Pedestrian deaths in children--potential for prevention.

The National Paediatric Mortality Database was reviewed for the six year period 1st January 2006 to 31st December 2011 and all pedestrian deaths extracted, after review of available data the deaths were categorized as either traffic or non-traffic related. There were 45 child pedestrian fatalities in the period examined. Traffic related deaths accounted for 26 (58%) vs. 19 (42%) non-traffic related. Analysis of the deaths showed there was a male preponderance 28 (62%), weekend trend 22 (49%) with an evening 16 (35%) and summer peak 20 (44%). The highest proportion of deaths occurred in the 1-4 year age group 24 (53%), with 13 (28%) due to low speed vehicle rollovers, mainly occurring in residential driveways 8 (61%). Child pedestrian fatalities are highly preventable through the modification of risk factors including behavioural, social and environmental. Preventative action needs to be addressed, particularly in relation to non-traffic related deaths i.e, low speed vehicle rollovers.

Sudden unexplained death in childhood. An audit of the quality of autopsy reporting.

Cases of sudden unexplained death in childhood (SUDC) in Ireland in children aged > 1 year and < 5 years were examined in order to assess the quality of autopsy reporting. All SUDC cases are notified to and documented by the National Sudden Infant Death Register (NSIDR) in Ireland along with all cases of sudden infant death syndrome (SIDS) referring to sudden infant deaths less than one year of age. The database of the NSIDR in Ireland was interrogated and cases of SIDS and SUDC were compared over a fifteen-year period (1995-2009). SIDS cases whose autopsies were conducted in the same hospital in the same year as the index SUDC case were used for comparison. The autopsy report for each case was examined and modified Rushton (MR) score(s1) calculated. MR scores were compared along with the number of paediatric pathology prosectors and the year of autopsy examination between the two groups. 45 cases were registered as SUDC (age 52 - 152 weeks) between 1995-2009. Autopsy reports were available for 43/45 (95%) of these. 43 SIDS cases from the same year and site of autopsy were used for comparison. Overall MR scores were higher in the SIDS cases, with 29/43 (67%) cases obtaining the minimum arbitrary score (MAS) of > 300 compared to 25/43 (58%) of SUDC cases. Paediatric pathologists in specialist centres carried out similar numbers of SIDS autopsies and SUDC autopsies (46% SIDS, 44% SUDC). Autopsies carried out by paediatric pathologists in specialist centres met the MAS in 19/21 (90%) SIDS cases and 18/19 (95%) SUDC cases. Based on our findings we recommend referral of all SUDC cases to specialist centres for optimal autopsy examination and investigation, and that cases of sudden unexpected death in children over 1 year of age are investigated according to the same guidelines as are used for unexpected death under one year of age.

Workload and short-term outcome of babies weighing 2,500 grams or more at birth admitted to the paediatric unit of the Rotunda Hospital.

BACKGROUND: Audit is important in ensuring adequate use of resources and maintaining optimum standards of care. Most of the emphasis in neonatal audit is focused on very low birth weight infants. However, term and near-term infants account for a significant proportion of the workload in neonatal units and warrant regular audit. In addition, audit of these infants may be useful as a marker of the organisation of the perinatal service. METHODS: A retrospective audit was performed of all infants with birth weights greater than or equal to 2,500 grams admitted to the neonatal department in the first week of life over a two-year period, examining mode of delivery, level of care, duration of stay, diagnosis and short-term outcome. RESULTS: Eight hundred and seventy infants were admitted greater than or equal to 2,500 grams birth weight, 54% of all neonatal admissions, during the study period. Six hundred and eighty seven of these infants were admitted in the first week of life and were included in the study; this was 5.8% of infants born with a birth weight 2500 grams or more. Infants born by caesarean section were twice as likely to require admission (9.8%) compared with infants born by vaginal delivery (4.5%). The median length of stay was 3 days (3 hours to 45 days). One hundred and six (15.4%) infants required level 1 or level 2 care. One hundred and eleven infants received normal care, only. Most of these infants were admitted for maternal or social reasons. Other common reasons for admission were jaundice, respiratory disease, neonatal abstinence syndrome and congenital abnormality. Forty-one infants required transfer to another hospital, most commonly for surgical or cardiac conditions. Six infants died after admission. However, only one normally formed infant delivered in our hospital died prior to discharge or transfer. One infant was born at home and four infants who had a lethal congenital abnormality are known to have died following transfer. CONCLUSION: Term and near-term infants account for a significant proportion of neonatal admissions and deserve regular audit. Many admissions are potentially avoidable. Survival for infants weighing 2,500 grams or greater is excellent. Only one normally formed infant died following admission during the study period. The number of "social" admissions of "well" infants highlighted by this study reflects poorly on the services available for well infant whose mothers are unable to care for them for whatever reason. We recommend regular audit of these infants in order to ensure efficient use of neonatal resources and to ensure optimum levels of neonatal intensive care.

