Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Brandee M. King

Bon Secours Memorial College of Nursing

Arlene Holowaychuk MSN, RN

Nursing Research NUR 4122

April 10, 2018

I pledge
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this paper is to compare the effect of cigarette smoking on Sudden Infant Death

Syndrome (SIDS) death compared to mothers who did not smoke during pregnancy during the

first year. The exact cause of SIDS remain unknown but certain risk factors place mothers at

high risk for experiencing a SIDS death. To study the relationship between maternal smoking on

the prevalence of SIDS, a search was conducted using EBSCO Discovery Services and PubMed,

each yielding 452 and 48 articles, respectively. Five articles were selected, published within the

last five years, and met inclusion criteria set forth by the researcher. Findings from the various

studies identify that stricter tobacco control policies and addressing health disparities can

positively impact the overall rate of SIDS. Education on smoking cessation and providing safe

sleep practices that correlate with the “Back to Sleep” campaign can be protective factors against

SIDS. Limitations of the study included a small number of studies on reported SIDS case deaths

and the smoking timeframe and duration was generalized to during pregnancy. Implications

indicate that if smoking cessation is not promoted and enforced, the overall SIDS rate will

continue to remain at a plateau and mothers who smoke will continue to be at risk for

experiencing a SIDS death. Recommendations include a need for tobacco control policies to be

updated and further strengthened, and education throughout a pregnancy on the harmful effects

of smoking. This change could thereby alleviate preventable death by SIDS.

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An Integrative Review

The purpose of this integrative review is to appraise literature regarding the effects of

prenatal and postnatal maternal smoking on the incidence of Sudden Infant Death Syndrome

(SIDS). SIDS is defined as the unexpected death of an infant under one year of age, with onset of

fatal episode often occurring in association with sleep, and which remains unexplained after a

thorough investigation has been conducted (Schwender et al., 2016) The exact cause of SIDS

remains unknown however, risk factors can be categorized into biological and environmental

risk factors. This is important because research has shown while there has been an overall

reduction in the prevalence of SIDS, it remains the leading cause of death in infancy in Western

countries (King, Markowitz & Ross, 2015). While the overall SIDS death rate was on a

downward trend, it has plateaued in recent years, raising questions and implying need for

additional research. The aim of this integrative review is to examine literature related to the

researchers PICOT question, are mothers who smoked during pregnancy at a greater risk of

having a SIDS death during the first year of life compared to mothers who did not smoke during

pregnancy?

Design and Search Methods

This integrative review focuses on five research articles that were determined relative to

the PICOT question. Key terms that were utilized in various searches included, ‘SIDS’, ‘Sudden

Infant Death Syndrome’, ‘smoking’, ‘maternal smoking during pregnancy’, postnatal smoking’,

‘death of infant’, and ‘risk factors’. EBSCO Discovery Services and PubMed were the main

databases used to conduct the search for articles that fit predetermined criteria that were specific

to the researcher. EBSCO Discovery Services yielded 452 articles and PubMed yielded 48

articles. The search criteria for articles was limited to year 2013 up until 2018. Criteria was
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further narrowed to only academic journals that were full text articles. The criteria also included

articles that were published in English and could contain articles published outside of the United

States. The articles selected were determined relevant to the researchers PICOT question, “Are

mothers who smoked during pregnancy at a greater risk of having a SIDS death during the first

year of life compared to mothers who did not smoke during pregnancy?”.

After significantly narrowing down search criteria, limitations to the search process did

exist. The researcher had difficulty finding articles that were not a meta-analysis and that were

available to the researcher without having to request the articles. The articles were required to

meet certain inclusion criteria that included: mothers who smoked during pregnancy, occurrence

of SIDS, mothers who did not smoke with an occurrence of SIDS, and first year of life. Any

articles that did not meet the required inclusion criteria were excluded from the review.

Findings/Results

The results and findings of the research clearly identify that maternal smoking is a strong

risk factor for the prevalence of a SIDS death (Hirabayashi et al., 2016; King et al., 2015;

Mitchel et al., 2017; Mohlman & Levy, 2016; Schwender et al., 2016). A synopsis of the

compiled research is presented in Table 1. The researcher framed the review according to the

following categories: tobacco control policies, cigarette smoke exposure and proper sleep

position.

