Denise Blum

A critical comparison of the history of sudden-death infants and infants hospitalised for near-miss for SIDS

To determine whether significant historical differences distinguish the near-miss for Sudden Infant Death from the infants who died of SIDS, we analysed the histories and clinical data from two groups of infants seen in our University Hospital and from collaborative research group. The data were obtained with the use of a standardised questionnaire and consultation of all available medical data.Sixty-five infants were identifed as near-miss for SIDS after they had suffered a severe cardiorespiratory incident during sleep for which no cause could be found despite a complet medical examination. After an autopsy had failed to reveal a cause for the unexpected death 95 cases of SIDS were retained in the study. A series of 353 variables were collected from the parents, the gynaecologists, neonatologists and attending physicians.After statistical analysis, only 15 of the 353 items studied significantly differentiated between the two groups. A stepwise discriminant analysis performed on these items led to the identification of six independent variables: the time of the incident; the circumstances leading to the observation of the child; the childs sleep position; previous minor intestinal problems; the size of the family and the mothers coffee consumption. Most variables indicate that the near-miss infants were discovered and rescued earlier than the infants who died. No other historical information appeared significantly to differentiate between the two groups of infants. These data need confirmation from a prospective epidemiological survey.

Controlled fall in natremia and risk of seizures in hypertonic dehydration

The aim of the study was to derive some practical measurements which might help in defining a “safe” infusion rate in order to avoid seizures during treatment of hypernatremic dehydration. Forty seven infants with hypernatremic dehydration were rehydrated on a 160 ml/kg/24 h basis: 9 developed seizures during treatment (group I), 22 matched for age did not convulse (group II). Nine subsequent cases were prescribed a 120 ml/kg/24 h regimen: none convulsed (group III). The three groups were comparable in many respects, including initial plasma Na and pH. Fluids were comparable regarding (Na), their rates of administration were respectively 216, 181 and 123 ml/kg/24 h. The rate of infusion affected slopes of decreases in natremia. It was suggested that the decrease in plasma Na should not exceed 0,5 mEq/l/h.

AUDITORY AROUSAL THRESHOLDS OF NORMAL AND NEAR-MISS SIDS INFANTS

The sleep characteristics and auditory arousal thresholds of 20 near‐miss sudden infant death syndrome (SIDS) infants and 97 age‐ and sex‐matched normal infants were studied. It was observed that spontaneous arousals occurred significantly less frequently in the near‐miss SIDS infants. In both groups, induced arousals occurred at comparable stimulation intensities, and arousal thresholds decreased significantly from the 44th to the 52nd postconceptional week. This supports the notion that both groups present a similar maturational process within the auditory pathways and brainstem, and that arousal is not related to differences in behavioural response to ambient noise during sleep.

Neonatal tuberous sclerosis. US, CT, and MR diagnosis of brain and cardiac lesions.

Cortical, subcortical and subependymal tubers were more completely and more clearly depicted by MR than by CT and US in a 3-week-old infant. These lesions were best shown on T1-weighted images as areas of high signal intensity.

Factors for Poor Prognosis in Fulminating Meningococcemia: Conclusions from Observations of 67 Childhood Cases

Between December, 1971, and May, 1976, 67 cases of proven meningococcemia were admitted to our pediatric intensive care unit, constituting 50 per cent of’ the admissions for meningococcemia in the pediatric department in general. Most of these admissions were from urban areas with center city clustering, and were more frequent in winter and spring. We have attempted to identify and quantify the factors which appear to be related to the outcome of these patients’ illnesses. Such risk factors have been defined elsewhere,5-7 but we felt that the high-risk group of children admitted to an intensive care unit required

Lower-Limb Hypoplasia Due to Intrauterine Infection with Herpes Simplex Virus Type 2: Possible Confusion with Intrauterine Varicella-Zoster Syndrome

A neonate with lower-limb hypoplasia, cutaneous scars, bilateral chorioretinitis, and multiple brain abnormalities is presented. Intrauterine herpes simplex virus type 2 (HSV-2) infection was established on the basis of serological testing of the mother and viral cultures of the childs cutaneous lesions, obtained soon after birth. This is, to the best of our knowledge, the first case of a patient with in utero-acquired HSV-2 infection presenting with a limb hypoplasia. It illustrates that, in addition to congenital varicella-zoster syndrome, HSV-2 infection should also be considered in patients presenting with limb hypoplasia.

Safe oral rehydration of hypertonic dehydration.

