Increasing Infant SafeIncreasing Infant SafeIncreasing Infant Safe Increasing Infant Safe Sleep Practices among MA Sleep Practices among MA

WIC ParticipantsWIC ParticipantsJune 5, 2013June 5, 2013June 5, 2013June 5, 2013

Carlene Pavlos, Director, Division of Violence and Injury Carlene Pavlos, Director, Division of Violence and Injury Prevention, MDPHPrevention, MDPH

Li M C th St t Child F t lit R i C di t MDPHLi M C th St t Child F t lit R i C di t MDPHLisa McCarthy, State Child Fatality Review Coordinator, MDPHLisa McCarthy, State Child Fatality Review Coordinator, MDPHSally Sally FogertyFogerty, Director, Children’s Safety Network, Director, Children’s Safety Network

O i f P t tiO i f P t tiOverview of PresentationOverview of Presentation

Background of safe sleep issue in MABackground of safe sleep issue in MA

Disparities in infant safe sleep Disparities in infant safe sleep practices by racepractices by race

WIC’s safe sleep initiativeWIC’s safe sleep initiative

E l i f WIC’ f lE l i f WIC’ f l Evaluation of WIC’s safe sleep Evaluation of WIC’s safe sleep initiativeinitiative

OverviewOverview

3

RecommendationsRecommendationsRecommendationsRecommendations

1. AAP Recommendations 1. AAP Recommendations (2011)(2011)

2. MA Department of Public 2. MA Department of Public Health Safe Sleep Policy (2012)Health Safe Sleep Policy (2012)

“The safest place for an infant to sleep“The safest place for an infant to sleepThe safest place for an infant to sleep The safest place for an infant to sleep is is on his or her backon his or her back in the same in the same room with a parent or caregiver room with a parent or caregiver and in a and in a separateseparate sleep space such sleep space such as aas a crib or bassinet.”crib or bassinet.”as a as a crib or bassinet.crib or bassinet.

“MDPH supports breastfeeding and “MDPH supports breastfeeding and encourages mothers to sleep in encourages mothers to sleep in close proximity to, but in separateclose proximity to, but in separateclose proximity to, but in separate close proximity to, but in separate space from, their infants, regardless space from, their infants, regardless of the feeding status.”of the feeding status.”

Leading causes of death among MA infants Leading causes of death among MA infants 11--11 months of age, 201011 months of age, 2010

Other causes23% SUID is the leading SUID is the leading

cause of infant death cause of infant death Unintentional injuries and injuries of 

undetermined intent**

Sudden Unexpected Infant Death*

45%

after the first month of after the first month of life.life.

Homicide6%

intent5%

Congenital Malformations

15%

An average of 41 MA An average of 41 MA infants died EACH YEAR infants died EACH YEAR (2004(2004 2010) from sleep2010) from sleepPerinatal 

Conditions6%

15% (2004(2004--2010) from sleep 2010) from sleep environments due to environments due to SUIDSUID--related sleep related sleep

environmentsenvironments*SUID includes: SIDS, unintentional suffocation in bed, and undetermined environments.environments., ,causes

**unintentional injuries and injuries of undetermined intent include unintentional MV occupant and unspecified causes

Source: Registry of Vital Records and Statistics, MDPH, 2010

Infant Sleep Deaths Data: Infant Sleep Deaths Data: ppDisparitiesDisparities The The raterate of infant sleep death in MA from 2004of infant sleep death in MA from 2004--2010 was over 2010 was over

three times higher among Black non Hispanic infants and nearly three times higher among Black non Hispanic infants and nearly two times higher among Hispanic infants than among White, two times higher among Hispanic infants than among White, NonNon--Hispanic infantsHispanic infantsNonNon--Hispanic infants.Hispanic infants.

Rate of MA Infant Sleep Death by Race, 2004‐2010128.9

120

140

72.8

60

80

100

120

 100,00

0 infants

41.3

0

20

40

60

rate per 1

Black non‐Hispanic Hispanic White non‐Hispanic

Why WIC?Why WIC?yy

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B k t SlB k t Sl WIC NWIC N WICWICBack to Sleep:Back to Sleep: WIC vs. NonWIC vs. Non--WICWIC

75%71%

84%76%

84%

80%

90%

t pos

ition

WICnon-WIC

56% 59%61%

50%

60%

70%

mos

t fre

quen

t

20%

30%

40%

ortin

gbac

k as

0%

10%

White, non Hispanic Black, non-Hispanic Hispanic Asian, non Hispanic

% re

po

Source: Pregnancy Risk Assessment Monitoring System, MDPH (2007‐2010)

C Sl i WIC N WICCo-Sleeping: WIC vs. Non-WIC

37%

35%

40%

WICnon-WIC

24%26% 26%

20%

25%

30%

g co

-sle

epin

g

15% 14%

10%

14%

10%

15%

20%

% re

porti

ng

0%

5%

White, non Hispanic Black, non-Hispanic Hispanic Asian, non Hispanic

Source: Pregnancy Risk Assessment Monitoring System, MDPH (2007-2010)

