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Placing Infants to Sleep in Safe Environments

Placing Infants to Sleep in Safe Environments. Kirsten Bechtel MD Eve Colson MD Fredericka Wolman MD. Department of Pediatrics Yale School of Medicine Department of Children and Families State of Connecticut June 12, 2014. Acknowledgements. No conflict of interest to disclose

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Placing Infants to Sleep in Safe Environments

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  1. Placing Infants to Sleep in Safe Environments Kirsten Bechtel MD Eve Colson MD Fredericka Wolman MD Department of Pediatrics Yale School of Medicine Department of Children and Families State of Connecticut June 12, 2014

  2. Acknowledgements • No conflict of interest to disclose • Dr. Colson’s research supported by the National Institute of Health and Human Development (NICHD)

  3. Overview • Demographics/Definitionsof Sudden Unexpected Infant Death (SUID) • Delivery of Safe Sleep Anticipatory Guidance • DCF

  4. Infant Mortality Rate 2012 United States: 5.98/1000 New Hampshire 3.9 Connecticut 5.2 Mississippi 9.6 Monaco: 1.8 Cuba 4.83 Canada: 4.85 Afghanistan: 121.6 UNICEF 2012

  5. Causes of Infant Mortality in US

  6. Sudden Unexpected Infant Death (SUID) Deaths in infants less than 1 year of age that occur suddenly and unexpectedly, and whose cause of death are not immediately obvious. In 2010, 2,063 deaths were SIDS, 918 Undetermined, and 629 accidental suffocation and strangulation within sleep environment. http://www.cdc.gov/sids/aboutsuidandsids.htm

  7. Diagnostic Shift in SUID after Back to Sleep SIDS went from 120 to 54.6/100,000 Suffocation went from3.1 to 12.5/100,000 Undetermined went from 19.7 to 25.3/100,000 Schnitzer et al American Journal of Public Health 2012

  8. National Center for Child Death Review NCDR-CRS 50 states, Guam, Navajo Nation Consistent collection and reporting of data from CDR teams Connecticut CFRP is model program

  9. SIDS is an autopsy diagnosis Category II = Suffocation Unclassifed=Undetermined Cause of Death

  10. Triple Risk Hypothesis SUID

  11. Vulnerable Infant: Intrinsic Risks Maternal Factors Infant Factors Substance use Males Smoking Native American Breastfeeding African American No prenatal care Small for Gestational Age Maternal age < 20 years Prematurity CPS Supervision

  12. Vulnerable Infant: Intrinsic Risks Genetic polymorphism Cardiac ion channels Sertoninergic systems brainstem Autonomic nervous system Nicotine metabolizing enzymes Fatty acid oxidation Similar deaths among siblings What is the ante-mortem phenotype?

  13. Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Shared Sleep Surface Tappin2005 Risk of SUID and shared sleep surface Case control study Shared sleep surface increased risk even when breastfeeding Highest risk with shared sleep surface: Less than 11 weeks Smoking Couch Between two adults in an adult bed

  14. Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Shared Sleep Surface Vennemann et al 2012 Meta-analysis of 11 studies Bed sharing strongly increases the risk of SUID. This risk is greatest: Parents smoke Infants who are <12 weeks of age. May also a significant interaction between bed sharing and SUID when: Parents use alcohol and drugs, Infants sleep on sofas with adults

  15. Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Naïve Prone Sleepers Daycare deaths Cote (2000) Autopsy study Infants inexperienced with prone sleeping more likely to die when first placed prone Palusszynska (2004) Live infants Infants inexperienced with prone sleeping have fewer protective movements when placed prone

  16. Exogenous Stressors: Extrinsic Risks Infant Sleep Practices Items within the crib Soft bedding/bumpers: Scheers et al 2003; Thach et al 2007 Sleep Positioners: FDA 2007 Swaddling Entrapment: Moon et al 2014; Blair et al 2009

  17. Unusual to see SUID in Connecticut in these circumstances

  18. SUID in Connecticut 2011-2013 63 deaths Mean age 3 months Boys>girls 48 (72%) exogenous stressors within sleep environment Sharing an adult bed with parents or siblings (59%) In a crib with blanket, pillows, or placed on their stomachs, swaddle around their face 10% Car seat 2% Put to sleep with a bottle propping in an adult bed 1% In 12%, the parent(s) had a history of DCF supervision.

