We read with interest the recent comprehensive review of
neonatal thyroid disorders, which gave evidence-based answers to many
important questions. The author recommended that all babies born to
mothers with Hashimoto's thyroiditis should be reviewed at 10 days to 2
weeks and a thyroid function test taken as infants may develop transient
hypothyroidism or very rarely hyperthyroidism.[1]
We read with interest the recent comprehensive review of
neonatal thyroid disorders, which gave evidence-based answers to many
important questions. The author recommended that all babies born to
mothers with Hashimoto's thyroiditis should be reviewed at 10 days to 2
weeks and a thyroid function test taken as infants may develop transient
hypothyroidism or very rarely hyperthyroidism.[1]
As Paediatricians, in a
hospital with Paediatric endocrine caseload similar to some tertiary
centres and sub-regional neonatal intensive care unit with local
deliveries of 6000 per annum, we think that the potential benefits of this
practice are difficult to justify. We do understand that such practice
will help in identifying babies who may develop transient congenital
hypothyroidism duo to maternal thyrotropine receptor blocking antibodies.
However the incidence of this form of hypothyroidism has been estimated to
be 1 in 180 000 normal infants(~2% of congenital hypothyroidism) and the
majority of them will have raised TSH levels that can be detected by the
current neonatal screening.[2] Based on simple calculation, in a unit of
our size only one baby will be detected every 30 years. We feel that,
there would be major disadvantages if we are to adopt the author's
recommendation. Firstly, an extra hospital visit for babies and parents;
secondly the need to bleed many healthy infants and finally the potential
for confusion and unnecessary anxiety. Until objective evidence emerges
about the significance of subtle thyroid dysfunction in early life we feel
that the current screening programme should not be extended.
(2) Brown RS et al. Incidence of transient congenital hypothyroidism
due to maternal thyrotropin receptor-blocking antibodies in over one
million babies. J Clin Endocrinol Metab 1996; 81:1147-1151
Use of diagnostic criteria in Down’s syndrome has been discussed in this
short report based on this local and national survey.
Although recording (presence or absence) of 7 out of 8 Fried’s
discriminatory characteristics were analysed, I was not sure why data for
commonly noted ‘epicanthic fold’ was not collected.
There is also no analysis of data of presence of these 7 noted
characteristics against Fr...
Use of diagnostic criteria in Down’s syndrome has been discussed in this
short report based on this local and national survey.
Although recording (presence or absence) of 7 out of 8 Fried’s
discriminatory characteristics were analysed, I was not sure why data for
commonly noted ‘epicanthic fold’ was not collected.
There is also no analysis of data of presence of these 7 noted
characteristics against Fried’s index before the authors recommend to use
it. But I know this is not the primary aim of the study.
There is no mention of how and why only 72 case notes were selected out of
total of 174 cases from Manchester.
Some of dermatoglyphic traits in Down’s syndrome like palmar triradius can
be easily noted. While others may be difficult to interpret by a usual
paediatrician without using a dermatoglyphic chart.
On the whole, I enjoyed reading this article which increased our awareness
to use discriminating characteristics to make an accurate clinical
diagnoses of Down’s syndrome.
As Laing and Wong [1] correctly state, there is increasing
recognition of the occurrence of hypernatraemic dehydration in breast fed
babies. However there continues to be confusion regarding the best way to
manage this life-threatening problem. The disagreement centres on whether
the deficit of free water should be replaced with an isotonic solution
(0.9% saline) or a hypotonic one.
As Laing and Wong [1] correctly state, there is increasing
recognition of the occurrence of hypernatraemic dehydration in breast fed
babies. However there continues to be confusion regarding the best way to
manage this life-threatening problem. The disagreement centres on whether
the deficit of free water should be replaced with an isotonic solution
(0.9% saline) or a hypotonic one.
Hypernatraemia results from the ingestion of sodium in excess of
water or the loss of water in excess of sodium. The latter is seen in
diabetes insipidus. However in breast fed babies presenting with this
problem, the evidence suggests that they may have received an excess of
sodium while at the same time being deficient in water. Sodium
concentrations of up to 104 mmol/l have been recorded in the breast milk
of mothers of babies presenting with hypernatraemic dehydration [2] and
this is thought to be the result of an arrest in the normal maturational
decline in the sodium content of breast milk from the 65 + 4 mmol/l of
early colostrum, to 7 + 2 mmol/l in mature milk [3,4]. As a result, these
babies do not need more sodium but require replacement of free water.
