Sudden Infant Death Syndrome
SIDS remains the leading cause of infant death in many developed countries. There are around 2,700 babies who die from cot death every year in the US – and around 300 in the UK.
Cot death occurs when a seemingly healthy infant – under 12 months of age – dies in their sleep with no cause of death established in a post-mortem investigation. Although many risk factors are known to increase the risk of cot death – such as maternal smoking and bed sharing – nobody is exactly sure why it happens.
The American Academy of Pediatrics (2016) now recommends that infants be put to sleep on their back instead of on their side or stomach. While this has reduced the incidence of SIDS somewhat, it certainly has not eliminated it.
The allostasis hypothesis
Allostasis is defined as "the process of achieving equilibrium through fluctuating neuroendocrine responses to physical and psychological stressors." Professor Eran Elhaik (2016) has postulated a hypothesis, based on allopathic (stress) load that may explain the cause of SIDS. According to Elhaik:
We postulate that while low-level stress can stimulate adaptation, prolonged and repetitive iatrogenic stressful, painful, or traumatic experiences during prenatal, perinatal, neonatal, and postneonatal development constitute allostatic overload and are risk factors for SIDS. Due to their total dependence, the infant’s ability to allostatically regulate exposure to stressors is severely constrained, which increases their vulnerability to disease and premature death. Due to their difficulties in maintaining homeostasis and inability to escape/avoid iatrogenic or non-medically nociceptive exposure, infants are vulnerable to toxic stress with preterm infants being the most vulnerable.
Elhaik lists infant stressors such as:
- maternal smoking
- maternal caffeine consumption
- preterm births
- non-urgent pediatric surgeries
- neonatal circumcision
Elhaik lists stressors from non-therapeutic neonatal circumcision as:
- intense pain
- circulatory shock
that can result in death. He points out that post-operative circumcision pain can last for 10-14 days.
Elhaik lists skin breaking procedures such as heel sticks and seasonal respiratory viral infection as additional stressors.
Elhaick observes that the SIDS rate in the UK where the NHS does not perform non-therapeutic circumcision is 0.38 per 1000 as compared with the US rate of 0.55 per 1000 where most male infants are circumcised.
Evidence of association with circumcision
Elhaik found Anglophone countries practice significantly more non-therapeutic neonatal circumcision than non-Anglophone countries and have a significantly higher SIDS rate than non-Anglophone countries.
Elhaik found great variation in the SIDS mortality rate. Of the 15 countries studied, The Netherlands, where the Dutch do not practice infant circumcision, was the lowest at 0.06 per 1000 births, while the United States where non-therapeutic infant circumcision is commonplace had the highest at 0.82 per 1000 births.
Hispanic people do not favor circumcision, so relatively few Hispanic boys are circumcised. Elhaik reported a lower incidence of unexplained neonatal death in states with a high Hispanic population.
Elhaik reported that the incidence of SIDS in states where Medicaid pays for non-therapeutic circumcision is higher than that of states where Medicaid does not pay for non-therapeutic circumcision.
Elhaik pointed out why infant circumcision has such an effect:
Our finding that MNC is associated with SIDS is not surprising. Circumcision is associated with intra-operative and postoperative risks, including bleeding, shock, sepsis, circulatory shock, hemorrhage, pain, and long-term consequences – all of which contribute toward allostatic load and, thereby, SIDS through various mechanisms. For instance, during circumcision there is an increase in the blood pressure, breathing rate, and heart rate. Even with the most advanced techniques, bleeding occurs in over 15% of the cases, in which case there is a danger that a lower blood volume would result in low blood pressure and reduced amount of oxygen that reaches the tissues. Reduced blood pressure has been associated with obstructive sleep apnea (OSA), a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing. Unsurprisingly, SIDS victims experienced significantly more frequent episodes of OSA. Preterm neonates experience over twice the rate of bleeding complications than full-term neonates. MNC-related complications are unavoidable. For instance, in 1949, Gairdner reported that 16 out of 100,000 UK boys under 1-year old died due to circumcision. In tandem with the lack of evidence of a meaningful and relevant health benefits to the infant, several countries chose to opt out of the operation.
Elhaik calls male neonatal circumcision "a major risk-factor for SIDS." He points to the effect of Medicaid funding of non-therapeutic infant circumcision on the increase in SIDS observed in states that pay for non-therapeutic circumcision of infant boys.
Elhaik views the association of non-therapeutic infant circumcision and SIDS as fully proven, but thinks additional research is necessary to determine cause and effect.
The American Academy of Pediatrics has not taken a position on the association of male non-therapeutic neonatal circumcision and SIDS, nor is it likely to because of the conflict of interest between good medicine and the financial interests of its fellows (members).
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