Breast feeding and the sudden infant death syndrome in Scandinavia, 1992-95

Evaluation of existing Home Based Newborn Care (HBNC) services and training for improving performance of Accredited Social Health Activists (ASHA) in rural India: A multiple observation study

BACKGROUND

One-fourth of global neonatal deaths occur in India alone. Accredited Social Health Activists (ASHA) was launched with the purpose of improving healthcare services, including neonatal survival primarily in rural areas. The aim of this study is to determine the status of ASHA's knowledge, practices, and attitude regarding Home Based Newborn Care (HBNC) services, as well as to provide necessary trainings for improvement of their performance.

METHODS

For this study, 102 ASHA working in Doiwala were recruited at random, and Quasi Experimental Design - Multiple Observation Method (single group time series design) was adopted. The data were collected using pretested tools consisting of knowledge questionnaires, attitude scale, and practices and skill-based questionnaires on various domains of HBNC. The data from the ASHA were collected 4 times at a regular interval of 30 days. Each time, the assessment of ASHA was accompanied by re-education and training on HBNC.

RESULTS

Even though, about 90% of ASHA had been working for more than 5 years, they possessed average knowledge regarding HBNC before the training. Less than 50% of them were aware of mandatory vaccines and infection care services for newborns. About 70% of them were uninformed about the potential risk of hypothermia in neonates and also lacked knowledge regarding its preventive measures. Their knowledge, practices and attitude regarding HBNC was significantly improved after the training (p ˂ 0.05). About 54% of ASHA became aware of the avoidance of pre-lacteal feeding in newborns. Their practices score regarding prevention of hypothermia was increased from 80% to 95%. The number of ASHA who understood the importance of Kangaroo Mother Care (KMC) was also increased from 56% to 87%. About 95% of the ASHA understood the significance of feeding breast milk to newborns. Moreover, the attitude of ASHA towards the traditional way of newborn care such as early bathing, giving pre-lacteal feed, application of turmeric and ghee to the umbilicus of baby etc. was significant improved.

CONCLUSION

ASHA must be assessed regularly in order to identify their basic needs, knowledge gaps, challenges and difficulties to quality HBNC services. Proper training on HBNC at regular interval significantly improved their knowledge, practices, and attitude toward their responsibilities, which is crucial for improving newborn health status.

Work as an Understudied Driver of Racial Inequities in Breastfeeding

Breastfeeding inequities by race are a persistent public health problem in the United States. Inequities in occupation and working conditions likely contribute to relatively less breastfeeding among Black compared to White mothers, yet little research has addressed these interrelationships. Here, we offer a critical review of the literature and a conceptual framework to guide future research about work and racial inequities in breastfeeding. There is a strong public health case for promoting breastfeeding equity for mothers across race groups and occupation types. Existing theory suggests that employment opportunities and working conditions are a likely pathway that connects structural racism to Black-White breastfeeding inequities, in addition to other known factors. We propose a new conceptual model for studying the interrelationships among work, race, and breastfeeding outcomes.

COVID-19 Illness: Mother–Baby Separation, Viruses, and Breastfeeding

Objectives

Some hospitals have instituted separation of mothers and their newborn(s) when SARS-CoV-2 is suspected or confirmed in the mother. Limited data are available for SARS-CoV-2 vertical transmission, including studies on breast milk. This article looks at SARS CoV-2 case studies and data to date as well as prior pertinent research.

Methods

Informal searches of PUBMED, CINAHL and Ovid Emcare were used to identify early reports of vertical transmissions of the novel Coronavirus, case reports, and population based reports of early evolving protocols and their outcomes. As this is a novel virus the authors used previously identified anti-infectivity and antiviral mechanisms of human milk on other similar viruses to guide analysis. Further this article reviewed the well established literature regarding the risks of undue infant separation which negatively affect nearly every aspect of infant and maternal health.

Results

Informal searches conducted in the spring and early summer of 2020 identified 14 early reports attempting to analyze the initial and evolving global response to SARS-CoV-2 and the effects of the virus on the maternal-infant dyad.

Conclusion

The feasibility of single-family rooms and support for breastfeeding as an alternative approach that addresses many of the risks favorably and reduces economic cost, both in lifetime disease burden and direct care are discussed. Initial reports seem to indicate that immediate separation of the mother from her newborn is likely to increase the risk to both mother and infant.

Mixed milk feeding: a systematic review and meta-analysis of its prevalence and drivers

CONTEXT

Extensive literature is available on exclusive breastfeeding and formula-feeding practices and health effects. In contrast, limited and unstructured literature exists on mixed milk feeding (MMF), here defined as the combination of breastfeeding and formula feeding during the same period in term infants > 72 hours old (inclusion criterion).

