B'more for Healthy Babies: Reducing Sudden Infant Death Syndrome in Baltimore City

1. Sudden Infant Death Syndrome in Baltimore CityStephanie Strauss Regenold, MD, MPHSenior Advisor,Babies Born Healthy InitiativeBureau of Maternal & Child HealthBaltimore City Health Departmentstephanie.regenold@baltimorecity.gov

2. BCHD’s new Birth Outcomes Initiative • Definitions • Epidemiology, Etiology, and Risk Factors • Recommendations • Parent Education Overview

3. New initiative by the Baltimore City Health Department & The Family League of Baltimore • 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

4. 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

5. 120 babies under the age of one died in Baltimore City last year • Baltimore has the 4th worst infant mortality rate in the U.S. • 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

6. B’more for Healthy Babies: BCHD’s New Initiative The leading causes of infant mortality in Baltimore are: #1 Prematurity and low birth weight complications #2 SIDS and unsafe sleep conditions #3 Birth defects Our First Campaign Will Address Safe Sleep

7. 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

8. Definitions: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”

9. Definitions: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

10. CDC.gov/SIDS/SUID, 2009

11. 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 baby.

12. 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

13. 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

14. 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

15. 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.

16. 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%

17. 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

18. SIDS Etiology:Triple Risk Model Infant at Critical Development Period SIDS Environmental Factors Genetic Predisposition Filiano JJ and Kinney HC, Biol Neonate, 65:194-197, 1994

19. Immature respiratory and autonomic nervous system. • Delayed neuronal maturation. • Poor sleep arousal responsiveness. SIDS Etiology:Critical Development Period Moon RY, et.al. Lancet. 2007;370:1578-1587.; Moon RY, Fu LY. Pediatrics in Review. 2007;28(6).

20. Serotonin receptor and transporter abnormalities that affect arousal response. • Polymorphisms in genes that effect ANS development. • Abnormalities in the Na+ and K+ channels that are associated with prolonged QT syndrome. • Complement gene deletions and IL-10 gene polymorphisms SIDS Etiology:Genetic Factors Moon RY, et.al. Lancet. 2007;370:1578-1587.; Moon RY, Fu LY. Pediatrics in Review. 2007;28(6).

21. 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 SIDS Etiology:Environmental Factors AAP Task Force on SIDS. Policy Statement. October 2005.

22. 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 appropriately SIDS Etiology:Rebreathing Theory Kinney HC, Thach BT. NEJM 2009;361:795-805.

23. SIDS Etiology:Proposed Causal Pathway Pregnancyrelated risk factors (low birth weight, smoking) Genetic risk factors 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

25. Stomach sleeping • Bed sharing (>75%) • Soft bedding • Smoke exposure SIDS in Baltimore City:Most Common Risks

26. AAP Infant SleepRecommendations

27. The ABC’s of Safe Sleep Alone On my Back In a Crib

28. Additional Safe Sleep Recommendations No smoke exposure No overheating Consider a pacifier

29. Alone 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 sleep

30. 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

31. 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

32. 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

33. 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

34. 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.”

35. Why is Bed Sharing Risky? Soft bedding, pillows, comforters No safety standards for adult beds Overheating Risk of entrapment

36. Not safe sleeping environments!

37. …on my Back Not on the stomach or side On the back every time the baby is laid down to sleep

38. Pre-AAP recommendation Post-AAPBTSCampaign (began in 1994) Sleep Position Source: NICHD Household Survey SIDS Rate Source: National Center for Health Statistics, CDC

39. Prone Prevalence Rates Among Black Infants, US National Center for Health Statistics, National Infant Sleep Position data

40. Comfort • Baby sleeps longer, doesn’t awake easily • Flattened Skull (plagiocephaly) • Safety • Concern about choking Why do People PlaceTheir Babies Prone?

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

42. 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.

43. 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, et.al. Adv Neonatal Care. 2006;6(5):281-294.

44. 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 recommended.” “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.

45. …in a Crib Not on an adult bed, sofa, cushion, or other soft surface A crib, bassinet, or portable crib which meets safety standards

46. Why a Firm Sleep Surface? Soft or loose bedding carries 5 times the risk of SIDS as firm bedding. Sleeping on the stomachon soft or loose beddingcarries 20 times the risk of SIDS than those infants who slept on their backs on firm bedding. Infants should not be placed to sleep on couches, cushioned chairs, beanbag chairs, sofas, waterbeds, air mattresses, memory foam mattresses, or lamb skins

47. I Sleep Safest: Alone On my Back In aCrib

48. 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

49. 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.

50. 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 established Use as infant is being put down to sleep Do not force Don’t have to reintroduce if it falls out