#sleepingbaby on Instagram: Nonadherence of images to safe sleeping advice and implications for prevention of Sudden Unexpected Death in Infancy.

OBJECTIVES: Safe sleep of infants is important to reduce the risk of Sudden Unexpected Death in Infancy (SUDI). The depiction of infant care behavior which is inconsistent with the safe sleep recommendations on social media has an impact on parental infant care thoughts, norms and behaviors. This study aims to determine the adherence of Instagram images to the Dutch safe sleeping advice. DESIGN: A systematic social media analysis on Instagram was performed using 22 hashtags and 9 accounts of Dutch companies or platforms related to infants. Images of sleeping infants were analyzed on consistency with the criteria: supine sleeping position, own cot or crib, sleep sack, and an empty bed. RESULTS: Based on 514 collected images, 5.9% was consistent with sleep sack use, 16.8% with an empty bed, 30.7% with an own cot or crib, and 67.5% with the supine sleeping position. For 311 images (60.5%), all four criteria could be rated, as for the others, at least one criterion was not clearly depicted. Only 6 of these images (1.9%) were consistent with all four criteria. CONCLUSIONS: Although Instagram images are probably not representative of regular infant care behavior, the exposure to these images that are mostly inconsistent with the safe sleep advice can contribute to the formation of norms, and therefore influence parental care behavior. Accurate communication of the safe sleep recommendations through social media is needed, and opportunities are described for preventive health professionals to engage more in this communication with their public.

[Infants with an unexplained event: management of brief resolved unexplained events revised]. / Zuigelingen met een kortdurend, onverklaard incident.

In this article, the new Dutch pediatric guideline Brief Resolved Unexplained Event is discussed, which replaces the old guideline Apparent Life Threatening Event. The main goal of the new guideline is identification of a group of low-risk infants who need not be admitted to the hospital and in which only limited diagnostic workup is indicated. Three fictional cases are presented to highlight the major changes in management of infants who present with an unexplained event. Application of the new guideline will likely result in less clinical admissions and diagnostic testing in these patients.

Risk and Preventive Factors for SUDI: Need We Adjust the Current Prevention Advice in a Low-Incidence Country.

Background: The incidence of Sudden Unexpected Death in Infancy (SUDI) is low in the Netherlands, with an incidence rate of 0.18 per 1,000 live births. Therefore, prevention advice may receive less attention, potentially leading to increasing incidence rates. It is currently unknown whether the risks for SUDI changed in the Netherlands, and if other risk factors might be present. The aim of this study was to examine the current risks and preventive factors for SUDI in Dutch infants, in order to determine if it is necessary to adapt the prevention advice toward the current needs. Methods: A case-control study was conducted comparing SUDI cases aged <12 months from 2014-2020 in the Netherlands (n = 47), to a Dutch national survey control group from 2017 including infants <12 months of age (n = 1,192). Results: Elevated risks for several well-known factors were observed, namely: duvet use (aOR = 8.6), mother smoked during pregnancy (aOR = 9.7), or after pregnancy (aOR = 5.4) and the prone sleeping position (aOR = 4.6). Reduced risks were observed for the well-known factors: room-sharing (aOR = 0.3), sleep sack use (aOR = 0.3), breastfeeding (aOR = 0.3), and the use of a pacifier (aOR = 0.4). For infants <4 months, the risk for SUDI was higher when bed-sharing (aOR = 3.3), and lower when room-sharing (aOR = 0.2) compared to older infants. For older infants, the sleep sack was found to be more protective (aOR = 0.2). A high risk for SUDI when bed-sharing was found when mother smoked, smoked during pregnancy, or if the infant did not receive any breastfeeding (respectively aOR = 17.7, aOR = 10.8, aOR = 9.2). Conclusions: Internationally known factors related to the sudden unexpected death of infants were also found in this study. Relatively new findings are related to specific groups of infants, in which the strengths of these risk factors differed. In a low-incidence country like the Netherlands, renewed attention to the current prevention advice is needed. Furthermore, additional attention for prevention measures in low educated groups, and additional advice specifically targeting high-risk groups is recommended.

Renewed Attention Needed for Prevention of Sudden Unexpected Death in Infancy in the Netherlands.

