1. Trends in Sudden Unexplained Infant Deaths (SUIDs) and the Impact of Medical Examiner Reporting, Florida 1990-2005 Angel Watson, MPH, RHIA William M. Sappenfield, MD, MPH Florida Department of Health Division of Family Health Services Office of Surveillance, Evaluation and Epidemiology December 2007

2. Acknowledgements Michael L. Haney, PhD, NCC, CCISM, LMHC Ken Jones, Deputy State Register Gary J. Sammet, Senior Management Analyst Supervisor Dave Goodman, PhD, MS Daniel R. Thompson, MPH Susan Potts, LCSW

3. Definitions SIDS is the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history. (Willinger et al, 1991) (Cause of Death—ICD-9: 798.0, ICD-10: R95) SUIDs is the sudden death of an infant under one year of age that is unexplained at the time of death. Includes: sudden infant death syndrome (SIDS), accidental suffocation and strangulation in bed (ASSB), other accidental suffocation and strangulation (OASS), neglect, abandonment, and other maltreatment syndrome and cause unknown/unspecified. (Shapiro-Mendoza, et al 2006)

4. Sudden Infant Death Syndrome (SIDS) Leading cause of SUIDs related deaths Pathophysiology is unknown Occurs mostly among infants 1 to 6 months Approximately 2,500 case per year in U.S. Third leading cause of infant death, until 2004 Source: National Center on Health Statistics (NCHS), 2000

5. SIDS, Florida Statues, Chapter 383 The medical examiner must perform an autopsy upon any infant under the age of 1 year who is suspected to have died of Sudden Infant Death Syndrome. The Medical Examiners Commission shall develop and implement a protocol for dealing with suspected sudden infant death syndrome. The protocol must be followed by all medical examiners when conducting the autopsies required under this subsection. Source: Florida Statues, Fla. Stat. Ann. § 383.3362Fla. Stat. Ann. § 383.3362

6. Background

8. Florida, 1990 to 2005 Infant mortality rate decreased 25%. Prevalence of Sudden Infant Death Syndrome (SIDS) deaths declined 65%. Prevalence of other Sudden Unexpected Infant Deaths (SUIDs) increased 205%.

9. Study Purpose How has reporting of SIDS, cause unknown/unspecified and other SUIDs changed over time in Florida? How have these trends varied over time by Medical Examiner districts?

10. Methods Death certificates from 1998 to 2005 were used to examine trends. Deaths were grouped into the state’s 24 medical examiner districts. Cause-specific mortality proportions were estimated using the categories proposed by Shapiro-Mendoza. Deaths by cause were limited to SIDS, causes unknown/unspecified and other SUIDs. Deaths due to abuse, neglect, and other maltreatment were excluded.

11. Results

12. Sudden Infant Death Syndrome (SIDS) (ICD-10 code: R95), Florida, 2006 CausesDescriptions Infant Death while co-sleeping between mother and sister Unexpected Death of infant while sleeping with parent and sibling in twin size bed Sudden Unexplained Infant Death Prone Sleeping position; Undetermined whether external causes involved; Co-sleeping with adults Sudden Infant Death SyndromeHistory of co-sleeping and prone sleeping position Sudden Unexpected Death in infancyWhile co-sleeping with sibling and adult Consistent with Sudden Infant Death Syndrome Co-sleeping with adult and older sibling; Face down on sofa Consistent with the definition of SIDS Unknown whether external causes contributed to death Sudden infant death syndrome associated with co-sleeping Prematurity (36 weeks), IUGR (symmetric), cleft soft palate Sudden infant death while co-sleeping The decedent was found unresponsive while co- sleeping Sudden infant death while co-sleeping with parent Premature infant died while sleeping with mother on couch Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis, Vital Statistics

13. Accidental suffocation and strangulation in bed (ICD-10 code: W75), Florida, 2005 CausesDescriptions SuffocationCo-sleeping with others Probable Asphyxia with overlayCo-sleeping with adults Positional AsphyxiaDecedent face down on pillow Mechanical AsphyxiaMother fell asleep over baby Possible OverlayCo-sleeping with others Anoxic encephalopathyCo-sleeping with others with soft bedding Asphyxia due to suffocationFound face down in bed Suffocation; Occlusion of nose and mouth and compression of torsoOverlay of adult caregiver during sleep Mechanical compression of head and torsoOverlay during co-sleep Mechanical suffocation by blanketHead wrapped by blanket in playpen Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis, Vital Statistics

14. Other specified/unspecified threats to breathing (ICD-10 codes: W83 & W84), Florida, 2005 CausesDescriptions Positional AsphyxiaFell off bed into clothes Probable AsphyxiaCo-sleeping with other children Positional AsphyxiaFell face first onto bedding SuffocationFound between cushions AsphyxiaDeceased asphyxiated during sleep due to positioning Positional AsphyxiaPositioned head between mattress and play pen wall AsphyxiaDeceased inadvertently asphyxiated during sleep Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis, Vital Statistics

15. Unknown/Unspecified (ICD-10 codes: R99), Florida, 2005 CausesDescriptions Undetermined after complete autopsy UndeterminedFound unresponsive while sleeping UndeterminedBed Sharing Presumed Natural Causes UndeterminedCould not be determined Termination due to potentially fatal maternal cardiac indications PendingUnknown Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis, Vital Statistics

16. Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis

19. Group 1Group 2Group 3Group 4

20. Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis

21. 1990-19932002-2005 Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis

22. 1990-19931994-19971998-20012002-2005 Data Source: Florida Department of Health, Office of Planning, Evaluation and Data Analysis

23. Conclusions Although SIDS rates have declined, the state SUIDs rates have not improved since 1998. This may be attributed to the shifting of reporting to different cause groups. Trends suggest varied changes in reporting by medical examiner districts rather than a uniform change in statewide reporting.

24. Public Health Implications Differences in reporting especially unknowns make it difficult for communities to assess, implement, and evaluate prevention strategies.

25. Recommendations Florida medical examiners should consider developing consistent SUIDs investigation and reporting guidelines.

26. SUIDI Reporting Form In March 2006, CDC released the SUIDI reporting form for state and local use in infant death scene investigations. This form replaced the investigation report form that accompanied the 1996 Guidelines for the death scene investigation of SUIDs. Source: The Centers for Disease Control and Prevention

27. Thank You Contact Information: Angel Watson, MPH, RHIA Research Scientist, Division of Family Health Services William M. Sappenfield, MD, MPH State MCH Epidemiologist, Division of Family Health Services Florida Department of Health 4052 Bald Cypress Way, Bin A 13 (Mail) 4025 Esplanade Way, Room 130G (Location) Tallahassee, FL 32399-1721 Phone: 850-245-4100 Fax: 850-414-6091 Email: Bill_Sappenfield@doh.state.fl.us Email: Angel_Watson@doh.state.fl.us

28. Supplemental Graphs

29. Medical Examiner Cause of Death Patterns