Apparent Life-Threatening Events in Presumably Healthy Newborns During Early Skin-to-Skin Contact

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Apparent Life-Threatening Events in Presumably

Healthy Newborns During Early Skin-to-Skin Contact

abstract

The death or near death of a presumably healthy newborn in the deliv-ery room is uncommon. We report here 6 cases of apparent life-threatening events (ALTEs) in the delivery room during the first 2 hours of life. In each case, the incident occurred in a healthy infant who was in a prone position on his or her mother’s abdomen during early skin-to-skin contact. In most cases, the mother was primiparous, and in all cases the mother and infant were not observed during the initiation of skin-to-skin contact and breastfeeding. There are many benefits of early skin-to-skin contact and breastfeeding in the delivery room. How-ever, in view of the risk of a rare but significant ALTE, we suggest that surveillance of newborns is needed. Although many ALTEs are appar-ently caused by obstruction, we suggest that a standardized investiga-tional workup be performed after an ALTE. Pediatrics 2011;127: e1073–e1076

AUTHORS:Virginie Andres, MD,a_{Patricia Garcia, MD,}a

Yves Rimet, MD,b_{Claire Nicaise, MD,}c_{and Umberto}

Simeoni, MDa

a_{Neonatal Intensive Care Unit, La Conception University Hospital,}

Marseille, France;b_{Neonatal Unit, Regional Hospital, Aix en}

Provence, France; andc_{Neonatal and Pediatric Intensive Care}

Unit, Nord University Hospital, Marseille, France

KEY WORDS

newborn, apparent life-threatening event, sudden death, skin-to-skin, delivery room

ABBREVIATIONS

ALTE—apparent life-threatening event SIDS—sudden infant death syndrome

www.pediatrics.org/cgi/doi/10.1542/peds.2009-3095

doi:10.1542/peds.2009-3095

Accepted for publication Jan 4, 2011

Address correspondence to Virginie Andres, MD, CHU La Conception, Médecine Néonatale, 147 bv Baille, 13385 Marseille, France. E-mail: virginie.andres@ap-hm.fr

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE:The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose.

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The incidence of apparent life-threatening events (ALTEs) or unex-pected death of presumably healthy newborns in delivery rooms is un-known, but most physicians consider it to be extremely uncommon.1–6 How-ever, the occurrence of an ALTE re-quires rapid response, because the consequences can be severe.

Physicians increasingly recommend prolonged skin-to-skin contact of the mother and her healthy newborn soon after birth because it is believed to improve mother-infant bonding and successful breastfeeding.7–11_However, such intervention has not been com-pletely adopted in the maternity wards of developing countries because of some concerns about safety. Indeed, a few reports have noted the risk of rare but severe neonatal adverse events, in-cluding ALTEs and sudden and unex-pected deaths.4–6,12–14

In this article we report our examination of 6 cases of ALTEs that occurred in pre-sumably healthy newborns who experi-enced early (⬍2 hours after birth) skin-to-skin contact with their mothers in the nurseries of a regional area (West Provence-Alpes-Côte d’Azur, France) be-tween 2004 and 2007.

CASE REPORTS

Table 1 summarizes the relevant peri-natal data of the 6 cases of neoperi-natal ALTEs described below. In all cases, af-ter normal physical examination

ﬁnd-ings at birth, the neonates were placed in direct skin-to-skin contact with their mothers while in the prone position in the delivery room, and breastfeeding was initiated. The neonate was then left with his or her mother and, later, the father.

Case 1

Thirty minutes after birth, the infant was found motionless while he was in his mother’s arms. Resuscitation was initiated because of cardiac and respi-ratory failure. He improved rapidly in the NICU and was discharged without obvious neurologic deﬁcit. Early-onset neonatal sepsis was excluded. Other clinical data, including results of an electrocardiogram, brain MRI, and in-vestigation of possible malformations, indicated no abnormality.

Case 2

Ninety minutes after birth, the infant ex-perienced cardiopulmonary arrest. After initial resuscitation, she required respi-ratory support and inotrope and anti-convulsant therapies. Brain MRI analysis excluded a major cerebral malforma-tion. This patient had a severe hypoxic-ischemic encephalopathy and died after 23 days. The results of all postnatal in-vestigations, including septic workup, metabolic screening, electrocardio-gram, assessment of malformation, and investigation for myotonic dystrophy, in-dicated no abnormality. Muscle biopsy

and autopsy were also unable to estab-lish causality.

