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June 1993, Vol 147, No. 6 >
Article | June 1993

A Sleep Position–Dependent Mechanism for Infant Death on Sheepskins FREE

James S. Kemp, MD; Bradley T. Thach, MD
[+] Author Affiliations

Accepted for publication December 17, 1992.

Reprint requests to the Department of Pediatrics, Washington University School of Medicine, One Children's Place, St Louis, MO 63110 (Dr Kemp).


Am J Dis Child. 1993;147(6):642-646. doi:10.1001/archpedi.1993.02160300048021.
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• Objective.  —To determine whether rebreathing of expired air is a plausible lethal mechanism of sudden death in infants sleeping face down on sheepskins.

Design.  —Case reports of infants who died on sheepskins combined with a controlled study of effects of their respiratory microenvironment at death.

Setting.  —Research laboratory.

Materials.  —Rabbits used experimentally to assist in simulation of an infant's respiratory microenvironment. Rabbits breathed into sheepskin through the airway of an infant mannequin.

Intervention.  —None.

Measurements/Main Results.  —Rebreathing of expired air was documented by carbon dioxide analysis of airway gas. Arterial blood gas analysis showed hypoxemia, hypercarbia, and acidosis in all experimental rabbits but not in controls. Rebreathing expired air was lethal for three of four experimental rabbits.

Conclusions.  —Infants sleeping prone on a sheepskin, with their faces straight down, experience potentially lethal rebreathing of expired air. Avoidance of the prone position would markedly reduce the risk of rebreathing expired air. The pronounced decrease in sudden infant death syndrome in southern New Zealand that followed a campaign to eliminate prone sleeping may have been attributable to reduced fatal rebreathing, as deaths of infants sleeping face down on sheepskins were common before the campaign.(AJDC. 1993;147:642-646)

