Chapter 11 Sudden and unexpected death in infancy

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Chapter 11 Sudden and unexpected death in infancy Powered By Docstoc
					Chapter 11: Sudden and unexpected death in infancy
Classification of sudden and                                                    Sudden and unexpected death in infancy
unexpected death in infancy                                                    in Queensland
                                                                               SUDI accounted for 63 deaths of infants under
Sudden and unexpected death in infancy (SUDI) is
                                                                               the age of one year during the 18 month reporting
defined as deaths of children under one year of age
                                                                               period from 1 January 2004 to 30 June 2005 in
in which no cause of death is immediately obvious.
SUDI is not a cause of death. Rather, it is best
                                                                               Figure 11.1 shows the main categories of
understood as a preliminary or ‘umbrella’
                                                                               postneonatal infant deaths (deaths of infants aged
classification, which delineates a class of deaths
                                                                               from 28 to 364 days).
that appear to share similar features and require
further investigation.                                                         Figure 11.1: Main categories of postneonatal infant deaths
                                                                               in Queensland
As indicated by the use of the term ‘unexpected’,
infants have generally been either completely well                               SIDS & undetermined Other diseases & morbid conditions
or have been suffering from only an apparently                                          17.5%                       8.7%
                                                                                                                       Infectious & parasitic
minor illness. SUDIs include the deaths of infants                                                                         diseases 4.8%
where, following a full investigation, a medical cause                                                                                     External
of death is established. The term SUDI therefore                                                                                           causes
includes deaths associated with unrecognised                                                                                                5.6%
                                                                               Cause of
infection or anatomical or developmental                                        death                                                       Respiratory
abnormalities, sleep accidents due to unsafe sleep                             pending                                                        system
                                                                                16.7%                                                        diseases
environments, and deaths which initially present as                                                                                            8.7%
sudden and unexpected, but are later found to be
the result of non-accidental injury. It also includes                                                                                 Nervous system
deaths due to sudden infant death syndrome (SIDS)                                                                                          9.5%
and other undetermined or ill-defined causes (NSW                                                                       Perinatal related
Child Death Review Team, 2005:7; Krous et al.,                                            14.3%                           conditions
2004:236).                                                                                                                  14.3%

Côté’s, Russo’s and Michaud’s (1999:442) review of                             Data source: Queensland Child Death Register (2004–05)

all 623 cases of sudden unexpected infant207 death                             Cases of SUDI can be classified into five categories:
in the Canadian province of Quebec between 1987                                • sudden infant death syndrome (SIDS)
and 1996, found that virtually all were sudden, and                            • sleep accidents including accidental suffocation
only 21 occurred when the infant was awake208.                                   and deaths caused by unsafe cots and bedding
On this basis, and in the absence of literature                                • unrecognised morbid processes or congenital
concerning the prevalence of sudden awake deaths,                                abnormalities, and
the authors concluded that it is appropriate to regard                         • deaths where the autopsy findings are
SUDI deaths as sleep related (that is, occurring after                           insufficient to determine the cause of death
the infant has been placed to sleep).                                            (undetermined/unascertained).
Some SUDIs may be preventable in the future;                                   Cases of SUDI analysed in this chapter also
however, this is only possible if causes of SUDI are                           include deaths which presented as a SUDI but the
established by appropriate investigations.                                     pathologist’s or coroner’s findings are pending.

207    Côté, Russo and Michaud (1999:442) extended their review to included children aged up to 18 months because “although sudden death is
      known to occur after one year of age, very little is known about the prevalence of the various causes of death in the 12 to 18 month age group”.
      The Commission defines an infant as a child under one year.
208 Seven cardiac causes, seven unexplained deaths, five child abuse situations and two infectious causes.

Annual Report Deaths of children and young people Queensland 2004–05                                                                                  131
Figure 11.2 shows the cause of death breakdown for              Sudden infant death syndrome
SUDI deaths during the reporting period.
                                                                and undetermined causes of
Figure 11.2: Sudden unexpected deaths in infancy causes
of death
                                                                infant death
        Infectious & parasitic diseases 3.2%                    Incidence of sudden infant death
                                           Respiratory system   syndrome in Queensland
                                                 12.7%          As discussed in chapter 2, SIDS was the leading
Pending                                                         cause of death of infants in Queensland during the
 36.5%                                                          period from 1991 to 2003. The SIDS rate peaked
                                                                in the late 1980s. A major SIDS information and
                                                                awareness raising campaign occurred in 1991. The
                                                                ‘Reducing the Risk of SIDS’ information campaign
                                                                launched by SIDS and Kids (formerly the National
                                                                SIDS Council of Australia) has been credited with
                                                                contributing to the reduction of the SIDS rate.
                                               SIDS &
      External causes                       undetermined        While the incidence of SIDS has decreased
           6.3%                                41.3%            significantly over the past 13 years (from 1.2
                                                                deaths per 1000 live births in 1991 to 0.2 deaths
Data source: Queensland Child Death Register (2004–05)          per 1000 live births in 2003), Queensland’s SIDS
SUDI has been a significant focus of the                         mortality rate remained above the national average
Commission’s child death research in 2004–05. A                 during this period (0.9 deaths per 1000 live births
detailed review of the contemporary literature on the           compared with an average of 0.7 per 1000 live births
changing definitions of SIDS, potentially modifiable              nationally). Moreover, while the Reducing the Risk of
SIDS risk factors and sleeping with an infant, is               SIDS campaign appears to have been effective in the
provided in this chapter. This is in recognition that:          mainstream population, evidence suggests that the
                                                                key messages are not reaching high risk populations,
• infants under one year are the most vulnerable                including Indigenous communities. This is particularly
  age group of children                                         the case in Queensland (Panaretto et al., 2002:132;
• Queensland’s SIDS rates have remained above                   Queensland Government Media Release, 2005).
  the national average during the 13 years from
  1991 to 2003 (reviewed in chapter 2)                          Defining sudden infant death syndrome:
• Aboriginal and Torres Strait Islander infants are
  significantly over-represented in rates of SIDS and
                                                                changes over time
  other SUDI, and                                               SIDS is a term to describe a distinctive subgroup
• there is widespread debate about whether shared               of infant deaths that share similar clinical,
  sleeping increases the risk of SIDS.                          epidemiological and pathological features,
                                                                but in which post-mortem investigations fail to
A detailed analysis of all SUDI deaths registered in
                                                                demonstrate a definite cause of death (Beckwith,
Queensland between 1 January 2004 and 30 June
                                                                2003:286; Krous et al., 2004:234; Willinger, James
2005 is presented in the trends and patterns section
                                                                & Catz, 1991).
of this chapter.

132                                                              Commission for Children and Young People and Child Guardian
The term SIDS was coined in 1969 at the Second                  association with sleep; a requirement for extensive
International Conference on Causes of Sudden Death              ancillary post-mortem investigations (such as
in Infants, hosted by the United States National                microbiological and toxicological testing); sub-
Institute of Child Health and Human Development                 classifications based on the presence or absence of
(NICHD). The definition, known as the 1969                       minor pathological findings; and upper and lower
definition, is:                                                  age limits (Willinger, James & Catz, 1991; Rambud,
                                                                Guilleminault & Campbell 1994; Sturner, 1998).
   “The sudden death of any infant or young child,
   which is unexpected by history, and in which                 In 2003, Beckwith again proposed a re-examination
   a thorough post-mortem examination fails to                  of the definition of SIDS to include positive diagnostic
   demonstrate an adequate cause of death”                      criteria and classification of particular subsets.
   (Beckwith, 2003:287).
                                                                In response, the SIDS Redefinition Conference in
For 20 years this definition remained unchanged                  San Diego, California was convened in January
and it continues to have many supporters. However,              2004. The conference brought together paediatric
it contains no limiting criteria and does not list the          pathologists, forensic pathologists, paediatricians
features common to most cases.                                  and epidemiologists with extensive experience with
                                                                sudden infant death.
In June 1989, the NICHD convened an expert panel
to better define SIDS. Pathologist Bruce Beckwith                The forum discussed the history of SIDS definitions,
proposed to incorporate the most consistent                     its present status and possible proposals for the
epidemiological features of the syndrome into the               future, including reporting factors that may have
definition and to establish the distinction between              contributed to the death on the death certificate.
‘typical’ and ‘non-typical’ SIDS cases. While the               The forum concluded that “creating and supporting
proposal generated significant discussion, the                   a more inclusive SIDS definition would facilitate
panel rejected the stratified diagnostic approach                uniformity in diagnosis, with a resultant increase in
(Beckwith, 2003:288). The revised version, termed               information on current cases” (Krous et al., 2004:235).
the 1989 definition, was published in 1991:
                                                                Existing SIDS definitions were considered
   “The sudden death of an infant under one year of             inadequate (applied either too generally or too
   age, which remains unexplained after a thorough              restrictively) and exclusionary, that is, failing to
   case investigation, including performance                    incorporate known features of the syndrome such as
   of a complete autopsy, examination of the                    age range and death occurring during sleep.
   death scene and review of the clinical history”
                                                                The forum developed a new SIDS definition, termed
   (Willinger, James & Catz, 1991:681).
                                                                the 2004 San Diego definition:
This definition, although only a slight revision of the
                                                                   “The sudden and unexpected death of an
1969 definition, limited the age to less than one
                                                                   infant under one year of age, with onset of the
year and added the requirements to examine the
                                                                   lethal episode apparently occurring during
death scene and review the clinical history.
                                                                   sleep, that remains unexplained after a
For a second time, at the SIDS International                       thorough investigation, including performance
Meeting in Sydney in 1992, Beckwith proposed                       of a complete autopsy and review of the
including categories in the SIDS definition. While                  circumstances of death and the clinical history”
the proposal was not accepted at the time, a                       (Krous et al., 2004:235).
number of pathologists later supported sub-
                                                                The forum also concluded that defining subsets
classification (Czegledy-Nagy, Cutz & Becker, 1993;
                                                                of SIDS would help officials monitor the effects of
Krous et al., 2004:234).
                                                                public health recommendations and changes in
Different SIDS definitions developed over the past               infant care practices.
decade have focused on various factors including an

Annual Report Deaths of children and young people Queensland 2004–05                                                 133
The stated goals of stratifying cases of SIDS into                          autopsies are not performed)”, be attributed to
subcategories include:                                                      unclassified sudden infant death (USID) (previously
                                                                            ‘undetermined’ or ‘unascertained’) (Krous et al.,
• providing recommended guidelines for general
  assessment, classification and diagnosis
• identifying and including cases that had previously                       Figure 6.3 shows the complete list of criteria for SIDS
  been excluded from SIDS groups, due to shared                             sub-categorisation.
  sleeping or prone sleeping position, and
                                                                            In previous definitions SIDS was seen as a
• separating cases on the basis of the degree
                                                                            ‘diagnosis of exclusion’. The 2004 San Diego
  of certainty and the confidence with which a
                                                                            definition recognised the existence of certain
  diagnosis of SIDS can be made (Krous et al.,
                                                                            elements common to the majority of cases. A general
                                                                            definition including these specific criteria was
Consequently, as part of the definition, the San                             created to capture as many cases as possible. The
Diego forum also achieved consensus on the                                  introduction of sub-categories was prompted partly
following sub-categories.                                                   because the number of classic SIDS cases – typical
                                                                            of those occurring in the 1970s and 1980s before
Category IA SIDS: The classic features of SIDS are
                                                                            the Back to Sleep (United States) and Reducing the
present and completely documented including
                                                                            Risk of SIDS (Australia) campaigns – has decreased,
the typical age range of 21 days to less than nine
                                                                            and the SIDS cases that continue to occur are
months. Cases in this category show no evidence
                                                                            more heterogenous with a variety of underlying
of trauma, disease or lesions at autopsy, and all
                                                                            mechanisms of death (Krous et al., 2004:236)209.
toxicology results are negative. Normal clinical
history, growth and development, and the death                               A four-month-old was found dead in his cot. The
scene shows nothing that could have contributed to                           infant was placed to sleep on his stomach with his
the death.                                                                   head to one side. The infant’s mother checked on
Category IB SIDS: As above, except an investigation                          him twice in a two hour period, at which time the
of death scene was not performed and at least                                infant appeared to be breathing. Shortly after the
one the following analyses were not performed:                               second check, the mother returned to the infant
toxicologic, microbiologic, radiologic, vitreous                             and rolled him onto his back. The infant was cold,
chemistry or metabolic screening studies.                                    pale and unresponsive.
Category II SIDS: Meets the criteria for IA or B, except                     An autopsy showed no signs of external, internal
the infant was either outside the typical age range;                         or radiological injury to the child, and no natural
had abnormal growth or development; an autopsy                               disease was recognised as a cause of death.
reveals an abnormality that appears significant                               Toxicology showed an absence of alcohol or other
but whose precise role in the death is difficult to                           drugs. The autopsy report noted that SIDS was
determine; or mechanical asphyxia due to overlay                             certified due to the negative results and lack of
(when an infant’s breathing is restricted by part of                         any suspicious findings at the death scene.
someone who is sleeping with the infant) cannot be                           There was no evidence that either of the parents
excluded.                                                                    were habitual smokers or used alcohol or drugs in
The forum also proposed that those cases that                                the home.
do not fall into the above categories, but in which                          Death scene examination revealed no sign of
“alternative diagnoses of natural or unnatural                               criminal or negligent behaviour at the home.
conditions are equivocal (including cases for which

209 The substantial reduction in the number of infant deaths associated with the Back to Sleep and Reducing the Risk of SIDS campaigns has
    primarily occurred among those infants who previously represented the most typical SIDS cases. The peak in the age distribution curve between
    two and four months has become less prominent. Infants now dying suddenly and unexpectedly include a higher proportion of atypical cases,
    where the index of suspicion is higher then previously. Beckwith (2003:287) contends that this change in demographics has contributed to an
    increasing reluctance on the part of many pathologists to use the diagnosis of SIDS.