Laing and Wong correctly state that initial resuscitation of the
child, to re-establish an adequate circulatory volume, should be with an
isotonic solution, either colloid or 0.9% saline. Some authors [5] would
advise that if the serum sodium concentration is known to be >175
mmol/l, extra sodium should be added to the fluids to bring the sodium
concentration to within 0-10 mmol/l of the serum sodium. The aim is to
fill the intravascular compartment without reducing the osmolality,
thereby avoiding cell oedema, particularly within the brain.
However the authors then advocate the continued use of 0.9% saline to
rehydrate the child.[1] The continued administration of large amounts of
sodium will contribute to the problem of excess total body sodium, which
will already have been increased by the sodium content of the initial
resuscitation fluids. The need is for slow replacement of free water and
this is best accomplished by rehydration with hypotonic solutions such as
0.18% NaCl + 4.5% dextrose. The aim is to reduce the serum sodium by 0.5
– 1 mmol/l/hr and this is guided through regular monitoring of serum
electrolytes. Two papers have described such management protocols.[5,6]
The idea that rehydration fluids must contain high sodium concentrations
needs to be finally laid to rest.
References
(1) Laing IA, Wong CM. Hypernatraemia in the first few days: is the
incidence rising? Arch Dis Child 2002;87: F158-F162.
(2) van Amerongen RH, Moretta AC, Gaeta TJ. Severe hypernatremic
dehydration and death in a breast-fed infant. Ped Emerg Care 2001;17: 175
-180.
(3) Koo WWK, Gupta JM. Breast milk sodium. Arch Dis Child 1982;57:
500-502.
(4) Aperia A, Broberger D, Herm P, Zetterstrom R. Salt content in
human breast milk during the first three weeks after delivery. Acta
Paediatr Scand 1979; 68: 441-442.
(5) Molteni KH. Initial management of hypernatraemic dehydration in
the breastfed infant. Clin Pediatr 1994; December: 731-740.
(6) Jacobsen J, Bohn D. Severe hypernatraemic dehydration and
hyperkalaemia in an infant with gastroenteritis secondary to rotavirus.
Ann Emerg Med 1993; 22: 1630-1632.
Response to: Alexander KC Leung
Thanks for the response. The baby shown in the picture was born at 24
weeks gestation which is considered as an extremely premature baby. Dr
Leung mentioned reports of preterm babies with natal teeth from 26 weeks
gestational age. But the case we had was even younger by two weeks. we
could not find any reports of a 24 week premature baby with fully formed...
Response to: Alexander KC Leung
Thanks for the response. The baby shown in the picture was born at 24
weeks gestation which is considered as an extremely premature baby. Dr
Leung mentioned reports of preterm babies with natal teeth from 26 weeks
gestational age. But the case we had was even younger by two weeks. we
could not find any reports of a 24 week premature baby with fully formed
gums with a tooth.
Drs Sureshkumar and McAulay recently reported a baby born at 24
weeks’ gestation with one natal tooth affecting the right lower central
incisor.[1] The authors claim that there are no reports of natal teeth in
extreme preterm babies.
I conducted a retrospective study based on record reviews of 50,892
infants born at the Foothills Provincial Hospital in Calgary, Alberta,
Canada, from 1967 to 1...
Drs Sureshkumar and McAulay recently reported a baby born at 24
weeks’ gestation with one natal tooth affecting the right lower central
incisor.[1] The authors claim that there are no reports of natal teeth in
extreme preterm babies.
I conducted a retrospective study based on record reviews of 50,892
infants born at the Foothills Provincial Hospital in Calgary, Alberta,
Canada, from 1967 to 1984 to determine the incidence of natal teeth.[2]
Fifteen infants were affected, for an incidence rate of one in 3392
births. The natal teeth were all noted in the first day of life. The
affected teeth were the lower central incisors. Of the 15 infants, 14
were white and one was of Chinese descent. There were four male and 11
female infants in the study. Eleven patients were born at term, and four
patients were born between 26 and 32 weeks’ gestation. As such, natal
teeth are not uncommon in preterm infants.
References
(1) Sureshkumar R, McAulay AH. Natal and neonatal teeth. Arch Dis Child Fetal Neonatal Ed 2002;87:F227.
