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BACKGROUND: Preterm infants are at risk of narrowing of the upper airway while restrained in infant car seats, leading to secondary apnea. However, some infants are able to maintain a normal airway. We hypothesized that this might reflect relatively smaller tongue size. METHODS: We retrospectively analyzed previously reported respiration-timed lateral radiographs of the upper airways of 17 preterm infants ready for discharge (32.6 ± 1.0 weeks gestation at birth, and 37.8 ± 9.7 days old at study) taken during sleep, first in a car safety seat with an insert that allowed the head to remain upright, and then without the insert, when the head slumped forward. The presence of air above the tongue was used as an index of relative tongue size. RESULTS: A smaller airspace around the tongue (relatively larger tongue) was associated with greater narrowing of the upper airway when the head was flexed forward in sleep (p < 0.002). In contrast, there was no significant correlation between baseline airway size and change in airway size (r (2) = 0.16, p = 0.11). CONCLUSION: The present study supports the hypothesis that the vulnerability of preterm infants to airways compromise while restrained in a car safety seat may be in part related to relative tongue size.

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BACKGROUND: Since the danger of prone sleeping in the first 6 months of life has been publicised, there has been a dramatic and consistent reduction in the incidence of sudden infant death syndrome (SIDS). However, unexpected infant deaths and apparent life-threatening events (ALTEs) continue to occur that are clearly not associated with known epidemiological risk factors. AIMS: To review the unique features of the anatomy and function of the upper airway of the young infant which contribute to increased vulnerability to hypoxia in this age group. We discuss the clinical identification of those infants at risk of obstruction or restriction of the upper airway and the management of the 'at risk' infant. CONCLUSIONS: In the era after the "back to sleep" campaigns, it is likely that an increasing proportion of cases of ALTEs and SIDS will be related to obstruction or limitation of upper airway size leading to sleep hypoxia/asphyxia. This type of problem may be anticipated by evaluation and investigation of infants with signs or a clinical history consistent with possible upper respiratory tract compromise, including micrognathia.

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We describe two cases of sudden infant death syndrome (SIDS) and one case of apparent life threatening apnoea where resuscitation was attempted by the mouth-to-mouth route. This was associated with evidence of gastric distension, including reflux of milk into the airway in the first two cases. In the second case the mother used mouth-to-mouth breathing after finding that she could not cover her baby's nose-and-open-mouth with her mouth. In the last case, the mother went on to try the mouth-to-nose route, with a good outcome. Systematic documentation of the route of resuscitation and its outcome in all cases of SIDS and near-miss SIDS may provide valuable insights into the optimal route for infant resuscitation.

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In order to determine if infants with clinical micrognathia identified in the newborn period have smaller upper airways than do normal infants, and if their airway size is related to risk of later apnoea, respiration-timed upper airway radiographic measurements were performed in 21 asymptomatic neonates with clinical micrognathia. Their radiographic measurements were compared with those of a previously reported cohort of 35 normal infants. The micrognathic infants and a control group of 27 infants referred for parental anxiety were followed for 6 mo on home apnoea monitors. Sleep apnoea at home requiring stimulation by the parents occurred in 6 of 7 infants with micrognathia associated with craniofacial anomalies, 9 of 14 (64%) infants with isolated micrognathia, but only 1 of the 27 control infants (p < 0.001). Upper airway measurements at term of the infants with isolated micrognathia who later experienced apnoea were significantly smaller than either those of normal infants (p < 0.01) or of micrognathic infants who did not have apnoea requiring stimulation (p < 0.05). In conclusion, upper airway measurements on timed lateral radiographs in asymptomatic micrognathic infants at term (corrected age) revealed them to be smaller than those of normal infants. Narrower upper airways were associated with increased risk of subsequent apnoea requiring stimulation.