134                                                                           Commission for Children and Young People and Child Guardian
Figure 6.3: Sudden infant death syndrome sub-categorisation

 Category IA SIDS: Classic features of SIDS present and completely documented
 Category IA includes infant deaths that meet the requirements of the general definition and also all of the following
 Clinical                      •   More than 21 days and < 9 months of age
                               •   Normal clinical history, including term pregnancy (gestational age of 37 weeks).
                               •   Normal growth and development.
                               •   No similar deaths among siblings, close genetic relatives (uncles, aunts or first-degree
                                   cousins), or other infants in the custody of the same caregiver.
 Circumstances of              • Investigation of the various scenes where incidents leading to death might have occurred
 death                           and determination that they do not provide an explanation for the death.
                               • Found in a safe sleeping environment, with no evidence of accidental death.
 Autopsy                       • Absence of potentially fatal pathological findings. Minor respiratory system inflammatory
                                 infiltrates are acceptable; intrathoracic petechial haemorrhage is a supportive but not
                                 obligatory or diagnostic finding.
                               • No evidence of unexplained trauma, abuse, neglect or unintentional injury.
                               • No evidence of substantial thymic stress effect (Thymic weight of < 15g and/or moderate/
                                 severe/cortical lymphocyte depletion). Occasional “starry sky” macrohages or minor
                                 cortical depletion is acceptable.
                               • Negative results of toxicologic, microbiologic, radiologic, vitreous chemistry, and
                                 metabolic screening studies.
 Category IB SIDS: Classic features of SIDS present but incompletely documented
 Category IB includes infant deaths that meet the requirements of the general definition and also meet all of the criteria
 for category IA except that investigation of the various scenes where incidents leading to death might have occurred
 was not performed and/or 1 of the following analyses was not performed: toxicologic, microbiologic, radiologic,
 vitreous chemistry, or metabolic screening studies.
 Category II SIDS
 Category II includes infant deaths that meet category I criteria except for     1 of the following.
 Clinical                      • Age range outside that of category IA or IB (i.e. 0–21 days or 270 days [9 months] through
                                 first birthday before 22 days or after nine months).
                               • Similar deaths among siblings, close relatives or other infants in the custody of the same
                                 caregiver that are not considered suspect for infanticide or recognised genetic disorders.
                               • Neonatal or perinatal conditions (for example those resulting from preterm birth) that have
                                 been resolved by the time of death.
 Circumstances of              • Mechanical asphyxia or suffocation caused by overlaying not determined with certainty.
 Autopsy                       • Abnormal growth and development not thought to have contributed to death.
                               • Marked inflammatory changes or abnormalities not sufficient to be unequivocal causes of
 Unclassified Sudden Infant Death
 The unclassified category includes deaths that do not meet the criteria for category I or II SIDS but for which alternative
 diagnoses of natural or unnatural conditions are equivocal, including cases in which autopsies were not performed.
Data source: Krous et al., (2004:235–236)

Annual Report Deaths of children and young people Queensland 2004–05                                                         135
Undetermined or unascertained                                               Contemporary research is inconsistent on whether
                                                                            suspected unintentional asphyxia, failure to thrive,
infant death
                                                                            abnormal development or similar deaths among
As shown in chapter 2, undetermined or                                      siblings should be considered sufficient to prevent
unascertained infant deaths210 account for a growing                        a SIDS diagnosis. While Mitchell and colleagues
proportion of unexpected infant death, increasing                           (2000:211) and Knight and colleagues (2005:29)
from one death in 1991 to 14 deaths in 2003.                                claim that these features raise enough concern to
The classification undetermined is applied in cases                          dissuade from a SIDS diagnosis, they are listed as
with a variety of conditions that raise sufficient                           possible criteria for category II SIDS under the sub-
doubt to deter from a SIDS diagnosis. Byard (2004                           categorisation.
cited in Krous et al., 2004:235) argues that these                          The Commission consulted a senior forensic
terms should be used to flag cases in which                                  pathologist from Queensland Health Scientific
significant parts of the investigation are lacking or in                     Services (known as the John Tonge Centre) to
which there are questions regarding possible causes                         determine whether sleeping with an infant
of death.                                                                   was sufficient to exclude a SIDS diagnosis. The
SUDIs should be defined as undetermined when:                                pathologist advised that until recently, it was
                                                                            not common practice to record shared sleeping
    “insufficient findings are present to support
                                                                            related deaths as SIDS because of the possibility of
    a particular diagnosis, but when sufficient
                                                                            accidental asphyxia. However, since the introduction
    abnormal features in the history or at the scene
                                                                            of the 2004 San Deigo definition, and after extensive
    examination, autopsy or laboratory workshop
                                                                            discussions among specialist pathologists, it is now
    were found that were not typical of SIDS”
                                                                            standard practice to record ‘sudden infant death
    (Mitchell et al., 2000:312).
                                                                            syndrome (co-sleeping)’ on the death certificate.
Following this definition, Mitchell and colleagues                           As a result, researchers should be able to
(2000:311) contend that cases of SUDI should be                             distinguish from the death certificate those cases
classified as undetermined if:                                               that are not characteristic of classic SIDS (category IA
• natural disease processes were detected that are                          SIDS) due to shared sleeping.
  not considered sufficient to cause death but that                            A three-week-old infant was found dead in a
  preclude a diagnosis of SIDS                                                double bed she was sharing with her parents. The
• there are signs of significant stress                                        infant normally slept in a cot, but on this occasion
• non-accidental, but non-lethal injuries were                                was sharing a bed with her mother and father.
  present, or
                                                                              The infant was found on her side in the same
• toxicologic screening detects non-prescribed but
                                                                              general position as when put to sleep. There was
  non-lethal drugs.
                                                                              evidence of habitual smoking in the home.
The 2004 San Deigo definition replaced
                                                                              The infant was of low birth weight and born
undetermined and unascertained with the term
‘unclassified sudden infant death’ (USID), defined
simply as including:                                                          The cause of death was certified as sudden infant
                                                                              death syndrome (co-sleeping).
    “deaths that do not meet the criteria for category
    I or II SIDS but for which alternative diagnoses
    of natural or unnatural conditions are equivocal,
    including cases for which autopsies were not
    performed” (Krous et al., 2004:236).

210 Within ICD-10 coding, there is no specific code for undetermined or unascertained infant deaths: ‘ill-defined and unknown causes of mortality’
    (ICD-10 codes R96 to R99) apply to all age groups (R95 sudden infant death syndrome is not considered an ‘ill-defined’ cause of mortality).

136                                                                           Commission for Children and Young People and Child Guardian
Definition and classification of sudden                                      While Queensland pathologists have adopted the
                                                                           new definition, they have not adopted the sub-
infant death syndrome in Queensland
                                                                           categorisations. However a QH senior forensic
Despite the significant number of conferences and                           pathologist advised the Commission that the sub-
forums held over the past 20 years, there is no                            categorisations are a useful tool for research and
internationally agreed and applied definition of                            that researchers should be able to assign cases of
SIDS. Jurisdictional differences in the definition and                      SIDS to the appropriate sub-categories on the basis
classification of SIDS remains an ongoing issue.                            of police, pathology and coronial reports.
In Australia, significant work has been done at                             Using the expertise of a heath advisory committee
the national level to standardise the definition of                         the Commission plans to classify cases of SIDS in
SIDS. In March 2004, SIDS and Kids Australia (the                          Queensland, according to the sub-categorisations,
peak non-government body on SIDS) hosted the                               to assess the usefulness of sub-categorisations as a
first Australian Sudden Infant Death Syndrome                               state wide data source212.
Pathology Workshop. The workshop brought
together paediatric and forensic pathologists from                         Risk factors for sudden infant death
forensic institutions in each state and territory
to discuss problems and issues related to the
diagnosis and forensic management of infant death                          Many studies compare the epidemiological
in Australia. Participants agreed to implement the                         characteristics of infants who died from SIDS
2004 San Diego definition of SIDS211. It was also                           with non-SIDS infants in an attempt to identify
agreed that the ill-defined terms unascertained and                         risk factors. Keens (2002:3) states the difference
undetermined would be replaced with unclassified                            between risk factors and causes as follows:
sudden infant death (USID).                                                    “When risk factors are found in a population the
The sub-categories developed at San Diego were                                 statistical risk of SIDS occurring in that population
also discussed extensively at the workshop.                                    increases. However, ‘risk factors’ are not causes
Although they were considered a valuable                                       of SIDS. They may provide clues for researchers to
instrument for researchers, with the exception                                 the cause of SIDS. Therefore they are important
of USID, no consensus could be reached on the                                  for research. However, no risk factor, singly or in
adoption of these classifications.                                              combination is sufficiently precise to predict the
                                                                               baby who will die from SIDS”213.
The Commission consulted with Queensland
Health (QH) to determine their position on the                             Maternal, infant and environmental factors have
categorisation of sudden infant death. While QH                            been consistently identified in the literature214 to be
has not formally endorsed or adopted the 2004 San                          associated with a statistically increased risk of SIDS.
Diego definition of SIDS, apparently all pathologists                       Parental factors include:
who conduct infant autopsies in Queensland
                                                                           • cigarette smoking during pregnancy and after birth
attended the Australian SIDS Pathology Workshop.
                                                                           • alcohol and drug abuse
As a result, it is now the practice of QH pathologists
                                                                           • young maternal age (under 20 years) and older
to certify the cause of an infant death as SIDS
according to the new definition.
                                                                           • high parity (number of births by mother) and
                                                                             short inter-pregnancy intervals, and
                                                                           • poor or delayed prenatal care.
211 SIDS and Kids also report that extensive progress was made towards the development of an agreed Australian SIDS Autopsy Protocol.
212 Under the Commission for Children and Young People and Child Guardian Act 2000, the Commission may establish expert health advisory
    committees to provide advice to the Commissioner on matters in relation to which the committee has expertise. In 2005-06 the Commission
    hopes to establish and/or utilise the expertise of an existing health advisory committee such as Queensland Paediatric Quality Council.
213 Emphasis included in original.
214 See for example: Alm et al., 1999; Alessandri et al., 1996; American Academy of Pediatrics, 2000; Beal, 1988; Beal, 1989; Beckwith, 2003;
    Byard, 2004:496-497; Carroll-Pankhurst & Mortimer, 2001; Golding, 1997; Hoffman & Hillman, 1992; Kandall et al., 1993; Keens, 2002; Mesich,
    2005; Spencer & Logan, 2004; Davidson Ward et al., 1990; Osmond & Murphy, 1988.

