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作者：Pam Harrison  
出處：WebMD醫學新聞

　　January 11, 2010 — 接受精神科住院照護的父母親所生下的嬰兒，發生嬰兒猝死症(sudden infant death syndrome，SIDS)的風險顯著高於一般人。新研究指出，如果雙親都有因為任何精神科的原因住院、或者母親或雙親有酒精或藥物異常之診斷，則此風險特別高。
　　
　　英國曼徹斯特大學的Roger Webb博士等人報告指出，在1978至2004年間，瑞典有將近250萬名活產紀錄，而如果雙親都有任何需要住院的心智疾病病史，其嬰兒的SIDS風險幾乎是一般人的7倍。
　　
　　如果母親有酒精或藥物異常之診斷，則此風險也幾乎是一般人的7倍，如果雙親都有酒精或藥物異常之診斷，則此風險幾乎是一般人的9倍以上。
　　
　　如果母親或父親有酒精或藥物異常之外需要住院的精神疾病病史，則嬰兒的SIDS風險是一般人的2倍。
　　
　　Webb博士向Medscape Psychiatry表示，不論是探討哪個小組，SIDS是一個罕見的結果，所以確認這點很重要，但是顯然的，這類家庭需要的支持大過其他家庭，其中，需告訴這些婦女有關SIDS的標準風險因素，特別是在懷孕期間要戒菸，對此，我們相當鼓勵。
　　
　　這項研究登載於1月號的一般精神醫學誌(Archives of General Psychiatry)。
　　
　　【相關的SIDS風險】
　　研究者估計了有精神病住院史的父母親以及一般族群的SIDS相關風險，並且比較雙親有無精神病住院史之嬰兒的風險因素盛行率。
　　
　　他們也探討瑞典如何降低此風險，於1992年開始推行對抗SIDS的活動，修飾SIDS的風險因素。將這27年的出生世代分成兩段期間：1978-1991年以及1992-2004年。
　　
　　研究作者報告指出，整個世代中，總共有1,531個SIDS案例，比率為每1,000件活產有0.6例，再者，這些案例中有11.2%是發生在出生前雙親中至少1人有精神疾病住院史的嬰兒中，其中將近半數是因為酒精或藥物異常住院。
　　
　　特別的是，有118例SIDS與母親住院史有關、82例與父親住院史有關。如果母親最後1次酒精或藥物異常住院史是在出生前1年內的話，其嬰兒的SIDS風險最高，如果是在出生前5年以上住院，則風險最低。
　　
　　相對的，在生育之前5年以上因為其他精神疾病住院的母親，其嬰兒的SIDS風險較高。
　　
　　表. 根據生育前最後一次母親精神病住院年數分類之SIDS勝算比 診斷組別以及最後一次住院後的年數
死亡數
每 1000 例活產之風險
校正OR (95% CI)

因任何診斷住院
  
  
  

<1
12
1.8
3.3 (1.9 – 5.8)

1 – 4
46
1.8
3.1 (2.3 – 4.1)

≧ 5
60
1.6
3.1 (2.4 – 4.1)

酒精或藥物異常
  
  
  

<1
8
5.2
9.0 (4.5 – 18.1)

1 – 4
25
3.6
6.9 (4.6 – 10.2)

≧ 5
16
2.6
5.4 (3.3 – 8.8)

酒精或藥物異常之外的所有診斷
  
  
  

<1
4
0.8
1.4 (0.5 – 3.9)

1 – 4
21
1.1
1.8 (1.2 – 2.8)

≧ 5
44
1.4
2.7 (2.0 – 3.7)

