Samuel Dzodzomenyo MD.
1.To identify risk factors associated with
sleep related mortality in infants
2. Understanding sleep-environment-related
infant deaths.
3.Best practices to reduce sleep related
infant death.
 The
number of infant deaths (one year of age
or younger) per 1000 live births
 Currently, the most common cause is
pneumonia.
 Traditionally, the most common cause
worldwide was dehydration from diarrhea
Rank
Country
Infant mortality
rate
(deaths/1,000
live births)
1
Angola
180.21
2
Sierra Leone
154.43
3
Afghanistan
151.95
4
Liberia
138.24
5
Niger
116.66
219
Hong Kong
2.92
220
Japan
2.79
221
Sweden
2.75
222
Bermuda
2.46
223
Singapore
2.31
-6.84 in 2003
-6.78 in 2004
-Range: 4.67 (Asian & Pacific
Islanders)
-13.6 (Non-Hispanic Blacks)
IMR United States/100,000
1. Congenital malformations
2. Low birth weight
3. SIDS
Together account for 45% of all
infant
deaths
Infant Mortality Rate (Deaths per 1,000 Live Births) by
Race/Ethnicity, Linked Files, 2004-2006
OH
US
Non-Hispanic
White
6.4
5.7
Non-Hispanic
Black
15.9
13.5
Hispanic
5.6
5.5
Total
7.8
6.8
Ohio’s infant mortality rate of 7.7 per
1,000 births ranked eighth worst in the
country in 2008. Montgomery County’s
infant mortality rate that year was
slightly higher at 8 per 1,000 births.
-Indicator of health of present and future
Populations
- Indicator of health disparities among
different populations
- Indicator of overall health/ quality of life in
a community
 SIDS
is the unexpected death of seemingly
healthy babies 12 months or younger.
 No cause of death is determined by
Death scene investigation and autopsy.
 Review of baby’s medical history.

 Experts
cannot predict which babies will die
from SIDS.
 Sleep studies give no answers
Revised – 12/08
 2009:
4 deaths where sleep environment was
determined to be a possible contributing
factor but there was not enough information
for the Coroner’s office to call it.
 4 more deaths identified “position asphyxia”
on the death certificate, so those are the
easy ones!
 2010: 3 sleep-related deaths for – one
positional, one overlay and one “ unsafe
sleeping”
 The
exact causes of SIDS are unknown, but SIDS
is NOT caused by


Revised – 12/08
Immunizations
Vomiting or choking
 Glial-neuronal
interactions in the cardiorespiratory centre of the brainstem.
 Gastric reflux, and especially
laryngopharyngeal reflux
 Role of serotonin in respiratory function and
dysfunction
 Reduced ventilatory response to CO2
challenge in the prone position
 Impaired ability to respond to respiratory
compromise
Fast Facts About SIDS
SIDS is one of the leading causes of death in infants between 1
month and 1 year of age.
Most SIDS deaths happen when babies are between 2 months
and 4 months of age.
African American babies are more than 2 times as likely to die
of SIDS as white babies.
American Indian/Alaskan Native babies are nearly 3 times as
likely to die of SIDS as white babies.
 Two
thirds of US infants younger than
1 year are in nonparental child care.
 Infants of employed mothers spend an average
of 22 hours per week in child care.
 32% of infants are in child care full time.
 Less than 9% of SIDS deaths should
occur in child care.

Revised – 12/08
Ehrle et al, 2001
 Approximately
20% of SIDS deaths occur while
the infant is in the care of a nonparental
caregiver.



60% in family child care
20% in child care centers
20% in relative care
 Infants
tend to be Caucasian, with older, more
educated parents.

Revised – 12/08
Moon et al, 2000
 Approximately 1/3
of SIDS-related deaths in child
care occur in the first week, and 1/2 of these
occur on the first day.
 Something intrinsic to child care? Not that we’ve
found yet

Stress, sleep deprivation?
 Unaccustomed
Revised – 12/08
tummy sleeping? Yes
-Requires the convergence of three
elements that may lead to the death of
an infant from SIDS:
1. Critical developmental period
2. Vulnerable infant
3. Outside stressor(s)
-All three elements must be present for
SIDS to occur.
-Removing one or more outside stressors
can reduce the risk of SIDS.
Critical development
period
SIDS
Vulnerable
infant
Revised – 12/08
External stressors
-Stomach sleep position
-Soft bedding
-Tobacco smoke
-Overheating
-Infection
 Low
birth weight (less than 5 pounds)
 Premature (less than 37 weeks)
 Maternal smoking during pregnancy
 Multiple births (eg, twins, triplets)
 Maternal age younger than 18 years
 Less than 18 months between births
 African