Annual Report Deaths of children and young people Queensland 2004–05                                                                          137
Infant factors include:                                                          Estimates of the SIDS rate for Indigenous infants in
• prematurity (less than 37 weeks gestation)215                                  Queensland vary. Studies by Panaretto, Smallwood
  and low birth weight (less than 2500 grams)                                    and colleagues (2002) and Panaretto, Whitehall and
• multiple gestation (twins, triplets)                                           colleagues (2002) conclude that in Queensland, SIDS
• neonatal health problems                                                       rates may be up to three times higher in Indigenous
• male gender, and                                                               communities, than in the non-Indigenous population.
• history of minor viral respiratory infections and/or                           Risk factors for SIDS are reportedly217 more prevalent
  gastrointestinal illness in the days leading up to                             in the Indigenous population. Compared to non-
  death216.                                                                      Indigenous mothers, Indigenous mothers:
Environmental factors include:
                                                                                 • are at least two times more likely to smoke during
• poor socioeconomic status (social disadvantage)                                  pregnancy and after birth
• sleeping on soft surfaces and loose bedding                                    • are sixteen times more likely to consume high or
• prone (on stomach) sleeping position and side                                    risky levels of alcohol
  sleeping position                                                              • have a higher incidence of reported drug abuse
• winter months                                                                  • are more likely to be under 20 years of age
• over wrapping/overheating, and                                                 • have higher parity
• some forms of shared sleeping.                                                 • have lower levels of nutrition leading to infant
                                                                                   growth retardation in the early stages of gestation
Aboriginal and Torres Strait Islander infants
                                                                                 • have poor antenatal care218, and
In Queensland, Aboriginal and Torres Strait Islander                             • have low birth weight babies219.
infants have a statistically increased risk of SIDS.
Indigenous infants in Queensland have a perinatal                                Potentially modifiable risk factors
mortality rate twice that of non-Indigenous infants                              During the past two decades research has identified
and an infant mortality rate between four and five                                several risk factors relating to parental behaviour
times higher than non-Indigenous infants (466.1                                  and environmental factors, particularly an infant’s
deaths per 100,000 Indigenous infants compared                                   sleep environment, which can be modified. While
to 150.2 deaths per 100,000 non-Indigenous                                       research has largely concentrated on SIDS, the New
infants) (Queensland Paediatric Quality Council,                                 South Wales Child Death Review Team’s (2005:57)
2004:82). A high infant mortality rate considered                                report on SUDI suggested that risk factors associated
to be an indicator of maternal health and lifestyle                              with SIDS can be applied to some forms of SUDI
and is associated with poor social and economic                                  (most notably undetermined or unascertained infant
conditions (Queensland Health, 2004).                                            deaths with similar epidemiological profiles to SIDS).
The rate of SIDS peaked in the late 1980s and fell                               Understanding risk factors for SIDS that are
significantly following the Reducing the Risk of SIDS                             potentially modifiable through behavioural, social
campaign. The rate of SIDS in Indigenous infants                                 and environmental changes can help health
remained high even after the campaign (Stanley,                                  professionals and public policy makers educate and
2002). At a national level, the ABS (2003:25)                                    support high risk infants and families (NSW Child
estimates the SIDS rate for Indigenous infants is                                Death Review Team, 2005:58).
almost six times higher than for non-Indigenous
infants in Australia.
215 For increased sensitivity, Knight et al.,’s (2005:30) recent study defined prematurity as less than 37 weeks of gestation. Thirty-two weeks or less
    is a more traditional definition of prematurity.
216 There is some conjecture surrounding reported symptoms of illnesses in period preceding infant death as ‘sniffles’ and other conditions (whether
    infections or physiologic) are common in this age group and are often reported by concerned family members after the unexpected death of an
    infant (Knight et al., 2005:30).
217 See for example: Panaretto, Whitehall et al., 2002:135; Panaretto, Smallwood et al., 2002:441; Australian Bureau of Statistics, 2003a:12;
    Queensland Health; 2005:31,33; Australian Bureau of Statistics & Australian Institute of Health and Welfare, 2005:76,104; Alessandri et al.,
    1996:241; Australian Bureau of Statistics, 2002; Douglas et al., 2001.
218 Around 10% of Aboriginal and 6% of Torres Strait Islander mothers report fewer than two antenatal visits to a general practitioner, clinic or midwife.
219 Thirteen percent of Aboriginal mothers compared to 6% of non-Indigenous mothers.

138                                                                                Commission for Children and Young People and Child Guardian
Low socioeconomic status                                                 Cigarette smoke exposure
A considerable body of literature examines the                           Exposure to cigarette smoke is associated with
link between low socioeconomic status and SUDI                           health problems for infants and an increased risk of
(Spencer & Logan, 2004:366; Byard, 2004:507;                             SIDS.
Valdes-Dapena, 1980).
                                                                         There have been nearly 50 studies conducted into
Spencer’s and Logan’s (2004:366–370) review of                           the relationship between smoking and infant death,
observational studies, documenting the relationship                      with a strong, independent association identified
between SUDI and socioeconomic status, found                             between smoking during pregnancy and SIDS, has
that in 51 of the 52 studies since 1965, the risk of                     been established (Haglund & Cnattingius, 1990;
death increased with greater exposure to adverse                         Malloy et al., 1988; McGlashan, 1990; Golding,
social circumstances. The review also found that                         1997; Byard, 2004; Mitchell, 1995). This finding is
socioeconomic status has an effect on sudden                             consistent over time and across jurisdictions.
infant death independent of other major risk factors.
                                                                         There is now a growing body of evidence to suggest
Socioeconomic status measures retained statistical
                                                                         that exposure to cigarette smoke after birth further
significance in the vast majority of studies adjusting
                                                                         increases the risk. While the methodological
for other variables such as maternal smoking during
                                                                         difficulties of identifying independent effects on
and after pregnancy, birth weight and sleeping
                                                                         SIDS of postnatal exposure to tobacco smoke
position. Further work is required to explain how
                                                                         have been noted220, evidence of the effect of
socioeconomic factors influence sudden infant
                                                                         environmental tobacco smoke exposure has been
                                                                         obtained by examining the risk of SIDS from paternal
Following the general decline in deaths attributed                       smoking where the mother is a non-smoker. There
to SIDS, the socioeconomic profile of affected                            have been at least six such studies to date. Mitchell
families has changed. Mitchell and colleagues                            (2000) suggests that infants who are exposed to
(2000:313) found that a significant percentage                            environmental cigarette smoke are almost one and a
of families that experience a SIDS death (or other                       half times more likely to die of SIDS than infants who
SUDI) have chaotic, itinerant lives characterised                        are not.
by social problems such as substandard housing,
                                                                         Recent evidence also suggests that the risk of death
unemployment, illicit drug use, multiple partners
                                                                         doubles if an infant shares a bed with a mother who
and domestic violence.
                                                                         smokes, although it is unclear how this occurs (Byard,
While some researchers argue that the                                    2004:501). The risks associated with shared sleeping
socioeconomic status of families with infants and                        and smoking are discussed later in this chapter.
young children can not be changed (Blair et al.,
                                                                         Byard (2004:499) reports that infants who have
1996; I’Hoir, 1998), Spencer and Logan (2004:371)
                                                                         been exposed to cigarette toxins during pregnancy
contend that this is primarily to justify “the exclusive
                                                                         and after birth have a five times greater risk of SIDS.
concentration on proximal risk factors in the
prevention of sudden infant death”.                                      While it is not clear how SIDS occurs, the
                                                                         predominant effect from maternal smoking is
Social disadvantage is an important factor when
                                                                         generally attributed to in utero exposure of the
considering the epidemiology of SUDI and should
                                                                         foetus. Evidence suggests that smoking may be
not be dismissed as an unmodifiable variable.
                                                                         responsible for reduction in body and placental
Rather, preventative programs need to address the
                                                                         size in SIDS infants. Impaired arousal has also been
social circumstances into which infants are born, in
                                                                         demonstrated in infants exposed to tobacco smoke
addition to promoting parental behaviour change.
                                                                         (Horne et al., 2002; Byard, 2004:499).

220 See Mitchell and Milerad, 2000 cited in NSW Child Death Review Team 2005:60.

Annual Report Deaths of children and young people Queensland 2004–05                                                        139
Parents and caregivers should be advised of the                               health professionals to recognise features of illness
risks associated with infant exposure to tobacco                              in infants and subsequently seek or provide medical
smoke both during pregnancy and after birth.                                  attention would reduce sudden infant death” (cited
Given the overwhelming evidence that maternal                                 in NSW Child Death Review Team, 2005:61).
smoking increases the risk of SIDS, interventions
to help pregnant women stop smoking should be                                 Stomach down and side sleeping
encouraged.                                                                   The association of infant death with sleeping
                                                                              position was first reported in 1944 by Abramson
Substance abuse                                                               (cited in Byard, 2004:497–498) who recommended
A number of studies have consistently identified                               that “the routine nursing practice of placing infants
increased risks of infant death associated with                               in the prone position be avoided except during such
parental substance abuse.                                                     times as the babies are constantly attended” and
                                                                              that “the practice should, furthermore, be entirely
For example:
                                                                              done away with at night”.
• heavy intake of alcohol by the mother after birth
                                                                              Australian and Dutch researchers (Beal, 1986;
  has been associated with an increased risk of
                                                                              de Jonge et al.,1989) were among the first to
  infant death (Alm et al., 1999; Byard, 2004:504)
                                                                              highlight the possible link between stomach
• maternal abuse of opiates increases the risk of
                                                                              down sleeping and sudden death in the scientific
  infant death and breastfed infants exposed to
                                                                              literature. De Jonge and Engleberts (1989) found
  opioids in breast milk have increased risks of
                                                                              an increased incidence of SIDS in the Netherlands
  apnoea, and
                                                                              after the introduction of policies recommending
• maternally ingested amphetamines may also
                                                                              stomach down sleeping for infants in the early
  contaminate breast milk and increase the risk of
                                                                              1970s. Following the publication of de Jonge’s
  infant death (Byard, 2004:503).
                                                                              initial findings, stomach down infant sleeping has
Infant illness                                                                decreased by almost 30% and SIDS by 40%.
Infant illness has increasingly been recognised as                            While researchers initially debated the association
a modifiable risk factor associated with sudden                                between sleeping position and sudden death222, the
infant death. The Confidential Inquiry into Stillbirths                        connection is now widely accepted. Many studies
and Deaths in Infancy (CESDI Study) in the United                             have found that infants who sleep stomach down
Kingdom is the largest epidemiological study of SIDS                          are between 3.5 and 9.3 times more likely to die
risk factors since the introduction of risk reduction                         of SIDS223 (Byard, 2004:498). This association is
campaigns in the early 1990s (Blair et al., 1996;                             maintained (and in some studies strengthened)
Fleming et al.,1996; 2000). The CESDI Study found                             after adjusting for confounding variables (Byard,
that more SIDS than control infants were reported                             2004:498; Beal, 1988; Beal, 1991; Mitchell et al.,
by parents to be in poor health. Significantly, more                           1992; Henderson-Smart et al., 1998; Dwyer et al.,
SIDS infants were unwell and needed a doctor’s                                1991; American Academy of Paediatrics, 2000).
assessment (10% compared to 4% for controls) or
                                                                              The Reducing the Risk of SIDS campaign introduced
needed medical attention (5% compared with 1%
                                                                              in Australia (and many other countries) in the early
for controls).
                                                                              1990s encouraged parents to place infants on
The CESDI Study found that parents and health                                 their backs or sides to sleep. However, evidence
professionals often underestimated the severity                               of a smaller but significantly increased risk of SIDS
of illness in infants221. The study concluded that                            associated with the side sleeping position has
“improvement in the ability of both parents and                               emerged in recent years (NSW Child Death Review
221   Health professionals included general practitioners, paediatricians, health visitors, nurses, midwives and obstetricians.
222 Byard (2004:498) cites the following examples in the academic and scientific literature: Golding, Limerick & Mcfarlane, 1985; Guntheroth, 1989;
    Guntheroth & Spiers, 1990; Hunt & Shannon, 1992; Milner & Ruggins, 1989; Naeye, 1988.
223 The American Academy of Paediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome (2000:650) report odds ratios for
    SIDS when an infant is slept prone range from 1.7 to as high as 12.9. Henderson-Smart, Ponsonby and Murphy (1998:213) report odds ratios
    ranging from 1.4 to 14.1.

