnea
• Approach
• ABCDs
• Stable

64
Approach to Al Tse

• Elements of history
• Details of event
• True apnea? not clear (it never is), maybe
  dusky
• Intervention stimulation, but hes on
  Caffeine
• Activity awake, not distressed, no motor
  activity
• Recently fed
• Back to normal after event
• Perinatal Hx, ROS, Fam Hx
• Infection risk, etc.

65
Handling Al Tse

• Focus of physical
• Cardiovascular
• Pulmonary
• Neurological

66
Managing Al Tse

• Work-up as indicated
• Might be similar to that for lethargy
• Correct abnormalities as able
• Disposition
• Monitored admission
• No serious events during hospitalization
• Parents burning question
• How do we watch for this at home?

67
Home Monitoring

• Steinschneider in 1972 documented apnea in two
  siblings who later died of SIDS under the care of
  their mother
• Home monitoring advocated for 20 years thereafter

68
Home Monitoring

• Uncontrolled studies done (no RCTs), havent
  shown effectiveness
• No epidemiologic evidence that monitors affect
  incidence of SIDS
• No evidence that ALTEs are precursors to SIDS
• No evidence that monitors are used in cases at
  risk for apnea or bradycardia (where they might
  be indicated)
• No evidence that monitors give enough warning for
  timely intervention, or that interventions would
  be effective

69
CHIME

• Collaborative Home Infant Monitoring Evaluation
  Study
• 1,079 infants, 718,000 hours of monitoring
• Ramanathan et al, JAMA 2001
• Conventional apnea and bradycardia and extreme
  apnea and bradycardia are relatively common
  events, even among healthy term infants.
• Preterm infants had an increased risk of such
  events compared with healthy term infants, but
  only up to 43 weeks' postconceptional age
• The peak incidence of SIDS is more than 43 weeks'
  postconceptional age for preterm infants of any
  gestational age
• The evidence suggests that prolonged apnea and
  bradycardia are not immediate precursors of SIDS

70
SIDS
71
Crib death, cot death

• Definition
• Sudden Unexpected Death (SUD) of a previously
  healthy infant lt12 months old
• Unexplained after
• Autopsy (Medical Examiners case)
• Within 24 hours
• Skeletal survey, metabolic and toxicologic screen
• Examination of death scene
• Review of medical records or clinical history

72
Theory

• Etiology unknown by definition
• Theories
• Multifactorial
• Numerous Triple Risk Hypotheses
• Autonomic dysfunction e.g. arcuate nucleus in
  brainstem underdeveloped
• Neurotransmitter anomalies
• Astrogliosis
• Inconsistent evidence, i.e. cause vs effect
• Guntheroth et al, Pediatrics 2002

73
A Theory of SIDS
74
The CPS Theory of SIDS

• SIDS occurs during sleep
• During sleep, the infant faces certain challenges
  ( airway obstruction, decreased heart rate and
  blood pressure, a period when breathing stops or
  the rebreathing of CO2 when something pockets
  around the airway
• Research has shown subtle differences in the
  brainstem of SIDS infants which normally trigger
  the 'alarm system'
• a normal baby's alarm system comes into play when
  faced with challenges or stressors
• a SIDS baby's alarm system does not seem to
  detect CO2 increases, decreased O2 levels,
  decreased heart rate or airway closure
• Therefore, the goal of the risk reduction program
  is to interrupt the outside stressors in order to
  reduce the chance of SIDS. Medical research is
  now focussed on the vulnerable infant and the
  critical development period.