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The current recommendation for resuscitation of infants is to blow air into both the nose and mouth. We have observed that mothers cannot cover both the nose and mouth of their infants. We compared postmortem tracheal and esophageal air entry by using the nose, combined nose and mouth, and mouth routes in eight infants. Air entry into the trachea occurred at lower pressures (P < 0.05) via a nose mask than via a combined nose and mouth mask or via a mouth mask. Air entry into the trachea occurred at lower pressures (P < 0.05) via the nose route in the neutral and extended neck positions compared with the flexed position. We were unable to demonstrate an effect of the route of air entry on esophageal air entry. The findings indicate that the nasal route of air entry is more effective than the combined nose and mouth or mouth routes and that neck flexion impedes air entry. We recommend that parents are taught to blow air into their infants' noses if the infant stops breathing.

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In infants under 6 months of age air normally enters the trachea by the nose because the tongue fills the oral cavity, and the oral route is open only when the infant is making muscular efforts such as crying or gasping. The present recommendation for infant resuscitation is for the resuscitator's mouth to cover the mouth and nose of the baby. We set out to test whether this recommendation is feasible. We measured the dimensions of the faces of 28 babies aged between 2 and 4 months (the age when resuscitation is most often needed) and of the mouths of 25 of their mothers. Only 2 mothers would have been able to cover with their mouths the nose and closed mouth of 2 babies (not their own). The mannequins often used to teach adults to resuscitate infants are misleading because they present a wide open mouth, thus implying that that is the preferred route. We recommend that the nasal route of air entry be taught to parents for resuscitation of babies who have stopped breathing.

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New Zealand has suffered a very high mortality rate from sudden infant death syndrome (SIDS), also known as "crib death" or "cot death." This prompted the development of the New Zealand Cot Death Study, a case-controlled epidemiological study. The preliminary findings of this study identified three risk behaviors potentially amenable to modification: prone sleeping position of the infant, maternal smoking, and not breastfeeding. These findings were discussed with the major stakeholders of child health. The Department of Health coordinated the development of a health education SIDS prevention program. Since the Help Prevent Cot Death Programme was launched in February 1991, the rate of total infant deaths, which was 10.1/1,000 live births in 1987, fell to 7.6/1,000 live births in 1991. The SIDS rate fell from 4.2/1,000 in 1987 to 2.5/1,000 in 1991. It is suggested that the described health education program had a significant influence on this improvement in infant survival.

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Upper airway measurements in nine infants considered to be at risk of upper airway insufficiency, six of whom presented after an apnoeic episode, were compared with measurements taken in two age groups of healthy infants. Paired, inspiratory and expiratory, lateral upper airway radiographs were obtained while the infants were awake and breathing quietly. The radiographs of all nine infants demonstrated narrowing in the oropharyngeal portion of the airway during inspiration and in six infants there was ballooning of the upper airway during expiration. Seven of the nine infants subsequently experienced recurrent apnoeic episodes which required vigorous stimulation to restore breathing. Experience suggests that respiratory phase timed radiographs are a useful adjunct to the evaluation of infants who are suspected of having upper airway dysfunction. They provide information regarding both the dimensions and compliance of the upper airway as well as the site of any restriction.

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AIMS: The National Cot Death Prevention Programme aims to reduce the prevalence of four modifiable risk factors for cot death, namely infant sleeping prone, maternal smoking, lack of breast feeding and infant sharing a bed with another person. This study evaluated the knowledge of 200 mothers of infants in South Auckland and estimated the prevalence of these infant care practices, which were compared with that found in the New Zealand Cot Death Study. METHODS: 200 mothers were interviewed. RESULTS: The prevalence of these modifiable risk factors in this study and that found in 1987/89 in Auckland were: prone sleep position: 2.5% compared with 36.8%, p < 0.001; infant sharing a bed with another person: 23.5% and 45.2%, p < 0.001; maternal smoking: 24.0% and 26.1%, p = ns; lack of breast feeding at 4 weeks of age: 11.0% and 13.6%, p = ns. The following percentage of mothers knew that there were risk factors for cot death: prone sleep position 95.5%, maternal smoking 89.4%, lack of breast feeding 63.1% and infant sharing a bed with another person 68.0%. CONCLUSIONS: This study shows that infant care practices are changing and highlights the need for continuing efforts, especially relating to maternal smoking and the practice of infants sharing a bed with another person.

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