Probiotic administration in congenital heart disease: a pilot study.

OBJECTIVE: To investigate the impact of probiotic Bifidobacterium longum ssp. infantis on the fecal microbiota and plasma cytokines in neonates with congenital heart disease. STUDY DESIGN: Sixteen infants with congenital heart disease were randomly assigned to receive either B. infantis (4.2 × 10(9) colony-forming units two times daily) or placebo for 8 weeks. Stool specimens from enrolled infants and from six term infants without heart disease were analyzed for microbial composition. Plasma cytokines were analyzed weekly in the infants with heart disease. RESULTS: Healthy control infants had increased total bacteria, total Bacteroidetes and total bifidobacteria compared to the infants with heart disease, but there were no significant differences between the placebo and probiotic groups. Plasma interleukin (IL)10, interferon (IFN)γ and IL1ß levels were transiently higher in the probiotic group. CONCLUSION: Congenital heart disease in infants is associated with dysbiosis. Probiotic B. infantis did not significantly alter the fecal microbiota. Alterations in plasma cytokines were found to be inconsistent.

Can magnetic resonance spectroscopy predict neurodevelopmental outcome in very low birth weight preterm infants?

OBJECTIVE: To determine if metabolite ratios at near-term age predict outcome in very low birth weight preterm infants at 18 to 24 months adjusted age. STUDY DESIGN: Thirty-six infants (birth weight

Movement, imaging and neurobehavioral assessment as predictors of cerebral palsy in preterm infants.

OBJECTIVE: To study the relative efficacy of three early predictors of cerebral palsy. METHOD: One Hundred and thirty infants with birth weight <1500 g were recruited. Video recordings of spontaneous general movements were made at 36 and 52 weeks postconceptional age. Magnetic resonance imaging and the neurobehavioral assessment of the preterm infant were done at 36 weeks postconceptional age. Follow-up neurological examination and Bayley assessments were made at 18 months corrected age to make early identification of cerebral palsy. RESULTS: Magnetic resonance imaging gave the best specificity and accuracy of 91 and 84% respectively. General movements at 52 weeks showed an improved specificity and accuracy over performance at 36 weeks postconceptional age. The negative predictive value for all methods tested was between 90 and 97%. Combining the results of magnetic resonance imaging and the neurobehavioral assessment improved the sensitivity of prediction to 80%, suggesting that a holistic approach to early detection of cerebral lesions is preferable to a single test. CONCLUSIONS: The majority of infants who appeared to behave within normal limits and exhibit normal brain structure in the newborn period were classified as neurologically intact at follow-up.

Fewer spontaneous arousals during prone sleep in preterm infants at 1 and 3 months corrected age.

OBJECTIVE: This study was performed to determine if there were fewer spontaneous arousals in prone sleep than in supine sleep. STUDY DESIGN: Home polysomnography/video recordings were done during daytime naps in 14 preterm infants: four at corrected age of 1 month, nine at both 1 and 3 months, and one only at 3 month. A body movement lasting 3 to 60 s during sleep was used as an indicator of spontaneous arousals. RESULTS: Most arousals had a heart rate increase and change in respiration pattern. The mean duration of the intervals between successive arousals in active and quiet sleep was significantly longer in prone at 1 and 3 months of age. The duration of arousals was significantly shorter at 3 months corrected age compared with one month corrected age during active sleep. The duration of arousals was shorter during quiet sleep at one month compared with active sleep. CONCLUSION: There were fewer spontaneous arousals that is, longer interval between successive arousals in prone, which may, in part, explain the increase in risk of Sudden Infant Death Syndrome.

Diffusion tensor brain imaging findings at term-equivalent age may predict neurologic abnormalities in low birth weight preterm infants.

