1. Sleep Related Infant Deaths Tulsa County 2004 - 2008 Carol Kuplicki, MPH Tulsa Health Department, TFIMR January 2011 Tulsa Fetal and Infant Mortality Review Project is supported in part by the Maternal and Child Health Block Grant in the Department of Health and Human Services, Health Resources and Services Administration, Maternal and child Health Bureau

2. TFIMR Sleep Related Infant Deaths 2004-2008 Selection & Method Selection  Deaths occurred during 2004 - 2008  Birth to <365 days old  Tulsa County resident at birth and death  Born and died in Tulsa County  Mother received prenatal care in Tulsa County  Not considered a homicide or accident other than sleep- related Method  Reviewed medical records, autopsy, EMSA, and police reports

3. TFIMR Sleep Related Infant Deaths 2004-2008 Tulsa County Resident Infant Deaths Background From 2004-2008* there has been a total of 384 Tulsa County resident infant deaths.  18 (4.7%) Sudden Infant Death Syndrome (SIDS)  47 (12.2%) Other symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified “Undetermined” Note: these are not all considered sleep related deaths.  7 (2.2%) Accidental suffocation and strangulation in bed, and positional asphyxia  312 (81.3%) All other causes of death Of the 384 infant deaths occurring during this time period TFIMR has abstracted data for 345* infant deaths. Of these 58 were considered sleep related deaths. Purpose To identify and review sleep related infant deaths occurring in Tulsa County. *The 345 infant deaths represent 340 pregnancies. Source: OK 2 Share OSDH 11/2010 *Preliminary data for 2007 & 2008

4. TFIMR Sleep Related Infant Deaths 2004-2008

5. Background information  Most infants do not receive an autopsy when they die  Reasons Infants receive an autopsy:  Die unexpectedly after leaving the hospital  If a parent or physician request an autopsy to find a reason for the infants death  If a congenital anomaly is present  Autopsies are completed by the Medical Examiner or hospital personnel in charge of performing them. Most are completed by the Medical Examiner  In the case of sleep related infant deaths the Medical Examiner has completed 100% of the autopsies  ~ 2004 the Medical Examiner began to standardize review of sleep related infant deaths across the state. The result was to classify infants that were co-sleeping at the time of death as Undetermined. Previously the death might have been classified as a SIDS death.

6. TFIMR Sleep Related Infant Deaths 2004-2008 Could these deaths have been prevented?  The infant had been sleeping with parents and was found unresponsive under a parent.  Infant found unresponsive lying under a sibling  Infant found unresponsive wedged between the wall and bed.  Infant found in the crib face down between a pillow and edge of crib.  Infant found unresponsive in bed under some pillows.

7. TFIMR Sleep Related Infant Deaths 2004-2008 Definitions Sleep Related Death – There is no “official” definition  TFIMR: A sleep related death is when an infant was put to bed either alone, or co-bedding and subsequently died during sleep and either asphyxia, SIDS or no other cause of death was found. Other Sleep Related Definitions  Sudden and unexpected infant deaths that occur during sleep, including SIDS, suffocation, asphyxia, entrapment, and undetermined. R Moon, MD, George Washington University  Less than 1 year, No specific medical cause (except SIDS), no specific unrelated injuries (ie fire), the remainder are asphyxia, SIDS, undetermined and unknown injury and undetermined and unknown medical causes, and cases where it is undetermined if medical or injury. M Wholf, RN, MPH, Ohio Dept of Health  Sudden unexplained infant death (SUID) applies to the death of an infant less than one year of age, in which investigation, autopsy, medical history review and appropriate laboratory testing fails to identify a specific cause of death. SUID includes cases that meet the definition of Sudden Infant Death Syndrome. H Krous, MD, Children’s Hospital San Diego, CA

8. TFIMR Sleep Related Infant Deaths 2004-2008 Definitions con’t Co-sleeping – This has been used different ways and may mean sharing the same sleep surface or sharing the same room. TFIMR has used this term to mean co-bedding. Co-bedding – Sharing the same sleep surface. SIDS-Sudden Infant Death Syndrome, ICD 10, R95 The sudden and unexpected death of an infant less than 1 year of age for which no exact cause of death can be determined Undetermined – ICD 10, R99, Other ill-defined and other unspecified causes of mortality Asphyxia – ICD 10, W75 Accidental suffocation and strangulation in bed, W83 Other specified threats to breathing (if it meets the other sleep-related criteria) Prone – Lying with the front or face downward Petechial hemorrhages - subcutaneous hemorrhage occurring in very small spots

