Strategies to Prevent Sleep-Related Sudden Unexpected ... · medical history to determine the cause...

Strategies to Prevent Sleep-Related Sudden Unexpected Infant Deaths

Michelle Chiezah, MPH, MA | State’s Infant Mortality Consultant

July 28, 2017

Outline

• Define sudden unexpected infant death

• Provide trend data

• Highlight risk and protective factors

• Discuss the American Academy of Pediatrics (AAP) safe sleep guidelines

• Discuss opportunities for intervention

• Guide meeting participants to useful resources

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What is a Sudden Unexpected Infant Death?

• Sudden and unexpected deaths (SUID) is a subset of infant fatalities that occur suddenly and unexpectedly before age one from causes that are not always immediately obvious.

• They require a thorough investigation, including an autopsy and review of medical history to determine the cause and manner of death.

• A sudden unexpected infant death is sometimes referred to as sudden unexplained death in infancy (SUDI).

• Most SUIDs occur during sleep (e.g., suffocation, strangulation, and entrapment).

• Sleep-related infant deaths are largely preventable.7/20/2017 3

Three Most Commonly Reported SUID in the U.S.

1. Sudden Infant Death Syndrome (SIDS)

2. Unknown Causes

3. Accidental Suffocation and Strangulation in Bed (ASSB)

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Sudden Infant Death Syndrome (SIDS)

• SIDS is defined as the sudden death of an infant under 1 year of age that cannot be explained after a thorough investigation has been conducted, including an autopsy, examination of the death scene, and a review of clinical history.

• A Triple Risk Model has been advanced to explain SIDS.

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Source: In Shapiro-Mendoza, Carrie. SIDS and Other Sleep-Related Infant Deaths. Governor’s Summit on Infant Mortality. Frankfort, Kentucky.. Maternal and Infant Health Branch. National Center for Chronic Disease Prevention and Health Promotion. Division of Reproductive Health. March 1, 2013. With permission.

Unknown Cause

The sudden death of an infant under 1 year of age that cannot be explained because a

thorough investigation was not conducted and cause of death could not be determined.

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Source: Research on Possible Causes of SIDS. Safe to Sleep Public Education Campaign. Eunice Kennedy Shriver National Institute of Child Health and Human Development. National Institutes of Health. https://www.nichd.nih.gov/sts/campaign/science/Pages/causes.aspx. Accessed on July 11, 2017.

https://www.nichd.nih.gov/sts/campaign/science/Pages/causes.aspx

Accidental Suffocation and Strangulation in Bed (ASSB)

• These are mostly unintentional sleep-related suffocation deaths. The reasons these

deaths happen are:

• Suffocation— happens when soft objects such as soft bedding, pillows, waterbed mattresses

cover the infants’ noses and mouths.

• Overlay— E.g., happens when another person rolls on top or against an infant while sleeping.

• Wedging— E.g., happens when an infant is wedged between two objects such as mattress

and wall, bed frame, or furniture.

• Strangulation— E.g., occurs when an infant’s head and neck get caught between crib railings.

• These deaths do not only happen in bed, they can also happen on sofas, couches, or

armchairs.

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Source: Research on Possible Causes of SIDS. Safe to Sleep Public Education Campaign. Eunice Kennedy Shriver National Institute of Child Health and Human Development. National Institutes of Health. https://www.nichd.nih.gov/sts/campaign/science/Pages/causes.aspx. Accessed on July 11, 2017.

https://www.nichd.nih.gov/sts/campaign/science/Pages/causes.aspx

Accidental Suffocation and Strangulation in Bed (ASSB)

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8Source: In Shapiro-Mendoza, Carrie. SIDS and Other Sleep-Related Infant Deaths. Governor’s Summit on Infant Mortality. Frankfort, Kentucky.. Maternal and Infant Health Branch. National Center for Chronic Disease Prevention and Health Promotion. Division of Reproductive Health. March 1, 2013. With permission.

TRENDS

• U.S.

