Infant Suffocation Deaths in the Sleep Environment

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* Recent trends in infant suffocation death rates …

* Recent trends in infant suffocation death rates
* Circumstances of the sleep environment and risk factors in infant suffocation
* State and local community efforts in risk reduction and prevention of infant suffocation
* Community-based safe sleep and suffocation prevention programs

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  • 1. Infant Suffocation Deaths in the Sleep Environment Sl E i t March 24, 2011 Moderator: C CAPT S Stephanie Bryn, MPH Director, Injury and Violence PreventionHealth RH lth Resources and Services Administration dS i Ad i i t ti Speakers: Carrie K. Shapiro-Mendoza, PhD MPH C i K Sh i M d PhD, Lena Camperlengo, RN, MPH, DrPH(c) Theresa Covington MPH Covington, Lindsey Myers, MPH Michael Goodstein, MD, FAAP Goodstein MD Judy Bannon
  • 2. Overview• Recent trends in infant suffocation death rates• Circumstances of the sleep environment and risk factors in infant suffocation• State and local community efforts in risk reduction and prevention of infant suffocation• Community-based safe sleep and suffocation prevention programs
  • 3. Speakers• Carrie K. Shapiro-Mendoza, PhD, MPH: Team Leader and Lead Epidemiologist, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention• Lena Camperlengo, RN, MPH, DrPH(c): EGS, Inc. Contractor, Project Coordinator, SUID Initiative, Division of Reproductive Health, Health National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention• Theresa (Teri) Covington, MPH: Director, National Center for Child Death Review
  • 4. • Lindsey Myers, MPH: Injury Prevention Program Manager, Colorado Department of Public Health and Environment• Michael Goodstein, MD, FAAP: Attending Neonatologist, York Hospital; Director, York County Cribs for Kids• Judy Bannon: Executive Director, Cribs for Kids & S.I.D.S. for Kids
  • 5. Understanding SUID:Definitions,Definitions Trends and the SUID Case Registry Carrie Shapiro-Mendoza PhD, MPH and Lena Camperlengo RN, MPH, DrPH(c) EGS, Inc. Infant Suffocation Deaths in the Sleep Environment Webinar March 24, 2011 National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health
  • 6. Overview Definition of SIDS and other SUID Trends in SIDS and other SUID mortality SUID surveillance and death certificates CDC’s SUID Case Registry Pilot Program
  • 8. SUID Definition SUID : Sudden, unexpected infant death , p Infant deaths that:  Occur suddenly and unexpectedly in previously healthy infants  Have no obvious cause of death prior to investigation (unexplained)  Excludes deaths with an obvious cause, e.g., motor vehicle accidents SIDS is a type of SUID
  • 9. Some Types of SUID
  • 10. SUID Categories Explained Unexplained* Long QT  SIDS MCAD  Undetermined cause U d t i d Head injury  Suffocation Infanticide Hyperthermia Infection Overdose*Cause of death was unexplained by autopsy or autopsy was not completed
  • 11. Sudden Infant Death Syndrome (SIDS) “…sudden death of an infant under one year of age y g which remains unexplained after a thorough case investigation, including performance of a complete autopsy, autopsy examination of the death scene and review scene, of the clinical history.”Willinger M, James LS, Catz C. Pediatr Pathol 1991
  • 12. Mechanisms of Accidental Suffocation and Strangulation in Bed (ASSB) Suffocation by soft bedding, pillow, waterbed mattress ill t b d tt Overlaying (rolling on top of or against baby while sleeping) Wedging or entrapment between mattress and wall, bed frame, etc Strangulation (infant’s head and neck caught between crib railings)*All could be designated as ICD 10 code W75
  • 14. Public Health Implications of SUID About 4600 per year, half are SIDS Most frequently reported causes:  SIDS • Leading cause of postneonatal mortality  Unknown or undetermined cause (UNK)  Accidental suffocation & strangulation in bed (ASSB) • Leading cause of infant injury mortality • Potentially preventable Less frequently reported causes:  Infanticide/intentional suffocation (<5%), inborn errors of metabolism (1%), cardiac channelopathies (5-10%), infectionSources: Shapiro-Mendoza et al, Peds, 2009. Kinney and Thach, NEJM, 2009.
