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Will nicotine replacement prevent new infant tragedy?

Three GPs discuss a difficult problem in general practice

Case history

Tina, 19, had a sudden infant death six months ago when her (unplanned) son was eight months old. She and her partner Terry live in a one-bedroom flat with little hope of moving to somewhere bigger. Terry has been off work with depression and drinks too much. He blames the hospital and wants nothing to do with the paediatric department. Tina has adjusted better than Terry. Unfortunately the health visitor is off sick long-term with stress and there is no funding for a replacement. Tina presents today 12 weeks pregnant. She admits to smoking at least 20 cigarettes a day but says she is so anxious she cannot stop.

She wonders if you could give her nicotine replacement or something to calm her nerves?

Dr Chris Hall

'Her partner's alcohol intake may be more of a problem here'

On the face of it, Terry is more of a potential problem. He has clearly not got beyond the anger and blame stages of bereavement. Perceived guilt may also be a factor here. Has he considered bereavement counselling, or would they benefit from contact with the Foundation for the Study of Infant Deaths?

Treading very carefully without administering blame (and losing the parents' trust entirely) I would educate them in the current thinking on SIDS. Suggesting they both attend Tina's antenatal appointments would give me an opportunity to explore their understanding of the concept of, for example, putting the baby to sleep in the supine position. The link between SIDS and parental smoking must also be pointed out to them. Most forms of nicotine-replacement therapy should be avoided in pregnancy. Rather it should be pointed out to Tina that for the health of her baby, both ante- and postnatal, she should stop smoking without medication. On balance, I would also decline her request for anxiolytics. On a more positive note, the opportunity presents at 12 weeks to give general antenatal advice including diet and folic acid, though she is approaching the end of the first trimester.

Living in one-bedroom flat carries an increased risk of one parent sleeping on the sofa with the baby ­ this together with alcohol ingestion can lead to overlying and infant asphyxiation. Terry's excess alcohol intake should be directly addressed, with the involvement of a community addictions team if necessary.

Three patients, many problems and only one doctor ­ frequent monitoring and the involvement of the midwife, social services and my partners would be invaluable here.

Dr Bill Laughey

'I have never prescribed NRT in pregnancy, but it's

a lot safer than smoking'

I'm thinking about three things. How can I help Tina stop smoking? What can I do to help her anxiety (and is Terry making a big contribution to it)? And who else can I get involved? OK, perhaps that's four things.

From the point of view of the unborn baby, quitting smoking is a huge priority. If it takes the whole 10 minutes to reach some solutions to this, so be it. It sounds like Tina is already committed to quit but I would gently ask what she knows about smoking and the risks to baby. She probably knows a lot, and will likely have read about the association with SIDS after the death of her first baby. I would admit to never before prescribing NRT in pregnancy, though I know there is a good argument to be made for using it on the basis that it's still a lot safer than smoking.

The very safest way would surely be to quit without the help of drugs if possible. If she were willing to try this, I would invite her to leave her cigarettes in the surgery bin in the hope that a little drama may give an extra ounce of motivation. If she remained keen on NRT, I would err towards prescribing, perhaps with the back-up of the cessation service.

Given that anxiety is infectious, and that there is little chance of finding space away from Terry in a one-bedroom flat, it would be important to find out how Terry is coping. Clearly, this pregnancy will rekindle the emotions he couldn't cope with six months ago. Is he making her anxious? If so, can we get him to surgery, if only on the premise that he would be accompanying Tina to the next appointment?

Perhaps they are short of some facts. Perhaps they need to be told that another SID is extremely unlikely. They are almost certainly short of support ­ anxiety, drinking and unemployment are all isolating. It's time to get the midwife involved. I would also advise a phone call to social services and perhaps to citizen's advice to see about benefits.

Dr Andrew Wordsworth

'It would seem like a fairly risky environment for a newborn baby'

This is clearly a heart-breaking situation. Currently it would seem like a fairly risky environment for a baby to be born into. It is understandable that Tina should have concerns about her current pregnancy and the future health of her baby.

There needs to be a co-ordinated multidisciplinary approach in dealing with as many problems as possible now, preparing the parents for the future and safeguarding the well-being of the child during infancy.

My first concern would be to offer reassurance about the viability of this pregnancy by accessing rapid booking and a scan.

Parental smoking is a recognised risk factor for SIDS and both Tina and Terry need to be encouraged to quit before the baby is born. Nicotine replacement is just one of a number of potentially useful means to this end. I would encourage both of them to attend our stop-smoking clinic for counselling and support.

The social situation of this family is entirely unacceptable. I would certainly support an application for a move into more appropriate accommodation. They may require help with providing things for the baby ­ low income could be a hindrance here.

Social services and charitable organisations may be able to offer advice and assistance.

Hopefully by the time the baby is born, a health visitor should be in post. Even with a health visitor off sick, another member of the team should be covering her workload.

I recognise fully the need for ongoing work with Terry to enable him to accept the death of his child and deal with the drinking. He may benefit variously from bereavement counselling, antidepressants or referral to an alcohol advisory service. I would encourage Terry's early involvement in all aspects of this pregnancy.

This may be just the motivation needed to encourage him to get on with life and deal with his problems constructively. With the right input this family can be helped to journey out of grief and into the challenge of a happy healthy young family.

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