Last month I wrote about a spate of infant deaths in so-called “Baby Friendly” hospitals and asked whether the Baby Friendly Hospital Initiative ought to be renamed the Baby Deadly Hospital Initiative.
The Initiative virtually mandates keeping babies in bed with exhausted new mothers even when multiple modifiable risk factors for infant suffocation are present, including maternal impairment due to sedating drugs or exhaustion and soft bedding. Why? To encourage breastfeeding, of course. The paper Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards (2014) reported on the results: 15 neonatal deaths and 2 near deaths.
Over the weekend, a reader alerted me that this phenomenon is far more common than I had realized. In fact, it is so common that it has a name, sudden unexpected postnatal collapse (SUPC), and multiple papers exist describing the phenomenon.
In Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment (2013), Pejovic and Herlenius describe the findings in just one city, Stockholm:
Twenty-six cases of SUPC were found among 68 364 live-born infants, an incidence of 38/100 000 live births. Sixteen of these cases of SUPC required resuscitation with ventilation >1 min, and 14 of these remained unexplained (21/100 000). Fifteen of the 26 children were found in a prone position, during skin-to-skin contact, 18 were primipara, and 13 occurred during unsupervised breastfeeding at
Conclusion
SUPC in apparent healthy babies is associated with initial, unsupervised breastfeeding, prone position, primiparity and distractions. Guidelines outlining the appropriate monitoring of newborns and safe early skin-to-skin contact should be implemented.
Unexpected collapse in apparently healthy newborns – a prospective national study of a missing cohort of neonatal deaths and near-death events (2012) describes the British experience:
45 cases were reported, an incidence of 0.05/1000 live births of whom 12 infants died. In 15/45 infants, an underlying disease/abnormality was determined. In 30/45 cases (0.035/1000 live births), no such cause was found, but in 24, the clinical/pathological diagnosis was airway obstruction during breast feeding or in prone position. Mothers were commonly primiparous and unattended by clinical staff before collapse was recognised.
Not surprisingly, most cases occurred at times of low supervision and many cases involved known risk factors for sudden infant death syndrome (SIDS):
Collapse occurred between 21:00 and 08:59 h in 25 (56%) cases. Thirteen (29%) infants were presumed to be feeding at the time of collapse. Thirty (67%) women had received analgesia in the form of opiates or had had a regional or general (one case) anaesthetic in the 8 h preceding the collapse.
In 23 cases, the mother or both parents were unattended with their new baby at the time of collapse. When mothers were left alone with their baby, they recognised signs of collapse in around a third of instances. When another parent was present, they recognised the signs of collapse more often (75%)…
The long term outcomes were terrible:
Nineteen of the 24 infants with presumed accidental suffocation survived to discharge. At 1 year, five were noted to have neurological abnormalities (26%). Three have cerebral palsy, one has probable cerebral palsy with significant motor delay and the other has mild global delay and hypotonia…
Poets et al. reported in Sudden Deaths and Severe Apparent Life-Threatening Events in Term Infants Within 24 Hours of Birth (2011) on 17 cases of SUPC, defined as unexpected sudden infant deaths (SID) and severe apparent life-threatening events (S-ALTE) that occurred within 24 hours of birth.
There were 7 deaths (ie, 1.1/100 000); 6 of the 10 S-ALTE infants were neurologically abnormal at discharge. Twelve infants were found lying on their mother’s chest or abdomen, or very close to and facing her. Nine events occurred in the first 2 hours after birth; 7, were only noticed by a health professional despite the mother being present and awake.
CONCLUSIONS: SID or S-ALTE may occur in the first 24 hours after birth, particularly within the first 2 hours. Events seem often related to a potentially asphyxiating position. Parents may be too fatigued or otherwise not able to assess their infant’s condition correctly. Closer observation during these earliest hours seems warranted.
An editorial in Archives of Diseases of the Child Fetal Neonatal Edition Unexpected collapse of apparently healthy newborn infants: the benefits and potential risks of skin-to-skin contact (2012) advises:
… it seems appropriate … to recommend that midwives check on the infant’s condition frequently during the first 2–3 h after birth, with particular emphasis on ensuring that when in skin-to-skin contact the infant’s position is safe and the nose and mouth are not occluded.
The ultimate irony, of course, is that there is no evidence that early breastfeeding or skin to skin contact has any impact on breastfeeding success. Correlation has been noted, but that is easily explained by the fact that women who entered labor committed to exclusive breastfeeding are more likely to initiate early breastfeeding and to value extended skin to skin contact than those who plan to bottlefeed. In other words, not only is one of the central tenets of the Baby Friendly Hospital Initiative unproven, but may actually lead to brain injury and death.
In a recent issue of The Journal of Perinatal and Neonatal Nursing, M. Terese Verklan, PhD, CCNS, RNC, FAAN points out that The Breast Can Be Lethal:
… I have recently heard of 2 incidences of newborns being suffocated when breast-feeding. One case involved a mother who was exhausted after feeding her newborn every 11/2 to 2 hours for the past 60 hours or so. It is believed that she fell asleep while the newborn was feeding and did not wake up until the morning. It was obvious that the baby did not survive the night. In the second case, the neonate was approximately 4 hours old when the parents excitedly summoned the postpartum nurse to check him because “he didn’t look right.” The nurse remembers seeing his legs looking mottled and dusky and that she had to lift the breast off his head and chest. He was in cardiopulmonary arrest and survived extensive resuscitation with major neurologic sequelae. Both mothers had had a lactation consultant spend some time instructing them on how to breastfeed, describing several positions to enhance latching for the baby and comfort for the mother. I believe both were being held in the football hold, but I am not 100% sure. I do know that both mothers were primiparas wanting to provide the best nutrition for these babies.
Verklan concludes:
… Given that we are using evidence-based practice interventions today as much as possible, perinatal researchers need to closely scrutinize the different practices taught to mothers and develop the science behind these “routine” interventions…
Mandated rooming in policies, encouragement of prolonged skin to skin contact, and pressure to breastfeed repeatedly and exclusively during the first postpartum days are interventions promoted by the Baby Friendly Hospital Initiative. Like all interventions, we need to examine whether there is scientific evidence to support them, and describe the harms that result from them.
Otherwise, the Baby Friendly Hospital Initiative will truly become the Baby Deadly Hospital Initiative.
