Workshop/Breakout Title Workshop/Breakout Speaker(s)

1. Changes in Infant Death Coding and Implications for Safe Sleep Campaigns Malinda Douglas, MPH, Oklahoma Department of Health Violanda Grigorescu, MD, MSPH, Michigan Dept. of Community Health Sandra Frank, JD, CAE, Tomorrow's Child/Michigan SIDS Workshop/Breakout Title Workshop/Breakout Speaker(s)

2. Sleep-Related Deaths Among Infants in Oklahoma, 2000-2003 • Malinda Reddish Douglas, MPH Tobacco Use Prevention Service, OSDH • Pam Archer, MPH Injury Prevention Service, OSDH • Jeff Gofton, MD Office of the Chief Medical Examiner

3. Background • Each year, 400 infants under 1 year old die in Oklahoma • 22% congenital and chromosomal abnormalities • 13% disorders related to premature birth • 9% sudden infant death syndrome • Death rate decreased 7% • 2000: 8.4/1,000 • 2003: 7.8/1,000

4. Introduction • Oklahoma Chief Medical Examiner noticed increase in co-sleeping deaths • Child Death Review Board and Department of Human Services concerned with increase in co-sleeping deaths • SAFE KIDS Coalition and other partners began development of SIDS – safe sleep materials

5. Unsafe Sleeping Environment • Prone sleeping • Exposure to secondhand smoke • Sofas, chairs, loveseats • Soft bedding, pillows, quilts, blankets • Entrapment hazards • Co-sleeping?

6. Co-Sleeping Recommendations

7. 2000 National Data on Nighttime Infant Bed Sharing with Adults • Prevalence • 13% entire night • Up from 6% in 1993 • 20% half of the time or more • 45% some time during past two weeks • Twice as likely as to be covered by quilt or comforter • Most common in mothers < 18 years, low income, non-white, and infants < 8 weeks

8. Potential Reasons for Co-Sleeping • Bonding • Breastfeeding • Cultural practice • Fear of SIDS • Fear of not hearing the baby • Baby sleeps better • Parents sleep more • No crib

9. Sleep-Related Infant Death Study • Purpose • Investigate infant deaths • Characterize sleeping practices • Determine co-sleeping trends over time

10. Medical Examiner System • Investigate deaths under certain circumstances • Determine manner of death (intention) • Determine cause of death • Statewide system

11. Methods • Analyzed Medical Examiner database • January 2000 through December 2003 • Oklahoma residents • Less than 12 months of age • Manner of death = Accidental • Cause = Asphyxia • Manner of death = Unknown • Cause = Asphyxia • Cause = Other • Cause = Unknown

12. Methods • Reviewed reports of investigation • Demographic data • Details of the death • Narrative of circumstances • Autopsy report • Last known activity was sleeping

13. Definitions • Unsafe sleeping • Not sleeping alone in a safe crib or bassinette • Not put to sleep on back or found on back • Pillows, stuffed toys, loose quilts or comforters • Co-sleeping • Sharing a sleep surface with another person • Surfaces include bed, couch, chair, and other

14. Unsafe Sleeping Case Selection • 124 possible cases reviewed • 113 infants sleeping prior to death • 2 following safe sleep guidelines • 5 lacked specific details to classify • 94% (106/113) involved unsafe sleeping conditions • 81% unknown manner of death • 80% other/unknown cause of death

15. Unsafe Sleeping Deaths by Age and Sex, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 106

16. Unsafe Sleeping Deaths by Race and Year, Oklahoma, 2000-2003 Rate/1,000 AA: 1.2 AI: 0.7 W: 0.4 Overall: 0.5 * includes Hispanic Source: Oklahoma State Medical Examiner, n = 104, excludes 2 cases coded as other

17. Time and Place of Occurrence • 82% at night • 97% occurred in a private home • 86% in own home • 11% in others home • 2% in licensed child care • 1% in hospital Source: Oklahoma State Medical Examiner, n = 106

18. Unsafe Sleeping Deaths by Sleep Surface, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 106

19. Unsafe Sleeping Deaths by Mechanism of Injury, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 106

20. Infant Health History • Breastfed – 6% • 74% not specified • Low birth weight – 6% • 87% not specified • Premature birth – 15% • 56% not specified • Respiratory illness – 25% • 68% not specified Source: Oklahoma State Medical Examiner, n = 106

21. Caregiver or Family Factors • Use of alcohol and/or drugs – 14% • History of drug/alcohol problems – 11% • CPS involvement – 21% • Previous SIDS death – 3% • Secondhand smoke exposure – 3% Source: Oklahoma State Medical Examiner, n = 106

22. Unsafe Sleeping Deaths by Co-Sleeping at the Time of Death, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 103, excludes 3 unknowns

23. Co-Sleeping Deaths by Age and Sex, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner, n = 68

24. Surface and Co-sleep • 71% on bed • 9% on couch/chair/love seat • 6% mattress on floor • 4% on waterbed • 1% in crib (sleeping with twin) • 9% all other/unk combined Source: Oklahoma State Medical Examiner, n = 68

25. Co-sleepers Deaths by Mechanism of Injury, Oklahoma, 2000-2003 • 55% possible/definite overlay • 4% entrapped • 3% pillow • 6% found on floor • 1% other • 31% not specified Source: Oklahoma State Medical Examiner, n = 68

26. Factors Present When Cases Lacked Details on Possible Mechanisms • 33% open or history of CPS involvement • 19% staying at someone else’s home • 10% previous apnea episodes • 10% face down on mattress • 5% waterbed Source: Oklahoma State Medical Examiner, n = 68

27. Co-sleeping Characteristics • Number co-sleeping • 50% two sleeping together • 40% three sleeping together • 10% four sleeping together • Classification of sleeper • 73% adult(s) • 18% child(ren) • 9% adult(s) and child(ren) Source: Oklahoma State Medical Examiner, n = 68

28. Medical Examiner Interview • Infant deaths increasing • Co-sleeping deaths increasing • Mainly among the white population • Beliefs, opinions, and experiences reflected in reporting • Budget cuts in 2003 • May have resulted in change in coding

29. Infant Deaths by Selected Cause, Oklahoma, 2000-2003

30. ME Investigated Infant Deaths by Selected Cause, Oklahoma, 2000-2003 Source: Oklahoma State Medical Examiner

31. Conclusions • Unsafe sleep deaths • Most were infants < 3 months of age • Half occurred in beds • Unsafe items used in cribs and bassinettes • Mechanism of injury varied by age • Co-sleep deaths • Increase in co-sleeping deaths • Increase among whites • Not clear if due to artifact of coding

32. Limitations • Non-standardized documentation • Medical Examiners and investigators limited by informants • Distinguishing SIDS from other causes • Budget cuts to the Medical Examiner

33. Discussion • Other States have similar trends • Cultural issue • Distinguishing SIDS from overlay • Coding of undetermined cause or intent

34. Recommendations • Education campaign for businesses • Crib displays in stores that show safe sleeping environments

35. Recommendations • Increase awareness of co-sleeping deaths • Promote consistent safe sleeping practice messages through collaborative efforts • Same safe sleeping environments can reduce risk factors for overlay, SIDS, and asphyxia • Messages that resonate with target populations

36. Questions? Questions?