• Minnesota

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Number and Percent Distribution of SUID by Cause: United States 2015

According to CDC, 3,700 SUID occurred in the U.S. in 2015

• 1,600 classified as SIDS

• 1,200 classified as Unknown Causes

• 900 classified as Accidental Suffocation and Strangulation in bed

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Source: Sudden Unexpected Infant Deaths and Sudden Infant Death Syndrome. https://www.cdc.gov/sids/data.htm. Accessed on July 12, 2017.

Sudden Unexpected Infant Deaths by Cause: United States 1990-2015

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Source: Sudden Unexpected Infant Deaths and Sudden Infant Death Syndrome. https://www.cdc.gov/sids/data.htm. Accessed on July 12, 2017.

SUID Rates by Race and Hispanic Origin of Mother: United States 2013

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SUID Rates by Maternal Race: Minnesota, 2014

7.6

30.9

21.6

5.53.6

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Total American Indian Black/African American White Asian

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SUID Rates in Minnesota by Maternal Race(N=53)

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Source: Injury Prevention Unit. SUID Case Registry. Minnesota Department of Health

Risk & Protective Factors

• Examples of risk and protective factors

• The Minnesota Case

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Established Risk & Protective Factors

Modifiable Factors Include:

• Prone/side sleep position• Soft sleep surface• Maternal smoking during pregnancy • Environment tobacco smoke• Bed sharing• Overheating• Late or no prenatal care

Protective Factors Include:

• Breastfeeding• Pacifier use

Non-Modifiable Factors Include:• Young maternal age• Prematurity and/or LBW• Male sex• African American• American Indian

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Source: In Shapiro-Mendoza, Carrie. SIDS and Other Sleep-Related Infant Deaths. Governor’s Summit on Infant Mortality. Frankfort, Kentucky.. Maternal and Infant Health Branch. National Center for Chronic Disease Prevention and Health Promotion. Division of Reproductive Health. March 1, 2013. With permission.

Risk and Protective Factors in SUID Cases: Minnesota, 2014

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Source: Thyden, Naomi, et. al. Sudden Unexpected Infant Deaths in Minnesota. Informing Prevention Strategies. Minnesota Medicine. 2014: 41-43.

Safe Sleep Guidelines and Recommendations

• Discussion of AAP Safe Sleep Guidelines

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2016 AAP Safe Sleep Recommendations: Level A

Level A

• Place babies on their backs to sleep for every sleep(includes naps)

• Use a firm sleep surface (excludes car seats, sofas, arm chairs, adult beds, waterbeds)

• Breastfeeding is recommended

• Room sharing with the infant on a separate sleep surface is recommended (i.e., a sleep surface designed for infants ideally for the first year of life, but for at least the first six months)

• Keep soft objects, toys and loose bedding out of the infant’s sleep area (e.g., no bumper pads, toys, pillows, blankets)

• Consider offering a pacifier at naptime and bedtime

Level A

• Avoid alcohol and illicit drug use during pregnancy and after birth

• Avoid smoke exposure during pregnancy and after birth

• Avoid overheating

• Pregnant women should seek and obtain regular prenatal care

• Infants should be immunized in accordance with AAP and CDC recommendations

• Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS

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2016 AAP Safe Sleep Recommendations: Level A & B

Level A

• Health care providers, staff in newborn nurseries and NICUs, and child care providers should endorse and model SIDS risk-reduction recommendation from birth

• Media and manufacturers should follow safe sleep guidelines in their messaging and advertising

• Continue the “Safe to Sleep” campaign, focusing on ways to reduce the risk of all sleep-related infant deaths, including SIDS, suffocation and other unintentional deaths. Pediatricians and other primary care providers should actively participate in the campaign

Level B

• Avoid the use of commercial devices that are inconsistent with safe sleep recommendations

• Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly

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2016 AAP Safe Sleep Recommendations: Level C

Level C

• Continue research and surveillance on the risk factors, causes, and pathophysiologic mechanisms of SIDS and other sleep-related infant deaths, with the ultimate goal of eliminating these deaths entirely

