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Welcome

Welcome to the beautiful city of Auckland and the Sixth SIDS International

Conference! How fortunate we are to have an opportunity to meet in such a lovely

location. We are gathered here together as a family to share our knowledge and

compassion for Sudden Infant Death Syndrome and the many families who have

lost precious little lives. We can be proud that through our years of research,

education and family support, the SIDS rate in developed countries has dropped

dramatically.

International conferences provide a special forum for scientists, health

professionals, SIDS parents, and community members to join together in the battle

against SIDS. Plenary sessions, workshops, poster walks and social activities all

allow us a chance to learn and share our special knowledge of SIDS. Networking

with others doing the same things in different countries has led to some very

beneficial relationships.

A special focus of this conference in New Zealand is the indigenous populations

and those countries with low SIDS awareness. The SIDS rate has not been reduced

in these areas and greater attention must be directed here. Learn, share and enjoy

your time in New Zealand. Make a special effort to meet others from different

parts of the world. When you go home, share what you have gained here and

nurture the relationships that you begin here in Auckland. Together we will continue

to make a difference.

Best wishes to you all

Kathy Dirks

Chairman, SIDS International

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Contents

Organisers 3

Venue Guide 4

Featured Speakers 5

Programme 6

Poster Presentations 19

Social Programme 23

General Information 24

Conference Abstracts 26

Authors List 127

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Organisers

Conference Steering Committee

Conference Chair: Felicity Price, SIDS parent, former chair SIDS InternationalProgramme Chair: Dr Ed Mitchell, Assoc. Professor of Paediatrics, University of

Auckland Medical School; SIDS researcherCommittee: Lee Schoushkoff, Chief Executive, Child Health Research Foundation,

New Zealand Cot Death AssociationRobyn McKeown, Chair, Parent Advisory Committee, New Zealand CotDeath AssociationRiripeti Haretuku, Co-ordinator, Maori SIDS Prevention TeamEseta Finau, Co-ordinator, Pacific Islands SIDS PreventionGraeme Baker, former Trustee, Sudden Infant Death Charitable Trust

SPONSORS

The Organising Committee thank the following organisations for their support:

ASB Bank

Corbans Wines Ltd

Cot Death Association of New Zealand

GeTeMed

G L Bowron & Co Ltd

Health Research Council of New Zealand

MAM Babyartikel

Ministry of Health (Child and Youth Health)

Scenic Circle Hotels

Safe T Sleep (NZ) Ltd

SIDS New Zealand Inc.

Smokefree

Ted and Mollie Carr Medical Travel Fund

Tommee Tippee

Abstract Review and ScientificCommittee Chairs

Epidemiology: Dr Ed MitchellPathology: Dr Roger ByardPhysiology: Professor Barry TaylorInterventions: Dr Rodney FordPriority Groups: Dr David Tipene-LeachPsychosocial: Dr Louise WebsterParent: Robyn McKeownManagement: Lee Schoushkoff

SIDS International ExecutiveCommittee

Chairman: Kathy Dirks (USA)Deputy Chair: Pietro Sebastiani (Italy)Secretary: Maxine Weber

(Australia)Executive: Hazel Brooke (Scotland)

Michael O’Doibholin(Ireland)Lauritz Stoltenberg(Norway)

Global Strategy Kaarene FitzgeraldTask Force: (Australia)

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Venue Guide

Registration Desk Conference Centre22 Symonds Street

Speaker Preparation ALR3Architecture School22 Symonds Street(same building asthe ConferenceCentre)

Plenary Sessions Maidment TheatreAlfred Street

People’s Forum Functions Room(Wednesday) (Student Union

Building)

Concurrent Sessions 1.401Engineering School20 Symonds Street

ALR1, ALR2, ALR4Architecture School22 Symonds Street(same building asthe ConferenceCentre)

Polynesian Evening Sheraton Hotel83 Symonds Street

HyattHotel

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Featured Speakers

Dick ObershawDick is the director and psychotherapist atthe Grief Center and Burnsville CounselingClinic in Minnesota. He is a master presenterwho has specialised in grief therapy. Hisplenary address will set the stage for the restof the conference and will be of value to bothSIDS parents and health professional alike.He will also run workshops for SIDS dads andfamilies during the conference.

André KahnAndre is Professor of Paediatrics at the FreeUniversity of Brussels in Belgium. He haspublished extensively on the physiology ofinfants. His knowledge on apparent lifethreatening episodes (ALTE) is second tonone.

Henry KrousHenry is Professor of Pathology at the SanDiego School of Medicine, California. He is aworld renown paediatric pathologist, whohas made a major contribution to ourknowledge of SIDS. He has been responsiblefor the development of the standardisedautopsies and death scene investigations,which has been implemented throughout theUnited States and in many other countries.

Leslie RandallLeslie is a member of the Ni Mii Pu (NezPerce) Nation. She is a nurse andepidemiologist. For the past 7 years she hasworked both as a researcher and a counsellorin the Aberdeen Area Indian HealthServicewith families who have lost infantsboth as a researcher and a counsellor in theAberdeen Area Indian Health Service. Shewas able to combine traditional methods ofsupport to the families as well as westernmethods.

Roseanne EnglishEighteen years ago, Roseanne experiencedthe death of her two-month old son to SIDS.She is also a nurse. In 1983, she foundedthe Philadelphia Chapter of the National SIDSFoundation and has been Executive Directorof the Pennsylvania SIDS Center for fourteenyears where she has gained a wealth ofexperience in providing SIDS services,particularly to African American and Native

American families.

Tony NelsonGraduated University of Cape Town in 1978,and worked in South Africa, Zimbabwe, SaudiArabia, New Zealand, Malawi and Hong Kong.He completed a doctoral thesis on “SuddenInfant Death Syndrome and Child CarePractices” in 1989. Currently he is AssociateProfessor in Paediatrics at the ChineseUniversity of Hong Kong. Research interestsinclude SIDS and child care, diarrhoealdiseases, childhood obesity andinternational development aid.

Jim McKennaJim is Professor of Anthropology andDirector of the Mother-Baby BehaviouralSleep Laboratory, University of Notre Dame.He studies the ecology and evolution ofhuman development, emphasizing culturalinfluences on childhood and infant sleepenvironments in relationship to SIDS risks,especially, the role of parental contact inregulating infant sleep physiology. Hepioneered laboratory studies of mother-infant co-sleeping in the bedsharing/breastfeeding context.

Lew LipsittLew is a developmental psychologist, and isnow Emeritus Professor at Brown University.He continues to be very active researcher andis supported by a four-year NIH grant tocontinue the longitudinal work intoadulthood on 4,000 children studied sincebirth. He has authored many articles oninfant learning and perception, includingpapers on SIDS.

Roger ByardRoger is a Specialist Forensic Pathologist atState Forensic Science in Adelaide and is anAssociate Professor with the University ofAdelaide. Dr Byard qualified in pathology inCanada and the United States. He has had alongstanding interest in SIDS, suddenchildhood death and other aspects ofpaediatric forensic pathology, and haswritten numerous papers on this topic.

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Programme

To locate the abstract, match the number in front of the title with the same number in theabstract section.

Tuesday 8 February1000 Powhiri Waipapa

Marae1230 Lunch

1400 Opening ceremony MaidmentChairperson: Felicity Price TheatreOfficial Poening by the Hon. Tariana Turia

1430 Keynote address: MaidmentChairperson: Felicity Price Theatre1 GriefRichard Obershaw (USA)

1530-1600 Afternoon tea MaidmentTheatre

1600-1730 Keynote addresses MaidmentChairperson: Ed Mitchell Theatre

1600 2 Disadvantaged communitiesLeslie Randall (USA), N Cobb, RT Bryan.

1620 3 Arousal and survival mechanismsAndré Kahn (Belgium)

1640 4 Contributions of Pathology to SIDSBeginning the New MillenniumHenry Krous (USA)

1700 5 A world view of infant care practicesTony Nelson (Hong Kong)

1730 Close

1830 Polynesian Evening SheratonHotel

Wednesday 9 February0900-1030 Plenary theme: Smoking Maidment

Chairpersons: Paul Johnson & Paparangi Reid Theatre

0900 6 Smoking and SIDS: an epidemiological overviewEd Mitchell (New Zealand)

0915 7 Pre and postnatal exposure to tobacco smoke– effectson the risk of SIDSPeter Blair (England), PJ Fleming, M Ward Platt, IJ Smith, P J Berry,Jean Golding and the CESDI SUDI research team.

0930 8 Smoking and Sudden Infant Death Syndrome- Tentative Biological MechanismsJoseph Milerad (Sweden)

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0945 9 Oxygen chemoreceptors in perinatal lungs expressfunctional nicotinic acetylcholine receptors-Implicationsfor SIDSErnest Cutz (Canada)

1000 10 The SmokeChange Programme: Successfully changingsmoking in pregnancyRodney Ford (New Zealand)

1015 11 How successfully are babies protected from passivesmoking – a biochemical validationRodney Ford (New Zealand)

1030-1100 Morning coffee ConferenceCentre

1100-1230 Concurrent symposiaConcurrent symposium: Co-sleeping Engineering

Chaipersons: Riripeti Haretuku & Carl Hunt 1.401

1100 12 Bed Sharing, Cot Death and Public Health Policy –the New Zealand ExperienceRobert Scragg (New Zealand)

1115 13 Potential Benefits of Mother-Infant Co-sleeping inRelationship To Reducing SIDS: Let’s Not Throw Outthe Baby With Dangerous Beds or Dangerous Co-sleepersJames McKenna (France)

1130 14 Cosleeping - A pathologist’s perspective (14)Roger Byard (Australia)

1145 15 Where should babies sleep, alone or with their parentsPeter Blair (England), PJ Fleming, IJ Smith, M Ward Platt, J Young,P Nadin, PJ Berry, J Golding, and the CESDI SUDI research team.

1200 16 Bed sharing: a marker for increased close physicalcontactPat Buckley (Australia), R Rigda, IC McMillen.

1215 17 A Maori perspectiveDavid Tipene-Leach (New Zealand)

Concurrent symposium: Pacifiers ConferenceChairpersons: Francesco Cozzi & Rodney Ford Centre

1100 18 A reduced risk of SIDS associated with the use ofdummies (pacifiers): Findings of the ECAS StudyBob Carpenter (England), P.D. England, P. Fleming, J. Huber,L.M. Irgens, G. Jorch, and P. Schroeder.

1115 19 Dummy (pacifier) use on the Day/Night of Death:Case-control study of sudden infant death syndrome(SIDS) in Scotland,1996-99Hazel Brooke (Scotland), DM Tappin, C Beckett, A Gibson.

1125 20 A preliminary investigation into when and howa pacifier falls out of a babies mouth during sleepPeter Weiss (England)

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1135 21 Influence of pacifier on sleep characteristics inhealthy infantsPatricia Franco (Belgium), S Scaillet, S Chabanski,J Grosswasser, A Kahn.

1145 22 Influence of pacifier on autonomic nervous control inhealthy infantsPatricia Franco (Belgium), S Scaillet, S Chabanski,J Grosswasser, A Kahn.

1155 23 The impact of pacifier use on breastfeedingdurationAlison Vogel (New Zealand)

1205 24 Pacifier and digit sucking infants I: morbidity in thefirst 18 months of lifePeter Fleming (England), Kate North, Jean Golding and theALSPAC study team.

1220 25 Non-nutritive sucking behaviours in children frombirth to twoArt Nowak (USA)

Concurrent symposium: SIDS organisations ALR1Chairpersons: Lee Schoushkoff & Joyce Epstein

1100 26 The future of SIDS organisationsJoyce Epstein (England)

1110 27 The future of SIDS organisations: an AustralianperspectiveKaarene Fitzgerald (Australia)

1120 28 Establishing an Economic Basis for the Norwegian SIDSSocietyTor G. Hake (Norway)

1130 29 Future directions in bereavement support for SIDSorganizationsAnne Giljohann (Australia)

1140 30 Developing a strategic alliance with the privatesector to increase public awareness on SIDSFionna Chapman (Canada), DJ Keays.

1150 31 Declining SIDS rate in Japan corresponds to reductionof risk factorsStephanie Fukui (Japan), T. Sawaguchi, H Nishida,Takeshi Horiuchi.

1200 32 Development of FSID’s Regional Programme 1990-2000Ann Deri-Bowen (England)

1210 33 Consensus on prevention leads to minimal incidenceReinier Hopmans (Netherlands)

1220 34 Kits for Kids - Resources for Bereaved ChildrenWendy Claridge (Australia)

1230-1400 Lunch and poster session ConferenceCentre

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1400-1530 Concurrent free paper sessionsEpidemiology EngineeringChairpersons: Tony Nelson & Peter Blair 1.401

1400 35 Changes in the epidemiological pattern for suddeninfant death syndrome (SIDS) in South-Eastern Norway1984-1998Marianne Arnestad (Norway), Marie Andersen, Åshild Vege,Torleiv O. Rognum

1410 36 A study of pregnancy outcomes within westernAustralian families in which a sudden infant deathsyndrome (SIDS) death occurredMaxine Croft (Australia), A Read, C Bower, M Hobbs,N de Klerk.

1420 37 Epidemiology of sudden infant death syndrome (SIDS)in the Tyrol before and after an intervention campaignUrsula Kiechl-Kohlendorfer (Austria), U. Pupp, E. Haberlandt,W. Oberaigner, W. Sperl.

1430 38 Current risk and preventative factors in theNetherlands, 1995-1999Monique L’Hoir (Netherlands), AC Engelberts, GA de Jonge.

1440 39 Current epidemiology of SIDS in Ireland, results froma case /control study 1994-98Tom Matthews (Ireland)

1450 40 Unaccustomed events and sudden infant deathsyndromePhilip Schluter (Australia), RPK Ford, EA Mitchell, BJ Taylor.

1500 41 Case-control study of sudden infant death syndromeScotland, 1996-99 - A previously used (old) infant mattressstill seems to increase SIDS riskDavid Tappin (Scotland), H Brooke, C Beckett, A Gibson.

1510 42 SIDS infants - How healthy and how normal? A clinicalcomparison with explained sudden unexpected deaths ininfancyMartin Ward Platt (England), PS Blair, PJ Fleming, IJ Smith, TJ Cole,CEA Leach, PJ Berry, J Golding and the CESDI SUDI researchteam.

1520 43 Are the risk factors for sudden infant deathsyndrome different at night?Sheila Williams (New Zealand), EA Mitchell, BJ Taylor.

Pathology ALR1Chairpersons: Jane Zuccollo & Peter Campbell

1400 44 Examination of cytokines in laryngeal secretionduring acute respiratory diseaseAashild Vege (Norway), M Arnestad, C Lindgren, TO Rognum..

1410 45 The potential relationship between apneas, apoptosis& brainstem plasticityToshiko Sawaguchi (Japan)

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1420 46 Changing practices in certification of suddenunexplained infant deaths in Scotland 1993-98Hazel Brooke (Scotland), A Gibson.

1430 47 Exclusion of non-SIDS cases from a group of suddenunexpected deaths in infancy and early childhood - whichdiagnostic tool gave the diagnosisAashild Vege (Norway), Marianne Arnestad, Torleiv O. Rognum.

1440 48 Mutations in the mtDNA Gene TRNAGLY in SIDS andControlsTorliev Rognum (Norway), Opdal SH, Musse MA, Vege Å.

1450 49 Analysis of Cardiovascular and Respiratory Nuclei inSudden Infant Death SyndromeTahera Ansari (England), M. Rossi, P. Sibbons.

1500 50 Detection of pyrogenic toxins of Staphylococcus aureusamong German SIDS infantsAnthony Busuttil (Scotland), A.M Alkout, V.S. James, R. Amberg,and C. C. Blackwell.

1510 51 The effect of Interleukin 10 (1L-10) on inflammatoryresponses induced by pyrogenic toxins implicated in SIDSOsama Al Madani (Scotland), A.E. Gordon, A.M. Alkout,D.M. Weir, A. Busuttil, C.C. Blackwell

1520 52 Sudden infant death syndrome: back to basicsLarry Becker (Canada)

Physiology Conference CentreChairpersons: André Kahn & Joseph Milerad

1400 53 Bedsharing and overnight monitoring: from thelaboratory to the home settingSally Baddock (New Zealand), BC Galland, CA Makowharemahihi,BJ Taylor, DPG Bolton.

1415 54 Bedsharing and the micro-environment of sleep inearly infancy: Physiological effects on the infantPeter Fleming (England), Andrew Sawczenko, Jeanine Young,Barbara Galland, Peter Blair.

1430 55 Vasoconstrictor responses following spontaneous sighsand head-up tilts in infants sleeping prone and supineBarbara Galland (New Zealand), Barry J Taylor, David PG Bolton,Rachel M Sayers.

1445 56 Sleeping position affects arousability of prematureinfantsRosemary Horne (Australia), Bandopadhayay P, Vitkovic J,Andrew S, Chau B, Cranage SM, Adamson TM.

1455 57 The effects of prone sleeping and antenatal maternalsmoking on the arousability of the term infantRosemary Horne (Australia), Ferens D, Watts A-M, Lacey B,Andrew S, Vitkovic J., Chau B, Cranage SM, Adamson TM.

1505 58 Evidence as to why phenothiazines are asssociatedwith SIDSHeather Jefferies (Australia), GM McKelvey, EJ Post, AKW Wood.

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1515 59 Cerebral circulatory resonses to repeated andcontinuous hypoxia in sleeping lambsAdrian Walker (Australia), Daniel A Grant, and Jennene Wild.

1530-1600 Afternoon tea ConferenceCentre

1600-1730 Concurrent sessionsSafe sleeping environment ConferenceChairpersons: Brad Thach & Shirley Tonkin Centre

1600 60 Mechanisms causing the sudden death of infants whilesharing a sleep surface with othersBrad Thach (USA), Kemp, B. Unger, M. Case, M. Graham.

1610 61 The development of movement in infantsSusan Beal (Australia)

1620 62 Hazardous situations for small infants: - car seats andstrollers etcShirley Tonkin (New Zealand)

1630 63 The CESDI SUDI study: cot deaths outside the cotPeter Blair (England), PJ Fleming, IJ Smith, M Ward Platt,J Young, P Nadin, PJ Berry, J Golding, and the CESDI SUDIresearch team.

1640 64 Dangerous sleeping environments of infants under twoyears of ageCaroline De Koning (Australia), Jodie Leditschke,Peter Campbell

1650 65 The infant positioning project: A professionaleducation initiativeStephanie Cowan (New Zealand)

1700 66 Safe Sleeping Environments for Infants: A CPSCPerspectiveN Scheers (USA), George W. Rutherford, Jr., M.S.

1710 67 Should the infant sleep in mother’s bed?Maurice Kibel (South Africa), M F Davies.

1720 68 Back to sleep and SIDS prevention: Is positionalplagiocephaly a real problem?Tristan de Chalain (New Zealand), G. Bartlett, A.Law,C. Furneaux, M. Rees.

Bereavement Engineering 1.401Chairpersons: Louise Webster & Ann Deri-Bowen

1600 69 Risk factors and sudden infant death syndrome: anoverview of parenting practices in the republic of IrelandMary McDonnell (Ireland)

1615 70 Training bereaved parents for peer supportNuala Harmey (Ireland), Ger O’Brien, Carmel Finnucane,Margarita Synnott.

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1630 71 New initiatives for supporting bereaved parentsAnn Deri-Bowen (England)

1645 72 Bereavement response to the death of a childIan Mitchell (Canada)

1700 73 Babies of the dreaming - aboriginal families supportingeach other in bereavementLynn Briggs (Australia)

SIDS service development and models ALR1Chairpersons: Carol Everard & Alison Waite

1600 74 Sudden death liaison officer program. A policeinitiated support service for bereaved parents thatensures best practice in reporting procedures forsudden infant death syndromeJoe Joyce (Australia), B Graydon.

1610 75 Integrated Emergency Response ModelMichael Corboy (Australia)

1620 76 Police investigation into the sudden and unexpecteddeaths of infants. The way forwardGill Piloni (England)

1630 77 Children’s protection workers and SIDS risk reduction.An exploratory project to reduce the risk of SIDS infamilies known to the Children’s Protection ServiceDorothy Ford (Australia), J Breen.

1640 78 Mortality of babies enrolled on a support programmefor vulnerable babies or anxious parentsAlison Waite (England), JL Emery, RG Carpenter, R Coombs,C Daman-Willems, CMA McKenzie..

1650 79 Risk factors and sudden infant death syndrome: anoverview of child health in the republic of IrelandMary McDonnell (Ireland)

1700 80 Unexpected Infant Deaths: The value of death sceneinvestigation and multidisciplinary reviewPeter Fleming (England), P Blair, J Berry.

1710 81 Health care visits by children from birth to two yearsin an urban health centerHelen Lerner (USA)

1720 82 Infant care practices in Victoria, Australia, 1997-1998:a population survey to evaluate the effectiveness ofenhanced SIDS risk reduction measuresDorothy Ford (Australia), C Sanderson, M Wilkinson.

1730 83 Getting the reduce the risk advice to disadvantagedpopulations – a mobile information projectJoyce Epstein (England)

1630-1730 Workshops

(1) 84 Fathers do survive SIDS ALR2Graeme Baker (New Zealand) & Richard Obershaw (USA)

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(2) 85 Parents & the media ALR4Helen Cormack (Scotland)

1730-1830 People’s forum FunctionsEpidemiology: Peter Fleming (England) RoomPhysiology: Adrian Walker (Australia) (Cash barGrief: Richard Obershaw (USA) available)Education: Stephanie Cowan (New Zealand)Indigenous: David Tipene-Leach (New Zealand)

1900-2000 Memorial Service WaipapaMarae

Thursday 10 February0900-1030 Plenary theme: Indigenous and at risk groups Maidment

Chairpersons: David Tipene-Leach & Naomi Hall Theatre

0900 86 Indigenous and high risk communitiesLeslie Randall (USA), TK Welty.

0915 87 At risk groups and socioeconomic determinantsRosanne English (USA)

0930 88 Sitisi: plight and response of pacificans in AoteroaEseta Finau (New Zealand) Nite Fuamatu, Sitaleki Finau,Colin Tukuitonga.

0945 89 Reducing the risk of SIDS for aboriginal infants inAustralia: developing collaborative strategiesJan Carey (Australia), DL Ford.

1000 90 Competent professional care at time of a SIDS deathprevents a lifetime of dysfunctionNuala Harmey (Ireland), M. McDonnell..

1015 91 Integrated SUDI death scene protocol in ChristchurchWendy Dallas Katoa (New Zealand)

1030-1100 Morning coffee ConferenceCentre

1100-1300 Concurrent SymposiumConcurrent symposium: Development and behaviour ALR1

Chairpersons: Lewis Lipsitt & James McKenna

1100 92 Psychobiological considerationsWilliam Fifer (USA)

1115 93 Defensive behaviour saves most babies’ livesLewis Lipsitt (USA)

1130 94 Childcare as an adaptive system and SIDS prevention:re-articulating the Infant’s dis-articulated caregivingenvironmentJames McKenna (France)

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1145 95 Influence sleep position experience on ability of pronesleeping infants to escape from asphyxiatingmicroenvironments by changing head positionBrad Thach (USA), Dorota A. Paluszynska, Kathleen A. Harris.

1200 96 A study of night-time infant care practices: Acomparison of room-sharing and bed-sharing in a groupof mothers and their infants of low-risk for SIDSJeanine Young (England), Peter Blair, Katie Pollard, Peter Fleming,Andrew Sawczenko.

1215 97 Exhaled air accumulation in the infant sleepingenvironment and the prevention of sudden infant deathAndrew Corbyn (Papua New Guinea)

1230 98 Infant care practices among Alberta Cree, CanadaElizabeth Wilson (Canada)

1245 98A Bedsharing practices of different cultural groupsSally Baddock (New Zealand)

Concurrent symposium: High risk populations and socioeconomic determinants EngineeringChairpersons: Laura Hillman & Pauline Hopa 1.401

1100 99 Child care decisions of deprived parents - whatmatters to them?Michael Wailoo (England), E. Anderson & SA Petersen.

115 100 Sudden Infant Death Syndrome (SIDS) and infantcare practices in Saskatchewan, CanadaKoravangattu Sankaran (Canada), Meleth, Annal Dhananjayan;Meleth, Sreelatha and Sankaran, Rajini.

1130 101 Infant sleeping practices in North Queensland:A survey of indigenous and non-indigenous womenJohn Whitehall (Australia), P Cole, R Muller and K. S. Panaretto.

1145 102 What do aboriginal mothers know about reducing therisks of SIDS?Sandra Eades (Australia), AW Read, The Bibbulung GnarneepTeam.

1200 103 “Reduce the Risk” – Efforts to improve effectivenessin reaching aboriginal peoples in CanadaDebra Keays (Canada) A Corriveau, F Chapman.

1215 104 Telephone subsidy enhances participation ofsocioeconomically disadvantaged families withouttelephones in collaborative home infant monitoringevaluation (CHIME)Carl Hunt (USA)

1230 105 Sudden infant death syndrome in native andnon-native population: trends over 19 yearsIan Mitchell (Canada)

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1240 106 Taking care of baby – a joint programme betweenaboriginal organisations and SIDS Northern Territoryto develop culturally appropriate resource materialJenny Ganter (Australia), Jenny Baraga, Dawn Cardona,Kim Low Choy, Margaret King, Marlene Liddle, MargaretRichards, Wanatu Stephenson, Pat Williams.

1250 107 Examination of SIDS risk factor, attitudes andbehaviours among racially diverse mothers in a high riskrural populationLaura Hillman (USA), J Davis, C. Molitor; C. Mothershead.

Concurrent symposium: Imposed apnoea ConferenceChairpersons: André Kahn & Hazel Brooke Centre

1100 108 Clinical aspectsMartin Samuels (UK)

1130 109 Unnatural deaths as a cause of SIDSSara Levene (UK)

1145 110 The differential diagnosis of imposed suffocation orSIDS? An approach to solve the questionTorliev Rognum (Norway)

1200 111 Intra-alveolar pulmonary siderophages, acutepulmonary haemorrhage and nasal haemorrhage:markers for imposed suffocation?David Becroft (New Zealand)

1215 112 Physiological recordings in SIDS, ALTEs and imposedapnoeaChristian Poets (Germany), Martin P Samuels, David P Southall.

1240 Discussion

1200-1300 Workshop

113 Bereaved children - their needs ALR2Nuala Harmey (Ireland)

1300 Lunch ConferenceCentre

Friday 11 February0900-1030 Plenary theme: Current controversies Maidment

Chairpersons: Ed Mitchell & Kaarene Fitzgerald Theatre

0900 114 The relationship between vaccines, breastfeeding,temporarily dysfunctional reticuloendothelial system,E.Coli, lipopolysaccharide, endotoxemia and SIDSHilary Butler (New Zealand)

0915 115 Immunisation: A protective factor against SIDSMartin Ward Platt (England), PJ Fleming , PS Blair, IJ Smith, P J Berry, Jean Golding, and the CESDI SUDI research team.

0925 116 Immunisation is not a eisk factor in SIDSMartina Findeisen (Germany), MMT. Vennemann, G. Jorch,E. Mueller, B. Brinkmann.

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0935 117 Microbiological Studies of Sheepskin BeddingWilliam Cullen (Canada)

0950 118 The CSEDI SUDI case-control study: No evidence tosupport the ‘Toxic gas’ hypothesis for SIDSPeter Fleming (England), Peter Blair, Jem Berry, Martin Ward-Platt,Iain Smith and the CESDI SUDI research team.

1010 119 Screening for long QT intervalMarco Stramba-Badiale (Italy)

1025 Discussion

1030-1100 Morning coffee ConferenceCentre

1100-1245 Concurrent sessionsEducation ConferenceChairpersons: Stephanie Cowan & David Tappin Centre

1100 120 Building social capital strategies to reduce SIDS incommunities of colourNaomi Hall (USA)

1110 121 The effect of home-based motivational interviewingon the smoking behaviour of pregnant women. A pilotrandomised controlled trialDavid Tappin (Scotland), MA Lumsden, C McKay, D McIntyre,H Gilmour, R Webber, S Cowan, F Crawford, F Currie.

1120 122 Impact of the back to sleep campaign on SIDS riskfactors in the United States, 1990-97Marian MacDorman (USA), C-W Ko, HJ Hoffman, M Willinger.

1130 123 Teaching and learning strategies for marginalisedgroups in societyCatherine Henniker (Australia)

1140 124 Development of a teaching package for accident andemergency nurses on the management of sudden death ininfancy from a personal involvementCarolyn Stead (England)

1150 125 Babysitters of today parents of tomorrow - Workingwith schools to inform, educate and promote the‘Reduce the risks’ messageLin Roche (England)

1200 126 “Reduce the risk” campaign in NorwayHilde Eriksen (Norway)

1210 127 Child death review: An effective community basedapproach to improve SIDS investigation, intervention, andrisk reduction effortsTheresa Covington (USA)

1220 128 Fran’s successful failureStephanie Cowan (New Zealand) Anne O’Malley, Rodney Ford.

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1230 129 Evaluation of a strategy to prevent sudden infantdeath syndrome (SIDS)Alejondro Jenik (Argentina), S Cowan, JM Ceriani Cernadas,EAS Nelson.

Physiology ALR1Chairpersons: Adrian Walker & Brad Thach

1100 130 Sudden infant death syndrome (SIDS) and the Jervelland Lange-Nielsen syndrome (JLNS) in NorwayMarie Andersen (Norway), M Arnestad, CV Isaksen, H Torgersen,Å Vege, TO Rognum.

1115 131 Dummy Sucking And Oral Breathing In NewbornInfantsFrancesco Cozzi (Italy), O Aljbour, C Tozzi, F Morini, E Bonci,DA Cozzi.

1130 132 Pacifier and digit sucking infants III: PhysiologicaleffectsPeter Fleming (England), Katie Pollard, Jeanine Young, Peter Blair,Andrew Sawczenko.

1145 133 Prone sleeping affects circulatory control in infantsTom Matthews (Ireland)

1200 134 Effects of risk factors for SIDS on the developmentof heart rate patternsStewart Peterson (England), MP Wailoo, A Jackson, C Pratt.

1215 135 Gastroesophageal reflux and apnea of prematurity:Is there a relationship?Christian Poets (Germany), CS Peter, N Sprodowski, B Bohnhorst,J Silny.

1230 136 The effects of maternal smoking and diet on growthand cardiorespiratory development telemetred from thehome during sleep in infantsPaul Johnson (England), Andrews DC, Bawtree L, Mathews F, &Neil A.

1245 137 Immunisation does not alter infant sleep-wakeactivityPat Buckley (Australia), A Lokuge, IC McMillen.

Bereavement EngineeringChairpersons: Judy Freiman & Graeme Baker 1.401

1100 138 The use of a bereavement assessment tool withfamilies after the sudden death of a child: Impact onquality of careAnn Dent (England), Peter Fleming, Peter Blair.

1115 139 Lessons from an ancient story of grief for the newmillenniumJudy Freiman (Australia)

1130 140 Care and assistance after SIDS and children-accidentsDag Nordanger (Norway), K. Dyregrov and A. Dyregrov

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1145 141 Grandparent bereavement - challenge and changeAlison Stewart (New Zealand)

1200 142 SIDS Parents Responding to Families:The Wellington ExperienceMadeleine Taylor (New Zealand)

1215 143 Creative MemoriesSue Wilkinson (Australia), Vivienne Bateman.

1200-1300 People’s Forum ALR2/ALR4Pathology: Roger Byard (Australia)Epidemiology: Peter Blair England)Indigenous: Riripeti Haretuku (New Zealand)

1245-1330 Lunch ConferenceCentre

1330-1430 POSTER WALK

Presenters to be by posters

Facilitators:Clinical & Physiology: Barry Taylor (New Zealand)Pathology: Roger Byard (Australia)Education, SIDS organisations: Rodney Ford (New Zealand)Bereavement: Richard Obershaw (USA)Epidemiology and Indigenous: Peter Fleming (England)

1430 Final Plenary Session MaidmentChairpersons: Sylvia Limerick & Marco Stramba-Badiale Theatre

1430 144 Infant care practices: what should we adviseTony Nelson (Hong Kong)

1445 145 Physiology: major questions to be addressedAndré Kahn (Belgium)

1500 146 Pathology: major questions to be addressedHenry Krous (USA)

1515 147 Disadvantaged communities – the futureRosanne English (USA)

1530 148 The future direction for SIDS research andprevention – to lead or be led?Kaarene Fitzgerald (Australia)

1545 Closing ceremony

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149 SUDDEN UNEXPECTED DEATHWHEN YOUR CHILD IS OVER ONEYEAR OF AGEGraeme Baker (New Zealand)

150 BEREAVEMENT SUPPORT VIATHE INTERNETKaron Cox (Australia)

151 VIDEO AS GRIEF SUPPORTT. Giving Kalstad (Norway)

152 SEMINAR FOR UNPROCESSEDGRIEFD. Nordanger, (Norway) T. Giving Kalstad

153 BEREAVED KIDSPauline Ingram (New Zealand)

154 REDUCTION OF SUDDEN INFANTDEATH SYNDROME - IMPACT ONBEREAVEMENT SUPPORT SERVICESFOR FAMILIESYani Switajewski (Australia)

155 SIDS PARENTS CONTRIBUTINGTO A SIDS ORGANISATIONLesley and Peter Jones (Australia)

156 DEVELOPING AN EFFECTIVEPUBLIC EDUCATION AND AWARENESSCAMPAIGN ON SIDSJF Hazel, (Canada) S Cotroneo

157 EXPANSION OF SERVICES BY SIDSNEW SOUTH WALES - THE PROCESSMichael Corboy (Australia)

158 FEWER BEREAVED PARENTS –LESS TAKE UP OF BEFRIENDERSUPPORT – WHAT NEXT FOR THESIDS ORGANISATIONS?Ann Deri-Bowen (UK)

159 THE AUSTRALIAN SIDS ONLINECATALOGUEJoanna Durst (Australia)

160 EXTENDED SEMINARS FORBETTER PARENTAL SUPPORTH.Eriksen (Norway)

161 REGIONAL BEREAVEMENTSUPPORT COOPERATIONH.Eriksen (Norway)

162 PARTICIPATION IN RESEARCH:INFORMED CONSENT, MOTIVATIONAND INFLUENCERebecca Hayman (New Zealand)

163 SUPPORT AND INFORMATIONOFFERED TO ACCIDENT ANDEMERGENCY DEPARTMENTS IN THENORTHERN REGION OF ENGLANDG. Latter (UK)

164 THE POWER OF THE HOME VISITFOR EXTENDING THE INFLUENCE OFSMOKING INTERVENTIONSCarol Reardon (New Zealand)

165 DEVELOPING AN EFFECTIVEPARTNERSHIP TO REDUCE THE RISKOF SIDS IN CANADAR. Sloan, (Canada) M. Labrèche

166 OUR BABY DIED FROM SUDDENINFANT DEATH SYNDROMECarolyn Stead (England)167 EVALUATION OF INFORMATIONCAMPAIGN AGAINST SIDS IN THENORTHEASTERN OF POLANDJolanta Wasilewska (Poland)

168 RISK SCORING FOR SIDS -EPIDEMIOLOGICAL &ENVIRONMENTAL FACTORSPS Blair, (UK) PJ Fleming, M Ward Platt, IJSmith P J Berry, Jean Golding, and theCESDI SUDI research team.

69 WEIGHT GAIN AND SIDS : POORGROWTH AMONGST THOSE INFANTSBORN WITH A NORMALBIRTHWEIGHTPS Blair, (UK) P Nadin, TJ Cole, PJFleming, IJ Smith, M Ward Platt, PJ Berry,J Golding, and the CESDI SUDI researchteam.

170 THE CESDI SUDI CASE-CONTROLSTUDY: THE THERMALENVIRONMENT OF INFANTS DURINGSLEEP AND THE RISK OF SIDSPeter Fleming, (UK) Peter Blair, Jem Berry,Martin Ward-Platt, Iain Smith and theCESDI SUDI research team.

Poster Presentations

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171 IS THERE A GENETICCOMPONENT TO THEINFLAMMATORY RESPONSESIMPLICATED IN SIDS?A.E. Gordon, (Scotland) D.A.C. MacKenzie,D.M. Weir, A. Busuttil, C.C. Blackwell

172 FUTURE DIRECTIONS FOR SIDSRESEARCHDr Sara Levene (UK)

173 HONG KONG CASE-CONTROLSTUDY OF UNEXPECTED INFANTDEATH: LEGAL, ETHICAL ANDPRACTICAL ISSUESEAS Nelson, (China) D Wong, NM Hjelm,JA Dickinson, Y Ou, CB Chow, NLS Tang,KF To, L Chen, LM Yu.

174 DEATH-SCENE INVESTIGATION INTHE GERMAN CASE-CONTROL STUDYON SIDSM Schlaud (Germany) A Fieguth, DGiebler, B Giebe, S Heide, K-P Larsch, CFPoets, U Schmidt, J Wulf, WJ Kleemann.

175 A WAY OF SIDS INVESTIGATIONIN FORENSIC PRACTICEKlara Toro, (Japan) Gyorgy Dunay,Toshiko Sawaguchi, Akiko Sawaguchi

176 THE BMBF SIDS STUDY INGERMANY: PRELIMINARY RESULTSFROM A NATION WIDE STUDYMMT Vennemann, (Germany) M.Findeisen, E. Müller, B. Brinkmann

177 SIDS INFANTS – HOW HEALTHYAND HOW NORMAL? A CLINICALCOMPARISON WITH EXPLAINEDSUDDEN UNEXPECTED DEATHS ININFANCYM Ward Platt, (UK) PS Blair, PJ Fleming, IJSmith, TJ Cole, CEA Leach, PJ Berry, JGolding and the CESDI SUDI researchteam.

178 PREVALENCE OF SMOKINGAMONG CREE REPRODUCTIVE AGEWOMENE. Wilson, (Canada) P. Sicotte

179 TOXIC GAS HYPOTHESISREJECTEDLady Sylvia Limerick (England)

180 ABORIGINAL MOTHERS: CHILDCARE KNOWLEDGE AND FACTORSIan Mitchell (Canada)

181 SUDDEN INFANT DEATHSYNDROME IN INDIGENOUS AND NONINDIGENOUS INFANTS IN NORTHQUEENSLAND: 1990-1998J Whitehall1, (Australia) KS Panaretto1, GMcBride.

182 VOLUMETRIC ANALYSIS OFPLACENTAL TISSUE FROM INFANTSSUCCUMBING TO SUDDEN INFANTDEATH SYNDROME (SIDS) AND INTRAUTERINE GROWTH RETARDED (IUGR)INFANTS.T. Ansari, (Ireland) B. O’Neill, JE. Gillan,PD Sibbons.

183 STEREOLOGICAL ESTIMATION OFTOTAL VILLOUS SURFACE AREA INPLACENTAS FROM SUDDEN INFANTDEATH SYNDROME (SIDS) CASES ANDINTRA UTERINE GROWTH RETARDED(IUGR) CASES.T. Ansari, (Ireland) B. O’Neil, JE. Gillan,PD Sibbons.

184 PLACENTAL VILLI ANDINTERVILLOUS SPACE DEVELOPMENTIN SUDDEN INFANT DEATH SYNDROME(SIDS) AND INTRA UTERINE GROWTHRETARDED (IUGR) CASES.T. Ansari, (Ireland) B. O’Neil, JE. Gillan,PD Sibbons.

185 GENETIC, DEVELOPMENTAL ANDENVIRONMENTAL FACTORSCONTRIBUTING TO SUSCEPTIBILITYTO SIDS: THE NEED FORMULTIETHNIC STUDIESC.C. Blackwell, (Scotland) D.M. Weir, A.Busuttil

186 WHY IS THE PRONE SLEEPINGPOSITION A SIGNIFICANT RISKFACTOR FOR SIDS?N. Molony, (Scotland) A. Busuttil, D.M.Weir, C.C. Blackwell

187 ACUTE GRIEF SUPPORT INSUDDEN UNEXPECTED DEATHS ININFANCY (SUDI)Ralph Franciosi (USA)

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188 CRIB DEATH, COT DEATH & SIDS.A TRIOLOGYRalph Franciosi (USA)

189 RESULTS OF THOROUGHINVESTIGATIONS IN 81 CONSECUTIVESUDDEN AND UNEXPECTED DEATHSIN INFANTS AND CHILDREN.C Rambaud, ( France) E Briand, MGuibert, D Cointe, H Razafimahefa, J deLaveaucoupet, A Coulomb, F Capron, MDehan.

190 PATHOGENESIS OF ALTE ININFANTS WITH NASAL OBSTRUCTIONDA Cozzi, (Italy) A Piserà, M Ilari, ACasati, F Morini, F Cozzi

191 ALTE IN INFANTS WITH NASALOBSTRUCTIONF Cozzi, (Italy) A Piserà, L Oriolo, FMorini, A Casati, DA Cozzi.

192 PARENT REPORTED SLEEPDISORDERED BREATHING ANDBEHAVIOURAL FEATURES IN2-4 -MONTH-OLD INFANTSIA Kelmanson (Russia)

193 IS YOUR MONITOR REALLYNECESSARY?Dr Ian Mitchell (Canada)

194 RESEARCH ON PREVENTION OFSUDDEN INFANT DEATH ANDMETHODS FOR SELECTION OF HIGHRISK GROUPSKlara Toro, (Hungary) Loretta Toth,Zsuzsanna Csukas, Ferenc Rozgonyi,Toshiko Sawaguchi, Akiko Sawaguchi.

195 KANGAROO CARE (KC), APNOEAOF PREMATURITY (AOP) AND BODYTEMPERATUREB Bohnhorst, (Germany) T Heyne, CSPeter, CF Poets.

196 THE EFFECT OF MATERNALSMOKING IN PREGNANCY ON INFANTRESPONSES TO PERIODIC THERMALSTIMULUSBrowne CA, Colditz PB, (Australia)Dunster KR.

197 GABA RECEPTOR IN HUMANPERINATAL ASPHYXIAAL Eckert, ( Australia) DL Andersen, PRDodd

198 PACIFIER AND DIGIT SUCKINGINFANTS II: DEVELOPMENTALCHANGE AND BEHAVIOURAL EFFECTSKatie Pollard, Peter Fleming, (UK) JeanineYoung, Peter Blair, Andrew Sawczenko

199 A MATHEMATICAL MODEL OFOVERNIGHT TEMPERATURE CHANGESIN INFANTS: INVESTIGATION OF THEEFFECTS OF EPIDEMIOLOGICAL RISKFACTORS FOR SIDS.Linda Hunt, Peter Fleming (UK) AndrewSawczenko, Ruth Wigfield.

200 RT-ISH: A NOVEL METHOD FORDETECTING RECEPTOR SUBUNITS INVIVO.A.J. Hawkins ( Australia) and P.R. Dodd

201 AUTOMONIC RESPONSES ININFANTS WHO HAD APPARENT LIFETHREATENING EVENTS (ALTE) ORIRRITABILITY (IRR)RM Hayman, (New Zealand) BC Galland,BJ Taylor, DPG Bolton, RM Sayers.

202 VENTILATORY RESPONSES OFALTE INFANTS AND INFANTS WITH AHISTORY OF IRRITABILITYRM Hayman, BC Galland, BJ Taylor, DPGBolton, RM Sayers.

203 EFFECTS OF HYPERTHERMIAAND MURAMYL DIPEPTIDE ON IL-1b,IL-6 AND MORTALITY IN NEONATALRAT MODELEAS Nelson, (China) Wong Yin, K Li, TFFok, LM Yu.204 THE MOEBIUS STRIP AND THESUDDEN DEATH OF AN INFANTDURING SLEEPT Sawaguchi (Japan)

205 CAPNOGRAPHY ANDPREMATURITY, AGE AND POSITIONEFFECTSE Tirosh, (Israel) A Bilker, D Bader, ACohen.

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207 TRANSIENT AROUSALS AT APNEAINITIATION AND SIGH-RELATEDAROUSALS AT APNEA TERMINATIONH. Wulbrand (UK)

208OXYGENATION AND BREATHINGPATTERN IN HEALTHY TERM INFANTSDURING SLEEPJ. Milerad, (Sweden) E Horemuzova, MKatz-Salamon

209 ALTERED BREATHING PATTERNAND TACHYCARDIA IN YOUNG LAMBSEXPOSED TO NICOTINE PRENATALLYJ. Milerad, (Sweden) H.W. Sundell, O.Hafström, P.A. Minton, S Poole

210 PRENATAL NICOTINE EXPOSURE(PNE) ALTERS SLEEP-RELATEDMODULATION OF VENTILATION INYOUNG LAMBSJ Milerad, (Sweden) HW. Sundell, O.Hafström, S. Poole, PA. Minton

211 FLEXIBLE LARYNGOSCOPICUPPER AIRWAY FINDINGS IN INFANTSWITH NOISY BREATHING ANDOBSTRUCTIVE SLEEP APNEAS OFUNCLEAR ORIGIN.Joseph Milerad, (Sweden) StefanJohansson , Gunnar Biorck , Miriam Katz-Salamon.

212 SAFE T SLEEP MAY REDUCEINCIDENCE OF SIDSMiriam Rutherford, (New Zealand)

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Social Programme

TUESDAY 8th

Polynesian Evening18:00hrsSheraton Auckland HotelDress: tidy casualOne ticket is included in the delegateregistration feeGuest tickets - $90 (subject to availability)

THURSDAY 10th

Waiheke Island Experience13:40-21:00Dress: tidy casual, take a hat and sunscreenTickets - $108 per person; including winetasting and dinner (bookings closeWednesday 13:00hrs)Beverages (other than wine tasting) – owncostAssemble at the Registration Desk 10minutes prior to departure

New Zealand’s Best14:00-20:00Dress: tidy casual, take a hat and sunscreenTickets - $60 per person; including dinner(bookings close Wednesday 13:00hrs)Beverages – own costAssemble at the Registration Desk 15minutes prior to departure

SIGHTSEEING TOURSWEDNESDAY 9th

Full Day Wilderness Experience09:15-17:00Dress: casual, take a hat and sunscreen, flat-soled sturdy shoes a mustWet weather gear supplied if required.Tickets - $99 per person; including lunch(bookings close Tuesday 15:00hrs)Assemble at the Registration Desk 10minutes prior to departure

SATURDAY 12th

Waitomo/Rotorua TourYou will be collected from your hotel/hostel.For your pick-up time please refer to yourticket.Dress: casualTickets - $215 per person; including morningtea, light lunch and an evening snack(subject to availability)

Wednesday 9th

19:00-2000 MEMORIAL SERVICE Waipapa Marae

FIELD OF FLOWERSWe are putting together a wall display of a “Field of Flowers”. Parents attending the conferenceare invited to provide a flower they have made themselves to commemorate the uniquelittle person they lost to SIDS. The flower can be made of any material but it must not bebigger than 5cm x 5cm. It needs to have a stem that will withstand being pushed throughflat matting (a toothpick, skewer or wire will work).

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General Information

The following information is offered to makeyour conference attendance as pleasant andas trouble-free as possible. If you requirehelp, please call at the Registration Desk inthe foyer of the Conference Centre and wewill do everything we can to assist you.

Airport Departure TaxAn airport tax of NZ$20 per person is payableon departure from New Zealand.

BadgesAs a security requirement, delegates will berequired to wear their conference namebadges to all sessions and social functions.No-one will be admitted to sessions withouta badge.

Banking FacilitiesThe following banks are located in or nearAuckland University:

ASB BankPenbrooke House31 Princes StTelephone: 306 3066Hours: 09.00-16.30hrs

National Bank19A Princes StTelephone: 358 5149Hours:09.00-16.30hrs

Bank of New ZealandOld Arts Building, Auckland UniversityTelephone: 373 6556Hours: Monday/Thursday/Friday09.00-16.30hrsTuesday/Wednesday 09.30-16.30hrs

BusesDetails of the Link Bus are included at theback of the Auckland Guide in your satcheland the route for the free inner city bus ison the fold-out map attached to the front ofthe guide.CarparkingCarparking is available in the Wilson Carparknear the intersection of Grafton Road andStanley Street. Entrance is from GraftonRoad.The carpark is open at the following times:Monday-Friday 24 hours

$4.00 per daySaturday & Sunday 24 hours - no charge

Credit CardsAmerican Express, Diners, Mastercard andVisa are accepted in most shops and hotelsin New Zealand. These credit cards will alsobe accepted for all conference fees.

DressDress for all business sessions and socialfunctions is casual.

FacsimilesIf you wish to send a facsimile, pleasecontact the Registration Desk.

Goods and Services TaxGoods and services in New Zealand aresubject to a 12.5% Goods and Services Tax(GST). This is usually included in the priceand it is clearly stated if it is not. This taxcannot be claimed back when leaving thecountry.

MessagesMessages will be displayed on the messageand information board by the RegistrationDesk. If you wish to have a message left foryou or a facsimile sent to you during theconference the numbers for those sendingthe message or the facsimile are:Telephone: +64 21 659 240Facsimile: +64 9 360 1242

Medical ServicesEmergency medical services are available ona 24 hour, 7 day basis at the Southern CrossAccident and Emergency Central Care, 122Remuera Road, Auckland, telephone: 5245943.In an emergency dial 111 for an ambulance,the police or the fire department.

PharmaciesPharmacy & Post OfficeAuckland UniversityOld Arts Building (by Clock Tower)Telephone: 373 7999Hours: Monday-Friday08.00-17.30hrs

Pharmacy 246246 Queen Street, AucklandTelephone: 379 4362Hours: Monday-Thursday08:00-18:00hrsFriday 08:00-19:00hrsSaturday 10:00-16:00hrsSunday Closed

Newmarket Urgent Pharmacy60 Broadway, NewmarketTelephone: 520 6634Hours: Monday-Friday18:00-23:00hrsSaturday-Sunday 09:00-23:00hrsPrescription only 23:00-07:30hrs

Postal FacilitiesThe nearest Post Office is in the BledisloeBuilding, adjacent to the Aotea Centre or atAuckland University in the Old Arts Buildingadjacent to the Clock Tower.

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RefreshmentsLunch, morning coffee and afternoon tea areincluded in your registration fee and areprovided during the programmed breaks inthe Conference Centre with the exception ofthe Tuesday afternoon tea which will beserved in the foyer of the Maidment Theatre.

Registration DeskThe Registration Desk is located in theConference Centre.

Telephone: +64 21 659 240Facsimile: +64 9 360 1242

It will be open at the following times:Monday 7th 1700-1900hrsTuesday 8th 0800-1800hrsWednesday 9th 0800-1730hrsThursday 10th 0800-1400hrsFriday 11th 0800-1530hrs

ShoppingShopping hours vary but are usually 09:00-17:30hrs Monday to Friday and 09:30-16:00hrs on Saturdays. There is some limitedshopping on Sundays.

SmokingAll the conference venues are smoke freebuildings. Delegates are requested toobserve this policy.

Special Dietary RequirementsIf you have advised any special dietaryrequirements on your registrationrequirements, these will have beenonforwarded to the caterers to preparespecial meals for lunches and the PolynesianEvening. Please ask the catering staff tobring you your special meal.

Speaker Preparation RoomPlease report to the room (ALR3) well inadvance of your presentation to chech youraudio-visual aids.

TaxisAs there is no taxi rank close to theconference venue, we suggest that you bookby telephone (there is a telephone whichaccepts Telecom phone cards and creditcards in the foyer of the Conference Centre).Tell the taxi company to collect you fromoutside the Architecture School at the

University, 22 Symonds Street.

TippingTipping is not usual practice in New Zealandand is only offered for good service.

Telephone DirectoryEmergency Services111(fire/police/ambulance)

Registration DeskTelephone: 021 659 240Facsimile: 360 1242

Accident & Medical ClinicTelephone: 524 5943(122 Remuera Rd, Remuera)

After Hours PharmacyTelephone: 520 6634

Auckland Visitors CentreTelephone: 366 6888

Telephone Directory EnquiresNational 018International 0172

Taxi ServicesCo-op Taxis 300 3000Corporate Cabs 0800 733 833 or 631 1111

AirlinesReservations Arrival/Departure

Information

Air New Zealand357 3000 306 5560

Ansett Australia0800 736 409 0800 736 409

Ansett New Zealand (Domestic)0800 267 388 0800 267 388

British Airways356 8690 306 5575

Cathy Pacific Airways379 0861 256 8232

Malaysia Airlines0800 657 472 306 5579

Qantas357 8900 367 2325

Singapore Airlines303 2129 306 5565

United Airlines379 3800 367 2324

HotelsCambridge Apartments 375 9300Cintra Apartments 379 6288Copthorne, Anzac Avenue 914 2610Hyatt Regency Hotel 366 1234O’Rorke Hall 373 7599Oxford Apartments 358 3328Park Towers Hotel 309 2800Sheraton Hotel 379 5132

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Conference Abstracts

1THE SURVIVORS OF A CHILD’SDEATH: PARENTS ANDPROFESSIONALSRichard ObershawBurnsville Grief Center, USIn this presentation we will explore the griefreactions of both groups and focus on theshared feelings. The focus will be on bringingtogether all of those assembled at thisconference with one shared experience-GRIEF

2DISADVANTAGED COMMUNITIESLL Randall, N Cobb, RT BryanCenters for Disease Control andPrevention and Indian Health Service,Albuquerque, NMWhat is a disadvantaged community and howdoes it differ from indigenous populations?Definitions of disadvantaged communities,indigenous populations, and the differencebetween the two will be examined along witha historical perspective of how someAmerican Indian and Alaska Native (AI/AN)and indigenous populations becamedisadvantaged. A disadvantaged communityis a group of people that experiencesdisparity of health, privilege, income andopportunity in relation to the largerpopulation. It can be a subgroup of anypopulation regardless of race or creedalthough skin color is often a factor.Indigenous populations are populations thathave lived in the area the longest time.These may be conquered or colonizedpopulations. They may be self sufficientwith health status and SES comparable to thetotal population. They, often, becomedisadvantaged populations afteracculturation or assimilation. Historically,through contact with European explorers,introduction of new species of mosquito,rats, and infectious diseases such assmallpox, yellow fever, many indigenouspopulations have been decimated (Bryan,1999). Other factors such as racism anddiscrimination affect disparities; opinionsdiffer over how much these factors influencethe disease process. In the United States theAI/AN have experienced a decline fromhealthy tribes that followed traditional dietsand culture to tribes riddled with chronicdiseases such as diabetes, cancer and heartdisease. While most infectious diseases aredeclining among AI/AN, chronic diseases areoccurring in epidemic proportions. AI/ANrates for diabetes are highest in the nation,and survival rates for cancer are among the

lowest. AI/AN suicide rate is 70% higher thanthe U.S. all races and diseases of the heartare the leading cause of death. Age adjusteddeath rates were greater by large percentagesthan the U.S All Races for alcoholism (579%),tuberculosis (475%), diabetes (231%), andaccidents (212%). Even though tremendousstrides have been made in reducing infantmortality, AI/AN have the highestpostneonatal mortality rate which is twicethe White rate and a SIDS rate three timesthe White rate (Trends 1997).