I congratulate Laing and Wong for a thorough review of the literature
on hypernatraemic dehydration in breastfed infant.[1] Their
appreciation of the importance of supporting breastfeeding as a way of
avoiding this very uncommon problem is most welcome. I entirely agree
that simply to promote breastfeeding is not enough, practical support must
be made available to women to ensure that problems with in...
I congratulate Laing and Wong for a thorough review of the literature
on hypernatraemic dehydration in breastfed infant.[1] Their
appreciation of the importance of supporting breastfeeding as a way of
avoiding this very uncommon problem is most welcome. I entirely agree
that simply to promote breastfeeding is not enough, practical support must
be made available to women to ensure that problems with initiating and
maintaining lactation are dealt with.
However I am concerned that the title of this piece, the use of the
word "epidemic" and the way it was introduced in the Fantoms piece lend
weight to the idea that the incidence of this problem is increasing. I
know of no reliable data supporting this idea, and for this reason alone
would be cautious about an "intensive education programme" directed at
parents. Clearly as the profile of this form of hypernatraemic
dehydration is raised, it will be more frequently diagnosed .[2]
The article appears to suggest that shortening postpartum hospital
stays may be responsible for this problem. The most frequently quoted
United Kingdom work to support this idea was published in 1967,[3] and
there is little evidence to shown that there is a causal association in
the United Kingdom where organised postpartum visiting has so long been
routine.
I am not at all convinced that weighing does actually cause parental
anxiety, and I have been struck by how little evidence exists to support
this idea.[4] Indeed I strongly support the authors assertion that all
infants should be weighed in the early postpartum period.[5]
However remarkably little evidence exists to suggest how such weights
should be interpreted. Most readers of Archives will be aware that
standard UK growth charts are not helpful in interpreting normal neonatal
weight changes, but some may not know quite how few published data support
the idea that normal weight loss is less than 10%.[4] For example the
paper quoted by Laing and Wong suggests that 2.5% of breastfed infants
babies will lose more than 12% of their birthweight.[6] However this
study was based on only 100 infants and importantly gives little
information as to the timing of the weight nadir.
Larger good quality studies defining the normal range of neonatal weight change and particularly the timing of the weight nadir may be in
progress. However until such work is published it may not be prudent to
measure the serum sodium on up to 5% of breastfed infants with weight loss
that may actually be "normal" and no other clinical findings, outside
ethically approved research studies. Rather it may be important to
concentrate on providing experienced breastfeeding support (usually not
medical) to mother infant dyads where there is unusual weight loss.
Clearly review and repeated weighing may be wise.
Particularly as six of their cases occurred in hospital, Laing and
Wong may be interested to look at the convincing evidence that where
breastfeeding is well supported in hospital, weight loss is less marked
and of shorter duration.[7,8] This literature has clear implications for
those planning a protocol for management of extreme newborn weight loss.
References
(1) Laing IA, Wong CA. Hypernatraemia in the first few days: is the
incidence increasing. Arch Dis Child 2002;87:F158-F162.
(2) Manganaro R, Mami C, Marrone T, et al. Incidence of dehydration and
hypernatremia in exclusively breast-fed infants. J Pediatr 2001;139:673–5.
(3) Arthurton MW, Bamford FN. Paediatric aspects of early discharge of
maternity patients. BMJ 1967;3:517-520.
(4) Sachs M, Oddie S. MIDIRS Midwifery digest 2002;12:296-300.
(5) Oddie S, Richmond S, Coulthard M. Hypernatraemic dehydration and
breast feeding: a population study. Arch Dis Child 2001;85:318–20.
(6) Maisels MJ, Gifford K. Breast feeding, weight loss, and jaundice. J
Pediatr 1983;102:117–18.
(7) Mikiel-Kostyra K, Mazur J. Hospital policies and their influence
on newborn body weight. Acta Paediatr 1999;88(1):72-5.
(8)Avoa A, Fischer PR. The influence of perinatal instruction about breast-
feeding on neonatal weight loss. Pediatrics1990;86(2):313-5
The letter of Hawkes et al.[1] raises the important issues of
swaddling and temperature on admission to the neonatal unit. Besch et al.[2] carried out a limited comparison of different swaddling materials
and found a transparent plastic bag together with radiant heat to be
effective in preventing heat loss in infants over 2kg. Following a report
in the literature,[3] we have begun wrapping...