• There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS

Notes: The following levels are based on the Strength-of-Recommendation Taxonomy (SORT) for the assignment of letter grades to each of its recommendations (A, B, or C).2 Level A: There is good-quality patient-oriented evidence. Level B: There is inconsistent or limited-quality patient-oriented evidence. Level C: The recommendation is based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening. Note: “patient-oriented evidence” measure outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life; “disease-oriented evidence” measures immediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (e.g., blood pressure, blood chemistry, physiologic function, pathologic findings). CDC, Centers for Disease Control and Prevention. Source: 2016 AAP Recommendations: http://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938

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Place babies on their backs to sleep for every sleep

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Source: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). U.S. Department of Health and Human Services (HHS):https://www.nichd.nih.gov/sts/news/downloadable/PublishingImages/baby_anatomy_image2.jpg


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Percent of mothers who reported that their infants slept on their back only/side/stomach/other: Minnesota, 2011-2014

Back Only Sides/Stomach/Other

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Source: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health.


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Percent of mothers who reported that their infants slept on their back only/side/stomach/other by maternal race/ethnicity: Minnesota, 2012-2014

Back Only Side/Stomach/Other

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Use a firm sleep Surface

• Infants should always sleep in a safety-approved crib, bassinet, or play yard that meets the Consumer Safety Product Commission (CPSC) standards

• Crib mattresses should be firm

• More than one infant should not sleep in a crib

• Pillows, arm chairs, sofas, waterbeds, sheep skin, quilts, comforters should not be used for infant sleep because they pose a risk for suffocation

• Crib slats should be less than 2-3/8 inches (12 ounce soda can should not pass through)

• Cribs, play yards and bassinets should be sturdy without missing or loose parts, slats, or screws

• There should be no gaps between the mattress and walls of cribs, bassinets, or play yards

• Car seats, strollers, swings, infant carriers and infant slings should not be used for routine sleep at home or in hospitals

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Use a firm sleep surface

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Percent of mothers who reported that their infants slept in a crib: Minnesota, 2012-2014

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Use a firm sleep surface

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Percent of mothers who report that their infants sleep in a crib by maternal race/ethnicity: Minnesota, 2012-2014

Yes No

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Breastfeeding is recommended

• Breastmilk is the best source of nutrition for babies

• Exclusive breastfeeding is recommended for 6 months (AAP 2016)

• Any amount of breastfeeding has been demonstrated to reduce the risk of SIDS (AAP 2016)

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Percent of mothers who reported that their infants are currently breastfed: Minnesota, 2012-2014

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Percent of mothers who report that their infants are currently being breastfed by maternal race/ethnicity: Minnesota, 2012-2014

Yes No

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Room sharing with the infant on a separate sleep surface is recommended

• Room sharing, not bed sharing is recommended

• Infant should always sleep alone— never with other siblings, adults, pets, or toys

• Only one infant per sleep space such as cribs and play yards

• Cribs, bassinets, and play yards may be kept in the parent’s room (an arm’s length away)

• Bed sharing increases the risk of suffocation, entrapment, and strangulation

• Infants should sleep on a surface designed for infants for about the first year of life but at least for the first 6 months

• Babies may be brought to bed for nursing and soothing but should be returned to their own sleep surface once done

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Source: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). U.S. Department of Health and Human Services (HHS):https://www.nichd.nih.gov/sts/news/downloadable/Pages/roomsharing1_image.aspx

Room sharing with an infant on a separate sleep surface is recommended

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Percent of mothers who reported that their infants usually sleep with another person: Minnesota, 2012-2014

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Percent of mothers who reported that their infants usually sleep with another person by maternal race/ethnicity: Minnesota, 2012-2014

Yes No

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Keep soft objects, toys and loose bedding out of the infant’s sleep area

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• Keep all soft objects such as toys, bumper pads, loose beddings, blankets, sheepskins, comforters, and non-fitted sheets out of the infant’s sleep area