3Arousal and Survival MechanismsAndré KahnFree University of Brussels, Brussels,Belgium

4CONTRIBUTIONS OF PATHOLOGY TOSIDS BEGINNING THE NEW MILLENIUMHenry F. KrousChildren’s Hospital-San Diego &University of California, San Diego Schoolof MedicinePathologists have added to ourunderstanding of SIDS in the past and arewell positioned to contribute in the future.This presentation focuses upon three recentSan Diego SIDS Research Project studies.Neck Rotation and VA CompressionHypothesisHypothesis: Some SIDS cases result from neckextension and/or rotation causing VAcompression and brainstem ischemia.Aim: To compare neck rotation & extensionin 246 SIDS cases and 56 natural infantdeaths. In this retrospective analysis, neckposition classified into 3 groups: 1. Eitherneutral or flexed forward, & not rotated, 2.Either extended or rotated and 3. Extendedand rotated. Since neck flexion has not beenhypothesized to cause VA compression, itwas treated the same as neutral neckposition.Results: Simultaneous neck extension &rotation was not reported in either group.When data regarding neutral/flexed/extended position and rotation of the neckwere combined, significant differences werenot found between the two groups (P=.94).40% of SIDS cases and 41% of natural deathswere found with the neck either extendedor rotated (OR 0.97, 95% CI 0.45, 2.11). Therewere no significant differences between thegroups when neck rotation & extension wereanalyzed independent of one another. Neckrotation among cases found prone was

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common and not significantly differentbetween the two groups (49% of 146 SIDScases, 58% of 24 natural deaths, P=.38; OR0.68, 95% CI 0.28, 1.62). Neck rotationamong infants found in the supine positionoccurred one third as often in the SIDS group(9% of 33 cases) as in the natural death group(29% of 14 cases), however, the differencewas not significant (P=.17; OR 0.25, 95% CI0.05, 1.31).Conclusion: Our analysis found no evidenceto affirm the importance of neck rotation inSIDS.Intrathoracic Petechiae (IP) and FoundFace PositionIP are common in SIDS and can develop afterbreathing against an obstructed airway ordeep gasping. Prone sleep, a risk factor forSIDS, may cause external oronasal airwayobstruction or allow rebreathing. If externalairway occlusion were important, then onewould have expected the rate of intrathoracicpetechiae to be higher in the group with thefacedown position compared to the otherface position group.Aims:: To determine (1) The rate of IP in thefacedown position in SIDS, and (2) If IP occurmore frequently and with greater severityin SIDS victims found facedown versus otherface positions.Results:: Face position groups were notsignificantly different with respect to age,sex ratio, or gestational age. 36.7% of the199 SIDS cases were found both prone andfacedown. 51.4% of 142 SIDS cases foundprone were facedown. IP were present in98.6% and 93.0% of the facedown and faceother groups respectively, (OR 6.35, 95% CI0.80, 50.63). IP were present on 0,1,2 or 3thoracic organs in 1.4%, 21.9%, 26.0% and50.7%, respectively, of the facedown groupcompared to 8.0%, 16.8%, 30.4% and 44.8%,respectively, of the face-other group.Thymic petechiae were present in 77.1% and70.6% of the facedown and face-othergroups, respectively; (OR 1.4, 95% CI 0.71,2.78). Thymic petechiae were absent, mild,moderate or severe in 22.8%, 37.1%, 14.3%and 25.7% of the facedown group,respectively, compared to 29.4%, 34.4%, 9.2%and 26.9% of the face-other group,respectively. None of the above differenceswere statistically significant.Conclusion: These data argue againstexternal airway obstruction, but do notexclude internal oronasal obstruction orrebreathing in SIDS.Vascular Endothelial Growth Factor(VEGF) and SIDSVEGF is highly sensitive to changes in tissue

PO2, even within the physiologic range andincreases peripheral O2 delivery bystimulating angiogenesis and capillarydensity.Aim: to determine whether hypoxia precedesSIDS by measuring CSF VEGF levels in 14 SIDScases and in 6 control infants dying of knowncauses.Results:: The mean CSF VEGF levels were158.8 ± 46.4 pg/dl in the SIDS cases(increased in 10 of 14 cases) and 65.0 ± 37.7pg/dl in the controls (elevated in 1* of 6cases, *massive intestinal infarction).Conclusion:: These preliminary resultssuggest that hypoxemia precedes death inSIDS.Future DirectionsFuture areas in SIDS to which pathology cancontribute are refinement of the definition,medical diagnosis, delineation of disordersmasquerading as SIDS, research and publicservice, the latter including providinginformation to survivors, clinicians and themedia. Pathologists still will play animportant role in grief support, legislationand education.

5A WORLD VIEW OF INFANT CAREPRACTICESEAS Nelson.Dept of Paediatrics, The ChineseUniversity of Hong Kong, Hong Kong SAR,China.Tremendous progress has been made intackling the problem of SIDS. In the 1980sNew Zealand was the world leader in SIDSmortality statistics. From the 1990s NewZealand has been a world leader in SIDSresearch. Many of the modifiable SIDS riskfactors identified in studies from NewZealand and elsewhere are related tomethods of child care and campaigns to“Reduce the Risk of SIDS” have focused onthese factors. Following the 2nd SIDSInternational conference in Sydney in 1992the SIDS Global Strategy Task Forceembarked on a study to document child carepractices in as many different countries andcultures as possible with the aim ofproviding baseline child care data and tostimulate new hypotheses. The protocol forthe International Child Care Practice Study(ICCPS) was distributed to 80 potentialcentres in 1995 and data from 20 centres in17 countries was received. Wide variationsin child care practices were demonstrated,including those linked to SIDS such as pronesleeping, side sleeping, bedsharing, use ofpacifiers (dummies or soothers), breast

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feeding, use of pillows. Four studies havereported that pacifiers are protective againstSIDS. Yet breast feeding promotioncampaigns, such as the Baby FriendlyHospital Initiative, advise that no artificialteats or pacifiers be given to breast feedinginfants. ICCPS data noted rates of pacifieruse ranging from 12% (Japan), 14% (Dunedin),16% (Chongqing) to 69% (Italy), 71% (Odessa)and exclusive breast feeding rates at 12weeks from 4% (Hong Kong) to 80%(Stockholm). Pacifier use was associated withnot exclusively breast feeding at 12 weeksor not ever breast feeding (p <0.001, Chi-square for trend). Although this associationis consistent with other studies, causationcannot be implied from this ecological data.However dogmatic advice on pacifier use –in either direction – is best avoided at thisstage. A campaign advising parents to wrapinfant mattresses with polythene hasreceived much publicity in the lay press inNew Zealand and the United Kingdom. ICCPSdata were analysed to look at mattresswrapping. Parents were asked to describe themattress covering and answers were codedas cloth, plastic, rubber, netting or other. Twocentres used additional codes. 14% of thetotal sample recorded that their infant’smattress was covered with plastic with ratesranging from 0-2% (Chinese samples) and 1%(Japan) to 59% (Scotland, Ireland) and 67%(Manitoba). There was no indication thatcentres with low rates of SIDS were morelikely have a higher rates of mattresses beingcovered with plastic. Although noconclusions should be drawn from this data,it helps demonstrate that these widedifferences probably reflect local culturalpreferences and types of products availablein different countries. In view of theheterogeneity of the samples in the ICCPS,it is important that such differences are notover-interpreted and that they are viewedwithin the qualitative context of eachindividual sample. The ICCPS data are notintended to show that any particular practiceincreases or decreases the risk of SIDS, butinstead to help us to better understand thecomplexity of child care within differentcultures. These findings should inject someadditional caveats to all of us involved inadvising parents, especially those from non-western cultures, how to reduce the risk ofSIDS.

6SMOKING AND SIDS: ANEPIDEMIOLOGICAL OVERVIEWMitchell EADepartment of Paediatrics, University ofAuckland, AucklandThere is substantial evidence to concludethat maternal smoking caused a markedincreased in SIDS. There have been almost50 studies that have examined thisrelationship and all indicate an increasedrisk. Since the reduction in the prevalenceof prone sleeping position there have beeneight studies examining maternal smokingand SIDS. The pooled unadjusted relativerisk (RR) from these studies is almost five,which suggests that infants of mothers thatsmoke have almost a five times risk of SIDScompared with infants of mothers who donot smoke. Adjustment for potentialconfounders lowers the risk estimate;however, many studies over adjust, such ascontrolling for birthweight, resulting in aninappropriate low estimate of the risk.Epidemiologically it is difficult to distinguishthe effect of active maternal smoking duringpregnancy from involuntary postnataltobacco smoking of the infant to smokingby the mother. The mechanism for SIDS isunknown; however, it is generally believedthat the predominant effect from maternalsmoking is from in utero exposure of thefetus.Clear evidence for environmental tobaccosmoke exposure can be obtained byexamining the risk of SIDS from paternalsmoking where the mother is non-smoker.There have been six such studies. The pooledunadjusted RR was 1.4, which is muchsmaller than the effect seen for maternalsmoking (RR=4.7)

7PRE AND POSTNATAL EXPOSURE TOTOBACCO SMOKE -EFFECTS ON THERISK OF SIDSPS Blair, PJ Fleming, M Ward Platt, IJSmith, P J Berry, Jean Golding, and theCESDI SUDI research team.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UKResults published from the first 2 years ofour study suggest the risk from tobaccoexposure is both prenatal and postnatal [1].This hypothesis is investigated more fullywith the complete three year data set.Methods A three year case-control studyconducted in 5 of 14 Health Regions in

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England (population ~ 17 million, 500,000livebirths). Parental interviews wereconducted for each infant who died and forfour controls matched for age and time ofsleep. Ascertainment was over 90% [2]. Thisanalysis includes 325 SIDS and 1300matched controls.Results In the multivariate model,controlling for all factors significant in theunivariate analysis, prenatal tobaccoexposure represented by maternal smokingduring pregnancy (OR=2.65[95% CI: 1.40-5.03]), and postnatal tobacco exposurerepresented both by paternal smoking(OR=2.01[95% CI: 1.09-3.68]) and a parentalestimate of infant exposure to tobaccosmoke on an average day (OR=2.01[95% CI:1.01-4.00] for no exposure compared to anhour or more) remained significant whenmodelled together. In the univariate analysisall three factors demonstrated a strong dose-response effect with the number of cigarettessmoked or the number of hours of exposure,but this was not so clear in the multivariatemodel when these factors were modelledeither together or independently. A strongdose-response effect was found however ifthe risk associated with smoking in thismultivariate model was represented by thenumber of smokers in the household (onesmoker : OR=4.44[95% CI: 2.07-9.53], twosmokers : OR=7.96[95% CI: 3.34-18.93], threeor more smokers : OR=23.76[95% CI: 4.44-127.16]).Conclusion Postnatal exposure to tobaccosmoke does not appear to be a proxymeasure for prenatal exposure, resultssuggest an additional risk which increaseswith the number of smokers in thehousehold.

1 Blair PS, Fleming PJ et al. Smoking and thesudden infant death syndrome : results from1993-5 case-control study for confidential inquiryinto stillbirths and deaths in infancy. BMJ 1996;313: 195-8.2 Fleming PJ, Blair PS, Pollard K, Platt MW, Leach C,Smith I, Berry PJ, Golding J.Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999;81:112-116.

8SMOKING AND SUDDEN INFANTDEATH SYNDROME – TentativeBiological mechanismsJoseph MileradDepartment of Women and Child Health,Astrid Lindgren Children Hospital atKarolinska Institute, S-171 76 Stockholm,SwedenEpidemiological studies indicate a causal

relationship between maternal smoking andSIDS, but the underlying biologicalmechanism has so far not been elucidated.Evidence derived from experimental studies,mostly based on chronic nicotineadministration during fetal life, suggest thatnicotine, through its effect on synapticneurotransmission impairs the neuralregulation of autonomic, behavioural andhomeostatic functions. The mainpharmacologic effect of nicotine is releaseof dopamine and noradrenaline fromsynaptic nerve terminals in the brain andelsewhere. Dopaminergic neurons are mainlyinvolved with regulation of neuroendocrinefunctions, locomotion and reward-seekingbehaviour like food intake whilenoradrenergic neurons regulate autonomicfunctions such as cardiorespiratory controlbut also cognition and responses to stress.Known adverse effects of prenatal exposureare dopamine mediated functions such ascortisone and pituitary hormones releaseand noradrenaline mediated functions suchas sympathetic activation in response toexogenous stress. The latter involvesmechanisms of arousal andautoresuscitation during hypoxemia i.e.those defence and survival mechanisms thatare believed to fail in infants who succumbto SIDS. Prenatally nicotine exposed rats lackfor instance the normal adrenomedullarycatecholamine release during hypoxia andmay die at hypoxic levels that unexposed ratpups would survive without major ill effects.Similar findings of a deficient “fight or flightresponse” during hypoxia have also observedin young lambs treated either before or afterafter birth and in infants born to smokingmothers.It appears likely that the combination ofadverse nicotine effects, reduced birthweight and visceral organ size and impairedthe ability to activate sympathetic defensemechanisms, may render an infant morevulnerable to stress. Whether thesemechanisms alone may explain SIDS inbabies is unclear, in particular the effects ofmaternal smoking on the infant’s immunesystem need to be further explored.

Supported by Swedish Medical Research Counciland The Laerdal Foundation

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9Oxygen Chemoreceptors in PerinatalLung Express Functional NicotinicAcetylcholine Receptors -Implications for Sudden Infant DeathErnest CutzThe Hospital For Sick Children, Toronto,Ontario, CanadaPulmonary neuroepithelial bodies (NEBs) arethought to function as airwaychemoreceptors involved in the autonomiccontrol of breathing, especially in theneonate. They are composed of innervatedclusters of amine (serotonin) - andneuropeptide-containing cells whichrespond to acute hypoxia (low Po2) via amembrane bound O2 sensing mechanism(Nature 365:153, 1993). Both the frequencyand size of NEBs have been shown toincrease in the lungs of infants who died ofSIDS, especially those born to smokingmothers (Pediatrics 98:668, 1996). Amongvarious known risk factors, maternalsmoking during pregnancy has beenindependently associated with SIDS.Nicotine, a major component of cigarettesmoke, may contribute to thepathophysiology of SIDS by interfering withthe function of respiratory controlmechanism components, includingperipheral chemoreceptors.Since the cellular effects of nicotine aremediated via nicotinic acetylcholine receptor(nACh-R) we have investigated its expressionand function in NEB cells using neonatalanimal lung models (hamster, rabbit). Ourstudies have shown: NEB cells express mRNAfor beta2 subunit of nACh-R as shown bynon-isotopic in-situ hybridization; at proteinlevel, nAChR (beta2) was localized to NEB cellmembrane using immunohistochemicalmethods; dose dependent inward currentwas elicited by application of nicotine (5-100microM) to NEB cells, using whole-cell patch-clamp method on fresh lung slicepreparation; cultures of NEB exposed tonicotine (100 microM) for 3 days showeddiminished response to acute hypoxiadefined by reduced serotonin releasemeasured by HPLC.Chronic nicotine exposure, via activation ofnACh-R may compromise the function of NEBas airway O2 sensor, in addition to carotidbody chemoreceptors and brain stemneurons, and increase the vulnerability ofinfants to SIDS.

Supported by grants from Can. Fund. for Study ofInfant Death, Ontario Lung Assoc. and MRC

10THE SMOKECHANGE PROGRAMME:SUCCESSFULLY CHANGING SMOKINGIN PREGNANCYRodney FordCanterbury Health Limited, NZSmokeChange is a personalised interventionstrategy to reduce tobacco smoke exposureto pregnant women and the foetus. Wereport on the process and outcomes of theparticipants.Background: Traditionally, smokingintervention programmes have focused oncessation. However, this approach is largelyineffectual for those with little desire to stop.SmokeChange was developed to be relevantfor all pregnant women who smoke: itpromotes personalised interventions thatconsider each woman’s readiness for change.Method: A cross-section of general medicalpractices, randomly selected, agreed toregister all pregnant women withSmokeChange. Smoking women werecontacted by a SmokeChange Educator, whovisited them at home. The Educator workedwith women and their families for up to 12months to support cognitive, environmentaland behavioural changes to smoking.Results: GPs registered 1,390 pregnantwomen. Current smoking was reported by437 (31.4%), of whom 352 expressed interestin the programme. Some 209 (47.8% ofsmokers) chose to enrol with theSmokeChange intervention programme and,of these, 149 women (34.1% of smokers)continued with the programme for at leastfour visits.Cessation: For this latter group, 28 (18.8%)reported that they had stopped smoking bytheir last visit in pregnancy. This self-reported cessation was supported bycotinine measurements. Quit attempts:another 26 (17.5%) reported at least onecessation attempt and reduced their smokingby 63%. The remaining 95 (63.8%)Continuing smokers reduced their smokingby 40%. Substantial smokefree environment(homes and cars) changes were also made.Conclusion: The SmokeChange approach(personalised interventions matched toindividual readiness for change) was bothacceptable to pregnant women and enabledparticipants to reduce tobacco toxinexposure to their developing infant.

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11HOW SUCCESSFULLY ARE BABIESPROTECTED FROM PASSIVE SMOKINGA BIOCHEMICAL VALIDATIONRodney FordCanterbury Health Limited, NZAim: To measure and compare the level ofenvironmental tobacco smoke exposure (ETSor passive smoking) in two groups of infants;one group having mothers that were givenregular SmokeChange advice while thesecond group received standard antenatalcare.Research Design: ETS exposure wasexamined in 85 infants: 36 SmokeChangeinfants and 49 control infants. The infantswere studied at 6 months of age. ETS wasassessed using a structured questionnaireand two biochemical measurements: theurine cotinine/creatinine ratio (short-termexposure) and hair nicotine concentration(long-term exposure).Results: There were no significantdifferences found between the SmokeChangeand control groups in any of the ETSmeasures. Overall, the questionnairerevealed that 75/85 (88.2%) infants wereexposed to ETS, with mothers contributinghalf of all exposure. The median ETSexposure to the infants was estimated at 2.4cigs/day (Q1=0 Q3=5.6) with 1.2 cigs/day(Q1=0 Q3=2.7) coming from the mother.Based upon the cotinine/creatinine ratio,evidence of short-term ETS exposure wasobserved in 66/81 (81.5%) infants, andbiochemical assay of hair nicotine revealedthat 44/63 (69.8%) of infants sufferedprolonged ETS exposure. Increased maternalsmoking consumption levels were associatedwith an increased likelihood of biochemicalevidence for ETS exposure.Conclusions: Over two thirds of infants hadbiochemical evidence of long-term ETSexposure. The source of ETS was primarilyfrom the mother. Much more needs to bedone to protect infants from ETS exposure.

12BED SHARING, COT DEATH ANDPUBLIC HEALTH POLICY – THE NEWZEALAND EXPERIENCERobert ScraggUniversity of Auckland, New ZealandMany parents bed share with their new borninfant, particularly in non-Europeanpopulations. Results from the New ZealandCot Death Study, published in 1993, revealedan interaction between maternal tobaccosmoking and bed sharing on the risk of the

sudden infant death syndrome (SIDS). Theeffect of the interaction was to make bedsharing a strong and statistically significantrisk factor of SIDS among infants withmothers who smoked, but not among infantsof non-smoking mothers. This finding hasbeen confirmed by case control studies inEngland, Scotland, the USA and by a furtherNew Zealand study.A meta-analysis of results from previouscase control studies produced a summarySIDS relative risk associated with bed sharingof 2.06 (95% confidence interval: 1.70, 2.50)for infants of smoking mothers. Thus, thereis strong evidence now that bed sharing is amajor risk factor for SIDS for infants whosemothers smoke. Public health policy shouldbe directed against bed sharing by theseinfants, since they carry an increased SIDSrisk from bed sharing additional to theiralready increased risk from maternalsmoking.In contrast, it is unclear from previousreports whether bed sharing is a risk factorfor infants of non-smoking mothers sincemost individual studies have not found asignificant (p>0.05) increase in SIDS risk forthese infants. A meta-analysis of previouscase control studies produced a summaryrelative risk associated with bed sharing of1.42 (1.12, 1.79) for infants of non-smokingmothers. Thus, bed sharing appears to be aweak risk factor for SIDS when the motherdoes not smoke. For these infants, who havea low absolute SIDS risk, the 40-50% increasein risk needs to be balanced against otherperceived benefits from bed sharing, suchas increased breast feeding.

In New Zealand, attributable riskcalculations have helped in setting publicpolicy on bed sharing. Only a smallproportion of the SIDS deaths attributed tobed sharing (11%) occur in infants of non-smoking mothers. These deaths make uponly 3% of all SIDS deaths but come from28% of the total infant population. Incontrast, 26% of all SIDS deaths can beattributed to bed sharing among infants ofsmoking mothers, who comprise 16% of thetotal infant population. Thus, extending thecurrent policy against bed sharing, which istargeted at infants of smoking mothers, toall infants would potentially save an extra3% of deaths. But, if public attitudes arefavourable to bed sharing, there could be amarginal cost (against accepting a policy notto bed share) by including infants of non-smoking mothers in the recommendation notto bed share, since in New Zealand theycomprise 28% of the total infant population.

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13Potential Benefits of Mother-InfantCosleeping in Relationship ToReducing SIDS: Let’s Not Throw Outthe Baby With Dangerous Beds orDangerous CosleepersJames J. McKennaUniversity of Notre Dame and Mother-Baby Behavioral Sleep LaboratoryThe biological and social appropriateness ofmother-infant cosleeping is illustrated bydevelopmental, clinical, andpsychobiological data, as well as findingsfrom our three separate laboratory studiesof mother-infants bedsharing (one form ofcosleeping). Mother-infant cosleepingevolved to protect and feed infantsthroughout the night. Millions of mothersworldwide know that strong emotionsunderlie and motivate co-sleeping, eventhough they may be unaware of co-sleepingas a biologically appropriate arrangementwhich, in turn induces important behavioraland physiological changes in both infantsand mothers. These changes have been reported inextensive peer-reviewed laboratory studiesand include increased use of the safe, supineinfant sleep position, increasedbreastfeeding, increased infant movement,arousal and awakenings during sleep,reduced deep and increased light sleep, moreaffectionate and protective maternalinterventions, increased sensitivity to thepresence of the co-sleeping partner, reducedinfant crying, fewer (infant) obstructiveapneas in deep sleep, longer infant sleep,and more positive evaluations by bedsharingmothers of their nighttime experiences.Many of these findings support ourcontention that in otherwise safe cosleepingconditions, cosleeping, and cosleeping in theform of bedsharing, ought to help someespecially arousal deficient infants resist aSIDS. Still, bedsharing remains controversialin the United States as evidenced by theConsumer Product Safety Commissionerannouncing to the American public that: “theonly safe place for an infant to sleep is in acrib”. I will show how and why this statementis wrong, and how her role in the controversybeautifully illustrates the extent to whichpersonal social ideologies are regularlypassed off to the public as proven scientificfacts, in this area of research.

14COSLEEPING – A PATHOLOGIST’SPERSPECTIVE.RW ByardForensic Science Centre, Adelaide,Australia‘Cosleeping’, or the shared sleeping of anadult with an infant, has been an emotiveand difficult issue. There is no doubt thatshared sleeping provides an opportunity forenhancing parent-infant bonding, as well asincreasing opportunities for breast feeding.There is also evidence that shared sleepingmay provide increased stimulation of aninfant thereby enhancing neurologicalmaturation. In addition, cosleeping is awidespread practice within manycommunities with few reported problems.However, it must be recognised that rarecases do occur where an infant has died fromaccidental suffocation due directly to theadverse effects of sleeping in the same bedas an adult. Soft bedding, heavy covers,overweight, sedated or intoxicated parents,or simple parental fatigue are all factorswhich logically should increase the risk ofaccidental asphyxia. Certain infants also donot show normal arousal responses whentheir airways are occluded.Problems that arise for the pathologist aretwofold. Firstly the autopsy findings in suchcases are invariably identical to those foundin SIDS. There has been disturbance of thescene and no coherent history may beavailable of the position of the infant whenfound. Airway compromise may also occurwithout a parent lying directly over an infant.Problems also arise when there may havebeen other young children in the bed at thetime of the death whose positions during thenight are not determinable. Thus, thediagnosis of accidental asphyxia may simplynot be possible. The second major problem that arises forpathologists is convincing colleagues that‘overlaying’ is a real, albeit rare, entity. Forexample, a case where a young infant wasfound dead in bed with two parents who hadbeen markedly intoxicated, and whosemother stated that she had not been awarethat she had been ‘sleeping on him’ was notaccepted as anything but a ’SIDS’ death byseveral clinical colleagues. Hospital staffhave challenged the concept of death due tooverlaying by stating that they coslept withall of their children, and so there can be norisk. The risk is not, however, absolute andit is well recognised that the majority ofinfants survive – however, some do not.For this reason further studies are needed

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to help us to define potentially dangerouscosleeping environments and perhaps toalso identify infants who may be at increasedrisk. Pathologists have a duty to provideparents with the most accurate assessmentof the circumstances leading up to theirinfant’s death and the subsequent autopsyfindings and conclusions. It is not our roleto ‘protect’ parents from our conclusions –rather we should be trying to help them tounderstand them as clearly as possible. Italso does not help the broader issue ofcommunity safety if potentially dangeroussituations are not identified and dealt withappropriately.

15WHERE SHOULD BABIES SLEEP, ALONEOR WITH PARENTS?PS Blair, PJ Fleming, IJ Smith, M WardPlatt, J Young, P Nadin, PJ Berry, JGolding, and the CESDI SUDI researchteamInstitute of Child Health, University ofBristol, Bristol BS2 8BJ, UKWhilst the benefits of the supine sleepingposition for infants are now clear, there isno consensus on where the infant shouldsleep in relation to the parents. The risksassociated with different sleepingenvironments and sudden infant deathsyndrome (SIDS) has been investigated.Methods A three year case-control studyconducted in 5 of 14 Health Regions inEngland (population ~ 17 million, 500,000livebirths). Parental interviews wereconducted for each infant who died and forfour controls matched for age and time ofsleep. Ascertainment was over 90% [1][2].This analysis includes 325 SIDS and 1300matched controls.Results In the multivariate analysis infantswho bed-shared and were then put back intheir own cot were not at an increased risk(OR=0.67 [95%CI:0.22-2.00]). There was anincreased risk associated with those whobed-shared for the whole sleep or were takento and found in the parental bed (OR=9.78[95%CI:4.02-23.83]), infants who slept in aseparate room from their parents (OR=10.49[95%CI:4.26-25.81]) and infants who shareda sofa (OR=48.99 [95%CI:5.04-475.60]). Therisk associated with being found in theparental bed was not significant for olderinfants (>14 weeks) or for infants of non-smoking parents. Certain risk factorsspecifically associated with the cotenvironment (e.g. prone position, head-covering) served to increase the significanceassociated with bed-sharing. In a more

restricted a priori model controlling forrecent maternal alcohol consumption (>2units), duvet covers (>4 togs), parentaltiredness (infant slept =4 hours for longestsleep in previous 24 hours) and overcrowdedhousing conditions (>2 people per room ofthe house), bed-sharing became non-significant.Conclusions There are certaincircumstances when bed-sharing should beavoided, particularly relevant for infants lessthan 4 months old. Sofa-sharing with infantsshould always be avoided. There is noevidence that bed-sharing is hazardous forinfants of non-smoking parents.

1 Fleming PJ; Blair PS; Pollard K, Platt MW, Leach C,Smith I, Berry PJ, Golding J. Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999;81:112-116.2 Leach CEA, Blair PJ, Fleming PJ, Smith IJ, PlattMW, Berry PJ, Golding J. Epidemiology of SIDS andexplained sudden infant deaths. Pediatrics1999;104:e43

16BED-SHARING: A MARKER FORINCREASED CLOSE PHYSICALCONTACTP Buckley1, R Rigda2, IC McMillen1

Department of Physiology, University ofAdelaide, South Australia 50051

Gastrointestinal Investigations Unit,Royal Adelaide Hospital, South Australia50002

The conditions under which bed sharing isor is not an independent risk factor for SIDSremain controversial. In preliminary studies,we have previously found that bed-sharinginfants appear to experience different child-care practices than their non-bed-sharingcounterparts. In the present study, wehypothesised that bed sharing may act as amarker for increased close physical contactbetween infants and their caregivers. Theaim of this study was to examine therelationship between bed sharing and otherinfant sleep environments in a longitudinalstudy in the first six months of life. A 24hsleep-wake diary was recorded weekly for 38healthy term infants (gestational age 37 - 41wks; 16 male, 22 female) between the 2nd and24th week after birth. Infants were classifiedas bed-sharing (BS) if, at 2 - 12 weeks afterbirth and again at 13 - 24 weeks after birth,their diary records showed two consecutiveepisodes of BS which had a duration of > 4hin one week and >2 h in the other week. Thisdefinition identified 8 BS infants and 30 non-bed-sharing (NBS) infants. When compared,infants in the BS group spent a significantly

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greater number of hours per 24 hours bed-sharing (3.9 ± 0.9) than infants in thecorresponding NBS group (0.17 ± 0.1) andthey also bed shared for significantly moreweeks (BS 18.4 ± 1.3, NBS 4.3 ± 0.9).When the sleeping environment of the BS andNBS groups were compared, we found thatBS infants spent significantly more timeasleep/24h in the carer’s lap or sling, thatis, in close body contact (eg. BS 2.0 ± 0.9 h/24, NBS 0.4 ± 0.2 h/24h at 12 wks). Althoughthe BS group also spent more time room-sharing with parents, this difference was notstatistically significant. However, the BSgroup did spend significantly less timesleeping alone than the NBS group (eg. BS2.6 ± 0.9 h/24h, NBS 7.2 ± 1.0h/24h at 12wks). We conclude that BS infants experiencegreater proximity to, and more close physicalcontact with their caregivers whilst sleepingin environments other than the bed.

17A MAORI PERSPECTIVEDavid Tipene-LeachSenior lecturer in Maori Health,University of Auckland, Auckland, NewZealandThis paper is about the changing messagesgiven by the Maori SIDS PreventionProgramme to their communities in responseto the developing state of knowledgeregarding the risk factors, bedsharing andmaternal cigarette smoking.We outline the progressive development ofrisk factor information about bedsharing andsmoking, starting with the consideration ofthese practices as independent risk factors.We then outline the position of smoking asa confounder for bedsharing and finish withthe identification of in-utero smoking, inparticular, as being of most significance.We trace the step by step refinement of thecorresponding Maori prevention messagesfrom one that did not reject bedsharing, andthus remained within the Maori world view,to one that included other infant sleepingoptions but was careful to mitigate thepotential backlash from Maori womenregarding the challenge to the culturallyvalued practice of bedsharing.

18A REDUCED RISK OF SIDSASSOCIATED WITH THE USE OFDUMMIES (PACIFIERS): FINDINGS OFTHE ECAS STUDY.R.G. Carpenter, P.D. England, P. Fleming,J. Huber, L.M. Irgens, G. Jorch, and P.Schroeder.

London School of Hygiene & TropicalMedicine, London WC1E 7HT, UK.In 1992-3 five major case/control studieswere set up in Europe to reassess SIDS riskfactors. In 1994 the European ConcertedAction on SIDS, ECAS, was funded to bringtogether the data from these and 12 otherstudies. Data on 745 cases and 2411 controlswere assembled from 20 centres. Extensivelogistic regression analysis resulted in amultivariate model using 19 statisticallysignificant variables and 36 parameters andshowed that the corresponding odds ratiosfor SIDS were remarkably homogeneousacross Europe.Substantial data on dummy use wereavailable. Odds ratios for SIDS (95%confidence limits) associated with dummyuse were:

Univariate Multivariate(adjusted for 35factors)

Dummy everused v.not used 0.88 (0.72; 1.06) 0.79 (0.62; 1.00)

Dummy usedin last sleep;Y v N 0.47 (0.36; 0.60) 0.51 (0.38; 0.73)

Univariate analysis suggested an increasedrisk if a dummy is sometimes used but wasnot used in the last sleep. But aftermultivariate adjustment the increased riskwas found to be completely insignificant, p= 0.345. There was no evidence that thereduction in risk associated with dummy usewas dependent on the position in which theinfant was put down to sleep.Calculations of population attributable risksuggest that overall SIDS rates in Europemight be reduced by 31% if dummies wereuniversally always used.

19DUMMY USE ON THE DAY/NIGHT OFDEATH: CASE-CONTROL STUDY OFSUDDEN INFANT DEATH SYNDROME(SIDS) IN SCOTLAND, 1996-99H Brooke, DM Tappin, C Beckett, AGibson.Scottish Cot Death Trust and University ofGlasgow, ScotlandIt has been reported that dummy (pacifier)use may protect against cot death (1, 2).Objective: To investigate the relationbetween infant care practices for SIDSvictims on the day/night of death comparedwith control infants the night beforeinterview, in Scotland.Methods: This was a national study of 159

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infants dying of SIDS (cases) and 229 controlsby means of home interviews comparingmethods of infant care and socio-economicfactors, from 1996-9. Matched multivariateanalysis used conditional logistic regressioncontrolling for: duration of breast feeding,deprivation category, birthweight, parity,maternal age, mother in paid employmentprior to birth, mother’s marital status, agemother left school, mother smokes.Unmatched multivariate analysis also tookaccount of infant age.Results: A dummy was sucked during thelast sleep by 39% (42/108) of SIDS infantscompared with 52% (118/229) of controlinfants on the night before interview (OR,0.59; 95% CI 0.36, 0.96). The protective effectof dummy use remained when multivariateadjustment was made using a matched (OR,0.33; 95% CI 0.15, 0.77) or unmatched model(OR, 0.39; 95% CI 0.20, 0.74).Conclusions: The protective effect ofdummy use against SIDS observed in studiesin New Zealand, England and Holland is alsoapparent in Scotland.

1 Fleming PJ, Blair PS, Bacon C, Bensley D, Smith I,Taylor E, Berry J, Golding J, Tripp J. Environmentof infants during sleep and risk of the suddeninfant death syndrome: results of 1993-5 case-control study for confidential inquiry into still-births and deaths in infancy. BMJ 1996; 313:180-1.2 Mitchell EA, Taylor BJ, Ford RP, Stewart AW,Becroft DM, Thompson JM, Scragg R, Hassall IB,Barry DM, Allen EM, et al. Dummies and thesudden infant death syndrome. Arch Dis Child1993; 68:501-4.

20A PRELIMINARY INVESTIGATIONINTO WHEN AND HOW A PACIFIERFALLS OUT OF A BABIES MOUTHDURING SLEEPPeter WeissInternational Children Medical ResearchAssociation, Birmingham, West MidlandsB30 1BY, UK.A number of reports have indicated that theuse of a pacifier is associated with a reducedrisk of SIDS. Mechanism(s) for such anassociation remains to be understood, butit is likely that any effect occurs during aninfant’s sleep-time. However, it has beensuggested that a pacifier does not remain inthe mouth for any significant length of timeduring sleep.We have therefore carried out thispreliminary study to investigate how oftena pacifier falls out of an infant’s mouthduring sleep and also to observe the reasonsfor dislodgment.

During the course of polygraphic studies,videotape recordings were made of 18healthy infants aged between 13 and 70 days(median = 36). Recordings commenced assoon as the infant fell asleep. The subjectswere allowed to suck on a pacifier which wasreplaced by the attendant if it fell out. Thevideotapes were analysed for the length oftime the subject held the pacifier in itsmouth and how the pacifier becamedislodged.The average length of time an infant kept apacifier in its mouth during sleep was 11minutes. The incidence of retaining a pacifierin the mouth for longer than 30 minutesaveraged 2 per infant during the 3-4 hoursof the recordings. The average maximumduration babies kept the pacifier in themouth was 60 minutes (range 33-132).Half of all pacifier falls occurred during arecognisable sucking state and 67% involveda movement of the infant’s head.Based on these observations it appearsunlikely that a direct influence of pacifieruse on autonomic (e.g. cardiorespiratory)functions may be responsible for thereduced risk of SIDS. Other possibleinteractions, e.g. improved oral clearancefrom bacteria in pacifier users have to beconsidered and remain to be elucidated.

21INFLUENCE OF PACIFIER ON SLEEPCHARACTERISTICS IN HEALTHYINFANTSP Franco,1 S Scaillet,2 S Chabanski,3 JGrosswasser,2 A Kahn.2

Pediatric Sleep Unit, Hôpital Erasme,1

Hôpital des Enfants Reine Fabiola,2

Université Libre de Bruxelles, 3 ATEC,Brussels, Belgium.Objective: To evaluate the influence of apacifier on sleep characteristics in healthyinfants.Patients and method: Two groups ofhealthy infants (median age of 10 weeks)were studied polygraphically during onenight: 36 infants were regular pacifier users,20 never used a pacifier. These infants wereexposed to white noises of increasingintensities during REM sleep. Arousalthresholds were defined by the auditorystimuli needed to induce polygraphicarousals. Spectral analysis of heart rate wasstudied in short segments of REM sleeppreceding auditory stimuli. The highfrequency component reflectedparasympathetic tonus (PS) and the lowfrequency on high frequency ratiocorresponded to sympathovagal balance (OS).

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Results: After 30 minutes of sleep, 56% of“pacifier users” lost their pacifier.Sleep parameters: There were no significantdifferences in sleep parameters between thetwo groups of infants.Arousability: Polygraphic arousals werehigher in “nonpacifier” than in “pacifier”users (p=.010).Autonomic nervous system: “Nonpacifierusers” had less PS (p=.038) and more OS(p=.050) compared to “pacifier users”.Conclusion: Propensity to arouse and PSwere greater in infants who were regularpacifier-users in REM sleep. It has beensuggested that the use of a pacifier reducesthe risk of SIDS. Some stresses known toincrease the risk of SIDS (prone position,high ambient temperature, infants ofsmoking mothers) also favour both anincrease in arousal thresholds and animbalance of autonomic nervous system,such as decrease in PS and/or increase inOS.

22INFLUENCE OF PACIFIER ONAUTONOMIC NERVOUS CONTROL INHEALTHY INFANTSP Franco,1 S Scaillet,2 S Chabanski,3 JGrosswasser,2 A Kahn.2

Pediatric Sleep Unit, Hôpital Erasme,1

Hôpital des Enfants Reine Fabiola,2

Université Libre de Bruxelles,3 ATEC,Brussels, Belgium.Objective: To evaluate the influence of apacifier on sleep autonomic nervous systemin healthy infants.Patients and method: Two groups ofhealthy infants (median age of 10 weeks)were recorded polygraphically during onenight: 36 infants were regular pacifier users,20 never used a pacifier. Autonomic nervoussystem (ANS) evaluated by spectral analysisof the heart rate (HR) and sleep parameterswere studied. The high frequencycomponent of HR spectral analysis reflectedparasympathetic tonus (PS) and the lowfrequency on high frequency ratiocorresponded to the sympathovagal balance(OS).Results: No differences were found in sleepparameters and ANS during the whole nightbetween “pacifiers users” and “non-pacifiersusers”. After 30 minutes of sleep, 56% of“pacifier users” had lost their pacifier.Comparing the “sucking” from the “non-sucking” periods in “pacifier users”, therewas more PS (p=.01) and less OS (p=.02)during the “non-sucking” periods in REMsleep. Comparing the “non-sucking” periods

in “pacifier users” with similar periods in“non-pacifier users”, PS was decreased(p=.038) and OS increased (p=.05) in “non-pacifier users” in REM sleep. These findingswere not found in NREM sleep.Conclusion: It has been suggested that theuse of pacifier reduces the risk of SIDS.Autonomic imbalance such as decreased PSand/or increased OS have been found infuture SIDS victims and in infants exposedto environmental factors known to increasethe risk of SIDS (prone position, high ambienttemperature, infants of smoking mothers).Sucking habits could regulate autonomiccontrol in healthy infants.

23THE IMPACT OF PACIFIER USE ONBREASTFEEDING DURATIONAlison VogelUniversity of Auckland, New ZealandBackground: There has been debate overthe influence of pacifier use onbreastfeeding. Avoidance of pacifier use isincluded as one of the “Ten Steps ToSuccessful Breastfeeding” promoted by theWHO and UNICEF. Only some studies haveadjusted for potential confounders.Objective: To determine predictors ofpacifier use in the first year of life and toassess the influence of pacifier use on theduration of breastfeeding,Study Design: We conducted a prospectivecohort study. Three hundred and fiftymother-infant pairs were followed to oneyear of age to determine the impact of theuse of a pacifier on the duration ofbreastfeeding.Results: Daily pacifier use was associatedwith early cessation of breastfeeding (RR1.71, 95% CI 1.29, 2.28) and a reducedduration of full breastfeeding (adj RR 1.35,95% CI 1.05, 1.74). Finger sucking was notassociated with a reduced duration ofbreastfeeding (RR 1.05, 95% CI 0.81, 1.37).Pacifier use less than daily was notassociated with a change in duration (RR1.02, 95% CI 0.75, 1.39). Most motherscommenced use of a pacifier within the firstmonth. Multiple logistic regression analysisfound the use of a pacifier was associatedwith male gender (adj RR 1.97, 95% CI 1.23,3.13), maternal smoking in pregnancy (adjRR 2.23, 95% CI 1.01, 4.95), and low maternalconfidence with breastfeeding (adj RR 2.70,95% CI 1.48, 4.93 ).Conclusions. Daily pacifier use isassociated with a reduced duration ofbreastfeeding. Less frequent use does notreduce the duration of breastfeeding.

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24PACIFIER AND DIGIT SUCKINGINFANTS I: MORBIDITY IN THE FIRST18 MONTHSKate North, Peter J. Fleming, JeanGolding and the ALSPAC study team.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UK.Pacifier use is associated with a decreasedrisk of SIDS [1], and is widely believed tosuppress digit sucking in infants, but littleis known of the relative effects of these twoforms of non-nutritive sucking on morbidityin infants.Methods. As part of a continuing cohortstudy (ALSPAC) of 14,000 infants born inAvon, UK, in 1991-2, [2] information wascollected on pacifier use at 4 weeks and 6months, and on pacifier and digit sucking at15 months of age. This was correlated withdata on infant morbidity from birth to 18months of age.Results. Pacifier use fell from 58% in infantsat 4 weeks to 49% at 6 months and 36% at 15months; it was most prevalent amongstinfants of younger, more deprived mothers,who smoked and did not breast feed.Adjusting for these factors, pacifier use wasassociated with a higher prevalence ofrespiratory (cough, wheeze, apnoea),gastrointestinal (vomiting, diarrhoea, colic),and other morbidity (e.g. earache, fever,excessive crying) throughout the first 18months. At 15 months, 21% infants suckedtheir thumb or finger, and 2% sucked both apacifier and a digit. Finger or thumb suckingwas most prevalent amongst infants of non-smoking, older mothers, who breast-fedmore than 4 weeks. In a multivariateanalysis, infants who sucked a digit alonewere less likely than pacifier users to havehad earache or to have seen a doctor as anemergency, and more likely to have a regularsleeping pattern. Morbidity was generallyhighest amongst those infants who suckedboth a pacifier and a digit.Conclusions Despite its association with alower risk of SIDS, pacifier use is associatedwith significantly higher morbidity ininfancy, than for infants not given a pacifier,particularly for those who also suck a fingeror thumb.

1. Fleming PJ, Blair PS, Pollard K, Platt MW, LeachC, Smith I, Berry PJ, Golding J. Pacifier use andSIDS - Results from the CESDI SUDI case-controlstudy. Arch Dis. Child 1999; 81: 112-116. North K, Fleming P, Golding J. Pacifier use andmorbility in the first six months of life.Pediatrics;1999:103:e34

25NON-NUTRITIVE SUCKINGBEHAVIOURS IN CHILDREN FROMBIRTH TO TWOA NowakUniversity of Iowa, Colleges of Dentistryand Medicine, 201 Dental Science Bldg. S.Iowa City, IA 52242-1001, USASucking behaviors in infants and youngchildren are derived from the physiologicalneed for nutrients. Current understandingof child development suggests that suckingbehaviors also arise and are continued inpart from psychological needs. Thus,normally developed infants have aninherent, biological drive for sucking. Thisneed for sucking can be satisfied throughnutritive sucking, including breast andbottle-feeding, whereby the infant obtainsfood, or through non-nutritive sucking onobjects such as digits, pacifiers or toys thatmay serve primarily to satisfy psychologicalneeds. While sucking behaviors are normalin infants and young children, prolongedduration of such behaviors may haveconsequences in regard to the developingorofacial structures and occlusion.We have been following non-nutritive andnutritive sucking in infants and youngchildren in a series of longitudinal studiessince 1980. Although there have been manyretrospective reports describing the effectsof habits on dental relationships there havebeen few, if any, prospective longitudinalstudies. Also claims are made bymanufacturers of artificial nipples andpacifiers on the advantages of their productson the development of oral structures.Professionals are frequently questioned byparents to provide recommendations forearly feeding methods as well as how tosatisfy the infant’s sucking reflexes.Additionally, although there is someinformation available regarding theprevalence of sucking behavior, there isrelatively little known about the patterns ofnutritive and non-nutritive sucking behaviorin normal infants and young children.It will be the intent of this presentation topresent longitudinal information on theprevalence of sucking behaviors from a largesample of infants and toddlers. Additionally,information will be provided on thediscontinuation of non-nutritive suckingbehavior of infants and toddlers. Finallyinformation on the effect of non-nutritivesucking on growth and development of theteeth and jaws will be demonstrated.

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26THE FUTURE OF SIDSORGANISATIONSJoyce EpsteinFoundation For The Study Of InfantDeaths (FSID), London, UKIn 1996 the Foundation for the Study ofInfant Deaths held a press conference inLondon to announce its future direction. Tofind the causes and prevention of SIDS, thefuture lies in broadening the work to focus,paradoxically, not solely on SIDS, but thewider field of infant death and infant health.The paper will describe the processes FSIDwent through that led to that decision andthe reasons why. The reasons were not just,as suggested above, dictated by the needsof research, but also included changes inpublic perceptions of FSID’s work andchanges on the environment within whichFSID was operating. The paper will show howthe organisation’s work has subsequentlyevolved, and continues to evolve, inresponse to the unique challenges that SIDSorganisations face in scientific research,family support and public informationcampaigning.

27THE FUTURE OF SIDSORGANISATIONS: AN AUSTRALIANPERSPECTIVEKaarene FitzgeraldSIDSaustraliaMost Australian SIDS Organisationscommenced independently in the late 1970’swith different names. There are now nine,still independent, organisations whoformerly joined together in 1990 in afederated body called SIDSaustralia to runthe Red Nose Day campaign, centrally fundresearch and produce national educationalmaterial. Support programs are undertakenlocally through the state/territory SIDSOrganisations.For several years a national office wasoperated with the charter of developing andimplementing national aims and objectives.This mode of management was unsuccessfuldue to a lack of understanding of localrequirements and lead to a major nationalstrategic planning process. A successfulsystem of subcommittees was implemented.This then lead to another new beginning.Now, with reducing numbers of SIDS deaths,less interest by researchers and cliniciansand increased competition from other non-profit organisations the need to present aunified and fresh approach is apparent.

There have been many changes, some minorand some major. In December 1998 it wasagreed all organisations would alter theirname to reflect their state/territory eg theSudden Infant Death Research Foundationbecame SIDSvictoria. And, in 1999 it wasagreed that services would be expanded tosupport the families of all children up to theage of six who died suddenly andunexpectedly regardless of cause.A new strategic planning process hasrecently been undertaken by one of theNational Directors and the nine ChiefExecutive Officers. Main issues surroundhow can the image of “one group, one voice,undertaking a wide range of programs” bedeveloped with autonomy still remaining ata local level. This paper will describe theprocesses followed to date and expectedoutcomes.

28ESTABLISHING AN ECONOMIC BASISFOR THE NORWEGIAN SIDS SOCIETYTor G. Hake.Secretary General, Norwegian SIDSSociety, Oslo, NorwaySince 1995, the Norwegian SIDS Society hasbeen able to carry out its tasks based on asolid economic foundation. The NorwegianMinistry of Health provides the organizationwith an annual contribution which coversapproximately one third of theadministration costs. But our main sourceof income has been fundraising throughnation-wide telemarketing. This economicbasis has enabled us to support nationalresearch on SIDS with more than US $2Mthroughout the nineties.In addition to funds generated fromtelemarketing, we have receivedconsiderable support from The NorwegianFoundation for Health and Rehabilitationwhich we have then distributed to variousrecipients. This funding has been used formedical research, nation-wide informationof risk factors and bereavement support.Our financial condition allows the NorwegianSIDS Society to not only keep a full-time staffof five, but also to contribute substantialsupport to several international projectssuch as the SIDSI News and to participateactively on international conferences.As we know that fund raising is among themajor problems for SIDS parents societiesin several other countries, we would like toshare our experiences in this area.

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29FUTURE DIRECTIONS INBEREAVEMENT SUPPORT FOR SIDSORGANISATIONSB. Anne GiljohannSIDSvictoria, Melbourne, AustraliaThe ‘model of service’ provided atSIDSvictoria by the partnership ofprofessional social workers and trainedvolunteer parent supporters, has beendeveloped and refined in response toparents’ wishes over many years. Thecombination of professional counselling andpeer support provides an excellent servicewhich is based on both up-to-date theoreticalknowledge, and the experiential knowledgethat comes from shared experience. Thisstaff mix enables a variety of opportunitiesand styles of support to be offered tobereaved families, according to their needs.Key components of this ‘model of service’will be detailed in this presentation.The dramatic reduction in the number ofchildren dying of SIDS as a result of theReducing the Risks of SIDS health promotionprogram, has enabled SIDSvictoria to trial aninnovative extension of its service. Thisextension of the outreach crisis and ongoingbereavement support service targets a widergroup of Victorian families whose childrenof six years and under die suddenly andunexpectedly from drowning, poisoning, afast-onset illness, a motor vehicle accident,through a fire, homicide or in some otherway. Surprisingly there has been no similarsupport offered to these families at the timeof their child’s death. Of course SIDS familiescontinue to receive the same support. In1993 a pilot program was initially set up ina regional Victorian city, in which theSIDSvictoria ‘model of service’ was offeredto families whose children had diedsuddenly and unexpectedly in a variety ofways. Following the success of this project,SIDSvictoria formally extended itsbereavement support service in 1997, andin June 1999 the ‘member organisations’comprising SIDSaustralia agreed to a similarextension of bereavement services.

30DEVELOPING A STRATEGIC ALLIANCEWITH THE PRIVATE SECTOR TOINCREASE PUBLIC AWARENESS ONSIDSF Chapman, DJ KeaysThe Canadian Foundation for the Studyof Infant Deaths,Toronto, Ontario,Canada

The mandate of the Canadian Foundation forthe Study of Infant Deaths (SIDS Foundation)includes working with Canadians to promotepublic awareness about SIDS. Our riskreduction campaign is called Back to Sleep.Campaign materials have been distributedto hospitals, health care professionals,public health units and daycares across thecountry.The feedback we received from our SIDS toll-free telephone line suggested that we neededto reach secondary caregivers (i.e.grandparents and babysitters) with the riskreduction message. Many callers also feltwe needed to adopt additional strategies toreach both health care professionals and newparents.The Foundation met with Procter and Gambleto discuss a partnership, with the goal ofincreasing awareness of SIDS. The companyhad already placed the SIDS toll-free numberon its “Pampers” packaging for newborninfants. Procter and Gamble has now agreedto place the “back to sleep” message inEnglish, French and Spanish on all diapersfor babies up to one year of age. In addition,the company has agreed to produce door orcrib-hangers carrying the risk reductionmessage, as a reminder for all parents andsecondary caregivers. Proctor and Gamblewill sponsor an ambitious marketingcampaign, which will include redevelopmentof the Back to Sleep brochures, TVinfomercials about SIDS, the hiring of aleading spokesperson for the SIDS campaignand finally, the distribution of SIDSinformation in all prenatal and newbornhospital packages distributed to parents.In support of the proposed campaign, theFoundation has identified the need foradditional background materials and animproved website in order to accommodateincreasing levels of interest and mediaenquires. The Foundation is currentlyworking with both private and public sectorpartners to develop and fund these projects.An initial partnership with Procter andGamble was successful and this allowed theFoundation to feel confident in seeking tobroaden the base of this alliance. In thiscase, the desire of Procter and Gamble to tapthe market of young families was matchedto the Foundation’s goal of increasing SIDSawareness at little or no cost to its members.

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31DECLINING SIDS RATE IN JAPANCORRESPONDS TO REDUCTION OFRISK FACTORSS. Fukui1 , T. Sawaguchi2, H Nishida2,Takeshi Horiuchi MD3

SIDS Family Association Japan1, TokyoWomen’s Medical University2, St MariannaUniversity School of Medicine, Yokohama3,JapanAfter a SIDS prevention campaign in Japan,a reduction of SIDS risk factors has beenobserved with a corresponding reduction inthe SIDS rate. The SIDS family AssociationJapan started a prevention campaign bydistributing information on risk factors tomedical professionals from mid 1996 and apamphlet for new and expectants mothersfrom mid 1997. Because of the results of agovernment study on SIDS cases, theJapanese Ministry of Health and Welfare hasfully endorsed the SIDS prevention campaignin Japan since mid 1998.In the winter of 1996/97 the SIDS FamilyAssociation Japan and the National SIDSResearch Group carried out the InternationalChild Care Practices Study. Two years later,in the winter of 1998/99 the SIDS FamilyAssociation took another sampling with thesame survey. The text of the questionnairewas supplied by the SIDS Global StrategyTask Force and translated to Japanese. Thesesurveys were distributed in four hospitalsin Yokohama and Tokyo and resulted in atotal of 289 completed surveys in 1996/97.In 1998/99 the surveys were distributed inone hospital in Yokohama only with aresulting 49 completed surveys.

96/97 (96/97 98/99Yokohama Total YokohamaSurvey Surveys) Survey

Sleep PositionProne 4.2% (6.3%) 2%Side 10.5% (4.9%) 2%Back 85.3% (88.8%) 96%SmokingMother 9.4% (9.3%) 0%Father 47.9% (49.8%) 51%BreastfeedingFormulaonly 10.4% (19%) 8%

Preliminary figures show the SIDS rate inYokohama City at 0.15 per 1000 live birthsin 1998. The government figures for thenationwide SIDS rate in Japan are as follows(birth to one year): 0.44 in 1995, 0.39 in 1996and 0.41 in 1997. Preliminary figures for1998 for birth to two years shows the SIDS

rate has dropped to 0.33 which represents adecrease of 24%.

32DEVELOPMENT OF FSID’S REGIONALPROGRAMME 1990-2000Ann Deri-BowenFoundation for the Study of Infant Deaths(FSID), 14 Halkin Street, London, UKThe regional development programmedeveloped from a pilot study whichidentified the following needs:• More guidance and training for volunteers.

The opportunity for volunteers toexchange ideas and feel less isolated.

• Identification of support available forbereaved parents in the regions

• More information for professionals.By 1990 the Foundation for the Study ofInfant Deaths (FSID) had appointed a parttime, paid, coordinator for each of the fifteenRegional Health Authorities in England andWales. Regional population ranged from 2.5.– 5 million covering 8 – 22 districts perregion. The coordinators worked 12 hoursper week from home.The presentation will show what impactregional development had on the work of theFoundation and the changes that evolvedduring the ten year period. It will include:• The need to redefine the regions from 15

to 13 and increase the number of workinghours from 12 to 14 each week

• The way in which the limited hours haveshaped the job description

• Changing pattern of FSID Groups ofFriends from 101 in 1990 to 140 at its peakin 1992 and down to 63 in 1999

• Change of befrienders and befriendersupport from 600 untrained befriendersin 1990 to 383 trained befrienders in 1999

• Development of the Care of the Next Infantproject from 51 centres in 1990 to 172centres in 1999

• Department of Health funded project tovisit every Accident & Emergencydepartment

33CONSENSUS ON PREVENTION LEADSTO MINIMAL INCIDENCERM HopmansStichting Wiegedood, The NetherlandsThe Netherlands today is proud of the lowestcot death incidence in western countries:0.14 per 1000 livebirths, 28 cases (<1 year)in 1998. (Central Bureau of Statistics).Significant progress has been made eversince the peakyear of 1984: 1.22. (1987: 0.91;1992: 0.41; 1995: 0.26; 1997: 0.17).

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This encouraging progress resulted from:1. concentration on epidemiologically foundrisk factors and translation of the findingsinto preventive recommendations.2. national consensus amongst all medicaldisciplines, starting with the back to sleepadvice in 1987.3. the widely spread dissemination of eighteasy to follow recommendations tailored tospecific conditions in the Netherlands (alsoto customs of ethnic minorities) andincorporated in the policies of the nationalinfant welfare system covering a largemajority of all infants.The 8 points are: sleep position, overheating,bedding, roomsharing, smoking, breastfeeding and dummy, sedatives, rest androutine.Since the early eighties, encouraged by aparents’ organisation, a small number ofphysicians with unflagging energy keptfocussing on cot death. In 1996, when ECAS(European Concerted Action on Sids) and thereport of the National Consensus onPrevention had drawn maximum attention,the Dutch Foundation for the Study of InfantDeath (Cot Death Foundation) wasestablished by volunteer professionals ofdifferent disciplines (medical, research,media, accountancy, law). A strategy forfurther reduction of incidence wasdeveloped, aimed at completion andintensifying of the 8 points above, supportedby meticulous study of remaining cases.We are possibly reaching a minimal‘unavoidable’ hard core incidence, estimatedat ± 0.10/1000. These may comprise:secundary prone position, smoking,extremely adverse social and psychologicalcircumstances, total lack of information,accidental death including infanticide,inability to provide care. This will not be easyto cope with. Yet efforts should be made inorder to reach out to these infants at greatrisk.

34KITS FOR KIDS – RESOURCES FORBEREAVED CHILDRENWendy ClaridgeSIDSvictoria, Australia“How do we help our other kids?” is acommon concern expressed by bereavedparents for their surviving children.SIDSvictoria established a Children’sProgram in 1993. The program developedout of this common concern expressed byparents and out of a need expressed by agroup of bereaved children.

The aims of the program are:· To acknowledge children’s grief and

resource their needs.· To provide diverse opportunities for

young people to meet together tonormalise their grief experience.

· To explore relevant ways for children toexpress their feelings and tell their stories.

· To encourage sensitive and understandingresponses to bereaved children byproviding information and support togrieving parents and the community.

Children have opinions, attitudes and theirown understanding of what has happenedin their lives. “I hate that Zoe was alive andthat I never saw her. But the happy thing isthat you (Mum) had two babies.” Tully 5. Theacknowledgement of their feelings and theright to express their stories is afundamental premise of the program.Resourcing the needs of bereaved childrenwithin the context of their family has becomean integral part of family support. The rangeof resources developed allows for individual,age appropriate materials to be madeavailable to children. Through the programchildren are empowered with theresponsibility to help in the development ofresources. This generates a unique, inbuiltintegrity - children resourcing andsupporting children.This paper will describe the development ofresources with and for bereaved children andthe application of these resources.

