Sudden Infant Death Syndrome (SIDS)

Information sheets:

Sudden Infant death syndrome (SIDS)

ANAGRAPHIC DATA of the MOTHER:

Last name …………………………….First name ………………………………

Date of birth (dd/mm/yyyy)…..…/…..…/…..…. Age……………………

Place of birth…………………………Province/state…………………

Race/ethnicity:

□Caucasian □ Ispanic□ Middle Eastern

□Indian (subcontinental) □ Asian □ Black

□mixed ethnicity □ Magrebin □ other □ unknown

□missing data

Occupation……………………………………

Previous conceptions □ Yes □ No □ Missing data

Number of previous births ………….

Number of live births ………….

Number of stillbirths (≥25th gestational week) ………….

Number of miscarriages …………..… at gestational week ……..…………

Number of voluntary abortions…………….

Date of the last birth: (dd/mm/yyyy)……………

CIGARETTE SMOKE / ACTIVE / PASSIVE/SECONDHAND
NO / YES / No. cigarettes/
day / at home / at workplace
NO / YES / NO / YES
before conception / from the age of______/ from the age of_____ / from the age of_____
during pregnancy / until gestational week no.____ / until gestational week no.___ / until gestational week no.___
after delivery / until baby reached age of__ / until baby reached the age of__ / until baby reached the age of___

Does the mother drink alcohol? □ yes □ No Missing data

Does the mother use drugs? □Yes □ No □ Missing data

Did the mother use drugs during pregnancy? □ Yes □ No □Missing data

Is the mother HIV positive? □ Yes □ No □ Missing data

Did the mother use sedative-drugs or other drugs during pregnancy?

□ Yes □ No □Missing data

INFORMATION ABOUT PREGNANCY

Date of last period (dd/mm/yyyy) ………………………

Anamnestic-estimated date of delivery (due date) (gg/mm/aaaa )…………………………

Ultrasound-estimated date of delivery (dd/mm/yyyy)……………………………

Number of check-ups during pregnancy…………………………………………..………

First pregnancy check-up ( gestational week)…………………………….

MOTHER’S DISEASES:

Hypertension □ Yes : gestational / pre-gestational

□ No □ Missing data

Diabetes □ Yes : gestational / pre-gestational

□ No □ Missing data

Hemoglobin alterations □ Yes, specify……………………………………...

□ No □ Missing data

Coagulation anomalies □Yes □ No □ Missing data

Autoimmune diseases □Yes □ No □ Missing data

MATERNAL INFECTIONS (peri/post-conceptional)

□ HIV □ HBV

□ HCV □ Syphilis (LUE)

□ TOX □ CMV

□ RUBEO □ other

OTHER DISEASES OF THE MOTHER

□ Thyroid gland □hypophysis

□ cardiopathy □kidneys

□ pregnancy-related cholestasis □ parodontopathies

□ other

SCREENING TESTS FOR CHROMOSOMAL ABNORMALITIES

Screening: □ Yes □ No □ Missing data

NT (Nuchal translucency): □ abnormal □ normal □ Missing data

NT+BI TEST: □ abnormal □ normal □ Missing data

Triple screen test: □ abnormal □ normal □ Missing data

↓

□ Down S. □ DTN □ Missing data

PRENATAL INVASIVE TESTS

Chorionic villus sampling (CVS): □ normal □ not performed □ missing data

□ pathologic, specify…………………………………………………………

Amniocentesis: □ normal □ not performed □ missing data

□ pathologic, specify…………………………………………………………

Funicolocentesis: □ normal □ not performed □ missing data

□ pathologic, specify…………………………………………………………

Fetoscopy: □ normal □ not performed □ missing data

□ pathologic, specify…………………………………………………………

Ultrasound: □ normal □ not performed □ missing data

□ pathologic

↓

Fetal abnormalities
□ heart □ CNS
□ abdominal wall □ gastrointestinal tract
□ single umbilical artery □ muscle/bones
placenta
□ premature detachment □ previa
□ vasa previa □ infarction
□ accreta-percreta
Uterus abnormalities:
…………………………………………………………………………………………….

ADMITTANCE TO HOSPITAL DURING PREGNANCY: □Yes, diagnosis…………………

□ No □ Missing data

SIBILINGS (of the dead fetus or newborn)

ALIVE
born on / died at age / cause*
months / years
1
2
3

*please specify if SIDS

ANAGRAPHIC DATA of the FATHER

Last name…………………………….First name ………………………………

Date of birth (dd/mm/yyyy)…..…/…..…/…..…. Age……………………

Place of birth…………………………Province/state…………………

Race/ethnicity:

□Caucasian □ Ispanic□ Middle Eastern

□Indian (subcontinental) □ Asian □ Black

□mixed ethnicity □ Magrebin □ other □ unknown

□missing data

Occupation……………………………

CIGARETTE SMOKE □ No □ Yes, specify time frame: from……………..until…………………

no. cigarettes/day: □ 1-5 □ 6-10 □ 11-20 □ >20

At what age did he start smoking? ………………………

ALCOHOL □ No □ Yes …………………………………….