  • 15. US SUID-specific infant mortality rates SUID- 160 1990-2007 1990- 140 hs 0000 birth 120 100Death per 100 80 60 hs 40 20 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 SIDS UNK ASSB Combined SUID SIDS: sudden infant death syndrome, UNK: Unknown cause, ASSB: accidental suffocation and strangulation in bed, Combined SUID: SIDS+UNK+ASSB Source: CDC WONDER, Mortality Files
  • 16. Infant Supine Sleep Position 1992 - 2010100% 90% 80% 73% 70% 60% 50% 40% 30% 20% 13% 10% 0% 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010Source: National Infant Sleep Position Study
  • 17. Proportion of SUIDUnexplained by Autopsy, or no Autopsy UNK ASSB ASSB 14% 2% 15% UNK SIDS 27% SIDS 84% 58% 1996 2006 SIDS: Sudden infant death syndrome UNK: Unknown cause ASSB: Accidental suffocation and strangulation in bed g
  • 18. What death certificates don’t tell us about SUIDSUID SURVEILLANCE AND DEATHCERTIFICATES
  • 19. Cause of Death Section from US Death Certificate flItu tlmn iraJ ~vem entn umniral events such n as. cardAl:: Enter only one cau5e on.a ....e. Ad::ladd:tionaJ ClI e Cal5E on a Ine. Adj ad d;;ionaJIMMED TEIMMEOlATE CAUSE (Fina! (Final is~a ~e or COI"IditlOn -----:>d is.ule Of ccndition - - > 01 • _ _ _ _ _ _ _ _ _- ". ." . . . , " ,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __resul1ilg in dea:h )resulh g d~a :h Due:o (or ~s. a c(lflS((!ueme of):SequEntiaU Ir.! C()nd!ions.,SeqKn:iaH lin cond~on5 y y b.----------".-.o;ru;;;;;-,-------------------------if any. k!,ad ing to the ~a u u- any_ leadine ~ause Out to (or n a COI" u-qUiI"Ci 01):tis.t ed 1)11 rlne a. En:e!lis.led I)ft kle i . Enter theUNDERLYING CAU!EUN DER LYINGC AU!E c.- - - - - - - - - - " " " " ";rn""oo""C- - - - - - - - - - - - - - - - - - - - - - -(diSoe,1se or in.ury lhal(d is.ease in~ th at D u~:o (or ~s. ill COIoUqUirQt of):in i:ia~Ed the events. ft s.ultingin~a~td th~ @Oents. ftsUltingndea:h) LASTin dea:h } LASf d. a Net pregm nt wi:h n pa.Sl rear o p regnln: w:Il p.a~1 o Natural N,1turaJ D Homici:le OHomici:!e o Yi s. a ? rob-Ollly o Yes. 0 rob,l)Jy a Pp.gnant .it &Ile c( dea:h ?r;-gn;lllt i UI"Ie of de,1;h o A.ccide nt Accide 0 Pendin,} lnYls-;gafon Pend illtJ Invulgaton [] No a C 0 Unknaom Un kncwn o Not preon:wlt. butcweona,t with ir 42 dol.,.. of deJth a preon,1llt. butpreonalt tlayS 01 tli~h Suici:le o Suici:!e 0 Could not be delenn:ned I ".m,n, a Net p regnlm. but pregnanl 43 d<l)"> 10 1 (ear betJre death i i o .(es. o (ts 0 tl o flo ,, o Dri~r~:lp~ra tc r D river{:l~ra:cr C PaSSeftOEf Pas...enoer
  • 20. Mechanism attributed to suffocation deaths, US death certificates, 2003-2004 2003- Shapiro-Mendoza et al , 2009
  • 21. Sleep surface or place where death occurred, US death certificates, 2003-2004 2003- Shapiro-Mendoza et al , 2009
  • 22. Bedsharing or co-sleeping reported, co- US death certificates, 2003-2004 2003-Shapiro-Mendoza et al , 2009
  • 23. What is needed? More comprehensive data to increase knowledge about:  Circumstances or factors that may have contributed to or caused the SUID case • Sl Sleep environment i t • Prior medical history  Quality of the death scene investigation or if one was even done A SUID surveillance system that builds upon child death review may be the answer
  • 24. A new surveillance system to monitor trends in SIDS and otherSUIDCDC’S SUID CASE REGISTRYPILOT PROGRAM
  • 25. Justification for SUID Case Registry Currently SUID surveillance is monitored using y g death certificate data Death certificate data are limited; do not describe ; circumstances and events surrounding death Need a more comprehensive data source to increase understanding of SUID-related factors CDC’s SUID Case Registry collects data from scene investigations, autopsies, and other sources
  • 26. Main Objectives for the SUID Case Registry To create state-level surveillance systems that build y upon Child Death Review activities To categorize SUID using standard definitions g g To monitor the incidence of different types of SUID To describe demographic and environmental factors for each type of SUID To inform prevention activities and potentially save lives
  • 27. Expected Outcomes and Impacts for the th SUID Case Registry C R i t Strengthen states’ ability to identify, review, and g y y, , enter data for all SUID case Improve the completeness and q p p quality of SUID case y investigations by promoting policy and practice changes Inform national, state and local policymakers and program planners Identify at-risk groups to target prevention programs Use as a potential source of cases for case-control study
  • 28. SUID Case Registry Model Builds upon current Child Death Review activities p and protocols  Uses pre-existing variables  Integrates new and/or modified SUID related variables into SUID-related NCCDR Case Reporting System v2.2S Supports states in their efforts to review child death cases per state mandates Strengthens states’ ability to identify, review, and g y y, , enter data for all SUID cases
  • 29. Variables included in the SUID Case Registry Individual variables  Sleep environment  Maternal health, including pregnancy complications and injury  Infant health, including newborn screening System variables  Components of death scene investigation p g  Tests and exams performed during autopsy
  • 30. SUID Case Review Data SourcesSUIDIRF EMS reports Medical records Death CertificateLaw Enforcement reports Hospital reports Social service records ME/C reportWitness interviews Autopsy reportScene reenactmentScene photos SUID case review by multidisciplinary team
  • 31. SUID Multidisciplinary Review Tea Team Medical Examiner/Coroner Law Enforcement Public HealthEEmergency S Services i Pediatrician or other Health Care Provider Child Protective Services
  • 32. The SUID Case Registry is… A process that m st in ol e m ltidisciplinar team must involve multidisciplinary review A qualitative and quantitative p q q process A tool for assessing and improving case investigations A vehicle for driving data to action
  • 33. The SUID Case Registry is NOT… A data linkage project A fill-in-the-blank exercise An isolated process implemented without input from key partners such as child death review, medico- legal professionals and public health
  • 34. Case Information Flow ChartInfant dies unexpectedly with no obvious cause of death Review team notified of death Case information and reports gatheredTeam reviews and discusses available data and potential prevention strategies Data entered into web-based reporting system State grantee reviews data for completeness NCCDR pools state level data and sends to CDC for analysis
  • 35. SUID Case Registry State GranteesNote:Green states: Colorado, Georgia, Michigan, New Jersey, New Mexico; funding began August 2009Orange states: Minnesota, New Hampshire; funding began August 2010
  • 36. First Year Progress Improved timeliness  Recei e monthly data files from Vital Statistics Receive monthl  Fund staff in ME/C office Improved death scene investigation reporting p g p g  Pay for completed SUIDIRFs  Train investigators to conduct doll reenactment and provide dolls Increased access to autopsy information  Create “summary sheets” for review teams  Fund staff in ME/C office Implemented quality assurance measures  Ensure SUID Case Registry staff attend all review meetings  Review each case for missing/unknown fields at state level
  • 37. 2010 SUID Cases* as of December 31, 2010 Identified: 567 Reviewed : 393 QA completed: 188*States reporting: CO, GA, MI, NJ, NM
  • 38. Acknowledgements Shin Y. Kim Terry Njoroge Rebecca Ludvigsen Cristina Rodrig e Hart Rodriguez-Hart For more information: more information please contact Centers for Disease Control andPrevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: Web: www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the officialposition of the Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health
  • 39. What is CDR Telling What is CDR Telling Us about Infant Suffocation Deaths S ff ti D th & What are States  Doing to Help   Doing to Help Reduce Risks? Theresa Covington, MPH Director National Center for Child Death Review
  • 40. Child Death Review is: Helping improve: investigations and diagnosis services to families services to families Helping to describe the  circumstances in infant sleep  i t i i f t l related deaths.