75
Differential

• Causes of SUD
• SIDS
• meningitis, sepsis, aspiration, pneumonia
• myocarditis, significant congenital lesions,
  arrhythmias (long QT)
• dehydration, fluid and electrolyte imbalance,
  inborn metabolic disorders
• carbon monoxide asphyxia, drowning, burns
• alcohol, drug, toxic exposure
• abdominal or other trauma, NAT

76
Non-Accidental

• lt5 of SIDS end up being discovered to have been
  abuse
• Increasing proportion as incidence of SIDS falls
• Autopsies cannot distinguish between asphyxiation
  (intentional or not) or SIDS

77
Non-Accidental

• Covert video recordings of life-threatening child
  abuse lessons for child protection
• Southall DP, et al. Pediatrics. 1997
• Of 39 cases of investigated recurrent ALTEs, 33
  were found to be abuse victims
• 30 had documented observations of intentional
  suffocation
• 12 of their 41 siblings had suffered SUD, 11
  diagnosed as SIDS 8 were later admitted to be
  from suffocation

78
Epidemiology of SIDS

• Peak 2-4 month olds
• 90 of SIDS lt6 months old
• 2 SUD gt12 months old also unexplained
• In Canada
• Third commonest cause of infant death
• Congenital anomalies, premature complications
• Commonest cause in 1-12 month olds
• 3 per week in Canada 1/2000 liveborns
• Relatively higher incidence in aboriginal
  population

79
Effects of Interventions

• Impact of 1993 statement and 1999 Back-To-Sleep
  campaigns in Canada
• 385 diagnoses of SIDS 1989, 269 in 1994, and 138
  in 1999
• In Ontario, 40 of caregivers before and 71
  after campaign placed their babies supine to
  sleep
• All evidence of effectiveness is observational
• Case-control
• Following advice campaigns
• National and local

80
Back To Sleep

• Plenty of observational studies
• Benefits
• Incidence of SIDS falls
• Most significant modifiable risk factor
• Supine gt side gt prone

81
Back To Sleep

• Risks
• Healthy babies do not choke when supine
• Exceptions Pierre-Robin and airway problems
• Malloy et al. Pediatrics 2000
• Plagiocephaly risked
• Tummy time required for normal development
• As develops motor skills, can find own
  comfortable sleeping position
• Kane et al. Pediatrics 1996

82
Tobacca Smoke avoidance

• Component of several observational studies
• Additional advice as part of campaigns
• Not just an independent factor
• Lack of smoke not harmful
• Second highest modifiable risk factor for SIDS

83
Tobacco Smoke avoidance

• Intrapartum smoke exposure is related to
  increased incidence of SIDS
• Other intrapartum drugs not clear but suspected
• Post-partum smoking definitely is too
• Meta-analysis Anderson et al. Health effects of
  passive smoking. 2 Passive smoking and sudden
  infant death syndrome review of the
  epidemiological evidence. Thorax 1997
• Other drug (e.g. EtOH) use not clear but suspected

84
Sleeping Surface

• No direct evidence
• Sheepskin bedding a possible concern
• NZ Cot Death Study Group, J Pediatr1998
• Recommendation
• Firm flat mattress best
• Related to over wrapping

85
Over heating or wrapping

• Advice as component of national campaigns
• Not clearly independent factor
• No evidence of harm from NOT bundling
• Recommendation
• Dress for comfort
• Do not overheat, do not restrict
• No pillows, stuffed toys, plastic wraps

86
Bed-sharing

• One observational study felt this was an
  attributable risk
• Not independent of maternal smoking
• Attributable risks
• Maternal smoking alone 44 (OR 5.17)
• Maternal smoking plus bed-sharing 33 (OR 11.1)
• Mitchell EA et al. Pediatrics 1997
• Another study found association between younger
  age of SIDS with bed-sharing, particularly if
  the parent is large
• Carroll-Pankhurst et al. Pediatrics 2001

87
Bed-sharing

• Most observational studies dont show this to be
  an independent risk factor
• CPS concensus still
• Bed-sharing does NOT impact incidence of SIDS
• Exceptions might include if drugs or EtOH
  involved
• N.B. Parents bed is a poor choice of surface

88
Breast-feeding

• Not good evidence
• Part of the parcel of advised interventions
• Alm B et al. Arch Dis Child 2002
• But combined with other suspected benefits

