Document Ev17OJageXD6QBq38Ewg0ZG9j

The Foundation for the Study of Infant Deaths 33 Belerave Square London 5VV1X 8QB Telephone' 071-2331721 / 071-235 0965 / 0/1-823 2216 Fax: 071-823 1986 'tron: H*r j. Jignne The Duthv o> (Joix-vs^r |W\i . ht\v-NCAil> / PRESS IZKLBASB July i3th 1SS0 REDUCING 'iim RISKS OF COT DEATH - research from Bristol. Dr. Fleming and his teas at Bristol confirmed in tbs British Medioal Journal today that the risk of oot death might be reduced by giving advioe to parents on sleeping positions for babies and keeping their baby cool rather than hot. In the Bristol study all infants (from birth to 1 year) who died suddenly and unexpectedly In a defined population in Avon and Sonerset were matched with two control taibies, of the saw age and in the sane neighbourhood, through the local health visitor. This study found that the Infants who died suddenly were more likely to have slept on their tissues and all night roam heating than the matched controls. The foundation for the Study of Infant Deaths - the major funder of all oot death research in the UK - has awarded over <191,000 to this important study. Erma De'Ath, Chief Executive for the Foundation said: These fladings demonstrate the reel importance of research and using oontrois for an under*tending of cot deaths. The possible link between tem perature, over-heating and sleeping positions has oanaemed researchers and doctors for several years but we had only anecdotal evidence until recently. The Foundation recognised the need to fund research in these topios and 250,000 has been awarded to work in Bristol, Northallerton, Leicester and Cardiff. This Bristol study oonfirse that overheating and sleeping positions are often different between those babies who die suddenly sod unexpectedly sad oontrol babies. This my be a major contributory factor at this vulnerable stage during the first few months. A new study in Cardiff by Professor Davies based on his work in Hang Kong will look at differences in patterns of infant care between oot deaths and oontrol infants. Ms still do not know what causes oot deaths but we osn be a little sure confi dent about giving advioe to parents an how to reduce sesar of the risks associ ated with oot deaths: * protect your baby from overheating - cheak how hot or oold your baby is by feeling has tunny * lay your baby on the side - but some babies need to lie on their tunsies for medioal reasons end your doctor will advise you on this * use several layers of thin blankets to adjust >wnng more easily - mny buby nests and duvets are too hot for infants s a baby who is i LI or developing a temperature will need lees clothes and wrapping - and oootact your doctor or health visitor if worried. i II m F-*h*- Noras 10 editors 1. Current grants for research into temperature, bedding, sleeping position* and oot death: BRISTOL Dr. Fleming 191,531 NORTHALLERTON micarriai Dr. Chris Bacon Dr Wailoo A Dr. Petersen 42,831 44,413 CARDIFF Prof. D. Davies Total funding in this area: approximately 250,000 45,702 Total Project grants approved by PSID for 1989: 728,849 2. The Foundation sponsored a one day meeting to explore links between testpen*cure and sudden infant deaths in 1988, Chaired by Or N Rutter, Nottingham. 3. Advice to parents - after one month old babies are quite good at keeping warm so it more important that they are not too hot especially with the in creased use of double glaxing, central heating, and duvets. 4. Research in Northallerton of 700 families indicated that meet mothers put too much clothing on their babies especially at night but thia was signifi cantly higher for more of the babies who died suddenly than for the oontrol babitM. No evidence mbs available from this study on sleeping positions. 5. the Foundation raises over 1.25 million a year and is the major funder of all oot death research in the UK. It offers s support programme for those families who have already had a oot death, OQNI (Care of the Next Infant) to all District Health Authorities. 6. The Bristol study also received support from Action Research for the crippled Child. For more information please oontaot: Krioa De'Ath, Chief Executive, The Foundation for the Study of Infanta Deaths Telephone 071 236 0985 FAX: 071 823 1985 cd/w 00TS80 '.'