Background: The incidence of sudden unexpected death in infancy (SUDI), which includes sudden infant death syndrome (SIDS), has declined in developed countries since the 1980s, including the Netherlands. To identify improvement opportunities in SUDI prevention, we monitored the adherence of parents to the prevention advice on infant care habits over the past 20 years, especially in relation to the SUDI incidence over time. Potential changes in parental adherence between the latest surveys are of specific interest, as these indicate where current focus is needed. Methods: Description of the prevalence of infant care factors related to the risk of SUDI, assessed from five Dutch national surveys from 1999 to 2017 among parents of infants under 12 months, and analysis of the potential differences in these prevalences between the two latest surveys in 2010/11 and 2017 with a z-test. Results: Supine sleeping position decreased from the highest prevalence of 92% in 2010/11, to 83% in 2017. Sleep sack use has increased to 55%, the highest prevalence up to now. Avoiding a duvet has remained reasonably stable since 2002/03 and now 95% of parents do not use a duvet. The prevalence of room-sharing, without sharing the bed, increased from 14% in 1999 to the highest prevalence in 2017 (31%). However, also bed-sharing almost doubled from 5.6% in 2010/11 to 10% in 2017. Breastfeeding decreased between 1999 and 2010/11, but increased from 34% in 2010/11 to 42% in 2017. An increased prevalence of mothers who abstained from smoking during pregnancy, as well as both parents not smoking, was observed, although mostly higher educated parents showed this beneficial behavior. Discussion and Conclusion: Much has already been achieved first by decreasing prone sleeping since the 80's, and subsequently promoting supine as the safest sleep position. The decrease in duvet use and smoking, and an increase in breastfeeding have also had impact. Indications of a recent decreased prevalence of the supine sleeping position and higher prevalence of bed-sharing might relate to the slightly increasing SUDI incidence in the Netherlands. Renewed attention for prevention of SUDI and specific advice targeting high-risk groups is needed. Modern, picture driven information via internet is recommended.

[Eleventh Safe Sleeping Survey in the Netherlands: parents' habits concerning infant sleep position and location]. / Elfde Peiling Veilig Slapen.

OBJECTIVE: To investigate to what extent parents of infants are following national safe sleep advice given for the prevention of Sudden Infant Death Syndrome (SIDS) and to study the reasons for not adhering to recommendations on sleep position (always on the back) and location (parents and infant not sleeping in the same bed). DESIGN: Quantitative and qualitative cross-sectional study. METHOD: Online survey among parents of 0-11 month old children via well-baby clinics and online media. RESULTS: Of the 1,209 respondents, 72.4% indicated that their child was usually placed on the back, and 34.1% indicated that their child slept in the same room as its parent(s), but not in the same bed. Of children aged 0-2 and 3-4 months 6.3% and 8.2% respectively slept with their parents in one bed. Parents of children of 0-6 months old (n = 199) who are not adhering to advice on sleeping position most often indicated that the child sleeps better (35%), that there is a preferred position or flat head syndrome (13%) or a desire to prevent it (16%, 29% combined). Reasons most frequently mentioned by parents for not following the recommendation not to sleep with their child in the same bed were: ease of breastfeeding (50%; n = 24) and better sleep of the child (40%; n = 19); this was for children of 0-6 months old. CONCLUSION: Parents do not automatically follow safe sleep recommendations for their child. Prevention may be improved by talking to parents about their reasons for not adhering to recommendations and determining together how to create a safe sleeping environment for the baby.

[Anorectal pain in children: rare or rarely recognised?]. / Anuskrampen bij kinderen: Zeldzaam of zelden herkend?

Anorectal pain is a common symptom, often as part of functional gastrointestinal disorders. Children seldom present with this complaint. Proctalgia fugax and chronic proctalgia are both anorectal pain syndromes but differ in duration and frequency of episodes and in pain characteristics. No research has been conducted on anorectal pain syndromes in children. We present two patients. Firstly, an 8-year-old girl who suffered from anorectal cramps. We found no underlying cause apart from constipation. The symptoms disappeared spontaneously. The second concerned an 8-year-old boy who presented with recurrent anorectal cramps. He was diagnosed with celiac disease. Anorectal dysfunction and visceral hypersensitivity have been described in adult celiac patients. Symptoms of anorectal pain in children are rare probably because it often remains unrecognised. Noninvasive diagnostic methods and interventions are preferred in paediatric medicine. Screening for celiac disease in children with anorectal pain episodes should be considered.

International comparison of sudden unexpected death in infancy rates using a newly proposed set of cause-of-death codes.

