Smoking in pregnancy and bed sharing, a fatal combination

Göran Wennergren

Smoking in pregnancy and bed sharing, a fatal combination

Acta Paediatrica, 2018

EDITORIAL DOI:10.1111/apa.14474 Smoking in pregnancy and bed sharing, a fatal combination Over the last three decades, epidemiological research in New Zealand has produced results that really have made a difference for our understanding of how to reduce the risk of cot death. Almost 30 years ago, the New Zealand Cot Death Study convincingly demonstrated that sleeping prone, smoking and bottle-feeding were factors that increased the risk of cot death (1). Further analyses showed that also sleeping in the same bed as an adult increased the risk of cot death, particularly among infants of mothers who smoked (2). Now, the New Zealand Sudden Unexpected Death in Infancy (SUDI) Nationwide Study (2012–2015) has reinvestigated the risk factors identiﬁed in the New Zealand Cot Death Study and speciﬁcally focused on the sleep environment (3). In New Zealand, there is a high incidence of SUDI in the indigenous population, the M aoris (4). SUDI rates for M aori have decreased, partly due to a successful Safe Sleep Programme (4), but remain higher than for the non-M aori population. In this issue of Acta Paediatrica, MacFarlane et al. (5) address the question why the SUDI incidence is so high among M aoris. Half of the SUDI cases in New Zealand between 2012 and 2015 were M aori, despite that M aori comprise less than a third of live births in the country. The SUDI mortality rate for M aori was 1.4 per 1000 live births compared to 0.5/1000 for non-M aori. The overall SUDI rate was 0.8/1000 (5). The MacFarlane study ﬁnds that a combination of smoking in pregnancy and bed sharing leads to an increased SUDI risk for M aori as well as for non-M aori infants. As such, the risk factors for SUDI, and the magnitude of the risks, are the same regardless of ethnicity. However, M aori infants are exposed more frequently to both behaviours because of a higher smoking rate among M aori women. Thus, the higher smoking rate explains the high incidence of SUDI among the M aoris. SUDI AND SIDS Sudden Unexpected Death in Infancy is a broader term than sudden infant death syndrome (SIDS). The SUDI term is used when an infant under one year of age dies suddenly, initially without explanation. SUDI includes SIDS deaths but also includes deaths where a possible cause is identiﬁed during work-up. SIDS deaths, on the other hand, are deaths that remain unexplained even after a thorough investigation comprising full autopsy, clinical history and review of the circumstances of death. MacFarlane et al. underline that the review of the circumstances of death should include an examination of the death scene. One mechanism that can lead to SUDI when bed sharing is practised, is accidental suffocation. There are reasons to believe that accidental suffocation has been underestimated as a cause of death in countries where the investigation of SUDI does not include an examination of the death scene. In New Zealand, there has been a decline in SIDS diagnoses, while the diagnosis of accidental suffocation in bed has increased. In 2010 in New Zealand, infant deaths from accidental suffocation were as frequent as deaths from SIDS (6). POPULATION ATTRIBUTABLE RISKS Smoking during pregnancy was associated with a signiﬁ- cantly increased risk of SUDI for M aori as well as for non- M aori