Transcript SIDS - Calgary Emergency Medicine

Neonatology,
Prematurity,
and SIDS
April 2003
Dr. Kevin Levere
Preceptor: Dr. Jeff Plant
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
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 (5th%ile) 60
• Term: >37, <42 weeks GA
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
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
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
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
What is a Preemie?
• Born at <37 weeks GA
• Not necessarily IUGR/SGA
• LBW < 2500 gm
• VLBW < 1500 gm
• ELBW < 1000 gm
• Prematurity and IUGR both increase
neonatal morbidity and mortality
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
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
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
Prematurity to the ED MD
• Significance
• They might be discharged
• YOU might be the next MD to see them
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
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
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
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
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
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
Millions in Pearls
Pass the Clearasil
Pustulence
Red Herring
Spot on
Skin problems of no concern
• Milia
• Tiny keratin collections, midline palatal occurrences called
Epstein’s 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
Hyper Billy
• Alert 5 day old boy
• Jaundiced from 3rd day of life
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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?
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 >20% total bilirubin
Approach to Neonatal Jaundice
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
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
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
Early Anemia (first few days)
• RBC destruction
• Hemolytic
• Immune – erythroblastosis fetalis, TORCHS
• RBC loss
• Transplactental
• Hemorrhage vs transfusion
• Hemorrhagic disease – “early” or “classic” < 1 week
• Vitamin K deficiency, intrapartum anticoagulant and
antiepileptic drug use
• IVH, liver laceration
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.
Polycythemia
• Hematocrit > 65%
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Placental transfusion at delivery
Placental insufficiency in utero
Maternal GDM
Dehydration
Idiopathic
• Rehydration
• Partial exchange transfusion
Thrombocytopenia
• Increased consumption
• Immune (PLA-1 antibody)
• Sepsis, DIC, TORCHS
• Vasculopathic (hemangiomas)
• Rarely decreased production
• TORCHS
• Rarely loss
• Exchange transfusion
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
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
Metabolic Emergencies
• Hypocalcemia
• Early (<72 hours)
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Preemies
DiGeorge Syndrome
Infants of GDM mothers
Birth asphyxia
• Late (end of first week)
• High PO4 containing formulas
• Hypomagnesemia
• Hypoparathyroidism
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
Metabolic Emergencies
• Hyponatremia and hyperkalemia
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Think congenital adrenal hyperplasia
Look for female virilization
Salt-wasting crisis can occur as neonate
DDx
• Gastroenteritis
• Pyloric stenosis
• Hypochloremic metabolic alkalosis
• +/- hyponatremia
• +/- hypokalemia
CAH
• Management
• ABCD’s
• Work-up
• Serum cortisol, aldosterone, 17-OHP
• Glucocorticoid and mineralocorticoid
replacement
• 2 mg/m2 Dexamethasone vs 100 mg/m2
Hydrocortisone
• Admit
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
Constipation
• 90% pass meconium in the 1st 24hrs of life
• If not, or if constipation during neonatal
period
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Hirschsprung’s
CF
Hypothyroidism
Anal stenosis
Neonatal Seizures
• Atypical manifestation
• Immature cortical organization and myelination
• Focal seizures with general insult
• Electroclinical dissociation common
• Common subtle presentations
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Lip smacking/chewing
Pedaling
Eye deviation
HR changes
Perinatal Causes
• HIE
• Hemorrhage
• Intraventricular vs subarachnoid
• Infection
• TORCHS included
• Metabolic
• Hypoglycemia, hypocalcemia, hyponatremia
• Pyridoxine deficiency
• Cerebral malformation
• Trauma
• Drug withdrawal
Management
• ABCD’s
• FSWU
• CBCd, C+S (blood, urine, CSF), CXR
• Metabolic screen
• Blood pH, Ca, PO4, sugar, electrolytes, renal
function, NH3
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CNS imaging
Address abnormalities
Benzodiazepines usually effective
Phenobarbital, phenytoin second line
Lessa G
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2 week old girl born at term
Lethargic
No symptoms
No signs until Neuro exam
• Babinksi present
• Is this significant?
Lethargy
• Top of differential?