BACKGROUND AND PURPOSE: Low birth weight preterm infants are at high risk of brain injury, particularly injury to the white matter. Diffusion tensor imaging is thought to be more sensitive than conventional MR imaging for detecting subtle white matter abnormalities. The objective of this study was to examine whether diffusion tensor imaging could detect abnormalities that may be associated with later neurologic abnormalities in infants with otherwise normal or minimally abnormal conventional MR imaging findings. METHODS: We prospectively studied 137 low birth weight (<1800 g) preterm infants. Neonatal conventional MR imaging and diffusion tensor imaging were performed near term-equivalent age before discharge, and neurologic development of the infants was later followed up at 18 to 24 months of age. RESULTS: Among the preterm infants who were fully studied, 63 underwent normal conventional MR imaging. Three of these infants developed cerebral palsy, and 10 others showed abnormal neurologic outcome. Diffusion tensor imaging results for these infants showed a significant reduction of fractional anisotropy in the posterior limb of the internal capsule in neurologically abnormal infants (including those with cerebral palsy) compared with control preterm infants with normal neurologic outcomes. CONCLUSION: These results suggest that neonatal diffusion tensor imaging may allow earlier detection of specific anatomic findings of microstructural abnormalities in infants at risk for neurologic abnormalities and disability. The combination of conventional MR imaging and diffusion tensor imaging may increase the predictive value of neonatal MR imaging for later neurologic outcome abnormalities and may become the basis for future interventional clinical studies to improve outcomes.

Cisapride associated with QTc prolongation in very low birth weight preterm infants.

OBJECTIVE: No systematic study has been performed to evaluate the effect of cisapride on the QT interval in premature infants. Cisapride, which has recently been withdrawn by the Food and Drug Administration and is no longer an approved therapy, was commonly used for preterm infant care to improve the advance of enteral feedings and to reduce reflux and associated apnea. Our aim was to evaluate the effect of recommended doses of cisapride on the QT interval in this population. STUDY DESIGN: Prospective blinded evaluation of electrocardiogram for QT, JT, QTc, and JTc measurements in 25 preterm infants before and after cisapride administration. RESULTS: Twelve of 25 infants (48%) developed repolarization abnormalities with cisapride administration: 32% of the infants (8/25) studied had QTc prolongation (>/=0.450 seconds), whereas 10/25 had JTc prolongation (>/=0.360 seconds). Preterm infants <32 weeks significantly prolonged their QTc interval from 0.41 +/- 0.02 to 0.44 +/- 0.02. The QTc and/or JTc was prolonged in 54% of infants receiving 0.1 mg/kg/dose and 42% receiving 0.2 mg/kg/dose. CONCLUSIONS: The QTc and JTc interval significantly prolonged in preterm infants <32 weeks on the recommended dose of cisapride therapy. A QTc >/=0.450 seconds developed in 32% of infants treated with cisapride, whereas the JTc prolonged in 40%. A significant percentage of infants (54%) developed prolonged QTc intervals at a dose of 0.1 mg/kg/dose. From these data we conclude that there is a higher risk of prolongation of the QTc interval and risk of arrhythmias with greater prematurity.

Cisapride decreases gastroesophageal reflux in preterm infants.