35CHANGES IN THE EPIDEMIOLOGICALPATTERN FOR SUDDEN INFANTDEATH SYNDROME (SIDS) IN SOUTH-EASTERN NORWAY 1984-1998Marianne Arnestad, Marie Andersen,Åshild Vege, Torleiv O. RognumInstitute of Forensic Medicine, Universityof Oslo, National Hospital of NorwaySince 1990 the SIDS rate in Norway decreasedfrom 2.4 to 0.6 per 1000 live births, beingstable after 1993. The prone position is stilla major risk factor, but as the number ofinfants found dead in this position hasdecreased, other less dominant risk factorshave become more visible. The objective ofthis study was to analyse possible changesin risk factors for SIDS during the last 15years.In a case-control study questionnaires weredistributed to 203 SIDS parents and 538control parents in the south-eastern regionof Norway. Factors related to pregnancy,birth, first year of life and time of death wererecorded.

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Before 1989 91% of the SIDS victims werefound in a prone position, while the figurenow is 55%. Only 10% of SIDS victims and 2%of controls now usually sleep prone. Somerisk factors seem stable despite the changein rate and decline in prone position, suchas cold last week (47%) and face covered(34%). More SIDS mothers than controlmothers smoke during pregnancy in thewhole period (OR 2.93, CI 2.77,3.13). Neverusing a dummy still seems to increase therisk for SIDS (night-time use 0-2 months OR1.82, CI 1.70,1.95), but no significantdifference was found for dummy sucking (OR1.98, CI 0.90,4.35).In the last years though, some changes areseen. An increasing number of SIDS victimsare found dead while co-sleeping (previouslyno difference; after 1993 OR 3.1, CI2.61,3.67). In the last three years 42% of theSIDS victims were found dead while co-sleeping while only 25% of controls used toco-sleep. Breastfeeding no longer shows anysignificant difference. More SIDS victimshave mothers under the age of 25 (since 1993OR 5.37, CI 3.97,7.24), and finally fewer SIDSvictims are found outdoors (24% until 1992,after 1993 8%).

36A STUDY OF PREGNANCY OUTCOMESWITHIN WESTERN AUSTRALIANFAMILIES IN WHICH A SUDDENINFANT DEATH SYNDROME (SIDS)DEATH OCCURRED.M Croft,1,2 A Read,2 C Bower,1,2 M Hobbs,1

N de Klerk1

Department of Public Health, Universityof Western Australia, Nedlands, WA,Australia 6907,1 TVW Telethon Institutefor Child Health Research, PO Box 855West Perth, WA, Australia 6872.2

Background: Midwives’ records ofWestern Australian (WA) births are routinelylinked to registrations of births and deathsfor infants delivered from 1980 to 1996, andthen linked to WA health data to create alongitudinal record for each infant.Objective: To compare the rates ofoccurrence of birth defects and otherpregnancy outcomes in SIDS infants andtheir siblings, with the rates in families inwhich there was no SIDS death.Methods: Probabilistic record linkage wasused to identify siblings using maternalinformation routinely recorded on themidwives’ record for births during 1980 to1992.

Results: Linkage of records of births in WAfrom 1980 to 1992 (n=310,255) resulted inthe formation of 181,133 sibships. Data forthose women (n=53,734) whose firstpregnancy occurred during 1980 to 1991,and who had at least two singleton birthswere analysed. The rates of occurrence ofbirth defects and death from other causesduring infancy or early childhood werefound to be similar in SIDS families to otherfamilies (of the same size).Conclusions: The rates of occurrence ofbirth defects and deaths from other causesin infancy and early childhood, in thefamilies in which SIDS infants were born, donot appear to be greater than those in otherWA families, of the same size. However,further record linkage is required to obtainthe population sizes needed to drawconfident conclusions.

37EPIDEMIOLOGY OF SUDDEN INFANTDEATH SYNDROME (SIDS) IN THETYROL BEFORE AND AFTER ANINTERVENTION CAMPAIGNU. Kiechl-Kohlendorfer1, U. Pupp1, E.Haberlandt1, W. Oberaigner2, W. Sperl3.Department of Paediatrics, University ofInnsbruck1, Medical Data Registry, Universityof Innsbruck2, Children’s Hospital, LKASalzburg, Austria3.We investigated the epidemiology of suddeninfant death syndrome (SIDS) in the Tyrol, awestern part of Austria, before and after anintervention campaign.Descriptive characteristics and risk factorsof SIDS before the campaign were assessedin a retrospective case-control study (1984to 1994). In April 1994 a country-wideinformation campaign on modifiable riskbehaviours was initiated. Afterwards weprospectively collected data on childcarepractices for all infants born in the Tyrol(participation rate 72%; n=28,361) andevaluated new SIDS cases (1994 to 1998).SIDS incidence decreased from 1.83 (averageincidence 1984-1994) to 0.4/1000 live birthsimmediately after the campaign andremained at this level until 1998. Thefrequency of maternal smoking duringpregnancy declined (22.9% vrs. 14.5%,p<0.01), as did the prevalence of the pronesleeping position (53.7% vrs. 5.4%, p<0.001)and of non-breastfeeding (21.3% vrs. 6.7%,p<0.001). All these variables were prominentrisk factors of SIDS before the campaign andremained significant thereafter. On accountof the marked decrease in the prone sleepingposition, smoking became the most

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prevalent SIDS risk factor. The side sleepingposition significantly increased (5.1% vrs.36.4%, p<0.001) and the social status ofmothers of SIDS infants tended to be lowerthan before the campaign. The clear winterpreponderance of SIDS evident before thecampaign disappeared or even reversed.Our study documents the long-term efficacyof a low-cost intervention campaign in theform of health education. Further effortshave to be targeted at the sociallydisadvantaged, thereby focusing moreattention on maternal smoking andavoidance of the side sleeping position.

38CURRENT RISK AND PREVENTATIVEFACTORS IN THE NETHERLANDS,1995-1999MP L’Hoir, AC Engelberts, GA de JongeUniversity Medical Centre Utrecht,Utrecht, The Netherlands; LeidenUniversity Medical Centre, Leiden, TheNetherlands.In the Netherlands two studies into cot deathhave been conducted since 1995. In a casecontrol study in 1995-1996 into cot deathwe investigated whether new risk orpreventive factors had emerged. Childrenbetween 1 week and 2 years of age who diedsuddenly and unexpectedly were reported.This study comprised 73 cot death cases andtwo controls per case. Next to well-knownrisk factors, it was demonstrated thatdummy use, independently of other factors,seemed to be a preventive factor for cotdeath. Mouth breathing appeared to beassociated with an increased risk.One general advice given in Dutch well-babyclinics is to gently close the infant’s lips ifthey sleep with their mouth open, whichmight prevent mouth breathing. In 1987 anation wide advice was given not placeinfants prone for sleep. In 1992 the advicewas modified from “not prone” to“exclusively on their back”. In 1990 too muchclothes and bedding were discouraged inorder to prevent overheating. From 1994onwards additional recommendations weregiven, namely discouraging the use ofduvets, pillows and ‘cot-buffers’. In 1996 aconsensus was reached about preventivemeasures including all medical and para-medical disciplines. As a result of the studyin 1995-1996, pacifiers are recommended forthose infants that are bottle-fed. Thesepreventive measures are incorporated in abrochure which is distributed at the Dutchwell-baby clinics.A second study was conducted from

September 1996 to October 1999. TheNational Working Group Cot Death visitedparents of infants that died suddenly andunexpectedly in the age from 1 week to 2years of age. Parents of 80 children agreedto home-interview. No controls are includedin this study, but in the Netherlands everytwo or three years a prevalence study iscarried at well-baby clinics to determine theprevalence of risk factors in the infantpopulation.Results are: Parental smoking (62%), primaryprone sleeping (14%) and use of a duvet (40%)are still important risk factors. Primary pronesleeping is correlated with excessive crying.Since 1995 40% of the cot death cases diedin secondary prone sleeping position (i.e.turned from side or back to prone). Thispercentage remains the same over the years.In 20% of the cases the child did not die athome, but elsewhere, i.e. at the grandparentshouse, baby care centre or hospital.Premature infants and infants with a lowbirth weight are over-represented ascompared to national data. Of these infants25% was placed prone at home and 20% hadused a duvet. The incidence of very lowbirthweight infants (< 1500 gram) andpremature infants (< 32 weeks gestationalage) is nowadays low compared to 1983 (1/1000 versus 1/100), but it remains 6 timeshigher than in the total population (1/6000live born infants). In the cot death cases co-sleeping was only an issue if the infant wasyounger than 4 months. Only a few caseswere placed to sleep with a pacifier the nightbefore they died.The cot death incidence (1wk-<1yr)decreased from from 0.25/1000 live borninfants in 1995 to 0.14/1000 live borninfants in 1998. We conclude that even in alow incidence country further prevention ispossible.

39CURRENT EPIDEMIOLOGY OF SIDS INIRELAND, RESULTS FROM A CASE/CONTROL STUDY 1994-98.Tom MatthewsUniversity College Dublin, Department ofPaediatrics, Dublin 1, Ireland.The aim of this study is to examine currentepidemiological factors associated with SIDSin the Republic of Ireland following ReduceThe Risks of SIDS campaigns in the early1990’s and the associated fall in the SIDS ratefrom 2.1 (1980-90 incl.) to 0.8 (1993-98incl.)/1000 live births. During the 5-yearperiod, 1994-98, 208 infants died from SIDSof whom 163 had a detailed questionnaire

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completed. A similar questionnaire wascompleted for 637 randomly selected controlinfants. Mothers of SIDS cases drank alcoholmore frequently while pregnant (64% v 50%p=0.002) and more heavily (39% v 12%>=5units per week p=0.0001) compared tocontrols.After the baby’s birth there was no differencein the number of mothers drinking (71%cases v 68% controls), however, SIDS mothersstill drank more heavily than controls (52%v 22% consuming >=5 units per weekp<0.0001). In the previous 24 hours moreSIDS mothers consumed alcohol (37% v 18%) and also consumed a large quantity(>=5units) of alcohol (20% v 2.5% p<0.0001).More fathers of SIDS also drank heavily afterthe baby’s birth (90% v 68% consuming >=5units per week p=0.002) and with more alsodrinking in the previous 24 hours (38% v 22%)and also drinking more heavily (28% v 7%consuming >=5 units p<0.0001) in theprevious 24 hours.Sleep position. When the (a) usual positionput to sleep; (b) usual position found awake;(c) position in which baby placed during thelast sleep period; (d) position in which infantfound dead or awake during the last sleepperiod; were examined all showed asignificant excess of both prone and sidesleep positions. Pillow use was morefrequent among cases, with a pillow usuallyused during the day in 18% of casescompared to 10% of controls (p=0.002),usually used at night in 28% of cases v 13%of controls (p=0.0001), and during the lastsleep period in 51% of cases v 15% of controls(p<0.0001). When the amount of beddingused was examined duvet use was morefrequent in cases than controls; during theday (21% v 10% p=0.0001), during the night(44% v 22% p< 0.0001), during the last sleepperiod (53% v 20% p < 0.0001). Soothers weremore commonly used in SIDS cases thancontrols (77% v 66% p=0.01) although lessSIDS cases used a soother during the lastsleep period (30% v 54% p< 0.0001). Animportant question is why parents chooselifestyle and parenting practices, such assmoking, drinking and using the pronesleeping position, that adversely impact ontheir infants health and how these decisionscan be influenced in the future.

40UNACCUSTOMED EVENTS ANDSUDDEN INFANT DEATH SYNDROMEPJ Schluter1,1 RPK Ford2, EA Mitchell3, BJTaylor4.University of Queensland, Australia1,Canterbury Health, New Zealand2,University of Auckland, New Zealand3,University of Otago, New Zealand4.It is widely accepted that various infant carepractices, such as the sleep position, arecausally linked with the occurrence ofsudden infant death syndrome (SIDS or cotdeath). It has also been speculated thatabrupt postnatal changes to an environmentor behaviour may exert excess stress andphysiological demands on an infant. In thissetting, the infant’s learned physiologicalresponses may be inadequate to avoid alethal combination of events therebyresulting in SIDS. This speculation wasexamined using data collected from a nation-wide case-control study in New Zealand. Inparticular, we focused on factors previouslydemonstrated to affect SIDS risk.Infants sleeping in an unfamiliar house,room or bed were at increased risk for SIDScompared to infants sleeping in their usualenvironment after adjustment for likelyconfounding factors (OR: 2.60; 95% CI: 1.77,3.80). Taking infants who usually slept non-prone and who were placed to sleep on theirbacks for the nominated sleep (or day ofdeath) as the reference group, infants usuallyplaced prone to sleep were significantlymore likely to die from SIDS (OR: 5.44; 95%CI: 2.48, 11.92) as were those infantssleeping prone for the first time (OR: 15.12;95% CI: 3.81, 59.99), after adjustment forconfounders. Infants sleeping prone for thefirst time were at further increased SIDS riskif they slept alone for the nominated sleep/death when they normally slept in a roomwith an adult (chi-square=4.3, df=1, p=0.04).The effect of sleeping alone for thenominated sleep/death when normally roomsharing with an adult was itself associatedwith increased SIDS risks after adjustmentfor confounders (OR: 1.96; 95% CI: 1.33,2.88).Unaccustomed infant care practices doappear to affect SIDS risk, as do unfamiliarsleeping environments. Many of theseunaccustomed practices can easily beavoided thereby potentially saving infantlives.

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41CASE-CONTROL STUDY OF SUDDENINFANT DEATH SYNDROMESCOTLAND, 1996-9. A PREVIOUSLYUSED (OLD) INFANT MATTRESS STILLSEEMS TO INCREASE SIDS RISK.DM Tappin, H Brooke, C Beckett, AGibson.Glasgow University, Glasgow, Scotland,UKMany environmental hazards associated withinfant bedding have been proposed. A linkbetween infant mattress and cot death ismade plausible by the risk of prone sleeping.A previous study in Scotland showed a riskwith routine old mattress use (1).Objective: To investigate the relationbetween infant care practices for cot deathvictims on the day/night of death comparedwith control infants the day/night beforeinterview.Methods: This was a national study of 159infants dying of sudden infant deathsyndrome (cases) and 229 controls by meansof home interviews comparing methods ofinfant care and socio-economic factors, from1996-9. Matched multivariate analysis usedconditional logistic regression controllingfor: duration of breast feeding, deprivationcategory, birthweight, parity, maternal age,mother in paid employment prior to birth,mother’s marital status, age mother leftschool, mother smokes. Unmatchedmultivariate analysis also took account ofinfant age.Results: Significantly more infants 54% (44/81) died of cot death who routinely slept onan old infant mattress compared withcontrols 29% (59/201) (OR, 3.2; 95%CI 1.7-6.0). This risk remained when multivariateadjustment was made using a matched (OR,9.0; 95% CI 1.9, 42.8) or unmatched model(OR, 3.3; 95% CI 1.6, 7.0). On the night ofdeath 62% of SIDS cases (24/39) who weresleeping on an infant mattress were sleepingon an old infant mattress, compared with29% (38/130) of controls (OR 3.9, 95%CI 1.7,8.8). We are still working on a satisfactorymultivariate model for this data, but the riskremains.Conclusion: Using an old infant mattress onthe day/night of death increases the risk ofSIDS.1 Brooke H, Gibson A, Tappin D, Brown H. Case-control study of sudden infant death syndrome inScotland, 1992-5. British Medical Journal 1997;314: 1516-20.

42SIDS INFANTS – HOW HEALTHY ANDHOW NORMAL? A CLINICALCOMPARISON WITH EXPLAINEDSUDDEN UNEXPECTED DEATHS ININFANCYM Ward Platt, PS Blair, PJ Fleming, IJSmith, TJ Cole, CEA Leach, PJ Berry, JGolding and the CESDI SUDI researchteam.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UKClinical features characteristic of suddeninfant death syndrome (SIDS) suggest infantvulnerability at birth, after discharge fromhospital, during life and shortly beforedeath. The relative significance of thesefeatures amongst SIDS infants and betweenSIDS and explained sudden infant deaths hasbeen investigated.Methods. A three year case-control studyconducted in 5 of 14 Health Regions inEngland (population ~ 17 million, 500,000livebirths). Parental interviews wereconducted for each infant who died and forfour controls matched for age and time ofsleep. Ascertainment was over 90% [1]. Thisanalysis includes 325 SIDS, 72 explainedSUDI and 1588 matched controls.Results In the multivariate analysis fourclinical features were associated with SIDSidentifiable at birth: < 37 weeks gestation(20% vs 5% controls, OR=4.93[2.16-11.24]),<10th birth centile (16% vs 8% controls,OR=2.44[1.13-5.26]), multiple births (5% vs1% controls, OR=7.81[1.35-45.28]) and majorcongenital anomalies (5% vs 2% controls,OR=4.54[1.32-15.56]) whilst explained SUDIdeaths were characterised by one: neonatalproblems (38% vs 26% controls,OR=4.64[1.34-16.03]).Of those postnatal clinical features afterdischarge, the most significant was a historyof apparent life-threatening events for bothindex groups (SIDS: 12% vs 3% controls,OR=2.55[1.02-6.41], explained SUDI: 15% vs4% controls, OR=16.81[2.52-112.30]).A retrospective scoring system based on the“Cambridge Baby Check” [2] was used toidentify infant illness in the last 24 hours.This marker of illness was associated withthe highest risk for both index groups (SIDS:22% vs 8% controls, OR=4.17[1.88-9.24],explained SUDI: 49% vs 8% controls,OR=31.20[6.93-140.5])Conclusions The clinical characteristics ofSIDS and explained SUDI are similar. ‘BabyCheck’ particularly in high risk infants, mayidentify seriously ill babies at risk of suddendeath.

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1 Fleming PJ, Blair PS, Pollard K, Platt KW, Leach C,Smith I, Berry PJ, Golding J. Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999; 81:112-116.2 Morley CJ, Thornton AJ, Cole TJ, Hewson PH,Fowler MA. Baby Check: a scoring system to gradethe severity of acute systemic illness in babiesunder 6 months. Arch Dis Child 1991; 66: 100-6.

43ARE THE RISK FACTORS FOR SUDDENINFANT DEATH SYNDROMEDIFFERENT AT NIGHT?S M Williams1, EA Mitchell2, BJ Taylor1.University of Otago, New Zealand1,University of Auckland, New Zealand2

Data from the New Zealand National CotDeath study were used to examineinteractions between the time of death andother risk factors. 62.6% of deaths occurredin the night, the period between 10 pm and7.30 am. The controls were allocated a timeabout which they were interviewed, 49.5 %of which were in the night. The risk of SIDSassociated with bed sharing was higherduring the night (OR=2.45, 95% CI 1.53 to3.92) using not bed sharing during the nightas the reference group than during the day(OR=0.97, 0.45 to 2.11). The odds ratios wereadjusted for confounding variables. Maternalsmoking (OR= 2.29, 1.52 to 3.45), the motherbeing unmarried (OR=2.69, 1.75 to 4.13) orthe infant being Maori (2.29 1.44 to 3.65)were also associated with increased the riskof death at night. The odds ratios for thesefactors during the day time were 0.97 (0.45to 2.11), 1.29 (0.81 to 2.04) and 1.15 (0.71to 1.87) respectively. Deaths in the day timedeclined with age (OR (trend)=0.69, 0.56-0.86) compared with those during the night(OR (trend) 0.91, 0.77 to 1.08). Pacific Islandinfants were also less likely to die duringthe day (OR=0.16, 0.04 to 0.59). The OR forprone sleep position was 3.66 (2.51 to 5.32)at night compared with 7.63 (4.79 to 12.1)during the day using not prone in the sametime period as the reference group.Illness (OR(trend)= 2.07, 1.40 to 3.07) andsweating (OR(trend)=1.67, 1.27 to 2.20) werealso associated with deaths which occurredat night but not with those which occurredin the day.Deaths occurring at night, therefore, appearto be more strongly associated with life stylepractices, sleeping prone and illness whereasthose occurring during the day were largelyassociated with prone sleep position.

44EXAMINATION OF CYTOKINES INLARYNGEAL SECRETIONS DURINGACUTE RESPIRATORY DISEASE.Å Vege1, M Arnestad1, C Lindgren2, JGrøgaard, TO Rognum1

Institute of Forensic Medicine, Universityof Oslo, Rikshospitalet, Norway1

Dpt of Womens and Childrens Health,Ullevål hospital, Oslo, Norway2

A large proportion of SIDS victims have signsof respiratory infection prior to death. Halfof the SIDS victims have elevatedInterleukin-6 (IL-6) levels in theircerebrospinal fluid, and victims with highIL-6 levels show laryngeal immunestimulation. Furthermore, such stimulationin respiratory syncytial virus (RSV) infectedinfants results in disturbances in theregulation of breathing. RSV infection hasbeen associated with elevated laryngeal IL-6and IL-1b levels and we have proposed thatlocal production of cytokines might alter thesensitivity of the laryngeal chemoreceptors,inducing irregular breathing with hypoxemiaand ultimately SIDS. The purpose of thisstudy was to examine whether laryngealcytokines could be related to the severity ofclinical symptoms.Laryngeal secretions from 66 infants withacute respiratory disease admitted to hospitalwere examined for concentrations of IL-6 andIL-1b by ELISA. The group was divided intothree categories according to a score basedon clinical findings; fever, respiratorysymptoms, ill appearance, need for treatment.This score was compared with cytokine levels.Interestingly and surprisingly, we found thatthe group of children with the mildestsymptoms (group I) had a tendency to higherIL-6 levels than the group with the most severesymptoms (group III) (p<0.06) and significantlyhigher than those with intermediate symptoms(group II) (p<0.05). Group I also tended to beyounger than group III (p=0.06).It is shown that the ability to producecytokines is independent of age. However, theamount of cytokines usually is correlated tothe severity of the disease. An exception fromthis is the findings of elevated cytokine levelsin SIDS infants, who usually have only slightsymptoms of infection prior to death. Wetherefore speculate that a subgroup of infantsmay have a tendency to overreact to trivialinfections, which in its severest consequencesleads to SIDS.

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45THE POTENTIAL RELATIONSHIPBETWEEN APNEAS, APOPTOSIS &BRAINSTEM PLASTICITYToshiko SawaguchiTokyo Women’s Medical University,Shinjuku, Tokyo, JapanAmong 27 000 infants studied prospectivelyto characterise their sleep-wake behaviour,33 infants died under the age of 6 months(including 27 cases of sudden infant deathsyndrome, 5 cases of congenital cardiacabnormality, 2 cases of infected pulmonarydysplasia, 2 cases of septic shock withmultiorgan failure, 1 case of prolongedseizure and 1 case of prolonged neonatalhypoxemia).The frequency and duration of the apneasrecorded some 3 to 12 weeks prior to theinfants death were analysed. Brainstemmaterial was retrospectively collected fromthese 33 infants and immunohistochemicalanalyses were conducted, together with thedetermination of growth-associatedphosphoprotein 43 (GAP43) as a marker ofsynaptic plasticity, and terminal-deoxynucleotidy1 transferase-mediateddUTP nick end labeling (TUNEL) method as amarker for apoptosis. The pathological andphysiological data were linked for each casefor correlation analysis. A statisticallysignificant positive correlation was notedbetween the number of TUNEL-positive gliasof the dorsal raphe nucleus and the durationof central apnea (p=0.049).Statistically significant positive correlationswere noted between the number of spinesof GAP43-positive neurons in thepedunculopontine tegmental nucleus andthe number of TUNEL-positive glias in theperiaqueductal gray matter (p=0.041), andthe pedunculopontine tegmental nucleus(p=0.041). The dorsal raphe nucleus andperiaqueductal gray matter of the midbrainand pedunculopontine tegmental nucleusplay important roles in the arousal pathway.The correlation of these specific findings atthese sites with apnea suggests thepossibility that these organic changes haveeffects on the arousal process.

46CHANGING PRACTICES INCERTIFICATION OF SUDDENUNEXPLAINED INFANT DEATHS INSCOTLAND 1993-98H Brooke, A Gibson.Scottish Cot Death Trust, Glasgow,Scotland, UK.For several years debate has taken placewithin the international SIDS community onthe most accurate definition of Sudden InfantDeath Syndrome (SIDS). In Scotland thisdebate is becoming of secondaryimportance. The pathologists, who mustissue the death certificate immediatelyfollowing post-mortem dissection, arebecoming increasingly reluctant to use theterm SIDS without all test results beingavailable. The reason for this is that a muchhigher proportion of sudden unexpectedinfant deaths now occurs in families whichare socially and economically deprived,where babies are of low birthweight andwhere alcohol and illegal substance abuseare more common. In 1993, 100% of suddeninfant deaths, apparently unexplained oninitial post-mortem examination, were givendeath certification as SIDS compared withonly 13% in 1998. The remaining 87% werevariously certified as Sudden UnexpectedDeath in Infancy, Cot Death, Unascertainedor Natural causes. Pathologists are willingto amend the death certificate and will givea final diagnosis of SIDS if all findingsincluding death scene investigation arenegative. However, this change in practicehas important implications for the bereavedfamilies and may also influence comparisonof statistics and future epidemiologicalstudies.

47EXCLUSION OF NON-SIDS CASES FROMA GROUP OF SUDDEN UNEXPECTEDDEATHS IN INFANCY AND EARLYCHILDHOOD - WHICH DIAGNOSTICTOOL GAVE THE DIAGNOSISÅshild Vege, Marianne Arnestad, TorleivO. RognumInstitute of Forensic Medicine, Universityof Oslo, National Hospital of NorwayIn the period between 1984-1998, 289 casesof sudden unexpected death in infancy andearly childhood (0-3 years) from SoutheastNorway were investigated at the Institute ofForensic Medicine in Oslo. In 188 cases SIDSwas diagnosed, whereas 101 cases weregrouped as either borderline-SIDS (43) ornon-SIDS; 39 due to disease, 14 due to

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accidents and 5 due to murder.The purpose of the present study was toanalyse by which diagnostic tool theborderline-SIDS and the non-SIDS werediagnosed. The most and the second mostimportant finding were registered. In 44cases one diagnostic tool alone gave thediagnosis.The definition of SIDS require a negativehistory, negative investigation of thecircumstances as well as negative autopsyresults, thus the following variables wereanalysed: medical history, circumstances,autopsy which included macroscopicalinvestigation, microscopy, neuropathology,microbiology, radiology and toxicology.Results: In 10% of the cases the medicalhistory led to the diagnosis, whereasinvestigation of the circumstances revealedthe diagnosis in 17%. The autopsy led todiagnosis in the remaining 73%;macroscopical investigation contributing in15% of the cases, microscopy in 25%,neuropathology in 18%, microbiology in 12%,radiology in 2% and toxicology in 2 %.Throughout the period studied our SIDScases constituted 65% of the total populationof sudden unexpected deaths. After the dropin SIDS rate in 1990, the proportion of pureSIDS has become less prominent in SoutheastNorway, comprising 50% in 1998. Theincreasing role of borderline and non-SIDScases is a challenge to improve the qualityof investigation in cases of sudden death ininfancy and early childhood. At the Instituteof Forensic Medicine we strive to includecompulsory death scene investigation andcase conferences.

48MUTATIONS IN THE MTDNA GENETRNAGLY IN SIDS AND CONTROLSOpdal SH, Rognum TO, Musse MA, Vege Å.Institute of Forensic Medicine, Universityof Oslo, NorwaySeveral investigations indicate involvementof mtDNA mutations in at least some casesof SIDS. The findings in our SIDS material sofar are of a high substitution rate in the D-loop and point mutations in the genestRNALeu(UUR) and ND1. The purpose of thisstudy is to investigate the tRNAGly gene,which has a point mutation in bp 10044assumed to be associated with suddenunexpected death. The subjects consisted of164 cases of SIDS (included 24 cases ofborderline SIDS) and 101 age matchedcontrols (living infants). The tRNAGly genewas investigated using polymerase chainreaction (PCR) and direct sequencing. In the

SIDS group two different point mutationswere detected, T10043C in one case andT10034C in six cases. In the control groupthree different point mutations weredetected in three controls (T10034C,A10042T, A10044G). It remains to beinvestigated wheether there is anypathological effect of the mutations. Thefindings may indicate either that mutationsin the tRNAGly gene are not involved in SIDS,or that SIDS victims may have a higherpercentage of mutated mtDNA than controls.By using direct sequencing it is not possibleto determine the percentage of mutatedmtDNA. It is interesting that one of themutations (T10034) was found in six casesof SIDS but only in one control. Thismutation is claimed to be a polymorphismrather than a pathological mutation, but maynevertheless be a part of a haplotypepredisposing to SIDS.

1 Opdal SH, Rognum TO, Vege Å, Dupuy BM,Egeland T. Increased number of substitutions inthe D-loop of mitochondrial DNA in the suddeninfant death syndrome. Acta Pædiatr1998;87:1039-442 Santorelli FM, Schlessel JS, Slonim AE, DiMauro S.Novel mutation in the mitochondrial DNA tRNAglycine gene associated with sudden unexpecteddeath. Pediatr Neurol 1996;15:145-9

49ANALYSIS OF CARDIOVASCULAR ANDRESPIRATORY NUCLEI IN SUDDENINFANT DEATH SYNDROMET. Ansari1, M. Rossi2, P. Sibbons1

Dept. of Surgical Research, NPIMR,Northwick Park Hospital, HarrowMiddlesex, UK1. Dept. of Neuropathology,WCNN, Fazakerley Hospital, Liverpool, UK2.It has been suggested that SIDS may be due tosubtle defects in the brainstem neural circuitrycontrolling respiration and/or cardiovascularstability, particularly during sleep and attransitional phases between sleep andawakening.Brainstems from 7 control cases, 10 SIDSnormal birth weight (NBW) cases and 8 SIDSlow birth weight (LBW) were selected fromarchived material. Each brainstem wasembedded in resin, serially sectioned (25µm)and stained with H&E. Volumes of the arcuateand hypoglossal nucleus was estimated usingthe Cavalieri’s Principle: the optical bricktechnique was used to estimate arcuate neuronand glial cell density. Total number of cellswas estimated by multiplying the volume ofthe nucleus by the numerical density. Crosssectional area (CSA) of the solitary tract wasestimated using simple, unbiased point

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counting.For the arcuate nuclei there was no significantdifference in the volume: (control and SIDSNBW (p=0.407) or control and SIDS LBW(p=0.240)), total numerical density: (controland SIDS NBW (p=0.962) or control and SIDSLBW (p=0.613)), total number of neuron andglial cells: (control and SIDS NBW (p=0.661) orcontrol SIDS LBW (p=0.201)). There was nostatistically significant difference in thevolume of hypoglossal nuclei between controland SIDS NBW (p=0.917) or between controland SIDS LBW cases (p=0.345). There was nosignificant difference in CSA for either the leftor right solitary tracts between any of thegroups. However, SIDS LBW casesdemonstrated an increase in CSA with age forboth the right (p= 0.001) and left (p=0.003)solitary tract.Subtle delay/arrest in the brainstem neuralcircuits has been hypothesised to impingeupon the stability of respiratory andcardiovascular functions in SIDS infants. It ispossible that abnormalities e.g. metabolicdefects or defects in neurotransmitterproduction or function, within those nucleiresponsible for cardiovascular functions, maybe present at a level not detectable byquantitative morphometric analysis.

50DETECTION OF PYROGENIC TOXINSOF STAPHYLOCOCCUS AUREUSAMONG GERMAN SIDS INFANTSA.M. Alkout1, V.S. James1, R. Amberg2, A.Busuttil1 and C. C. Blackwell1.Department of Medical Microbiology &Forensic Medicine Unit, University ofEdinburgh1, Institut für Rechtsmedizin,University of Basel2

Introduction: Pyrogenic toxins ofStaphylococcus aureus were detected in >50 % of frozen or fixed tissues from SIDSinfants from Scotland, France and Australia[Zorgani et al., 1999]. This study assessedhistological specimens to determine if asimilar pattern was present in a Germancohort (n = 20) of SIDS cases.Materials and methods: Formalin-fixedparaffin-embedded samples of thymus and/or spleen were dewaxed and rehydrated.After homogenisation of the tissues, cellswere examined for presence ofstaphylococcal enterotoxins A, B and C andtoxic shock syndrome toxin (TSST) by flowcytometry and the supernatant by ELISA asdescribed previously [Zorgani et al., 1999].Because of the age of the specimens(collected between 1992-1995), a sample wasconsidered positive in the flow cytometry

assay if 3% or more of the test cells showedfluorescence above that of the control cellsto which only flourescein-labelled anti-sheepantiserum was added.Results: The ELISA method did not detecttoxins in any samples. By flow cytometry,tissues from 13 / 20 (65%} SIDS cases werepositive for one or more toxins (range 3-31.2% positive cells)Discussion: As in the previous study, toxinswere not detected in formalin fixed tissues18 months of age or older. In the previousstudy, specimens were considered positiveif 10% of test cells had fluorescence valuesgreater than their respective controls;however, the percentage of positive cells intoxin-containing specimens decreasedsignificantly after 4-5 years. The proportionof toxin-positive specimen in this study(65%) was similar to the Australian serieswhen that data was reassessed using thecriteria of this survey (21/30, 70%). Theproportion of German SIDS infants in whompyrogenic staphylococcal toxins wereidentified is similar to that for infants fromother parts of Europe and Australia.Zorgani et al. FEMS Immunology MedicalMicrobiology 1999; 25: 103-108.

51THE EFFECT OF INTERLEUKIN 10 (1L-10) ON INFLAMMATORY RESPONSESINDUCED BY PYROGENIC TOXINSIMPLICATED IN SIDSO.Al Madani, A.E. Gordon, A.M. Alkout,D.M. Weir, A. Busuttil, C.C. BlackwellDepartment of Medical Microbiology andForensic Medicine Unit, University ofEdinburghWe proposed that some SIDS deaths mightresult from uncontrolled inflammatoryresponses, particularly those induced bypyrogenic staphylococcal toxins, during adevelopmental stage in which infants areless able to control inflammation because oflow levels of night time cortisol. Thecytokine IL-10 plays an important role incontrol of inflammation. The objectiveswere: 1) to determine if toxic shocksyndrome toxins (TSST) and staphylococcalenterotoxins C and A (SEC and SEA) inducedIL-10 as well as pro-inflammatory cytokines;2) if IL-10 levels induced were sufficient toreduce production of pro-inflammatorycytokines implicated in pathogenesis of toxicshock, interleukin 6 and tumour necrosisfactor a (TNF).Leukocytes obtained from blood donors werestimulated as described [Al Madani et al.,

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1999] by 0.1 mg ml-1 of the individualtoxins. After 16 hr incubation at 37°C, TNFwas assessed by bioassay and IL-6 and IL-10by ELISA. Various concentrations of humanrecombinant IL-10 were examined forinhibition of TNF and IL-6.IL-10 induced by the toxins ranged from 8-40 ng ml-1 at 16 hr. The donor with thelowest level of IL-10 (8 ng ml-1) had thehighest increase in TNF and IL-6 responses.The recombinant form exerted suppressiveeffects on both TNF and IL-6 production. Thelowest level of IL-10 that reduced IL-6production by 50% was 25 ng ml-1; morethan half the donors produced levels of IL-10 sufficient to reduce IL-6 production.None of the donors produced levels of IL-10(100 ng ml-1) needed to reduce TNFproduction. Genetically controlled lowIL-10 responses are associated with adultrespiratory distress syndrome and severityof Epstein Barr virus infection. IL-10 wasreported to protect mice againststaphylococcal toxins and from endotoxininduced shock. The genetics of IL-10production in families in which there hasbeen a SIDS death is currently underinvestigation.Al Madani et al. FEMS Immunology MedicalMicrobiology 1999; 25: 207-219.

52SUDDEN INFANT DEATH SYNDROME:BACK TO BASICSL.E. BeckerThe Hospital for Sick Children, Toronto,Ontario, CanadaSudden death occurs in every age group fromfetal to adolescent to adult. In infancy, thefrequency of sudden death and of theabsence of an anatomical cause for death arehigher than in any other age group. Theunique feature of sudden infant deathsyndrome (SIDS) is the developmentalvulnerability that characterizes infants in thefirst six months of life. The peak incidenceof SIDS is between one and six months ofage and developmentally an infant of thisage is quite different than a child of 12 -18months of age. This is more evident in thebrain and neuromuscular system than in anyother system of the body.Therefore, recent suggestions to change thedefinition to include older children createssignificant difficulties. Tampering withbasic definitions is dangerous because itjeopardizes the validity of data comparisons,before and after such changes. Raising theage also detracts from the importance of

understanding developmental factors.Structural and functional developmentalmaturation is critical because it is the onlyconsistent vulnerability in all cases of SIDS.In our SIDS Registry at The Hospital for SickChildren, from 759 cases we have selectedsmall cohorts with appropriate age-matchedcontrols. We have documented delayedmaturation of dendritic spine developmentin the brainstem, delayed myelination of thevagus nerve and delayed fiber typematuration in the diaphragm.In SIDS, the maturation of these anatomicalstructures related to cardio-respiratory-sleepfunctions is delayed, compared to age-matched non SIDS infants, suggestingrelative immaturity and greatervulnerability to environmental factors suchas sleep position, exposure to cigarettesmoke, elevated ambient temperature, mildinfections and other factors.Becker LE. Sudden infant death syndrome(SIDS): A neural perspective. In: Encylopediaof Neuroscience, 2nd edn, Adelman G, SmithB, eds, Elsevier Science, Amsterdam 1999,1971-1975.

53BEDSHARING AND OVERNIGHTMONITORING: FROM THELABORATORY TO THE HOMESETTINGSA Baddock, BC Galland, CAMakowharemahihi, BJ Taylor, DPG Bolton.Dept. of Women’s & Children’s Health,Dept. of Physiology, University of OtagoDunedin, New ZealandEpidemiological studies have identifiedbedsharing as an important issue in SIDS.Physiological studies, focussing on possiblemechanisms, have been in sleep laboratoriesand have included only mothers and infants.This pilot study was preparation for a homebased study to better reflect diversity ofsleeping environments and encourage usualchildcare practices.Objectives:1. To measure infant physiological variablesand to video sleep positions and infant-adultinteractions overnight without significantdisturbance to the infant or parents.2. To identify physiological and behaviouralindices that may indicate infant stress duringbedshare sleep.Study design: Mothers and/or fathers andinfants (new-born to 5 months) who regularlybedshared (>5hrs/night) were recruited frompostnatal organisations and advertisements.Supervised, physiological and videomonitoring was performed with 9 infant/

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mother pairs and 1 infant/mother/fathergroup sleeping overnight in the sleeplaboratory. The physiological recordingsmeasured respiratory pattern, respiratoryflow, inspired CO2, SaO2, heart rate andtemperature – core, peripheral andenvironmental. Parents were given aquestionnaire to evaluate the study. Thisprotocol was used unsupervised with 1infant/ mother and 2 infant/mother/fathergroups in participants’ own homes.Results: Questionnaires showed allparents were “absolutely satisfied” withthe execution of the study and 8/9laboratory participants indicated theywould have been ‘interested’ or ‘keen’to participate in a home study. Allrecordings were achieved as easily inthe home, as in the sleep laboratory.Adverse cardio-respiratory events wereidentified in 2/13 infants: one where highenvironmental temperature was coupledwith close parental contact. Another wherethe infant repeatedly pulled bedding overits face, resulting in inspired CO2 of 5%. Noother adverse effects were identified.Conclusions: Comprehensivephysiological and behaviouralovernight studies can be successfullycarried out in the home. Early resultsshow a wide range of movements andpositions of babies in the bedsharingscenario.

54BED-SHARING AND THE MICRO-ENVIRONMENT OF SLEEP IN EARLYINFANCY: PHYSIOLOGICAL EFFECTSIN THE INFANTAndrew Sawczenko, Peter Fleming,Jeanine Young, Barbara Galland, PeterBlair.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UK.Overheating and rebreathing have beensuggested as possible contributory factorstoSIDS. Asphyxia and overlaying have beensuggested as additional factors when infantsbedshare with parents.Aim: To compare infant microenvironmentand thermal physiology whilst bedsharingand whilst sleeping in a crib in the sameroom as mother (“room-sharing”).Methods: Polygraphic recordings of infantand environmental temperature, inspiredCO2, sleep state, respiration, ECG, oxygensaturation and infrared video were made of10 mother infant pairs (5 routine bed-sharers, 5 room-sharers) on two consecutive

nights (randomized to 1 night bed-sharing(BS) then 1 room-sharing (RS), or vice versa)at monthly intervals from 2 to 5 months ofage in a thermally-controlled sleeplaboratory.Results: Complete physiological and videorecordings of 19 pairs of BS and RS nights(38 recordings) were obtained. Infant sleeppatterns were no different between BS & RS.All infants slept supine, and were fullybreast-fed. Insulation of bedding was higher(6.3 tog vs 4.6 tog, p =0.015), and thetemperature under the bedding and aroundthe infant’s head was 1 - 2.5∞C higher on BSthan on RS. Oscillations in rectaltemperature with sleep state (higher in RapidEye Movement sleep) were no differentbetween BS and RS. Infant skin (shin,abdomen, forehead) temperatures werehigher, but the nadir of rectal temperaturewas lower on BS nights. Skin temperatures,but not rectal temperatures, were higherwhen infants slept in direct skin to skincontact with their mothers. Inspired CO2 wasno higher on BS than RS nights, and thehighest value (2.4%) was for a swaddled RSinfant.Conclusions: Despite higher environmentaltemperatures, infants could thermoregulateas effectively when bedsharing as whenalone. Close mother-baby contact during thenight did not result in CO2 rebreathing orimpaired thermoregulation in healthyinfants.

55VASOCONSTRICTOR RESPONSESFOLLOWING SPONTANEOUS SIGHSAND HEAD-UP TILTS IN INFANTSSLEEPING PRONE AND SUPINE.Barbara C Galland, Barry J Taylor, DavidPG Bolton, Rachel M Sayers.Dept. of Women’s & Children’s Health,University of Otago Dunedin, NZ.Autonomic dysfunction or maturationaldelay is a feature of some infants that havesubsequently succumbed to SIDS. In theprone position, some autonomically-mediated physiological responses aredepressed. The array of autonomic functiontests in infants is limited to those notrequiring co-operation on the part of theindividual. A recent study has suggested thatmeasurement of cutaneous vasoconstrictionby laser flow Dopplometry (LDF) following aspontaneous sigh may be a useful tool forassessing autonomic function in infants.Aims: To compare the effects of sleepposition, age, and sleep state on the degreeof peripheral vasoconstriction measured by

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LDF during: 1) test conditions; 60° head-uptilt, and 2) basal conditions; a spontaneoussigh.Methods: The cutaneous vasoconstrictorresponses following a rapid (2-3 s) 60° head-up tilt and a spontaneous sigh weremeasured in 36 healthy infants at 1 and 3months age. Infants were studied duringquiet sleep (QS) and active sleep (AS) and inthe supine and prone sleep positions.Respiratory pattern was recorded byinductive plethysmography. Thevasoconstrictor response was determined bya measure of cutaneous blood flow by LDF.Results: The mean reduction in blood flow(vasoconstriction) was 52% following the tilt,and 33 % following the sigh. Pronepositioning of 1 month old infants, ascompared to supine, reduced the degree ofvasoconstriction following the tilt (P = 0.03)and sigh (P = 0.03). The supine to pronereduction was: tilt, -11% in QS and -25% inAS and; sigh, -26% in QS and -15% in AS. Thedegree of vasoconstriction following the sighwas greater in 3 month compared to 1month-old infants (+26%, P = 0.04). Thisolder age effect was also apparent inresponse to the tilt (+12.0%, P = 0.07)although was not significant. Sleep state didnot effect the degree of vasoconstriction butinfluenced transmission so that latency tominimal vasoconstriction was 1 secondshorter in AS than QS.Conclusions: This study provides data ontwo simple measures of sympathetic activityduring sleep that have not previously beendescribed in any detail in infant studies, andadd more evidence that autonomic activityis reduced in the prone position comparedto supine during sleep.(Supported by HRC 97/136 and in part bythe Cot Death Association of New Zealand)

56SLEEPING POSITION AFFECTSAROUSABILITY OF PREMATUREINFANTS.Bandopadhayay P, Horne RSC, Vitkovic J,Andrew S, Chau B, Cranage SM, AdamsonTM.Melbourne Children’s Sleep Unit,Department of Paediatrics, MonashUniversity, Melbourne, Australia.It is well recognised that the prone sleepingposition and prematurity both represent riskfactors for the Sudden Infant DeathSyndrome (SIDS). Failure to arouse fromsleep in response to a life-threatening eventhas been hypothesised to contribute to amultifactorial pathogenesis for SIDS. This

study investigates the effects of sleepingposition and postnatal age on sleep arousalin a group of healthy premature infants.Thirteen premature infants born at 31 to35weeks (w) gestation (mean 33 ± 0.4w) whohad faced no significant neonatal morbidityunderwent three daytime polysomnographicstudies. Studies were performed at ages 36-38w gestation, 1-3w post term, and at 2 -3months (m) post term, with the third studycoinciding with the peak SIDS incidence.Each infant underwent two sleeps, one in theprone position and the other supine at eachstudy. A non-invasive air-jet stimulus,applied alternatively to the nares waspresented in both positions, in both activesleep (AS) and quiet sleep (QS). The pressurepresented was altered, and arousalthresholds calculated based on a modifieddouble staircase method . Data was analysedusing 2 ways repeated measures ANOVA.The prone sleeping position significantlyincreased arousal thresholds in AS in all 3studies (p<0.05). Furthermore, at the 2-3mstudy, arousal thresholds in QS were elevatedwhen infants slept prone (p=0.03). A staterelated difference in arousal threshold wasevident at the 2-3w (p=0.01) and 2-3mstudies (p=0.03), with thresholds elevatedin QS compared to AS in infants whilstsleeping supine.This observed association of the pronesleeping position, the largest risk factor ofSIDS, with decreased infant arousability mayadd weight to the hypothesis that failure toarouse from sleep contributes to thepathogenesis of SIDS.Table: Arousal thresholds (cm H2O, mean ±SEM) in the prone and supine sleepingpositions.

(This project was supported by SIDSaustralia)

57THE EFFECTS OF PRONE SLEEPINGAND ANTENATAL MATERNALSMOKING ON THE AROUSABILITY OFTHE TERM INFANTFerens D, Horne RSC, Watts A-M, Lacey B,Andrew S, Vitkovic J., Chau B, CranageSM, Adamson TM.Melbourne Children’s Sleep Unit,Department of Paediatrics, MonashUniversity, Melbourne, AUSTRALIASudden Infant Death Syndrome (SIDS) isbelieved to be multifactorial and a failure toarouse from sleep has been proposed as afinal mechanism. In this study we examinedthe effects of the two major modifiable riskfactors for SIDS: sleeping position and

53

maternal smoking, on arousal from sleep inhealthy term infants.In this study, we investigated arousalresponses in 24 healthy term infants, 13from non-smoking mothers and 11 fromsmoking mothers (>5cigarettes/day). Infantgroups were not different for birth weights,gestation at birth, or APGAR scores at 1 and5 minutes. Infants were studied at 2-3w and2-3m with daytime polysomnography,sleeping in both prone and supine positions.Arousal responses were measured inresponse to a non-invasive pulsatile air-jetstimulus applied to the nares during activesleep (AS) and quiet sleep (QS). Data wereanalysed by repeated 2-way ANOVA, and alldata are presented as mean ±SEM.In the combined group of infants (n=24)arousal thresholds were elevated in QScompared to AS when infants slept bothprone and supine at 2-3m, and when proneat 2-3w (p<0.01). Arousal thresholds wereelevated in the prone position, in both ASand QS, at both 2-3w and 2-3m (p<0.05). Ininfants from smoking mothers arousalthresholds in response to our stimulus wereelevated and spontaneous arousalsdecreased in QS when sleeping supine at 2-3m (p<0.05), when compared to infants fromnon-smoking mothers.This study demonstrates that arousal isimpaired in infants sleeping in the proneposition in both sleep states. Maternalsmoking appears to alter the arousalmechanism as both spontaneous arousalfrom sleep and arousal in response to asomatosensory stimulus are impaired in thesupine position at the age when SIDSincidence is highest.

AS QS AS QSSUBJ PRONE PRONE SUPINE SUPINE

Non-smoking

2-3w 264 ± 30 347 ± 52 175 ± 21 246 ± 36

2-3m 257 ± 40 443 ± 62 107 ± 22 181 ± 32

Smoking

2-3w 206 ± 31 272 ± 42 157 ± 22 202 ± 38

2-3m 154 ± 23 409 ± 57 106 ± 15 384 ± 74 *

* smoking vs non-smoking p < 0.05

(This project was supported bySIDSaustralia)

58EVIDENCE AS TO WHYPHENOTHIAZINES ARE ASSOCIATEDWITH SIDSHE Jeffery,1,2 GM McKelvey,2 EJ Post,2 AKWWood.2

Royal Prince Alfred Hospital1 and theUniversity of Sydney2, Sydney, Australia.Introduction: Phenothiazines, such aspromethazine, available in over-the-counterinfant medications have been implicated inapparent life-threatening events (ALTEs) andSIDS, however the mechanism of action isunclear.Hypothesis: Phenothiazines may impairairway protective responses in sleep,exposing infants to life-threatening laryngealchemoreflex (LCR) stimulation.Aim: To examine the effects of a commonlyused promethazine-containing medicationon airway protective reflexes in sleepingpiglets.Methods: Responses to pharyngeal andoesophageal fluid simulation during activesleep (AS) were recorded in 21 control and21 promethazine piglets (1.5 mg.kg-1 ).Computer recordings of AS(electroencephalogram, movement andbehaviour), swallowing (fluid-filled catheter),breathing (pneumogram and nasal airflow),heart rate and oxygen saturation (SaO2) weremade. 1.5 mL boluses of 0.9% NaCl or HCl(pH2 or pH3) were infused into the pharynx,upper and lower oesophagus. The data wasanalysed using the ?2 test and a repeatedmeasures design ANOVA, probability valuesof p<0.05 were considered significant .Ethics Committee approval was given.Results: A total of 320 infusions wereadministered in AS. The results (mean ± SEM,and % occurrence) are given in Table 1. Thesignificant differences between the controland promethazine piglets for each level offluid infusion are denoted by * (*p<0.05).Table 1.Pharyngeal infusion (n=148)Upper oesophageal infusion(n=94)Lower oesophageal infusion(n=78)Control Promethazine ControlPromethazine Control Promethazine

Swallow rate(swallow.min-1) 8.8 ± 0.6 5.8 ± 0.2* 3.3 ± 0.4

3.0 ± 0.3 3.3 ± 0.4 3.2 ± 0.3SaO2(% change) -1.3 ± 1.1 -6.6 ± 0.8* -1.6 ± 0.5

-1.8 ± 0.5 -1.1 ± 0.4 -2.9 ± 0.8Heart rate(change bpm) -4.1 ± 2.8 -11.1 ± 1.4*-6.7 ± 3.5

-5.4 ± 0.8 -4.1 ± 0.8 -4.3 ± 1.5Arousal(% occurrence) 57% 57% 42%

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12%* 24% 25%Apnea(≥5 secs)(% occurrence) 43% 62%* 13%

22% 22% 36%

Conclusion: Infant doses of promethazineprofoundly altered airway protective andcardio-respiratory responses in normal,healthy sleeping piglets following pharyngealfluid stimulation. These results suggest thatpharyngeal fluid insults (such as high refluxor post-nasal secretions) are a mechanism forthe association observed betweenpromethazine use, and the occurrence ofALTEs and SIDS. The current cautions on theuse of promethazine-containing preparationsin infants are supported by the findings ofthis study, and we recommend that greaterenforcement is needed to prevent over-the-counter sale of such drugs, especially foryoung infants.

59CEREBRAL CIRCULATORY RESPONSESTO REPEATED AND CONTINUOUSHYPOXIA IN SLEEPING LAMBSAdrian M Walker, Daniel A Grant, andJennene WildRitchie Centre for Baby Health Research,Monash University, Melbourne, AustraliaRapid-eye-movement (REM) sleep isremarkable among sleep-wake states forelevated cerebral blood flow (CBF) and forgreater risk of cerebro-vascular injury.Possibly the brain is more vulnerable in REMbecause cerebral vasodilatory reserves arelimited in this state (Grant et al 1998), leavingit exposed to the cardiovascular instabilitythat is characteristic of normal REM andwhich is exaggerated during sleep disruptedby apnoea. This study examined thehypothesis that the pronounced basalvasodilation of REM limits vasodilatoryresponses to hypoxia. We: (a) contrasted theresponse of the cerebral circulation duringREM and non-REM sleep to transient, episodicarterial oxygen desaturations designed tomimic sleep apnoea (HYPOXIA IN SLEEP); and(b) determined the changes of CBF associated

with REM and non-REM sleep cyclesoccurring against a background ofcontinuous hypoxia (SLEEP IN HYPOXIA).Lambs (n = 8) were instrumented to recordbeat-to-beat cerebral blood flow (CBF) usingan ultrasonic flow probe implanted aroundthe superior sagittal sinus (Grant et al 1995),and implanted with catheters to recordcerebral perfusion pressure (CPP) andelectrodes to define sleep-wake states.Arterial oxygen saturation (SpO2) wasrecorded with a pulse oximeter. CBF, CPP,and cerebral vascular resistance (CVR=CPP/CBF) were contrasted between REM and non-REM sleep occurring naturally duringnormoxia (FiO2 0.21) and during hypoxiainduced by reducing FiO2 to 0.10 either (a)transiently (60 sec) within sleep epochs; or(b) continuously (1 hr) across sleep epochs.Under baseline (normoxia) conditions, CBFwas significantly greater (15±1 vs. 13±1,P<0.02 mean ± SE) and CVR was significantlyless (4.2±0.2 vs. 5.6±0.5, P<0.02) in REM thanin non-REM. During transient (60 sec)hypoxia, significant increases of CBF fromcontrol values occurred in both REM (35±6percent, P<0.001) and non-REM (23± 7percent, P<0.01). Though the CBF increasewas greater in REM than in non-REM, so toowas the fall in SpO2 (REM 30±1 vs. non-REM22±2, P<0.01). Plotted against SpO2 toaccount for the deeper desaturationoccurring in REM (Figure). CBF and CVRexhibited a similar sensitivity to hypoxia(slope) in REM and non-REM, whilemaintaining the characteristic sleep state-related differences (position) over a widerange of arterial oxygenation. Moreover,there was preservation of the significantlygreater CBF of REM compared withwakefulness (W) and non-REM underconditions of continuous hypoxia.These experiments show that the majorcerebral blood flow differences of sleep andwakefulness (REM > W > non-REM) arepreserved in hypoxia, regardless of itsduration. Thus, the vasodilatorymechanisms that contribute to the markedcerebral vasodilation and the elevatedcerebral perfusion of REM remain effectiveduring hypoxia.

ACTIVE SLEEP QUIET SLEEP

STUDY PRONE SUPINE PRONE SUPINE

36-38 w 304 ± 41 190 ± 24 275 ± 39 218 ± 36

2-3 w 278 ± 36 199 ± 33 385 ± 58 289 ± 47

2-3 m 248 ± 64 76 ± 10 453 ± 68 287 ± 72

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Grant, D.A., Wild J, Franzini, C., Walker, A.M.Continuous measurement of superior sagittalsinus blood flow in the lamb. Am J Physiol 1995,269: R274-R279.Grant, D.A., Franzini, C., Wild, J., and Walker, A.M.Cerebral circulation in sleep: vasodilatory re-sponse to cerebral hypotension. J Cereb BloodFlow Metab 1998, 18: 639-645.