• Infection
• Neurologic injury or anomaly
• Metabolic disorder
The Misfits
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T—Trauma/non accidental trauma
H—Heart disease (congenital)/Hypovolemia
E—Electrolyte disturbances
M—Metabolic disturbances
I—Inborn errors of metabolism
S—Sepsis
F—Formula dilution or over concentration
I—Intestinal catastrophes
T—Toxins (home remedies)
S—Seizures/CNS abnormalities
Lethargy
• Critically ill until proven otherwise
• ABCD’s
• FSWU
• CBCd, C+S (blood, urine, CSF), CXR
• Metabolic screen
• Blood pH, Ca, PO4, sugar, electrolytes, renal
function, NH3
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
Irritability
• Think pain
• Surgical problems
• Trauma
• Similar DDx to lethargy
• “The Misfits”
• A bit young for colic, needs an explanation
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
• Etiology
• Pulmonary
• Hypoxia, aspiration, pneumothorax, CDH
• Cardiovascular
• CHF (CHD, dysrhythmia), anemia
• Infection
• Pneumonia, bronchiolitis, sepsis
• Metabolic
• Hypoglycemia, hypocalcemia, hypothyroidism,
acidosis
Cyanosis
• Manifest when >5 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 <100 in FiO2 100% suggests R-L shunt or mixing CHD
• Cyanotic heart diseases
• Not all present with CHF
• Key diseases
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Tetralogy Of Fallot
Transposition of the Great Arteries
Tricuspid atresia
Total Anomalous Pulmonay Venous Return
Truncus arteriosus
Hypoplastic Left Heart
Pulmonary atresia
Ebstein’s Anomaly
• Management of cyanotic CHD
• ABCD’s
• 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
Apnea
• Definition of Apnea
• Respiratory pause
• >20 seconds OR…
• Associated bradycardia, cyanosis, pallor, or
hypotonia
• Hypoxia, hypercarbia
• Risk of cor pulmonale, hypertension, FTT
• CNS effects not clear
Apnea
• Apnea of Prematurity
• Obstructive (with inspiratory effort)
• Central (without inspiratory effort)
• Mixed
• Diagnosis of exclusion
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< 30 weeks GA 80%
30 - 31 weeks GA 50%
32 - 33 weeks GA 14%
34 - 35 weeks GA 7%
Apnea
• Apnea of prematurity
• Management if several a day, or severe
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Trial of xanthines
Doxapram infusion
CPAP
Ventilation
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”
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”
Causes of ALTE, A’s and B’s
• 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
Alan B. Tse
• 4 week old ex34 week preemie
• Home one day, presents with apnea
• Approach
• ABCD’s
• Stable
Approach to Al Tse
• Elements of history
• Details of event
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True apnea? – not clear (it never is), maybe dusky
Intervention – stimulation, “but he’s on Caffeine”
Activity – awake, not distressed, no motor activity
Recently fed
Back to normal after event
• Perinatal Hx, ROS, Fam Hx
• Infection risk, etc.
Handling Al Tse
• Focus of physical
• Cardiovascular
• Pulmonary
• Neurological
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?”
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
Home Monitoring
• Uncontrolled studies done (no RCTs), haven’t
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
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
SIDS
Crib death, cot death
• Definition
• Sudden Unexpected Death (SUD) of a
previously healthy infant <12 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
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
A Theory of SIDS
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.
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
Non-Accidental
• <5% 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
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
Epidemiology of SIDS
• Peak 2-4 month olds
• 90% of SIDS <6 months old
• 2% SUD >12 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
Effects of Interventions
• Impact of 1993 statement and 1999 “Back-ToSleep” 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
“Back To Sleep”
• Plenty of observational studies
• Benefits
• Incidence of SIDS falls
• Most significant modifiable risk factor
• Supine > side > prone
“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
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
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
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
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…
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
Bed-sharing
• Most observational studies don’t 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
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…
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
Risk Factors (CPS)
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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)
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 <10% of SIDS
Not proven risks
• Sibling
• No conclusive data, most of it prior to 1990s
• Twin’s RR=1.13 (95% CI, 0.97-1.31), second
twin dying of SIDS RR=8.17 (90% confidence
interval, 1.18-56.67)
• 23,464 singleton SIDS deaths and 1,056 twin SIDS
deaths
• Malloy MH et al. Pediatrics 1999
More Unproven risks
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Viral syndromes, URTIs
Maternal EtOH use
Caffeine use for A’s and B’s
Vaccination status
• ‘…the author of the study, concluded that
“vaccination is the single most prevalent and most
preventable cause of infant deaths.”’ (n=1; 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.’
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
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
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
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
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