An Acute Event in a Newborn. Nancy Rodriguez, PhD, NNP,*. â . Matthew Pellerite, MD,*. â . Patrick Hughes, DO,*. Bridget Wild, MD,*. â . Monica Joseph, MD,*. â .
Video Corner An Acute Event in a Newborn Nancy Rodriguez, PhD, NNP,*† Matthew Pellerite, MD,*† Patrick Hughes, DO,* Bridget Wild, MD,*† Monica Joseph, MD,*† Joseph R. Hageman, MD* *Pritzker School of Medicine, The University of Chicago, Chicago, IL † NorthShore University HealthSystem, Evanston, IL
Please view the video of a newborn with an acute event.
Video 1. Click here to view the video.
The most likely diagnosis for the infant in this video is a(n): A. Sudden unexpected postnatal collapse B. Brief resolved unexplained event C. Ductal-dependent congenital heart lesion D. Severe combined immune deficiency E. Inborn error of metabolism
CRITIQUE Case
AUTHOR DISCLOSURE Drs Rodriguez, Pellerite, Hughes, Wild, Joseph, and Hageman have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device.
The 3-kg female infant described in this case was born at 39 weeks’ gestation to a 31year-old gravida 2, para 2 woman via spontaneous vaginal delivery. Prenatal maternal laboratory testing revealed blood type A positive with unremarkable serologic findings. Rupture of membranes occurred 7 hours before delivery and the amniotic fluid was clear. The infant emerged active and had an Apgar score of 9 at 1 and 5 minutes after birth. The infant was then placed skin to skin with her mother. Subsequently, the infant was breastfed and fell asleep in her mother’s arms. Within 2 hours, the nurse found the infant to be limp and cyanotic. A full resuscitation was initiated with positive pressure ventilation and chest compressions, and the infant underwent intubation. An umbilical venous catheter was placed and 2 doses of epinephrine were administered. However, after 20 minutes of cardiopulmonary resuscitation, the infant remained asystolic so resuscitative efforts were stopped and the infant was pronounced dead. A postmortem examination and case review was unrevealing about underlying infectious, metabolic, or structural etiologies. A diagnosis of sudden unexpected postnatal collapse was rendered.
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Video 2. Click here to view the video.
Sudden Unexpected Postnatal Collapse A “new” clinical entity has been characterized in the European, Australian, and United States literature, which has been called by various names including sudden unexpected postnatal collapse (SUPC). (1)(2)(3)(4)(5)(6) This sudden collapse occurs in apparently healthy term newborns soon after birth, commonly during initial skin-to-skin contact or the initial breastfeeding session. (1)(2)(7) Video 1 depicts a simulated case of SUPC in a postpartum department. Diagnostic criteria and risk factors for SUPC are detailed in Tables 1 and 2, respectively. The true incidence of SUPC is not known because there is wide variation in the definition. For example, inclusion and exclusion criteria in published reports range from: • A gestational age of more than 35 weeks or 38 weeks (8) • Onset of the event before 2, 12, 24, or 72 hours of postnatal life, or within the first 7 days after birth (8) • The presence or absence of an underlying pathologic condition (1) Also, infants who experience SUPC but respond favorably to resuscitation (near misses) are often not included in published reports. Given the lack of consensus in definition
TABLE 1.
Diagnostic Criteria for Sudden Unexpected Postnatal Collapse
• ‡37 weeks’ gestation at birth • Apgar score ‡8 at 5 minutes of postnatal age • Collapse within 12 hours of birth in hospital • Required resuscitation after collapse with positive pressure ventilation • Died or received ongoing intensive care Modified from Becher et al, 2012. (1)
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and no International Classification of Diseases 10 coding to report “unexpected postnatal collapse,” it is likely that the true incidence of SUPC is underreported. International data show an incidence of 0.026 to 0.05 per 1,000 live births. (3) In Australia, the reported incidence is 0.05 per 1,000 live births >37 weeks’ gestation per year. (3) A twofold difference in the reported incidence in Australia, compared with New South Wales (0.1/1,000 live births) suggests reluctance on the part of clinicians to report cases. (3) Failure to investigate cases by autopsy leaves parents uninformed about the cause of death and without relevant information that may affect future pregnancies. (3) Based on published literature, the median age at SUPC occurrence is 70 minutes after birth, for infants without an underlying pathology. (1) For infants with an underlying condition (as detailed in Table 2) the median age at SUPC is 195 minutes after birth. (1) Approximately one-third of cases occur in the first 2 hours after birth (often during the first breastfeeding session), one-third occur between 2 and 24 hours of age, and one-third between 1 and 7 days postnatally. (8) Previously known risk factors include primiparous mother, maternal analgesia, prone position of infant during skin-to-skin contact, first breastfeeding session, and mothers falling asleep while breastfeeding. (3) In a recent report, up to 53% (24/45) of cases were attributed to airway obstruction associated with breastfeeding, skin-to-skin contact, or prone positioning. (1) More recent evidence suggests that there are many additional risk factors, as detailed in Table 2.
