Sleep Related Infant Deaths Tulsa County 2004 - 2008 Carol Kuplicki, MPH Tulsa Health Department, TFIMR January 2011 Tulsa Fetal and Infant Mortality Review

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


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


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


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


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.


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.


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


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


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


What did we find?


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.


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


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


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


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


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


*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


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


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


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


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


10

2 1 2

3

2

26

4

1

4

3

0

5

10

15

20

25

30

35


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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.



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



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


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]

Documents

Sleep Related Infant Deaths Tulsa County 2004 - 2008 Carol Kuplicki, MPH Tulsa Health Department, TFIMR January 2011 Tulsa Fetal and Infant Mortality Review