eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Sudden Infant Death Syndrome: Follow-up

Author: Lynn Barkley Burnett, EdD, MS, LLB(c), Medical Advisor, Fresno County Sheriff's Department; Attending Consultant-in-Chief and Chairman, Medical Ethics, Clinical Faculty, Community Medical Centers; Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program
Coauthor(s): Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Contributor Information and Disclosures

Updated: Mar 17, 2009

Follow-up

Further Inpatient Care

  • Admit all infants presenting with nontrivial apnea or apparent life-threatening events (ALTEs) associated with cyanosis or alterations in mental status or tone. Those infants with a brief choking episode during feeding, or choking associated with a suspected reflux episode, can be safely discharged home after a period of observation.
  • Higher risk groups include infants who meet the criteria for an ALTE with occurrence during sleep, those in whom cyanosis was observed, those with a history of previous events, and those who required vigorous stimulation or any type of resuscitation.
  • Stable children may be admitted to the floor with a continuous cardiorespiratory monitor to determine frequency and length of apnea and associated bradydysrhythmias.
  • Infants who required any type of resuscitative measures should be monitored in a pediatric intensive care unit (PICU) or, if appropriate, given the severity of the event, in a pediatric step-down unit.
  • Inpatient evaluation may include the following:  
    • EEG (seizures may cause or result from apnea)
    • Evaluation for GER or swallowing incoordination
    • Cultures for occult infection
    • Pneumography
    • Polysomnography
    • ABGs
    • Upper airway studies to identify suspected obstruction
    • ECG, echocardiography, and other studies to identify congenital heart disease

Further Outpatient Care

  • A 1986 consensus statement of the National Institutes of Health identified 3 types of patients as candidates for home monitoring.
    • Group I - Term infants with unexplained apnea of infancy, usually manifested by an ALTE and/or abnormal pneumogram
    • Group II - Preterm infants who continue to demonstrate apnea or bradycardia beyond term, ie, at 40 weeks post conception
    • Group III - Subsequent siblings of 2 or more infants who died of SIDS
    • Other appropriate candidates include infants with bronchopulmonary dysplasia, particularly if oxygen dependent, and infants requiring tracheostomy for airway support.
  • Monitoring devices designed for home use typically measure chest wall movement and heart rate. The most important parameter is heart rate, because documented death recordings have indicated severe bradycardia before prolonged central apnea. The ability of monitors to detect bradycardia is also of significance in obstructive apnea, since such a state does not cause diminished movement of the chest wall.
  • Death recordings reflect that home monitoring does not prevent death from sudden infant death syndrome (SIDS). Parental interviews indicate that, even though a home monitor was present, it was not used in 50% or more of cases. One of the reasons for this apparent inattention is that home monitors are subject to false alarms due to the infants' shallow breathing or normal cardiac decelerations.
  • Meny et al report that 2 of the 3 SIDS patients they studied had monitor alarm activations to which parents did not respond for 2 hours.2 In both cases, the lethal occasion had been preceded by a large number of false or meaningless alarms—in 1 case, 60 false alarms in a single day.
  • Thus, parents with home monitoring devices need training in use of the monitor and in recognition of true alarms. They should be taught simple equipment maintenance and should receive instruction in CPR for infants.
  • The estimated expense of home monitors is in the range of $3000-5000 per infant, with rental and maintenance costs ranging from $150-300. Monitoring is cost effective in siblings of infants who have died of SIDS, but cost has yet to be studied in other infant groups.

Inpatient & Outpatient Medications

  • Xanthines (ie, caffeine, theophylline) are used to treat apnea of prematurity and periodic breathing. While their central excitatory effect is successful in normalizing the respiratory patterns of 80-94% of infants with apnea of prematurity, these agents' efficacy in preventing SIDS is unclear.
  • Anti-adrenergic interventions might protect patients with prolonged QT interval.

Transfer

  • Transfer is indicated if inpatient facilities are not available to meet the patient's needs for monitoring and critical care.

