Safe Sleeping

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Safe Sleeping
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Sara H. Sinal, M.D. Wake Forest University School
of Medicine Winston-Salem, North Carolina
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How Much of a Problem is Death Due to Unsafe
Sleeping?

• Deaths of children 0-18 yr in N.C. - 2007
• Accidental Deaths of Children 253
• Natural Death (100 SIDS) 196
• Homicides 65
• Suicides 28

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Child Deaths by Means Accident - 2007
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Asphyxia

• 41 Deaths
• 78 (32) Infants
• 94 of infants lt6 months of age

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Types of Asphyxia

• Positional refers to body position that somehow
  obstructs the airway
• Smothering obstruction of airway usually refers
  to something occluding or covering the nose and
  mouth like a pillow or plastic bag
• Mechanical - usually means an object on chest
  thus limiting ability to inhale/exhale overlying
  could be a form of mechanical asphyxia
• Overlying another person prevents infant from
  breathing by lying fully or partially on the
  child while co-sleeping

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Infant Asphyxiation Deaths by Mechanism, Accident
- 2007
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• Co-sleeping present in 81 of infant deaths

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Infant Asphyxiation Deaths by Location, Accident
- 2007
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Alcohol or Drugs

• Adult use in 19

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In Older Children 1-18 year

• 9 asphyxia deaths
• 2 children ages 1-4 years died being wedged
  between bed and wall

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• SIDS remains the leading cause of death for
  infants in the U.S. outside of the neonatal
  period.
• Infant child lt 1 year of age
• Cause not known probably multifactorial

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SIDS Sudden Infant Death Syndrome

• Definition The sudden death of an infant under
  1 year of age, which remains unexplained after a
  thorough case investigation, including
  performance of a complete autopsy, examination of
  the death scene and review of clinical history

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SIDS

• SIDS rare in the first month of life
• Peaks between 2-3 months and then decreases
• Since the American Academy of Pediatrics (AAP)
  recommendation in 1992 that infants be put to
  sleep in nonprone position, SIDS has 50
• BACK TO SLEEP CAMPAIGN

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Babies Sleeping Prone and Supine Positions
SUPINE
PRONE
SUPINE
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Factors Which are Associated with Increased Risk
of SIDS

• Prone sleep position
• Sleeping on a soft surface (e.g., waterbed,
  sheepskin)
• Mother smoked during pregnancy
• Overheating
• Late or no prenatal care
• Young maternal age
• Preterm birth or low weight birth
• Male gender
• Ethnicity rate 2-3x in African-American,
  American Indians, Alaska Natives

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Rate of SIDS

• 1992 1.2/1000 live birth2001 0.56/1000 live
  births
• It is possible that some children previously
  classified as SIDS are now being assigned to
  other categories

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• SUID Sudden Unexpected Infant Death sudden
  and unexpected death of an infant
• due to natural or unnatural causes
• ASSB a subtype of SUID
• Accidental Suffocation and Strangulation
• in Bed
• SIDS also a type of SUID

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Percent of SUID deaths
Deaths per 100,000 live births
Year
Figure 1. Proportionate SUID mortality
attributable to ASSB, SIDS, and unknown cause
(primary y-axis) and total SUID mortality rate
(secondary y-axis), United States, 1984-2004.
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Prone Sleeping Rate in U.S.

• 1992 70
• 2002 11.3
• 2004 13.0
• 2001
• Whites - 11
• Blacks - 21
• This may account for some of racial disparity in
  SIDS

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Seasonal Difference

• 1992
• 16.3 seasonal difference
• ? in colder months

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New Recommendations from the AAP Since 1992
Policy Statement

• Side position
• 2 studies showing side position ? risk over
  back position
• Bedding
• Children dying of SIDS often found with face in
  pillows or soft bedding
• Bed Sharing (co-sleeping)
• Very controversial!
• More data than anyone can possibly analyze

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• New AAP Policy
• Some studies show ? SIDS and bed sharing only
  in mothers who smoke
• Large multisite European study 2004 bed sharing
  ? risk up to 8 weeks
• Scottish study 2005
• bed sharing ? risk up to 11 weeks
• Multiple studies show extreme hazard of adults
  sleeping with infants on a couch
• Risk of bed sharing ? with amount of time in
  bed 1 study showed ? risk only if gt 1 hour

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• These studies have led European and Scottish
  experts to endorse infant sleeping in a crib in
  the parents room as safest for first 6 months.

