5 16
Commentary
The Journal of Pediatrics March 1976
Commentary T HE c o N CLU SI ON of Naeye and associates that victims of the sudden infant death syndrome display before death a distinct temperament profile should stimulate much disctlssion and further study. AS the developer of the temperament questionnaire1 they used and as a pediatric practitioner, I should like to elaborate upon two of the areas of concern mentioned by them: (1) the problems related to retrospective behavioral data and (2) the danger of misuse of their conclusions by others. We cannot be sure how accurately their modification of the temperament questionnaire assessed the antemortem behavior of these SIDS infants. The original questionnaire was designed for contemporaneous maternal reporthag of reaction patterns in four- to eight-month-old infants. It is not even certain how well it does that, mainly because there has been no suitable observation scheme for a validity study. On the basis of available data 1 and clinical impressions we assume for the present that it is more or less accurate. However, neither the questionnaire nor the research interview2 on which it is based has been used for infants younger than three months of age, and neither of them has been employed in retrospective data gathering. Retrospective histories are known to be particularly inaccurate in regard to illnesses3 and generally "must be evaluated with great cautionTM when utilized in research. The death of the infants confounds the situation even further. Recollections of these parents are likely to be colored by unresolved feelings of guilt and overprotectiveness toward the surviving siblings and by the frequent emotional disturbances in these siblings as a result of the experience? Therefore, since the validity of the authors' method is so uncertain, their results should be substantiated by other means. Naeye and associates are rightly apprehensive about possible professional and popular misuse of the conclusion that prospective SIDS babies may be inactive and mild in their temperaments. This combination of characteristics is a very common one, involving to at least some degree 37% (74 of 200) of normal babies, whereas 6% (12 of 200) are extremely inactive and mild. 6 Since SIDS strikes about 0.2% of infants,7 it would be difficult to select
Vol. 88, No. 3, pp. 516-517
the potential victims from the general population by use of these criteria. If babies of this temperament profile were now labeled as potential SIDS victims, it would be a colossi/1 iatrogenic disaster. Needless parental anxiety would be epidemic, and we would witness a sharp increase in the vulnerable child syndrome? Abbreviation used SIDS: sudden infant death syndrome
The only way to resolve this uncertainty will be a prospective study: an arduous project because of the large numbers of subjects needed. If the temperament questionnaire is employed, it should be appropriately revised for infants less than three months of age. The Brazelton Neonatal Behavioral Scale 9 may be a more suitable instrument, since it consists of observations in the early days of life. Also, feeding behavior and abnormal cries can be recorded better by trained observers. By these means, we may be able to find out to what extent potential SIDS babies are indeed objectively different from others in their behavior. The latest research does support the thesis that there may be subtle physiologic differences in these babies. 7 In the meantime, let us reflect soberly on the staggering prospect that some day parents and physicians may have to live through several months of terror while a substantial number of infants earmarked as being at risk pass through the dangerous period. We are definitely not at that point now.
William B. Carey, M.D. 319 W. Front St. Media, Pa. 19063
REFERENCES
1. Carey WB: A simplified method for measuring infant temperament, J PEmATR77:188, 1970. 2. Thomas A, Chess S, Birch HG, Hertzig ME, and Korn S: Behavioral individuality in early childhood, New York, 1963, New York University Press.
Volume 88 Number 3
3.
Wenar C: The reliability of developmental histories, Psychosom Med 25:505, 1963. 4. Chess S, Thomas A, and Birch HG: Distortions in developmental reporting made by parents of behaviorally disturbed children, J Am Acad Child Psychiat 5:226, 1966. 5. Salk L: Sudden infant death: Impact on family and physician, Clin Pediatr 10:248, 1971. 6. Carey WB: Unpublished data.
Commentary
5 17
7. Marx JL: Crib death: some promising leads but no solution yet, Science 189:367, 1975. 8. Green M, and Solnit A: Reactions to the threatened loss of a child: a vulnerable child syndrome, Pediatrics 34:58, 1964. 9. Brazelton TB: Neonatal behavioral assessment scale, Philadelphia, 1973, JB Lippincott Company.
