Crib death in the eastern regions of Norway 1984-1992. A survey of risk factors

Cot death is the most important cause of death during the first year of life after the newborn period in Norway. A case control study was performed by sending questionnaires to 188 cot death parents and 475 control parents with infants matched for age, sex and time of birth. 76% of the cot death parents and 79% of the control parents completed the questionnaires. The male/female ratio of the babies in both groups was 64/36. The age distribution showed a peak between two and four months. 65% succumbed during the winter months. During the winter 32% died outdoors. This was true for only 16% of those who died during summer. A higher proportion of the cot death cases than the controls were premature (more than eight weeks). 78% of the cot death victims usually slept prone, whereas this was true for only 50% of the controls (p < 0.01). 91% of the cot death victims were found dead in a prone position. When comparing live babies during the first three months of life, significantly more cot death mothers than control mothers had stopped breastfeeding. A larger proportion of the cot death victims than the controls had had apparent life threatening events (p < 0.01). Foam mattresses were equally frequent in both groups.     

Effect of prostaglandin F2 alpha (PGF2 alpha) on oviductal nitric oxide synthase (NOS) activity: possible role of endogenous NO on PGF2 alpha-induced contractions in rat oviduct

The objective was to analyse differences in the epidemiological pattern of sudden death in infancy during two time periods--the Sudden Infant Death Syndrome (SIDS) 'epidemic': 1984-1989, and the period of rapid decline in the SIDS rate 1990-1996. Sex distribution, age, sleeping position, signs of infection, day of the week and place of death were registered and compared for the two time periods studied in all SIDS cases autopsied at the Institute of Forensic Medicine, Oslo. There were significantly more deaths in the age group under four months in the period 1984-89 than in the second period. Prone sleeping position, signs of infection, death outdoors and during the winter were more frequent during the first period than in the second. These features also were more frequent in the age group under four months than in the older babies during the first period. The shift in the epidemiological pattern after 1990, when the risk factor campaign was launched, indicates that prone sleeping position, cold climate, sleeping outdoors and infections seem to be risk factors that are particularly harmful to the youngest infants.     

Sleeping position, orientation, and proximity in bedsharing infants and mothers

The impact of mother-infant bedsharing on infant sleeping position, orientation, and proximity to the mother was assessed in 12 breast-feeding Latino mother-infant pairs. Six routinely bedsharing and six routinely solitary-sleeping pairs slept 3 nights in the sleep laboratory. The first night matched the routine home condition, followed by 1 bedsharing night and 1 solitary-sleeping night in random order. During bedsharing infants were never placed prone, regardless of their routine sleeping condition. On the bedsharing night, mothers and infants spent most of the night oriented toward each other; seven of 12 infants remained oriented toward their mothers the entire night. While sleeping in a face-to-face orientation, most pairs slept most of the time less than 30 cm apart with appreciable amounts of time at less than 20 cm. This orientation and proximity should facilitate sensory exchanges between mother and infant which, we hypothesize, influence the infant's sleep physiology and nocturnal behavior. We conclude that bedsharing minimizes the use of the prone infant sleeping position, probably in part to facilitate breast feeding. By promoting nonprone positions, bedsharing may protect some infants from sudden infant death syndrome (SIDS), since prone sleeping is a known risk factor for SIDS. The large percentage of the night that mothers spent oriented toward their infants suggests that a higher degree of maternal vigilance may also result from bedsharing.     

SIDS--a retrospective study in Slovakia

This is an analysis of 102 cases of SIDS from retrospective studies in the Zilina and Senica districts. The incidence of SIDS in the Zilina district was 2.04/1000 (period 1969-1978) and 1.04/1000 (period 1980-1984). The incidence of SIDS in the Senica district was 0.82/1000 (period 1979-1990). According to preliminary results of the epidemiological study of SIDS in Slovakia (1991) the incidence is only 0.89/1000 which amounts, however, to 23.1% of the post-neonatal mortality. In the investigation nine indicators were evaluated: age at the time of death, morbidity before death, place of death, education of mother, position of infant at time of death, birth weight succession of child in family. The assembled results were compared with data in the literature. Because of similar results it is assumed that the following risk factors participate in the incidence of SIDS: age (2-4 months), time between midnight and 6 a.m., low socio-economic status of family, lower education of mother, incidence of SIDS in the family, short interval between childbirths, prone position during sleep, succession of child in family (third or subsequent), effect of smoking. The investigation did not confirm as risk factors a lower birth weight and inadequate postnatal adaptation. In the conclusions some possible ways of prevention are outlined.     

