Risk factors for sudden infant death syndrome following the prevention campaign in New Zealand: a prospective study

Metabolomic profiles of infants classified as sudden infant death syndrome: a case-control analysis

BACKGROUND

Sudden Infant Death Syndrome (SIDS) is a leading cause of postneonatal mortality. The absence of specific biomarkers of SIDS diagnosis and risk leaves a significant gap in understanding SIDS pathophysiology. Metabolomics offers an avenue to better understand SIDS biology and identifying potential biomarkers.

METHODS

Using Metabolon Inc., global discovery panel, we analysed 828 metabolites from post-mortem serum samples of infants from the Chicago Infant Mortality Study (CIMS) and the NIH NeuroBioBank (NBB). In total, 300 infants (195 SIDS; 105 non-SIDS) across multiple race/ethnicities (70% Black, 13% White, and 16% Hispanic) were included. Metabolite associations with SIDS were performed using Welch's t-tests, linear and logistic regression, and network-cluster analyses.

FINDINGS

We identified thirty-five significant metabolite predictors of SIDS after adjustment for age, sex, race and ethnicity, and post-mortem interval, including ornithine (OR 21.98; p-value 6.44e-7), 5-hydroxylysine (OR 19.48; p-value 6.78e-7), 1-stearoyl-2-linoleoyl-GPC (18:0/18:2) (OR 16.80; p-value 3.4e-7), ribitol (OR 8.19; p-value 4.2e-8), and arabitol/xylitol. Using Weighted Gene Co-expression Network Analysis (WGCNA), ten metabolite clusters were identified. Four exhibited significant associations with SIDS. The two most correlated clusters were enriched for metabolites in the tyrosine metabolism pathway and lipid (sphingomyelins) pathways.

INTERPRETATION

We identified metabolite biomarkers within key biological pathways and processes (e.g., nitrogen metabolism, lipid and fatty acid metabolism, stress response, nerve cell communication, hormone regulation, oxidative stress) with potential implications in SIDS pathology. Further research is needed to validate these biomarkers in additional SIDS cohorts.

FUNDING

The Chicago Infant Mortality Study was funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute on Deafness and Other Communication Disorders under contract number NO1-HD-3-3188, the Centers for Disease Control and Prevention and the Association of Teachers of Preventive Medicine under cooperative agreement number U50/CCU300860-06, and the Playmates in Heaven Foundation. The current analyses were funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development under 5R01HD101518-04.

The Awareness of Sudden Infant Death Among Saudi Arabian Women in 2023

Background Sudden infant death syndrome (SIDS) refers to the unexpected and unexplained death of a child under one year old. The pathogenesis of SIDS remains unclear. However, certain factors such as the child's sleeping position, sleeping on a soft mattress, and maternal smoking have been suggested to contribute to its occurrence. The objective of this study was to evaluate the level of awareness of SIDS among Saudi Arabian women in 2023. Methodology A cross-sectional study was conducted among 300 mothers in Saudi Arabia, over a period of three months, from June to August 2023, using an online questionnaire to gather socio-demographic information from mothers of infants younger than one year old in Saudi Arabia, the sleeping practices of their infants, and their knowledge about SIDS risk factors. Data were coded using the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY), and statistical significance tests were employed for data analysis. A p-value of <0.05 was considered significant. Results Among the 277 participating mothers, 44% were 31-40 years old, 93% were Saudi, 60% were employed, 65% were nonsmokers, and 64% placed babies in a supine position for sleep. About 37% of mothers used a duvet for bedding during summer, compared to 66% who used a duvet during winter, and 81% utilized a soft mattress cover in their children's beds. Additionally, 67% of mothers reported that their children used a pacifier while sleeping. More than half (54%) of mothers were aware of SIDS with media as their primary source of information. Among those under 21 years old, 50% demonstrated a high level of awareness, compared to 36% of those aged over 50. Conclusion Most women in this study were found to be unaware of SIDS. Among those who were aware, the media was the primary source of information. Higher educational attainment was associated with better understanding.

Pre- and postnatal safe sleep knowledge and planned as compared to actual infant sleep practices

BACKGROUND

Our objectives were to compare safe sleep knowledge, attitudes and planned vs. actual infant sleep practices among expectant mothers before and after their infant's birth and to determine whether differences (if present) were associated with any demographic variables.

METHODS

Study participants were surveyed at their 28-week prenatal and 6-week postpartum obstetric clinic visits from November 2019-February 2021. Due to COVID-19 pandemic cancellation of in-person postpartum visits, many participants received text messaging encouraging them to take the follow-up survey online. Frequency and comparative analyses were performed.

RESULTS

355 women (44%) completed both pre- and postnatal surveys. Many participants increased their safe sleep knowledge during the study. For example, of those who were unsure or thought it safe for a baby to sleep in a baby swing/bouncy seat, two-thirds (67/102, 66%) stated it was unsafe on the postnatal survey. In addition, many who were unsure or planned sleep practices considered unsafe prenatally reported utilizing safe sleep practices on their postnatal survey. For example, of those unsure or planning to use a crib bumper (17% of the total), almost all (88%) were not using one postnatally. Conversely, some participants who reported they would be following safe sleep practices prenatally were not doing so postpartum. For example, 13% of those stating they would place their child on their back reported using another sleep position on the postnatal survey. Certain demographics had higher proportions reporting this reversal for specific safe sleep practices. For example, non-Hispanic Whites (19%) as compared to other races/ethnicities (5%) and those with incomes ≥ $75,000 (21%) as compared with those with less income (9%) had higher proportions stating their infant would sleep in the same room but then reported postnatally they were sleeping in a different room, p = 0.0094 and p = 0.0138, respectively.

CONCLUSIONS

We observed increases in safe sleep knowledge and that some participants followed safer sleep practices than they had planned. However, there were also participants who planned to use safe sleep practices prenatally who were not doing so after their baby's birth. Our study identified demographics for which targeted safe sleep education and more effective interventions may be needed.

Association of maternal snuff use and smoking with Sudden Infant Death Syndrome: a national register study

BACKGROUND

The aim was to study whether non-combustible nicotine (Swedish snuff) use in pregnancy is associated with elevated risk of post neonatal mortality, Sudden Infant Death Syndrome (SIDS), and Sudden Unexpected Infant Death (SUID) and to study how cessation before the antenatal booking influenced these risks.

METHODS

This was a population-based register study of all infants with information on tobacco exposure in early pregnancy born in Sweden 1999-2019, n = 2,061,514. Self-reported tobacco use in early pregnancy was categorized as nonuse, snuff use, and moderate and heavy smoking. Multiple logistic regression models were used to estimate crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

Maternal snuff use was associated with increased risks of post neonatal mortality, SIDS, and SUID. The risks of snuff use and moderate smoking were of similar magnitude. Heavy smoking was associated with the highest risks. Cessation of smoking and snuff use before the antenatal booking was associated with lower risks of SIDS and SUID compared to that of continuous usage.

CONCLUSIONS

Maternal snuff use was associated with increased risks of post neonatal mortality, SIDS, and SUID. Nicotine is the common substance in cigarette smoke and snuff. These findings support the hypothesis that nicotine contributes to an elevated risk of SIDS.