OBJECTIVE

A systematic review and meta-analysis were performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, on the global prevalence of MMF (primary outcome) and related drivers and practices (secondary outcomes).

DATA SOURCES

The search of MMF in generally healthy populations was conducted across 6 databases, restricted to publications from January 2000 to August 2018 in English, Spanish, French, and Mandarin.

DATA EXTRACTION

Two reviewers independently performed screenings and data extraction according to a priori inclusion and exclusion criteria.

DATA ANALYSIS

Of the 2931 abstracts identified, 151 full-text publications were included for data extraction and 96 of those were included for data synthesis (the majority of those were cross-sectional and cohort studies). The authors summarized data across 5 different categories (feeding intention prenatally, and 4 age intervals between > 72 hours and > 6-23 months) and 5 regional subgroups. The overall prevalence of MMF across different age intervals and regions varied between 23% and 32%; the highest rate was found for the age group 4-6 months (32%; 95% confidence interval, 27%-38%); regional comparisons indicated highest MMF rates in Asia (34%), North and South America (33%), and Middle East and Africa together (36%), using a random effects meta-analysis model for proportions. Some drivers and practices for MMF were identified.

CONCLUSION

MMF is a widespread feeding reality. A shared and aligned definition of MMF will help shed light on this feeding practice and evaluate its influence on the duration of total breastfeeding, as well as on infants' nutrition status, growth, development, and health status in the short and long terms. PROSPERO registration number CRD42018105337.

Drugs in lactation

Although most medications can be taken safely during breastfeeding, potential risks of infant toxicity do exist because all medications will be excreted into the breast milk to some extent. The amount of medication excreted in the milk depends mainly on (i) within-drug variation, such as dosing; (ii) between-drug variation including chemical characteristics of the medication; and (iii) host factors, such as maternal pharmacokinetics (PK), including variations of pregnancy-associated changes and their post-partum recovery. Neonatal drug exposure is usually assessed by calculating an expected total infant daily dose through breast milk and comparing it to the normal therapeutic dose. However, clinical PK studies in this population are challenging to conduct. Recently, research methods using population PK analyses and physiologically-based PK modeling and simulation techniques have been recognized as a complementary approach to the conventional PK studies in this field. These efforts are important for rational risk assessment balancing the toxicity risk against the benefits of human milk. Health benefits of lactation for both mother and child are significant and a decision to withhold from this should not be taken lightly. In case limited information is present, additional expertise from pharmacists or clinical pharmacologist with expertise in this area should be sought.

Breastfeeding Trends Among Very Low Birth Weight, Low Birth Weight, and Normal Birth Weight Infants

OBJECTIVE

To examine the change in breastfeeding behaviors over time, among low birth weight (LBW), very low birth weight (VLBW), and normal birth weight (NBW) infants using nationally representative US data.

STUDY DESIGN

Univariate statistics and bivariate logistic models were examined using the Early Child Longitudinal Study-Birth Cohort (2001) and National Study of Children's Health (2007 and 2011/2012).

RESULTS

Breastfeeding behaviors improved for infants of all birth weights from 2007 to 2011/2012. In 2011/2012, a higher percentage of VLBW infants were ever breastfed compared with LBW and NBW infants. In 2011/2012, LBW infants had a 28% lower odds (95% CI, 0.57-0.92) of ever breastfeeding and a 52% lower odds (95% CI, 0.38-0.61) of breastfeeding for ≥6 months compared with NBW infants. Among black infants, a larger percentage of VLBW infants were breastfed for ≥6 months (26.2%) compared with LBW infants (14.9%).

CONCLUSIONS

Breastfeeding rates for VLBW and NBW infants have improved over time. Both VLBW and NBW infants are close to meeting the Healthy People 2020 ever breastfeeding goal of 81.9%. LBW infants are farther from this goal than VLBW infants. The results suggest a need for policies that encourage breastfeeding specifically among LBW infants.

Both Prenatal and Postnatal Interventions Are Needed to Improve Breastfeeding Outcomes in a Low-Income Population

BACKGROUND

Breastfeeding provides many health benefits for mothers and their infants that span their life course. Despite this, national breastfeeding rates are below benchmarks set by the CDC (Centers for Disease Control and Prevention). Breastfeeding rates in the Detroit low-income population are particularly low.

OBJECTIVE

To measure the effect of hospital-based prenatal and postnatal breastfeeding interventions on breastfeeding initiation and continuation rates in a low-income population. The interventions implemented were a prenatal breastfeeding education curriculum and a hospital-based breastfeeding support group.

