Infant Deaths Occurring in the Sleep Environment

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Infant Deaths Occurring in the Sleep Environment

• Federal/State Partnership Meeting
• October 18, 2005
• Mary D. Overpeck, DrPH
• U.S. Department of Health and Human Services
• Health Resources and Services Administration,
• Maternal and Child Health Bureau

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Contributors

• Sara Rich, MPA
• Teri Covington, MPH
• Monique Shepard, PhD
• Douglas Hill, PhD
• Child Death Review Teams across US

National MCH Center for Child Death
Review Childrens Safety Network, Pacific
Institute for Research Evaluation
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Data needed for Evidence

• Sudden Infant Death Syndrome (SIDS) workshop
  appeal for evidence related to potential for a
  National Crib Campaign to reduce sleep-related
  infant deaths
• Identifiable risk factor data was needed to
• Assess factors pertinent for targeting
  appropriate audiences for crib campaigns
• Assess potential for success in reducing deaths.

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Why not use U.S. Infant Mortality Rates?

• Rates based on death certification by over 2000
  medical examiner and coroner systems
• Inconsistent investigations and cause
  classification of sleep-related deaths
• Cause classification from death certificates uses
  International Classification of Disease (ICD)
• ICD sleep-related death data are incomplete,
  inaccurate and not specific enough

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Diagnostic Shifts on Death Certificates

• More jurisdictions requiring mandatory autopsies
  of unexpected infant deaths
• Medical certifiers are shifting designations to
  categories other than SIDS
• Recognition of multiple mechanisms
• Mechanisms may involve infections, metabolic
  problems together with some
• form of suffocation or strangulation

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Ambiguity in SIDS as Cause of Death

• Sudden Infant Death Syndrome (SIDS)
• Unexplained cause after thorough autopsy and
  death scene investigation
• Sudden Unexpected Infant Death (SUID/SUDI)
• Mentioned as option to SIDS in ICD-10 since 1999
• Recognizes diagnostic shift away from SIDS to
  undetermined or unknown cause and suffocations
• SIDS SUID/SUDI Manner of death classified as
  Natural events
• Asphyxiation Suffocations Manner of death
  classified Traumatic (Injury) events

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SIDS and Injury Mortality US Death
Certificates, 1991-2002
ICD-9
ICD-10
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Nature of Infant Injury Deaths as Classified by
Cause/Mechanism
Deaths per 100,000 live births
US, Certificates1999-2002
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Infant Injury Deaths US, 1991-2002
US, Certificates1999-2002
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SIDS, SUID/SUDI, and InjuryCause by Age at
Death, 1999-2002
Source US, Certificates1999-2002
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Supportive Investigations

• Manner and mechanisms of sleep-related deaths,
  including injuries
• - Infant Death Scene Investigation
• - Scene re-enactments for infant deaths occurring
  in sleeping environment
• - Child Death Review (CDR)

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Query for Help to CDR Teams

• Some CDR teams are participating in development
  of a data review tool
• Tool includes standardized report format for
  sleep-related deaths
• Other CDR teams review infants deaths and
  document sleep-related deaths

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Availability of More Accurate Sleep-Related
Information

• CDR may be able to provide information on items
  related to
• Sleep-related surfaces in use at death
• Location where infant found dead
• Primary caretaker at time of death
• Multiple risk factors for sleep-related deaths

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State CDR Team Contributors

• Alabama
• Delaware
• Hawaii
• Illinois
• Kentucky
• Michigan

• Minnesota
• Missouri
• Nebraska
• Ohio
• South Carolina
• Washington

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Questions to CDR Teams on Sleep-Related Deaths

• How many infant deaths were reviewed in your
  state in 2001-2003?
• 6,359 deaths varying review time periods or
  completeness of records among teams
• Sleep-related deaths are those occurring while
  infant was sleeping or in a sleeping environment.
  Of those infant deaths reviewed, how many were
  sleep-related?
• About 1/3rd were considered to be sleep-related

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Sleep-Related DeathsQuestions Responses

• Of the deaths deemed sleep-related, what was the
  official cause of death by age?
• CDR team responses affected by review criteria
• Most review all infant deaths from SIDS,
  suffocation/strangulation, other trauma, and
  deaths undetermined for cause or intent
• Fewer review other medical conditions

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Sleep-Related Deaths Reported by Manner/Cause

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Age at DeathN 1,337 from 9 States

• About 1/3rd died during first month of life
• Almost 40 died during 2nd and 3rd month
• Almost 20 died during 4th and 5th month
• Questions raised
• Are most deaths occurring before age when most
  infants are placed in cribs?
• Are more dead infants found in bassinets and on
  other surfaces at younger ages?

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Sleep Surface Where Infant was FoundN 1501
from 9 States

• Bed mattress
• Crib/Bassinette
• Couch/chair
• Playpen
• Waterbed
• Other Places
• Dont know

• 39
• 23
• 15
• 2
• lt1
• 10
• 10

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Where did the Death Occur?N 1,184 from 7 States

• 78
• 22

• Own home
• Other homes, places

Relatives home and child care specified only
by 3 states and type of child care setting not
included
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Relationship of Caretaker at Time of DeathN
640 from 6 States

• Biological parents
• Both parents (20)
• Father (10)
• Mother (50)
• Other relative
• Child care provider
• Other

• 81
• 5
• 11
• 3

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Co-Sleeping / Bedsharing?

• At least 46 of 1486 Deaths in 9 States involved
  co-sleeping and/or bed-sharing
• No or dont know in remaining deaths
• If co-sleeping, sleeping with 1 adults?
• About 80 of co-sleeping included adults

Some information collected only for the SIDS
diagnosis and bedsharing rather than for
co-sleeping
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Multiple Risk Factors for Sleep-Related Deaths
Various State Reporting

• Prone position 35 (8 States)
• Blankets/pillows/toys 30 (7 States)
• Sleeping with others 48 (9 States)

More than one factor may be present.
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Summary

• Death certificate information is not accurate for
  assessing number of SIDS or sleep-related deaths
• CDR teams can provide new information on
  sleep-related deaths and risk factors
• Infant death scene investigations and death scene
  reenactments are needed to assist death
  certifiers prior to determinations

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Conclusion Crib-related Evidence

• Data systems are not sufficient to evaluate
• How often cribs were available but not used
• Reasons available cribs were not used
• Locations of deaths when cribs were not available
• Who we need to target for use of cribs, bassinets
  and safe alternative surfaces

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Where From Here?

• Identifiable risk factor data from death
  investigations and review teams are needed
• Assess factors pertinent for targeting
  appropriate audiences for crib campaigns
• Assess campaign success in reducing deaths.

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For Further Information

• National MCH Center for Child Death Review
  (www.childdeathreview.org)
• Mary Overpeck (overpecm_at_hrsa.gov)
• Health Resources and Services Administration,
  Maternal and Child Health Bureau