Most Frequent Infant Sleep Position Most Frequent Infant Sleep Position Reported by MA Mothers By WIC StatusReported by MA Mothers By WIC StatusReported by MA Mothers, By WIC Status, Reported by MA Mothers, By WIC Status,

20072007--20102010

67%

83%

70%

80%

90%

ositi

on

WIC

50%

60%

st fr

eque

nt p

o WICnon WIC

17%20%

30%

40%

repo

rting

mos

11%6%6%

10%

1%0%

10%

%

Back Position Stomach Position Side Position More than One

% r

Source: Pregnancy Risk Assessment and Monitoring Survey, MDPH

Back Position Stomach Position Side Position More than OnePosition

Usual Infant Sleep Location Reported by Usual Infant Sleep Location Reported by MA M th B WIC St t 2007MA M th B WIC St t 2007 20102010MA Mothers, By WIC Status, 2007MA Mothers, By WIC Status, 2007--20102010

79%83%

80%

90%

WIC

50%

60%

70%

s re

porti

ng

non WIC

30%

40%

% o

f mot

hers

17%12%

0%

10%

20%

Source: Pregnancy Risk Assessment and Monitoring Survey, MDPH

0%Crib/Bassinet Adult bed w/ another person(s)

Why WIC?Why WIC?Why WIC?Why WIC?

Parents trust WIC when it comes to babies! Parents trust WIC when it comes to babies!

WIC Staff:WIC Staff: WIC Staff:WIC Staff:•• Provide direct service to more than 40% of all Provide direct service to more than 40% of all

babies born in Massachusetts, including African babies born in Massachusetts, including African A i d Hi i i f t h tA i d Hi i i f t h tAmerican and Hispanic infants who are at American and Hispanic infants who are at highest risk of infant sleep deaths.highest risk of infant sleep deaths.

•• Can address this emotional issue using TouchingCan address this emotional issue using TouchingCan address this emotional issue using Touching Can address this emotional issue using Touching Heart, Touching Minds (THTM) approach.Heart, Touching Minds (THTM) approach.

•• Are able to reinforce safe sleep messages over Are able to reinforce safe sleep messages over l ll lmultiple visits.multiple visits.

•• Can reinforce importance of breastfeeding.Can reinforce importance of breastfeeding.

WIC’ S f Sl I iti tiWIC’ S f Sl I iti tiWIC’s Safe Sleep InitiativeWIC’s Safe Sleep Initiative

Raising the Issue (2012)Raising the Issue (2012) Train the Trainer (2013)Train the Trainer (2013) Train the Trainer (2013)Train the Trainer (2013) Implement Staff Trainings and Participant Implement Staff Trainings and Participant

DiscussionsDiscussionsDiscussionsDiscussions WIC’s nutrition service guidance will include WIC’s nutrition service guidance will include

information regarding the inclusion ofinformation regarding the inclusion ofinformation regarding the inclusion of information regarding the inclusion of infant safe sleep in nutrition counseling.infant safe sleep in nutrition counseling.

Evaluation Evaluation –– pre/postpre/post--tests, 6 month post tests, 6 month post p /pp /p , p, ptrainingtraining

Major Components of Major Components of j pj pWIC’s TrainingWIC’s Training

1.1. Understand the leading causes of deaths of Understand the leading causes of deaths of infants and childreninfants and children

22 Identify the major components of infant safeIdentify the major components of infant safe2.2. Identify the major components of infant safe Identify the major components of infant safe sleep practices sleep practices

3.3. Describe the risk and protective factors for Describe the risk and protective factors for ppinfant safe sleep infant safe sleep

4.4. Identify challenges and understand the Identify challenges and understand the d l t f i f t i l ti t ld l t f i f t i l ti t ldevelopment of infants in relation to sleepdevelopment of infants in relation to sleep

5.5. Crying and calming techniquesCrying and calming techniques66 Incorporate safe sleep education into theirIncorporate safe sleep education into their6.6. Incorporate safe sleep education into their Incorporate safe sleep education into their

workwork

MessagingMessaging

Want effective messages that reach all communities

Goal of reducing disparities Use of “emotion based messaging” Use of emotion-based messaging Addresses the challenges we hear

f tfrom parents

Focus of the MessageFocus of the MessageFocus of the MessageFocus of the Message

1.1. BackBack--Only SleepOnly Sleep22 Separate Sleep EnvironmentSeparate Sleep Environment2.2. Separate Sleep EnvironmentSeparate Sleep Environment3.3. Uncluttered CribUncluttered Crib4.4. BreastfeedingBreastfeeding55 SmokeSmoke--Free EnvironmentFree Environment5.5. SmokeSmoke--Free EnvironmentFree Environment

WICWIC Door Knob HangersDoor Knob HangersWIC WIC –– Door Knob HangersDoor Knob Hangers

EducationalEducationalEducational Educational tool for WIC tool for WIC staff tostaff tostaff to staff to distribute to distribute to participantsparticipantsparticipants.participants.

Including Safe SleepIncluding Safe SleepIncluding Safe Sleep Including Safe Sleep Messages in WIC CounselingMessages in WIC Counseling When?When?