IMPACT

Maternal snuff use and smoking in early pregnancy were associated with increased risks of post neonatal mortality, SIDS, and SUID. Cessation of smoking and snuff use before the first antenatal visit was associated with reduced risks of SIDS and SUID. The common substance in cigarette smoke and snuff is nicotine. Our findings suggest that nicotine contributes to an elevated risk of SIDS and SUID. The implication of our findings is that all forms of nicotine should be avoided in pregnancy.

Airway pollution and smoking in reproductive health

Environmental exposure refers to contact with chemical, biological, or physical substances found in air, water, food, or soil that may have a harmful effect on a person's health. Almost all of the global population (99%) breathe air that contains high levels of pollutants. Smoking is one of the most common forms of recreational drug use and is the leading preventable cause of morbidity and mortality worldwide. The small particles from either ambient (outdoor) pollution or cigarette smoke are inhaled to the lungs and quickly absorbed into the bloodstream. These substances can affect virtually every organ in our body and have been associated with various respiratory, cardiovascular, endocrine, and also reproductive morbidities, including decreased fertility, adverse pregnancy outcomes, and offspring long-term morbidity. This review summarizes the latest literature reporting the reproductive consequences of women exposed to ambient (outdoor) air pollution and cigarette smoking.

The Fish Oil to Reduce Tobacco Use iN Expectant mothers (FORTUNE) feasibility trial

BACKGROUND

Three small clinical trials have suggested that supplementation with n-3 long-chain polyunsaturated fatty acids (eicosapentaenoic acid and docosahexaenoic acid) found in fish oils may reduce nicotine cravings and at higher doses reduce cigarette consumption. Pregnant women who smoke have fewer pharmacologic options to aid them with smoking cessation. Although n-3 long-chain polyunsaturated fatty acid supplementation has been studied in pregnancy, few studies have evaluated doses of ≥4 g per day, and no previous studies have selectively enrolled pregnant women who smoke. High-dose n-3 long-chain polyunsaturated fatty acids may aid cessation but could be poorly tolerated in pregnant women who smoke because of gastrointestinal side effects.

OBJECTIVE

We conducted a feasibility trial to determine the tolerability of high-dose n-3 long-chain polyunsaturated fatty acid supplementation in pregnant women who smoked. We hypothesized that n-3 long-chain polyunsaturated fatty acid doses of 4.2 g a day would be well-tolerated relative to an olive oil placebo. We assessed red blood cell phospholipid membrane concentrations at baseline and end of therapy (4 weeks) and piloted outcomes for a future efficacy trial of n-3 long-chain polyunsaturated fatty acid supplementation for smoking cessation in pregnancy.

STUDY DESIGN

We recruited 28 pregnant women between the gestational ages of 6 and 36 weeks who reported daily cigarette smoking and were motivated to quit to participate in a double-blind placebo-controlled randomized feasibility trial of 4.2 g per day of n-3 long-chain polyunsaturated fatty acid supplementation. Participants reported cigarettes per day, completed the Fagerström Test for Cigarette Dependence, and provided blood, urine, and exhaled CO samples. We used repeated-measures analysis of variance to pilot analyses of changes in cigarettes per day and Fagerström Test for Cigarette Dependence scores.

RESULTS

At baseline, red blood cell membrane eicosapentaenoic acid concentrations were negatively correlated with cigarettes per day (r=-0.44; P=.04). By 4 weeks, circulating n-3 long-chain polyunsaturated fatty acid levels increased by 18% in the n-3 long-chain polyunsaturated fatty acid supplementation arm vs a decrease of 3% in the placebo arm. Occurrence of gastrointestinal side effects such as burping, heartburn, diarrhea, abdominal pain, or nausea did not differ statistically between study arms. At 4 weeks, participants allocated to the n-3 long-chain polyunsaturated fatty acids arm reported a median of 3 cigarettes per day (interquartile range, 1-8) vs 7 cigarettes per day (interquartile range, 1-14) in the placebo arm, which was not statistically significant (P=.99). Participants allocated to the n-3 long-chain polyunsaturated fatty acids arm had a decrease of 1 (interquartile range, 0-1) on the Fagerström Test for Cigarette Dependence score vs 0 (interquartile range, 0-0) for placebo (P=.46).

CONCLUSION

High-dose n-3 long-chain polyunsaturated fatty acids may be tolerated in pregnant women who smoke; however, there was a high level of participant dropout, with more participants allocated to the fish oil arm becoming lost to follow-up. These results will inform the design of a future large-scale randomized controlled trial to test the impact of fish oil supplements on smoking cessation in pregnancy.

Effect of sleep position in term healthy newborns on sudden infant death syndrome and other infant outcomes: A systematic review

Background

Though recommended by numerous guidelines, adherence to supine sleep position during the first year of life is variable across the globe.

Methods

This systematic review of randomized trials and observational studies assessed the effect of the supine compared to non-supine (prone or side) sleep position on healthy newborns. Key outcomes were neonatal mortality, sudden infant death syndrome (SIDS), sudden unexpected death in infancy (SUDI), acute life-threatening event (ALTE), neurodevelopment, and positional plagiocephaly. We searched MEDLINE via PubMed, Cochrane CENTRAL, EMBASE, and CINAHL (updated till November 2021). Two authors separately evaluated the risk of bias, extracted data, and synthesised effect estimates using relative risk (RR) or odds ratio (OR). The GRADE approach was used to assess the certainty of evidence.

Results

We included 54 studies (43 observational studies and 11 intervention trials) involving 474 672 participants. A single study meeting the inclusion criteria suggested that the supine sleep position might reduce the risk of SUDI (0-1 year; OR = 0.39, 95% confidence interval (CI) = 0.23-0.65; 384 infants), compared to non-supine position. Supine sleep position might reduce the risk of SIDS (0-1 year; OR = 0.51, 95% CI = 0.42-0.61; 26 studies, 59332 infants) and unexplained SIDS/severe ALTE (neonatal period; OR = 0.16, 95% CI = 0.03-0.82; 1 study, 119 newborns), but the evidence was very uncertain. Supine sleep position probably increased the odds of being 0.5 standard deviation (SD) below mean on Gross Motor Scale at 6 months (OR = 1.67, 95% CI = 1.22-2.27; 1 study, 2097 participants), but might have little to no effect at 18 months of age (OR = 1.16, 95% CI = 0.96, 1.43; 1 study, 1919 participants). An increase in positional plagiocephaly at 2-7 months of age with supine sleep position is possible (OR = 2.77, 95% CI = 2.06-3.72; 6 studies, 1774 participants).

