SIDS

BY Dr. A.Sridhar

Definition:
• “Sudden death of an infant under one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical hist
• Pediatr Pathology 1991;11(5):677-684.

Facts About Sudden Infant Death Syndrome (SIDS)
• Many more children die of SIDS in a year than all who die of cancer, heart disease, pneumonia, child abuse, AIDS, cystic fibrosis and muscular dystrophy combined . . .

SIDS?
• Sudden Infant Death Syndrome (SIDS) is a medical term that describes the sudden death of an infant which remains unexplained after all known and possible causes have been carefully ruled out through autopsy, death scene investigation, and review of the medical history

PATHOPHYSIOLOGY

Multifactorial in origin Triple Risk Hypothesis  Vulnerable infant  Critical developmental period in homeostatic control  Exogenous stressors Final pathway believed to involve immature cardiorespiratory and autonomic control along with failure of arousal responsiveness from sleep

AUTONOMIC CONTROL AND AROUSAL

SIDS infants higher baseline heart rates, lower heart rate variability, prolonged QT indexes, lower parasympathetic tone and/or high sympathovagal balance Abnormalities of arousal  Kato and colleagues report infants who died of SIDS had fewer spontaneous arousals from sleep and immature sleep patterns Prone sleeping  Increases total time infants spend asleep particularly time spent in quiet sleep, a state of reduced arousability  Also decreased spontaneous arousability, induced arousability and fewer full cortical arousals  Associated with altered autonomic control manifest by raised heart rates, decreased heart rate variability and increased sympathetic tone Infants exposed to smoking in utero have decreased spontaneous and stimulus-induced arousal from sleep

RISK FACTORS

SUBSTANCE USE

Major association between intrauterine exposure to cigarette smoking and risk of SIDS  Risk of death is progressively greater with increased smoking  May be small independent effect of paternal smoking  An independent effect of postnatal exposure to tobacco smoke has been found in a small number of studies as well as dose-response effect with number of household smokers Evidence linking prenatal illegal drug is conflicting  Opiates increase risk of SIDS 2-15 fold  Alcohol not clearly linked, but siblings of infants with FAS 20 fold increased risk of SIDS compared to controls

INFANT SLEEP PRACTICES & ENVIRONMENT

 

Prone sleeping consistently shown to increase risk of SIDS  Highest risk when usually placed in another sleeping position but were placed on stomach for last sleep, “unaccustomed prone”, more likely to occur outside the home such as day care centers  Also risk of choking highest in prone position Placing infant on side still places risk twice as likely to die of SIDS compared to sleeping supine  Exceptions may be made with certain medical conditions Soft sleeping surfaces 2 to 3 fold increase risk of SIDS  Prone sleeping + soft bedding  20 fold increase Overheating with increased room temperature, high body temperature, sweating or excessive clothing increase incidence  No increase with high external environment temperature No protective effect from bed sharing  Advocates of this practice typically promoters of breast feeding  1/3 reduction with sleeping in parent’s bedroom in separate crib

What Causes SIDS?
• No adequate medical explanations for SIDS deaths, current theories include: – Stress in a normal baby, caused by infection or other factors. – A birth defect. – Failure to develop. – A critical period when all babies are especially vulnerable, such as a time of rapid growth.

Basic Facts about SIDS
• SIDS victims appear to be healthy prior to death. • Currently, SIDS cannot be predicted or prevented, even by a physician. • There appears to be no suffering; death occurs very rapidly, usually during sleep.

What SIDS is not:
• • • • SIDS is not caused by external suffocation. SIDS is not caused by vomiting and choking. SIDS is not contagious. SIDS does not cause pain or suffering in the infant. • SIDS cannot be predicted. • SIDS is not new.

GENE ENVIRONMENT INTERACTIONS

PLACED POSITION

FOUND POSITION

AAP SIDS RISK REDUCTION RECOMMENDATIONS 2005

RISK REDUCTION

Campaign to reduce risk of SIDS began in 1994 in the United States
Largely focused on reducing prone sleeping and promoting supine positioning  Some campaigns also included messages to reduce smoking during pregnancy

No significant changes in these behaviors and reduced SIDS rates mostly attributed to avoidance of prone sleeping

Breast-feeding advocates have opposed discouraging bed sharing as they worry these measures will reduce breastfeeding frequency and duration and prevent families from enjoying the experience and benefits of bed sharing

MANAGEMENT AND SUPPORT
 

Loss of infant is devastating for everyone concerned In addition to loss of infant, families face could face police investigation, long wait for autopsy results and continued uncertainty leading to prolonged emotional distress consequently affecting the grieving process Physician can play active role by advocating for an autopsy, discussing autopsy results with the family and providing emotional support Surviving siblings and other family members need age appropriate emotional support If appropriate refer family for genetic counseling and/or metabolic testing Direct family to local counseling and support groups which are available in most communities

FUTURE DIRECTIONS
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Despite decrease in prevalence of SIDS, more work is needed Elucidation of risk and protective factors with appropriately targeted and implemented interventions leading to increased adoption by families Unlikely disorder is completely eliminated or reduced to lowest possible rates until specific causative mechanisms are more fully understood  Need studies with larger sample sizes and infants from highest risk groups  Investigations of still births and sudden unexplained deaths in children over 1 year of age might provide additional insights Surveillance of trends in rates of SIDS comparisons across jurisdictions and internationally according to a universal, standardized classification protocol Will require multidisciplinary and collaborative effort to understand more

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