Deterrence/Prevention

  • Start prenatal care early. Schedule frequent well-baby checkups, and ensure that immunizations are current.
  • Avoid cigarettes, alcohol, and other drugs while pregnant.
  • Avoid exposing the baby to cigarette smoke.
  • If possible, breastfeed the baby.
  • Burp the baby during and after feedings, especially before putting the baby to sleep.
  • Place the baby on a firm, flat mattress in a safety-approved crib; avoid pillows, blankets, sheepskins, foam pads, or waterbeds.
  • Do not restrain the baby during sleep.
  • Use of a fan in the infant's room was associated with a 72% reduction in the risk of SIDS.32  It is thought that inadequate ventilation may result in pooling of carbon dioxide around the dead air space around an infant's mouth and nose, increasing the likelihood of rebreathing. The fan functions to dispense this accumulated carbon dioxide.
  • The supine sleeping position
    • Parents should discuss the supine sleeping position with their physician. While the preferred sleeping position for most infants, this position may be inappropriate for premature babies with respiratory distress or any baby with GER or abnormalities of the upper airway.
    • In Australia, New Zealand, the United Kingdom, and the Netherlands, public campaigns against the prone sleeping position were accompanied by reductions in SIDS incidence ranging from 20-67%.21 Deaths from aspiration or other disorders resulting from use of the supine position for sleep did not increase.
    • The Task Force on Infant Positioning and SIDS reports that, in 1992, telephone surveys revealed the prevalence of the prone sleeping position in the US to be 70%; this had dropped to 24% in 1996. This reduction in prone sleeping position coincided with a progressive decline in the rate of SIDS, a 15-20% decrease since before the 1992 recommendation and the largest significant decrease in the last decade. The American Academy of Pediatrics states that relative risks and benefits should be considered when making a recommendation for sleeping position, since GER, malformations that predispose to airway obstruction (eg, Pierre Robin syndrome), and other illnesses may be indications for a prone sleeping position. The Task Force on Sudden Infant Death Syndrome (2005) makes the following recommendations for healthy infants only:9
      • Do not smoke during pregnancy.
      • Back to sleep: Place infants in the supine position for sleep.
      • Avoid soft surfaces and gas-trapping objects in an infant's sleeping environment. Of particular importance, do not place soft objects, such as pillows or quilts, under a sleeping infant.
      • A certain amount of tummy time, while the infant is awake and observed, is recommended for developmental reasons and to help prevent flat spots on the occiput.
      • Separate but proximate sleeping environment. While bed-sharing is hazardous, the risk of SIDS is reduced when the infant sleeps in the same room as the mother.
      • Consider offering a pacifier at nap and bedtime. Pacifiers may have a number of effects: protecting infants from nasal compression, enlarging the infant's pharyngeal airway, lowering arousal thresholds, and strengthening the pharyngeal muscles responsible for maintaining the airway.29
      • Avoid overheating. A previous recommendation from this Task Force raised the caution flag especially when the infant is ill, or when he or she is recovering from an illness.  
      • Avoid commercial devices advertised to reduce the risk of SIDS, such as devices purported to maintain sleep position or reduce the risk of rebreathing, as none of these devices have been tested sufficiently for efficacy or safety.
      • Do not routinely use home monitors to reduce the risk of SIDS; rather their use is indicated only for selected infants who have extreme cardiorespiratory instability.
      • A previous recommendation from the American Academy of Pediatrics Task Force on Infant Positioning and SIDS was to put infants to bed in the supine position when they can turn easily from the prone position but allow them to adopt whatever position they prefer.
  • With reference to prevention of a cardiac cause of SIDS, Towbin and Friedman believe that ECG screening of infants at high risk for SIDS (eg, those with a family history of SIDS or long QT syndrome, those infants who have had an ALTE) is appropriate and justified.33

Patient Education

  • Emergency physicians should use appropriate opportunities to provide education to parents about the prevention of sudden infant death syndrome (SIDS), including the supine sleep position, prevention of overheating, and nonsmoking.
  • Knowledge of various theories concerning the etiology of SIDS as well as the limitations of current understanding is useful in parental discussions concerning ALTEs and SIDS.
  • When an infant has died, provide parents with information about SIDS and the telephone number of a local SIDS support group if one exists.
  • For excellent patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education articles Sudden Infant Death Syndrome (SIDS) and Bruises.

Miscellaneous

Medicolegal Pitfalls

  • The emergency physician untrained in forensic medicine may inadvertently overlook or destroy gross and/or trace evidence. Furthermore, misinterpretation of physical injuries or other objective evidence may lead to an inaccurate opinion that, if documented on the chart, may pose considerable problems when used in future court proceedings.
  • Tragic consequences follow the misattribution of an infant's death.
    • One example is that of a young African American couple who were criminally charged after a medical examiner indicated their baby had died of abandonment—despite autopsy findings consistent with SIDS and a lack of any signs of abuse or neglect. The couple spent 6 months in jail due to an inability to post bond before the charges were dismissed.
    • Other egregious examples may be found at the other end of the spectrum, represented by the errors and lapses in judgment evident in the case of Mary Beth Tining. Only when she was charged with the smothering death of her adopted daughter was it discovered that 8 of her biological children had died, their deaths having been attributed to SIDS or other natural causes.
    • A similar case is that of Waneta Hoyt, who was convicted in 1995 of murdering her 5 children between 1965 and 1971, all of whom were described as having succumbed to SIDS.
 


More on Pediatrics, Sudden Infant Death Syndrome

Overview: Pediatrics, Sudden Infant Death Syndrome
Differential Diagnoses & Workup: Pediatrics, Sudden Infant Death Syndrome
Treatment & Medication: Pediatrics, Sudden Infant Death Syndrome
Follow-up: Pediatrics, Sudden Infant Death Syndrome
References
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Further Reading

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Keywords

sudden infant death syndrome, SIDS, sudden infant death, crib death, cot death, long QT syndrome, ALTE, apparent life-threatening event, sudden infant death causes, back sleeping, back to sleep, sudden infant death prevention, prolonged QT interval hypothesis, apnea hypothesis, sudden unexpected death in infancy, SUDI

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Contributor Information and Disclosures

Author

Lynn Barkley Burnett, EdD, MS, LLB(c), Medical Advisor, Fresno County Sheriff's Department; Attending Consultant-in-Chief and Chairman, Medical Ethics, Clinical Faculty, Community Medical Centers; Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program
Lynn Barkley Burnett, EdD, MS, LLB(c) is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Association for the Advancement of Science, American Association of Suicidology, American Cancer Society, American College of Sports Medicine, American Heart Association, American Professional Society on the Abuse of Children, American Public Health Association, American Society for Bioethics and Humanities, American Society of Law Medicine and Ethics, American Stroke Association, Association of Military Surgeons of the US, Christian Medical & Dental Society, European Society for Trauma and Emergency Surgery, European Society of Cardiology, European Society of Intensive Care Medicine, European Society of Paediatric and Neonatal Intensive Care, Faculty of Forensic and Legal Medicine of the Royal College of Physicians of London, International Homicide Investigators Association, New York Academy of Sciences, Royal College of Surgeons of Edinburgh, Royal Society of Medicine, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and World Association for Disaster and Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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