METHODS

A total of 650 women were tracked via chart review and telephone survey after delivery to assess breastfeeding initiation, continuation, and goal achievement. The baseline group (n = 330) received care in the hospital-associated prenatal clinic before intervention implementation; the postintervention group (n = 320) received breastfeeding education and had a hospital-based breastfeeding support group made available to them, in which some participated. Data were analyzed using the chi-squared test and the Student's t-test.

RESULTS

Breastfeeding initiation rates were greater in the postintervention group (p < 0.0001). The breastfeeding continuation rate at or beyond 6 months did not differ among baseline and postintervention groups (p = 0.5), but was greater among women who also participated in the breastfeeding support group compared with women who participated in the prenatal intervention alone. Participation in interventions did not affect the rate, at which women reported meeting their breastfeeding goals.

CONCLUSION

Both prenatal education and ongoing postdischarge support are needed to improve breastfeeding continuation.

Is breast best? Is early solid feeding harmful?

The health benefits of breastfeeding for babies and mothers have long been recognised and it is now globally recommended that it be continued exclusively for six months. Although there are few controlled trials to support this recommendation, the most important advantage is less morbidity from gastrointestinal infection in developing countries. There is also evidence that respiratory tract infections and atopic dermatitis is reduced, and the maternal risk of breast cancer decreases, particularly with a longer duration of breastfeeding and a high parity. There is little to suggest that exclusive breastfeeding for six months adversely affects infant growth, nutritional status or infant feeding skills, but more studies are needed. Equally, there is no evidence that introduction of solids from 17 weeks is harmful in developed countries. However, in the UK breastfeeding prevalence is low and solids are introduced early for the majority of infants and much can be done to positively encourage and support all mothers to continue breastfeeding for a longer period.

Breastfeeding and dummy use have a protective effect on sudden infant death syndrome

We conducted a literature review on the effect of breastfeeding and dummy (pacifier) use on sudden infant death syndrome (SIDS). From 4343 abstracts, we identified 35 relevant studies on breastfeeding and SIDS, 27 on dummy use and SIDS and 59 on dummy use versus breastfeeding.

Conclusion

We found ample evidence that both breastfeeding and dummy use reduce the risk of SIDS. There has been a general reluctance to endorse dummy use in case it has a detrimental effect of breastfeeding. However, recent evidence suggests that dummy use might not be as harmful to breastfeeding as previously believed.

Exploring the risk factors for sudden infant deaths and their role in inflammatory responses to infection

The risk factors for sudden infant death syndrome (SIDS) parallel those associated with susceptibility to or severity of infectious diseases. There is no evidence that a single infectious agent is associated with SIDS; the common thread appears to be induction of inflammatory responses to infections. In this review, interactions between genetic and environmental risk factors for SIDS are assessed in relation to the hypothesis that many infant deaths result from dysregulation of inflammatory responses to "minor" infections. Risk factors are assessed in relation to three important stages of infection: (1) bacterial colonization (frequency or density); (2) induction of temperature-dependent toxins; (3) induction or control of inflammatory responses. In this article, we review the interactions among risk factors for SIDS for their effects on induction or control of inflammatory responses. The risk factors studied are genetic factors (sex, cytokine gene polymorphisms among ethnic groups at high or low risk of SIDS); developmental stage (changes in cortisol and testosterone levels associated with 2- to 4-month age range); environmental factors (virus infection, exposure to cigarette smoke). These interactions help to explain differences in the incidences of SIDS observed between ethnic groups prior to public health campaigns to reduce these infant deaths.

Family medicine obstetrics: pregnancy and nutrition

This article discusses pregnancy and nutrition in 3 main timeframes, the prepregnancy nutritional health evaluation, nutrition during pregnancy, and nutrition during the puerperium, and also includes comments on nutrition and lactation. This article begins with a brief review of the risks of obesity (increased body mass index [BMI]) and anorexia (decreased BMI), with special attention to these undesired conditions during pregnancy, followed by a section on nutrients other than calories. Information on body weight, minerals, and vitamins during pregnancy is reviewed. This article ends with information on nutrition in the postpartum period.

SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment

Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death occurring during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in this technical report. The recommendations are published in the accompanying "Policy Statement--Sudden Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).

Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis

CONTEXT

Benefits of breastfeeding include lower risk of postneonatal mortality. However, it is unclear whether breastfeeding specifically lowers sudden infant death syndrome (SIDS) risk, because study results have been conflicting.

OBJECTIVE

To perform a meta-analysis to measure the association between breastfeeding and SIDS.