60MECHANISMS CAUSING THE SUDDENDEATH OF INFANTS WHILE SHARINGA SLEEP SURFACE WITH OTHERSBT. Thach, J. Kemp, B. Unger, M. Case, M.GrahamWashington University, St. LouisUniversity, USASeveral epidemiological studies haveindicated that when an infant shares asleeping surface with others the risk for SIDSis increased. Still other studies havesuggested that particular aspects of thetypical bedsharing environment (eq. pillows,soft sleep surface, bulky overbedding) createunsafe conditions for a sleeping infant. Weconducted a 4 year study (1994-97) of allinfant deaths (<2 years old) diagnosed asSudden Infant Death Syndrome, accidentalsuffocation or “cause of deathundetermined” in a defined geographicregion (St. Louis and St. Louis County, USA)inhabited by diverse socioeconomic groups.Death scene investigations were performedto determine potential causal mechanisms.All infants were less than 1 year of age (meanage+109 days). Fifty-six of 119 infants(47.1%) died while sharing a sleep surfacewith an average of 1.4 +-. 07 bedmates. Theshared sleep surfaces included adult bedsor mattresses, sofas, and cushioned chairs.Forty-three of the 56 were diagnosed as SIDS(77%); 10 were accidental suffocations (18%)and 3 were “undetermined” (5%). Of the SIDSand “undetermined” deaths, 12 (27%) werefound with either head or face covered bysoft bedding. In 13 of the 56 shared sleepsurface deaths (23%) there was evidence thatthe infant would have been unable to escapefrom an asphyxiating environment becausethe infant’s head or body was either wedgedagainst or under a sleeping a bedmate’s body(7 cases) or an inanimate object (6 cases).We conclude that a large proportion ofsudden infant deaths in a typical USpopulation including SIDS, occur whilesharing a sleep surface. Also, in 39% of suchcosleeping deaths respiratory impairmentleading to asphyxia (10 deaths) possibly withassociated overheating (head/face coveredin 12 deaths) appeared to be a primary causeof death. Finally, when we consider how

often it was that a non cosleeping personarrived by chance and observed the deadinfant beneath a cosleeper, a situation thatother wise might never have be documented,we conclude that our findings for occurrenceof this particular fatal mechanism likelyunderestimated its truce incidence.Funded by HD 10993

61THE DEVELOPMENT OF MOVEMENTIN INFANTSSusan BealWomen’s & Children’s Hospital Adelaide,Adelaide, Australia ADELAIDE, AUSTRALIANewborn infants are under the influence ofthe asymmetrical tonic neck reflex (fencer’sposition) when stressed which tends to makethem turn the face from side to side. By 4-6weeks of life this is beginning to be replacedby the symmetric tonic neck reflex (crawlingposition) which causes them to bob the faceup and down in the midline when stressed.This presents a problem of airwayobstruction in prone.At about 4-6 months age infants begin to rollfrom supine to prone, initiating the roll bythrowing one leg over the other. For a shorttime, usually 1-3 weeks, they are unable toreturn to supine and so are vulnerablebecause of their prone position.At about 6 to 8 months infants begin to movein prone, frequently creeping backwardsdespite wanting to move forwards. Thisusually lasts for 1-2 weeks and such infantsare in danger if they move back underbedclothes.These dangerous situations can beminimised.1. No infant should be left unobserved inprone before they can easily turn to supine.2. Infants who can roll to prone but not backagain should sleep in sleeping bags (toreduce the likelihood of one leg crossing theother, or have other means to restrictmovement (e.g. swaddling, wedges, or Dutchstyle sleeping bags with straps).3. Bedclothes should not be used for infantsuntil they have learned to crawl forwards.Video recordings will be used to demonstratethese movements.

62HAZARDOUS SITUATIONS FOR SMALLINFANTS: - CAR SEATS ANDSTROLLERS ETC.S. Tonkin27 Eastbourne Road, Auckland, NZThe upper airway of a small infant is throughthe nose unless the infant is crying orgasping The large tongue fills the mouth

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and until the mandibular ramus haslengthened and the tongue has descendedwith the jaw easy oral breathing is notpossible.In addition the mandibular articulation withthe skull is mobile and the jaw can slideposteriorly. Thus the tongue which sits inthe jaw can be taken back to compromisethe upper air passage from the nose to thelarynx. After the infant is about 6 monthsold this slide can no longer take place andinternal upper airway restriction is unusual.When a very small infant is supported in anupright position the head usually fallsforward and the chin rests on the chest. Insome infants the weight of the head issufficient to push the mandible backwardsand thus restrict, or block air entry to thelungs. This may lead to oxygen lack and astoppage of breathing. Babies have beenfound dead in this situation. Immediateresuscitation is needed for any babies whohave stopped breathing in this position. Themost efficient way to give this is by adultmouth to infant nose.Small babies should not be put into car seatsor strollers that do not allow their heads torest in an extended position.They should be taken out of the car seatsand allowed to lie flat when they are out ofthe car.

63THE CESDI SUDI STUDY: COT DEATHSOUTSIDE THE COTPS Blair, PJ Fleming, IJ Smith, M WardPlatt, J Young, P Nadin, PJ Berry, JGolding, and the CESDI SUDI researchteamInstitute of Child Health, University ofBristol, Bristol BS2 8BJ, UKAlthough sudden infant death syndrome(SIDS) is referred to as ‘cot’ death, aproportion of these deaths occur outside thisenvironment. The prevalence and riskassociated with the different sleepingenvironments in which these deaths werediscovered has been investigated.Methods A three year case-control studyconducted in 5 of 14 Health Regions inEngland (population ~ 17 million, 500,000livebirths). Parental interviews wereconducted for each infant who died and forfour controls matched for age and time ofsleep. Ascertainment was over 90% [1][2].This analysis includes 325 SIDS and 1300matched controls.Results Just over half the deaths (54.7%)were discovered in a cot compared to three-quarters of the control infants (74.3%) who

woke up in a cot after the reference sleep. Asimilar proportion were found in a pram,bouncy chair or car seat (7.2% SIDS vs 8.1%controls). Using these ‘baby-designed’environments as a reference group there wasa significant risk associated with infantsfound in bed with the parents (25.8% SIDSvs 14.7% controls, OR=2.47 [95% CI: 1.74-3.52] this will be dealt with in a separatepresentation) and an even greater risk forthose infants who slept in an adult bedwithout the parents (4.7% vs 0.3%, OR=18.99[95% CI: 4.84-72.92]). Of these 15 deaths, 14were in a room unattended, 2 of these infantswere discovered on the floor, 2 under thebedcovers at the bottom of the bed and 2were extremely overwrapped. A highlysignificant risk was also associated withinfants found sleeping with an adult on asofa (6.3% vs 0.5%, OR=23.96 [95% CI: 7.08-81.10]). The narrative account suggests thatfor 4 of these 20 deaths the infant waswedged between the parent and the back ofthe sofa. Of the 10 SIDS mothers and 10partners, 7 had not intended to fall asleepon the sofa, but for 9 this practice was notunusual. In 5 of these deaths the co-sleepingparent had consumed up to 2 units of alcoholand a further 3 had consumed much morethan this. There was no risk associated withinfants who slept on a sofa alone (1.3% vs2.2%, OR=0.68 [95% CI: 0.22-2.14]).Conclusions In this study more than 1 in10 deaths occurred whilst the infant sleptalone on an adult bed or slept with an adulton the sofa. These deaths could be avoidedif parents are issued with the appropriateadvice.

1 PJ Fleming, PS Blair, K Pollard, MW Platt, C Leach,I Smith, PJ Berry, J Golding. Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999;81:112-116. 2 Leach CEA, Blair PS, Fleming PJ, Smith IJ, WardPlatt M, Berry PJ, Golding J.Sudden UnexpectedDeaths in Infancy: Similarities and differences inthe epidemiology of SIDS and explained deathsPediatrics 1999

64DANGEROUS SLEEPINGENVIRONMENTS OF INFANTS UNDERTWO YEARS OF AGEC. De Koning , Jodie Leditschke, PeterCampbell.Victorian Institute of Forensic Medicine,Victoria, Australia.All SIDS deaths that occur within a 3 hourradius of Melbourne, Victoria areinvestigated by a representative from theVictorian Institute of Forensic Medicine

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(VIFM). This retrospective study is based oninformation collected from Event SceneInvestigations performed during 1995, 1996and 1997. The aim of this project is toexamine the sleeping environments ofinfants who died suddenly andunexpectedly. The definition of a dangerousor hazardous sleeping environment isdebated. For the purpose of this study it isdefined as any environment which increasesthe risk of injury or death to an infant.Ofthe 99 infants in the group, in 94 cases thecause of death was SIDS, 4 asphyxial deathsand 1 death which was described asunascertainable. A faulty cot was present in5 cases. 33% of the 99 infants werediscovered lying prone with their face downin bedding. 43% of infants were sleeping withat least one other person, with the majorityof these infants (32/43, 74%) being underthree months of age. Additional factors suchas age, type of sleeping surfaces, overheatingand bedding covering the head arediscussed.

65THE INFANT POSITIONING PROJECT:A PROFESSIONAL EDUCATIONINITIATIVE.Stephanie CowanFamily Education Services, Christchurch,New ZealandAim: To increase the prevalence of face-upsleeping in maternity hospitals.Background: Much of the increasedprotection from sudden infant deathsyndrome (SIDS) in New Zealand (NZ), hasbeen achieved with a change from prone toside rather than back for positioning babiesfor sleep. High levels of side sleeping persist.An education initiative was designed toinfluence infant positioning practices inmaternity hospitals and, indirectly byexample, parent practices in homes.Method: A national assessment was madeof infant positioning practices in hospitalsby means of a maternity management surveyof “usual” and “recommended” practice andan audit of “actual” practice. An educationresource of research evidence and expertcomment was developed and distributed toall participating hospitals. After six-monthsa follow-up survey and audit was undertakento assess any change.Results: Responding hospitals represented82% of all live births in the country. Themanagement survey showed that mosthospitals had no written policy, auditprocess or staff guidelines for infantpositioning practices. Side sleeping was both

widely practiced and promoted, influencingmore than 50% of babies born. Both back andside positions were observed in similarproportions for both normal and special carebabies, younger (<48 hours) and older babiesand in smaller and larger hospitals. Hospitalsgiving “back only” as the “recommended” and“usual” infant sleep position for normal carebabies had equal levels of back and sidesleeping observed in the audit of “actual”practice. The results of the post interventionsurvey, yet to be completed will be presentedin this paper.Conclusion: There was low awareness of“back is best” by maternity professionals inNZ. Response to the assessment report andeducation resource has been excellent. It ishoped that this carefully designedintervention will result in the confidentpromotion of face-up sleeping as best forhealthy babies from birth and special carebabies from discharge.

66Safe Sleeping Environments forInfants: A CPSC PerspectiveN.J. Scheers, Ph.D. and George W.Rutherford, Jr., M.S.U.S. Consumer Product SafetyCommission (CPSC), 4330 East WestHighway, MD 20814, USABackground and Purpose. The U.S.Consumer Product Safety Commission(CPSC) is an independent regulatory agencywithin the U.S. Federal Government. Theagency was created in 1973 and since itsinception has emphasized protecting infantsand children from the unreasonable risk ofinjury and death associated with consumerproducts. These products include cribs,portable cribs, bassinets, bedding, and otherproducts used as, or found in, infants’sleeping environments. The purpose of thispaper is to: (1) review actions taken by CPSCto make infant sleeping environments safer,including the use of mandatory andvoluntary safety standards, safety alerts andpublic warnings, and (2) present the resultsof two CPSC studies on the hazards of softbedding for infants. One study examines therisk of certain bedding use for SIDS infantsfound with their heads covered comparedto SIDS infants found without their headscovered. The second study examines thecharacteristics of infant deaths in cribscompared to infant deaths in other sleepingenvironments.Methods. Data on head covering is from aCPSC study conducted from 1992-1994 at 18sites in 9 states were reanalyzed to examine

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factors associated with sudden infant deathwith head covered. The study proceduresincluded structured interviews as soon aspossible after the infant’s death, mannequinplacement by the caregiver who found thebaby, and photographs of the mannequinplacement. The methodology for this studyhas been reported previously [1].Data on deaths in various sleepingenvironments will be described by searchingthree CPSC databases: the Death Certificate(DTHS) database that includes product-related deaths purchased from all 50 states;the Injury and Potential Injury Incidents (IPII)database that contains deaths reportedthrough sources such as medical examiners,coroners, newclips, and consumercomplaints; and the In-Depth Investigations(INDP) database that includes on-siteinvestigations into selected injuries anddeaths. We will examine data from two timeperiods, 1980 and 1997, for infants under12 months.Results. Results for the head covering studyfound that approximately 8% of the infantswere found with their heads completely orpartially covered, as documented byphotographs of mannequin placement. Mostof the infants with their heads covered werefound covered by blankets or comforters.However, one infant’s head was completelycovered by a jacket and one infant wascovered “from waist to head” by a pillow.Four of these infants were found in the proneposition and two in the supine position. Oneinfant, the oldest of the group at 10 months,was placed prone to sleep but found withhis head and body covered in the supineposition. Infants found with their headscovered were, on the average, 5.1 monthsold compared to infants found without theirheads covered at 2.8 months old (t = 5.44,df = 204, p = .000). Significantly more head-covered infants were covered by comforterscompared to infants without their headscovered (P2 = 11.34, df = 1., p = .01) but nosignificant difference was found betweengroups in the use of blankets or in the useof sheets.Data used to compare the characteristics ofdeaths in various sleeping environments arecurrently being analyzed and will beincluded in the presentation.

1. Scheers NJ, Dayton CM, Kemp JS (1998). Suddeninfant death with external airways covered: case-comparison study of 206 deaths in the UnitedStates. Arch Pediatr Adoles Med, 132:540-547.

67SHOULD THE INFANT SLEEP INMOTHER’S BED?MA. Kibel1 , M F Davies2.University of Cape Town1, South Africa,University College London Hospital,London, England2

The role of co-sleeping is an unansweredquestion in SIDS. Since biblical times thishas been considered a risk factor, and thereare certainly well documented cases wheredeath from ‘overlaying’ has occurred. InWestern society, where solitary infant sleepis considered a normal and desirablearrangement, babies sleep alone andseparate from the parents. Yet co-sleepingis culturally normal in Japan, where cot deathrates are among the lowest in the world. Forthe majority of non-western contemporarypeople, bed sharing is the predominantsleeping arrangement especially in socio-economically-disadvantaged groups. Infantsare brought up in a busy environment,almost invariably sleep in the mother’s bed,and for many hours of the day are in closecontact with her body.A study in Cape Town, found that 94% ofblack infants sleep with their motherscompared with 4% of white babies.Anecdotal evidence from many experiencedclinicians supports the view that SIDS is lesscommon in ethnic African households. Werecently calculated the rates based onnotifications to the Central StatisticalServices and found an incidence of 0.09/1000 in blacks, 0.29 in whites and 1.11 inbabies of mixed race. In a prospective study,Wolf and Ikeogou, reported an incidence of0.2/1000 in a Zimbabwean townshippopulation. The evidence suggests that theremay be potential benefits to bed sharing.The bodies of infants are highly dependenton and responsive to a caregiver on whom,for a considerable period of time, theirsurvival depends. It may be safer for theinfant to sleep in the parent’s room. “Forbabies to endure increasingly long periodsof solitude after birth is biologicallyunreasonable”. It would seem entirelybiologically reasonable for the young infantto sleep in close proximity to its mother, andperhaps this is actually protective. Thisaspect requires further study incommunities where co-sleeping is common.

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68BACK TO SLEEP AND SIDSPREVENTION: IS POSITIONALPLAGIOCEPHALY A REAL PROBLEM?T.M.B. de Chalain,1 G. Bartlett,1 A.Law,2 C.Furneaux,2 M. Rees1

Regional Centre for Plastic Surgery,1 andDepartment of Neurosurgery,2 TheMiddlemore Craniofacial Clinic, MiddlemoreHospital, Auckland, New Zealand.Since 1992, when the American Academy ofPediatrics officially endorsed the practice ofsupine sleeping position for babies, as asimple measure to help reduce the risk ofSIDS (sudden infant death syndrome),enough data has accumulated to support thepractice as one of unquestioned benefit andefficacy in SIDS prevention. However,persistent lying in any one position,especially supine, has other attendant risks,which tend to be ignored by the paediatrichealth care community. Concomitant withthe rise in popularity of supine sleepingpositions, there has been a worldwideepidemic of referrals to paediatricneurosurgical and craniofacial centres, ofchildren with occipital plagiocephaly. InAuckland, in one of the major craniofacialcentres in Australasia, we have seen a risein the rate of referral of over 300% in thepast two years. Our concerns revolve aroundtwo issues: 1. In the first instance thepaediatric healthcare community seemseither unwilling to recognise the problem, orreluctant to acknowledge it, for fear ofundermining the very worthwhile messagethat supine sleeping is best in terms of SIDSprevention. Valid parental concerns arebrushed aside with unwarranted reassurances,which engender anger and resentment whenthe predicted self-correction of skull shapefails to materialize. Most practitioners believethat the natural history is self correction, butnot all children with positional plagiocephalywill self-correct; a significant proportion willbe left with visible deformity and in 2-4% thisis severe enough to warrant craniofacialsurgical correction. 2. The frequency ofoccurrence of OP (occipital plagiocephaly)tends to breed a contemptuous familiarityamongst frontline health care workers andthere is a real risk of missing other diagnosessuch as sutural synostosis or torticollis, whichrequire early intervention rather thanexpectant optimism. There are several simplestrategies available for recognizing the risk ofOP, preventing its development, orameliorating the deformation once present,but it is no longer acceptable to deny that aproblem exists.

69RISK FACTORS AND SUDDEN INFANTDEATH SYNDROME: AN OVERVIEW OFPARENTING PRACTICES IN THEREPUBLIC OF IRELAND.Mary McDonnellNational Sudden Infant Death Register,Dublin, IrelandAim: The aim of this study is to examineparental and childcare practices pertinent toSudden Infant Death Syndrome. Risk factorsfor Sudden Infant Death Syndromehighlighted by this study raised the questionas to how these results can be incorporatedinto childcare guidelines.Method: The information presented here isthe preliminary results of a case controlstudy conducted between the years 1994 to1998, with 208 SIDS cases and 637 controlsyielding a population sample of 845 women.Controls were matched for date of birth andgeographical location.Results: Mothers of SIDS cases were youngerthan the control mothers. (Mothers of caseswho were less than 20 years of age accountedfor 7% as opposed to 3% of the controlmothers. 25% of the case mothers were inthe age group 20 to 24 years as opposed to8% of the controls). Forty three per cent ofmothers of cases were single compared to12% of controls. Of the cases 59% hadmedical card status with 22% of the controls,26% of the case mothers were unemployedas opposed to 5% of the controls. Sixty sevenper cent of the mothers of the cases belongedto social class 4 to 6 in comparison to only33% of the controls. Only 10% of the mothersof the cases obtained tertiary education asopposed to 26% of the controls. In the cases29% of the fathers left school before 16yearsof age as opposed to 11% of the controls,and only 10 % of the case fathers receivedtertiary education as opposed to 31% of thecontrols. Of the fathers of the cases 32% wereunemployed and 69% belonged to socialclass 4 to 6. The corresponding figures forthe controls were 8% and 44% respectively.Results also show that in the cases thepercentage of women smoking is muchhigher (74%) than the controls (28%). Theamount of cigarettes smoked by the mothersshowed that in the cases 47% smoked 11-20cigarettes per day as opposed 34% of thecontrols during pregnancy. The patternremained the same following delivery of thebaby. Sixty three per cent of the fathers ofthe cases smoked during pregnancy asopposed to 27% of the controls. This patternremained unchanged after birth. Mothersdrank alcohol in 64% of cases as opposed to

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50% of the controls. Almost 40% of the casemothers took greater than 5 units of alcoholper week while pregnant as opposed to 12%of the controls. After the baby was born 52%of the case mothers took greater than 5 unitsof alcohol. This figure increased as opposedto the controls whereby only 22% tookalcohol. There was no significant differencebetween the number of fathers drinkingbetween cases and controls.Discussion and Conclusion: The datapresented from Ireland’s case control studydemonstrates that childcare practices varyamongst families whose infants die fromSudden Infant Death Syndrome. The issueremains as to how best to implement anappropriate advisory package to address theissues of parental practices paying particularattention to the Risk factors for SuddenInfant Death Syndrome especially smokingand alcohol. The percentage of womensmoking is still increasing in six EU countriesincluding Ireland.

70TRAINING BEREAVED PARENTS FORPEER SUPPORTNuala Harmey, Ger O’Brien, CarmelFinnucane, Margarita SynnottI.S.I.D.A., Children’s Hospital, Dublin,Ireland.Parents newly bereaved by the death of theirinfant from S.I.D.S. continually request(through I.S.I.D.A’s register) that they be putin touch with other parents who haverecently experienced the same trauma.However it is important that such contactbe productive to both parties.In order to safeguard both parents makingthe request and the supporting parentsI.S.I.D.A has devised a residential trainingprogramme for parents. This paper presentsan outline of the training given to parentsto act as befrienders over two residentialweekends. It describes areas covered i.e.normal grieving, basic counselling skillsamong other issues. Also discussed are theactual structures used in providing theservice and the supports put in place forbefrienders. The criteria used in selectingbefrienders are also discussed.An evaluation of the training and befriendersassessment of their need for support willalso be presented.

71NEW INITIATIVES FOR SUPPORTINGBEREAVED PARENTSAnn Deri-BowenFoundation for the Study of Infant Deaths(FSID), 14 Halkin Street, London, UKIn 1997, 403 babies died suddenly andunexpectedly in England, Wales and NorthernIreland. In 88% of these cases the Foundationfor the Study of Infant Deaths had contacteither with the family directly or with aprofessional working with the family.With the changing profile of bereavedparents the FSID Information and SupportCommittee, which includes Paediatricians,Counsellors, Psychiatrists, Psychologist,statistician, and representatives of otherprofessions, has constantly reviewedstrategies for offering support. Thepresentation will highlight the following newinitiatives and expand on the reason for theirintroduction:• Providing ‘Support for Bereaved Parents

Days’ which encourage parents to reflectafter at least a year on their own personalexperience and share with others.

• Health Visitors involved with a bereavedfamily have been contacted after the deathby regional staff. The aim is to provideinformation and support the healthprofessional in their role of supporting thefamily.

• Bereaved families were invited to meetFSID and other bereaved families over acup of tea and have free entry to amuseum. Many newly bereaved parents,not known to FSID, attended and the dayprovided an opportunity for supportwhich would have historically beenprovided by Groups of Friends.

• A free phone card for the 24 hour helplinehas been offered to all bereaved parentssince 1998 and has increased the supportoffered. The presentation will look at thenumber of parents who have used the cardduring the year and comments from users.

• Bereaved parents attending the AnnualNational Conference have been ‘paired’with Befrienders which has provided anadditional welcome and a friendly face.

72BEREAVEMENT RESPONSE TO THEDEATH OF A CHILDIan MitchellAlberta Children’s Hospital, Alberta,CanadaParental bereavement, including the deathof a child due to SIDS, produces major andlong-lasting effect on the parents. Studies

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of bereavement needs have not generallyused a population-based approach. We sent2 copies of a questionnaire on bereavementto the parents of all children (including stillbirths) less than 19 years who died in a 6month period in Alberta (700). 114questionnaires were returned and 7 parents(6.1%) indicated their child had died of SIDS.Three parents had attended the SIDS groupand had found it helpful.Responses are not divided by diagnoses, aswe did not link the anonymous questionnaireresponse with the cause of death. Parentsrequested information on bereavement butdid not indicate that any one time was betterthan another. A specific request was formore information on bereavement affectingsiblings. The commonest sources of supportwere immediate family and friends, buthealth care practitioners also were perceivedas supportive. Psychosocial professionals,clergy, funeral directors and police officerswere fund to be helpful by a majority, butthere was a significant number in eachprofession that was not thought to be helpfulby the parents. 78% of the parents would likea health care professional to contact them,and they varied in their suggested time.46.5% suggested within 2 to 3 weeks, 29.8%suggested around anniversary of death, and18.4% around special holidays. There werea number of barriers to receiving servicessuch as travelling distance (19%), cost(16.7%), and work commitments (14.9%).Interestingly, 27.2% of the parents did notfeel the need for services.A population-based assessment of needs canhelp design services for bereaved parentswhatever the diagnosis. Traditionalbereavement services have often beenfocused on families whose child is alreadyknown to health care professionals.

73BABIES OF THE DREAMING –ABORIGINAL FAMILIES SUPPORTINGEACH OTHER IN BEREAVEMENTLyn BriggsVictoria Aboriginal Health Service (VAHS),Melbourne, AustraliaVAHS provide a state wide service thatincludes a medical, mental health and dentalservices, community health research andeducation, and a Women’s & Children’sProgram. The address will outline the wayVAHS supports families that haveexperienced the grief and loss of losing achild. The history of colonial and post-colonial Australia is such that manyAboriginal families have suffered this kind

of grief in ways that you may not have evenheard of. For example, Government Policyfor many decades involved the removal ofchildren from their Aboriginal families andplacing them in institutions for the rest oftheir life. Most never knew their real parents.And their mothers, fathers and extendedfamilies suffered the same heartbreak thatlosing a child to SIDS can bring. The lossesfor the Aboriginal community go beyondSIDS. Another element that is noteworthy isthe cultural diversity of indigenouscommunities in Australia, and hence theneed to respect the sensitivities and culturalpractices of a range of communities.Aboriginal communities have been undersustained pressure for a long period of time.Survival is a major focus. The VAHS approachtries to acknowledge this, and thereforetakes a holistic approach when caring for thefamilies in our community.The VAHS became actively involved with SIDSDay in 1997. Since then a number ofactivities have been conducted each yearduring SIDS week. This is yet another waythat the VAHS provides support for families.A significant effort has been made to raiseawareness of SIDS in a culturally appropriateway. From this small community asubstantial fundraising contribution for theSIDS Foundation has also been made. Majorevents like the development of the Babiesof the Dreaming banner and the CandleMemorial Day will be outlined.

74SUDDEN DEATH LIAISON OFFICERPROGRAM. A POLICE INITIATEDSUPPORT SERVICE FOR BEREAVEDPARENTS THAT ENSURES BESTPRACTICE IN REPORTINGPROCEDURES FOR SUDDEN INFANTDEATH SYNDROME.J Joyce, B GraydonQueensland Police Service, AustraliaThe Queensland Police Service is leading theway in providing a professional and caringservice to bereaved parents. This ensurescorrect reporting procedures of SuddenInfant Death Syndrome.The Sudden Death Liaison Officer (SDLO)program was implemented in a small areaof Queensland in November 1996. Since thatdate, the program has been adopted in otherregions and included into the Policeoperations manual as best practiceguidelines. The program has now beenendorsed at international levels.Police Officers are tasked with investigating

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the deaths of infants. Traditionally nothought has been given as to who shouldattend these high grief situations. Too often,inexperienced Police have been assignedthese tasks. The negative impact that thiscan have has been well documented. TheSDLO program provides the family with aprofessional and caring officer, who buildsa rapport, provides information, andbecomes a central focal point for them aftertheir ordeal. The positive impact this hashad on bereaved families cannot beoverstated.The reasons for the program’s success aremany. Paramount to this success howeverhas proven to be the provision ofprofessional service delivery the familiesdeserve, and the correct reporting ofaccidental deaths which may have previouslybeen recorded as SIDS.Additionally, Police are no longer over-exposed to child death. This is due to thecoping mechanisms built into the program.The SDLO program has been described as oneof the finest policing initiatives ever seenand has generated enormous interestthroughout the world. The program hasintroduced the highest possible standard ofPolice professionalism in the area of deathinvestigation.

75INTEGRATED EMERGENCY RESPONSEMODELMichael CorboySIDSnew south wales, NSW, AustraliaOver many years, Sergeant Michael Corboyof the New South Wales Police Service hasbeen lecturing Police on the processes, legalrequirements, emotional impact on parentsand coping mechanisms for Police in relationto attendance at SIDS deaths. Michael, who’sown daughter Erin died on 1986, is alsoChairman of SIDSnew south wales. Overthese years Police, Ambulance Officers andsupport services from both SIDSorganizations and government authoritiesprovided many cross-over services whenattending to SIDS deaths. In recent timeswhen many other charities are competing forfunding that in the past went to SIDSorganizations and the changing nature ofSIDS charities with the expansion of services,it is becoming increasingly difficult to coverall aspects from a support services aspect.In a new look at the entire process relatingto services provided by all organizationswhether Government, Emergency Services orSupport Organizations, an IntegratedResponse Model can assist all support

organizations from both a resourceperspective and a funding perspective.Training of Support Services staff, providing24 hour a day telephone response, callingout support service volunteers and therecruiting of volunteers have all becomeincreasingly difficult.In this paper Michael will discuss andpropose an Integrated Emergency ResponseModel where not only funding and resourcescan be directed toward the training ofvolunteers but also a greater collaborativeapproach can be taken. Directing resourcestoward greater integrated training of Policeand Ambulance Officers as well as Hospitalstaff can greatly assist SIDS organizationswith both proper use of resources andfinances. Michael will discuss processes,cultural/organizational change and barriersto his Integrated Response Model.

76POLICE INVESTIGATION INTO THESUDDEN AND UNEXPECTED DEATHSOF INFANTS. THE WAY FORWARDG. PiloniFoundation for the Study of InfantDeaths, 14, Halkin Street, London SW1X7DP, UKThe first contact for bereaved parentsfollowing the sudden and unexpected deathof their infant is often with uniformed policeofficers, many of whom are parentsthemselves, but most have no experience indealing with bereaved parents. In England,Wales and Northern Ireland, there are 44 policeforces, all with different guidelines in dealingwith these deaths.During 1997, a number of problems wereidentified by parents and professionalsregarding the handling of these deaths bypolice. Complaints included :-• Bereaved parents were denied access totheir infant following confirmation of

death, and parents were only allowed tohold or touch their infant while closely

supervised by police officers.• Parents were not informed when their

child was being taken to another hospitalor region for a post mortem examination.

• The body of their infant was not beingreleased by H.M. Coroner for the funeral.As a result of these complaints, Sussex Policerecognised that these problems needed to beaddressed. They met with the author, an FSIDRegional Co-ordinator, a bereaved parent anda part-time serving Police Officer, andconsultations were made into a Joint AgencyProtocol for Unexplained and UnexpectedInfant Death. This involves all Child Protection

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Committees, H.M. Coroners, the Home Office,F.S.I.D. and health professionals workingtogether. Initiatives include:-• A Detective Sergeant, will attend each deathpreferably from the Child Protection Team(C.P.T.) with consideration being given to aCPT officer attending as an alternative touniformed police, whose attendance shouldbe kept to a minimum.• Parents or carers should be allowed to see

and hold their infant while being observeddiscreetly by a professional.

• Professionals must endeavour to concludetheir investigations expeditiously, as thefuneral must not be delayedunnecessarily.

These guidelines form a basis for us toencourage other forces to update theirprotocols in dealing with these deaths. Theguidelines are available to view.

77CHILDREN’S PROTECTION WORKERSAND SIDS RISK REDUCTION. ANEXPLORATORY PROJECT TO REDUCETHE RISK OF SIDS IN FAMILIESKNOWN TO THE CHILDREN’SPROTECTION SERVICE.D Ford1, J Breen2

SIDSvictoria, Australia1, and Protectionand Care Branch, Department of HumanServices, Victoria, Australia2.Between 1989 and 1996, 36 deaths occurredof infants aged under one year of age infamilies known to the Child ProtectionService in the Department of HumanServices, Victoria, Australia. Nineteen ofthese 36 infant deaths were diagnosed asSIDS.In 1997, a ministerial advisory committee,the Victorian Child Deaths ReviewCommittee, recommended that Children’sProtection Workers, who investigatenotifications of child abuse and neglectreceive training “…to provide information onprevention strategies that can bedisseminated to young parents with younginfants who are subject to protectiveinvestigation, and assists these workers incoping with SIDS deaths among theircaseloads.” Annual Report of Inquiries intoChild Deaths: Protection and Care 1997.Victorian Child Death Review Committee.Victoria. p21.The paper describes this exploratoryprogram in health promotion for families athigh risk and discusses the implementationand practice issues arising, both from theperspective of health promotion and thechildren’s protection service.

78MORTALITY OF BABIES ENROLLED ONA SUPPORT PROGRAMME FORVULNERABLE BABIES OR ANXIOUSPARENTSAJ Waite,1 JL Emery,1 RG Carpenter,2 RCoombs, C Daman-Willems, CMAMcKenzie2

University of Sheffield, UK,1 LondonSchool of Hygiene and Tropical Medicine,UK2

Since 1989, the Foundation for the Study ofInfant Deaths has funded the Care of NextInfant (CONI) programme to provide supportfor families with children born following acot death. CONI has been widely taken upand is used by 85% of the community healthtrusts in England, Wales and NorthernIreland. By 1st January, 1999, 5922 babieshad been enrolled, although as participationon the programme is optional, this is not thecomplete population of subsequent siblings.Due to demand from clinicians theprogramme was made available for otherfamilies who were assessed locally asneeding additional support e.g. followingALTE, family history of cot death, previousinfant death of known cause. 729 babieshave been enrolled in this group. Thepostperinatal mortality of babies on thescheme in the initial 5922 is 8.3/1000 livebirths. To date 8 have died of the additional729 enrolled on the wider programme, 4amongst 231 baies enrolled because of aclose family history of cot death.These are very high death rates but appearto be about half the rate of previous deathsin the same families. Studies of these babydeaths reveal that only a small proportionare truly unexplained and possiblypreventable factors have been identified.Where suitable regimes have beenimplemented with subsequent children, nofurther deaths have occurred. It appears thatfamilies enrolling on this scheme are a highrisk group identified by the primary careteam and by the parents themselves.Satisfaction rates recorded by both parentsand the health visitors show that the schemeis greatly appreciated.Our present objectives are to obtain totaldata in some areas to further quantify thebeneficial effects of the service. We shouldlike to discuss the implementation of similarscheme elsewhere to evaluate our findings.

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79RISK FACTORS AND SUDDEN INFANTDEATH SYNDROME: AN OVERVIEW OFCHILD HEALTH IN THE REPUBLIC OFIRELAND.Mary McDonnellNational Sudden Infant Death Register,Dublin, IrelandAim: The aim of this study is to highlightfactors that may influence infant health. Thedata from Ireland’s case control studydemonstrates differences amongst thoseinfants who die from Sudden Infant DeathSyndrome and those in the generalpopulation.Method: The information presented here isthe preliminary results of a case controlstudy conducted between the years 1994 to1998 with 208 SIDS cases and 637 controlsyielding a sample of 845 children. Controlswere matched for date of birth andgeographical location.Results: Two per cent of mothers of SIDScases received no antenatal care with 22%of them waiting until they were more than17 weeks pregnant to receive care asopposed to 14% of the controls. Twenty fourper cent of the cases received less than 14weeks maternity leave as opposed to only15% of the controls. In the cases 12% of themothers returned to work when the child wasless than 4 weeks of age in comparison to4% of the controls. Seventy one per cent ofthe cases and 74% of controls were cared forby their mothers during the day however in19% of the cases both the mother and fatherwere recorded as the primary carer duringthe day as opposed to only 4% of thecontrols. At nighttime 62% of the cases hadboth parents as carers as opposed to only27% of the controls. SIDS cases were foundto come from larger families with 4% of themothers having 6 or more children asopposed to only 0.5% in the controls. In 3%of cases the mothers had a previous stillbirthas opposed to 0.8% of the controls. Four percent of the cases were a twin with 11.7% bornbefore they were 37 weeks gestation asopposed to 4% of the controls. In 13% of thecases the birthweight was less than 2500 gmsas opposed 3% of the controls.Discussion and Conclusion: Thediscussion will explore the issues ofimportance in relation to the antenatal careof mothers and potential parenting practicesso that their infant’s health can bemaximized to ensure a better outcome.

80UNEXPECTED INFANT DEATHS: THEVALUE OF DEATH SCENEINVESTIGATION ANDMLTIDISCIPLINARY REVIEWP Fleming, P Blair, J Berry.Institute of Child Health, University ofBristol, BS2 8BJ, UK.The proportion of sudden unexpected deathsin infancy (SUDI) attributed to accidentalasphyxia or to non-accidental injury (NAI)by a parent or carer remains controversial,and the importance of a careful history andscene investigation have been emphasised(1).Aim: Investigation of all infant deaths inAvon (population 940,000).Methods: Information was collected, from1985-1998 inclusive, on all SUDI in Avon bya paediatrician or research health visitor, ata home visit, within 24 hours after discoveryof the death, followed by a full post-mortemexamination, and a multidisciplinary casereview meeting (2). SIDS was defined as:“sudden unexpected death of an infant,which remains unexplained after a fullautopsy, review of clinical history andcircumstances of death”. Detailedexamination of the death scene wheneverpossible was added from 1992.Results: Interviews and case reviewmeetings were completed for 280/285 (98%)of the deaths, post-mortems for 100%.In 1985-1991, 228 SUDI occurred, including204 SIDS (2.3 / 1000 live births). Of“explained” SUDI (total 24), 5 were attributedto NAI (2 %), 2 to accidental suffocation (1%),and 17 (7%) to other causes, (e.g. infection).In 1992-1998, 58 SUDI occurred, including34 SIDS (0.7 / 1000 live births). Death sceneexamination was completed for 41 (71%)deaths. Of “explained” SUDI (total 24), 6 wereattributed to NAI (10 %), 6 to accidentalsuffocation (10 %), and 12 (21%) to othercauses, (e.g. infection).Conclusions: Despite a marked fall in thenumber of SUDI, (especially SIDS) “fullyexplained” deaths remained constant (1 in3,500 births) as did those attributed to NAI(1 in 16,000 births). Death scene examinationhas led to raised awareness of the possibilityof accidental suffocation. These studiesdemonstrate that investigation of the sceneand multidisciplinary case review arepractical and valuable for all suddenunexpected deaths in infancy.1. Editorial (anon). Unexplained deaths ininfancy. Lancet 1999; 353:161.2. Fleming PJ, Blair P, Bacon C, Bensley D,

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Smith I, Taylor E, Berry PJ, Golding J, TrippJ. The environment of infants during sleepand the risk of sudden infant deathsyndrome: results of 1993-5 case-controlstudy for confidential enquiry into stillbirthsand deaths in infancy. BMJ. 1996; 313:191-5.

81HEALTH CARE VISITS BY CHILDRENFROM BIRTH TO TWO YEARS IN ANURBAN HEALTH CENTREHelen LernerProfessor Parent Child Nursing, LehmanCollege CUNYCounseling parents about sleeping positionand supporting infant care activities areimportant services to provide for theprevention of SIDS (sudden infant deathsyndrome) and other causes of post neonatalmortality. Frequent visits to the health careprovider during the first 6 months of life areessential. To determine opportunities thatproviders have to give this information, ababy track program was started and theinfants were tracked upon registration at anurban Health Center until their secondbirthday.Objectives of the study:1). Determine the pattern of health care visitsfor children from birth to age 2 years in anurban Health Center.2). Identify factors relating to the frequencyof visits to the Health Center.3). Relate number and timing of visits to theinfant’s being up to date with immunizationat 3, 6, 9, 12, and 18 months.Methods: Infants born to mothers cared forin the antepartum practice at a Health Centerwere tracked from the time they wereregistered in the Center as newborns untilage two years. Demographic data as well asimmunizations, numbers of visits, andreasons for visits were collected and updatedmonthly from reports from the Center’sinformation system.Results: Preliminary results of children bornduring the previous nine months reveal that74.2% of infants visit the health care providerbefore 2 weeks of age. Ninety one percentsee the health care provider within the firstmonth of life. Eighty five percent of firstvisits have the only diagnosis as well infant.Present findings show that 75.8% of infantsare up to date with their immunizations at 3months of age. Further data are beinganalyzed.

82INFANT CARE PRACTICES INVICTORIA, AUSTRALIA, 1997-1998: APOPULATION SURVEY TO EVALUATETHE EFFECTIVENESS OF ENHANCEDSIDS RISK REDUCTION MEASURES.D Ford1, C Sanderson2, M Wilkinson3

SIDSvictoria1, Paediatrician, Geelong,Victoria2, Ritchie Centre for Baby HealthResearch, Institute of Reproduction andGrowth, Monash University, Melbourne,Victoria3

In June 1997, the National SIDS Council ofAustralia launched the ‘KIDS&SIDS. Threeways to reduce the risk.’ communityeducation program. This programrecommends that parents ‘put baby on theback to sleep; ensure that baby’s headremains uncovered during sleep and keepbaby in a smokefree environment beforebirth and after.’To evaluate the effectiveness of the program,a population based study was undertaken toestablish current infant care practices andassess the impact of the revisedrecommendations on SIDS risk reduction.Parents who had given birth to live infantsin Victoria during April 1997 and May 1998were surveyed using a brief questionnaire.The questionnaire was administered byMaternal and Child Health nurses during thefirst routine home visit to the family, aroundten days after the birth. In each of thesurveyed months over 2000 responses werereceived. This represents approximately 50%of the population of live births during thesemonths.The paper reports on infant care practicesin the state before and after theimplementation of the revised reducing therisk of SIDS program. The results provide uswith a window in time on which to evaluatefuture change in infant care practices. Theconclusions have indications for the multipleetiologies of SIDS.

83GETTING THE REDUCE THE RISKADVICE TO DISADVANTAGEDPOPULATIONS - A MOBILEINFORMATION PROJECTJoyce EpsteinFoundation For The Study Of InfantDeaths (FSID), London, UKIn the UK, as elsewhere, the incidence of SIDShas become concentrated in recent yearsamongst families living in conditions ofsocioeconomic disadvantage. Concern thatthese families have not heard or heeded the

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Reduce the Risk message led to thedevelopment and launch, by FSID, of amobile information project in impoverishedareas of inner London in 1998, to take themessage more forcefully into thecommunities in which it is most needed.The project consists of a mobile informationunit (VW van) staffed by two informationofficers, who site the van at various innerLondon venues three days per week,including street markets, playgrounds,health clinics, supermarkets and other publicsites, and proactively engage the interestsof passers-by in the Reduce the Risk mesageand other infant care advice.The van staff, selected to reflect the diversityof cultural and ethnic populations in theinner city, are managed by a projectcoordinator who also researches, plans andpublicises the sites for the van.The paper will report on the first 12 monthsof operation of this unique project,including: level and nature of usage,assessment by local health professionals,and a user survey including the finding that78% of people who used the van’s serviceslearned something new about infant c;arethat they had not known before.

84FATHERS DO SURVIVE SIDSGraeme BakerSIDS Canterbury, New ZealandThe reaction of fathers, mothers and otherchildren, to the unexpected death of theyoungest family member, are all individualand follow differing paths and timeframes.The future direction the family proceeds ischanged from that day.A father’s ‘responsibilities in life’, sometimestend to overshadow the real needs that wemen as individuals are requiring to have met.I have been fortunate to participate in severalgatherings where as a group of men we havehad the opportunity to share about the deathof our child and listen to others tell theirstory. Equally important has been theopportunity to talk to other men one to one.These have been a valuable part of surviving.This workshop is for men only, and providean opportunity to share experiences.

85PARENTS & THE MEDIAHelen CormackScottish Cot Death Trust, Greenock,Renfrewshire, Scotland.Each time new research on SIDS emerges,each time a health promotion is launched, anew poster commissioned, the media

request an interview with a parent whosebaby has died of SIDS. The reliving ofparents’ experiences in this forum is not oneto be taken on lightly and parents who agreeto be interviewed are often unaware of theeffect the interview will have on their griefand recovery.This workshop aims to look at preparationfor such an interview, what is likely tohappen during it and the care which parentsshould take of themselves following theinterview. Some parents who have neverconsidered offering their perspective mayfind that with some forethought they couldbecome involved in this way. Thedifferences between TV, radio and printmedia will be discussed. It is anticipatedthat there will be a sharing of experienceduring the workshop.

86INDIGENOUS AND HIGH RISKCOMMUNITIESLL Randall, TK WeltyCenters for Disease Control andPrevention and Indian Health Service,Albuquerque, NMAn Indigenous population is defined as apopulation that is native to a specific area.One of the most interesting things aboutmost indigenous populations is that theyoften call themselves “the people”. They areoften culturally and linguistically intact.Most American Indian and Alaska Native (AI/AN) are both. There have been cases ofalmost total assimilation into the greater U.S.society, cases of cultures remaining intactand cases of total extinction after contact.Acculturation and assimilation haveincreased risks for many diseases andincreased mortality for various causes. Thisis often due to change in diet and level ofactivity, abuse of alcohol and tobacco, lossof self esteem, loss of social structure and aloss of traditional healing practices not yetfully replaced by western medicine.While infant mortality has decreaseddramatically for AI/AN over the past onehundred years, SIDS rates have declined lessdramatically and is one of the areas wherethis is noticeable. AI/AN infant mortality issecond only to the African Americanpopulation, is higher for post-neonatalmortality and is highest for SIDS. This hasput them into a high risk community profilefor SIDS. While infant mortality rates havedeclined for AI/AN, some AI/ANcommunities experience rates arecomparable to developing nations. The SIDSrates range from 112.7 per 100,000 live

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births to 366.1 per 100,000 live births. Inone area, 47% of the infant deaths were dueto SIDS. In all but three of the 12 areas ofIndian Health Service, SIDS was the leadingcause of infant death and in the other threeit was the second after congenital anomalies.The ratio of SIDS for all infant deaths amongAI/AN to the White population has increasedto 2.8. For postneonatal SIDS deaths it is2.9.

87AT RISK GROUPS ANDSOCIOECONOMIC DETERMINANTSRG EnglishThomas Jefferson University,Philadelphia, PAAlthough infant mortality in the UnitedStates is at a record low of 7.2 per 1,000 livebirths, the U. S. still ranks 24th in infantmortality when compared to otherindustrialized nations. Infant mortality ratesvary significantly among and within racialand ethnic groups. The greatest disparityexists for African Americans; whose infantdeath rate (14.2) is nearly 2 + times that ofwhite infants (6.0). The overall AmericanIndian rate of 9.0 does not reflect thediversity among Indian communities, someof which have rates approaching twice thenational rate. Similarly, the overall Hispanicrate of 7.6 does not reflect the diversityamong this group which had a rate of 8.9among Puerto Ricans (CDC/NCHS, 1996).Although we have done a good job ofreducing infant mortality overall, we still donot understand why there is a disparity inrates for certain racial and ethnic groups.When you control for socioeconomic statusand education, the gap is still there. Becausethis disparity occurs in a wide range ofcauses (low birth weight, injuries, infections,chronic diseases, and maternal mortality –which is four times greater for black women);we need a new way of looking at thisdilemma. Problems such as environmentalexposures, institutional racism, andpsychosocial factors not only influence thehealth outcomes of the individual, but leadto what is obviously a uniform gap inpopulations in terms of their health status.Cultural competency and other innovativestrategies will be explored.

88SITISI : PLIGHT AND RESPONSE OFPACIFICANS IN AOTEAROA'Eseta Finau, Nite Fuamatu, SitalekiFinau, Colin TukuitongaPacific Health Research Centre,Department of Maori and PacificHealth, Faculty of Medical and HealthSciences, The University of Auckland,New ZealandFor sometime Sudden Infant Death Syndrome(SIDS) or SITISI was considered a rare andlow priority problem among Pacificansworldwide. However, recent findings inAotearoa have shown that at least 33% ofPacific infant deaths since 1991 have beendue to SIDS; in addition, the incidence of SIDSamong Pacificans has been on the increasesince 1986. These findings havenecessitated the development of a Pacificresponse. This have occurred in Aotearoawhere a National SIDS Programme,implemented in 1991, has led to decreasingrates amongst Pakeha only. This paperreports the context of these discoveries andthe response of Pacificans to control yetanother epidemic amongst migrants. Theimportance and initiation of community-based strategies is central to the Pacificans'response to SITISI and its determinants.

89REDUCING THE RISK OF SIDS FORABORIGINAL INFANTS IN AUSTRALIA:DEVELOPING COLLABORATIVESTRATEGIESJM Carey, DL FordSIDSaustralia, Melbourne, AustraliaDeaths from SIDS in Aboriginal infants werenearly 5 times higher for boys and nearly 7times higher for girls when compared withother Australian infants.Since the introduction of the Reducing theRisk of SIDS community health program in1990 in Australia, the number of infantsdying of SIDS in the non-Aboriginalcommunity has dropped by more than 75%,from approximately 500 in 1989 to about120 in 1998. There has not been a similarreduction in SIDS among Aboriginal babies.SIDSaustralia has undertaken to address thisissue through collaborative work withaboriginal health services and aboriginalcommunities. The strategy has a twopronged focus: the grass roots up and thetop down. SIDSaustralia and its memberorganisations are reaching out to Aboriginalgroups in their own areas and at the sametime they are also in contact with the health

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authorities. The aim is to establish the mosteffective ways of working together todevelop and disseminate culturallyappropriate health information and to fundand support these efforts to reduce the riskof SIDS and improve the safety of sleepingenvironments for Aboriginal infants.This paper describes the strategy anddiscusses its implementation so far. It hasimportant implications for the developmentof health promotion approaches withinindigenous communities.

90COMPETENT PROFESSIONAL CARE ATTIME OF A SIDS DEATH PREVENTS ALIFETIME OF DYSFUNCTION.Nuala Harmey,1 M. McDonnell2

Childrens Hospital , Temple St. Dublin,1

N.S.I.D.R. Ireland.2

Compassionate professional care at the timeof a SIDS death, which empowers parents tomake decisions, involves them in all aspects(legal, psychological, and practical) of thedeath of their child, supports them in caringfor, and involving, their other children andprovides professional facilitated bereavedgroups for parents and children within sixmonths of the death will, the authorcontents, prevents dysfunctional families inthe aftermath of the death.This paper presents a programme of careprovided at the Childrens Hospital, Dublinwhere parents are supported intensively andempowered from the time of the SIDS deathuntil the funeral. Afterwards they areprovided with on going care in the form ofparents bereavement groups. A shortdescription and an evaluation of thesegroups (1996 –1999) will be included in thepresentation. The involvement of siblings isvital for the future mental well being of thesechildren. The author (1997), who interviewedbereaved children to obtain their views,carried out a survey of the issues significantto children. The results of this survey willbe used to support the necessity of involvingchildren. Excerpts from a video made withthe children discussing the aspects of thesibling’s death which were handled badly orwell, in their view will be shown. For familiesfrom other areas, where babies are notbrought to a children’s hospital, I.S.I.D.A.(through its register) has evolved ‘A Modelof Care’ for professionals – with a 24 hourhotline to advise professionals on theoptimum care for families at the time of thedeath. The presentation will include a shortsynopsis of the workings of this ‘Model ofCare’.

91INTEGRATED SUDI DEATH SCENEPROTOCOL IN CHRISTCHURCHWendy Dallas-KatoaMaori SIDS Prevention Team, Dept ofMaori and Pacific Health, University ofAuckland,The Maori SIDS Prevention Team has workedfor 6 years in the NZ SIDS environment onprevention strategies and support for SIDSfamilies in the Maori community. This issue,the death scene investigation, is an issue forall SIDS families. There are some isolatedexamples of good service for SIDS familiesin New Zealand from which we have learned.The present investigation of a SIDS death,carried out by frontline policemen and apathologist under the auspices of theCoroner, has multiple problems thatcomplicate issues for confused andemotionally battered SIDS parents. Thesecan be easily and usefully modified by theinclusion of medical and social support atthe death scene and by providing long termsupport of SIDS families.An integrated national death scene protocolis being developed, with a change in focusaway from a purely forensic investigation toone which is family focused and balancedwith the inclusion of medical and socialsupport. The greatest advances in socialsupport offered to families are currentlybeing made in the Christchurch region. TheSouth Island Maori SIDS Co-ordinator willdescribe the process of unifying theprofessional SUDI team; the development ofsafe and supportive investigative practicesfor SUDI families and the agencies involved;the importance of debriefing theinvestigative team together to learn fromeach death and build codes of best practiceand describe the type of multi-disciplinaryteam needed to provide long term effectivesupport for SUDI families.

92PSYCHOBIOLOGICALCONSIDERATIONSWilliam P. FiferColumbia University, New York, USAPsychobiological research on the long-termconsequences of genotype-phenotypeinteractions during the perinatal and earlyinfant periods of development has a longhistory. There has been a recent resurgenceof interest into investigations of the effectsof early experience on subsequent risk for

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disease, e.g., maternal diet, smoking andstress during pregnancy. Epidemiologicaldata gathered from studies of infants whohave succumbed to SIDS clearly points to avulnerability, which also has its originsduring the perinatal period. The at-riskinfant’s inability to respond to potentiallylife threatening physiological challenges islikely shaped by both pre and postnatalexperience.Results from studies conducted in ourlaboratory and others will be reviewed anddiscussed in an attempt to generate testablehypotheses regarding the effects ofexperience on neurobehavioral capacities.Data will be presented showing changes insleep state distribution and baselineautonomic functioning as a function of sleepposition. The interaction of postprandialinfluences with positional changes on “basal”physiological activity will also be discussed.Such baseline differences in autonomicnervous system activity may reflect thecapacity to respond to postnatal stressorsor challenges. Additionally, these functionalchanges form the context in which theinfants may develop or learn responses tolife threatening stimulation. Finally, datawill be presented quantifying the ability ofinfants to respond to cardiorespiratory andcardiovascular challenges as a function ofrisk status.

93DEFENSIVE BEHAVIOUR SAVES MOSTBABIES’ LIVESLewis P. LipsittMedical Science, and HumanDevelopment, Brown University,Providence, Rhode Island, USA.Humans pass through a criticaldevelopmental period at 2-4 months inwhich a shift occurs from reflexive controlof behaviour to cortically mediated “learned”control. During that transition, the infantpasses through a state whichdevelopmentalist Myrtle McGraw called“disorganized” (1943); during that period95% of crib deaths occur. A small proportionof babies do not achieve the transitionsuccessfully. These are babies who havediminished reflexes to respiratory occlusionin the first 2 months and thus do not havesufficient learned control by the age ofvulnerability to behaviorally adjust theirheads, especially when in the prone position,to recapture their respiratory passages forbreathing. Before the age of vulnerability,their reflexes are life-preserving; after thecritical age, their acquired responses are self-

protective. Crib death occurs, in this view,as a consequence of a neuromuscular andbehavioural deficiency, likely related to pre-and perinatal as well as subsequentenvironmental insufficiencies that are inprinciple controllable.

94CHILDCARE AS AN ADAPTIVE SYSTEMAND SIDS PREVENTION: RE-ARTICULATING THE INFANT’S DIS-ARTICULATED CAREGIVINGENVIRONMENTJames J. McKennaUniversity of Noptre Dame. Mother-BabyBehavioral Sleep LaboratoryMother-infant co-sleeping and all of thevarious physiological and behavioralsubsystems which support this arrangementevolved in tandem, specifically to enhanceinfant survival and to maximize parentalreproductive success. Millions of mothersworldwide know that strong emotions and acertain amount of common sense underlieand motivate co-sleeping, even thoughparents (and researchers) may be unawarethat co-sleeping is the biologicallyappropriate sleeping arrangement whichinduces important behavioral andphysiological changes in the participants.Researchers have yet to appreciate, however,that the “continuum of outcomes” associatedwith various forms of mother-infantcosleeping, most notably bedsharing, willnever be understood unless the variablesthat underlie the mutual physiologicalregulation that accompanies it areinterpreted in relationship to each other,within the overall system within which eachvariable is expressed. Using data from ourthree mother-baby cosleeping laboratorystudies, and more recent ethnographic homestudies, I suggest that the “he said, she said”interpretations of bedsharing will never beresolved, nor an accurate understanding ofinfant sleep biology and healthy sleepenvironments realized unless new analytictechniques are used which can accomodatethe simultaneous transactions that occur, orfail to occur, when the breast feeding mothersleeps alongside and interacts with herinfant during the night. The concept of“bedsharing” should be the beginning pointfor SIDS analyses, not the endpoint.Reference only to sleep location orarrangement reveals nothing about thephysical structures, social conditions, orpsychological content of the interactionsoccurring in the bed (for example) whichaltogether determine outcomes. Simply to

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assume that any cosleeping (or bedsharing)environment provides explicit, inevitabledangers rather than hidden or real orpotential benefits, is to confuse dangerousconditions (which can be eliminated in manycase) with biological adaptation. My researchcontinues to suggest that for a small subclassof SIDS prone infants cosleeping with breastfeeding, even when practised in beds, shouldprovide increased protection from SIDS.

