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
Search
•
•
•
•
Sudden OR unexpected AND
Neonatal OR postnatal AND
Collapse or death
Limit to English Language and humans and age <1
month
• 199 results
Result
• 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
Analysis
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
• 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
Analysis
• 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
• 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
Results
• 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 – causes of collapse
No underlying disease/abnormality
determined
30 infants Died
Abnormal
neurologic
al
examinatio
n 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
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
7
3 (43%)
10
2 (20%)
Parents alone in room at time of collapse
parents recognised baby unwell
1
1 (100%)
7
5 (71%)
Clinical staff in room at time of collapse
staff first to recognise baby unwell
7
7 (100%)
13
13 (100%)
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
Position of baby
Results – Following collapse
•
•
•
•
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 – infants w/o underlying condition
Results - deaths
• 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 - survivors
• 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
• 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
Will the results help me locally
• 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
• 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