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• Alcohol as an important risk factors for Sudden Unexplained Death in Infancy
  Nisar A Mir
  Published on: 22 March 2016
• Recommendations for sudden infant death syndrome prevention: a response from FSID
  George B Haycock
  Published on: 22 March 2016

• Published on: 22 March 2016

  Alcohol as an important risk factors for Sudden Unexplained Death in Infancy

  • Nisar A Mir, Consultant Paediatrician

  Dear Editor,

  Professor E A Michell1 has the summarised the evidence for the current UK Department of Health (DOH) recommendations for the prevention of Sudden Infant Death Syndrome (SIDS) and suggested other recommendations including the importance of advice on breast feeding and baby pacifiers(1).

  Various studies have documented maternal alcohol consumption, both prenatal and post-natal as an important r...

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  Dear Editor,

  Professor E A Michell1 has the summarised the evidence for the current UK Department of Health (DOH) recommendations for the prevention of Sudden Infant Death Syndrome (SIDS) and suggested other recommendations including the importance of advice on breast feeding and baby pacifiers(1).

  Various studies have documented maternal alcohol consumption, both prenatal and post-natal as an important risk factor for SIDS(2,3).

  At the North Cheshire Hospital NHS Trust, between 2001-6, among 64 mothers who attended our Care of the Next Infant (CONI) clinic for prenatal counselling following a recent Sudden Unexplained Infant Death, there was clear evidence of association of maternal alcohol consumption and infant death in 5 cases with either through bed sharing with the carer (2 cases), infant and the carer falling asleep on the sofa (2 cases) and/or the infant sleeping on the sofa (1 case).

  It is recommended that DOH recommendations for prevention of SIDS should include education on prenatal and postnatal parental alcohol consumption and its association with SUDI.

  Nisar A Mir North Cheshire Hospitals NHS Trust Lovely Lane, Warrington Cheshire WA5 1QG E-mail: nisar.mir@nch.nhs.uk

  References:

  1. Mitchell E A. Recommendations for sudden infant death syndrome prevention: a discussion document. Arch Dis Child 2007;92:155-159; doi:10.1136/adc.2005.076752.

  2. Alm B, Wennergren G, Norvenius G, Skjærven R, Øyen N, Helweg- Larsen K, Lagercrantz H, Irgens L M, on behalf of the Nordic Epidemiological SIDS Study. Caffeine and alcohol as risk factors for sudden infant death syndrome Arch Dis Child 1999;81:107-111 ( August ).

  3. Leach C E A, Blair P S, Peter Fleming J, Smith IJ, Platt W, Berry PJ, Golding J and the CESDI SUDI Research Group. Epidemiology of SIDS and Explained Sudden Infant Deaths. Pediatrics Vol. 104 No. 4 October 1999, p. e43.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Recommendations for sudden infant death syndrome prevention: a response from FSID

  • George B Haycock, Retired paediatrician

  In the February 2007 issue of the Archives, Mitchell(1) published a discussion document on recommendations for prevention of sudden infant death syndrome (SIDS), focussing particularly on the advice issued by the Department of Health (DoH) in England on 3 occasions, in 2000, 2004 and 2005. A revised version was published in February 2007,(2) too late for inclusion in Mitchell’s paper. In the paper he reviews some of the...

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  In the February 2007 issue of the Archives, Mitchell(1) published a discussion document on recommendations for prevention of sudden infant death syndrome (SIDS), focussing particularly on the advice issued by the Department of Health (DoH) in England on 3 occasions, in 2000, 2004 and 2005. A revised version was published in February 2007,(2) too late for inclusion in Mitchell’s paper. In the paper he reviews some of the recent evidence pertaining to prevention of such deaths, and criticises the DoH for some of its current recommendations and, more generally, for relying largely on the Foundation for the Study of Infant Deaths (FSID) for the scientific advice on which their advice is based. This letter is a response to the paper on behalf of FSID. I shall take the specific points raised by Mitchell in the order in which they appear in his paper.

  The definition of cot death

  Mitchell states that “...the DoH uses the FSID definition of cot death” and “The FSID definition equates cot death with sudden unexpected death in infants (SUDI)”. The category SUDI includes some cases in which a complete or partial explanation for the death is found either from the autopsy findings or by detailed examination of the circumstances of the death: SIDS does not. This is true, but it is not clear that this has any important bearing on the advice that is given to prevent unexpected death in infancy generally, and Mitchell presents no evidence that it does.

