Workshop/Breakout Title Workshop/Breakout Speaker(s) Changes in Infant Death Coding and Implications for Safe Sleep Campaigns Malinda Douglas, MPH, Oklahoma.

Workshop/Breakout Title

Workshop/Breakout Speaker(s)

Changes in Infant Death Coding and Implications for Safe Sleep Campaigns

Malinda Douglas, MPH, Oklahoma Department of Health Violanda Grigorescu, MD, MSPH, Michigan Dept. of Community

HealthSandra Frank, JD, CAE, Tomorrow's Child/Michigan SIDS

Sleep-Related Deaths Among Infants in

Oklahoma, 2000-2003

• Malinda Reddish Douglas, MPHTobacco Use Prevention Service, OSDH

• Pam Archer, MPHInjury Prevention Service, OSDH

• Jeff Gofton, MDOffice of the Chief Medical Examiner

Background

• Each year, 400 infants under 1 year old die in Oklahoma– 22% congenital and chromosomal

abnormalities– 13% disorders related to premature birth– 9% sudden infant death syndrome

• Death rate decreased 7%– 2000: 8.4/1,000– 2003: 7.8/1,000

Introduction

• Oklahoma Chief Medical Examiner noticed increase in co-sleeping deaths

• Child Death Review Board and Department of Human Services concerned with increase in co-sleeping deaths

• SAFE KIDS Coalition and other partners began development of SIDS – safe sleep materials

Unsafe Sleeping Environment

• Prone sleeping• Exposure to secondhand smoke• Sofas, chairs, loveseats• Soft bedding, pillows, quilts,

blankets• Entrapment hazards• Co-sleeping?

Co-Sleeping Recommendations

Discourages Cautions Encourages

•CPSC •AAP •Attachment parenting groups

•Child death review boards

•NICHHD •La Leche International

•SIDS Alliance

•Some health departments

•Mother-Baby Sleep Laboratory

2000 National Data on Nighttime Infant Bed Sharing with Adults

• Prevalence– 13% entire night

• Up from 6% in 1993

– 20% half of the time or more– 45% some time during past two weeks– Twice as likely as to be covered by quilt or

comforter– Most common in mothers < 18 years, low

income, non-white, and infants < 8 weeks

Potential Reasons for Co-Sleeping

• Bonding• Breastfeeding• Cultural practice• Fear of SIDS• Fear of not hearing the baby• Baby sleeps better• Parents sleep more• No crib

Sleep-Related Infant Death Study

• Purpose – Investigate infant deaths– Characterize sleeping practices– Determine co-sleeping trends over

time

Medical Examiner System

• Investigate deaths under certain circumstances

• Determine manner of death (intention)

• Determine cause of death

• Statewide system

Methods

• Analyzed Medical Examiner database– January 2000 through December 2003– Oklahoma residents– Less than 12 months of age– Manner of death = Accidental

– Cause = Asphyxia

– Manner of death = Unknown– Cause = Asphyxia– Cause = Other– Cause = Unknown

Methods

• Reviewed reports of investigation– Demographic data– Details of the death– Narrative of circumstances– Autopsy report

• Last known activity was sleeping

Definitions

• Unsafe sleeping– Not sleeping alone in a safe crib or bassinette– Not put to sleep on back or found on back– Pillows, stuffed toys, loose quilts or comforters

• Co-sleeping– Sharing a sleep surface with another person– Surfaces include bed, couch, chair, and other

Unsafe Sleeping Case Selection

• 124 possible cases reviewed• 113 infants sleeping prior to death

– 2 following safe sleep guidelines– 5 lacked specific details to classify

• 94% (106/113) involved unsafe sleeping conditions– 81% unknown manner of death– 80% other/unknown cause of death

Unsafe Sleeping Deaths by Age and Sex, Oklahoma,

2000-2003

0

5

10

15

20

25N

um

ber

of

case

s

0 1 2 3 4 5 6 7 8 9 10 11

Age in months

Females Males

Source: Oklahoma State Medical Examiner, n = 106

Unsafe Sleeping Deaths by Race and Year, Oklahoma,

2000-2003

0

5

10

15

20

25

30

35N

um

ber

of

death

s

2000 2001 2002 2003

Year of death

African American American Indian White

Source: Oklahoma State Medical Examiner, n = 104, excludes 2 cases coded as other