Conclusions

Low- to very low-certainty evidence suggests that supine sleep position may reduce the risk of SUDI (0-1 year) and SIDS (0-1 year). Limited evidence suggests that supine sleeping probably delays short-term ‘gross motor’ development at 6 months, but the effect on long-term neurodevelopment at 18 months may be negligible.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

A proof-of-concept study to construct Bayesian network decision models for supporting the categorization of sudden unexpected infant death

Sudden infant death syndrome (SIDS) remains a leading cause of infant death in high-income countries. Supporting models for categorization of sudden unexpected infant death into SIDS/non-SIDS could reduce mortality. Therefore, we aimed to develop such a tool utilizing forensic data, but the reduced number of SIDS cases renders this task inherently difficult. To overcome this, we constructed Bayesian network models according to diagnoses performed by expert pathologists and created conditional probability tables in a proof-of-concept study. In the diagnostic support model, the data of 64 sudden unexpected infant death cases was employed as the training dataset, and 16 known-risk factors, including age at death and co-sleeping, were added. In the validation study, which included 8 new cases, the models reproduced experts’ diagnoses in 4 or 5 of the 6 SIDS cases. Next, to confirm the effectiveness of this approach for onset prediction, the data from 41 SIDS cases was employed. The model predicted that the risk of SIDS in 0- to 2-month-old infants exposed to passive smoking and co-sleeping is eightfold higher than that in the general infant population, which is comparable with previously published findings. The Bayesian approach could be a promising tool for constructing SIDS prevention models.

Investigating N-3 Fatty Acids to prevent Neonatal Tobacco-related outcomeS (INFANTS): study protocol for a double-blind, randomized, placebo-controlled parallel clinical trial of n-3 polyunsaturated fatty acids in pregnant smokers

BACKGROUND

Tobacco use during pregnancy is the most important modifiable risk factor associated with adverse pregnancy outcomes, increasing the risk of preterm birth, intrauterine growth restriction and sudden infant death syndrome. Fewer than half of pregnant smokers can quit on their own. Identifying safe and effective therapies to prevent tobacco-related adverse pregnancy outcomes and/or increase smoking cessation in pregnant women would have a substantial public health impact. Cigarette smoking is associated with a relative deficiency in circulating n-3 long-chain polyunsaturated fatty acid (n-3 LCPUFA) levels. A recent analysis found that smokers taking n-3 LCPUFAs during pregnancy had a reduction in preterm labor risk when compared to non-smokers. Studies have shown that supplemental n-3 LCPUFAs may also reduce nicotine cravings and daily cigarette use. Thus, smokers may benefit from supplemental n-3 LCPUFAs by lowering the risk of preterm labor and/or increased smoking cessation. To address important remaining knowledge gaps, we propose the Investigating N-3 Fatty Acids to prevent Neonatal Tobacco related outcomeS (INFANTS).

METHODS

The INFANTS study is a multicenter, randomized, double-blind, placebo-controlled study that will randomize 400 pregnant smokers to either supplemental n-3 LCPUFAs or placebo. Participants will be enrolled between 12 and 24 weeks' gestation and followed until 6 weeks after delivery. We will recruit from clinical centers throughout Middle Tennessee. We will assess smoking behavior after 12 weeks of supplementation using self-report and validated biomarkers of tobacco exposure. We will measure response to supplementation using biological markers of n-3 LCPUFA status. Our primary endpoint will be preterm labor as reflected by gestational age at delivery. Our secondary endpoint will be change from baseline in cigarettes per day at 12 weeks.

DISCUSSION

This study tests the hypothesis that smoking-induced n-3 LCPUFA deficiencies contribute to tobacco-related adverse pregnancy outcomes and that supplementation of n-3 LCPUFAs in pregnant smokers may prevent these complications. If our study demonstrates that supplemental n-3 LCPUFAs are effective at reducing the risk of tobacco-related adverse neonatal outcomes and/or reducing tobacco use during pregnancy, our results could have an immediate and major impact on pregnancy care and neonatal outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04417595. Registered on April 21, 2020.

Factors Associated with Safe Infant Sleep Practices in Saudi Arabia

Purpose

To assess mothers’ approaches to infant sleep practices.

Patients and Methods

A cross-sectional survey study was conducted on mothers with babies aged below five months who were attending paediatric clinics between November 1st, 2020, and January 5th, 2021, in Riyadh, Saudi Arabia.

Results

A total of 522 mothers participated in this study. A total of 38.9% practised exclusive formula feeding. A total of 61.9% of the participants practised the supine position. The majority (93.3%) of the mothers shared a room with their babies, while 34.7% shared a bed. Only 6.9% did not use any soft bedding. Age was a significant predictor associated with participant practices regarding sleeping and feeding positions (p < 0.05). Having two or more children was associated with improper sleeping practices (p < 0.05). Being non-Saudi and having a university degree or higher were associated with having a higher risk of unsafe practices regarding bed-sharing (p < 0.05). On the other hand, being contacted by a doctor, nurse, or other healthcare worker about safe sleep practices were an important factor that influenced safe practices regarding feeding (p < 0.05). Receiving care at a private hospital was associated with safer practices regarding sleeping position and bed-sharing (p < 0.05).

Conclusion

We observed high-risk sleeping practices among Saudi mothers. This includes using soft bedding and unsafe sleeping positions. The importance of this study lies in the future implementation of this result through public health measures aimed at at-risk populations.

Norwegian parents avoid placing infants in prone sleeping positions but frequently share beds in hazardous ways

AIM

Campaigns to prevent prone sleeping and other modifiable risk factors have greatly reduced the incidence of sudden infant death syndrome in Norway. Sleep-related infant deaths still occur sporadically and may be preventable. We studied infants' sleeping environments and whether parents followed safe sleep recommendations.

METHODS

Parents with infants up to 12 months of age were invited to complete an online questionnaire from May to December 2018. It was publicised by health centres and on websites and social media.

RESULTS

We received 4886 responses and 4150 met the age criteria and were included. Just under two-thirds (62.7%) reported routine bed-sharing, and this practice was associated with increased nocturnal breastfeeding, single parents and having more than one child. A small number of infants under six months were occasionally placed prone when they were laid down to sleep (2.1%) and 29.7% were placed on their side. Nearly three-quarters (72.6%) of the 2330 parents with infants under six months of age reported previous high-risk behaviour, such as sleeping together on a sofa or bed-sharing after smoking or drinking.

CONCLUSION

Norwegian parents rarely used prone sleeping positions for infants. However, bed-sharing was common, including high-risk scenarios such as smoking, alcohol use and sofas.

Inconsistent classification of unexplained sudden deaths in infants and children hinders surveillance, prevention and research: recommendations from The 3rd International Congress on Sudden Infant and Child Death

This report details the proceedings and conclusions from the 3rd International Congress on Unexplained Deaths in Infants and Children, held November 26–27, 2018 at the Radcliffe Institute at Harvard University. The Congress was motivated by the increasing rejection of the diagnosis Sudden Infant Death Syndrome (SIDS) in the medical examiner community, leading to falsely depressed reported SIDS rates and undermining the validity and reliability of the diagnosis, which remains a leading cause of infant and child mortality. We describe the diagnostic shift away from SIDS and the practical issues contributing to it. The Congress was attended by major figures and opinion leaders in this area from countries significantly engaged in this problem. Four categories (International Classification of Diseases (ICD)-11 categories of MH11, MH12, MH14, PB00-PB0Z) were recommended for classification, and explicit definitions and guidance were provided for death certifiers. SIDS was reframed as unexplained sudden death in infancy or SIDS/MH11 to emphasize that either term signifies the lack of explanation following a rigorous investigation. A distinct category for children over the age of 1 was recommended (MH12). Definitions and exclusions were provided for the alternative categories of accidental asphyxia and undetermined. As recommended, unexplained sudden death in infancy or SIDS on a death certificate will code a unique, trackable entity, accurately reflecting the inability to determine a definitive explanation, while satisfying surveillance needs and reliable identification for research efforts. The conclusions will be submitted to the World Health Organization for inclusion in the upcoming ICD-11.