-NTS "rei 25 BRITISH PLASTICS FEDO71-2J5-8045 indicate that attitudes among the medical profession and patients ate changing. There h* neon much disovumion about clinical trials and informed consent,** and, though we believe that informed consent is msndatory, w accept that a proportion of patienu do not enter trial* beeauae they may dislike the idea of a random decision being mode about treatment or because they refuse or request one par; of the random option offered. A further group of patients are excluded because they do not fulfil the entry criteria for the trial, and this group may be larger than forecast at the time the tnal was planned. These factors may be the reason why accrual to the Scottish breast conservation trial ha* been slower than anticipated. The planned total intake was 900 patients, and after four years *20 patient! had been entered.' In conclusion more than half of the petienta thought initially to be suitable for conservation were excluded 01 623 1966 v P.^S P . 84 from our trials and one third of the remainder refused to take pert. Those planning prospective clinical trials should therefore take into account the ioes of patients through ineligibility and refusal when predicting the scerusl rite end overall duration of any proposed trial and the possible effects of this selection on conclusions drawn from the result*. l O* Vie VT. Snm aac-r iV- Mtrviiu* ill aw anna. \ ivwjjs-.snr. .11*1 J HJ, PmrvnRJ. Fvm* VX. CMOT'oritA of bmtt hvwcr Lmut l V7>mb ftA, K* A. rfew f)DV Mnmmaii *r cvnareguM. iIm parMt'i <*- * MfC Iftlart: t 1474. * Inftara D. ItmM mi 9k h*. mAh wi lt(wKlKRK 3 lava H. ZUkM K, Uu*wt* J. |<Jim rWM !wn>Mh; im-JVIdSl k wwm fjf TV 4 CX> C Fioau pedanmg m4 cuato! tritfc. Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case*control study Peter J Fleming, Ruth Gilbert, Yehu Am, P Jeremy Berry, Peter TRudd, Alison Stewart, Elizabeth Hall Uelth, CT, w lutrck , rtnarck arch isto >A1 JNG . 'tMjrzh .ormJun: ioiplUl, rPATH, lul. 'Aik, Dr l*eter at of ;| Hr i' Abstract Otyecittw-To dttarmiae the relation between sleeping position and quantity of bedding and the risk of sudden unexpected Infant death. Daign-\study of all Infanta dying suddenly end unexpectedly ud of two controls matched for age and dels with each index caae. The partata of control infants were iateniswad within 72 hour* of the index infant's death. Information wts collected on bedding, sleeping position, heating, and recent ilgna of Illness for Index and control infanta. Sitting--A defined geographical arte comprising moat of the county of Avon sad put of Somanat. Sxtyscu--72 Infants who bad died auddanly and unexpectedly (of whom 67 had died from the sudden infsnt death syndrome) ud 144 control infants. Rtiulu--Compared with the control infants tbs Infants who hsd died from the suddso Infant death syndrome were more likely to have been sleeping prone (relative risk l-g, 9SH confidence Interval 7 0 to ll-O; p<0*00l), to have been more heavily wrapped (relative risk 1* 14 per tog above 8 tort 103 to 1-2$; p<0-05), and to have had the heating on all night (relative risk 2-7; 1-4 to 5-2; p<0 01). These differ ences ware less pronounced in the younger Infanta (lee* thsn 70 days) than the older ones. The risk of sudden unexpected death among infants older than 70 days, nursed prone, and with clothing sod bedding of total thermal resistance greater than 10 tog wts Increased by factors of 1S-1 (2 6 to $9 6) and 2S-2 (3-7 to 168-0) respectively compared with the risk in infants of the same age aursed supine or on their tide and under less than 6 tog of bedding. Corscfuitom--Overheating and the prone position arc independently associated with on Increased risk of sudden unexpected infant death, particularly in infanta aged more than 70 day*. Educating parent* about appropriate thermal cars and steeping position of infants may help to reduee the incidence of the sudden infant death syndrome. Introduction Tht role of thermal stress in the aetiology of the suddtQ infum death syndrome hsi been suggested by many authors,1' and Walloo rl recently showed that many babies are put to bed under excessive amount* of bedding.' The low incidence of the sudden Infant death syndrome in Hoag Kong, which has a hot, humid climate but whore most infants sleep supine, his led to the suggestion that the prone position may be in important risk factor.1 Recently, Nelson r< at suggested on the bods of a simple model of Infant hett balance chat infants sleeping la the prone position with an excess of bedding would be more likely to become hyperthermic than infants in the supine position with equal bedding.* W have shown an appreciable rise in oxygen consumption and carbon dioxide production (and bonce heat production) between birth and 1 month ofage In healthy Infants.' This higher metabolic rate is maintained until at least 3 month*. We have also shown that raising th* environmental temperature around healthy infant* sged 3 months or leu increases respiratory oscillations, suggesting an effect on the respiratory control system.