9. TFIMR Sleep Related Infant Deaths 2004-2008 Risk Factors Modifiable Risk Factors Placed to sleep on their stomachs (Mayo Clinic, CDC) or sides (CDC) Born to mothers who smoke or use drugs (Mayo Clinic, CDC) Exposed to environmental tobacco smoke (Mayo Clinic, CDC) Overheated (Mayo Clinic, CDC) Babies born to mothers who had no or late PNC (CDC) Babies who are placed to sleep on soft surfaces or in an environment containing fluffy and loose bedding (CDC) Co-bedding, sharing the sleep surface with someone else Non-Modifiable Risk Factors Male (Mayo Clinic) Between 1 month and 6 months of age (Mayo Clinic) Premature or LBW (Mayo Clinic, CDC) Black, Native American or Alaskan (Mayo Clinic) Born during the fall or winter months (Mayo Clinic) Recently recovered from an upper respiratory infection (Mayo Clinic) Siblings of a baby who died of SIDS (Mayo Clinic) Babies born to mothers <20 yrs old at their first pregnancy (CDC) Listed by modifiable/non-modifiable risk factor by TFIMR

10. What did we find?

11. TFIMR Sleep Related Infant Deaths 2004-2008 Most of the infants that died never went home from the hospital. Of infants that were healthy enough to be released from the hospital, 57.4% died from sleep related causes. Of the infant deaths reviewed from 2004 -2008, only 101 (29.3%) infants were discharged to home. Of the infants discharged to home 58 (57.4%) died from sleep related causes.

12. TFIMR Sleep Related Infant Deaths 2004-2008 Of the 101 infants that were well enough to leave the hospital: 58 (57.4%) Sleep related causes 34 Undetermined R99 16 SIDS R95 8 Asphyxia/Strangulation/Overlays/Positional Asphyxia W75, W83 12 (11.9%) Congenital malformations, deformations and chromosomal abnormalities, Q00-Q99 6 (5.9%) Certain conditions originating in the perinatal period P00-P96 6 (5.9%) Certain infections and parasitic diseases A00-B99 6 (5.9%) Diseases of the respiratory system J00-J99 6 (5.9%) Diseases of the digestive system K00-K93 4 (4.0%) Neoplasms C00-D48, diseases of the blood & blood forming organs D50-D89 3 (3.0%) Diseases of the nervous system G00-G99

13. TFIMR Sleep Related Infant Deaths 2004-2008

16. Sleep Environment Unsafe Sleep Conditions  Infant placed or found in a prone position  Co-bedding: sharing the same sleep surface.  Sleeping on a couch, chair or on soft bedding  Bedding, pillows or other items found over the infant’s face

17. TFIMR Sleep Related Infant Deaths 2004-2008 *Unknown values subtracted from denominator prior to calculations.

18. TFIMR Sleep Related Infant Deaths 2004-2008 Age and Sleep Surface

19. TFIMR Sleep Related Infant Deaths 2004-2008

20. Most infants died in a bed or on a couch while sleeping with someone else.

21. TFIMR Sleep Related Infant Deaths 2004-2008

22. Infant’s sleep position when put to bed or when found

23. TFIMR Sleep Related Infant Deaths 2004-2008 Sleep Environment - Most infants were not placed in a safe sleep environment. Unsafe sleep environment  Prone sleep position  Not in a crib or bassinet  Co-bedding  Loose blankets, pillows or clothing in sleep area Based on review of available records 50 (86.2%) Unsafe sleep environment 8* (13.8%) Safe sleep environment (*of the 8 infants noted to be in a safe sleep environment, sleep position was unknown for 5 infants)

24. TFIMR Sleep Related Infant Deaths 2004-2008 Other Risk Factors for Sleep Related Infant Deaths Maternal smoking during pregnancy *Second hand smoke exposure after birth Upper respiratory illnesses *Room temperature/overheating Month of death Race?? Maternal drug use * because some data elements are not available for the majority of cases, analysis on these risk factors is not available

25. TFIMR Sleep Related Infant Deaths 2004-2008 Surgeon General’s Report on The Health Consequences of Smoking - 2004 In 2004 the Surgeon General concluded “The evidence is sufficient to infer a causal relationship between sudden infant death syndrome and maternal smoking during and after pregnancy.” Implications: “Mothers who smoke increase their children’s risk of SIDS substantially: smoking during pregnancy and after the child’s birth should be a target for forceful and effective interventions.” Source: 2004 – The Health Consequences of Smoking: A Report of the Surgeon General