infants. The population attributable risk (PAR) for smoking in pregnancy for M aori and non-M aori was calcu- lated to be 67% and 49%, respectively. Also, the PAR for bed sharing was high, 49% for M aori and 47% for non-M aori. The PAR for the combination of smoking in pregnancy and bed sharing was 74% for M aori and 50% for non- M aori. This means that 74% of SUDI in M aori infants could be prevented if the combination of smoking in pregnancy and bed sharing was eliminated. Although bed-sharing prevalence was similar, more M aori controls than non- M aori smoked during pregnancy, 47% vs 23% giving an increased SUDI risk in M aori infants due to an increased prevalence of the combination of smoking in pregnancy and bed sharing. The higher risk was driven by the higher prevalence of smoking. BED SHARING It is well known that bed sharing may be associated with an increased risk of SIDS, especially if the infant is below three months of age (7,8). This has raised the question whether bed sharing should be dissuaded or not for the very young infant. However, bed sharing facilitates breastfeeding and many mothers want to bed share. Furthermore, it has been argued that the risk of bed sharing is linked to speciﬁc hazardous circumstances. In an analysis based on two case–control studies conducted in the UK, Blair et al. found 1848 ª2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2018 107, pp. 1848–1849 Acta Pædiatrica ISSN 0803-5253

that the risk associated with bed sharing was not signiﬁcant in the absence of hazards like bed sharing with a smoker or with a person who had consumed alcohol or sleeping together on a sofa (9). This applied to infants of less than three months old as well. Anyway, the high PAR for bed sharing argues that we need to make bed sharing as safe as possible for those mothers who have decided that they want to practice it. If the mother chooses to keep the baby in her bed, bed sharing should be made as safe as possible, by creating a space of its own for the baby, for example. Furthermore, bed sharing should always be avoided during obviously hazardous circumstances, such as when the parents have consumed alcohol (10). In New Zealand, safe sleep devices have been promoted. Safe sleep devices include woven M aori ﬂax baskets called wahakura, and specially designed lined plastic containers called Pepi-Pods. Wahakura and Pepi-Pods were developed speciﬁcally to support safe infant sleep and infant bed sharing. In many countries, so-called baby-nests have become a popular way to create a space of its own for the baby. Whether they provide safe infant sleep to the same extent as devices like wahakura and Pepi-Pods is, however, not established. TAKE-HOME MESSAGES The higher prevalence of smoking in M aori means that M aori infants are more likely to be exposed to the dangerous combination of bed sharing and smoking, as illustrated in the control group where almost 10% of M aori infants were exposed to both risk factors compared with 3% of non-M aori infants. This explains the high incidence of SUDI in the M aori population. The high PAR for bed sharing, almost 50% regardless of ethnicity, highlights the importance of promoting safer bed sharing (10). In order to be able to diagnose causes of death such as accidental suffocation, just an autopsy and clinical history is not sufﬁcient. It is obvious from the New Zealand experi- ence that the review of the circumstances of death