SCH Medics Journal Club Unexpected collapse in apparently healthy newborns – a prospective study of a missing cohort of neonatal deaths and near death events Steph Borg 17 May 2012

SUPC is rare in infants –How often does it occur? –What are the causes? Jessop guidelines include –Immediate care of the newborn –Bed sharing and co-sleeping guideine

Sudden OR unexpected AND Neonatal OR postnatal AND Collapse or death Limit to English Language and humans and age <1 month 199 results Search

Unexpected collapse in apparently healthy newborns – a prospective study of a missing cohort of neonatal deaths and near death event J-C Becher, S Bhushan & A Lyon Arch Dis Child Fetal Neonatal Ed :F30-F34 Result

Analysis

“We sought to establish the population incidence of sudden unexpected postnatal collapse (SUPC) in apparently healthy infants within the UK to describe situational factors and the cause for collapse was determined” Population – –infants ≥37/40 –Apgar score of ≥ 8 at 5mins –Collapse within 12hrs of birth in hospital requiring resuscitation with PPV and died or received ongoing intensive care Analysis

Risk factors –Maternal sedation –Breastfeeding/prone position –Unattended –Underlying disease/pathology Outcomes –Incidence of death and collapse –Identification of cause of death –Neurological follow up at 1 year Analysis

Yes –A method of establishing an association between exposure and outcome by following a population over time Analysis

Cases referred to BPSU over 13 months Active surveillance via network of 3000 paediatricians Response rate 94.6% When cases identified further information collected from clinicians Could not verify if all cases reported Study incidence may be underestimate

Exposure to risk factors identified retrospectively from BPSU collected data Ix performed decided by clinical time at the time – not consistent Cases were anonymised to study team Analysis

Study incidence may be underestimated 4 excluded cases due to uncertain eligibility Ix to cause of collapse not always successful –1 death – no cause found and no PM –5 cases no cause identified Clinical judgment of cause where no objective cause identified Outcome data for all surviving cases available Analysis

All infants surviving to discharge followed up at 1 yr with neurological assessment Is age 1 yr too early to assess for long term developmental/neurological outcome?

Results 91 cases referred, 32 errors 10 duplications 4 excluded 45 infants of SUPC included 12 (27%) died 33 survived to discharge Population incidence of SUPC in first 12 hours 0.05/1000 (1 in 19000) term live births Mortality 0.01/1000 (1/72000) term live births Where no underlying disease or abnormality id’d population incidence 0.035/1000 (1/29000) term live births

Characteristics of mother, labour and delivery –Infants with an underlying condition (n=15) 10 (67%) primiparous Non smokers and healthy 6 SVD, 3 instrumental, 6 LSCS –Infants without an underlying condition (n=30) 23 (77%) primiparous 2 smokers, 4 PIH, 8 health professionals Results

Characteristics of infant –22 (49%) male –Mean gestational age 40/40 (range weeks) –Mean birthweight 3328g (range 2260g-4030g) –Apgar of 8 or above at 5 mins –Routine postnatal care Results

No underlying disease/abnormality determined 30 infantsDiedAbnormal neurologic al examinatio n by 1 yr Apparent accidental suffocation during breast feeding or skin-to-skin 24 (80%)55 No cause identified6 (20%)10 Disease or abnormality15 infants Bacterial pneumonia/sepsis (2 GBS, 3 culture –ve) 521 Cardiac (TGA, hypoplastic left heart)220 Metabolic disorder (Zellweger’s, unidentified)211 Intracranial haemorrhage/infarcation201 Meconium aspiration syndrome200 Severe chronic anaemia (parvovirus)110 Congenital diaphragmatic hernia100 Results – causes of collapse

Details of CollapseUnderlying condition (15) No underlying condition (30) Age in minutes (median(range))195 (10-688)70 (6-643) Collapse in first 2h7 (47%)22 (73%) Baby in care of mother/parents at collapse 1324 Mother alone in room at time of collapse mother recognised baby unwell 7 3 (43%) 10 2 (20%) Parents alone in room at time of collapse parents recognised baby unwell 1 1 (100%) 7 5 (71%) Clinical staff in room at time of collapse staff first to recognise baby unwell 7 7 (100%) (100%) Position of baby mother’s breast/chest abdomen3 (20%)18 (60%) arms3 (20%)9 (30%) in cot (1 prone)6 (40%)3 (10%) uncertain position3 (20%)0

All infants required PPV 22 received CPR 10 received resuscitation drugs 2 died immediately –1 sepsis –1 TGA 43 admitted to neonatal unit –Median pH within 1 hr 6.98 ( IQR ) –Median base deficit 17.7mmol/l (IQR ) –23 multiorgan dysfunction –17 single organ dysfunction Results – Following collapse

Results – infants w/o underlying condition

12/45 infants died 10/12 underwent postmortem –Underlying cause found in 5 (50%) 2 sepsis; TGA; unidentified metabolic condition; parvovirus –No underlying cause found Apparent asphyxiation as per pathologist/clinician 2/10 no PM –hyoplastic left heart on echo pre mortem –collapse following presumed suffocation – consent for PM not given Results - deaths

33/45 survived to discharge –8 (24%) neurological abnormalities at 1yr f/u 3 had underlying cause for collapse identified Zellweger’s syndrome Cerebral infarction Culture negative sepsis Results - survivors

30 infants with no underlying cause/disease 19/24 presumed accidental suffocation survived to discharge –5 had neurological abnormality at 1 yr f/u 3 with cerebral palsy 1 with probable cerebral palsy 1 with mild global delay and hypotonia 6 infants with no cause identified normal at follow up –(but 1 died..) Results – survivors

There is no statistical analysis in this study Results

Results as accurate as medical records kept Clinical decisions on cause of collapse may be subjective 6/45 infants no cause for collapse identified Results

Yes – Jessop provides care to term babies with Apgars >8 at 5 mins Currently have pathways in our guidelines re –Co-sleeping and bed sharing –Prevention, detection and management of known risks of hypoglycaemia, GBS Will the results help me locally

The first study to document the population incidence in the UK of SUPC in infants assessed as being healthy at birth Previous case series document risks of accidental suffocation