Using Coronial Records to Understand Deaths of Infants

Through Co-sleepingJoe Clarke4, Catherine Coyle2, Sharon Beattie5, Cathy MacPherson4, Una Turbitt2, Brid Farrell2, Anne Lazenbatt1, Lisa Bunting1, John Devaney4, David Hayes1, 1Queen's University Belfast, Belfast, UK, 2Public Health Agency Northern Ireland, Belfast, UK, 3Southern Health & Social Care Trust, Armagh, UK, 4South Eastern Health & Social Care Trust, 5Safeguarding Board for Northern Ireland, Belfast, UK

Research Study• Partnership approach • Research strands:– a scoping review of the international literature on co-

sleeping and infant death– a retrospective review of deaths of infants of relevant

causes (aged 0-2 years) (n=45)– Qualitative research involving interviews with

international experts and focus groups with professionals and parents

2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

44000

45000

46000

47000

48000

49000

50000

51000

52000

Population < 1 Year and Infant Deaths by Year

Mid Year Population 0-1 YearsNo of Deaths to those <1 year

Source: NI Statistics and Research Agency (NISRA)

THE LITERATURE

Objectives

• Definitions

• Contribution of co-sleeping to sudden infant deaths – the literature

• Limitations of the evidence base

Definitions – SUDI/SIDS

• SUDI = all sudden deaths of infants

• After full investigations; explained and unexplained

• SIDS = unexplained classification of infant death

Triple-Risk Hypothesis

1.A vulnerable infant;

2.A vulnerable time of development;

3.External stressors.

Definitions – Co-Sleeping/Bed-SharingUNICEF:• Bed-sharing: Bringing baby onto a sleep

surface when co-sleeping is possible, whether intended or not

• Co-sleeping: Mother +/-partner or other person, being asleep on the same sleep surface as the baby

Evidence of Increased Risk?• Consistent evidence on factors which increase

the risk of infant death while bed-sharing:– Smoking– Ingestion of alcohol– Consumption of drugs – LBW or premature infant– Age under 12 weeks

• Lack of evidence supporting bed-sharing and a reduction in risk of SIDS

Evidence of Increased Risk?• Sofa-sharing appears to be increasingly

implicated in unexplained infant deaths

• Often excluded / not examined

• Co-sleeping with an adult on a sofa or chair was

x18 higher risk than those who did not co-sleep,

adjusting for other factors

– Increased risk regardless of age

Breastfeeding and Bed Sharing

• Link between the two behaviours, probably bi-directional

• Breastfeeding associated with a reduction in risk of SIDS

• Impact of breastfeeding on risk of SIDS among infants who are bed-sharing is not clear-cut

What is the Risk of Co-Sleeping in the Absence of other Risk Factors?

• Conflicting results from recent studies:– Carpenter 2013 – breast-fed babies with no other

risk factors who co-sleep have an increased risk of death (OR=2.7). Risk highest in first 3 months

– Blair 2014 – examination of the same question resulted in no evidence of increased risk; no increased risk for bed-sharing in absence of sofa-sharing, alcohol and smoking

• Methodological differences

NICE Guidance Postnatal Care CG37

• Updated December 2014 on basis of recent evidence

• No inference of causation but association highlighted in the guidance

• Factors in recommendations: smoking, alcohol, drug use, premature or LBW infants

Limitations of Evidence Base

• Case-control studies; methodological limitations such as establishing causation

• Inconsistency in data recording

• Definitions of behaviours and practices

• Lack of data about fathers bed-sharing

Summary •Co-sleeping varies by culture and country and is known to be a common practice in the UK

•Evidence shows an increased risk of SIDS among infants who are bed-sharing especially in the presence of other factors

•There are limitations in the evidence of the inter-relationships with factors such as breastfeeding

Public Health Messages?

• Need to recognise that some parents will bed-share with infants

• Need to be provided with advice about risk

• ‘one size fits all’ information is unlikely to be effective

Discourage Completely

Encourage Completely

CASE REVIEW

Objectives

• In low risk healthy infants under three months of age it is predicted that over 80% of deaths would have been prevented had co-sleeping not occurred.

• In Northern Ireland a small number of child deaths of undetermined cause within a one year period emphasised the need to understand what the sleeping practices and culture are in N Ireland.

• This study seeks to understand this phenomenon within the Northern Ireland.