Rate/1,000

AA: 1.2

AI: 0.7

W: 0.4

Overall: 0.5

* includes Hispanic

Time and Place of Occurrence

• 82% at night

• 97% occurred in a private home– 86% in own home– 11% in others home

• 2% in licensed child care

• 1% in hospital

Source: Oklahoma State Medical Examiner, n = 106

Unsafe Sleeping Deaths by Sleep Surface, Oklahoma,

2000-2003

Bed50%

Couch8%

Crib13%

Unknown/ Other12%

Mattress on floor5%

Playpen5%

Waterbed3%

Bassinette4%

Source: Oklahoma State Medical Examiner, n = 106

Unsafe Sleeping Deaths by Mechanism of Injury,

Oklahoma, 2000-2003

Overlay - definite

6%Pillow

8%

Unknown/ Other33%

Overlay - possible

31%

Blanket6% Entrapped

10%

Found on floor6%

Source: Oklahoma State Medical Examiner, n = 106

Infant Health History

• Breastfed – 6%– 74% not specified

• Low birth weight – 6%– 87% not specified

• Premature birth – 15%– 56% not specified

• Respiratory illness – 25%– 68% not specified

Source: Oklahoma State Medical Examiner, n = 106

Caregiver or Family Factors

• Use of alcohol and/or drugs – 14%

• History of drug/alcohol problems – 11%

• CPS involvement – 21%

• Previous SIDS death – 3%

• Secondhand smoke exposure – 3%

Source: Oklahoma State Medical Examiner, n = 106

Unsafe Sleeping Deaths by Co-Sleeping at the Time of

Death, Oklahoma, 2000-2003

0

5

10

15

20

25

30

35

Num

ber

of

death

s

2000 2001 2002 2003

Year of death

Co-sleep Not co-sleep

Source: Oklahoma State Medical Examiner, n = 103, excludes 3 unknowns

Co-Sleeping Deaths by Age and Sex, Oklahoma,

2000-2003

0

2

4

6

8

10

12

14

16

18

20

Num

ber

of

dea

ths

0 1 2 3 4 5 6 7 8 9 10 11

Age in months

Female Male

Source: Oklahoma State Medical Examiner, n = 68

Surface and Co-sleep

• 71% on bed

• 9% on couch/chair/love seat

• 6% mattress on floor

• 4% on waterbed

• 1% in crib (sleeping with twin)

• 9% all other/unk combined

Source: Oklahoma State Medical Examiner, n = 68

Co-sleepers Deaths by Mechanism of Injury,

Oklahoma, 2000-2003• 55% possible/definite overlay

• 4% entrapped

• 3% pillow

• 6% found on floor

• 1% other

• 31% not specified

Source: Oklahoma State Medical Examiner, n = 68

Factors Present When Cases Lacked Details on

Possible Mechanisms• 33% open or history of CPS

involvement

• 19% staying at someone else’s home

• 10% previous apnea episodes

• 10% face down on mattress

• 5% waterbedSource: Oklahoma State Medical Examiner, n = 68

Co-sleeping Characteristics

• Number co-sleeping– 50% two sleeping together– 40% three sleeping together– 10% four sleeping together

• Classification of sleeper– 73% adult(s)– 18% child(ren)– 9% adult(s) and child(ren)

Source: Oklahoma State Medical Examiner, n = 68

Medical Examiner Interview

• Infant deaths increasing• Co-sleeping deaths increasing

– Mainly among the white population

• Beliefs, opinions, and experiences reflected in reporting

• Budget cuts in 2003– May have resulted in change in coding

Infant Deaths by Selected Cause, Oklahoma,

2000-2003Database/Cause 2000 2001 2002 2003

VS – all infant #

(Rate/1,000 births)

420

(8.4)

362

(7.2)

406

(8.1)

395

(7.8)

ME – all infant #

(Percent of VS infant deaths)

216

(51%)

222

(61%)

248

(61%)

278

(70%)

ME – unsafe sleep #

(Percent of ME infant cases)

21

(10%)

23

(10%)

17

(7%)

47

(17%)

ME Investigated Infant Deaths by Selected Cause,

Oklahoma, 2000-2003

0

10

20

30

40

50

60

2000 2001 2002 2003

Year

Num

ber

of

death

s

ME unsafe sleep ME SIDS

Source: Oklahoma State Medical Examiner

Conclusions

• Unsafe sleep deaths– Most were infants < 3 months of age

– Half occurred in beds

– Unsafe items used in cribs and bassinettes

– Mechanism of injury varied by age

• Co-sleep deaths– Increase in co-sleeping deaths

– Increase among whites

– Not clear if due to artifact of coding

Limitations

• Non-standardized documentation• Medical Examiners and

investigators limited by informants • Distinguishing SIDS from other

causes• Budget cuts to the Medical

Examiner

Discussion

• Other States have similar trends

• Cultural issue

• Distinguishing SIDS from overlay

• Coding of undetermined cause or intent

Recommendations

• Education campaign for businesses– Crib displays in

stores that show safe sleeping environments

Recommendations

• Increase awareness of co-sleeping deaths• Promote consistent safe sleeping practice

messages through collaborative efforts– Same safe sleeping environments can reduce

risk factors for overlay, SIDS, and asphyxia

• Messages that resonate with target populations

Questions?Questions?