Sudden infant death syndrome--are parents getting the message?

BACKGROUND: Factors that place an infant at increased risk of sudden infant death include the prone sleep position, overheating and parental smoking, while practices such as bottle-feeding, co-sleeping and the use of pacifiers remain controversial. Major publicity campaigns have been undertaken, which have included the distribution of printed material and extensive media coverage. AIMS: To examine if Irish parents follow the currently recommended childcare guidelines to reduce the risk of sudden infant death and to examine factors that may have impact on their acceptance. METHODS: A random selection of 197 infants from the Birth Register of the Eastern Health Board. Parents were interviewed and a semi-structured survey questionnaire was completed. RESULTS: Forty one per cent of infants are still placed on their side to sleep, an inherently unstable position. First time parents are more likely to place their infants on their backs. Over 60% of infants are exposed to one or more adults smoking in the home despite parental knowledge of its association with sudden infant death syndrome (SIDS). Sixty eight per cent of infants are overwrapped at night and parental understanding of what constitutes overwrapping is poor. Thirteen per cent of infants regularly co-sleep with their parents and 20% of these parents smoke. Pacifier use is common. CONCLUSION: Future programmes should target first time parents, should provide clear information regarding appropriate infant thermal environment, and should ensure regular updating of medical personnel so that they can instruct families on best current practice. Smoking remains a significant health issue with an impact on sudden infant death.

Concentrations of antimony in infants dying from SIDS and infants dying from other causes.

OBJECTIVES: Raised concentrations of antimony have been found in infants dying of sudden infant death syndrome (SIDS). The presumed source of this antimony is toxic gases generated from fire retardants that are present in cot mattresses. The aim of this study was to determine the role of antimony in SIDS. DESIGN: Samples of liver, brain, serum, and urine were collected from all patients dying from SIDS and a group of aged matched control infants who had died of other causes. SETTING: Nationwide study in Ireland. SUBJECTS: 52 infants dying from SIDS and 19 control infants aged > 7 days and < 1 year. RESULTS: The median concentration of antimony in the liver and brain of infants dying of SIDS was < 1 ng/g, with no difference detected between the infants dying from SIDS and the control infants. The range of antimony in the serum of infants dying of SIDS was 0.09-0.71 microg/litre (median, 0.26). Although no difference was found between infants dying from SIDS and control infants, SIDS infants were found to have higher concentrations when compared with healthy infants in the 1st year of life, probably as a result of release of antimony into serum after death. Urine antimony concentrations in infants dying from SIDS were < 3.91 ng/mg (corrected for creatinine) and similar to values found both in control infants and healthy infants. CONCLUSION: There is no evidence to support a causal role for antimony in SIDS.

Strategies for reduction of neonatal mortality.

Infant mortality rates in developed countries have shown significant decreases in recent years. Two-thirds of infant mortality still occurs in the neonatal period and our aim in this study was to review the causes of these neonatal deaths and see where further improvements may be possible. A 6-yr review of all neonatal deaths of live-born infants over 500 g birthweight from 1991 to 1996 was made. The 1989 amended Wigglesworth classification was used to categorize cause of death and other perinatal variables were also recorded. Results show there were 34,375 births and 153 neonatal deaths. Classification of these deaths by Wigglesworth found 78 (51 per cent) due to congenital malformations, 58 (38 per cent) due to prematurity, 6 (4 per cent) due to asphyxia and 11 (7 per cent) due to specific other causes. The corrected neonatal mortality was 2.18. Neural tube defects alone accounted for 10 per cent of the total neonatal mortality. Fifty-five out of 58 infants who died due to prematurity had birthweight < 1000 g and survival rates in this group compared well to international standards. We conclude that a reduction in neonatal mortality is possible but is most likely to result from community focused measures such as increased use of pre- and peri-conceptional folate.