95INFLUENCE SLEEP POSITIONEXPERIENCE ON ABILITY OF PRONESLEEPING INFANTS TO ESCAPE FROMASPHYXIATINGMICROENVIRONMENTS BY CHANGINGHEAD POSITION.Bradley T. Thach, Dorota A. Paluszynska,Kathleen A. HarrisWashington University Department ofPediatrics, St. Louis Children’s Hospital,St. Louis, Missouri, USASeveral studies have found that back or sidesleeping infants who are unaccustomed toprone sleeping are at much higher risk forSudden Infant Death Syndrome (SIDS), whenplaced prone for sleep than infants whoregularly sleep prone. Moreover, when suchunaccustomed infants die of SIDS they aremore likely to be found with their faces downand covered by bedding than infants whoregularly sleep prone. As an explanation forthese findings, we hypothesized that infantswho are unaccustomed to prone sleepinghave greater difficulty in changing headposition to avoid an asphyxiating sleepenvironment when they sleep prone and facedown. We studied 37 healthy infants whileawake and while sleeping prone. Eighteenwere unaccustomed to prone sleeping (meanage=110 days) and 19 were accustomed(mean=122 days). To create an asphyxiatingmicroenvironment we placed infants to sleepprone on soft bedding, face down, with a 2inch deep circular depression beneath theirheads. We recorded Inspired (CO2 I) and endtidal C02, EKG, O2 saturation, respiration andhead movements. In a standardized test ofgross motor development, infants who wereunaccustomed to prone sleep were found tobe less advanced than accustomed to proneinfants. When sleeping prone, face coveredby bedding, all infants experienced mildasphyxia due to rebreathing expired air (CO2

I up to 5%; O2) and all aroused and attemptedto change head position. Infants could becategorized by their use of either of 3 headrepositioning strategies. (1) rapid side toside movements of the face against the

bedding (“nuzzling”) with occasional briefhead lifts. This did not result in significantpermanent change in head position or lowerCO2 I. (Score = 1). (2) “nuzzling” and headlifts which occasionally were combined witha head turn, always to the same side, rightor left. This sometimes resulted in apermanent change in head position andreduced CO2 (Score =2). (3) a sudden headlift, combined with a large head turn(including both turns to right and to left)which resulted in a prompt, permanentchange in head position and fall in CO2 I.(Score =3). Each infant was scored 1, 2 or 3depending the strategy used. Unaccustomedto prone sleep infants scored lower than“accustomed” infants (p<.001). Twelve of 18“unaccustomed” infants had scores of 1 asopposed to 2 of 19 “accustomed” infants.Only 2 “unaccustomed” infants had a scoreof 3, as opposed to 9 of 19 “accustomed”infants. Infant age had little or no effect onscores. We conclude that: 1) inexperiencein prone sleeping is associated not only withmild delay in gross motor development butalso with decreased ability to escape fromasphyxiating sleep environments caused byrebreathing expired air. 2). The ability tocoordinate head lifting, an innate reflex, withhead turning, is acquired and perfectedthrough practice, in other words “learned”through experience. 3) These observationspotentially explain the increased SIDS riskand occurrence of the face down deathposition in unaccustomed to prone sleepinginfants.Funded By HD10993

96A STUDY OF NIGHT-TIME INFANTCARE PRACTICES: A COMPARISON OFROOM-SHARING AND BED-SHARING INA GROUP OF MOTHERS AND THEIRINFANTS OF LOW RISK FOR SIDSJeanine Young, Peter Blair, Katie Pollard,Peter Fleming, Andrew Sawczenko.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, United Kingdom.Aim: Little is known about how parents carefor their babies at night. Bed-sharing is apractice which appears to carry differentrisks depending upon parentalcharacteristics and the sleepingenvironments in which it occurs. This studyinvestigated night-time behaviour of 10 non-smoking, breastfeeding mother-infant pairs.Methods: Polysomnographic and infra-redvideo recordings in a sleep laboratorycommenced when babies were about 4 weeksold, and continued monthly for 5 months.

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Five pairs were routine bed-sharers (RBS) andfive were routine room-sharers (RRS). Eachmonth, pairs were randomised to one nightbed-sharing then one night room-sharing, orvice versa. Behaviour and interactions wereanalysed using a behavioural code.Results: Mother and baby sleep/wake statesdemonstrated some concordance. For themajority of time when babies were awake,mothers were awake; and when babies werein Quiet sleep, mothers were asleep. Allmothers spent more time awake when theirbaby was in active sleep on bed-sharingnights compared to room-sharing nights.Babies initiated most interactions. RBS pairsdemonstrated more interactions than RRSpairs on both night conditions, and RBSmothers responded more quickly to babyinitiated interactions compared to RRSmothers. RBS pairs breastfed twice asfrequently as RRS pairs on both nights, butfeeds were of shorter duration. Mothers mostcommonly placed their infants supine tosleep. The prone position was only usedwhen infants were settled to sleep on theirmothers’ chest. Bed-sharing mothers morefrequently faced their infant, and were inclose physical contact, often within 20 cmof their baby. Bedding on both nightconditions was most commonly placed at thelevel of the infants’ shoulders, with one orboth arms free. When bed-sharing, mothersmore frequently secured the duvet undertheir arm which prevented it moving overtheir shoulder during sleep and accidentallycovering their baby’s head.Conclusions: No adverse effects of bed-sharing were observed. Studies investigatingbed-sharing must define the conditionsprecisely. Recommendations regarding bed-sharing should distinguish between theeffects of potentially hazardous sleepingenvironments and close contact betweenmother and baby.

97EXHALED AIR ACCUMULATION INTHE INFANT SLEEPINGENVIRONMENT AND THEPREVENTION OF SUDDEN INFANTDEATH.A CorbynUniversity of Technology, C/o Post Office,Lae, Papua New GuineaThe relationship between SIDS and themicroclimate at the face is examined.Attention is given to the inhalation ofpreviously exhaled air or re-breathing.Studies of the physics of airflow at the faceand the physiology of re-breathing are

reported. Statistical data concerning SIDSand environmental conditions are presented.It is found that exhaled air can accumulateat the face of a sleeping infant. Theaccumulated exhaled air can have an excessof carbon dioxide and a deficiency of oxygen.Transport of these gases is affected by jetaction of the nose, temperature, humidity,pollution (which affects aerosol formation)and other conditions. A simulator forstudying sleeping environments isdescribed. It is found that the carbon dioxidecontent of inhaled air can be above theindustrial threshold limit of 0.5% with valuesof over 2% occurring.Physiological mechanisms are identifiedwhereby re-breathing of vitiated air canaccount for a proportion of SIDS cases. It wasfound that a sleeping infant acclimatized toan atmosphere with excess carbon dioxidemay suffer from reduced lung ventilationrate on subsequent exposure to a normalatmosphere.The associations between SIDS and particularenvironmental conditions are found to beconsistent with re-breathing as a cause ofSIDS. It is recommended that sleepinginfants have an unobstructed passage ofexhaled air away from the face. Detailedderived safety precautions are given. It issuggested that studies of SIDS deaths shouldinclude physical modeling of the sleepingenvironment and investigations for evidenceof re-breathing.

1 Corbyn J.A. (1999) Air movement in the humansleeping environment and sudden infant death.Ph.D. Thesis, Murdoch University, Western Aus-tralia.2 Corbyn J.A. (1993) Sudden infant death due tocarbon dioxide and other pollutant accumulationat the face of a sleeping baby. Medical Hypotheses,41:483-495

98INFANT CARE PRACTICES AMONGALBERTA CREE, CANADAElizabeth WilsonDept. of Anthropology, University ofCalgary, Calgary, Alberta CanadaHigher SIDS among Aboriginal populationshas been confirmed by information gatheredfrom data based records. Details on preciserisk factors within contemporary society ofthis higher SIDS population have remainedunrecorded . A prospective study usinganthropological methodology conductedamong Cree Aboriginals in Alberta, Canada,identified that aspects of infant care includepositive components, such as, supinesleeping and breast feeding which may

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protect infants from SIDS. Risk factors whichmay counteract positive practices, includematernal smoking (ante, post-natal) and theinfant’s exposure to secondary smoking byone or more persons within the infant’ssurroundings, tightly swaddled infants inextremely warm houses, and co-sleeping (bysmoking mothers). The risk factors mayrepresent a “bundle” of perturbations withinthe infant’s environment too disparate to beovercome by the protective factors of supinesleeping and breast feeding.This Canadian Cree study surveyed over fiftypercent of contemporary aged mothers livingexclusively in a reserve setting. A total of70 Cree women took part in the researchproject. Environmental studies within theinfant’s surroundings identified high levelsof bacteria and fungus which appears to bea result of houses which are not adequatelysuited for the climate (up to -50F in wintermonths) and the cultural behaviour of theinhabitants.Death records for the years 1990-1994 wereused to obtain relative risk data. Calculationof SIDS incidence per 1000 live births bymaternal age group among Aboriginal andnon-Aboriginal Albertans yielded thefollowing results. The highest SIDSincidence was observed within the youngestage group for both the Aboriginal (4.1) andnon-Aboriginal (0.9) populations,respectively. Incidence among mothers aged19-24 years declined in each population, to3.9 among Aboriginals and 0.6 among non-Aboriginals. Among the oldest maternal agegroup (25+ years of age) only a slight declinein incidence was observed amongAboriginals (3.8), whereas among non-Aboriginals the incidence declined to 0.3SIDS deaths/1000 live births.Calculation of relative risks amongAboriginal maternal age groups failed todemonstrate ratios significantly differentthan 1.0 (<19 to 19-24, 1.05; <19 to 25+, 1.08;19-24 to 25+, 1.03). In contrast, among non-Aboriginals the risk ratio among theyoungest maternal age group relative tomothers 19-24 was 1.57 and relative tomothers 25+ years of age was 3.5 timesgreater. Thus, within each population thehighest incidence and relative risk occurredin the youngest maternal age groups anddeclined with the age of the mother. Agecategory with age category comparisons ofrelative risk between the populationsdemonstrated greater risk amongAboriginals (<19, 4.6 times greater risk; 19-24, 6.5 times greater; and 25+, 12.7 timesgreater risk than comparably aged non-

Aboriginal mothers). The greater relativerisk among Aboriginals is consistent withearlier reports.

98ABEDSHARING PRACTICES OFDIFFERENT CULTURAL GROUPSSally BaddockResearch Fellow/PhD Student, UniversityOf OtagoBedsharing between parent(s) and theirinfant is a practice carried out by many butthe benefits and/or risks are not fullyunderstood. Several studies have suggestedthat bedsharing may increase the risk of SIDSfor the infant and that the risk may varybetween ethnic groups. However, there isvery little information documented as towhat bedsharing actually is.In this qualitative study, 13 families from 4different cultural groups (Pacific Island,Maori, Parents’ Centre and young singlemothers) were interviewed, in their ownhomes, and about their bedshare practicesand their reasons for bedsharing. Theinterviews were largely unstructured withfew prompts, to avoid channelling theresponses into culturally prescribedcategories. The material was analysed withthe aid of NUD.IST software to identifythemes and patterns.We found actual bedshare practices andreasons for bedsharing were diverse, butsome common themes emerged withincultural groups. Many outcomes for familiesappeared as universal themes. The resultsfrom this study indicate that the term‘bedsharing’ does not describe a coherentpractice. Infants who bedshare are exposedto diverse situations. Research thatidentifies specific risk bedshare behavioursmay explain the variable risks amongdifferent cultural groups and help to identifysafe ways of bedsharing.

99CHILD CARE DECISIONS OF DEPRIVEDPARENTS - WHAT MATTERS TOTHEM?Michael Wailoo (England) E. Anderson &SA PetersenLeicester Warwick Medical School, UnitedKingdomBabies living in deprived conditions aremuch more likely to become ill and die.Many risk factors for sudden death in infancyare more prevalent in poor homes, and somesuch as parental smoking are potentiallymodifiable.

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In this study we compared the factorsinfluencing childcare decisions in poor andaffluent homes. Subjects were 73 familiesliving in a deprived inner city area (Jarmanscore 64.1) and 58 affluent families from asuburban area (Jarman score -6). All werewhite, and the babies were born at term.Interviewers from the local areas weretrained, and used a structured interview tocollect information on social and economicfactors, life stresses, social support,Edinburgh post natal depression score andchildcare practices. In addition, thedevelopment of body temperature patternsand urinary cortisol excretion weremeasured on the babies.The deprived group were significantlyyounger mothers, living predominantly inpoor rented accommodation, oftenunemployed with low family income.Mothers in deprived families weresignificantly less likely to breast feed, andthe majority smoked heavily. They hadsignificantly less social support and verymany more life stresses. There wassignificantly more postnatal depression inthe deprived mothers.Deprived mothers made it clear that smokingis a coping strategy for the stresses of poorliving, and that it allows them better to carefor their babies. Intervention targeted justat stopping smoking, even if successful intheir aim, may not reduce mortality in theway expected. Mothers require interventions to reduce lifestresses to a level that may be tolerated, andwere able to circulate specificrecommendations as to how this could beachieved.

100SUDDEN INFANT DEATH SYNDROME(SIDS) AND INFANT CARE PRACTICESIN SASKATCHEWAN CANADA.Koravangattu Sankaran; Meleth, AnnalDhananjayan; Meleth, Sreelatha andSankaran, Rajini.Department of Pediatrics, College ofMedicine, University of Saskatchewan,Saskatoon, Saskatchewan, Canada.The SIDS rate in Saskatchewan is higher thanthe other provinces in Canada (1.2/1000).Sleeping position, sleeping quarters,ethnicity (native/non-native), clothing,exposure to smoke, co-sleeping, and breastfeeding are some of the factors known toaffect SIDS. There is little informationregarding infant care practices that relate toSIDS in Saskatchewan. In an attempt toelucidate these factors, we reviewed

documents in the Chief Coroners Office withthe diagnosis of SIDS for the period 1982 to1994. We then selected 80 live infants fromthe representative communities as theyvisited for routine care in the PediatricOutpatient Department (OPD) and matchedfor race, sex, age, gestation and birth weightto infants who died of SIDS. The datacollected for both groups included sleepingquarters (safe or unsafe), sleep position,layers of clothing, co-sleeping, breastfeeding, and autopsy reports for SIDS group.Unsafe sleeping quarters included sleepingin playpens, strollers, bean bags, the sofa,water beds, etc. Circumstantial information(smoking, alcohol, drugs) was collectedsurrounding death and OPD visit. Autopsyand circumstantial data were used to classifydeath. Logistic regression and univariatediscriminant analyses were used forstatistics.Results: There were 258 SIDS and 80controls. In SIDS there were 157 males (60%)(P=.007) and 101 females (40%). The meanage of death was 14.7 ± 10 wks (± SD), 111(45%) were natives (P=.008), 72% were foundin prone position (P=.0001). 23 deaths (9%)were of undetermined etiology. Unsafequarters (P=0.01) increased the deathrisk.The risk increased (P=.00001) whenexposed to smoke. Three or more layers ofclothing increased the risk (P=.0001).Undesirable circumstances also increasedthe risk of death (P=0.00001). Co-sleepingand breast feeding were protective (P=0.005).Odds of dying increased 15 times with >3layers of clothing. Native infants had a 5.5times greater risk of than non-native. 72%of the control infants were sleepingsupine.Summary: The increase in the SIDSrate in Saskatchewan is in part related toincreased death in native infants.Improvement in infant care practices shoulddecrease SIDS even further. A strategy toimprove infant care practices should beadopted.

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101INFANT SLEEPING PRACTICES INNORTH QUEENSLAND: A SURVEY OFINDIGENOUS AND NON-INDIGENOUSWOMEN.KS Panaretto,1 P Cole,3 R Muller4 and JWhitehall2

School of Public Health and TropicalMedicine, James Cook University,Townsville,1,2,4 Kirwan Hospital forWomen, Townsville,1,2,3 and the TownsvilleAboriginal and Islander Health Service,Townsville, Qld, Australia1,3

Background: Sudden Infant DeathSyndrome (SIDS) is the most common causeof postneonatal death in Queensland (0.98per 1000 live births, 1994-1996). SIDS rateshave fallen dramatically in the non-indigenous population due to aggressive riskreduction education. Indigenous SIDS ratesin Queensland have not been estimated untilrecently. Other states of Australia reportindigenous rates to be 3-5 times higher thannon-indigenous and a recent review of SIDSdeaths in North Queensland suggests therate in the indigenous population is up to 6times that of the non-indigenous population.This may be because education campaignsare not reaching the indigenous population.Aim: To assess awareness of SIDS risk factorsin the indigenous and non-indigenouspopulation of Townsville, North Queensland,Australia.Methods: A cross-sectional study is beingconducted using the relevant sections of theWest Australian Infancy and PregnancySurvey 1997-1998, developed by the TVWTelethon Institute for Child Research,Princess Margaret Hospital, Perth, WesternAustralia. The survey will assess theprevalence of SIDS risk factors, includingdemographic data, smoking, infant feeding,sleeping position, bedding, and bed sharing.The survey will additionally assesssuggestions for appropriate SIDS educationmodalities. A random sample of 40 youngindigenous women with children less than2 years of age and 40 non-indigenouscontrols will be surveyed. The study has thefull support of the indigenous communityin Townsville. Incidence, medians andunivariate association between indigenousand non-indigenous groups will beperformed where appropriate using SPSS.Results: The results of the survey will bepresented.Conclusion: If results suggest it is neededand having canvassed appropriate media andother education modalities amongst

indigenous women, it is hoped a riskreduction campaign can be then be designedto better target indigenous women in NorthQueensland.

102WHAT DO ABORIGINAL MOTHERSKNOW ABOUT REDUCING THE RISKOF SIDS?SJ Eades, AW Read, The BibbulungGnarneep Team.TVW Telethon Institute for Child HealthResearch, Perth, Australia.The SIDS rate for Aboriginal infants inWestern Australia continues to be high, being5.6 for infants born in 1996, compared with0.6 for non-Aboriginal infants. TheBibbulung Gnarneep (“Solid Kid”) project wasa population-based cohort study whichcollected information on a large number ofvariables relating to Aboriginal mothers,children and families during a series of fiveinterviews. The fifth interview which tookplace when the index child turned two yearsold, included questions about mothers’knowledge of the SIDS prevention campaign.All families resided in Perth and suburbs and130 mothers remained in the study for thefifth interview.81% of the mothers were aware of thecampaign. Mothers were asked what advicethey remembered with 37% noting “do notoverwrap baby”, 26% “no smoking aroundbaby”, 21% “do not lay baby on tummy”, 14%“lay baby on back”, 14% “something aboutsleeping position”, 10%”lay baby on side”and 6% “lay baby on back or side”. Less than2% of mothers remembered advice aboutusing a firm mattress or about breastfeedingwith less than 1% remembering advice aboutsmoking in pregnancy. Mothers were alsoasked the source of their knowledge aboutSIDS prevention with 60% replying television,42% newspapers, 42% brochures, 41% familyor friends, 39% radio, 35% hospital were babyborn, 32% general practitioner and 32%magazines. When asked, “What is the bestway to provide SIDS information tomothers?”, 33% replied “in hospital wherebaby born”, 27% noted television, 22%brochures, 15% home visits, 11% generalpractitioners and 7% antenatal classes.This is valuable information to use for afocused SIDS prevention campaign in thiscommunity. The Bibbulung Gnarneep Teamhave commenced by producing a suitablebrochure but funding is required for furtherefforts, including the production anddistribution of a video. Clear messages arerequired regarding the SIDS risk factors and

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one of the best places to communicate theseis in hospital directly after baby’s birth.

103“REDUCE THE RISK” - EFFORTS TOIMPROVE EFFECTIVENESS INREACHING ABORIGINAL PEOPLES INCANADADJ Keays, A Corriveau, F ChapmanCanadian Foundation for the Study ofInfant Deaths, Toronto, Ontario, CanadaIn Towards a Healthy Future, the SecondReport on the Health of Canadians(September, 1999), the Federal, Provincialand Territorial Ministers of Health in Canadaacknowledged that although Canadiansenjoy one of the highest standards of healthin the world, this standard is not sharedequally by all members of its society. Forexample, although our Canadian SIDS rate islow, and has decreased on average, itremains significantly higher in theAboriginal population.The Foundation is working with the FederalGovernment to more effectively informAboriginal people about Sudden InfantDeath, and ways they can reduce the risks.Health Canada is conducting a series ofdialogue circles in many Aboriginalcommunities. Our foundation is sponsoringthe production of two videos targetingAboriginal peoples, one to educate andpromote awareness, the other to assist withgrief support following the loss of a baby toSIDS. We have recruited a physicianepidemiologist to our board of directors whohas extensive experience with northernAboriginal people, to assist our foundation’sleadership to better recognise and be moresensitive to the needs of this population.Our foundation has established somepartnerships with representatives of ournative peoples, and will move to expand andenhance these relationships, so we can moreeffectively reach those who need our supportthe most.

104TELEPHONE SUBSIDY ENHANCESPARTICIPATION OFSOCIOECONOMICALLYDISADVANTAGED FAMILIES WITHOUTTELEPHONES IN COLLABORATIVEHOME INFANT MONITORINGEVALUATION (CHIME)Dr Carl E HuntDepartment of Pediatrics, Medical Collegeof Ohio, USACHIME enrolled 4 infant groups: healthy

terms, preterms <1750 g birth weight,siblings of SIDS, and idiopathic apparent life-threatening events. Families withouttelephones appeared to be severelysocioeconomically disadvantaged andtherefore at highest risk for adverse healthoutcomes pertinent to the CHIME study, butwere ineligible for enrollment in CHIMEwithout a home telephone. We hypothesizedthat providing a telephone subsidy toestablish and maintain phone service andenrolling these subjects (TELSUB) in CHIMEwould result in the TELSUB achievingprotocol compliance rates equivalent tosocioeconomically disadvantaged controlsubjects (CON) able to afford telephones.Thirty-one TELSUB from Ohio and Hawaiiwere enrolled. The research protocol wasidentical for all CHIME enrollees, includingperiodic telephone contact with studypersonnel. Following completion of CHIME,TELSUB were compared with 55 CONmatched for study group, site, birth weight,maternal race, age, and education (28% <12thgrade education). TELSUB achievedcomparable completion rates to CON for thepolysomnogram, cry recording, anddevelopmental follow-ups. In addition,TELSUB were significantly more compliantwith home memory monitor use (Table, Mean+/- SD). Mean cost of the subsidy was $402/TELSUB, just $3.32/day of total monitor use.In summary, the additional socioeconomicbarrier to health care access in familieswithout a telephone may be reversible. Whenthis additional barrier increases risk forhealth-damaging outcomes pertinent tostudy objectives, telephone subsidy may bea cost-effective intervention yieldingparticipation rates at least equivalent tocontrols. Future studies should addresswhether these results are unique to CHIMEor applicable to other research projects andother clinical settings.

*NICHD HD 28971, 29056, 29060, 29067, 29071,29073, 34625

105SUDDEN INFANT DEATH SYNDROMEIN NATIVE AND NON-NATIVEPOPULATION: TRENDS OVER 19YEARSIan MitchellAlberta Children’s Hospital, Calgary,Canada.Sudden infant death syndrome (SIDS) is theleading cause of post-neonatal mortality inCanada. In Alberta, since 1977, all suddenunexpected deaths (SUD) in infancy are

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reported to the Medical Examiner, there is ascene investigation, autopsy and review ofmedical records. We reviewed the files ofall SUD and abstracted information fromthose confirmed as SIDS, reviewing trendsin SIDS in native Canadians and othersThere has been a fall in the number of non-native SIDS despite an increase in populationbut no fall in Native deaths. We examinedfactors which may differ between Native andnon-Native infants. There was a tendencyfor more of the Native mothers to be smokingboth during pregnancy and at the time ofthe infant’s death and for more of the Nativefathers to be smokers. More of the Nativeinfants were first born. Native parents weremore likely to use a bed type (such as anadult bed) other than a crib or bassinet.Natives were significantly less likely to besleeping alone, on a firm bed surface or tobe found in a prone position.While further investigation into reasons whyNative SIDS numbers have not fallen, thesedata suggest publicity and education in theNative community on bed type, sleepposition and smoking habits focused on thefirst time parents is needed. Native leadersin the area of childcare should be informedof these findings.

106TAKING CARE OF BABY – A JOINTPROGRAM BETWEEN ABORIGINALORGANISATIONS AND SIDSNORTHERN TERRITORY TO DEVELOPCULTURALLY APPROPRIATERESOURCE MATERIALJ Ganter, Jenny Baraga, Dawn Cardona,Kim Low Choy, Margaret King, MarleneLiddle, Margaret Richards, WanatuStephenson, Pat WilliamsSIDSnorthern territory, NT, Australia.The first culturally appropriate resource forAboriginal communities was prepared in1994 by Aboriginal women undertaking acourse in bi-cultural studies at NungalinyaCollege in Darwin. It was called the ‘Best ForBaby’ banner and was used within Aboriginalcommunities between 1995 and 1999.On average about six deaths are attributedto SIDS in the Northern Territory each year.However in 1997 there were 12 SIDS deaths,of which 10 were Aboriginal babies. ANational report released in January 1999found that deaths from SIDS were nearly fivetimes higher for indigenous boys and seventimes higher for indigenous girls.Due to this high death rate there was someurgency to re-establish relationships withinthe indigenous communities and to work

towards providing culturally appropriateprograms. In March1999 SIDSnorthernterritory formed an Aboriginal Health ProjectGroup with representatives from the groupslisted above. This project group reviewed theexisting brochure and decided to update itwith a clearer and more current Reducingthe Risks message. The brochure now called‘Taking Care of Your Baby’ was re-launchedin June 1999. New posters have also beenproduced as part of the resource.The third and major part of this program isthe production of a video based on thebrochure. The video is being produced inthe six major NT Aboriginal languages andwith the brochures and posters, will bedistributed to communities throughout theNorthern Territory. The video will also beshown on the remote community TVservices.A key factor in the success of this programhas been the development of a workingrelationship with indigenous and non-indigenous workers keen to reduce infantmortality. All organisations involved in thisproject agree that by working together wehave ensured an increased acceptance of thismaterial by Aboriginal communities. Thispaper outlines how the project worked andthe outcome to date.

107EXAMINATION OF SIDS RISK FACTORATTITUDES AND BEHAVIORS AMONGRACIALLY DIVERSE MOTHERS IN AHIGH RISK, RURAL POPULATIONHillman, MD1, 2 , J Davis, PhD1, C. Molitor,BS1; C. Mothershead, MBA3

University of Missouri, Columbia,Missouri, United States1; Sudden InfantDeath Syndrome Resources, Inc., St.Louis, Missouri, United States2; BootheelHealthy Start Project, Sikeston, Missouri,United States3.Data was collected (1998-1999, n=319) in afive county rural area of Missouri with a highincidence of infant mortality. Mothers ofinfants two years and younger wereinterviewed in clinics. The average age ofwomen interviewed was 24. The racialcomposition of participants was 69%Caucasian, 30% African-American, and 1%Hispanic. Approximately 69% had completedhigh school, 36% were employed, and 46%were married. Women were asked about theirattitudes and behaviors relating to SIDS riskfactors (sleep position, smoking aroundinfants, and breastfeeding) and whetherinformation had been given to them in theclinic on each topic. Receiving information

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on sleep position was associated withattitude toward sleep position (*p<.05information given was associated withattitude). However, women did seem toalready have correct attitudes towardsmoking and breastfeeding, which were notsignificantly associated with informationgiven. Examining racial differences, for thethree risk factors measured attitude wasassociated with behavior in the Caucasianpopulation (+p<.05 attitude was associatedwith behavior). In the African-Americanpopulation, positive non-smoking behaviorsand negative breastfeeding behaviors relatedto factors other than measured attitudes.Education and attempts to change attitudeswere important. However, other culturalfactors both positive and negative, must alsobe considered.

108CLINICAL ASPECTSMartin SamuelsFellow RCPCH, Longnor, Buxton, Derbys,UK.

109UNNATURAL DEATHS AS A CAUSE OFSIDSS LeveneFoundation for the Study of Infant Deaths(FSID), London SW1X 7DP, UK.Publicity given to parental prosecutions forasphyxiating infants up to 50 years aftersuch deaths were ascribed to Sudden InfantDeath Syndrome (SIDS), and to cases ofMunchausen Syndrome by Proxy (MSBP),have led to public suspicion that most SIDSdeaths are in fact filicide. Generalisationshave also been made ascribing second deathsin a family to filicide.The validity of such claims was examinedby literature review. This considered paperslinking filicide and SIDS, as well asdiscussing forms of death that are notobvious at postmortem, such asasphyxiation and poisoning. Informationrelating to second deaths in family, MSBP andthe social and psychological factorsidentified in filicide were also examined.Material was found on Medline and in thelibrary of the FSID, dating back to the 1940s.There was no detailed series of cases whichsupported assertions that the proportion ofSIDS deaths due to initially undetectedunnatural events exceeded 10% even atcurrent reduced rates of incidence. Manyauthors relied on personal opinions withoutdocumentation, referred to single cases, orextrapolated the estimates of others to their

own results. By contrast, a carefullydocumented UK study concluded thatmaltreatment, as broadly defined, was themain cause in 6% of the SIDS deaths.(1)An important issue was the second death ina family. Investigations of second deaths didnot support the view that most were filicide.Mathematically, the chances of a seconddeath in a high risk disadvantaged familydiffer little from the chance of a single deathin an affluent family.Full death scene investigation, paediatricpostmortem and local case enquiry shouldbe mandatory for all sudden infant deaths.This would identify the small proportion ofdeaths that are filicide, and enable supportfor all parents including the vast majoritywho are innocent of all blame.

1. Limerick S. Not time to put cot death to bed.Brit Med J 1999; 319:698-670

110THE DIFFERENTIAL DIAGNOSIS OFIMPOSED SUFFOCATION OR SIDS? ANAPPROACH TO SOLVE THE QUESTIONTorliev RognumInstitute of Forensic Medicine, Oslo,NorwayRecently Meadow (1) has suggested that thepresence of frank blood from the nose and/or mouth may be suggestive of imposedsuffocation. Twenty-seven out of 70 childrenwho had been killed by their parents, werereported to have been found with bloodapparent in the mouth, nose or on the face.On examination by medical staff, stale bloodwas seen on 20 of those 27 children. Meadowstresses that care was taken to establish thatthe finding was of frank blood, rather thanthe common sero-sanguineous froth that canbe present in moribund children, particularlywhen subject to resuscitation.We have examined 202 cases of SIDS and 119cases of sudden explained death in infantsand small children, between January 1984and July 1999. Frank blood from the noseand/or from the mouth has been describedin 14 cases of SIDS and in one case ofpneumonia. White-red froth in the nose and/or the mouth had been recorded in 17 casesof SIDS and in two cases of pneumonia.In a recent case of imposed suffocation thegeneral practitioner that first came to thedeath scene, observed sero-sanguineousfroth from the nose and the mouth. He wasquestioned during the trial whether it couldhave been frank blood, but denied. Thisparticular mother had lost four subsequentinfants suddenly and unexpectedly. During

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all events she had been alone with the infantsand the autopsy had revealed no cause ofdeath. The first three deaths were notfollowed by death-scene investigation.However, after the fourth death a thoroughscene investigation was performed. In thegarbage a plastic bag was found with lipmarks from the baby. Furthermore, twosmall blood spots and other biologicalmaterial had the same DNA-profile as thedead infant. Also the fingerprints from themother was found on the plastic bag. Thesetechnical proofs led to conviction.Based on our experience it seems that forthe time being it is not possible todifferentiate between imposed suffocationbased on autopsy findings, such as thepresence of frank blood from the nose andmouth. We therefore think that death sceneinvestigation should be performed in allcases of sudden infant death.

1. Meadow R. Unnatural sudden infant death.Arch Dis Child 1999; 80: 7-14

111INTRA-ALVEOLAR PULMONARYSIDEROPHAGES, ACUTE PULMONARYHAEMORRHAGE AND NASALHAEMORRHAGE: MARKERS FORIMPOSED SUFFOCATION?David M.O. BecroftDepartment of Obstetrics andGynaecology, University of Auckland,New ZealandWe have reported1 the finding of abundantiron-containing macrophages(siderophages), indicative of previoushaemorrhage, in the lung alveoli of four NewZealand infants who died suddenly. All hadprevious severe “apparent life-threateningevents” and caregivers were convicted ofcausing their deaths. We know of similarfindings in other infant deaths occurring insuspicious circumstances. We founddiffusely-distributed alveolar siderophagesin 5% of 158 infants with diagnoses of SIDS.Most of the many causes of intra-alveolarhaemorrhage in infancy are easily excludedby history or at autopsy, but in younger

infants previous perinatal haemorrhage maybe difficult to exclude retrospectively. Weconcluded that the lungs of all infants dyingsuddenly should be stained for iron and thatthe finding of substantial numbers ofsiderophages demands further investigationand if no accidental or natural cause is foundshould cause suspicion of imposedsuffocation. The finding is not specific forimposed suffocation and its absence doesnot exclude the possibility.Recently, it has been suggested that theseverity of acute haemorrhage in the lungsin sudden infant deaths also can be used asa marker for imposed suffocation oroverlaying.2 Pulmonary haemorrhage occursmore frequently in younger infants andthose co-sleeping. Bleeding from the noseor mouth has been reported as a verycommon feature of imposed suffocation andoccurs, but probably less frequently, in SIDS.15% of 385 cases in the New Zealand CotDeath Study were reported to have nasalbleeding and were significantly younger,more likely to have slept supine, and to havebed-shared.The finding of abundant intra-alveolarsiderophages in sudden infant deathsprovides a marker for suspicion of imposedsuffocation, but more study of acutepulmonary haemorrhage and nasalhaemorrhage is required to show that thesehave diagnostic and medicolegalsignificance.

1. Becroft DMO, Lockett BK. Pathology 1997; 29:60-3.2. Yukawa et al. J Clin Pathol 1999; 52: 581-7.

112PHYSIOLOGICAL RECORDINGS INSIDS, ALTES AND IMPOSED APNOEAChristian F Poets1, Martin P Samuels,David P Southall2

Department of Paediatric Pulmonologyand Neonatology, Medical School,Hannover, Germany (1) and AcademicDepartment of Paediatrics, NorthStaffordshire Hospital Centre, Stoke-on-Trent, UK (2)

VARIABLE TELESUB CONTROLSTotal Hrs,Wks 2-5 190 +/- 157 (P=.025) 116 +/- 132 #>10Hours/Wk (2-5) 81% (p=.033) 56%#Days Usedin 6 M 121 +/- 87 (p=0.003) 64 +/- 63

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Event recording or documented monitoringis a valuable tool for the identification ofmechanisms for SIDS and/or ALTE as itallows the recording of data during theseevents. Published studies have shown that(a) a significant proportion of infants withrecurrent ALTE initially consideredidiopathic after a complete clinical workup(63% of those with further events) hadpotentially preventable mechanisms such asseizure-induced hypoxaemia, changes inskin perfusion but without hypoxaemia, orparentally induced or fabricated eventsidentified with documented monitoring; (b)during documented ALTE in which nospecific mechanism could be identified,abnormal prolonged hypoxaemia was theonly consistent finding, whereas prolongedapnoea occurred in only 5, and bradycardiain only 4, of 22 events, (c) in recordingsobtained during SIDS, 7 of 9 patients werealready gasping at or within 2.7 min. afterthe first monitor alarm, whereas prolongedapnoea was the reason for the first monitoralarm in only 3 infants; (d) during imposedapnoea (suffocation), the changes in signalsrecorded included a clear increase in theamplitude and irregularity of the breathingmovement signal which preceded theoccurrence of hypoxaemia and wasassociated with an initial sinus tachycardiaand artifact on the electrocardiogram and onthe pulse waveform signal from the oximeter,suggesting massive body movements,followed by prolonged severe hypoxaemiaand/or (often nodal) bradycardia. In thelatter cases, however, documentedmonitoring can mostly only raise a suspicionof suffocation, which should be confirmedby covert video surveillance wheneverpossible.

Samuels et al., Arch Dis Child 1992;67:162-170Poets et al, J Pediatr 1993;123:693-701Southall et al., Pediatrics 1997;100:735-760Poets et al., Pediatr Res 1999;45:350-354

113BEREAVED CHILDREN – THEIR NEEDSNuala HarmeyChildren’s Hospital. Temple Street, Dublin1, Ireland.The author of this paper establishedbereavement services for children in theChildren’s Hospital, Dublin 1 over 10 yearsago.Approximately 60 deaths occur in thehospital each year. All bereaved children areoffered a support programme.This paper will discuss the needs of bereavedchildren, for information, involvement and

freedom to express emotions. These topicswill be illustrated by slides of children’sdrawings on these topics. The differencebetween children grieving an anticipateddeath or a sudden death unexpected deathwill be discussed.A short video showing the author workingwith bereaved children will illustratedifferent techniques. This video was madewith children from a very deprived area whohave poor expressive skills and shows thatdeprivation and poor social skills are nobarrier to helping children express theirgrief.

114THE RELATIONSHIP BETWEENVACCINES, BREASTFEEDING,TEMPORARILY DYSFUNCTIONALRETICULOENDOTHELIAL SYSTEM,E.COLI LIPOPOLYSACCHARIDEENDOTOXAEMIA AND SIDSHilary ButlerImmunisation Awareness Society,Auckland, New ZealandVeterinary studies show E.Coli to be themajor cause of death, (including SIDS) incalves, Rhesus monkeys etc. The onepublished study in human infants yieldedsimilar results (Bendig, J and Haenel, H.:1969). Bettelhem K et al., established (1988)E.Coli association with SIDS, and OppenhemB et al (1994) antibody evidence of systemicendotoxaemia in SIDS. Capps R.B.et al (1955)stated DPT caused temporary liverdysfunction in infants similar to that causedby viral hepatitis.Anser S and Habig W (1990) showed DPTvaccine endotoxin significantly disrupts P-450, and other microsomal and cytosolicenzyme activities (which detoxify endotoxin)in mice. Rook, G.A.W (1997) details otherways vaccines disrupt the immune system.The effect of neonatal endotoxinencephalopathy was stated by Reisinger, R.C.(1973) and demonstrated by Gilles, F.H. et al(1974). Reisinger RC’s ‘A final mechanismof cardiac and respiratory failure’ (1974)stated that platelet injury by endotoxin mayresult in a dramatic rise in serotonin.Serotonin can initiate coronary chemoreflexcausing profound bradycardia, hypotensionand cardiac collapse. Tissier. H (1900 and1925) reported that bottle-fed babies havemuch higher levels of intestinal E.Coli thanbreastfed babies, a fact subsequentlydemonstrated by others. Hauck F.R. (1996)stated bottle-fed babies had three times therisk of SIDS as breastfed babies.

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Pourcyrous, M et al (1998) detailed severecardio-respiratory symptoms of apnoea,bradycardia, and oxygen desaturation(compatible with E.Coli endotoxaemia)following administration of DPT vaccines,and Hib, HBV and IPV together. Althoughimmunological findings suggested bacterialinfection, no foci could be found. WoodruffP.W.H. et al (1973) showed absence of foci isconsistent with evidence of endotoxaemiaof intestinal origin as a result ofreticuloendothelial system damage. Manyarticles establish that breastfeeding reducesE. Coli colonisation. Svanborg C (1995 and1999) expands dramatically medicalunderstanding of breastmilk’simmunological policing properties.

1 Reisinger, R.C.: A final mechanism of cardiac andrespiratory failure. Pub. In SIDS 1974. Proc. OfCamps International Symp. on SUD in Infancy. Alsocongressional record S.1745, September 20, 1973.Website: erols.com/drrobert.sids2 Pourcyrous, M. et al., Interleukin-6, C-ReactiveProtein, and Abnormal Cardiorespiratory Re-sponses to Immunization in Premature Infants.Pediatrics Vol. 101 No. 3, March 1998.

115IMMUNISATION: A PROTECTIVEFACTOR AGAINST SIDSM Ward Platt, PJ Fleming , PS Blair, IJSmith, P J Berry, Jean Golding, and theCESDI SUDI research team.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UKIn the UK, the recommended immunisationprogramme for all three immunisations(Haemophilus Influenzae type B, oral polioand diphtheria, tetanus and pertussis) aregiven at 2,3, and 4 months of age. Despite acomplete lack of epidemiological evidence,the media have raised public concern thatroutine childhood immunisations mayincrease the risk of SIDS.Methods A three year case-control studyconducted in 5 of 14 Health Regions inEngland (population ~ 17 million, 500,000livebirths). Parental interviews were

conducted for each infant who died and forfour controls matched for age and time ofsleep. Ascertainment was over 90% [1][2]. Wehave details on infant immunisations for303/325 SIDS and 1234/1300 matchedcontrols.Results Of the control infants, 66.6% hadbegun or had completed their immunisationprogramme, compared with 48.8% of theSIDS. In a univariate comparison, taking ageinto account, this difference was highlysignificant (OR=0.23 [95%CI:0.14-0.37]) andwas not affected by controlling for socio-economic status or maternal smoking duringpregnancy. This comparison remainedsignificant in the multivariate analysis takinginto account all other factors (OR=0.25[95%CI:0.09-0.67]). For those infants who hadcommenced their immunisation programme,the median age and the interquartile rangeof ages at which the first immunisation wasgiven were virtually the same for the SIDSand controls (SIDS: 60 days [IQR: 56-70 days],Controls: 59 days [IQR: 55-63 days]). Themedian time from last immunisation tointerview or death was also similar in thetwo groups (SIDS: 28 days [IQR: 16-68 days],Controls: 29 days [IQR: 13-70 days]). In the48 hours before death 7/303 SIDS infants(2.3%) were immunised compared to 41/1234control infants (3.3%) in the 48 hours beforethe reference sleep.Conclusion There was no evidence thatrecent immunisation was associated with anincreased risk of SIDS, and indeed the datasuggest that immunisation may have aprotective effect.

1 Fleming PJ, Blair PS, Pollard K, Platt WM, Leach C,Smith I, Berry J, Golding J. Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999; 81:112-116.2 Leach CEA, Blair PS, Fleming PJ, Smith IJ, WardPlatt M, Berry PJ, Golding J. Epidemiology of SIDSand explained sudden infant deaths. Pediatics1999;104:e43.

Information Given Correct Attitude Correct BehaviourTopic Caucasian African Caucasian African Caucasian African

American American AmericanSleep position 87% 87% 71% 60%* 52%+ 44%+Smoking around infants(smokers only) 90% 92% 97% 99% 40%+ 69%Breastfeeding 95% 90% 89% 82% 35%+ 17%Bootheel Healthy Start is funded by Maternal and Child Health Bureau, #5 U93 MC 00062-02.

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116Immunisation is not a Risk Factorfor SIDSM. Findeisen, MMT. Vennemann, G. Jorch,E. Mueller, B. BrinkmannUniversity of Muenster, Germany.Introduction: This investigation exploresthe vaccination status of two age and gendermatched case control studies for SuddenInfant Death Syndrome (SIDS) in Germanyand whether vaccination is a risk factor forSIDS.Methods: The pilot phase was located in thearea of 3 forensic medicine centers(Hamburg, Hannover and Muenster) betweenOctober 1996 and July 1997. The ongoingstudy (main study) is a nation widemulticenter study. Autopsies are carried outin 14 forensic medicine centers andquestionnaires are filled in by interviewingthe parents. During the first periodinvestigations of 56 SIDS victims werecompared with 181 controls. From thepresent main study we present thepreliminary data from 77 SIDS cases and 203controls.Results: In the pilot phase 68% of thecontrols and 50% of the cases receivedimmunization (Odds ratio (OR): 0.47, 95%Confidence interval (CI): 0.25 – 0.91).Investigating the influence of the differentvaccinations we found that in the pilot phasehaemophilus influenza B immunization wasgiven to 42.7% of the controls and 26.8% ofthe cases (OR: 0.47, CI: 0.23 – 0.96). Howeverlooking at tetanus, polio, pertussis, hepatitisB and BCG we found no significantdifferences. In the ongoing study 46.2% ofthe controls and 50.8% of the cases arevaccinated (not significant). In the currentlyrunning study no differences were found inthe vaccination status of the cases orcontrols until now.Discussion: From this preliminary resultswe conclude that it is not likely that thevaccination schedule as presentlyrecommended in Germany is a risk factor forSIDS in our data. From the ongoing study weexpect 600 cases and more detailedinformation for further analysis.

117MICROBIOLOGICAL STUDIES OFSHEEPSKIN BEDDINGW CullenUniversity of British Columbia, Canada.Microorganisms have been isolated fromNew Zealand sheepskin bedding on fourdifferent media. The number of fungi foundon used bedding and on SIDS-associated

bedding is the same but the number ofbacteria is higher on the latter. The forty-five (to date) isolates are being characterizedby using conventional methods and by 16sribosomal DNA PCR methodology. Thestudies are focused on organisms that arehuman pathogens and that transform arseniccompounds in the bedding.

118THE CESDI SUDI CASE-CONTROLSTUDY: NO EVIDENCE TO SUPPORTTHE “TOXIC GAS” HYPOTHESIS FORSIDSPeter Fleming, Peter Blair, Jem Berry,Martin Ward-Platt, Iain Smith and theCESDI SUDI research team.Institute of Child Health, University ofBristol, BS2 8BJ, UK.In 1989 Richardson proposed that acontributory factor in SIDS might be theproduction of toxic trihydride gases, arsine,stibine and phosphene by fungaldegradation of flame retardants orplasticisers added to the PVC of mattresscovers. The hypothesis predicted: i) SIDSinfants would be sleeping on oldermattresses, those previously used by otherinfants, and those with PVC covers. ii) highertissue antimony concentrations in infantssleeping on PVC mattresses with higherconcentrations of antimony, and iii) ifparents wrapped PVC mattresses inimpermeable covers (e.g. polythene) SIDSwould be prevented.Methods. Information was collected for allthree years of the CESDI SUDI case-controlstudy (1) on the type, age and coverings ofmattresses used by infants who died andcontrol infants. For the third year, samplesof mattress covers and filling were subjectto mycological and chemical analyses, andtissue and hair samples were collected frominfants who died, together with hair samplesfrom mothers of SIDS and control infants,plus hair samples from control infants (2).Results. The fungus implicated byRichardson (Scopularis brevicaulis) wasrarely found on mattresses and never on aSIDS mattress; no association was foundbetween mattress antimony concentrationsand those of tissue or hair; mattresses withintegral PVC covers were associated with aslightly lower risk of SIDS, regardless ofantimony content. Higher concentrations ofhair antimony in infants than mothersrepresented prenatal accumulation, not post-natal exposure. The use of older mattressesby some SIDS families was accounted for ina multivariate analysis by the lower socio-

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economic status and larger sibships of theSIDS infants compared with the controls.Identical proportions (2%) of SIDS andcontrol infants slept on mattresses whichhad been wrapped in polythene sheeting,and 3 SIDS deaths occurred on such wrappedmattresses.Conclusions. No evidence was found tosupport the “toxic gas” hypothesis.

1 Fleming PJ, Blair P, Bacon C, Bensley D, Smith I,Taylor E, Berry PJ, Golding J, Tripp J. The environ-ment of infants during sleep and the risk ofsudden infant death syndrome: results of 1993-5case-control study for confidential enquiry intostillbirths and deaths in infancy. BMJ. 1996;313:191-5.2 Fleming PJ, Blair P, Cooke M, Warnock D, BerryPJ, Smith I, Thompson M, Ward-Platt M, Hall D.Studies to establish whether antimony or otherchemicals added to cot mattress covers are ofsignificance in the aetiology of sudden infantdeath. Appendix III, In: The Report of the ExpertGroup to Investigate Cot Death Theories: Toxic GasHypothesis. Dept Health London. ISBN185839 8746. 1998

119SCREENING FOR LONG QT INTERVALMarco Stramba-BadialeIstituto Auxologico Italiano IRCCS, Milano,ItalyThe incidence of Sudden Infant DeathSyndrome (SIDS) appears to have recentlydeclined after the identification of severalbehavioral risk factors and their subsequentmodification through public campaigns.Nonetheless, SIDS remains the leading causeof mortality in the first year of life after theneonatal period and effective preventivemeasures are still lacking due to the poorunderstanding of the underlyingmechanisms. There is a consensus that SIDSis multifactorial, but despite the manyhypotheses proposed, none has yet beenproven. In 1976 we proposed that aprolongation of the QT interval on theelectrocardiogram (ECG) may increase therisk for life-threatening arrhythmias andcontribute to SIDS. In order to test thathypothesis we recorded the ECG on the 3rd-4th day of life in 34,442 newborns andfollowed them prospectively for one year.The QT interval was analyzed with (QTc) andwithout correction for heart rate. A one-yearfollow-up was obtained in 33,034 infants.There were 34 deaths, of which 24 were dueto SIDS. The SIDS victims had a longer QTccompared to the one-year survivors (435 ±26 vs 400 ± 20 ms, p<0.01), and to the non-SIDS victims (392 ± 26 ms, p<0.05).Moreover, 12 of 24 (50%) SIDS victims andnone of the non-SIDS victims had a

prolonged QTc (> 440 ms). When the absoluteQT was determined for the same range ofcycle lengths it was found that 12/24 (50%)of SIDS victims had a QT value exceedingthe 97.5th percentile. The Odds ratio of SIDSfor infants with a prolonged QTc (> 440 ms)is 41.3 (95% confidence interval 17.3-98.4).This large prospective study based on morethan 33,000 infants provides the firstdemonstration that QT intervalprolongation, on the standard ECG recordedon the 3rd-4th day of life, is a risk factor forSIDS. Neonatal ECG screening may allowearly identification of a significantpercentage of infants at risk for SIDS and theinstitution of preventive measures may bepossible.

120BUILDING SOCIAL CAPITALSTRATEGIES TO REDUCE SIDS INCOMMUNITIES OF COLOURNaomi HallPerinatal Network Of Alameda/ContraCosta, Oakland, Ca, USAThe risk of an infant dying from SIDS isgreater among communities of color andhistorical oppression anddisenfranchisement. In the United States,SIDS mortality rates in these communities(e.g. African-American, Native Americans)have not responded to the ‘Back to Sleep’campaign to the same degree as the majoritypopulation. Most SIDS risk reductioncampaigns focus on changing individualbehaviors rather than the larger issue of howSIDS relates to a particular community’soverall health. By overlooking this broaderperspective, SIDS risk reduction campaignscontinue to be ineffective in communitiesmost affected by SIDS. In order to succeedin our goal of reducing the risk of SIDS inthese communities, we must first recognizethe common threads found in these groupsand examine the societal conditionscontributing to their ‘at-risk’ status.To meet the challenge of working withfamilies and communities in the mostaffected groups, we must assist in increasingthe ‘social capital’ of the community. Socialcapital has been defined as those featuresof social organization - such as the extent ofinterpersonal trust between citizens, normsof reciprocity, and density of civicassociations - that facilitate cooperation formutual benefit.Since 1995, the Oakland Healthy Start Fetal/Infant Mortality Review (FIMR) has generatedcase summaries of all fetal and infant deathswithin a defined project area in Oakland,

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California. Case studies of SIDS deathsillustrate situations were social capitalbuilding strategies could greatly improve thehealth outcomes of families. Linking socialcapital to improved outcomes in SIDS riskreduction is an area in need of moreattention and development. FIMR iscurrently exploring social capital buildingstrategies in communities of color in hopesof reducing the risk of SIDS and improvingthe community’s overall health.

121THE EFFECT OF HOME-BASEDMOTIVATIONAL INTERVIEWING ONTHE SMOKING BEHAVIOUR OFPREGNANT WOMEN. A PILOTRANDOMISED CONTROLLED TRIAL.DM Tappin,1 MA Lumsden,1 C McKay,1 DMcIntyre,2 H Gilmour,1 R Webber,3 SCowan,4 F Crawford,2 F Currie.1,Glasgow University,1 Greater GlasgowHealth Board,2 Yorkhill NHS Trust,3

Glasgow, Scotland, UK, and FamilyEducation Services, Christchurch, NewZealand.4

Fifty percent of cot deaths are attributableto smoking. Routine antenatal contact is anopportunity to provide effective help (1). Acost-effective strength or style ofintervention has still not been established(1).Objectives were to teach a midwifemotivational interviewing (MI)(2), pilot a trialwith pregnant smokers, and develop aninstrument to document the process.Design was randomised-controlled,intervention-normal care.Subjects were 100 self-reported smokersbooking at the Queen Mothers Hospital,Glasgow from March-May 1997.Intervention involved 2-5 home-based MIsessions.Outcome measure was self-reportedsmoking corroborated by cotinine in residualroutine early and late pregnancy bloodsamples. All sessions were audio-taped and49 interviews from 13 randomly selectedclients were transcribed for process analysis.Rollnick(2) supervised Miller’s rating scaleto described therapist and client behaviours.Reproducibility was examined using 3independent raters. Postnatal telephoneinterview sought client opinion. Routinemidwives were consulted by focus group.Results: 100/133 smokers (75%) wereenrolled, 27 refused and 6 lived outsideGlasgow.One intervention client had an intrauterinedeath, another left Glasgow, 38/48 (79%) had

at least 2 counselling sessions, eight hadone, and two had none. More than 75% ofinterviews showed satisfactory MI. Therating scale was reliable (intraclasscorrelation coefficient>0.5). Self-report atbooking (100/100 available) corroborated bycotinine (93/100) compared with latepregnancy self-reports (intervention-47/48,control-49/49) and cotinine (intervention-44/48, control 44/49) showed no significantdifference between groups. All clientsinterviewed (36/48) would recommend theprogramme. Routine midwives weresupportive.Conclusions: A midwife providedsatisfactory home-based counselling forpregnant smokers. Procedures for a fullefficacy study have been established.

1 Lumley J, Oliver S, Waters E. Smoking cessationprograms implemented during pregnancy.(Cochrane Systematic Review) Cochrane Library,Issue 3, 1998. Oxford: Update Software.2 Miller WR, Rollnick S. Motivational Interviewing.Preparing People to Change Addictive Behaviour.1991, New York: Guilford Press.

122IMPACT OF THE BACK TO SLEEPCAMPAIGN ON SIDS RISK FACTORS INTHE UNITED STATES, 1990-97MF MacDorman1, C-W Ko2, HJ Hoffman2,M Willinger3.National Center for Health Statistics,Hyattsville, Maryland, United States1,National Institute on Deafness and OtherCommunication Disorders, Bethesda,Maryland, United States2, NationalInstitute of Child Health and HumanDevelopment, Bethesda, Maryland, UnitedStates3.From 1990-97, the SIDS rate in the UnitedStates declined by more than 40%, from130.3 to 77.1 SIDS cases per 100,000 livebirths. This decline coincided with theAmerican Academy of Pediatricsrecommendation to place infants non-pronein 1992 and the “Back to Sleep” campaign in1994. Prone prevalence declined by morethan 70% during the time period, from 73%in 1992 to 21% in 1997. This paper useslinked birth/infant death data to examine theSIDS risk factor profile both before and afterthe Back to Sleep campaign and to look atthe changing impact of maternal smoking onSIDS epidemiology in the US. From 1990-97 SIDS declined more rapidly fornonsmokers (38%) than for smokers (25%) fora 45 state reporting area. In 1990 SIDS ratesfor mothers who smoked were 3.0 timesthose for nonsmokers (295.9 and 98.1,

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respectively); by 1997 rates for smokerswere 3.7 times those for nonsmokers (221.4and 60.4, respectively). SIDS risk factorswere fairly consistent between the beforeand after periods. Adjusted SIDS risks werehigher in both 1990 and 1996 for maleinfants, those born preterm or small forgestational age, and those whose motherswere teenagers, less educated, unmarried,multiparous, smokers, African American,American Indian, and US-born (compared toforeign born). However, upon closeexamination, important differences doemerge. For example, the odds ratios forteenage childbearing, late or no prenatalcare, and preterm delivery decreased(though not always significantly) during thetime period, while odds ratios for maternalsmoking increased. Adjusted odds ratiosfor moderate smokers (1-9 cigarettes/day)were 1.93 in 1990 and 2.23 in 1996;respective odds ratios for heavy smokers(10+ cigarettes/day) were 2.14 and 2.29.Although further progress is needed incommunicating the “Back to Sleep” message,particularly to minority women, in theabsence of prone sleep position, maternalsmoking emerges as one of the mainpreventable risk factors for SIDS.

123TEACHING & LEARNING STRATEGIESFOR MARGINALISED GROUPS INSOCIETYCatherine HennikerSIDSnew south wales, NSW, AustraliaThe reducing the Risk of SIDS HealthPromotion message has been heard andadopted by a large number of middle classAustralians. However, SIDSnew south walesis faced with promoting the Reduce the Riskof SIDS message to the “hard to reach” groupsin our community. These people may havelimited education, be poor, young,unemployed, ethnic, aboriginal, and/orisolated from large urban areas. The new taskof SIDS educators is to reach these groupswith the RTR message.While literate and articulate groups mayeasily understand a lecture format, thosewho make up this “target” or “hard to reach”group will require other teaching andlearning approaches.The proposed workshop will explore avariety of identified learning styles andintroduce active learning strategies.Participants in the workshop will enhancetheir skills in meeting the needs of themarginalised members of society.

124DEVELOPMENT OF A TEACHINGPACKAGE FOR ACCIDENT ANDEMERGENCY NURSES ON THEMANAGEMENT OF SUDDEN DEATH ININFANCY FROM A PERSONALINVOVLEMENT.Carolyn SteadParent and Staff Nurse Coronary CareUnit, Dewsbury and District Hospital,West Yorkshire, England.Accident and Emergency staff need to be wellinformed about Cot Death in order to be ableto cope and to help bereaved parents. Noone should be expected to cope with such atraumatic situation without being fullytrained beforehand (Murphy 1990). Mysecond child Dominic fell victim to SuddenInfant Death Syndrome in February 1996aged 3 months. At that time and untilrecently I worked as a Staff Nurse within theAccident and Emergency (A&E) departmentsof the Leeds Teaching Hospitals NHS Trust.This presentation will describe how, usingmy own experiences as a bereaved parentand A&E Staff Nurse I produced a teachingpackage for A&E nurses, which would enablethem to feel more confident whenresponding to the sudden and unexpecteddeath of a baby. This was a way of makingmy sons short life meaningful and of gainingsomething positive from his death.