BACKGROUND: Comparing rates of sudden unexpected death in infancy (SUDI) in different countries and over time is difficult, as these deaths are certified differently in different countries, and, even within the same jurisdiction, changes in this death certification process have occurred over time. AIMS: To identify if International Classification of Diseases-10 (ICD-10) codes are being applied differently in different countries, and to develop a more robust tool for international comparison of these types of deaths. METHODS: Usage of six ICD-10 codes, which code for the majority of SUDI, was compared for the years 2002-2010 in eight high-income countries. RESULTS: There was a great variability in how each country codes SUDI. For example, the proportion of SUDI coded as sudden infant death syndrome (R95) ranged from 32.6% in Japan to 72.5% in Germany. The proportion of deaths coded as accidental suffocation and strangulation in bed (W75) ranged from 1.1% in Germany to 31.7% in New Zealand. Japan was the only country to consistently use the R96 code, with 44.8% of SUDI attributed to that code. The lowest, overall, SUDI rate was seen in the Netherlands (0.19/1000 live births (LB)), and the highest in New Zealand (1.00/1000 LB). SUDI accounted for one-third to half of postneonatal mortality in 2002-2010 for all of the countries except for the Netherlands. CONCLUSIONS: The proposed set of ICD-10 codes encompasses the codes used in different countries for most SUDI cases. Use of these codes will allow for better international comparisons and tracking of trends over time.

[An infant with yellow spots in the mouth]. / Een zuigeling met gele plekjes in de mond.

A 3-days-old infant was seen with jaundice and yellow spots in the oral mucosa . The jaundice was treated with phototherapy, after which the lesions became white. The spots appeared on the mucosa of the lower lip; their diameter was approximately 1 mm. The diagnosis Fordyce's spots was made.

The excessively crying infant: etiology and treatment.

Excessive crying, often described as infantile colic, is the cause of 10% to 20% of all early pediatrician visits of infants aged 2 weeks to 3 months. Although usually benign and self-limiting, excessive crying is associated with parental exhaustion and stress. However, an underlying organic cause is found in less than 5% of these infants. In the majority of cases, treatment consists not of "curing the colic," although usually it is possible to reduce crying, but of helping the parents to get through this challenging period in their baby's development. The aims of this review are to discuss definition, etiology, and evaluate different treatment regimes in infants who cry excessively.

PHOX2B polyalanine repeat length is associated with sudden infant death syndrome and unclassified sudden infant death in the Dutch population.

Unclassified sudden infant death (USID) is the sudden and unexpected death of an infant that remains unexplained after thorough case investigation including performance of a complete autopsy and review of the circumstances of death and the clinical history. When the infant is below 1 year of age and with onset of the fatal episode apparently occurring during sleep, this is referred to as sudden infant death syndrome (SIDS). USID and SIDS remain poorly understood despite the identification of several environmental and some genetic risk factors. In this study, we investigated genetic risk factors involved in the autonomous nervous system in 195 Dutch USID/SIDS cases and 846 Dutch, age-matched healthy controls. Twenty-five DNA variants from 11 genes previously implicated in the serotonin household or in the congenital central hypoventilation syndrome, of which some have been associated with SIDS before, were tested. Of all DNA variants considered, only the length variation of the polyalanine repeat in exon 3 of the PHOX2B gene was found to be statistically significantly associated with USID/SIDS in the Dutch population after multiple test correction. Interestingly, our data suggest that contraction of the PHOX2B exon 3 polyalanine repeat that we found in six of 160 SIDS and USID cases and in six of 814 controls serves as a probable genetic risk factor for USID/SIDS at least in the Dutch population. Future studies are needed to confirm this finding and to understand the functional effect of the polyalanine repeat length variation, in particular contraction, in exon 3 of the PHOX2B gene.

[Additional recommendations for safe sleep to prevent SIDS]. / Aanvullende adviezen voor veilig slapen ter preventie van wiegendood.

Great progress has been made in reducing the incidence of SIDS in the Netherlands, but the number of SIDS cases has remained constant in recent years. The American Academy of Pediatrics has new guidelines for safe sleep. Existing recommendations remain valid such as (a) discouraging prone- and side-sleeping; (b) encouraging parent and child to sleep in one room but not in one bed; and (c) avoiding second-hand smoke. The new recommendations include: (a) pre-term neonates born after 32 weeks should be placed in a supine position; (b) twins should not sleep in the same bed ('co-bedding'); (c) use of a pacifier is recommended once breastfeeding is well underway; and (d) use of stabilization pillows is not recommended. There should also be an emphasis on educating parents before discharging their newborn from the hospital.

Postnatal parental smoking: an important risk factor for SIDS.