Americans (2x greater risk)
Partly genetic
Partly behavioral (sleep position, bedsharing)
 American



Indians (more than 2x greater risk)
Secondhand smoke exposure
Binge alcohol drinking during pregnancy
Overdressing of babies
•
•
•
•
Mothers who smoke during pregnancy (3x
greater risk)
Babies who breathe secondhand smoke
(2.5x greater risk)
Babies who sleep prone (on their tummies)
or on their sides (2-3x greater risk)
Babies put on their tummies to sleep who
usually sleep on their backs or babies who
roll over onto their tummies (as much as 18x)
 Launched
in 2003
 Activities



Revised – 12/08
Increase awareness.
Decrease incidence of SIDS in child care.
Educate policy makers to include back-to-sleep
positioning in child care regulations.
SIDS Rate and Sleep Position, 1988-2003
(Deaths per 1,000 Live Births)
100
1.4 1.39
1.3
1.3
SIDS Rate
1.2 1.17
71.6
1.03
1
64.4
0.87
0.74
38.6
0.5
0.77
72.8
55.7
0.72
53.1
71.1
66.6
0.67
35.3
0.62
50
0.56 0.57 0.53
26.9
Percent Back Sleeping
1.5
17
13
SIDS rates have decreased
and percent of back
sleeping has increased
since the campaign began.
Revised – 12/08
20
03
20
02
20
00
20
01
19
98
19
99
19
97
19
95
19
96
19
94
19
92
19
93
19
90
19
91
0
19
89
19
88
0
Yellow (1985–1991):
Pre-AAP recommendation
Year
Blue (1992–1994): Post-AAP recommendation
Red (1995–1999): Back to Sleep campaign
Source: National Institute of
Child Health and Human
Development Household
Survey Final Data 2003,
National Center for Health
Statistics, Centers for
Disease Control and
Prevention
 They
think that babies are more likely to choke
or aspirate if they vomit or spit up
 They are worried that babies won’t sleep as well
 When babies sleep on the backs, they don’t
develop normally.
 The baby’s parent(s) wants the baby to sleep on
the tummy
Revised – 12/08
Reasons that people place
babies on their tummies
Babies sleep better/longer/more deeply
when they’re on their stomachs.
The baby will get a flat head if the baby
sleeps on the back.
The baby will get a bald spot from
sleeping on the back.
When the baby is on the back, s/he
startles more easily and wakes up.
Revised – 12/08
Revised - 0408
Revised – 12/08
 Lack

of awareness
25% of licensed child care providers say they never
heard of the relationship between SIDS and sleep
position.
 Misconceptions


Supine and aspiration, choking
Belief that tummy sleeping improves infant comfort
 Parental


Revised – 12/08
about risk of sleep position
preference
Lack of information
Lack of education
 Tummy
to play and back to sleep.
 Use safe sleep practices.
 Provide a safe sleep environment.
Revised – 12/08
 Supervised
tummy time when babies
are awake,2-3times a day.
Promotes healthy physical and brain development
 Strengthens neck, arm, and shoulder muscles
 Decreases risk of head flattening and balding
 Encourages bonding and play between the
supervising adult and the baby

 Back


Revised – 12/08
to sleep
Reduces the risk of SIDS
Comfortable and safe
 Avoid



Revised – 12/08
overheating.
Do not overdress baby.
Never cover baby’s head with a blanket.
Room temperature should be comfortable for a lightly
clothed adult.
 Always
put healthy babies to sleep on their
backs for naps and at bedtime.
 Do not have more than one baby per crib.
Revised – 12/08
 Pacifiers
may be offered to babies to reduce the
risk of SIDS



Revised – 12/08
If breastfed, wait until breastfeeding is well
established (approximately 3 - 4 weeks of age),
before offering a pacifier.
If the baby refuses the pacifier, don’t force it.
If the pacifier falls out while the baby is asleep, you
do not have to re-insert it.
 Safe
crib, firm mattress.
 Avoid chairs, sofas, air mattresses, water beds,
and adult beds.
Revised – 12/08
 May
be hazardous under certain conditions.
 The American Academy of Pediatrics
recommends that babies not bed share.
 Bed sharing is especially dangerous when
Baby bed shares with someone other than the parents.
Therefore, children or other adults should not bed
sharing with an infant.
 Bed sharing occurs on a waterbed, couch, or armchair.
 The adult is a smoker.
 The adult drinks alcohol or uses medications or drugs
that can make it more difficult to arouse or wake up.

