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 2012 97: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

Analysis

• Cases referred to BPSU over 13 months 2008-2009• 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

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 37-42 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 infants Died Abnormal neurological examination by 1 yr

Apparent accidental suffocation during breast feeding or skin-to-skin

24 (80%) 5 5

No cause identified 6 (20%) 1 0

Disease or abnormality 15 infants

Bacterial pneumonia/sepsis (2 GBS, 3 culture –ve)

5 2 1

Cardiac (TGA, hypoplastic left heart) 2 2 0

Metabolic disorder (Zellweger’s, unidentified) 2 1 1

Intracranial haemorrhage/infarcation 2 0 1

Meconium aspiration syndrome 2 0 0

Severe chronic anaemia (parvovirus) 1 1 0

Congenital diaphragmatic hernia 1 0 0

Results – causes of collapse

Details of Collapse Underlying condition (15)

No underlying condition (30)

Age in minutes (median(range)) 195 (10-688) 70 (6-643)

Collapse in first 2h 7 (47%) 22 (73%)

Baby in care of mother/parents at collapse

13 24

Mother alone in room at time of collapse mother recognised baby unwell

73 (43%)

10 2 (20%)

Parents alone in room at time of collapse parents recognised baby unwell

11 (100%)

75 (71%)

Clinical staff in room at time of collapse staff first to recognise baby unwell

7 7 (100%)

1313 (100%)

Position of baby

mother’s breast/chest abdomen 3 (20%) 18 (60%)

arms 3 (20%) 9 (30%)

in cot (1 prone) 6 (40%) 3 (10%)

uncertain position 3 (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 6.8-7.18)– Median base deficit 17.7mmol/l (IQR 11.4-23.5)– 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