must include an examination of the death scene. This is an important take-home message for countries like Sweden where forensic autopsy is performed in all cases of SUDI, but an examination of the death scene is not performed. CONFLICT OF INTEREST The author has no conﬂict of interest. G€ oran Wennergren (goran.wennergren@pediat.gu.se) Department of Paediatrics, University of Gothenburg, Queen Silvia Children’s Hospital, Gothenburg, Sweden References 1. Mitchell EA, Scragg R, Stewart AW, Becroft DM, Taylor BJ, Ford RP, et al. Results from the ﬁrst year of the New Zealand cot death study. N Z Med J 1991; 104: 71–6. 2. Scragg R, Mitchell EA, Taylor BJ, Stewart AW, Ford RP, Thompson JM, et al. Bed sharing, smoking, and alcohol in the sudden infant death syndrome. New Zealand Cot Death Study Group. BMJ 1993; 307: 1312–8. 3. Mitchell EA, Thompson JM, Zuccollo J, MacFarlane M, Taylor B, Elder D, et al. The combination of bed sharing and maternal smoking leads to a greatly increased risk of sudden unexpected death in infancy: the New Zealand SUDI Nationwide Case Control Study. N Z Med J 2017; 130: 52–64. 4. Mitchell EA, Cowan S, Tipene-Leach D. The recent fall in post- perinatal mortality in New Zealand and the Safe Sleep Programme. Acta Paediatr 2016; 105: 1312–20. 5. MacFarlane M, Thompson JMD, Zuccollo J, McDonald G, Elder D, Stewart AW, et al. Smoking in pregnancy is a key factor for sudden infant death among M aori. Acta Paediatr 2018; 107: 1924–31. 6. Mitchell EA. Co-sleeping and suffocation. Forensic Sci Med Pathol 2015; 11: 277–8. 7. Carpenter R, McGarvey C, Mitchell EA, Tappin DM, Vennemann MM, Smuk M, et al. Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of ﬁve major case-control studies. BMJ Open 2013; 3: e002299. 8. M€ ollborg P, Wennergren G, Almqvist P, Alm B. Bed sharing is more common in sudden infant death syndrome than in explained sudden unexpected deaths in infancy. Acta Paediatr 2015; 104: 777–83. 9. Blair PS, Sidebotham P, Pease A, Fleming PJ. Bed-sharing in the absence of hazardous circumstances: is there a risk of sudden infant death syndrome? An analysis from two case- control studies conducted in the UK. PLoS One 2014; 9: e107799. 10. Wennergren G. No bed sharing or safer bed sharing? Acta Paediatr 2016; 105: 1321. ª2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2018 107, pp. 1848–1849 1849 Editorial Editorial

Acta Pædiatrica ISSN 0803-5253 EDITORIAL DOI:10.1111/apa.14474 Smoking in pregnancy and bed sharing, a fatal combination Over the last three decades, epidemiological research in New Zealand has produced results that really have made a difference for our understanding of how to reduce the risk of cot death. Almost 30 years ago, the New Zealand Cot Death Study convincingly demonstrated that sleeping prone, smoking and bottle-feeding were factors that increased the risk of cot death (1). Further analyses showed that also sleeping in the same bed as an adult increased the risk of cot death, particularly among infants of mothers who smoked (2). Now, the New Zealand Sudden Unexpected Death in Infancy (SUDI) Nationwide Study (2012–2015) has reinvestigated the risk factors identified in the New Zealand Cot Death Study and specifically focused on the sleep environment (3). In New Zealand, there is a high incidence of SUDI in the oris (4). SUDI rates for indigenous population, the Ma ori have decreased, partly due to a successful Safe Sleep Ma ori Programme (4), but remain higher than for the non-Ma population. In this issue of Acta Paediatrica, MacFarlane et al. (5) address the question why the SUDI incidence is so oris. Half of the SUDI cases in New high among Ma ori, despite that Zealand between 2012 and 2015 were Ma ori comprise less than a third of live births in the Ma ori was 1.4 per country. The SUDI mortality rate for Ma ori. The 1000 live births compared to 0.5/1000 for non-Ma overall SUDI rate was 0.8/1000 (5). The MacFarlane study finds that a combination of smoking in pregnancy and bed sharing leads to an increased ori as well as for non-Ma ori infants. As SUDI risk for Ma such, the risk factors for SUDI, and the magnitude of the ori risks, are the same regardless of ethnicity. However, Ma infants are exposed more frequently to both behaviours ori women. because of a higher smoking rate among Ma Thus, the higher smoking rate explains the high incidence of oris. SUDI among the Ma SUDI AND SIDS Sudden Unexpected Death in Infancy is a broader term than sudden infant death syndrome (SIDS). The SUDI term is used when an infant under one year of age dies suddenly, initially without explanation. SUDI includes SIDS deaths but also includes deaths where a possible cause is identified during work-up. SIDS deaths, on the other hand, are deaths that remain unexplained even after a thorough investigation comprising full autopsy, clinical history and review of the circumstances of death. MacFarlane et al. underline that the review of the circumstances of death should include an examination of the death scene. One mechanism that can lead to SUDI when bed sharing is practised, is accidental suffocation. There are reasons to 1848 believe that accidental suffocation has been underestimated as a cause of death in countries where the investigation of SUDI does not include an examination of the death scene. In New Zealand, there has been a decline in SIDS diagnoses, while the diagnosis of accidental suffocation in bed has increased. In 2010 in New Zealand, infant deaths from accidental suffocation were as frequent as deaths from SIDS (6). POPULATION ATTRIBUTABLE RISKS Smoking during pregnancy was associated with a signifiori as well as for noncantly increased risk of SUDI for Ma ori infants. The population attributable risk (PAR) for Ma ori and non-Ma ori was calcusmoking in pregnancy for Ma lated to be 67% and 49%, respectively. Also, the PAR for bed ori and 47% for non-Ma ori. sharing was high, 49% for Ma The PAR for the combination of smoking in pregnancy ori and 50% for nonand bed sharing was 74% for Ma ori. This means that 74% of SUDI in Ma ori infants could Ma be prevented if the combination of smoking in pregnancy and bed sharing was eliminated. Although bed-sharing ori controls than nonprevalence was similar, more Ma ori smoked during pregnancy, 47% vs 23% giving an Ma ori infants due to an increased increased SUDI risk in Ma prevalence of the combination of smoking in pregnancy and bed sharing. The higher risk was driven by the higher prevalence of smoking. BED SHARING It is well known that bed sharing may be associated with an increased risk of SIDS, especially if the infant is below three months of age (7,8). This has raised the question whether bed sharing should be dissuaded or not for the very young infant. However, bed sharing facilitates breastfeeding and many mothers want to bed share. Furthermore, it has been argued that the risk of