PEDIATRICS Vol. 117 No. 1 January 2006, pp. 210-211 (doi:10.1542/10.1542/peds.2005-1197)
COMMENTARY |
Predicting the Risk of Sudden Infant Death Syndrome From Obstetric Characteristics
Department of Obstetrics and Gynaecology, University of Sydney, Sydney, Australia; Department of Obstetrics and Gynaecology, Hornsby Ku-Ring-Gai Hospital, Sydney, Australia
Every day clinicians discuss risk with their patients. On the basis of this discussion, people under stress are asked to make complex decisions that may have far-ranging effects both for themselves and their families.
No clinician can be unaware of the severe limitations of the data on which many of our estimations of risk are based. Data are rarely population-based and often refer back to relatively small cohort studies or case series, the design of which may leave much to be desired.
Each individual brings with them a unique combination of clinical and sociodemographic factors. However, most risk-scoring systems cannot use this additional information to allocate a patient-specific risk. Thus, a great deal of modifying information is lost, and risk is dichotomized as "high" or "low." Faced with an individual patient, the best estimate of risk available to the clinician is usually oversimplified and therefore often inaccurate. A population-based and validated system that can incorporate patient-specific factors to modify background risk gives power back to the patients, their families, and clinicians.
The approach described by Smith and White1 in this issue of Pediatrics has been used effectively in the antenatal estimation of Down syndrome risk. Initially, risk allocation on the basis of age and prior history was based on the assumption that all women of a given age carried a similar risk. The nuchal translucency/first trimester serum-screening program combined patient-specific background data (age, parity, weight), information from imaging techniques (nuchal translucency), and biochemical data (pregnancy-associated plasma protein A, free β human chorionic gonadotrophin) to allow an individual risk assessment to be made for a given woman in a given pregnancy.2 Additional refinements have been suggested to allow even greater positive predictive values by decreasing the false-positive rate, without decreasing sensitivity.3, 4
The team who presents their data has extended this approach further. Using 10 years of population-based data, they have been able to determine how specific factors impact on the background population risk of sudden infant death syndrome. By calculating a summary likelihood ratio on the basis of these factors and applying it to the known population risk, a patient-specific risk can be calculated. Given the disruptive nature of the available monitoring systems for sudden infant death syndrome, this more refined risk assessment puts power back in the parent's hands by providing information in a form that is more palpable.
As with all systems that deal with risk, there is the need to assess the potential for harm to flow from the perception that a patient carries increased risk. A "number," even a low one, can make a nebulous risk seem concrete and threatening. Although this may create genuine dilemmas for both doctors and families, it does move the emphasis away from patient dependence on their doctor's interpretation of what qualifies as significant risk. This undoubtedly will be uncomfortable for many and is the challenge of this new approach. However, it conforms with the general thrust of medicine today in seeking to empower the people who actually carry the risk to make their own informed decisions.
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FOOTNOTES |
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Accepted May 23, 2005.
Address correspondence to John Keogh, MBBS, MRCOG, FRANZCOG, Department of Obstetrics and Gynaecology, Hornsby Ku-Ring-Gai Hospital, Palmerston Road, Sydney, NSW 2077, Australia. E-mail: keoghj1{at}optushome.com.au
Opinions expressed in this commentary are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
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REFERENCES |
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- Smith GCS, White IR. Predicting the risk for sudden infant death syndrome from obstetric characteristics: a retrospective cohort study of 505,011 livebirths.
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[Abstract/Free Full Text] - Spencer K, Liao AW, Skentou H, Cicero S, Nicolaides KH. Screening for triploidy by fetal nuchal translucency and maternal serum free beta-hCG and PAPP-A at 10–14 weeks of gestation. Prenat Diagn. 2000;20 :495 –499[Medline]
- Wald NJ, Watt HC, Hackshaw AK. Integrated screening for Down's syndrome based on tests performed during the first and second trimesters.
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[Abstract/Free Full Text] - Cuckle H, Sehmi I. Calculating correct Down's syndrome risks. Br J Obstet Gynaecol. 1999;106 :371 –372[Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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