Maternal Smoking Before and During Pregnancy and the Risk of Sudden Unexpected Infant Death

OBJECTIVES

Maternal smoking during pregnancy is an established risk factor for sudden unexpected infant death (SUID). Here, we aim to investigate the effects of maternal prepregnancy smoking, reduction during pregnancy, and smoking during pregnancy on SUID rates.

METHODS

We analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2007-2011: 20 685 463 births and 19 127 SUIDs). SUID was defined as deaths at <1 year of age with International Classification of Diseases, 10th Revision codes R95 (sudden infant death syndrome), R99 (ill-defined or unknown cause), or W75 (accidental suffocation or strangulation in bed).

RESULTS

SUID risk more than doubled (adjusted odds ratio [aOR] = 2.44; 95% confidence interval [CI] 2.31-2.57) with any maternal smoking during pregnancy and increased twofold between no smoking and smoking 1 cigarette daily throughout pregnancy. For 1 to 20 cigarettes per day, the probability of SUID increased linearly, with each additional cigarette smoked per day increasing the odds by 0.07 from 1 to 20 cigarettes; beyond 20 cigarettes, the relationship plateaued. Mothers who quit or reduced their smoking decreased their odds compared with those who continued smoking (reduced: aOR = 0.88, 95% CI 0.79-0.98; quit: aOR = 0.77, 95% CI 0.67-0.87). If we assume causality, 22% of SUIDs in the United States can be directly attributed to maternal smoking during pregnancy.

CONCLUSIONS

These data support the need for smoking cessation before pregnancy. If no women smoked in pregnancy, SUID rates in the United States could be reduced substantially.

Detoxification genes polymorphisms in SIDS exposed to tobacco smoke

The best hypothesis to explain Sudden Infant Death Syndrome (SIDS) pathogenesis is offered by the "triple risk model", which suggests that an interaction of different variables related to exogenous stressors and infant vulnerability may lead to the syndrome. Environmental factors are triggers that act during a particular sensible period, modulated by intrinsic genetic characteristics. Although literature data show that one of the major SIDS risk factors is smoking exposure, a specific involvement of molecular components has never been highlighted. Starting from these observations and considering the role of GSTT1 and GSTM1 genes functional polymorphisms in the detoxification process, we analyzed GSTM1 and GSTT1 null genotype frequencies in 47 SIDS exposed to tobacco smoke and 75 healthy individuals. A significant association (p < .0001) between the GSTM1 null genotype and SIDS exposed to smoke was found. On the contrary, no association between GSTT1 polymorphism and SIDS was determined. Results indicated the contribution of the GSTM1 -/- genotype resulting in null detoxification activity in SIDS cases, and led to a better comprehension of the triple risk model, highlighting smoking exposure as a real SIDS risk factor on a biochemical basis.

Health Messaging and African-American Infant Sleep Location: A Randomized Controlled Trial

Infant-parent bedsharing increases the risk of SIDS and other sleep-related deaths. Despite AAP recommendations to avoid bedsharing, public health efforts have been unsuccessful in changing behaviors. African-American infants are more than twice as likely to die from SIDS and other sleep-related deaths, and are also twice as likely to bedshare with their parents. Further, African-American parents have a high degree of self-efficacy with regards to preventing infant suffocation, but low self-efficacy with regards to SIDS risk reduction. It is unclear whether messages emphasizing suffocation prevention will decrease bedsharing. To evaluate the impact of specific health messages on African-American parental decisions regarding infant sleep location. We conducted a randomized, controlled trial of African-American mothers of infants. The control group received standard messaging emphasizing AAP-recommended safe sleep practices, including avoidance of bedsharing, for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices, including avoidance of bedsharing, for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth. 1194 mothers were enrolled in the study, and 637 completed all interviews. Bedsharing, both usually (aOR 1.005 [95 % CI 1.003, 1.006]) and last night (aOR 1.004 [95 % CI 1.002, 1.007]) increased slightly but statistically significantly with infant age (p < 0.001). Receipt of the enhanced message did not impact on sleep location. Maternal belief that bedsharing increased the risk of SIDS or suffocation declined over 6 months (p < 0.001) and did not differ by group assignment. African-American mothers who received an enhanced message about SIDS risk reduction and suffocation prevention were no less likely to bedshare with their infants.

CLINICAL TRIALS REGISTRATION

Clinical Trials.gov identifier NCT01361880.

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution

PURPOSE

To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution.

METHODS

This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors.

RESULTS

In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6-3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3-6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0-9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05-1.09; p = .02), asthma (OR 1.9; 95%CI 1.1-3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1-3.2; p = .02) were associated with increased SSI.

CONCLUSIONS

Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.

[Gastroesophageal reflux and sleep position of infants. A survey conducted in France by 493 pediatricians]

BACKGROUND AND AIMS

The supine sleeping position with the head higher than the legs has no impact on regurgitations in infants. Inclined ventral decubitus decreases regurgitations but is associated with an increased risk of sudden infant death syndrome (SIDS). The LUNE study aimed to evaluate the impact of regurgitations on the choice of sleeping position by pediatricians and parents.

METHODS

Cross-sectional case-control study (ratio 1:1) conducted in France in 2013. A representative sample of pediatricians recruited 3-week to 4-month-old breast- or formula-fed infants. Cases and controls were defined by the presence or absence of regurgitations. Collected data included Vandenplas codification for regurgitations (VD, range 0-6), associated symptoms, and variations in sleeping position since maternity hospital discharge.

RESULTS

A total of 1347 cases and 1346 controls were recruited by 493 pediatricians. Regurgitations were evaluated at VD1 (minor, 22 % of cases), VD2 (mild, 47 % of cases), or VD≥3 (moderate to severe, 31 % of cases). At the maternity hospital, the supine position was recommended to 96 % of parents for SIDS prevention. Since discharge, parents asked questions about the relationship between sleeping position and regurgitations (79 % of infants with GER versus 45 % of controls). The sleeping position was modified at least once since maternity discharge (42 % of infants with GER versus 35 % of controls). At inclusion, 86 % of infants with GER and 86 % of controls were sleeping on their back. Fifty-one percent of infants with GER and 28 % of controls slept in an inclined position. Pediatricians repeated the prescription of dorsal decubitus for 91 % of infants with GER and recommended an inclined position in 70 %.

CONCLUSIONS

Regurgitations had no impact on supine sleeping position. The inclined supine sleeping position was more frequent in infants with regurgitations with pediatricians' assent, which is not in agreement with evidence-based medicine.

SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment

Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. After an initial decrease in the 1990s, the overall sleep-related infant death rate has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," which is included in this issue.