The letter of Hawkes et al.[1] raises the important issues of
swaddling and temperature on admission to the neonatal unit. Besch et al.[2] carried out a limited comparison of different swaddling materials
and found a transparent plastic bag together with radiant heat to be
effective in preventing heat loss in infants over 2kg. Following a report
in the literature,[3] we have begun wrapping all preterm infants <_1000g in="in" a="a" thin="thin" plastic="plastic" wrap.="wrap." the="the" wrap="wrap" is="is" preheated="preheated" on="on" radiant="radiant" warmer="warmer" and="and" infant="infant" immediately="immediately" placed="placed" undried="undried" sheet="sheet" which="which" folded="folded" over="over" to="to" completely="completely" but="but" loosely="loosely" enclose="enclose" torso="torso" extremities="extremities" from="from" neck="neck" down.="down." left="left" until="until" transported="transported" neonatal="neonatal" unit="unit" temperature="temperature" has="has" stabilized="stabilized" humidified="humidified" environment.="environment." median="median" of="of" _19="_19" _1000g="_1000g" infants="infants" admitted="admitted" since="since" wrapping="wrapping" was="was" commenced="commenced" _36.7="_36.7" _176c="_176c" arrival="arrival" nursery="nursery" compared="compared" _35.5="_35.5" for="for" previous="previous" _86="_86" unwrapped="unwrapped" p="p" using="using" mann="mann" whitney="whitney" u="u" test.="test." there="there" were="were" no="no" significant="significant" differences="differences" birth="birth" weight="weight" gestational="gestational" age="age" or="or" apgar="apgar" scores="scores" between="between" groups.="groups."/> Although our experience is in smaller preterm infants (who are more
prone to hypothermia) our results are in keeping with those of Vohra et al.
who studied infants <_32 weeks.3="weeks.3" we="we" now="now" plan="plan" to="to" wrap="wrap" all="all" preterm="preterm" infants="infants" _1500g.="_1500g." p="p"/> The plastic wrap is likely to be more effective than towels because
of reduction in evaporative heat loss and because it allows observation of
the infant. However, the plastic wrap is unlikely to significantly reduce
radiant heat loss so that an additional heat source is essential for
preterm infants. Some form of head swaddling is also important and needs
further study. Aluminum foil may reduce evaporative, convective and
radiant heat loss but does not allow observation or radiant warming.
It appears there are many aspects of swaddling that require further
investigation.
References
(1) Hawkes DJ, Spendley DG, Alfaham M. Hypothesis waiting for proof:
unwrapping neonates for transfer. Arch Dis Child 2002; 87:F232.
(2) Besch NJ, Perlstein PH, Edwards NK, et al. The transparent baby bag: a
shield against heat loss. N Engl J Med 1971; 284: 121-124
(3) Vohra S, Frent G, Campbell V, et al. Effect of polyehtylene occlusive
skin wrapping on heat loss in very low birth weight infants at delivery: a
randomized trial. J Pediatr 1999;134: 547-551.
Laing and Wong [1] highlight the fact that hypernatraemic dehydration
can be difficult to recognise and may have serious consequences. We
describe an extreme case.
An 8-day-old infant was admitted to hospital with a small
haematemesis. She had lost 19% of her birth weight and her plasma sodium
was 173 mmol/l. She had renal and hepatic impairment and was found to
have a thrombosis of th...
Laing and Wong [1] highlight the fact that hypernatraemic dehydration
can be difficult to recognise and may have serious consequences. We
describe an extreme case.
An 8-day-old infant was admitted to hospital with a small
haematemesis. She had lost 19% of her birth weight and her plasma sodium
was 173 mmol/l. She had renal and hepatic impairment and was found to
have a thrombosis of the descending aorta. In spite of rehydration,
thrombolysis and full intensive care support, she died the following day
from progressive sub-diaphragmatic ischaemia and multi-organ failure. A
post mortem revealed no underlying abnormalities. Parental thrombophilia
screens were normal.
The maternity notes revealed that she was born at term weighing
3.18kg after an uneventful pregnancy. She was breastfed from birth. On
day 3 she had 5 wet nappies and appeared to be feeding well. She was
allowed home, with a discharge weight of 2.77kg, and visited several times
by the community midwives. On each occasion she seemed contented and was
thought to be feeding well.
