Sudden Infant Death Syndrome in Baltimore City - PowerPoint

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					  Sudden Infant
Death Syndrome in
  Baltimore City
Stephanie Strauss Regenold, MD, MPH
           Senior Advisor,
    Babies Born Healthy Initiative
 Bureau of Maternal & Child Health
  Baltimore City Health Department

• BCHD‘s new Birth Outcomes Initiative
• Definitions
• Epidemiology, Etiology, and Risk
• Recommendations
• Parent Education
             B’more for Healthy Babies:
                         BCHD’s New Initiative

• New initiative by the Baltimore City Health
  Department & The Family League of
• Multi-year grant from CareFirst Blue
  Cross/Blue Shield to improve birth outcomes
  in Baltimore City
• Strategic approach to affect change on all
  levels- policy, service, community and
  individual levels
                B’more for Healthy Babies:
                             BCHD’s New Initiative

Our vision is to ensure that all of
 Baltimore’s babies are born healthy
 weight, full term, and ready to thrive in
 healthy families.
B’more for Healthy Babies will include:
• A citywide media campaign
• Intensive, innovative efforts in high-risk
  neighborhoods…and more!
                     B’more for Healthy Babies:
                                     BCHD’s New Initiative

• 120 babies under the age of one died in Baltimore City
  last year
• Baltimore has the 4th worst infant mortality rate in the
    • The national rate is 6.9 deaths per 1000 live births
    • Baltimore‘s rate is 12.1 deaths per 1000 live births
       African American: 14.3 per 1,000
       White: 7.3 per 1,000
                  B’more for Healthy Babies:
                               BCHD’s New Initiative

The leading causes of infant mortality in Baltimore are:
      #1    Prematurity and low birth weight
      #2    SIDS and unsafe sleep conditions
      #3    Birth defects

   Our First Campaign Will Address Safe Sleep
               B’more for Healthy Babies:
                             BCHD’s New Initiative

• The campaign will take a tough stance against
  a tough problem
• We will show real people telling real stories
  about their own tragic losses
• We will not sugarcoat the issue…

          It’s a matter of life or death
            Sudden Infant Death Syndrome (SIDS)

• The sudden death of an infant younger than 1 year
  of age, that remains unexplained after a thorough
  case investigation, including:
   – autopsy
   – death scene investigation
   – clinical history review

• No cause of death is determined
• Manner of death is ―Natural‖
               Sudden Unexplained Infant Death (SUID), or
              Sudden Unexplained Death in Infancy (SUDI)

• No cause of death able to be determined
• Infant found in an unsafe sleeping environment
   • on an adult mattress or sofa
   • sleeping with another adult or child
   • sleeping on the stomach

• Inconclusive for asphyxia
• Manner of death is ―Undetermined‖
• Coded as SIDS for Vital Statistics, 2009
                                Case #1

A 22-year old single African American
  woman lived in an apartment with her three
  children (ages 3 months, 2 years, and 4
  years). She fell asleep on the couch with
  her 3-month-old. When she awoke 2 hours
  later, the baby was unresponsive. The
  EMS team was unable to resuscitate the
                   SIDS Epidemiology

• SIDS is the 3rd leading cause of infant
  mortality in the US, and the 2nd leading
  cause of death in Baltimore City
• It is the leading cause of postneonatal
  mortality nationally and locally
• Over 2,000 babies die in the US each year
  from SIDS
• Peak incidence occurs when a baby is
  between 2 and 4 months
                   SIDS Epidemiology:
                       Established Risk Factors

•   Prematurity and/or low birth weight
•   African American
•   Native American
•   Male gender
•   Young maternal age
•   Late or no prenatal care
•   High parity
                 SIDS Epidemiology:
                    Established Risk Factors

•   Maternal drug use during pregnancy
•   Maternal smoking during pregnancy
•   Environmental tobacco smoke
•   Overheating
•   Bed sharing
•   Prone/side sleep position
•   Soft bedding
                                  Case #2

A 6-month-old girl was sleeping in an adult bed
  with her 10-year-old brother. When their
  mother checked in on them, the baby was not
  breathing and was cold and stiff to the touch.
  The boy‘s leg was resting on top of the baby‘s
  head. EMS was called and resuscitation
  efforts were started but were unsuccessful.
                                                               SIDS Epidemiology:
                                                                                  United States

                                                         Back to Sleep Campaign

AAP Task Force on SIDS. Policy Statement. October 2005

Since the introduction of the Back to Sleep Campaign, SIDS deaths
have decreased by 50%
                                                              SIDS Epidemiology:
                                                                                           Baltimore City
Deaths per 1,000 live births

                  Baltimore City - BCHD analysis of data from the Maryland VSA, MD - Maryland Vital Statistics Reports, U.S. -
                  NCHS Vital Statistics Reports
                                     SIDS Etiology:
                                          Triple Risk Model

                Infant at Critical
              Development Period

    Genetic                          Environmental
 Predisposition                         Factors

Filiano JJ and Kinney HC, Biol Neonate, 65:194-197, 1994
                                                       SIDS Etiology:
                                         Critical Development Period

• Immature respiratory and autonomic nervous
• Delayed neuronal maturation.
• Poor sleep arousal responsiveness.