• These products increase the risk of suffocation, entrapment, and strangulation

Keep Soft Objects, toys and loose bedding out of the infant’s sleep area

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Source: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). U.S. Department of Health and Human Services (HHS):https://www.nichd.nih.gov/sts/news/downloadable/Pages/environment1_image.aspx

Consider offering a pacifier at naptime and at bedtime

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• Offer pacifiers to babies only after breastfeeding has been well-established

• Pacifiers should not replace breastfeeding

• Do not tie the pacifier to a string and put it around the infant’s neck

• Can increase the risk for strangulation

Avoid Alcohol and illicit drug use during pregnancy and after birth

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• The risk of SIDS increases when mothers use alcohol prenatally and postnatally (AAP 2016)

• The risk of SIDS and unintentional suffocation increases when parental alcohol use is combined with bed sharing (AAP 2016)

• Kandall et. al. (1993) found, after controlling for race/ethnicity, maternal age, parity, birth weight, year or birth, and maternal smoking in a prospective cohort study, that the risk for SIDS/SUID increased significantly when infants were exposed to several drugs in utero:

• methadone (OR: 3.6; 95% CI: 2.5-5.1)

• heroin (OR: 2.3: 95% CI: 1.3-4.0)

• methadone and heroine(OR: 3.2; 95% CI: 1.2-8.6)

• cocaine (OR: 1.6; 95% CI: 1.2-2.2)

Source: Kandall et. al. Relationship of maternal substance abuse to subsequent sudden infant death syndrome in offspring. J Pediatr. 1993.123(1): 120-1

3.8

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Non-HispanicBlack

American Indian Hispanic* Non-HispanicWhite

Other Minnesota Total

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Percent of Women Who Consumed Alcohol During the Last 3 Months of Pregnancy by Race/Ethnicity, 2009-2013

*Can be of any race

Consumed any amount of alcohol during pregnancy among those who drank any alcoholic beverages in the previous two years.Other includes Asians, Foreign-born, Mixed Race, and data for which the race of the respondent is unknown.Source: Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS), Minnesota Department of Health, Division of Community and Family Health, Maternal and Child Health.

Avoid smoke exposure during pregnancy and after birth

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• There is a well-established link between exposure to tobacco smoke/smoking during pregnancy and poor birth outcomes such as low birth weight and preterm births SIDS/SUID.

• LBW and preterm births are risk factors for SIDS/SUID (AAP 2016)

• The risk for SIDS/SUID is higher when infants share a bed with an adult who smokes, and this risk is present even if smoking is not done in bed (AAP 2016)

Avoid smoke exposure during pregnancy and after birth

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Percent of mothers who reported that they smoke now among women who smoked in the past 2 years: Minnesota, 2012-2014

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Avoid Overheating

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• Excessive clothing and covering with blankets and comforters can increase the risk of overheating

• Overheating in combination with a room’s temperature can increase the risk of SIDS/SUID (AAP 2016)

• Infants who sleep on their stomachs as opposed to their backs are at greater risk of overheating (AAP 2016)

• If the temperature in a room is comfortable for an adult, then it is also right for the baby— with one more layer of clothing than the adult is wearing

• The baby’s face should not be covered and blankets and comforters should not be used in the baby’s sleep area

Pregnant women should seek and obtain regular prenatal care

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• Infants born to mothers who seek regular prenatal care have a lower risk of SIDS/SUID than infants whose mothers do not (AAP 2016)

• The American Congress of Obstetricians and Gynecologists (ACOG) has developed prenatal guidelines and recommendations, and has made available a variety of resources to physicians to help them screen and/or counsel pregnant women who smoke, drink alcohol, or use illicit drugs, including opioids during pregnancy

• Examples of effective smoking cessation interventions during pregnancy (contains information about the 5-As smoking cessation intervention): https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Smoking-Cessation-During-Pregnancy

• Examples of Alcohol Screening Tool: https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/At-Risk-Drinking-and-Alcohol-Dependence-Obstetric-and-Gynecologic-Implications

• Examples of Clinical Screening Tools for Prenatal Substance Use and Abuse (includes the 4Ps): https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Opioid-Abuse-Dependence-and-Addiction-in-Pregnancy

Pregnant women should seek and obtain regular prenatal care

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Percent of women who initiated prenatal care during the first trimester and later or no prenatal care: Minnesota and the U.S. Overall, 2016

First Trimester

Later or None

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Notes: Care beginning in the third trimesterSource: Births: Provisional Data for 2016. National Center for Health Statistics. National Vital Statistics System.

