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Prematurity, Neonatology, SIDS

Prematurity, Neonatology, SIDS. Jay Green Emergency Medicine Resident, PGY-2 July 19, 2007. Outline. Apparent Life-Threatening Events Sudden Infant Death Syndrome Other causes of apnea ± Quick snappers Won’t cover Fever/sepsis in the newborn Bronchopulmonary dysplasia Cerebral palsy

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Prematurity, Neonatology, SIDS

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  1. Prematurity, Neonatology, SIDS Jay Green Emergency Medicine Resident, PGY-2 July 19, 2007

  2. Outline • Apparent Life-Threatening Events • Sudden Infant Death Syndrome • Other causes of apnea • ±Quick snappers • Won’t cover • Fever/sepsis in the newborn • Bronchopulmonary dysplasia • Cerebral palsy • Obstructive hydrocehpalus

  3. Case 1 • 5mo M, stopped breathing x ?1-2min • Blue colour, limp • Resolved before EMS arrived • No vomiting, no sz activity • Position - supine • Noise - ?choking • No abnormal eye mvts • No intervention by parents

  4. Case 1 cont • OB Hx: no complications, SVD @ 38wks • PMH: well child • FHx • øApnea, øSIDS, øSz, øCHD

  5. Case 1 cont • O/E: • Well-looking child • Vitals • HR 125, bp 85/55, RR 35, T 369 • Nothing remarkable to find • Anything specific not to miss O/E? • Fundoscopy, SpO2

  6. What is on your differential diagnosis?

  7. Apparent Life-Threatening Event ALTE

  8. ALTE Definition • An episode that is frightening to the observer and is characterized by some combination of: • Apnea • Colour change • Marked change in muscle tone • Choking • Gagging National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring

  9. ALTE Quick Stats • Incidence 0.5-6% • 4-8% of SIDS had a previous ALTE • Not considered same disease process • 82% occur between 8am-8pm • Usually < 6mo, avg 8-14wks • Can be > 1yr • 13% risk of death if needed CPR and discovered during sleep

  10. ALTE Hx/Exam • Most NB parts of ED diagnostic evaluation • History • Colour, tone, resp effort • Onset (sleep, feeding, awake), duration • Position (prone, sitting, supine) • Noises (stridor, choking) • Eye movements • Vomiting • Intervention

  11. ALTE - Exam • PE usually normal • N = 73 • Dilated fundoscopic exam • Retinal hemorrhages in 1pt, child abuse in 4

  12. Back to Case 1 • 5mo M ?ALTE • What would you like to do now? • Labs? • Imaging? • Discharge patient?

  13. ALTE Investigations • 50% have specific diagnosis found • Infection, GI, Sz

  14. ALTE Investigations • 196 infants with ALTE, mean age 2mo • 83% hospital admission • 50% had normal exam • 25% had infection/fever • Diagnoses: • Seizure (25%), GER (18%), febrile convulsion (12%), LRTI (9%), apnea (9%) • No infant subsequently died

  15. 65 infants with ALTE, mean age 7wks • 100% hospital admission (required) • 54% had normal exam • Diagnoses: • GER (25%), unknown (23%), pertussis (9%), Other LRTI (9%), Sz (9%), UTI (8%) • No infant subsequently died Thanks Yael!

  16. Investigation protocol • 13% anemia, 33% ↑WBC (50% had inf) • Metabolic screen, urine reducing substances, ammonia not helpful • ↓Bicarb in 20% - 7 dx with sepsis/sz • ↑Lactate in 7, 5 had serious illness • U/A, pertussis swab useful in 5% & 8% • CXR abN in 9 who had N exam

  17. Return to Case 1 • Labs N • CXR N • ECG N • Nasal swab, urine cultures pending • What would you like to do now?

  18. ALTE - Some Perspective • Pre-hospital study, retrospective • N = 60, mean age 3.1mo • 83% no distress, 13% mild distress, 3% moderate distress • Diagnoses • Pneumonia (12%), sz (8%), sepsis (7%), ICH (3%), bacterial meningitis (2%), anemia (2%) • ALTE can be presenting sign of serious illness, even in well-looking child Thanks Yael!

  19. ALTE Disposition • Most studies recommend mandatory period of inpatient observation • Majority suffer only 1 event • No single test has a high PPV for detecting anything that will alter the outcome • Recurrence rate for severe ALTE as high as 68% in one study • More likely in the few days after first event

  20. ALTE Disposition • If no cause for ALTE found • Referred to as “apnea of infancy” • ±home apnea-bradycardia monitoring • Lack efficacy, frequent false alarms, misinterpretation of alarm by parents • Potential candidates • Premature infants exhibiting apnea beyond term • Term infants with ALTE requiring resus • Siblings of 2+ SIDS victims • Infants with BPD/tracheostomies

  21. ALTE Causes • Infection • Seizure • A/W Obstruction • Breath-Holding Spells • GER • Metabolic • Nonaccidental See EM Reports Aug 7, 2006

  22. ALTE  SIDS? • Prospective cohort study, N=141, 8yrs • ?Association between SIDS & ALTE • Conclusions • RF for all ALTE’s • Common to SIDS: single parent, FHx infant death, smoking during preg, marked night sweating • Early behaviours: repeated apnea, cyanotic episodes, feeding difficulties, marked pallor • RF for “idiopathic ALTE” • No common SIDS RF • No subsequent SIDS deaths

  23. Conclusions • ALTE/SIDS not part of the same disease process • SIDS prevention programs not expected to lower ALTE frequency

  24. ALTE Take-home Points • Scary + apnea, ∆colour, choking, ∆tone • Usually < 6mo • Well-looking ALTE  ?serious illness • Inpatient work-up • Not same disease process as SIDS • Questions?