Increase in the incidence of occipital plagiocephaly

INTRODUCTION: The diagnosis and treatment of posterior plagiocephaly is one of the most controversial aspects of craniofacial surgery. PATIENTS AND METHODS: The purpose of this study is to describe a recent increase in the incidence of occipital plagiocephaly without synostosis in our hospital during the last 6 months. The shift in the referral patterns is roughly contemporaneous with the American Academy of Pediatrics recommendations regarding infant sleep position. The temporal coincidence of this increase with the recommendation to avoid the prone sleeping position, to reduce the risk of sudden infant death syndrome, suggests a possible causal relationship. If the association is causal, education regarding the need of head position rotation coupled with that for sudden infant death syndrome should obviate positional occipital plagiocephaly. CONCLUSIONS: The feature of true lambdoid synostosis versus those of deformational plagiocephaly secondary to positional molding are inadequately described in the literature and poorly understood; the differential diagnosis is important in relation to a conservative diagnostical and therapeutical intervention in patients with positional molding.     

Sleep position, autonomic function, and arousal

AIMS: To investigate and compare heart rate variability (HRV) and responses of heart rate and arousal to head-up tilting in infants sleeping prone and supine. METHODS: Thirty seven healthy infants aged 2-4 months were studied. HRV was measured for 500 beats while they were in a horizontal position. Subjects were then tilted 60 degrees head-up, and heart rate recorded over 1 minute and arousal responses observed. Data were collected during both quiet and active sleep for both prone and supine sleep positions. RESULTS: HRV, as assessed by the point dispersion of Poincaré plots, was significantly reduced in the prone position for both sleep states. Sleep position did not influence the changes in heart rate seen during a head-up tilt. Full awakening to the tilt was common in active sleep but significantly less so in the prone position (15% of prone tests vs 54% supine). Full awakening to the tilt rarely occurred during quiet sleep in either sleep position. CONCLUSION: This study provides some evidence that blunted arousal responses and/or altered autonomic function are a feature of the prone sleeping position. Decreased HRV may be a sign of autonomic impairment. It is seen in many disease states and in infants who later die of sudden infant death syndrome (SIDS).     

Prone position favors motor development of infants

OBJECTIVE: To determine the motor development in infants sleeping in the supine position compared to infants sleeping in the prone position, and to compare the levels of motor development of infants playing only in the supine position and of infants playing in the prone position as well. DESIGN: Prospective blinded comparing study. SETTING: Department of Physical Therapy, Maasziekenhuis, Boxmeer, the Netherlands. METHODS: Various measuring instruments were used in the home environment to determine the levels of motor development at the age of 5 months of 21 healthy infants born at term selected from a group of 160 infants attending the infant welfare clinic. RESULTS: Infants sleeping in the prone position (n = 8) showed a higher motor development than infants sleeping in the supine position (n = 13). Infants playing in the prone and supine position (n = 5) had a higher motor development than infants who played exclusively in the supine position (n = 15). CONCLUSION: Sleeping and playing in the prone position was accompanied by a higher motor development in healthy mature-born infants at the age of 5 months.     

Pathological fear of cot death

Cot death (sudden infant death syndrome) is one of the most common causes of death in the first year of life. Four cases with a pathological fear of cot death are presented. All the patients were depressed and in 2 cases the fear of cot death had an obsessional quality. In all cases there were complications during pregnancy (miscarriage, threatened abortion, recurrent vomiting in last trimester). In 1 case, the patient knew 3 mothers who had suffered cot deaths; in another, the infant was gravely ill in the neonatal period. Pathological fear of cot death can be recognised by the presence of two central features - overvigilance and excessive nocturnal checking of the baby's breathing. Therapeutic interventions are discussed.     