bed sharing is linked to specific hazardous circumstances. In an analysis based on two case–control studies conducted in the UK, Blair et al. found ª2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2018 107, pp. 1848–1849 Editorial that the risk associated with bed sharing was not significant in the absence of hazards like bed sharing with a smoker or with a person who had consumed alcohol or sleeping together on a sofa (9). This applied to infants of less than three months old as well. Anyway, the high PAR for bed sharing argues that we need to make bed sharing as safe as possible for those mothers who have decided that they want to practice it. If the mother chooses to keep the baby in her bed, bed sharing should be made as safe as possible, by creating a space of its own for the baby, for example. Furthermore, bed sharing should always be avoided during obviously hazardous circumstances, such as when the parents have consumed alcohol (10). In New Zealand, safe sleep devices have been promoted. Safe sleep devices ori flax baskets called wahakura, and include woven Ma specially designed lined plastic containers called Pepi-Pods. Wahakura and Pepi-Pods were developed specifically to support safe infant sleep and infant bed sharing. In many countries, so-called baby-nests have become a popular way to create a space of its own for the baby. Whether they provide safe infant sleep to the same extent as devices like wahakura and Pepi-Pods is, however, not established. TAKE-HOME MESSAGES ori means that The higher prevalence of smoking in Ma ori infants are more likely to be exposed to the Ma dangerous combination of bed sharing and smoking, as ori illustrated in the control group where almost 10% of Ma infants were exposed to both risk factors compared with 3% ori infants. This explains the high incidence of of non-Ma ori population. SUDI in the Ma The high PAR for bed sharing, almost 50% regardless of ethnicity, highlights the importance of promoting safer bed sharing (10). In order to be able to diagnose causes of death such as accidental suffocation, just an autopsy and clinical history is not sufficient. It is obvious from the New Zealand experience that the review of the circumstances of death must include an examination of the death scene. This is an important take-home message for countries like Sweden where forensic autopsy is performed in all cases of SUDI, but an examination of the death scene is not performed. Editorial CONFLICT OF INTEREST The author has no conflict of interest. € ran Wennergren (goran.wennergren@pediat.gu.se) Go Department of Paediatrics, University of Gothenburg, Queen Silvia Children’s Hospital, Gothenburg, Sweden References 1. Mitchell EA, Scragg R, Stewart AW, Becroft DM, Taylor BJ, Ford RP, et al. Results from the first year of the New Zealand cot death study. N Z Med J 1991; 104: 71–6. 2. Scragg R, Mitchell EA, Taylor BJ, Stewart AW, Ford RP, Thompson JM, et al. Bed sharing, smoking, and alcohol in the sudden infant death syndrome. New Zealand Cot Death Study Group. BMJ 1993; 307: 1312–8. 3. Mitchell EA, Thompson JM, Zuccollo J, MacFarlane M, Taylor B, Elder D, et al. The combination of bed sharing and maternal smoking leads to a greatly increased risk of sudden unexpected death in infancy: the New Zealand SUDI Nationwide Case Control Study. N Z Med J 2017; 130: 52–64. 4. Mitchell EA, Cowan S, Tipene-Leach D. The recent fall in postperinatal mortality in New Zealand and the Safe Sleep Programme. Acta Paediatr 2016; 105: 1312–20. 