  • 41. Healthy People 2020• IVP 5: (Developmental) Increase the number of IVP–5: (Developmental) Increase the number of  States and the District of Columbia where 90  p percent of sudden and unexpected deaths to  p infants are reviewed by a child fatality review  team.• Baseline data from 2007: 4,211 SUID deaths in  the US, 37 states reviewed  2,849 SUIDs or 68%.
  • 42. . III r t 88 .5 ~ 0000 I!!:! 00000 ! 0 !II !Ii! !I! ! ! " , 0000 0000 c f t I I ! I I . 1,!d~h 1000000 1.!1 ~h l 1000000 ! !Hlllli , • • • j , 00000000 c I I ! I t t . c I ! I I ! I I;,!lHJ1!!! 1 ! Iql ! • , c • • H~ 00000000 ! . f ! .fl lJuJl!! lJ!!JlI 1 · I 0000 0001 000 0001 I I "i II l! I I il t !Hl!q !HI!1 11lid! til !!ooo l l. !!ooo l l .• I.0 000 0 00 ~ . 0000 I
  • 43. • :: .iGRA.Co.
  • 44. Preliminary CDR data (November 15, 2010,   28 states,    30,920 infant deaths) Infant’s airway was fully or partially obstructed when found Undetermined/  CDR Team Findings Suffocation SIDS Total Unknown Cause Unknown CauseTotal Number of cases 1613 201 459 2273Soft bedding* was relevant to death 716 45% 152 76% 282 62% 1150Sharing a sleep surface** was relevant  f ** lto death 719 45% 31 16% 169 37% 919*Blanket or pillow or comforter or mattress or pillowtop mattress or waterbed or air mattress or bumperpad or stuffed toy or clothing.** With adults, other children or animals
  • 45. Infant’s Sleep Place Undetermine Suffocation SIDS d/ Unknown  TotalIncident Sleep place CauseTotal number of Cases 1613 201 459 2273 Crib 135 55 63 253 Bassinette 65 17 34 116 Couch 259 12 63 334 ~50% Adult Bed 810 90 228 1128 Other 277 27 66 370 Unknown 67 0 5 72
  • 46. So What are States Doing?So What are States Doing?
  • 47. 37 States with Safe Sleep Promotion Activities What are these activities? Homo Yio.U
  • 48. Differences in MessagingWhat AAP Message Do You Explicitly  li i lInclude in Your  g gState’s Messaging?N=37
  • 49. Safe Sleep for Baby is: ill baby on back in a safe cribIt NoToys • .,--_....._ - _....._-.-- _-- ............_-_ ..... ....... -- - ...... ._--_ - -................__.. _...--_ ....- ... --_ _"_.11_ _... -"-_" A CribIt No Pillows -...................... .-~-- -.........-, ...........-.-... ..............__.._._......._-.. A Mattress ........ ._--11 No Bumper Pads ::::...~- _-- 0 _ _ _ _ _ _ ...K No Quiltsor BlanketsIt No Stomach or Side SleepingWhy? A TIght-Fitt ing Sheet A Baby Placed o n his Bac k to Sleep ~ _- ----- ---- _..... --.--0,...- ... _ _ ....-. :::..:::- - ------ --_ _- _--- _- .... ...... __ --_ .._........... ..- -... ~-::..=.:: ... _ . ...,. .. .ro- .... ..... .. . _ __ -_ - -"- ;::..-:.......... , ... - .- ..... ---- - .:::::....::.::::...":"..::: -_ -......... - . . . ... .... • _ _ .. w_ - ... .... - -, ..-Because babies who sleep alone in a crib without bum r dblan kets, loys"o r p iliowsall LESS likely 10 d ie from SIDr pa 5, ----~--. ----..-,..-- :-.::.::::................ --__.... .....-.-- _.__... ......- _ .. ...... -~ .... ..... . _--- .... ... . - ~-- __-, ..-_.. _-- ._ ... __-- ..... --_. ..... " ...... -"-"-- ..... .......