Methodology

• A retrospective review of all paediatric deaths of infants (aged 0-2 years) referred to the Coroner's Office for Northern Ireland between January 2007 and December 2013 where the death was certified as SUDI / Unascertained / Wedging / SIDS / Co-Sleeping / Overlaying or any combination of these causes (n=45)

Results (Demographics)

Sex– 33.33% Female– 66.67% Male

Age

Ethnicity91% white ethnicity9% Irish Traveller

Results (Age)

• The literature reports that 90% deaths have occurred by age 6 months

• Using age in weeks (and 4 weeks approximately corresponding to one month) cases were broken down into age bands by months

• 75% deaths occurred by age 6 months

Results (Age)

Age in WeeksAge in Months

Frequency Percent0 – 8 0-2 Months

2-4 Months4-6 Months> 6 Months

Total

14 31.8

9 – 16 12 27.3

17 – 24 7 15.9

≥ 25 11 25.0

44 100.0

Results (Maternal History)

• Average age of Mother at time of death = 26.27 years (n=41) (range: 17-41 years)

• ⅓ of mothers do have a significant past medical history, most commonly depression

• 71% smoked during pregnancy (n=42)• 8 out of 10 mothers took alcohol before

pregnancy, limited info on alcohol antenatally• Under 20% had pregnancy complications, the

most common of which was preterm delivery

Results (Delivery and birth)

• Mean gestation at birth was 38.47 weeks (n=45)• Median Gestation at birth was 40 weeks

• All singleton, hospital births • ¾ by NVD

Results (Infant health)

• GOR most common diagnosis• All infants were UTD with vaccinations and

had no history of ALTEs• 11% breastfed at time of death; very few on

artificial feeding had a history of breastfeeding

Results (Social History)

• All cases lived at home with their mother, over 75% were co-habiting or married

• Half of mothers did not work• Drug use and substance misuse not commonly

reported among mothers• Most cases 2nd caregiver was their father

(93%) • Mean age of father was 28 years (n=31)

Results (Social History)

• 74% of fathers were smokers at time of birth (34%)• 33% of fathers used drugs recreationally (n=33)• 20% of fathers have a history of substance abuse (n=30)

• Just under 1/3 cases were in contact with social services for a range of reasons

• <10% reported domestic violence• 7% cases were on the child protection register (n=45)

Results (Circumstances of death)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

31.11%

11.11%

8.89%

15.56%

11.11%

6.67%

15.56%

% of Cases by Day of Death

Results (Circumstances of death)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

4

6

5

4

2

3

4

9

1

3 3

1

Cases by MonthJan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Results (Circumstances of death)

Time found Percentage

Midnight - 6am 11.11%

6am - 10am 48.89%

10am - 12pm 31.11%

> 12 Noon < Midnight 8.89%

Grand Total 100.00%

Room found Percentage

A bedroom not at Home 13.33%

Living Room 20.00%

Living room not at home 2.22%

Own room 8.89%

Parent or Parents' Room 55.56%

Grand Total 100.00%

Row Labels Count of Location found within roomBeside bed 2.22%Cot 20.00%In car seat 2.22%On Bed 51.11%On Chair 2.22%On Sofa 17.78%Travel Cot 4.44%Grand Total 100.00%

Results (Circumstances of death)

Position found Percentage

Arms of Parent 11.63%

On side 18.60%

Prone 27.91%Prone and on knees 2.33%

Supine 34.88%

Wedging 4.65%

Grand Total 100.00%

Position put to sleep Percentage

Arms / Body of Parent 22.50%

On side 12.50%

Prone 5.00%

Supine 60.00%

Grand Total 100.00%

Results (Circumstances of death)

• 71.1% cases were co-sleeping (n=45)

• For the 32/45 cases who were co-sleeping – 59% were co-sleeping with one other person – 41% were co-sleeping with 2 people

Results (Circumstances of death)

• In 2% cases were covers found over the child’s head (n=45)

• 16% cases the child was away from home (n=45)

• 24% cases it was a family occasion (n=45)

• 52% cases alcohol was taken by caregivers (n=44)

• 59% cases who were co-sleeping the co-sleeper had taken alcohol (n=32)

Results (Circumstances of death)

Location of co-sleeping Percentage

Chair 3.13%

Mattress 68.75%

Mother's arms 3.13%

Sofa 25.00%

Grand Total 100.00%

Results (Co-sleeping)

• 44% of cases were aged 12 weeks and younger

• Of those cases ≤ 12 weeks 95% were co-sleeping compared with 52% of those over age of 12 weeks.

Results (Child health in 72 hours prior to death)

• 1/3 cases had symptoms in 72 hours before death (n=45), most commonly cough and coryza

• 6/15 seen by a healthcare professional and 50% prescribed medication

• 18% reported problems with feeding within this time period (n=45)

Results (Post-mortem results)• 89% had abnormal PM results (40/45) [Totals below will add up to

more than 40 as some cases have more than one abnormal result]– 38/40 had abnormal bacteriology results– 10/40 had abnormal skeletal survey– 5/40 had abnormal virology results– 4/40 had abnormal toxicology results– 1/40 had abnormal genetics results– 3/40 had raised WCC or abnormal haematology– 5/40 had at least 3 types of abnormal results– 11/40 had 2 types of abnormal results– 24/40 had 1 type of abnormal result

Using Coronial Records to Understand Deaths of Infants

Through Co-sleeping

Questions?

Summary

• 71.1% cases were co-sleeping

• 59% cases who were co-sleeping the co-sleeper had taken alcohol

Using Coronial Records to Understand Deaths of Infants

Through Co-sleeping

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