* Thus infanta in this age range, which is the age of peak incidence of the sudden infant death syndrome, would be at increased risk of the consequences of cvwwrapping. The effects of overwrapping would be likely to be greeter at the time of scute rinl infection, when the metabolic rite rises, and two studies hovt shown that many parents in the United Kingdom end is New Zeniand respond to infections in their babies by increasing tht amount of clothing and bedding.* * To investigate the posalble interactions between quantity of bedding end sleeping position in normal infants tad in infants dying suddenly and unexpected! y we conducted a ease-control study of all such infant deaths in a defined part of the counties of Avon end Somerset over 18 months. This study formed part of s prospective investigation of all infsnt deaths in the county of Avon, which will be reported In full elsewhere. Methods Wt wore notified of ell sudden and unexpected deaths of infant* (from birth to 1 year; in i defined am comprising most of the counry of Avon and part of Somerset. On the dey of *n infant's death his or he; 7-i 14 jvuy 1990 85 ! I Dwnimivj* e.fifn of t t-ta W oatf efrW l. rt Rwnten Iftfuut Wfto >(*f0t*?4**'4' nnilne-(tw;it;v;;; Id; >P> ,0 "*) 21%4-,1179.} 1ij12d1(?9' general practitioner and heslih viutor were contacted. to increase the effective therm*! resistance ol the The health visitor wes asked to identify from her swaddling bedding by s factor of two. The data os caseload the two infants living in the same neighbour thermal resistance of bedding and clothing and on hood who were cioseat in age to the infant who haa the proportional covering by 'siriouj garments were died. A* pari of i programme of support fur bereave supplied by the Shirley Institute, Manchester <E families the parent! of the dead baby were contactca Qulow, personal communication,. and seen by one of us, usually at home and with either Ststistical methods used were the 7/ method of the general practitioner or health viaitor, i soon at ditcoMani triplets, the Maniel-Haettud test for possible after the baby had died 'Revisited the parent* compering an Index case with two matched controls, on two to four further occasion* over the nest two to and multiple logistic regression for an index case and three months. A detailed, structured hinory was taken rwo controls.'' The study ns approved by the hospital fiom the parents, including social factor*, maternal ethical committees is the participating districts. medical history, family history, tad detail* of the pregnancy and pcruutaJ period. A full medical history of the dead beby wai taken with emphasis on recent Results sign* of illneit, feeding, and sleeping. Precise details Seventy (wo unexpected iafant deaths that occurred were collected of the infant'* last aleep, with particular from November 1987 to April 1989 were included in note of the time end position in which the baby had the study. A further six unexpected deaths occurred of been put down, the position is which he or she bad infants normally resident in the am, but were not been found, the precise quantity and nature of the included because of the absence of one of the investi ciothing and bedding, whether the beby hed been gators (four infants) or because the death had occurred swaddled, whether the bedclothes had been over the while the infant was outside the study ires (two baby's head when found, what heating was in the infants). Remits are given for the 72 desths and 144 baby's room, and the time the heating had been on. control infants.' Medical records of both the mother and beby were Most families of the infants who had died were aeen used to obtain information on the pregnancy, perinatal within 24 hours of the death (50), and dJ were teen period, and any subsequent problems, together with within 72 hour*. The median time from the death of the infant's growth chan. the index infects until the control infants were seen was Aa soon a* possible after the death of the index two days (92 ware tecs within three day* and 129 infant we visited the two control infants at home and within ievcn day*). took an exactly comparable detailed history, with The mean ages of the index end control infests were particular reference to the 24 hours preceding the dote (94-4 and 97-0 days respectively) (table 1). The home visit. The control Infanta were weighed and mean age ofthe two control infants was within 10 day* microbiological sample* takes for an investigation of of the age of the deed infant for 65 deed infants, and the role of infection in the sudden Infant death within three day* for JJ. syndrome (to be reported in full elsewhere).11 The minimum tempwitum in the 24 hours before Data were obtained from the Meteorological Office the oootrol infants were moo were clcee to those m the on the daily rriwim and minimum