Revised – 12/08
 The
safest place for a baby to sleep is in a
separate sleep surface (eg, bassinet, crib,
cradle) next to the parents’ bed.
Revised – 12/08
 No


excess bedding, comforters, or pillows
Consider a blanket sleeper or sleep sack for the
baby instead of a blanket if extra warmth is needed
No bib around the baby’s neck
 Bumper
pads are not needed
 Wedges or positioners are not recommended
 No toys or stuffed animals in the crib
 Be aware that parents like their baby to have
things from home with them- help caregivers
to identify other ways to allow this.
Revised – 12/08
 Maintain
Revised – 12/08
a smoke-free environment
The Montgomery County Child Fatality
Review Board (CFRB) is charged with
preventing
infant deaths in our community. The goal is
to
raise awareness about unsafe sleep practices
that lead to the death of infants less than
one
year of age.
In Montgomery County nearly one baby a
month dies due to unsafe sleep practices.
Ohio’s infant mortality rate of 7.7 per
1,000 births ranked eighth worst in the
country in 2008. Montgomery County’s
infant mortality rate that year was
slightly higher at 8 per 1,000 births.
 2009:
4 deaths where sleep environment was
determined to be a possible contributing
factor but there was not enough information
for the Coroner’s office to call it.
 4 more deaths identified “position asphyxia”
on the death certificate, so those are the
easy ones!
 2010: 3 sleep-related deaths for – one
positional, one overlay and one “ unsafe
sleeping”
The ABCs of Safe Sleep.
I sleep safest.
Alone on my Back in a Crib.
A
Your baby should always sleep
ALONE.
-Some Moms and Dads sleep with their
babies in an adult bed. Or, they allow
babies to sleep with other children or
pets. This is not safe. ----Baby’s mouth
or nose can become covered, keeping the
baby from breathing.
- Your baby should sleep alone in a safe,
empty crib.
- Baby’s caregiver should be nearby, in the
same room, but not in the same bed.
- If your baby is in your bed to feed or
comfort, put your baby in the crib for
sleep.
B
Your baby should always be on his
or her BACK to sleep.
The safest position for babies to sleep is
on
their backs. (Your baby should always
sleep
on his or her back unless your doctor has
instructed you otherwise for medical
reasons.)
• Keep baby’s room at 68 – 72 degrees.
Not too warm. Not too cold.
• Have baby in a one-piece sleeper or
sleep sack. Baby will stay warm and
comfortable.
No blankets needed.
• Keep the room smoke-free!
C
In a safe empty CRIB with a
firm mattress.
A safe crib is the best place for your baby
to sleep. It is not safe for a baby to sleep
in
an adult bed, on a couch, chair, bean bag,
waterbed, featherbed, futon or recliner.
A safe crib has:
• A firm mattress that fits the headboard
and footboard tightly with no gaps.
• A sheet and mattress that fit tightly.
• No corner posts or cutouts in the
headboard or footboard.
• No missing slats. Also, slats are not more
than 2 and 3/8 inches apart (about the
width of a soda pop can).
• No pillows, bumper pads, quilts, lamb
skins, blankets, or stuffed toys.
More information about safe sleep
is in the Safe Sleep for your Baby
brochure.
You can find it at www.phdmc.org
or
by calling 937-225-4981.
 May
save lives of babies
 Shows parents baby’s health and safety is your
#1 priority
 Educates staff



Revised – 12/08
Consistent care
Educate parents
Professional development
 It
empowers child care providers
 If followed, helps reduce your risk of liability
Revised – 12/08
Healthy babies always sleep on their backs.
 Obtain physician’s note for non–back sleepers.


The note should include prescribed sleep position and the
medical reason for not using the back position.
Use safety-approved cribs and firm mattresses.
 Crib: free of toys, stuffed animals, and excess
bedding.
 If blankets are to be used, practice feet-to-foot rule.
 Sleep only one baby per crib.

