1. S L I D E 0 Placing Infants to Sleep in Safe Environments Kirsten Bechtel MD Eve Colson MD Fredericka Wolman MD Department of Pediatrics Yale School of Medicine Department of Children and Families State of Connecticut June 12, 2014

2. S L I D E 1 Acknowledgements No conflict of interest to disclose Dr. Colson’s research supported by the National Institute of Health and Human Development (NICHD)

3. S L I D E 2 Overview Demographics/Definitions of Sudden Unexpected Infant Death (SUID) Delivery of Safe Sleep Anticipatory Guidance DCF

4. S L I D E 3 Infant Mortality Rate 2012 United States: 5.98/1000 New Hampshire 3.9 Connecticut 5.2 Mississippi 9.6 Monaco: 1.8 Cuba 4.83 Canada: 4.85 Afghanistan: 121.6 UNICEF 2012

5. S L I D E 4 Causes of Infant Mortality in US

6. S L I D E 5 Sudden Unexpected Infant Death (SUID) Deaths in infants less than 1 year of age that occur suddenly and unexpectedly, and whose cause of death are not immediately obvious. In 2010, 2,063 deaths were SIDS, 918 Undetermined, and 629 accidental suffocation and strangulation within sleep environment. http://www.cdc.gov/sids/aboutsuidandsids.htm

7. S L I D E 6 Diagnostic Shift in SUID after Back to Sleep SIDS went from 120 to 54.6/100,000 Suffocation went from 3.1 to 12.5/100,000 Undetermined went from 19.7 to 25.3/100,000 Schnitzer et al American Journal of Public Health 2012

8. S L I D E 7 National Center for Child Death Review NCDR-CRS 50 states, Guam, Navajo Nation Consistent collection and reporting of data from CDR teams Connecticut CFRP is model program

9. S L I D E 8 SIDS is an autopsy diagnosis Classic >21 days < 9 mos No significant history No similar deaths among siblings Safe sleep environment Negative autopsy Category II 9 mos Neonatal or perinatal conditions Similar deaths among siblings Mechanical asphyxia Nonspecific changes Unclassified SIDS Do not meet Category I or II Alternative diagnoses for natural or unnatural conditions are equivocal Include cases where no autopsy performed Category II = Suffocation Unclassifed=Undetermined Cause of Death

10. S L I D E 9 Triple Risk Hypothesis Critical Developmental Period 2-4 months of age Intrinsic Risks Exogenous Stressor Extrinsic Risks Vulnerable Infant Intrinsic Risks SUID

11. S L I D E 10 Vulnerable Infant: Intrinsic Risks Maternal Factors Infant Factors Substance useMales SmokingNative American Breastfeeding African American No prenatal careSmall for Gestational Age Maternal age < 20 yearsPrematurity CPS Supervision

12. S L I D E 11 Vulnerable Infant: Intrinsic Risks Genetic polymorphism Cardiac ion channels Sertoninergic systems brainstem Autonomic nervous system Nicotine metabolizing enzymes Fatty acid oxidation Similar deaths among siblings What is the ante-mortem phenotype?

13. S L I D E 12 Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Shared Sleep Surface Tappin 2005 Risk of SUID and shared sleep surface Case control study Shared sleep surface increased risk even when breastfeeding Highest risk with shared sleep surface: Less than 11 weeks Smoking Couch Between two adults in an adult bed

14. S L I D E 13 Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Shared Sleep Surface Vennemann et al 2012 Meta-analysis of 11 studies Bed sharing strongly increases the risk of SUID. This risk is greatest: Parents smoke Infants who are <12 weeks of age. May also a significant interaction between bed sharing and SUID when: Parents use alcohol and drugs, Infants sleep on sofas with adults

15. S L I D E 14 Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Naïve Prone Sleepers Daycare deaths Cote (2000) Autopsy study Infants inexperienced with prone sleeping more likely to die when first placed prone Palusszynska (2004) Live infants Infants inexperienced with prone sleeping have fewer protective movements when placed prone

16. S L I D E 15 Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Items within the crib Soft bedding/bumpers: Scheers et al 2003; Thach et al 2007 Sleep Positioners: FDA 2007 Swaddling Entrapment: Moon et al 2014; Blair et al 2009

17. S L I D E 16 Unusual to see SUID in Connecticut in these circumstances

18. S L I D E 17 SUID in Connecticut 2011-2013 63 deaths Mean age 3 months Boys>girls 48 (72%) exogenous stressors within sleep environment Sharing an adult bed with parents or siblings (59%) In a crib with blanket, pillows, or placed on their stomachs, swaddle around their face 10% Car seat 2% Put to sleep with a bottle propping in an adult bed 1% In 12%, the parent(s) had a history of DCF supervision.