Effectiveness of the 'Back-to-Sleep' campaigns among healthcare professionals in the past 20 years: a systematic review

OBJECTIVES

From the late 1980s 'Back-to-Sleep' (BTS) campaigns were run in most developed countries to increase awareness of the supine position's protective effect against sleep-related infant deaths. Once the media awareness-raising action associated with these campaigns ended, healthcare professionals' role became crucial. The goal of this paper is to determine if healthcare professionals' knowledge and parent advice consistent with evidence-based infant sleep recommendations have changed over the past 20 years.

SETTING

All studies investigating healthcare professionals' knowledge and/or advice to parents were included in a systematic review. The search was performed in PubMed and in MEDLINE, and 21 studies were identified.

RESULTS

The correctness of healthcare professionals' knowledge and parent advice about the supine sleeping position increased over the past 20 years. However, the percentage of those aware that parents should avoid putting their babies to sleep in a prone position is decreasing over time: from about 97% in the 1990s to about 90% at the end of the 2000s.

CONCLUSIONS

The effectiveness of the BTS campaigns in publicising the benefits of the supine position is confirmed by this paper. More and more healthcare professionals know that it is the best position to reduce the risk of sleep-related deaths and they recommend it exclusively. However, the decrease in the knowledge about non-prone positions suggests that the campaigns may not have focused enough on the dangers of the prone position.

An updated review on gastro-esophageal reflux in pediatrics

Comprehensive guidelines for the diagnosis and management of gastro-esophageal reflux (GER) and GER disease (GERD) were developed by the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. GERD is reflux associated with troublesome symptoms or complications. The recognition of GER and GERD is relevant to implement best management practices. A conservative management is indicated in infants with uncomplicated physiologic reflux. Children with GERD may benefit from further evaluation and treatment. Since the publications of the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition guidelines in 2009, no important novelties in drug treatment have been reported. Innovations are mainly restricted to the management of regurgitation in infants. During the last 5 years, pros and cons of multichannel intraluminal impedance have been highlighted. However, overall 'not much has changed' in the diagnosis and management of GER and GERD in infants and children.

Messaging Affects the Behavior of African American Parents with Regards to Soft Bedding in the Infant Sleep Environment: A Randomized Controlled Trial

OBJECTIVE

To evaluate the impact of specific health messages on the decisions of African American parents regarding soft bedding use, specifically related to the high degree of self-efficacy that African American parents have with regards to preventing infant suffocation vs low self-efficacy with regards to sudden infant death syndrome (SIDS) risk reduction.

STUDY DESIGN

We conducted a randomized, controlled clinical trial of African American mothers of infants. The control group received standard messaging emphasizing safe sleep practices recommended by the American Academy of Pediatrics for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth.

RESULTS

Of 1194 mothers enrolled, 637 completed all interviews. The use of soft bedding both in the past week and last night declined with age (P < .001). Infants in the enhanced group had a lower rate of use of soft bedding in the past week (P = .006) and last night (P = .013). Mothers who received the enhanced message were more likely to state that they avoided soft bedding to protect their infant from suffocation.

CONCLUSIONS

African American mothers who receive an enhanced message about SIDS risk reduction and suffocation prevention are less likely to use soft bedding in their infant's sleep environment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01361880.

Ventilatory Responses to Hypercarbia in Infants of Mothers Who Smoke and Misuse Substances

The ventilatory response of infants of mothers who smoke and misuse substances and controls to carbon dioxide was assessed at 6-12 weeks and the perinatal period. Infants of mothers who smoke and misuse substances had a dampened response at the peak age of sudden infant death syndrome, greater than in the perinatal period.

Parent-child bed-sharing: The good, the bad, and the burden of evidence

The practice of parent and child sharing a sleeping surface, or 'bed-sharing', is one of the most controversial topics in parenting research. The lay literature has popularized and polarized this debate, offering on one hand claims of dangers, and on the other, of benefits - both physical and psychological - associated with bed-sharing. To address the scientific evidence behind such claims, we systematically reviewed 659 published papers (peer-reviewed, editorial pieces, and commentaries) on the topic of parent-child bed-sharing. Our review offers a narrative walkthrough of the many subdomains of bed-sharing research, including its many correlates (e.g., socioeconomic and cultural factors) and purported risks or outcomes (e.g., sudden infant death syndrome, sleep problems). We found general design limitations and a lack of convincing evidence in the literature, which preclude making strong generalizations. A heat-map based on 98 eligible studies aids the reader to visualize world-wide prevalence in bed-sharing and highlights the need for further research in societies where bed-sharing is the norm. We urge for multiple subfields - anthropology, psychology/psychiatry, and pediatrics - to come together with the aim of understanding infant sleep and how nightly proximity to the parents influences children's social, emotional, and physical development.

Antenatal substance misuse and smoking and newborn hypoxic challenge response

OBJECTIVES

Infants of smoking (S) and substance misusing (SM) mothers have an increased risk of sudden infant death syndrome. The aim of this study was to test the hypothesis that infants of SM or S mothers compared with infants of non-SM, non-smoking mothers (controls) would have a poorer ventilatory response to hypoxia, which was particularly marked in the SM infants.

DESIGN

Physiological study.

SETTING

Tertiary perinatal centre.

PATIENTS

21 SM; 21 S and 19 control infants. Infants were assessed before maternity/neonatal unit discharge.

INTERVENTIONS

Maternal and infant urine samples were tested for cotinine, cannabinoids, opiates, amphetamines, methadone, cocaine and benzodiazepines.

MAIN OUTCOME MEASURES

During quiet sleep, the infants were switched from breathing room air to 15% oxygen and changes in minute volume were assessed.

RESULTS

The SM infants had a greater mean increase (p=0.028, p=0.034, respectively) and a greater magnitude of decline (p<0.001, p=0.018, respectively) in minute volume than the S infants and the controls. The rate of decline in minute volume was greater in the SM infants (p=0.008) and the S infants (p=0.011) compared with the controls.

CONCLUSIONS

Antenatal substance misuse and smoking affect the infant's ventilatory response to a hypoxic challenge.

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.

Prenatally buprenorphine-exposed children: health to 3 years of age

Our prospective study is among the first attempts to examine the health of prenatally buprenorphine-exposed children after neonatal age and to determine the types of child maltreatment in this patient group. The study population included 102 children (61/41 Caucasian males/females) who had a positive urine screen for buprenorphine as a newborn. In addition to buprenorphine, the children were also prenatally exposed to other substances. The data were collected by pediatricians in follow-up visits until 3 years of age and from medical records. Ten prenatally buprenorphine-exposed children (10 %) had some birth defect. The study children had slightly more major anomalies than newborns on average in Finland (3.4 %). Eye disorders (nystagmus, opticus atrophy, and strabismus) occurred in 11 % of children. One child was diagnosed with hepatitis C transmission. One female died of sudden infant death syndrome (SIDS), and one male died of congenital heart disease. Pediatricians submitted altogether 70 reports to child welfare services of suspected maltreatment. Of these reports, 45 (64 %) involved medical neglect. Physical abuse was suspected in four reports.

CONCLUSION

We suggest that prenatally buprenorphine-exposed children have several types of problems with their health at toddler age and that they are susceptible to child maltreatment, especially to medical neglect.

Ventilatory response to hypercarbia in newborns of smoking and substance-misusing mothers

RATIONALE

Infants of mothers who smoked (S) or substance misused (SM) during pregnancy have an increased risk of sudden infant death syndrome (SIDS).