METHODS

We identified 288 studies with data on breastfeeding and SIDS through a Medline search (1966-2009), review articles, and meta-analyses. Twenty-four original case-control studies were identified that provided data on the relationship between breastfeeding and SIDS risk. Two teams of 2 reviewers evaluated study quality according to preset criteria; 6 studies were excluded, which resulted in 18 studies for analysis. Univariable and multivariable odds ratios were extracted. A summary odds ratio (SOR) was calculated for the odds ratios by using the fixed-effect and random-effect inverse-variance methods of meta-analysis. The Breslow-Day test for heterogeneity was performed.

RESULTS

For infants who received any amount of breast milk for any duration, the univariable SOR was 0.40 (95% confidence interval [CI]: 0.35-0.44), and the multivariable SOR was 0.55 (95% CI: 0.44-0.69). For any breastfeeding at 2 months of age or older, the univariable SOR was 0.38 (95% CI: 0.27-0.54). The univariable SOR for exclusive breastfeeding of any duration was 0.27 (95% CI: 0.24-0.31).

CONCLUSIONS

Breastfeeding is protective against SIDS, and this effect is stronger when breastfeeding is exclusive. The recommendation to breastfeed infants should be included with other SIDS risk-reduction messages to both reduce the risk of SIDS and promote breastfeeding for its many other infant and maternal health benefits.

SIDS: past, present and future

Despite the large reduction in SIDS mortality, which occurred in the early 1990s following the 'Back to Sleep' campaigns, SIDS remains the leading cause of death in the postneonatal age group. This paper describes the position in the 1980s, the contribution of the New Zealand Cot Death Study, what should be recommended and the current research priorities.

CONCLUSION

SIDS is preventable. Application of what we currently know could eliminate SIDS. The challenge is to find ways of implementing our knowledge.

Health professional knowledge of breastfeeding: are the health risks of infant formula feeding accurately conveyed by the titles and abstracts of journal articles?

Effective promotion of breastfeeding is constrained if health professionals' knowledge on its importance is deficient. This study asks whether formula feeding is named as the risk factor in published research or whether it is considered the unspoken norm. A systematic analysis is conducted of the information content of titles and abstracts of 78 studies that report poorer health among formula-fed infants. This shows a surprising silence in the studies examined; formula is rarely named in publication titles or abstracts as an exposure increasing health risk. In 30% of cases, titles imply misleadingly that breastfeeding raises health risk. Only 11% of abstracts identify formula feeding as a health risk exposure. Initiatives to increase breastfeeding have described the importance of accurate language and well-informed health professional support. If widespread, this skew in communication of research findings may reduce health professionals' knowledge and support for breastfeeding.

Benefícios da amamentação para a saúde da mulher e da criança: um ensaio sobre as evidências

Este ensaio reúne uma seleção de estudos, particularmente revisões sistemáticas que têm contribuído para aumentar a compreensão sobre os benefícios do aleitamento materno para a criança e para a mulher e sua implementação. Realizou-se uma busca de artigos publicados a partir do ano 2000, sem, no entanto, deixar de lado estudos relevantes para o avanço do conhecimento publicados décadas atrás. Para a seleção dos estudos efetuou-se uma busca na Internet com base nas ferramentas disponíveis no PubMed e SciELO. Além dos aspectos para os quais há consenso, procurou-se incluir estudos sobre resultados controversos e outros que são instigantes, como os provenientes da neurobiologia. Verificam-se mudanças substanciais nas recomendações para políticas públicas em decorrência desses novos conhecimentos. Algumas investigações também têm sido realizadas com o objetivo de avaliar quais intervenções seriam mais efetivas para um aumento das práticas de amamentação. Procurou-se neste artigo dar destaque a: recomendações atuais sobre alimentação da criança pequena; importância da amamentação no início da vida; implicações do aleitamento materno para a saúde da criança; implicações do aleitamento materno para a saúde da mulher; e efetividade de algumas ações pró-amamentação.

Sudden infant death syndrome

Despite declines in prevalence during the past two decades, sudden infant death syndrome (SIDS) continues to be the leading cause of death for infants aged between 1 month and 1 year in developed countries. Behavioural risk factors identified in epidemiological studies include prone and side positions for infant sleep, smoke exposure, soft bedding and sleep surfaces, and overheating. Evidence also suggests that pacifier use at sleep time and room sharing without bed sharing are associated with decreased risk of SIDS. Although the cause of SIDS is unknown, immature cardiorespiratory autonomic control and failure of arousal responsiveness from sleep are important factors. Gene polymorphisms relating to serotonin transport and autonomic nervous system development might make affected infants more vulnerable to SIDS. Campaigns for risk reduction have helped to reduce SIDS incidence by 50-90%. However, to reduce the incidence even further, greater strides must be made in reducing prenatal smoke exposure and implementing other recommended infant care practices. Continued research is needed to identify the pathophysiological basis of SIDS.

