Regarding the apparent decrease in SIDS here is part of an editorial by Scripps Howard News Service published on October 12, 2007 which casts doubt on the often cited statistic that there has been an approximately 50% decline in SIDS since the Back to Sleep Campaign began in 1992:
“In the early '90s, the 'Back to Sleep' campaign was launched to persuade parents to have their newborns sleep exclusively on their backs. And the campaign appeared to have dramatic results, with authorities claiming that by 2004 SIDS deaths had fallen by more than half.
But an investigation by Scripps Howard News Service reporters Thomas Hargrove and Lee Bowman casts deep doubt on the accuracy of those figures. Because of sloppy procedures, manipulation of statistics and lack of standardization, the success of public health efforts against SIDS has been substantially overstated.
The harsh fact is that while deaths attributed to SIDS appear to have fallen dramatically, the overall number of sudden infant deaths has declined only slightly. Researchers believe that much of this apparent reduction is only on paper, what is called "code shifting." Instead of a diagnosis of SIDS, the death certificates now often list other, vaguer causes such as ‘threats to breathing’ or simply ‘undetermined cause.’
That would explain why 15 years ago SIDS was listed as the cause of 80 percent of sudden infant deaths versus just over 50 percent today. It also explains the wide disparity in SIDS diagnoses -- North Dakota reports four times the rate of New York -- and suggests that a finding of SIDS is often a function of geography, not medicine.”
http://www.sids-network.org/experts/scripps_editorial.htm
In addition to the editorial above here are three other reasons why I am skeptical that there has been a 50% decline in the rate of SIDS. In addition, these three reasons explain why that to the extent that there has been an actual decrease in the rate of SIDS I am skeptical that the increase in the back sleeping position is the primary factor for this decrease:
I. In 2002, smoking during pregnancy was reported by 11.4% of all women giving birth in the United States, a decrease of 38% from 1990, when 18.4% reported smoking (1). Considering that smoking has been shown to correlate with a 3 fold increase in the rate of SIDS (2) I think that the decrease in SIDS between 1990 and 2002 is at least partially attributable to the decrease in smoking rates during that time period.
II. Between 1996 and 2004 there was a 14% year over year increase in Accidental Suffocation and Strangulation in Bed (ASSB) according to a CDC report by Shapiro-Mendoza, et al. (3). WebMD interviewed Shapiro-Mendoza (4) regarding this story and here are two paragraphs from the article - Paragraph 1:"The decline in SIDS rates has been offset by an increase in other sudden unexplained infant deaths, a new category called SUIDs. ASSB death, a subgroup of SUIDs, is a leading cause of infant mortality, says Shapiro-Mendoza." Paragraph 2: "Shapiro-Mendoza tells WebMD that infant deaths attributed to ASSB increased from 2.8 to 12.5 deaths per 100,000 live births between 1984 and 2004. She says such deaths increased dramatically between 1996 and 2004 (14% average yearly increase), a period in which mortality attributed to SIDS declined."
III. Here are 2 paragraphs from a Scripps News Investigation published on October 8, 2007 and written by Hargrove and Bowman (5). Paragraph 1: "'A lot of us are concerned that the rate (of SIDS) isn't decreasing significantly, but that a lot of it is just code shifting,' said John Kattwinkel, chairman of the Centers for Disease Control and Prevention's special task force on SIDS." Paragraph 2:"Among the other findings of the Scripps investigation:-- In some states and counties, investigators are told not to issue a SIDS diagnosis if any other cause is suspected, causing the rate at which the syndrome is reported to the Centers for Disease Control and Prevention to plummet to just a fraction of the national average. Several large metro areas reported no SIDS cases during the five-year period even though there were dozens of sudden infant deaths."
References:
(1) Martin JA, et al.; Births: final data for 2002. Natl Vital Stat Rep 2003;52(10):1--113.
(2) MacDorman MF, et al.; Am J Epidemiol 1997; 146(3):249-257.
