Bührer, Christoph

Dame, Christof

Gratopp, Alexander

Storz, Dennis

Wendt, Anke

English

Institutional Repository of the Freie Universität Berlin

Sudden Unexpected Death of Two Infants inBaby CarriersDennis Storz, Christof Dame, Anke Wendt, Alexander Gratopp,Christoph BührerDocument typePostprint (accepted version)This version is available athttps://doi.org/10.17169/refubium-36245Citation detailsStorz D, Dame C, Wendt A, Gratopp A, Bührer C. Sudden Unexpected Death of Two Infants in BabyCarriers. Klinische Pädiatrie. Georg Thieme Verlag KG; 2021;234(4): 241-243.DOI: 10.1055/a-1545-4590Terms of useAll rights reserved. This document is intended solely for personal, non-commercial use.© 2021. Thieme. All rights reserved.Sudden	unexpected	death	of	two	infants	in	baby	carriers			Plötzlicher	Kindstod	von	zwei	Säuglingen	in	Babytragehilfen				Dennis	 Storz1,	 Christof	 Dame1,	 Anke	 Wendt2,	 Alexander	 Gratopp2,	 Christoph	Bührer1		1Department	of	Neonatology,	Charité	–	Universitätsmedizin	Berlin	2Department	 of	 Pediatric	 Pulmonology,	 Immunology	 and	 Intensive	 Care,	 Charité	 –	Universitätsmedizin	Berlin										Abbreviations	BRUE	 Brief	resolved	unexplained	event	HIE	 Hypoxic-ischemic	encephalopathy	OECD	 Organisation	for	Economic	Co-operation	and	Development	SIDS	 Sudden	infant	death	syndrome	SUDI	 Sudden	unexpected	death	in	infancy			Interessenskonflikt:		Die	Autoren	erklären,	dass	kein	Interessenkonflikt	besteht.				Korrespondenzadresse:		Dennis	Storz,	MD	Klinik	für	Neonatologie	Charité	–	Universitätsmedizin	Berlin	Augustenburger	Platz	1		13353	Berlin	Tel.:	030	/	450	566	122	Fax:	030	/	450	566	922	Email:	dennis.storz@charite.de				 	Introduction			 Sudden	 unexpected	 death	 in	 infancy	 (SUDI),	 previously	 termed	 sudden	 infant	death	 syndrome	 (SIDS),	 is	 the	 second	 leading	 cause	 of	 death	 in	 infants	 beyond	 the	neonatal	period	in	Germany,	and	a	major	cause	of	infant	mortality	in	economically	well	developed	countries	(OECD	Health	Statistics,	2019).	The	risk	of	SUDI	peaks	at	the	age	of	2	to	4	months	and	then	decreases	continuously	till	the	end	of	the	first	year.	A	complex	multifactorial	cause,	rather	than	a	single	characteristic	factor,	may	cause	SUDI	within	a	critical	period	of	infant	development	(Guntheroth	WG	et	al.,	Pediatrics	2002;	110:	e64-e64).	 Risk	 factors	 include	 prematurity,	 male	 gender,	 bottle-feeding,	 prone	 sleeping	position,	overheating,	as	well	as	exposure	to	smoke	amongst	others	(Carpenter	RG	et	al.,	Lancet	2004;	363:	185-191).	Thus,	health	professionals	consistently	advise	and	educate	parents	about	avoidable	risk	factors	of	SUDI	at	routine	well-baby	examinations.	Since	the	advent	of	SUDI	prevention	strategies	in	the	1980s,	the	incidence	has	decreased	10fold,	from	1,55/1.000	live	births	in	1991	to	0,15/1000	in	2015.	This	number	seems	to	have	reached	a	steady	state	(Statistisches	Bundesamt	Germany,	2015).		 In	 recent	years,	 baby	 carriers	with	 full	 or	half	 buckles	 for	 easier	handling	have	become	popular	in	Western	countries.	These	tools	mimic	traditional	baby	slings	allowing	to	carry	the	infant	conveniently	during	daily	routines	for	facilitating	close	body	contact.	However,	 they	also	raise	health	concerns	when	such	devices	are	not	applied	correctly.	