temperature* 24 hours preceding the deaths of the index infants. In recorded in Avon over the period ofthe study. For each 48 cases the temperature difference wes lest than J*C infant who had died and for each control infant these and in 54 It ww leas than 4*C. The median temperature temperatures were recorded fur the 24 hours preceding difference was 1"C, with the temperatures being lower the death or the home visit respectively. in the periods before the controls were tees. All the infants who had died were discussed at a There was a weak negative relation between the confidential meeting, at which the binary and patho minimum outside temperature in the preceding 24 logical finding* (including histulogicel, biochemical, hours and the total thermal resistance of applied and microbiological findings) were discussed. Each of bedding and ciothingfor both the infants who had died the infants was then assigned to one of two groups for and thecontrol*, withawidtseaneitall temperatures. the purpose of this study: group 1 comprised infanta Table U show* the relation between social cists for whom a full and sufficient explanation of their (according to theRegistrar General's dassifiesuos) and death wes found by pathological examination sad total thennal resistance for bedding and clothing. group 2 comprised infants fur whom t full and Among the oostroii there was a alight social class sufficient explanation wet not found, though sums gradient with infant* in social classes IV and V tending abnormalities that might have been contributory were to have higher values titan those in tocial claim I and identified in many infants. Group 2 thus equates to II. This gradient was sot apparent among the infants infects who hed died from the sudden infant death who had died, for whom values of total thennsi syndrome. resistance were slightly higher for ail tocial classes. We tabulatod the information os the infants' bedding From the information eeiiected on signs of illness in and clothing and then calculated the total therms! ih* preceding 24 hour*'' infants were identified who resistance using published values for the thermal resis had shown signs ofiiinets that have been considered to tance of esch material*a These values were expressed be potentially serious.1' These signs included difficulty in tog units (the tog value uf a fabric is defined s* 10 breathing, frequent coughing (>5 bout* in 24 hours), times the temperature difference In degrees Celsius diarrhoea, vomiting, high temperature, irritability, between it* two feces when the heat flow is equal to 1 lethargy, and missing more than one feed. Such signs U'/nv). We estimated the proportion of the infant's were reported bythe parents of 16 ofthe 72 infants who suffice are* covered by each garment or item of hid died and 14 of the 144 controls (odds r*tio2-4, bedding, end these values were used to calculate an effective tots! thermal refinance for the coverings on each infant. The estimates of surface arcs covered by each garment were based on data produced by the usu ;s - *fw* 'SO'/ stl tttrmal rtiiiunu *** Wimr '*ie)/WVtf<iii l.4 WiuS n4f&emlrtlt*fmuk) urii/tUv International StandardsOrganisation forsduit clothing modified by factors reining proportional surface tress of body parts in infants and (dulls.11" Blanket! and other bedding were mumed to cover 80% of the infant's surface ares unless the infant was reported to have been completely covered. Swiddlingwei assumed Seul'ba IwWS 111 1V4V UJvptwvor Inffeu wHv 4M t-s'Tvjutwis; S*t <;'*> ioim*5)(-ii) Cottlfttl IflfhfiO I-JSCSIUbsi*! $4*0 JM;p BMJ vol'-'MZ SOI 14 JVZ.Y 1990 rill i >< i t ri] i, M M w. <k r *s **? a I . A i ttCr -01 lc-28 BRITI5- PLASTICS PlDBTI-23S-8045 v *** PRUI'l p 9 i y z: E23 1986 w ui5ee: P.b'A p. et n m ihick u *m* to Ka Cdfilttl r<3 iMfimi* I n I! J ist mpir.i- pnv ' OiU o, tltmffr duvmitekti vtmmbm to Caned uUuu (tt-lW 201 *(*> 15 <1*1 mu; 2i :i: i;2) id) data for sngtawxt Jdpimpnjmt srsnvmhart b Casual 1 'lis tsj /()) 5(2) ;) i(; 1*(2I) (H) *< 1(1! 9534 confidence intcrvsl M to 3 1,x1,r5 *, p=0 02 by bees prone. Of the 12 control infants who had had Mbnwl-Httaucl test). Values obtained for the tote! value* greater than 12 tog, seven had been supine nr on thermal resistance of bedding and clothing for the ihetr sides with Yates's correction 6-674, p<0-01). infant* who hul potentially seriou* sign* were no Among the control infants i higher proportion of different from the value* for thute wiihout such signs thou with more bedding had slept supine or on their for either the Infants who had died (mean 9-3 and 9-1 sides than prone (for example, 35*4 (19) of iafam* who tog respectively) or the control infams (mean 7-8 and had slept supine or on their side