* 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

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 Prevention
Health R
H 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

7. DEFINITIONS OF SIDS AND
OTHER SUID

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

13. TRENDS IN SIDS AND OTHER
SUID MORTALITY

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%), infection
Sources: 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
100
Death 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 - 2010
100%
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
2010
Source: National Infant Sleep Position Study

17. Proportion of SUID
Unexplained 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 SUID
SUID SURVEILLANCE AND DEATH
CERTIFICATES

19. Cause of Death Section from US Death
Certificate
flItu tlmn iraJ ~vem
entn umniral events such n card.ac
as. cardAl::
Enter only one cau5e on.a ....e. Ad::ladd:tionaJ
Cl'I e Cal5E on a Ine. Adj ad d;;ionaJ
IMMED TE
IMMEOlATE CAUSE (Fina! (Final
is~a ~e or COI"IditlOn -----:>
d is.ule Of ccndition - - > 01 • _ _ _ _ _ _ _ _ _- ". ." ' ' ' '' ' '. . . , ' ' ' ' ' ' " ' ' ' ' ' ' ' ' ,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
resul'1ilg 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-qUi'I"Ci' 01):
tis.t ed 1)11 rlne a. En:e!
lis.led I)ft kle i . Enter the
UNDERLYING CAU!E
UN 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 COIoU'qUi'rQt of):
in i:ia~Ed the events. ft s.ulting
in~a~td th~ @'Oents. ftsUlting
ndea:h) LAST
in 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,} lnYl's-;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 '(t's 0 tl o
flo
,,
o Dri~r~:lp~ra tc r
D river{:l~ra:cr
C PaSSeftOE'f
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 other
SUID
CDC’S SUID CASE REGISTRY
PILOT 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
Sources
SUIDIRF
EMS reports Medical records Death Certificate
Law Enforcement reports
Hospital reports Social service records ME/C report
Witness interviews
Autopsy report
Scene reenactment
Scene 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 Chart
Infant dies unexpectedly with no obvious cause of death
Review team notified of death
Case information and reports gathered
Team 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 Grantees
Note:
Green states: Colorado, Georgia, Michigan, New Jersey, New Mexico; funding began August 2009
Orange 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:
www.cdc.gov/sids
For more information please contact Centers for Disease Control and
Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position 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%.

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57. 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 Cause
Total Number of cases 1613 201 459 2273
Soft bedding* was
relevant to death 716 45% 152 76% 282 62% 1150
Sharing a sleep
surface** was relevant
f ** l
to 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

58. Infant’s Sleep Place
Undetermine
Suffocation SIDS d/ Unknown Total
Incident Sleep place Cause
Total 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

59. So What are States Doing?
So What are States Doing?

60. 37 States with Safe Sleep Promotion Activities
What are these activities?
Homo Yio.U

61. Differences in Messaging
What AAP Message
Do You Explicitly
li i l
Include in Your
g g
State’s Messaging?
N=37

62. Safe Sleep for Baby is:
ill baby on back
in a safe crib
It NoToys
•
.,--_....._ -
_....._-.-- _--
............_-_ .....
.......
-- -
...... ._--_
-
-................__..
_...--_ ....- ...
--_ _"_.11_ _...
-"'-_"''''''''
A Crib
It No Pillows
-......................
.-~--
-.........-, ...........-.-... ..............__.._._......._-..
A Mattress
........ ._--
11 No Bumper Pads ::::...~-
_--
0 _ _ _ _ _ _ ...
K No Quiltsor Blankets
It No Stomach or Side Sleeping
Why?
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 d
blan kets, loys"o r p iliowsall' LESS likely 10 d ie from SIDr pa 5,
----~--.
----..-,..--
:-.::.::::................
--__.... .....-.--
_.__... ......-
_ .. ......
-~ .... .....
. _---
.... ...
. - ~--
__-,
..-_.. _--
._ ...
__-- ..... --_.
..... " ......
-"-"'--
..... .......

64. Lots of Target Populations

65. Lead Agencies
Lead Agencies
Other:
Multi‐agency
coalitiolns

66. Lots of Partners
Lots of Partners
Delaware’s Multi‐Agency Mass Media effort

67. SIDS Center of New Jersey
SIDS 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

68. Infant Mortality Minnesota's Safe and Asleep Campaign
Reduction
Initiative 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 a's 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 pagE
Maternal &
Child Health .,... 0<><._ .' MN Coroners and Me d ica l Exam iners' letter to prov iders. Ju l y. 2007 ( PDF
More 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. • • ~

69. Messaging Can Be Inconsistent
THE SOLACE OF THE
family bed
A renowned doctor
reassures pare nt!> that
infant night waking is normal.
And it's 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

70. If Babies
Could Talk
Could Talk

71. 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, 2011
Lindsey Myers, MPH
Colorado Department of Public Health and Environment

72. Colorado Child Fatality
72
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

73. Colorado SUID Case Registry
g y
73
• 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

74. 2010 SUID Cases
74
• 2010 cases identified to date = 51
• Common Risk Factors
 Bed-sharing
 Soft-bedding
 Unsafe sleep position

75. Prevention Recommendations
75
• Systems
 Death Scene Investigations
 Autopsies
 State Agencies
• Policy and Legislation
• Community Level
 Education campaigns and programs