  • 50. Lots of Target Populations
  • 51. Lead AgenciesLead Agencies Other: Multi‐agency  coalitiolns
  • 52. Lots of PartnersLots of Partners Delaware’s Multi‐Agency Mass Media effort
  • 53. SIDS Center of New JerseySIDS Center of New Jersey Institutionalizes Safe Sleep Messages and  Policies by Working With: Policies by Working With  State Child Protection Services  Primary Care Centers including  Primary Care Centers including Federally Qualified Health Centers  Nursing staff in Newborn and  Neonatal Intensive Care Units  Maternal and Child Health Consortia l d h ld lh  Child care programs  Education programs for pediatricians,  family practitioners, trainees family practitioners trainees
  • 54. Infant Mortality Minnesotas Safe and Asleep CampaignReductionInitiative Annua ll y, 40 or m or e ot herw ise hea lthy Minneso t a bab ies d ie of s leep -re lat ed un int enti ona l injuries wh il e • Infant Morta li ty s leep ing in unsafe conditi ons such as in an adu lt be d or on a sofa w ith parent s or o lder ch il dren . Bab ies Hom e Pag e becom e t ang led in be dd ing , get st uck under p ill ows, or t rappe d be t wee n a s leep ing adul t and cus hions of • MN Safe and a sofa or rec li ner. Som eti m es t he ir own s leep ing parent s r o ll over on t hem unint enti ona ll y, ca us in g dea t h As lee p Campa ign from suffoca ti on and ches t co mpress ion .• Ord e r Infant Slee p Safe ty Minneso t as Safe and Asleep in a Crib of Their Own Campa ign was launched in Edu c ationa l Mate ria ls July 2007, and co nti nues as a par t nersh ip be t wee n t he Mat ern a l and Ch i ld Hea lth Sec ti on of t he Minneso t a Department of Hea lth and t he Minneso t a Sudd en Infa nt ~r~~~n~~pti~n Ueath Lenter or Lh ll dren·s HOsp ita ls and Ll ln lcs. Add it iona l partn ers Inc lude the Intercon ce ption Depart m ent of Human Serv ices Ch il d Mort a lity Re v iew Pane l, t he Minneso t a Assoc iati on of Coroners and Med ica l Examiners, Tw in Citi es Hea lthy St ar t, t he Crad le• Res ources Minneso t a Chap t er of t he Am erica n Aca dem y of Pe d iat rics and loca l pub li c hea lth d e~ ••• w 0<><._ . Safe and As leep Campa ign Press Re lease. July. 2007 ( PDF: 53KB12 pagEMaternal &Child Health .,... 0<><._ . MN Coroners and Me d ica l Exam iners letter to prov iders. Ju l y. 2007 ( PDFMore from MDH The Am erica n Aca dem y of Pe d iat r ics recommends t hat a ll infa nt s s leep o n t he ir back:• Po s iti ve approve d cr ib and in a sm oke - free env ironment t o reduce t he risk bo t h of Sudden Infa nt Dea t h Syndrom e ( SI C Alt e rnati ves prevent ab le injury d ea t hs.• Po s tpartum De press ion Edu c ation Materia ls Educational Materials• Shake n Baby Syndrom e Preve ntion Download or order educational materials from t he MDH Mat ern a l and Chi ld Hea lth Sec ti on t o Materia ls safe infa nt s leep m essa ges fo r parent s and ot her ca reg ive rs. Ot her recommend m at eria ls ca n t at ht t p :// www. njchd .njh .gov/pub li cations/ includ ing m agnet s and t he genera l ou t reach door h which MDH no longer has ava il ab le. Additional Educational Materials T • • I. • .., I. • • ~
  • 55. Messaging Can Be InconsistentTHE SOLACE OF THE family bed A renowned doctor reassures pare nt!> that infant night waking is normal. And its safe to 5leep with your kids. Tips IOf caregivers Follow these recommendations t o help reduce the risk 01 sudden infanl death s yndrome ar.d prevent accidental deaths: • BabOe s should s leep an their backs (not stomach Of SIdes). whether sleepong d~ Of """, • Keep loose or ftully bedding away from the infant and hisJher sleep are a. and us. a firm. l!jhl.fitting matren
  • 56. If Babies Could TalkCould Talk
  • 57. 71 Safe Sleep: a S S f Sl State’s ’ Perspective of Linking MCH and I j d Injury Prevention and P i d SUID Case Registry INFANT SUFFOCATION DEATHS IN THE SLEEP ENVIRONMENT WEBINAR March 24, 2011Lindsey Myers, MPHColorado Department of Public Health and Environment
  • 58. Colorado Child Fatality72 Prevention System • Began in 1989 • Legislatively mandated in 2005  45 member St t T b State Team  Review deaths of all children under age 18  Understand the U d t d th causes of child d th f hild deaths  Make recommendations for policy changes • Currently reviewing 2008 deaths
  • 59. Colorado SUID Case Registry g y73 • Case Identification: Death Certificates—2010 & 2011deaths • Data collection  Coroner Reports and Autopsies  Law Enforcement  Medical Records  Child Protective Services • Case abstraction • Multidisciplinary review of circumstances • Identify factors that contributed to or caused death • Identify prevention strategies
  • 60. 2010 SUID Cases74 • 2010 cases identified to date = 51 • Common Risk Factors  Bed-sharing  Soft-bedding  Unsafe sleep position
  • 61. Prevention Recommendations75 • Systems  Death Scene Investigations  Autopsies  State Agencies • Policy and Legislation • Community Level  Education campaigns and programs
  • 62. Investigation Recommendations g76  Use the SUIDI-RF for a c d dea s e SU o all child deaths  Doll reenactment  Training for lay coroners and hospital pathologists g y p p g regarding the national recommendation for child deaths to be investigated by forensic pathologists  Training for law enforcement regarding how to look for evidence of suffocation  Take th T k the actual t t l temperature of th room, rather th t f the th than make an estimated guess
  • 63. Autopsy Recommendations p y77  C a y e Nation ssoc a o o Medical a e s Clarify the Na o Association of Med ca Examiners “autopsy standards” to define what a “complete autopsy” means and what test should be run  Educate coroners about filling out death certificates correctly, and about the danger of using the term SUDI  Toxicology screens f all i f T i l for ll infant d h deaths