Session 1: Feeding and infant development breast-feeding and immune function

The newborn receives, via the placenta, maternal IgG antibodies against the microbes present in its surroundings, but such antibodies have a pro-inflammatory action, initiating the complement system and phagocytes. Although the host defence mechanisms of the neonate that involve inflammatory reactivity are somewhat inefficient, this defence system can still have catabolic effects. Breast-feeding compensates for this relative inefficiency of host defence in the neonate by providing considerable amounts of secretory IgA antibodies directed particularly against the microbial flora of the mother and her environment. These antibodies bind the microbes that are appearing on the infant's mucosal membranes, preventing activation of the pro-inflammatory defence. The major milk protein lactoferrin can destroy microbes and reduce inflammatory responses. The non-absorbed milk oligosaccharides block attachment of microbes to the infant's mucosae, preventing infections. The milk may contain anti-secretory factor, which is anti-inflammatory, preventing mastitis in mothers and diarrhoea in infants. Numerous additional factors in the milk are of unknown function, although IL-7 is linked to the larger size of the thymus and the enhanced development of intestinal Tgammadelta lymphocytes in breast-fed compared with non-breast-fed infants. Several additional components in the milk may help to explain why breast-feeding can reduce infant mortality, protecting against neonatal septicaemia and meningitis. It is therefore important to start breast-feeding immediately. Protection is also apparent against diarrhoea, respiratory infections and otitis media. There may be protection against urinary tract infections and necrotizing enterocolitis, and possibly also against allergy and certain other immunological diseases, and tumours. In conclusion, breast-feeding provides a very broad multifactorial anti-inflammatory defence for the infant.

Recommendations for sudden infant death syndrome prevention: a discussion document

This article reviews the evidence for the current UK Department of Health recommendations for prevention of sudden infant death syndrome (SIDS) and suggests other factors that should be considered. The wording of the Department of Health recommendations for SIDS prevention has changed over the past 6 years, but the specific recommendations are largely consistent with the scientific evidence. The emphasis on thermal and illness factors and immunisation could be reduced. Bed sharing and sharing the parental bedroom should be given more emphasis. Two major recommendations need to be discussed in greater detail: (1) breast feeding and (2) pacifier use. Meta-analyses or reviews looking at each risk factor or a combination of risk factors are required. Further, it is recommended that a committee is established that reviews the recommendations and publishes the evidence that leads to these recommendations, as is done by the American Academy of Pediatrics Taskforce on Sudden Infant Death Syndrome.

SIDS risk factors and factors associated with prone sleeping in Sweden

OBJECTIVE

To compare the current prevalence of risk factors for sudden infant death syndrome (SIDS) in Sweden with a decade earlier, and assess factors associated with prone sleeping.

METHODS

The results of a cohort study (Infants of Western Sweden) and a population based case-control study (Nordic Epidemiological SIDS Study) were examined. Subjects were 5600 healthy 6 month old infants born in 2003 in the Western Sweden region and 430 healthy Swedish infants born between 1991 and 1995.

RESULTS

Prone sleeping decreased from 31.8% to 5.6% and supine sleeping increased from 35.3% to 47.3%. Side or side/supine sleeping increased from 25.2% to 43.8%. Maternal smoking during pregnancy decreased from 23.5% to 9.5%. The risk for prone sleeping increased if the mother was unemployed (OR 2.4, 95% CI 1.5 to 4.0), if she was a heavy smoker in the third trimester (OR 44.1, 95% CI 1.6 to 1199.6), and if the child was irritable (OR 2.5, 95% CI 1.3 to 5.1), shared a bedroom with siblings (OR 2.6, 95% CI 1.0 to 6.6), or never used a dummy (OR 3.2, 95% CI 1.9 to 5.4).

CONCLUSIONS

Parents have complied with advice to prevent SIDS given at infant welfare centres for the last 10 years. A change in the preferred sleeping position from side variants to exclusively supine, and reducing the number of pregnant women smoking may be beneficial. Use of a prone sleeping position was associated with maternal employment status, maternal smoking, temperament of the child, dummy use, and sharing a bedroom with siblings.

Improved estimates of the benefits of breastfeeding using sibling comparisons to reduce selection bias

OBJECTIVE

Better measurement of the health and cognitive benefits of breastfeeding by using sibling comparisons to reduce sample selection bias.

DATA

We use data on the breastfeeding history, physical and emotional health, academic performance, cognitive ability, and demographic characteristics of 16,903 adolescents from the first (1994) wave of the National Longitudinal Study of Adolescent Health. The sample includes 2,734 sibling pairs.

