Sleep Related Mortalities in very early life. How can we help?

1. Sleep Related Mortalities in very early life. How can we help? Samuel Dzodzomenyo MD.

2. Overview • The role of unsafe sleep in infant mortality • Understanding sleep-environment-related infant deaths. • Preventing sleep-environment-related deaths

3. Objectives 1.To identify risk factors associated with sleep related mortality in infants 2. Understanding sleep-environment-related infant deaths. 3.Best practices to reduce sleep related infant death.

4. Infant mortality rate:Global • The number of infant deaths (one year of age or younger) per 1000 live births • Currently, the most common cause is pneumonia. • Traditionally, the most common cause worldwide was dehydration from diarrhea

5. Infant Mortality Rate

6. Infant Mortality Rate: US -6.84 in 2003 -6.78 in 2004 -Range: 4.67 (Asian & Pacific Islanders) -13.6 (Non-Hispanic Blacks)

7. IMR United States/100,000

8. Infant Mortality in the US:Leading Causes 1. Congenital malformations 2. Low birth weight 3. SIDS Together account for 45% of all infant deaths

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10. Montgomery County(OH) Ohio’s infant mortality rate of 7.7 per 1,000 births ranked eighth worst in the country in 2008. Montgomery County’s infant mortality rate that year was slightly higher at 8 per 1,000 births.

11. Why look at Infant Mortality? -Indicator of health of present and future Populations - Indicator of health disparities among different populations - Indicator of overall health/ quality of life in a community

12. What is Sudden Infant Death Syndrome (SIDS)? • SIDS is the unexpected death of seemingly healthy babies 12 months or younger. • No cause of death is determined by • Death scene investigation and autopsy. • Review of baby’s medical history. • Experts cannot predict which babies will die from SIDS. Revised – 12/08

13. Montgomery County (OH) • 2009: 4 deaths where sleep environment was determined to be a possible contributing factor but there was not enough information for the Coroner’s office to call it.  • 4 more deaths identified “position asphyxia” on the death certificate, so those are the easy ones!   • 2010: 3 sleep-related deaths for – one positional, one overlay and one “ unsafe sleeping”

14. SIDS Facts • The exact causes of SIDS are unknown, but SIDS is NOT caused by • Immunizations • Vomiting or choking Revised – 12/08

15. Do we Have THEORIES? • Glial-neuronal interactions in the cardio-respiratory centre of the brainstem. • Gastric reflux, and especially laryngopharyngeal reflux • Role of serotonin in respiratory function and dysfunction • Reduced ventilatory response to CO2 challenge in the prone position • Impaired ability to respond to respiratory compromise

16. Fast Facts About SIDS SIDS is one of the leading causes of death in infants between 1 month and 1 year of age. Most SIDS deaths happen when babies are between 2 months and 4 months of age. African American babies are more than 2 times as likely to die of SIDS as white babies. American Indian/Alaskan Native babies are nearly 3 times as likely to die of SIDS as white babies.

17. SIDS in Child Care • Two thirds of US infants younger than 1 year are in nonparental child care. • Infants of employed mothers spend an average of 22 hours per week in child care. • 32% of infants are in child care full time. • Less than 9% of SIDS deaths should occur in child care. • Ehrle et al, 2001 Revised – 12/08

18. SIDS in Child Care • Approximately 20% of SIDS deaths occur while the infant is in the care of a nonparental caregiver. • 60% in family child care • 20% in child care centers • 20% in relative care • Infants tend to be Caucasian, with older, more educated parents. • Moon et al, 2000 Revised – 12/08

19. SIDS in Child Care • Approximately 1/3 of SIDS-related deaths in child care occur in the first week, and 1/2 of these occur on the first day. • Something intrinsic to child care? Not that we’ve found yet • Stress, sleep deprivation? • Unaccustomed tummy sleeping? Yes Revised – 12/08

20. The Triple Risk Model -Requires the convergence of three elements that may lead to the death of an infant from SIDS: Critical developmental period Vulnerable infant 3. Outside stressor(s) -All three elements must be present for SIDS to occur. -Removing one or more outside stressors can reduce the risk of SIDS.

21. Critical development period SIDS Vulnerable infant External stressors Triple Risk Model Revised – 12/08

22. Outside Stressors -Stomach sleep position -Soft bedding -Tobacco smoke -Overheating -Infection

23. SIDS Risk Factors—Pregnancy • Low birth weight (less than 5 pounds) • Premature (less than 37 weeks) • Maternal smoking during pregnancy • Multiple births (eg, twins, triplets) • Maternal age younger than 18 years • Less than 18 months between births

24. Babies at Risk for SIDS • African Americans (2x greater risk) • Partly genetic • Partly behavioral (sleep position, bedsharing) • American Indians (more than 2x greater risk) • Secondhand smoke exposure • Binge alcohol drinking during pregnancy • Overdressing of babies

25. Babies at Risk for SIDS • Mothers who smoke during pregnancy (3x greater risk) • Babies who breathe secondhand smoke (2.5x greater risk) • Babies who sleep prone (on their tummies) or on their sides (2-3x greater risk) • Babies put on their tummies to sleep who usually sleep on their backs or babies who roll over onto their tummies (as much as 18x)

26. Healthy Child Care America Back to Sleep Campaign • Launched in 2003 • Activities • Increase awareness. • Decrease incidence of SIDS in child care. • Educate policy makers to include back-to-sleep positioning in child care regulations. Revised – 12/08