Sleep position and SIDS in Irish infants.

A retrospective case-controlled study has compared the frequency of different sleeping positions in a group of 97 SIDS infants and a group of 98 control infants. The results show a clear excess of SIDS deaths among Irish infants sleeping in the prone (lying on abdomen) position with the risk of a SIDS increased 2.3 fold comparing prone to side and 10.5 fold comparing prone to back positions. Among the SIDS group 79% of infants were lying prone when found dead compared to 25% of the control group (chi square = 64.3, p < 0.001) with only 7% and 9% sleeping on their sides and backs respectively (control group 48% and 27% respectively). Irish parents should be advised to avoid placing infants in the prone position (on abdomen) to sleep as this position is associated with a significantly increased risk of the Sudden Infant Death Syndrome.

Surfactant therapy in respiratory distress syndrome: the effect of a learning curve in improving outcome.

A retrospective study of all premature neonates who received artificial surfactant (Curosurf) at the Rotunda Hospital was performed. The period from October 1990 to June 1992 (n = 48) was compared with the initial experience from June 1987 to January 1988 (n = 15). In the initial period mortality rate was 67% in surfactant treated infants, and use of surfactant was not associated with an improvement in outcome compared with the previous six years. In the more recent period overall mortality was 21%. Overall survival in normally formed very low birthweight infants improved from 59% in 1986 to 86% in 1991-1992. Improvement in survival rates was most noticeable in infants with birthweight 750-999 grams, with survival increasing from 44% (before introduction of surfactant treatment) to 91% (in 1991-1992). It is probable that a certain level of experience with use of surfactant is required before optimal effects can be obtained.

Alcohol and cigarette use in a pregnant Irish population.

One hundred women were selected at random and interviewed. All were postnatal. The object was to establish the level of alcohol and cigarette consumption and the level of knowledge to potential adverse effects. Of the 100 women interviewed 89% drank prior to pregnancy, six drank between 100-120 grams/week and 19 drank > 120 grams/week. 11 women stopped drinking when they became pregnant. In the group which drank 100-120 grams/week, 66% decreased their alcohol consumption considerably ie > 100 grams/week while pregnant, while in the group which drank > 120 grams/week only 15% decreased their alcohol consumption. 38 women binged on at least one occasion while 21 said they had binged on at least one occasion during the first trimester. 58% of women were aware of the harmful effects of alcohol during pregnancy. They compared with 93% who were aware of the harmful effects of smoking during pregnancy. Only 11% of women said a doctor had mentioned alcohol as harmful, while 57% said that a doctor had mentioned the hazard of smoking in pregnancy. The overall results show a general ignorance to the effects of alcohol consumption in pregnancy compared to the level of knowledge about smoking. The results also highlight the fact that doctors do not make patients aware of the effects of alcohol in pregnancy while they make an effort to educate people about the problems of smoking during pregnancy.

Contemporary risk factors for sudden infant death in an Irish population--a case control study.

This case-controlled study examines some recently implicated risk factors for Sudden Infant Death Syndrome (S.I.D.S.) in Irish infants. Irish S.I.D.S. infants are lighter at birth than controls (3463g) compared to (3542g) and boys out-number girls by a ratio of 1.3:1. S.I.D.S. infants are more frequently: breast-fed (42% vs 25%) and sleep in a location other than the parent's bedroom (54% vs 21%), but start solids at a similar age and appear not to be sicker prior to death than the control group. This study highlights the frequency of symptoms of possible ill-health (i.e. snuffles and being "chesty") in well infants during the first months of life with 32% of the control group having snuffles and 35% described as "chesty". In addition these symptoms are frequently treated with antibiotics with 31% of the control group having already received antibiotics by 2 months of age. A majority of S.I.D.S. infants were described as cold when found (52%) with 39% described as warm and 15% as sweaty. Obviously the recently implicated role of overheating may be relevant in the latter 15% of S.I.D.S. cases. In this series, 88% of infants had died by 6 months of age. Of the 97 parents of S.I.D.S. infants questioned, 78 had subsequently become pregnant by the time the study was conducted at an average time of 5 months post the S.I.D.S. event.