  • 64. Prevention Recommendations78  Safe sleep statewide campaign and education— p p g multilingual and multicultural  Professional education for hospital nurses and home visitation nurses  Professional education for social workers during new DHS Training Academy  Safe sleep education during home assessments for child placement  Start a Cribs for Kids Program S C ib f Kid P  Expand nurse home visitation programs to serve more families
  • 65. 79 Local S f Sl L l Safe Sleep C Campaigns i
  • 66. El Paso/Teller County CFR80 Safe Sl S f Sleep CCampaign i Collaboration b C ll b between the local CFR T h l l Team and two local hospitals Training for health care providers and child care providers on safe sleep Co-messaging with abusing head trauma program Posters Billboards Radio Spots Education programs through churches Local Health Fairs
  • 67. Mesa County CFR81 Safe Sl S f Sleep C Campaign i Does not use the term SIDS i campaign D h in i  Press releases  Flyers distributed to WIC, Nurse Family Partnership, and doctors offices  30 minute segment on government access channel featuring the coroner, law enforcement, and pediatricians Letter sent to health care providers to encourage them to adopt a policy to discuss safe sleep with patients i Print and Radio ads
  • 68. 82 Statewide Safe Sleep I i i i S id S f Sl Initiative
  • 69. Linking MCH, IP, and CFPS g , ,83 Child Fatality y Prevention System Dept. of Safe Kids Human Colorado Services Colorado Safe Sleep Initiative Injury Maternal Prevention and Child g Program Health Program
  • 70. Colorado Safe Sleep Initiative p84 • Collaboration with Safe Kids Colorado, based out of The Children’s Hospital • Interest in creating a unified statewide approach • Safe Sleep Summit held in January 2011  Reviewed data from CFPS  Learned about local safe sleep programs  Round Table Discussions
  • 71. Safe Sleep Partners p85  Child Fatality Prevention  Prenatal Plus Programs System Review Team  State child care licensing  State MCH program p g p g program  Home visitation programs  Child welfare programs  Local health departments  WIC agencies (esp. (esp MCH and injury  Colorado B C l d Breast F di t Feeding prevention programs) Coalition  Public health nurses  Local Safe Kids coalitions  Hospitals H i l  Coroners  Community birthing centers  County Attorney’s Office  Physicians y
  • 72. Challenges g86 • Inconsistent messaging coming from the health g g g department • Some lactation specialists do not agree with AAP recommendations d i • Crib distribution controversial because of liability issues • Due to shift in diagnosis from SIDS to undetermined or ASSB, some are reluctant to use national resources that link SIDS with safe sleep • Limited funding • Program evaluation is difficult
  • 73. Round Table Discussions87 • Messaging  AAP Guidelines  Bed-Sharing  Terminology (to use SIDS or not to use SIDS) gy ( )  Culturally specific messages • Community Strategies  Current opportunities/venues • Provider Strategies  Child care  Health care  Social workers • Policy  Training curricula (nurses, social workers)  Hospital policies
  • 74. Safe Sleep Summit Outcomes p88 • Agreement that there is a need for a statewide Safe Sleep Initiative • Agreement to use AAP Guidelines • Commitment to participate • Vision Statement Draft: A coordinated coordinated, collaborative statewide message and strategy to reduce sleep-related deaths among Colorado sleep related infants.
  • 75. Next Steps p89 • Develop Statewide Safe Sleep Coalition p p  Initial Subcommittees • Data/Evaluation • M Messaging i • Funding • Literature review on best practices • Pilot hospital survey • Develop consistent safe sleep messaging to be used by all partners • Create statewide strategic plan to disseminate message • Id if funding sources f i l Identify f di for implementation i
  • 76. Opportunities pp90 • Data from SUID Case Registry Pilot will help develop stronger prevention recommendations • Public/private partnership could be beneficial to fund prevention activities • Funding through state MCH Program to help fund local level MCH programs work on safe sleep • Partners around the state using the same language will making it easier for parents to understand safe sleep recommendations
  • 77. Evaluation of a Novel SIDSRisk-Reduction Program at a Community Hospital Creating a Hospital and Community B FAAP, Iand t C it Based Infant Michael Goodstein, MD, d f Safe Sleep Education and Theodore Bell, MS Bell Awareness Program: The York Hospital Experience p p Michael Goodstein, MD, FAAP 91
  • 78. York, York Pennsylvania• Population base 425,000 (city 40,500)• Inner city, suburban, and rural populations• Almost 4,500 deliveries per y , p year 92
  • 79. Infant Coroner Cases York Co. 2005-2010 8 7 eaths 6 mber of De 5 4 * 3Num 2 1 0 2005 2006 2007 2008 2009 2010 Year total deaths SUID Inappropriate sleep 93
  • 80. Infant Sleep SafetyRequires a consistent and repetitivemessage in the community to prevent accidental deaths 94
  • 81. Advice on Infant Sleep Safety: p y Who Do You Listen to…• Family and Friends• Doctors, Nurses, Doctors Nurses Lactation Counselors• Magazines, Newspapers, Internet• Oprah, Dr. Phil, Dr. Spock, Dr. Sears O h D Phil D S k D S• Grandma!!! 95
  • 82. Why Develop a Hospital-Based Program? P ?• It is the only way to capture 100% of the birthing population for education• It is the point of intersection for all the members of the health care team including obstetrician, pediatrician, nursing, obstetrician pediatrician nursing and lactation counselor with family members• N Nurses are critical role models iti l l d l• It is efficient and cost-effective 96
  • 83. Hospital-Based Infant Safe Sleep ProgramGoal: Reduce the risk of injury or death to infants while sleeping • P id accurate and consistent infant safe Provide t d i t ti f t f sleep information to hospital personnel • Enable hospitals to implement and model infant safe sleep practices throughout the facility • Provide direction to health care professionals so parents receive consistent, repetitive safe sleep education l d ti 97