STUDY DESIGN

We examine the relationship between breastfeeding history and 15 indicators of physical health, emotional health, and cognitive ability, using ordinary least squares and logit regression. For each indicator, we estimate, in addition to the usual between-family model, a within-family model to see whether differences in siblings' outcomes are associated with differences in the siblings' breastfeeding histories.

PRINCIPAL FINDINGS

Nearly all of the correlations found in the between-family model become statistically insignificant in the within-family model. The notable exception is a persistent positive correlation between breastfeeding and cognitive ability. These findings hold whether breastfeeding is measured in terms of duration or as a Yes/No variable.

CONCLUSIONS

This study provides persuasive evidence of a causal connection between breastfeeding and intelligence. However, it also suggests that nonexperimental studies of breastfeeding overstate some of its other long-term benefits, even if controls are included for race, ethnicity, income, and education.

The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk

There has been a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed down for sleep in a nonprone position. Although the SIDS rate continues to fall, some of the recent decrease of the last several years may be a result of coding shifts to other causes of unexpected infant deaths. Since the AAP published its last statement on SIDS in 2000, several issues have become relevant, including the significant risk of side sleeping position; the AAP no longer recognizes side sleeping as a reasonable alternative to fully supine sleeping. The AAP also stresses the need to avoid redundant soft bedding and soft objects in the infant's sleeping environment, the hazards of adults sleeping with an infant in the same bed, the SIDS risk reduction associated with having infants sleep in the same room as adults and with using pacifiers at the time of sleep, the importance of educating secondary caregivers and neonatology practitioners on the importance of "back to sleep," and strategies to reduce the incidence of positional plagiocephaly associated with supine positioning. This statement reviews the evidence associated with these and other SIDS-related issues and proposes new recommendations for further reducing SIDS risk.

Modifiable risk factors for SIDS in Germany: results of GeSID

BACKGROUND

The incidence of sudden infant death syndrome (SIDS) has been falling in Germany over the last decade. However, little is known about the prevalence and the importance of well-known risk factors in Germany since a local prevention campaign in 1992.

DESIGN

A 3-y, population-based, case-control study was conducted in half of Germany, consisting of 333 cases. All sudden and unexpected deaths in infancy, if they fitted the inclusion criteria, were included in the study. Parental interview was carried out soon after the death, and three living control infants, matched for age, gender, region and sleep time, were recruited.

RESULTS

The prevalence of placing infants prone to sleep was only 4% in the control group, but this was associated with a markedly increased risk of SIDS (adjusted odds ration, aOR=6.08). Other modifiable risk factors for SIDS were: maternal smoking during pregnancy, breastfeeding for less than 2 wk (aOR=1.71) and co-sleeping (aOR=2.71), while using a pacifier during the last sleep reduced the risk (aOR=0.39).

CONCLUSIONS

Previously recognized risk factors for SIDS also occur in Germany. Despite knowledge about the major modifiable risk factors for SIDS, these factors are still present in Germany. To reduce the incidence of SIDS in Germany, a continued effort is needed to inform all parents about preventable risk factors for SIDS.

Breastfeeding and the use of human milk

Considerable advances have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding. This policy statement on breastfeeding replaces the 1997 policy statement of the American Academy of Pediatrics and reflects this newer knowledge and the supporting publications. The benefits of breastfeeding for the infant, the mother, and the community are summarized, and recommendations to guide the pediatrician and other health care professionals in assisting mothers in the initiation and maintenance of breastfeeding for healthy term infants and high-risk infants are presented. The policy statement delineates various ways in which pediatricians can promote, protect, and support breastfeeding not only in their individual practices but also in the hospital, medical school, community, and nation.

Development of mucosal immunity in the first year of life and relationship to sudden infant death syndrome

The common mucosal immune system (CMIS) is an interconnecting network of immune structures that provides effective immunity to mucosal surfaces. The structures of the mucosal immune system are fully developed in utero by 28 weeks gestation, but in the absence of intrauterine infection, activation does not occur until after birth. Mucosal immune responses occur rapidly in the first weeks of life in response to extensive antigenic exposure. Maturation of the mucosal immune system and establishment of protective immunity varies between individuals but is usually fully developed in the first year of life, irrespective of gestational age at birth. In addition to exposure to pathogenic and commensal bacteria, the major modifier of the developmental patterns in the neonatal period is infant feeding practices. A period of heightened immune responses occurs during the maturation process, particularly between 1 and 6 months, which coincides with the age range during which most cases of sudden infant death syndrome (SIDS) occur. A hyper-immune mucosal response has been a common finding in infants whose death is classified as SIDS, particularly if in association with a prior upper respiratory infection. Inappropriate mucosal immune responses to an otherwise innocuous common antigen and the resulting inflammatory processes have been proposed as factors contributing to SIDS.