Sudden death of adults in Japan

Epidemiological features, risk factors and preventive methods of sudden death (SD) derived from studies the authors have performed since 1987 together with colleagues in Niigata University School of Medicine were reviewed. When SD was defined as death occurring within 24 hours of the onset of symptoms, the annual incidence was 145/100,000 for people aged 15 years and older in Niigata Prefecture. The incidence increased sharply along with the advance of age, while the proportion of SD to natural death due to circulatory diseases was higher in younger people. Though diseases of the circulatory system made up approximately 90 percent of all causes of death, SD due to ischemic heart disease was less frequent in Japan than in western countries. SD showed various patterns in seasonal and "within-a-day" occurrences according to sex, age and cause of death. The months of the highest SD occurrence differed by occupation and matched the busiest work periods. A decrease in sleeping hours and mental stress experienced during the preceding week were related to the occurrence of both sudden death and non-fatal acute myocardial infarction. People having structural circulatory diseases were shown to be predisposed to SD when stress occurred, because fatal arrhythmia is easily induced by the above factors in such people. Health examinations were shown to have preventive effects, though limited, against SD. Differences in the resuscitated rates in cases where a witness was present and where one was not indicates that educating people about correct resuscitation methods is important to minimizing SD.     

Housing and sudden infant death syndrome. The New Zealand Cot Death Study Group

AIMS: This paper examined factors relating to the infants' place of domicile to see whether they increased the risk of sudden infant death syndrome (SIDS) beyond social and environmental effects previously published. METHODS: A case control study was undertaken in New Zealand between the years 1987-90. From all sudden infant death syndrome diagnoses over this time, parents of 393 (81%) sudden infant death syndrome infants consented to participate and these derive the cases. Controls were ascertained by randomly sampling 1800 infants from all babies born over 78% of the country. Parents of 1592 (88%) control infants consented to participate in the study. RESULTS: The relative risk of sudden infant death for infants usually residing in houses rented from the government (State houses) was 1.73 (95% CI: 1.13, 2.66) times that of infants with parents owning their house, after adjusting for likely social, economic and environmental confounding factors. However, the type of housing, construction of housing, heating and age of housing was not associated with sudden infant death syndrome. Although house size, measured in terms of bedroom numbers, was similar for sudden infant death syndrome and control infants (chi 2 = 0.40, df = 2, p = 0.82), the number of people normally residing within these houses was different. Sudden infant death syndrome infants' houses were less likely to have two adults and more likely to have more children normally resident. Density calculations (derived by calculating the children and/or adult numbers divided by bedroom numbers) revealed a non significant increase in relative risk, suggesting that housing overcrowding was not associated with sudden infant death syndrome in New Zealand. CONCLUSIONS: Infants domiciled in State houses are more likely to experience sudden infant death syndrome. However, this increased relative risk for sudden infant death syndrome appears to have little to do with the house per se and, perhaps, more to do with socioeconomic characteristics.     

Sudden infant death syndrome: risk factor profiles for distinct subgroups

The authors investigated risk profiles of sudden infant death syndrome (SIDS) as a function of age at death. A case-control study carried out in the Tyrol region of Austria enrolled 99 infants who died of SIDS between 1984 and 1994 and 136 randomly selected controls. Early and late SIDS (< 120 days of age vs. > or = 120 days) were defined according to the clear-cut bimodal age-at-death distribution. Inadequate antenatal care, low parental social and educational level, and the prone sleeping position were risk conditions that applied to both early and late SIDS. A marked seasonal variation (winter preponderance) was the most outstanding feature of late SIDS. A gestational age of < 37 weeks (odds ratio (OR) = 8.4, 95% confidence interval (CI) 2.6-26.0), repeated episodes of apnea (OR = 5.7, 95% CI 1.2-27.0), low birth weight (< 2,500 g) (OR = 3.4, 95% CI 1.1-11.0), a family history of sudden infant death (OR = 2.9, 95% CI 1.1-7.5), and maternal smoking during pregnancy (OR = 2.2, 95% CI 1.0-4.5) were associated with early SIDS. This study identified two distinct subgroups of SIDS infants characterized by different risk conditions and ages at death. These results underline a multiple-cause hypothesis for SIDS etiology which involves a genetic predisposition, immaturity in the first months of life, and environmental factors acting at various ages.     

Patients with acute respiratory distress syndrome mechanically ventilated in prone position

Animal experiments and human studies have shown better oxygenation in mechanically ventilated patients with ARDS when the patient is situated in the prone position. In contradiction to former theories of a gravitational gradient of lung perfusion, a number of investigators have found that lung perfusion is preferentially distributed to the dorsal lung regions regardless of body position. The basal atelectasis and oedema in ARDS are resolved and only partly distributed anteriorly in the prone position, and these areas are thereby better ventilated. The combination of better ventilation and unchanged perfusion improves the ventilation/perfusion ratio and decreases the shunt in the prone position. In two cases of prone position in mechanically ventilated patients the PaO2/FiO2 ratio increased from 7.5 to 14.3 and from 8.8 to 19.8 after one hour in the prone position, and some of the improvement was permanent. Prone position has only minor side effects and is recommended as the first choice amongst adjunct therapies in mechanical ventilation in patients with ARDS remaining hypoxic in conventional therapy in the supine position.     

