Does cot death still exist?

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Abstract
Vanishing diagnosis The term SIDS was introduced in 1969, 3 “partly for humanitarian reasons, being intended as a recognized category of natural death that carried no implication of blame for bereaved parents.”4 Since then, however, a lot has been learnt about the major modifiable risk factors and the role of parenting in cot death. The number of cases in the UK has fallen by 75% since the 1991 Back to Sleep campaign.5 In 2005 there were 2107 deaths registered as SIDS in America6 and 191 in England and Wales,7 but from this April all sudden unexpected infant deaths in the UK will be investigated according to a new national multiagency protocol that is expected to reduce by half the number of deaths registered as SIDS.8 Meanwhile, in October Britain’s leading SIDS research team concluded that maternal smoking during pregnancy—already a recognised factor in 90% of cot death cases—met the criteria for causality and was directly responsible for 60% of such deaths.9 The Foundation for the Study of Infant Death, which funds the work of the Bristol research unit, endorsed this conclusion. George Haycock, the foundation’s scientific adviser, delivered this plain message: “If no women smoked in pregnancy, about 60% of cot deaths could be avoided. This means that in the UK the number of deaths could fall from around 300 a year to 120 a year.”10 It seems that SIDS, a spectre that for more than 40 years has caused fear and anxiety for countless parents, is simply withering away in the face of closer and closer scrutiny, undermining the popular myth propagated by much media coverage that cot death is a bolt from the blue that can strike any child from any family. Smoking is, of course, not the only advice being missed or ignored by the majority of parents whose children die from SIDS, as the American experience chronicled by Scripps Howard anecdotally attests. In a 2006 paper, Peter Fleming and colleagues at Bristol described how the epidemiological profile of SIDS had changed between 1984 and 2003, partly because of the impact of the Back to Sleep campaign. The most worrying finding was the increase from 57% to 86% in the proportion of mothers who smoked during pregnancy, but also of concern was the enduring prevalence of inappropriate sleeping position. Before the campaign, 89% of babies dying from SIDS in Avon had been put down to sleep on their fronts. Although by 2003 there had been a large reduction, babies who had been placed to sleep in the prone position still accounted for a quarter of SIDS deaths. The proportion of SIDS babies who died while co-sleeping with their parents had risen from 12% to 50% of cases. The number of deaths in the parental bed had halved but the number of co-sleeping deaths on sofas had risen.5 Tony Risdon, the only forensic paediatric pathologist in the UK, is based at Great Ormond Street Hospital, where his department sees about one third of all infants who have died suddenly and unexpectedly. He never uses the term SIDS: “When you get down to it, the cases that absolutely fulfil all the international criteria of SIDS are a tiny minority and if every parent followed the advice on safe sleeping environments and so on, this problem would probably disappear.” Thanks to ongoing controversy over how some sudden infant deaths are categorised, even the scale of the problem in the UK remains uncertain.11 12 The Foundation for Study of Infant Deaths, Britain’s leading funder of cot death research, says that in 2005 there were 300 cot deaths in the UK,13 but this figure includes 77 deaths registered in England and Wales as “unascertained.”7