Impact of Sleep Related deaths on Michigans Infant Mortality

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Washtenaw Countys Safer Sleep Campaign
W.I.S.S.H.
Washtenaw Infants Sleep Safer Here
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By the end of the presentation you will

• Have an awareness of the issue
• Know the prevention strategies
• See the value in informing others
• Know the importance of becoming an advocate for
  Infant Safer Sleep

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Who Needs This Info

• Parents
• Child care providers and baby sitters
• Grandparents and family members
• Siblings
• Health care providers
• Friends
• All first responders
• EVERYONE in the babys life

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The Problem

• Infants (12 months and younger) in Michigan and
  Washtenaw County are dying in unsafe sleep
  environments.
• These are preventable deaths!

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Impact of Sleep Related Deaths on Michigans
Infant Mortality

• Annually, 30 of all infant deaths occur from
  28 days to one year of age.
• Many of these deaths are attributed to unsafe
  sleep environments.
• Prevention of sleep related deaths has a huge
  potential to impact the overall Infant Mortality
  Rate in Michigan.

Report of the 2004 Safe Sleep Task Force,
Division of Family Community Health, MDCH)
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Michigan Infant Death Data

• Approximately 500 infant deaths in Michigan
  between 2000-2003 were sleep related,
  representing 12 of all Michigan infant deaths.
  
  
  
• Source Vital Statistics MDCH.

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Michigan Infant Death Data

• In 2004, there were 984 infant deaths (all
  causes).
• 128 deaths or 13 were attributed to sleep
  issues.
• Michigan Child Death Review Team Data

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Infant Death From Accidental Suffocation
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Michigan Infant Death Data

• In Michigan
• 94 of infant sleep-related deaths had one of
  the following
• Infant on adult sleep surfaces
• Bed sharing
• Unsafe items in crib

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How Do We Know That Sleep Environment is
Contributing to Infant Deaths?

• Over time there has been a shift in diagnosis on
  death certificates because more jurisdictions are
  requiring a complete autopsy.
• Many of those autopsies include death scene
  information.

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How Do We Know That Sleep Environment is
Contributing to Infant Deaths?

• Those who certify death certificates are starting
  to move away from saying these cases are SIDS and
  looking into causes such as suffocation and
  asphyxiation.
• Some death review teams are using dolls to create
  reenactments of infant deaths.

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The Importance of Death Scene Investigation

• The death scene investigation is a
• critical component.
• It allows for differentiation between
• SIDS deaths and suffocation or
• asphyxiation deaths.

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Death Scene Investigations

• The quality of death scene investigations has
  improved, leading to better information on the
  circumstances surrounding these deaths
• Sleeping location
• Sleep position
• Bedding
• Bed-sharing

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Importance of CDR and FIMR
Teams

• More and more states and counties are
  establishing Child Death Review and Fetal and
  Infant Mortality Review Teams to examine and
  discuss infant deaths in their communities.
• They are uncovering data which previously was not
  captured.

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Sleep Location

• The highest percentage (60-80) of sleep-related
  deaths involved non-crib locations
• Adult beds
• Water beds
• Couches
• Recliners

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Sleep Location (2002-2003)from Child Death Review
N 253
Source 5th Annual Keeping Kids Alive report on
Child Deaths in Michigan, MPHI
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Bedding and Bed-sharing

• Approximately half the cases of infant sleep
  deaths involved heavy or soft bedding.
• Bed-sharing was particularly high (over 70) in
  infant sleep deaths from suffocation.

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Bedding (2002-2003)from Child Death Review
N 253
Source 5th Annual Keeping Kids Alive report on
Child Deaths in Michigan, MPHI
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Bed-sharing (2002-2003)from Child Death Review
N 253
Source 5th Annual Keeping Kids Alive report on
Child Deaths in Michigan, MPHI
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SIDS, Suffocation, or
Undetermined?

• From a PREVENTION perspective, how
  these deaths are classified is not
  as important as the fact that these infants share
  the same or similar risk factors in their sleep
  environments.

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Hazardous Sleep Environments for Infants

• Water beds
• Sleeping with baby in arms
• Couches/Chairs
• Sleeping in swings/car seats
• Smoking in the house

• Sleeping with others
• Soft bedding
• Pillows
• Heavy quilts/
• blankets
• Bean bags

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The AAP RecommendedPrevention Strategies

• American Academy of Pediatrics (AAP)
• 1992 - Released guidelines to help reduce infant
  deaths classified as SIDS cases.
• 1994 Launched the Back To Sleep Campaign.
• Since the introduction of the Back To Sleep
  recommendations, sleep related deaths have
  decreased by 50.
• Source Bed Sharing and Infant Sleep Practices in
  Michigan
• Michigan Department of Community
  Health

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Beyond Back to Sleep

• The Back To Sleep campaign has been successful.
• This sleeping position, by itself, is not
  protective when the infants sleep environment is
  unsafe.
• We need to move beyond Back To Sleep and teach
  the importance of safer infant sleep environments.