OBJECTIVE: Gastrointestinal prokinetic agents, such as cisapride, are commonly used in pediatric practice to improve gastric emptying, to decrease emesis, to improve lower esophageal sphincter tone, and to improve irritability and feeding aversion associated with gastroesophageal reflux (GER). Although cisapride seems to be effective in infants from 2 months to 14 years old, data for younger and preterm infants are not available. Whether reflux is a significant cause of reflex apnea or feeding intolerance in the preterm infant is controversial. The objective of this 1-year prospective study, started in 1998, was to determine the efficacy of cisapride for treatment of reflux and reflux-associated apnea (RAAP) in preterm infants. Before this study, the diagnosis of reflux was often made clinically and the effect of therapy on reflux or the decision to increase the dose of cisapride was made empirically. The clinical bias was that persistent apnea, not responding to caffeine, was caused by GER. We reasoned that a systematic approach to the diagnosis and treatment of reflux would improve the care of preterm infants and reduce the risk of toxicity, especially if an increased dose of cisapride showed no improvement in reflux or apnea. STUDY DESIGN: Twenty-four preterm infants (24-36 weeks' gestational age) had clinical apnea/pH studies when they were referred by the attending neonatologist for suspected GER. These infants were born at 28.8 +/- 3.1 weeks with birth weight of 1169 +/- 387 g (range: 631-2263 g). Each infant was studied before and 8 days after starting cisapride treatment. Cisapride dose was 0.09 to 0.25 mg/kg every 6 hours enterally. Treatment decisions regarding dose of cisapride were the responsibility of the attending neonatologist. The pH was recorded continuously for 24 hours at 0.25 Hz and was analyzed using EsopHogram software. A single sensor pH catheter was inserted to ~2 cm above the esophageal gastric junction. GER was defined as a drop in esophageal pH below 4.0 for a least 5 seconds, or pathologic GER was defined as a reflux index (RI) >2 standard deviation (SD) from the mean based on published norms for term infants. The following parameters were calculated from the pH recording: number of reflux events per 24 hours, duration of the longest episode, number of episodes >5 minutes per 24 hours, and RI, ie, percentage of time with pH <4.0. Each study had a combined time-lapse video recording and multichannel digital recording. Recorded parameters were: continuous pulse oximetry, electrocardiogram, respiratory effort (piezo sensor), and airflow (temperature sensor at nostrils and mouth). The recording was scored for central apneas of 10 to 14 seconds and >/=15 seconds (prolonged) and >/=10 seconds for obstructive and mixed apneas. RAAP was scored when an apnea (irrespective of the type) occurred within 1 minute of a GER event. Baseline, after cisapride, and follow-up electrocardiograms were performed because of concern about prolonged QTc and cardiac arrhythmias. The infants were 35.6 +/- 4.5 weeks postconceptional age when first studied. Twelve infants (mean birth weight: 1821 +/- 749 g; gestational age: 32 +/- 2 weeks; postconceptional age: 35.6 +/- 2.6 weeks) were identified retrospectively as controls because their baseline GER parameters were within the normal range using Vandenplas' criteria. RESULTS: Overall, cisapride treatment significantly improved the RI from 16.6 +/- 15.2 to 9.1 +/- 8.4 SD. The number of reflux episodes >/=5 minutes was reduced from 7.1 +/- 5.8 to 4.3 +/- 4.4 SD. No significant effect was seen on the total number of refluxes (/24 hours). Eight infants (33%) had no decrease in the RI after a week of treatment. Three of these infants improved after cisapride dose was increased from 0.09 to 0.25 mg/kg/dose every 6 hours. Although 0.09 mg/kg/day is the minimum effective dose, 67% of our infants did respond to this low dose. Cisapride was discontinued in 3 infants because of prolonged QTc >/=0.450 seconds (0.473 in 1 and 0.470 in 2). More data about the effect of cisapride on QTc interval are reported in Pediatrics in a separate article. Only 1 infant showed no improvement with increased dose. Caffeine treatment had no effect on the baseline or follow-up GER values. Although apnea indexes for central and obstructive apnea were similar before and after cisapride, mixed apnea was less during treatment. There was a significant decrease (0.32 +/- 0.40 to 0.12 +/- 0.17/hour) in RAAP when the one infant who had increased reflux on increased dose of cisapride was excluded as an outlier. The statistical difference, before and after cisapride, for the group is significant with the outlier omitted. The clinical significance is unclear because ~50% of the infants had minimal changes in their apnea indexes. Furthermore, ~40% of infants did not have RAAP. (ABSTRACT TRUNCATED)

Growth, neurobehavioral and circadian rhythm development in newborn baboons.

We measured body temperature continuously using telemetry to determine the development of circadian rhythmicity in neonatal baboons after birth. Twelve fetal baboons (nine males and three females) of known gestational age ranging from 167 to 193 d were studied. We eliminated the influence of maternal factors by hand rearing these infants from the moment of birth until 45 d of life. All infants showed steady growth in body weight, head circumference, and crown-rump length. Neurobehavioral responses including visual and auditory orientation, motor maturity, irritability, and consolability increased as a function of age. Circadian rhythms of body temperature were present in the second week of life, and the amplitude of this rhythm increased throughout the developmental period studied. The increase in the amplitude of circadian body temperature rhythm independent of environmental time cues may indicate the maturation of the brain. These neonatal nonhuman primates offer an excellent model for studying neurobehavioral development and maturation of circadian rhythms while controlling external factors in a manner that is not possible with human neonates.

The hour of birth: comparisons of circadian pattern between women cared for by midwives and obstetricians.