REFERENCES

1 +
Wigfield RE, Fleming PJ, Berry PJ, Rudd PT, Golding J.  Can the fall in Avon's sudden infant death rate be explained by changes in sleeping position? BMJ . 1992;;304:282-283.
2 +
de Jonge GA, Engelberts AC, Koomen-Liefting AJM, Kostense PJ.  Cot death and prone sleeping position in the Netherlands . BMJ . 1989;;298:272.
3 +
Taylor BJ.  A review of epidemiological studies of sudden infant death syndrome in southern New Zealand . J Paediatr Child Health . 1991;; 27:344-348.
4 +
Kemp JS, Thach BT.  Sudden death in infants sleeping on polystyrenefilled cushions . N Engl J Med . 1991;;423:1858-1864.
5 +
Gilbert-Barness E, Hegstrand L, Chandra S, et al.  Hazards of mattresses, beds, and bedding in deaths of infants . Am J Forensic Med Pathol . 1991;;12:27-32.
6 +
Nelson EAS, Taylor BJ, Mackay SC.  Child care practices and the sudden infant death syndrome . Aust Pediatr J . 1989;;25:202-204.
7 +
Mountcastle VB, ed. Medical Physiology . St Louis, Mo: Mosby–Year Book; 1980;:1369.
8 +
British Standards Institution. Specification for Performance Requirements for Hardness of, and Air Flow Through, Infant Pillows . London, England: British Standards House; 1970;. Publication 4578.
9 +
Swedlow DB.  Capnometry and capnography: the anesthesia disaster and early warning system . Semin Anesth . 1986;;5:194-205.
10 +
Newman NM, Sherrey JH, Megirian D.  Infant death and sheepskin rugs . Med J Aust . 1983;;1:453-454.
11 +
Hassal IB, Vandenberg M.  Infant sleep position: a New Zealand survey . N Z Med J . 1985;;98:97-99.
12 +
Mitchell EA.  Cot death: should the prone sleeping position be discouraged? J Paediatr Child Health . 1991;;27:319-321.
13 +
Hill AB.  The environment and disease: association or causation? Proc R Soc Med . 1965;;58:295-300.
14 +
Dwyer T, Ponsonby A-L.  Sudden infant death syndrome: insights from epidemiological research . J Epidemiol Community Health . 1992;;46:98-102.
15 +
Nunn JF. Applied Respiratory Physiology . 3rd ed. Stoneham, Mass: Butterworths; 1987;:166.
16 +
Leiter JC, Mortola JP, Tenney SM.  A comparative analysis of contractile characteristics of the diaphragm and respiratory system mechanics . Respir Physiol . 1986;;64:267-276.
17 +
Kemp JS, Kowalski RM, Burch PM, Graham MA, Thach BT. Unintentional suffocation by rebreathing: a death scene and physiological investigation of a possible cause of sudden infant death. J Pediatr. In press.
18 +
Crossfill ML, Widdicombe JG.  Physical characteristics of the chest and lungs and the work of breathing in different mammalian species . J Physiol . 1961;;158:1-14.
19 +
Easton PA, Slykerman LJ, Anthonisen NR.  Ventilatory response to sustained hypoxia in normal adults . J Appl Physiol . 1986;;61:906-911.
20 +
Grunstein MM, Hazinski TA, Schlueter MA.  Respiratory control during hypoxia in newborn rabbits: implied action of endorphins . J Appl Physiol . 1981;;51:122-130.
21 +
