SIDS in Children

7/27/2019 SIDS in Children

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Sudden Infant Deaths Syndrome:

The Myth and The Truth

Dr Norzila Mohamed Zainudin

Consultant Paediatrician & Paediatric RespiratoryPhysician

Respiratory Unit

Paediatric Institute

Hospital Kuala Lumpur


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INSTITUT PEDIATRIK

HOSPITAL KUALA LUMPUR


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Definition

Sudden unexplained death before one year

of age in a previously healthy infant.

The cause is unexplained

Thorough investigations are performedincluding an autopsy, death scene

investigations and review of clinical history


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SIDS is a polygenic, multifactorial

condition Genetic

Environmental

Behavioral/sociocultural

Failure of arousal mechanisms


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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


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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


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Petechial haemorrhages in SIDS are small spot

haemorrhages of unknown aetiology found on

the surfaces and within the tissues ofintrathoracic organs.

Their presence is regarded by some

pathologists as a pre-requisite for making the

diagnosis of SIDS


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Findings on 474 autopsied SIDS cases and foundmacroscopic petechial hemorrhages in the visceralpleura, capsule of thymus, and epicardium in 458(96.6%)

Multivariable analysis of this study showedsignificant associations among increasedfrequencies of thymic petechiae and parity, age at

death, Maori ethnicity, pacifier (dummy) use, andhead covering at death.

Significant associations between increasedfrequencies of epicardial petechiae and headcovering at death and estimated time of death

between 00:00 and 05:59 h and between increasedfrequencies of pleural petechiae and maternalsmoking and parity


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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% SIDSand 43.6% non-SIDS (P < 0.000001; OR 5.3 (CL 2.6 to

10.8)

Petechiae in all three sites (thymus, pleura, heart) werefound in 62.7% of SIDS and 26.8% of non-SIDS cases

(P < 0.000001; OR 4.6 (CL 2.3 to 9.0)


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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 pre-

existing, 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 inbrain stem regions relevant to neural cardiorespiratory regulation


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Risks Factors

Genetic Predisposition

Prenatal influences

Postnatal risks


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Demographic Factors

Ethnicity

Low Social Economic status

Gender


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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


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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


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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


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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)


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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 sleep-

related 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 sleep-

related infant deaths: expansion of recommendations for a safe infant sleeping environ- ment.

Pediatrics. 2011;128(5):e1341e1367

.


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Risks Reductions

SLEEP POSITION.

Risk for SIDS (odds ratio [OR]2.313.1). The side position

places infants at similarly highrisk for SIDS,

Altered autonomic control ofthe infant cardiovascularsystem during sleep,

particularly at 2 to 3 months ofage

May result in decreasedcerebral oxygenation.


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Risk Reductions

BED SHARING.

Infants share a room with theirparents without bed sharing.

Shown to be safer than bothbed sharing (when the infantsleeps on the same surface asanother person) and

solitary sleeping (when theinfant sleeps in a separate

room from the parent) Decreases the risk of SIDS by50%.


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Bed Sharing

Specific bed-sharing situations are especially hazardous. When the infant is


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CRIB AND BEDDING

ACCESSORIES.

Blankets, pillows, and other soft beddingincrease the risk suffocation.

Not to place pillows, quilts, comforters,sheepskins, and other soft surfacesunder, on top of, or close to the infant.

Increase SIDS risk up to 21-fold,particularly when the infant is placedprone in the presence of soft bedding.

Use of soft bedding also has beenassociated with accidental suffocationdeaths.

AAP recommends that infants sleepon a firm surface, without any soft orloose bedding in the area.

Infant sleep clothing can be used inplace of blankets.


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Crib Bumper

Crib bumper pads or similar products generally are used because ofthe perception that they will protect the infant from injury (eg, limbentrapment 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


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Breast Feeding

A protective effect of breastfeeding (nursingor 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 areassociated with increased risk of SIDS)

Overall immune benefits.

Easily aroused from sleep than formula-fedinfants.


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Pacifiers

Multiple studies, including two meta- analyses, have found pacifieruse 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 encouragedas a SIDS risk reduction strategy.

S ddli


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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.


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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 inextension and adduction.

loosely applied swaddling could result in head covering andstrangulation

The AAP has not made any recommendations for oragainst swaddling as a SIDS risk reduction strategy.


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Immunisation

A recent meta-analysis found

that immunization decreasedthe risk of SIDS by 46%.


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Documents

SIDS in Children