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Use of Fan During Sleep and the Risk of Sudden Infant Death Syndrome De-Kun Li, MD, PhD Division of Research Kaiser Permanente Oakland, California March 24, 2009
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Background What do we know about SIDS etiology? Heterogeneity in etiology – diagnosis by exclusion
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Underlying Biological Susceptibility Underlying Biological Susceptibility Brain Stem Heart Problem Environmental Triggers Environmental Triggers Sleep Environment Air Pollution SIDS RISK First 9 months SIDS RISK WITH AGE Infections
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Brain Stem Deficiency Brain Stem Deficiency Resuscitation Capability Thermoregulation Prenatal Exposure Prenatal Exposure Genetic Factors? Genetic Factors? Gestational Diabetes Gestational Diabetes Preeclampsia Infection Maternal smoking Maternal smoking
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Sleep Environment Sleep Environment Sleep Position Pacifier Use Soft Bedding Fan Use Bed Sharing
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Background Sleep environment matters Oxygen deprivation CO 2 re-breathing? Thermal factor? Other factors?
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Objectives To examine whether use of a fan in the room impacts the risk of SIDS To examine whether any other factors influence the relationship between use of a fan and the risk of SIDS To examine whether opening of a window also has a similar effect on the risk of SIDS as use of a fan
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Study Design Population-based case-control study Study population All confirmed SIDS cases in 11 counties in California Infant age-, ethnicity-matched controls in the same county English or Spanish speaking Participation rate: 50% in cases and 41% in controls
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Study Design In-person interview Use of a fan during the last sleep Sleep positions Sleep environment (co-sleep, pacifier, etc) Other risk factors for SIDS
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Statistical analysis Logistic regression to adjust for confounders Stratification for evaluating interaction Comparison with birth certificate data to assess participation bias
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Table 1. Characteristics of the Study Population Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI)* N (%) Maternal Characteristics Race/ Ethnicity White59 (31.9)119 (38.1)1.00 † Black34 (18.4)59 (18.9)0.96(0.52, 1.76) Latino61 (33.0)98 (31.4)1.22(0.67, 2.19) Other31 (16.8)36 (11.5)2.23(1.13, 4.39) Age (years) < 2025 (13.5)27 (8.7)1.80(0.88, 3.70) 20 - 2455 (29.7)54 (17.3)1.86(1.12, 3.09) ≥ 25 105 (56.8)231 (74.0)1.00 †
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Table 1. Characteristics of the Study Population (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI)* N (%) Maternal Characteristics (cont.) Education ≤ 12 113 (61.1) 141 (45.2)1.31(0.81, 2.13) > 1272 (38.9)171 (54.8)1.00 † Marital Status Married93 (50.3)206 (66.0)1.00 † Cohabiting61 (33.0)72 (23.1)1.49(0.87, 2.52) Single31 (16.8)34 (10.9)1.79(0.93, 3.47) Region Northern CA 115 (35.3) 211 (64.7)1.00 † Southern CA 70 (40.9) 101 (59.1)1.07(0.68, 1.68)
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Table 1. Characteristics of the Study Population (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI)* N (%) Maternal Characteristics (cont.) Parity (Prior To Index Birth) 0 57 (30.81)132 (42.3)1.00 † 1 69 (37.3)96 (30.8)1.51(0.91, 2.51) 2 32 (17.3)52 (16.7)1.46(0.77,2.80) ≥ 3 27 (14.6)32 (10.3)2.16(1.02, 4.59) Smoked During Pregnancy No 137 (74.5)265 (85.2)1.00 † Yes 47 (25.4)46 (14.8)1.91(1.14, 3.28) Wks Gestation at First Prenatal Visit < 12 120 (65.6)238 (77.8)1.00 † ≥ 12 63 (34.4)68 (22.2)1.59(1.00, 2.53)
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Table 1. Characteristics of the Study Population (Cont.) Characteristic CasesControls ( n = 185)(n = 312)aOR (95% CI)* N (%) Infant Characteristics Age (Months) < 2 45 (24.3)62 (19.9)1.57(0.87, 2.81) 2 - 3 90 (48.7)155 (49.7)1.08(0.66, 1.76) ≥ 4 Months 50 (27.0)95 (30.5)1.00 † Birth Weight (Grams) ≥ 2500 148 (81.8)297 (95.5)1.00 † < 2500 33 (18.2)14 (4.5)4.90(2.34, 10.26) Infant Health During Previous 48 Hours No Illness 107 (58.5)196 (62.8)1.00 † Sick, No Fever 67 (36.6)109 (34.9)1.20(0.78, 1.85) Sick with Fever9 (4.9)7 (2.2)2.6(0.84, 8.03)
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Table 1. Characteristics of the Study Population (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI)* N (%) Infant Characteristics (cont.) Premature (< 37 Wks Gestation) No 150 (81.2)287 (92.0)1.00 † Yes 35 (18.9)25 (8.0)2.96(1.58, 5.54) Sleep Environment Last Sleep Position On Back 52 (31.1)175 (56.1)1.00 † On Stomach or Side 115 (68.9)137 (43.9)2.74(1.79, 4.21) Used a Pacifier No 162 (95.9)236 (76.4)1.00 † Yes 7 (4.1)73 (23.6)0.10(0.04, 0.23)