Revised – 12/08
 Room
temperature is comfortable for a lightly
clothed adult.
 Monitor sleeping babies.
 Have supervised tummy time for awake babies.
Revised – 12/08
Elements of a Safe Sleep Policy
• Teach staff, substitutes and volunteers about
safe sleep policy and practices.
• Provide parents with safe sleep policy.
Revised – 12/08
Alternate Sleep Position
• Inform all child care providers and
substitutes.
• Keep physician’s note in baby’s medical
file and post notice on crib.
Revised – 12/08
 Discuss
SIDS and risk reduction strategies with
parents.
 Discuss sleep position policies.
 Discuss medical waiver and implications.
Revised – 12/08
 Implement
the Caring for Our Children
standards.
 Have a safe sleep policy.
 Train all caregivers.
 Talk with a child care health consultant.
 Be able to handle an infant medical emergency.
 Be aware of bereavement resources.
Revised – 12/08
 Have
a plan in place.
 Review the plan with all staff periodically.
 Be sure you have received training and have
successfully practiced rescue breathing and skills
for handling a blocked airway for infants in a
first aid course.
Revised – 12/08
Teaching resuscitation skills may be useful.
 Call 911.
 Get help to care for the other children.
 Call the child’s parents or emergency contact.
 Call the parents of the other children.
 Do not disturb the scene (e.g., don’t try to tidy up).
 Notify licensing agency and insurance agency.

Revised – 12/08
 Investigation

Several people will ask for the same information so
they can help.
 Law



Revised – 12/08
enforcement
Note baby’s health, behavior, etc.
Take photos.
Limit disturbance of the area.
 Licensing


agency
Questions about licensing regulations.
SIDS death not a reason for revoking a license.
 Coroner/medical


Revised – 12/08
examiner
Conducts autopsy.
Determines cause of death.
Infant Death Investigation?
Comprehensive Forensic Investigation of Infant Death.
Social History
Family Information,
Child Caregivers,
Social Services, Child
Protective Services,
Other
Scene Information
Police, Forensic
Investigator, EMS,
Other
Infant Death Investigation?
Comprehensive Forensic Investigation of Infant Death.
Medical History
Pre-Natal and Birth
History, Pediatric and
Primary Care History,
Other
Forensic Autopsy
External, Internal &
Histological Examination,
Toxicological and
Microbiological Tests,
Metabolic
 What
SIDS is
 SIDS risk factors
 How to reduce the risk
 Caring for Our Children: National Health and
Safety Performance Standards
 Developing a safe sleep policy
 Handling a medical emergency
 Resources for more information
Revised – 12/08
• American Academy of Pediatrics
141 Northwest Point Blvd
Elk Grove Village, IL 60007-1098




Revised – 12/08
Phone: 888/227-5409
Fax: 847/228-7320
E-mail: childcare@aap.org
Web site: www.healthychildcare.org
 Back



Revised – 12/08
to Sleep campaign
www.nichd.nih.gov/sids
Phone: 1-800-505-CRIB (2742)
You can receive informational brochures, posters to
provide to families and child care providers
First Candle/SIDS Alliance
 1314 Bedford Ave, Suite 210, Baltimore, MD 21208
 Phone: 800/221-7437 or 410/653-8226
 Fax: 410/653-8709
 E-mail: info@firstcandle.org
 Web site: www.firstcandle.org
 National SIDS and Infant Death Program Support Center
 112 E Allegan, Suite 500, Lansing, MI 48933
 Phone: 800/930-SIDS or 800/930-7437
 E-mail: info@sidsprojectimpact.com
 Web site: www.sidsprojectimpact.com

Revised – 12/08
 National

866/866-7437, www.sidscenter.org
 CJ

Revised – 12/08
SIDS/Infant Death Resource Center
Foundation for SIDS
888/8CJ-SIDS (825-7437), www.cjsids.com
 Public
health clinics
 Home visiting programs
 Hospitals—in L&D, pediatric units and
 outpatient clinics, EDs, OB clinics
 Emergency services
 Churches
 Community organizations
 But it’s not easy – we must move “Beyond
Basic Brochure Distribution”
Is needed to change social norms about
sleep-environment-related risks
 Needs to be addressed early and often!
 Must involve credible “key informants” or
“key influencers”
 Should be institutionalized in settings such as
newborn nurseries and pediatrics.
 Must address barriers to adoption and
opposing messages
 Must be repeated and reinforced – at the
community level







Police and EMS personnel, if educated, can provide
us with essential information
Such as the presence and/or use of a crib; sleep
position, etc
Day care providers,baby sitters, grandparents , and
others who care for infants must be included
Physicians, nurses, child birth educators and social
services providers are valuable influencers
The child passenger safety community (can
integrate infant sleep safety and installation of
infant safety seats)
The media