Las bases de datos

SIDS receives a great deal of attention in the UK because it is the main cause of death of infants between the neonatal period and one year of age (World Health Organisation 2006). Yet it is not a primary health concern for infants in a global context. This is because in many other cultural and geographical areas, other causes

9 Low Birthweight (LBW) is defined as an infant being born with a weight less than 2500g (UNICEF 2004)

51 of infant mortality are far more prevalent than SIDS. The main global cause of death in children under five is pneumonia, which kills two million children each year. Other significant causes of infant deaths worldwide include diarrheal diseases, measles, and malaria (Wardlaw and colleagues 2006).

Populations globally are well aware of these other threats to infant survival, especially in areas where rates of infant mortality in the past few generations have been particularly high. These relatively high rates of infant death in some countries may have shaped existing beliefs regarding infant care practices designed to

mitigate risks and promote survival. It is logical, then, that for the majority of the world’s population culturally-informed patterns of infant care have evolved to focus on preventing the most significant threats to infant health, such as respiratory illness caused by infectious disease. Given the lesser threat posed by SIDS in these contexts, it is also likely that infant care strategies designed to mitigate SIDS risk specifically will be relatively non-existent in all areas where infectious disease continues to overshadow other causes of death in infancy. Given the prevalence of pneumonia in early childhood, and given the fact that less than 20% of children with pneumonia receive the recommended treatment of antibiotics (Wardlaw et al 2006), we would also expect lay strategies to have evolved to protect infants from pneumonia, especially where access to and affordability of health services is lacking.

Global health research too often reflect biases toward examining the health concerns that are relevant in a Western, developed context, regardless of whether these same issues are as relevant or pressing for local populations (Lee and Mills 2000). Since SIDS is such a significant issue for infant health in Western countries, SIDS research has received relatively widespread attention and interest worldwide among health professionals, parents, and researchers. However, it is important to note that although SIDS is the leading cause of death among infants after the neonatal period in the UK, decades ago it was even more common. The decline is correlated with improvements in the general health of populations alongside other causes of infant mortality (Moore, 2005).

52 3.2.3 Does SIDS go undetected in non-Western Countries?

The extent to which SIDS occurs in low and middle-income countries is extremely difficult to determine. This difficulty is due to the prevalence of multiple causes of morbidity and mortality, especially involving infectious diseases, high rates of infant mortality, and limited resources for systematically recording infant deaths compared to more developed countries. Infectious diseases are more likely to be cited as the cause of death, both because such diseases are indeed so common and because autopsies required to identify alternative causes of death are not widely available. There are further difficulties involved in finding resources for postmortem examinations or accessing reliable statistics.

In the UK, victims of SIDS are often noted to have had respiratory infections on the day of or leading up to the death (Ashild and Torleiv 1999), but autopsies are able to rule out if these infections were the cause of death. Where pneumonia kills thousands of infants and where there are few resources for post-mortem examinations or death-scene investigations, infection is likely to be recorded on a death certificate if the child had an infection at the time of death. SIDS can only be established after an autopsy fails to identify any cause of death. In developing countries, against the ‘background’ of high infant mortality, other causes of death are much more likely to be recorded (Bergman 2006). However this does not provide evidence that SIDS deaths do not occur in these countries, and there is reason to believe that efforts to prevent SIDS are of potential benefit to infants in these contexts as well as in western countries.

Efforts to address SIDS in developing countries are further complicated by the fact that risk factors derived from research in high-income contexts may not be applicable for other populations. Geib and Nunes (2006) explored risk factors associated with sleeping environments for infants from low-income backgrounds in Brazil, where there is a low incidence of SIDS. They found that infants were exposed to both protective and risk factors at night, suggesting that other factors should be considered in addition to those typically addressed in developed

countries, such as the practice of infants sleeping with other children. Conducting autopsies in cases of unexpected infant death where SIDS risk factors may differ

53 from those typically acknowledged in populations that have been well studied, makes the prospect of identifying a true SIDS case even more problematic. For example, colder months and prone sleeping are considered to be risk factors for SIDS (Douglas 1996), but in Lithuania 60% of SIDS deaths during1997-2000 were in the warmer months and there was no association with prone sleeping

(Bubnaitiene and colleagues 2005). This suggests that the risk factors of most consequence may differ for each population because of differing infant care practices and sleep environments. SIDS is often considered to be a disease of higher income countries, but the difficulties in identifying a SIDS death in non-Western countries, as illustrated by the above example, suggests that it is not possible to conclude that SIDS is not a cause of infant death in other populations.