Reply

Abstract

We appreciate the opportunity to respond to the comments of Drs Bartick and Feldman-Winter concerning our recent publication on trends in newborn sudden unexpected infant deaths (SUID). They state that we concluded “an increase in suffocation deaths is due in part to skin-to-skin care (SSC) and resultant sudden unexpected postnatal collapse (SUPC).” We actually noted that the decrease in SUID that occurred in the postneonatal period before 2002 did not occur in neonates and that SUPC may have contributed to that outcome. The association of SSC to SUPC is well-established1Herlenius E. Kuhn P. Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks and preventive measures.Transl Stroke Res. 2013; 4: 236-247Crossref PubMed Scopus (77) Google Scholar and has been clearly recognized by the American Academy of Pediatrics.2Goldsmith J.P. Hospitals should balance skin-to-skin contact with safe sleep practices.AAP News. 2013; 34: 22Google Scholar, 3Feldman-Winter L. Goldsmith J.P. American Academy of Pediatrics Committee on Fetus and Newborn, Task Force on Sudden Infant DeathSafe sleep and skin-to-skin care in the neonatal period for healthy term newborns.Pediatrics. 2016; 138 (e20161889)https://doi.org/10.1542/peds2016-1889Crossref PubMed Google Scholar The correspondents also imply that our data do not support a significant contribution of SUPC to the SUID deaths in newborns. We believe it does. As we stated in the article, although there is no specific International Classification of Diseases code for SUPC, deaths owing to SUPC conform to the definition of SUID put forth by the Centers for Disease Control and Prevention. Although hospital location is not a required criterion for SUPC, it has been most frequently associated with the birth hospital stay. We aggregated the data by the first hour, day, and week of life because we believe that the closer the death to the time of birth, the more likely these events would occur in hospital. We agree that SUID involving infants of ≤35 weeks' gestational age warrants further investigation and have suggested that national registries should be developed to help better understand and track these events at all gestational ages. Drs Bartick and Feldman-Winter suggest that diagnostic shift may be responsible for the observed neonatal SUID rates. The inclusion of all International Classification of Diseases codes for SUID in the data we reported makes that very unlikely. They also contend that demographic confounding occurred, which diminishes the validity of our conclusions. We explicitly note in our article that other variables are important factors related to SUID. These variables may be even more consequential when making transnational comparisons among countries with significantly varied high-risk demographic groups. The International Classification of Diseases comparisons the correspondents present in Table I are also inherently inaccurate given the coding inconsistencies noted in the source they cite.4Taylor B.J. Garstang J. Engelberts A. Obonai T. Cote A. Freemantle J. et al.International comparison of sudden unexpected death in infancy rates using a newly proposed set of cause-of-death codes.Arch Dis Child. 2015; 100: 1018-1023Crossref PubMed Scopus (65) Google Scholar In relation to Table II, we agree that New Zealand has made impressive improvements, which we cited in our report. It should be recognized that these efforts included a Ministry of Health consensus statement recognizing the risk of sudden unexpected early neonatal death associated with SSC. The correspondents also refer to the Swedish experience, including an early death in which a newborn was found lifeless when a mother fell asleep while breastfeeding,5Mollborg P. Wennergren G. Almqvist P. Alm B. Bed sharing is more common in sudden infant death syndrome than in explained sudden unexpected deaths in infancy.Acta Paediatr. 2015; 104: 777-783Crossref PubMed Scopus (23) Google Scholar another well-recognized risk factor for SUPC.1Herlenius E. Kuhn P. Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks and preventive measures.Transl Stroke Res. 2013; 4: 236-247Crossref PubMed Scopus (77) Google Scholar, 3Feldman-Winter L. Goldsmith J.P. American Academy of Pediatrics Committee on Fetus and Newborn, Task Force on Sudden Infant DeathSafe sleep and skin-to-skin care in the neonatal period for healthy term newborns.Pediatrics. 2016; 138 (e20161889)https://doi.org/10.1542/peds2016-1889Crossref PubMed Google Scholar The Swedish authors state that this demonstrated the need for caution when the infant is in the skin-to-skin position. Drs Bartick and Feldman's claim that this was the only documented SUPC hospital death in Sweden related to SSC from 2005 to 2011 cannot be substantiated, because the report they cited does not provide the day of life of each death and, more to the point, hospital practice of SSC was not included in the list of factors that were systematically analyzed.5Mollborg P. Wennergren G. Almqvist P. Alm B. Bed sharing is more common in sudden infant death syndrome than in explained sudden unexpected deaths in infancy.Acta Paediatr. 2015; 104: 777-783Crossref PubMed Scopus (23) Google Scholar Swedish researchers have actually been among the leading proponents of the risk of SUPC associated with SSC.1Herlenius E. Kuhn P. Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks and preventive measures.Transl Stroke Res. 2013; 4: 236-247Crossref PubMed Scopus (77) Google Scholar This includes an investigation of 26 cases of SUPC survivors in 30 months in a Stockholm delivery center, reporting on the use of hypothermia treatment to mitigate the impact of SUPC and noting the need for safety measures during SSC.6Pejovic N.J. Herlenius E. Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment.Acta Paediatr. 2013; 102: 680-688Crossref PubMed Scopus (71) Google Scholar As Drs Bartick and Feldman state, Sweden has universal Baby Friendly implementation, which is associated with higher rates of SSC. Based on the experience of Stockholm University Hospitals representing one-quarter of all Swedish births, the Swedish rate of SUPC after widespread implementation of early SSC, was found to be 10 times the national surveillance rates reported by the United Kingdom and Germany,1Herlenius E. Kuhn P. Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks and preventive measures.Transl Stroke Res. 2013; 4: 236-247Crossref PubMed Scopus (77) Google Scholar, 6Pejovic N.J. Herlenius E. Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment.Acta Paediatr. 2013; 102: 680-688Crossref PubMed Scopus (71) Google Scholar which have far lower Baby Friendly designation rates (Figure). In addition, despite the substantial decline of sudden infant death syndrome in Sweden, the Swedish National Board of Health and Welfare has updated its sudden infant death syndrome preventive recommendations to address safe sleep issues, including suffocation related to SSC.7Wennergren G. Nordstrand K. Alm B. Möllborg P. Öhman A. Berlin A. et al.Updated Swedish advice on reducing the risk of sudden infant death syndrome.Acta Paediatr. 2015; 104: 444-448Crossref PubMed Scopus (21) Google Scholar Skin-to-skin care cannot be blamed for increase in suffocation deathsThe Journal of PediatricsVol. 200PreviewWe read with interest the report by Bass et al1; however, we believe the data presented are insufficient to support the authors' conclusions that an increase in suffocation deaths is due, in part, to skin-to-skin care (SSC) and resultant sudden unexpected perinatal collapse. Full-Text PDF