TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Sleep Related Infant DeathsTulsa County 2004 - 2008
Carol Kuplicki, MPHTulsa Health Department, TFIMRJanuary 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Selection & MethodSelection 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
4061 60
7056
6
719
16
1015
86
6
4
0
20
40
60
80
100
2004 2005 2006 2007* 2008*
Num
ber o
f inf
ant d
eath
sTulsa County Resident Infant Deaths by Year of Death
Excluded
Sleep related
All other infant deaths
*Preliminary data for total number of deaths
384 Total number of infant deaths2004-61 2007*-922005-76 2008*-702006-85
39 (10.2%) Excluded from TFIMR review345 (89.8%) Data abstracted by TFIMR
58 (16.8%) Sleep related deaths287 (83.2%) All other infant deaths
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
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.
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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.
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
What did we find?
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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.
TFIMR Infant Deaths by Year of Death, Discharge Status, and Cause of Death
Year of Death
Total Infant
Deaths (Data
Abstracted)
Infants Discharged
to Home from Birth Hospital
Sleep Related Deaths
Reviewed by TFIMR* SIDS Undetermined Asphyxia
2004 46 13 6 3 2 12005 68 16 7 2 4 12006 79 29 19 8 8 32007 86 28 16 3 11 22008 66 15 10 0 9 1Total 345 101 58 16 34 8
*Due to TFIMR case selection criteria the number of sleep-related deaths may differ from total Tulsa County sleep-related deaths.
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
24
811
93
2
8 3
11
3
2
1
0
2
4
6
8
10
12
14
16
18
20
2004 2005 2006 2007 2008
Num
ber o
f in
fant
dea
ths
Year of death
Deaths by Year and Cause
Asphyxia
SIDS
Undetermined
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
6
15
18
5
8
4
1 1
0
2
4
6
8
10
12
14
16
18
20
<1 1 2 3 4 5 6 7 8 9 10 11
Num
ber o
f inf
ant d
eath
s
Age at death (months)
Deaths by Age of Infant
39 ( 67.2%) < 3 months 19 (32.8%) 3 to <12 months
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
4
9 10
3 4 31
1
55
1
3
1
1
1
3
1
1
10
2
4
6
8
10
12
14
16
18
20
<1 1 2 3 4 5 6 7 8 9 10 11
Num
ber o
f inf
ant d
eath
s
Age at death (months)
Deaths by Age of Infant and Cause
Asphyxia SIDS Undetermined
Deaths by Age:39 (67.2%) were less than 3 months old
18 (31.0%) were 2 months old19 (32.8 %) were 3 months old or greater Deaths by Cause: 16 (27.6%) SIDS 34 (58.6%) Undetermined8 (13.8%) Asphyxia
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Sleep EnvironmentUnsafe 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
*Unknown values subtracted from denominator prior to calculations.
13
4
31
9
10
5
10
15
20
25
30
35
Crib Bassinet Bed Couch/loveseat Unknown
Nu
mb
er o
f in
fan
t d
eath
s
Sleep surface
Deaths by Sleep Surface
17 (29.8%) Crib/Bassinet40 (70.2%) Bed-twin or larger, Couch/Loveseat
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Age and Sleep Surface
Crib6, 32%
Bed12, 63%
Couch/ loveseat
1, 5%
Age at death 3+ months by sleep surfacen=19
Crib7, 18%
Bassinet, 4, 10%
Bed, 19, 49%
Couch/ loveseat,
8, 20%
Unknown, 1, 3%
Age at death <3 months by sleep surfacen=39
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
2 29 7
2
22
4 5
109
8
36
0
10
20
30
40
50
60
70
2004 2005 2006 2007 2008 Total
Nu
mb
er o
f in
fan
t d
eath
s
Year of death
Infant Deaths by Co-bedding Status by Year of Death
Co-bedding Sleeping alone36 (62.1%) Co-bedding 19 - 1 adult
4 - 1 adult and 1 other child2- 1 adult and 2 other children8 - 2 adults1 - 2 adults and 1 other child2 - 1 other child
22 (37.9%) Sleeping alone
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Most infants died in a bed or on a couch while sleeping with someone else.