had had beddit-4 plus 8-1 tog respectively). clothing with t tout thermal resistance of mure than 10 After pathological investigation a full explanation tog, compered with 1134 (14; of prone Infams). Such a was found for the deaths of five infants (severe breakdown of poeltions was not possible for the infants gastroenteritis tod dehydration) septicaemia, who had died because few of (hem had beta either haemorrhagicdiacaae, perforated stomach, and Down's supine or oa their sides. syndrome with atrioventricular canal defect and cardiac The beating had been left on ell night in the homes of failure). That* infant* were therefore assigned to significantly higher proportion of the infants who had group l. Hour of these infants had shown maior signs of died (28 of67) than of (he control infants (34 of 134) (y/ illntwa ia their last 24 hours. Values obtained for the for discordant triplets, nlerivc risk 2 -7,9334 confidence total thermal rtsiatance of clothing and bedding for the interval 1-4 to 5-2, p<0'01). five infants in group 1 (median 8 7 tog, range 3-6 to The weights of the deed infants at necropsy wr 12 2 togj were no different from those for the 67 infants lower than thou of the matched controls, though in group 2, whether they had signs of illness (mean dctailed asiaumcm of the preceding growth charts did 8-63, SE 0-67 tog) or not (mean 9-1, SE 0 43 tog). not suggest that there bad been an appreciable weight For the detailed analysis of the effects of sleeping loss before death. The mean difference in weight position and total thermal resistance of bedding plus between tbe value for the infanta who had died and (he clothing only the 67 infants in group 2 (that is, those mean value for the two controls wu 660 f (9534 who died from the sudden infant death syndrome) and confidence interval 180 to 1140, p<0-01). Tbcee dau their controls were considered. Complete data on will be reported in full elsewhere. In view of the bedding and position for the index infant and the two difference ta weight between the two groups we control infants were available for 62 of the 67 infants examined (he relation between tbe total thermal retle- who had died. Table III shows the positrons in which tance of bedding afldxlothiag and the infants' weight the infants had been put to sleep. Sixty two of the index for both the infants who had died and the control infants had been put to sleep prone and for 60 this was infanta. Tbe control Infanta showed no significant their usual sleeping position. Of 134 controls, 76 had retauoo berween weight and total thermal resistance of been put to sleep prone. This difference was highly bedding and clothing, but the infants who bad died significant (x* test for discordant triplets, relative risk 8-8,9534 confidence interval 7-0 to 110, p<0-001). Table IV show* the calculated values for total showed a weak but significant positive correlation (r 0-31, p<0-01), Simdariy, there we* no significant rektioD betwueu tbe values of total thermal resistance thermal resistance of bedding and clothing for the for dotbing plus bedding and age for tbe controls but infants who had died and the control infanta. The there was a significant power* condition for the infants who had died were more hcerily wrapped than infants who had died (r0-42, p<0 001). Thus the (he control infants (mean thermal resistance for infants older infanta who had died suddenly and uncapcctediy who had died was 9-11> I 0 tog for control infants). The (who aise bed been heavier) had been more heavily mean difference in thermal resistance of bedding and wrapped then (he younger infants. clothing between the value for the infants who bsd died Because of the bioodai distribution of the ages of the and the mean value for their matched controls was 1 -1 infants who died (table 1) the anaiyiis of the effects of tog (9344 confidence interval 0-13 to 2-2, pwO-023, sleeping portico end the quantity of bedding was paired nest). repeated for (he younger (<70 days) and older (*70 After allowing for the difference in sleeping position days) Infant* separately. This analysis showed that for between the infants who had died and controls the the younger infant* for whom complete data were difference in thermal resistance of bedding plus available there wu no significant difference is toul clothing was significant by multiple logistic regression thermal tsauluion of bedding plus clothing between (relative risk associated with each 1 tog rise above 8 the infanta who had died (n24) and the control tog was 1 -14, 9534 confidence interval 103 to 1-28, Infants (xJ"0-7J, pX)-05) whereas the prose position p<0`05). A further multipit logistical regression was was usodated with an Increased risk of sudden