Previous studies have not addressed the relationship of intrathoracic petechiae (IP) to the position of the face when a caretaker finds a victim of sudden infant death syndrome (SIDS). The aims of this retrospective study were to determine (1) the rate of the facedown position in SIDS (not to be confused with the prone body position), (2) if the facedown position occurred more frequently among SIDS victims with intrathoracic petechiae than those without petechiae, and (3) if the facedown position occurred more frequently among cases with more severe petechial hemorrhage of the thymus. We selected 199 SIDS cases from the San Diego SIDS Research Project database and grouped them as IP-present and IP-absent. Each case was analyzed with regard to the face position when found unresponsive or dead. Among these 199 cases, 37% were found facedown, which represents 51% of the 142 cases found prone. The two groups were similar with respect to age, sex, and rate of premature birth. Thirty-nine percent (39%) of the IP-present group and 9% of the IP-absent group were found in the facedown position (P = 0.057; 95% confidence interval for the difference = 0.3%, 40%). Cases were also grouped by severity of thymic petechiae and analyzed regarding face position. Neither age nor the facedown position was associated with greater severity of thymic petechiae. The wide confidence interval yielded by our analysis of IP limits our ability to clarify the precise pathophysiologic role of external oronasal obstruction in SIDS. While it remains possible that a subset of SIDS cases occur as a result of external obstruction, we are unable to generalize its importance. Internal airway obstruction and rebreathing with terminal gasping, both of which have been documented in sudden infant death, remain other possible scenarios leading to the production of IP.
WillingerM, JamesLS, CatzC.Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol1991;11:677–684.
2.
AdamsEJ, ChavezGF, SteenD, ShahR, IyasuS, KrousHF. Changes in the epidemiologic profile of sudden infant death syndrome as rates decline among California infants: 1990–1995. Pediatrics1998;102:1445–1451.
3.
KrousHF. The microscopic distribution of intrathoracic petechiae in sudden infant death syndrome. Arch Pathol Lab Med1984;108:77–79.
4.
BeckwithJB. Intrathoracic petechial hemorrhages: a clue to the mechanism of death in sudden infant death syndrome?Ann N Y Acad Sci1988;533:37–47.
5.
KrousHF, JordanJ.A necropsy study of distribution of petechiae in non-sudden infant death syndrome. Arch Pathol Lab Med1984;108:75–76.
6.
BeckwithJ.Observations on the pathologic anatomy of SIDS. In: BergmanA, BeckwithJ, RayC, eds. Sudden Infant Death Syndrome. Seattle: University of Washington Press, 1970;83.
CampbellCJ, ReadDJ. Circulatory and respiratory factors in the experimental production of lung petechiae and their possible significance in the sudden infant death syndrome. Pathology1980;12:181–188.
9.
Bromberger-BarneaB.Mechanical effects of inspiration on heart functions: a review. Fed Proc1981;40:2172–2177.
10.
FlemingPJ, BlairPS, BaconC, Environment of infants during sleep and risk of the sudden infant death syndrome: results of 1993–5 case–control study for confidential inquiry into stillbirths and deaths in infancy. Confidential Enquiry into Stillbirths and Deaths Regional Coordinators and Researchers. BMJ1996;313:191–195.
11.
MitchellEA, FordRP, TaylorBJ, Further evidence supporting a causal relationship between prone sleeping position and SIDS. J Paediatr Child Health1992;28(Suppl 1):S9–S12.
12.
PonsonbyAL, DwyerT, GibbonsLE, CochraneJA, WangYG. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med1993;329:377–382.
13.
TaylorJA, KriegerJW, ReayDT, DavisRL, HarruffR, CheneyLK. Prone sleep position and the sudden infant death syndrome in King County, Washington: a case–control study. J Pediatr1996;128:626–630.
14.
ChiodiniBA, ThachBT. Impaired ventilation in infants sleeping facedown: potential significance for sudden infant death syndrome. J Pediatr1993;123:686–692.
15.
StanleyFJ, ByardRW. The association between the prone sleeping position and sudden infant death syndrome (SIDS): an editorial overview. J Paediatr Child Health1991;27:325–328.
16.
MitchellEA. Cot death: should the prone sleeping position be discouraged?J Paediatr Child Health1991;27:319–321.
17.
TonkinS.Sudden infant death syndrome: hypothesis of causation. Pediatrics1975;55:650–661.
18.
SiebertJR, HaasJE. Enlargement of the tongue in sudden infant death syndrome. Pediatr Pathol1991;11:813–826.
19.
WatersKA, GonzalezA, JeanC, MorielliA, BrouilletteRT. Face-straight-down and face-near-straight-down positions in healthy, prone-sleeping infants. J Pediatr1996;128:616–625.
20.
