title: Sudden infant death syndrome: insulation from bedding and clothing and its effect modifiers. The National Cot Death Study Group.
abstract: BACKGROUND
  Thermal stress related to excessive insulation from bedding and clothing has been postulated to be associated with sudden infant death syndrome (SIDS).
  
  
  METHODS
  The parents of 393 (81%) of the infants who died of SIDS in the post neonatal period were interviewed at home. Interviews were also completed with the parents of 1592 (88.4% of total) controls, a representative sample of all hospital births. The study was conducted in regions of the North and South Island of New Zealand in which 78% of all New Zealand births occurred in 1987-1990. Temperatures for the infant's bedroom estimated from the outside temperature and a model were used to predict the appropriate insulation for lower critical temperature (temperature below which the metabolic rate is likely to increase).
  
  
  RESULTS
  Sudden infant death syndrome was associated with extra thermal insulation of > 2 tog above the lower critical value, the odds ratio (OR) was 1.70 (95% confidence interval [Cl] : 1.3-2.20) after adjusting for season. After adjusting for a number of confounding factors the CR was reduced to 1.35 (95% Cl: 0.97-1.87). Also associated with SIDS was too little thermal insulation OR = 1.67(95% Cl: 1.13-2.48; and 2.63 (95% Cl: 1.61-4.30) when adjustments were made for the confounding factors. The interaction effect between infants sleeping prone and >2 tog extra thermal insulation was significant (OR = 6.07, 95% Cl: 3.83-9.60). Infants with too little thermal insulation were at increased risk if they were not tightly wrapped (OR = 3.81, 95% Cl: 2.04-7.09). There were also small additive interaction effects if the mother smoked and the infants had > 2 tog extra thermal insulation, or they were ill and had > 4 tog extra insulation. Interaction effects between thermal insulation and other factors were not significant.
  
  
  CONCLUSIONS
  More thermal insulation than was necessary to maintain the lower critical temperature increased the risk of SIDS primarily among infants in the prone sleep position, and to a lesser degree in infants whose mothers smoked and in infants who were unwell.
authors.affiliation: Department of Preventive and Social Medicine, University of Otago Medical School, Dunedin, New Zealand.
authors.forename: S M
authors.initials: SM
authors.lastname: Williams
authors.forename: B J
authors.initials: BJ
authors.lastname: Taylor
authors.forename: E A
authors.initials: EA
authors.lastname: Mitchell
mesh_terms: D001512:Bedding and Linens / Q000009:adverse effects*; D016022:Case-Control Studies; D003020:Clothing / Q000009:adverse effects*; D015987:Effect Modifier, Epidemiologic; D018882:Heat Stress Disorders / Q000209:etiology*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D009520:New Zealand; D016017:Odds Ratio; D011237:Predictive Value of Tests; D012307:Risk Factors; D012621:Seasons; D013398:Sudden Infant Death / Q000209:etiology*; D011795:Surveys and Questionnaires; D013696:Temperature