  Sleeping position

  Both the DoH and FSID recommend supine sleeping (on the back) for all infants, with rare exceptions for medical reasons, in accordance with the international consensus which is based on much evidence from many countries. This includes a recommendation to avoid side, as well as front (prone) sleeping which has been shown to increase the risk of SIDS although much less so than for front sleeping. Mitchell hypothesises that the risk of side sleeping may be explained by the fact that infants placed on their side are more likely to roll into the prone position than those placed on their backs. However, this is unlikely to be the whole explanation since one recent study found that SIDS infants were more likely to be found dead on their sides, as well as having been placed in that position.(3) There is no obvious disparity between the advice currently issued by the DoH and that which Mitchell would favour.

  Maternal smoking in pregnancy

  Mitchell supports the advice that women should not smoke in pregnancy. He argues that “...the greatest benefit is achieved by getting light smokers to stop rather than heavy smokers to reduce the amount smoked”, based on figures published in the CESDI report into SUDI.(4) This conclusion depends on exactly how the odds ratios (ORs) are interpreted. If one converts the ORs into real figures, as advocated by Gigerenzer,(5) it is not quite so clear cut. Compared with a reference group of non- smoking mothers (group 1), the OR (95% confidence interval) of the risk of SUDI for babies born to mothers smoking 1-9 cigarettes daily (group 2) is 4.25 (2.93-6.18), that for babies born to mothers smoking 10-19 daily (group 3) is 6.49 (4.23-9.96) and that for babies born to mothers smoking 20+ daily (group 4) is 8.56 (5.12-14.31). If one makes the reasonable assumption that the incidence of SIDS in the reference group at the time of the study was 0.5 per 1,000 live births, for every 10,000 women in group 2 who stopped smoking the mean estimate of infant lives saved would be 16.25, while for every 10,000 women in group 4 who reduced their cigarette consumption to 10-19 per day the number of lives saved would be 10.35. However, for every 10,000 group 4 women who reduced their smoking to 1-9 cigarettes per day, the estimated number of lives saved would be 21.55. If a different estimate of the SIDS incidence in the reference group is substituted, the calculated numbers of lives saved would be somewhat different but the ratios between the effects of different degrees of smoking reduction would not. If the same exercise is performed using the ORs calculated in another published study,(6) not cited by Mitchell, the estimate of lives saved for every 10,000 women in group 2 who stopped smoking would be 8, as compared with 20.5 for every 10,000 group 4 women who reduced their consumption to that of those in group 3. It is obvious that, however the figures are manipulated, the greatest number of lives would be saved if all women abstained completely from smoking during pregnancy. Inserting small print into the advice to the effect that light smokers should stop and heavy ones should merely reduce their cigarette consumption seems likely to dilute the message and would very probably be counterproductive.

  Bed sharing and room sharing

  There is no dispute that bed sharing increases the risk of SIDS if the mother is a smoker, is under the influence of alcohol or other sedative drugs (prescription or not) or is ‘excessively tired’ (whatever that may mean for a woman caring for a baby aged less than 6 months). There is less agreement as to the risk if the mother does not come into any of the above risk categories, and especially if she is a non-smoker. As Mitchell points out, a meta-analysis by the European Concerted Action on SIDS Study(7) has shown a small but significant increase in risk for infants under about 12 weeks of age, and this is reinforced by the finding of 2 more recent studies.(8 9) Several reports have demonstrated that the risk of SIDS is approximately doubled if an infant sleeps in a separate room as compared with sleeping in a cot in the parents’ bedroom.(7 8 10 11) The FSID and DoH advice that “The safest place for your baby to sleep is in a cot in your room for the first six months of life” incorporates both these sets of findings as well as being unequivocal and easy to understand. The observation that “the advice is not explicit as to which components are most important” reflects the fact that we do not actually know which components are most important, but does not invalidate the advice.

  Illness and infection

  Mitchell argues that, because a recent German study (of which he is a co-author)(12) “has shown that infection is not a risk factor for SIDS in a population where few infants sleep prone” (the reference is wrongly cited in Mitchell’s article: his reference number 50 is an earlier study from New Zealand). Firstly, failure to demonstrate an effect does not mean that no effect exists (‘the curse of the null hypothesis’). Secondly, another recent study found that parents in families who had lost a previous child to SIDS were more likely to report non-specific symptoms and signs of illness in subsequent infants who died than in those who did not.(13) While doubt exists, it seems prudent to continue the advice to bring ill babies to professional advice in view of the vulnerability of small infants to illness of all kinds.