Arousal responses in babies at risk of sudden infant death syndrome at different postnatal ages.

Hypercarbic and hypoxic arousal responses during sleep were measured in healthy term infants, infants where a previous sibling died from sudden infant death syndrome (SIDS) and infants suffering a clearly defined apparent life threatening event (ALTE) requiring vigorous or mouth to mouth resuscitation. Groups of infants were tested at approximately one, six and 13 weeks postnatally. Arousal was defined as gross body movement with eyes opening and moving or crying. Hypercarbic arousal was by step increases in F1 Co2 until arousal occurred or until endtidal (PETCO2) reached 8.7 KpA (65 mm Hg) Hypoxic arousal was by step decreases in FIO2 until arousal occurred or until an FIO2 of 0.15 had been maintained for 20 minutes. There was no difference in hypercaribic arousal threshold with age in any group. Hypercarbic arousal threshold was significantly higher in siblings (mean 53.4, 53.6, 54.7 mmHg. [7.12, 7.14, 7.29 KPA] at 0, 6, 13 postnatal weeks) compared to controls (mean 50.9, 52.3, 53.0mm Hg. [6.78, 6.97, 7.29 KPS respectively). ALTE infants differed only at 12 weeks having a significantly lower threshold (51.0mmHg. [6.80 KPA] V 53.0mm Hg. (7.06 KPA]) compared to controls. There was no difference in hypoxic arousal response with age in any group. An arousal response to hypoxia occurred in only 22% of ALTE infants and 40% of siblings compared to 67% of normal infants. Deficient sleep arousal, especially to hypoxia, is common in infants and especially those considered at increased risk from SIDS. This deficiency is present in the first postnatal week and did not vary overy the first three months of postnatal life.

Snuffles in infants--infection or autonomic dysfunction.

The presence of excess nasal mucus causing noisy nasal breathing with an obvious mucus discharge (snuffles) is a common problem in infants in the first three months of life. The presence of "snuffles" has traditionally been ascribed, unproven, to an upper respiratory tract infection despite there being no other signs of an acute infection in the majority of infants with "snuffles". To assess the possible role of impaired vasomotor control (autonomic function) in the pathogenesis of snuffles we measured the effect of a change from the supine to the upright position on resting blood pressure in 50 infants with "snuffles" and 50 healthy control infants. The mean age in both groups was 7 weeks post delivery, all infants were attending a well baby clinic for a routine examination, had no signs of an acute infection and none were on any medication (including nasal drops). A fall of greater than 10% of resting blood pressure was taken to indicate postural hypotension. Four of fifty infants in the control group compared to 22 of 50 in the snuffles group demonstrated postural hypotension (Chi square 16.84, p less than 0.001). The results suggest that in some infants "snuffles" may be associated with impaired vasomotor control.

Blood cultures and antibiotic use in a neonatal intensive care unit.

A review of the duration of antibiotic courses in our Neonatal Intensive Care Unit (N.I.C.U.) has shown that in a significant number of cases there was non compliance with the antibiotic policy. An audit of neonatal sepsis and antibiotic usage over a six month period was performed in the N.I.C.U. at the Rotunda Hospital. Three hundred and forty-nine of the 3,163 infants born during this time were admitted to the N.I.C.U. One hundred and fifty-two infants had one or more episodes of suspected sepsis. In 168 instances this preceded a course of antibiotic therapy lasting longer than 48 hours. In 56 (33%) the infant was clinically septic and in 16 (9.5%) of those there was bacteriological proven sepsis. There were 112 episodes (60%) where there was no strong clinical evidence of sepsis and a negative investigation for sepsis where antibiotics were continued for more than 48 hours. The possible reasons why antibiotics were not stopped include the non specific nature of signs of sepsis in neonates, physicians' reluctance to discontinue antibiotics once started, and the logistic difficulty of obtaining routine culture results at weekends. The study emphasizes the need for regular surveillance of antibiotic usage in a N.I.C.U.