OBJECTIVE: To examine the difference, if any, between midwives' care and obstetricians' care in the circadian pattern of the hour of birth in spontaneous labour and delivery. DESIGN: A descriptive study comparing the circadian pattern of the hour of birth between women cared for by a midwife or an obstetrician. SETTING: Data were derived from the Perinatal Database of the Netherlands (LVR), comprising 83% of all births under midwives' care and 75% of all births under obstetricians' care. SUBJECTS: 57,871 women receiving midwives' care and 31,999 women receiving obstetricians' care with spontaneous labour and spontaneous delivery. MAIN OUTCOME MEASURES: Differences in the circadian rhythms between women receiving midwives' care and obstetricians' care. FINDINGS: There was a difference in the circadian pattern of the hour of birth between midwives' and obstetricians' care. Peak times differed 5.43 hours (CI 4.23-7.03) for primiparous and 3.34 hours (CI 3.00-4.08) for multiparous women between the midwives' group and the obstetricians' group. CONCLUSION: This study demonstrates a remarkable difference in circadian pattern of the hour of birth between midwives' care and obstetricians' care. In obstetricians' care the duration of normal labour appears to be prolonged, presumably by an increased level of stress. In normal birth the care of midwives is preferable.

Influence of light in the NICU on the development of circadian rhythms in preterm infants.

The fetal biological clock is an endogenous clock capable of generating circadian rhythms and responding to maternal entraining signals. By at least the third trimester of pregnancy fetal diurnal rhythms are entrainable by maternal day-night rhythms. Maternal illness during pregnancy and premature birth are obvious clinical factors that may adversely affect circadian rhythm development. Premature birth of the fetus has a most dramatic impact on maternal fetal interactions. The effect on biorhythms appears to be temporary and is greatest on the most immature infants. The results to date support the importance of fetal circadian rhythms and the relative lack of these rhythms in the preterm infant. It is well known that growth and development in the prematurely born infant are influenced by a multitude of factors; clearly, the neonatal intensive care unit is not a surrogate for the maternal placental unit. This article reviews what is known about circadian development in the human infant with an emphasis on the unique circumstances of the preterm infant. The research on the short- and long-term effects of environmental interventions on circadian, sleep, and neurologic development is discussed. Although an earlier onset of circadian development did not result with cycled lighting in the neonatal nursery, there may still be important biological effects that have not been studied. There are sufficient data to state that there is no reason for continuing a chaotic, noncircadian environmental approach for the care of the prematurely born infant.

Predictive value of neonatal neurological tests for developmental outcome of preterm infants.

BACKGROUND: There is a need to identify, as early as possible, infants who are at risk for long-term neurological morbidity. METHODS: To predict neurodevelopment outcome of preterm infants <30 weeks' gestation in a population of 100 infants, we used several neonatal and neurobehavioral tests, including cranial ultrasonography, the Prechtl neurological test, quality of spontaneous general movements, and quality of sleep-wake organization. RESULTS: The Prechtl test at corrected term age and findings on cranial sonograms both had high specificity, but the Prechtl test had better overall positive predictive power for normal neurological and developmental outcomes at 2 years' corrected age. Developmental changes in sleep and the amount of indeterminate sleep did not correlate with outcome. Scoring general movement quality did not predict outcome and did not augment the positive predictive power of the Prechtl test. CONCLUSIONS: The Prechtl test at corrected term age (independent of the other tests) is the best positive predictor of normal neurological outcome and Bayley test results at 2 years' corrected age.

Effects of prone and supine position on sleep characteristics in preterm infants.

The purpose of this study was to address the influence of sleep position on sleep characteristics in preterm infants. We studied 16 infants at a mean post-conceptional age of 36.5 weeks. Infants were successfully recorded with videopolysomnograph in the supine and prone position. Between the two positions, there were no significant differences in percentage of active sleep and quiet sleep (QS), the occurrence of arousal, and the incidence of apnea. The first QS after the feeding was longer in the prone position. The sleep position could affect sleep characteristics but not respiratory characteristics in preterm infants.

Effects of skin-to-skin holding on general movements of preterm infants.

The study objective was to test the hypothesis that the effect of skin-to-skin (STS) holding increases the ratio of rest to activity in low birth weight preterm infants. Ten infants with birthweight < 2,000 grams were videotaped before and after STS holding. Video recordings were analyzed to determine the number of general movements. We found no statistically significant difference between the percentage of general movements over the two periods. We conclude that the ratio of rest-activity before and after STS holding does not change as measured by occurrence of general movements.

Dietary 18:3n-3 and 22:6n-3 as sources of 22:6n-3 accretion in neonatal baboon brain and associated organs.