Infants should be immunized

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• Immunizations do not cause SIDS (AAP 2016)

• In fact, Vennemann et. al. (2007) conducted a meta-analysis of four studies and found that immunizations are associated with an ~50% lower risk of SIDS/SUID— OR: .54 (95% CI: 0.39-0.76)

• Immunization Requirements by Age: Are Your Kids Ready? http://www.health.state.mn.us/divs/idepc/immunize/readykidswhento.pdf

• CDC Immunizations Schedulehttps://www.cdc.gov/vaccines/schedules/index.html https://www.cdc.gov/vaccines/schedules/index.html

Source: Vennemann MM, et.al. Do immunisations reduce the risk of SIDS? A meta-analysis. Vaccine. 2007; 25(26): 4875-4879

http://www.health.state.mn.us/divs/idepc/immunize/readykidswhento.pdf

Do not use home cardiorespiratory monitors as a strategy to reduce SIDS

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• Sometimes prescribed to detect apnea and bradycardia at home, for example

• There is no evidence that they reduce the risk of SIDS/SUIDs (AAP 2016)

Health care providers, staff in newborn nurseries and NICUs, and child care providers should endorse and model SIDS risk-reduction recommendations…

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• Modelling safe sleep occurs when health care providers, staff in newborn nurseries and NICUS, and childcare providers serve as role models for safe sleep by implementing best practices

• Safe sleep modelling includes: offering safe sleep messages and counselling, demonstrating the safest ways for babies to sleep, developing, implementing, enforcing and updating safe sleep policies and staff trainings based on current evidence-based safe sleep guidelines

Health care providers, staff in newborn nurseries and NICUs, and child care providers should endorse and model SIDS risk-reduction recommendation from

birth

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• Crib for Kids®National Safe Sleep Hospital Certification Program offers certification/recognition at three levels— bronze, silver, and gold— for hospitals that demonstrate leadership around safe sleep: http://www.cribsforkids.org/hospitalinitiative/

• MDH-Crib for Kids®webinar on the National Safe Sleep Hospital Certificationprogram (December 8, 2016)https://www.youtube.com/watch?v=PtNGptKClIQ&feature=youtu.be

Media and manufacturers should follow safe sleep guidelines in their messaging and advertising

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• Safe sleep messages should be consistent across all advertisements media sources and reflect AAP safe sleep guidelines. This goes for movies, newspapers, magazines, billboards, etc.

• Kreth et. al. (2017) reviewed magazines advertisements depicting sleep in parenting magazines from 1992, 2012, and 2015 (n=1,893) to determine adherence to AAP safe sleep guidelines. Crib displays from retailers were also reviewed (n-=1,758).

• 35% of advertisements did not adhere to AAP safe sleep guidelines

• The most common reasons for non-adherence were use of loose bedding and bumper pads

Source: Kreth M. et. al. Safe sleep guideline adherence in nationwide marketing of infant cribs and products. Pediatrics. 2017; 139(1).

Continue the “safe to sleep” campaign, focusing on ways to reduce the risk of all sleep-related infant deaths…

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• The Back to Sleep campaign, now called, Safe to Sleep, was first launched in 1994.

• The campaign has seeks to educate Americans about best practices associated with infant sleep safety and has developed culturally-responsive materials

• Since its inception, the campaign has been credited with reducing the incidence of sleep-related SUID by 50% or more in the U.S. overall and within certain racial/ethnic populations

• This campaign has demonstrated that, indeed, safe sleep saves lives!

