SIDS: How to minimize your infant's risk

Sudden infant death syndrome (SIDS) is defined as the "sudden death of an infant younger than one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history."

SIDS is the leading cause of death for infants between 1 month and 12 months of age and is most common between 1 to 4 months old, with 90% of cases occurring before 6 months old.

Fortunately, the SIDS rate in the United States has dropped significantly over the last 30 years. The greatest reduction occurred in the first 10 years after the American Academy of Pediatrics (AAP) started the "Back to Sleep" campaign to reduce the risk of SIDS which recommends placing infants in a supine position (on the back) for sleep. Between 1992 and 2001, the SIDS rate in the United States fell from 0.12% to 0.06%, while the proportion of infants sleeping in the supine position increased from 13% to 72%.

More than 95% of SIDS cases are associated with one or more risk factors, and in many cases, the risk factors are modifiable (usually sleeping position, sleep environment, or parental co-sleeping).

Major Pre-natal SIDS Risk Factors:
-Young maternal age (less than 20 years old)
-Maternal smoking during pregnancy
-Late or no prenatal care
-Preterm birth and/or low birth weight

MajorPost-natal SIDS Risk Factors
-Sleeping on stomach
-Sleeping on a soft surface and/or with bedding accessories such as loose blankets and pillows
-Bed-sharing (sleeping in parents’ bed)
-Overheating

SIDS Risk Reducers
The following factors are somewhat protective against SIDS. However, these effects are outweighed by the modifiable risk factors described above:
-Breastfeeding (36% lower risk of SIDS, if BF lasts more than 1 mo)
-Room-sharing without bed-sharing
-Pacifier use that does not interfere with the establishment of breastfeeding.
-Fan use

In summary, infants whose mothers received appropriate prenatal care and who sleep on their backs in an appropriate sleep environment (see first link below for picture), are breastfed beyond 1 month old, and have never been exposed prenatally or postnatally to tobacco smoke are at the lowest risk for SIDS.

Take a look at the following links for more information:

http://dhhs.ne.gov/publichealth/Pages/sids_environment.aspx

http://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

http://www.cdc.gov/sids/

http://www.uptodate.com/contents/sudden-infant-death-syndrome-sids-beyond-the-basics?source=search_result&search=Sids&selectedTitle=1%7E4&view=outline



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5/7/13 Addendum

Here is a link to the recent FDA warning to NOT use infant sleep positioners because of the risk of death by suffocation.
http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM227719.pdf

Autism risk is not related to more vaccines under 2 years old

A new study published on 3/29/13 is the latest of more than 20 studies showing no connection between autism and vaccines.

What is noteworthy about this study is that it is the first to prove that neither the total number of early vaccines nor the total number of vaccine antigens (the proteins in vaccines that trigger an immune response) lead to an increased risk of autism.

This is an important study because it should help address the fear that pediatricians frequently hear from parents (and grandparents) that the modern multiple vaccine schedule will "overwhelm" their (grand)child's immune system.
This study concludes that children who receive the full schedule of vaccinations in the first two years of life have no increased risk of autism. "Splitting them up" is not going to lower the risk of autism and it delays protection against life-threatening infections in vulnerable infants and young children.

Also of note, in order to fully vaccinate a 2 year old the 2012 CDC vaccine schedule uses 315 total antigens, whereas in the late 1990s it took several thousand antigens to do the same job. This is because modern vaccines need fewer antigens to stimulate adequate immune responses.
To state it plainly, while we don't know why there had been an increase in autism prevalence over the last two decades, we do know that it is not due to a increased antigen load overwhelming the immune system. On the contrary, we have been able to add protection against more bacteria and viruses over the last 20 years while at the same time decreasing the antigen load.

Here is the NPR blog post about the Journal of Pediatrics paper:
http://www.npr.org/blogs/health/2013/03/29/175626824/the-number-of-early-childhood-vaccines-not-linked-to-autism

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Vaccines during pregnancy

As all of my patient families know, I strongly agree with the AAP and CDC recommended vaccine schedule for children.
In addition to these recommendations for the direct protection of our pediatric patients, pediatricians also support specific vaccinations for household and other close contacts of our pediatric patients.

I really like this recent blog entry written by Rachel Cunningham, MPH, a vaccine expert at Texas Children's Hospital Immunization Project.  In addition to her professional expertise, the article includes her parental perspective as a mother of two young children: http://www.texaschildrensblog.org/2013/03/what-vaccines-to-expect-when-youre-expecting/

The CDC's webpage on this topic also has specific and useful information: http://www.cdc.gov/vaccines/parents/pregnant.html.


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AAP Drowning Prevention tips

With the weather getting nicer and many of my patients having access to swimming pools, I thought I should post some info on pediatric drowning prevention and overall water safety.

In May 2010, the American Acedemy of Pediatrics revised the minimum age that pediatricians recommend swim/water safety lessons down from 4yo to 1yo, in developmentally appropriate children.

