Sudden Infant Deaths Syndrome: The Myth and The Truth

Dr Norzila Mohamed Zainudin Consultant Paediatrician & Paediatric Respiratory Physician Respiratory Unit Paediatric Institute Hospital Kuala Lumpur

INSTITUT PEDIATRIK HOSPITAL KUALA LUMPUR

Definition
Sudden unexplained death before one year of age in a previously healthy infant.

The cause is unexplained

Thorough investigations are performed including an autopsy, death scene investigations and review of clinical history

 SIDS is a polygenic, multifactorial condition Genetic Environmental Behavioral/sociocultural Failure of arousal mechanisms

 The National Institute of Child Health and Development SIDS Strategic Plan 2001 Knowledge acquired during the past decade supports the general hypothesis that infants who die from SIDS have abnormalities at birth that render them vulnerable to potentially life-threatening challenges during infancy.

Evidence of viral infection in SIDS Hypoxaemia Cardiogenic Shock including anaphylaxis Thermal stress

Pathology
Evidence that pathological findings in SIDS : intrathoracic petechial haemorrhage thymomegaly Encephalomegaly evidence of microcardia liquid unclotted blood in the chambers of the heart kidney growth-restriction is also well described an empty bladder and rectum

 Petechial haemorrhages in SIDS are small spot haemorrhages of unknown aetiology found on the surfaces and within the tissues of intrathoracic organs. Their presence is regarded by some pathologists as a pre-requisite for making the diagnosis of SIDS

 Findings on 474 autopsied SIDS cases and found macroscopic petechial hemorrhages in the visceral pleura, capsule of thymus, and epicardium in 458 (96.6%) Multivariable analysis of this study showed significant associations among increased frequencies of thymic petechiae and parity, age at death, Maori ethnicity, pacifier (dummy) use, and head covering at death. Significant associations between increased frequencies of epicardial petechiae and head covering at death and estimated time of death between 00:00 and 05:59 h and between increased frequencies of pleural petechiae and maternal smoking and parity

 Pleural petechiae were found in 80% SIDS and 47.5% non-SIDS (P = 0.000002; OR 4.6 (CL 2.3 to 9.1)). Epicardial/cardiac petechiae were found in 79.9% SIDS and 43.6% non-SIDS (P < 0.000001; OR 5.3 (CL 2.6 to 10.8) Petechiae in all three sites (thymus, pleura, heart) were found in 62.7% of SIDS and 26.8% of non-SIDS cases (P < 0.000001; OR 4.6 (CL 2.3 to 9.0)

Hypothesis
SIDS deaths commonly occur during a sleep period. Abnormal brainstem control of cardiac and/or respiratory function due to braim stem abnormaility The hypothesis is based on autopsy studies indicating possible preexisting, chronic low-grade hypoxemia attributed to sleep-related hypoventilation. The autopsy evidence for chronic hypoxemia includes persistence of adrenal brown fat, hepatic erythropoiesis, brain stem gliosis and other structural abnormalities and evidence of hypodevelopment of brainstem structures and multiple neurotransmitter abnormalities in brain stem regions relevant to neural cardiorespiratory regulation

Risks Factors
Genetic Predisposition Prenatal influences Postnatal risks

Demographic Factors
Ethnicity Low Social Economic status Gender

Genetic Predisposition: Genetic Control

Genetic control of inflammatory response Genetic control of NOS Genetic control of brainstem function Genetic control of metabolic pathways eg: flavin monooxygenase 3 (FMO3) Genetic control of cardiac function

Prenatal Risks
Maternal smoking/nicotine use Inadequate prenatal care Inadequate prenatal nutrition Use of heroin, cocaine and other drugs Subsequent birth less than one year apart Alcohol use Infant being overweight Mother being over weight Teen pregnancy Maternal anaemia

Post natal risks

Seasonality Viral respiratory or gastrointestinal symptoms in the days before death Low birth Exposure to tobacco smoke Prone sleep position Not breastfeeding

Post Natal Risks

Elevated or reduced room temperature Excess bedding, clothing, soft sleep surface and stuffed animals Co-sleeping with parents or other siblings may increase risk for SIDS, but the mechanism remains unclear Sofa-sleeping Infants age (incidence rises from zero at birth, is highest from two to four months, and declines towards zero at one year Prematurity (increases risk of SIDS death by about four times) Probable anemia (haemoglobin cannot be measured post mortem)

 The American Academy of Pediatrics (AAP) Task Force on SIDS recently published an updated policy statement and technical report.