CI = 信心區間(confidence interval)；OR =勝算比(odds ratio)；SIDS =嬰兒猝死症(sudden infant death syndrome)
　　
　　【修飾風險因素】
　　如同研究者指出的，已知的SIDS可修飾風險因素包括母親抽菸以及嬰兒的睡姿。預防SIDS的全國風險降低活動，成功地針對一般人的這些因素，讓母親抽菸率減少將近一半。
　　
　　不過，該活動對於風險較高組之母親抽菸率效果小很多，因為酒精或藥物相關住院的母親，有半數以上在該活動之後還繼續抽菸。
　　
　　研究作者們寫道，的確，任何類型的雙親(母親、父親或雙親)精神病住院史的嬰兒，SIDS的相對風險在該活動之後顯著增加，反映出這個風險降低活動對於此類有風險之族群的效果沒有一般人那麼好。
　　
　　Webb博士表示，在這些特殊病患中，同時有許多問題，如果一個家庭正經歷所有艱難的社會困境，很難要求家中的女性戒菸或要求她們讓不仰睡的嬰兒仰睡，這相當有壓力。因此，對這些家庭要有更多的健康促進訊息，我認為關鍵之一在於醫療和其他公共衛生服務的更佳溝通。
　　
　　【母親的憂鬱和SIDS】
　　英國布里斯托大學的Peter Blair博士向Medscape Psychiatry表示，之前著眼在母親的憂鬱與SIDS風險的研究，顯示有增加的關聯。
　　
　　他表示，表面上，這個研究顯示父母親和母親的心智疾病與SIDS有相當強烈的關聯，當雙親都有心智健康問題時，風險甚至更高，這顯示出一種生物梯度(biological gradient)。
　　
　　不過，如同所有的大型世代研究，你只有這些細節，心智健康疾病引起SIDS風險增加的機轉則是難以確定。
　　
　　Blair博士表示，例如，有酒精或藥物異常之父母親，其嬰兒的SIDS風險似乎最高，但是該研究無法釐清此風險是否對嬰兒照護有所影響，包括嬰兒在睡覺時是否被正確地以仰睡姿勢放置，而酒精和藥物異常這兩者的影響也是。
　　
　　他認為研究者報告的這些發現是正確的，他們也正確地執行了研究，但是，就是否確定瞭解而言，則還有相當距離。
　　
　　不過，Blair博士同意研究者的結論，應針對有心智健康問題以及酒精或藥物異常的雙親，進行特定的介入，以讓他們更可以遵守產前戒菸等預防方法。
　　
　　Wellcome Trust 以及嬰兒死亡研究基金會提供計畫資金。作者們皆宣告沒有相關財務關係。


Serious Mental Illness in Parents Significantly Increases Infants' Risk for SIDS

By Pam Harrison
Medscape Medical News

January 11, 2010 — The risk for sudden infant death syndrome (SIDS) among infants born to parents who have received psychiatric inpatient care is significantly higher than in the general population. The risk is especially high if both parents have been admitted for any psychiatric reason or if the mother or both parents have been diagnosed as having an alcohol or drug disorder, new research suggests.

Roger Webb, MD, PhD, University of Manchester, England, and colleagues, report that of approximately 2.5 million live births recorded in Sweden between 1978 and 2004, the risk for SIDS was almost 7 times higher than in the general population if both parents had a history of any mental illness requiring hospital admission.

It was also almost 7 times higher than the general population if the mother had an alcohol or drug disorder, and it was more than 9 times higher than in the general population if both parents had an alcohol or drug disorder.

The risk for SIDS among infants was also 2-fold higher than in the general population if either the mother or the father had a history of hospital admission for any psychiatric illness other than an alcohol or drug disorder.

"Regardless of what group we are looking at, SIDS is a rare outcome so it’s important to recognize this, but clearly these families require greater levels of support than other families, and part of this is talking to these women about standard risk factors for SIDS, particularly stopping smoking during pregnancy, which we really need to encourage these women to do," Dr. Webb told Medscape Psychiatry.

The study is published in the January issue of Archives of General Psychiatry.

Relative SIDS Risk

For the study, investigators estimated the relative risk for SIDS in parents with a history of psychiatric inpatient care vs the general population and compared the prevalence of risk factors in infants with and without a parental psychiatric inpatient history.

They also explored how the Swedish risk reduction campaign against SIDS, introduced in 1992, modified risk factors for SIDS. The 27-year birth cohort was then categorized into 2 periods — 1978 through 1991 and 1992 through 2004.