  • 84. A Model Program• Replicate Shaken Baby Program (now called p y g abusive head trauma)• 50% reduction in shaken baby injuries reported by Dr. Dias (Peds April 2005)• Program Components: g p  DVD presentation on infant sleep safety  Face-to-face review with nursing staff g  Sign voluntary acknowledgement statement 98
  • 85. Infant Safe Sleep DVDs 99
  • 86. Parent Education• Prior to discharge, all parents view g , p the Safe Sleep DVD• Nurse modeling of safe sleep g p environment• Review of the “Safe Sleep for y p your Baby” pamphlet.• Confirm there is a safe place for the p baby to sleep. If not, social work referral to obtain a Pack ‘N’ Play. 100
  • 87. Voluntary Acknowledgment Statement…. that I have received this information and understand that babies should sleep on the back, and that sleeping with my baby increases the risk of my baby dying from SIDS. • An acknowledgement form only • Focuses family on the importance of the information y p • Not for legal purposes 101
  • 88. Infant Safe Sleep Program: Supplemental Components• Posters placed prominently in every labor, maternity, and pediatric room, offered to all OB, Peds, FP offices• Sleep sacks available for p p purchase at discount at gift shop and lactation center• Display nursery: Infant Sleep Safety Center• Hospital phone service (on-hold message) 102
  • 89. Safe Sleep Posters 103
  • 90. Model Nursery/Infant Sleep Safety Center 104
  • 91. Organizational Chart for an Infant Sleep Safety Program Hospital Based Infant Safe Sleep ProgramProgram Acceptance Curriculum Development Community Support Hospital Administration Initial Staff Education Local Health Bureaus Physicians Maintenance of Education Safe Kids Coalition Nursing Staff Family Education Cribs for Kids Programs Other Staff (RT, LC, Aides) Child Death Review Teams 105
  • 92. Presentation for Administration• Support from p y pp physicians already y knowledgeable about SIDS/SUID• Scope of problem: National and local statistics• Logistics of program: A successful program model that has produced excellent public health results• Cost-effectiveness 106
  • 93. Infant Mortality Statistics SIDS - United States 1999 The major cause of infant death after the first month SIDS/SUID 26.5 Congenital Anomalies 17.2 Accident/Adverse Effects 8.1 Pneumonia/Influenza 3.1Homicide/Legal Intervention 3.0 Septicemia p 3.1 Meningitis 1.0 Respiratory Distress 0.7 % of total infant deaths 28 364 28-364 days old Bronchitis 0.7 07 Malignant Neoplasms 0.6 107
  • 94. Staff Acceptance “Buy-In” Buy In• Pediatric and NBN nurses with knowledge about SUID make quick allies• Resistance to “another program” is easily another program overcome by: CConcept of a program to reduce infant t f t d i f t mortality locally  Use of statistics  Use of Evidence-Based Medicine 108
  • 95. Allegheny County, PA Study f St d of 88 SIDS D th 1994 2000 Deaths, 1994-2000 11% (10 babies) Found in cribs or bassinets 89% (78 babies) Found in unsafe sleeping environmentsSource: Allegheny County Coroner’s Office, Stephen Koehler, Ph. D., Forensic Epidemiologist 109
  • 96. Nursing Buy-In g y• Nurse Managers: NBN, ICN, L&D, Pediatrics, ED g• Discussions at staff organizational levels: multidisciplinary committees ( (neonatal care), nursing counsels ), g (education, practice)  Nurse leaders: Support dissemination of pp program concept to general staff  Follow-up discussions at nurse staff p meetings, reinforcement through e-mail 110
  • 97. Healthcare Provider Education• Develop an infant sleep safety policy for the hospital:  Set the standard of care at the institution  Sample policies on the Allegheny County Dept of Health and First Candle websites  York Hospital policy modified the Allegheny sample and was merged with existing policy  Finalized through newborn and pediatric hospital committees p 111
  • 98. Hospital Nursing Education• In-service lectures vs. computer-based In service computer based training• Lecture compliance may be difficult if not mandatory…non-productive hours• Computer based easier to do but teaching Computer-based do, may be less effective• P id d CME credits Provided di 112
  • 99. Hospital Nursing Education• Core group of volunteers to provide lectures• Developed PowerPoint presentation and had practice sessions  Materials included: AAP SIDS policy statement, NIH materials, Cribs for Kids lecture materials materials• Supplemental poster boards in clinical areas• M d t Mandatory viewing of S f Sl i i f Safe Sleep DVD  Reinforce materials, know what parents will see 113
  • 100. Avoiding Potential Pitfalls• Focus on back vs. side sleeping and fear of aspiration• Claims made against the p g g program:  Anti-bonding  Anti-breastfeeding Anti breastfeeding• Focus on evidence-based medicine  Eliminate emotion 114
  • 101. Maintenance of Education• Safe sleep toolkit at nurses’ stations (modified nurses from Allegheny county)  Hospital safe sleep policy  Review of appropriate practices  Discussion points to review with families• Informational flip charts (scripted prompts, stats)• Computer-based review course with test as part of yearly competencies 115
  • 102. Healthcare Provider Education: In the Community• Went into local physician offices to lecture during staff meetings  Pediatric and obstetrical • OB office visits focused on prenatal educators  Provided posters and teaching materials  Discussed bad information in free magazines• Family Practice Grand Rounds• Emergency Department Education• VNA• Red Cross Educators 116• Prenatal Class Educators
  • 103. Anticipated Outcomes• Back to Sleep Campaign – 50% reduction in SIDS (compliance 87%)• Shaken Baby Program 50% reduction in Program- abusive head trauma injuries• S Some SUID experts estimate up t 90% of t ti t to f these deaths are related to suffocation• Reasonable expectation of up to 50% reduction in SIDS/SUID events 117
