The death or near death of a presumably healthy newborn in the delivery room is uncommon. We report here 6 cases of apparent life-threatening events (ALTEs) in the delivery room during the first 2 hours of life. In each case, the incident occurred in a healthy infant who was in a prone position on his or her mother's abdomen during early skin-to-skin contact. In most cases, the mother was primiparous, and in all cases the mother and infant were not observed during the initiation of skin-to-skin contact and breastfeeding. There are many benefits of early skin-to-skin contact and breastfeeding in the delivery room. However, in view of the risk of a rare but significant ALTE, we suggest that surveillance of newborns is needed. Although many ALTEs are apparently caused by obstruction, we suggest that a standardized investigational workup be performed after an ALTE.
The incidence of apparent life-threatening events (ALTEs) or unexpected death of presumably healthy newborns in delivery rooms is unknown, but most physicians consider it to be extremely uncommon.1,–,6 However, the occurrence of an ALTE requires rapid response, because the consequences can be severe.
Physicians increasingly recommend prolonged skin-to-skin contact of the mother and her healthy newborn soon after birth because it is believed to improve mother-infant bonding and successful breastfeeding.7,–,11 However, such intervention has not been completely adopted in the maternity wards of developing countries because of some concerns about safety. Indeed, a few reports have noted the risk of rare but severe neonatal adverse events, including ALTEs and sudden and unexpected deaths.4,–,6,12,–,14
In this article we report our examination of 6 cases of ALTEs that occurred in presumably healthy newborns who experienced early (<2 hours after birth) skin-to-skin contact with their mothers in the nurseries of a regional area (West Provence-Alpes-Côte d'Azur, France) between 2004 and 2007.
Table 1 summarizes the relevant perinatal data of the 6 cases of neonatal ALTEs described below. In all cases, after normal physical examination findings at birth, the neonates were placed in direct skin-to-skin contact with their mothers while in the prone position in the delivery room, and breastfeeding was initiated. The neonate was then left with his or her mother and, later, the father.
Thirty minutes after birth, the infant was found motionless while he was in his mother's arms. Resuscitation was initiated because of cardiac and respiratory failure. He improved rapidly in the NICU and was discharged without obvious neurologic deficit. Early-onset neonatal sepsis was excluded. Other clinical data, including results of an electrocardiogram, brain MRI, and investigation of possible malformations, indicated no abnormality.
Ninety minutes after birth, the infant experienced cardiopulmonary arrest. After initial resuscitation, she required respiratory support and inotrope and anticonvulsant therapies. Brain MRI analysis excluded a major cerebral malformation. This patient had a severe hypoxic-ischemic encephalopathy and died after 23 days. The results of all postnatal investigations, including septic workup, metabolic screening, electrocardiogram, assessment of malformation, and investigation for myotonic dystrophy, indicated no abnormality. Muscle biopsy and autopsy were also unable to establish causality.
Sixty minutes after birth, cardiorespiratory arrest occurred in the second twin born. Resuscitation required tracheal intubation and mechanical ventilation with inotrope, anticonvulsant, and antibiotic treatment. Severe cerebral bleeding occurred and was associated with hypoxic-ischemic encephalopathy, as confirmed by electroencephalography and brain computed-tomography scanning. The infant died after 15 days. Infection markers and the results of investigations of inborn metabolic errors were negative, and findings of an electrocardiogram were normal. The parents refused an autopsy.
One hundred twenty minutes after birth, the infant became motionless, and his face indicated cyanosis. After vigorous stimulation, he recovered rapidly. Clinical examination findings and his glycemic values were normal. No new event occurred during the following 3 days of observation.
Several minutes after birth, the infant became motionless, cyanotic, and bradycardic. After vigorous stimulation, rapid recovery occurred. The infant's clinical examination findings and glycemic values were normal. Infection markers and results of investigations of inborn metabolic errors were negative. No new event occurred during the following 5 days of observation.
One hundred twenty minutes after birth, cardiopulmonary arrest occurred. Resuscitation required tracheal intubation and mechanical ventilation with inotrope, anticonvulsant, and antibiotic treatment. Severe hypoxic-ischemic encephalopathy was confirmed by electroencephalography and brain MRI. Results of infectious and metabolic investigations were negative. The infant died after 15 days. The parents refused an autopsy.
An ALTE or sudden death of a presumably healthy newborn soon after birth is usually considered an exceptional event, but more of these cases have been reported in recent years.1,–,6,12,–,14 There have been no systematic surveys, so the exact incidence of such events is unknown. On the basis of the literature, the overall incidence rate of ALTEs has been estimated as 0.025 to 0.032 per 1000 births and the mortality rate as 0.018 per 1000 births.4,–,6 These rates are concordant with our findings of an ALTE incidence of 0.034 per 1000 births and a mortality rate of 0.017 per 1000 births. Nonetheless, we believe that these estimates are low, because they may not include many of the newborns who have had ALTEs with rapid and favorable outcomes.