Tobacco Control Policies

Two quantitative studies identified that stricter tobacco control policies such as

increasing the cigarette tax and raising the legal age of tobacco purchase could reduce the overall

SIDS rate (King et al., 2015; Mohlman & Levy, 2016). In the quantitative experimental study

conducted by King et al. (2015), SIDS cases that were reported between the years 1990 and 2009
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were compared to the relative cost of cigarettes at the local and international level. The aim of

this study was to observe the effect of government policy on reducing the consumption of

cigarettes thereby reducing the prevalence of SIDS in developed countries other than the United

States. The sample of the study was 23 countries that were determined by obtaining previously

recorded data from multiple organizations. The country and year of where a SIDS death occurred

between the years 1990 and 2009, was obtained from the World Health Organization (WHO),

and was further determined to be a SIDS death by the International Classification of Diseases 9th

Revision (ICD-9). Cigarette prices were then obtained from the Economist Intelligence Unit

(EIU), which are collected twice a year in various capital cities and large cities worldwide. Data

was analyzed using a reduced form equation that accounts for a SIDS occurrence in a country for

year, function of cigarette prices and smoke-free regulations, other factors that may be related to

SIDS, and country effects. The model estimates the direct effect of cigarette prices and smoke-

free policies on SIDS causes using a Poisson fixed effects model by accounting for unobserved

heterogeneity with standard errors adjusted for heteroscedasticity. Researchers determined,

higher cigarette prices are associated with a reduction in the prevalence of SIDS. For each dollar

increase in cigarette prices, an average 12 to 13 infant deaths are avoided.

Similarly, the quantitative study conducted by Mohlman & Levy (2016) addressed the

need for stricter tobacco control policies to aid in reducing adverse maternal child health

outcomes. The sample group consisted of mothers who indicated smoking on their child’s birth

certificate from eight states within the United States, and data from this study was then collected

by using the CDC WONDER database that contained these birth certificates. Data was analyzed

through inferential statistics by using a fraction formula that determines prevalence of adverse

health outcomes. Upper and lower bounds are provided to account for the estimate of maternal
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smoking prevalence and relative risk uncertainty. The number of adverse maternal child health

outcomes, such as SIDS, was determined by the prevalence of each outcome: age,

socioeconomic status and racial/ethnic group multiplied by the population of women giving

birth. The results indicated that reducing prenatal smoking has the potential to reduce adverse

birth outcomes, including SIDS. Stricter tobacco control policies including raising the cigarette

tax and minimum purchase age of tobacco, can help reduce disparities that contribute to adverse

maternal child health outcomes.

Cigarette Smoke Exposure

Three of the articles also agree that cigarette smoke exposure is a risk factor for SIDS

(Hirabayashi et al., 2016; Mitchell et al., 2017; Schwender et al., 2016). In the qualitative study

conducted by Hirabayashi et al. (2016), researchers sought to compare previous research of SIDS

with the effect of environmental risk factors such as prone position and smoke exposure through

the first year of life. The sample of the study consisted of 4,319 parents of newborns that were

asked about environmental factors related to SIDS through questionnaires at a one-month

checkup and one year. Data was analyzed through statistical analysis using IBM SPSS Statistics

Desktop Version 21.0. Maternal smoking habits were used as the dependent variable and

paternal smoking habits were used as the independent variable. The age and smoking habits of

both parents were determined at the one-month medical checkup of the newborn. The results of

the study found that parental smoking included mother and father as an environmental factor of

SIDS and posed a significant risk. Hirabayashi et al. found “mothers that smoked during

pregnancy had a fourfold greater risk of SIDS than infants of mothers who did not smoke”

(p.1925).
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The quantitative experimental study conducted by Schwender et al (2016) aimed to

determine whether there is a difference in DNA methylation level between SIDS cases with

smoking mothers compared to SIDS cases with mothers who did not smoke during pregnancy.

The sample of the study was 22 autopsies from documented SIDS cases. Peripheral blood

samples were obtained from a German study on SIDS conducted between 1998-2001 and parents

were interviewed on major topics such as family and child history, economic factors, sleeping

and feeding habits of the child, cigarette and alcohol consumption of both parents during and

after birth of the child. Analysis of peripheral blood samples including DNA from the blood

samples were extracted using DNA IQ Case Work Pro Kit, treated with sodium bisulfite using

EZ DNA Methylation Kit and provided pertinent data using capillary gel electrophoresis.