Source: Explore the campaign. Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). https://www.nichd.nih.gov/sts/campaign/Pages/default.aspx . Accessed on July 14, 201

Safe to Sleep campaign resources

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A-B-Cs of Safe Sleep

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Avoid the use of commercial devices that are inconsistent with safe sleep recommendations

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• Safety-approved evidence-based products such as bassinets, cribs, play yards, sleep sacks are best at protecting babies during sleep

• Wedges and positional products claiming to reduce the risk of SIDS/SUID can increase the risk of suffocation and entrapment (AAP 2016)

Supervised, awake tummy time is recommended to facilitate development and to minimize …positional plagiocephaly

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• Tummy time requires some time on the stomach or in the prone position

• Tummy time should be supervised and both caregiver and baby should be wide awake

• Tummy time helps with developing infants’ strength (AAP 2016)

• Tummy time helps with minimizing the chance that babies will develop [ plagiocephaly(flattened head)

Supervised, awake tummy time is recommended to facilitate development and to minimize …positional plagiocephaly

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This flyer and many other safe sleep resources and materials may be obtained on MDH’s Infant Mortality Reduction Initiatives website at: http://www.health.state.mn.us/divs/cfh/program/infantmortality/

Continue research and surveillance on the risk factors, causes…of SIDS and other sleep-related infant deaths…

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• Since 2011, MDH and DHS have been collecting data on SUID cases via a CDC-funded SUID case registry

• Data are collected and reviewed from multiple source, including: birth certificates, death certificates, autopsy reports, law enforcement and medical records

• Recommendations are made

• Since 2014, those data have been highlighted during Safe Sleep Week in Minnesota, which occurs in the fall

There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS

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“There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS. Infants who are swaddled have an increase risk of death if they are placed in or roll to the prone position. If swaddling is used, infants should always be placed on the back. When an infant exhibits signs of attempting to roll, swaddling should no longer be used.” (AAP 2016)

Opportunities for Interventions

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• Social Ecological Model

• Critical Points of Intervention

Who is Responsible for Infants’ Sleep Safety?

To improve infant sleep safety, all persons who take care of children should follow the American Academy of Pediatrics (AAP) evidence-based safe sleep recommendations

The Socioecological Model

7/20/2017 MATERNAL AND CHILD HEALTH SECTION | http://www.health.state.mn.us/divs/cfh/program/infantmortality/ 58

Source: In Health Equity Resource Toolkit for State Practitioners Addressing Obesity Disparities. National Center for Chronic Disease Prevention and Health Promotion. Division of Nutrition, Physical Activity and Obesity (model modified).https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equity/pdf/toolkit.pdf. Accessed on July 12, 2017.

https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equity/pdf/toolkit.pdf

Health Care Providers and Safe Sleep

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Percent of mothers who reported that their providers talked to them about how to lay their babies down to sleep: Minnesota, 2012-2014

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Health Care Providers and Safe Sleep

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Percent of mothers who reported that their providers talked to them about how to lay their babies down to sleep by maternal race/ethnicity: Minnesota, 2012-2014

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Moving from Data to Action to Prevent SUID and Reduce Risks

• Implement policies and trainings based on AAP safe sleep guidelines

• Do not missed opportunities for critical points of intervention in health care and other settings

• Prenatal care

• Postpartum Care

• 2012-2014 PRAMS data show that 91% of mothers receive postpartum care

• MDH postpartum depression resourceshttp://www.health.state.mn.us/divs/cfh/topic/pmad/materials.cfm

• Well-child visits

• AAP Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescent Pocket Guide (age-appropriate anticipatory guidance for safe sleep)

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Moving from Data to Action to Prevent SUID and Reduce Risks

• Child and Teens Checkups (C&TC) Program Information for Providers (Age-appropriate tools) http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_028848

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Question & Answer

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Thank you!

Michelle A. Chiezah, MA, MPH

[email protected]

651-201-3621

7/20/2017Maternal and Child Health Section |

http://www.health.state.mn.us/divs/cfh/program/infantmortality/64

mailto:[email protected]

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