76. Investigation Recommendations
g
76
 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

77. Autopsy Recommendations
p y
77
 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

78. Prevention Recommendations
78
 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

79. 79 Local S f Sl
L l Safe Sleep C
Campaigns
i

80. El Paso/Teller County CFR
80
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

81. Mesa County CFR
81
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

82. 82 Statewide Safe Sleep I i i i
S id S f Sl Initiative

83. 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

84. Colorado Safe Sleep Initiative
p
84
• 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

85. Safe Sleep Partners
p
85
 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

86. Challenges
g
86
• 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

87. Round Table Discussions
87
• 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

88. Safe Sleep Summit Outcomes
p
88
• 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.

89. Next Steps
p
89
• 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

90. Opportunities
pp
90
• 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

91. Evaluation of a Novel SIDS
Risk-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

92. 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

93. Infant Coroner Cases
York Co. 2005-2010
8
7
eaths
6
mber of De
5
4
*
3
Num
2
1
0
2005 2006 2007 2008 2009 2010
Year
total deaths SUID Inappropriate sleep
93

94. Infant Sleep Safety
Requires a consistent and repetitive
message in the community to prevent
accidental deaths
94

95. 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

96. 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

97. Hospital-Based Infant Safe
Sleep Program
Goal: 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

98. 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

99. Infant Safe Sleep DVDs
99

100. 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

101. 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

102. 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

103. Safe Sleep Posters
103

104. Model Nursery/Infant Sleep Safety
Center
104

105. Organizational Chart for an
Infant Sleep Safety Program
Hospital Based Infant Safe Sleep Program
Program 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

106. 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

107. 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 3.1
Homicide/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

108. 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

109. 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 environments
Source: Allegheny County Coroner’s Office, Stephen Koehler, Ph. D., Forensic Epidemiologist
109

110. 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

111. 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

112. 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

113. 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

114. 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

115. 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

116. 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

117. 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

118. $$$ Cost of Program $$$
• 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

119. 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

120. 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

121. 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

122. 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

123. 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

124. 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

125. 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)
mgoodstein@wellspan.org 125

126. THANK YOU!!!
126

127. Cribs for Kids
C ib f Kid ®
National Infant Safe Sleep Education and
Crib Distribution Program
Judy Bannon, Executive Director/Founder
y ,
www.cribsforkids.org

128. 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

129. 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!

130. 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!

131. 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 SC
HI AR
AZ NM GA
MS AL
TX LA
FL
To Date:
262 Partners in 48 States
Cribs for Kids locations Awaiting signed agreement

132. National Cribs for Kids Partners ®
140
119
120
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)
( )

133. SIDS is NOT Suffocation
Although SIDS is different from
suffocation, all the measures we use for
SIDS risk reduction also help to prevent
reduction,
accidental deaths such as positional
asphyxia, overlay,
asphyxia overlay and entrapment
entrapment.
These d th are 100%
Th deaths
PREVENTABLE!

134. The Ideal Safe Sleep Environment
Baby sleeps in crib.
Nothing in
sleep area.
Firm mattress,
tight-fitting sheet.
Used with permission from
Tomorrow’s Child, Michigan SIDS

135. Unsafe Sleep Environment:
Soft Bedding

136. Unsafe Sleep Environment

137. Unsafe Sleep Environment
j

138. 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

139. National Sponsors
Graco Children s Products
Children’s
 In January, 2006, Cribs for Kids was
made the exclusive commercial
distributor of the Graco Pack n’ Play
n
Pitt-Ohio E
Pitt 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!

140. Cribs for Kids® Graco Pack ‘n Play
Graco ‘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

141. 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.
www.cribsforkids.org
1.888.721.CRIB
Portable Crib Sheet Design

142. Cribs for Kids® Logo Halo Sleep Sack
$14.99
$14 99 each
HALO SleepSack
HALO™ SleepSack™ Wearable Blanket
Replaces loose blankets
in the crib, lessening the
likelihood of babies
getting blankets over or
around their face.

143. Respironic Soothie Pacifier
$1.50
Soothie®
For Babies Without Teeth
Soothie is a premium pacifier
designed for newborns and babies without
teeth who are successfully b l or
h h f ll bottle
breastfeeding. Its one-piece construction
adheres to the American Academy of
Pediatrics guidelines.
Respironic Pacifier

144. “Keep Me Safe” Photo Magnet
$.75
$ 75
• New item added to Safe Sleep Survival Kit
• Safe Sleep Survival Kit same price still $69.99

145. 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.
www.cribsforkids.org
1.888.721.CRIB

146. 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.
www.cribsforkids.org
1.888.721.CRIB

147. Becoming a Partner….
How d I begin?
H do b i ?
Go to www.cribsforkids.org
Or
Call: 412 322 5680 Ext 3
412-322-5680

148. Components of the ‘Cribs for Kids®’ Program
Application Form

149. Components of the ‘Cribs for Kids®’ Program
Trademark License Agreement

150. Components of the ‘Cribs for Kids®’ Program
Standardized Brochures

151. www.nichd.gov/SIDS
g
For more educational supplies request from
www.nichd.nih.gov/SIDS

152. Components of the ‘Cribs for Kids®’ Program
Survey Instruments – Pre & Post Tests
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153. Components of the ‘Cribs for Kids®’ Program
Sample Grant Materials
p

154. Components of the ‘Cribs for Kids®’ Program
Sample Grant Materials

155. Components of the ‘Cribs for Kids®’ Program -- Standardized Forms
Hold Harmless Agreement

156. Components of the ‘Cribs for Kids®’ Program
Safe-Sleep Checklist

157. How to Order a
Safe-Sleep Environment
Safe Sleep En ironment

158. Mandated Legislation
(language and guidance)
Pennsylvania Act 73 of 2010
SIDS Ed
Education and P
ti d Prevention P
ti Program
Signed 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.

159. 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

160. FACT!
Knowing is not enough:
we must apply.
Willing is not enough:
we must do.
……Goethe

161.  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 (http://www.mchcom.com) within a few
days.