Statistical analysis was then used to determine the relative methylation state by calculating the

relative peak height of methylated cytosine and documented in percentage. The results of the

study mention that the greatest difference between SIDS cases exposed to prenatal smoke, and

SIDS cases not exposed to prenatal smoke, is a transcription factor binding site located within

the analyzed region. SIDS cases with prenatal smoke exposure were found to have statistically

higher hypomethylation of the transcription factor binding site compared to SIDS cases without

prenatal smoke exposure.

The quantitative experimental study conducted by Mitchell et al. (2017) sought to study

modifiable risk factors for sudden unexpected death in infancy (SUDI) in New Zealand. Risk

factors examined included: maternal smoking in pregnancy, sleep position of the infant, whether

the infant was prone or supine, and if the infant shared a bed with the parents. The sample of the

study included 137 cases of reported unexpected infant death. The cases were obtained from the

National Initial Investigation Office (NIIO) and an initial assessment was performed by a
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specially trained investigator who was a SUDI expert. The assessment included a death scene

investigation that contained photography and doll reconstruction of the position in which the

infant was placed to sleep and found dead. A detailed research interview was also performed

with caregivers of the infant once informed consent was obtained. A control group of children of

similar ages to those in the case studies was randomly selected. Statistical analysis using

standard methods of the Mantel-Haenszel odds ratio was utilized to analyze the data found in the

study. The results of the study found that maternal smoking in pregnancy increased the risk for

SUDI and was present in 74% of the cases studied. Additional risk factors such as bed sharing

and sleep position further increased this risk.

Proper Sleep Position

Two articles highlighted the importance of the sleep position in relation to the

development of SIDS (Hirabayashi et al., 2016; Mitchell et al., 2017). Hirabayashi et al. (2016)

noted that behavioral risk factors identified in epidemiological studies identify that prone and

side infant sleeping positions place the infant at risk of a SIDS death. The results of the study

mention that 96.7% of parents avoid laying their infants down in the prone position however, the

need for proper teaching and education is essential in protecting the infant. The study discusses

literature after the “Back to Sleep” campaign and found that 95% of parents were unaware of the

proper sleep position and would lay the infant in the prone position but the overall rate has

drastically improved. The study also states that a high risk of SIDS may occur in infants who are

usually placed non-prone but placed prone for last sleep or found prone. Mitchell et al. (2017)

report that infants placed in the prone position were at an increased risk of SUDI at 95%,

compared to infants placed on their back to sleep. Infants placed on their side to sleep had a non-
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significant increased risk of SUDI. However, nearly 57.5% of deaths were a result from the side

sleeping position in combination with bed sharing.

Discussion/Implications

Each of the five articles chosen for this integrative review address the PICOT question

and indicate an increased risk of SIDS in infants who were exposed to smoke during pregnancy

compared to mothers who did not smoke during pregnancy. The study conducted by Hirabayashi

et al. (2016) determined that infants of mothers who smoked during pregnancy in addition to

various environment factors had a significantly increased risk of experiencing a SIDS death.

King et al. (2015) concluded that “for each dollar increase in cigarette prices on average, 12 to

13 infant deaths annually can be avoided” (p. 1047). Mitchell et al. (2017) determined that the

combination of maternal smoking in pregnancy and bed sharing is extremely hazardous for

infants indicating that SUDI prevention messages are still applicable today and should still be

reinforced with parents. Additionally, Mohlman & Levy (2016) found that reducing prenatal

smoking has the potential to reduce adverse birth outcomes such as SIDS, preterm birth (PTB)

and low birth weight (LBW). These adverse health outcomes have long term implications

regarding pain and suffering and higher healthcare costs. A 2016 study by Schwender et al.

suggested that SIDS is multifactorial in origin. However, smoking is a known risk factor for

SIDS and can ultimately alter DNA methylation, which can be a predisposing factor for SIDS.

All five articles generated similar conclusions that mothers who smoked during pregnancy are at

increased risk of experiencing a SIDS death.