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AAP Revises Guidelines

• 2000 Modified recommendations
• Emphasis on infants sleep environment.
• 2005 - Clarified recommendations
• Bed-sharing is not recommended.
• Infants should be placed in a separate but nearby
  sleeping environment.
• Infant side sleeping is not recommended.
• Source Bed Sharing and Infant Sleep Practices in
  Michigan
• Michigan Department of Community
  Health

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AAP Recommendations

• Infants should be placed to sleep on their BACKS
  for every sleep - no side sleeping.
• Use a firm sleep surface, firm mattress covered
  only with a fitted sheet.
• Keep soft objects and loose bedding out of the
  crib (no pillows, quilts, comforters, stuffed
  toys, or other soft objects).

Revised AAP Policy Statement, October 2005
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AAP Recommendations

• Do not smoke when you are pregnant.
• Do not smoke or let others smoke around baby.
• Do not share a bed with your baby. A safe crib
  in the parents room, next to the adult bed is
  recommended.
• Avoid overheating baby.

Revised AAP Policy Statement, October 2005
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AAP Recommendations

• Encourage Tummy Time when baby is awake.
• Consider offering a pacifier at nap time and
  bedtime.
• Make sure everyone caring for your baby knows
  these guidelines.

Revised AAP Policy Statement, October 2005
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Safer Sleep Environment

• Baby sleeps alone in a crib, portable crib or
  bassinet.
• Not more than one baby
• per crib.
• Safe crib, firm mattress,
• tightly fitted sheet.

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Safer Sleep Environment

• Avoid chairs, recliners, sofas, water beds, adult
  beds.
• Nothing in sleep area no pillows,
• blankets, comforters,
• stuffed animals or
• other soft things.
• Bumper pads and
  wedges are NOT
  recommended.

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Safer Sleep Environment

• Dont allow
• anyone to
• smoke
• ANYTHING
• around baby.

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Safer Sleep Environment

• Dont overheat or overdress baby.
• Dress the baby in
• as much or as little
• clothing as you
• are wearing.

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Avoid Overheating Baby

• Problem
  If baby is dressed
  for outdoors, brought inside and left to sleep in
  outdoor clothes/coverings, baby may become
  overheated.
• Be aware of babys changing environment.
• Remove outdoor clothes before placing baby to
  sleep in the crib.

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Creating a Safer Nursery

• Consider what items are needed to provide SAFEST
  Sleep Environment.
• Its best not to purchase bumper pads but if you
  already have them and want to use them, they can
  be attached on the outside of crib below the
  level of the mattress.
• Bumper pads can also be used as a window valance.

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Creating a Safer Nursery

• Hang quilts/blankets on the wall.
• Use soft quilts/blankets during Tummy Time when
  baby is awake and being observed.
• Sleeveless sleep sacks are an excellent
  substitute for blankets.

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Baby in Sleep Sack
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Creating a Safer Nursery

• Devices, such as wedges to position infant,
  should not be used during sleep.
• NEVER use pillows in the babys sleep
  environment.

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Baby in a Safe Crib

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State Licensing for Child Care Providers

• Does not allow ANYTHING in the infants
• crib at the child care center or home day
• care.
• All child care providers are required to have
  training re safer sleep environments.

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Important Considerations when Discussing
Safer Sleep

• Tummy (Stomach) Sleeping and Tummy Time
  
  
  
• Co-Sleeping
• Fostering Attachment

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1 Tummy (Stomach) Sleeping and Tummy Time
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Tummy (Stomach) Sleeping

• Babies should never be placed to sleep on
  their stomachs.

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Unaccustomed Tummy Sleeping

• Places infants at extremely high risk for
• death.
• Increases risk as much as 18-times compared to
  consistent back sleeping.
• Less ability to lift head in tummy position.
• Delays development of upper body strength
• Non-parental caregivers should be made
• aware of the risks of tummy sleeping.
• Mitchell et al, 1999

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Why Child Care Providers and Others Might Use
Stomach Sleeping

• Lack of awareness
• 25 of licensed child care providers say they
  have never heard of the relationship between
  infant death and sleep position.

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Why Child Care Providers and Others Might Use
Stomach Sleeping

• Misconceptions about the risk of sleep positions
• Back sleeping and aspiration (choking).
• Belief that tummy sleeping improves infant
  comfort.
• Cultural beliefs.

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Why Child Care Providers and Others Might Use
Stomach Sleeping

• Parental preference
• - Lack of information.
• - Lack of education about risks.