1 Murphy. S.Coping with Cot Death (1990) LondonSheldon Press

125BABYSITTERS OF TODAY PARENTS OFTOMORROW - WORKING WITHSCHOOLS TO INFORM, EDUCATE ANDPROMOTE THE ‘REDUCE THE RISKS’MESSAGE.Lin RocheFoundation for the Study of InfantDeaths, London, UKThe Foundation for the Study of InfantDeaths (FSID) is taking new initiatives toprovide infant care information and adviceto 14-15 year olds. With Britain having thehighest rate of teenage pregnancies inEurope and teenage girls representing themajor growth in smokers, the ‘Reduce theRisks’ message needs to be targeted at ayounger audience. The presentation will lookat the work done in the Yorkshire Region,which has a population of 3,846,890. It has9 Local Education Authorities with 202schools for children in the chosen age group.During a 3 year period (1996-1999) there

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have been 75 individual classroom sessions,3 whole school assembly presentations and9 health promotion days. The purpose of thevisit is to:• Raise awareness of the ‘Reduce the Risk’

information,• provide a stimulating interactive session

with the use of posters, video and leaflets,• distribute the “Are you babysitting

tonight?” leaflet,• use practical demonstrations of how to put

a ‘doll’ to bed - on the back, ‘feet to foot’with blankets and sheets, alsodemonstrate overheating by dressing thedoll and using a room thermometer,

• briefly discuss what happens when a babydies and the professionals involved andlook at the possible employmentsituations for them in the future.

The presentation will conclude withevaluations and feedback from teachers andpupils. For example many of the studentsboth boys and girls have been looking aftervery young babies.

126“REDUCE THE RISK” CAMPAIGN INNORWAYH.EriksenNorwegian SIDS Society, Oslo, NorwayThe Norwegian SIDS Society wants to informall Norwegians of the risk factors involvedwith SIDS. We got the idea at the RouenConference (Rosemary Claus-Gray, Missouri,USA) and have started a campaign where theparents of newborns (60,000 a year) receivea baby body with the text “This side up” anda RTR brochure. The midwife presents thegift when she talks with parents before theyleave the hospital.Good cooperation with the staff of ourmaternity wards is crucial, therefore we areoffering ”Reduce the Risk” seminars to thestaff of hospital maternity wards. So far, wehave been warmly welcomed everywherealthough some staff members are stillskeptical to supine sleeping. We have alsoarranged a national “Reduce the Risk”seminar for health professionals as a startingpoint for the campaign, and reduce the riskleaflets are now available in Lappish andUrdu as well as Norwegian.To evaluate the campaign, the level ofknowledge among women giving birth wasassessed. Before the campaign, a two-pagequestionnaire was mailed to 10,000 motherswhen their infants were 6 months of age. Thequestionnaire contained questions on babycare, i. e. sleeping position, feeding, clothingand other risk factors such as smoking.

Answers will be compared to those obtainedin a similar survey in which 10,000 motherswill be contacted after the campaign. Thisquestionnaire may also serve as a basis forfuture epidemiological monitoring of theoccurrence and the effects of risk factors forSIDS. This evaluation project is completedby Medical Birth Registry of Norway.We want to share with you our experiencesafter 6 months of this nationwide campaign.We will also present results of the first partof the evaluation of the campaign, assessingthe initial level of knowledge among womengiving birth.

127CHILD DEATH REVIEW: AN EFFECTIVECOMMUNITY BASED APPROACH TOIMPROVE SIDS INVESTIGATION,INTERVENTION AND RISKREDUCTION EFFORTS.Theresa CovingtonMichigan Public Health Institute, Okemos,Michigan ,USAChild Death Review Teams have beenestablished in 49 of the 50 states in the U.S.as well as in a number of other countries,including Australia, England and Canada.The State of Michigan in the United Stateshas developed a program that supportsvoluntary local review, at the county level,of all child deaths in the state, includingapproximately 140 SIDS deaths each year.These reviews have been very effective inimproving the quality of death sceneinvestigations, compliance with new state-wide autopsy and scene investigationstandards, the provision of bereavementsupport and other services to SIDS families,the identification of the risk factors involvedin the deaths, and the development andimplementation of local and state riskreduction initiatives.The child death reporting system capturescomprehensive data on all SIDS deaths,including death scene analysis, risk factors,autopsy findings, and family history. Thisinformation is presented to the governor andstate legislature, to influence public healthpolicy. For example, information on sleepposition from the 1998 state report foundthat of the 104 babies who died of SIDS, 40were sleeping in cribs, 83 were sleeping inprone position, and 45 were co-sleeping.Only five of the infants were sleeping incribs, on their backs, alone. This informationwas used to support state-wide public healthrisk reduction programming.This presentation will describe the elementsof designing and implementing an effective

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and comprehensive child death reviewprogram; describe steps taken to obtainwidespread support and participation;describe the process of conducting a reviewof a sudden and unexplained infant death;describe the state death investigationstandards; describe risk reductioninterventions proposed and implementedfollowing review; and present findings fromthe review of SIDS deaths in Michigan.

128FRAN’S SUCCESSFUL FAILUREStephanie Cowan, Anne O’Malley, RodneyFordFamily Education Services, Christchurch,New ZealandBackground: Many pregnancy smokinginterventions are fraught withcontradictions. In NZ, we have smokefreeenvironments legislation, increasing tobaccotaxation, high profile anti-smoking mediacampaigns, national training programmesand a national “Quit Line” telephonecounselling service. Yet smoking inpregnancy persists at around 30% andpersists as the main risk factor for SIDS. Aswe gear up to deal with the smoking risk weneed to go beyond simple informationstrategies and brief advice to stop, anddesign interventions that are based on anunderstanding of the struggle to change forwomen who carry the greatest burden ofdisadvantage from smoking - women likeFran.Aim: To expose some of the contradictionsfor smoking in pregnancy interventionschallenge effectiveness, using Fran’sexperience as a case study.Results: Fran was a participant ofSmokechange - a study of personalised helpto change smoking in pregnancy. Challengedby high nicotine dependence, a crumblingrelationship with her smoking, alcohol-dependent, abusive partner, and more, Franfailed to achieve much behavioural changeduring her 12 months as a participant of thestudy. However, she went on to succeed withcessation independently and without relapsejust three months after finishing theprogramme . Although a “failure for thestudy”, Fran attributes her subsequentsuccess to the support of her SmokechangeEducator, Paula. In her own words “My goodthoughts about myself started with Paula.Paula got me ready for quitting.”Discussion: This case study showed thatreadiness was an important pre-requisite tosmoking cessation and that it was influencedby intervention. Cessation rates are the usual

markers of success and programmes tend torecruit “ready to quit” people then supportthem through the final stage of cessation.Without appropriate programmes the “notready” people are left to time or chance. Thesad contradiction is that, it is the “not ready”women like Fran who most need appropriateinterventions because they carry the greaterrisk to themselves and their babies.

129EVALUATION OF A STRATEGY TOPREVENT SUDDEN INFANT DEATHSYNDROME (SIDS)A Jenik1, S Cowan2, JM Ceriani Cernadas1,EAS Nelson3.Departamento de Pediatría, HospìtalItaliano de Buenos Aires (HIBA),Argentina, 1 Family Education Services,Christchurch, New Zealand, 2 Dept.Paediatrics, The Chinese University ofHong Kong, Hong Kong SAR, China.3

Diverse strategies, mainly advising changinginfant sleeping position from prone tosupine and to a lesser extent promotingbreastfeeding and a non-smokingenvironment, have contributed to dramaticreductions in the incidence of SIDS. “ProyectoVínculo” (Project Link) involved collaborationwith New Zealand to increase awareness ofSIDS risk factors in Argentina. However arecent survey of infants born at the HospìtalItaliano de Buenos Aires showed only 40%were sleeping supine at three months despitepromotion of such advice. To furtherpromote supine sleeping, the “Tarjeta Cuna”(Crib Card) strategy was devised. A speciallydesigned card carrying key messages forSIDS prevention and infant health (safe sleepposition, breastfeeding and not smoking)will be displayed in all newborn cribs. Thisstudy will test the hypothesis that the“Tarjeta Cuna” strategy will increase theuptake of these SIDS risk reductionmessages. Families with healthy full-termnewborns will be randomized into study andcontrol groups. Study group members willreceive conventional messages about SIDSprevention traditionally provided by ourpractice, together with “Tarjeta Cuna”.Control group members will receive the sameconventional messages as the study group,but without the “Tarjeta Cuna”. At twelveweeks a questionnaire about baby and familyhabits will be mailed to participants. Thepercentage of three-month old infants thatsleep in the supine position will be the mainoutcome measure. Assuming that exposureto the “Tarjeta Cuna” will increase thepercentage of infants sleeping supine from

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40% to 60%, and that data loss will be 15%, asample of 250 families will be recruited(alpha = 0.05 and beta = 80%, Epiinfo Version6.04c Statcal program).

130SUDDEN INFANT DEATH SYNDROME(SIDS) AND THE JERVELL AND LANGE-NIELSEN SYNDROME (JLNS) INNORWAY.M Arnestad1, M Andersen1, CV Isaksen2, HTorgersen1, Å Vege1, TO Rognum1.Institute of Forensic Medicine, Universityof Oslo, National Hospital of Norway1

Institute of Morphology, TrondheimUniversity Hospital, Norwegian Universityof Science and Technology, Norway2.Twelve out of 24 infants who later died fromSIDS had a prolonged QT interval (1). Jervelland Lange-Nielsen syndrome (JLNS) is anautosomal recessive disorder that comprisesdeafness and long-QT interval associated withsyncopal episodes. The syncopal episodes area consequence of abnormal ventricularrepolarisation, and can induce sudden cardiacdeath due to ventricular arrythmias.Several genetic markers for long-QT syndrome,included markers for JLNS, are known. Aprevious study has shown that three familieswith clinically diagnosed JLNS, all from themiddle region of Norway, have the samehomozygous 5 bp deletion of the KVLQT1 geneon chromosome 11 (2). KVLQT1 encodes apotassium channel involved in the currentresponsible for cardiac repolarisation. The 5bp deletion in the KVLQT1 gene encodes a S2-S3 membrane spanning segment of thechannel, and will cause a frameshift which islikely to cause disease. This deletion abolishesa HhaI restriction enzyme site (2).This study was set up to investigate whetherthis mutation could be found amongNorwegian SIDS victims, especially SIDSvictims from the mentioned region. 20 SIDSfrom the middle region and 140 SIDS from thesoutheastern region of Norway were studied.PCR was performed to amplify the DNAproduct from the S2-S3 domain of the KVLQT1gene from blood and spleen tissue. The HhaIrestriction enzyme was then added. In normalcontrols, digestion with the enzyme yieldsfragments of 98 and ~80 bp. In a mutant, the5 bp deletion abolishes the cut site for theenzyme, resulting in a fragment of ~180 bp.All SIDS studied so far does not show the 5 bpdeletion. Not all families with JLNS ofNorwegian origin show a common haplotype(2). A lack of deletions at the site studied doestherefore not rule out long-QT syndrome asan explanation for some cases of SIDS.

1 Schwartz PJ, Stramba-Badiale M, SegantiniA, Austoni P, Bosi G, Giorgetti R et al.Prolongation of the QT interval and the suddeninfant death syndrome. N Eng J Med1998;338:1709-142 Tyson J, Tranebjærg L, Bellman S, Wren C,Taylor JFN, Bathen J et al. IsK andKvLQT1:mutations in either of the twosubunits of the slow component of the delayedrectifier potassium channel can cause Jervelland Lange-Nielsen syndrome. Hum Mol Gen1997;6:2179-85

131DUMMY SUCKING AND ORALBREATHING IN NEWBORN INFANTSF Cozzi, O Aljbour, C Tozzi, F Morini, EBonci, DA Cozzi.Paediatric Surgery Unit, University ofRome “La Sapienza”, Italy.Aim: Mitchell’s study (1) gave some credit tothe old hypothesis of Cozzi’s on dummysucking as a preventive strategy against SIDS(2). However, the relationship between dummyuse and SIDS, although confirmed bysubsequent studies, is still widely considereda bias, probably because the possiblemechanisms of protective effects of dummysucking in normal infants has not been fullyinvestigated. Therefore, we tested thehypothesis that a dummy can serve as an oralairway during early life.Methods: Three nasal occlusion tests withoutdummy and three with dummy wereperformed for each of 20 healthy term infants(aged 2-5 days). Following the first adequateair entry, nasal occlusion was continued up to90 seconds provided the infant did not startcrying and provided the pulse oximeter didnot show a drop in oxygen saturation (SaO2)to £ 80%. The response to nasal occlusion wasconsidered normal when mouth breathingstarted without movements or crying.Results: Table shows the main clinicalfindings:

Without Withdummy dummy* P

Average responsetime (sec.) 11.3 ± 0.5 SE 17.6 ± 1 SE<0.001Infants with normalresponse (No) 9 19 <0.01

Tests with normalresponse (%) † 21 51 <0.001* Infants were able to breathe through the moutharound the dummy;† no differences between infants awake orsleeping.Figures show the correlation between typeof response and average amount ofdesaturation (DSaO2) from baseline following

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prolonged nasal occlusion tests (values aremeans ± SEM).Note no difference between normal andabnormal responses in dummy suckinginfants and significant greater DSaO2 whendummy slipped out of the mouth during thetest.Conclusion: In normal infants, dummysucking enhances the ability to switch fromnasal to oral breathing and sustain anadequate oral ventilation. Dummy serves asan oral airway.1 Mitchell EA et al. Dummies and sudden infantdeath syndrome. Arch Dis Child 1993, 68:501-5042 Cozzi F et al. A common pathophysiology forsudden cot death and sleep apnoea. “The vacuum-glossoptosis syndrome”. Med Hypothesis 1979; 5:329-338.

132PACIFIER AND DIGIT SUCKINGINFANTS III: PHYSIOLOGICALEFFECTS.Katie Pollard, Peter Fleming, JeanineYoung, Peter Blair, Andrew Sawczenko.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UK.Pacifier use is associated with a decreasedrisk of SIDS [1], and is widely believed tosuppress digit sucking in infants, but littleis known of the relative prevalence andphysiological effects of these two forms ofnon-nutritive sucking (NNS) during earlyinfancy.Methods. Overnight polygraphic recordingsof sleep state, respiration, ECG, oxygensaturation and infrared video were made of10 mother infant pairs (5 routine bed-sharers, 5 room-sharers) on two consecutivenights, at monthly intervals from 2 to 5months of age in a sleep laboratory. Eachmonth, mother baby pairs were randomizedto 1 night bed-sharing then 1 room-sharing,or vice versa. ‘Episodes’ of pacifier, own digitand mother’s digit sucking (>1 minute) wereidentified and compared with 2 state-matched control periods, before and aftereach such episode [2].Results: Full recordings, on 74 nights (749hours), showed 329 episodes of NNS on 54nights. During episodes, median oxygensaturation was higher (p=0.0037),desaturations were fewer (p=0.030), andinterquartile range of respiratory rate wasgreater (p=0.0007). Median respiratory ratewas slightly, but not significantly, lower.Median and interquartile range of heart ratewere not significantly different duringepisodes. The effect of sucking upon medianoxygen saturation depended on the type ofsucking involved, with mothers’ digit

sucking being associated with the greatestincrease in median oxygen saturation. Meandurations of infant movements and noiseswere reduced during sucking episodes,particularly during mothers’ digit sucking.Conclusion: Pacifier use is associated withimproved oxygenation, but the same effectis seen with digit sucking. Loss of digitsucking may compromise pacifier-usinginfants on nights without the pacifier.

1. P.J.Fleming, P.S.Blair, K.Pollard, M.W.Platt,C.Leach, I.Smith, P.J.Berry, J.Golding. Pacifier useand SIDS - Results from the CESDI SUDI case-control study. Arch Dis. Child 1999; 81:112-116.2. K.Pollard, P.J.Fleming, J.Young, A Sawczenko,P.Blair. Nighttime non-nutritive sucking in infantsaged 1 to 5 months: relationship with infant state,breast feeding, and bed- versus room-sharing. (Inpress) Early Human Development 1999.

133PRONE SLEEPING AFFECTSCIRCULATORY CONTROL IN INFANTST MatthewsDepartment of Paediatrics, UniversityCollege Dublin, Temple Street, Dublin 1,Ireland.Background: The mechanism of death inSIDS remains unclear. A recent report ofinfants dying from SIDS, while attached to acardiorespiratory monitor, showed that aprogressive bradycardia, with continuedbreathing movements, was the pre-eminentterminal event and has suggested thatcirculatory failure is an important part of thelethal sequence of events. Vasomotor tonehas a critical role in circulatory control byregulating, and altering, blood volumedistribution while maintaining bloodpressure. This study looks at the effect ofprone sleep on circulatory control in a groupof healthy infants, during an overnight sleep,at 7-8 weeks, factors increasing the risk ofSIDS.Methods: 75 full-term healthy infants werestudied during an unsedated overnight sleepat a mean of 7.6 weeks post delivery.Recordings were made while the infants weresleeping in the prone and supine positionsand repeated following a head up tilt to 60degrees while sleeping in both prone andsupine positions. Physiologic variablesmeasured included blood pressure, heartrate, and anterior abdominal wall andanterior shin skin temperature.Results: Systolic blood pressure is lower(78.4mmHg.v 81.8mmHg, p<0.05),andperipheral skin temperature (33.9°C v 33.6°C,p<0.05)is higher, while heart rate andanterior abdominal wall skin temperature are

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unchanged during prone, compared tosupine sleep, in the horizontal position.While in a 60 degree head up position therewas a greater reduction in blood pressure (-3.8% v-1.7%, p<0.05), and a greater rise inperipheral skin temperature (+0.3°C v +0.1°C,p<0.05), and heart rate (130.7 v 127.5,p<0.05), when in the prone positioncompared to the supine position.Conclusion: These results suggest thatprone sleeping has a measurable effect oncirculatory control, compared to supinesleeping, with a reduction in vasomotor toneresulting in peripheral vasodilation, a higherperipheral skin temperature, a lower bloodpressure, and a higher resting heart rate. Asvasomotor tone is critically important incirculatory control, this may be a factor inhow the prone sleeping position increasesan infants risk of SIDS.

134EFFECTS OF RISK FACTORS FOR SIDSON THE DEVELOPMENT OF HEARTRATE PATTERNSSA Petersen, MP Wailoo, A Jackson, CPrattLeicester Warwick Medical School, UnitedKingdomMost cot deaths occur at an age when aninfant’s physiology is changing rapidly. Wehave previously shown that there are largeindividual differences in the development ofbody temperature patterns, and that infantswith risk factors for SIDS both develop bodytemperature patterns later and change thebody temperature more during infections.1,2.Changes in body temperature are a part of acomplex of physiological changes inendocrine secretion, respiration andcardiovascular control. In this study we haveexamined the relationship between bodytemperature and heart rate patterns innormal infants and those with risk factorsfor SIDS. Overnight body temperature andheart rate patterns were recorded in 119normal and 48 infants with IUGR, sleepingat home every week from 6 to at least 16weeks of age, including the night afterimmunisation against Diphtheria, Pertussusand Tetanus. All infants developed an adult-like body temperature pattern abruptly, butat different ages. The onset of an adult-likebody temperature pattern was associatedwith a marked fall in sleeping heart rate from128 ± 2 bpm to 118 ± 2 bpm (P<0.01). Theheart rate of IUGR infants was significantly(P<0.01) higher before the adult liketemperature appeared, and the heart rate of

babies with smoking parents significantlylower once the adult like temperature patterndeveloped.In all babies heart rate is significantlyelevated the night after immunisation, witha significantly larger increase in IUGR infantsand the normal birth weight infants ofsmoking parents.Risk factors for SIDS therefore have markedeffects upon cardiovascular control at theage when most cot deaths occur.

1 Lodemore, M.R., Petersen, S.A. & Wailoo, M.P.(1992) Factors affecting the development of nighttime temperature rhythms. Arch Dis Child.67:1259-12612 Tuffnell, C, Petersen, S.A. & Wailoo, M.P. (1995)Factors affecting rectal temperature in infancy.Arch Dis Child. 73:443-446

135GASTROESOPHAGEAL REFLUX ANDAPNEA OF PREMATURITY: IS THERE ARELATIONSHIP?CS Peter, N Sprodowski, B Bohnhorst, JSilny (1), CF PoetsDept. of Pediatric Pulmonology andNeonatology, Medical School, Hannover,Germany, and Helmholtz Institute,Technical University, Aachen, Germany(1)Background: A causal relationship betweenGER and AOP has repeatedly been suspected.Failure to prove this may have been fortechnical reasons, i.e. that most GER inpreterms is non-acidic and thus difficult todetect with pH-monitoring, the current “goldstandard” for GER detection. We used thenew, pH-independent multiple intraluminalimpedance (MII) technique (1) to detect GER.Methods: Ten infants (median GA at birth29 wk (range 24-32), birth weight 860 g (600-1865), age at study 30 d (13-93), weight atstudy 1670 g (980-2200)) with recurrent AOPunderwent 6 h recordings of MII, pulseoximeter saturation (SpO2), pulse waveforms,ECG, nasal airflow and breathingmovements. MII and respiratory signals wereindependently analyzed. A reflux episode(RE) was defined as a fall in impedance in atleast the 2 most distal channels, an apneaas a pause in breathing movements of >4 s,a desaturation as a fall in SpO2 to <80% anda bradycardia as a fall in heart rate to <100/min.Results: A total of 226 RE occurred, with amedian rate of 16.5/infant (range 8-62). Thiscompared with 1341 apneas, 85desaturations and 31 bradycardias. 41 (18%)of the reflux episodes occurred within 20 sbefore, and 48 (21%) within 20 s after an

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apnea. The majority of RE had no temporalrelationship with a respiratory event.Conversely, only 4 desaturations and 1bradycardia were associated with a RE.Conclusion: GER was common in theseinfants, but occurred independent of AOP.These data do not support the hypothesisthat GER and AOP are related events.

1 Skopnik H, Silny J, Heiber O, Schulz J, Rau G,Heimann G. Gastroesophageal Reflux in Infants:Evaluation of a New Intraluminal ImpedanceTechnique. J Pediatr Gastroenterol Nutr Vol 23, No5, 1996

136The effects of maternal smoking anddiet on growth and cardiorespiratorydevelopment telemetred from thehome during sleep in infants.Johnson P, Andrews DC, Bawtree L,Mathews F*, & Neil A*.Maternal Infant Healthcare andTelemonitoring Research Centre, Dept ofObstetrics & Gynaecology, John RadcliffeHospital, Oxford. * Division of PublicHealth and Primary Care, RadcliffeInfirmary, Oxford.A number of studies demonstrate that infantlung function relates to antenatal smoking,many presuming a causative a role1. Infantsof mothers who smoke are of lower birthweight and are considered to be at increasedrisk of SIDS, wheezing, asthma2. One aim ofthis study was to determine whether dietaryand socio-economic factors might influencethe relationship of smoking to infantcardiorespiratory function and growth.From a cohort of 655 infants whose mothershad detailed antenatal, demographics andserum cotinine levels measured, 175 werestudied at home at 3 weeks and 3 months ofage. Cardiorespiratory measurements weremade overnight, from which breathingfrequency, Tme (maximal expiratory flow)and chest-abdomen phase angle werederived.Infants of mothers who smoked from theinitial cohort had disproportionate growthat birth (e.g. head circumference/crownrump, p<0.001). In the studied cohortmothers were older, of higher social andeducational status and this effect was notfound. They also had better diets than thosedeclining the study (higher VitC, Se & Fe,p<0.001). The monitored infants of maternalsmokers were disproportionately grown by3m, although of similar weight. Thesemothers were younger (23.9 vs 26.8 yrp<0.001) and their diets were deficient in

carotenoids (1252 vs 1963 µg, p<0.001) andß-carotene (786 vs 1251 µ g, p<0.001)compared to non-smokers. The dietarydeficits occurred during the first trimesterand were followed by increased levels duringthe third trimester. The only difference incardiorespiratory function in infants ofsmokers was a lower phase angle at 3m.However, when infants of the mothers withthe highest (n=10) cotinines (220 mg/ml)were compared with those with none, Tmewas decreased at 3w (p<0.01) and 3m(p<0.05). This effect was more pronouncedwith low VitC but did not relate tobirthweight. However, low levels of VitC innon-smokers was also related to a lower Tme.There are growth and restrictive airwayseffects in infants of heavy smokers that arerelated to diet. Furthermore the organ andgrowth specific effects of dietary deficits inearly gestation followed by increased dietaryintake in later pregnancy may also have tobe taken into account3. There appear to beindependent dietary effects on respiratorydevelopment. Thus diet may modify orcontribute to affects previously attributedto smoking. Socio-economic factors wereclearly a strong influence on smoking, dietand outcome.

1. Blair PS et al, 1996, BMJ, 313:195-198.2. Tager IB et al. 1995, Am J Respir Crit Care Med,152:977-983.3. Clarke L, Heasman L, Juniper, DT, Symonds ME.Br J Nutrition 1998;79:359-364

137IMMUNISATION DOES NOT ALTERINFANT SLEEP-WAKE ACTIVITYP Buckley, A Lokuge, IC McMillen.Department of Physiology, University ofAdelaide, South Australia 5005.Whether the temporal association betweentime of immunisation and time of suddeninfant death (SIDS) constitutes a causalrelationship has been debated in theliterature. The most recent epidemologicalreports have concluded that immunisationdoes not increase the risk of SIDS and,indeed, may lower the risk. However,immunisation rates in Australia remain sub-optimal, with only 70.4% of all infants fullyimmunised by 2 years of age (AustralianChildhood Immunisation Register, 1998).The aim of this study was to investigate theeffect of immunisation on the developmentalprofile of infant sleep. Sleep-wake data wererecorded for ninety nine healthy term infants(gestational age 38-42 weeks; 44 male, 55female) around the time of their first andsecond diphtheria-tetanus-pertussis (DTP)

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immunisations (at 3 and 5 months,respectively). A 24-hour sleep-wake chartwas completed by parents once in the weekprior to immunisation, and twice in the twoweeks following immunisation. Sleep-wakedata were available from each immunisedinfant and from infants within the group atmatched post-conceptional ages who werenot immunised in that time period. Thenumber of sleep bouts per 24 hours, totaltime asleep in 24 hours, length of longestsleep bout, and amount of night waking weremeasured. Results showed that there wasno significant difference in these parametersbetween the immunised and control infantsin the weeks following immunisation, at thetime of either the first or secondimmunisation. Our results suggest that thematurational stage of the sleep-wake systemis not significantly altered by DTPimmunisation.

138THE USE OF A BEREAVEMENTASSESSMENT TOOL WITH FAMILIESAFTER THE SUDDEN DEATH OF ACHILD: IMPACT ON QUALITY OFCARE.Ann Dent, Peter Fleming, Peter Blair.Institute of Child Health, University ofBristol, BS2 8BJ, UK.In a previous study we found that fewbereaved families received appropriate careor support from primary healthcareprofessionals, and many professionals feltill-equipped to provide such care despitewishing to do so (1,2). Subsequently,teaching and support has been offered toprofessionals, and an information packdeveloped, including a bereavementassessment tool (based on stress theory) andinformation booklets for parents and healthvisitors.Objectives: To test the efficacy of anintervention guide for Health Visitorssupporting bereaved families: from thefamilies’ and the health visitors’perspectives.Design: A prospective, 2-year, population-based randomised controlled trial in oneEnglish Health Region (population 7 million).Districts (2-300,000 people) were matchedfor socio-economic and urban/rural factors,and randomised for Health Visitors to receiveor not receive the assessment tool. Data wascollected on all sudden deaths in childhood(1 week to 12 years), and questionnaires sentto parents six months after the death, andto their health visitors 3 months after thedeath.

Results: Informed consent for contact wasgiven for 122/167 families in which a childdied suddenly; 72 (59%) parents, and 110(75%) health visitors responded. Both thestudy and control families reported highlevels of formal and informal support(median 6 HV contacts/family in bothgroups); 66% health visitors had receivedtraining in bereavement care. Many healthvisitors expressed the need for informationand training on the needs of siblings, as wellas more clinical supervision and support forthemselves. Anxiety and depression scoresin parents were not affected by theintervention, but 95% health visitors foundit useful and 81% considered it should begenerally available to professionals caring forbereaved families.Conclusions: Care of bereaved families hasimproved. The bereavement assessment toolfacilitates provision of high quality care, buthealth visitors would appreciate moresupport. The needs of bereaved siblingsrequire greater emphasis.

1. Dent A, Condon L, Blair P, Fleming PJ. A Study ofbereavement care after a sudden and unexpecteddeath Arch Dis Child 1996;74:522-5262. Dent A, Condon L, Blair P, Fleming PJ. BereavedChildren-Who cares? Health Visitor 1996;69:270-271

139LESSONS FROM AN ANCIENT STORYOF GRIEF FOR THE NEW MILLENNIUMJudy FreimanBereavement Counselling, Woollahra,Sydney, NSW, AustraliaA gift of wisdom from an ancient millenniumto a new one: I’d like to speak to you of astory written about 3000 years ago. The storyis called Demeter & Persephone and tracesthe journey of a mother’s grief over the lossof her child. This story is as relevant todayas it was then. Amidst all the changes in ourincreasingly complex world- a world whichpresents us with unique challenges, oftenfocusing on the differences between usrather than the similarities, offering up onesophisticated bereavement model afteranother, it is reassuring to reflect on anancient Greek myth and find a magnificentguide for our parental grief.Despite the unique challenges we face in thecourse of our grief, there are some thingsnot contingent on externals, personalhistories, or the details of the loss. Some arecontingent on simply being human. There issome place in us where we’re the same,always were, always will be and this givesour grief a sense of belonging, a community

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and ultimately a sense of normality.Demeter’s journey not only instructs us, buther journey is consolingly familiar to ourown, because she makes mistakes, falls inthe pit and learns how to crawl back outagain.This is the stuff of true inspiration. Herjourney is an archetypal one, the journey weall make when our child is lost to us- ajourney we’ll make as long as we are humanbeings and as long as we have hearts thatlove and at times break.

140CARE AND ASSISTANCE AFTER SIDSAND CHILDREN-ACCIDENTSD Nordanger, K Dyregrov, A DyregrovCentre for Crisis Psychology, 5037Solheimsviken, NorwayIn the first part of a three year project, asurvey was distributed to 481 localauthorities and city-districts in Norway. Therespondents, mainly community physicians,were invited to describe different aspects ofthe local care and assistance for parentsbereaved by SIDS and children accidents. Thefollowing aspects were covered by pre-codedquestions: a) The kind of assistanceprovided, b) care-givers involved, c) lines ofresponsibility and co-ordination, d) time-framing of the assistance, e) existing writtenroutines for the assistance, and f) existingassistance for children/siblings. Under openquestions respondents presented their ownjudgements regarding obstacles andfacilitators for better bereavement services.In a second part, a survey was distributedto all families known to have lost childrenin SIDS and by children accidents in Norwaybetween 1.7.1997 and 1.1.1999 (N=132). Thesurvey investigated 1) the kind of assistancereceived, 2) provided by whom, 3) time-framing of the assistance, 4) assistance forchildren/siblings in particular and 5) theparents’ evaluation of the assistance. Socialsupport and eventual self-help strategieswere also included in the questionnaire.Psychosocial health/functioning wasmapped by three standardised scales.Responding to open questions parentsdescribed what they had experienced as themost valuable care, and what to their opinionought to characterise assistance after suchevents.Apart from describing the “state” of thebereavement services in Norway and theexperiences and needs of the bereaved,results contains comparisons on differentlevels: Differences between the two groupsregarding received help and psychosocial

functioning are described, co-variationsbetween provided and received help anddifferent demographic variables areinvestigated, and likewise co-variationsbetween measures of psychosocial healthand aspects of received help. In sum, thisforms a basis for the aim of the project; todevelop guidelines for the structure andcontent of assistance after such events.

141GRANDPARENT BEREAVEMENT -CHALLENGE AND CHANGEAlison StewartDept Nursing & Midwifery, OtagoPolytechnic, Dunedin, New ZealandBereavement research and clinical practicehave focused on parents, and more recentlysiblings, of infants who die suddenly.Grandparents are often seen as supportersof the family- but what is their experienceof bereavement?This research used constructivist inquiry toexplore, in a series of interviews and letters,how 16 grandparents and 6 parents from 11families, living in New Zealand and theUnited Kingdom, constructed theirexperiences of grandparent bereavement,both as individuals and within the contextof the family. All the grandchildren had diedsuddenly and unexpectedly with; 3 SIDS, 4stillbirths, 3 perinatal deaths, and 1 infantdeath. Key aspects of this constructioninclude the following:• Facing challenge with the world turning

upside down and you have got all theseother ones when you are a grandparent.This encompasses the ‘pain’ of own loss,child’s loss (as parent of the grandchild),grandchild’s loss of a future, and othergrandchildren’s loss of a sibling.

• Responding to the challenge whichincludes physically going to be with thefamily and an active role as parents ofadult parents which means walking a fineline of ‘helping out but not taking over’from the parents.

• Managing changes from the challenge isabout living with the grandchild’s deathand what this means. Parents perceive thatgrandparents have an important role,

• Placing the grandchild in the family, as‘family-keepers’ who remember, andacknowledge the grandchild. Putting lossin life in place can involve revisitingother losses such as grandparents’ ownexperiences of miscarriage.

Whilst this joint construction is groundedon the experiences of these 23 participantsand cannot be generalised, it does offer us,

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both as clinicians and researchers, an insightto be aware of bringing grandparents intothe foreground when an infant suddenlydies.

142SIDS PARENT RESPONDING TOFAMILIES: THE WELLINGTONEXPERIENCEMadeleine TaylorSIDS Wellington Inc, Lower Hutt, NewZealandThis presentation outlines why and how thecurrent family support process came intoexistence. What structure was put in placeto ensure a professional and consistentresponse to families.Defining the service:• Family Support Coordinator PositionVision:The committee had a vision to ensure thatthe families they were trying to reachreceived a consistently, supportive, andeffective service.An opportunity arose in September 1997 tore-look at the counselling service and torefocus the committees work. A draft charterabout SIDS Wellington had been developedfocusing on four goals:1. To ensure that all families who experiencethe death of a child to SIDS, have access tothe best possible support that is right forthem2. To provide an apnoea monitor service forsubsequent siblings of SIDS babies3. To promote SIDS information4. To increase community awareness aboutways of protecting babies from SIDS fromthis document a job description was drawnup: Major role: To facilitate and co-ordinatea quality counselling and support service forfamilies affected by SIDS.Key Tasks: (1) Ensuring SIDS Families areoffered appropriate support and counsellingservices, (2) ensuring that Maori SIDSfamilies have access to professional supportfrom people of their own culture, (3)assisting SIDS families of all cultures accessprofessional support from people of theirown culture where it is available, (4) to co-ordinate parent supporters and otherappropriate people to support SIDS families,(5) to provide a direct counselling service,(6) to accept counselling phone calls throughthe 24 hr answering service, (7) to providesupport and supervision to SIDS parentsupporters, (8) to initiate and develop ourcounselling service in conjunction with theparent support group and the committee,and (9) to speak about our counselling

service to other community groups and/ororganisations. Working with the wider SIDSCommunityBuilding the Team:• First Responder

- role,- tasks,- training, this includes:

discussing: outlining the theories of grieveresolution, talking about boundary issuesVisiting: Funeral Home, mortuary, methodsof training: role play, feedback, tandam homevisits,debriefing, hands on supervisedpractise,• Life enhancement workshopDeveloping the Networks:• Getting out into the community• Hui• Maintaining links• Working within the SIDS Wellington GroupOngoing Supervision:• monthly supervision - upskilling, issues,

training, ethics,• on going learning and updating resourcesPublic Relations:• Public speaking• Health shows

143CREATIVE MEMORIESSue Wilkinson, Vivienne BatemanSIDSvictoria, Melbourne, AustraliaSince1993, SIDSvictoria has provided anumber of opportunities for bereavedparents to come together to talk about,create and share with others, items they havecreated in memory of children who havedied. The entire process has been driven andguided by parents with support provided bystaff members of the Family Services andCommunity Education Unit of SIDSvictoria.Early gatherings of the Creativity inBereavement group included sessions on art,music and writing; and the “Homage”exhibition at the Australian National SIDSConference in 1993. A special album, andthe Patchwork Poster Quilt, both of whichdisplay photographs of works created byparents and others, were made. The StarryCurtain, a focal point for parents at the 1997Australian SIDS Conference, providedanother opportunity for parents toparticipate in the Creativity in Bereavementprogram. In June 1999, the ‘RememberingExhibition’ was a part of the Red Nose DayMemorial Service. A number of familiesshared with others items they had createdin loving memory of children who have died.These items included needlework, poetry,prose, leadlight, paintings and so on. Books

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written by parents in memory of their childhave been shared with others. A card makinggroup has begun the process of designingand producing cards which moreappropriately and sensitively reflect theexperience of the loss of a young child. It isenvisaged that the cards will initially be usedto remember significant anniversaries,sensitively celebrate the birth of asubsequent child, and in other ways. Mostrecently, the Continuing Links Activity Group(C.L.A.G.) has met together to make upContinuing Links of Love packs which arenow being given to families to decorate inmemory of their child. The squares will belinked together in a continuous, and sadly,continuing length, and displayed atSIDSvictoria.Generally grieving parents at some stageseek involvement in an activity that helpsin some way integrate, or reduce the feelingsof emptiness, sadness, loneliness andhelplessness. Often parents make thecomment that doing something creativeallows them to maintain a connection withtheir child. It provides them with a tangibleopportunity to recognise the importance oftheir child’s life, often when others areencouraging them to ‘move on’. Creativityshould be emotionally safe for the (bereaved)parent. It is the parent’s choice as to thetype of project, when to begin, and their levelof involvement.This program illustrates the value of a closecollaboration between parents and healthprofessionals. Personal and community-based creativity projects at SIDSvictoria willbe shared with the conference through aslide presentation.

144INFANT CARE PRACTICES: WHATSHOULD WE ADVISETony Nelson.Dept of Paediatrics, The ChineseUniversity of Hong Kong, Hong Kong SAR,China.How do we develop education messagesbased on SIDS risk factors and how docultural factors complicate this process? Oneof the first Reduce the Risks (RTR) campaignswas proposed by the Canterbury Cot DeathSociety in Christchurch, New Zealand titled“Cot Death – you cannot predict it, youcannot prevent it, you can reduce the risks”.Since this time our understanding of thesignificance and inter-relationship of theserisk factors has greatly increased. Althoughsimple association does not imply causationwe are now confident that certain risk factors

(prone sleep position) are causallyassociated. However for other factors theevidence is less strong and implied causationis speculative. A diversity of RTR campaignshave developed and although mostconcentrate on 3 or 4 main messages, thereare often a number of minor messagesincluded. Important questions to considerinclude whether all messages are equallyimportant and, if not, whether the recipientof the message can tell the difference,whether all messages are equally evidenced-based, and whether all messages are equallyvalid across cultures? If there is very strongevidence for a particular message then it islikely that the message is relatively moreimportant. In terms of SIDS risk factors thereis very strong evidence that non-prone sleepposition and smoking increase the risk ofSIDS. For many of the other messages theevidence is weaker, variable or non-existent.Sometimes the main messages are obscuredby lesser but more newsworthy messages.Advice on how to prevent babies from rollingprone is difficult and at times controversial.Advice on “feet-to-foot” for preventing babiesheads from being covered may seemreasonable and common-sense but appearsnot to be evidenced-based. It could be arguedthat infant restraint, as used in traditionalsocieties, might also prevent rolling-over andhead-covering. Messages on roomtemperature regulation and clothing are notstraight forward, when heavy wrapping andhigh room temperatures appear to be riskfactors for SIDS only when infants sleepprone. Likewise advice that infants shouldbe given “tummy-time” to develop theirmuscles properly is not convincingly basedon evidence. Western-trainedphysiotherapists and paediatricians appearto be the main source of this advice,although whether tummy-time is adevelopmental necessity is debatable. Cross-cultural comparisons suggest not. Althoughit might be speculated that tummy-time mayhelp to teach a baby to roll over from thedangerous prone position to the safe supineposition, the reverse is also possible.Messages related to pacifiers are often notincluded in RTR campaigns. Should parentsbe told “Yes, pacifiers may protect againstSIDS” but “Yes, pacifiers may interfere withsuccessfully breast feeding”? DevelopingRTR messages is not easy. One option is ahierarchy of risk factors, ranked accordingto the weight of the evidence. Key messagesshould be presented as such. Factors withless or limited evidence could be includedwith suitable qualification. However this

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creates a dilemma, as the general public maylose confidence in a campaign that containsmessages with too much qualification or ifthe messages keep changing. The effect of amessage when given within a differentcultural context also needs to be considered.Our aim is to reduce deaths from SIDS byadvising parents about risk factors but at thesame time we do not wish to create otherproblems by giving misleading advice oradvice only applicable to a specific culturalgroup.

145PHYSIOLOGY MAJOR QUESTIONS TOBE ADDRESSEDAndré KahnFree University of Brussels, Brussels,Belgium

146PATHOLOGY; MAJOR QUESTIONS TOBE ADDRESSEDHenry KrousChildren’s Hospital-San Diego &University of California, San Diego Schoolof Medicine, USA

147DISADVANTAGED COMMUNITIES –THE FUTURERG EnglishThomas Jefferson University,Philadelphia, PAIn President Clinton’s radio address onFebruary 21st, 1998, he committed the UnitedStates to a goal of eliminating by the year2010, longstanding disparities in healthstatus experienced by racial and ethnicminorities. Despite the progress in theoverall health of the Nation, significantdisparities continue to exist in illness anddeath among African Americans, Hispanics,American Indians, Alaska Natives, and PacificIslanders, compared to the U.S. populationas a whole. President Clinton’s Racial andHealth Disparities Initiative to eliminateserious health differences between minorityand white Americans targets the followingsix areas: Infant Mortality, Cancer Screeningand Management, Cardiovascular Disease,Diabetes, Immunizations, and HIV/AIDS(DHHS, 1998).Although infant mortality in the U. S. hasdeclined steadily over the past severaldecades and is at a record low of 7.2 deathsper 1,000 live births, the black/white gap ininfant mortality rates has worsened.Consistently from 1960 to 1984, black babies

were twice as likely to die in infancy thanwhite babies were. In 1984, infant mortalityfor blacks was 18.4 deaths/1,000 births andwas 9.4 deaths/1,000 births for whites.Between 1992 (the year the AmericanAcademy of Pediatrics’ statement on infantsleep position was released) and 1995, theSIDS rates declined 31% among whites andonly 23% among blacks. The white rate fellfrom 11 to 6.5 and the black rate fell from23.3 to 16.8 per 1,000 live births. As a result,the black/white gap in the SIDS rates alsocalled the black/white mortality rate ratio,actually increased. In 1985, there was a 2.1gap between black and white deaths. By1995, that gap had risen to 2.4, which hasremained consistent through 1998 (CDC/NCHS). Planned strategies and interventionsfor reducing these alarming trends will beexplored.

148THE FUTURE DIRECTION FOR SIDSRESEARCH AND PREVENTION – TOLEAD OR BE LED?Kaarene FitzgeraldSIDSaustraliaCurrent debate about the use of‘undetermined’, ‘positional asphyxia’ and‘unascertainable’ as causes of death due tocurrent methods of investigation may leaveus with little or no deaths ascribed to SIDSin the not too distant future.The SIDS movement is at a major watershed.Within the past 18 months articles featuredin newspapers and journals, often based onlimited or ‘mother-in-law’ research, read likesomething from the early 1960' or 1970’s.Child abuse, neglect, Munchausen Syndromeby Proxy and homicide have raised their uglyheads casting doubts over all SIDS deaths.Whilst these areas of concern must bestudied it should be within a properlyplanned framework and not to the exclusionof developing further research into thecauses of genuine sudden unexpected infantdeaths.We are running the risk of following a linesimilar to the frenzy of apnoea monitors.Agreement must be reached about minimumstandards required to reach a cause of deathbut should include a case history, eventscene investigation and autopsy.Worldwide Reducing The Risks of SIDSprograms have contributed to a significantdrop in deaths enabling better investigationsabout the circumstances surrounding eachchild’s death. Unsafe sleeping environments,accidental deaths and prior illness have nowbeen highlighted leading to the question of

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how do we further reduce infant mortality?New initiatives, as a result of the AustralianScientific Forum held on December 4th and5th 1999 will be outlined in this paper.

149SUDDEN UNEXPECTED DEATH WHENYOUR CHILD IS OVER ONE YEAR OFAGEGraeme BakerSIDS Canterbury, New Zealand.When Phillip died he was more than thirteenmonths old. The Pathologists reportdetermined that it was SIDS.We receivedsupport from our local SIDS Canterburyteam. Most of the SIDS information refers tobabies and it just didn’t seem relevant in thiscase. After all Phillip was at two years familyChristmas parties, had celebrated his firstbirthday, could walk and even say a fewwords. It just didn’t stack up, after all hehad reached one year of age and was ‘safe’!I suppose that you could even say we werelucky that we had this amount of time withhim, given that most SIDS occur at an earlierage. The unfortunate reality is that one yearout from birth is not a magical date. Giveninfancy may refer to the first year of life andSIDS by definition to deaths during the firstyear, the sudden unexpected death of a childdoes, as we know, happen beyond thisperiod.Other families have no doubt been in thissituation and experienced similar thoughtsand feelings of not quite fitting the patternand even thinking that SIDS was suspicionraising, and a diagnosis of convenience.I will include in this presentation a broadoverview from my experience along with mycontacts with other families who have lostchildren at this end of the SIDS spectrum.

150BEREAVEMENT SUPPORT VIA THEINTERNETKaron CoxSIDSaustralia, New South Wales, AustraliaSupporting bereaved family members via theInternet. To provide a safe caringenvironment in a chat room where peoplecan express their feelings and share theirgrief when they have no one else to turn to,or are unaware of services offered in thecommunity.

151VIDEO AS GRIEF SUPPORTT. Giving KalstadNorwegian SIDS Society, Oslo, NorwayAfter the devastating loss of a child, it isimportant for the bereavement process toknow that one is not alone – that there areothers who share the same thoughts andfeelings of chaos and hopelessness.Not everyone who has lost a child will be ableto participate in support groups, andexperience has shown that men in particularare hesitant. Although the use of a video cannever replace a personal contact; it can be ofassistance as it is less threatening and can bemade available throughout the country. It canthus be considered both a supplement and analternative to participation in a support group.The video “A Conversation about Grief – afterthe loss of a child” contains recordings of twosets of parents in separate conversations withDr. Atle Dyregrov. One set of parents lost achild to SIDS, while the other lost their childto suicide. The main themes in theconversations are:a) the circumstances surrounding the death

of the childb) acute grief and delayed grief reactionsc) differences between men’s and women’s

reactions to grief as well as how theyexpress their grief

d) interaction in bereaved families.The last part of the video contains informationabout support groups for people who have lostchildren and about public agencies. We hopethe video can encourage individuals to use thepossibilities for support and assistance whichare available. Although the video is designedfor parents who have lost children, the openand forthright conversations will allowprofessionals to increase their understandingof grief and bereavement.The 115-minute video is distributed free-of-charge to our contacts and sold to hospitals,health departments and church offices. It is acooperative effort between the Norwegian SIDSSociety and the Center for Crisis Psychology.

152SEMINAR FOR UNPROCESSED GRIEFD. Nordanger, T. Giving KalstadNorwegian SIDS Society, Oslo, NorwayThe Norwegian SIDS Society is aware of thelife-long grief members must deal with. Theytackle the grief they feel in different ways,according to the type of help and follow-upthey received. We are also aware that the helpand follow-up families receive is coincidentaland dependent on location and resources atthe individual hospital. As a result, we have

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initiated a project designed to give themnecessary support and care, aimed at reducingthe occurrence and complications ofcomplicated grief among parents/families whohave lost a child to SIDS or others who haveexperienced the sudden, unexpected death ofan infant. This offer has also been given tomembers of another association.The project consists of 3 parts in addition toan evaluation. Part I was a day seminar aboutbereavement which was led by a psychologistand had 112 participants. Based on aquestionnaire, the group was mappedaccording to physical, mental andpsychosocial relations in addition to theirexperiences as support parents. By using thesequestionnaires, we were able to determine whosuffers the most. This group of 40 will be giventhe chance to receive help in Part II: 3 groupmeetings over 3 weekends, one month apart.Each of these meetings will be led by 2psychologists. After these seminars arecompleted, participants will fill out a newquestionnaire which will be used to evaluatethe seminars plus determine if participantsneed more help. The final part of the seminarwill be to offer 20 people individual therapyfor up to 8 hours.By February 2000, parts 1 and 2 will becompleted and we will be able to share someof our experiences with you.The seminar is a cooperative effort betweenthe Norwegian SIDS Society and Center forCrisis Psychology.

153BEREAVED KIDSPauline IngramDunedin Hospital, DunedinChildren are often the overlooked familymembers when a family is faced withbereavement. Adults are distraught oftenexperiencing difficulties themselves with whatis happened to their loved one.Two Paediatric nurses in Dunedin have beenrunning a bereaved kids (B.K’s) programme forseveral years. It is a programme for childrenwho have experienced the death of a lovedone – sibling, parent or relative. The aim is toallow children to deal openly with grief andthen get on with the business of living. Thisprogramme has helped children come to termswith the death and meet peers with similarissues.As the silent sufferers children are often notable to express their needs and nurses needto advocate for their rights to help at thisstressful time.

154REDUCTION OF SUDDEN INFANTDEATH SYNDROME - IMPACT ONBEREAVEMENT SUPPORT SERVICESFOR FAMILIESYani SwitajewskiSIDSaustralia, Royston Park, Adelaide,South AustraliaFamilies who have recently had infants diefrom both Sudden Infant Death Syndromeand sudden death due to other causes,require different support services, than werepreviously provided.This paper will offer reasons why and howpast bereavement support services havebeen adapted to change.

155SIDS PARENTS CONTRIBUTING TO ASIDS ORGANISATIONLesley and Peter JonesSIDSvictoria, Melbourne, AustraliaIn 1988 our son Brendan died of SIDS.Ironically this was the beginning of yearsthat would be filled with sadness, challenges,growth and personal rewards.By chance Lesley began weekly visits to theFoundation at Malvern where she was offeredthe opportunity to shed a tear or two over acup of coffee with other ‘SIDS Mums’. Thisweekly coffee morning was hosted by a ‘SIDSmum’ who was an example of ‘life after SIDS’for her. She was smiling, something thatLesley didn’t believe she would ever be ableto do again.As time moved on we became volunteers atthe Foundation assisting in many differentways. We were trained as Parent Supportersso that we could offer support to familiesbased on a shared experience bothindividually and in groups; we becamemembers of the Speakers Bureau so that wecould assist with speaking engagements onbehalf of the Foundation; Lesley became aSupport Group Co-ordinator where she nowhosts the monthly ‘coffee mornings’; we arerostered members of the 24-hour Crisis HelpLine; we have been closely involved in thedevelopment of a booklet ‘Choices inArranging a Child’s Funeral’; Peter is involvedin some of the Foundation’s creativeprojects, and Lesley has become a BoardMember and Secretary of the ExecutiveCommittee of SIDSvictoria.As we have moved from being ‘receivers’ to‘givers’ of support in a variety of ways, wehave had a unique opportunity to be withother people in times of great need. We havefound it to be a personally invaluable

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experience, and in return we hope that wecan offer families ‘hope’ for their future.

156DEVELOPING AN EFFECTIVE PUBLICEDUCATION AND AWARENESSCAMPAIGN ON SIDSJF Hazel, S CotroneoPartnerships and Marketing Division,Health Canada, Ottawa, Ontario, CanadaIn Canada, it is estimated that 3 babies dieper week of SIDS. In the fall of 1998, a jointstatement was released from the CanadianPaediatric Society, the Canadian Institute ofChild Health, the Canadian Foundation forthe Study of Infant Deaths, and HealthCanada which outlined the most currentresearch on how to reduce the risk of SIDS.It was information care givers and parentsboth wanted and needed to know.Given that there was a lack of currentresearch on awareness levels, attitudes andbehaviors of the primary target audience(mothers to be/parents/care givers) aroundSIDS, a benchmark survey was conducted toprobe these issues and provide insight intothe target group. The results indicated thatSIDS is the most weighty fear of new parentsand there exists a high level of confusionand conflicting advice on the appropriatesleep position for an infant. Based on theresults of this survey as well as multiplefocus groups across the country, acomprehensive public education andawareness campaign was developed.Our strategy involved the use of multi mediato reach both the primary and secondarytargets, in conjunction with our 3 partners.The public awareness campaign capitalizedon the international slogan Back to Sleep toboth build on the equity of this tagline andcreate consistency in all SIDS messages. Thecomponents of the campaign included abrochure, poster, print advertisement,television public service announcement anda Web site. The materials were distributedthrough parenting magazines, doctor’soffices, hospitals, and contained a 1-800number to call for further information.Currently a series of dialogue circles invarious Aboriginal communities areunderway, so that the campaign can beadapted to this target group.The feedback from the campaign has beenextremely positive to date. In March a postcampaign tracking survey is planned,replicating the pre-campaign benchmarksurvey to test awareness and attitude shifts,and suggest any necessary modifications tothe campaign.

157EXPANSION OF SERVICES BY SIDS NEWSOUTH WALES - THE PROCESSMichael CorboySIDSnew south wales, NSW, AustraliaAs the rate of Sudden Infant Death fell inNew South Wales it became obvious to theNew South Wales Board of the Sudden InfantDeath Association of New South Wales, asindeed with other SIDS organizationsthroughout Australia, that there were manyother target groups that were receiving noservice or minimal service from government,quasi government or charitableorganizations. Those groups were identifiedas children who died as a result of fire,drowning and electrocution. Also receivingminimal support were families of childrenthat died of quick onset disease, accidentaldeath and death resulting from motorvehicle accidents.In association with continued assistance ofSIDS families as a priority, SIDA New SouthWales (now SIDSnew south wales) embarkedon research to determine a number ofimportant factors as to whether they couldprovide assistance to these target groups.Factors such as volunteer support, staffinglevels, funding required, governmentsupport and the size of New South Waleswere all seen as contributing to the outcomeof the decision.The process also involvedspeaking with other member organizationsat a national level and having support ofthose other member organizations. Havingthe support of the National SIDS Council ofAustralia and other M.O.’s, specificallyVictoria, already showing vision inexpanding their services, New South Walesembarked on a lengthy and detailed surveyfollowed by regional focus groups whichconcluded in support for those expandedservices.This paper outlines the process, the findings,the marketing and problems associated withthe expanded services as well as the currentposition in that process.

158FEWER BEREAVED PARENTS – LESSTAKE UP OF BEFRIENDER SUPPORT –WHAT NEXT FOR THE SIDSORGANISATIONS?Ann Deri-BowenFoundation for the Study of InfantDeaths, (FSID) 14 Halkin Street, London,UKThis paper looks at the issues facing SIDSorganisations today with the volunteer

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support they offer bereaved parents. Withthe large, welcomed decrease in the numberof bereaved families each year and thereduced take up of the support offered bybefrienders there is a need to address thefollowing issues.• What support do we offer, when should it

be offered and does it match the needs ofthe family?

• Should we look at different ways ofproviding parent to parent support otherthan by Befrienders and in Groups?

• With the decline of parent support groupshow can we support volunteers?

• How can we continue to train befrienderswhen they are scattered over a large area?

• How can we value Befrienders and usetheir skills in other ways?

159THE AUSTRALIAN SIDS ONLINECATALOGUEJoanna DurstSIDSaustralia, Victoria, AustraliaThe Australian SIDS Online Catalogue (ASOC),an initiative and tool of SIDSaustralia, hastwo components. Firstly, it is a collection ofover 2,300 articles, reports, bibliographies,letters to the editor and other publicationsthat are about SIDS, grief and trauma.Secondly, it is a computer listing of thesedocuments, which is placed on the Internetand is therefore available to be searched byany interested party. The collection iscomprehensive and ever-growing.This paper will explain what ASOC is, whathelp it can provide to health professionals,parents and researchers, the purposes it hasbeen used for recently and how the cataloguecan be accessed and searched.

160EXTENDED SEMINARS FOR BETTERPARENTAL SUPPORTH.EriksenNorwegian SIDS, Oslo, NorwayParental support to grieving families is thebasis for our work, along with informationand the funding of research. We have morethan 50 people all over the country availableto assist bereaved families. All of thesesupport parents have experienced the lossof a child to SIDS and are highly motivatedto be of help to those in need. Some have amedical/nursing/social work/pedagogicalprofessional background, others don’t. Inorder to secure the quality of parentalsupport, we have developed a three step(three weekend) process-oriented seminar inhow to support grieving parents. The

seminar is arranged so as to allow forlearning in a safe environment and givesparticipants practical information as to howto lead a discussion (basics about grief,active listening skills, etc.) as well as on theleadership of support groups. The seminaris led by a psychologist with long experiencein helping volunteers work with people ingrief and by one of our members who hasan advanced teaching degree. Our nationalboard has decided that all our parentalsupport volunteers will be required toparticipate in this seminar.Our aim is to give you a brief understandingof how these seminars are run and the resultsof our first three-step seminar and a half-way report on our second.

