1. Sleep Related Infant Deaths Tulsa County 2004 - 2007 Carol Kuplicki, MPH Tulsa Health Department, TFIMR Tulsa Fetal and Infant Mortality Review Project is supported in part by the Maternal and Child Health Block Grant in the Department of Health and Human Services, Health Resources and Services Administration, Maternal and child Health Bureau

2. The FIMR Process The Cycle of Improvement

3. Could these deaths have been prevented?  Children found on top of the infant.  Infant found unresponsive in sleeping bag wedged between the wall and bed.  Infant found in crib face down between a pillow and edge of crib.  Infant found unresponsive in bed under some pillows.  Infant found unresponsive lying under a sibling.  The infant had been sleeping in the bed with the parents. The child was found under the mother in bed.

4. Background  From 2004-2007 there has been a total of 314 Tulsa County resident infant deaths.  17 Sudden Infant Death Syndrome (SIDS)  35 Other symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified “Undetermined”  5 Accidental suffocation and strangulation in bed

5. Purpose and Definition Purpose  To identify and review sleep related infant deaths occurring in Tulsa County Definitions  Sleep related death – Infant was put to bed either alone or co- sleeping or had fallen asleep while being held, and subsequently died during sleep  Co-sleeping – Sharing the same sleep surface  SIDS-Sudden Infant Death Syndrome, ICD 10, R95 The sudden and unexpected death of an infant less than 1 year of age for which no exact cause of death can be determined  Undetermined – ICD 10, R99, Other ill-defined and other unspecified causes of mortality  Asphyxia – ICD 10, W 75 Accidental suffocation and strangulation in bed  Prone – Lying with the front or face downward  Petechial hemorrhages - subcutaneous hemorrhage occurring in very small spots

6. Sleep Environment Unsafe Sleep Conditions  Infant placed or found in a prone position  Co-sleeping  Sleeping on a couch, chair or on soft bedding  Bedding, pillows or other items found over the infant’s face

7. Cause of Death/Medical Examiner  Performs autopsies on sleep related infant deaths  Completes the death certificate as to the manner and cause of death  ~ 2004 the Medical Examiner began to standardize review of sleep related infant deaths across the state  The result was to classify infants that were co- sleeping at the time of death as Undetermined. Previously the death might have been classified as a SIDS death.

8. Selection & Method Selection  Deaths occurred during 2004 - 2007  Birth to <365 days old  Tulsa County resident at birth and death  Born and died in Tulsa County  Mother received prenatal care in Tulsa County Method  Reviewed medical records, Medical Examiner reports, EMSA reports

9. Cases Selected N=48 (15.3%) 314 infant deaths, all causes (2004-2007) Of the sleep related deaths occurring to Tulsa County residents, TFIMR reviewed 48. 2004200520062007Total Born outside Tulsa County132.6 Died outside Tulsa county...11 Non-resident...11 Accident, not sleep related...11 *Other exclusions3..14 Total Excluded432413 Number reviewed67191648 *Other exclusions could be possible homicide, death certificate received over 1 year after death, accident that was not sleep related or any other causes that would not fit into the sleep related death definition.

10. Findings

11. Most infants that died never went home from the hospital. Infant deaths reviewed by TFIMR: Of infants that were healthy enough to be released from the hospital, 57.1% died from sleep related causes. Infant Deaths by Year of Death, Discharge Status, and Cause of Death Year of Death Total Deaths (Data Abstracted) Infants Discharge to Home from Birth Hospital Sleep Related Deaths Reviewed by TFIMR* SIDSUndetermined Asphyxia 200446136321 200568167241 2006792719883 200786**28163112 Total 27984 (30.1%)48 (57.1%)16257 Of the infant deaths reviewed from 2004- 2007, only 84 (30.1%) infants were discharged to home. Of the infants discharged to home 48 (57.1%) died from sleep related causes. *The number of sleep-related deaths may differ from total Tulsa County Sleep-related deaths because of TFIMR case selection criteria. **Fetal deaths were excluded

12. Most infants died in a bed or on a couch while sleeping with someone else. 28 (58.3%) Co-sleeping 22 with an adult(s) 5 with an adult(s) and another child(ren) 1 with another child(ren) 33 (68.7%) Sleep surface other than bassinet/crib

13. Most infants died at 2 months of age or less. Red italic numbers - Co-Sleeping Blue numbers - No co-sleeping Deaths by Age: 33 (68.7%) were less than 3 months old 18 (37.5%) were 2 months old Deaths by Cause: 16 (33.3%) SIDS 25 (52.1%) Undetermined 7(14.6%) Asphyxia

14. Sleep Environment - Most infants were not placed in a safe sleep environment. Unsafe sleep environment  Prone sleep position  Not in a crib or bassinet  Co-sleeping  Loose blankets, pillows or clothing in sleep area Based on review of available records 39 (81.3%) Unsafe sleep environment 9* (18.8%) Safe sleep environment (*of the 9 infants noted to be in a safe sleep environment, sleep position was unknown for 5 infants)

15. Infant Health  10 (20.8%) recent illness with cough, congestion, or fever in days preceding death  14 (29.2%) at autopsy had petechial hemorrhages on the thymus, plura and/or epicardium

16. Summary Information  39 (81.3%) Non-safe environment  36 (75.0%) were not in a crib or bassinet, or had loose bedding or pillows in the crib or bassinet  28 (58.3%) were co-sleeping  33 (68.7%) occurred prior to the 3 rd month of life  10 (20.8%) had been having symptoms of an illness with recent cough, congestion, or fever in the days preceding death  8 (16.7%) were pre-term (<37 weeks gestation)  14 (29.2%) at autopsy had petechial hemorrhages on the thymus, plura and/or epicardium

17. Recommendations for Preventing Sleep Related Deaths NIH Back to Sleep Campaign Recommendations 1. Always place your baby on his or her back to sleep, for naps and at night. 2. Place your baby on a firm sleep surface, such as on a safety-approved crib mattress, covered by a fitted sheet. 3. Keep soft objects, toys, and loose bedding out of your baby’s sleep area. 4. Do not allow smoking around your baby.

18. Recommendations for Preventing Sleep Related Deaths 5. Keep your baby’s sleep area close to, but separate from, where you and others sleep. 6. Think about using a clean, dry pacifier when placing the infant down to sleep. 7. Do not let your baby overheat during sleep. 8. Avoid products that claim to reduce the risk of SIDS. 9. Do not use home monitors to reduce the risk of SIDS. 10. Reduce the chance that flat spots will develop on your baby’s head: provide “Tummy Time”. Source: NIH Back to Sleep Campaign

19. Recommendations for Preventing Sleep Related Deaths Educational campaign of Safe Sleep Environment  Hospitals via discharge instructions, posters, informational videos  Sleep environment education for the public  Clinics – Prenatal care providers, Pediatricians, Family Practice  Media – Billboards, TV, Radio, Newspapers  Faith-based Organizations  Tulsa Area Immunization Coalition – KICK packets

20. Acknowledgements / Further Information Tulsa Fetal and Infant Mortality Review Project is supported in part by the Maternal and Child Health Block Grant in the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. For further information contact:  Carol Kuplicki, MPH, MCH Epidemiologist (918) 595-4499, ckuplicki@tulsa-health.org ckuplicki@tulsa-health.org  Pam Rask, MPH, Manager – School Health/TFIMR (918) 595-4418, prask@tulsa-health.org prask@tulsa-health.org