(3) Shapiro-Mendoz, et al; Am J Epidemiol. 2006 Apr 15;163(8):762-9
(4) Hendric, Bill. WebMD. Infant Suffocation Deaths are Rising. Website:(5) Bowman and Hargove. Scripps News Service. Saving Babies: Exposing Sudden Infant Death in America. Website:http://www.scrippsnews.com/node/27463http://www.webmd.com/parenting/baby/news/20090123/infant-suffocation-deaths-are-rising
Sunday, December 26, 2010
Infant Sleep Position and Motor Skills Delays
Since 1998 there have been several studies published which report that infants placed to sleep in the supine position lag in motor skills, social skills, and cognitive ability development when compared to infants who sleep in the prone position (1-3). A 1998 study (4) reported that prone sleeping infants slept an average of 225.2 hours more (8.3%) in their first 6 months of life than the supine sleeping infants and had statistically significant earlier milestone acquisition for creeps, crawls, pulls to stand, rolls prone to supine, and rolls supine to prone. In addition every other milestone tested was acquired faster by prone sleepers but the results were not statistically significant.
Another 1998 study analyzed the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort (5) and utilized the Denver Developmental Screening Test (DDST) to study infants at 6 and 18 months of age. According to this study, at 6 months of age, the infants who were placed to sleep in the prone position had statistically significant higher fine motor skills scores, gross motor skills scores, and total development scores than those infants who were put to sleep in the supine position. In addition prone sleepers had higher social skills scores and communication skills scores at both 6 and 18 months compared to supine sleeping infants. Finally, the total development scores of prone sleeping infants were still higher than supine sleeping infants at 18 months of age but were no longer statistically significant. The article concluded that:
“There is some evidence that putting infants to sleep in the supine position results in a reduced developmental score at 6 months of age, but this disadvantage appears to be transient.”
In addition the researchers stated:
“These findings would be disturbing for the Back to Sleep Campaigns around the world were it not for the findings at 18 months, by which time there were no statistically significant advantages for the prone (or varied) sleeper.”
Another study compared the motor skills of 71 supine sleeping 4 month old infants and 50 supine sleeping 6 month old infants to Alberta Infant Motor Scale (AIMS) and Peabody Developmental Motor Scale (PDMS) normative standards (6). Infants who slept in the prone position prior to 4 months of age were not included in this study. In this study 22% of supine sleeping infants at 6 months of age could sit without arm support versus 50% in the normative sample. In addition, 22% of the supine sleeping infants displayed gross motor delays. Older mothers had infants with lower motor skills scores and the researchers suggested that this may be due to older parents having more knowledge of avoiding the prone sleep position due SIDS education. One of the conclusions the researchers drew from this study was:
“…it may be necessary to re-normalize infant developmental assessments.”
In a March 2007 article entitled “New reference values for the Alberta Infant Motor Scale need to be established" (7) by Fleuren, et al. of the Erasmus MC Sophia Children’s Hospital in Rotterdam, Netherlands, the authors reported their analysis of the motor performance, using the AIMS scale, of 100 Dutch children. The AIMS scores used were developed by Piper and Darrah and calculated for Canadian Children between 1990 and 1992. It should be noted that the first infant supine sleep position campaign in Canada began in 1993 and these AIMS scores were calculated before Canada began it’s 1993 supine sleep campaign (8). Also, this study comes 20 years after the first supine sleep campaign began in the Netherlands in 1987 (9). According to the Fleuren, Smit, Stijnen, and Hartman study (10) the results showed that:
"The percentile scores of the group were significantly lower than scores of the Canadian norm population (p<.001), whereby 75% of the Dutch children scored below the 50th percentile. These lower scores were not explained by sex, racial differences or congenital disorders and were seen in all age groups."
The authors concluded that:
“We conclude that new reference values on the AIMS test for the age group of 0-12 months need to be established for Dutch children. It is recommended that the need for new normative data is also determined in all other European countries.”
According to the article “Motor Profile of Children with Developmental Speech and Language Disorders" (11) by Visscher, et al. 51% of children with Developmental Speech and Language Disorders ( DSLD’s) had definite or borderline motor problems.
Since the 1990’s there has also been a reported increase in the United States of cases of Plagiocephaly (12). In 1974, plagiocphaly was estimated to have occurred in one out of every 300 live births (13). Following the “Back To Sleep” campaign the occurrence of plagiocephaly increased to 1 in every 60 children (14) in 1996. In one study it was reported that this incidence level has increased to 1 in 12 infants (15). According to the paper “Prevention and Management of Positional Skull Deformities in Infants" (16) by Persing, et al:
“The increasing incidence of deformational plagiocephaly is likely related to the recommendation of the American Academy of Pediatrics (AAP) and others that infants be placed to sleep on their backs.”