140                                                                             Commission for Children and Young People and Child Guardian
Team, 2005:59; Henderson-Smart et al., 1998:214).               The risk associated with overheating is less clear
Infants sleeping on their sides have an increased               when infants are placed on their backs.
risk of SIDS due to the possibility of them rolling
                                                                An infant’s relatively large head (particularly the
onto their stomachs.
                                                                face) becomes the main route for heat loss when
Although it is often assumed that stomach down                  thick clothing and bedding are used. For an infant
sleeping is dangerous because it causes suffocation,            sleeping on its stomach with its face against the
Byard (2004:498) warns that such an interpretation              mattress, heavy clothing or bedding, wearing a
is overly simplistic.                                           bonnet or covering the head with blankets, interferes
                                                                with normal heat exchange (Guntheroth & Spires,
   “Suffocation may certainly occur if an infant slips
   between a mattress and cot side and the upper
   airway obstructs, but whereas all infants placed             The New South Wales Child Death Review Team has
   in this position for long enough will die, 99% of            reported many incidents of SUDI in which infants
   infants who sleep prone will survive”.                       were found with their heads covered by quilts,
                                                                blankets or pillows (NSW Child Death Review Team
The mechanism of death in stomach down infant
                                                                2002a; 2003). Raising room temperature also
sleep position is therefore believed to be more
                                                                increases the danger of overheating.
complex than simple smothering, involving a
number of factors.                                              Over wrapping of infants often occurs when parents
                                                                overcompensate for a minor fall in room temperature
Despite concerns that back sleeping may be
                                                                by adding extra clothes and blankets. A study
associated with an increased risk of gastric
                                                                by Wailoo and colleagues (1989 cited in Byard,
aspiration, research shows that healthy babies
                                                                2004:501) found increases in thermal insulation up
placed on their backs are no more likely to
                                                                to 188% in response to falls in temperatures of as
regurgitate food and choke on vomit than babies
                                                                little as 4.4°C.
lying in other positions (Henderson-Smart et al.,
1998:214; Byard & Beal, 2000; Hunt et al., 2003).               Overheating can also occur when infants move
                                                                and become tangled in bed clothes or their heads
Parents should be advised that the risk of SIDS is
                                                                become covered by doonas or quilts.
increased if babies sleep on their stomachs or sides
and that the best position for babies is on their backs.        Sleeping on soft surfaces and loose bedding
Head coverings, over wrapping and overheating                   Epidemiological studies have identified soft surfaces
                                                                such as pillows, quilts, comforters, sheepskins and
Increasing evidence points to a significant association
                                                                porous mattresses as significant risk factors for SIDS
between overheating and SIDS (Henderson-Smart et
                                                                (American Academy of Pediatrics, 2000:651). In
al., 1998; Bass, 1989; Byard, 2004).
                                                                some cases loose bedding has been found covering
While elevated temperatures in SIDS infants may                 an infant’s face, obstructing the airways and
be due to infections, a number of studies have                  resulting in accidental suffocation.
shown that high temperatures frequently result from
                                                                The findings at autopsy in these cases are entirely
external factors such as increased room heating
                                                                non-specific and do not help to distinguish SIDS
or excessive clothing. A number of case control
                                                                from this type of asphyxia (Mitchell, Krous & Byard,
studies have found heavy wrapping in bed clothing
                                                                2002:313). It is difficult to determine the precise
to be an independent risk factor for SIDS (Fleming
                                                                mechanism of death in many cases where infants
et al., 1990; Bass, 1989) with infants placed in
                                                                become trapped or covered by loose bedding,
the stomach down position more vulnerable to
                                                                but accidental asphyxiation accounts for a certain
overheating (Henderson-Smart et al., 1998:216).
                                                                proportion (Byard, 2004:502).

Annual Report Deaths of children and young people Queensland 2004–05                                                 141
Shared sleeping                                                             Prevalence of shared sleeping
Shared sleeping (also known as co-sleeping or                               The National Infant Sleep Position Study (NISP
bed sharing) is common in certain communities                               Study) found that the practice of bed sharing was
(Panaretto, Whitehall et al., 2002), particularly in                        growing in the United States (US). The longitudinal
non-Western cultures (Byard, 2004; McKenna et al.,                          study, conducted between 1993 and 2000 and
2001; Blair et al., 1999). A review of the literature                       involving 10,000 families, found that the number of
indicates that mothers in Western societies are also                        mothers sharing a bed with an infant for part or all of
increasingly sleeping close to their infants.                               the night more than doubled (from 5.5% to 12.8%)
                                                                            over the seven year period examined. The study also
The sleep environment of infants contributes                                found that as many as 50% of infants under the age
significantly to health outcomes. While numerous                             of eight months spent at least some time at night on
epidemiological studies have found a significant                             an adult bed (Willinger et al., 2003:44).
association between stomach down sleeping and
SIDS, the role of shared sleeping in infant deaths                          The NISP Study provided the first national data on
is unclear and increasingly debated. Some studies                           the use of an adult bed for infant sleeping in the US.
have shown an increased risk of SIDS (and other                             Significantly, shared sleeping on an adult bed was
SUDI) associated with shared sleeping (Scragg et al.,                       much more common than expected at the beginning
1993; 1995; Kemp et al., 2000; Knight et al., 2005;                         of the research (Willinger et al., 2003:46).
Blair et al., 1999). Others have shown no significant                        McKenna’s and McDade’s (2005:135) recent review
relationship while some studies have suggested that                         of co-sleeping in the US found that while only 9.2%
sleeping near an infant may protect against SIDS                            of infants routinely sleep on an adult bed, 44.7%
(McKenna & Mosko, 1993; McKenna et al., 1994;                               spend some time on an adult bed at night. The study
McKenna & Mosko, 2001).                                                     also found that infants of young mothers (under 18
                                                                            years) were much more likely to sleep on an adult
Defining co-sleeping and bed sharing
                                                                            bed than infants of mothers over 18 years.
Co-sleeping is defined in the literature as including
a variety of sleeping arrangements, ranging from                            Similar trends are apparent in Australia with many
infants and parents sharing a bed, to parents or                            families engaging in shared sleeping arrangements.
siblings sleeping together on a couch as well as                            In Queensland, a recent study by Young, Battistutta
having the infant’s crib or bassinet in the same room                       and O’Rourke (2005) found 45% of infants shared
as the mother’s bed (Shields et al., 2005; Blair et                         a bed225. Further, shared sleeping is reported to
al., 1999:1457). The terms ‘co-sleeping’ and ‘bed-                          be significantly more common among Indigenous
sharing’ are often used interchangeably and these                           families (74%) than non-Indigenous families
terms are not clearly articulated in the research224.                       (Panaretto, Whitehall et al., 2002:137). Additionally,
Therefore, it has been necessary to use the terms                           Young, Battistutta and O’Rourke (2005) found that
interchangeably in the following literature review.                         58% of Indigenous mothers reported that their baby
                                                                            had recently been put to sleep with another person,
In the trends and patterns section of this chapter,                         for example a sibling or parent; 66% reported that
which analyses infant deaths that occurred in the                           they had shared a bed with their infant within the
period January 2004 to June 2005, the Commission                            last fortnight.
uses the term ‘shared sleeping’ to refer to sharing
the same sleep surface (such as a mattress) by
an infant and one or more people. When a child is
sleeping on a surface not designated for sleep (such
as a sofa) this is clearly stated.

224 Mesich (2005) identifies the lack of consistent definitions of shared sleep arrangements as one of the problematic themes in co-sleeping and bed
    sharing literature.
225 Young, Battistutta and O’Rourke surveyed 64% of the primary caregivers of the 3952 infants born in April 2002. Infants were aged three months
    at the time of the survey.

142                                                                           Commission for Children and Young People and Child Guardian
Shared sleeping research in Queensland                                   that mothers who breastfed their infants were three
In Queensland, research into cases of SUDI where                         times more likely to bed share than those who
shared sleeping is a factor was difficult up until                        bottlefed their infants. The frequency and duration
the introduction of the ‘Police report of death to a                     of breastfeeding is also found to increase when
Coroner’ (Form 1) in December 2003. Prior to this,                       mothers and infants share a bed. Such findings have
the report used by police officers to notify a coroner                    led McKenna and colleagues (1997) to promote bed
of a death, which was also provided to pathologists,                     sharing to encourage and lengthen the duration
did not contain a detailed death scene examination.                      of breastfeeding. The United Nations Children’s
Therefore it was not possible to identify cases of                       Fund (UNICEF) also claims that discouraging bed
unexpected infant death where shared sleeping was                        sharing for babies under seven weeks of age could
a factor.                                                                seriously undermine international efforts to promote
The new Form 1 introduced in conjunction with the
Coroners Act 2003 makes provision for detailed                           There is some inconclusive evidence that
information to be included in cases of unexpected                        breastfeeding may protect against SIDS.
child deaths, and includes a death scene                                 Retrospective case-control studies in the US
examination. Cases of SUDI where shared sleeping                         (Hoffman et al., 1988), New Zealand (Ford et
was a factor are now clearly identified.                                  al., 1993) and Scandinavia (Alm, 2002) have
                                                                         demonstrated a protective effect of breastfeeding
In addition, forensic pathologists are reportedly                        against SIDS, providing the mother is a non-smoker.
moving towards indicating whether an infant was                          However, other analysis has failed to find any
sharing a sleep surface with another person on                           significantly altered risk for SIDS after adjusting
death certificates in cases of SIDS.                                      for confounding variables (Krous et al., 1989;
These positive changes will improve research into                        Ponsonby et al., 1995; Gilbert et al., 1995; Mitchell
SUDI in Queensland.                                                      et al., 1997). Although breastfeeding is beneficial
                                                                         and should be promoted for many reasons, the
Reasons for the increase in shared sleeping                              American Academy of Pediatrics Task Force on Infant
The increased prevalence of infant parent co-                            Sleep Position and Sudden Infant Death Syndrome
sleeping, bed sharing and room sharing has been                          believes that current evidence “is insufficient to
largely attributed to an increase in breastfeeding                       recommend breastfeeding as a strategy to reduce
(Arnestad et al., 2001:112).                                             SIDS” (American Academy of Pediatrics, 2000:652).
Breastfeeding is increasingly encouraged through                         It should also be noted that the overwhelming
organisations such as the World Health Organisation                      number of suspected accidental overlays or fatal
(WHO), as research indicates that breastfeeding                          accidents do not occur within breastfeeding/
protects infants and mothers against a range of                          bed sharing communities but in chaotic, poor
illnesses including respiratory and gastric infections,                  communities, where multiple independent SIDS risk
allergies, urinary tract infections, ear infections                      factors converge, and bottlefeeding is more common
and diabetes226. The WHO identified that all health                       than breastfeeding (McKenna & McDade, 2005:135).
outcomes were more favourable in breastfed children
than bottle-fed children, with outcomes particularly                     Reasons for shared sleeping in Indigenous
improved for lower socioeconomic groups.                                 communities
                                                                         In a recent study conducted in Townsville,
Shared mother and infant sleeping promotes
                                                                         Queensland, health workers suggested that
successful breastfeeding (Hooker, 2001; Ball,
                                                                         shared sleeping was the norm in the Indigenous
2003). Arnestad and colleagues (2001:115) found
                                                                         community. Indigenous health workers report that

226 World Health Organisation press release, 10 November 2004.
227 UNICEF response to Lancet publication on Sudden Infant Death among bed sharing babies,
    research_update_20040116.htm, 16 February 2004.

Annual Report Deaths of children and young people Queensland 2004–05                                                                     143
many Indigenous women believe that sleeping                                   The high rate of bed sharing in many overcrowded
together with an infant protects the baby (Panaretto,                         and disadvantaged Indigenous homes supports
Smallwood et al., 2002:129).                                                  McKenna’s and McDade’s (2005:139) argument
                                                                              that many people may prefer not to bed share but
SIDS and Kids Queensland Aboriginal and Torres
                                                                              find that this is the only option available to them.
Strait Islander Advisory Group (QATSIAG) consider that
                                                                              The importance of socioeconomic deprivation and
there is a need to assist Indigenous communities to
                                                                              shared sleeping has also been highlighted in the
sleep infants safely to reduce infant mortality. Areas
                                                                              New Zealand Maori population and in poor African
identified by QATSIAG that impact on safe sleeping in
                                                                              American populations (Blair et al., 1999:1457).
these communities include cultural practices, poverty,
overcrowded dwellings, smoking, drug and alcohol                              The relationship between shared sleeping and
abuse and perceived fear228.                                                  sudden infant death
The Department of Aboriginal and Torres Strait                                Research increasingly indicates that sensory contact
Islander Policy (DATSIP) also identified that cultural                         and proximity between the mother and the infant
practices, overcrowding and economic disadvantage                             induces potentially beneficial behavioural and
contribute to the prevalence of shared sleeping                               physiological changes in infants. Mothers report
arrangements in Indigenous households.                                        less infant crying, more maternal and infant sleep
DATSIP reports that nearly 25% of Aboriginal                                  and increased milk supply (due to the increased
and Torres Strait Islander homes in Queensland                                frequency of night-time breast feeding) when
are overcrowded compared to only 6% of non-                                   sleeping close to their infant (McKenna & McDade,
Indigenous households. This rate is significantly                              2005:135). Both room and bed sharing increases
higher in remote Aboriginal and Torres Strait                                 the number of sensory exchanges between parent
Islander communities. The average income for                                  and infant.
Aboriginals and Torres Strait Islanders is $265,                              Increasing evidence also indicates that infants
significantly less than the $372 for non-Indigenous                            who sleep near their parents have a reduced risk
Australians. In remote communities where there is                             of SIDS due to increased arousals (McKenna &
a high dependence on the Community Development                                Mosko, 1993; McKenna & Mosko 2001; McKenna et
Employment Projects scheme229, and a significantly                             al., 1997; Byard, 2004). Behavioural studies have
higher cost of living, available funds for infant care                        demonstrated that infants experience more arousals
products such as cots and bassinets is very limited.                          and have less deep sleep (slow wave sleep) when
Access to stores that supply goods is also limited.                           bed sharing than when sleeping alone (Mosko,
DATSIP also advise that the well person check                                 McKenna et al., 1993; Mosko, Richard, et al., 1996).
undertaken in select Indigenous communities by                                In response to findings that extra simulation may
Queensland Health in 2001, found that 40% of                                  reduce deep sleep, alter breathing patterns, and
women of child bearing age consumed harmful                                   enhance neurological maturation (Byard, 2004:502),
amounts of alcohol. This figure is significant given                            McKenna and colleagues (1997:218) suggest that
the impact of alcoholism on an individual’s ability                           bed sharing may protect infants against SIDS231.
to care for an infant safely as well as on the infant’s                       However, the social and biological connection
health status230.