.
Ref: Moon RY; Task Force on Sudden Infant Death Syndrome. Policy statement: SIDS and other sleeprelated infant deaths: expansion of recommendations for a safe infant sleeping environ- ment. Pediatrics. 2011;128(5):10301039

Moon RY; Task Force on Sudden Infant Death Syndrome. Technical report: SIDS and other sleeprelated infant deaths: expansion of recommendations for a safe infant sleeping environ- ment. Pediatrics. 2011;128(5):e1341e1367 .

Risks Reductions
SLEEP POSITION. Risk for SIDS (odds ratio [OR] 2.313.1). The side position places infants at similarly high risk for SIDS, Altered autonomic control of the infant cardiovascular system during sleep, particularly at 2 to 3 months of age May result in decreased cerebral oxygenation.

Risk Reductions
BED SHARING. Infants share a room with their parents without bed sharing. Shown to be safer than both bed sharing (when the infant sleeps on the same surface as another person) and solitary sleeping (when the infant sleeps in a separate room from the parent) Decreases the risk of SIDS by 50%.

Bed Sharing
Specific bed-sharing situations are especially hazardous. When the infant is <2 to 3 months of age, regardless of whether or not parents are smokers When one or both parents are smokers When the infant is placed on sofas, armchairs, or water beds (extremely soft surfaces) When pillows or blankets are present When there are multiple bed sharers (ie, other than the parents) When the person bed sharing with the infant is not a parent When the person bed sharing with the infant has consumed alcohol, medications, or illicit drugs that can affect arousal

CRIB AND BEDDING

ACCESSORIES.
Blankets, pillows, and other soft bedding increase the risk suffocation. Not to place pillows, quilts, comforters, sheepskins, and other soft surfaces under, on top of, or close to the infant. Increase SIDS risk up to 21-fold, particularly when the infant is placed prone in the presence of soft bedding. Use of soft bedding also has been associated with accidental suffocation deaths.

AAP recommends that infants sleep on a firm surface, without any soft or loose bedding in the area. Infant sleep clothing can be used in place of blankets.

Crib Bumper
Crib bumper pads or similar products generally are used because of the perception that they will protect the infant from injury (eg, limb entrapment between crib slats or head injury from hitting railings) and for esthetic reasons Concerns about infant deaths from suffocation entrapment strangulation

A recent study of crib injuries concluded that the risk of suffocation or strangulation far outweighed the potential benefits of preventing minor injury with bumper pad use

Breast Feeding
A protective effect of breastfeeding (nursing or pumped human milk) against SIDS Approximate halving of the risk when the baby is breastfed Possible reasons for this protective effect Decreased infectious diseases (which are associated with increased risk of SIDS)

Overall immune benefits.

Easily aroused from sleep than formula-fed infants.

Pacifiers
Multiple studies, including two meta- analyses, have found pacifier use to be associated with a decreased risk of SIDS (adjusted OR 0.390.48). Mechanism of action is unknown May alter arousal thresholds or autonomic responses during sleep . Pacifiers can be used for breastfed infants, but they should not be introduced until breastfeeding has been well established.

The AAP recommends that pacifier use be encouraged as a SIDS risk reduction strategy.

Swaddling
Swaddling, or wrapping the infant in light blanket, has been used in many cultures to calm infants and promote sleep. Risk of SIDS if the infant is swaddled and placed in a non-supine position.

Swaddling decreases startling Increases sleep duration Decreases spontaneous awakenings can reduce the infants functional residual lung capacity Can exacerbate hip dysplasia if the hips are kept in extension and adduction. loosely applied swaddling could result in head covering and strangulation
The AAP has not made any recommendations for or against swaddling as a SIDS risk reduction strategy.

Immunisation
A recent meta-analysis found that immunization decreased the risk of SIDS by 46%.