  25. Case 2 • 4mo F, found blue, not breathing in crib • EMS called, begin CPR, and patch in • Baby cyanotic, initial rhythm asystole, no resp efforts • What do you tell them? • Continue CPR and come in? • Call it in the field?

  26. Sudden Infant Death Syndrome • Sudden death of an infant <1y old • Remains unexplained after investigation: • Complete autopsy • Examination of the death scene • A review of the clinical history National Institute of Child Health and Human Development

  27. SIDS Fast Facts • US data • 0.72/1000 live births in 1998 • Declining incidence • 3000 deaths/yr • 95% < 6-8mo, peak 2-4mo • 1% < 1mo, 2% > 2yr

  28. What are some risk factors for SIDS? • Maternal • Smoking • Drug use • ↓SES • Age<20 at G1 • Ethnicity • ↓Education • No prenatal care • Prenatal • IUGR • Multiples • Prematuriy • BW < 2500g • Postnatal • Prone sleeping • ETS • Warm temp • Loose bedding • Soft surface • Bed sharing • ?infection • ?GER • ?arrhythmia What is the most important modifiable risk factor? Prone sleeping 78%17%, SIDS ↓ 40%!

  29. SIDS – What Happens? • >70 theories: “triple-risk theory” – Rosen’s Immature cardiorespiratory control Autonomic dysfunction Physiologic stuff Predisposing factors ↓ baroreceptor reflex ↓vasomotor control ↓central venous return, CO, bp Is sleep ever bad…I guess so… Sleep Exacerbate these effects Progressive bradycardia Poor lung perfusion  hypoxia Various badness that doesn’t help Prone sleep URTI Overheating SIDS SIDS

  30. Case 2 cont • 4mo F just arrived in your ED • CPR continuing • Pupils fixed mid-dilated • Rhythm asystole • Unknown downtime • How long do you continue the resus? • ~3 rounds of drugs

  31. SIDS Outcome • After infant declared dead • Blood, urine, skin samples • Family meeting • Coroner notified • House inspection • Autopsy

  32. SIDS Pathologically Speaking • Nothing pathognomonic • Some typical findings • PA smooth muscle hypertrophy • RVH • ↑ hepatic hematopoiesis • ↑ periadrenal brown fat • Adrenal medullary hyperplasia • Carotid body abnormalities • Brainstem gliosis

  33. SIDS Effects • Guilt, blaming, social alienation • ↑ miscarriage rate, divorce, infertility • Potentially helpful steps: • Openly accepting grief reactions • Allowing family to vocalize their feelings • Clarifying misconceptions • Allowing the family to hold/be along with infant • Private place for family to gather • Explanation of cause of death

  34. Case 2 cont • Unsuccessful resuscitation • Infant declared dead • Parents inform you that infant has a twin brother • What should you do about this? • Inform them there’s no increased risk? • Admit the twin for observation?

  35. SIDS - Twins • Cohort studies looking at twins • Variable findings, 2x increased risk of SIDS • Any sibling of SIDS victims • 5-6x increased risk of SIDS • Reasonable to admit the twin for a period of observation

  36. SIDS Prevention • Non-prone sleeping (supine preferred) • No sleeping in waterbeds, sofas, soft mattresses/surfaces • No soft materials in sleeping env’t • Avoid bed-sharing and co-sleeping • Avoid overheating

  37. Retrospective review, 10yrs • All deaths < 1yr in Quebec • 396 SIDS deaths • Infants <1mo • 10.2% died sitting • Infants >1mo • 1.4% died sitting • P<0.001 • RR 7.35 • ?↑ risk with ↑ time • ?↑ risk with position • No ↑ risk with premature infants Conclusions: -an excess of infants <1mo died in sitting position compared to those >1mo -length of time in seat and position may be NB contributors

  38. SIDS Take-home points • Peak age 2-4mo • Prone sleeping most NB modifiable RF • SIDS death can be called in the field • Resus of asystolic neonate x ~3 rounds • Admit twin of SIDS victim • Questions?

  39. Apnea Definitions • Pathological apnea • Respiratory pause > 20sec or assoc with cyanosis, pallor, hypotonia, bradycardia • Apnea of prematurity • Periodic breathing with pathological apnea • Apnea of infancy • Infant > 37wks, pathological apnea or shorter apneic pauses & bradycardia, cyanosis, pallor, or hypotonia • “Idiopathic ALTE”

  40. Case 3 • 10d F breathing pauses lasting ~5s • 4-5 episodes/min, comes & goes • Born at 39wks • Uncomplicated preg/delivery to G1P1 • No fever, rash, lethargy • Feeding well • 10-12 wet diapers/d, 3-4 seedy stools/d • Regained birthweight at 7d

  41. Case 3 • O/E • VS N • Well looking child, no apneic episodes in ED • What next? • Labs? • Imaging? • Discharge? • What do you think is going on?

  42. Periodic Breathing • Normal • 3 or more pauses of >3sec with less than 20sec of N respirations between pauses • Treatment? • Caffeine

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