228 Information provided verbally to the Commission by SIDS and Kids Queensland.
229 The Community Development Employment Projects (CDEP) scheme is the Australian Government’s most extensive Indigenous program,
    providing employment and training to more than 35,000 people. CDEP’s objective is to provide work for unemployed Indigenous people in
    community-managed activities which assist the individual acquire skills which benefit the community, develop business enterprises and which
    lead to unsubsidised employment. CDEP participants voluntarily forego their rights to income-benefit entitlements and instead work on CDEP
    activities for wages paid by CDEP organisations. The scheme commenced in 1977 in a number of remote communities as both an alternative
    to the payment of welfare benefits to individuals and a means of community development. Since then it has extended to both rural and urban
230 Provided by the Department of Aboriginal and Torres Strait Islander Policy, July 2005.
231 Other postulated benefits of close contact between infants and parents include improved cardiorespiratory stability and oxygenation and better
    thermoregulation (Blair et al., 1999:1457).

144                                                                             Commission for Children and Young People and Child Guardian
between an infant and its caregiver is of critical                             risk of death in infants of non-smoking mothers who
importance if shared sleeping is to be protective to                           bed share (Scragg & Mitchell, 1998 cited in Byard,
the infant (McKenna & Mosko, 2001:260).                                        2004:501). While there is strong evidence that
                                                                               shared sleeping increases the risk of SIDS in infants
Nevertheless, controversy continues over whether
                                                                               of smokers, “the data are currently insufficient
shared sleeping increases the risk of SIDS (NSW
                                                                               to provide complete reassurance to non-smoking
Child Death Review Team, 2005:61). A study of 174
                                                                               parents that bed sharing is safe” (Henderson-Smart
cases of SIDS between 1984 and 1998 by Arnestad
                                                                               et al., 1998:216).
and colleagues (2001) found that as the number of
SIDS cases has decreased the number of deaths of                               Parents who smoke should be advised that sleeping
infants while bed sharing has increased232.                                    with their baby may increase the risk of SIDS.
Research on shared sleeping and infant mortality                               Overheating
found that increased risks of infant mortality when
                                                                               Some research indicates that bed sharing may
bed sharing are due to:
                                                                               increase the risk of SIDS due to hypoxia (when
•     cigarette smoking while bed sharing                                      the infant breaths air expired by a parent), airway
•     overheating                                                              obstruction and overheating. Tuffnell, Petersen and
•     suffocation overlay and entrapment                                       colleagues (1996:249) have shown that infants
•     substance abuse, and                                                     sharing a bed had higher rectal temperatures than
•     the social influences on sleep choices.                                   infants sleeping alone. Close proximity to a warm
                                                                               body and being covered by a warm adult duvet or
Smoking and shared sleeping                                                    other bedding could result in a higher infant body
There is an increased risk of SIDS when mothers who                            temperature.
smoke share a bed with their infants.
                                                                               Shared sleeping and accidental death
The New Zealand Cot Death Study (1992) revealed an
interaction between smoking and bed sharing, with                              The risk of accidental death due to suffocation
the relative risk from bed sharing only significantly                           and strangulation is increased in shared sleeping
increased when the mother smoked. The 1993 to                                  arrangements, and certain shared sleeping
1995 case-control study for the Confidential Enquiry                            situations may be particularity dangerous (Byard,
into Stillbirths and Deaths in Infancy demonstrated                            2004:502; NSW Child Death Review Team, 2005:61;
a significantly increased risk of SIDS for infants who                          Henderson-Smart, 1998:216).
share a sleep surface with mothers who smoke                                   Difficulties assessing the risk of accidental death
(Henderson-Smart et al., 1998:216). The risk of infant                         associated with shared sleeping arise from
death is reported to double if an infant sleeps with a                         problems in defining the cause of death in these
mother who smokes (Byard, 2004:501).                                           circumstances. As previously mentioned, pathologic
A case-control study by Blair and colleagues                                   findings at autopsy are non-specific, making it
(1999:1460) found no association between SIDS                                  difficult to differentiate between a death due to
and shared sleeping for infants whose parents do                               SIDS and accidental suffocation. It is therefore
not smoke, infants older than fourteen weeks233 or                             difficult to determine the precise cause of death in
when an infant is returned to its cot after a period                           the increasing numbers of infants who are dying in
of bed sharing. Blair and colleagues (1999:1657)                               shared sleep environments (Byard, 2004:502).
concluded that “there is no evidence that bed                                  Several reports describe the dangers of shared
sharing is hazardous for infants of parents who do                             sleeping on an adult bed, sofa or other furniture,
not smoke”. Other studies have found an increased                              including:

232    It has been noted elsewhere that the since the introduction of the Back to Sleep and Reducing the Risk of SIDS campaigns, the socio-
       demographic profile of affected families has changed significantly (Krous et al., 2004; Mitchell et al., 2000).
233 The risk linked with shared sleeping for younger infants appears to be associated with recent parental consumption of alcohol, overcrowded
    housing, parental tiredness and the infant being under a duvet or other covers.

Annual Report Deaths of children and young people Queensland 2004–05                                                                             145
• suffocation from overlay or being trapped face                              Social influences on sleep environments
  down in a space between a parent and the bed or                             Studies in New Zealand (Ford, 2000), Sweden
  the back of a couch                                                         (Lindgren et al., 1998) the UK (Blair et al., 1999;
• facial obstruction or head covering from adult                              Carpenter et al., 2004) and Australia (Buckley et
  pillows or bedclothes                                                       al., 2002) support the need to understand the
• facial obstruction from being face down in an                               social and psychological aspects of different sleep
  indentation pocket of an adult water bed, and                               arrangements. These studies have shown that when
• strangulation from entrapment (Henderson-Smart,                             a committed caregiver, usually the mother, sleeps
  1998; Nakamura et al., 1999; Byard, 2004).                                  in the same room but not in the same bed as their
A review of the accidental deaths of 515 children                             infant, the risk of SIDS is reduced by up to 50%.
under the age of two years, who were put to                                   They conclude that it is not shared sleeping but the
sleep on adult beds234, found that 394 were due                               environment and circumstances in which shared
to suffocation or strangulation caused by the                                 sleeping occurs that is dangerous.
entrapment of the child’s head in various structures                          According to McKenna (2001:140–141) safe co-
of the bed. The remaining 121 deaths were due to                              sleeping occurs where a responsible adult and an
overlay of the child by a parent, other adult or sibling                      infant use at least two mutually reinforcing senses
sleeping in the same bed (Nakamura et al., 1999).                             (such as touch, sight, sound, smell) to communicate
These findings led Nakamura and colleagues                                     with each other. Safe co-sleeping can take place
(1999:1022) to argue that unlike cots, which are                              when the overall bed sharing context (physical
designed to meet safety needs of infants, adult                               and social) is made as safe as current knowledge
beds carry a risk of accidental entrapment and                                permits, and when at least one adult is physically
suffocation. Nakamura and colleagues (1999) assert                            capable of detecting and responding to changes in
that placing children younger than two years to                               the infant’s status, and willing and motivated to do
sleep in adult beds exposes them to potentially fatal                         so. Safe co-sleeping is therefore a proactive sleeping
hazards that are not generally recognised by the                              arrangement in which at least one responsible adult
parent or sibling, or other adults sharing the bed.                           takes safety precautions unique to the shared sleep
                                                                              practice, regardless of the surface.
Scheers and colleagues (2003:883) found that
the deaths of infants from suffocation on sleep                               McKenna and McDade (2005:135) argue that the
surfaces other than those designed for infants                                quality of care received by an infant outside the sleep
were increasing. Results indicated that the risk of                           environment partially determines both the reason for
suffocation was approximately forty times higher for                          shared sleeping and the impact of shared sleeping
infants in adult beds than in cots.                                           on the infant. For example, bed sharing by smoking
                                                                              mothers in socially chaotic households, where shared
In Queensland, the Paediatric Quality Council
                                                                              sleeping is the only option, leads to significantly
(2003:4) found that in 17 of the 41 cases of SUDI in
                                                                              different outcomes from situations in which bed
2000, infants were sharing a sleep surface at the time
                                                                              sharing is chosen by a non-smoking mother to
of death. In 2001 it found that co-sleeping occurred
                                                                              protect, nurture and breastfeed her infant, in routine
in six of 17 SIDS deaths (Paediatric Quality Council,
                                                                              and stable social circumstances. A consistent
2003:80). In four of these cases it was found that
                                                                              feature of populations where shared sleeping and
sleep accidents may have contributed to the death.
                                                                              high numbers of infant deaths co-exist is extreme
                                                                              poverty and stressful circumstances including chaotic
                                                                              households (McKenna & McDade, 2005:139).

234 This figure is was not a complete count of all (adult) bed related deaths for children younger than two years of age.

146                                                                             Commission for Children and Young People and Child Guardian
                                                                So variable is the range of factors associated with
    A three-month-old Indigenous infant was found
                                                                shared sleeping, and the impact it has on different
    dead on a double foam mattress placed on the
                                                                families, that it is not appropriate to recommend in
    floor. The infant was placed to sleep on her side
                                                                any unqualified way against bed sharing or to advise
    and was sharing the mattress with her mother.
                                                                that infants should always sleep alone in a cot. Such
    When found, the infant was on her front with her
                                                                advice is “misleading and unjustified” and does not
    head turned to the side. Unusual bruising to the
                                                                help explain the factors that make shared sleeping
    bottom of the infant’s legs was noted.
                                                                arrangements dangerous (McKenna & McDade,
    The parents had a history of domestic violence,             2005:141).
    drug related activity and mental health issues.
                                                                As a number of communities around the world
    There was evidence of habitual smoking, alcohol
                                                                have traditionally practiced bed sharing without
    or drug use at the location of the death.
                                                                significantly increasing infant death, it appears that
    The infant was of low weight and had traces of              certain contemporary practices are responsible for
    narcotics in her blood at birth.                            making this practice dangerous (Byard, 2004:502).
    The cause of death was certified as undetermined.            For example, in Hong Kong where shared sleeping is
                                                                the norm, the rate of SIDS is one of the lowest in the
                                                                world (McKenna & McDade, 2005:147).
Summary of shared sleeping risk factors
Research examining shared sleeping and infant                   Role of health care professionals in promoting
mortality suggests that increased risk of infant death          safe infant sleeping
when bed sharing is due to:                                     UNICEF notes that health professionals may simply
•    cigarette smoking while bed sharing                        advise parents against bed sharing if they perceive
•    overheating                                                it to be discouraged at an institutional or national
•    suffocation, overlay and entrapment                        level. This means that parents are often denied a full
•    substance abuse, and                                       discussion about the benefits, contradictions and
•    the social influences on sleep choices.                     relevant safety issues related to shared sleeping.
                                                                Parents may also be unlikely to raise the subject
Bed sharing does not appear to significantly increase            with hospital staff for fear of disapproval.
the risk of SIDS for any of the following groups:
                                                                The Confidential Inquiry into Stillbirths and Deaths
• mothers who bed share to feed and cuddle their                in Infancy (Blair et al., 1996; Fleming et al., 1996;
  baby and return the infant to a cot to sleep                  2000) reported that health care professionals may
• infants over the age of four months, and                      have contributed to up to 32% of deaths due to
• infants of parents who are non-smokers.                       SIDS through:
Conflicting evidence of harm and benefits from                    • poor identification of key SIDS risk factors
bed sharing has generated popular beliefs about                 • poor communication, and
whether it is appropriate. However, the sleep                   • poor support of vulnerable families.
location is the beginning rather than the end point
when analysing risk factors in an infant’s death                Recent evidence also suggests that many
(McKenna & Mosko, 2001; McKenna & McDade,                       nurses have knowledge deficits about SIDS risk
2005). Other key factors, such as parent’s ability and          factors and disagree with current risk reduction
willingness to respond to the infant and the reason             recommendations. The knowledge deficits and
for shared sleeping also need to be considered in               attitudinal differences impact upon nursing practices
future research.                                                and the information provided to parents about SIDS
                                                                risk factors (Young et al., 2005; Willinger et al., 2000).