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Pacifiers another controversy

• Use of pacifiers may cause ? arousal and
  therefore ? SIDS
• Concerns are
• ? breastfeeding
• hooking child on pacifier
• ? ear infections

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Non-parent Caregivers

• Studies have shown daycare providers have poor
  knowledge of prone sleeping recommendations
• ? risk if prone and infant not used to it

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Breast Feeding

• Studies are contradictory
• AAP strongly supports breastfeeding, but sees no
  evidence of it ? SIDS

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La Leche League International (LLLI)Statement in
Response to AAP Statement

• Although the authors do state that breastfeeding
  is beneficial and should be promoted, their
  recommendations about pacifier use and cosleeping
  could have a negative impact on a mothers
  efforts to breastfeed. The statement causes
  confusion for parents and falls seriously short
  of being a useful and comprehensive policy.

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ICN graduates

• Less likely to be placed supine
• may be learned in nursery when monitors
  available / skin concerns
• More education needed at discharge

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New AAP Policy Statement 2005

• Based on these and other factors, the AAP
  recommends
• Back to sleep / side not as safe
• Use firm sleeping surface / crib mattress/sheet
• Avoid pillows, bumper pads, toys, sheepskin,
  wedge devices, puffy bedding
• Avoid smoking during pregnancy
• Separate but proximate (same room) sleeping
  recommended
• Breastfeeding in bed, then return to crib
• No sibling sleeping
• Alcohol, drugs increase co-sleeping risk
• No couches or arm chairs
• Consider pacifier 1-6 mo
• Avoid overheating
• Avoid monitors

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Co-Sleeping also Called Bed SharingNot a New
Problem

• Co-sleeping has been practiced for thousand of
  years.
• Mentioned in the Old Testament King Solomon, I
  Kings 319
• And this womans child died in the
• night because she overlaid it

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• Bed sharing rates vary widely from country to
  country
• 2 - 98 from birth to 3 months
• 46 New Zealand
• 96 Chile
• 65 Northern Europe
• 46 Philadelphia

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Bed Sharing

• Another Study
• Japanese 59 for entire night
• 23 of them father not in bed
• Japanese slept on futon on floor
• U.S. 11 entire night
• Korean - 88
• Often on Yo thin floor mat

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Negative effects

• Co-sleeping may lead to poor quality of sleep
• Co-sleeping with older children more likely to
  have
• less regular bedtimes
• difficulty with sleep onset
• more nighttime awakening
• may interfere with child developing autonomy

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Positive effects

• improved cognition
• may reflect lifestyle and may have no long term
  effects (more common in parents with alternative
  lifestyles)
• may improve breastfeeding

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Important to Remember

• Remember Just because a child dies in the
  parents bed does not prove death due to
  co-sleeping just as if a child dies in a crib,
  it does not prove death due to solitary sleeping.

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Scene investigations are very important and often
not done (money issue)

• Autopsy may reveal medical cause e.g., heart
  disease, infection
• Scene CPSC over 17 years looked at (2178 lt 2
  year)
• suffocation
• strangulation
• Most frequent patterns
• wedging
• mouth/nose obstructed
• overlaying
• entrapment with suspension, hanging

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Types of Suffocation / Strangulation

• 40 wedging (3 7 mo need to be able to move)
• 32 bed and wall
• 22 crib and ill-fitting mattress
• 24 oral/nasal obstruction (birth 7 mo)
• bedding, pillows, plastic bags
• 5 overlying lt 3 mo
• bed (57)
• couch (37)

