Transcript Sudden Infant Death Syndrome in Baltimore City Stephanie Strauss Regenold, MD, MPH Senior Advisor, Babies Born Healthy Initiative Bureau of Maternal & Child Health Baltimore City Health.

Sudden Infant
Death Syndrome in
Baltimore City
Stephanie Strauss Regenold, MD, MPH
Senior Advisor,
Babies Born Healthy Initiative
Bureau of Maternal & Child Health
Baltimore City Health Department
[email protected]
Overview
• BCHD’s new Birth Outcomes Initiative
• Definitions
• Epidemiology, Etiology, and Risk
Factors
• Recommendations
• Parent Education
B’more for Healthy Babies:
BCHD’s New Initiative
• 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
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
• 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
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
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
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”
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
CDC.gov/SIDS/SUID, 2009
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.
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
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
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
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.
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%
SIDS Epidemiology:
Deaths per 1,000 live births
Baltimore City
Baltimore City - BCHD analysis of data from the Maryland VSA, MD - Maryland Vital Statistics Reports, U.S. NCHS Vital Statistics Reports
SIDS Etiology:
Triple Risk Model
Infant at Critical
Development Period
SIDS
Genetic
Predisposition
Environmental
Factors
Filiano JJ and Kinney HC, Biol Neonate, 65:194-197, 1994
SIDS Etiology:
Critical Development Period
• Immature respiratory and autonomic nervous
system.
• Delayed neuronal maturation.
• Poor sleep arousal responsiveness.
Moon RY, et.al. Lancet. 2007;370:1578-1587.; Moon RY, Fu LY. Pediatrics in Review. 2007;28(6).
SIDS Etiology:
Genetic Factors
• 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
Moon RY, et.al. Lancet. 2007;370:1578-1587.; Moon RY, Fu LY. Pediatrics in Review. 2007;28(6).
SIDS Etiology:
Environmental Factors
•
•
•
•
•
•
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
AAP Task Force on SIDS. Policy Statement. October 2005.
SIDS Etiology:
Rebreathing Theory
• 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
Kinney HC, Thach BT. NEJM 2009;361:795-805.
SIDS Etiology:
Proposed Causal Pathway
Pregnancy related 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
Unexpected Infant Deaths that Occured During Sleep:
Baltimore City Child Fatality Review, 2002-2009
30
1
Number of Deaths
25
20
15
0
5
2
3
10
4
1
0
21
2
19
20
13
17
19
19
12
4
0
2002
2003
Sleep environment not yet reviewed
2004
2005
2006
Unsafe sleep environment confirmed
2007
2008
2009
Unsafe sleep environment not confirmed*
* Deaths for which the evidence did not indicate an unsafe sleep environment, however, data on unsafe sleep risk factors may have been missing or
unknown. Baltimore City Health Department analysis of data from cases reviewed by the Baltimore City Child Fatality Review.
SIDS in Baltimore City:
Most Common Risks
•
•
•
•
Stomach sleeping
Bed sharing (>75%)
Soft bedding
Smoke exposure
AAP Infant Sleep
Recommendations
The ABC’s of Safe Sleep
Alone
On my Back
In a Crib
Additional Safe Sleep
Recommendations
• No smoke exposure
• No overheating
• Consider a pacifier
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
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
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
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
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
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.”
Why is Bed Sharing Risky?
•
•
•
•
Soft bedding, pillows, comforters
No safety standards for adult beds
Overheating
Risk of entrapment
Not safe
sleeping
environments!
