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PEDIATRICS Vol. 104 No. 4 October 1999, p. e43
Received Dec 7 1998; accepted Apr 27, 1999.
,
From the * FSID Unit, Department of Child Health, Royal Hospital
for Children, St Michael's Hill, Bristol, United Kingdom; the
Nuffield Institute for Health, Leeds, United Kingdom; and the
§ Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle upon
Tyne, United Kingdom.
Objectives. To establish whether epidemiologic characteristics for sudden infant death syndrome (SIDS) have changed since the decrease in death rate after the "Back to Sleep" campaign in 1991, and to compare these characteristics with sudden and unexpected deaths in infancy (SUDI) from explained causes.
Design. Three-year, population-based, case-control study. Parental interviews were conducted soon after the death and for 4 controls matched for age and date of interview. All sudden unexpected deaths were included in the study and the cause of death was established by a multidisciplinary panel of the relevant health care professionals taking into account past medical and social history of the mother and infant, the circumstances of death, and a full pediatric postmortem examination. Contributory factors and the final classification of death were made using the Avon clinicopathologic system.
Setting. Five regions in England, with a total population of >17 million people, took part in the study. The number of live births within these regions during the particular time each region was involved in the study was 473 000.
Study Participants. Three hundred twenty-five SIDS infants (91.3% of those available), 72 explained SUDI infants (86.7% of those available), and 1588 matched control infants (100% of total for cases included).
Results. Many of the epidemiologic features that characterize SIDS infants and families have remained the same, despite the recent decrease in SIDS incidence in the United Kingdom. These include the same characteristic age distribution, few deaths in the first few weeks of life or after 6 months, with a peak between 4 and 16 weeks, a higher incidence in males, lower birth weight, shorter gestation, and more neonatal problems at delivery. As in previous studies there was a strong correlation with young maternal age and higher parity and the risk increased for infants of single mothers and for multiple births. A small but significant proportion of index mothers had also experienced a previous stillbirth or infant death. The majority of the SIDS deaths (83%) occurred during the night sleep and there was no particular day of the week on which a significantly higher proportion of deaths occurred. Major epidemiologic features to change since the decrease in SIDS rate include a reduction in the previous high winter peaks of death and a shift of SIDS families to the more deprived social grouping. Just more than one quarter of the SIDS deaths (27%) occurred in the 3 winter months (December through February) in the 3 years of this study. In half of the SIDS families (49%), the lone parent or both parents were unemployed compared with less than a fifth of control families (18%). This difference was not explained by an excess of single mothers in the index group. Many of the significant factors relating to the SIDS infants and families that distinguish them from the normal population did not distinguish between SIDS and explained SUDI. In the univariate analysis many of the epidemiologic characteristics significant among the SIDS group were also identified and in the same direction among the infants dying as SUDI attributable to known causes. The explained deaths were similarly characterized by the same infant, maternal, and social factors, 48% of these families received no waged income. Using logistic regression to make a direct comparison between the two index groups there were only three significant differences between the two groups of deaths: 1) a different age distribution, the age distribution of the explained deaths peaked in the first 2 months and was more uniform thereafter; 2) more congenital anomalies were noted at birth (odds ratio [OR] = 3.14; 95% confidence intervals [CI]: 1.52-6.51) among the explained deaths (20%) compared with the SIDS (8%), which was not surprising given that 10% of these deaths were explained by congenital anomalies; and 3) a higher incidence of maternal smoking during pregnancy among the SIDS mothers, the proportion of smokers within the explained SUDI group was much higher (49%) than the controls (27%), but among SIDS mothers the proportion of smokers was higher still (66%) and this difference was significant (66% vs 49%; OR = 2.03; 95% CI: 1.16-3.54). The largest subgroup of explained SUDI deaths were those attributable to infection (46%). There was a winter peak of deaths from infection, the highest number occurring in December (21%) but this was not significant. A multivariate model of these deaths showed parental unemployment to be the most significant factor (OR = 27.74; 95% CI: 3.19-241.34). Short gestational age (OR = 11.67; 95% CI: 1.84-74.14), neonatal problems (OR = 14.27; 95% CI: 1.89-107.81), and higher prevalence of males (OR = 9.26; 95% CI: 1.63-52.52) were also significant. Half of the deaths from infection occurred in crowded households (>1 adult or child per room excluding hallways, toilets, bathrooms, and kitchens if not used as a dining room) which was also a significant factor (OR = 10.37; 95% CI: 1.08-99.59).
Conclusions. The study identifies changes in the epidemiologic characteristics of SIDS that have followed the "Back to Sleep" campaign, and confirms that many underlying factors are similar between infants who die as SIDS and those dying suddenly of explained causes. Many studies investigating SIDS have reported numerous epidemiologic characteristics and risk factors strongly associated with SIDS when compared with live control infants. It has been generally assumed that these factors are specific to SIDS to the extent that the syndrome has been described as an "epidemiologic entity." Many of the factors associated with SIDS that were significantly different from the control population were not significantly different when compared with the explained deaths. This suggests that SUDI share some of the same underlying factors irrespective of the clinical or pathologic findings, and challenges a rigid concept of SIDS as an epidemiologic entity. The particular finding that the incidence of maternal smoking during pregnancy, although high among mothers of explained SUDI infants, was significantly higher among SIDS mothers, lends weight to the mounting evidence that the association between smoking and SIDS may be part of a causal mechanism. Key words: SIDS, SUDI, epidemiology, smoking, social deprivation.
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