•• Prenatal visits (before bedding purchases) Prenatal visits (before bedding purchases) ( g p )( g p )•• Infant certification and early followInfant certification and early follow--up visitsup visits•• Peer counseling contactsPeer counseling contacts•• Breastfeeding classesBreastfeeding classes

H ?H ? How?How?•• Use emotionUse emotion--based, patientbased, patient--centered counselingcentered counseling

oo Build on parents’ desire to keep baby as safe asBuild on parents’ desire to keep baby as safe asoo Build on parents desire to keep baby as safe as Build on parents desire to keep baby as safe as possiblepossible

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Smoking and SIDSSmoking and SIDSSmoking and SIDSSmoking and SIDS

Both pre and post natal smoking increases SIDS Both pre and post natal smoking increases SIDS riskrisk

Infants coInfants co--sleeping with smoking mothers have a sleeping with smoking mothers have a higher risk of SIDShigher risk of SIDShigher risk of SIDShigher risk of SIDS

AAP and DPH include recommendations to avoid AAP and DPH include recommendations to avoid k f f l lk f f l lsmoking as part of safe sleep policiessmoking as part of safe sleep policies

Reference: Zhang K, Wang X. Maternal smoking and increased risk of sudden infant death syndrome: A meta-analysis. Leg Med (2013), http://dx.doi.org

Breastfeeding and SUIDBreastfeeding and SUIDBreastfeeding and SUIDBreastfeeding and SUID

Infant sleep death occurs in Infant sleep death occurs in both breastfed and formulaboth breastfed and formulaboth breastfed and formula both breastfed and formula fed babiesfed babies

Breastfeeding reduces butBreastfeeding reduces but–– Breastfeeding reduces, but Breastfeeding reduces, but does not eliminate, riskdoes not eliminate, risk

–– Longer duration andLonger duration and–– Longer duration and Longer duration and exclusivity of breastfeeding exclusivity of breastfeeding may increase protectionmay increase protectionay c ease p otect oay c ease p otect o

Source: Fern RH et al. Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta‐analysis. Pediatrics. 2011; 128(1): 103‐110.

WIC’s Safe Sleep InitiativeWIC’s Safe Sleep InitiativeWIC s Safe Sleep Initiative WIC s Safe Sleep Initiative ––Preliminary DATAPreliminary DATAyy

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Who has been trained?Who has been trained?Who has been trained?Who has been trained?

Out of 35 WIC sites, 22 sites have trained their Out of 35 WIC sites, 22 sites have trained their staff membersstaff members

Evaluation:Evaluation:–– Assess knowledge, attitude and behavior about safe sleepAssess knowledge, attitude and behavior about safe sleep

h d /h d /–– 15 sites have returned pre/post tests15 sites have returned pre/post tests–– Pre/Post tests Pre/Post tests –– 12 questions12 questions

Future evaluation Future evaluation –– 6 months follow (post6 months follow (post--test)test)

Knowledge:Knowledge:1 Health babies placed on thei

ggQuestions 1Questions 1--66

1. Healthy babies placed on their backs are more likely to have serious or fatal choking episodes than those placed on their stomachsstomachs.

2. Lying infants down on either their sides or backs for sleep is recommended to prevent infantrecommended to prevent infant sleep death.

3. A smoke-free environment reduces the risk of infant sleep death.

4. It is good practice to use bumper pads in an infant’s crib to protect the infant from harm.

5. It is safe for infants to sleep with their twin, an older brother or sister or a pet.

6 It i t f f i f t t l6. It is not safe for an infant to sleep with one stuffed toy or one blanket.

AttitudeAttitude Question 7Question 7Attitude Attitude –– Question 7Question 7

AttitudeAttitude Question 8Question 8Attitude Attitude –– Question 8Question 8

AttitudeAttitude Question 9Question 9Attitude Attitude –– Question 9Question 9

Behavior Behavior –– Question 10Question 10QQ(baseline)(baseline)

Behavior Behavior –– Question 11Question 11QQ(baseline)(baseline)

Behavior Behavior –– Question 12Question 12QQ(baseline)(baseline)

Keys to this WorkKeys to this WorkKeys to this WorkKeys to this Work

Reinforce message where and whenever we canReinforce message where and whenever we canReinforce message where and whenever we canReinforce message where and whenever we canMessage needs to be consistentMessage needs to be consistent

M d t k t t dM d t k t t dMessage needs to make sense to parents and Message needs to make sense to parents and address parental concerns address parental concerns Effo ts to enco age oom sha ing itho t bedEffo ts to enco age oom sha ing itho t bedEfforts to encourage room sharing without bed Efforts to encourage room sharing without bed sharing must address parent safety concerns sharing must address parent safety concerns

Breastfeeding is recommended!Breastfeeding is recommended!Breastfeeding is recommended!Breastfeeding is recommended!Recommendations need to stress the Recommendations need to stress the

“preventability” of infant death“preventability” of infant deathpreventability of infant deathpreventability of infant deathRespect parents’ culture and beliefsRespect parents’ culture and beliefs

Questions/CommentsQuestions/Comments