FUll SUID Transcript These types of infant deaths fall under the authority and review of state-appointed medical examiners. These types of deaths fall under the purview of Medical Examiners. This slide represents just a few of the possible underlying causes of SUID including: SIDS Suffocation, overlaying, wedging or entrapment Strangulation Neglect or homicide Metabolic disorders Intoxication or poisoning Hypothermia or hyperthermia After an investigation of a SUID you might be able to explain the cause and manner of the death. In this case we call that an explained SUID. Examples of explained SUIDs include: poisoning, metabolic disorders, neglect or homicide. However, if an investigation of an infant death results in an ambiguous diagnosis or if key information from a scene investigation or autopsy are missing, the SUID is referred to as unexplained. SIDS is one example of an unexplained infant death. CLICK The SUID Initiative struggled with which category ‘accidental suffocation’ should fall under. Since autopsy information lends little information to distinguish between a SIDS death and a suffocation death, this is one category that may rely more heavily on contextual information from a good scene investigation. In 2004 and 2005 SIDS was replaced by Unintentional Injury (accidents) This slide lists the primary cause of death and the description of the circumstances surrounding the death for selected cases of SIDS in 2006. These are literally translation of what the physician’s wrote on the death certificates. Our vital records system has only been able to provide this information starting in 2005. With SIDS deaths in 1005, other causes of death were rarely listed, and therefore, are not shown on this slide. This cause of death information is what the National Center for Health Statistics uses to first assign ICD 10 codes to each cause and then uses all of the assigned ICD 10 codes for that death to determine the underlying causes of death. The provided descriptions are not used to assign the underlying case of death. I’m sharing this data with you today to give you some understanding of which deaths are labeled as SIDS and which deaths are labeled other sudden unexplained infant deaths. As you can see on this slide, those deaths reported as some form of SIDS are generally classified as SIDS. However, some other deaths also end up being classified as SIDS. A co-sleeping infant death is classified as a SIDS unless some sort of respiratory compromise is listed such as overlay, asphyxia, or suffocation. Interestingly, those deaths that are reported as Sudden Unexplained Infant deaths are also classified as SIDS. W75 or “Accidental suffocation and strangulation in bed” is the ICD 10 Classification Used on Infant Deaths for Accidental suffocation and strangulation that take place in a literal bed. This category is generally not to include deaths that take place in other location, but it can happen. As can be seen in this slide, the certifying physician may call this suffocation, asphyxia, overlay, asphyxia with overlay, positional or mechanical asphyxia, anoxia, and mechanical compression. Labeling causes as possible does not alter how causes are coding. Looking at descriptions, most of these are in beds, but this list does include a pillow and playpen. W83 and W84 or “Other specified/unspecified threats to breathing” is the ICD 10 Classification Used on Infant Deaths for accidental suffocation, strangulation, or asphyxia that takes place not in a literal bed. This category is generally not to include deaths that take place in in a bed. As can be seen in this slide, the certifying physician may call this suffocation, asphyxia, positional asphyxia, anoxia, and mechanical compression. Labeling causes as “probable” also does not alter how causes are coding. Looking at descriptions, most of these are in beds, but this list does include a pillow and playpen. This last category is R99 or Unknown/Unspecified. This is to give you some idea of those labeled as unknown. Death in this category are undetermined, natural causes, pending, or other non-specific causes. This is important as many SIDS are now being labeled as undetermined… Add Cause Unknown/Unspecified which excludes SIDS This slide shows the 24 Medical Examiner Groups. From these groups we derived 4 distinct patterns of infant death reporting. Currently there are 4 counties using the new CDC SUIDs investigation Form. Maternal characteristics that were assessed were available from PRAMS and the birth certificate. These factors included demographic factors specifically maternal age, race, marital status, and birth country. Economic factors included maternal education, the method of payment for delivery, and use of public services during pregnancy specifically the Women, Infants and Children program, which provides nutritional supplementation for lower income pregnant women. Grandmothers, aunts, other caregivers can have a major influence on decisions involving baby’s care. Perception of SIDs risk – no one really knows what causes SIDS. Parents say that some kids on their backs still die so sleep position can’t be a risk factor. Parent feels she knows her baby better than anyone else and is the best equipped to make the decision Parent needs to get more sleep Worry about choking. May also have concerns about baby developing flat head. Baby looks uncomfortable on his/her back Baby sleeps longer and better on stomach Baby will roll to prone anyway Convenience - Easier to feed the baby Don’t want to get up and walk to crib Safety – Easier to check on infant. Increased vigilance can prevent SIDS Don’t want infant to die of crib death For low income parents – worried about kidnapping and stray gunfire Parental comfort – desire to bond with baby parent feels more at ease because she is keeping baby safe Infant comfort – infant does not sleep well in crib Infant sleeps better when with parent We