performed tv examine the interaction between thermal unexpected infant death (x'*7 l4, relative risk 4-13, resistance ofbedding and clothing and sleeping position 9534 confidence Interval 1-32 to 13-0*, p<0 01). For for three ranges of therms! resistance (<6 tog, 6-10 tog, the older Infants for whom complete dsti w*re available >10 tug). This showed that the prone position and there had been a highly significant excess of bedding thermal resistance > 10 tog were independently associ and clothing on the infinu who had died (n38) ated with an increased risk of sudden unexpected compered with control infants. The mean difference in infant death, with relative risks of 7-39 (2-57 to 21-2, thermal resistance of bedding plus clothing between p<0-00l)and7-89 (2 51 to 24-8, p<0-001) respectively the value for the iafanu who had died and the mean when compered with supine or side position and value for their controls wu 2-39 tog (paired t test thermal resistance <6 tog respectively. Thermal p<0-01). There wu a significant usociation between resistance of bedding plus clothing in the range 6-10 prone position and the risk of sudden unexpected tog a as not associated with an increased riak of sudden infantdath (y-'w 13-9,rtiauve risk9-8i, 2-05 to 46-95, unexpected infant death (relative risk 1-93, 0-83 pcO-OOl), 4-54, p>0-03) A multiple logistical regression wu performed on Tabie V shows the total thermal resistance for bedding and clothing for Uinse infiuis whu had bees put to bed prone. The difference* between the Infinu data from these infants to esses* the interaction between sleeping jxwition and valu of thermal resistance in the three ranges previously investigated for tnc whole who had died and the control Infants inerw-ed. with * greater proportion of the dead infent* having been both prune and under excessive thermal insulation. Ail of the 11 infants who had died end had had t tout thermal resistance of clothing plus bedding greater than 12 had group (<6 tog, 6-10 tog, >10 tog). For the prone position compared with the side or supine position the relative risk wu 15-i (2-6 to *9-6, p<0-00l). For thermal resistance of bedding plus clothing >10 tog comptred with thermal resistance <6 log the relauve it 44 I *' r I- 51 20851005 m* 301 1* jiri.v 1V0C 87 *I risk W* 25-2 (3-7 tu 169-0, p<0-OOJ). Values of therm*) rcsntir.ee in the rangt of 6-10 tog were na: esteemed with an increased risk (relative nsk 4 3, C 9 to 21 0, p>0-05). Discussion The relation between overheating and the sudden infant death syndrome hi* bean suggested previously, but the evidence has been mainly anecdotal. ` Our study has shown that among a defined population of infant* those who died were more heavily wrapped than control infants of the same age and in the same community seen shortly after the death of the index infant*, is eddtoon to the excess of duthing and bedding on the infant* who had died a higher proportion of them had boon in room* in which the hoi ung wai on all night. Vailoo ti a! showed a weak negative correlation between room temperature and quantity of bedding.* Because of the nature of our irudy we were unable to investigate this relation directly but used outside temperature an indirect meaaurt of the likely thermal environment in the bedroom; several authors have shown a direct relation between the outside temperature and room tanpertiun.*"' On average the days on which the infants died were slightly wanner than the days un which the controls were seen, suggesting that their bedrooms may also have been wanner. Thus the effects of the relative exccas of clothing and bedding oo the infants who died were likely to have been greater, This study also confirmed the observations of other investigators that there is u association between the prose position and the sudden infant death syndrome. In our study to few of the infants who had died had been supine or on their tides that wc were unable to look in detail at the ways in which these positions interacted with other factors/'1 In the prone position the exposed surface area ofthe baby that can contribute to rtdiant beat lots is lets than that in the supine position. " In the prone position infants arc also more likely to tolerate bedding rising up and covering part or all of their heads than in the supine or tide position, as in these latter positions the bedding will make contact with the malar region, which is very sensitive to changes in physiol contact, particularly during rapid eve movement sleep." Fot art infant who is heavily wrapped in a cot, 15% of iota! beat loss may be through the heed," and thus partially or completely covering the head is likely to have a considerable effect on the infant's thermal balance and may lead to an inability to loae heat and thus to overheating. Spontaneous move ments by infants are more likely to lead to the covers rising up over them in the prune pontine than in the supine or side position, in which the bedding may be thrown of! by the same types of movements. Wc have thus confirmed the theoretical suggestion by Nelson ft at that when there is excess bedding the risk of sudden unexpected death Is higher for infants who are prone.