Sleep Related Infant DeathsTulsa County 2004 - 2007

Carol Kuplicki, MPHTulsa Health Department, TFIMR

Tulsa Fetal and Infant Mortality Review Project is supported in part by the Maternal and Child Health Block Grant in the Department of Health and Human Services, Health Resources and Services Administration, Maternal and child Health Bureau

The FIMR Process

The Cycle of Improvement

Could these deaths have been prevented?

Children found on top of the infant. Infant found unresponsive in sleeping bag

wedged between the wall and bed. Infant found in crib face down between a pillow

and edge of crib. Infant found unresponsive in bed under some

pillows. Infant found unresponsive lying under a sibling. The infant had been sleeping in the bed with the

parents. The child was found under the mother in bed.

Background From 2004-2007 there has been a total of 314

Tulsa County resident infant deaths.

17 Sudden Infant Death Syndrome (SIDS) 35 Other symptoms, signs and abnormal

clinical and laboratory findings, not elsewhere classified “Undetermined”

5 Accidental suffocation and strangulation in bed

Purpose and Definition Purpose To identify and review sleep related infant deaths occurring in

Tulsa County

Definitions Sleep related death – Infant was put to bed either alone or co-

sleeping or had fallen asleep while being held, and subsequently died during sleep

Co-sleeping – Sharing the same sleep surface SIDS-Sudden Infant Death Syndrome, ICD 10, R95 The sudden

and unexpected death of an infant less than 1 year of age for which no exact cause of death can be determined

Undetermined – ICD 10, R99, Other ill-defined and other unspecified causes of mortality

Asphyxia – ICD 10, W 75 Accidental suffocation and strangulation in bed

Prone – Lying with the front or face downward Petechial hemorrhages - subcutaneous hemorrhage occurring in

very small spots

Sleep Environment

Unsafe Sleep Conditions Infant placed or found in a prone position Co-sleeping Sleeping on a couch, chair or on soft

bedding Bedding, pillows or other items found over

the infant’s face

Cause of Death/Medical Examiner

Performs autopsies on sleep related infant deaths

Completes the death certificate as to the manner and cause of death

~ 2004 the Medical Examiner began to standardize review of sleep related infant deaths across the state The result was to classify infants that were co-

sleeping at the time of death as Undetermined. Previously the death might have been classified as a SIDS death.

Selection & Method

Selection Deaths occurred during 2004 - 2007 Birth to <365 days old Tulsa County resident at birth and death Born and died in Tulsa County Mother received prenatal care in Tulsa County

Method Reviewed medical records, Medical Examiner

reports, EMSA reports

Cases SelectedN=48 (15.3%) 314 infant deaths, all causes (2004-2007)

Of the sleep related deaths occurring to TulsaCounty residents, TFIMR reviewed 48.

2004 2005 2006 2007 Total

Born outside Tulsa County 1 3 2 . 6

Died outside Tulsa county . . . 1 1

Non-resident . . . 1 1

Accident, not sleep related . . . 1 1

*Other exclusions 3 . . 1 4

Total Excluded 4 3 2 4 13

Number reviewed 6 7 19 16 48

*Other exclusions could be possible homicide, death certificate received over 1 year after death, accident that was not sleep related or any other causes that would not fit into the sleep related death definition.

Findings

Most infants that died never went home from the hospital.

Infant deaths reviewed by TFIMR: Of infants that were healthy enough to be released from the hospital, 57.1% died from sleep related causes.

Infant Deaths by Year of Death, Discharge Status, and Cause of Death

Year of Death

Total Deaths

(Data Abstracted)

Infants Discharge to Home from

Birth Hospital

Sleep Related Deaths Reviewed

by TFIMR*SIDS Undetermined Asphyxia

2004 46 13 6 3 2 1

2005 68 16 7 2 4 1

2006 79 27 19 8 8 3

2007 86** 28 16 3 11 2

Total 279 84 (30.1%) 48 (57.1%) 16 25 7

Of the infant deaths reviewed from 2004- 2007, only 84 (30.1%) infants were discharged to home. Of the infants discharged to home 48 (57.1%) died from sleep related causes.

*The number of sleep-related deaths may differ from total Tulsa County Sleep-related deaths because of TFIMR case selection criteria. **Fetal deaths were excluded

Infant Deaths by CauseTFIMR Sleep Related Deaths

3 2

8

3

2 4

8

11

11

3

2

0

5

10

15

20

2004 2005 2006 2007

Year of Death

Nu

mb

er

of

Dea

ths

SIDS Undetermined Asphyxia

Most infants died in a bed or on a couch

while sleeping with someone else.