SUDI	associated	with	the	use	of	full	or	half	buckle	baby	carriers,	as	well	as	baby	slings,	have	been	reported	in	the	United	Kingdom,	France,	Spain,	Australia,	and	the	US	(Batra	EK	et	al.,	J	Pediatr	2015;	167:	183-187;	Bergounioux	J	et	al.,	Eur	J	Pediatr	2015;	174:	1665-1670;	Maqueda	Castellote	E	et	al.,	An	Pediatr	(Barc)	2012;	77:	416-417).			 To	our	knowledge,	SUDI	associated	with	baby	carriers	has	not	yet	been	reported	in	Germany	despite	the	popularity	of	these	devices.	Here,	we	present	two	recent	cases	of	SUDI	associated	with	parental	care	of	the	infants	in	full	buckle	baby	carriers.		Case	reports		 Case	No1.	A	healthy,	term,	then	one-month-old	girl	(see	Table	1)	was	carried	in	a	full	buckle	baby	carrier	by	her	father.	The	device	was	suitable	for	the	two-year-old	sibling.	An	adjustment	to	adapt	the	baby	carrier	to	the	weight	of	the	infant	was	not	performed.	Due	to	winter	season,	the	strap-on	device	was	partially	covered	with	the	father’s	coat.	The	infant	was	initially	agitated	while	the	father	went	for	a	walk,	and	was	later	presumably	asleep.	When	returning	home	after	30	minutes,	spontaneous	breathing	was	noted	to	have	ceased,	and	there	was	bloody	mouth	and	nasal	exudate.	Cardiopulmonary	resuscitation	was	initiated	by	the	parents.	The	medical	emergency	team	was	successful	in	establishing	spontaneous	circulation	after	50	minutes,	and	after	endotracheal	intubation	and	single	doses	 of	 epinephrine.	 After	 transfer	 to	 our	 neonatal	 intensive	 care	 unit,	 laboratory	examinations	 indicated	multi-organ	 failure.	 Neurological	 examination	 revealed	 absent	brain	 stem	 reflexes.	 Amplitude-integrated	 EEG	 evolved	 from	burst-suppression	 to	 flat	trace.	 MRI	 scan	 showed	 bihemispheric	 cytotoxic	 edema	 of	 the	 brain	 consistent	 with	hypoxic-ischemic	 encephalopathy	 (HIE).	 Further	 clinical	 and	 apparative	 examinations	showed	no	signs	of	child	abuse,	such	as	retinal	bleeding,	hematomas,	or	bone	fractures.	Tracheal/oropharyngeal	 swab	 was	 positive	 for	 E.	 coli	 and	 entero/rhinovirus.	 Blood	culture	 was	 positive	 for	 Staph.	 epidermidis	 and	 Staph.	 hominis	 (interpreted	 as	contamination).	Chest	x-ray	showed	no	signs	of	viral	bronchitis	or	pneumonia.		A	multidisciplinary	panel	recommended	to	withdraw	life	support,	considering	the	loss	of	brain	function.	The	infant	died	7	days	after	admission	in	mutual	consent	with	the	parents.	Post	mortem	examination	lead	to	the	overall	conclusion	on	SUDI.				 Case	No2.	A	healthy,	term	male	infant	at	2	½	months	of	age	(see	Table	1)	received	osteopathic	treatment	due	to	torticollis.	Minutes	after	the	treatment	while	being	carried	in	a	full	buckle	baby	carrier	by	the	mother,	the	infant	was	reported	to	be	very	agitated.	During	a	short	walk,	the	mother	tried	to	comfort	the	boy,	holding	him	thoroughly.	The	infant	 then	presumably	 fell	 asleep.	After	5	minutes,	 the	 infant	presented	bloody	nasal	exudate	and	had	stopped	breathing.	Cardiopulmonary	resuscitation	was	initiated.	After	arrival	 of	 the	 medical	 emergency	 team,	 the	 infant	 received	 an	 endotracheal	 tube,	epinephrine,	 and	 was	 defibrillated	 with	 a	 single	 shock	 of	 10	 Joule,	 because	 ECG	monitoring	initially	indicated	ventricular	fibrillation.	Return	of	spontaneous	circulation	was	established	after	45	minutes.	After	admission	 to	 the	pediatric	 intensive	 care	unit,	laboratory	examinations	indicated	multi-organ	failure.	There	was	no	sign	of	child	abuse.	ECG	 showed	 low	 voltage	 without	 further	 pathologies	 (QTc	 404	 ms).	 Clinical	 and	apparative	examinations	revealed	signs	of	HIE,	 including	diffusion-weighted	MRI	scan.	