19. S L I D E 18 SUID in the Post Back-To-Sleep era “Using 2005 to 2008 data from 9 US states to assess 3136 sleep related sudden unexpected infant deaths (SUIDs); only 25% of infants were sleeping in a crib or on their back when found; 70% were on a surface not intended for infant sleep (e.g., adult bed).Importantly, 64% of infants were sharing a sleep surface, and almost half of these infants were sleeping with an adult.” Schnitzer et al J Amer Public Health 2012

20. S L I D E 19 SUID in the Post Back-To-Sleep era “Between 1991–1993 and 1996–2008, the percentage of infants found prone decreased from 84.0% to 48.5%, bed-sharing increased from 19.2% to 37.9% especially among infants < 2 months (29.0% vs 63.8%)” “ The occurrence of extrinsic risks in virtually all (cases) implies that SUID is precipitated by a ‘trigger’ at the time of death…that are consistent with asphyxia generating conditions ( face-down position, prone position, and adult mattress).” Trachtenberg et al Pediatrics 2012

21. S L I D E 20 Infant Sleeping Behaviors and Recommendations Eve R. Colson, MD, MHPE Professor of Pediatrics Yale School of Medicine

22. S L I D E 21 Overview AAP Recommendations Prevalence Advice Guidance for families

23. S L I D E 22 Overview AAP Recommendations Prevalence Advice Guidance for families

24. S L I D E 23 AAP Recommendation Back sleep Firm mattress No soft bedding

25. S L I D E 24 AAP Recommendation Room sharing, not bedsharing

26. S L I D E 25 AAP Recommendation Pacifier once breasfeeding established

27. S L I D E 26 Overview AAP Recommendations Prevalence Advice Guidance for families

28. S L I D E 27 Prevalence of Usual Sleep Position by Race/Ethnicity (N=1031) 74% 9% 20% 15% 63%

29. S L I D E 28 Prevalence of Usual Sleep Position by Region (N=1031) 65% 14% 74% 15%

30. S L I D E 29 Prevalence of Usual Bedsharing by Race/Ethnicity 19% 23% 66% 19% 15% 29% 18%

31. S L I D E 30 Prevalence of Usual Bedsharing by Region 19%12%14%20%26%

32. S L I D E 31 Overview AAP Recommendations Prevalence Advice Guidance for families

33. S L I D E 32 Advice

34. S L I D E 33 Overview AAP Recommendations Prevalence Advice Guidance for families

35. S L I D E 34 Guidance for Families Back for sleep Firm mattress No soft bedding Room share but not bedshare Offer a pacifier when breastfeeding established

36. S L I D E 35 Guidance for Families Concerns about choking

37. S L I D E 36 Guidance for Families Concerns about comfort

38. S L I D E 37 Guidance for Families Concerns about side sleep

39. S L I D E 38 Guidance for Families Concerns about head shape

40. S L I D E 39 Guidance for Families Concerns about pacifier use

41. S L I D E 40 Department of Children and Families Safe Sleep Initiative Fredericka Wolman MD Department of Children and Families State of Connecticut

42. S L I D E 41 DCF’s Initiative on Safe Sleep Environments DCF’s Safe Sleep Environments Flyer Add link

43. S L I D E 42 Why a priority for DCF Children involved with DCF at high risk Factors include: –substance use, –multiple stressors (poverty, parental isolation and lack of social supports); –domestic violence –mental health challenges (depression)

44. S L I D E 43 Strategies for DCF Education –DCF Workers –Families and caregivers DCF serves –Providers who work with families we serve (CPA, –Statewide initiative Policy and Practice Guide –Monitoring practice –Documentation –Direct support to families Assessing sleeping arrangements Accessing safe sleep furniture / supplies –Partnering with pediatricians / home visitors

45. S L I D E 44 Questions? Thank you for participating in this webinar!

46. S L I D E 45 Resources http://www.cdc.gov/SIDS/INDEX.HTM http://www.nichd.nih.gov/sts/Pages/default.aspx http://www.firstcandle.org http://www2.luriechildrens.org/ce/online/article.aspx?articleID=2 23 http://www.cribsforkids.org