Sleep Surface and Bed Sharing 2004-2007 Infant Deaths, TFIMR

19

7

1 1

5

111

30

5

10

15

20

25

Infa

nt

dea

ths

Sleeping alone 3 5 1 11 0

Co-sleeping 0 19 7 1 1

Bassinet Bed Couch Crib Unk Sleep Surface

28 (58.3%) Co-sleeping 22 with an adult(s)

5 with an adult(s) and another child(ren)

1 with another child(ren)

33 (68.7%) Sleep surface other than bassinet/crib

Age at Death and Cause of Death 2004-2007 Infant Deaths

2 223+1

1+41

2+1 2

2+9

4

3 1

1

1

1

3

1

1

0

2

4

6

8

10

12

14

16

18

20

<1 1 2 3 4 5 6 7 8 9 10 11

Age at Death (months)

Nu

mb

er o

f In

fan

t D

eath

s

SIDS Undetermined Asphyxia

Most infants died at 2 months of age or less.

Red italic numbers - Co-SleepingBlue numbers - No co-sleeping

Deaths by Age:33 (68.7%) were less than 3 months old18 (37.5%) were 2 months old Deaths by Cause:16 (33.3%) SIDS25 (52.1%) Undetermined7(14.6%) Asphyxia

Sleep Environment - Most infants were not placed in a safe sleep environment.

Unsafe sleep environment Prone sleep position Not in a crib or bassinet Co-sleeping Loose blankets, pillows or clothing

in sleep area

Based on review of available records39 (81.3%) Unsafe sleep environment 9* (18.8%) Safe sleep environment

(*of the 9 infants noted to be in a safe sleep environment, sleep position was unknown for 5 infants)

0

5

10

15

20

25

30

35

40

Unsafe Safe*

Infant Health

10 (20.8%) recent illness with cough, congestion, or fever in days preceding death

14 (29.2%) at autopsy had petechial hemorrhages on the thymus, plura and/or epicardium

Summary Information 39 (81.3%) Non-safe environment

36 (75.0%) were not in a crib or bassinet, or had loose bedding or pillows in the crib or bassinet

28 (58.3%) were co-sleeping

33 (68.7%) occurred prior to the 3rd month of life

10 (20.8%) had been having symptoms of an illness with recent cough, congestion, or fever in the days preceding death

8 (16.7%) were pre-term (<37 weeks gestation)

14 (29.2%) at autopsy had petechial hemorrhages on the thymus, plura and/or epicardium

Infant Deaths TFIMR Sleep Related Deaths

81.3%

75.0%

58.3%

68.7%

20.8%

16.7%

29.2%

0% 20% 40% 60% 80% 100%

Non-safe sleepenvironment

Sleep surface notrecommended

Co-sleeping

<3 months old

History of illness

P re-term <37weeks

P etechialhemorrhages

Recommendations for Preventing Sleep Related Deaths

NIH Back to Sleep Campaign Recommendations 1. Always place your baby on his or her back to sleep, for

naps and at night. 2. Place your baby on a firm sleep surface, such as on a

safety-approved crib mattress, covered by a fitted sheet. 3. Keep soft objects, toys, and loose bedding out of your

baby’s sleep area. 4. Do not allow smoking around your baby.

Recommendations for Preventing Sleep Related Deaths

5. Keep your baby’s sleep area close to, but separate from, where you and others sleep.

6. Think about using a clean, dry pacifier when placing the infant down to sleep.

7. Do not let your baby overheat during sleep.

8. Avoid products that claim to reduce the risk of SIDS.

9. Do not use home monitors to reduce the risk of SIDS.

10. Reduce the chance that flat spots will develop on your baby’s head: provide “Tummy Time”.

Source: NIH Back to Sleep Campaign

Recommendations for Preventing Sleep Related Deaths

Educational campaign of Safe Sleep Environment

Hospitals via discharge instructions, posters, informational videos

Sleep environment education for the public Clinics – Prenatal care providers, Pediatricians,

Family Practice Media – Billboards, TV, Radio, Newspapers Faith-based Organizations Tulsa Area Immunization Coalition – KICK

packets

Acknowledgements / Further Information

• Tulsa Fetal and Infant Mortality Review Project is supported in part by the Maternal and Child Health Block Grant in the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

• For further information contact: Carol Kuplicki, MPH, MCH Epidemiologist (918) 595-4499,

ckuplicki@tulsa-health.org Pam Rask, MPH, Manager – School Health/TFIMR (918) 595-4418,

prask@tulsa-health.org