Due	 to	 the	 absence	 of	 spontaneous	 breathing	 and	 the	 persistence	 of	 abnormal	neurological	examinations,	the	patient	died	8	days	after	admission	in	mutual	consent	with	the	parents	to	withdraw	life	support.	Post	 mortem	 examination	 did	 not	 show	 signs	 of	 a	 vascular	 dissection	 as	 putative	association	between	osteopathic	 treatment	 and	 cardio-respiratory	 arrest	 or	 any	other	traumatic	injury,	as	well	as	congenital	organ	malformation	or	acquired	disease.	Klebsiella	(not	further	specified)	was	detected	post	mortem	in	the	tissue	of	trachea,	lung	and	spleen	(no	consequence).	SUDI	was	concluded	the	likely	cause	leading	to	infant’s	death.			Discussion		 We	report	two	cases	of	SUDI	in	full	buckle	baby	carriers,	to	our	knowledge	the	first	cases	reported	in	Germany.	Patients’	histories,	clinical	and	apparative	findings	combined	with	 post	 mortem	 examinations	 strongly	 suggest	 suffocation	 as	 mechanism	 of	 death.	Reviewing	previous	reports,	the	circumstances	leading	to	suffocation	in	adult-worn	(full	or	 half	 buckle)	 baby	 carriers	 and	 baby	 slings	 are	 similar.	 Airway	 obstruction	 and	suffocation	 presumably	 occur	 when	 the	 infant	 falls	 into	 a	 chin-to-chest	 position.	Furthermore,	when	the	infant	is	fully	contained	by	the	baby	carrier	or	baby	sling,	it	may	be	forced	into	a	C-shaped,	curved	positioning	of	the	spine,	which	may	aggravate	airway	obstruction.	 In	addition,	 the	 infant’s	nose	or	mouth	might	be	obstructed	by	the	adult’s	body	or	the	device	itself,	especially	when	the	size	of	the	carrying	device	is	inadequate.	In	the	first	case	presented,	an	adjustment	of	the	baby	carrier	to	the	low	weight	of	the	infant,	and	therefore	preventing	the	infant	from	a	lower	sitting	position,	was	not	performed.		 Until	neurodevelopment	allows	complete	head	control	at	about	4	months	of	age,	infants	appear	to	be	at	high	risk	for	SUDI	in	baby	carriers.	There	are	various	factors	that	may	increase	this	risk	constellation:	Infants	in	this	age	group	generally	do	not	show	a	lot	of	body	movement	while	being	carried.	Therefore,	critical	situations	might	be	overlooked	by	the	parents,	thinking	that	the	infant	is	presumably	asleep.	In	winter	season,	parents	may	 cover	 the	 baby	 carrier	with	 their	 jacket	 or	 a	 blanket.	 This	may	 not	 only	 lead	 to	overheating	but	also	to	poor	visibility	of	the	infant	and	a	lack	of	observation.		 Carrying	devices	currently	on	the	market	can	be	divided	into	3	groups.	Firstly,	the	‘traditional’	baby	sling	made	of	soft	fabric	is	especially	used	to	carry	infants	within	the	first	weeks	of	life.	Secondly,	the	full	buckle	baby	carrier	is	a	strap-on	device	with	buckles	to	 adjust	 its	 fitting.	 Its	 construction	 allows	 carrying	 infants	 up	 to	 20	 kilograms	 of	bodyweight.	Thirdly,	the	product	in	between	those	two	groups,	i.e.	the	half	buckle	baby	carrier,	 combines	 the	main	 characteristics	 of	 the	 preceding:	 It	 enables	 to	 individually	wrap	the	carrier	and	adjust	 its	fitting	with	buckles.	Reviewing	published	SUDI	cases,	 it	seems	that	neither	of	the	devices	possess	a	particular,	higher	risk	of	SUDI	when	compared	to	each	other.			 It	should	be	considered	that	there	are	various	other	devices	such	as	sitting	devices	and	car	seats	that	also	pose	a	risk	of	SUDI.	Nevertheless,	public	health	authorities	in	non-EU	 countries	 have	 already	 issued	 safety	 warnings	 concerning	 baby	 slings	 and	 baby	carriers	(Health	Canada,	2010;	U.S.	