A total of 1531 SIDS cases occurred in the whole cohort at a rate of 0.6 per 1000 live births. Furthermore, in 11.2% of all cases there had been at least 1 parental psychiatric inpatient admission before the birth, with almost half of this group having been admitted for alcohol or drug disorders, the study authors report.

Specifically, 118 instances of SIDS occurred in association with maternal admission histories and 82 episodes with paternal admission histories. The risk for SIDS was also highest among infants whose mothers were admitted with an alcohol or drug disorder if the last admission was within a year of the birth of the infant and lowest if it was 5 or more years previously.

In contrast, the risk for SIDS was higher among infants whose mothers were admitted for other types of psychiatric illnesses 5 or more years before the birth of the child.

Table. Odds Ratios for SIDS Stratified by Number of Years Since Last Maternal Psychiatric Inpatient Episode Before Birth

Diagnostic Group and Years Since Last Inpatient Episode  No. of Deaths  Risk per 1000 Live Births  Adjusted OR (95% CI)  
Admitted with any diagnosis  ? ? ?
<1 12 1.8 3.3 (1.9 – 5.8)
1 – 4 46 1.8 3.1 (2.3 – 4.1)
?5 60 1.6 3.1 (2.4 – 4.1)
Alcohol or drug disorders  ? ? ?
<1 8 5.2 9.0 (4.5 – 18.1)
1 – 4 25 3.6 6.9 (4.6 – 10.2)
?5 16 2.6 5.4 (3.3 – 8.8)
All diagnoses other than alcohol or drug disorders  ? ? ?
<1 4 0.8 1.4 (0.5 – 3.9)
1 – 4 21 1.1 1.8 (1.2 – 2.8)
?5 44 1.4 2.7 (2.0 – 3.7)

CI = confidence interval; OR = odds ratio; SIDS = sudden infant death syndrome.

Modifiable Risk Factors

As investigators point out, known modifiable risk factors for SIDS include maternal smoking and the infant’s sleeping position. National risk reduction campaigns for the prevention of SIDS have successfully targeted these factors in the general population, where maternal smoking rates decreased by almost half.

However, the campaign had a much smaller effect on rates of maternal smoking among the highest-risk groups, where more than half of mothers with an alcohol- or drug-related admission still smoked antenatally after the campaign.

Indeed, "among infants with any parental psychiatric admission history (mother, father, or both parents), the relative risk [for SIDS] increased significantly after the campaign," the study authors write, a reflection of the risk reduction campaign not working as well in the at-risk population relative to the general population.

"In these particular groups of patients, a lot of problems coalesce, and if a family is experiencing a whole range of intractable social difficulties, it may be very difficult for women to stop smoking or to put the baby to sleep on their back because babies don’t sleep as well on their backs and this can be very stressful,” said Dr. Webb "So there are wider messages for health promotion for these families, and I think a key thing is better communication between medicine and other public health services."

Maternal Depression and SIDS

Peter Blair, PhD, University of Bristol, United Kingdom, told Medscape Psychiatry that previous work looking at maternal depression and increased SIDS risk has shown a link.

"On the surface, this study shows a significantly strong link between parents with mental health illnesses and SIDS, the risk being even higher when both parents have mental health issues, which suggests there is a biological gradient," he said.

However, as with all large cohort studies, "you have only so much detail and the mechanism by which mental health illness is causing an increase in SIDS risk is difficult to identify."

For example, the risk for SIDS among infants born to parents with alcohol and drug disorders seems to be highest, but the study is not able to tease out whether this risk is attributable to infant care practices in general, including whether the infant was correctly placed on its back while sleeping, or the alcohol and drug disorder per se, said Dr. Blair.

"I think it’s right that investigators reported these findings and what they have done they have done correctly, but you are standing too far away from the problem in studies like these to know for sure," he said.

Dr. Blair nevertheless agrees with the study authors’ conclusion that parents with mental health and alcohol or drug disorders should be targeted for special intervention so that they are more likely to adhere to preventive measures such as antenatal smoking cessation.

The project was funded by a grant from both the Wellcome Trust and the Foundation for the Study of Infant Deaths. The authors have disclosed no relevant financial relationships.

Arch Gen Psychiatry. 2010;67:69-77.