…on my Back
• Not on the stomach or side
• On the back every time the baby
is laid down to sleep
SIDS Rate and Sleep Position, 1988-2005
(Deaths per 1,000 Live Births)
1.5
100
1.4 1.39
1.3
1.3
1.17
72.2
71.6 71.1 72.8
70.1
1.03
64.4
1
0.87
66.6
55.7
0.77
0.74
0.72
53.1
0.62
38.6
35.3
0.5
50
0.67
0.56 0.57
0.53 0.55 0.54
26.9
17
13
0
0
Year
Pre-AAP recommendation Post-AAP BTS Campaign (began in 1994)
Sleep Position Source: NICHD Household Survey
SIDS Rate Source: National Center for Health Statistics, CDC
Percent Back Sleeping
SIDS Rate
1.2
Prone Prevalence Rates Among
Black Infants, US
90
2.5
80
2
70
1.5
50
40
1
30
20
0.5
10
0
0
1992
1993
1994
1995
1996
1997
Prone-B
1998
Prone-NB
1999
2000
SIDS-B
2001
2002
2003
SIDS-NB
National Center for Health Statistics, National Infant Sleep Position data
2004
2005
Deaths/1000 LB
Percent Prone
60
Why do People Place
Their Babies Prone?
• Comfort
– Baby sleeps longer, doesn’t awake easily
• Flattened Skull (plagiocephaly)
• Safety
– Concern about choking
Why is Prone Sleeping Risky?
• Babies sleep deeper, experience less
movement, and are less arousable 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.
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.
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.
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.
…in a Crib
• Not on an adult bed, sofa, cushion, or
other soft surface
• A crib, bassinet, or portable crib which
meets safety standards
Why a Firm Sleep Surface?
• Soft or loose bedding carries 5 times the risk
of SIDS as firm bedding.
• Sleeping on the stomach on soft or loose
bedding carries 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
I Sleep Safest:
Alone
On my Back
In a Crib
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
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.
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
Other Considerations:
“Tummy Time”
• Persistent flat spots on an infant’s head, positional
plagiocephaly, can be caused by repeated time in one
position.
• Flat spots usually disappear in the months after learning
to sit up
• To help reduce flat spots:
– Daily ‘Tummy Time’ while awake
and supervised.
– Alternate end of crib where baby’s head is
placed to sleep, or rotate position of crib.
– Limit amount of time baby spends in
car seats, carriers, etc.
Other Considerations:
Breastfeeding
• May be associated with reduced risk of SIDS.
– Breastfed infants are more arousable at 2-3
months.
– Some studies show protective effect, others
none.
• Mothers can breastfeed successfully
without bed sharing.
Moon FY, et.al. Lancet. 2007;370:1578-1587
Other Considerations:
Positioners & Monitors
• Wedges, blanket rolls can be a potential
suffocation risk.
• Use of home monitors does not prevent
SIDS
– In certain situations a home monitor may be
ordered by the physician for apnea, but these
monitors do not prevent SIDS.
Safe Sleep Education for Parents
and Caregivers
MUST:
• Be addressed early and often
• Help parents prepare to counter contrary advice they
receive
• Help parents prepare to insist on consistent provision
of a safe sleep environment when others care for the
infant (grandparents, babysitters, child care providers,
family members)
• Be modeled by respected and credible role models
Gallup Poll 2006, Top List of Most
Honest and Ethical Professionals
Car salesmen
HMO Managers
Congressman
Stockholders
Business Ex.
Journalists
Bankers
Policemen
College teachers
Dentists
Vets
Nurses
0
10
20
30
40
50
60
70
80
90
Nurses as Role Models
• Nurses can model SIDS risk-reduction
techniques to ensure that families know how to
reduce SIDS risk.
– Nurses who placed infants to sleep on their backs
during the postpartum hospital stay changed parents’
behaviors significantly (Colson, 2002)
• The most critical period during which nurses can
influence parents’ behavior is during the 24 to 48
hours following delivery.
Knowledge vs. Practice
•
1999 American Academy of Pediatrics study (Peeke et el)
– 97% of nurses reported awareness of back sleeping
recommendation
– 67% followed the recommendation
– The majority cited “experience” or “the potential adverse
consequences of the back position” as their reason for
disregarding the recommendation
•
2004 survey (Bullock et al)
– 96% of nurses reported awareness of back sleeping
recommendation
– 75% reported using either side position or a mixture of side and
back positioning
– Most nurses thought side sleeping was still acceptable
•
Nursery staff do not uniformly recommend the back sleeping
position.
The ABCs of Safe Sleep
Alone
On my Back
In a Crib
Every Baby Counts on You!
Thank you!