Consumer	Product	Safety	Commission,	2010).	To	our	knowledge,	this	kind	of	information	and	public	communication	is	not	present	in	Germany	to	 date.	 Recently,	 a	 bulletin	 by	 Stiftung	 Warentest,	 a	 leading	 German	 consumer	 test	magazine,	revealed	concerns	about	various	baby	carriers.	Among	11	tested	baby	carriers,	four	were	tested	and	specified	as	 ‘defective’	 in	terms	of	basic	manufacturing,	handling,	ergonomics	and	noxious	substances,	but	most	importantly	the	general	risk	of	SUDI	was	not	addressed	in	their	report	written	for	the	general	public	(Stiftung	Warentest,	2020;	64-70).			 Up-to-date	counseling	by	health	professionals	and	media	targeting	parents	could	be	relevant	for	avoiding	this	preventable	cause	of	death.	To	date,	the	number	of	cases	with	SUDI	associated	with	baby	slings	or	carriers	appears	to	be	low,	but	additional	cases	may	have	 not	 been	 reported	 in	 medical	 journals.	 It	 is	 imaginable	 that	 brief	 resolved	unexplained	events	(BRUE)	in	baby	slings	or	carriers	are	not	recorded	at	all.			Conclusion		 While	 baby	 slings	 and	 baby	 carriers	 have	 growing	 popularity,	 the	 devices	may	exhibit	 a	 significant	 risk	 for	 SUDI.	 Baby	 slings	 and	 baby	 carriers	 should	 be	 used	with	particular	caution	in	infants	below	4	months	of	age.	According	to	the	age	and	weight	of	the	 infant,	 parents	 should	 focus	 on	 correct	 size	 and	 fitting	 of	 the	 strap-on	 device.	Appropriate	warnings	and	instructions	need	to	be	provided	by	manufacturers	and	health	professionals,	e.g.	at	the	well-baby	examinations	scheduled	for	3-10	days	(U2)	and	4-6	weeks	(U3).				Table	1:	Clinical	findings	and	further	investigations	in	two	cases	with	SUDI	associated	with	baby	carriers			 Case	No1	 Case	No2	Weeks	of	gestation	 38	2/7	 41	6/7	Birth	weight	(g)	 3110	 3830	Sex	 F	 M	Antenatal	sonography	Past	medical	history	No	pathological	findings	0	No	pathological	findings	Amniotic	infection	syndrome,		5	days	of	antibiotic	treatment	Family	medical	history	 0	 0	Current	Age	(days	/	months)	 25	/	1		 65	/	2	½	Current	Weight	(g)	 3700	 6040	Carrying	device	-	Recommended	age	(months)	-	Recommended	weight	(kg)	Carrying	position	  Clinical	signs	 pH	at	admission	Serum	 lactate	 at	 admission	(mg/dl)	Neurological	signs	Full	buckle	baby	carrier	0	-	36	3.5	-	20	(min.	–	max.)	Device	in	front	of	carrier,	infant	sitting	in	the	device,	face	towards	the	carrier	Bloody	mouth	and	nasal	discharge	<	6,3	167	 Absent	brain	stem	reflexes	Full	buckle	baby	carrier	0	-	36	3.5	-	20	(min.	–	max.)	Device	in	front	of	carrier,	infant	sitting	in	the	device,	face	towards	the	carrier	Bloody	nasal	discharge	 6,6	175	 Absent	brain	stem	reflexes	EEG	MRI				Toxicological	screen	Burst-suppression,	flat	trace	Bihemispheric	cytotoxic	edema	with	minor	infarction	in	putamina		Negative	Low	voltage,	flat	trace	General	hypoxia	with	infarction	of	putamina,	hippocampi,	fornici	cerebri,	brain	stem.	No	signs	of	vascular	dissection	Negative	Post	mortem	examination			Further	details	were	not	made	available	by	the	state	prosecutor No	signs	of	organ	anomaly,	external	force	injury,	chronic	illness		

Plötzlicher Kindstod von zwei Säuglingen in Babytragehilfen

https://refubium.fu-berlin.de/bitstream/fub188/36532/4/2022_Storz_etal.pdf

Plötzlicher Kindstod von zwei Säuglingen in Babytragehilfen

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