Change in immunisation schedule and sudden infant death syndrome in Hungary

Infant mortality in Hungary was higher than in other European countries; however, the reported incidence of sudden infant death syndrome (SIDS) has been lower than those for Western Europe and the United States. Childhood immunisation has been reported to be a protective factor for SIDS. In Britain, the change to an earlier immunisation schedule for diphtheria, pertussis, and tetanus appeared to be associated with a shift in the age distribution of SIDS. In 1999, immunisation for Haemophilus influenzae type b (Hib) was introduced for Hungarian infants at the age of 2 months. Data for total infant mortality and SIDS in Hungary were analysed between 1990 and 2002. Infection was the major cause of death among Hungarian infants followed by SIDS. Following introduction of Hib immunisation, there was a decrease in deaths due to meningitis from an average of 3.5% of all infant deaths between 1990 and 1998 to an average of 1% of all infant deaths between 1999 and 2002 (p=0.00). There was also a significant decrease in the proportion of SIDS in the age range > or =2 months from 48% in the earlier period to 39% after introduction of the vaccine (p=0.03). The decrease in SIDS might be due in part to decrease in unrecognised Hib infections or to induction of antibodies by the tetanus toxoid to which the Hib polysaccharide is conjugated that are cross reactive with bacterial toxins implicated in SIDS.

Detection of specific antibodies in cord blood, infant and maternal saliva and breast milk to staphylococcal toxins implicated in sudden infant death syndrome (SIDS)

The common bacterial toxins hypothesis of sudden infant death syndrome (SIDS) is that nasopharyngeal bacterial toxins can trigger events leading to death in infants with absent/low levels of antibody that can neutralise the toxins. The aim of this study was to investigate nasopharyngeal carriage of Staphylococcus aureus and determine levels of immunity in the first year of life to toxic shock syndrome toxin (TSST-1) and staphylococcal enterotoxin C (SEC). Both toxins have been implicated in SIDS cases. Seventy-three mothers and their infants (39 males and 34 females) were enrolled onto the study. The infants had birth dates spread evenly throughout the year. In infants, S. aureus carriage decreased significantly with age (P<0.001). Between 40% and 50% of infants were colonised with S. aureus in the first three months of life and 49% of the isolates produced one or both of the staphylococcal toxins. There was a significant correlation between nasopharyngeal carriage of S. aureus in mothers and infants in the three months following the birth (P<0.001). Carriage of S. aureus in infants and their mothers was not significantly associated with levels of antibody to TSST-1 or SEC in cord blood, adult saliva or breast milk. Infants colonised by S. aureus had higher levels of salivary IgA to TSST-1 than infants who were culture negative. Analysis of cord blood samples by a quantitative ELISA detected IgG bound to TSST-1 and SEC in 95.5% and 91.8% of cases respectively. There was a marked variation in levels of maternal IgG to both TSST-1 and SEC among cord blood samples. Maternal age, birth weight, and seasonality significantly affected the levels of IgG binding to TSST-1 or SEC. Analysis of infant saliva samples detected IgA to TSST-1 and SEC in the first month after birth; 11% of samples tested positive for salivary IgA to TSST-1 and 5% for salivary IgA to SEC. By the age of two months these proportions had increased to 36% and 33% respectively. More infants who used a dummy tested positive for salivary IgA to TSST-1 compared to infants who did not use a dummy. Levels of IgA to TSST-1 and SEC detected in the breast-milk samples varied greatly among mothers. There was a trend for infants receiving breast milk with low levels of antibody to TSST-1 or SEC to have higher levels of salivary antibody to the toxins. In conclusion, passive immunity to toxins implicated in SIDS cases varies greatly among infants. Infants are able to mount an active mucosal immune response to TSST-1 and SEC in the first month of life.

Methadone maintenance and lactation: a review of the literature and current management guidelines

Methadone offers significant therapeutic benefits to the population of pregnant, opiate-dependent women and is currently the treatment of choice for this group. Yet the problem of women who elect to breastfeed while on methadone maintenance frequently vexes providers. Although breast milk offers advantages clearly beneficial to the general population of infants, there is debate about recommending breastfeeding to postpartum women receiving methadone maintenance. Although previous research has shown that amounts of methadone in breast milk appear to be very small, and therefore breastfeeding seems to be safe, women on methadone do not often breastfeed, for a variety of reasons. This article provides an overview of the issues facing providers in treating methadone-maintained women who elect to breastfeed. A comprehensive review of existing literature on the subject is offered, along with clinical advice for practitioners providing care to this population of women and children.