Summary: Eighteen infants with severe hypernatremic dehydration secondary to acute gastroenteritis were rehydrated during the 1st day with an oral glucose electrolyte solution containing 60 mmol sodium/L at a mean rate of 120 ml/kg/24 h. These 18 children were safely treated with oral therapy alone. No convulsions were observed during treatment. The mean decrease in natremia was 0.32 mmol/L/h, which compared favorably with the mean fall in natremia of 26 other infants in similar initial conditions who were treated intravenously. The present study lends additional support to the opinion that a slow decrease in plasma sodium (<0.5 mmol/L/h) helps to avoid seizures during treatment. As no other untoward effects were observed, this study also confirms that oral solutions given at a slow rate can effectively replace intravenous fluids in the majority of such children.

Diagnostic categories in infants referred for an acute event suggesting near-miss SIDS

Among 857 infants admitted between 1977 and 1984 for a life-threatening apnoeic event a definite pathologic condition was found in 576 (66%). In 32 (6.5%) of the latter the polysomnogram was abnormal. The major clinical diagnostic categorics were, with decreasing frequency: digestive (n=263), vasovagal (n=95), neurological (n=78), respiratory obstructions (n=33), and respiratory infections (n=27); miscellaneous causes were found in 80 infants. No obvious cause could be traced in the remaining 281 infants. According to those caring for them the episode was severe in 77 (27%) of these infants, 57 (74%) of which had an abnormal polysomnogram, and minor in 204 (73%), 36 (18%) of which had an abnormal sleep study. Home monitoring was performed for 145 patients: all those with an abnormal polysomnogram and the 20 infants with an unexplained severe episode associated with a normal sleep study. We conclude from our experience that when an infant is referred for an acute event suggesting nearmiss sudden infant death syndrome (SIDS), a large array of diagnoses can be found and that an electric monitoring device will ultimately be advocated for only 17% of all infants presented, but for all those with an unexplained severe episode, irrespective of the results of the sleep study.

Home monitoring of infants considered at risk for the sudden infant death syndrome

From 1977 to 1981, 500 infants had been referred to evaluate their risk for the sudden infant death syndrome (SIDS). These included 186 infants who had presented an event (prolonged apnea, hypotonia, pallor or cyanosis) initated while asleep, 133 siblings and 181 “controls”. All-night polygraphic recordings were performed in all infants, and if indicated by the history of the infants, complementary clinical investigations were done. These procedures led to the identification of 50 infants considered at risk for SIDS (10% of all referrals): 30 near-misses for SIDS, 10 siblings and 10 infants with a minor incident during sleep but with abnormal polygraphic recordings. These 50 infants (group I) were monitored at home during sleep with the help of a cardiac and respiratory monitor. Eight infants not considered at risk were monitored similarly at the request of their parents (group II). Forty of the 50 infants in group I presented with repetitive sleep apneas and bradycardias, and required stimulation by their parents to regain normal cardiorespiratory rhythm. Twelve had to be resuscitated at least once for a life-threatening event. None of the infants in group II showed alarms during sleep. Monitoring could be discontinued after a mean length of 7.2 months for the infants in group I, 4.1 months in group II. It is concluded that if identified in time through adequate investigations, some infants may be protected against SIDS through home monitoring. This approach requires expensive and well trained teams, ready, at any time, to cope with the problems that may arise in the homes of the monitored infants.

Polysomnographic studies and home monitoring of siblings of SIDS victims and of infants with no family history of sudden infant death.

We report preliminary results of a prospective study conducted to prevent sudden death in asymptomatic infants. From 1977–1984, 3658 infants were studied polygraphically. There were 923 siblings of SIDS victims and 2735 infants with no personal of family history of SIDS. The infants were studied at 8 weeks of age. Polygraphic “risk factors” were defined by central apnoeas longer than 15s; periodic breathing above 5% sleep time; or obstructive apnoeas above 3s. In 937 infants “risk factors” were seen and a second study was requested 4 weeks later. Out of 891 infants re-studied at 12 weeks, 153 still presented some “risk factors” and were selected for a home monitoring programme; 150 families agreed to monitor their infants at home with a cardiorespiratory monitor with the alarms set at 20s apnoea, and 50 beats per min bradycardia. Repeated alarms were reported for 97/150 (65%) infants; 48/150 (32%) infants were stimulated and 8/150 (5.3%) were resuscitated on at least one occasion. No death occurred during monitoring, which could be interrupted before the end of the first year of life in all infants. In the group of 3459 infants with normal results and not monitored, three siblings (0.35%) and one infant without history (0.04%) died of SIDS. Of the infants with abnormal polygraphic results, one sibling not returned for the second recording, and two out of three infants for whom the parents refused monitoring, died of SIDS. It is concluded that the programme, may prevent the death of some infants, but that the outcome of a child with normal results cannot be foreseen.