The bioequivalence of dietary linolenic acid (LNA) and docosahexaenoic acid (DHA) for brain DHA accretion was measured in neonatal baboons at 4-6 wk of age using stable isotope tracers. Neonates consumed a conventional U.S. term-infant formula devoid of long chain polyunsaturates and with an n-6/n-3 ratio of about 10:1. At 4 wk of age, neonates were dosed with either 13C LNA or 13C DHA. At 6 wk of age, neonate brain, retina, and other organs were harvested for fatty acid and isotopic analyses. The relative accretion of labeled DHA was 7-fold greater as a percentage of dose for the DHA-dosed animals compared to the LNA-dosed animals. The baboon is an omnivore that regularly consumes meat and insects; its plasma lipid profile responds similarly to humans in response to changes in feeding and living habits. These observations suggest that the baboon is a suitable model for human unsaturated fatty acid studies.

More awakenings and heart rate variability during supine sleep in preterm infants.

OBJECTIVE: The Task Force of The American Academy of Pediatrics (1996) recommends the nonprone sleeping position for asymptomatic preterm infants to prevent sudden infant death syndrome. The mechanism by which the nonprone sleeping position reduces the rate of sudden infant death syndrome is unclear for full-term infants and the precise effect of sleeping position on sleep and cardiorespiratory characteristics has never been addressed in preterm infants. The purpose of the present study was to clarify the effect of sleeping position on sleep and cardiorespiratory characteristics in preterm infants at an age when they are ready for discharge. STUDY DESIGN: Sixteen asymptomatic preterm infants were studied in both supine and prone sleeping positions at 36.5 +/- 0.6 weeks' postconceptional age using videosomnography. Sleep, respiratory, and heart rate characteristics were compared between the two positions using each infant as his/her own control. RESULTS: More awakenings (ie, arousals >/=60 seconds) were seen during all sleep states in the supine sleeping position but overall the total sleep and percent sleep state were not affected by sleeping position. After each feeding, the first quiet sleep was significantly shorter, with more heart rate variability and awakenings in the supine position. There were no significant differences in the occurrence of arousals (<60 seconds) or the incidence or severity of apnea and periodic breathing. No clinically significant apnea (>/=15 seconds), bradycardia, or oxygen desaturations were seen. CONCLUSION: In 36-week-postconceptional age preterm infants, the supine sleeping position had less quiet sleep and was associated with greater heart rate variability during the first sleep cycle after the feeding. More awakenings were seen during all sleep states in the supine position. These data support the American Academy of Pediatrics recommendation for "Back to Sleep" for asymptomatic preterm infants because more awakenings and lower threshold for arousal may provide some benefit for the infant responding to a life-threatening event. However, further studies are needed to address positional effect on the physiologic measures in preterm infants at older ages (later stages of development). Precisely what constitutes the most healthy or advantageous sleep for newborn infants remains an important question.

Bioequivalence of dietary alpha-linolenic and docosahexaenoic acids as sources of docosahexaenoate accretion in brain and associated organs of neonatal baboons.

The dietary bioequivalence of alpha-linolenic (LNA) and docosahexaenoic acids (DHA) as substrates for brain and retinal n-3 fatty acid accretion during the brain growth spurt is reported for neonatal baboons who consumed a long-chain-polyunsaturate free commercial human infant formula with a n-6/n-3 ratio of 10:1. Neonates received oral doses of 13C-labeled fatty acids (LNA*) or (DHA*) at 4 wk of age, and at 6 wk brain (occipital cortex), retina, retinal pigment epithelium, liver, erythrocytes, and plasma were analyzed. In the brain, 1.71% of the preformed DHA* dose was detected, whereas 0.23% of the LNA* dose was detected as DHA*, indicating that preformed DHA is 7-fold more effective than LNA-derived DHA as a source for DHA accretion. In LNA*-dosed animals, DHA* was greater than 60% of labeled fatty acids in all tissues except erythrocytes, where docosapentaenoic acid was 55%. Estimates using dietary LNA levels as tracees indicate that brain turnover of DHA is less than 5% per week between weeks 4 and 6 of life. For retina and retinal pigment epithelium, preformed DHA was at levels 12-fold and 15-fold greater than LNA-derived DHA. Liver, plasma, and erythrocytes ratios were 27, 29, and 51, respectively, showing that these pools do not parallel tissue metabolism of a single dose of omega-3 fatty acids. The distributions of labeled fatty acids for LNA*-dosed animals were similar, in the order DHA > DPA > EPA > LNA, except for erythrocytes where docosapentaenoic acid predominated. These are the first direct measurements of the bioequivalence of DHA and LNA in neonatal primate brain and associated tissues.