In each of the five articles, authors discuss implications for nursing practice and

recommendations for further research. Many of the articles included continuing education and

establishing a baseline understanding with parents of the infant were important in SIDS
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prevention. King et al. (2015) and Mohlman & Levy (2016) recommend increasing cigarette tax

and addressing disparities that increase the prevalence of cigarette smoking. Future research

should focus on protective factors against SIDS and smoking cessation programs should be

utilized to decrease the risk of SIDS rather than smoking cessation only during pregnancy.

Hirabayashi et al. (2016) states that maternal smoking prevalence significantly increased from

the one-month checkup to one year later leading future research to be aimed at smoking

cessation prior to pregnancy. Mitchell et al. (2017) also suggests that “more could be done to

promote the protective effect of infants sharing the parental bedroom, as in this high-risk

population 31% of infants did not share the parental bedroom and the population attributable risk

was 21% (p.60).

Limitations

It is important to mention the limitations of this integrative review. The information

found in this integrative review was limited to five research articles, written within the last five

years. A majority of the available research regarding SIDS was outside of the determined five-

year limit for the assignment and was concentrated around the 1994 “Back to Sleep” campaign.

This was also the researchers first experience with writing an integrative review which indicates

limited knowledge and experience in the field of research. Limitations of the study include a

small number of studies of SIDS death cases that can be attributed to the “Back to Sleep”

campaign. Other limitations mentioned determine smoking during pregnancy was generalized to

the entire time of pregnancy and not categorized by prenatal and postnatal smoking. Further

limitations include the unknown degree or compliance of smoke free regulations in developed

nations.
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Conclusion

The findings of this integrative highlight the importance of smoking cessation during the

prenatal and postnatal period. The exact cause of SIDS remains unknown however, knowing the

various risk factors that place a mother at risk for a SIDS death are important for a mother to

recognize to prevent harm to the newborn. Providing stricter tobacco control policies and

addressing maternal health disparities are essential in reducing the overall SIDS rate.

Additionally, providing education to parents that promote the “Back to Sleep” campaign while

adding additional environmental factors that can prevent the occurrence SIDs is essential for

reduced harm to the infant. This integrative review concludes that mothers who smoke during

pregnancy are at an increased risk of a SIDS death compared to mothers who do not smoke

during pregnancy and the findings are sufficient to evaluate the PICOT question.
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References
Hirabayashi, M., Yoshinaga, M., Nomura, Y., Ushinohama, H., Sata, S., Tauchi, N.,…Horigome,

H. (2016). Environmental risk factors for sudden infant death syndrome in Japan.

European Journal of Pediatrics, 175, 1921-1926. doi: 10.1007/s00431-016-2786-7

King, C., Markowitz, S., & Ross, H. (2015). Tobacco control policies and sudden infant death

syndrome in developed nations. Health Economics, 24, 1042-1048.

doi: 10.1002/hec.3090

Mitchell, E.A., Thompson, J.M., Zuccollo, J., MacFarlane, M., Taylor, B., Elder, D.,…Fleming,

P. (2017). The combination of bed sharing and maternal smoking leads to a greatly

increased risk of sudden unexpected death in infancy: the New Zealand SUDI nationwide

case control study. New Zealand Medical Journal, 130(1456). 52-64. Retrieved from

http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=4&sid=26feda86-7033-493e-

a966-8c7f3dffec0a%40sessionmgr101

Mohlman, M.K., & Levy D.L. (2016). Disparities in maternal child and health outcomes

attributable to prenatal tobacco use. Matern Child Health Journal, 20, 701-709.

doi: 10.1007/s10995-015-1870-3

Schwender, K., Holtkotter, H., Johann, K.S., Glaub, A., Schurenkamp, M., Sibbing,

U.,…Vennemann, M. (2016). Sudden infant death syndrome: exposure to cigarette

smoke leads to hypomethylation upstream of the growth factor independent 1 (GFI1)

gene promotor. Forensic Science Medicine & Pathology, 12, 399-406.

doi: 10.1007/s12024-016-9812-y
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Table 1- Qualitative and Quantitative Article Evaluation