Annual Report Deaths of children and young people Queensland 2004–05                                                  147
In Queensland, Young and O’Rourke (2002) found                               Sudden unexpected death
that the attitudes of nurses and midwives were
inconsistent with the messages of the Reducing
                                                                             in infancy in Queensland 2004–05
the Risk of SIDS campaign, and that these attitudes                          Under section 8 of the Coroners Act 2003 all violent
influenced the information that nurses gave parents.                          or unnatural/unusual deaths in Queensland must
SIDS and Kids Queensland have similar concerns                               be reported to the State Coroner. Sudden and
about maternity and child health professionals, and                          unexpected deaths of infants fall into that category.
have modified a training kit to deliver Reducing the
                                                                             All cases of SUDI require a comprehensive
Risk of SIDS messages to health professionals in
                                                                             investigation, which should include a full autopsy,
Queensland hospitals.
                                                                             examination of the death scene and review of the
Another Queensland study found that a considerable                           clinical history.
proportion of nurses and midwives were unaware of
                                                                             To improve the investigation of child deaths, and in
the potential hazards of various sleep environments
                                                                             particular unexpected infant deaths, in June 2005
including the risks associated with sofa sharing
                                                                             the Queensland Police Service (QPS) implemented
(Young & Schluter, 2002). Less than half of the
                                                                             a new operational policy in relation to the
nurses and midwives surveyed agreed with the
                                                                             investigation of ‘reportable’ child deaths.
recommendation that infants sharing a room with
their parents for at least the first six months of life                       The new QPS policy requires that all reportable
helps reduce the risk of SIDS. Young and O’Rouke                             child deaths are to be managed by a senior and
(2002) found the attitudes and practices of health                           experienced police investigator. First response
professionals changed considerably after reading                             officers are required to contact the Department of
literature about SIDS risks factors and attending an                         Child Safety (DChS) Crisis Care Unit to establish
education session235.                                                        whether the death was a ‘death in care’ (s.9 of the
                                                                             Coroners Act) or whether the child was ‘known’
Knowledge of risk factors (both modifiable and non-
                                                                             to the DChS. Specific operational policy and
modifiable) can help health professionals and policy
                                                                             procedures apply to the investigation of child
makers target infants and families most at risk of
                                                                             reportable deaths, including the sudden unexpected
SUDI with support, services and education (NSW
                                                                             deaths of infants. The new policy also discourages
Child Death Review Team, 2005:58).
                                                                             the use of the term SIDS in the initial investigation of
Health education programs teaching parents to create                         unexpected infant deaths.
a safe sleep environment should accommodate the
                                                                             The QPS Child Safety Director is required to review
variety of sleeping arrangements in any given family
                                                                             the investigation of all child reportable deaths
and respond to the reality that many infants experience
                                                                             to identify and respond to any training, policy or
multiple sleep locations and arrangements. Parents
                                                                             operational issues.
should be informed about the particular precautions
that each location or arrangement requires (McKenna &                        In addition, the QPS, in partnership with the Office
McDade, 2005:150).                                                           of the State Coroner, has revised the form for Police
                                                                             Report of Death to a Coroner (Form 1) to improve
Health professionals should inform parents
                                                                             the type and consistency of initial information
and caregivers of the Reducing the Risk of SIDS
                                                                             provided to assist the pathologist in determining
messages, as well as avoidable hazards when
                                                                             the cause of death.
sharing a sleep surface with an infant, such as:
•   minimising soft bedding and entrapment
•   not smoking
•   avoiding alcohol and drugs, and
•   never leaving infants alone on adult beds.

235 The New South Wales Child Death Review Team (2005) also notes that not all health professionals have taken the Reducing the Risk of SIDS
    messages into their practice. Health professionals may know the major risk factors associated with SIDS but may not advise parents correctly or
    may not practise the recommendations in a hospital setting.

148                                                                            Commission for Children and Young People and Child Guardian
The QPS’ new operational policy is consistent                   Sudden unexpected death in
with the recommendations of the Queensland
Ombudsman’s 2003 Report An investigation into
                                                                infancy trends and patterns,
the adequacy of the actions of certain government               2004–05
agencies in relation to the safety, well being and care
                                                                Between 1 January 2004 and 30 June 2005, there
of late baby Kate, who died aged 10 weeks.
                                                                were 63 sudden and unexpected deaths in infancy
The Commission commends the changes to the QPS                  in Queensland, a rate of 131.1 deaths per 100,000
Policy and Procedures and it is hoped that these                infants aged under one year (1.3 per 1000 live
recent changes, as well as the work undertaken by               births).
the Commission, will lead to a greater understanding
of why children die suddenly and unexpectedly in                Age
Queensland.                                                     Figure 11.3 shows SUDIs by age at death. The infants
                                                                ranged in age from three days to eight months. Most
Classification of sudden unexpected                              were aged two months and under (60.3%).
death in infancy
                                                                Figure 11.3: Sudden unexpected death in infancy by age
The Commission has analysed coronial information                at death
in order to classify the deaths in this chapter.                                   16
Coronial information includes:
• the Police Report of Death to a Coroner (Form 1)
• pathologists findings (including autopsy reports,
                                                                Number of deaths

  toxicology reports), and                                                         10
• Coroners’ findings.                                                                8
In line with contemporary research, the Commission                                  6
has classified an infant death as a SUDI if, when
initially reported (before investigation and autopsy),
the death:                                                                          2

• involved an infant less than one year of age                                      0
                                                                                        <1   1   2    3      4    5   6   7   8
• was sudden in nature and totally unexpected,
                                                                                                     Age in months
  with no previously known condition that is likely
                                                                Data source: Queensland Child Deaths Register (2004–05)
  to cause death, and
• occurred after the infant had been placed for                 Gender
                                                                Of the 63 infants who died, 35 were males (54.7%)
This classification excludes all clear cases of                  and 28 were females (44.4%). Male deaths occurred
accidental death and deaths known to result from                between the ages of three days to eight months,
inflicted injuries. It also excludes all cases of                while female deaths occurred between the ages of
infants with serious congenital anomalies or genetic            18 days and seven months.
syndromes (such as Down Syndrome) that were
identified before death.

Annual Report Deaths of children and young people Queensland 2004–05                                                          149
Geographical distribution (ARIA)                                             Geographical distribution (ARIA)
An equal number of infants lived in regional and                             Eleven of the 18 Aboriginal and Torres Strait Islander
metropolitan areas of Queensland (27 deaths,                                 infants who died (72.7%) were living in regional areas,
42.9% each) and nine in remote areas (14.3%).                                mostly in outer regional areas. Four of the infants were
                                                                             living in remote or very remote areas (22.2%). Only
The rate of sudden unexpected deaths in remote
                                                                             three of the Aboriginal and Torres Strait Islander infants
areas was nearly double the overall rate, with
                                                                             were residing in metropolitan areas (16.7%).
244.2 deaths per 100,000 infants in remote areas,
compared to 131.1 per 100,000 infants in all areas.                          In comparison, 53.3% of non-Indigenous SUDI
                                                                             deaths involved infants living in metropolitan areas,
The rate of SUDI in regional areas was also above the
                                                                             35.6% in regional areas and 11.1% in remote areas.
overall rate, with 164.0 deaths per 100,000 infants,
while the metropolitan rate was 98.7 deaths per                              Socioeconomic status (SEIFA)
100,000 infants.                                                             Fifteen of the 18 Aboriginal and Torres Strait
                                                                             Islander infants who died lived in low and very
Socioeconomic status (SEIFA)                                                 low socioeconomic areas (83.3%) and 12 of these
Of the 63 infants who died, 41 lived in low or very                          were living in the lowest socioeconomic areas in
low socioeconomic areas (65.0%), including 26 in                             Queensland (80.0%). Only three Aboriginal and
the lowest socioeconomic areas in Queensland.                                Torres Strait Islander infants were living in high or
Only 14 infants were from high or very high                                  very high socioeconomic areas (16.7%).
socioeconomic areas (22.2%), while eight lived in a
                                                                             In comparison, 57.8% of non-Indigenous SUDI
moderate area (12.7%).
                                                                             deaths involved infants living in low or very low
Aboriginal and Torres Strait Islander                                        socioeconomic areas, 24.4% in high or very high
                                                                             socioeconomic areas and 17.8% in moderate areas.
Eighteen of the 63 infants who died were Indigenous                          Known to the Department of Child Safety
(28.6%); 16 were Aboriginal and two were Torres                              During the 18 month reporting period, 12 of the
Strait Islander.                                                             63 infants who died suddenly and unexpectedly
Aboriginal and Torres Strait Islander infants were                           were known to DChS or the former Department
significantly over-represented in SUDI deaths,                                of Families. Six of these infants were Indigenous.
accounting for 561.6 deaths per 100,000 Indigenous                           The department’s involvement with four infants
infants (5.3 per 1000 Indigenous live births),                               will be considered by the Child Death Case Review
compared to 100.3 per 100,000 non-Indigenous                                 Committee (CDCRC)236.
infants (1.0 per 1000 non-Indigenous live births).                           Families with child protection concerns are
This is consistent with findings that the Reducing                            considered an ‘at risk’ population for SIDS and
the Risk of SIDS messages are not reaching high risk                         other SUDI. This population is often characterised
groups including Indigenous populations (Panaretto                           by chaotic and dysfunctional social circumstances
et al., 2002:132; Queensland Government Media                                which include many risk factors for SIDS. The social
Release, 2005).                                                              conditions of these families make them difficult to
                                                                             reach through traditional public health education
                                                                             strategies. These families may require more direct
                                                                             intervention to ensure that messages are understood
                                                                             and implemented.

236 Since 1 August 2004, DChS has been required to conduct a review of its involvement with a child if the child was known to the department within
    the three years before death. The CDCRC is an independent committee responsible for considering the department’s review. The committee is
    multi-disciplinary and is chaired by the Commissioner. As eight of the fatal assaults occurred before 1 August 2004 they will not be reviewed by
    the CDCRC.

150                                                                            Commission for Children and Young People and Child Guardian
The Victorian Child Death Review Committee has                                Table 11.1: Sudden unexpected death in infancy by cause
repeatedly noted the prevalence of SIDS in the                                of death
child protection population and has expressed                                  Cause of Death                                                 Total
concern that SIDS deaths in this population have not
                                                                               SIDS and other ill-defined causes of mortality
decreased over time.
                                                                               Sudden infant death syndrome                                    21
The Commission is concerned about the rate of SUDI                             Undetermined                                                     5
in the child protection population. SIDS risk factors
                                                                               External causes of accidental injury
should be addressed by child safety officers when
                                                                               Accidental poisoning by and exposure to                          1
an infant is at home, placed in care and before any
                                                                               narcotics and psychodysleptics [hallucinogens]
                                                                               Accidental suffocation and strangulation in bed                  1
Coronial findings                                                               Other specified threats to breathing                              2
At the time of reporting, coronial findings were                                Natural Causes
pending in 38 of the 63 cases of SUDI. Coronial                                Bronchopneumonia                                                 6
proceedings had been finalised in 24 cases. One                                 Pneumonia due to Klebsiella pneumoniae                           1
SIDS case appears not to have been reported to the                             Cytomegaloviral disease                                          1
Coroner237. Autopsy test results are also pending in                           Hypertrophy of tonsils                                           1
23 cases.
                                                                               Scabies                                                          1
                                                                               Pending test results                                            23
Cause of death
                                                                               Total                                                           63
Cases that presented as a SUDI when initially
                                                                              Data source: Queensland Child Death Register (2004–05)
reported were classified into five categories of
death:                                                                        Sudden infant death syndrome and
• sudden infant death syndrome (SIDS)                                         undetermined causes
• external causes of accidental injury, including
                                                                              Between 1 January 2004 and 30 June 2005, there
  sleep accidents (i.e. accidental suffocation and
                                                                              were 21 SIDS deaths and five undetermined infant
  deaths caused by unsafe sleep environments
                                                                              deaths. A number of known SIDS risk factors were
  such as unsafe cots and bedding)
                                                                              found in these deaths.
• unrecognised morbid processes or congenital
  abnormalities                                                               In another 23 cases the cause of death has yet
• deaths where there are insufficient findings                                  to be certified238. The Commission has found that
  at autopsy to determine the cause of death                                  factors associated with SIDS were also apparent in
  (undetermined/unascertained), and                                           SUDI cases in which the cause of death is pending.
• deaths for which pathologist’s or coroner’s                                 These cases have been included in this analysis
  findings are pending.                                                        to provide an indication of the prevalence of risk
                                                                              factors in SUDI cases.
Table 11.1 shows the cause of death (as determined
by a coroner and/or pathologist) for the 63 cases of                          Table 11.2 provides a summary of known SIDS
SUDI during the 18 month reporting period.                                    risk factors for the 26 infants who died from SIDS
                                                                              and undetermined causes. Table 11.3 provides a
                                                                              summary of known SIDS risk factors for the 23 cases
                                                                              of SUDI in which the cause of death is pending.
                                                                              Indigenous status is also indicated in these tables.

237 A doctor must not issue a cause of death certificate in relation to an apparently reportable death unless authorised by a coroner to do so. In this
    situation the doctor needs to complete Form 1A—Notification of reportable death by medical practitioner and authorisation of coroner to issue
    cause of death under the Coroners Act 2003 and send this to the coroner for consideration. A coronial consent death certificate was not issued in
    this case.
238 As at 30 June 2005.