5. MacFarlane M, Thompson JMD, Zuccollo J, McDonald G, Elder D, Stewart AW, et al. Smoking in pregnancy is a key ori. Acta Paediatr factor for sudden infant death among Ma 2018; 107: 1924–31. 6. Mitchell EA. Co-sleeping and suffocation. Forensic Sci Med Pathol 2015; 11: 277–8. 7. Carpenter R, McGarvey C, Mitchell EA, Tappin DM, Vennemann MM, Smuk M, et al. Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case-control studies. BMJ Open 2013; 3: e002299. € llborg P, Wennergren G, Almqvist P, Alm B. Bed sharing is 8. Mo more common in sudden infant death syndrome than in explained sudden unexpected deaths in infancy. Acta Paediatr 2015; 104: 777–83. 9. Blair PS, Sidebotham P, Pease A, Fleming PJ. Bed-sharing in the absence of hazardous circumstances: is there a risk of sudden infant death syndrome? An analysis from two casecontrol studies conducted in the UK. PLoS One 2014; 9: e107799. 10. Wennergren G. No bed sharing or safer bed sharing? Acta Paediatr 2016; 105: 1321. ª2018 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2018 107, pp. 1848–1849 1849

国外文凭推荐《英国西伦敦大学文凭西伦敦大学毕业证购买》《Q微信/1954292140》学费单办理：加急办理西伦敦大学电子版成绩单毕业证书PDF电子版《西伦敦大学毕业证成绩单GPA修改案例》、（制作英国西伦敦大学毕业证成绩单英国西伦敦大学文凭证书样本）、英国西伦敦大学毕业证购买西伦敦大学文凭办理制作高仿学历、购买英国文凭制作英国学历认证多少钱、英国成绩单分数修改怎么购买英国英国西伦敦大学 Master Diploma西伦敦大学Graduation。《加急办理西伦敦大学毕业证书PDF电子版》【Q/微1954 292 140】《英国西伦敦大学成绩单分数修改原版定制》本公司一直专注于为英国 #加拿大 #美国 #新西兰 #澳洲 #法国 #德国 #爱尔兰 #意大利等国家各高校留学生办理学历、西伦敦大学毕业证、学位证、成绩单、教育部学历学位认证和留学回国人员证明，在认证业务上开创了良好的市场势头，一直占据了的地位，成为无数留学回国人员办理西伦敦大学学历学位认证的。 √如果您在英、加、美、澳、欧洲等留学过程中或回国后： 1、在校期间因各种原因未能顺利毕业《英国西伦敦大学毕业证书PDF电子版加急办理》【Q/微1954292140】《怎么购买西伦敦大学学历认证证书文凭证书英文》，拿不到官方毕业证； 2、面对父母的压力，希望尽快拿到； 3、不清楚认证流程以及材料该如何准备； 4、回国时间很长，忘记办理； 5、回国马上就要找工作《英国西伦敦大学成绩单分数修改西伦敦大学文凭证书英文原版定制》【Q/微1954292140】《怎么购买英国西伦敦大学毕业证书PDF电子版成绩单分数修改》办给用人单位看；　　 6、企事业单位必须要求办理的； 7、需要报考公务员、购买免税车、落转户口、申请留学生创业基金。主营项目： 1、办理毕业证，改成绩单《加急办理西伦敦大学毕业证书PDF电子版》【Q/微1954292140】《英国西伦敦大学成绩单分数修改原版定制》，西伦敦大学Offer、在读证明、学生卡、信封、证明信等全套材料，从防伪到印刷，从水印到钢印烫金，高精仿度跟学校原版100%相同. 2、真实使馆认证（即留学人员回国证明），使馆存档可通过大使馆查询确认. 3、真实教育部国外学历学位认证《英国文凭证书英文怎么购买西伦敦大学毕业证书PDF电子版》【Q/微1954292140】《原版定制西伦敦大学成绩单分数修改》，教育部存档，教育部留服网站100%可查. 4、留信网认证，国家专业人才认证中心颁发入库证书，留信网存档可查. 我们主要项目有：美国毕业证办理，英国毕业证办理，加拿大毕业证办理，澳洲毕业证办理，德国文凭，（高仿文凭样本展示《英国文凭证书英文怎么购买西伦敦大学毕业证书PDF电子版》【Q/微1954292140】《原版定制西伦敦大学成绩单分数修改》）法国文凭，新西兰文凭，新加坡文凭，马来西亚文凭等国大学文凭制作，如果那您有需要希望你与我们联系。《加急办理西伦敦大学毕业证书PDF电子版》文凭学历证书办理流程《Q微1954292140》： 1、客户提供办理信息：姓名、生日、专业、学位、毕业时间等（如信息不确定可以咨询顾问：微信1954292140我们有专业老师帮你查询）； 2、客户付定金下单； 3、公司确认到账转制作点做电子图； 4、电子图做好发给客户确认； 5、电子图确认好转成品部做成品； 6、成品做好拍照或者视频确认再付余款； 7、快递给客户（国内顺丰，国外DHL）。真实网上可查的证明材料 1 #教育部学历学位认证《英国文凭证书英文怎么购买西伦敦大学毕业证书PDF电子版》【Q/微1954292140】《原版定制西伦敦大学成绩单分数修改》留服官网真实存档可查，永久存档。 2 #留学回国人员证明（使馆认证）《英国西伦敦大学毕业证书PDF电子版加急办理》【Q/微1954292140】《怎么购买西伦敦大学学历认证证书文凭证书英文》使馆网站真实存档可查。真实可查留信认证的作用(私企，外企，荣誉的见证): 1：该专业认证可证明留学生真实留学身份《英国西伦敦大学成绩单分数修改西伦敦大学文凭证书英文原版定制》【Q/微1954292140】《怎么购买英国西伦敦大学毕业证书PDF电子版成绩单分数修改》同时对留学生所学专业等级给予评定，国家专业人才认证中心颁发入库证书。 2：个人职称评审加20分，个人信誉贷款加10分。 3：在国家人才网主办的全国网络招聘大会中纳入资料，供国家500强等高端企业选择人才。在留学之路上，千万不要觉得挂科是离自己很遥远的事，如果只是抱着车到山前必有路的想法，在无法毕业《加急办理西伦敦大学毕业证书PDF电子版》【Q/微1954 292 140】《英国西伦敦大学成绩单分数修改原版定制》的边缘疯狂试探，到了事情已经是无法挽回的地步，才会后悔莫及。因为现在没有顺利毕业，拿不到本科学位《英国文凭证书英文怎么购买西伦敦大学毕业证书PDF电子版》【Q/微1954 292 140】《原版定制西伦敦大学成绩单分数修改》，回国是根本没有办法可以做学历认证《英国西伦敦大学毕业证书PDF电子版加急办理》【Q/微1954 292 140】《怎么购买西伦敦大学文凭证书英文》的。而本科没有顺利毕业就是一件非常遗憾的事了，不仅花费了大量的时间和费用，后没有一个学位给自己的留学生涯一个交代，回国之后受认可的就只有出国前的学历，拿着这样的学历去找工作只会变得举步维艰。

Log In

Smoking in pregnancy and bed sharing, a fatal combination