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Sleeping position amongst preterm infants after discharge: are we getting the message across?

Presented at the Neonatal Society 2003 Summer Meeting (programme).

Blair P, Ward-Platt M, Fleming P and the CESDI SUDI Research Group

Institute of Child Health, UBHT Education Centre, Bristol BS2 8AE, UK

Background: The dramatic reduction in the numbers of infants dying suddenly and unexpectedly as Sudden Infant Death Syndrome (SIDS) that followed the widespread adoption of the supine sleeping position for term infants has raised the question of the potential risks and benefits of prone sleeping amongst preterm infants. The benefits in the early neonatal period of prone position for preterm infants in oxygenation and in thermal balance are well recognised, but the Nordic SIDS study showed a very high odds ratio for SIDS in ex-preterm infants sleeping in a non-supine position (1).

Methods: The three-year case-control study of Sudden Unexpected Deaths in Infancy, conducted in England from 1993-1996 as part of the Confidential Enquiry into Stillbirths and Deaths in Infancy included detailed information collected at interview and from medical records for 450 infants who died suddenly and unexpectedly, and 1800 age and locality matched control infants. The study included 325 infants whose deaths were classified as SIDS, and 1300 matched controls (2).

Results: Of the 24.8% SIDS infants and 7.1% controls who had been admitted to a SCBU (OR for SIDS 4.25, [95% CI 2.91-6.21]), 62.5% of the SIDS infants and 41.3% controls were of less than 37 weeks gestation. Amongst the term infants admitted to SCBU the risk of SIDS was significantly raised (OR=2.26 [95%|CI 1.39-3.66]), the most common reasons for such admissions being intrapartum asphyxia, feeding difficulties and respiratory distress. Overall, 22.8% of SIDS and 5.1% controls were of birthweight less than 2500g (OR=5.48 [95%CI:3.77-7.96]), and 10.5% of SIDS and 1.2% of controls were of gestation less than 34 weeks (OR=9.98 [95%CI:5.18-19.47]). Admission to a SCBU remained a risk factor for SIDS in the multivariate analysis including all other risk factors, including sleeping position in the last sleep, but excluding being found with the head covered (OR 3.06[95% CI 1.49 - 6.26]). When this last factor was included admission to SCBU became non-significant (OR=1.46 [95% CI 0.57 - 3.74]). In the final sleep (SIDS) or "reference" sleep (controls) significantly more preterm SIDS infants (35.6%) than controls (1.4%) slept prone, giving an odds ratio of 85 [95% CI:13.6-3536]. In contrast however, amongst the preterm controls the prevalence of prone sleeping (1.4%) was lower than amongst the term controls (6.3%), although this was not significant (p=0.12). For preterm infants sleeping in non-prone positions the OR for SIDS was 3.96 [95% CI 2.5-6.2].

Conclusions: Thus whatever the benefits of prone sleeping in the neonatal period for preterm infants the risk of prone sleeping after discharge is very much greater than for term infants. Admission to a SCBU offers an opportunity to educate parents about appropriate infants care practices, and the lower prone sleeping rate amongst ex-preterm controls suggests that, at least for some families these messages may be effective.

1. M.Ward-Platt, P.S.Blair, P.J.Fleming, I.J.Smith, T.J.Cole, C.E.A.Leach, J.Golding. Sudden Unexpected death In Infancy: A clinical comparison of explained and unexplained deaths - how healthy and how normal? Arch Dis Child 2000;82: 98-106
2. P.J.Fleming, P.S.Blair, Sudden Unexpected deaths after discharge from the NICU. Seminars in Neonatology. 2003;8:159-167

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