We agree with Laing and Wong that health professionals may fail to
realise how dehydrated some infants have become until they are dangerously
unwell. Our infant had lost 12.8% of her birth weight at initial
discharge. The severity of this weight loss was not recognised and no
further attention was paid to the weight as the baby was considered to be
feeding well. To target at risk infants, we consider that clinical skills
need to be supplemented with a clear policy of regular weight monitoring
with defined thresholds for intervention.
Reference
(1) Laing IA, Wong CM. Hypernatraemia in the first few days: is the incidence rising? Arch Dis Child 2002; 87(3): F158-F162.
In response to the letter from Tom Blyth and Sheila McKenzie[1] we wish
to clarify the following points. Our study is the first to examine the
effects of both sleeping position and maternal smoking, both factors which
are associated with an increased risk for Sudden Infant Death Syndrome
(SIDS), on arousal from sleep. We had hypothesised that the effects of
these two risk factors might be additive. O...
In response to the letter from Tom Blyth and Sheila McKenzie[1] we wish
to clarify the following points. Our study is the first to examine the
effects of both sleeping position and maternal smoking, both factors which
are associated with an increased risk for Sudden Infant Death Syndrome
(SIDS), on arousal from sleep. We had hypothesised that the effects of
these two risk factors might be additive. Our findings however, showed
that sleeping position had no effect on arousal threshold in the smoking
group, but arousal was impaired in the non-smoking group when they slept
prone. The arousal responses to both stimulus induced and spontaneous
arousal were however impaired in the smoking group in the supine position.
The significant findings that Drs Blyth and McKenzie highlight as being
supportive of the idea that passive smoking is protective of SIDS may be
explained by this finding that prone sleeping elevated arousal thresholds
only in the non-smoking group.
We strongly disagree with the suggestion that passive smoking might
be protective of SIDS when infants sleep prone. Our finding of depressed
arousal responses in infants of smoking mothers is also supported by those
of other workers (Lewis and Bosque[2] 1995 and Franco et al.[3]). As yet the
mechanism(s) which cause some infants to die suddenly and unexpectedly are
unknown, it is thus of great importance that research should focus on how
the known risk factors for SIDS might act. At present, a failure to arouse
from sleep in the face of a life-threatening event is a leading hypothesis
for SIDS. In support of this, prone sleeping, maternal smoking, recent
infection, head covering, overheating and prematurity, all risk factors
for SIDS, have all been demonstrated to decrease arousability in otherwise
healthy infants. Conversely, the use of pacifiers, which decrease the risk
of SIDS[4] has been shown to increase arousability.[3]
References
(1) Blyth T, McKenzie S. SIDS, smoking and arousal thresholds: conclusions not supported by data [electronic response to Horne RSC et al., Effects of maternal tobacco smoking, sleeping position, and sleep state on arousal in healthy term infants] archdischild.com 2002.http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;87/2/F100#143
(2) Lewis KL, Bosque EM. Deficient hypoxia awakening response in infants of smoking mothers: possible relationship to sudden infant death syndrome. J Pediatr 1995;127:691–9.
(3) Franco P, Pardou A, Hassid S, et al. Auditory arousal thresholds are higher when infants sleep in the prone position. J Pediatr 1998;132:240–3.
(4) L'Hoir MP. Proceedings 7th SIDS International Conference. Florence, 2002.
The investigation of the effect of maternal tobacco smoking on
arousal in healthy infants[1] concluded that maternal tobacco smoking
increases arousal thresholds (i.e. impairing arousal) in infants of 2-3
months of age, in quiet sleep, in the supine position. It is suggested
that this may provide an explanation for the association between smoking
and sudden infant death syndrome (SIDS).
The investigation of the effect of maternal tobacco smoking on
arousal in healthy infants[1] concluded that maternal tobacco smoking
increases arousal thresholds (i.e. impairing arousal) in infants of 2-3
months of age, in quiet sleep, in the supine position. It is suggested
that this may provide an explanation for the association between smoking
and sudden infant death syndrome (SIDS).
This conclusion is not supported by the data since the study also
found that maternal tobacco smoking reduces arousal thresholds in 2-3
month old infants, in active sleep, in the prone position, the very position
in which victims of SIDS are still most commonly found.[2,3] Could
passive smoking then be protective of death from SIDS?
Smoking is undoubtedly associated with SIDS. However, these
contradictory findings do not support the hypothesis that an alteration of
infants’ arousal thresholds by passive smoking is explanatory.
Is it not time that SIDS research concentrated less on smoking and
more on alternative mechanisms?
