A 5-day-old girl is brought to the office by her parents after nursery discharge. She was born at 37 weeks gestation via cesarean delivery due to a nonreassuring fetal status secondary to fetal growth restriction. The patient was discharged from the hospital on day of life 4. She is exclusively breastfed, and the mother says the patient often spits up breast milk, sometimes while asleep. She occasionally rests on the mother's chest in the prone position while both are awake. The patient uses a pacifier for sleep. The parents are concerned about her varied breathing pattern because she often takes rapid, shallow breaths followed by 5-10 second pauses. The patient lives at home with her mother and father, who occasionally smoke cigarettes. Vital signs and physical examination are appropriate for age. The mother says that a neighbor's 2-month-old infant recently passed away in her sleep and is wondering if there is anything she should do differently. Which of the following interventions has the greatest impact on this patient's safety?

Question

A 5-day-old girl is brought to the office by her parents after nursery discharge.  She was born at 37 weeks gestation via cesarean delivery due to a nonreassuring fetal status secondary to fetal growth restriction.  The patient was discharged from the hospital on day of life 4.  She is exclusively breastfed, and the mother says the patient often spits up breast milk, sometimes while asleep.  She occasionally rests on the mother's chest in the prone position while both are awake.  The patient uses a pacifier for sleep.  The parents are concerned about her varied breathing pattern because she often takes rapid, shallow breaths followed by 5-10 second pauses.  The patient lives at home with her mother and father, who occasionally smoke cigarettes.  Vital signs and physical examination are appropriate for age.  The mother says that a neighbor's 2-month-old infant recently passed away in her sleep and is wondering if there is anything she should do differently.  Which of the following interventions has the greatest impact on this patient's safety?

Quizplus · Accepted Answer

11ec25c8_d6fe_9c6f_bc81_9fb505c3719f_MD0003_00 Sudden infant death syndrome (SIDS) is the leading cause of mortality in infants age 1 month to 1 year in the United States. It is defined as a sudden, unexpected death that cannot be explained by history or postmortem examination. Pathogenesis is uncertain but may involve delayed brain maturation resulting in inadequate CNS arousal responses to hypoxia and hypercarbia in the setting of an inciting event (eg, airway obstruction). Although this condition has no direct cause, there are modifiable risk factors associated with SIDS. One such factor is smoke exposure, including maternal smoking during pregnancy and passive postnatal exposure. Impaired cardiovascular reflexes (eg, increased heart rate due to hypercarbia) and diminished arousal responses may account for this elevated risk. Other important modifiable risk factors are sleep position and environment. Prone-sleep positioning increases the risk of SIDS and should be avoided. Although prone positioning (tummy time) is recommended for gross motor development and positional plagiocephaly prevention, it should occur only during awake, observed periods (Choice C). Side-sleep positioning is a less significant risk factor but should also be avoided due to an increased ability to roll into the prone position (Choice E). Instead, infants should be placed to sleep in a supine position on a firm, flat surface with no other objects (eg, pillow, stuffed animals) in the crib/bassinet. supine position Parents should be informed that in otherwise healthy infants with gastroesophageal reflux, a condition likely present in this patient with frequent spit-ups, aspiration risk is not greater in the supine position due to an intact gag reflex. (Choice A) Pacifier use during sleep is associated with a decreased risk of SIDS. The mechanism is unclear but may relate to increased arousability from sleep while using a pacifier. (Choice D) Home apnea monitors can be considered for infants with chronic lung disease or recurrent episodes of apnea/bradycardia. This patient's breathing pattern is consistent with periodic breathing, a normal newborn respiratory pattern characterized by brief (5-10 sec) pauses. In addition, monitors are not recommended even if an infant has a history of a single brief resolved unexplained event (BRUE) or SIDS risk factors (eg, prematurity), and their use can lead to increased parental anxiety and false reassurance. Educational objective: Sudden infant death syndrome refers to the unexplained death of infants age <1. Modifiable risk factors include smoke exposure (prenatal and postnatal) and prone- and side-sleep positioning. References: SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. (http://www.ncbi.nlm.nih.gov/pubmed/27940805)

A 5-Day-Old Girl Is Brought to the Office by Her