Commentary
The Journal of Pediatrics March 1976
Commentary T HE c o N CLU SI ON of Naeye and associates that victims of the sudden infant death syndrome display before death a distinct temperament profile should stimulate much disctlssion and further study. AS the developer of the temperament questionnaire1 they used and as a pediatric practitioner, I should like to elaborate upon two of the areas of concern mentioned by them: (1) the problems related to retrospective behavioral data and (2) the danger of misuse of their conclusions by others. We cannot be sure how accurately their modification of the temperament questionnaire assessed the antemortem behavior of these SIDS infants. The original questionnaire was designed for contemporaneous maternal reporthag of reaction patterns in four- to eight-month-old infants. It is not even certain how well it does that, mainly because there has been no suitable observation scheme for a validity study. On the basis of available data 1 and clinical impressions we assume for the present that it is more or less accurate. However, neither the questionnaire nor the research interview2 on which it is based has been used for infants younger than three months of age, and neither of them has been employed in retrospective data gathering. Retrospective histories are known to be particularly inaccurate in regard to illnesses3 and generally "must be evaluated with great cautionTM when utilized in research. The death of the infants confounds the situation even further. Recollections of these parents are likely to be colored by unresolved feelings of guilt and overprotectiveness toward the surviving siblings and by the frequent emotional disturbances in these siblings as a result of the experience? Therefore, since the validity of the authors' method is so uncertain, their results should be substantiated by other means. Naeye and associates are rightly apprehensive about possible professional and popular misuse of the conclusion that prospective SIDS babies may be inactive and mild in their temperaments. This combination of characteristics is a very common one, involving to at least some degree 37% (74 of 200) of normal babies, whereas 6% (12 of 200) are extremely inactive and mild. 6 Since SIDS strikes about 0.2% of infants,7 it would be difficult to select
Vol. 88, No. 3, pp. 516-517
the potential victims from the general population by use of these criteria. If babies of this temperament profile were now labeled as potential SIDS victims, it would be a colossi/1 iatrogenic disaster. Needless parental anxiety would be epidemic, and we would witness a sharp increase in the vulnerable child syndrome? Abbreviation used SIDS: sudden infant death syndrome
The only way to resolve this uncertainty will be a prospective study: an arduous project because of the large numbers of subjects needed. If the temperament questionnaire is employed, it should be appropriately revised for infants less than three months of age. The Brazelton Neonatal Behavioral Scale 9 may be a more suitable instrument, since it consists of observations in the early days of life. Also, feeding behavior and abnormal cries can be recorded better by trained observers. By these means, we may be able to find out to what extent potential SIDS babies are indeed objectively different from others in their behavior. The latest research does support the thesis that there may be subtle physiologic differences in these babies. 7 In the meantime, let us reflect soberly on the staggering prospect that some day parents and physicians may have to live through several months of terror while a substantial number of infants earmarked as being at risk pass through the dangerous period. We are definitely not at that point now.
William B. Carey, M.D. 319 W. Front St. Media, Pa. 19063
REFERENCES
1. Carey WB: A simplified method for measuring infant temperament, J PEmATR77:188, 1970. 2. Thomas A, Chess S, Birch HG, Hertzig ME, and Korn S: Behavioral individuality in early childhood, New York, 1963, New York University Press.
Volume 88 Number 3
3.
Wenar C: The reliability of developmental histories, Psychosom Med 25:505, 1963. 4. Chess S, Thomas A, and Birch HG: Distortions in developmental reporting made by parents of behaviorally disturbed children, J Am Acad Child Psychiat 5:226, 1966. 5. Salk L: Sudden infant death: Impact on family and physician, Clin Pediatr 10:248, 1971. 6. Carey WB: Unpublished data.
Commentary
5 17
7. Marx JL: Crib death: some promising leads but no solution yet, Science 189:367, 1975. 8. Green M, and Solnit A: Reactions to the threatened loss of a child: a vulnerable child syndrome, Pediatrics 34:58, 1964. 9. Brazelton TB: Neonatal behavioral assessment scale, Philadelphia, 1973, JB Lippincott Company.