Moon RY, Lancet. 2007;370:1578-1587.; Moon RY, Fu LY. Pediatrics in Review. 2007;28(6).
                                                             SIDS Etiology:
                                                                        Genetic Factors

   • Serotonin receptor and transporter
     abnormalities that affect arousal response.
   • Polymorphisms in genes that effect ANS
   • Abnormalities in the Na+ and K+ channels that
     are associated with prolonged QT syndrome.
   • Complement gene deletions and IL-10 gene

Moon RY, Lancet. 2007;370:1578-1587.; Moon RY, Fu LY. Pediatrics in Review. 2007;28(6).
                                                 SIDS Etiology:
                                             Environmental Factors

• Prone and side sleeping positions
• Smoking during pregnancy
• Exposure to smoking after birth
• Bed sharing
• Use of soft sleep surfaces (adult bed, sofas)
• Presence of soft objects and loose bedding
  (toys, pillows, blankets and comforters)
• Overheating
      AAP Task Force on SIDS. Policy Statement. October 2005.
                                                SIDS Etiology:
                                                     Rebreathing Theory

• Infants in certain sleep environments are more
  likely to trap exhaled CO2 around the face
  – Lie prone and near-face-down/face-down
  – Soft bedding
  – Tobacco smoke exposure
• Infants rebreathe exhaled CO2 : CO2 ↑ & O2 ↓
• Infants die if they cannot arouse/respond

       Kinney HC, Thach BT. NEJM 2009;361:795-805.
                                              SIDS Etiology:
                                   Proposed Causal Pathway
                                              Pregnancy related risk factors
   Genetic risk factors
                                               (low birth weight, smoking)

                          Vulnerable infant
                  (impaired autonomic regulation)

                          At risk age group

                    Environmental risk factors
(sleep position, bed sharing, thermal stress, head covering, etc.)

                             SIDS              Mitchell EA, Acta Paediatrica, 2009
                                   Unexpected Infant Deaths that Occured During Sleep:
                                     Baltimore City Child Fatality Review, 2002-2009

                     25                                                                                                           1
  Number of Deaths

                     20                                    1                                       4
                                            0                                      2                               0
                     15        3                                                                                                 21
                     10                     19            20                                      19              19
                               13                                     12
                             2002         2003            2004      2005         2006            2007           2008            2009
                     Sleep environment not yet reviewed    Unsafe sleep environment confirmed      Unsafe sleep environment not confirmed*

* Deaths for which the evidence did not indicate an unsafe sleep environment, however, data on unsafe sleep risk factors may have been missing or
unknown. Baltimore City Health Department analysis of data from cases reviewed by the Baltimore City Child Fatality Review.
           SIDS in Baltimore City:
                         Most Common Risks

•   Stomach sleeping
•   Bed sharing (>75%)
•   Soft bedding
•   Smoke exposure
 AAP Infant Sleep
       The ABC’s of Safe Sleep

On my Back

 In a Crib
                   Additional Safe Sleep

• No smoke exposure
• No overheating
• Consider a pacifier
• Not with Mom, Dad, or anyone else
• No pillows, blankets, or stuffed toys
• Baby‘s sleep area should be close
  to, but separate from, where parents
                                       Infant Bed Sharing
                                           and SIDS Risk

• Earlier studies showed increased risk associated primarily with bed
  sharing among smoking mothers

• More recently, two European studies showed increased risk for
  younger infants even among non-smoking mothers
   – European Concerted Action on SIDS (Carpenter, 2004) – under
     8 weeks
   – Scotland (Tappin, 2005) – under 11 weeks

• Germany (Vennemann, 2005) – risk was independent of age,
  independent of smoking

• England (Blair, 2009) – bed sharing on bed or couch had almost 3
  times higher risk of SIDS; 10 times higher with recent drug or
  alcohol use
                                            Infant Bed Sharing
                                                and SIDS Risk

• Other factors that increase risk:
   –   Multiple bed sharers
   –   Bed sharing with other children
   –   Parent consumed alcohol or is overtired
   –   Infant between both parents
   –   Sleeping on sofas or couches

• Returning the infant to his/her own
  crib is not associated with increased risk