  • 104. $$$ Cost of Program $$$• DVD- Safe sleep for your baby – right from the start- $20• Voluntary commitment statement – paper y p p supplies• Safe sleep toolkit – more paper supplies• Safe sleep educational brochures – free from NIH• Computer-based training – no charge• Volunteerism – to assist with in-services 118
  • 105. Infant Safe Sleep Program Results• 6 months baseline; 6 months intervention• 2 725 healthy deliveries 2 256 surveys 2,725 deliveries, 2,256• Excellent knowledge base about sleep environment (94 99% supine, 99% crib) i t (94-99% i ib)• Knowledge does not equal intent (15% drop) 119
  • 106. Infant Safe Sleep Program Results• Improvement after program intervention• I t ti to follow through with: Intention t f ll th h ith  Supine sleep position increased from 82% to 97% ( < .01) (p 01)  Crib or bassinette use increased from 81% to 92% (p < .01) 01) 120
  • 107. Results of HCP Education• Understanding of the AAP guidelines increased from 75% to 99% (p < 0.01)• Agreement with all of the AAP guidelines increased from 88% to 94% (p = 0.049) % % )• Staff adequately trained about ISS increased from 43% to 99% (p < 0 01) 0.01) 121
  • 108. Conclusions• A hospital-based community-wide Infant hospital based community wide Sleep Safety program can be maintained successfully at minimal cost cost.• To be successful:  Id tif infant sleep safety champions Identify i f t l f t h i  Build consensus  Eff Effort, time, and passion i d i 122
  • 109. Program Replication• York Hospital • Magee Women’s Hospital• Memorial Hospital • Mercy Hospital y p• Gettysburg Hospital • St. Clair Hospital• Harrisburg Hospital • Franklin Square Hospital q p (Pinnacle Health) • Williamsport Hospital• Doylestown Hospital • *Lancaster Women and Lancaster• Hanover Hospital Children’s Hospital• West Penn Hospital • *Heart of Lancaster• Forbes Hospital Hospital• Sewickley Hospital • *Geisinger Health System g y • *Hershey Medical Center 123
  • 110. Achieving a Cultural Shift on ISS Inconsistency of message. National campaign with Lack of HCP education. consistency of message. Wrong advice from g Improved HCP education education. family and friends. Partnership: Religious Unsafe sleep images. Leaders. Inappropriate sleep Safe sleep images. products. products Social S i l marketing. k i Legislation? Safe Sleep p Safe Sleep 124
  • 111. References and Contacts• The American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the shifts sleeping environment, and new variables to consider in reducing risk. Pediatrics 2005;116:1245-55.• Colson et al. Trends and factors associated with infant sleeping al position: The national infant sleep position study 1993-2007. Arch Pediatr Adolesc Med 2009;163(12):1122-1128.• Kinney and Thach. Medical Progress: The sudden infant death Thach syndrome. N Engl J Med 2009;361:785-805.• Contact Information:  Michael H Goodstein MD FAAP H. Goodstein, MD, Office of Newborn Medicine York Hospital 1001 S. George St. York, PA 17405 717-851-3452 717 851 3452 717-851-2602 (fax) 125
  • 112. THANK YOU!!! 126
  • 113. Cribs for Kids C ib f Kid ®National Infant Safe Sleep Education and Crib Distribution Program Judy Bannon, Executive Director/Founder y ,
  • 114. Cribs for Kids®• Originated in Pittsburgh in Nov. 1998 through the combined efforts of District Attorney Stephen Zappala, Mayor Bob O’Connor, Cmdr. Gwen Elliott, and O’C C d G Elli tt d Judy Bannon (SIDS of PA)• Steering committee consisting of public health, political and business leaders and child death review teams was formed
  • 115. Of the 68 infant deaths between 2001-06, how many babies were in an ideal sleeping space? (on the back, in ( th b k i a safe crib, no cigarette smoke, no soft b ddi ) f ib i tt k ft bedding) Allegheny County, Pittsburgh, PA Unsafe! Only 2!
  • 116. FACT!The overwhelming majority of babies who die from SUID/SIDS are discovered in an unacceptable sleep position or sleep location! The overwhelming majority of babies who continue to die from SUID/SIDS are African American babies!
  • 117. Growth between 2006 and present!AK BC ME WA MT V VE ND MN NY NH OR ID WI MI NYC WY PA IA NJ NE OH MD DE IN WV NV IL DC VA UT CO CA KS MO KY NC TN OK SCHI AR AZ NM GA MS AL TX LA FLTo Date:262 Partners in 48 States Cribs for Kids locations Awaiting signed agreement
  • 118. National Cribs for Kids Partners ®140 119120 Health Departments & 100 DPW Agencies DPW Agencies Hospitals 80 59 SafeKids Coalitions 60 47 40 Community Based  32 Organizations 20 Other Oth 5 0 Number of Partners (262) ( )
  • 119. SIDS is NOT SuffocationAlthough SIDS is different fromsuffocation, all the measures we use forSIDS risk reduction also help to prevent reduction,accidental deaths such as positionalasphyxia, overlay,asphyxia overlay and entrapment entrapment. These d th are 100% Th deaths PREVENTABLE!
  • 120. The Ideal Safe Sleep Environment Baby sleeps in crib. Nothing in sleep area. Firm mattress, tight-fitting sheet.Used with permission fromTomorrow’s Child, Michigan SIDS
  • 121. Unsafe Sleep Environment: Soft Bedding
  • 122. Unsafe Sleep Environment
  • 123. Unsafe Sleep Environment j
  • 124. Components of the Cribs for Kids® program• Standardized materials  Safe-sleep brochures, posters, etc.  Training manuals  Standardized forms  Grant writing language  Current safe-sleep literature review  PowerPoint presentations P P i t t ti• National fundraising initiatives• Crib distribution system• Networking opportunities• Ongoing support g g pp
  • 125. National SponsorsGraco Children s Products Children’s In January, 2006, Cribs for Kids was made the exclusive commercial distributor of the Graco Pack n’ Play nPitt-Ohio EPitt Ohi Express In March, 2006 Pitt-Ohio Express p partners with us and offers free shipping pp g to partners across the country. They also donated a forklift to help with our shipping needs!