Polysomnography in the prevention of crib death

The authors stress the importance of polysomnography--a new electrophysiologic method--in the prevention of SIDS (cot death). SIDS is the most important and frequent cause of infant mortality between 1 and 12 months of age in western countries (nowadays between 1-2/1000!). In Hungary the frequency is not so high. In the last few years the incidence declined after the "back to sleep" campaigns, but to reach further success, it is very important to seek the so called "risk" babies. The unique cause of cot death is not yet understood exactly, but some instability in respiration (mostly during the sleep) is one of the accepted principal basic factors. The mentioned new method helps in choosing the SIDS risk infants from the "normal" population, allows to examine their respiratory irregularity or even disorders during the sleep and gives possibility for the prevention of lethal apneas. The authors describe the details of the prevention in case of abnormal polysomnography in their other publications.     

A longitudinal analysis of risk factors for child maltreatment: findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect

OBJECTIVE: To identify demographic, family, parent, and child factors prospectively associated with risk for child abuse and neglect among families in the community, using data on child maltreatment obtained from both official records and youth self-reports. METHOD: Surveys assessing demographic variables, family relationships, parental behavior, and characteristics of parents and children were administered to a representative sample of 644 families in upstate New York on four occasions between 1975 and 1992. Data on child abuse and neglect were obtained from New York State records and retrospective self-report instruments administered when youths were > or = 18 years old. RESULTS: Logistic regression analyses indicated that different patterns of risk factors predicted the occurrence of physical abuse, sexual abuse, and neglect, although maternal youth and maternal sociopathy predicted the occurrence of all three forms of child maltreatment. In addition, the prevalence of child abuse or neglect increased from 3% when no risk factors were present to 24% when > or = 4 risk factors were present. State records and self-reports of child maltreatment did not correspond in most cases when maltreatment was reported through at least one data source, underlining the importance of obtaining data from both official records and self-reports. CONCLUSIONS: Assessment of a number of risk factors may permit health professionals to identify parents and children who are at high risk for child maltreatment, facilitating appropriate implementation of prevention and treatment interventions.     

Closure, covert warnings, and escalating child abuse

Research into prevention of child abuse deaths is notoriously difficult, both clinically and methodologically. Korbin (1989) supports the conclusions of Fontana and Alfaro (1987) that it may not be possible to predict which child maltreatment case might result in a fatality. Our study was retrospective, concerned a selected group of cases and was unable to compare cases in which closure or approaches to professionals did not culminate in a child's death. Nonetheless, it points to particular patterns that occur which may help alert practitioners in the field. It is our hope that clinical research based on these observations will enhance the practice of child protection in the future.     

Demographic characteristics, pigmentary and cutaneous risk factors for squamous cell carcinoma of the skin: a case-control study

We conducted a case-control study of squamous cell carcinoma of the skin (SCC) in a cohort of people followed from 1987 to 1994. Subjects were residents of Geraldton, Western Australia, who were between 40 and 64 years of age in 1987. On 2 occasions, in 1987 and 1992, dermatologists examined participants for skin cancers. Subjects were also asked on several occasions about skin cancers that they had had treated. Migrants to Australia had reduced risks of SCC. Furthermore, people who migrated to Australia early in life or, equivalently, lived in Australia for a long time had a higher risk than immigrants who arrived later in life or more recently. People who had southern European ancestry had a much lower risk of SCC than other subjects, most of whom were of British or northern European origin. Among Australian-born subjects of British or northern European ancestry, the skin's sensitivity to sunlight was strongly associated with SCC. The pigmentary traits of hair colour, eye colour and skin colour showed weaker associations. The degree of freckling on the arm was strongly predictive of risk. The risk of SCC increased strongly with increasing evidence of cutaneous solar damage and was most strongly associated with the number of solar keratoses. Our results show that sensitivity to sunlight and high levels of exposure to sunlight are important determinants of the risk of SCC.     

Early childhood intervention: A promising preventative for juvenile delinquency.