First Author  Hirabayashi (2016)- Department of Pediatrics, National

(Year)/Qualifications Hospital Organization Kagoshima Medical Center,
Kagoshima, Japan
Background/Problem  Researchers wanted to compare previous research of SIDS
Statement with the effect of environmental risk factors and the
importance of smoking cessation programs
Conceptual/theoretical  Assess parental knowledge and current practices of
Framework environmental factors related to SIDS and change current
strategies for resuming a continued decrease in prevalence of
SIDS
Design/  Qualitative experimental
Method/Philosophical  Analysis conducted off of previous studies but
Underpinnings environmental risk factor analysis added
Sample/  4319 parents of newborns already used but without
Setting/Ethical environmental risk factor analysis, parents invited to
Considerations participate in study at discharge
 Questionnaire about attitudes or practices
 Permission obtained from Ethics Committee of the National
Hospital Organization, informed consent obtained from all
parents
Major Variables  Age, awareness of risk factors, sleeping position, smoking
Studied (and their habit, number of cigarettes and feeding habit
definition), if
appropriate
Measurement  Questionnaires that included; parent age, sleeping position,
Tool/Data Collection parental awareness of risk factors and SIDS, current paternal
Method and maternal smoking, number of cigarettes, awareness of
breastfeeding
 Time of discharge and 1 year later
Data Analysis  Statistical analysis- Chi squared tests
 Multivariate logistical regression analysis
Findings/Discussion  Maternal smoking significantly increased from one-month
checkup to one year later; smoking mothers were more
likely to feed formula rather than breastmilk
 Parents tended to avoid lying infants in prone position
 Mothers who smoked during pregnancy had a fourfold
greater risk of SIDS than infants of mothers who did not
smoke
Appraisal/Worth to  Smoking cessation programs should be further implemented
practice to increase breastfeeding and decrease risk of SIDS
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First Author King (2014) – Assistant professor, PhD, Department of Health

(Year)/Qualifications Management and Informatics, Georgia State University, University of
Central Florida
Background/Problem  The exact cause and mechanism of SIDS remains unclear; risk
Statement factors such as biological and environmental play a key role
 Prenatal smoking and postnatal environmental smoking
significantly increase the risk of SIDS
Conceptual/theoretical  Researchers wanted to see the effect of government on reducing
Framework the consumption of cigarettes by adopting tobacco control policies
thereby reducing the prevalence of SIDS in developed countries
other than US
Design/  Quantitative experimental
Method/Philosophical  Empirical specification using reduced form equation
Underpinnings  The model estimates direct effect of cigarette prices and smoke-
free policies on SIDS using a Poisson fixed effect model that
accounts for unobserved heterogeneity with standard errors
adjusted for
Sample/ Setting/Ethical  Data was obtained from multiple sources. Country and years
Considerations where SIDS cases were obtained from world health organization,
coding of SIDS from International Classification of Diseases 9th
Revision, cigarette prices and taxes obtained from Economist
Intelligence Unit
 Ethical considerations not addressed
 Setting: developed Nations excluding Japan and Netherlands
Major Variables  Three categories of smoke free air laws pertaining to restrictions at
Studied (and their workplaces, restaurants, and child care-facilities
definition), if  Counting the number of smoking bans from each country and year
appropriate

Measurement  Data obtained and collected on cigarette prices and the occurrence
Tool/Data Collection of SIDS from various sources
Method  Information from smoke-free regulations across countries
Data Analysis  T-statistics- evidence of significant difference between population
means
 Use of table analyses

Findings/Discussion  A $1 increase in average cigarette price, significantly decreases

SIDS death
Appraisal/Worth to  Higher cigarette prices are associated with a reduction in the
practice prevalence of SIDS, for each dollar increase in cigarette prices, an
average 12 to 13 infant deaths are avoided
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First Author  Mitchel (2017) – Professorial research fellow, Department