In addition, in a 2004 reply (17) to a letter regarding this study Dr. Persing wrote:
“…we do not think the condition is as benign from a skull deformity and social/psychological standpoint as assumed in the past.”
According to the article “Neurodevelopmental delays in children with deformational plagiocephaly" (18) by Kordestani, et al.:
“Infants with deformational plagiocephaly were found to have significantly different psychomotor development indexes and mental developmental indexes when compared with the standardized population (p < 0.0001; p < 0.0001). With regards to the mental developmental index scores, none of the infants with deformational plagiocephaly were accelerated, 90 percent were normal, 7 percent were mildly delayed, and 3 percent were severely delayed. With regards to the psychomotor development index scores, none of infants were accelerated, 74 percent were normal, 19 percent were mildly delayed, and 7 percent were severely delayed.”
The authors concluded that prior to any intervention infants that have deformational plagiocephaly have significant delays in both psychomotor development and mental development. Other studies have reported that plagiocephaly is known to be associated with both visual impairments (19) and a high-risk of long-term difficulties due to cerebral dysfunction (20).
References
1. Majnemer A, Barr R. Influence of supine sleep positioning on early milestone acquisition. Developmental Medicine & Child Neurology. 2005;47:370-376
2. Davis B, Moon R, Sachs H, Ottolini M. Effects of Sleep Position on Infant Motor Development. Pediatrics. 1998;102:1135-1140
3. Davis B, Moon R, Sachs H, Ottolini M. Effects of Sleep Position on Infant Motor Development. Pediatrics. 1998;102:1135-1140
4. Davis B, Moon R, Sachs H, Ottolini M. Effects of Sleep Position on Infant Motor Development. Pediatrics. 1998;102:1135-1140
5. Dewey C, Fleming P, Golding J, the ALSPAC Study Team. Does the Supine Sleeping Position Have Any Adverse Effects on the Child? II. Development in the First 18 Months. Pediatrics. 1998;101:1-5
6. Majnemer A, Barr R. Influence of supine sleep positioning on early milestone acquisition. Developmental Medicine & Child Neurology. 2005;47:370-376
7. Fleuren K, Smit L, Stijnen T, Hartman A. New reference values for the Alberta Motor Scale need to be established. Acta Paediatr. 2007;96(3):424-427
8. Rusen I, Shiliang L, Sauve R, Joseph K, Kramer M. Sudden infant death syndrome in Canada: Trends in rates and risk factors, 1985-1998. Chronic Diseases in Canada. 2005;24:1 (105)
9. Högberg U, Bergström E. Suffocated Prone: The Iatrogenic Tragedy of SIDS. Am J Public Health. 2000;90:527–531 (104)
10. Fleuren K, Smit L, Stijnen T, Hartman A. New reference values for the Alberta Motor Scale need to be established. Acta Paediatr. 2007;96(3):424-427
11. Visscher C, Houwen S, Scherder E, Moolenaar B, Hartman E. Motor Profile of Children With Developmental Speech and Language Disorders. Pediatrics. 2007 Jul;120(1):e158-63
12. Biggs W. The 'Epidemic' of Deformational Plagiocephaly and the American Academy of Pediatrics' Response. JPO. 2004:16:5-8
13. Graham J, Gomez M, Halberg A, Earl D, Kreuzman J, Cui J, Guo X. Management of Deformational Plagiocephaly: Repositioning Versus Orthotic Therapy. The Journal of Pediatrics. 2005;10.016:258-22
14. Graham J, Gomez M, Halberg A, Earl D, Kreuzman J, Cui J, Guo X. Management of Deformational Plagiocephaly: Repositioning Versus Orthotic Therapy. The Journal of Pediatrics. 2005;10.016:258-22
15. Siatkowski R, Fortney A, Nazir S, Cannon S, Panchal J, Francel P, Feuer W, Ahmad W. Visual field defects in deformational posterior plagiocephaly JAAPOS. 2005;9(3):274-278
16. Persing J, James H, Swanson J, Kattwinkel J, Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery, Section on Neurological Surgery. Prevention and Management of Positional Skull Deformities in Infants
17. Martin W. Stallings, John Arthur Persing, Peter D. Rappo, John Arthur Persing. Management of Positional Skull Deformities: Who Needs a Helmet?. Pediatrics 2004;113;422-424
18. Kordestani R, Patel S, Bard D, Gurwitch R, Panchal J. Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg. 2006 Jan;117(1):207-218;
19. Siatkowski R, Fortney A, Nazir S, Cannon S, Panchal J, Francel P, Feuer W, Ahmad W. Visual field defects in deformational posterior plagiocephaly JAAPOS. 2005;9(3):274-278
20. Miller R, Clarren S. Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics. 2000 Feb;105(2):E26
Another 1998 study analyzed the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort (5) and utilized the Denver Developmental Screening Test (DDST) to study infants at 6 and 18 months of age. According to this study, at 6 months of age, the infants who were placed to sleep in the prone position had statistically significant higher fine motor skills scores, gross motor skills scores, and total development scores than those infants who were put to sleep in the supine position. In addition prone sleepers had higher social skills scores and communication skills scores at both 6 and 18 months compared to supine sleeping infants. Finally, the total development scores of prone sleeping infants were still higher than supine sleeping infants at 18 months of age but were no longer statistically significant. The article concluded that:
“There is some evidence that putting infants to sleep in the supine position results in a reduced developmental score at 6 months of age, but this disadvantage appears to be transient.”