Programs to reduce or prevent juvenile delinquency have been generally unsuccessful. Apparently the risk factors that make a child prone to delinquency are based in too many systems, including the individual, the family, and community networks, to make isolated treatment methods effective. Surprisingly, longitudinal studies of some early childhood intervention programs suggest they may help to reduce future delinquency. These programs take an ecological approach to enhancing child development by attempting to promote overall social competence in the many systems impacting on children. Not engaging in criminal acts is one indicator of competence that is related to others, such as being successful in school and in personal relationships. Evaluators must gather more data to confirm this unanticipated benefit of comprehensive interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preventing sleep problems in infants: a randomized controlled trial

In the pre-school years sleep problems are one of the most common subjects on which parents seek advice from health professionals. In the majority of cases a sleepless child causes significant stress within the family, and if parents do not obtain sufficient sleep this can have a detrimental effect on their physical and emotional well-being. In a small number of cases a child who wakes frequently and will not settle back to sleep may be at risk of physical abuse. In recent years it has been suggested that it may be possible to prevent sleep problems developing by providing parents with advice in the post-natal period. Parents have stated that they find this type of intervention helpful, however, there has been no attempt to establish whether a preventive approach is effective. The aim of this research was to evaluate the efficacy of health education in reducing the incidence of sleep problems. Adopting an experimental approach, participants were randomly allocated to a control group or an intervention group. Parental knowledge of sleep and settling behaviour was manipulated when the children in the intervention group were 3 months old. The sleeping behaviour of the infants in both groups was compared 6 months later, when the children were 9 months old. Data was collected from 86 families in the intervention group and 83 families in the control group. A comprehensive analysis of the sleeping behaviour demonstrated that a significantly smaller percentage of babies in the intervention group had settling and night-waking difficulties than in the control group.     

Postpartum amenorrhoea in Ethiopia: the role of weaning, child death, and socioeconomic factors

Using data from the 1990 National Family and Fertility Survey (NFFS) and employing discrete-time hazards models, we examine the effect of weaning, child death, and socioeconomic factors on postpartum amenorrhoea in Ethiopia. The results show that 91 in every 100 mothers breastfed their child for at least 6 months. The median duration of breastfeeding stands at 18 months, and amenorrhoea lasts for a median duration of 12 months. Significant variations in breastfeeding and amenorrhoea duration are also observed among the different categories of breastfeeding women. The median duration of breastfeeding for lactating women is 24 months, 6 months for those who weaned, and 2 months for those whose child died. The median duration of postpartum amenorrhoea is 14 months for breastfeeding women, 12 months for those who weaned, and 6 months for those whose child died. Discrete-time hazard models reveal that child death has the strongest effect on the resumption of menses. Net of other factors, the risk of returning to menses increased 3 times for mothers whose child died. The effect of child death, however, decreases over time. Weaning also has a significant positive effect; and, like child death, its effect diminishes as time passes. The study further shows significant differences in the risk of returning to postpartum menses by socioeconomic characteristics of the women, even though they are breastfeeding.     

Risk factors for death in homeless adults in Boston

BACKGROUND: Homeless individuals experience high mortality rates. Males, whites, and substance abusers are more likely to die, but other high-risk characteristics are unknown. OBJECTIVE: To identify demographic and clinical factors associated with an increased risk of death in homeless individuals. METHODS: We conducted a case-control study of 558 adults who were seen by a health care program for the homeless in Boston, Mass, and who died in 1988 to 1993. Age-matched paired controls were selected from among individuals seen by the program who were alive at the end of 1993. Predictive data were obtained by blinded review of medical records. Odds ratios (ORs) for death were calculated using logistic regression analysis models. RESULTS: In a multivariate analysis, the strongest risk factors for death were acquired immunodeficiency syndrome (OR, 55.8), symptomatic human immunodeficiency virus infection (OR, 17.7), asymptomatic human immunodeficiency virus infection (OR, 4.1), renal disease (OR, 18.4), a history of cold-related injury (OR, 8.0), liver disease (OR, 3.8), and arrhythmia (OR, 3.3). A history of substance abuse involving injection drugs (OR, 1.6) or alcohol (OR, 1.5) also increased the risk of mortality. Nonfluency in English was associated with a decreased risk of death (OR, 0.4). CONCLUSIONS: In a group of adults seen by a health care program for the homeless, specific medical illnesses were associated with the greatest risk of death. Substance abuse alone was less strongly associated with death. Interventions to reduce mortality among the homeless should focus on individuals with high-risk characteristics.