OBJECTIVES

To test the hypothesis that infants of S and SM mothers compared with infants of non-substance-misusing, nonsmoking mothers (control subjects) would have a reduced ventilatory response to hypercarbia and that any reduction would be greater in the SM infants.

METHODS

Infants were assessed before maternity/neonatal unit discharge. Maternal and infant urine samples were obtained and tested for cotinine, cannabinoids, opiates, amphetamines, methadone, cocaine, and benzodiazepines.

MEASUREMENTS AND MAIN RESULTS

Respiratory flow and Vt were measured using a pneumotachograph inserted into a face mask placed over the infant's mouth and nose. The ventilatory responses to three levels of inspired carbon dioxide (0 [baseline], 2, and 4% CO2) were assessed. Twenty-three SM, 34 S, and 22 control infants were assessed. The birth weight of the control subjects was higher than the SM and S infants (P = 0.017). At baseline, SM infants had a higher respiratory rate (P = 0.003) and minute volume (P = 0.007) compared with control subjects and S infants. Both the SM and S infants had a lower ventilatory response to 2% (P < 0.001) and 4% (P < 0.001) CO2 than the control subjects. The ventilatory response to CO2 was lower in the SM infants compared with the S infants (P = 0.009).

CONCLUSIONS

These results are consistent with infants of smoking mothers and substance misuse/smoking mothers having a dampened ventilatory response to hypercarbia, which is particularly marked in the latter group.

The effect of 900 and 1800 MHz GSM-like radiofrequency irradiation and nicotine sulfate administration on the embryonic development of Xenopus laevis

The aim of this study was to investigate the effects of GSM-like radiofrequency electromagnetic radiation (RF EMR) and nicotine sulfate (NS) exposure on Xenopus embryonic development.The developmental effects of GSM-like RF-EMR (900-1800 MHz, at a SAR value of 1W/kg and NS on Xenopus laevis embryos were investigated). Following the application of radiofrequency radiation and/or NS administration, the embryos were closely examined in order to determine their possible teratogenic effects. Xenopus frogs obtained from the Department of Physiology of the Cukurova University, in accordance described by the Standard Guide of the American Society for Testing and Materials (ASTM). Following the exposure of Xenopus embryos to RF-EMR at 900 and 1800 MHz (1.0W/kg) for 4, 6 and 8h; the whole body specific energy absorption rate (SAR) of the embryos was calculated. With the exception of irradiation at 1800 MHz no dramatic developmental anomalies were observed in the Xenopus embryos in association with RF-EMR applications. Combined RF-EMR and NS applications resulted in dramatic abnormalities and death among the Xenopus embryos. The study results indicated that GSM-like RF-EMR (e.g. radiation from cell phones) was not as harmful to Xenopus embryos as might have been expected. However, the combined effects of GSM-like RF-EMR and NS on Xenopus embryos were more severe than the effect of RF-EMR or NS alone. In conclusion, the study results appear to suggest that the combined use of nicotine and cell phones might result in more pronounced detrimental effects on the health of smokers.

Not living with both parents is associated with more health- and developmental problems in infants aged 7 to 11 months: a cross sectional study

BACKGROUND

In Western countries, many children are affected by the separation of their parents. Our main objective was to assess the possible impact of parental separation family structure on certain aspects of somatic health in low-age children.

METHODS

We conducted a cross-sectional study based on data collected in the framework of free preventive medicine consultations in the French Community of Belgium. The data was derived from assessments conducted, between 2006 and 2012, on children 7 to 11 months after birth during which information of 79701 infants was collected regarding the risk of sudden infant death, psychomotor development, and development in terms of height and weight. The main outcome measures were: episode of risk of sudden infant death, polysomnography, home monitoring, psychomotor development, and body mass index.

RESULTS

The parents of 6.6% of the infants were separated. We established multivariable models, based on the presence or absence of confounders. The adjusted ORs (95% CI) of symptoms perceived as frightening, notably at night, of a prescription for a polysomnography, of an abnormal polysomnography result, and of follow-up by home monitoring were thus respectively 1.3 (1.1-1.6), 1.1 (0.9-1.3), 1.8 (1.3-2.4), and 1.3 (1.1-1.6). The adjusted ORs (95% CI) for psychomotor delay and for a body mass index above the 97(th) percentile were respectively 1.3 (1.0-1.6) and 1.2 (1.1-1.3) in the event of separation.

CONCLUSIONS

This study confirms the possibility that not living with both parents is an independent risk factor for the somatic health and psychomotor development of infants. This observation should be verified because it would have a major impact on the actions of family doctors and other first-line healthcare providers, in particular with regard to information and targeted prevention.

Safe sleep practices in a New Zealand community and development of a Sudden Unexpected Death in Infancy (SUDI) risk assessment instrument

Background

Interventions to prevent sudden unexpected death in infancy (SUDI) have generally been population wide interventions instituted after case–control studies identified specific childcare practices associated with sudden death. While successful overall, in New Zealand (NZ), the rates are still relatively high by international comparison. This study aims to describe childcare practices related to SUDI prevention messages in a New Zealand community, and to develop and explore the utility of a risk assessment instrument based on international guidelines and evidence.

Methods

Prospective longitudinal study of 209 infants recruited antenatally. Participant characteristics and infant care data were collected by questionnaire at: baseline (third trimester), and monthly from infant age 3 weeks through 23 weeks. Published meta-analyses data were used to estimate individual risk ratios for 6 important SUDI risk factors which, when combined, yielded a “SUDI risk score”.

Results

Most infants were at low risk for SUDI with 72% at the lowest or slightly elevated risk (combined risk ratio ≤1.5). There was a high prevalence of the safe practices: supine sleeping (86-89% over 3–19 weeks), mother not smoking (90-92% over 3–19 weeks), and not bed sharing at a young age (87% at 3 weeks). Five independent predictors of a high SUDI risk score were: higher parity (P =0.028), younger age (P =0.030), not working or caring for other children antenatally (P =0.031), higher depression scores antenatally (P =0.036), and lower education (P =0.042).

Conclusions

Groups within the community identified as priorities for education about safe sleep practices beyond standard care are mothers who are young, have high parity, low educational levels, and have symptoms of depression antenatally. These findings emphasize the importance of addressing maternal depression as a modifiable risk factor in pregnancy.

Management of paediatric GERD

Paediatric GERD is complicated to manage, as symptoms are diverse and often difficult to interpret. In infants, regurgitation is a common physiological condition. Nevertheless, when it occurs frequently (>4 times per day) and causes the infant distress, parents often seek medical help. In children 2-10 years of age, GERD is often considered to cause extra-oesophageal symptoms, despite the absence of hard evidence. Diagnostic investigations often lack solid validation and the signs and symptoms of GERD overlap with those of cow's milk protein allergy and eosinophillic oesophagitis. Reassurance, dietary treatment and positional adaptations are recommended for troublesome infant reflux. Anti-acid medication, mainly PPIs, is over-used in infants even though, in many children, reflux is not an acid-related condition. Moreover, evidence is increasing that PPIs cause adverse events such as gastroenteritis and respiratory tract infections. Management in children older than 10 years is similar to that in adults. Using prokinetics to treat nonerosive reflux disease remains only a promising theoretical concept, as no such molecule is currently available. Today, the adverse effects of each prokinetic molecule largely outweigh its potential benefit. Laparoscopic surgery is indicated in children who have life-threatening symptoms or in cases of drug dependence.

