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Placing Infants to Sleep in Safe Environments

Kirsten Bechtel MDEve Colson MD

Fredericka Wolman MD

Department of Pediatrics Yale School of Medicine

Department of Children and FamiliesState of Connecticut

June 12, 2014

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Acknowledgements

• No conflict of interest to disclose

• Dr. Colson’s research supported by the National Institute of Health and Human Development (NICHD)

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Overview

• Demographics/Definitions of Sudden Unexpected Infant Death (SUID)

• Delivery of Safe Sleep Anticipatory Guidance

• DCF

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Infant Mortality Rate 2012

United States: 5.98/1000 New Hampshire 3.9

Connecticut 5.2Mississippi 9.6

Monaco: 1.8Cuba 4.83Canada: 4.85Afghanistan: 121.6

UNICEF 2012

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Causes of Infant Mortality in US

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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

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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

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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

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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< 21 days > 9 mos

Neonatal or perinatal conditions

Similar deaths among siblings

Mechanical asphyxia

Nonspecific changes

Unclassified SIDSDo 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

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Triple Risk Hypothesis

Critical Developmenta

lPeriod

2-4 months of age

Intrinsic Risks

Exogenous Stressor

Extrinsic Risks

Vulnerable Infant

Intrinsic Risks

SUID

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Vulnerable Infant: Intrinsic Risks

Maternal Factors Infant FactorsSubstance use MalesSmoking Native American Breastfeeding African AmericanNo prenatal care Small for Gestational AgeMaternal age < 20 years Prematurity CPS Supervision

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Vulnerable Infant: Intrinsic Risks

Genetic polymorphismCardiac ion channelsSertoninergic systems brainstemAutonomic nervous systemNicotine metabolizing enzymesFatty acid oxidation

Similar deaths among siblings

What is the ante-mortem phenotype?

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Exogenous Stressors: Extrinsic Risks

Infant Sleep Practices Shared Sleep Surface

Tappin 2005Risk of SUID and shared sleep surfaceCase control study

Shared sleep surface increased risk even when breastfeedingHighest risk with shared sleep surface:

Less than 11 weeksSmokingCouchBetween two adults in an adult bed

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Exogenous Stressors: Extrinsic Risks

Infant Sleep Practices Shared Sleep Surface

Vennemann et al 2012Meta-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

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Exogenous Stressors: Extrinsic Risks

Infant Sleep Practices Naïve Prone SleepersDaycare deathsCote (2000)

Autopsy studyInfants inexperienced with prone sleeping more likely to die when first placed prone

Palusszynska (2004)Live infantsInfants inexperienced with prone sleeping have fewer protective movements when placed prone

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Exogenous Stressors: Extrinsic Risks

Infant Sleep Practices

Items within the crib Soft bedding/bumpers: Scheers et al 2003; Thach et

al 2007Sleep Positioners: FDA 2007

SwaddlingEntrapment: Moon et al 2014; Blair et al 2009

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Unusual to see SUID in Connecticut in these circumstances

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SUID in Connecticut

2011-201363 deaths

Mean age 3 monthsBoys>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.

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SUID in the Post Back-To-Sleep era

“Using 2005 to 2008 data from 9 US states to assess 3136 sleep relatedsudden 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

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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

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Infant Sleeping Behaviors and Recommendations 

Eve R. Colson, MD, MHPEProfessor of Pediatrics Yale School of Medicine

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Overview

• AAP Recommendations• Prevalence • Advice• Guidance for families

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Overview

• AAP Recommendations• Prevalence • Advice• Guidance for families

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AAP Recommendation

• Back sleep• Firm mattress• No soft bedding

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AAP Recommendation

• Room sharing, not bedsharing

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AAP Recommendation

• Pacifier once breasfeeding established

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Overview

• AAP Recommendations• Prevalence • Advice• Guidance for families

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Prevalence of Usual Sleep Position by Race/Ethnicity (N=1031)

Overall White Black Hispanic0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OtherProneSideSupine

15%

74%

9%20%

15%

63%

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Prevalence of Usual Sleep Position by Region (N=1031)

Overall Northeast Midwest South West0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OtherProneSideSupine

9%

65%

14%

74%

15%

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Prevalence of Usual Bedsharing by Race/Ethnicity

Overall White Black Hispanic0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BedshareOwn Bed,Own RoomRoom Share,not Bedshare

19%

23%

66%

19%15%

29%18%

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Prevalence of Usual Bedsharing by Region

Overall Northeast Midwest South West0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bedshare Own Bed, Own Room

Roomshare, not Bedshare

19% 12% 14% 20% 26%

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Overview

• AAP Recommendations• Prevalence • Advice• Guidance for families

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Vaccin

ation

Breas

tfeed

ing

Sleep

Pos

ition

Bed Sh

aring

Pacifie

r

Vaccin

ation

Breas

tfeed

ing

Sleep

Pos

ition

Bed Sh

aring

Pacifie

r

Vaccin

ation

Breas

tfeed

ing

Sleep

Pos

ition

Bed Sh

aring

Pacifie

r

Vaccin

ation

Breas

tfeed

ing

Sleep

Pos

ition

Bed Sh

aring

Pacifie

r0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

86.4

62.176.4

44.2

11.7

52.1

72.169.2

37.8

10.2

46.348.646.144.5

14.2

30.4

56.3

39

23.8

8.8

2.6

15.3

3.5

1.8

13.8

2.6

15.3

3.0

2.8

12.3

6.915.1

9.33.9

21.3

11.4

11.6

1.7

3.4

10.8

11.622.520.1

55.4

74.6

45.3

12.7

27.9

59.4

77.5

46.836.4

44.651.6

64.458.2

32.1

59.372.8

80.4

Consistent with Recommendations NOT Consistent with RecommendationsNo Advice

DOCTOR NURSE FAMILY MEDIA

Advice

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Overview

• AAP Recommendations• Prevalence • Advice• Guidance for families

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Guidance for Families

• Back for sleep• Firm mattress• No soft bedding• Room share but not bedshare• Offer a pacifier when breastfeeding

established

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Guidance for Families

• Concerns about choking

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Guidance for Families

• Concerns about comfort

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Guidance for Families

• Concerns about side sleep

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Guidance for Families

• Concerns about head shape

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Guidance for Families

• Concerns about pacifier use

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Department of Children and Families Safe Sleep Initiative

Fredericka Wolman MDDepartment of Children and Families

State of Connecticut

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DCF’s Initiative on Safe Sleep Environments

DCF’s Safe SleepEnvironments Flyer

Add link

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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)

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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

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Questions?

Thank you for participating in this webinar!

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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=223

• http://www.cribsforkids.org