In our 6 reported cases, most of the infants were born to primiparous women after uneventful vaginal deliveries, and the mothers were left alone with their infants in the delivery room. In each case, the ALTE or sudden unexpected death occurred with the healthy infant in a prone position on his or her mother's abdomen during early skin-to-skin care and initiation of breastfeeding. There were no apparent reasons for such serious incidents in these infants, and neither postresuscitation studies nor postmortem investigations identified possible causes. In most of the published cases of ALTEs, 3 risk factors were identified: primiparous mother; skin-to-skin contact of the mother and newborn; and mother and infant left alone in the delivery room.4,–,6,12,–,14
Classically, the definition of the sudden infant death syndrome (SIDS) excludes early neonatal cases.15 However, it is possible that the risk factors for SIDS may also be risk factors for ALTEs or sudden unexpected deaths of presumably healthy newborns. Thus, a prone position and overheating are potential behavioral risk factors for ALTEs. Authors of some previous studies reported a dramatic deterioration of newborns during and after breastfeeding, possibly caused by oronasal obstruction.16,17 Mechanical upper airway obstruction and an asphyxiating position of the infant, with the infant's face covered while facing his or her mother's abdomen, breast, or neck, may be a result of the lack of experience of a primiparous mother, the mother's slow recovery after giving birth, or the unavailability of medical personnel. Results of other studies have suggested that increased vagal tone was a cause of cardiorespiratory arrest.18 Results of studies of the pathophysiology of SIDS have indicated that prone sleeping was associated with altered autonomic control and manifested as an increased heart rate, reduced heart-rate variability, and increased sympathetic tone. In addition, the postdelivery period is known to be associated with an increased vagal tone in newborns.19
Among our 6 ALTE cases, we observed heterogeneous signs and symptoms. For the 3 infants who died, brain imaging and biological, infectious, and metabolic assessments were performed, but cardiologic evaluation was only performed in 1 case. When the ALTE evolution was rapid and favorable, we observed that the assessments were often incomplete, particularly in terms of brain imaging and cardiologic evaluation, which was only performed for 1 case. Thus, a cerebral or cardiologic malformation could predispose an infant to an ALTE. As with the management of SIDS, it is reasonable to propose that an infant who experiences an ALTE be given a standardized diagnostic investigation, complete medical evaluation, and an autopsy if death occurs.
All 6 of our infants had skin-to-skin contact with their mothers at the time of the ALTE. This practice, therefore, could be a risk factor for neonatal ALTEs or unexpected death in the delivery room. The World Health Organization recommends early skin-to-skin contact for mothers and their presumably healthy newborns, because it is believed to improve breastfeeding outcomes, mother-infant attachment, and infant cardiorespiratory stability, to reduce infant crying, and to have no apparent short-term or long-term negative effects. However, ALTEs and unexpected deaths have been reported to occur during this period. Several national committees have recommended medical supervision during early skin-to-skin contact, but the nature of this supervision has not yet been clearly defined. Death and near-death episodes suggest a lack of medical supervision. We believe that careful positioning of the infant and unobtrusive medical supervision should be encouraged. There have been recent tests of wireless, wearable pulse-oximetry monitoring systems for surveillance of infants at risk of an ALTE in the delivery room.20 Such monitors, however, would be considered as a help and not as the only tool of surveillance. Furthermore, standard counterindications for skin-to-skin mother-infant care, such as maternal use of a sedative, sepsis, tiredness (especially if primiparous), and unavailability of a midwife, should be strictly respected.
Unexpected and rare ALTEs can affect an apparently healthy newborn in the delivery room during the first hours of life, especially during early skin-to-skin contact with the mother. ALTEs are rare, but they can be serious and even lead to death. Some risk factors for ALTEs have been suggested, although they are poorly defined. Promotion of early mother-infant skin-to-skin contact and breastfeeding in the delivery room should be encouraged, but perinatal medical personnel (gynecologists, midwifes, nurses, and pediatricians) should be aware of ALTEs and carefully monitor and ensure proper positioning of healthy neonates during this delicate period of mother-infant attachment, especially for primiparous mothers. Airway obstruction is a likely cause for some cases of ALTEs. We suggest that standardized investigations be implemented after the occurrence of ALTEs to better identify the risk factors.
- Accepted January 4, 2011.
- Address correspondence to Virginie Andres, MD, CHU La Conception, Médecine Néonatale, 147 bv Baille, 13385 Marseille, France. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- ALTE =
- apparent life-threatening event •
- SIDS =
- sudden infant death syndrome
- Grylack LJ,
- Williams AD
- Moore ER,
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- Bergman N
- 8.↵World Health Organization, United Nations Children's Fund. The Baby-Friendly Hospital Initiative: ten steps to successful breastfeeding. Available at: www.unicef.org/programme/breastfeeding/baby.htm. Accessed February 6, 2008
- Ferber SG,
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- Copyright © 2011 by the American Academy of Pediatrics