Case 3

Sixty minutes after birth, cardiorespi-ratory arrest occurred in the second twin born. Resuscitation required tra-cheal intubation and mechanical ventilation with inotrope, anticonvul-sant, and antibiotic treatment. Severe cerebral bleeding occurred and was associated with hypoxic-ischemic en-cephalopathy, as conﬁrmed by electro-encephalography and brain computed-tomography scanning. The infant died after 15 days. Infection markers and the results of investigations of inborn metabolic errors were negative, and ﬁndings of an electrocardiogram were normal. The parents refused an autopsy.

Case 4

One hundred twenty minutes after birth, the infant became motionless, and his face indicated cyanosis. After vigorous stimulation, he recovered rapidly. Clinical examination ﬁndings and his glycemic values were normal. No new event occurred during the fol-lowing 3 days of observation.

Case 5

Several minutes after birth, the infant became motionless, cyanotic, and bra-dycardic. After vigorous stimulation, rapid recovery occurred. The infant’s

TABLE 1 Main Perinatal Characteristics of 6 Cases of ALTEs During the First 2 Hours After Birth

Case 1 Case 2 Case 3 Case 4 Case 5 Case 6

Maternal age, y 39 31 23 27 25 25

Maternal antecedents G2P0 G2P0 G1P0, Leiden factor V mutation G2P1 G2P1 G1P0 Pregnancy Uneventful PROM Twin pregnancy Gestational diabetes

mellitus (insulin)

Uneventful PROM

Vaginal delivery Spontaneous Spontaneous Instrumental Spontaneous Spontaneous tinted AF Spontaneous

Gestational age, wk 39 40 366_⁄₇ ₃₆5_⁄₇ ₃₆5_⁄₇ ₄₀2_⁄₇

Infant weight, g 2930 4280 2680 2800 2750 3340

Apgar score at 5 and 10 min

5 min 10 10 10 10 10 10

10 min 10 10 10 10 10 10

Prevention of infection risk was conducted with appropriate maternal antibiotics in each case. G indicates gravida; P, para; PROM,⬎2-hour premature rupture of membranes; AF, amniotic ﬂuid.

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clinical examination ﬁndings and gly-cemic values were normal. Infection markers and results of investigations of inborn metabolic errors were nega-tive. No new event occurred during the following 5 days of observation.

Case 6

One hundred twenty minutes after birth, cardiopulmonary arrest oc-curred. Resuscitation required tra-cheal intubation and mechanical venti-lation with inotrope, anticonvulsant, and antibiotic treatment. Severe hypoxic-ischemic encephalopathy was conﬁrmed by electroencephalography and brain MRI. Results of infectious and metabolic investigations were negative. The infant died after 15 days. The parents refused an autopsy.

DISCUSSION

An ALTE or sudden death of a presum-ably healthy newborn soon after birth is usually considered an exceptional event, but more of these cases have been reported in recent years.1–6,12–14 There have been no systematic sur-veys, so the exact incidence of such events is unknown. On the basis of the literature, the overall incidence rate of ALTEs has been estimated as 0.025 to 0.032 per 1000 births and the mortality rate as 0.018 per 1000 births.4–6_These rates are concordant with our ﬁndings of an ALTE incidence of 0.034 per 1000 births and a mortality rate of 0.017 per 1000 births. Nonetheless, we believe that these estimates are low, because they may not include many of the new-borns who have had ALTEs with rapid and favorable outcomes.

In our 6 reported cases, most of the infants were born to primiparous women after uneventful vaginal deliv-eries, and the mothers were left alone with their infants in the delivery room. In each case, the ALTE or sudden unex-pected death occurred with the healthy infant in a prone position on

his or her mother’s abdomen during early skin-to-skin care and initiation of breastfeeding. There were no appar-ent reasons for such serious incidappar-ents in these infants, and neither postre-suscitation studies nor postmortem investigations identiﬁed possible causes. In most of the published cases of ALTEs, 3 risk factors were identiﬁed: primiparous mother; skin-to-skin con-tact of the mother and newborn; and mother and infant left alone in the de-livery room.4–6,12–14