89
Soother Use

• Statistical reduction of SIDS with soother use
• Not strong enough association for promoting
  soother use
• Abstract, Zotter et al. Wien Klin Wochenschr 2002

90
Risk Factors (CPS)

• Babies who sleep on their tummies (6.6x)
• Babies who sleep on their sides (2x)
• Smoking during pregnancy (3x)
• Exposure to second-hand smoke (2x)
• Overheating
• Cluttered sleeping area
• Soft sleeping surface (increases with tummy
  sleeping)
• Boys slightly more than girls
• Aboriginal (3x)
• Substance abuse during pregnancy
• Teen mothers (less than 20 yrs of age)
• Mothers with late or no prenatal care
• Preterm infants (before 37 weeks gestation)
• Low birthweight infants (under 2500 g)
• Multiples (twins, triplets, etc.)
• Mild respiratory infections
• Unaccustomed tummy sleepers (18-20x)

91
Not proven risks

• Recurrent cyanosis
• Rates of apnea
• 757 cases to 1514 BW matched controls
• National Institute of Child Health and Human
  Development data, 1988
• ALTE history
• Reported in lt10 of SIDS

92
Not proven risks

• Sibling
• No conclusive data, most of it prior to 1990s
• Twins RR1.13 (95 CI, 0.97-1.31), second twin
  dying of SIDS RR8.17 (90 confidence interval,
  1.18-56.67)
• 23,464 singleton SIDS deaths and 1,056 twin SIDS
  deaths
• Malloy MH et al. Pediatrics 1999

93
More Unproven risks

• Viral syndromes, URTIs
• Maternal EtOH use
• Caffeine use for As and Bs
• Vaccination status
• the author of the study, concluded that
  vaccination is the single most prevalent and
  most preventable cause of infant deaths. (n1
  1991)
• A study published in JAMA found that children
  diagnosed with asthma (a respiratory ailment not
  unlike SIDS) were five times more likely than not
  to have received pertussis vaccine.

94
Clinical management

• EMS trained to make observations
• Position of the infant, type of bed or crib and
  any defects, amount and position of clothing and
  bedding
• Marks on the body, body temperature and rigor,
  room temperature, type of ventilation and heating
• Terminal motor activity (e.g. clenched fists,
  postmortem anal dilation), mottling or postmortem
  lividity, oronasal d/c
• Reaction of the caregivers

95
In the ED

• ABCD/DOA as indicated
• Diagnosis Probable SIDS
• Explain to the family the need for thorough
  investigation to explain this SUD
• Involvement of
• Social worker /- pastoral care
• Law enforcement officer
• Medical examiner
• Pathologist
• Child abuse expert
• Work-up as described by AAP Committee on Child
  Abuse and Neglect, Pediatrics 2001

96
In the ED

• History
• Non-accusatory, empathic it will be stressful
• HPI
• Setting, recent feed, position when put to sleep
  vs when found, CPR performed, caregivers and
  other children around, EMS findings
• ROS
• General health, recent infection, cardiopulmonary
  status, GER, seizures, ALTEs
• PMHx
• Perinatal course, growth and development
• FamHx
• Lost pregnancies, SUD, congenital problems,
  consanguinity, medication or drug exposure

97
In the ED

• History
• Suspicious findings
• Age at death older than 6 months
• Previous recurrent cyanosis, apnea, or ALTE while
  in the care of the same person
• Discovery of blood on the infant's nose or mouth
  in association with ALTEs
• Previous unexpected or unexplained deaths of 1 or
  more siblings
• Simultaneous or nearly simultaneous death of
  twins
• Previous death of infants under the care of the
  same unrelated person

98
Lesson Learnt

• The mother Steinschneider was involved with had
  had 3 other infants die previously under her care
• She was successfully convicted of murder x5 more
  than 20 years after the fact