161REGIONAL BEREAVEMENT SUPPORTCOOPERATIONH.EriksenNorwegian SIDS, Oslo, NorwayFamilies who lose a child, regardless ofcause, have a significant need for support;often long after the child’s death.Bereavement support to these families is themain objective of the Norwegian SIDS Societyand the Norwegian Association of Lost aChild.Many factors indicate the wisdom ofcoordinating the activities of these twosocieties. With their network of volunteersupport parents, they will be able to reachout to more families, and their volunteerswill be able to represent the needs thebereaved have in regard to hospitals andpublic agencies. One condition for thesuccessful creation of such an arrangementis that the cooperation between the membersat a regional level must be strengthened.Support parents from both societies haveattended four regional seminars with thispurpose in mind. The following topics havebeen focused on:a) establishment of contact between the two

societiesb) exchange of experiences and ideasc) increase knowledge of mutual activity in

both societies,d) lay foundation for regional activity of

support,e) secure the quality of the volunteer workf) encourage contact based on confidence

between the network of volunteers andpublic agencies.

We have thus been able to determine whatresources are available in the differentregions. This cooperation allows us toestablish contact with potential support

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parents/leaders of support groups andmaintain contact with functioning supportparents.We plan to arrange a follow-up educationprogramme at a regional level with 2 basicseminars for new volunteer support parentsand 2 follow-up seminars for experiencedleaders of support groups. Topics of focuswill be 1) partner relations after the loss ofa child, 2) siblings and interaction inbereaved families and 3) self-help to theleader of a support group. By February 2000all four seminars will have been completed

162PARTICIPATION IN RESEARCH:INFORMED CONSENT, MOTIVATIONAND INFLUENCERebecca HaymanDepartment Of Children’s And WomensHealth, University of Otago, Dunedin, NZObjectives: To investigate the process andquality of informed consent in parents whowere invited to enroll their baby in a non-therapeutic research project. The motivationof parents who participated and declined andthe effect of external influence were alsoexplored.Design: A mixed quantitative/qualitativequestionnaire was sent to a cohort invited toparticipate in a physiological research projectin the area of Sudden Infant Death Syndrome(SIDS). Separate questionnaires were used forparents who participated and those whodeclined to participate.Setting: Dunedin Public Hospital, New ZealandSubjects: 94 consenting parent and 103declining parent questionnaires were sent;response rate respectively was 69% and 42%.Results: Participant parents: All consentingparents felt they understood the purpose andprocedure of the study. They also felt able toask questions about the study. The majority(90%) felt the information about the study wasvery good; 6.5% felt more detail was required.Eighty-five percent found the verbalexplanation was the most useful source ofinformation. All participated for altruisticreasons such as to prevent SIDS. Their infant’svulnerability to SIDS was the second mostimportant reason for participating. Although27% had concerns about safety of the tests,after the tests all responders felt happy withthe safety of the tests. All participants felt ableto withdraw their child from the study at anytime. Non participant parents: Inconveniencewas the main reason (53%) for declining toparticipate. Twenty-eight percent wereconcerned about the safety of the tests.Parents provided many comments to back up

their choices on the questionnaire. Thesecomments will be presented with thequantitative data.Conclusion: The process for obtaininginformed consent in these studies wassatisfactory. Parents’ motives for participatingwere mostly altruistic. To improveparticipation and ensure the participantsconfidence in the study, further attentioncould be made toward parent understandingof safety issues.

163SUPPORT AND INFORMATIONOFFERED TO ACCIDENT ANDEMERGENCY DEPARTMENTS IN THENORTHERN REGION OF ENGLANDG. LatterThe Foundation for the Study of InfantDeaths, London, UKIn 1997 there were 416 sudden andunexpected infant deaths in England, Walesand Northern Ireland. In the Northern Regionof England, covering Cumbria,Northumberland, Tyne and Wear, Durham andTeesside, a population of 3,086,500 there were25 such deaths. The majority of these weretaken to the Accident and Emergency (A&E)Department of the local hospital forcertification of death.Since 1993, as part of the Foundation for theStudy of Infant Deaths (FSID) regionalprogramme for education and support, A&Edepartments have been visited by regionalstaff.The aims of these visits have been to:• offer a personal local contact• identify facilities for bereaved parents• provide current information• discuss support initiatives for families• ook at guidelines and support for staff.In the Northern Region there are twentygeneral hospitals, one with a specialistpaediatric A&E Department, and five cottagehospitals with Minor Injury Units. Thepresentation will look at the outcome of thevisits to A&E departments in this region duringthe period 1993-1998. It will:• discuss which A&E Departments have been

visited and how many visits made to each,• identify the facilities for bereaved families

and changes during the period,• highlight questions frequently raised by

A&E staff,• give details of presentations given to staff

which include the FSID video ‘Words Can’tDescribe How You Feel’, and the promotionof befriender and telephone Helpline

support.As a result of this preliminary work, the

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Department of Health have funded theregional staff to visit 120 A&E departmentseach year for the next three years.

164THE POWER OF THE HOME VISIT FOREXTENDING THE INFLUENCE OFSMOKING INTERVENTIONSCarol ReardonSmokechange Trust, Christchurch, NZAim: To demonstrate the ripple effect ofchange on family and friends from workingin homes with pregnant women who smoke.Background:. Smokechange is an intensivehome-visiting intervention for reducingsmoking in pregnancy that is matched to acomprehensive assessment of individualreadiness for change. Women are referred toSmokechange by their doctor or midwife.Although it is the pregnant woman whoenrols, family and friends are welcomed intodiscussions and change plans, too. Babiesof teenaged, Maori, smoking women are atincreased risk for SIDS. Three such womenwere attracted to the support ofSmokechange because it was in their homesand schools.Results: A 16 year old Maori girl calledShelly was one of a group of 20 Maoristudents in a pilot Smokechange programmeat a local High School in June 1998. Shellysubsequently became pregnant and acceptedsupport from the pregnancy programme. Shereduced her smoking during pregnancy andbecame completely smokefree soon after herbaby was born. There were at least fourfamily members living with her who alsosmoked and many visitors, too. Contact withShelly’s family has been extended due to thepregnancies of her teenaged sister andcousin who both wanted the support ofSmokechange. During the 16 months ofcontact 10 people have been directlyinfluenced: the step-father becamesmokefree and has sustained this for over12 months, Shelly is still smokefree after 6months, her mother is recently smokefree,her sister and cousin are smoking less than5 per day and seriously attempting to stopcompletely, the sisters’ partners havereduced their smoking and all seven adultsare committed to a smokefree home. Mostimportantly, 3 babies have had increasedprotection at vulnerable times - pregnancyand infancy.Conclusion: This presentation describesone instance of the ripple of influencesresulting from “taking the programme to thepeople”. Other effects on schools and thecommunity will also be presented.

165DEVELOPING AN EFFECTIVEPARTNERSHIP TO REDUCE THE RISKOF SIDS IN CANADAR. Sloan, M. LabrècheChildhood and Youth Division, HealthCanada, Ottawa, Ontario, CanadaSIDS is the leading cause of death in Canadafor infants between 28 days and oneyear ofage. Although there has been a decrease inthe number of infant deaths reported asSIDS, from 1/1500 live births in 1993 to 1/2200 live births in 1996, it remains,nevertheless, a significant public healthconcern in Canada. SIDS is of particularconcern in the Aboriginal population wherethe rates of SIDS deaths are considerablyhigher than in the general population.Based on research in the1980s and early1990s that reported a relationship betweenthe prone sleeping position of a healthy terminfants and the rate of SIDS, there wasconcern in Canada that this issue needed tobe addressed. In 1993, Health Canadaapproached other groups concerned with thehealth of Canada’s children to hold aconsensus workshop to respond to the issueof SIDS. A Committee was formed whichincluded the Canadian Paediatric Society, theCanadian Foundation for the Study of InfantDeaths, the Canadian Institute of ChildHealth and Health Canada. Such acollaborative approach was found to be mosteffective in promoting consistent messagesto multidisciplinary health professionals andthe general public.As a result of the 1993 consensus workshop,which reviewed and studied the most recentresearch, and recommended a plan of action,Health Canada and its three partnersdeveloped a joint strategy to raise awarenessof the risk factors related to SIDS. Elementsof the joint strategy included a nationalconsensus statement, targeted to healthprofessionals that defined SIDS andrecommended ways to reduce its occurrence.The information in the joint statement wasthen adapted into a brochure for parents, aposter and a television public serviceannouncement. Together with its partners,Health Canada ensured that the resourceswere broadly disseminated to healthprofessionals and the general public.In the spring of 1999, Health Canada andthree partners successfully launched the“Back to Sleep” campaign to reflect the latestresearch findings concerning SIDS.

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166OUR BABY DIED FROM SUDDENINFANT DEATH SYNDROMECarolyn SteadParent and Staff Nurse Coronary CareUnit, Dewsbury and District Hospital,West Yorkshire, England.This presentation tells of the fateful daywhen I found Dominic faced down in the car.“I turned him over aggressively, panicking, Igasped! I never even checked to see if he wasbreathing, I knew he wasn’t. There are nowords to describe finding your baby dead.“I began a frenzied attempt at resuscitationhoping that my skills would kick into action.They didn’t. I was a mum fightingdesperately to save a baby’s life, not anexperienced Accident and Emergency (A&E)Nurse, which I was at that time until recently.All the basic life support training I had everhad was hopeless. I did everything wrong.It’s so different doing it for real on someoneyou love so much”.”The speech describes what we found to behelpful and not so helpful nursingintervention when our baby son Dominicdied in February 1996 aged 3 months as aresult of Sudden Infant Death Syndrome.The main aim is to help other professionals,if faced with a similar incident, deal with itcompassionately and skillfully. This is anexperience which will remain in the parents’lives forever, it’s important that healthprofessionals ‘get it right’ in order tofacilitate the grieving process rather thanhinder it.

167EVALUATION OF INFORMATIONCAMPAIGN AGAINST SIDS IN THENORTHEASTERN OF POLANDJolanta WasilewskaMedical Academy of Bialystok, PolandAim: Evaluation of the methods used toreduce risk factors of SIDS in the years 1992-1999. The first results were presented in theSIDS Congress in Graz,1995.Material And Methods:The SIDS preventionprogramme was addressed to 3 groups: I-parents (information in mass media);II-doctors (specialization programme); IIImedical students (obligatory lectures, annualreports from ESPID Congresses). After 4years,comparative questionnnaire studieswere conducted comprising 331 subjects: I -123 parents + 56 women in 1 pregnancy; II-72 family doctors; III- 80 medical students.Results: During prevention programme wefound: 1/ An increase in the number ofpoeple who received information on SIDS:

in parents group from 61.8% to 85.4%. 2/Inparents group the main source ofinformation on SIDS was still based on massmedia. 3/ 9.7%kneww or heard about a SIDSaffected family; 4/ Parents became lessaware that prone sleep position is a riskfactor of SIDS (in 1999 66.0% of parentsregarded this position as safe for baby; 5/The number of back-sleeping infantsdecreased from 60.4% in 1995 to 21.1% in1999; 6/ Women in first pregnancy declaredthat they would put their children on back(37.5%) or side (57.1%), only 1.8% in proneposition; 7/ Despite significantly increasedawareness that smoking is harmful (from52.6 to 99.9%) 23% of children are stillexposed to passive smoking.Conclusions1. The SIDS information campaign addressedmainly to doctors and medical studentscontributed to the increased theoreticalknowledge on SIDS in this group.2. Practical knowledge of parents hasdecreased as a consequence of reducedinformation in mass media.3. Pregnant women are the best respondentsof SIDS information and actively search forit.4. The study indicates that theoreticaltraining of doctors is not sufficient. Theinformation should be mainly addressed toparents. There is necessity to intensify thecampaign in mass media again.

168RISK SCORING FOR SIDS -EPIDEMIOLOGICAL &ENVIRONMENTAL FACTORSPS Blair, PJ Fleming, M Ward Platt, IJSmith P J Berry, Jean Golding, and theCESDI SUDI research team.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UKScoring systems to identify families at higherrisk of sudden infant death syndrome (SIDS)have previously been attempted but lackedthe sensitivity or specificity to be used as apractical tool for preventative care. However,given the decrease in SIDS rate and increasein both the proportion of socially deprivedfamilies and significance of factors withinthe sleeping environment, the “high risk”group itself may be worthy ofepidemiological study.Methods A three year case-control studyconducted in 5 of 14 Health Regions inEngland (population ~ 17 million, 500,000livebirths). Parental interviews wereconducted for each infant who died and forfour controls matched for age and time of

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sleep. Ascertainment was over 90% [1][2].The scoring system was developed on theSIDS dataset from the first two years andtested on the third year data (130 SIDS and520 controls).Results The presence of three of fourepidemiological factors recognisableprenatally (maternal smoking, low socio-economic status, young maternal age andhigh parity) identified 42% of SIDS familiescompared to 8% of the control families(OR=8.3 [95%CI:6.2, 11.3]). The 8%(44) ofcontrol infants identified by this score asbeing at “high” risk demonstrated a higherprevalence of several adverse environmentalfactors compared to other control infants at“normal” or “low” risk, though the relativelysmall sample size limits the significance ofthese findings (e.g. non-supine sleepingposition 40.9% vs 24.5%; OR=2.1 [95%CI:1.1,4.2], head covering 9.1% vs 3.6%; OR=2.66[95%CI:0.62, 8.72], recent poor health 27.3%vs 19.1%; OR=1.59 [95%CI:0.74, 3.35]).Conclusion At least part of the increasedrisk of SIDS in the “high risk” group may thusbe related to postnatal care practices.Studying this group may increase ourunderstanding of adverse environmentalconditions associated with SIDS

1 Fleming PJ, Blair PS, Pollard K, Platt MW, Leach C,Smith I, Berry PJ, Golding J. Pacifier use and SIDS-Results from the CESDI SUDI case-control study.Arch Dis Child 1999;81:112-116.2 Leach CEA, Blair PS, Fleming PJ, Smith IJ, WardPlatt M, Berry PJ, Golding J. Epidemiology of SIDSand ‘explained sudden infant deaths Paediatrics1999;104:e43.

169WEIGHT GAIN AND SIDS : POORGROWTH AMONGST THOSE INFANTSBORN WITH A NORMALBIRTHWEIGHTPS Blair, P Nadin, TJ Cole, PJ Fleming, IJSmith, M Ward Platt, PJ Berry, J Golding,and the CESDI SUDI research team.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UKThe results of studies that have investigatedgrowth patterns in relation to the risk ofsudden infant death syndrome (SIDS) areconflicting. The recent development ofconditional reference charts [1] to assessweight gain in infants (The British 1990growth reference), comparing current weightwith that predicted from previous weightand allowing for regression towards themean have allowed us to reassess this issue.Methods A three year case-control studyconducted in 5 of 14 Health Regions in

England (population ~ 17 million, 500,000livebirths). Parental interviews wereconducted for each infant who died and forfour controls matched for age and time ofsleep. Ascertainment was over 90% [2].Prospective weight observations wereobtained for 247/325 SIDS and 1110/1300controls.Results The mean birth weight centile forSIDS infants was significantly lowercompared to the controls (42nd vs 53rdcentile, p<0.0001). The difference in meancentiles for the last recorded weight wereeven more marked (34th centile vs 58thcentile, p<0.0001).The growth rate from birth to the final weightobservation was significantly pooreramongst the SIDS infants (SIDS mean changein weight z-score (dzw)=-0.38[sd:1.40] vsC o n t r o l s = + 0 . 2 2 [ s d : 1 . 1 0 ] ,multivariate:p<0.0001). Weight gain waspoorer amongst SIDS infants with a normalbirthweight (above the 16th centile :OR=1.75[95%CI: 1.48-2.07], p<0.0001 ) thanfor those with lower birthweight(OR=1.09[95%CI:0.61-1.95], p=0.76). Therewas no evidence of increased growthretardation before death and the differencein growth rate was observed as early as 6weeks of age.Conclusions Poor postnatal weight gain wasindependently associated with an increasedrisk of SIDS. The difference was more markedamongst SIDS infants born of normal ratherthan low birthweight. Monitoring weight gainmay be of particular importance amongthose families which are identified fromother criteria as being at increased risk forSIDS.

1 Cole TJ. Conditional reference charts to assessweight gain in British infants. Arch Dis Child 1995;73: 8-16.2 Fleming PJ, Blair PS, Pollard K, Platt MW, Leach C,Smith I, Berry PJ, Golding J. Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999;81:112-116.

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170THE CESDI SUDI CASE-CONTROLSTUDY: THE THERMALENVIRONMENT OF INFANTS DURINGSLEEP AND THE RISK OF SIDSPeter Fleming, Peter Blair, Jem Berry,Martin Ward-Platt, Iain Smith and theCESDI SUDI research team.Institute of Child Health, University ofBristol, BS2 8BJ, UK.Objectives. To investigate the role of heatstress in the aetiology of SIDS after the “Backto Sleep” campaign.Design. Three-year population-based case-control study [1][2]. Parental interviews wereconducted for each sudden infant death andfor four controls matched for age, locality andtime of sleep.Setting. Five Health Regions (population 17million) in England.Subjects. 325 SIDS infants and 1300 controls.Results. SIDS infants were more heavilywrapped than controls, both usually and forthe final/reference sleep (median: 5.0 vs 4.2tog, p < 0.0001). More SIDS than controls werewrapped in 10 tog or more (OR 2.54 [95% CI1.76, 3.67]), and SIDS infants were more likelyto have the heating on all night (OR 1.54 [1.07,2.22]). More SIDS infants wore a hat (OR 3.12[95% CI 1.39, 7.01]). Having a mother whoworried about the baby getting too hot wasprotective (OR 0.53 [95% CI 0.36, 0.78]). Theuse of a duvet was a risk factor (OR 2.92 [95%CI 2.15, 3.95]) whether an adult or infant duvetwas used. Being found with the covers overthe head (16.2% SIDS, 2.9% controls) wasassociated with the use of a duvet, andcommonly with the infant having moved downthe cot (OR 3.51 [955 CI 2.00, 6.12]).In a multivariate analysis, including allsignificant factors, being found with the headcovered (OR 33.22 [95% CI 9.46, 116.69]), useof a duvet (OR 2.00 [95% CI 1.03, 3.85]), andhaving a mother who worried about her babybeing too hot (OR 0.44 [95% CI 0.23, 0.87])remained significant.Conclusions. Heat stress remains a riskfactor for SIDS, as does the use of a duvet.Putting babies in the “feet to foot” position,and educating mothers about avoiding heatstress may reduce the risk of SIDS.

1 Fleming PJ, Blair PS, Pollard K, Platt MW, LeachC ,Smith I, Berry PJ, Golding J.Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999; 81(2): 112-116.2 Leach CEA, Blair PS, Fleming PJ, Smith IJ, WardPlatt M, Berry PJ, Golding J. Epidemiology of SIDSand explained sudden infant deaths Pediatrics1999;104:e43.

171IS THERE A GENETIC COMPONENT TOTHE INFLAMMATORY RESPONSESIMPLICATED IN SIDS?A.E. Gordon, D.A.C. MacKenzie, D.M. Weir,A. Busuttil, C.C. BlackwellDepartment of Medical Microbiology andForensic Medicine Unit, University ofEdinburgh, Edinburgh, ScotlandStudies of invasive bacterial diseases haveshown that genetic control of inflammatoryresponses plays a role in severity or fataloutcome of the infection (1). There isincreasing evidence that inflammatoryresponses have been induced in many SIDSinfants, and our group has identifiedpyrogenic toxins of Staphylococcus aureus,including toxic shock syndrome toxin (TSST),in >50% of tissues from SIDS infants sent tous for analysis from Britain, France, Australiaand Germany. In vitro analysis ofinflammatory responses to TSST indicate aminority of individuals produced muchhigher levels of tumour necrosis factor (TNF)(2). We examined the hypothesis thatcompared with parents who have not had a‘cot death’, parents of SIDS infants have: 1)higher pro-inflammatory responses in toTSST; 2) lower levels of the anti-inflammatory cytokine interleukin-10 (IL-10)involved in control of the pro-inflammatorycytokines identified in experimental modelsof toxic shock syndrome and in many SIDSinfants, interleukin-6 (IL-6) and TNF.Whole blood from 44 donors (29 SIDS parentsand 15 control parents) was stimulated withTSST-1 (0.5 mg ml-1) for 24 h. Preliminaryresults found a mean of 1.4 ng ml-1 IL-6(range 0.2 - 3.8 ng ml-1) for SIDS parents anda mean of 1.8 ng ml-1 (range 0.1 - 8.2 ng ml-1) for the controls. These samples are beingtested at present for TNF and IL-10.We are recruiting additional SIDS parentsand controls and in the next phase of thisstudy will compare the inflammatoryresponses of Asian families in which thereis a low incidence of SIDS with those of non-Asian parents.

1 Westendorp et al. Lancet 1997; 349 170-173.2 Raza et al. FEMS Immunology Medical Microbiol-ogy 1999; 25: 145-154.

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172FUTURE DIRECTIONS FOR SIDSRESEARCHDr Sara LeveneFoundation for the Study of InfantDeaths, London , UKThe Foundation for the Study of InfantDeaths hosted a workshop examining futureresearch strategies. 24 participants includedbasic scientists and epidemiologists, someexpert in SIDS research and others new tothe field. A trained facilitator organised aprocess in which small groups, composedof members with similar interests,exchanged members then slowly convergedinto a whole group discussion.Agreed background concepts:• All infants who die suddenly and

unexpectedly should be included. Abroader range of health outcomes, suchas low birth weight, could be considered.

• SIDS is not a single aetiological entity.Summary of outcomes:The insults, what they are and when they actTrained paediatric pathologists briefed by afull history must carry out all postmortemexaminations in infants who die suddenly.Death scene examination should be included.Work in basic science must continue toexamine:• the basic processes (physiological,

biochemical, nutritional etc.) thatcontribute to SIDS

• normal infant development and protectivemechanisms.

The “at risk” groupsContinued monitoring of the population, andinternational comparisons, help determinethose insults remaining responsible forsudden infant death, following recentchanges in child care. This monitoring alsohelps target preventative measures.A scoring system sufficiently simple forroutine clinical practice should bedeveloped.Research relating to basic mechanisms mustincorporate known at risk groups andprotective factors; eg, stratification forsocioeconomic status is essential.PreventionMore information is needed on how topromote changes in knowledge, attitudesand behaviour in the vulnerable group.Different forms of intervention should beexplored. This exploration could take theform of discussion and information sharingwith other groups interested in healthpromotion.Properly designed intervention studies arerequired. Interventions must be generalisable

to regular practice rather than onlyapplicable in research settings.

173HONG KONG CASE-CONTROL STUDYOF UNEXPECTED INFANT DEATH:LEGAL, ETHICAL AND PRACTICALISSUESEAS Nelson,1 D Wong,1 NM Hjelm,2 JADickinson,3 Y Ou,4 CB Chow,5 NLS Tang,2

KF To,6 L Chen,1 LM Yu.7

Dept of Paediatrics,1 Dept. of ChemicalPathology,2 Department of Community &Family Medicine,3 Department ofAnatomical and Cellular Pathology,6 andthe Centre for Clinical Trials andEpidemiology Research,7 The ChineseUniversity of Hong Kong, Tuen MunHospital,4 Princess Margaret Hospital,5

Hong Kong SAR, China.A 1987 Hong Kong study documented a SIDSincidence of 0.3/1000 but official statisticsclassified only 6 of these 21 deaths as SIDS.This case-control study will document overa 2 year period all unexpected deaths inchildren under two years of age. Hong Kong’sPersonal Data Privacy Ordinance preventedideal controls being identified from theBirths Registration Office. Instead 160controls (4 for each of the anticipated 20deaths per year) are being selected fromindividual maternity hospitals (in proportionto number of births). Dates of interview(nominated dates) were randomly selectedfor all 730 days of the study. Age andnominated time were randomly selectedaccording to anticipated distribution (basedon New Zealand and Hong Kong data) anddate of birth calculated. HospitalAdministrators of 10 government hospitals(70% of births) and 10 private hospitals (30%of births) that provide maternity serviceswere contacted, some of whom had concernsabout the Ordinance and additionalworkload. One government hospital refusedto participate and another intended to chargefor anticipated extra workload. Althoughethical approval had been obtained fromboth the Clinical Research Ethical Committeeand the Survey Ethics Committee of theChinese University of Hong Kong, a numberof hospitals required their own approval.Private hospitals had initial concerns aboutpractical implications of contactingnumerous individual doctors. Selectedcontrol families are approached shortly afterbirth by the research nurse and, once writtenconsent is obtained, arrangement forinterview on the nominated date is made.

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All unexpected deaths are legally requiredto undergo a post-mortem examination atone of three public mortuaries. Workloadconcerns required that a designatedpathologist from the study group undertakethese examinations to enable theInternational Standardized Autopsy protocolto be completed. Mortuary staff arrangecontact between the family and researchnurse which is made 7-21 days after thedeath.

174DEATH-SCENE INVESTIGATION IN THEGERMAN CASE-CONTROL STUDY ONSIDSM Schlaud1, A Fieguth2, D Giebler3, BGiebe3, S Heide4, K-P Larsch2, CF Poets5, USchmidt6, J Wulf7, WJ Kleemann2.Hannover Medical School:Dept. ofEpidemiology, Social Medicine and HealthSystem Research1; Institute of LegalMedicine2; Dept. of Paediatrics. Universityof Jena3; Halle4; Magdeburg6; Hamburg7:Institute of Legal Medicine. Germany.In the ongoing German case-control studyon SIDS, a two-year substudy of death-sceneinvestigation has been running since 1 April1999. Infants who died suddenly andunexpectedly between the 8th and 365th dayof life are eligible for this study, whichincludes an autopsy (with full virology andtoxicology) and a parent interview. In the 5substudy areas, an additional death-sceneinvestigation is carried out for each case bya doctor of legal medicine within a few hoursafter death.Following a standardised protocol, thefollowing observations and measurementsare taken: temperatures of the room, theheating device, the body, and outdoors;dimensions of the room and the cot; type,dimensions and weight of the bedclothes;type, dimensions and softness of themattress; type of the infant’s clothing;pacifiers or other objects found in the cot.For each index case, three living controls areenrolled, matched to cases by gender, age,region, and season. Each control infant’swake-up scene gets observed anddocumented identically. Additionalinformation, including socioeconomic statusand other confounders, is available fromparent interviews. The main question of thissubstudy is whether indications of hypoxia,rebreathing or hyperthermia as themechanisms of death can be revealed bycomparing ‘objective’ scene data from casesand controls. Additional explorative analyses

will be performed in order to generate newhypotheses, which may be tested in futureconfirmatory studies. Total sample size is100 cases and 300 controls within two years;interim results of the first study year willbe communicated.

175A WAY OF SIDS INVESTIGATION INFORENSIC PRACTICEKlara Toro1, Gyorgy Dunay1, ToshikoSawaguchi2, Akiko Sawaguchi2

Institute of Forensic Medicine1,Semmelweis University of Medicine,Budapest, Hungary, Department of LegalMedicine2, College of Medicine, TokyoWomen’s Medical University, Tokyo, JapanThe objective of the study was to identifythe classical pathomorphological changesfor sudden infant death syndrome. For fiveyears (1994-1998) data were collectedretrospectively from the autopsy andhistology reports of the Institute of ForensicMedicine, Budapest. Infant death casesconstitute a small part of forensic autopsies.All together there were 78 cases (28 SIDS and50 non-SIDS) between 1 week and 1 year ofage among the autopsy reports. Theproportion of infants died suddenly andunexpectedly or of any violent cause of deathwas 0.6 % of the total number of autopsycases. In non-SIDS group there were 4 violentdeath cases. In the SIDS group there were 13male and 15 female, and in the non-SIDSgroup 31 male and 19 female cases. Datafrom the scene investigation, signs ofinjuries, signs of inflammation macroscopicand histological changes of internal organswere examined. Age groups and seasonalvariation were not associated with differentcause of death. Petechial haemorrhages onthe surface of thymus showed highernumber in SIDS group than in non-SIDSgroup: adjusted odds ratio (OR) = 5.26: (95%confidence interval (CI) = 1.67, 17.03). Nosignificant differences were found forpathomorphological changes of the otherinternal organs. However, the number ofinvestigated cases seems to be relatively low.

176THE BMBF SIDS STUDY IN GERMANY:PRELIMINARY RESULTS FROM ANATION WIDE STUDYMMT Vennemann, M. Findeisen, E. Müller,B. BrinkmannUniversity of Muenster, Germany.Introduction: Since October 1998 amulticenter case-control study of Sudden

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Infant Death Syndrome (SIDS) is underwayin Germany. The study cooperates with the14 forensic medicine centers in Germany,sponsored by the Ministry for Education andScience and is coordinated by the Institutefor Forensic Medicine in Muenster.Methods: The study uses a classicalmatched case control approach (3 controlsmatched for age and gender). In apreliminary analyses of 77 cases and 203controls we explored the relationshipbetween SIDS and prone sleeping, smoking,breastfeeding, co-sleeping, extra heating;and young age and a low educational levelof the mother using univariate analyses Thedata are presented with odd ratios and 95%confidence intervals.Results: 59.7% of the SIDS cases are maleinfants, 46.8 % died within the first 4 monthsof life. 52.7% of the SIDS children were foundin a prone sleeping position, but only 7.5 %of the controls woke up prone (Odds: 13.82,CI: 6.54 – 29.54). Smoking of the motherduring pregnancy (OR: 9.56 CI: 4.86 – 18.92)and breastfeeding for less than 7 weeks (OR:6.15 CI: 3.35 – 11.34) were found to be strongrisk factors for SIDS. While co-sleeping in thebed of the mother was not a risk in our data(odds: 1.29, not sign.), but extra warming ofthe baby was corresponding with an oddsratio of 2.25 (CI: 1.13 – 4.48). In 17.6 % ofthe cases the mother was 21 years oryounger, but in the randomly selectedcontrol group we found only 1.58 % of themothers in this age group (Odds ratio: 13.28,CI: 3.38 – 60.89). Low maternal education,defined as less than 12 years of formaleducation, is a clear risk in our study (OR:8.91, CI: 4.23 –18.97).Discussion: These preliminary data suggestthat prone sleeping position and young ageof the mother are the highest predictor ofSudden Infant Death Syndrome in our study,followed by smoking and low education. Co-sleeping in the bed with the mother is notlikely to be a risk factor in our data set.

177SIDS INFANTS – HOW HEALTHY ANDHOW NORMAL? A CLINICALCOMPARISON WITH EXPLAINEDSUDDEN UNEXPECTED DEATHS ININFANCYM Ward Platt, PS Blair, PJ Fleming, IJSmith, TJ Cole, CEA Leach, PJ Berry, JGolding and the CESDI SUDI researchteam.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UK

Clinical features characteristic of suddeninfant death syndrome (SIDS) suggest infantvulnerability at birth, after discharge fromhospital, during life and shortly beforedeath. The relative significance of thesefeatures amongst SIDS infants and betweenSIDS and explained sudden infant deaths hasbeen investigated.Methods. A three year case-control studyconducted in 5 of 14 Health Regions inEngland (population ~ 17 million, 500,000livebirths). Parental interviews wereconducted for each infant who died and forfour controls matched for age and time ofsleep. Ascertainment was over 90% [1]. Thisanalysis includes 325 SIDS, 72 explainedSUDI and 1588 matched controls.Results In the multivariate analysis fourclinical features were associated with SIDSidentifiable at birth: < 37 weeks gestation(20% vs 5% controls, OR=4.93[2.16-11.24]),<10th birth centile (16% vs 8% controls,OR=2.44[1.13-5.26]), multiple births (5% vs1% controls, OR=7.81[1.35-45.28]) and majorcongenital anomalies (5% vs 2% controls,OR=4.54[1.32-15.56]) whilst explained SUDIdeaths were characterised by one: neonatalproblems (38% vs 26% controls,OR=4.64[1.34-16.03]).Of those postnatal clinical features afterdischarge, the most significant was a historyof apparent life-threatening events for bothindex groups (SIDS: 12% vs 3% controls,OR=2.55[1.02-6.41], explained SUDI: 15% vs4% controls, OR=16.81[2.52-112.30]).A retrospective scoring system based on the“Cambridge Baby Check” [2] was used toidentify infant illness in the last 24 hours.This marker of illness was associated withthe highest risk for both index groups (SIDS:22% vs 8% controls, OR=4.17[1.88-9.24],explained SUDI: 49% vs 8% controls,OR=31.20[6.93-140.5])Conclusions The clinical characteristics ofSIDS and explained SUDI are similar. ‘BabyCheck’ particularly in high risk infants, mayidentify seriously ill babies at risk of suddendeath.1 Fleming PJ, Blair PS, Pollard K, Platt KW, Leach C,Smith I, Berry PJ, Golding J. Pacifier use and SIDS -Results from the CESDI SUDI case-control study.Arch Dis Child 1999; 81:112-116.2 Morley CJ, Thornton AJ, Cole TJ, Hewson PH,Fowler MA. Baby Check: a scoring system to gradethe severity of acute systemic illness in babiesunder 6 months. Arch Dis Child 1991; 66: 100-6.

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178PREVALENCE OF SMOKING AMONGCREE REPRODUCTIVE AGE WOMENE. Wilson, P. SicotteDept. of Anthropology, University ofCalgary, Calgary, Alberta CanadaObjective: To determine the rate(s) ofsmoking among reproductive age Creefemales after smoking cessation campaigns.Setting: A Cree reservation in Alberta,located north of Edmonton.Methodology: Cree women from 16 to 39years of age, with infants under 12 monthsof age, were interviewed in their homes todetermine: a) whether they currently smokedb) if they smoked, how many cigarettes a daydid they smoke c) where there other smokesin the home, and how many cigarettes didthey smoke per day d) whether smoking wasinside the home (and where), if outside thehome where; e) did the women smoke duringpregnancy f) did they stop smoking duringpregnancy, if yes, when? g) if no, how manycigarettes did they smoke during pregnancyand h) did they smoke during the time frameof breast-feeding? Women were asked ifthey were aware of the smoking cessationcampaigns? And if so, why they continuedto smoke?Results: A total of 70 homes were visitedin the Cree community with 47 smokingmothers and 22 non-smoking homes. No agedifference was found between non-smokingand smoking mothers (N=48, DF=1 X2=0.196n.s.). However, higher number of oldermothers smoked than younger mothers andsmoke in the house. Infants were exposedto cigarette smoke when mothers continuedto smoke in conjunction with “others” whosmoked in the house. In 37 homes, bothmother and others were smokers. Themedian number of cigarettes smoked in thehouseholds where the mothers only smokedwas 5. However, if other members smokedthe median number of cigarettes in thehousehold was 20.Conclusions: Cree women continue tosmoke at a rate that may compound the riskof SIDS in their community.

179TOXIC GAS HYPOTHESIS REJECTEDLady Sylvia LimerickChairman of the Expert Group toInvestigate Cot Death Theories,Department of Health, London 5E1 6LW,EnglandThere is no evidence that compoundscontaining antimony and phosphorus, usedas fire retardants or plasticisers in PVC andother cot mattress materials, are a cause ofsudden infant death syndrome (SIDS) or posea danger to infants. An Independent ExpertGroup, appointed by England’s CMO, reachedthis unanimous conclusion in 1998 afterthorough investigation of the hypothesisfirst publicised in 1989 by Barry Richardson,a consultant on biodeterioration of materialsin England. He suggested the primary causeof SIDS was poisoning by gaseous phosphine,arsine and stibine generated by the fungus,Scopulariopsis brevicaulis, from chemicalcompounds added to PVC mattresses.The Expert Group based their conclusion onthe following:-1. Cot mattress contamination with thefungus S. brevicaulis is rare and no morecommon in the SIDS infants’ mattresses thanin other used mattresses;2. There is no evidence for the generationof any toxic gases by the fungus from cotmattress PVC samples when tested underconditions relevant to an infant’s cot. TheGroup identified laboratory conditions,wholly unlike those that could occur in aninfant’s cot, in which antimony compoundscan be biovolatilised but to the much lesstoxic trimethylantimony and not to stibine.3. There is no evidence of poisoning byphosphine, arsine or stibine or theirmethylated derivatives in infants who havedied as SIDS.4. Low amounts of antimony are detected insamples from the majority of infantsincluding newborns and foetal tissue,placenta and cord blood indicating pre-natalacquisition. The concentrations in SIDSinfants are no different from those in infantsdying from known causes and are within thenormal range;5. There is no evidence that the changingSudden Infant Death rates correspond to theintroduction and removal of antimony- andphosphorus- containing fire retardants in cotmattresses.

*Expert Group to Investigate Cot Death Theories:Toxic Gas Hypothesis. Chairman Lady Limerick.Final Report, 1998

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180ABORIGINAL MOTHERS: CHILD CAREKNOWLEDGE AND FACTORSIan MitchellAlberta Children’s Hospital, Calgary,Canada.Aboriginal people in Alberta have a SIDS rateabout nine times the rate of the rest of thecommunity. The study aimed to determinechildcare knowledge in the aboriginalcommunity in Morley, Alberta, and also todetermine how these mothers would like tofind out about childcare knowledge.This was a sample of twenty-five mothers,all with children under one year old, whocompleted an anonymous culturallysensitive questionnaire. The questionnairedealt with type and number of SIDS riskfactors, the type of childcare practices used,level of anxiety about SIDS, preferred andactual methods of childcare knowledgedissemination.Mothers were aged from 17 to 37 years 20%had a high school diploma and 28% wereemployed outside the home. In 96% therewas at least one modifiable SIDS risk factorin their childcare practice. Eighty-eightpercent had heard of SIDS but only 28% couldname a SIDS risk factor. Those factors knownincluded prone sleeping (12%), notbreastfeeding (4%), smoking (4%), co-sleeping(4%). Those mothers who did not know SIDSrisk factors were more likely to use childcarepractice, which increased the risk of SIDS.We noted that passive smoking occurred in68%, not breastfeeding in 64%, infant co-sleeping in 44% prone sleeping in 12%.As far as childcare information is concerned,the sources of information were family,literature and health care workers. Ninety-six percent of the mothers surveyedrequested further parenting and SIDSinformation.Childcare providers in this particularcommunity have a high percentage ofmodifiable childcare practices known toincrease SIDS risk, and very little knowledge.They do wish further information, would likethis from healthcare workers and theirfamily.

181SUDDEN INFANT DEATH SYNDROMEIN INDIGENOUS AND NONINDIGENOUS INFANTS IN NORTHQUEENSLAND: 1990-1998J Whitehall1, KS Panaretto1, G McBride2.School of Public Health and TropicalMedicine, James Cook University andKirwan Hospital for Women, Townsville,Qld, Australia1, Townsville GeneralHospital, Townsville, Qld, Australia.2

Background: Sudden Infant Death Syndrome(SIDS) is the most common cause ofpostneonatal death in Queensland (0.98 per1000 live births, 1994-1996). SIDS rates havefallen dramatically in non-indigenouspopulations. Indigenous SIDS rates in NorthQueensland are unknown, but in other statesremain 3-5 times higher than non-indigenousrates.Aims: To ascertain SIDS rates in indigenousand non-indigenous infants in NorthQueensland between 1990-1998. To assessthe quality of data recorded for SIDS deaths.Methods: Records were obtained for possibleSIDS cases from all coroners courts in NorthQueensland from 1990 to 1998. Data wasrecorded for demographic factors, ethnicity,age at death, sleeping and feeding factors,smoking and post mortem findings.Incidence, medians and univariateassociation (&#61539;2) between indigenousand non-indigenous groups were performedwhere appropriate.Results: There were 83 248 live births forthis period; 71 389 non-indigenous and 11859 indigenous. There were 67 SIDS deaths,0.80 per 1000 live births. Overall recordingof demographic and death scene data waspoor. There were 21 (31%) non-indigenous,22 (33%) indigenous deaths (24 unknown),relative risk 6.3(CI 4.7,8.4). Median age atdeath was 12.0 weeks for non-indigenousand 16.0 for indigenous babies; 14.3%occurring in the neonatal period for bothgroups. Prone position was reported in 69%,shared bed in 48% of cases with reporteddata. 44% cases occurred in the wet, 55% inthe dry season. There were no differencesin gender, season, sleeping position betweenthe two groups. Indigenous babies (72%)were significantly more likely to have beenbed sharing than non-indigenous (39%), p <0.05.Conclusion: Data recorded for SIDS deathsin North Queensland is poor. SIDS rates maybe up to 6.3 times higher in the indigenouspopulation. A uniform system of postmortem and death scene data reporting isurgently needed in North Queensland.

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182VOLUMETRIC ANALYSIS OFPLACENTAL TISSUE FROM INFANTSSUCCUMBING TO SUDDEN INFANTDEATH SYNDROME (SIDS) AND INTRAUTERINE GROWTH RETARDED (IUGR)INFANTS.T. Ansari1, B. O’Neill2, JE. Gillan2, PDSibbons1.Department of Surgical Research, NPIMR,Northwick Park Hospital, Harrow, UK1.Department of Histopathology, RotundaHospital, Dublin, Ireland2.The placenta is the major organ for gasexchange and nutrient delivery to thedeveloping fetus and as such any placentalinsufficiency (in either gas exchange ornutrient delivery) may result indevelopmental delays/arrest, manifesting asdeficiencies in the number of functioningunits in specific organs. The aim of thisstudy was to determine whether placentaefrom term delivered infants who latersuccumb to SIDS and those infants born IUGRdevelop differently from those of normalinfants.Control placentae (n=16), placentae frominfants later succumbing to SIDS (NBW n=10,LBW n=4) and term delivered IUGR placentas(n=7) were selected from an archived tissuebank. Each placenta was weighed and thevolume estimated using a fluid displacementtechnique. Approximately 10 full depthblocks of tissue (taken from the fetal tomaternal side) were obtained from eachplacenta using a uniform random samplingtechnique. Each tissue block was cut in halflongitudinally, embedded in wax and 5µmsections cut and stained with H&E. Using asimple point but unbiaased countingtechnique, the number of points presentwithin the villi and maternal inter villousspace were counted.Mean fixed placental weight for control caseswas 485g (CV=6%), for SIDS NBW cases 507g(CV=5%), SIDS LBW cases 405g (CV=3%) andfor IUGR cases 440g (CV=3%). There wasstatistically significant difference in meanplacental weight between control and IUGRcases (p=0.023) and between control andSIDS LBW cases (p=0.038). Mean volumeestimated by fluid displacement for controlcases was 452cm3 (CV=7%), for SIDS NBWcases 489cm3 (CV=5%) cm3 SIDS LBW 422 cm3

(CV=2%) and for IUGR cases 415cm3 (CV=3%).For all study groups, approximately 80% ofthe total fixed placental volume was madeup of villous tissue and the remaining 20%being maternal intervillous space volume.Although no differences were observed in

total volume of the villous tissue and totalvolume of maternal intervillous space,detailed quantitative analysis of the placentawith increased numbers within each studygroup and additional quantitativeparameters may reveal subtle changes thatcan not be detected by gross volumetricanalysis.

183STEREOLOGICAL ESTIMATION OFTOTAL VILLOUS SURFACE AREA INPLACENTAS FROM SUDDEN INFANTDEATH SYNDROME (SIDS) CASES ANDINTRA UTERINE GROWTH RETARDED(IUGR) CASES.T. Ansari1, B. O’Neil2, JE. Gillan2, PDSibbons1.Department of Surgical Research, NPIMR,Northwick Park Hospital, Harrow, UK1.Department of Histopathology, RotundaHospital Dublin, Ireland2

Transfer of nutrients and gas exchangeacross the maternal/fetal interface isgoverned to a degree, by the amount ofvillous tissue surface area available. The aimof this study was to determine the totalamount of villous surface area available inplacentae collected consecutively from SIDSinfants and infant born IUGR.Control placentae (n=6), placentae from NBWinfants later succumbing to SIDS (n=6), LBWSIDS infants (n=4) and IUGR placentae (n=4)were selected from an archived tissue bank.Each placenta was weighed and the volumeestimated using a fluid displacementtechnique. Approximately 10 full depthblocks of tissue (taken from the fetal tomaternal side) were obtained from eachplacenta using a uniform random samplingtechnique. Each block was then cut in halflongitudinally, embedded in wax and 5µmsections cut and stained with H&E. Usingdesign based stereological techniques,principally the surface estimator technique,total villous surface area was estimated foreach placenta.Mean placental volume for control cases was452cm3 (CV=7%), mean surface density was0.0191µm2/µm3 (CV= 8%) producing a totalmean villous surface area of 8.61m2

(CV=11%). Mean placental volume for SIDSNBW cases was 489cm3 (CV=5%), meansurface density was 0.0187 µm2/µm3 (CV=7%) producing a total mean villous surfacearea of 8.65m2 (CV=11%). Mean placentalvolume for SIDS LBW cases was 422cm3

(CV=2%) mean surface density was0.0203µm2/µm3 (CV= 10%) producing a totalmean villous surface area of 8.51m2

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(CV=11%). Mean placental volume for IUGRcases was 415cm3 (CV=3%), mean surfacedensity was 0.0156µ m2/µ m3 (CV= 18%)producing a total mean villous surface areaof 6.30m2 (CV=6%). No statisticallysignificant difference was observed for anyparameter estimated, between any studygroups.Based on the limited number of casesanalysed so far, no differences exist withregards to the total amount of surface areaavailable for nutrient and gas exchangeacross the maternal fetal interface. Althoughthe IUGR cases show a reduced value for totalsurface area this failed to reach statisticalsignificance. However, whether there existproportional differences between surfaceareas for the villous components, has yet tobe determined.

184PLACENTAL VILLI AND INTERVILLOUSSPACE DEVELOPMENT IN SUDDENINFANT DEATH SYNDROME (SIDS)AND INTRA UTERINE GROWTHRETARDED (IUGR) CASES.T. Ansari1, B. O’Neil2, JE. Gillan2, PDSibbons1.Dept. of Surgical Research, NPIMR,Northwick Park Hospital, Harrow, UK1.Dept. of Histopathology, RotundaHospital, Dublin, Ireland2

Geometry of the villi and maternal and fetalvascular beds plays a major role in bothplacental transport and haemodynamics.The aim of this study was to examineplacentas from both SIDS and IUGR infantsin order to better understand the physicaland possible functional consequences ofchanges in the dimensions of villi andmaternal intervillous space (IVS). The starvolume can be used to investigate thechanging geometric relationship betweenvillous arborisation and IVS.Control placentas (n=6), placentas frominfants NBW later succumbing to SIDS (n=6),LBW infants dying of SIDS (n=4) and IUGRplacentas (n=4) were selected from anarchived tissue bank. Each placenta wasweighed and the volume estimated usingfluid displacement technique.Approximately 10 full depth blocks of tissue(taken from the fetal to maternal side) wereobtained from each placenta using a uniformrandom sampling technique. Each block wasthen cut in half longitudinally and embeddedin wax and 5µm sections cut, stained withH&E. Using design based stereologicaltechniques, principally the star volume, both

IVS volume and villous volume wereestimated.The mean star volume for maternal IVS forcontrol cases was 2.09x106µm3 (CV=16%) forSIDS NBW 5.77x106µm3 (CV=15%), SIDS LBW2.48x106µm3 (CV=27%) and for IUGR cases2.46x106µm3 (CV=19%). Mean star volumefor villous tissue for control cases was 4.02x106µm3 (CV=9%) for SIDS NBW cases 2.75x106µm3 (CV=14%), SIDS NLW cases 1.64x106µm3 (CV=6%) and for IUGR cases 3.67x106µm3 (CV=16%).Although SIDS LBW group showed reducedvalues for both maternal IVS and villousarborisation volumes, they failed to reachstatistical significance. Star volume is a“noisy” estimate of villous domains volumeand IVS pore volume, this was reflected inthe large variation in values within eachgroup. Before firm conclusions can be drawnthe total number of cases within each groupwill be increased.

185GENETIC, DEVELOPMENTAL ANDENVIRONMENTAL FACTORSCONTRIBUTING TO SUSCEPTIBILITYTO SIDS: THE NEED FORMULTIETHNIC STUDIESC.C. Blackwell, D.M. Weir, A. BusuttilDepartment of Medical Microbiology andForensic Medicine Unit, University ofEdinburgh, Edinburgh, ScotlandRisk factors for SIDS parallel those forrespiratory tract infections. Many ethnicgroups in which there is a high incidence ofSIDS also have high levels of seriousrespiratory tract infections among theirinfants; e.g., Native Americans andAboriginal peoples of Australia. Infants inthese groups are colonised earlier and moredensely with potential respiratorypathogens, and their immune responses tosome bacterial antigens differ significantlyfrom those of European-derived populationsin the same area.There is no animal model that reflectsgenetic developmental and environmentalfactors associated with susceptibility to SIDS;consequently we have combinedepidemiological and experimental studies toassess both risk factors for SIDS and factorsthat reduce the risk. Human secretions, milk,cells and cell lines have been used todetermine how risk factors could affect: 1)colonisation by potentially pathogenicbacteria; 2) production of pyrogenic toxins;3) induction and control of inflammatoryresponses to the bacterial toxins identifiedin over 50% of SIDS infants. New evidence

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suggests that there are genetic factorsinvolved in induction and/or control ofinflammatory responses to some bacterialantigens implicated in SIDS.There is an urgent need for multidisciplinarystudies among different ethnic groups tocompare the following for those with a highincidence of SIDS with those in which theincidence is low: 1) epidemiologicalinvestigations similar to those in Britain onthe role of risk factors in relation tocolonisation by potentially pathogenicbacteria; 2) studies of inflammatoryresponses to toxins implicated in SIDS andcomponents of cigarette smoke using bloodsamples from SIDS and non-SIDS familiesfrom different ethnic groups; 3) comparisonof levels of anti-toxin antibodies at birth a)to identify the effect of maternal smokingon infants’ passive immunity and b) toidentify infants that lack protection againstthe toxins implicated in SIDS.

186WHY IS THE PRONE SLEEPINGPOSITION A SIGNIFICANT RISKFACTOR FOR SIDS?N. Molony, A. Busuttil, D.M. Weir, C.C.BlackwellDepartments of Otorhinolaryngology,Medical Microbiology, and ForensicMedicine Unit, University of Edinburgh,Edinburgh, ScotlandThe major campaigns to discourage theprone sleeping position resulted in dramaticdecreases in the incidence of SIDSworldwide. As yet, there is no clearexplanation as to why the prone positionshould increase the risk of these deaths. Wefound over half of SIDS infants had pyrogenictoxins of Staphylococcus aureus in tissuesor body fluids. These toxins are not postmortem artifacts because refrigeration of thebody prior to autopsy would prevent theirinduction which requires a minimumtemperature of 37°C. The temperature ofthe upper respiratory tract of young healthychildren in an upright position is about 34-35°C. In the prone position, however, thetemperature rises to 36°C and in 5/30 (16.7%)of young children examined, thetemperature reached 37°C or higher [Molonyet al., 1999].Other studies indicate that density ofbacterial colonisation in the nose is greaterin the prone position, probably due to theeffect of gravity draining mucosal secretionsinto the nasal passages rather than down theoesophagus as in the supine position. Older

infants (12-18 months) who had minorrespiratory infections and who slept in theprone position had significantly highernumbers of bacteria and more species intheir secretions than infants who sleptsupine. The composition of the bacterialflora of the infants who slept supine wassimilar to that observed in SIDS infants[Harrison et al., 1999].We suggest that the prone positioncontributes to the risk of SIDS 1) byenhancing density of colonisation by S.aureus and other potentially toxigenicbacteria and 2) by raising the temperatureof the upper respiratory tract to the rangein which the pyrogenic toxins of thesebacteria can be induced.

Harrison et al. FEMS Immunology Medical Microbi-ology 1999; 25: 29-35Molony et al. FEMS Immunology Medical Microbiol-ogy 1999; 25: 109-113.

187ACUTE GRIEF SUPPORT IN SUDDENUNEXPECTED DEATHS IN INFANCY(SUDI)Ralph FranciosiChildren’s Hospital Of Wisconsin &Medical College of Wisconsin, Milwaukee,Wisconsin, USAIn my experience as a paediatric pathologistthe communication of the cause of death(COD) to parents of a SUDI victim is thecornerstorm of grief resolution; however,establishing the COD usually requires twoto three weeks. Therefore, there is a needto support the family prior to a specificdiagnosis. Sudden unexpected death ininfancy (SUDI) is defined as the sudden andunexpected death of an infant who has noapparent life threatening illness. The deathcan be due to natural or unnatural cause.Natural death is the consequence of amedical disease/disorder, e.g. bacterialmeningitis, whereas unnatural death is not,e.g. unintentional injury.The pathologist establishes the cause andmanner of death by a thorough postmortemexamination that includes information fromthe scene of death, medical history, autopsyand selected studies, e.g. x-rays, toxicology.The preliminary diagnosis is usuallyavailable within 48 hours; however, the finaldiagnosis requires completion of themicroscopic examination and results fromelective tests, e.g. cultures. The finaldiagnosis is usually available in three to fourweeks.In our community infants that are SUDI

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victims are usually pronounced dead in theChildren’s Hospital emergency room. Griefcounselors from the Infant Death Centre areavailable to support the family. In addition,they explain the role of the coroner/medicalexaminer in establishing the cause of death.The coroner/medical examiner isencouraged to contact the family withpreliminary results from the autopsy. Thisallows communication of the approximatetime in which the final diagnosis can beexpected.

188CRIB DEATH, COT DEATH & SIDS. ATRIOLOGYRalph FranciosiChildren’s Hospital Of Wisconsin &Medical College of Wisconsin, Milwaukee,wisconsin, USASudden and unexpected death in infancy(SUDI) has been referred to as crib death inthe United States and cot death in other partsof the world. The diagnostic term suddeninfant syndrome (SIDS) was adopted at thesecond international conference on cause ofsudden death in infants (1). SIDS was definedas ‘the sudden death of any infant or youngchild, which is unexpected by history, andin which a thorough postmortemexamination fails to demonstrate anadequate cause of death’. Variation in thediagnosis of SIDS cases is expected since thedefinition lists adequate cause and thoroughautopsy examination. A realistic expectationis that this variation can be kept to aminimum and therefore not significantlyaffect epidemiology studies.Concerns were raised by coroners/medicalexaminers that cases of unnatural death canmasquerade as SIDS. They insisted uponlisting the death scene investigation as acritical part of the criteria for SIDS. Inresponse to these concerns an updateddefinition was established by the NationalInstitute by Child Health and HumanDevelopment in 1989. The definition stated:‘The sudden death of an infant under oneyear of age which remained unexplainedafter a thorough case investigation,including the performance of a completeautopsy, examination of the death scene anda review of the clinical history’.Diagnostic guidelines for pathologistsinvolved in the diagnosis of suddenunexpected infant deaths have beenpublished in a histopathology atlas. Thismonograph illustrates a thoroughpostmortem examination in an infant,

histopathology lesion (s) sufficient to causedeath and death scene investigation (2).

189RESULTS OF THOROUGHINVESTIGATIONS IN 81 CONSECUTIVESUDDEN AND UNEXPECTED DEATHSIN INFANTS AND CHILDREN.C Rambaud, E Briand, M Guibert, DCointe, H Razafimahefa, J deLaveaucoupet, A Coulomb, F Capron, MDehan.Centre de Référence pour la Mort Subitedu Nourrisson, hôpital Antoine Béclère,92140 Clamart, and Dpt Universitaire deMédecine Légale, Université Paris V, Paris,France.Between November 1994 and August 1999,81 consecutive sudden and unexpecteddeaths in infants and children werethoroughly investigated with the samemultidisciplinary postmortem protocolincluding extensive microbiology studies.The cases were then classified according toTaylor and Emery (1)␣ as: a=explainabledeath, b=partially explainable death,c=minor pathology, d=nothing, e=accident,and f=child abuse.Results: 8 neonates (< 28 days; n=8) 8 a: 4materno-fetal infections (2 group BSteptococcus, 1 E.coli, and 1 Enterobactercloacae), 2 metabolic diseases, 1 cardiacmalformation, and 1 accidentalhyperthermia.Children (> 1year-old; n=8) 8 a : 3gastroenteritis, 3 bacterial infections, 1hypertrophic cardiomyopathy and 1previously known Thomsen myotonia.Infants (28 to 365 days old; n=65): 50 a, 5b, 1 c, 1 d, 4 e, and 2 f; 2 infants had lesionsdue to their intensive care stay prior todeath. The 50 a diagnoses were:- 13 bacterial infections (including 3 urinary

infections, 2 septicaemias and 1meningitis),

- 15 viral infections (including 2gastroenteritis, 1 myocarditis, 1encephalitis, 1 cardioneuropathy),

- 13 both bacterial and viral infections(including 2 gastroenteritis and 1septicaemia)

- 9 miscellaneous (3 previously knownpaediatric diseases, 2 isolated gastriccontent aspirations, 2 right ventricularcardiomyopathies, and 2cardioneuropathies).