Classically, the deﬁnition of the sudden infant death syndrome (SIDS) excludes early neonatal cases.15_{However, it is} possible that the risk factors for SIDS may also be risk factors for ALTEs or sudden unexpected deaths of presum-ably healthy newborns. Thus, a prone position and overheating are potential behavioral risk factors for ALTEs. Au-thors of some previous studies re-ported a dramatic deterioration of newborns during and after breast-feeding, possibly caused by oronasal obstruction.16,17_{Mechanical upper} air-way obstruction and an asphyxiating position of the infant, with the infant’s face covered while facing his or her mother’s abdomen, breast, or neck, may be a result of the lack of experi-ence of a primiparous mother, the mother’s slow recovery after giving birth, or the unavailability of medical personnel. Results of other studies have suggested that increased vagal tone was a cause of cardiorespiratory arrest.18 _{Results of studies of the} pathophysiology of SIDS have indicated that prone sleeping was associated with altered autonomic control and manifested as an increased heart rate, reduced heart-rate variability, and in-creased sympathetic tone. In addition, the postdelivery period is known to be associated with an increased vagal tone in newborns.19

Among our 6 ALTE cases, we observed heterogeneous signs and symptoms.

For the 3 infants who died, brain imag-ing and biological, infectious, and met-abolic assessments were performed, but cardiologic evaluation was only performed in 1 case. When the ALTE evolution was rapid and favorable, we observed that the assessments were often incomplete, particularly in terms of brain imaging and cardiologic eval-uation, which was only performed for 1 case. Thus, a cerebral or cardiologic malformation could predispose an in-fant to an ALTE. As with the manage-ment of SIDS, it is reasonable to pro-pose that an infant who experiences an ALTE be given a standardized diagnos-tic investigation, complete medical evaluation, and an autopsy if death occurs.

All 6 of our infants had skin-to-skin con-tact with their mothers at the time of the ALTE. This practice, therefore, could be a risk factor for neonatal ALTEs or unexpected death in the deliv-ery room. The World Health Organiza-tion recommends early skin-to-skin contact for mothers and their presum-ably healthy newborns, because it is believed to improve breastfeeding out-comes, mother-infant attachment, and infant cardiorespiratory stability, to reduce infant crying, and to have no apparent short-term or long-term neg-ative effects. However, ALTEs and unex-pected deaths have been reported to occur during this period. Several na-tional committees have recommended medical supervision during early skin-to-skin contact, but the nature of this supervision has not yet been clearly deﬁned. Death and near-death epi-sodes suggest a lack of medical super-vision. We believe that careful position-ing of the infant and unobtrusive medical supervision should be encour-aged. There have been recent tests of wireless, wearable pulse-oximetry monitoring systems for surveillance of infants at risk of an ALTE in the delivery room.20 _Such _monitors, _however,

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would be considered as a help and not as the only tool of surveillance. Fur-thermore, standard counterindica-tions for skin-to-skin mother-infant care, such as maternal use of a seda-tive, sepsis, tiredness (especially if pri-miparous), and unavailability of a mid-wife, should be strictly respected.

CONCLUSIONS

Unexpected and rare ALTEs can af-fect an apparently healthy newborn

in the delivery room during the ﬁrst hours of life, especially during early skin-to-skin contact with the mother. ALTEs are rare, but they can be seri-ous and even lead to death. Some risk factors for ALTEs have been sug-gested, although they are poorly de-ﬁned. Promotion of early mother-infant skin-to-skin contact and breastfeeding in the delivery room should be encouraged, but perinatal medical personnel (gynecologists,

midwifes, nurses, and pediatricians) should be aware of ALTEs and care-fully monitor and ensure proper po-sitioning of healthy neonates during this delicate period of mother-infant attachment, especially for primipa-rous mothers. Airway obstruction is a likely cause for some cases of ALTEs. We suggest that standardized investigations be implemented after the occurrence of ALTEs to better identify the risk factors.

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DOI: 10.1542/peds.2009-3095 originally published online March 14, 2011;

2011;127;e1073

Pediatrics

Virginie Andres, Patricia Garcia, Yves Rimet, Claire Nicaise and Umberto Simeoni

Early Skin-to-Skin Contact

Apparent Life-Threatening Events in Presumably Healthy Newborns During

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