  Breast feeding

  Breast feeding has now been included in the FSID recommendations for prevention of SIDS following the recent publication of a meta-analysis by the US Agency for Healthcare Research and Quality,(14) which showed an OR of 0.64 (95% CI 0.51-0.81) for ‘ever’ breast feeding compared with no breast feeding.

  Pacifier (dummy) use

  Since February 2007 the DoH and FSID have advised that pacifier use may provide significant protection against SIDS following the publication of the two meta-analyses cited by Mitchell.(15 16) There was much overlap between the material analysed in these two reports and the statistical results of the two were very similar. Resistance to the use of pacifiers has largely been based on the fear that early use might interfere with the establishment of breast feeding, but there is no convincing evidence to this effect despite the publication of three controlled trials(17-19) (although one of them(19) showed a small negative effect of early introduction of a pacifier, at a mean age of 7 days, but none when the introduction was delayed until a mean of 28 days). Accordingly, the new recommendation is that dummies should be offered for all sleep periods from 1 month to 6 months of age.

  Publication of the evidence base

  FSID has produced a document (Factfile 2) summarising the published scientific evidence on which their recommendations are based. This has just been updated (2007) and is available on the FSID website at www.fsid.org.uk.

  George Haycock Foundation for the Study of Infant Deaths, 11-19 Artillery Row, London SW1P 1RT Correspondence to: Professor G B Haycock, Scientific advisor, Foundation for the Study of Infant Deaths, 11-19 Artillery Row, London SW1P 1RT research@fsid.org.uk

  References

  1 Mitchell EA. Recommendations for sudden infant death syndrome prevention: a discussion document. Arch Dis Child 2007;92(2):155- 9. 2 Department of Health. Reduce the risk of cot death: an easy guide, 2007. http://www.dh.gov.uk/en/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/DH_4123625. 3 Blair PS, Platt MW, Smith IJ, et al. Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention. Arch Dis Child 2006;91(2):101-6. 4 Fleming PJ, Bacon C, Blair PS, et al., editors. Sudden unexpected deaths in infancy. The CESDI SUDI studies 1993-1996. London: The Stationery Office, 2000. 5 Gigerenzer G. Reckoning with risk: learning to live with uncertainty London: Penguin Books Ltd., 2002. 6 Poets CF, Schlaud M, Kleemann WJ, et al. Sudden infant death and maternal cigarette smoking: results from the Lower Saxony Perinatal Working Group. Eur J Pediatr 1995;154(4):326-9. 7 Carpenter RG, Irgens LM, Blair PS, et al. Sudden unexplained infant death in 20 regions in Europe: case control study. Lancet 2004;363(9404):185-91. 8 Tappin D, Ecob R, Brooke H. Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-control study. J Pediatr 2005;147(1):32-7. 9 McGarvey C, McDonnell M, Hamilton K, et al. An 8 year study of risk factors for SIDS: bed-sharing versus non-bed-sharing. Arch Dis Child 2006;91(4):318-23. 10 Blair PS, Fleming PJ, Smith IJ, et al. Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI research group. BMJ 1999;319(7223):1457- 61. 11 Mitchell EA, Thompson JMD. Co-sleeping increases the risk of SIDS, but sleeping in the parents' bedroom lowers it. In: Rognum TO, editor. Sudden infant death syndrome: new trends in the nineties. Oslo: Scandinavian University Press, 1995:266-9. 12 Vennemann MM, Findeisen M, Butterfass-Bahloul T, et al. Infection, health problems, and health care utilisation, and the risk of sudden infant death syndrome. Arch Dis Child 2005;90(5):520-2. 13 Wailoo M, Thompson JR, Waite AJ, et al. Signs and symptoms of illness in early infancy: associations with sudden infant death. Arch Dis Child 2003;88(11):1001-4. 14 Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence report/technology assessment No. 153 (prepared by Tufts-New England Medical Center Evidence- based Practice Center, under contract No. 290-02-0022): Agency for Healthcare Research and Quality, 2007:1-186. http://www.ahrq.gov/clinic/tp/brfouttp.htm. 15 Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics 2005;116(5):e716-23. 16 Mitchell EA, Blair PS, L'Hoir MP. Should pacifiers be recommended to prevent sudden infant death syndrome? Pediatrics 2006;117(5):1755-8. 17 Schubiger G, Schwarz U, Tonz O. UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Neonatal Study Group. Eur J Pediatr 1997;156(11):874-7. 18 Kramer MS, Barr RG, Dagenais S, et al. Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial. Jama 2001;286(3):322-6. 19 Howard CR, Howard FM, Lanphear B, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003;111(3):511-8.

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  Conflict of Interest:
  None declared.

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