Development of macronutrient composition of very preterm human milk.

The effects of gestational age at delivery (GA), postnatal age (PNA) and post-menstrual age (PMA = PNA + GA, an indicator of autonomous developmental processes not affected by the moment of birth) on macronutrient composition of very preterm milk were studied. Total N, fat, lactose and carbohydrate concentrations, energy density and 24 h volume were determined in 282 24 h milk samples collected at weekly intervals (days 7-55 of lactation) from seventy-nine women delivering their babies between 25 and 29 weeks of gestation. GA related differences were found for carbohydrate concentration only: carbohydrate concentration was lower with increasing GA. PNA was related to a decrease in total N and an increase in lactose concentration. PMA was not related to milk composition. Our data indicate that PNA strongly influences the development of the composition of very preterm human milk, while GA affects carbohydrate content with a negligible effect on the nutritional value of the milk. We conclude that in accordance with current opinion in paediatrics, human milk is the best source of nutrients even for very preterm (< 30 weeks GA) infants.

Membrane properties and morphology of vasopressin neurons in slices of rat suprachiasmatic nucleus.

Vasopressin (VP) neurons in the suprachiasmatic nucleus (SCN) are thought to be closely linked to neural mechanisms for circadian timekeeping. To gain insight into the cellular-physiological principles that govern spike-driven VP release and to examine whether VP cells can be electrophysiologically and morphologically identified by a unique combination of features, we recorded membrane properties by whole cell patch-clamp methods and stained the cells with biocytin. In current-clamp mode, VP neurons recorded during subjective daytime expressed a clear time-dependent inward rectification but no pronounced low-threshold Ca2+ potential after hyperpolarizing current pulses. Their spontaneous firing rate varied between 0.6 and 13.4 Hz and was generally tonic and irregular. Spike afterhyperpolarizations (AHPs) were steeply rising and monophasic. Spikes were preceded by depolarizing ramps mediated by a slow component of Na+ current. Spike trains evoked by depolarizing current pulses displayed frequency adaptation and were usually followed by an AHP lasting 0.5-2.0 s. Spontaneous postsynaptic potentials were present in a majority of cells. Voltage-clamp recordings revealed a Ba2+-sensitive K+ current that exerts a tonic, hyperpolarizing influence on the membrane potential. This set of membrane properties was not significantly different from other cells in the dorsomedial region and is characteristic for cluster I cells, which were described previously and are widely encountered throughout the SCN. None of the cells could be classified as belonging to cluster II or III, which were indeed found mainly outside the dorsomedial region. Morphologically, single VP neurons were characterized by compact, mono- or bipolar dendritic branching patterns and numerous varicosities throughout the dendrites. They generally possessed few axon collaterals, most of which remained inside the boundaries of the SCN but were occasionally seen to project to SCN target areas. In conclusion, VP neurons in the SCN express several active membrane poperties, including time-dependent inward rectification, frequency adaptation in spike trains, monophasic spike AHPs, and Ba2+-sensitive K+ current. VP release is proposed to be governed by tonic and irregular patterns of spontaneous firing. The electrophysiological and cytological properties of VP neurons are representative for a majority of SCN cells and define them as a subset of previously defined cluster I cells.

Survey of sleeping position after hospital discharge in healthy preterm infants.

OBJECTIVE: To evaluate the prevalence of nonprone (supine or side) versus prone sleeping position in healthy preterm infants. STUDY DESIGN: A questionnaire on sleeping position was mailed to mothers of 167 preterm infants discharged from the intermediate nursery at Packard Children's Hospital at Stanford. The prevalence of nonprone sleeping at 1 month (term corrected age) and 3 months (2 months corrected age) after nursery discharge was analyzed by an unpaired t test. RESULTS: Nonprone position sleeping occurred in 64% initially and dropped to 35% at 2 months corrected age. CONCLUSIONS: Overall, nonprone sleeping was widespread in our healthy preterm infants after hospital discharge but may not persist. A majority of these infants were sleeping prone during a high-risk period for sudden infant death syndrome.