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Tummy Time

• Tummy Time is for babies who are awake and being
  watched.
• 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!

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Tummy to Play and Back to Sleep

• Supervised Tummy Time when babies are awake
• Promotes healthy physical and brain development.
• Strengthens neck, arm, shoulder, back and stomach
  muscles.
• Back to sleep
• Reduces the risk of infant death.
• Is comfortable and safe for babies.

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Tummy Time

• Tummy Time is only safe when someone is present
  to watch the baby.
• If the parent needs to leave the area, the baby
  must be placed on his/her back in a bassinet,
  playpen or crib.

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2Co-Sleeping
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What is Co-Sleeping?

• Diverse ways in which infants sleep in close
  social and/or physical contact with a
  committed caregiver (usually the mother).
• Mother and baby are close enough to detect and
  act on the sensory stimuli of the other.

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What is Co-Sleeping?

• Co-sleeping implies close proximity but not
  necessarily sleeping on the same surface.
• Co-sleeping includes
• Room sharing
• Infant sleep space (crib, bassinet, side-car)
  next to adult bed
• Bed-sharing

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Bed-sharing

• One of many forms of co-sleeping.
• It is never recommended.
• Adult beds are not designed to meet federal
  safety standards for infants.

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Prevalence of Bed-Sharing
www.michigan.gov/prams
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Bed-Sharing Prevalence

• About half of all families practice bed-sharing
  at some time with their infants.
• Dont assume families practice only one sleeping
  arrangement all night.
• Many parents bring baby to bed for some or all of
  the night.
• Bed-sharing is more common in Black, and
  Asian/Pacific Islander populations.

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Prevalence of Ever Bed-Sharing By Geographic
Region in Michigan

www.michigan.gov/prams
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Prevalence of Bed-Sharing by Maternal
Race/Ethnicity
www.michigan.gov/prams
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Bed-sharing is Not Without Risks

• There are 10 well documented studies that show
  bed-sharing increases the risk of
  accidental death.
• There is no evidence to support that parents who
  dont drink or use drugs can safely
  sleep with babies.
• Source Dr. John Kattwinkel, chair of SIDS Task
  Force for AAPS and professor of pediatrics at
• University of Virginia

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Death Scene Data

• In the state of Michigan, FIMR and CDR data is
  finding that suffocation deaths of infants is
  occurring among sober, breastfeeding and devoted
  mothers.
• Only 21 of infant sleep-related deaths reviewed
  in bed-sharing situations between 2000-2002 cited
  drug or alcohol as a contributing factor to
  death.
• Source Rosemary Fournier, State of Michigan FIMR
  Coordinator

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2004 Sleep-Related Data

• 128 deaths were attributed to sleep issues
• 45 were sleeping on a bed
• 13 were sleeping on a couch
• In at least 16 feeding (breast or bottle) was
  involved prior to someone falling asleep.
• In at least 15 cases the only other person in the
  bed was the mom.
• 2004 Michigan Child Death Review Data

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2004 Sleep-Related Data

• 81 deaths involved co-sleeping
• - 62 were bed-sharing
• - 20 were sleeping on a couch
• 2004 Michigan Child Death Review Data

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Entrapment in Adult Bed

• The primary cause of death of infants
• sleeping in adult beds is entrapment.
• 52.3 - Baby becomes wedged between a part of the
  bed and a wall.
• 29.6 - Baby becomes caught between the adult bed
  and frame.

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Entrapment in Adult Bed
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Entrapment in Adult Bed
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Overlaying/Accidental Suffocation
The second most common cause of death is
overlaying, or the accidental suffocation of
an infant by being covered by another person
when they are sleeping together.
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Overlaying/Accidental Suffocation

• The first recorded reference to overlaying is
  in the Judgment of Solomon in the Book of Kings
  in the Bible
• (And this woman's child died in the night
  because she overlaid it. Kings I 319 Old
  Testament)
• The majority of unexpected infant deaths well
  into the 20th century is thought to be attributed
  to overlaying.

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Overlaying/Accidental Suffocation
Risk of suffocation is about 40 times higher in
adult beds compared with those infants sleeping
in cribs. Source St. Louis University of
Medicine, October 2003 Pediatrics
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Overlaying may include

• Occlusion of the infant's nose
• Compression of his chest (not allowing it to
  expand during breathing)
• Compression of an infant's neck, cutting off
  circulation to an infant's brain.
• Source Carol Berkowitz, M.D. is a professor of
  Clinical Pediatrics at the David Geffen
• School of Medicine at UCLA, and
  Executive Vice Chair of the Department of
• Pediatrics at Harbor-UCLA Medical
  Center in Torrance, California. She is the
• President of the American Academy of
  Pediatrics.