BACKGROUND: Sudden infant death syndrome (SIDS) is the unexpected death of an infant that remains unexplained after a thorough investigation of the circumstances, family history, paediatric investigation and complete autopsy. In Western society, it is the leading cause of post-neonatal death below 1 year of age. In the Netherlands, the SIDS incidence is very low, which offers opportunities to assess the importance of old and new environmental risk factors. For this purpose, cases were collected through pathology departments and the working group on SIDS of the Dutch Paediatrician Foundation. A total of 142 cases were included; these occurred after the parental education on sleeping position (1987), restricted to the international age criteria and had no histological explanation. Age-matched healthy controls (N = 2,841) came from a survey of the Netherlands Paediatric Surveillance Unit, completed between November 2002 and April 2003. A multivariate analysis was performed to determine the risk factors for SIDS, including sleeping position, antenatal maternal smoking, postnatal parental smoking, premature birth, gender, lack of breastfeeding and socio-economic status. Postnatal smoking was identified as an important environmental risk factor for SIDS (OR one parent = 2.5 [1.2, 5.0]; both parents = 5.77 [2.2, 15.5]; maternal = 2.7 [1.0, 6.4]; paternal = 2.4 [1.3, 4.5] ) as was prone sleeping (OR put prone to sleep = 21.5 [10.6, 43.5]; turned prone during sleep = 100 [46, 219]). Premature birth was also significantly associated with SIDS (OR = 2.4 [1.2, 4.8]). CONCLUSION: Postnatal parental smoking is currently a major environmental risk factor for SIDS in the Netherlands together with the long-established risk of prone sleeping.

Surveillance study of apparent life-threatening events (ALTE) in the Netherlands.

SIDS and ALTE are different entities that somehow show some similarities. Both constitute heterogeneous conditions. The Netherlands is a low-incidence country for SIDS. To study whether the same would hold for ALTE, we studied the incidence, etiology, and current treatment of ALTE in The Netherlands. Using the Dutch Pediatric Surveillance Unit, pediatricians working in second- and third-level hospitals in the Netherlands were asked to report any case of ALTE presented in their hospital from January 2002 to January 2003. A questionnaire was subsequently sent to collect personal data, data on pregnancy and birth, condition preceding the incident, the incident itself, condition after the incident, investigations performed, monitoring or treatment initiated during admission, any diagnosis made at discharge, and treatment or parental support offered after discharge. A total of 115 cases of ALTE were reported, of which 110 questionnaires were filled in and returned (response rate 97%). Based on the national birth rate of 200,000, the incidence of ALTE amounted 0.58/1,000 live born infants. No deaths occurred. Clinical diagnoses could be assessed in 58.2%. Most frequent diagnoses were (percentages of the total of 110 cases) gastro-esophageal reflux and respiratory tract infection (37.3% and 8.2%, respectively); main symptoms were change of color and muscle tone, choking, and gagging. The differences in diagnoses are heterogeneous. In 34%, parents shook their infants, which is alarmingly high. Pre- and postmature infants were overrepresented in this survey (29.5% and 8.2%, respectively). Ten percent had recurrent ALTE. In total, 15.5% of the infants were discharged with a home monitor. In conclusion, ALTE has a low incidence in second- and third-level hospitals in the Netherlands. Parents should be systematically informed about the possible devastating effects of shaking an infant. Careful history taking and targeted additional investigations are of utmost importance.

Health care interventions for excessive crying in infants: regularity with and without swaddling.

This article describes two health care interventions developed to support parents whose infant cries excessively. Intervention 1 consists of advice to caregivers to bring about regularity and uniformity in daily infant care and to reduce external stimuli. Intervention 2 is the same advice accompanied by instructions to swaddle during sleep. Nurses can teach parents these interventions easily. The goal is to help infants to establish a stable sleep-wake rhythm, for overtiredness to disappear and excessive crying to stop. The approach is based on offering predictability, which helps to develop infant self-regulating ability. If the intervention succeeds, which is often the case, the baby cries less, drinks adequately, is able to fall asleep on their own and to sleep sufficiently, and therefore is no longer overtired. Parental stress is reduced, which could translate into an improvement in family health and quality of interaction between the parents and the child.

[Multidisciplinary guidelines for 'Apparent life threatening event' (ALTE)]. / Multidisciplinaire richtlijn 'Apparent life threatening event' (ALTE).