Gordon I, Shapiro HA, Berson SD. Forensic Medicine: A Guide to Principles . 3rd ed. New York, NY: Churchill Livingstone Inc; 1988;:95-96.
22 +
Abramson H.  Accidental mechanical suffocation in infants . J Pediatr . 1944;;25:404-413.
23 +
Valdes-Dapena MA.  Sudden and unexpected death in infancy: a review of the world literature, 1954-1966 . Pediatrics . 1967;;39:123-138.
24 +
Ryan EL.  Distribution of expired air in carry cots: a possible explanation for some sudden infant deaths . Austr Phys Eng Sci Med . 1991;;14:112-118.
25 +
Chiodini BA, Thach BT. Mechanism of increased sudden infant death syndrome risk in prone-sleeping infants. Pediatr Res. In press.
26 +
Kemp J, Thach B.  New method for quantifying asphyxial rebreathing prior to death in 'SIDS' infants . FASEB J. 1992;;6:1703A. Abstract.
27 +
Mitchell EA, Scragg R, Stewart AW, et al.  Results from the first year of the New Zealand cot death study . N Z Med J. 1991;;104:71-76.
28 +
Hoffman HJ, Damus K, Hillman L, Krongrad E.  Risk factors for SIDS: results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study . Ann N Y Acad Sci . 1988;:533:16.
29 +
Ponsonby A-L, Dwyer T, Gibbons LE, Cochrane JA, Jones ME, McCall MJ.  Thermal environment and sudden infant death syndrome: case-control study . BMJ . 1992;;304:277-282.
30 +
Fleming PJ, Gilbert R, Azaz Y, et al.  Interaction between bedding and sleeping position in the sudden infant death syndrome: a population-based case-control study . BMJ . 1990;;301:85-89.
31 +
Wheldon AE.  Energy balance in the newborn baby: use of a manikin to estimate radiant and convective heat loss . Phys Med Biol . 1982;;27:285-296.
32 +
Petersen SA, Anderson ES, Lodemore M, Rawson D, Wailoo MP.  Sleeping position and rectal temperature . Arch Dis Child . 1991;;66:976-979.
33 +
Phillipson EA, Sullivan CE.  Arousal: the forgotten response to respiratory stimuli . Am Rev Respir Dis . 1978;;118:807-809.
34 +
Fewell JE, Konduri GG.  Influence of repeated exposure to rapidly developing hypoxaemia on the arousal and cardiopulmonary response to rapidly developing hypoxaemia in lambs . J Dev Physiol . 1989;;11:77-82.
35 +
Illingworth RS. The Development of the Infant and Young Child . 7th ed. New York, NY: Churchill Livingstone Inc; 1980;:117-119.
36 +
Stark AR, Thach BT.  Mechanisms of airway obstruction leading to apnea in newborn infants . J Pediatr . 1976;;89:982-985.
37 +
Tonkin S.  Sudden infant death syndrome: hypothesis of causation . Pediatrics . 1975;;55:650-651.
38 +
Peiper A. Cerebral Function in Infancy and Childhood . New York, NY: Consultants Bureau; 1963;:327.
39 +
Beal SM, Finch CF.  An overview of retrospective case-control studies investigating the relationship between prone sleeping position and SIDS . J Paediatr Child Health . 1991;;27:334-339.
40 +
Kattwinkel J, Brooks J, Myerberg D.  Positioning and SIDS . Pediatrics . 1992;;89:1120-1126.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