(Year)/Qualifications of Pediatrics, University of Auckland
Background/Problem  Despite a reduction in overall infant mortality, sudden
Statement unexpected death in infancy continues to be a concern in
New Zealand, the rate is high by international standards
Conceptual/theoretical  Researchers wanted to identify modifiable risk factors for
Framework sudden unexpected death in infancy
Design/  Case-control study
Method/Philosophical  Quantitative
Underpinnings  The case studied had to include an infant death between age
seven days-1 year. Categories of death included: asphyxia
during sleep, unsafe sleeping, congenital anomalies,
unexplained causes
Sample/  137 cases of SUDI
Setting/Ethical  Written consent was obtained from parents
Considerations  Ethical approval obtained from Central Regional Ethics
Committee
Major Variables  Ethnicity, maternal age, birth weight and age of infant,
Studied (and their maternal smoking, bed sharing, sleep position of infant,
definition), if breastfeeding
appropriate
Measurement  Assessment conducted by a specially trained investigator,
Tool/Data Collection included death scene investigation which captured photos
Method and included doll reconstruction demonstrating position of
infant while asleep and the way found dead and the sleeping
surface
 Detailed research interview with caregivers
Data Analysis  Statistical analysis – Mantel- Haenszel odds ratio analysis
 Logistical regression for unmatched analysis of categorical
variables to adjust for potential confounders
Findings/Discussion  Maternal smoking in pregnancy increased the risk of SUDI
and was present in 74% of cases
 Infants of mothers who smoked in pregnancy and were bed
sharing were at an increased risk compared to infants not
exposed to smoking and did not bed share
Appraisal/Worth to  The combination of maternal smoking in pregnancy and bed
practice sharing is extremely hazardous for infants. SUDI prevention
messages are still applicable and should be reinforced
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First Author Mohlman (2016) – PhD, Professor, Georgetown University,
(Year)/Qualifications Specialty in Oncology
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
16
 The relationship between cigarette smoking during
pregnancy on adverse maternal and child outcomes
 Not identified
 Quantitative
 Correlational Design
 Specific method for data obtainment not identified
however, a fraction formula was used for smoking
attributable factors on the data collected
 Birth certificates of mothers who reported prenatal
smoking, data collected from 8 states
 Ethical considerations not addressed, no mention of IRB
approval
 Age, socioeconomic status and racial/ethnic groupings
 Low birth weight, preterm birth and Sudden Infant Death
Syndrome
 CDC wonder database that contained birth certificates of
mothers who reported prenatal smoking
 PRAMS questionnaire-Pregnancy risk assessment
monitoring system, contains 3 parts
 Inferential statistics-fraction formula that determines
prevalence of adverse health outcomes
 Prevalence of adverse birth outcomes by age, SES and
racial/ethnic and presented in tables
 Positive correlation between attributable factors: age, SES
and racial ethnic groupings on child health outcomes: low
birth weight, preterm birth and SIDS
 Increasing the cigarette tax and raising the legal age to
buy cigarettes can reduce the incidence of PTB, LBW and
SIDS occurring
 Reducing smoking can reduce adverse child health
outcomes (LBW, PTB and SIDS)
 Reducing adverse child health outcomes reduces pain and
suffering and high healthcare costs
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First Author Schwender (2016) – MS, Forensic Genetics and Molecular Biology,
(Year)/Qualifications University of Münster
Background/Problem  Aim of the study was to determine whether there’s is a
Statement difference in DNA methylation level between SIDS cases
with smoking mothers and SIDS cases with nonsmoking
mothers during pregnancy
Conceptual/theoretical  Researchers wanted to see the effect of exposure to cigarette
Framework smoke on DNA methylation and its modification

Design/  Quantitative experimental

Method/Philosophical  Samples obtained from a multi-center-case control study that
Underpinnings was run from 1998-2001
Sample/  Informed consent, collection during medico-legal autopsies
Setting/Ethical  22 SIDS cases
Considerations
Major Variables  Experimental group: newborns exposed to cigarette smoke
Studied (and their in-utero
definition), if  Control group: suitable non-SIDS, not exposed in-utero
appropriate
Measurement  Peripheral blood samples obtained from German study on
Tool/Data Collection SIDS
Method  Interviews with parents- family and child history, economic
factors, sleeping and feeding habits of child, cigarette and
alcohol consumption of parents during pregnancy and after
birth
Data Analysis  DNA was extracted using DNA IQ Case work Pro Kit,
treated with sodium bisulfite using EZ DNA Methylation
Kit and were fractioned and analyzed using capillary gel
electrophoresis
 Statistical analysis- determination of relative methylation
state (%) by calculating g relative peak height of methylated
cytosine
Findings/Discussion  SIDS cases with prenatal tobacco smoke exposure showed
highly significant hypomethylation of the transcription
factor binding site compared to exposed non-SIDS cases
 Hypomethylation located in genes involved in chemical
detoxification, developmental processes, tumor formation,
and regulation of lipid levels
Appraisal/Worth to  Findings show how smoking for a known long time, can
practice influences the child’s methylation pattern and how these
alterations in DNA methylation could be predisposing factor
for SIDS