need to do a better job of explaining to parents why back sleeping is important because for some parents this seems very counterintuitive. Begin this discussion during pregnancy. The postpartum hospital stay is a good window of opportunity. Everyone is excited about the birth and mew mothers are interested in learning about how to care for the baby. It is a good time to reinforce what has been discussed during pregnancy and to include family members in the discussion Use motivational interviewing techniques. MI provides a great framework for how to share information without preaching or pushing. Position – stomach and side are considered unsafe Sleep environment – no soft bedding, including bumpers, that infants could burrow into resulting in their noses and mouths being covered Sleep location – couches, chairs, very dangerous. Adult beds also have hazards ; pillows, comforters, and adult bodies. Infants should be on a firm surface with no soft objects, loose bedding such as blankets. Studies have shown that bed sharing poses a significant risk even for those mothers who are breastfeeding. Safer alternative is to room share. DOH position statement states the department recommends against bed sharing. Smoking: a recent article in the Journal Sleep suggests that maternal smoking has replaced stomach sleeping as the greatest modifiable risk factor for SIDS. Maternal smoking impairs the arousal pathways in normal infants. Infants born to smoking mothers have a 2 fold increased risk of SIDS. As SIDS rates declined, the attributed risk of SIDS with smoking has increased. Cold Medicine – should not be given to infants No bibs in bed – poses risk of strangulation Car seats – very young infants who do not have good head control yet are at risk if left alone for long period of time in car seat. The head can fall forward and jaws can press against the chest narrowing the airway and making it hard to breathe. Depressed mothers less likely to follow safety recommendations including using back sleeping position German study found that BF reduced the risk of SIDS by 50% at all ages throughout infancy. Epidemiologic studies cannot prove causation. Mechanisms by which risk is reduced include increased protection against infection and increased arousal (BF infants more easily aroused than formula fed). Pacifiers reduce risk by lowering arousal threshold. Two meta-analyses of 7 case control studies have shown a protective effect for pacifier use with a potential risk reduction for SIDS by as much as 61%. This growing evidence let the AAP to recommend offering a pacifier at naptime and bed time. For BF infants, delay offering pacifier for one month, until BF is well established. Concern has been expressed about use of a pacifier and shortened duration of BF but a systematic review of the evidence does not support this claim. Fan use – a population based case control study in 11 California counties found that fan use during sleep was associated with a 72% reduction in SIDS risk. Increased movement of air in the room of a sleeping infant may decrease the accumulation of carbon dioxide round the infant’s nose and mouth and reduce the risk of rebreathing. Babies do tend to cry more when they are on their backs. For many hard-to-soothe babies, placing them on their stomachs may have a calming effect and help them to fall asleep. They also tend to sleep longer and more soundly. But as we have already seen, that is not necessarily a good thing for young babies. Arousability from sleep is a protective mechanism. Waking up easily is a good thing for babies, but not necessarily welcomed by parents who are tired and exhausted. Help parents to understand that back sleeping is a learned behavior and not to give up. Babies who sleep on their backs have a heightened swallow reflex which helps keep their airway clear as well as clears their Eustachian tubes. Carl Hunt conducted a study of 3,733 U.S. infants whose mothers reported that they always placed them in the same position to sleep. When the infants were one, three, and six months old, the researchers asked them whether their infants had fever, cough, wheezing, stuffy nose, trouble breathing, trouble sleeping, and vomiting. Alex N, Thompson JM, Becroft DM, Mitchell EA. Pulmonary aspiration of gastric contents and the sudden infant death syndrome. J Paediatr Child Health. 2005 Aug;41(8):428-31. Department of Pediatrics, University of Auckland, Auckland, New Zealand. “Objective: To determine ante-mortem and post-mortem risk factors for the finding of gastric contents in pulmonary airways (aspiration of gastric contents) at post-mortem examination in the sudden infant death syndrome (SIDS). Methods: There were 217 post-neonatal deaths in the Auckland region of the New Zealand Cot Death Study. No deaths were certified as due to aspiration of gastric contents. There were 138 SIDS cases. The parents of 110 (80%) of these cases were interviewed. Histological sections from the periphery of the lungs in 99 of the 110 cases were reviewed for evidence of aspiration of gastric contents. A wide range of variables were analyzed in SIDS cases with and without aspiration to determine risk factors. Results: Aspiration of gastric contents was identified in 37 (37%) of SIDS cases. Aspiration was of mild-to-moderate degree and in no case was severe and a potential cause of death. Finding infants on their backs at death (P = 0.024) and conducting the post-mortem on the day after the death or subsequently (P = 0.033) were statistically significant variables linked to identification of aspiration. Position placed to sleep, symptoms of gastro-esophageal reflux and other variables were not related to aspiration. Conclusions: The only determinants for aspiration of gastric contents identified were agonal or post-mortem events, supporting the contention that aspiration has limited relevance to the mechanism of SIDS.” Back sleeping babies