In addition the researchers stated:
“These findings would be disturbing for the Back to Sleep Campaigns around the world were it not for the findings at 18 months, by which time there were no statistically significant advantages for the prone (or varied) sleeper.”
Another study compared the motor skills of 71 supine sleeping 4 month old infants and 50 supine sleeping 6 month old infants to Alberta Infant Motor Scale (AIMS) and Peabody Developmental Motor Scale (PDMS) normative standards (6). Infants who slept in the prone position prior to 4 months of age were not included in this study. In this study 22% of supine sleeping infants at 6 months of age could sit without arm support versus 50% in the normative sample. In addition, 22% of the supine sleeping infants displayed gross motor delays. Older mothers had infants with lower motor skills scores and the researchers suggested that this may be due to older parents having more knowledge of avoiding the prone sleep position due SIDS education. One of the conclusions the researchers drew from this study was:
“…it may be necessary to re-normalize infant developmental assessments.”
In a March 2007 article entitled “New reference values for the Alberta Infant Motor Scale need to be established" (7) by Fleuren, et al. of the Erasmus MC Sophia Children’s Hospital in Rotterdam, Netherlands, the authors reported their analysis of the motor performance, using the AIMS scale, of 100 Dutch children. The AIMS scores used were developed by Piper and Darrah and calculated for Canadian Children between 1990 and 1992. It should be noted that the first infant supine sleep position campaign in Canada began in 1993 and these AIMS scores were calculated before Canada began it’s 1993 supine sleep campaign (8). Also, this study comes 20 years after the first supine sleep campaign began in the Netherlands in 1987 (9). According to the Fleuren, Smit, Stijnen, and Hartman study (10) the results showed that:
"The percentile scores of the group were significantly lower than scores of the Canadian norm population (p<.001), whereby 75% of the Dutch children scored below the 50th percentile. These lower scores were not explained by sex, racial differences or congenital disorders and were seen in all age groups."
The authors concluded that:
“We conclude that new reference values on the AIMS test for the age group of 0-12 months need to be established for Dutch children. It is recommended that the need for new normative data is also determined in all other European countries.”
According to the article “Motor Profile of Children with Developmental Speech and Language Disorders" (11) by Visscher, et al. 51% of children with Developmental Speech and Language Disorders ( DSLD’s) had definite or borderline motor problems.
Since the 1990’s there has also been a reported increase in the United States of cases of Plagiocephaly (12). In 1974, plagiocphaly was estimated to have occurred in one out of every 300 live births (13). Following the “Back To Sleep” campaign the occurrence of plagiocephaly increased to 1 in every 60 children (14) in 1996. In one study it was reported that this incidence level has increased to 1 in 12 infants (15). According to the paper “Prevention and Management of Positional Skull Deformities in Infants" (16) by Persing, et al:
“The increasing incidence of deformational plagiocephaly is likely related to the recommendation of the American Academy of Pediatrics (AAP) and others that infants be placed to sleep on their backs.”
In addition, in a 2004 reply (17) to a letter regarding this study Dr. Persing wrote:
“…we do not think the condition is as benign from a skull deformity and social/psychological standpoint as assumed in the past.”