Comparing Clinical Entities In 2016, the American Academy of Pediatrics (AAP) published a clinical practice guideline to reclassify the clinical entity of apparent life-threatening event (ALTE) as brief resolved unexplained event (BRUE) in an effort to more accurately label often self-limited events, and to offer evidencebased guidance for minimizing unnecessary medical evaluation of those patients deemed to have a low risk for serious adverse outcomes. (9) BRUE is defined as a brief, resolved event observed by a caregiver in a child younger than 1 year with at least 1 of the following features: • cyanosis or pallor • absent, decreased, or irregular breathing • marked change in tone • altered responsiveness A diagnosis of low-risk BRUE is made only in well-appearing infants after no explanation for the event can be identified on history and physical examination. If an infant is categorized as low risk, as evidenced by being more than 60 days of age, born ‡32 weeks of gestation, with a postmenstrual age >45 weeks’ gestation, the absence of cardiopulmonary resuscitation by
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TABLE 2.
Risk Factors for Sudden Unexpected Postnatal Collapse
MATERNAL
PERINATAL
NEONATAL
ENVIRONMENTAL/ SITUATIONAL
Primiparous status
Prenatal compromise
Prone position of the infant while mother supine
Breastfeeding (especially first attempt)
Maternal opiate analgesia
Passage of meconium in utero
Infant fatigue
Unobserved skin-to-skin care with infant prone or side-lying on mother’s chest
Regional or general anesthesia within 8 hours of event
Need for extensive neonatal resuscitation after delivery
Late preterm or preterm infant deemed safe to be left in the delivery room
Mother in supine position during skin-to-skin contact
Magnesium sulfate administration during labor
Delivery via cesarean section
Accidental suffocation due to occluded airway
Parental distraction (including use of smartphones)
Maternal body mass index >25 kg/m2
Need for extensive repair after vaginal delivery
Underlying conditions, including:
Fatigued parents
Large breasts
• Cardiac disease (HLHS, interrupted aortic arch)
Mother left alone with neonate
Maternal fatigue/falling asleep during breastfeeding
• Pulmonary disease (PPHN) • Infection (pneumonia, sepsis) • Inborn error of metabolism (congenital lactic academia, urea cycle defect) • Otolaryngology (prolapsed epiglottis with laryngomalacia)
HLHS¼hypoplastic left heart syndrome; PPHN¼persistent pulmonary hypertension of the newborn.
medical providers, and with a first-time event that lasted less than 1 minute, then they may not require further evaluation or hospitalization. (9) High-risk BRUEs and additional evaluation of some low-risk BRUEs are left to clinical judgment. As awareness of perinatal infant collapse has developed, the nomenclature continues to evolve. In keeping with prior existing terminology, severe apparent life-threatening event (s-ALTE) and unexplained sudden infant death were terms first used in a German case series to distinguish between surviving and deceased term infants who received assisted breaths or chest compressions due to cyanosis, pallor, or unconsciousness when less than 24 hours old, having had a 10-minute Apgar score greater than or equal to 8. (2) Currently, the term SUPC consists of more concise clinical inclusion criteria, while uniting surviving and deceased infants under the same label. Infants must be ‡37 weeks’ gestation, with a 5-minute Apgar score greater than or equal to 8, presenting with collapse within 12 hours of birth in a hospital, and requiring resuscitation with positive pressure ventilation. (1) SUPC involves cardiorespiratory collapse that leads to ongoing intensive care or death, and thus, is fundamentally different from a BRUE, which is a resolved event in a well-
appearing infant. Some characteristics of SUPC are similar to potential characteristics of a high-risk BRUE. Similar to SUPC, a high-risk BRUE does not fulfill low-risk criteria, may last over 1 minute, and/or occur in an infant less than 60 days old, and/or require resuscitation. SUPC is similar to high-risk BRUE in that underlying predisposing conditions can often be identified, such as accidental suffocation, underlying cardiac disease, pulmonary disease, pneumonia, sepsis, inborn errors of metabolism, or airway abnormalities. (1)(9)
Prevention The numerous benefits of early skin-to-skin contact and breastfeeding, for both mother and infant, are undisputed. To optimize health outcomes, clinicians must facilitate these sessions in the early postpartum period, yet promote a safe environment for the infant/mother dyad. Current recommendations support continuous “rooming in” of newborn infants with their mothers, from the time of delivery until hospital discharge. Yet, there is also increasing awareness that healthy “well-appearing” infants are at risk for SUPC. (1)(2)(3)(8)(10)(11) The peak incidence of SUPC is within the first 2 hours after birth, (2) typically, the time when the