• No studies have ever shown a protective effect of bed
  sharing on SIDS
           Why do Parents Bed Share?
• Safety
   – Can keep close watch on baby
   – Belief that ―crib death‖ occurs in crib

• Convenience
   – Feeding
   – Checking on baby

• Comfort
   – Baby sleeps better
   – Mother sleeps better
   – Bonding

• Space/availability of crib
                           Bed Sharing Has Become
                                     More Popular
• Renewed popularity of breastfeeding

• Bed sharing all night long has more than doubled in the
  past 10 years from 6% to 13% (Willinger M, 2003, National Infant
  Sleep Position Survey)

• More recent study: 1/3 bed share in first 3 months, 27%
  at 12 months (Hauck F, 2009, Infant Feeding Practices Study II)

• Higher numbers in low SES, certain ethnic groups
  (African Americans, Latinos) - more than 50% may be
  bed sharing all night long
Shhh...MyShhh...My Child Is Sleeping (in My Bed, Um, With Me)
Child Is Sleeping (in My Bed, Um, With Me)
                            By TARA PARKER-POPE
                           Published: October 23, 2007

 “Ask parents if they sleep with their kids, and most will say no. But
 there is evidence that the prevalence of bed sharing is far greater than
 reported. Many parents are ''closet co-sleepers,'' fearful of disapproval if
 anyone finds out, notes James J. McKenna, professor of anthropology
 and director of the Mother-Baby Behavioral Sleep Laboratory at the
 University of Notre Dame.”
           Why is Bed Sharing Risky?

•   Soft bedding, pillows, comforters
•   No safety standards for adult beds
•   Overheating
•   Risk of entrapment
Not safe
            …on my Back

• Not on the stomach or side
• On the back every time the baby
  is laid down to sleep
                              SIDS Rate and Sleep Position, 1988-2005
                                   (Deaths per 1,000 Live Births)
            1.5                                                                                                                      100
                  1.4 1.39

                             1.3   1.3

                                                                                                        71.6 71.1 72.8      72.2

                                                      1.03                                       66.6

                                                                                                                                           Percent Back Sleeping
                                                             0.87                  55.7
                                                                    0.74           0.72                                              50
                                                                            53.1          0.67
                                                             38.6                                0.62
                                                                                                        0.56 0.57
                                                                    35.3                                            0.53 0.55 0.54
            0.5                                       26.9


             0                                                                                                                       0

         Pre-AAP recommendation Post-AAP BTS Campaign (began in 1994)
Sleep Position Source: NICHD Household Survey
SIDS Rate Source: National Center for Health Statistics, CDC
                                                  Prone Prevalence Rates Among
                                                               Black Infants, US

                 90                                                                                                             2.5




                                                                                                                                      Deaths/1000 LB
 Percent Prone





                 0                                                                                                              0
                      1992   1993   1994   1995   1996    1997    1998      1999   2000     2001    2002   2003   2004   2005

                                                     Prone-B     Prone-NB     SIDS-B      SIDS-NB

National Center for Health Statistics, National Infant Sleep Position data
                          Why do People Place
                          Their Babies Prone?

• Comfort
  – Baby sleeps longer, doesn‘t awake easily

• Flattened Skull (plagiocephaly)

• Safety
  – Concern about choking
           Why is Prone Sleeping Risky?

• Babies sleep deeper, experience less
  movement, and are less arousable when
• Rebreathing theory: carbon dioxide gets
  trapped around the mouth and nose.
• Risk is higher when infant is used to back
• Risk of side sleeping similar to prone.
                                 Prone Sleeping and
                                    Aspiration Risk

Being on the back is actually less risky for aspiration:
       secretions pool in the back of the throat,
       near the esophagus.
                                                           Prone Sleeping
                                                            and the NICU

• Premature babies are often placed prone to
  improve respiratory mechanics.
• Parents are likely to continue this practice at home.
• Teaching and modeling appropriate sleep position
  may not occur in the NICU.
  – 52% of NICU nurses promoted supine sleeping at discharge
    (Aris 2006)
• Recommendation:
  – Place all premature babies supine when respiratory dynamics
    are stable, well before anticipated discharge.
  – Parents should be taught and shown to place
    babies supine during sleep before discharge.
    Aris C, Adv Neonatal Care. 2006;6(5):281-294.
                         Prone Sleeping and Gastroesophageal
                                      Reflux Disease (GERD)

• Supine positioning may worsen GERD symptoms in some.
• North American Society for Pediatric Gastroenterology and
  Nutrition guidelines state:
   – ―In infants from birth to 12 months of age with GERD, the risk of SIDS
     generally outweighs the potential benefits of prone sleeping.
     Therefore, non-prone positioning during sleep is generally
   – ―Prone positioning during sleep is only considered in unusual cases
     where the risk of death from complications of GER outweighs the
     potential increased risk of SIDS.‖
   – ―When prone positioning is necessary, it is particularly important that
     parents be advised not to use soft bedding, which increases the risk
     of SIDS in infants placed prone.‖
   ―Pediatric GE Reflux Clinical Guidelines.‖ J Ped Gastro Nutr. 2001;32:Suppl 2.
                …in a Crib

• Not on an adult bed, sofa, cushion, or
  other soft surface
• A crib, bassinet, or portable crib which
  meets safety standards
             Why a Firm Sleep Surface?