also have a lower chance of getting overheated because their heads and faces are not covered. The prime avenue for heat loss is through the head and face. Kangaroo care – skin-to-skin contact with a caregiver helps to regulate the infant’s temperature and heart rate. Touch makes babies feel more regulated. The baby uses this sensory information to become calmed and soothed. Breastfeeding has a calming effect on babies. The harmony between a breastfeeding mother and her suckling infant has on organizing effect on the baby’s sleep-wake cycle. Swaddled infants sleep longer. Excessively crying infants cry less and swaddling can soothe pain. Swaddled infants have a lower risk of SIDS. Make sure not to cover head and to place infant in supine position. Swaddling helps some infants tolerate the supine position better. When parents respond quickly to baby’s cries, baby’s brain begins to develop patterns and will learn to be comforted more easily. Hold or comfort baby for all fussy crying during the early months. Gently rocking and cuddling are helpful. Don’t use feeding as a pacifier. Carried babies seem to fuss less. One theory is that “baby wearing” extends the womb experience which helps to organize the baby’s biorhythms so that they are more regulated. (Dr. Sears www.askdrsears.com/html/5/t051300.asp.) Motion calms babies. When infants are in the quiet alert state, they are able to learn from their environment. Babies who are carried in cloth carriers or baby slings for several hours a day settle better at night. Studies have shown that cloth carriers helped to calm and quiet newborns which gave mothers a feeling of competency. They also helped fathers to feel more comfortable and successful. Studies have also shown that mothers who used cloth carriers were more sensitive to their babies’ cues and the babies developed a more secure attachment. (Source: “Does Infant Carrying Promote Attachment?” Anisfeld, et.al., Child Development, 1990, 61, 1617-1627) Harvey Karp, M.D. wrote The Happiest Baby on the Block: the New Way to Calm Crying and Help your Newborn Baby Sleep Longer. Using cross-cultural techniques combined with his own research, Dr. Karp has developed the "five S's system." Some babies will need all five, others just a few to help induce what he calls the "calming reflex." Swaddling - Tight swaddling provides the continuous touching and support the fetus experienced while still in Mom's womb. Side/stomach position - You place your baby, while holding her, either on her left side to assist in digestion, or on her stomach to provide reassuring support. Once your baby is happily asleep, you can safely put her in her crib, on her back. Shushing Sounds - These sounds imitate the continual whooshing sound made by the blood flowing through arteries near the womb. This white noise can be in the form of a vacuum cleaner, a hair dryer, a fan, and so on. The good news is that you can easily save the motors on your household appliances and get a CD which can be played over and over again with no worries. Swinging - Newborns are used to the swinging motions that were present when they were still in Mom's womb. Every step mom took, every movement, caused a swinging motion for baby. After your baby is born, this calming motion, which was so comforting and familiar, is abruptly taken away. Your baby misses the motion and has a difficult time getting used to it not being there. "It's disorienting and unnatural," says Karp. Rocking, car rides, and other swinging movements all can help. Sucking - "Sucking has its effects deep within the nervous system," notes Karp, "and triggers the calming reflex and releases natural chemicals within the brain." This ‘S’ can be accomplished with breast, bottle, pacifier, or even a finger. Infant massage has also been found to have a calming effect on infants. Routines help to regulate arousal by providing appropriate stimulation when the child is awake and soothing routines that precede periods of sleep. a bit to help baby practice some self regulatory skill. Predictable routines help child develop emotional control. They are less frantic when hungry or tired. They quiet at the site of the caregiver or the beginning of a familiar comforting ritual. Babies who have consistent nap routines during the day sleep longer stretches at night. But Don’t let the baby sleep for more than 3 consecutive hours during the day. Familiar bed time rituals set up baby for sleep. Warm bath, soothing massage, stories, rocking, lullabies, nursing let baby know that sleep is expected to follow. Infants who go to bed earlier at night (between 6 and 7) gradually develop longer initial periods of uninterrupted sleep. Some parents have trouble doing this because they feel guilty that they haven’t seen their child all day while they have been an work. Keeping an infant up late does not result in the infant sleeping later in the morning. When the baby starts to act sleepy, place her in her crib. The baby’s last memory before going to sleep should be of the crib, not of the breast or bottle. If she is fussy, rock her until she settles down and is almost asleep but not asleep. If she learns how to put herself back to sleep, she will not cry after normal awakenings. Babies wake up at least briefly 1-3 times a night, on average after 4-6 hours of sleep. Breastfeeding advocates disagree with putting a child into bed drowsy but awake. They feel children are biologically programmed to fall asleep while nursing. The disadvantage is that the breast becomes the baby’s security object and the child does not learn to comfort herself and fall asleep without the breast Sensitive care in the early months of life is one of the most powerful predictors of the quality of the child’s attachment. Rather than providing developmental guidance based on what a baby should be doing week to week, we should be focusing on the relationship between the parent and the baby. .