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Table 1. Characteristics of the Study Population (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI)* N (%) Sleep Environment (cont.) Room Temp (°F) ≤ 70 96 (69.1)176 (61.5)1.00 † > 70 43 (30.9)110 (38.5)0.65(0.40, 1.06) Soft Bedding Under Infant No 125 (76.2)250 (80.4)1.00 † Yes 39 (23.8)61 (19.6)0.95(0.57, 1.59) Soft Sleep Surface No 153 (87.9)289 (93.2)1.00 † Yes 21 (12.1)21 (6.8)1.36(0.68, 2.71) Covers Over Head No 147 (88.6)297 (95.5) 1.00 † Yes 19 (11.5)14 (4.5) 3.13(1.40, 7.02)
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Table 1. Characteristics of the Study Population (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI)* N (%) Sleep Environment (cont.) Bed Sharing Status Slept Alone 103 (59.9)195 (67.2)1.00 † Slept with Parent(s) Only 45 (26.2)79 (27.2)1.01(0.61, 1.68) Slept with Non-Parent(s) # 24 (14.0)16 (5.5)2.86(1.35, 6.07) Regular Smoking in Home Postpartum No 164 (89.1)291 (94.2)1.00 † Yes 20 (10.9)18 (5.8)1.50(0.68, 3.31) * Odds ratio and 95% confidence interval adjusted for race/ethnicity, maternal age, education, region, smoking during pregnancy, infant age, birth year and last sleep position unless the variable itself was the exposure of interest. Maternal race/ethnicity, infant age at last sleep, and region are matching variables. † Reference group # Presence of other individuals (with or without parents)
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Table 2. Use of a Fan or having an open window in Relations to SIDS Risk* Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI) † N (%) Fan on in Room at Last Sleep No 161 (96.4)273 (88.4)1.00 ‡ Yes 6 (3.6)36 (11.7)0.28(0.10, 0.77) Window Open in Room at Last Sleep No 136 (84.0)232 (75.1)1.00 ‡ Yes 26 (16.1)77 (24.9)0.64(0.33, 1.21)
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Table 3. The Effect of Fan Use on SIDS Risk by Sleep Environment Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI) † N (%) Room Temperature Room Temperature ≤ 70° F at Last Sleep No Fan 91 (94.8)163 (93.1)1.00 ‡ Fan On 5 (5.2)12 (6.9)0.77(0.22, 2.73) Room Temperature > 70° F at Last Sleep No Fan 41 (97.6)88 (80.0)1.00 ‡ Fan On 1 (2.4)22 (20.0)0.06(0.01, 0.52)
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Table 3. The Effect of Fan Use on SIDS Risk by Sleep Environment (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI) † N (%) Window Closure Room with Window Closed at Last Sleep No Fan 132 (98.5)211 (91.0)1.00 ‡ Fan On 2 (1.5)21 (9.1)0.15(0.03, 0.71) Room with Window Open at Last Sleep No Fan 22 (84.6)62 (80.5)1.00 ‡ Fan on 4 (15.4)15 (19.5)0.73(0.17, 3.08) Placed on Back at Last Sleep No Fan 48 (94.1)156 (90.2)1.00 ‡ Fan On 3 (5.9)17 (9.8)0.84(0.21, 3.39) Placed Prone or on Side at Last Sleep No Fan 108 (97.3)117 (86.0)1.00 ‡ Fan on 3 (2.7)19 (14.0)0.14(0.03, 0.55)
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Table 3. The Effect of Fan Use on SIDS Risk by Sleep Environment (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI) † N (%) Bed Sharing Slept Alone at Last Sleep No Fan 93 (96.9)169 (86.7)1.00 ‡ Fan On 3 (3.1)26 (13.3)0.23(0.06, 0.90) Slept with Parents only at Last Sleep No Fan 44 (47.8)75 (94.9)1.00 ‡ Fan On 1 (2.2)4 (5.1)0.40(0.03, 4.68) Slept with Non-Parents at Last Sleep § No Fan 22 (95.6)11 (68.8)1.00 ‡ Fan on 1 (4.3)5 (31.3)0.15(0.01, 1.85)
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Table 3. The Effect of Fan Use on SIDS Risk by Sleep Environment (Cont.) Characteristic CasesControls (n = 185)(n = 312)aOR (95% CI) † N (%) Pacifier Use Used Pacifier at Last Sleep No Fan6 (85.7)65 (89.0)1.00 ‡ Fan On1 (14.3)8 (11.0)1.99(0.16, 24.4) No Pacifier Used at Last Sleep No Fan153 (96.8)206 (88.0)1.00 ‡ Fan On5 (3.2)28 (12.0)0.22(0.07, 0.69)
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Limitations Low participation rate l Adjustment for socio-demographic factors l Strong protective effect ---- strong participation bias l Compare to birth certificate data Recall bias? Adjusting for recall interval
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Comparison between Participants and Source Population
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Limitations Limited information related to fan use Duration Location Type of fan used (ceiling, floor, etc) Orientation of the fan (facing or away)
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Conclusions Use of fan in the sleeping room may reduce the risk of SIDS The finding is consistent with other known factors in the sleep environment that influence the SIDS risk Use of a fan could be another simple and effective way to further reduce SIDS
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