Scientific consensus forum to review the evidence underpinning the recommendations of the Australian SIDS and Kids Safe Sleeping Health Promotion Programme--October 2010

This paper summarises a 1-day scientific consensus forum that reviewed the evidence underpinning the Australian SIDS and Kids Safe Sleeping Health Promotion Programme. The focus was on each of the potentially modifiable risk factors for sudden unexpected deaths in infancy, including sudden infant death syndrome (SIDS) and fatal sleeping accidents. In particular infant sleeping position, covering of the face, exposure to cigarette smoke, room sharing, unsafe sleeping environments, bed sharing, immunisation, breastfeeding, pacifier use and Indigenous issues were discussed in depth. The participants recommended that future 'Reducing the Risk' campaign messages should focus on back to sleep, face uncovered, avoidance of cigarette smoke before and after birth, safe sleeping environment, room sharing and sleeping baby in own cot.

Interleukin-19 in fetal systemic inflammation

OBJECTIVE

The fetal inflammatory response syndrome (FIRS) is considered the fetal counterpart of the systemic inflammatory response syndrome (SIRS), which can be caused by infection and non-infection-related insults. Although the initial response is mediated by pro-inflammatory signals, the control of this response is achieved by anti-inflammatory mediators which are essential for the successful outcome of the affected individual. Interleukin (IL)-19 is capable of stimulating the production of IL-10, a major anti-inflammatory cytokine, and is a potent inducer of the T-helper 2 (Th2) response. The aim of this study was to determine if there is a change in umbilical cord plasma IL-19 and IL-10 concentrations in preterm neonates with and without acute funisitis, the histologic counterpart of FIRS.

METHODS

A case-control study was conducted including 80 preterm neonates born after spontaneous labor. Neonates were classified according to the presence (n = 40) or absence of funisitis (n = 40), which is the pathologic hallmark of FIRS. Neonates in each group were also matched for gestational age. Umbilical cord plasma IL-19 and IL-10 concentrations were determined by ELISA.

RESULTS

1) The median umbilical cord plasma IL-19 concentration was 2.5-fold higher in neonates with funisitis than in those without funisitis (median 87 pg/mL; range 20.6-412.6 pg/mL vs. median 37 pg/mL; range 0-101.7 pg/mL; p < 0.001); 2) newborns with funisitis had a significantly higher median umbilical cord plasma IL-10 concentration than those without funisitis (median 4 pg/mL; range 0-33.5 pg/mL vs. median 2 pg/mL; range 0-13.8 pg/mL; p < 0.001); and 3) the results were similar when we included only patients with funisitis who met the definition of FIRS by umbilical cord plasma IL-6 concentrations ≥ 17.5 pg/mL (p < 0.001).

CONCLUSION

IL-19 and IL-10 are parts of the immunologic response of FIRS. A subset of fetuses with FIRS had high umbilical cord plasma IL-19 concentrations. In utero exposure to high systemic concentrations of IL-19 may reprogram the immune response.

Racial differences in trends and predictors of infant sleep positioning in South Carolina, 1996-2007

This paper examines racial differences in trends and predictors of prone and lateral infant sleep positioning among South Carolina mothers and infants. Pregnancy Risk Assessment Monitoring System data were used to analyze linear trends in prone, lateral, and supine infant sleep positioning among 14,648 mother-infant pairs from 1996 to 2007. Logistic regression models were used to examine the predictors of prone and lateral positioning among 9,015 mother-infant pairs from 2000 to 2007. From 1996 to 2007, white infants experienced a reduction in both prone and lateral positioning and an increase in supine positioning (28.2-66.7%), while black infants had smaller decreases in prone and lateral positioning and a smaller increase in supine positioning (22.6-47.1%) than white infants. Compared to births in 2000-2005, births after the explicit recommendation that infants not be placed in the lateral sleep position (2006-2007) were associated with decreased odds of lateral positioning among white infants (odds ratio [OR]: 0.66; 95% confidence interval [CI]: 0.51, 0.87) but not among black infants. The significant predictors of white infants being placed in the prone position were different from the predictors for black infants. Additionally, with regard to lateral sleep positioning, more significant predictors were observed among white infants than black infants. These findings suggest that efforts are warranted to increase the prevalence of supine sleep positioning, especially among black infants. Race-specific programs may efficiently reduce non-supine sleep positioning to help narrow racial gaps in sudden infant death syndrome.

Prenatal cigarette smoke exposure and postnatal respiratory responses to hypoxia and hypercapnia

Prenatal cigarette smoke (CS) exposure, in combination with hypoxia and/or hyperthermia can lead to gasping and attenuated recovery from hypoxia in 7 days old rat pups. We studied 95 unanesthetized spontaneously breathing 14 days old rat pups to investigate if the destabilizing effects of increased ambient temperature and prenatal CS exposure on respiratory control observed in 7 days old rats were still evident at day 14. This postnatal age was selected as it is beyond the analogous risk period for SIDS in human. Furthermore, we investigated if the breathing responses to hypercapnia are affected by prenatal CS exposure. Since high ambient (HA) temperature can lead to gasping and aberrant respiratory control, we recorded respiratory patterns at low (24-25°C) and high (29-30°C) ambient temperatures, and under hypoxic or hypercapnic states. No gasping was observed in 14 days old rat pups. During hypoxia, breathing frequency increased in the CS-exposed group under low and HA temperatures. Rectal temperature decreased only in the sham group in response to low ambient temperature hypoxia. At HA temperature, breathing frequency increased in both sham and CS-exposed groups during hypercapnia, however, it remained elevated during washout period only in the sham group. We demonstrate that prenatal CS exposure continues to have profound effects on respiratory and thermoregulatory responses to hypoxia and hypercapnia at day 14. The attenuated respiratory and thermoregulatory responses to acute hypoxia and hypercapnia on day 14 demonstrate a strong interaction between CS exposure, respiratory control, and thermoregulation during postnatal maturation.

Risk factor changes for sudden infant death syndrome after initiation of Back-to-Sleep campaign

OBJECTIVE

To test the hypothesis that the profile of sudden infant death syndrome (SIDS) changed after the Back-to-Sleep (BTS) campaign initiation, document prevalence and patterns of multiple risks, and determine the age profile of risk factors.

METHODS

The San Diego SIDS/Sudden Unexplained Death in Childhood Research Project recorded risk factors for 568 SIDS deaths from 1991 to 2008 based upon standardized death scene investigations and autopsies. Risks were divided into intrinsic (eg, male gender) and extrinsic (eg, prone sleep).