* This risk is likely to be further increased if the metsbolic rate rises, such at normally happens by 1 or 2 months of age.' Other ftetora that increase metabolic rate, such as acute viral infections, are also likely to increase the risk of overheating. Previous studies have shown a high correlation between the presenoe of signs suggestive of acute viral infections and sudden infim death syndrome. *'* In the present study seme evidence of such n association was found, but mxny of the control infants, had similar signs to those of the infants who had died. Although two previous studies have shown thst many parents respond to perceived illness in their infant by increasing the bedding,*" we found no such trend, in Mew Zealand parents with higher educational achievement* wrapped their babies more than those v-ith lower achievements,' whereas a Exeter the .cvctk ws true.* Among the control infants in our study a trend was seen of less wrapping in the higher socioeconomic groups, as in Exeter. Among the infants who had died, however, there *u no such trend, suggesting tint the subgroup of parents from social classes 1 and II who tended to overwrap their infants were overrepresented among the parents of infants who had died. Unexpected findings were that among the infants who had died the older infants tended to be more heavily wrapped than the young ones, though no such trends were noted among the control infanta, and that the increased risk of audden unexpected death with overwrapping wea significant for only the older infants. The higher ratio of man to surface tret in (he older infants, together with their higher metabolic rata, may make them more vulnerable to the effect* of isercaaed thermal insulation. There it no reason to believe that the pventi ofthe Infants who bid died had ineraacd the amounts of bedding or clothing on their infants with berating age. Thua the tame degree of overwrapping, particularly in the prone position, may be more hazardous to these slightly older infants particularly when they have mild viral infections, which arc commonly present in older infanta who die suddenly end unexpectedly. Reliable information on what constitute* appropriate thermal cam for normal infant* beyond the foil month of life it tome and many sources of information for parents and fee health care professional* emphasise the risk of cold ttresa but my little about overbating. For infants who sleep on their sides or supine the effects of excess bedding may be kit than for infants who deep prone, and tome may think that this warrants wide spread adoption ofthe recommendation that all infants would be put to sleep tuppe or os their aide. Infant* who arc lupine art potentially more vulnerable to the effects of cold stress than infants who art prose," and gastro-oesophagcal reflux is more common and more severe in the aupme position. In newborn preterm infants oxygenation is better in the prone position than the supine position," but link is known about this in older infants. For infants with gaetrooesophageal reflux tad preterm infanta the prone position is preferable. For othei infant* the moat appropriate sleeping position may be oo their tide or tupine. For all infant* particular attention should be paid to thermal care and the avoidance of her tires*. Parent* should be encouraged to cheek whether their bebits feel hot or cold and to adjust the bedding accordingly. This may be easier if multiple this Jsyers of bedding are used (for example, blanket*) rather than a angle thick covering (for example, a duvet). Educating parents about sleep ing position for and correct thermal care oftheir babies may help reduce the incidence ofsudden infant deaths. RG supported by UK Foundation for the Study of Infant Death*, YA by a mot (No S/P/I70J) from Actios Research for the Crippled Quid, and AS bygnat from Cet Death Rewercb Appeal We thank Maggie Shaplaad fot help sad edvioe on data proemmg and computing, Julie-Ana Evan* and Catherine Wtters for statistical advice, and Dr Jcan Golding for bslp in planning and signing the tu>dy. i **icj.Ov,,snai*a>,nfwv xirt/vcfcu mi:a*?v* : AN. bsi DJ, D*Wfi MAOS. U roiteia^ i Im-u si mv unatpMM k>bm wltSPUilOM.: I S-miw A*. Cm>kMfci an* m timi. In* i*S.j|:) iss.set 4 WUJao M*. Am SA, WVnVt M, !*n<nn,u r. 