References
(1) Horne RSC, Ferens D, Watts A-M, Vitkovic J, Lacey B, Andrew A,
Cranage SM, Chau B, Greaves R, Adamson TM. Effects of maternal tobacco
smoking, sleeping posistion and sleep state on arousal in healthy term
infants. Arch Dis Child Fetal Neonatal Ed 2002;87: F100-F105
(2) Fleming PJ, Blair PS, Bacon C et al. Environment of infants during
sleep and the risk of sudden infant death syndrome: results of 1993-1995
case-control study for confidential inquiry into stillbirths and deaths in
infancy. BMJ 1996;313:191-5.
(3) Skadberg BT, Marild I, Markestad T. Abandoning prone sleeping: Effect
on the risk of sudden infant death syndrome. J Pediatr 1998;132(2):340-3.
Dear Editor
We read with interest the recent comprehensive review of neonatal thyroid disorders, which gave evidence-based answers to many important questions. The author recommended that all babies born to mothers with Hashimoto's thyroiditis should be reviewed at 10 days to 2 weeks and a thyroid function test taken as infants may develop transient hypothyroidism or very rarely hyperthyroidism.[1]
As Paedia...
Dear Editor
Use of diagnostic criteria in Down’s syndrome has been discussed in this short report based on this local and national survey. Although recording (presence or absence) of 7 out of 8 Fried’s discriminatory characteristics were analysed, I was not sure why data for commonly noted ‘epicanthic fold’ was not collected. There is also no analysis of data of presence of these 7 noted characteristics against Fr...
Dear Editor
As Laing and Wong [1] correctly state, there is increasing recognition of the occurrence of hypernatraemic dehydration in breast fed babies. However there continues to be confusion regarding the best way to manage this life-threatening problem. The disagreement centres on whether the deficit of free water should be replaced with an isotonic solution (0.9% saline) or a hypotonic one.
Hype...
Dear Editor
Response to: Alexander KC Leung
Thanks for the response. The baby shown in the picture was born at 24 weeks gestation which is considered as an extremely premature baby. Dr Leung mentioned reports of preterm babies with natal teeth from 26 weeks gestational age. But the case we had was even younger by two weeks. we could not find any reports of a 24 week premature baby with fully formed...
Dear Editor
Drs Sureshkumar and McAulay recently reported a baby born at 24 weeks’ gestation with one natal tooth affecting the right lower central incisor.[1] The authors claim that there are no reports of natal teeth in extreme preterm babies.
I conducted a retrospective study based on record reviews of 50,892 infants born at the Foothills Provincial Hospital in Calgary, Alberta, Canada, from 1967 to 1...
Dear Editor
I congratulate Laing and Wong for a thorough review of the literature on hypernatraemic dehydration in breastfed infant.[1] Their appreciation of the importance of supporting breastfeeding as a way of avoiding this very uncommon problem is most welcome. I entirely agree that simply to promote breastfeeding is not enough, practical support must be made available to women to ensure that problems with in...
Dear Editor
The letter of Hawkes et al.[1] raises the important issues of swaddling and temperature on admission to the neonatal unit. Besch et al.[2] carried out a limited comparison of different swaddling materials and found a transparent plastic bag together with radiant heat to be effective in preventing heat loss in infants over 2kg. Following a report in the literature,[3] we have begun wrapping...
Dear Editor
Laing and Wong [1] highlight the fact that hypernatraemic dehydration can be difficult to recognise and may have serious consequences. We describe an extreme case.
An 8-day-old infant was admitted to hospital with a small haematemesis. She had lost 19% of her birth weight and her plasma sodium was 173 mmol/l. She had renal and hepatic impairment and was found to have a thrombosis of th...
Dear Editor
In response to the letter from Tom Blyth and Sheila McKenzie[1] we wish to clarify the following points. Our study is the first to examine the effects of both sleeping position and maternal smoking, both factors which are associated with an increased risk for Sudden Infant Death Syndrome (SIDS), on arousal from sleep. We had hypothesised that the effects of these two risk factors might be additive. O...
Dear Editor
The investigation of the effect of maternal tobacco smoking on arousal in healthy infants[1] concluded that maternal tobacco smoking increases arousal thresholds (i.e. impairing arousal) in infants of 2-3 months of age, in quiet sleep, in the supine position. It is suggested that this may provide an explanation for the association between smoking and sudden infant death syndrome (SIDS).
This con...
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