DRUGS □ No □ Yes …………………………………….

Present pathologic anamnesis

………………………………………………………………………………………………………………………………………..

Remote pathologic anamnesis

………………………………………………………………………………………………………………………………………..

Familiarity for diseases:

………………………………………………………………………………………………………………………………………..

SIDS FORM

Last name ……………………..……………..

First name ……………………..……………..

Address: street……………………..……………..No.………...... Area code……..…………..

City…………………………………..….. Province/State………...……..………..

Sex: □ Male

□ Female

Postconceptional age ……………….(gestational age……..+ postnatal age…..)

date of death ……..………….

Time of death (if known) (hh:mm)……..………….

when was he/she found dead (hh:mm)…………………..

a parent/caregiver last checked on infant at (hh:mm)……………..……..

Feeding:

 Breast-fed, until age…………………………………

 Formula-fed, until age ………………………………….

 Mistom since age……………………………………

 Weaned, since age……………………………….

 Unknown

Usual infant sleeping position:

 Supine

 Prone

 Side

 Unknown



Did he/she sleep with pacifier?

 Yes

 No

 Missing data

Last pediatric check-up ……..………….

Diseases at last pediatric check-up:

□ Cold□ Exanthem/eczema

□ Cough □ Other……………………………..

□ Fever

□ Diarrhoea

□ Vomiting/regurgitation

Breathing troubles

 No

 Yes (specify):

 Sleep Apnea

 Other ………………………………..

Vaccination/s administered in the last month:

□ yes, specify……………………………… □ no □ unknown

Post-mortem examination:

□ Performed □ Not performed □ Unknown

Sampling performed according to the Italian protocol:

□ Yes □ No □ unknown

Date of post-mortem examination ……………………………..

Performed by Dr.……………………………

DEATH SCENE

name of baby ………………………………

found dead on ……………………………… time ………………………………

place:

□ AT HOSPITAL: name ………………………………

□ AT HOME:

□ in crib/cot

□ in parents’ room □ in a different room

□ in another room of the house, specify ………………………………

□ in bed with the parents

□ in bed with another person, specify ………………………………

□ in child’s high chair □ while someone was holding the baby

□ in pram/stroller □ in infant-seat

room temperature ……………°C

infant’s body temperature ……………. °C

□ OUTSIDE specify ………………………………

□ in pram/stroller □ in infant car-seat □ while someone was holding the baby

□ other people’s house, specify ………………………………

IF THE INFANT WAS LyiNG DOWN, specify position: □ supine □ prone □ on side

□ other, specify ………………………………

clothes description ………………………………………………………………

pillow □ No □ Yes

pacifier □ No □ Yes

necklace □ No □ Yes

mattress firmness ………………………………

objects/toys in crib □ No □ Yes

last meal, time ………………………………

organic material : in mouth □ No □ Yes, specify ………………………………

in nose □ No □ Yes, specify ………………………………

in diaper/nappy □ No □ Yes, specify ………………………………

Resuscitation attempts □ No □ Yes

INFANT APPEARENCE AT DEATH:

□face/mouth discoloration □ sweaty

□ secretions (foamy, saliva) □ flaccid

□ skin discoloration (livor mortis) □ warm

□ signs of applied pressure (pale areas, discolorations) □ cold

□ rash o petechiae (small red areas on skin, membranes, eyes) □ rigid

□other signs (bruising, scratches) □ not evaluated

□ other………………………………

DAY AND TIME OF LAST MEAL:

date ………………………………Time ………………………………

Person who administered the last meal

………………………………………………………………………………………………

Food/fluids administered in the last 24 hours (last meal included), specify quantities:

□ Mother’s milk ………………..… ml

□ powder milk …………………… gr

□ cow’s milk ………………..… ml

□ water ………………..… ml

□ other fluids (tea, fruit juice) ………………..… ml

□ solid/liquid food …………………… gr

□ other …………………… gr/ml

Any new food given in the last 24 hours?

□ No

□ Yes, specify (switching to formula-feeding, weaning) …………………………………………………….……

Who found the dead baby?

physician □ mother □ father □other, specify …………………………………………

Person who made the collection of anamnestic data

Name ......

Qualification ......

Date ......