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Sudden Infant Death Syndrome (SIDS) Highlights of its Epidemiology and History BIOS601: Dec. 5, 2007.

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Presentation on theme: "Sudden Infant Death Syndrome (SIDS) Highlights of its Epidemiology and History BIOS601: Dec. 5, 2007."— Presentation transcript:

1 Sudden Infant Death Syndrome (SIDS) Highlights of its Epidemiology and History BIOS601: Dec. 5, 2007

2 SIDS: Introduction Definition: “The sudden death of an infant under one year of age which remains unexplained after thorough investigation, including the performance of a complete autopsy, examination of the death scene, and review of the clinical history” SIDS continues to be the leading cause of death for infants aged between 1 month and 1 year in developed countries: –Lowest:Japan (0.09/1000), The Netherlands (0.1/1000) –Highest:New Zealand (0.8/1000) –Intermediate:USA (0.57/1000), UK (0.41/1000) –2162 infants died of SIDS in the USA alone (2003). “An elusive disease that strikes not only the child, but his whole family”

3 NICHD (National Institute of Child Health & Human Development)

4 Issues of Definition “In the technical medical language, a ‘syndrome’ refers only to the set of detectable characteristics. A specific disease, condition, or disorder may or may not be identified as the underlying cause.” (Wikipedia) “… diagnosis of SIDS is a diagnosis of exclusion, and the means of exclusion are imperfect … a diagnostic dustbin” (Emery) “the diagnosis of cot death … excused all concerned from any defect in care, diagnosis, and treatment’ and ‘facilitated the development of parent support groups and the raising of money for research SIDS vs pneumonia (Loberg and Naess, 1991), 55% of 1,144 cases eliminated (Haas 1993),1.6% of 400 cases reclassified (Valdes- Dapena, 1988)

5 SIDS: Epidemiology (SIDS deaths, Auckland, New Zealand, 1970-1979) Age Structure Seasonality - Gender, birth order, pacifiers, prior fetal loss, time of day, regional differences, race and ethnicity, family recurrence - Cigarette smoking, bed-sharing, swaddling, breastfeeding, socioeconomic

6 SIDS: Pathology Paradox: The baby is observed to be clean and well-cared-for with apparently good to excellent state of development, nutrition, and hydration. External Findings: Moderate amount of cyanosis, mucoid fluid in the mouth and nostrils (> 50% of cases), soiled diapers Internal Findings: Intrathoracic petechiae: observed more consistently in SIDS cases than in any other condition at this age (>50%), some pulmonary congestion and edema, some inflammation of the upper respiratory tract SIDS: Final Pathways Cardiovascular Apnea

7 Mechanism EpidemiologyPathology Causality? Hill’s Criteria …

8 SIDS Timeline Old Testament (I Kings 3:19), Middle Ages mid 1800s (rise and fall of thymic theory; negligence; other causes) 1942-1953 (Werne and Garrow, SIDS as a distinct medical entity) 1953+ (accumulation of epidemiologic and pathologic data, as well as a ‘parade of theories’). 1969 (definition of SIDS established) Early 1990s (identification of acceptance of sleeping position as the most powerful risk factor, followed by a worldwide decline in SIDS incidence) 2007 (still the leading cause of infant mortality, but with changing epidemiology)

9 Sleeping Position Timeline 1950-1985 – sleep position observed but not noticed in SIDS studies 1972 – public campaign in the Netherlands against the supine position 1985 – sleep position first clearly raised as a possible important factor (Davies, Hong Kong) 1986 – 1 st study with clear recommendation against the prone sleeping position (Beal), with subsequent drop in SIDS rates 1989 – 1 st thorough analysis of the effects of the prone sleeping position (deJonge, Netherlands) 1991 – 1 st prospective study of the prone position (Dwyer, Tasmania) 1991-1994 – controversy and delay in policy implementation in the United States 2007 – still the leading cause of infant mortality, but with changing epidemiology

10 1991-1994 SIDS controversy in the United States 1991 Guntheroth and Spier (JAMA) April 15, 1992 AAP press release followed by report in Pediatrics Criticisms: –Hunt and Shannon (1992) –SIDS Alliance (Mary Willinger) –Orenstein (1992) Sources of epidemiological controversy: statistics, literature, causality vs. association, intuition, population differences, iatrogenesis, levels of rigour.“Hindsight is 20/20” “willingness to ignore 2000-3000 infant deaths per year” National campaign announced by Surgeon General

11 AAP Task Force on Infant Positioning and SIDS (Pediatrics, 1992)

12 Four modifiable and other major risk factors for cot death: The New Zealand study (Mitchell et. al., 1992)

13 SIDS rates in Avon compared with England and Wales, during 1984-2003

14 SIDS: An ongoing area of investigation 6335 Hits

15 SIDS: An epidemiological study in progress Sudden infant death syndrome: another year of new hope but no cure. (Curr Opin Pulm Med. 2007 Nov;13(6):497-504) Risk of sudden infant death syndrome with parental mental illness. (Arch Gen Psychiatry. 2007 Nov;64(11):1323-30 ) Unexpected sudden death related to medullary brain lesions (Acta Neuropathol. 2005 May;109(5):554-5. Epub 2005 May 18) Vitamin A and sudden infant death syndrome in Scandinavia 1992-1995. (Acta Paediatr. 2003;92(2):162-4) Enzyme-linked immunoassay for respiratory syncytial virus is not predictive of bronchiolitis in sudden infant death syndrome. (Pediatr Dev Pathol. 1998 Sep-Oct;1(5):375-9) SIDS and chaos. (Med Hypotheses. 1994 Jan;42(1):11-2) Passive fear--a possible cause of sudden infant death? (Tidsskr Nor Laegeforen. 1986 Apr 30;106(11):898-902) Structure of periadrenal brown fat in childhood in both expected and cot deaths (Arch Dis Child. 1978 Feb;53(2):154-8) etc. …..

16 Conclusions Risk factors vs. causality (Hill’s criteria) Importance of policy in epidemiology Epidemiology changes Sources of epidemiological controversy Another breakthrough?



19 The continuing decline in SIDS mortality (Mitchell, 2007)

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