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Crib CornerpostsStrangulation Hazard Children'
s clothing or other items can catch on corner
posts or knobs.
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Crib ToysStrangulation Hazard Remove all crib
toys which are strung across crib or playpen area
when your child is beginning to push up on hands
or knees or is 5 months of age, whichever occurs
first.
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Horizontal Blinds Cut the cord above the
tassel, remove the equalizer buckle, and add a
separate tassel at the end of each cord, or Cut
the cord above the tassel, remove the equalizer
buckle, and add a breakaway tassel which will
separate if a child becomes entangled in the
loop. To prevent inner cords from being pulled
into a loop, install cord stops as shown at
www.windowcoverings.org/howtorepair.html - and,
for basic publications visit www.windowcoverings.o
rg
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StrollersStrangulation/Suffocation
Hazard NEVER leave a child unattended in a
stroller because the child may slip into a leg
opening, become entrapped by the head, and die.
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Strings, Cords, and NecklacesStrangulation
Hazard
NEVER tie pacifiers or other items around your
child's neck.
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BedsSuffocation Hazard Use a crib which meets
Federal Safety Standards and Industry Voluntary
Standards for cribs and has a firm tight-fitting
mattress.
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Mesh-sided Playpens and CribsSuffocation Hazard
The playpen must be securely locked into open
position so it cannot collapse.
The side in a lowered position forms a hazardous
"pocket" or gap.
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Plastic BagsSuffocation HazardChildren have
suffocated when plastic bags (usually
dry-cleaning, garbage or trash bags) have blocked
the nose and mouth and prevented breathing.Keep
plastic bags away from children. Do NOT use as a
mattress cover.
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Another study of co-sleeping 515
deaths(children lt2 years of age)1990 - 1997
U.S.

• 23 suffocation of child by adult
• 77 entrapment object and child
• 75 on adult bed
• 20 water bed
• 3 each adult bed with rails, daybed

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Another study 119 infant deaths2000 St.
Louis

• 74 SIDS
• 13 suffocation
• 13 undetermined 3 suspicious for abuse
• Position
• only 1 infant supine
• 61 prone
• 75.9 unsuitable surface
• 47 shared surface

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• Overlying smothering that happens when a
  larger person sleeps on top of an infant.
• obstruction of infant airway
• compression of chest
• impairment of circulation neck
• Overheating SIDS deaths more likely in children
  in 2 layers of clothing
• ? risk with multiple bed sharers
• Number of co-sleepers
• ? temperature
• ? weight
• ? carbon dioxide

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Other factors

• maternal weight
• intoxication, illicit substance use 20-60
• Case must be seen by medical examiner and have
  full autopsy, but SIDS and suffocation may look
  the same

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History May ? Concern for Intentional
Suffocation

• recurrent apnea
• SIDS in a sibling
• Index case gt 6 mo of age
• Non-frothy blood in mouth or nares
• bruising to face
• oral trauma
• skeletal injuries no money for x-rays

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Summary of Risk Factors for Co-Sleepers

• young age lt 8-12 week
• prone position
• multiple co-sleepers
• adult bed or sofa
• maternal smoking
• maternal overweight
• intoxication
• overheating

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Summary

• AAP Policy probably best summary of safe sleep.

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References

1. Kattwinkel J, Hauck TR, Kennan ME, et al. The
   Changing Concept of Sudden Infant Death Syndrome
   Diagnostic Coding Shifts, Controversies Regarding
   the Sleeping Environment, and New Variables to
   Consider in Reducing Risks. Pediatrics
   20051161245-1255.
2. Berkowitz CD. Co-sleeping Benefits, Risks, and
   Cautions. Advances in Pediatrics 200451329-349.
3. Blair PS, Fleming PJ, Smith IJ, et al. Babies
   sleeping with parents case control studies of
   factors influencing the risk of sudden infant
   death syndrome. BMJ 19993191457-1462.
4. Knight LD, Hunsucker DM, Corey TS. Co-sleeping
   and Sudden Unexpected Infant Deaths in Kentucky.
   Am J of Forensic Med and Path 20052628-32.

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References

1. Latz S, Wolf AW, Lozoff B. Co-sleeping in
   context. Arch Pediatr Adolesc Med
   1999153339-346.
2. Mosko s, Richard C, McKenna J. Infant Arousals
   During Mother-Infant Bed Sharing Implications
   for Infant Sleep and Sudden Infant Death Syndrome
   Research. Pediatrics 1997100841-849.
3. Nakamura S, Ward M, Donello MA. Review of Hazards
   Associated with Children Placed in Adult Beds.
   Arch Pediatr Adolesc Med 19991531019-1023.
4. Shapiro-Mendoza CK, Kimball M. Tomashek KM,
   et.al. U.S. Infant Mortality Trends Attributable
   to Accidental Suffocation and Strangulation in
   Bed from 1984 Through 2004 Are Rates Increasing?
   Pediatrics 2009123533-539.