The most frequently identified pathogenswere E.coli (n=12) and enterovirus (n=11).Some infants were found to have associateddiseases with their infections including 1

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cystic pancreatitis, 1 cardiacrhabdomyomas, and 1 muscular disease.Thus in this series of 65 post neonataldeaths, only 2 (3%) were diagnosed asunexplained deaths (SIDS) (1 c and 1 d).Among the fatal mechanisms were: gastriccontent aspiration, pulmonary oedema,cardiac arrhythmia, infectious shock,hyperthermia, dehydration, sleepingposition and bedding (61% were foundprone).

1 Taylor and J Emery. Trends in unexpected infantdeaths in Sheffield. Lancet 1988:1121-1123.

190PATHOGENESIS OF ALTE IN INFANTSWITH NASAL OBSTRUCTIONDA Cozzi, A Piserà, M Ilari, A Casati, FMorini, F CozziPaediatric Surgical Unit, University ofRome “La Sapienza,” Italy.Aim: Infants with nasal obstruction maypresent with signs both of inspiratory andexpiratory airway obstruction. Vacuum-glossoptosis plays a very important role inthe pathogenesis of inspiratory obstruction.Approximation of the soft palate and thetongue on expiration has been hypothesizedas the cause of the expiratory block. Aim ofthis study was to further investigate thepathogenesis of respiratory problems ininfants with nasal obstruction.Patients and methods: Oesophagealpressure and airflow changes in three infantswith bilateral choanal atresia and one infantwith simple rhinitis were measured. Therespiratory pattern was studied in the supineposition with and without an oropharyngealairway. An attempt was made to correlate therespiratory patterns with the clinicalmanifestations.Results: When the oropharyngeal airwaywas withdrawn, all infants presented a sharpreduction in, or an absence of inspiratoryflow despite markedly increased inspiratoryefforts. Clinically, the tongue was sucked upand backwards to the hard palate sometimesproducing a seal which prevented air entry.The expiratory pattern was characterized byan increase in the expiratory time,interruption of the expiratory flow despitethe positive oesophageal pressure and aretarded expiratory flow. Clinically,expiration was associated with gruntingwhich was loudest over the neck andmimicking a bronchospasm over the chest.Conclusion: In infants with nasalobstruction, the expiratory airwayobstruction is, at least in part, due to an

active braking of the expiratory flow broughtabout to defend lower airway patency. Thesefindings support the concept that upperairway instability, obstructive apnoea, lowerairway instability, absorption collapse,massive intrapulmonary shunt and ALTE arethe result of a cascade reaction.

191ALTE IN INFANTS WITH NASALOBSTRUCTIONF Cozzi, A Piserà, L Oriolo, F Morini, ACasati, DA Cozzi.Paediatric Surgery Unit, University ofRome “La Sapienza”, Italy.Aim: In infancy, not only bilateral choanalatresia or stenosis (BCA/S), but alsounilateral choanal atresia or stenosis (UCA/S), or even a simple rhinitis may be relatedto ALTE. To support this concept we studiedthe relationship between ALTE and degreeof nasal blockage in a large series of infantswith various types of nasal obstruction.Patients and methods: We reviewed therecords of 84 infants admitted to our surgicalunit between 1970 and 1998 with suspectednasal obstruction. The final diagnosis wasBCA/S in 41 patients, UCA/S in 25 andrhinitis in 18. ALTE was defined as a cyanoticepisode of sufficient severity to promptvigorous stimulation.Results: The main findings in 38 infantswith one or more ALTEs in comparison with46 infants without ALTE are shown in thetable:Conclusion: In infants with nasalobstruction, ALTE is related to the severityof the associated respiratory controldisorder more than to the degree of nasalobstruction. The respiratory control disorderis a manifestation of a more generalabnormality in the autonomic nervoussystem. Not only removal of the anatomicobstacle but also, in selected infants,glossopexy may be required to avoid severecomplications.

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192PARENT REPORTED SLEEPDISORDERED BREATHING ANDBEHAVIOURAL FEATURES IN2-4 -MONTH-OLD INFANTSIA KelmansonDepartment of Paediatrics No. 3, St.Petersburg State Paediatric MedicalAcademy, St. Petersburg 194 100, RussiaThe study aimed to evaluate possibleassociation between sleep disorderedbreathing (SDB) and behavioural features in2-4-month-old infants using Early InfancyTemperament Questionnaire (EITQ) as a tool.It covered the period from 1997 to 1998 andcomprised 200 randomly selected clinicallyhealthy infants aged 2-4 months who weresingletons and born in St. Petersburg withinthe period in consideration. The motherswere asked to complete the questionnairesaddressing infant, maternal, anddemographic major characteristics, someinfant care practices as well as infant’shabitual breathing symptoms in sleep. As apart of interview, the mothers filled in theEITQ consisting of 76 items which describedifferent aspects of infant behaviour. Groupsof questions were added according toscoring sheet to produce total scores todescribe nine different aspects of infanttemperament: activity, rhythmicity,approach, adaptability, intensity, mood,persistence, distractibility and threshold.In 129 cases (64.5%), mothers failed to reportSDB in their infants. Mothers of 10 infants(5.0%) described their babies as habitualsnorers; 48 babies (24.0%) were characterisedas having other than snoring noisy breathingin sleep, and 13 (6.5%) habitually had bothsnoring and noisy breathing. Breathingpauses were noticed in only one infant withsnoring and noisy breathing in sleep. Infantswith SDB were rated as having more negativemood compared withasymptomatic ones, and mostnegative mood was the featureof those infants who had bothsnoring and noisy breathing insleep. These associationsremained after adjustment hasbeen made for major potentialconfounders. Minor breathingdisturbances in sleep, rathercommon in the young infants, may beassociated with specific behaviouraldeviations, and infants presented withnegative mood should be consideredcautiously for possible obscure respiratorytroubles.

193IS YOUR MONITOR REALLYNECESSARY?Dr Ian MitchellUniversity of Calgary, Canada.Home cardiorespirator monitors (HCRM)were suggested as a way to prevent SIDS inthe 1970’s. Despite a lack of evidence ofbenefit, they continue to be prescribed anduse the latest technology. The major groupsare: SIDS siblings; infants with Apparent LifeThreatening Events (ALTE); preterm infants(all or specific subgroups).We report trends in HCRM at the AlbertaChildren’s Hospital (ACH), the referral centrefor 1.2 million, approximately 22,000deliveries per year. All HCRM in this areaare supplied at ACH since 1982. No vendorshave supplied HCRM directly to patients.All infants requiring assessment for apneaare referred to ACH as are all infants on homeoxygen.Monitor use is shown:There has been a steady fall in numbers andduration of HCRM prescribed. The trend wasreversed, possibly related to recruitment ofnew staff. SIDS rates have fallen from 1.98/1000 live births in 1982 to 0.89 in 1995.This fall in HCRM has occurred because of:continued physician education and criticalreview of literature; close contact andsupport of patient groups; demedicalizng ofthe NICU graduate and encouraging thoseparents to focus on the child’s developmentand social needs; a centralized programinvolving a small number of personnel.Conflict has been avoided by working withparents and physicians and acceptingoccasional use of HCRM for parental orphysician anxiety.Rational limited use of HCRM is possiblewithout major conflict with a consistentsupportive approach.

Years SIDS ALTE Premature Totalsiblings infants

1982-85 82 70 67 2191986-89 49 26 38 1131990-93 27 15 5 471994-99 20 43 1 64

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194RESEARCH ON PREVENTION OFSUDDEN INFANT DEATH ANDMETHODS FOR SELECTION OF HIGHRISK GROUPSKlara Toro1, Loretta Toth1, ZsuzsannaCsukas2, Ferenc Rozgonyi2, ToshikoSawaguchi3, Akiko Sawaguchi3.

Institute of Forensic Medicine1 andMicrobiological Institute2 of SemmelweisUniversity of Medicine, Budapest,Hungary, Department of Legal Medicine3,College of Medicine, Tokyo Women’sMedical University, Tokyo, JapanMonitoring is considered to be essential forprevention of sudden infant death syndrome(SIDS). Currently there is no establishedmethodology for the selection of a high riskgroup to be targeted for monitoring. In thisstudy, we attempted to deploy an easymethod for identifying target groups formonitoring. We investigated whether theeffect of pre- and postnatal factors andbacterial colonisation in throat increase therisk for SIDS. Our aim was to select SIDS highrisk groups by making use of the results ofa door-to-door survey conducted in Hungaryfrom 1996 to 1998. The number of riskfactors of a single infant was calculated. Acomparison was made between a normalinfant group and SIDS group, in contrast tothe low risk factor group (having 0-3 riskfactors) and the high risk factor group(having 7-10 risk factors). In the normalinfant group the low risk factor groupincluded 66.21 % of the infants. The high riskfactor group accounted for 5.4 % of theseinfants. The rate of risk factors frombacteriological investigation was 17% amonghealthy infants. In the SIDS group the lowrisk factor group accounted for 11.1 % ofinfants. The high risk factor group accountedfor 22.2%. As a result a tendency wasindicated that multiple risk factors are foundfor the development of SIDS group. Thepossibility might be suggested thatidentification of the number of risk factorsin normal infants is effective in assisting inthe determination of target groups formonitoring.

195KANGAROO CARE (KC), APNOEA OFPREMATURITY (AOP) AND BODYTEMPERATUREB Bohnhorst, T Heyne, CS Peter, CF Poets.Dept. of Neonatology and PaediatricPulmonology, Medical School, Hannover,

Germany.Background: KC improves parental bondingand, through vestibular stimulation, mayhave stabilising effects on respiratorycontrol. The latter hypothesis, however, hasnever been proven.Methods: To investigate the effect of KC onepisodes of apnoea, bradycardia anddesaturation, we performed three 2 hrecordings of breathing movements, nasalairflow, heart rate, pulse oximeter saturation(SpO2) and pulse waveforms before, duringand after 2 h of KC in 22 spontaneouslybreathing preterm infants, median GA atbirth 29 wk (23-31), age at study 26 d (7-72).Rectal temperature was obtained every 2 h.Recordings were analyzed for apnoea (>20s), bradycardia (<100/min.) and desaturation(SpO2 <80%) as well as for breathing patterns,baseline SpO2, heart and respiratory rate.Results: Median heart and respiratory rateincreased from 150/min (range 130-160) and64/min (50-84) before to 157/min. (140-165)and 76/min (45-112) during KC (p<0.01);baseline SpO2 remained unchanged. Therewas no significant change in apnoeafrequency, but both bradycardia (1.1/h (0-21) vs. 0.6 (0-3), p<0.05) and desaturation(0.9/h (0-14) vs. 0.0 (0-7), p<0.05) occurredsignificantly more often during than beforeor after KC. Rectal temperature increasedfrom 36.9°C (36.2-37.4) immediately beforeto 37.3 (36.6-38.6) during KC and returnedto 36.9 (36.6-37.4) thereafter (p<0.01).Regular breathing pattern, whichcorresponds well with quiet sleep, decreasedfrom 14% (2-28) before to 7% (3-26) duringKC (p<0.01).Conclusion: KC resulted in a significantincrease in the frequency of bothbradycardia and desaturation in theseinfants. This increase could be related toheat stress and/or a reduction in theproportion of time spent in quiet sleep. Bodytemperature should be carefully monitoredduring KC.

196THE EFFECT OF MATERNAL SMOKINGIN PREGNANCY ON INFANTRESPONSES TO PERIODIC THERMALSTIMULUSBrowne CA, Colditz PB, Dunster KR.Perinatal Research Centre, The Universityof Queensland, Royal Women’s Hospital,Brisbane, AustraliaMaternal smoking during pregnancy isassociated with a significantly increased riskof SIDS but underlying mechanisms remain

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unknown. Because inappropriatethermoregulatory mechanisms andautonomic dysfunction have been implicatedin the aetiology of SIDS, this studyinvestigated the effect of maternal smokingon infant responses to periodic thermalstimulation at 2-3 days and at 3 months ofage. This response is mediated by theautonomic nervous system, possibly due tosympathetic vasoactive reflexes.Methods: Laser Doppler spectroscopsy wasused to measure skin blood flow. R-R intervaldata was acquired from a Medtel HS18neonatal monitor. Two minutes of baselinedata were collected when the baby wasasleep. Alternation of warm and cool settingson a hairdryer directed at the lower left legwas used to administer the periodic thermalstimulus at a frequency of 0.05Hz for threeminutes. Power spectral analysis was appliedto heart rate variability and skin blood flowsignals to determine relative levels ofautonomic activity in low frequency (0.04-0.15Hz) and high frequency (0.15-0.3Hz)bands. The low:high frequency (LF:HF) powerspectral ratio was also determined.Differences in response between infants ofsmokers and non-smokers in power spectralvariables were sought using Mann-WhitneyU-test and in heart rate and skin blood flowusing Student’s t-test.Results: In the neonatal study, the median(range) relative change in heart ratevariability spectral power in the lowfrequency band was 1.25␣ (0.2-8.3) forcontrols (n=25) and 0.5 (0.1-6.6) for infantsof smokers (n=26, p=0.03). There was nodifference in any other variables. At 3months, control infants (n=15) significantlyincreased skin blood flow with a mean±SE

increase of 8.5±3.9% while there was adecrease of 6.9±5.3% (p=0.04) in infants ofsmokers (n=17).Conclusions: The attenuated skin bloodflow response to a periodic thermal stimulusin 3 month old infants of smokers suggestsalterations in autonomically controlledthermal responses.

197GABA RECEPTOR IN HUMANPERINATAL ASPHYXIAAL Eckert, DL Andersen, PR DoddDepartment of Biochemistry, University ofQueensland, Brisbane AustraliaGABA (g-aminobutyric acid) is the majorinhibitory neurotransmitter in the brain,being used by 20-25% of central synapses.It is metabolically and functionally closelyassociated with the major excitatory

transmitter, glutamate, which is used by 65-70% of synapses. We have previously shownthat localized abnormalities in the densityand activity of the NMDA class of glutamatereceptors are associated with increasedvulnerability to perinatal asphyxia in late-gestation human infants (1). Forcomparison, we have now extended thestudy to GABA-A receptor sites in similarcases. Tissue from Frontal, Motor, Temporaland Occipital Cortex was obtained at autopsyfrom infants with gestational ages rangingfrom 22 to 42 weeks. Mean post mortemdelay was 44 h. Homogenate binding assayswere carried out with the benzodiazepineligands [3H]flunitrazepam ([3H]Fnz) and[3H]diazepam ([3H]Dz); GABA enhancementof [3H]Dz binding was also assessed as ameasure of receptor functionality. As forglutamate-NMDA receptor site assays (1), itwas found to be necessary to modify theassay protocol substantially from thestandard procedure used with adult tissue.The results showed that the density (Bmax)of [3H]Fnz sites increased markedly duringthe third trimester, particularly in Occipitalcortex. Moreover, the affinity (Kd) for [3H]Dzin infant tissue preparations differedsignificantly from the adult parameter; andit was not possible to quantify GABAenhancement of [3H]Dz binding in thismaterial. The data suggest that differentforms of GABA receptor sites are expressedduring inter-uterine development, and thatthe full complement of receptor sites is stillbeing acquired at this stage. However, noassociation with birth asphyxia was found.That is, there was no compensation in theseindices of inhibitory amino acidneurotransmission for the alterations wehave observed in excitatoryneurotransmission.

Supported by SIDSaustralia(1). Andersen D.L. et al. (1998) J. Child Neurol.13, 149-157.

198PACIFIER AND DIGIT SUCKINGINFANTS II: DEVELOPMENTALCHANGE AND BEHAVIOURAL EFFECTSKatie Pollard, Peter Fleming, JeanineYoung, Peter Blair, Andrew Sawczenko.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UK.Pacifier use is associated with a decreasedrisk of SIDS [1], and is widely believed tosuppress digit sucking in infants, but littleis known of the relative prevalence andbehavioural effects of these two forms of

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non-nutritive sucking (NNS), and their effectson breast feeding during early infancy.Methods. Overnight polygraphic recordingsof sleep state, respiration, oxygen saturationand infrared video were made of 10 motherinfant pairs (5 routine bed-sharers, 5 room-sharers) on two consecutive nights, atmonthly intervals from 2 to 5 months of agein a sleep laboratory. Each month, motherbaby pairs were randomized to 1 night bed-sharing then 1 room-sharing, or vice versa.‘Episodes’ of pacifier, own digit and mother’sdigit sucking (>1 minute) were identified andcompared with 2 state-matched controlperiods, before and after each such episode[2].Results: Full recordings, on 74 nights (749hours), showed 329 episodes of NNS on 54nights. Infants were awake throughout 66%episodes, but some (particularly digitsucking) occurred during sleep (Rapid EyeMovement > Quiet Sleep). Pacifier suckingdecreased with age, whilst digit suckingincreased. Routine pacifier users rarelysucked their digits. Sleeping in the ‘non-routine’ location was associated with a largerpercentage of nights with sucking episodesand increased sleep latency. Bed sharing(routinely or on a given night) was associatedwith less sucking behavior and morebreastfeeding. Non-nutritive sucking wasnot, however, associated with decreasedtotal time breast feeding per night or numberof feeds per night.Conclusion: Patterns of NNS during thenight change with age and are affected bymaternal proximity. Digit sucking has statemodulating effects, and may be suppressedby pacifier use. Thus any benefits of pacifieruse must be set against the potential loss ofa self-directed ability to modulate stateduring the night, and possible shortening ofbreastfeeding duration.

1. P.J.Fleming, P.S.Blair, K.Pollard, M.W.Platt,C.Leach, I.Smith, P.J.Berry, J.Golding. Pacifier useand SIDS - Results from the CESDI SUDI case-control study. Arch Dis. Child 1999; 81:112-116.2. K.Pollard, P.J.Fleming, J.Young, A Sawczenko,P.Blair. Nighttime non-nutritive sucking in infantsaged 1 to 5 months: relationship with infant state,breast feeding, and bed- versus room-sharing. (Inpress) Early Human Development 1999.

199A MATHEMATICAL MODEL OFOVERNIGHT TEMPERATURE CHANGESIN INFANTS: INVESTIGATION OF THEEFFECTS OF EPIDEMIOLOGICAL RISKFACTORS FOR SIDS.Linda Hunt, Peter Fleming, AndrewSawczenko, Ruth Wigfield.Institute of Child Health, University ofBristol, Bristol BS2 8BJ, UK.Overheating may be a contributory factor inSIDS. Certain risk factors for SIDS(e.g. maternal smoking, bottle feeding) areassociated with delayed maturation ofdiurnal temperature patterns, but little isknown of how such factors interact withenvironmental factors to affect thermalbalance during sleep in infancy.Methods Sequential overnight recordingswere made at home of rectal, peripheral andenvironmental temperatures in 151 infantsat 1, 3 and 5 months of age. Data weremodeled as polynomial functions of timeusing ‘Mixed’ models to account forcorrelation due to repeated measurements.The effect of babies’ age on the temperature‘profile’ was studied by including age andage x time interactions in the model. Otherfactors were then investigated by addingterms at the appropriate level: i.e. baby level- factors (e.g. maternal smoking, birthweightof baby) which varied from one baby toanother but were constant for individualbabies, ii) visit level - factors (e.g. baby’s age,tog value of bedding, sleeping position)which varied from one visit to another, butwere constant for individual visits, and iii)observation level - factors (e.g.environmental temperature) which changedfrom hour to hour.Results The characteristic falls in overnightrectal temperatures could be reliablydescribed by a cubic polynomial, andshowed lower nadir values as age increased,whilst changes in shin temperature wereopposite in direction, suggesting activevasomotor mechanisms for the temperaturechanges.In the mathematical modelling, baby’s ageand environmental temperature stronglycorrelated with rectal and surfacetemperature; rectal and axillarytemperatures were also related to the togvalue of bedding. Axillary temperature wasstrongly influenced by sleeping position andmaternal smoking.Conclusions Environmental temperatureand tog value of bedding has significanteffects upon infants’ overnight

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temperatures. Sleeping position andmaternal smoking have effects uponperipheral temperatures and may thusinfluence heat balance.

200RT-ISH: A NOVEL METHOD FORDETECTING RECEPTOR SUBUNITS INVIVO.A.J. Hawkins and P.R. DoddDepartment of Biochemistry, University ofQueensland, Brisbane, 4072, AustraliaThe apnea hypothesis suggests SIDS is dueto a subtle defect in brainstem neural circuitsthat control respiration and/or cardiacstability [1]. The brainstem contains theprinciple sites that regulatecardiorespiration. The neurochemicalcontrol of respiration involves a complexinterplay between rapidly actingtransmitters and longer-lastingneuromodulators respond to variousphysiological and pathological stimuli. Todetermine if neurotransmission is defectivein brain regions vital to respiratory control,we have developed a method of in situ RT-PCR (RT-ISH) to measure the distribution ofmRNA transcripts in human, post-mortem,paraffin-embedded sections. Patient andcontrol samples were obtained from theextensive collection of brain samples heldin our laboratory. Brain regions of interest,collected at autopsy 9-48 hours post-mortem, were fixed in phosphate-bufferedformalin for at least 2 weeks (average 2months) prior to processing. Small blocks oftissue were embedded in paraffin accordingto standard protocols and sectioned at 6 µm.Brainstem sections were taken for RT-ISHusing PCR conditions already established inour laboratory for the amplification of the&#61537; &#61489; &#61485; &#61491; and&#61538; &#61489; &#61485; &#61491;&#61472; subunits of the GABA-A receptor[2]. A one-step RT-PCR method was used toamplify the transcripts; digoxigenin-labellednucleotides were directly incorporated intothe amplified products during cycling on aDNA engine (PTC 2000, MJ Research). RT-PCRproducts were detected using either alkaline-phosphatase or FITC-conjugated antibodydirected against digoxigenin and signalswere visualized using light andepifluoresence on a Nikon microscope at400X magnification. Amplification of the ?and ß subunits of the GABA-A receptor wassuccessfully carried out on brainstemsections from SIDS and control infants usingthis method. In negative controls processedunder the same conditions, where either the

RNA has been digested prior to RT-PCR orwhere the antibody was omitted, no signalwas apparent. We were able to localise mRNAtranscripts to individual neurons in discretebrain regions. Amplified signal wasrestricted to neurons, with none detected inglial cells.

1 Coumbe et al., (1990). Pediatric Pathology. 10,483-490.2 Lewohl et al., (1997). Brain Research Protocols.1, 347-356.

201AUTOMONIC RESPONSES IN INFANTSWHO HAD APPARENT LIFETHREATENING EVENTS (ALTE) ORIRRITABILITY (IRR)RM Hayman, BC Galland, BJ Taylor, DPGBolton, RM Sayers.Dept. of Women’s & Children’s Health,University of Otago Dunedin, NZ.Aim: To compare the responses of infantswho have had an apparent life threateningevent (ALTE) or who have a history ofirritability (IRR) with control infants to twotests of autonomic function and arousal.Method: ALTE infants (age 0-10 weeks n=7,10-24 weeks n=6) and IRR infants (age 0-10weeks n=1, 10-24 weeks n=6) were recruitedfollowing admission to the Paediatric ward,Dunedin Hospital. Control infants (CO) werestudied at 1 month (n = 49) and 3 months(n=46) of age. Each infant slept supine andthe heart rate changes in response to a tilttest and the heart rate variability (HRV) wererecorded twice in each sleep state i.e. quietsleep (QS) and active sleep (AS). Arousaland sleep states were assessed bybehavioural criteria. Tilt Test: 60° head uptilt maintained for 1-1/2 min or until arousaloccurred. ECG measured infant heart ratechanges. The mean heart rate was derivedfrom 30 baseline RR intervals before the tilt.Arousal was coded on a 5 point system.Heart Rate Variability: RR waves wererecorded continuously for 500 beats. TheSDRR and SD?RR derived from the poincaréplot (a scatter plot of the variation from beatto beat) was used as a quantitative measureof autonomic function. Regression analysiscompared variables for sleep state, age, andcase diagnosis (ALTE, IRR or CO)Results: The difference between ALTE andCO mean and the difference between IRR andCO mean for heart rate changes in responseto the tilt and for the measures of HRV (SDRR,SD?RR) was not significant. There were alsono significant differences between groupsfor the ratio of the maximum RR interval to

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the minimum RR interval after the tilt. TheALTE and IRR infants had significantly lowerheart rates than controls; respectively 19.3,p=0.051 and 27.7, p=0.046. Sweats at nightwere more common in cases (41%) thancontrols (11%).Conclusion: ALTE and IRR infants appearto have normal autonomic responses tothese two tests. Dysfunction of theautonomic nervous system may bemanifested in a different way in theseinfants. For all tests the normal rangeincludes some values that may describe adampening of control.Acknowledgements: Sheila Williams, Departmentof Social and Preventive Medicine and Maurice andPhyllis Paykel Trust

202VENTILATORY RESPONSES OF ALTEINFANTS AND INFANTS WITH AHISTORY OF IRRITABILITYRM Hayman, BC Galland, BJ Taylor, DPGBolton, RM Sayers.Dept. of Women’s & Children’s Health,University of Otago Dunedin, NZ.Aims: To compare ventilatory responses toa rebreathe test in infants having sufferedan Apparent Life Threatening Event (ALTE)and infants with symptoms of irritability(IRR), with that of control infants.Methods: ALTE infants (n=13) and IRRinfants (n=7) were recruited followingadmission to the Paediatric ward. Controlinfants (n=49[1month] and n=46[3month])were recruited from the maternity ward.Infants were studied at 2 ages: study 1 (0-10weeks) and study 2 (11 to 24 weeks). Infantssleeping supine were exposed to a mildasphyxial test, which mimicked rebreathingface down into soft bedding. Gases weredelivered through a perspex hood to changethe content of inspired air with a slow buildup of CO2 (maximum 5%) and depletion ofO2 (minimum 13.5%) over 5-6 minutes.Respiratory pattern was recorded byinductive plethysmography. The slope of alinear curve plotting Ln ventilation againstinspired CO2 was used as a measure of theventilatory asphyxial sensitivity (VAS).Arousal and sleep state was determined bybehavioral criteria.Key Findings: After controlling for age andsleep state, ventilatory responses of ALTEinfants were similar to those of controlinfants (VAS for ALTE 0.233 vs. VAS forcontrol 0.225). IRR infants had a significantlyhigher ventilatory response than controlinfants did (VAS = 0.322, p = 0.02). VAS washigher in older infants but was not

significantly associated with sleep state.Conclusion: Infants with a history of IRRhave a higher ventilatory response torebreathing than controls. This could be areflection of hyperactivity also presented assleep disturbance/irritability. ALTE havenormal ventilatory response to rebreathingconsistent with the majority of findings onventilatory studies of such infants.Acknowledgements: Sheila Williams, Departmentof Social and Preventive Medicine, University ofOtago and Maurice and Phyllis Paykel Trust

203EFFECTS OF HYPERTHERMIA ANDMURAMYL DIPEPTIDE ON IL-1b, IL-6AND MORTALITY IN NEONATAL RATMODELEAS Nelson,1 Wong Yin,1 K Li,1 TF Fok,1 LMYu.2

Dept of Paediatrics,1 and the Centre forClinical Trials and EpidemiologyResearch,2 The Chinese University ofHong Kong, Hong Kong SAR, China.Sudden infant death syndrome may be linkedto an interaction between infection,hyperthermia, sleep state and cytokineproduction. This study investigated theeffects of hyperthermia and a surrogate ofinfection (muramyl dipeptide or MDP) in aneonatal rat model. The study was in twoparts. In the first part 80 neonatal rats infour groups had their body temperatureraised to the desired level for one hour(34∞C, 38∞C, 39∞C or 40∞C) and then keptat a baseline level of 34∞C for one hour.Intraperitoneal injection of 0.1 ml 0.9%normal saline was given 30 min before startto control for MDP. In the second part of thestudy 80 animals, in four equivalenttemperature groups (34∞C, 38∞C, 39∞C or40∞C), were pretreated with MDP (25 nmol/animal) instead of Normal Saline. The resultsshowed that hyperthermia significantlyincreased the production of IL-6 (p=0.049)but not in the production of IL-1b (p=0.28),and as anticipated significantly increasedmortality. Administration of MDP (asurrogate for infection) significantlyincreased the IL-1b production (p= 0.008) butnot IL-6 (p=0.42). MDP in combination withhyperthermia had a significant effect onmortality (p=0.016 Cox’s regression analysis)in the neonatal rat.These findings may have implications forunderstanding the mechanism of suddeninfant death syndrome.

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204THE MOEBIUS STRIP AND THESUDDEN DEATH OF AN INFANTDURING SLEEPT SawaguchiTokyo Women’s Medical University, Dept.Of Legal Medicine, 8-1 Kawadacho,Shinjuku, Tokyo 162-8666, JapanA Moebius belt is formed by attaching oneend of a long strip of material to the otherend, and by twisting the latter 180 degrees.In the process of forming a Moebius strip,one can consider that the sleep/wakecontinuum in an infant can be seen as aMoebius strip model. Because in an infantthe sleep-wakefulness states forms acontinuous process, a Moebius model can bebuilt by attaching the top surface (thewakefulness phase) to the end of the backsurface (the sleep phase). In an infant, thesleep phase is the longest branche of theMoebius strip. The site where the back (thesleep phase) is joined to the top (thewakefulness phase), constitutes the infant’sarousal process. It can be measured by theevaluation of the arousal threshold.A variety of risk factors could alter theadjustment between the sleep-wake portionsof the Moebius rinp model. Such factorsinclude prenatal and postnatal

environmental conditions shown to favourthe occurrence of sudden unexpected deathsin infants.In the Moebius strip model for the sleep-wakefulness continuum, death occurs whenthe continuous strip is broken. Thisdisruption occurs when the passage fromone side of the strip to the other is madeimpossible. Such condition could occur,when the arousal of the infant becomesimpossible. Exposure to prenatal cigarettesmoke, as well as postnatal exposure to heator prone sleeping are conditions that byincreasing the arousal thresholds of theinfants, favour the disruption of the Moebiusstrip.

Infants with ALTE Infants without ALTE% % p

BCA/S 52.6 45.7 n.s.

UCA/S 26.3 32.6 n.s.

Rhinitis 21.1 21.7 n.s.

Obstructive apnoea * 97.4 76.0 < 0.02

Wheezing / grunting 63.0 28.3 < 0.01

Cyanosis during crying 44.7 15.0 < 0.01

Oro-pharyngeal dysphagia 71.0 52.2 n.s.

Vomiting 42.2 23.9 n.s

Hyperhidrosis 26.3 24.0 n.s.

Sialorroea 21.0 10.9 n.s.

Failure to thrive 36.8 32.6 n.s

Cor pulmonale 18.4 4.3 n.s.

Deaths 18.4 4.3 † n.s.

Asphyxic brain damage 10.5 - n.s.

* Relieved by introduction of oro-pharyngeal cannula or by dummy sucking. † Oneinfant was found dead in his cot.

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205CAPNOGRAPHY AND PREMATURITY,AGE AND POSITION EFFECTSE Tirosh, A Bilker, D Bader, A Cohen.The Jacob Lichtman Apnea InvestigationUnit The Neonatal Department Bnai ZionMedical Center, Bruce Rappaport Facultyof Medicine The Faculty of IndustrialEngineering and Management TheTechnion Israel Institute of TechnologyHaifa Israel.Sleep position and prematurity areconsidered as risk factors for SIDS.Objectives: To delineate the effect ofmaturity and sleep position on capnographyof premature infants.Methods: Twenty preterm infants of 32weeks post conceptional age (PCA) and above(BW 1464 g, 296 SD) were longitudinallyfollowed until 37 weeks PCA. A controlgroup (N=39) of term infants was assessedcross sectionally.Procedure: Sidestream capnography (Datex,Normocap) with a sampling rate of 150ml/min was employed in the followingpositions: Supine, prone and side, inclined(30∞) and supine-horizontal.Results: Maturity effect: Preterm infantspresent a predominant type of wave patternsignificantly different from controls(p=0.005-0.04). No maturation effect wasnoted until 36 weeks PCA. Inspiratory periodwas significantly correlated with respiratoryrate (RR) among your prematures only at 32-34 weeks of PCA, whereas expiratory periodwas correlated with RR across all age groups.In prone, peak EtCO2 as well as inspiratoryperiod were significantly increased acrossages only among preterm infants.Conclusion: Capnography reflects a delayedmaturation in the respiratory system amongpreterm infants. There is a specific effectof prone sleeping position. These findingshave a possible implication related to SIDSand prematurity.

206SPERMINE ACTIVATION OF THE NMDARECEPTOR IN SIDSL. Warden, P.R. DoddDepartment of Biochemistry,University ofQueensland, Brisbane, Australia.Glutamate is present in the central nervoussystem well before birth and participates inmost neural circuits, including thoseinvolved in the control of respiratoryactivity, cardiovascular and refluxresponses1. Recent studies suggest that pre-existing abnormalities of the N-methyl-D-aspartate (NMDA) class of glutamatereceptors in discrete brain regions maypredispose infants to apnea, asphyxia, acute-life threatening events and SIDS2. Polyaminebinding sites are located on NMDA glutamatereceptors and play a neuromodulatory role,in that binding increases the amplitude ofNMDA receptor responsiveness. Spermine isan example of such a polyamine.

This study examined spermineactivation of NMDA receptor sties in humaninfant brain tissue from 10 SIDS and 10control cases. MK-801 and spermineenhancement assays with the aid of a cellharvester allowed spermine activationcurves to be obtained. Preliminary analysissuggested that spermine activation of theNMDA receptor is decreased in the SIDS casescompared with the controls. This varyingresponse may be due to a different pre-existing conformation of protein subunitsthat make up the NMDA receptor.

1 Haxhiu M et al., (1997) Journal of the AutonomicNervous System 67, 192-1992 Andersen D et al., (1998) Journal of ChildNeurology 13:4 149-157

Variable Sleep state AS QS Change with age

SaO2 (%) 96.1±1.0 96.6±1.4 n.s

tcpO2 (kPa) 10.6±0.4 10.7±0.4 n.s.

tcCO2 (kPa) 5.4±01 5.4±0.1 Decrease (p=0.002)

HR (beats/min) 122±7.5 121±3.7 Decrease (p=0.02)

RR (breaths/min) 29±5.4 29±10.5 Decrease (p=0.0002)

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207TRANSIENT AROUSALS AT APNEAINITIATION AND SIGH-RELATEDAROUSALS AT APNEA TERMINATIONH. WulbrandDepartment of Child Health, UnitedKingdomFailure of arousal from apnea is considereda potential risk factor in sudden infant deathduring sleep. We hypothesized 1) thatarousal related changes in EEG andsubmental as well as diaphragmatic EMGactivity may occur not only at terminationbut at onset and during the course of sleepapneas and 2) that termination of apnoeasis frequently characterised by a specificbiphasic sigh-related arousal mechanism(Lijowska 1997, Thach 1976, 1997, Wulbrand1995, 1998).Twelve preterm infants (gestational age 29to 34 weeks) were studied at 36, 40, 44 and52 weeks age during sleep including EEG,submental/diaphragmatic EMG, ECG,tcpO2/pCO2, and breathing movements. EEG andEMG activities were continuously quantifiedby using spectral analysis techniques. Sighswere defined by a specific biphasicdiaphragmatic EMG activity increase.33 N-REM and 69 REM related apneas >10sec havebeen recorded. 8 N-REM and 16 REM relatedapneas followed a sigh, 26 N-REM and 44 REMrelated events were terminated by a sigh.An EEG desynchronisation reflected by anactivity (power) decrease was found duringREM related inactive apnoeas (5-18 Hz,p<0.05) and during N-REM related mixed /obstructive apnoeas (3-13 Hz, p<0.05). Amore distinct activity decrease was relatedto the incidence of a sigh, initiating apnoeasin both sleep phases (8-13 Hz, p<0.01). Weconclude that in contrast to widespreadopinions a transient arousal is alreadypresent at onset of many apneas. Moreoverapnoea termination is frequentlycharacterised by a specific arousalmechanism related to a sigh.

208OXYGENATION AND BREATHINGPATTERN IN HEALTHY TERM INFANTSDURING SLEEPJ. Milerad, E Horemuzova, M Katz-SalamonDept. of Woman and Child Health,Neonatal Unit, Astrid Lindgren’s ChildrenHospital, Stockholm, Sweden.Background: Infants who are considered tobe at risk for life threatening respiratoryevents and infants with pulmonary problemsare often monitored during sleep forepisodes of hypoxemia and/or abnormalrespiratory events. There is however littleagreement among different institutionswhich respiratory events constitute normalfindings in this age group and which mayrequire intervention. The prime aim of thisstudy was to study oxygenation andbreathing patterns (particularly periodicbreathing (PB)) in healthy sleeping infants.Patients and Methods: Forty four healthyterm infants aged 2-36 weeks and originallyrecruited as age and sex-matched controlsfor babies with life threatening events (ALTE)were admitted to the study. Their mean GAwas 39±0.9 wk, BW 3520±520g and meanweight at study 5699±1663g. Overnightpolysomnography (mean duration 330± 45min) was performed in all infants. SaO2,transcutaneous pO2 and pCO2, heart rate, andrib cage and abdominal breathingmovements were recorded continuouslyusing a computerized Respitrace – baseddevice. Data were stratified for sleep states(active sleep-AS, quiet sleep-QS) andanalysed with respect to age-related changes.In addition to an automated analysis, allrecordings were manually reviewed forrecording artifacts.Results: main respiratory parameters areshown in the tableFive infants (11.3 %) had hypoxic episodesdefined as SaO2 <90% (mean SaO2 86.2±1.5%). Four of those events occurred inconjunction with partial upper airwayobstructions during AS. Periodic breathing(PB) defined as more than 3 consecutive

VI VT RR TI/TT) P0.1 VT/TI PETCO2 P0.1/(VT/TI))(ml·kg-1·min-1) (ml·kg-1) (min-1) (cmH2O) (ml·s-1) (%) (%) (cmH2O·ml-1·s)C382± 86 10.2±2.1 40± 6 0.34±0.04 2.5±1.1 114±11 5.3±0.3 0.02±0.01N446±112 7.6±1.5 60±16 0.39±0.08 5.2±2.0 109±35 4.5±0.5 0.05±0.03PNS <0.05 <0.01 NS <0.05 NS <0.001 <0.001

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respiratory pauses > 3sec was observed in38.6 % of infants.Conclusion: Oxygenation and CO2 levels inhealthy sleeping infants are comparable tothose of older children. Hypoxic episodes arevery infrequent and if present, are associatedwith partial upper airway obstruction. PB,often assumed to be a pathological feature,is a normal breathing pattern in this agegroup.

(Supported by MFR grant (k98-27x-11265-04a)

209ALTERED BREATHING PATTERN ANDTACHYCARDIA IN YOUNG LAMBSEXPOSED TO NICOTINE PRENATALLYJ. Milerad, H.W. Sundell, O. Hafström, P.A.Minton, S Poole.Dept. of Woman and Child Health,Neonatal Unit, Astrid Lindgren’s ChildrenHospital, Stockholm, SwedenMaternal smoking during pregnancy mayresult in multiple severe consequences forthe young child, e.g. obstructive lung andincreased risk for the sudden infant deathsyndrome. The responsible ingredients intobacco smoke for these effects are notknown. We have investigated effects ofprenatal nicotine exposure in young lambsand have previously reported that prenatalnicotine exposure attenuates oxygensensitivity, delays hypoxic arousal andimpairs the cardiorespiratory response toacute hypoxemia in sleeping young lambs(Pediatr Res 41:302A, 1997). Studies withdopamine receptor blockers indicated thatthese effects were, in part, mediated bydopaminergic modulation of the peripheralchemoreceptors (Pediatr Res 43:332A, 1998).In addition, we have observed alteredbreathing patterns in these prenatallynicotine-exposed young lambs, which pointto alterations in mechanical properties of therespiratory system.Subjects & Methods: Seven pregnant eweswere infused continuously with nicotine,40mg/d during the last trimester. Sevenlambs exposed to nicotine before birth only(N) and 7 control lambs (C) were studiedduring quiet sleep at an age of 3 - 9 d with a

breath-by-breath method (Eur J Appl Physiol74:44,1996) for determination of minuteventilation (VI), tidal volume (VT), respiratoryrate (RR), inspiratory/total breath time (TI/TT), airway occlusion pressure (P0.1), meaninspiratory flow (VT/TI), end tidal PCO2

(PETCO2), effective impedance (P0.1/(VT/TI),heart rate (HR) and blood pressure (BP).Results: Plasma nicotine concentration inthe ewes was 7±1 ng/ml (mean ± SD) andthe nicotine metabolite cotinine was 18±5ng/ml. HR was significantly increased in N:241±22 bpm compared with C: 185±19 bpm(p<0.001, t test). BP was not significantlydifferent, N: 86±13 mmHg, C: 92±10 mmHg.Ventilatory parameters are presented in thetable.Summary: The higher heart rate in thenicotine-exposed lambs suggests anincreased resting sympathetic tone.Compared with control lambs, nicotineexposed lambs were breathing faster withreduced tidal volume and increasedinspiratory drive (P0.1). Effective impedancewas higher in the nicotine-exposed lambswhich might reflect decreased complianceand/or increased airway resistance. Themarkedly altered breathing pattern suggeststhat prenatal exposure to a lowconcentration of nicotine results in abnormallung development and postnatal function.Conclusion: The combined effects ofaltered control of breathing and decreasedlung function may predispose both to SIDSin infancy and obstructive lung disease laterin childhood.

during normoxia :Activity state VI (ml·kg-1·min-1) fR (min-1) P0.1 (cm H2O) VT/TT

-1)W 430±79 42±9 3.5±1.9 136±31QS 374±74* 37±6+ 2.5±1.2** 115±25**W 436±106 58±14 4.8±2.0 114±42QS 446±112 60±16 5.2±2.0 109±35

D; *p<0.05; **p<0.01; +p=0.05 (paired t-test)

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210PRENATAL NICOTINE EXPOSURE (PNE)ALTERS SLEEP-RELATEDMODULATION OF VENTILATION INYOUNG LAMBSJ Milerad, HW. Sundell, O. Hafström, S.Poole, PA. MintonDept. of Woman and Child Health,Neonatal Unit, Astrid Lindgren’s ChildrenHospital, Stockholm, Sweden.Activity states influence autonomic controlmechanisms including regulation ofcardiorespiratory functions. Chemoreceptorand other cardiorespiratory reflexes areusually stronger during quiet sleep (QS)compared to wakefulness (W), while restingventilation and metabolic rate are lower. Wehave reported that PNE attenuates oxygensensitivity, impairs arousal andcardioventilatory responses to acute hypoxiain young lambs during QS (Pediatr Res41:302A,1997; 43:332A,1998). To determinewhether the observed impairment in hypoxicdefense mechanisms could in part beattributed to nicotine-induced alteration ofautonomic control during sleep, wemeasured how QS modulates minuteventilation (VI), tidal volume (VT), respiratoryrate (fR), airway occlusion pressure (P0.1),mean inspiratory flow (VT/TI) and end-tidalPCO2 (PETCO2) before and during 4 minutesof hypoxia (0.1FIO2) in 11 5-d-old control (C)and 7 5-d-old lambs exposed to nicotine (N)during the last trimester (40 mg/d maternaldose).QS significantly decreased VI, fR, P0.1 and VT/TI only in C, while VT and PETCO2 wereunaffected in both groups. The ventilatoryresponse to hypoxia was higher during QScompared to W only in control lambs(p=0.01, ANOVA).In conclusion, the expected decrease inresting ventilation and augmentation of theventilatory response to hypoxia were absentin lambs exposed to nicotine before birth.Nicotine-induced changes in metabolic rate,oxygen utilization and sleep organizationmay account for our findings.

211FLEXIBLE LARYNGOSCOPIC UPPERAIRWAY FINDINGS IN INFANTS WITHNOISY BREATHING ANDOBSTRUCTIVE SLEEP APNEAS OFUNCLEAR ORIGIN.Joseph Milerad, Stefan Johansson ,Gunnar Biorck , Miriam Katz-Salamon.Dept. of Woman and Child Health and

Department of Phoniatrics Hospital,Stockholm, Sweden.Background: Videorecorded flexiblelaryngoscopy (VFL) is a well establishedclinical method for evaluating upper airwayfunction in children and adults with speechabnormalities and upper airway motordysfunction . Since the investigation usuallytakes less then 10 minutes and requires onlytopical anaesthesia it may be well suited forevaluation of infants. So far only it is onlyoccasionally performed in infants less thanone year of age. The aim of this study wasto evaluate the diagnostic value of flexiblelaryngoscopy in infants with noisy breathingand sleep-related airway obstructions.Patients and Method: Sixteen infantsconsecutively referred for investigation dueto noisy breathing or apneas during sleepwere admitted to the study. Their mean agewas 7.6 ±6.7 mo (8 d - 18 mo).Ten of these infants had no other medicalconditions apart from the respiratoryproblems, 2 infants had palatal clefts, 3 weredevelopmentally retarded and one infant wasborn preterm and had a mild CLD. Fourteeninfants underwent a polygraphic sleep studybefore VLF. All had increased inspiratoryresistance as diagnosed by vector analysisof chest and abdominal breathingmovements and repeated airwayobstructions with hypoxic episodes (SaO2 <90%). Two infants who had inspiratorystridor at physical examination wereexamined by VFL only.Results: In six of the ten infants a definitediagnosis could be obtained after VFL.Other health problems VFL -diagnosisNone Left sided vocal cord palsyCleft soft palate Midline palatalteratomaPsychomotor developmental delayLaryngomalacia collapsing epiglottis”Tracheomalacia” Abnormal movements ofarytenoid cartilageCHD, hypoxic brain damage Massive GEreflux and with aspirationsCornelia de Lange syndromePharyngeal hypotonia and nasopharyngealstenosis.Conclusion: VFL can be performed alreadyin the newborn period and can lead to adefinite diagnosis. It is not possible topredict on clinical grounds which infantsmay diagnostically benefit from VFLalthough infants who had other medicalconditions appeared to be over representedin the group with VLF abnormalities.

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212SAFE T SLEEP MAY REDUCEINCIDENCE OF SIDSMiriam Rutherford, (New Zealand) Safe TSleep (NZ) Ltd, PO Box 135, Takanini,Auckland

It is well established that prone sleepposition increases the risk of SIDS and SIDSmortality has decreased dramatically sincethe recommendation that infants are notplaced prone to sleep. However, SIDSmortality in New Zealand continues to behigh (1996:1/9/1000 live births). A sidesleeping position is also associated with atwo fold increased risk of SIDS comparedwith the back sleeping position (1), probablydue to infants turning ontotheir fronts (secondary prone). But even ifthe infant is placed on the back to sleep hemay still turn to the prone position (2).Meanwhile the recommendation to sleephealthy infants only in a supine position hasreportedly been linked to increasing ratesof plagiocephaly.The Safe T Sleep Sleepwrap has beendeveloped as a tool to help prevent babiescreeping into dangerous positions duringsleep and eliminating the risk of an infantturning onto their front from either a supineor side sleeping position. Already more than48,000 have been used inNew Zealand without a single reported death,whereas national statistics suggest that wecould have expected 91 SIDS deaths to haveoccurred. Even if the Safe T Sleep Sleepwrapis used mainly by families at lower risk ofSIDS (such as non-Maori and socio-economically advantaged families) thisresult is still outstanding. Safe T SleepSleepwrap should be formally evaluated toconfirm this observation.The potential for a safe side sleeping optionusing the Safe T Sleep Sleepwrap could beseen as a means to encourage caregiversconcerned about plagiocephaly tosimultaneously address the increased SIDSrisks of prone or secondary prone sleeping.

1. Scragg RKR, Mitchell EA. Side sleeping positionand bed sharing inthe sudden infant death syndrome. Ann Med1998; 30: 345-349.2. Mitchell EA, Thach BT, Thompson JMD, WilliamsSM. Changing infants'sleep position increases risk of sudden infantdeath syndrome. Arch PediatrAdolescent Med 1999; 153: 1136-1441.

127

Adamson, TM 56, 57Aljbour, O 131Alkout, A 50, 51Al Madani, O 51Amberg, R 50Anderson, DL 197Anderson, E 99Anderson, M 35, 130Andrew, S 56, 57Andrews, DC 136Ansari, T 49, 182, 183,

184Arnestad, M 35, 44, 47, 130Baddock, S 53, 98ABader, D 205Baker, G 84, 149Bandopadhayay, P 56Baraga J 106Bartlett, G 68Bateman, V 143Bawtree, L 136Beal, S 61Becker, L 52Beckett, C 19, 41Becroft, D 111Berry, J 7, 15, 42,63, 80,

115,118, 168,169,170, 177

Bilker, A 205Biorck, G 211Blackwell, C 50, 51, 171, 185,

186Blair, P 7,15, 42,54,63,80,

96,115,118,132,138,168,169,170,177, 198

Bohnhorst, B 135, 195Bolton, D 53, 55, 201,202Bonci, E 131Bower, C 36Breen, J 77Briand, E 189Briggs, L 73Brinkmann, B 116, 176Brooke, H 19, 41, 46Browne, CA 196Bryan, RT 2Buckley, P 16, 137Busuttil, A 50, 51, 171, 185,

186Butler, H 114Byard, R 14Campbell, P 64Capron, F 189Cardona, D 106Carey, J 89Carpenter, R 18, 78Casati, A 190, 191Case, M 60Ceriani Cernadas, J 129

Chabanski, J 21, 22Chapman, F 30, 103Chau, B 56, 57Chen, L 173Chow, CB 173Claridge, W 34Cobb, N 2Cohen, A 205Cointe, D 189Cole, P 42, 101Cole, TJ 169, 177Colditz, 196Coombs, R 78Corboy, M 75, 157Corbyn, A 97Cormack, H 85Corriveau, A 103Cotroneo, S 156Coulomb, A 189Covington, T 127Cowan, S 65, 121, 128, 129Cox, K 150Cozzi, F 131, 190, 191Cozzi, DA 131, 190, 193Cranage, SM 56, 57Crawford, F 121Croft, M 36Csukas, Z 194Cullen, W 117Currie, F 121Cutz, E 9Dallas-Katoa, W 91Daman-Williams, C 78Davies, MF 67Davies, J 107De Chalain, T 68de Jonge, GA 38de Klerk, N 36De Koning, C 64De Laveaucoupet, J 189Dehan 189Dent, A 138Deri-Bowen, A 32, 71, 158Dickinson, J 173Dodd, P 197, 200,206Dunay, G 175Dunster, K 196Durigon, M 188Durst, J 159Dyregrov, A 140Dyregrov, K 140Eades ,S 102Engelberts, AC 38Eckert, A 197Emery, JL 78England, P 18English, R 87, 147Epstein, J 26, 83Eriksen, H 126, 160, 161Ferens, D 57

Authors

128

Fieguth, A 174Fifer, W 92Finau, E 88Finau, S 88Finnucane, C 70Findeisen, M 116, 176Fitzgerald, AC K 27, 148Fleming, P 7, 15, 18, 24, 42,

54, 63, 80, 96,115, 118, 132,138, 168, 169,170, 177, 198,199

Fok, T 203Ford, R 10, 11, 40, 128Ford, D 77, 82, 89Franciosi, R 187, 188,Franco, P 21, 22Freiman, J 139Fuamatu, N 88Fukui, S 31Furneaux, C 68Galland, B 53, 54, 55, 201,

202Ganter, J 106Gibson, A 19, 41, 46Giebe, B 174Giebler, D 174Giljohann, A 29Gillan, J 182, 183, 184Gilmour, H 121Giving Kalstad, T 151, 152Golding, J 7, 15, 24, 42, 63,

115, 168, 169, 177Gordon, A 51, 171Graham, M 60Grant, D 59Graydon, B 74Grogaard, J 44Groswasser, J 21, 22Guibert, M 189Hake, Tor G 28Hall, N 120Haberlandt, E 37Hafstrom, O 209, 210Harmey, N 70, 90, 113Harris, KA 95Hawkins, A 200Hayman, R 162, 201, 202Hazel, JF 156Heide, S 174Henniker, K 123Heyne, T 195Hillman, L 107Hjelm, N 173Hobbs, M 36Hoffman, H 122Hopmans, R 33Horemuzova, E 208Horiuchi, T 31

Horne, R 56, 57Huber, J 18Hunt, C 104Hunt, L 199Ilari, M 190Ingram, P 153Irgens, L 18Isaksen, C 130Jackson, A 134James, VS 50Jeffery, H 58Jenik, A 129Johansson, S 211Johnson, P 136Jones, L & P 155Jorch, G 18, 116Joyce, J 74Kahn, A 3, 21, 22, 145Katz-Salamon, M 208, 211Keays, D 30, 103Kelmanson ,I 192Kemp, J 60Kibel, M 67Kiechl-Kohlendorfer, U 37King, M 106Kleeman, WJ 174Ko, C 122Krous, H 4, 146Labreche, M 165Lacey, B 57Larsch, K-P 174Latter, G 163Law, A 68Leach, CEA 42, 177Leditschke, J 64Lerner, H 81Levene, S 109, 172L’Hoir, M 38Li, K 203Limerick, S 179Liddle, M 106Lindgren, C 44Lipsitt, L 93Lokuge, A 137Low Choy, K 106Lumsden, M 121MacDorman, M 122MacKenzie, DAC 171Makowharemahihi, C 53Matthews, F 136Matthews, T 39, 133McBride, G 181McDonnell, M 69, 79, 90McIntyre, D 121McKay, C 121McKelvey, GM 58McKenna, J 13, 94McKenzie, CMA 78McMillen, C 16, 137Meleth, A D 100

129

Meleth, S 100Milerad, J 8, 208, 209, 210,

211Mitchell, E 6, 40, 43Mitchell, I 72, 105, 180, 193Minton, P 209, 210Molitor, C 107Molony, N 186Morini, F 131, 190, 191Mothershead, C 107Mueller, E 116, 176Muller, R 101Musse, MA 48Nadin, P 15, 63, 169Neil, A 136Nelson, T 5, 129, 144, 173,

203Nishida, H 31Nordanger, D 140, 152North, K 24Nowak, A 25Oberaigner, W 37Obershaw, R 1O’Brien, G 70O’Malley, A 128O’Neill, B 182, 183, 184Opdal, SH 48Oriolo, L 191Ou, Y 173Paluszynska, DA 95Panaretto, K 101, 181Peter, C 135, 195Petersen, S 99, 134Piloni, G 76Pisera, A 190, 191Poets, C 112, 135, 174,

195Pollard, K 96, 132, 198Poole, S 209, 210Post, EJ 58Pratt, C 134Pupp, U 37Rajini, Sa 100Rajini, Sr 100Rambaud, C 189Randall, L 2, 86Razafimahefa, H 189Read, A 36, 102Reardon, C 164Rees, M 68Richards, M 106Rigda, R 16Roche, L 125Rognum, T 35, 44, 47, 48,

110, 130Rossi, M 49Rozgonyi, F 194Rutherford, GW 66Rutherford, M 212Samuels, M 108, 112

Sankaran, K 100Sankaran, R 100Sanderson, C 82Sawczenko, A 54, 96, 132, 198,

199Sawaguchi, A 175, 194Sawaguchi, T 31, 45, 175, 194,

204Sayers, R 55, 201, 202Scaillet, S 21, 22Scheers, NJ 66Schlaud, M 174Schluter, P 40Schmidt, U 174Schroeder, P 18Scragg, R 12Sibbons, P 49, 182, 183, 184Sicotte, P 178Silny, J 135Sloan, R 165Smith, I 7, 15, 42, 63, 115,

118, 168, 169,170, 177

Southall, D 112Sperl, W 37Sprodowski, N 135Stead, C 124, 166Stephenson, W 106Stewart, A 141Stramba-Badiale, M 119Sundell, H 209, 210Switajewski, Y 154Synnott, M 70Tang, N 173Tappin, D 19, 41, 121Taylor, M 142Taylor, B 40, 43, 53, 55,

201, 202Thach, B 60, 95Tipene-Leach, D 17Tirosh, E 205To, KF 173Torgersen, H 130Tonkin, S 62Toro, K 175, 194Toth, L 194Tozzi, C 131Tukuitonga, C 88Unger, B 60Vege, A 35, 44, 47, 48,

130Vennemann ,M 116, 176Vitkovic, J 56, 57Vogel, A 23Wailoo, M 99, 134Waite, A 78Walker, A 59Ward Platt, M 7, 15, 42, 63, 115,

118, 168, 169,170, 177

130

Warden, L 206Wasilewska, J 167Watts, A 57Webber, R 121Weir, D 51, 171, 185, 186Weiss, P 20Welty, T 86Whitehall, J 101, 181Wigfield, R 199Wilkinson, M 82Wild, J 59Wilkinson, S 143Williams, P 106Williams, S 43Willinger, M 122Wilson, E 98, 178Wong, D 173Wood, AKW 58Wulbrand, H 207Wulf, J 174Young, J 15, 54, 63, 96,

132, 198Yin, W 203Yu, L 173, 203