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Bed-Sharing

• It is NEVER recommended for baby to sleep in an
  adult bed, but if parents choose to bed-share,
  that bed needs to be made as safe as possible.
• It is important to discuss with parents why they
  want to bed-share and what other alternatives
  would be acceptable.

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Safer Sleep and Breastfeeding

• Many breastfeeding mothers find it easiest to
  nurse in bed during the night.
• Breastfeeding mothers are 3 times more likely to
  bed-share. (McCoy, 2000)
• Both breastfeeding and safer infant sleep are
  important health issues.
• How do we promote both breastfeeding and safer
  sleep?

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Breastfeeding and Room
Sharing

• Mother and infant should sleep in proximity to
  each other to facilitate breastfeeding. (AAP Feb.
  2005)
• Infants may be brought into bed for nursing or
  comforting but should be returned to their own
  crib or bassinet when the parent is ready to
  return to sleep. (AAP Oct. 2005)

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Room Sharing Important

• AAP Policy Statement, October 2005
• The risk of infant death has been shown to be
  reduced when the infant sleeps in the same room
  as the mother.
• Recommended for the first 6 months.
• Placing an infant in a separate room with a home
  monitor is not recommended.

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Making the Adult Bed Safer

• Use a firm, flat surface.
• Make sure sheets fit snugly.
• Recommend parents place the mattress on the floor
  away from walls.
• Ensure that there is no space between the
  mattress and headboard, walls, and other
  surfaces, which may entrap the infant.
• Avoid quilts, duvets, comforters, pillows and
  stuffed animals in infants sleep environment.

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Strategies for Safer Bed-Sharing

• Place infant on his/her back for sleeping.
• Dress baby in a sleep sack.
• Ensure that infants head is not covered.
• Never put infant down to sleep on or near a
  pillow.
• Never leave infant alone in an adult bed.

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People Who Should DEFINITELY Not Bed-Share

• Smokers
• Anyone who drinks alcoholic beverages or uses
  mind-altering drugs.
• Anyone who takes medication that impairs
  alertness.
• Anyone who is exceptionally obese
• Anyone who is exceptionally tired
• Siblings (including twin) or other children

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REMEMBER While all sleep environments can
pose risks for infants, the SAFEST place for
baby to sleep is on his/her back in own crib with
nothing in it but a firm mattress and tightly
fitted sheet.
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3 Fostering Attachment
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Attachment

• Attachment is crucial
  for young babies.
• There are many ways
  to build a strong
  relationship with your
  baby.

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Ways to Form Attachment

• During awake
• time keep baby close
  (only
  when parent is
  FULLY awake)

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Ways to Form Attachment

• Quick and consistent response to the
  cries and needs
  of the baby.

• You cannot SPOIL an infant!

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Ways to Form Attachment

• Eye to eye contact (newborns see best from a
  12-18 inch range).
• Singing and speaking with a soothing and calm
  tone.

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Ways to Form Attachment

• Kangaroo Care (skin to skin) holding of the baby.

• Wearing the baby during waking hours using a
  sling, front carrier or back carrier.

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Ways to Form Attachment
Spend time using rocking or dancing movements
while holding the baby.
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Ways to Form Attachment

• Keep baby in close proximity during the
• night
• Place baby in
  a safety
  approved
  
  crib or
  
  bassinet
  next to
  
  parents bed.

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Ways to Form Attachment

• Use an approved
  co-sleeper next to parental bed.

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Bedtime Routine

• Establish a regular bedtime routine which may
  include
• - bath time
• And once baby is fed, diapered and comfortable
  consider
• - Singing and/or reading
• - Infant massage
• - Rocking

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Calming Your Baby

• It is often tempting to bring a fussy baby
  
• into bed. Try the following instead
• White noise machines or music
• Rocking
• Self soothing with thumb, hand or pacifier
• Swaddling-remove blanket before placing in crib

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Calming Your Baby

• Parental touch is very
• soothing
• Try rubbing or patting babys back
• Hold your baby
• Breastfeeding

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Important Points to
Remember

• No sleep environment can be 100 risk free, but
  some can be made SAFER than others.
• The more factors present in the sleep
  environment, the greater the risk.

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Important Points to
Remember

• EVERYONE caring for a baby must be made aware of
  sleep environment risks.
• Breastfeeding and attachment can and should be
  encouraged while promoting safer sleep
  environments.

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Wont You Help Our WISSH Come True?
Wont You Help Our WISSH Come True?
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Heres How
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We need you to

• Assess your policies and practices.
• Revise if necessary to reflect infant safer sleep
  recommendations.
• Advocate for infant safer sleep.
• Provide resources to those caring for infants.

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