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mother first places the newborn skin to skin and also breastfeeds for the first time. Although many risk factors have been identified (Table 2), prone positioning, first-time mother, unsupervised first attempt at breastfeeding, and parental distraction, including smartphones, appear to be primary among them. (8)(10)(11) In a recent report involving 26 cases of SUPC, 15 of the infants were positioned prone during skin-to-skin contact, 18 were born to primiparous mothers, 13 occurred during unsupervised breastfeeding within the first 2 hours after birth, and 3 cases occurred during maternal use of a cellular smartphone. (10) Some of these (situational) risk factors are easily modifiable. Although SUPC events are relatively rare, the clinical outcomes for these infants are devastating, with many infants dying either at the time of the event or after a prolonged hospital course. (1) (2)(3)(10) Those who survive are at risk for hypoxic-ischemic encephalopathy, which is often severe, with seizures occurring as early as 6 hours after the period of asphyxia. (10) Despite prompt hypothermia treatment, SUPC survivors may suffer severe neurodevelopmental disabilities. (1)(10)(12) With increased awareness of SUPC, some authors have proposed clinical guidelines for prevention. For example, Davanzo et al (11) proposed a nursing guideline for monitoring at-risk infants during the first 2 hours after birth, a high-risk period for SUPC. In addition to increased surveillance of the infant during this critical postpartum transitional period, parental education is key to prevention. Physicians and nurses play a pivotal role in SUPC prevention by counseling parents during the immediate postpartum period. However, it is important that the education be provided in a manner that does not frighten parents and discourage breastfeeding/skin-to-skin sessions. The teaching should focus on the following: • Proper positioning of the infant to maintain upper airway patency • “Distraction-free” breastfeeding and skin-to-skin contact • Emphasis should be placed on “no distractions” (ie, no use of smartphone by mother) during sessions of skinto-skin contact and/or breastfeeding • Parents must also be cognizant that maternal fatigue is common. They must be taught that if the mother is overly fatigued, and without additional help, the infant should be placed back to sleep in the bassinet so that the mother does not risk falling asleep while holding the infant.
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By increasing awareness of SUPC, better identifying infants who are at risk, and providing counseling to parents in the immediate postpartum period, future cases of this devastating phenomenon may be prevented. Please view Video 2, showing a physician counseling a mother in the immediate postpartum period.
CORRECT RESPONSE A. Sudden unexpected postnatal collapse
References 1. Becher JC, Bhushan SS, Lyon AJ. Unexpected collapse in apparently healthy newborns–a prospective national study of a missing cohort of neonatal deaths and near-death events. Arch Dis Child Fetal Neonatal Ed. 2012;97(1):F30–F34 2. Poets A, Steinfeldt R, Poets CF. Sudden deaths and severe apparent life-threatening events in term infants within 24 hours of birth. Pediatrics. 2011;127(4):e869–e873 3. Lutz TL, Elliott EJ, Jeffery HE. Sudden unexplained early neonatal death or collapse: a national surveillance study. Pediatr Res. 2016;80 (4):493–498 4. Radovanovic T, Spasojevic S, Stojanovic V, Doronjski A. Etiology and outcome of severe apparent life-threatening events in infants [published online ahead of print October 30]. Pediatr Emerg Care. 2016 5. Thach BT. Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards. J Perinatol. 2014;34(4):275–279 6. Chu A, Hageman JR. Apparent life-threatening events in infancy. Pediatr Ann. 2013;42(2):78–83 7. Andres V, Garcia P, Rimet Y, Nicaise C, Simeoni U. Apparent lifethreatening events in presumably healthy newborns during early skin-to-skin contact. Pediatrics. 2011;127(4):e1073–e1076 8. Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks, and preventive measures. Transl Stroke Res. 2013;4(2):236–247 9. Tieder JS, Bonkowsky JL, Etzel RA, et al; Subcommittee on Apparent Life Threatening Events. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lowerrisk infants. Pediatrics. 2016;137:e1–e32. doi: 10.1542/peds.2016-0590 10. Pejovic NJ, Herlenius E. Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment. Acta Paediatr. 2013;102(7):680–688 11. Davanzo R, De Cunto A, Paviotti G, et al. Making the first days of life safer: preventing sudden unexpected postnatal collapse while promoting breastfeeding. J Hum Lact. 2015;31(1):47–52 12. Foran A, Cinnante C, Groves A, Azzopardi DV, Rutherford MA, Cowan FM. Patterns of brain injury and outcome in term neonates presenting with postnatal collapse. Arch Dis Child Fetal Neonatal Ed. 2009;94(3):F168–F177
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An Acute Event in a Newborn Nancy Rodriguez, Matthew Pellerite, Patrick Hughes, Bridget Wild, Monica Joseph and Joseph R. Hageman NeoReviews 2017;18;e717 DOI: 10.1542/neo.18-12-e717
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An Acute Event in a Newborn Nancy Rodriguez, Matthew Pellerite, Patrick Hughes, Bridget Wild, Monica Joseph and Joseph R. Hageman NeoReviews 2017;18;e717 DOI: 10.1542/neo.18-12-e717
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