Take a look at following summary of the May 2010 updated recs: http://tinyurl.com/ce3ojgf

Busy 2012-2013 Flu Season

As I'm sure almost everyone is aware, this has turned into a heavy flu season. Here are a couple of web links to info on what to look out for if you suspect or know that your child has the flu.

http://www.cdc.gov/flu/pdf/freeresources/updated/fluguideforparents_brochure.pdf

http://www.texaschildrensblog.org/2013/01/flu-symptoms-when-to-bring-your-child-into-the-emergency-center/


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Breastfeeding Infant Health Statistics

In my experience, nearly all parents and/or expectant parents are aware of the fact that pediatricians heavily favor breast milk as the best nutrition source for infants.
However, I'm not so sure we always do a great job explaining what evidence we have to support our strong preference or what factors lead to successful breastfeeding. 

Here is a slightly updated version of my 2013 blog post on the same topic.   

Current American Academy of Pediatrics (AAP) recommendation:
Exclusive breastfeeding for "about 6 months", then continued breastfeeding while complementary solid foods are introduced, and then continued breastfeeding until at least 1 year old, or as long as it is mutually desired by mother or infant.

So what is the evidence behind the current AAP recommendation?

ANY breastfeeding is associated with...
64% lower risk of gastroenteritis (viral vomiting/diarrhea infection)
40% lower risk of type 2 diabetes
40% lower risk of asthma, if any BF lasts > 3 mo AND there is a positive FH of asthma/eczema/allergies
36% lower risk of SIDS (sudden infant death syndrome), if any BF lasts > 1mo
31% lower risk of IBD (ulcerative colitis or Crohn's disease)
26% lower risk of Acute Lymphoblastic Leukemia (ALL), if any BF lasts > 6mo
26% lower risk of asthma, if any BF lasts > 3 mo AND no FH of asthma/eczema/allergies
24% lower risk of obesity (teen and adult)
23% lower risk of otitis media (ear infection)
15% lower risk of AML leukemia, if BF lasts > 6mo

EXCLUSIVE breastfeeding is associated with...
63% lower risk of URI (common cold), if 100% BF lasts > 6mo
52% lower risk of celiac disease, if gluten-containing foods are introduced before infant formula or cow's milk are started.
50% lower risk of otitis media, if 100% BF lasts > 3 mo.
42% lower risk of eczema, if 100% BF lasts > 3mo AND positive FH of eczema
30% lower risk of type 1 diabetes, if 100% BF lasts > 3 mo
27% lower risk of eczema, if 100% BF lasts > 3mo and no FH of eczema

So how are we doing in the US as far as breastfeeding rates?
75% initiate any BF.
44% continue any BF at 6 mo.
22% continue any BF at 12 mo.
34% continue exclusive BF at 3 mo.
14% continue exclusive BF at 6 mo.

What can we do to get mothers off to a better start with breastfeeding?
1. Encourage and promote breastfeeding and skin-to-skin contact within the first hour of life.
2. Avoid supplementing with any formula, water, or any other fluid besides human breast milk in the hospital.
3. Minimize separation of mother and newborn in the hospital (aka "rooming-in").
4. Avoid all pacifiers except when necessary to soothe during painful procedures such as male circumcision.
5. Provide written resources for post-hospital discharge breastfeeding support such as lactation consultant list with contact info before hospital discharge.

Take home messages:
1. Even just a partial diet of breastmilk through 1 mo lowers the SIDS risk by 36% and reduces the risk of gastroenteritis, type 2 diabetes, asthma, leukemia and obesity to varying degrees.
2. An infant diet of 100% breast milk until 3 mo lowers the risk of ear infections, eczema, type 1 diabetes.
3. The closer an infant can get to 6 months old without any other nutrition besides breast milk, the better.
4.  Infants who are introduced to gluten-containing foods before infant formula or cow's milk are introduced are substantially less likely to develop celiac disease.

Breastfeeding also has multiple known maternal health benefits such as decreased postpartum depression, decreased risk of maternal type 2 diabetes, and maternal cardiovascular disease.

Therefore, unless there is a medical contraindication to breastfeeding or the mother has a strong preference against breastfeeding, it makes sense to try breastfeeding and see how long it continues to make sense for both baby and mother.

Most US Measles Cases are Travel Related

In 2011 there were 222 cases of measles reported in the US which was the highest number since 1996. This included 72 imported cases, mainly from Western Europe. Most importantly, over 60% of the 2011 US cases occurred in patients who were eligible for the vaccine and therefore were likely preventable.

So which patients should get the MMR vaccine?
Current recommendations include a first MMR at 12-15 mo and a second MMR at 4-6 yo. The majority of my patients follow this recommendation. However, fewer families follow the recommendation that infants 6-12 mo who are traveling internationally also get at least one dose of MMR in addition to the other two MMR doses already mentioned. I think this is because many parents are not aware of the international travel recommendation for measles protection, especially when planning to travel to Western Europe, Canada, or Mexico.

The take home message is that parents should start the process for appropriate travel health planning as soon as possible after booking the travel. I suggest that parents first review the current US government recs for travel to the specific country or countries on their itinerary by looking it up on www.cdc.gov/travel and then contact our office or bring it up at the next well check (if time allows) so we can help make appropriate plans. These plans will include confirmation that maximum MMR protection is achieved.





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