Annual Report Deaths of children and young people Queensland 2004–05                                                                                151
                                                              The information provided in the following tables and analysis has been drawn from the Police Report of Death to a Coroner (Form 1),

                                                              autopsy reports and coronial findings.
                                                              Table 11.2: Summary of SIDS risk factors for infants who died from SIDS and undetermined causes, 2004–05

                                                              Cause                Indigenous        Shared         Sleep surface           Prone/   Low              Pre-       Smoking       Drugs/      Chaotic social  Living in low
                                                              of Death                               sleeping                               side     birth            term                     alcohol     circumstances** socioeconomic
                                                                                                                                            sleeping weight           birth                                                area
                                                              SIDS                                                  couch                       ✓                                     ✓                            ✓               ✓
                                                              SIDS                        ✓                ✓        mattress                                                          ✓            n/a             ✓               ✓
                                                                                                                    on floor
                                                              SIDS                                                  cardboard box                ✓                                    ✓                              ✓                      ✓
                                                              SIDS                                                  couch                                                                          n/a               ✓                      ✓
                                                              SIDS                                         *        cot                          ✓                        ✓
                                                              SIDS                                         ✓        double bed                   ✓            ✓           ✓           ✓                              ✓                      ✓
                                                              SIDS                                         ✓        double bed                                            ✓           ✓            ✓                                        ✓
                                                              SIDS                                                  cot                                      n/a          ✓           ✓            ✓✓
                                                              SIDS                                                  bassinette                   ✓                                    ✓            ✓
                                                              SIDS                        ✓                         cot                         n/a          n/a         n/a         n/a           ✓                 ✓                      ✓
                                                              SIDS                                                  bed                          ✓           n/a         n/a                                                                ✓
                                                              SIDS                                                  cot                          ✓                                    ✓
                                                              SIDS                                                  cot                          ✓                                                                                          ✓
                                                              SIDS                        ✓                         double bed                   ✓           n/a         n/a         n/a           n/a               ✓                      ✓
                                                              SIDS                                                  cot                          ✓                                                  ✓                ✓                      ✓
                                                              SIDS                                                  cot                          ✓
                                                              SIDS                                                  cot                                       ✓           ✓           ✓                                                     ✓
                                                              SIDS                        ✓                ✓        double bed                  n/a                                   ✓                                                     ✓
                                                              SIDS                        ✓                                                        No information available                                                                 ✓
                                                              SIDS                                                                                 No information available
                                                              SIDS                                                                                 No information available                                                                 ✓
                                                              Undetermined                                          couch                                 n/a       ✓                                               n/a                     ✓
                                                              Undetermined                ✓                ✓        mattress on floor             ✓         ✓                          ✓             ✓                ✓                      ✓
                                                              Undetermined                                 ✓        double bed                                                       n/a
                                                              Undetermined                                 ✓        double bed                   ✓           n/a         n/a
                                                              Undetermined                                 ✓        double bed                               n/a         n/a          ✓            n/a               ✓                      ✓
                                                              Total (26)                   6               9                                    13            3           6           12            6                9                      18
                                                              Data source: Queensland Child Deaths Register (2004–05)

Commission for Children and Young People and Child Guardian
                                                              ✓ = Yes, the child has this risk factor. N/A = information not recorded or unknown to police.
                                                              * child sleeping in cot with twin.       ** known to DChS and/or Form 1 indicated that family are known to police for criminal activities, and/or domestic violence issues.
                                                                       Table 11.3: Summary of SIDS risk factors for infants where cause of death is pending, 2004–05

                                                                        Cause                Indigenous       Shared          Sleep surface           Prone/   Low               Pre-       Smoking        Drugs/       Chaotic social  Living in low
                                                                        of Death                              sleeping                                side     birth             term                      alcohol      circumstances** socioeconomic
                                                                                                                                                      sleeping weight            birth                                                  area
                                                                        Pending                                               cot                         ✓                                       ✓             ✓               ✓               ✓
                                                                        Pending                                               cradle                                                              ✓                                             ✓
                                                                        Pending                                               couch                                      ✓                        ✓                                             ✓
                                                                        Pending                                               cot                           ✓            ✓                        ✓
                                                                        Pending                     ✓                ✓        mattress on floor                                      n/a           ✓
                                                                        Pending                                      ✓        double bed                                                          ✓            n/a                            ✓
                                                                        Pending                     ✓                ✓        single bed                                 ✓           ✓            ✓             ✓                             ✓
                                                                        Pending                                      ✓        mattress on floor              ✓                                     ✓                                           ✓
                                                                        Pending                                               cot                           ✓                                     ✓
                                                                        Pending                                               double bed                                                          ✓
                                                                        Pending                                               mattress on floor                                                    ✓
                                                                        Pending                                               cot                           ✓
                                                                        Pending                     ✓                ✓        mattress on floor                          n/a         n/a           ✓
                                                                        Pending                                      ✓        double bed                   n/a                                    ✓                               ✓           ✓
                                                                        Pending                                               cradle                        ✓            ✓           ✓
                                                                        Pending                                      ✓        mattress on floor                                                    ✓             ✓                 ✓

Annual Report Deaths of children and young people Queensland 2004–05
                                                                        Pending                     ✓                ✓        double bed                   n/a          n/a         n/a          n/a            ✓                 ✓           ✓
                                                                        Pending                                               cot                           ✓                                                                                 ✓
                                                                        Pending                                               cot                                       n/a         n/a                                                       ✓
                                                                        Pending                                     ✓         couch                        n/a                      n/a           ✓                               ✓           ✓
                                                                        Pending                                     ✓         mattress on floor                                                    ✓
                                                                        Pending                     ✓               ✓         mattress on floor                                       ✓                                            ✓          ✓
                                                                        Pending                                     ✓         double bed                    ✓                                    n/a           n/a                           ✓
                                                                        Total (23)                  5               12                                      8            4            3          16             4                 6          13
                                                                       Data source: Queensland Child Deaths Register (2004–05)
                                                                       ✓ = Yes, the child has this risk factor.
                                                                       ** known to Department of Child Safety and/or Form 1 indicated that family are known to police for criminal activities, and/or domestic violence issues.
                                                                       N/A = information not recorded or unknown to police

Infant factors                                                               Pre-term birth and low birth weight
                                                                             Infant birth data was not available in all cases
                                                                             and the figures presented here are likely to be
Figure 11.4 shows gender for deaths certified as                              an undercount of pre-term and low birth weight
SIDS and undetermined and where cause of death is                            infants239.
                                                                             SIDS and undetermined causes
Figure 11.4: Sudden unexpected deaths of infants by
cause of death and gender                                                    Six of the 26 infants who died from SIDS and
                   30                                                        undetermined causes were pre-term (less than 37
                                                                             weeks gestation) and three had low birth weight
                   25                                                        (less than 2500 grams). Two were both pre-term and
                                                                             had low birth weight.
                                                                             Cause of death pending
Number of deaths

                                                                             In three of the 23 cases of SUDI where cause of
                                                                             death is pending, the infants were pre-term and four
                                                                             had low birth weight. Two were both pre-term and
                   5                                                         low birth weight.
                                                                             In total, nine of the 49 infants who died from SIDS
                           SIDS &          Pending         Total             and undetermined causes, or where cause of death
                        Undetermined                                         is pending, were pre-term, seven were low birth
                                       Cause of death   Female     Male      weight and four were both pre-term and low birth
Data source: Queensland Child Deaths Register (2004–05).                     weight.

SIDS and undetermined causes                                                 Aboriginal and Torres Strait Islander status
Of the 26 infants who died from SIDS and                                     SIDS and undetermined causes
undetermined causes, 18 were male (16 SIDS, two
                                                                             Six of the 26 infants who died from SIDS and
undetermined) and eight were female (five SIDS,
                                                                             undetermined causes were Indigenous (five
three undetermined).
                                                                             Aboriginal and one Torres Strait Islander). Three were
Males accounted for a significantly higher proportion of                      sharing a sleep surface at the time of death.
infants who died from SIDS and undetermined causes
                                                                             Cause of death pending
(69.2%). This is consistent with the 13 year review
(see chapter 2) which found that 60.2% of infants who                        Five of the 23 cases where cause of death is pending
died of SIDS were males. Males have consistently been                        were Aboriginal. All were sharing a sleep surface at
associated with an increased risk of SIDS.                                   the time of death.
Cause of death pending                                                       In total, 11 of the 49 infants who died from SIDS
                                                                             and undetermined causes, or where cause of
Of the 23 cases of SUDI where cause of death is
                                                                             death is pending, were Indigenous. Eight of the
pending, 11 were male and 12 were female.
                                                                             11 Indigenous infants were sharing a sleep surface
In total, 29 of the 49 infants who died from SIDS and                        at the time of death.
undetermined causes, or where cause of death is
pending, were male and 20 were female.

239 This information was not consistently recorded across all Police Reports of Death to a Coroner (Form 1). This information may not always be
    available to police when initially investigating the death, or before submitting the form to the Coroner.

154                                                                            Commission for Children and Young People and Child Guardian
Parental factors                                                Sleeping practices
Smoking                                                         Infant sleep position
The Police Report of Death to a Coroner (Form 1)                Table 11.5 shows the position of the infants when
identifies whether there were “signs of habitual                 placed for sleep and when found.
smoking at [the] location of [the] event” for all cases
                                                                Table 11.5: Sudden unexpected death in infancy by sleep
of unexpected infant death. However, the form does              position and cause of death
not require officers to identify which of the parents
smoke, whether they smoked in the same room                      Sleep                 SIDS &             Pending         Total
as the infant, whether the mother smoked during                  position           undetermined
pregnancy or the amount of smoke to which the                    Position when placed to sleep
infant was exposed.                                              Back                       7                12            19
There was evidence of habitual smoking in the                    Side                       7                 3            10
homes of 12 of the 26 infants who died from SIDS                 Stomach                    6                 5            11
and undetermined causes (46.2%), and in homes of                 Other                      1                 0            1
16 of the 23 infants where cause of death is pending             (propped up
(69.6%).                                                         on pillows)
                                                                 Unknown                    5                 3            8
In total, evidence of habitual smoking was found in
                                                                 Total                     26                23            49
28 of the 49 households where an infant died from
SIDS and undetermined causes or where cause of                   Position when found
death is pending.                                                Back                       7                 8            15
                                                                 Side                       5                 2            7
Parental drug and/or alcohol use
                                                                 Stomach/                  10                11            21
The Police Report of Death to a Coroner (Form 1)                 face down
identifies whether there was “any evidence of                     Unknown                    4                 2            6
alcohol or drug use at [the] location of [the] event”.
                                                                 Total                     26                23            49
However, the form does not require officers to record
                                                                Datat source: Queensland Child Death Register (2004–05)
the extent of alcohol or drug use.
There was evidence of drug or alcohol use in the                SIDS and undetermined causes
homes of six of the 26 infants who died of SIDS or
                                                                Of the 26 infants who died of SIDS and undetermined
undetermined causes (23.1%), and in the homes
                                                                causes, seven were placed to sleep on their backs,
of four of the 23 infants where cause of death is
                                                                seven on their sides, six on their stomachs and one
pending (17.4%).
                                                                propped up against two pillows. Information on sleep
In total, evidence of drug or alcohol use was found in          position is not available in five cases.
10 of the 49 households where an infant died from
                                                                Ten of the infants were found face down, including
SIDS and undetermined causes, or where cause of
                                                                the infant propped up against two pillows (who was
death is pending.
                                                                found face down between the pillows). Six infants
                                                                were found on their backs (one infant was found
                                                                with a pillow covering its face). Five infants were
                                                                found on their sides. The position of the infant when
                                                                found is not available in four cases.

