1. Workshop/Breakout Title Workshop/Breakout Speaker(s) Changes in Infant Death Coding and Implications for Safe Sleep Campaigns Malinda Douglas, MPH, Oklahoma Department of Health Violanda Grigorescu, MD, MSPH, Michigan Dept. of Community Health Sandra Frank, JD, CAE, Tomorrow's Child/Michigan SIDS

2. Sleep-Related Deaths Among Infants in Oklahoma, 2000-2003 Malinda Reddish Douglas, MPH Tobacco Use Prevention Service, OSDH Pam Archer, MPH Injury Prevention Service, OSDH Jeff Gofton, MD Office of the Chief Medical Examiner

3. Background Each year, 400 infants under 1 year old die in Oklahoma –22% congenital and chromosomal abnormalities –13% disorders related to premature birth –9% sudden infant death syndrome Death rate decreased 7% –2000: 8.4/1,000 –2003: 7.8/1,000

4. Introduction Oklahoma Chief Medical Examiner noticed increase in co-sleeping deaths Child Death Review Board and Department of Human Services concerned with increase in co-sleeping deaths SAFE KIDS Coalition and other partners began development of SIDS – safe sleep materials

5. Unsafe Sleeping Environment Prone sleeping Exposure to secondhand smoke Sofas, chairs, loveseats Soft bedding, pillows, quilts, blankets Entrapment hazards Co-sleeping?

6. Co-Sleeping Recommendations DiscouragesCautionsEncourages CPSCAAPAttachment parenting groups Child death review boards NICHHDLa Leche International SIDS Alliance Some health departments Mother-Baby Sleep Laboratory

7. 2000 National Data on Nighttime Infant Bed Sharing with Adults Prevalence –13% entire night Up from 6% in 1993 –20% half of the time or more –45% some time during past two weeks –Twice as likely as to be covered by quilt or comforter –Most common in mothers < 18 years, low income, non-white, and infants < 8 weeks

8. Potential Reasons for Co-Sleeping Bonding Breastfeeding Cultural practice Fear of SIDS Fear of not hearing the baby Baby sleeps better Parents sleep more No crib

9. Sleep-Related Infant Death Study Purpose –Investigate infant deaths –Characterize sleeping practices –Determine co-sleeping trends over time

10. Medical Examiner System Investigate deaths under certain circumstances Determine manner of death (intention) Determine cause of death Statewide system

11. Methods Analyzed Medical Examiner database –January 2000 through December 2003 –Oklahoma residents –Less than 12 months of age –Manner of death = Accidental –Cause = Asphyxia –Manner of death = Unknown –Cause = Asphyxia –Cause = Other –Cause = Unknown

12. Methods Reviewed reports of investigation –Demographic data –Details of the death –Narrative of circumstances –Autopsy report Last known activity was sleeping

13. Definitions Unsafe sleeping –Not sleeping alone in a safe crib or bassinette –Not put to sleep on back or found on back –Pillows, stuffed toys, loose quilts or comforters Co-sleeping –Sharing a sleep surface with another person –Surfaces include bed, couch, chair, and other

14. Unsafe Sleeping Case Selection 124 possible cases reviewed 113 infants sleeping prior to death –2 following safe sleep guidelines –5 lacked specific details to classify 94% (106/113) involved unsafe sleeping conditions –81% unknown manner of death –80% other/unknown cause of death

15. Unsafe Sleeping Deaths by Age and Sex, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 106

16. Unsafe Sleeping Deaths by Race and Year, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 104, excludes 2 cases coded as other Rate/1,000 AA: 1.2 AI: 0.7 W: 0.4 Overall: 0.5 * includes Hispanic

17. Time and Place of Occurrence 82% at night 97% occurred in a private home –86% in own home –11% in others home 2% in licensed child care 1% in hospital Source: Oklahoma State Medical Examiner, n = 106

18. Unsafe Sleeping Deaths by Sleep Surface, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 106

19. Unsafe Sleeping Deaths by Mechanism of Injury, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 106

20. Infant Health History Breastfed – 6% –74% not specified Low birth weight – 6% –87% not specified Premature birth – 15% –56% not specified Respiratory illness – 25% –68% not specified Source: Oklahoma State Medical Examiner, n = 106

21. Caregiver or Family Factors Use of alcohol and/or drugs – 14% History of drug/alcohol problems – 11% CPS involvement – 21% Previous SIDS death – 3% Secondhand smoke exposure – 3% Source: Oklahoma State Medical Examiner, n = 106

22. Unsafe Sleeping Deaths by Co-Sleeping at the Time of Death, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 103, excludes 3 unknowns

23. Co-Sleeping Deaths by Age and Sex, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 68

24. Surface and Co-sleep 71% on bed 9% on couch/chair/love seat 6% mattress on floor 4% on waterbed 1% in crib (sleeping with twin) 9% all other/unk combined Source: Oklahoma State Medical Examiner, n = 68

25. Co-sleepers Deaths by Mechanism of Injury, Oklahoma, 2000-2003 55% possible/definite overlay 4% entrapped 3% pillow 6% found on floor 1% other 31% not specified Source: Oklahoma State Medical Examiner, n = 68

26. Factors Present When Cases Lacked Details on Possible Mechanisms 33% open or history of CPS involvement 19% staying at someone elses home 10% previous apnea episodes 10% face down on mattress 5% waterbed Source: Oklahoma State Medical Examiner, n = 68

27. Co-sleeping Characteristics Number co-sleeping –50% two sleeping together –40% three sleeping together –10% four sleeping together Classification of sleeper –73% adult(s) –18% child(ren) –9% adult(s) and child(ren) Source: Oklahoma State Medical Examiner, n = 68

28. Medical Examiner Interview Infant deaths increasing Co-sleeping deaths increasing –Mainly among the white population Beliefs, opinions, and experiences reflected in reporting Budget cuts in 2003 –May have resulted in change in coding

29. Infant Deaths by Selected Cause, Oklahoma, 2000-2003 Database/Cause2000200120022003 VS – all infant # (Rate/1,000 births) 420 (8.4) 362 (7.2) 406 (8.1) 395 (7.8) ME – all infant # (Percent of VS infant deaths) 216 (51%) 222 (61%) 248 (61%) 278 (70%) ME – unsafe sleep # (Percent of ME infant cases) 21 (10%) 23 (10%) 17 (7%) 47 (17%)

30. ME Investigated Infant Deaths by Selected Cause, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner

31. Conclusions Unsafe sleep deaths –Most were infants < 3 months of age –Half occurred in beds –Unsafe items used in cribs and bassinettes –Mechanism of injury varied by age Co-sleep deaths –Increase in co-sleeping deaths –Increase among whites –Not clear if due to artifact of coding

32. Limitations Non-standardized documentation Medical Examiners and investigators limited by informants Distinguishing SIDS from other causes Budget cuts to the Medical Examiner

33. Discussion Other States have similar trends Cultural issue Distinguishing SIDS from overlay Coding of undetermined cause or intent

34. Recommendations Education campaign for businesses –Crib displays in stores that show safe sleeping environments

35. Recommendations Increase awareness of co-sleeping deaths Promote consistent safe sleeping practice messages through collaborative efforts –Same safe sleeping environments can reduce risk factors for overlay, SIDS, and asphyxia Messages that resonate with target populations

36. Questions?