  • 126. Cribs for Kids® Graco Pack ‘n PlayGraco ‘P k n Pl ®’ --G ‘Pack Play$49.99 Our own C4K SKU number Can not be returned to any retail store Safety S f t approved d Portable Compact Easy to assemble
  • 127. Cribs for Kids® Crib Sheet with Safe Sleep Message $5.00 $5 00 each Please Keep Me Safe… Back to Sleep For naps & at night to reduce the risk of SIDS Now I lay me down to sleep, Alone in my crib, without a peep. On my back, in smoke-free air, Thank you for showing me that you care. 1.888.721.CRIB Portable Crib Sheet Design
  • 128. Cribs for Kids® Logo Halo Sleep Sack $14.99 $14 99 eachHALO SleepSackHALO™ SleepSack™ Wearable Blanket Replaces loose blankets in the crib, lessening the likelihood of babies getting blankets over or around their face.
  • 129. Respironic Soothie Pacifier $1.50Soothie®For Babies Without TeethSoothie is a premium pacifier designed for newborns and babies withoutteeth who are successfully b l or h h f ll bottlebreastfeeding. Its one-piece constructionadheres to the American Academy ofPediatrics guidelines. Respironic Pacifier
  • 130. “Keep Me Safe” Photo Magnet $.75 $ 75• New item added to Safe Sleep Survival Kit• Safe Sleep Survival Kit same price still $69.99
  • 131. Safe-Sleep Survival Kit $69.99 Safe Sleep Survival Kit Please Keep Me Safe… Back to Sleep For naps & at night to reduce the risk of SIDS Now I lay me down to sleep, Alone in my crib, without a peep. On my back, in smoke-free air, Thank you for showing me that you care. 1.888.721.CRIB
  • 132. Public Service Announcement Infant Safe Sleep Video Please Keep Me Safe… Back to Sleep For naps & at night to reduce the risk of SIDS Now I lay me down to sleep, Alone in my crib, without a peep. On my back, in smoke-free air, Thank you for showing me that you care. 1.888.721.CRIB
  • 133. Becoming a Partner…. How d I begin? H do b i ?Go to Or Call: 412 322 5680 Ext 3 412-322-5680
  • 134. Components of the ‘Cribs for Kids®’ Program Application Form
  • 135. Components of the ‘Cribs for Kids®’ ProgramTrademark License Agreement
  • 136. Components of the ‘Cribs for Kids®’ ProgramStandardized Brochures
  • 137. gFor more educational supplies request from
  • 138. Components of the ‘Cribs for Kids®’ Program Survey Instruments – Pre & Post Tests~.-,- , -_. ........ -c... ... ...... I -- I -, ,- TIIfJl I12U -- , ~ -- " ,-- ""--.==----- - ~ • ..... _-~,---"---~~ .,...--- . ~. , p,.,.l .... ~:~~. .. K lIll , ... "............._.-_....,..-_.............. _.-:0;. ---)-----_.- .......- -.----" -::c.- , .......,... ... .......,_. ..,~..,. IU-.~."""t."___ G :r; - " . . , ... ..... , "" """"- - --,.,. --" ..--, ,..___ - - ._- .- - .--- , . ...... , , ......-..- :. -.-"- - -,- -" ",.. -. - ....... ..._. La . - ......... . -~. . --... _ . .--. ... " ",,,,,, • ."",. ...". "-~ . _..., - -, :c:r.,,::"l0l ...,. .,..---- ... m ....--.... . - , , , , -""- .....-.... ....-. , ,, , , , ",..- --,...- ..... , .... -,..~ -:: ........... ---_. . ".,..-,.., ... _ . ,.._ •..r....--. --...• _ ... _ .. 00"". __ -- ~- , , , , , , , , , , , ---.......---- -- , , .....,..... ..... . . .............._J<, - ,..~ ....... ....... ... ..., --_-,..--- .--................-.".---.~....... - ....... -,.....,.. _,.....,. , , , , ...... - , , , • -------.:::::: . ......... , , , , , --~ "" "" ..... ......... ~. ........... ~-. -
  • 139. Components of the ‘Cribs for Kids®’ ProgramSample Grant Materials p
  • 140. Components of the ‘Cribs for Kids®’ ProgramSample Grant Materials
  • 141. Components of the ‘Cribs for Kids®’ Program -- Standardized Forms Hold Harmless Agreement
  • 142. Components of the ‘Cribs for Kids®’ ProgramSafe-Sleep Checklist
  • 143. How to Order aSafe-Sleep EnvironmentSafe Sleep En ironment
  • 144. Mandated Legislation (language and guidance) Pennsylvania Act 73 of 2010 SIDS Ed Education and P ti d Prevention P ti ProgramSigned into law on October 19, 2010 by Governor Edward Rendell of Pennsylvania, providing for education of parents relating to SIDS and unexpected deaths in infancy, infanc taking effect on December 16 2010 16, 2010.
  • 145. Networking & Ongoing Support• Semi-Annual conference Semi Annual• 24-Hour Hotline• E Experienced staff at national office i d t ff t ti l ffi answers questions & provides guidance• Fundraising Advice• Easy ordering of Safe Sleep Survival Kits y g p
  • 146. FACT!Knowing is not enough: we must apply. Willing is not enough: we must do. ……Goethe
  • 147.  Questions and Answers Thank you for attending this event. Please complete the evaluation directly following the p y g webcast. An archive of this events will be posted ( within a few days.