RESULTS

Between 1991-1993 and 1996-2008, the percentage of SIDS infants found prone decreased from 84.0% to 48.5% (P < .001), bed-sharing increased from 19.2% to 37.9% (P < .001), especially among infants <2 months (29.0% vs 63.8%), prematurity rate increased from 20.0% to 29.0% (P = .05), whereas symptoms of upper respiratory tract infection decreased from 46.6% to 24.8% (P < .001). Ninety-nine percent of SIDS infants had at least 1 risk factor, 57% had at least 2 extrinsic and 1 intrinsic risk factor, and only 5% had no extrinsic risk. The average number of risks per SIDS infant did not change after initiation of the BTS campaign.

CONCLUSIONS

SIDS infants in the BTS era show more variation in risk factors. There was a consistently high prevalence of both intrinsic and especially extrinsic risks both before and during the Back-to-Sleep era. Risk reduction campaigns emphasizing the importance of avoiding multiple and simultaneous SIDS risks are essential to prevent SIDS, including among infants who may already be vulnerable.

Bed- and sofa-sharing practices in a UK biethnic population

OBJECTIVE

To describe the prevalence and associations of bed- and sofa-sharing in a biethnic UK birth cohort.

METHODS

We surveyed 3082 participants in the Born in Bradford birth cohort study by using a telephone interview when infants were aged 2 to 4 months. We asked families about sleep surface sharing behaviors, and other sudden unexpected death in infancy (SUDI)-related behaviors.

RESULTS

There were 15.5% of families that had ever bed-shared, 7.2% of families regularly bed-shared, and 9.4% of families had ever sofa-shared with their infants; 1.4% reported both. Regular bed-sharers were more commonly Pakistani (adjusted odds ratio [aOR] = 3.02, 95% confidence interval [CI] 1.96-4.66), had further or higher educational qualifications (aOR = 1.62, 95% CI 1.03-2.57), or breastfed for at least 8 weeks (aOR = 3.06, 95% CI 2.00-4.66). The association between breastfeeding and bed-sharing was greater among white British than Pakistani families. Sofa-sharing occurred in association with smoking (aOR = 1.79, 95% CI 1.14-2.80) and breastfeeding for more than 8 weeks (aOR = 1.76, 95% CI 1.19-2.58), and was less likely in Pakistani families (aOR = 0.21, 95% CI 0.14-0.31), or single-parent families (aOR = 0.50, 95% CI 0.29-0.87).

CONCLUSIONS

The data confirm that bed-sharing and sofa-sharing are distinct practices, which should not be combined in studies of unexpected infant deaths as a single exposure. The determinants of sleep-surface sharing differ between the UK Pakistani and UK majority communities, and from those of US minority communities. Caution is needed in generalizing SUDI/SIDS risk factors across populations with differing risk factor profiles, and care should be taken in adopting SUDI/SIDS reduction guidelines from other contexts.

Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate?

OBJECTIVE

To conduct a meta-analysis on the relationship between bed sharing and sudden infant death syndrome (SIDS) risk.

STUDY DESIGN

Data from PubMed and Medline were searched for studies published after Jan 1, 1970. The search strategy included articles with the terms "sudden infant death syndrome," "sudden unexpected death," and "cot death" with "bed sharing" or "co-sleeping." To further specify the potential risk of bed sharing and SIDS, subgroup analyses were performed.

RESULTS

Eleven studies met inclusion criteria and were included in the final meta-analysis. The combined OR for SIDS in all bed sharing versus non-bed sharing infants was 2.89 (95% CI, 1.99-4.18). The risk was highest for infants of smoking mothers (OR, 6.27; 95% CI, 3.94-9.99), and infants <12 weeks old (OR, 10.37; 95% CI, 4.44-24.21).

CONCLUSIONS

Bed sharing is a risk factor for SIDS and is especially enhanced in smoking parents and in very young infants.

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).

Non-cancer effects of chemical agents on children's health

This paper provides an overview about the non-cancer health effects for children from relevant chemical agents in our environment. In addition, a meta-analysis was conducted on the association between sudden infant death syndrome (SIDS) and maternal smoking during pregnancy as well as postnatal exposure to environmental tobacco smoke (ETS). In children, birth deformities, neurodevelopment, reproductive outcomes and respiratory system are mainly affected by chemical exposures. According to recent systematic reviews, evidence is sufficient for cognitive impairments caused by low lead exposure levels. Evidence for neurotoxicity from prenatal methylmercury exposure is sufficient for high exposure levels and limited for low levels. Prenatal exposure to polychlorinated biphenyls (PCB) and related toxicants results in cognitive and motor deficits. Maternal smoking during pregnancy is a risk factor for preterm birth, foetal growth deficit and SIDS. The meta-analytic pooled risk estimate for SIDS based on 15 studies is 2.94 (95% confidence interval: 2.43-3.57). Postnatal exposure to ETS was found to increase the SIDS risk by a factor of 1.72 (95% CI: 1.28-2.30) based on six studies which took into account maternal smoking during pregnancy. Additionally, postnatal ETS exposure causes acute respiratory infections, ear problems, respiratory symptoms, more severe asthma, and it slows lung growth. These health effects are also of concern for postnatal exposure to ambient and indoor air pollution. Children differ from adults with respect to several aspects which are relevant for assessing their health risk. Thus, independent evaluation of toxicity in childhood populations is essential.

Racial and ethnic disparities in infant mortality

Racial and ethnic disparities in infant mortality in the United States seem to defy all attempts at elimination. Despite national priorities to eliminate these disparities, black infants are 2.5 times more likely to die in infancy compared with non-Hispanic white infants. This disparity is largely related to the greater incidence among black infants of prematurity and low birth weight, congenital malformations, sudden infant death syndrome, and unintentional injuries. This greater incidence, in turn, is related to a complex interaction of behavioral, social, political, genetic, medical, and health care access factors. Thus, to influence the persistent racial disparity in infant mortality, a highly integrated approach is needed, with interventions adapted along a continuum from childhood through the periods of young adulthood, pregnancy, postpartum and beyond. The content and methodologies of these interventions need to be adapted to the underlying behaviors, social influences, and technology and access issues they are meant to address.

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.

Sudden infant death syndrome: how much mothers and health professionals know

BACKGROUND

Behavioral risk factors are associated with sudden infant death syndrome (SIDS). Education about the risk factors of SIDS is important for prevention. Our aim was to determine the knowledge and attitude of parents and health professionals about SIDS.

METHODS

A total of 174 health professionals and 150 mothers were enrolled in this study. Mothers' data were collected by telephone interview and health-care professionals were interviewed by the same investigator.

RESULTS

Only 39% of mothers were aware of SIDS. Forty-six percent of the mothers preferred a supine sleeping position for their infant and 16% of the parents were bed-sharing with their infants. Seventy-three percent of health professionals selected side, 17% supine and 10% prone sleeping position as the safest sleeping position. Frequencies for awareness of risk factors were: bed-sharing (75%), soft bedding (70%), pillow use (52%), toys in bed (90%), high room temperature (67%) and smoking (88%). Total knowledge score of health professionals who selected supine sleeping position as the safest was significantly higher (P < 0.001).

CONCLUSION

Most of the mothers were unaware of SIDS and less than half preferred a supine sleeping position for their infant. Only 72% of health professionals recommended a certain sleeping position during family interviews. Health professionals are more often recommending the side sleeping position or prone. Education of families and health professionals for the risk factors of SIDS may reduce the number of deaths from SIDS in Istanbul.