26. TFIMR Sleep Related Infant Deaths 2004-2008 Surgeon General’s Report on The Health Consequences of Involuntary Exposure to Tobacco Smoke - 2006 In 2006 the Surgeon General concluded: “The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and sudden infant death syndrome.” Implications: “On the basis of the epidemiologic risk data, researchers have estimated that the population attributable risk of SIDS associated with postnatal exposure to secondhand smoke is about 10 percent (Cal/EPA 2005). Therefore, the evidence indicates that these exposures are one of the major preventable risk factors for SIDS, and all measures should be taken to protect infants from exposure to secondhand smoke.” Source: 2006 – The Health Consequences of Involuntary Exposure to Tobacco Smoking

27. TFIMR Sleep Related Infant Deaths 2004-2008 Maternal Tobacco Use Included are females who reported smoking at any time during pregnancy. Most of the females smoked cigarettes however one reported smoking cigars Reported number smoked was from 1 to 40 cigarettes per day

28. TFIMR Sleep Related Infant Deaths 2004-2008 Maternal Tobacco Use- Reported smoking at anytime during pregnancy Statistically significant difference between sleep related deaths and all other causes. Chi Square p-value.001

29. TFIMR Sleep Related Infant Deaths 2004-2008 Infant Health  14 (24.1%) recent illness with cough, congestion, or fever in days preceding death.  17 (29.3%) at autopsy had petechial hemorrhages on the thymus, plura and/or epicardium  Of the 14 with reported recent illness 7 had petechial hemorrhages

30. TFIMR Sleep Related Infant Deaths 2004-2008

32. Race and Ethnicity of the mother Ethnicity is unknown for 2

33. TFIMR Sleep Related Infant Deaths 2004-2008

36. Summary of Modifiable Risk Factors  50 (86.2%) Non-safe environment  36 (75.0%) Not in a crib or bassinet, or had loose bedding or pillows in the crib or bassinet  40 (70.2%) Sleep surface other than a crib or basinet  36 (62.1%) Were co-bedding  13 Prone sleep position  36 (63%) Infants had mothers that reported tobacco use during pregnancy  Passive smoke exposure  Room temperature/Overheating of infant Health Insurance (socioeconomic status) 77.6% Soonercare indicating lower economic status

37. TFIMR Sleep Related Infant Deaths 2004-2008 Summary of Non-Modifiable Risk Factors Race/Ethnicity 75.9% white 22.4% black 92.9% non-Hispanic Gestation 19% Preterm Month of death 17.2% February 13.8% September 12.1% December & May 10.3% January Gender 58.6% Male

38. TFIMR Sleep Related Infant Deaths 2004-2008 Recommendations for Preventing Sleep Related Deaths NIH Back to Sleep Campaign Recommendations 1. Always place your baby on his or her back to sleep, for naps and at night. 2. Place your baby on a firm sleep surface, such as on a safety-approved crib mattress, covered by a fitted sheet. 3. Keep soft objects, toys, and loose bedding out of your baby’s sleep area. 4. Do not allow smoking around your baby.

39. TFIMR Sleep Related Infant Deaths 2004-2008 Recommendations for Preventing Sleep Related Deaths 5. Keep your baby’s sleep area close to, but separate from, where you and others sleep. 6. Think about using a clean, dry pacifier when placing the infant down to sleep. 7. Do not let your baby overheat during sleep. 8. Avoid products that claim to reduce the risk of SIDS. 9. Do not use home monitors to reduce the risk of SIDS. 10. Reduce the chance that flat spots will develop on your baby’s head: provide “Tummy Time”. Source: NIH Back to Sleep Campaign

40. TFIMR Sleep Related Infant Deaths 2004-2008 Recommendations for Preventing Sleep Related Deaths Educational campaign of Safe Sleep Environment  Hospitals via discharge instructions, posters, informational videos  Sleep environment education for the public  Clinics – Prenatal care providers, Pediatricians, Family Practice  Media – Billboards, TV, Radio, Newspapers  Faith-based Organizations  Tulsa Area Immunization Coalition – KICK packets

41. TFIMR Sleep Related Infant Deaths 2004-2008 Acknowledgements / Further Information Tulsa Fetal and Infant Mortality Review Project is supported in part by the Maternal and Child Health Block Grant in the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. For further information contact:  Carol Kuplicki, MPH, MCH Epidemiologist (918) 595-4499, ckuplicki@tulsa-health.org ckuplicki@tulsa-health.org  Pam Rask, MPH, Deputy Associate Director, Community Health Services (918) 595-4418, prask@tulsa-health.orgprask@tulsa-health.org