Annual Report Deaths of children and young people Queensland 2004–05                                                              155
Cause of death pending                                  Evidence of habitual smoking was found in seven
                                                        of the nine homes in which shared sleeping was
Of the 23 infants where cause of death is pending,
                                                        reported (77.8%). Drug or alcohol use was noted in
12 were placed to sleep on their backs, five on their
                                                        three of these homes.
stomachs and three on their sides. Information on
sleep position is not available for three cases.        Five of the nine infants who died from SIDS and
                                                        undetermined causes and were sharing a sleep
Eight of the infants were found on their backs.
                                                        surface were currently being breastfed. Evidence of
One of these infants had a pillow over the face
                                                        habitual smoking was found in four of these infant’s
and another’s face was covered by the mother’s
                                                        Cause of death pending
Eleven infants were found face down, with three of
these infants wedged between two surfaces, and          Twelve of the 23 infants where cause of death is
another was found face down on a beanbag beside         pending were sharing a sleep surface with one or
the bed. Two infants were found on their sides, with    more people. Four infants were sleeping with the
one of these infants pressed against its mother’s       mother only, one with the father only, two were
body and overlaid by an eight-year-old sibling. The     sleeping with both parents and two with the mother
position of the infant is not available in two cases.   and siblings. There was also one infant sharing a
                                                        mattress on the floor with his twin sister.
Non-designated sleep surfaces
                                                        Evidence of habitual smoking was found in nine of
SIDS and undetermined causes
                                                        the 12 households in which shared sleeping was
Four of the infants who died from SIDS and              reported and drug or alcohol use was noted in three
undetermined causes were sleeping on non-               households.
designated sleep surfaces. Three were sleeping
                                                        Six of the 12 infants where cause of death is pending
on a sofa and one was sleeping face down on an
                                                        and who were sharing a sleep surface were currently
upturned cardboard box covered with a towel and a
                                                        being breastfed. Evidence of habitual smoking was
doona. The infants were sleeping on these surfaces
                                                        found in four of these infant’s homes.
alone in all cases. In three of the four cases, SIDS
was the certified cause of death.                        Multiple risk factors
Cause of death pending                                  Information about SIDS risk factors was available
                                                        in 46 of the 49 cases of infants who died from SIDS
Two infants, in cases where cause of death is
                                                        and undetermined causes, and where the cause of
pending, were sleeping on a sofa at the time of
                                                        death is pending.
death. In one case the infant was sharing the sofa
with its mother and a sibling.                          All 46 cases had at least one or two known risk
                                                        factors. In 17 cases, three or more risk factors were
Shared sleeping                                         present (37.0%), six cases had four or more risk
SIDS and undetermined causes                            factors (13.0%) and in a further four cases between
Nine of the 26 infants who died of SIDS and             five and six risk factors were evident (8.7%).
undetermined causes were sharing a sleep surface        Consistent with contemporary research (Mitchell et
with one or more people. Three infants were sleeping    al., 2000), a significant number of deaths appear
with the mother only, two with the father only, two     to have occurred in chaotic, poor households,
infants were sleeping with both parents and one         characterised by significant social problems where
with an older sibling. There was also one infant        multiple independent SIDS risk factors converge.
sharing a cot with his twin brother. Information on
whether the infant was sharing a sleep surface was
not available for three cases.

156                                                      Commission for Children and Young People and Child Guardian
Sleep accidents                                                                reportedly missed two hospital appointments before
                                                                               the infant’s death. The child appeared malnourished
During the reporting period three cases of SUDI were
                                                                               and grossly underweight when found dead.
caused by accidental asphyxia. All three infants were
sharing a sleep surface. In two cases the infants                              The infant who died from pneumonia due to
were sharing a bed with family members and in                                  Klebsiella pneumoniae had a cold, runny nose, a
one case the infant asphyxiated when a parent fell                             cough and difficulty feeding. The day before death,
asleep in a single arm chair during feeding.                                   the infant was treated by a doctor who provided
                                                                               antibiotics and advised treating the infant with non-
Two of the children who died from accidental
                                                                               prescription medication if symptoms persist.
asphyxia were Aboriginal infants.
                                                                               Three of the infants who died from unrecognised infant
Additionally, the death of one infant has been
                                                                               illness (two cases of bronchopneumonia, one case
certified by a pathologist as due to morphine
                                                                               of scabies) were found in positions likely to cause
toxicity. As coronial proceedings are still open, at
                                                                               accidental asphyxia. One infant was found with an
this stage this death has been coded as accidental.
                                                                               older sibling lying over its chest and two were found
While the death presented as a SUDI, only limited
                                                                               face down wedged between the mattress and a wall.
death scene information was available. It is reported
that the infant was sleeping alone in a cot at the                             Five of the infants who died from unrecognised
time of death. The parents’ social circumstances                               illness were Indigenous Australians (four Aboriginal,
were characterised by domestic violence, drug                                  one Torres Strait Islander).
issues and child protection concerns.                                          Infant illness is increasingly recognised as a
                                                                               modifiable risk factor for sudden infant death.
Unrecognised infant illness                                                    Consistent with the findings of the CESDI Study240, it
During the reporting period, 10 cases of SUDI were                             appears that both parents and health professionals
found at autopsy to be caused by unrecognised                                  underestimated the severity of illness in the infants
illness. Table 11.6 shows the breakdown of                                     who died. The Commission is concerned about
unrecognised infant illness by cause of death.                                 unrecognised infant illness and has identified it as a
Table 11.6: Cause of death for unrecognised infant illness                     focus area for further research.

 Cause of death                                               Total
                                                                               Prevention and intervention
 Bronchopneumonia                                                6
 Pneumonia due to Klebsiella pneumoniae                          1             Queensland Health initiatives
 Cytomegaloviral disease                                         1
                                                                               Queensland Health has developed the following
 Hypertrophy of tonsils                                          1             initiatives to reduce SIDS and other SUDI241.
 Scabies                                                         1
                                                                               • Child Health Information: Your guide to the
 Total                                                          10
                                                                                 first 12 months is distributed to all parents of
Data source: Queensland Child Deaths Register (2004–05).                         new infants as an insert in the Personal Health
                                                                                 Record. The booklet contains safe sleeping
In all six cases of bronchopneumonia, the infant                                 recommendations, including a diagram of correct
had been sick within the fortnight before death.                                 placement of baby in a cot. The information is
Symptoms included cold or flu like symptoms,                                      also available as a fact sheet on the internet.
sniffles, cough, rattly chest and difficulty breathing.                            This booklet does not contain guidelines for
One child had been treated for an audible cough                                  minimising the risks associated with shared
in hospital two days before dying. Another mother                                sleep environments.

240 The Confidential Inquiry into Stillbirths and Deaths in Infancy (CESDI Study) is the largest epidemiological study of SIDS risk factors since the
    introduction of risk reduction campaigns in the early 1990s.
241 Information provided by QH Child and Youth Health Unit, 2 August 2004.

Annual Report Deaths of children and young people Queensland 2004–05                                                                                   157
• An education package to improve the knowledge         to pilot in Aboriginal communities. The soft, woven
  and practices of Queensland midwives and              basket (with similar design features and function
  nurses regarding SIDS risk reduction strategies is    to a bassinet) is based on carry/sleeping baskets
  being developed at the Royal Children’s Hospital.     used in traditional Aboriginal communities. It has
  This should improve the quality, accuracy and         a flat bottom, stiff sides and carry-handles, and
  consistency of SIDS information provided to           can be placed on or beside a mattress to enable
  parents by nurses and midwives.                       the family to continue to sleep together with fewer
                                                        risks of sleep accidents. The basket is designed for
SIDS and Kids Queensland                                infants up to eight months of age. SIDS and Kids
SIDS and Kids Queensland promote and deliver            Queensland are looking for a research partner or
education programs designed to reduce infant            funding to trial this initiative.
mortality, and assist in funding research with money
raised through the Red Nose Day Campaign. SIDS          National Initiatives: New South Wales
and Kids Queensland provide bereavement support         In May 2005 the New South Wales Department of
to anyone affected by the sudden and unexpected         Health updated clinical nursing staff on the most recent
death of a child, from 20 weeks gestation up to the     information about safe sleeping practices, including
age of six, regardless of cause242.                     the messages of SIDS and Kids Australia’s Reducing
                                                        the Risk of SIDS campaigns243. The update included
Safe Sleeping in Midwifery Practice
                                                        information about circumstances in which shared
SIDS and Kids Australia has developed a training        sleeping increases the risk of infant death, as well
kit for health professionals regarding safe sleeping.   as guidance on how to minimise risks and maximise
During the reporting period, SIDS and Kids              safety when parents share a bed with an infant.
Queensland delivered many of the components of
                                                        The New South Wales Department of Health has
the national package to midwives in Brisbane, the
                                                        also developed a policy directive244 to all health
Gold Coast, the Sunshine Coast, Townsville and
                                                        professionals on how to provide safe sleeping
                                                        environments for babies in maternity units, including
Queensland Aboriginal and Torres Strait Islander        postnatal wards, birthing units and special care
Advisory Group                                          nurseries.
In 2002, SIDS and Kids Queensland established           This policy directive is aimed at ensuring that
the Queensland Aboriginal and Torres Strait             relevant health professionals:
Islander Advisory Group (QATSIAG) in response to
                                                        • provide the safest possible environment for
the high rate of SIDS in Indigenous communities.
                                                          mothers and babies in maternity facilities
This volunteer group of 14 Aboriginal and Torres
                                                        • practice and promote safe sleeping positions,
Strait Islander women provides advice on ways to
                                                          including positioning babies on their backs from
communicate the Reducing the Risk of SIDS and
safe sleeping messages to Aboriginal and Torres
                                                        • strongly encourage parents to maintain these
Strait Islander people (SIDS & Kids Queensland,
                                                          practices when they return home
2003). QATSIAG women also communicate key SIDS
                                                        • are aware of relevant and current information to
messages back to their own communities.
                                                          enable them to support and provide guidance to
QATSIAG has reported that in many communities             parents to make fully informed choices
bed sharing is ‘a way of life’, with parents and        • reduce the risks associated with bed sharing, and
siblings frequently sharing the same mattress.          • are sensitive to the emotional and physical needs
QATSIAG has been developing a ‘sleeping basket’           of the baby and mother.

242 See
243 Guideline document GL2005_063 dated 24 May 2005.
244 Document number PD2005_594, dated 7 June 2005.

158                                                      Commission for Children and Young People and Child Guardian
International initiatives                                                     Recommendations
UNICEF and the WHO have developed a global
program to help health organisations improve infant                             The Commission recommends that Queensland
care practices so that parents can make informed                                Health develop and implement a State wide
choices about how to feed and care for their babies.                            policy, to be followed by all relevant staff
                                                                                including midwives and health workers, in
Part of this program, ‘The Baby Friendly Initiative’,                           relation to information provided to new and
developed in conjunction with the Foundation                                    expectant parents about safe sleeping practices
for the Study of Infant Deaths (FSID), specifically                              (such as the UNICEF UK Baby Friendly Initiative).
targets safe bed sharing. Materials include a leaflet
informing parents how to safely share a bed with                                Reason: Health professionals are in a position
their baby and a sample hospital policy for nursing                             to educate, promote and influence safe sleeping
staff to educate parents to share beds safely while in                          practices to parents.
hospital245.                                                                    Following the development of the above policy, it
The UNICEF initiative recommends that the                                       is also recommended that Queensland Health:
benefits, risks and alternatives to bed sharing are                              • develop a training package in relation to the
carefully considered, and that parents be given full                              policy, and
information appropriate to their needs to encourage                             • develop culturally appropriate materials and
safe practice and to protect breastfeeding. Such                                  communication strategies that convey consistent
information should be provided in the antenatal and                               and appropriate messages about safe sleeping
early postnatal period and community staff should                                 messages to all new and expectant parents,
reinforce the information once mothers and babies                                 particularly those at high risk.
are at home246.
                                                                                Reason: To ensure consistent messages are
UNICEF recommends that discussions with parents                                 being communicated by Queensland Health staff,
about bed sharing should address:                                               particularly to parents of high risk infants.
• the circumstances under which shared sleeping
  should be discouraged (parental smoking,                                    In accordance with the requirements of section
  alcohol or drug consumption, excessive tiredness,                           89ZF(3) of the Commission for Children and Young
  inappropriate sleep surfaces such as sofas)                                 People and Child Guardian Act, the Commission
• the use of bed sharing by breastfeeding mothers                             provided the Director-General of Queensland Health
  and babies, and                                                             with the opportunity to comment on the above
• the risk of accidents if a baby sleeps in an adult                          recommendations. The Commission is pleased
  bed, coupled with support to avoid or minimise                              that Queensland Health advised that it supported
  these risks.                                                                the recommendations. The Commission looks
                                                                              forward to working collaboratively with Queensland
                                                                              Health and monitoring their implementation of the
                                                                              recommendations in 2005–06.

245 The FSID has recently changed its guidance on bed sharing in response to the Carpenter et al. (2004) study into sudden infant deaths across
    Europe and an opinion poll, commissioned by FSID of 428 parents in the United Kingdom, which asked parents about their infant sleep practices.
    The FSID found that parents were confused about safe sleeping practices, and that parents were inadvertently putting their infants at risk of SIDS.
    The FSID found that one in six infants were at risk of SIDS because of parental smoking while bed sharing. As a result the FSID has departed from
    the Baby Friendly Initiative (safe bed sharing campaign) to instead highlight the importance of room sharing and the dangers associated with
    shared sleeping. The key message of the FSIDs new campaign is that “the safest place for a baby to sleep is in a cot in the parents’ room for the
    first six months”.
246 The UNICEF/FSID leaflet ‘Sharing a bed with your baby’ is designed to support this.

Annual Report Deaths of children and young people Queensland 2004–05                                                                              159

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