• Soft or loose bedding carries 5 times the risk
  of SIDS as firm bedding.
• Sleeping on the stomach on soft or loose
  bedding carries 20 times the risk of SIDS than
  those infants who slept on their backs on firm
• Infants should not be placed to sleep on
  couches, cushioned chairs, beanbag chairs,
  sofas, waterbeds, air mattresses, memory foam
  mattresses, or lamb skins
             I Sleep Safest:

On my Back

 In a Crib
                   Additional Recommendations:
                     Avoid Tobacco Smoke

• In utero tobacco exposure increases the
  risk of SIDS
    • Possibly related to effect on birth weight
    • Prenatal tobacco exposure associated
      with arousal defect

• Post partum exposure to tobacco smoke
  also increases the risk of SIDS
                         Additional Recommendations:
                             Avoid Overheating
• Dress infant according to room temperature.
• Keep temperature comfortable for a lightly
  clothed adult.
• Use sleeper or sleep sack.
• If a thin blanket is used—tuck it in on 3 sides to
  keep at chest level or below.
• Don‘t over-bundle.
                  Additional Recommendations:
             Consider Pacifier Use While Sleeping

• Recommendation added in 2005 after multiple studies
  showed an independent protective effect
• Possible mechanisms:
      • Lower arousal threshold
      • Airway patency
      • Sleep position

• Specific Recommendations:
      • Introduce around 1 month of age or after breastfeeding is
      • Use as infant is being put down to sleep
      • Do not force
      • Don‘t have to reintroduce if it falls out
                                          Other Considerations:
                                            “Tummy Time”

• Persistent flat spots on an infant‘s head, positional
  plagiocephaly, can be caused by repeated time in one
• Flat spots usually disappear in the months after learning
  to sit up
• To help reduce flat spots:
   – Daily ‗Tummy Time‘ while awake
     and supervised.
   – Alternate end of crib where baby‘s head is
     placed to sleep, or rotate position of crib.
   – Limit amount of time baby spends in
     car seats, carriers, etc.
                                     Other Considerations:

• May be associated with reduced risk of SIDS.
  – Breastfed infants are more arousable at 2-3
  – Some studies show protective effect, others

• Mothers can breastfeed successfully
  without bed sharing.

   Moon FY, Lancet. 2007;370:1578-1587
                            Other Considerations:
                 Positioners & Monitors

• Wedges, blanket rolls can be a potential
  suffocation risk.
• Use of home monitors does not prevent
  – In certain situations a home monitor may be
    ordered by the physician for apnea, but these
    monitors do not prevent SIDS.
               Safe Sleep Education for Parents
                                and Caregivers

• Be addressed early and often
• Help parents prepare to counter contrary advice they
• Help parents prepare to insist on consistent provision
  of a safe sleep environment when others care for the
  infant (grandparents, babysitters, child care providers,
  family members)
• Be modeled by respected and credible role models
                            Gallup Poll 2006, Top List of Most
                            Honest and Ethical Professionals
  Car salesmen

 HMO Managers



   Business Ex.




College teachers



                   0   10      20   30   40   50   60   70   80   90
                      Nurses as Role Models

• Nurses can model SIDS risk-reduction
  techniques to ensure that families know how to
  reduce SIDS risk.
   – Nurses who placed infants to sleep on their backs
     during the postpartum hospital stay changed parents‘
     behaviors significantly (Colson, 2002)

• The most critical period during which nurses can
  influence parents‘ behavior is during the 24 to 48
  hours following delivery.
                          Knowledge vs. Practice

•   1999 American Academy of Pediatrics study (Peeke et el)
     – 97% of nurses reported awareness of back sleeping
     – 67% followed the recommendation
     – The majority cited ―experience‖ or ―the potential adverse
       consequences of the back position‖ as their reason for
       disregarding the recommendation

•   2004 survey (Bullock et al)
     – 96% of nurses reported awareness of back sleeping
     – 75% reported using either side position or a mixture of side and
       back positioning
     – Most nurses thought side sleeping was still acceptable

•   Nursery staff do not uniformly recommend the back sleeping
  The ABCs of Safe Sleep

On my Back

 In a Crib
Every Baby Counts on You!

       Thank you!