In order to reach a consensus concerning diagnosis, support and follow-up in children with an 'apparent life threatening event' (ALTE) multidisciplinary guidelines have been developed by the Dutch Paediatric Association and the Dutch Institute for Healthcare Improvement (CBO). All children presenting as an emergency with ALTE should undergo inpatient clinical observation for 24-72 h, with at least 24 h of cardio-respiratory monitoring. Observation does not need to be continued once an explanation for the incident has been established. The most common causes of ALTE are: gastro-oesophageal reflux (31%), neurological insult (11%) and lower respiratory tract infection (8%). Results from a targeted case history and from physical and neurological examination serve as a guideline for further investigations and support, in accordance with the formulated flowchart. A complete blood-count, CRP- and glucose concentration determination, blood-gas analysis and exploratory urine analysis should be carried out in all infants admitted with an ALTE, and an acute phase urine sample should be collected and frozen for possible metabolic investigation at a later date. Routine monitoring at home is not recommended following an ALTE.

Swaddling: a systematic review.

Swaddling was an almost universal child-care practice before the 18th century. It is still tradition in certain parts of the Middle East and is gaining popularity in the United Kingdom, the United States, and The Netherlands to curb excessive crying. We have systematically reviewed all articles on swaddling to evaluate its possible benefits and disadvantages. In general, swaddled infants arouse less and sleep longer. Preterm infants have shown improved neuromuscular development, less physiologic distress, better motor organization, and more self-regulatory ability when they are swaddled. When compared with massage, excessively crying infants cried less when swaddled, and swaddling can soothe pain in infants. It is supportive in cases of neonatal abstinence syndrome and infants with neonatal cerebral lesions. It can be helpful in regulating temperature but can also cause hyperthermia when misapplied. Another possible adverse effect is an increased risk of the development of hip dysplasia, which is related to swaddling with the legs in extension and adduction. Although swaddling promotes the favorable supine position, the combination of swaddling with prone position increases the risk of sudden infant death syndrome, which makes it necessary to warn parents to stop swaddling if infants attempt to turn. There is some evidence that there is a higher risk of respiratory infections related to the tightness of swaddling. Furthermore, swaddling does not influence rickets onset or bone properties. Swaddling immediately after birth can cause delayed postnatal weight gain under certain conditions, but does not seem to influence breastfeeding parameters.

Bed-sharing in the first four months of life: a risk factor for sudden infant death.

AIM: To investigate the risk of sudden infant death in the Netherlands during bed-sharing in the first half year of life and the protective effect of breastfeeding on it. METHODS: During a 10-year period between September 1996 and September 2006 nationwide, 213 cot deaths were investigated. RESULTS AND DISCUSSION: Of 138 cot deaths of less than 6 months of age, 36 (26%) bed-shared. In a reference group of 1628 babies from infant welfare centres only 9.4% were bed-sharing in the night prior to the interview. After correction for smoking of one or both parents the odds ratio for cot death during bed-sharing with parents decreased with age from 9.1 (CI 4.2-19.4) at 1 month, to 4.0 (CI 2.3-6.7) at 2 months, to 1.7 (CI 0.9-3.4) at 3 months and to 1.3 (CI 1.0-1.6) at 4 through 5 months of age. The excess risk (OR > 1) associated with bed-sharing is itself not significantly influenced by the presence or absence of breastfeeding. CONCLUSION: Bed-sharing is a serious risk factor for sudden infant death for all babies of less than 4 months of age. From 4 months onwards bed-sharing did not contribute significantly to the risk of cot death anymore in our study.

Referral patterns between the child health service, general practitioners, and secondary healthcare: a prospective descriptive study in the Netherlands.

BACKGROUND: In the Netherlands, preventive child health service (CHS) screening plays an important role in the early detection of congenital, developmental, physical, and mental disorders. OBJECTIVE: To obtain insight into the referral patterns of children from CHS to general practitioners and from general practitioners to medical specialists. METHODS: Prospective study over 6 months in a semi-urban area in the Netherlands. All correspondence from the participating doctors was sticker marked and, after each contact, a registration card was sent to a central secretariat. The referral stream between general practitioners and specialists or allied health professionals was extracted from a central database. The general practitioners and the participating paediatricians were asked to complete a questionnaire about the quality and necessity of the referral. RESULTS: Out of an estimated 2600 examinations, 45 children were referred to their general practitioners for further examination. The problems of eight children were settled by the GP, 10 children were referred to allied health professionals, and 24 children were referred to specialists. The median time span of showing up at the GP's office was 6.5 days. Sixteen per cent showed up long after having been referred by the CHS. The parents of three children did not comply. Of the 397 referrals from GPs to medical specialists and allied health professionals, 8.5% were initiated by the CHS. CONCLUSION: The amount of referrals from the CHS to GPs and of referrals from GPs to medical specialists and allied health professionals initiated by the CHS is low in terms of absolute percentages. Most referrals by the CHS were considered useful.