AdelsonL, KinneyE.Sudden and unexpected death in infancy and childhood. Pediatrics1956;17:663–699.
21.
BergmanAB, RayCG, PomeroyMA, WahlPW, BeckwithJB. Studies of the sudden infant death syndrome in King County, Washington. 3. Epidemiology. Pediatrics1972;49:860–870.
22.
CarpenterRG, ShaddickCW. Role of infection, suffocation, and bottle feeding in cot death: an analysis of some factors in the histories of 110 cases and their controls. Br J Prev Soc Med1965;19:1–7.
23.
PonsonbyAL, DwyerT, GibbonsLE, CochraneJA, JonesME, McCallMJ. Thermal environment and sudden infant death syndrome: case–control study. BMJ1992;304:277–282.
24.
ScheersNJ, DaytonCM, KempJS. Sudden infant death with external airways covered: case–comparison study of 206 deaths in the United States. Arch Pediatr Adolesc Med1998;152:540–547.
25.
L'HoirMP, EngelbertsAC, Van WellGT, Risk and preventive factors for cot death in The Netherlands, a low-incidence country. Eur J Pediatr1998;157:681–688.
26.
ByardRW, StewartWA, BealSM. Pathological findings in SIDS infants found in the supine position compared to the prone. J SIDS Infant Mortal1996;1:45–50.
27.
BecroftDM, ThompsonJM, MitchellEA. Epidemiology of intrathoracic petechial hemorrhages in sudden infant death syndrome. Pediatr Dev Pathol1998;1:200–209.
28.
BealSM. Thymic petechiae in sudden infant death. In: WalkerCM, ed. 2nd SIDS International Conference. Sydney, Australia: Perinatology Press, 1992:77–89.
29.
KrousH.Instruction and Reference Manual for the International Standardized Autopsy Protocol for Sudden Unexpected Infant Death. J SIDS Infant Mortal1996;1:203–246.
30.
IyasuS, RowleyD, HanzlickR.Guidelines for Death Scene Investigation of Sudden, Unexplained Infant Deaths: Recommendations of the Interagency Panel on Sudden Infant Death Syndrome. J SIDS Infant Mortal1996;1:183–202.
31.
WillingerM, HoffmanHJ, HartfordRB. Infant sleep position and risk for sudden infant death syndrome: report of meeting held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD. Pediatrics1994;93:814–819.
32.
TonkinSL, DavisSL, GunnTR. Upper airway radiographs in infants with upper airway insufficiency. Arch Dis Child1994;70:523–529.
33.
MartinezFD. Sudden infant death syndrome and small airway occlusion: facts and a hypothesis. Pediatrics1991; 87:190–198.
34.
KempJS, ThachBT. Sudden death in infants sleeping on polystyrene-filled cushions. N Engl J Med1991;324:1858–1864.
35.
KempJS, LivneM, WhiteDK, ArfkenCL. Softness and potential to cause rebreathing: differences in bedding used by infants at high and low risk for sudden infant death syndrome. J Pediatr1998;132:234–239.
36.
KempJS, KowalskiRM, BurchPM, GrahamMA, ThachBT. Unintentional suffocation by rebreathing: a death scene and physiologic investigation of a possible cause of sudden infant death. J Pediatr1993;122:874–880.
37.
KempJS, NelsonVE, ThachBT. Physical properties of bedding that may increase risk of sudden infant death syndrome in prone-sleeping infants. Pediatr Res1994;36:7–11.
38.
KempJS. Rebreathing of exhaled gases: importance as a mechanism for the causal association between prone sleep and sudden infant death syndrome. Sleep1996;19:S263–S266.
39.
PoetsCF, MenyRG, ChobanianMR, BonofigloRE. Gasping and other cardiorespiratory patterns during sudden infant deaths. Pediatr Res1999;45:350–354.
40.
MaskreyM.Influence of body temperature on responses to hypoxia and hypercapnia: implications for SIDS. Clin Exp Pharmacol Physiol1995;22:527–532.
41.
NelsonEA, TaylorBJ, WeatherallIL. Sleeping position and infant bedding may predispose to hyperthermia and the sudden infant death syndrome. Lancet1989;1:199–201.
42.
KahnA, Van de MercktC, DramaixM, Transepidermal water loss during sleep in infants at risk for sudden death. Pediatrics1987;80:245–250.
43.
DwyerT, PonsonbyAL, GibbonsLE, NewmanNM. Prone sleeping position and SIDS: evidence from recent case-control and cohort studies in Tasmania. J Paediatr Child Health1991;27:340–343.
44.
WillingerM, HoffmanHJ, WuKT, Factors associated with the transition to nonprone sleep positions of infants in the United States: the National Infant Sleep Position Study. JAMA1998;280:329–335.