1
26
8
1
12
4
5
1
0
5
10
15
20
25
30
35
Crib Bassinet Bed Couch/loveseat Unknown
Nu
mb
er
of
infa
nt
death
s
Sleep surface
Infant Deaths by Sleep Surface
Sleeping aloneCo-bedding
36 (62.1%) Co-bedding22 (37.9%) Sleeping alone
Co-bedding by Sleep Surface1/17 - Crib or bassinet34/40 (85%) Bed or couch
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
10
2 1 2
3
2
26
4
1
4
3
0
5
10
15
20
25
30
35
Crib Bassinet Bed Couch/loveseat Unknown
Nu
mb
er o
f in
fan
t d
eath
s
Sleep surface
Infant Deaths by Sleep Surface and Cause of Death
Asphyxia
Undetermined
SIDS
12/17 SIDS in Crib or Basinett30/40 (75%) Undetermined in Bed or couch
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Infant’s sleep position when put to bed or when found
0 10 20 30 40
Prone
Side
Sitting up
Supine
Other
Unknown
13
2
1
8
1
33
Number of Infant Deaths
Sleep Position
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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)
50
8
0
10
20
30
40
50
60
Non-Safe Safe*
Nu
mb
er
of i
nfa
nt
de
ath
s
Sleep Environment
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Surgeon General’s Report on The Health Consequencesof 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
36 (63%)
100 (38%) 136 (43%)
21 (37%)
162 (62%) 183 (57%)
0%
20%
40%
60%
80%
100%
Sleep-Related Deathn=57
All other Causesn=262
Totaln=319
Perc
ent t
obac
co u
se
Tobacco Use
No reported tobacco exposure Reported tobacco exposure
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
6
31
5
1 1
6
13
7
3
2
2
1
2
2
1
2
1
3
2
11
1
0
2
4
6
8
10
12
Num
ber o
f inf
ant
deat
hsMonth of Death and Cause
Asphyxia
SIDS
Undetermined
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
Race and Ethnicity of the mother
White44 (75.9%)
Black13 (22.4%)
Native American1 (1.7%)
Race
Non-Hispanic
52 (92.9%)
Hispanic4 (7.1%)
Ethnicity
Ethnicity is unknown for 2
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
44 75.9%
18565.6%
22967.4%
13 (22.4%)
7727.3%
9026.5%
Native Am 1 (1.7%)
12 (4.3%)
13 (3.8%)
0
50
100
150
200
250
300
350
Sleep relatedn=58
All other deathsn=282
Total infant deathsn=340
Perc
ent o
f inf
ant d
eath
s Infant Deaths by Race of the Mother
Other Race White & Native American Native American Black White
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
34(58.6%)
157 (54.7%)191 (55.4%)
24 (41.4%)
130(45.3%)
154 (44.6%)
0
50
100
150
200
250
300
350
400
Sleep relatedn=58
All other causesn=287
Total infant deathsn=345
Num
ber o
f inf
ant d
eath
sGender of Infant
Female
Male
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
45 (77.6%) 150 (53.2%) 195 (57.3%)
10 (17.2%) 100 (35.5%) 110 (32.4%)
2
6 8
120 216 6
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sleep related All other deaths All deaths
Pe
rce
nt
of i
nfa
nt
de
ath
sInfant Deaths by Type of Health Insurance
Multiple Health Insurance
Selfpay
Soonercare and Private
Private
Soonercare only
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR Sleep Related Infant Deaths 2004-2008
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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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.
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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
TFIMR Sleep Related Infant Deaths 2004-2008TFIMR 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, [email protected]
Pam Rask, MPH, Deputy Associate Director, Community Health Services (918) 595-4418, [email protected]
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