References

1 +
Wigfield RE, Fleming PJ, Berry PJ, Rudd PT, Golding J.  Can the fall in Avon's sudden infant death rate be explained by changes in sleeping position? BMJ . 1992;;304:282-283.
2 +
de Jonge GA, Engelberts AC, Koomen-Liefting AJM, Kostense PJ.  Cot death and prone sleeping position in the Netherlands . BMJ . 1989;;298:272.
3 +
Taylor BJ.  A review of epidemiological studies of sudden infant death syndrome in southern New Zealand . J Paediatr Child Health . 1991;; 27:344-348.
4 +
Kemp JS, Thach BT.  Sudden death in infants sleeping on polystyrenefilled cushions . N Engl J Med . 1991;;423:1858-1864.
5 +
Gilbert-Barness E, Hegstrand L, Chandra S, et al.  Hazards of mattresses, beds, and bedding in deaths of infants . Am J Forensic Med Pathol . 1991;;12:27-32.
6 +
Nelson EAS, Taylor BJ, Mackay SC.  Child care practices and the sudden infant death syndrome . Aust Pediatr J . 1989;;25:202-204.
7 +
Mountcastle VB, ed. Medical Physiology . St Louis, Mo: Mosby–Year Book; 1980;:1369.
8 +
British Standards Institution. Specification for Performance Requirements for Hardness of, and Air Flow Through, Infant Pillows . London, England: British Standards House; 1970;. Publication 4578.
9 +
Swedlow DB.  Capnometry and capnography: the anesthesia disaster and early warning system . Semin Anesth . 1986;;5:194-205.
10 +
Newman NM, Sherrey JH, Megirian D.  Infant death and sheepskin rugs . Med J Aust . 1983;;1:453-454.
11 +
Hassal IB, Vandenberg M.  Infant sleep position: a New Zealand survey . N Z Med J . 1985;;98:97-99.
12 +
Mitchell EA.  Cot death: should the prone sleeping position be discouraged? J Paediatr Child Health . 1991;;27:319-321.
13 +
Hill AB.  The environment and disease: association or causation? Proc R Soc Med . 1965;;58:295-300.
14 +
Dwyer T, Ponsonby A-L.  Sudden infant death syndrome: insights from epidemiological research . J Epidemiol Community Health . 1992;;46:98-102.
15 +
Nunn JF. Applied Respiratory Physiology . 3rd ed. Stoneham, Mass: Butterworths; 1987;:166.
16 +
Leiter JC, Mortola JP, Tenney SM.  A comparative analysis of contractile characteristics of the diaphragm and respiratory system mechanics . Respir Physiol . 1986;;64:267-276.
17 +
Kemp JS, Kowalski RM, Burch PM, Graham MA, Thach BT. Unintentional suffocation by rebreathing: a death scene and physiological investigation of a possible cause of sudden infant death. J Pediatr. In press.
18 +
Crossfill ML, Widdicombe JG.  Physical characteristics of the chest and lungs and the work of breathing in different mammalian species . J Physiol . 1961;;158:1-14.
19 +
Easton PA, Slykerman LJ, Anthonisen NR.  Ventilatory response to sustained hypoxia in normal adults . J Appl Physiol . 1986;;61:906-911.
20 +
Grunstein MM, Hazinski TA, Schlueter MA.  Respiratory control during hypoxia in newborn rabbits: implied action of endorphins . J Appl Physiol . 1981;;51:122-130.
21 +
Gordon I, Shapiro HA, Berson SD. Forensic Medicine: A Guide to Principles . 3rd ed. New York, NY: Churchill Livingstone Inc; 1988;:95-96.
22 +
Abramson H.  Accidental mechanical suffocation in infants . J Pediatr . 1944;;25:404-413.
23 +
Valdes-Dapena MA.  Sudden and unexpected death in infancy: a review of the world literature, 1954-1966 . Pediatrics . 1967;;39:123-138.
24 +
Ryan EL.  Distribution of expired air in carry cots: a possible explanation for some sudden infant deaths . Austr Phys Eng Sci Med . 1991;;14:112-118.
25 +
Chiodini BA, Thach BT. Mechanism of increased sudden infant death syndrome risk in prone-sleeping infants. Pediatr Res. In press.
26 +
Kemp J, Thach B.  New method for quantifying asphyxial rebreathing prior to death in 'SIDS' infants . FASEB J. 1992;;6:1703A. Abstract.
27 +
Mitchell EA, Scragg R, Stewart AW, et al.  Results from the first year of the New Zealand cot death study . N Z Med J. 1991;;104:71-76.
28 +
Hoffman HJ, Damus K, Hillman L, Krongrad E.  Risk factors for SIDS: results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study . Ann N Y Acad Sci . 1988;:533:16.
29 +
Ponsonby A-L, Dwyer T, Gibbons LE, Cochrane JA, Jones ME, McCall MJ.  Thermal environment and sudden infant death syndrome: case-control study . BMJ . 1992;;304:277-282.
30 +
Fleming PJ, Gilbert R, Azaz Y, et al.  Interaction between bedding and sleeping position in the sudden infant death syndrome: a population-based case-control study . BMJ . 1990;;301:85-89.
31 +
Wheldon AE.  Energy balance in the newborn baby: use of a manikin to estimate radiant and convective heat loss . Phys Med Biol . 1982;;27:285-296.
32 +
Petersen SA, Anderson ES, Lodemore M, Rawson D, Wailoo MP.  Sleeping position and rectal temperature . Arch Dis Child . 1991;;66:976-979.
33 +
Phillipson EA, Sullivan CE.  Arousal: the forgotten response to respiratory stimuli . Am Rev Respir Dis . 1978;;118:807-809.
34 +
Fewell JE, Konduri GG.  Influence of repeated exposure to rapidly developing hypoxaemia on the arousal and cardiopulmonary response to rapidly developing hypoxaemia in lambs . J Dev Physiol . 1989;;11:77-82.
35 +
Illingworth RS. The Development of the Infant and Young Child . 7th ed. New York, NY: Churchill Livingstone Inc; 1980;:117-119.
36 +
Stark AR, Thach BT.  Mechanisms of airway obstruction leading to apnea in newborn infants . J Pediatr . 1976;;89:982-985.
37 +
Tonkin S.  Sudden infant death syndrome: hypothesis of causation . Pediatrics . 1975;;55:650-651.
38 +
Peiper A. Cerebral Function in Infancy and Childhood . New York, NY: Consultants Bureau; 1963;:327.
39 +
Beal SM, Finch CF.  An overview of retrospective case-control studies investigating the relationship between prone sleeping position and SIDS . J Paediatr Child Health . 1991;;27:334-339.
40 +
Kattwinkel J, Brooks J, Myerberg D.  Positioning and SIDS . Pediatrics . 1992;;89:1120-1126.

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