Comparison of evoked arousability in breast and formula fed infants

BACKGROUND

Currently, there is no consistent evidence that breast feeding reduces the risk for sudden infant death syndrome (SIDS). Arousal from sleep is believed to be an important survival mechanism that may be impaired in victims of SIDS. Previously it has been shown that arousability is impaired by the major risk factors for SIDS such as prone sleeping and maternal smoking.

AIMS

To establish whether arousability was altered by method of feeding, and whether breast fed infants would have lower arousal thresholds.

METHODS

Forty three healthy term infants were studied using daytime polysomnography on three occasions: 2-4 weeks post-term, 2-3 months post-term, and 5-6 months post-term. Multiple measurements of arousal threshold (cm H(2)O) in response to nasal air jet stimulation applied alternately to the nares were made in both active sleep (AS) and quiet sleep (QS) while infants slept supine. Arousal thresholds and sleep period lengths were compared between formula fed and breast fed infants at each age.

RESULTS

Arousal thresholds were not different between breast fed and formula fed infants in QS. However, in AS breast fed infants were significantly more arousable than formula fed infants at 2-3 months of age. There was no difference between groups of infants when sleep period length was compared at any study.

CONCLUSIONS

Breast fed infants are more easily aroused from AS at 2-3 months of age than formula fed infants. This age coincides with the peak incidence of SIDS.

[Sudden infant death--prevention programs in Austria]

In the current study, design and success of intervention programmes to prevent sudden infant death syndrome (SIDS) in Austria are described and major future challenges indicated. Various prevention programmes are being carried out in the federal states of Austria and they focus on the detailed information of parents about modifiable SIDS risk factors. Relevant topics such as guidelines for home monitoring are carefully addressed in the Austrian consensus statements. With the introduction of the first campaigns SIDS incidence rates have gradually dropped from 1.69 (1988) to 0.51 per 1000 life births (2000). In line, there was a decline in the prevalence of risk behaviour, especially of the prone sleeping position (federal state of the Tyrol: 53.7% before the campaign (1984-1994) vs. 4.7% thereafter (1995-2001), p < 0.001). Because of this latter trend smoking during pregnancy became the most prevalent SIDS risk factor and the prevalence of the side sleeping position substantially increased. To maintain the current success in lowering SIDS frequency, prevention programmes ought to continue and changes in the weight of risk factors should be considered. Further efforts are required to achieve a thorough post-mortem examination in virtually all sudden unexpected deaths, to establish a country-wide SIDS data base and to continuously update SIDS risk profiles in Austria.

Factors relating to the infant's last sleep environment in sudden infant death syndrome in the Republic of Ireland

AIM

To identify risk factors for sudden infant death syndrome (SIDS) in the sleeping environment of Irish infants.

METHODS

A five year population based case-control study with parental interviews conducted for each case and three controls matched for age, place of birth, and last sleep period. A total of 203 SIDS cases and 622 control infants born 1994-98 were studied.

RESULTS

In a multivariate analysis, co-sleeping significantly increased the risk of SIDS both as a usual practice (adjusted OR 4.31; 95% CI 1.07 to 17.37) and during the last sleep period (adjusted OR 16.47; 95% CI 3.73 to 72.75). The associated risk was dependent on maternal smoking (OR 21.84; 95% CI 2.27 to 209.89), and was not significant for infants who were > or =20 weeks of age (OR 2.63; 95% CI 0.49 to 70.10) or placed back in their own cot/bed to sleep (OR 1.07; 95% CI 0.21 to 5.41). The use of pillows, duvets, and bedding with tog value > or =10 were not significant risk factors when adjusted for the effects of confounding variables, including maternal smoking and social disadvantage. However, the prone sleeping position remains a significant SIDS risk factor, and among infants using soothers, the absence of soother use during the last sleep period also significantly increased the SIDS risk (OR 5.83; CI 2.37 to 14.36).

CONCLUSION

Co-sleeping should be avoided in infants who are <20 weeks of age, or whose mothers smoked during pregnancy. The prone position remains a factor in some SIDS deaths, and the relation between soother use and SIDS is a complex variable requiring further study.

Low breastfeeding rates and public health in the United States

The medical community has orchestrated breastfeeding campaigns in response to low breastfeeding rates twice in US history. The first campaigns occurred in the early 20th century after reformers linked diarrhea, which caused the majority of infant deaths, to the use of cows' milk as an infant food. Today, given studies showing that numerous diseases and conditions can be prevented or limited in severity by prolonged breastfeeding, a practice shunned by most American mothers, the medical community is again inaugurating efforts to endorse breastfeeding as a preventive health measure. This article describes infant feeding practices and resulting public health campaigns in the early 20th and 21st centuries and finds lessons in the original campaigns for the promoters of breastfeeding today.