  19. SUID in the Post Back-To-Sleep era “Using 2005 to 2008 data from 9 US states to assess 3136 sleep related sudden unexpected infant deaths (SUIDs); only 25% of infants were sleeping in a crib or on their back when found; 70% were on a surface not intended for infant sleep (e.g., adult bed).Importantly, 64% of infants were sharing a sleep surface, and almost half of these infants were sleeping with an adult.” Schnitzer et al J Amer Public Health 2012

  20. SUID in the Post Back-To-Sleep era “Between 1991–1993 and 1996–2008, the percentage of infants found prone decreased from 84.0% to 48.5% ,bed-sharing increased from 19.2% to 37.9% especially among infants < 2 months (29.0% vs 63.8%)” “ The occurrence of extrinsic risks in virtually all (cases) implies that SUID is precipitated by a ‘trigger’ at the time of death…that are consistent with asphyxia generating conditions ( face-down position, prone position, and adult mattress).” Trachtenberg et al Pediatrics 2012

  21. Infant Sleeping Behaviors and Recommendations Eve R. Colson, MD, MHPE Professor of Pediatrics Yale School of Medicine

  22. Overview • AAP Recommendations • Prevalence • Advice • Guidance for families

  23. Overview • AAP Recommendations • Prevalence • Advice • Guidance for families

  24. AAP Recommendation • Back sleep • Firm mattress • No soft bedding

  25. AAP Recommendation • Room sharing, not bedsharing

  26. AAP Recommendation • Pacifier once breasfeeding established

  27. Overview • AAP Recommendations • Prevalence • Advice • Guidance for families

  28. Prevalence of Usual Sleep Position by Race/Ethnicity (N=1031) 9% 20% 15% 74% 63%

  29. Prevalence of Usual Sleep Position by Region (N=1031) 14% 15% 74% 65%

  30. Prevalence of Usual Bedsharing by Race/Ethnicity 19% 18% 29% 19% 23% 15% 66%

  31. Prevalence of Usual Bedsharing by Region 19% 12% 14% 20% 26%

  32. Overview • AAP Recommendations • Prevalence • Advice • Guidance for families

  33. Advice

  34. Overview • AAP Recommendations • Prevalence • Advice • Guidance for families

  35. Guidance for Families • Back for sleep • Firm mattress • No soft bedding • Room share but not bedshare • Offer a pacifier when breastfeeding established

  36. Guidance for Families • Concerns about choking

  37. Guidance for Families • Concerns about comfort

  38. Guidance for Families • Concerns about side sleep

  39. Guidance for Families • Concerns about head shape

  40. Guidance for Families • Concerns about pacifier use

  41. Department of Children and Families Safe Sleep Initiative Fredericka Wolman MD Department of Children and Families State of Connecticut

  42. DCF’s Initiative on Safe Sleep Environments DCF’s Safe Sleep Environments Flyer Add link

  43. Why a priority for DCF • Children involved with DCF at high risk • Factors include: • substance use, • multiple stressors (poverty, parental isolation and lack of social supports); • domestic violence • mental health challenges (depression)

  44. Strategies for DCF • Education • DCF Workers • Families and caregivers DCF serves • Providers who work with families we serve (CPA, • Statewide initiative • Policy and Practice Guide • Monitoring practice • Documentation • Direct support to families • Assessing sleeping arrangements • Accessing safe sleep furniture / supplies • Partnering with pediatricians / home visitors

  45. Questions? Thank you for participating in this webinar!

  46. Resources • http://www.cdc.gov/SIDS/INDEX.HTM • http://www.nichd.nih.gov/sts/Pages/default.aspx • http://www.firstcandle.org • http://www2.luriechildrens.org/ce/online/article.aspx?articleID=223 • http://www.cribsforkids.org

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