27. SIDS Rate and Sleep Position Source: National Institute of Child Health and Human Development Household Survey Final Data 2003, National Center for Health Statistics, Centers for Disease Control and Prevention SIDS rates have decreased and percent of back sleeping has increased since the campaign began. Yellow (1985–1991): Pre-AAP recommendation Blue (1992–1994): Post-AAP recommendation Red (1995–1999): Back to Sleep campaign Revised – 12/08

28. Reasons that people place babies on their tummies • They think that babies are more likely to choke or aspirate if they vomit or spit up • They are worried that babies won’t sleep as well • When babies sleep on the backs, they don’t develop normally. • The baby’s parent(s) wants the baby to sleep on the tummy Revised – 12/08

29. Reasons that people place babies on their tummies • Babies sleep better/longer/more deeply when they’re on their stomachs. • The baby will get a flat head if the baby sleeps on the back. • The baby will get a bald spot from sleeping on the back. • When the baby is on the back, s/he startles more easily and wakes up. Revised – 12/08

30. Anatomy when sleeping on stomach Revised - 0408

31. Anatomy when supine Revised – 12/08

32. Why Child Care Providers Use Tummy Sleeping • Lack of awareness • 25% of licensed child care providers say they never heard of the relationship between SIDS and sleep position. • Misconceptions about risk of sleep position • Supine and aspiration, choking • Belief that tummy sleeping improves infant comfort • Parental preference • Lack of information • Lack of education Revised – 12/08

33. Implementing SIDS Risk Reduction • Tummy to play and back to sleep. • Use safe sleep practices. • Provide a safe sleep environment. Revised – 12/08

34. Tummy to Play and Back to Sleep • Supervised tummy time when babies are awake • Promotes healthy physical and brain development • Strengthens neck, arm, and shoulder muscles • Decreases risk of head flattening and balding • Encourages bonding and play between the supervising adult and the baby • Back to sleep • Reduces the risk of SIDS • Comfortable and safe Revised – 12/08

37. Tummy Time • Tummy time is for babies who are awake and being observed. • It is needed to develop strong muscles. • Have tummy time 2 to 3 times a day and increase the amount of tummy time per day as the baby gets stronger. • There are lots of ways for babies to enjoy tummy time! Revised – 12/08

38. Safe Sleep Practices • Avoid overheating. • Do not overdress baby. • Never cover baby’s head with a blanket. • Room temperature should be comfortable for a lightly clothed adult. Revised – 12/08

39. Safe Sleep Practices • Always put healthy babies to sleep on their backs for naps and at bedtime. • Do not have more than one baby per crib. Revised – 12/08

40. Safe Sleep Practices • Pacifiers may be offered to babies to reduce the risk of SIDS • If breastfed, wait until breastfeeding is well established (approximately 3 - 4 weeks of age), before offering a pacifier. • If the baby refuses the pacifier, don’t force it. • If the pacifier falls out while the baby is asleep, you do not have to re-insert it. Revised – 12/08

41. Safe Sleep Environment • Safe crib, firm mattress. • Avoid chairs, sofas, air mattresses, water beds, and adult beds. Revised – 12/08

42. Bed Sharing or Co-sleeping • May be hazardous under certain conditions. • The American Academy of Pediatrics recommends that babies not bed share. • Bed sharing is especially dangerous when • Baby bed shares with someone other than the parents. Therefore, children or other adults should not bed sharing with an infant. • Bed sharing occurs on a waterbed, couch, or armchair. • The adult is a smoker. • The adult drinks alcohol or uses medications or drugs that can make it more difficult to arouse or wake up. Revised – 12/08

43. Bed Sharing or Co-sleeping • The safest place for a baby to sleep is in a separate sleep surface (eg, bassinet, crib, cradle) next to the parents’ bed. Revised – 12/08

44. Safe Sleep Environment • No excess bedding, comforters, or pillows • Consider a blanket sleeper or sleep sack for the baby instead of a blanket if extra warmth is needed • No bib around the baby’s neck • Bumper pads are not needed • Wedges or positioners are not recommended • No toys or stuffed animals in the crib • Be aware that parents like their baby to have things from home with them- help caregivers to identify other ways to allow this. Revised – 12/08

45. Safe Sleep Environment • Maintain a smoke-free environment Revised – 12/08

46. MCCFRB The Montgomery County Child Fatality Review Board (CFRB) is charged with preventing infant deaths in our community. The goal is to raise awareness about unsafe sleep practices that lead to the death of infants less than one year of age. In Montgomery County nearly one baby a month dies due to unsafe sleep practices.

47. Montgomery County(OH) Ohio’s infant mortality rate of 7.7 per 1,000 births ranked eighth worst in the country in 2008. Montgomery County’s infant mortality rate that year was slightly higher at 8 per 1,000 births.

48. Montgomery County • 2009: 4 deaths where sleep environment was determined to be a possible contributing factor but there was not enough information for the Coroner’s office to call it.  • 4 more deaths identified “position asphyxia” on the death certificate, so those are the easy ones!   • 2010: 3 sleep-related deaths for – one positional, one overlay and one “ unsafe sleeping”

49. MCCFRB The ABCs of Safe Sleep. I sleep safest. Alone on my Back in a Crib.

50. Your baby should always sleep ALONE. -Some Moms and Dads sleep with their babies in an adult bed. Or, they allow babies to sleep with other children or pets. This is not safe. ----Baby’s mouth or nose can become covered, keeping the baby from breathing. - Your baby should sleep alone in a safe, empty crib. -Baby’s caregiver should be nearby, in the same room, but not in the same bed. -If your baby is in your bed to feed or comfort, put your baby in the crib for sleep. A