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Sudden Infant Death Syndrome (SIDS) Highlights of its Epidemiology and History

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

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Sudden Infant Death Syndrome (SIDS) Highlights of its Epidemiology and History

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  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 Age Structure Seasonality (SIDS deaths, Auckland, New Zealand, 1970-1979) • 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. Epidemiology Pathology Causality? Mechanism 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 – 1st study with clear recommendation against the prone sleeping position (Beal), with subsequent drop in SIDS rates 1989 – 1st thorough analysis of the effects of the prone sleeping position (deJonge, Netherlands) 1991 – 1st 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?

  17. The continuing decline in SIDS mortality (Mitchell, 2007)

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