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Into: Doivsnsnisf Kokl tM local Srewuy. IMS a Oiii ||M 1A Uhn aI Mt-nuiut >wsUa( H .sfsni sin>ss.|lil|ul MM. MtarfU IMIJ.JMQ. 2. Ossosmm M, TbinSMSM 9f. Ot*vui OM. TM infsm n.i nt unuosni Miwuniiphmalssgm MVS Mil IMJ-JMiW-). r Mam Ij. HonsO S, luM 0, FsivvR A. tffsa of iu.im M owns MM * .train HMn it* fiwn Mat. PHttmtt IrMMlMI. MMMffAMfWf Sources of stress in women junior bouse officers Jetmy Firth*Cozea* of Pjycholojy. tniV of Ld, Lssiis > firifi-Corcn., fHif. al pvckeioivt .7 IMiJOl m: Abstract Objtcrivt--To tftn&iiN tbt ciumi of strtM to wobwo doctor* &4 rclata tbM to lv*U of dopra*tioa- Dnign--Quctioanlrc itudy. Subyrcu--Of 92 wooicd doctor* who had nduattd fron the vtfranitict of Lcedi, Mu* Chester, sod Sheffield is 19M and bed bees worid&g M junior house officer* for eight month* 70 (76%) returned completed quetfionaairet. Main muhi--Mtta KOre on the feacral health qutftioa&aire wet 13*79 (SD 3*20) asd oo the symptom checklist for depression wss 1-0 (Q'33). The scores of 32 subjects (46%) were above the criterion for clinical depression. Overwork was perceived as creating the most itrain, followed by effect* on personal Ufe, serious failures of treatment, tad talking to distressed relatives. Both stress end daprestloa were related to effects on personal Ufe, overwork, relations with consultants, and making decieioo*. Sea related sources of sues* were con* diet* between career tod personal life, sexual harass* meat at work, n lack of female role models, sad prejudice from patients. In addition to these, dis crimination by senior doctors was related to depres sion. Conclusion--Change* are needed in the career paths at women doctors, sad could be implemented. Introduction Symptom* of stmi and depreseioa have been found to oc high in junior doctors,'both is Britain1 and Id North America,1 ` and these findings arc true for both men and women. Several studies have shown, however, that the itrcH end depression level* of women doetori are coniidcrubly higher than thou uf other profes sional women' ind of male doctors' for example, in a stud) of junior house officers, Hsu and Marshal found thst w omen were one snd a hslf time* more likely to be claiuifled a- depressed end eight rinrei more likely to be severely depressed.1 In addition, women doctors in general have been rejxwted to have suicide rate* of up to four times those of their age mate#.' Though it is alwiy* difficult to compare relatively small group, with the general population, a recent Swedish study used a 10 year ample ud comptritons with academia to find that women doctors had higher suicide rata when com pared with both the general population and women aidamka, while men doctor* had retca equal to die general population and higher than those of andemica.' Although higher levels of occupational stress have been reported is women generally,' a recent metaanalysis of comparison* of male and female workers showed no differences.* Noonan <i ol found no sex difference* at intake to medical school," and a British longitudinal study showed that there were so sex difrereocee in turn or depression when the subjecta were students but that higher rite* of depression existed when they were junior house officcn."1 Despite any difficulties in interpretation, it seems dear that women doctors arc an occupational group at risk for depression and suicide and it is particularly important to attend to possible reasons for these difference*. Studies compering men end women junicr doctors on work factors have found similar score* for satis faction with career choice, perceived competence, and reported level* of ietigue,' and no difference* have b*en reported on job perceptions or sources of strew.111 Studies looking specifically at women doctors, however, have reported strew arising from career and family conflict,'** prejudic*,'1' and a lack of role models.1' A recent British study that categorised accounts of stresaAil events of male and female junioc house officer* found not one account of tuch problem*, but this may haw been because this method report* acute rather than chronic *cre*on.11 there fore considered the perceived causa of ttrts* in women doctors in more detail and related these to levels uf depration. Method A list of haplul addresses of preregut.-tuon doctors who had graduated from the universities of Leeds, Manchester, and Sheffield in 1986 was provided by the postgraduate offiota of those universities as part uf the junior doctors project.' The 92 women doctors who had not been contacted previously under that proieet were sent posts! questionnaires and stamped addressed envelopes along with a letter explaining that thu w a ' vouiMk 301 14 ;vtr 1W0 89