According to the article “Neurodevelopmental delays in children with deformational plagiocephaly" (18) by Kordestani, et al.:
“Infants with deformational plagiocephaly were found to have significantly different psychomotor development indexes and mental developmental indexes when compared with the standardized population (p < 0.0001; p < 0.0001). With regards to the mental developmental index scores, none of the infants with deformational plagiocephaly were accelerated, 90 percent were normal, 7 percent were mildly delayed, and 3 percent were severely delayed. With regards to the psychomotor development index scores, none of infants were accelerated, 74 percent were normal, 19 percent were mildly delayed, and 7 percent were severely delayed.”
The authors concluded that prior to any intervention infants that have deformational plagiocephaly have significant delays in both psychomotor development and mental development. Other studies have reported that plagiocephaly is known to be associated with both visual impairments (19) and a high-risk of long-term difficulties due to cerebral dysfunction (20).
References
1. Majnemer A, Barr R. Influence of supine sleep positioning on early milestone acquisition. Developmental Medicine & Child Neurology. 2005;47:370-376
2. Davis B, Moon R, Sachs H, Ottolini M. Effects of Sleep Position on Infant Motor Development. Pediatrics. 1998;102:1135-1140
3. Davis B, Moon R, Sachs H, Ottolini M. Effects of Sleep Position on Infant Motor Development. Pediatrics. 1998;102:1135-1140
4. Davis B, Moon R, Sachs H, Ottolini M. Effects of Sleep Position on Infant Motor Development. Pediatrics. 1998;102:1135-1140
5. Dewey C, Fleming P, Golding J, the ALSPAC Study Team. Does the Supine Sleeping Position Have Any Adverse Effects on the Child? II. Development in the First 18 Months. Pediatrics. 1998;101:1-5
6. Majnemer A, Barr R. Influence of supine sleep positioning on early milestone acquisition. Developmental Medicine & Child Neurology. 2005;47:370-376
7. Fleuren K, Smit L, Stijnen T, Hartman A. New reference values for the Alberta Motor Scale need to be established. Acta Paediatr. 2007;96(3):424-427
8. Rusen I, Shiliang L, Sauve R, Joseph K, Kramer M. Sudden infant death syndrome in Canada: Trends in rates and risk factors, 1985-1998. Chronic Diseases in Canada. 2005;24:1 (105)
9. Högberg U, Bergström E. Suffocated Prone: The Iatrogenic Tragedy of SIDS. Am J Public Health. 2000;90:527–531 (104)
10. Fleuren K, Smit L, Stijnen T, Hartman A. New reference values for the Alberta Motor Scale need to be established. Acta Paediatr. 2007;96(3):424-427
11. Visscher C, Houwen S, Scherder E, Moolenaar B, Hartman E. Motor Profile of Children With Developmental Speech and Language Disorders. Pediatrics. 2007 Jul;120(1):e158-63
12. Biggs W. The 'Epidemic' of Deformational Plagiocephaly and the American Academy of Pediatrics' Response. JPO. 2004:16:5-8
13. Graham J, Gomez M, Halberg A, Earl D, Kreuzman J, Cui J, Guo X. Management of Deformational Plagiocephaly: Repositioning Versus Orthotic Therapy. The Journal of Pediatrics. 2005;10.016:258-22
14. Graham J, Gomez M, Halberg A, Earl D, Kreuzman J, Cui J, Guo X. Management of Deformational Plagiocephaly: Repositioning Versus Orthotic Therapy. The Journal of Pediatrics. 2005;10.016:258-22
15. Siatkowski R, Fortney A, Nazir S, Cannon S, Panchal J, Francel P, Feuer W, Ahmad W. Visual field defects in deformational posterior plagiocephaly JAAPOS. 2005;9(3):274-278
16. Persing J, James H, Swanson J, Kattwinkel J, Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery, Section on Neurological Surgery. Prevention and Management of Positional Skull Deformities in Infants
17. Martin W. Stallings, John Arthur Persing, Peter D. Rappo, John Arthur Persing. Management of Positional Skull Deformities: Who Needs a Helmet?. Pediatrics 2004;113;422-424
18. Kordestani R, Patel S, Bard D, Gurwitch R, Panchal J. Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg. 2006 Jan;117(1):207-218;
19. Siatkowski R, Fortney A, Nazir S, Cannon S, Panchal J, Francel P, Feuer W, Ahmad W. Visual field defects in deformational posterior plagiocephaly JAAPOS. 2005;9(3):274-278
20. Miller R, Clarren S. Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics. 2000 Feb;105(2):E26
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