# Presentation: 287734

## Child Death Review: Evidence for National Safety Initiatives

- Mary D. Overpeck, Dr.P.H.
- Manager, New Mexico Office of Injury Prevention
- Previously with:
- U.S. Department of Health and Human Services
- Health Resources and Services Administration
- Maternal and Child Health Bureau

**Notes:**
Q. Thanks Teri.  Let’s move now to Dr. Mary Overpeck who recently moved from the MCHB to New Mexico, to manage the State’s Injury Prevention Program.  Thanks for being with us today Mary and congratulations on your move.

A.  Thank you Beth.  

## Examples of CDR Data Uses at a National Level

***2005 Omnibus Transportation Act***
***SEC. 7258. POWER WINDOW SWITCHES.***
*The Secretary of Transportation shall upgrade Federal Motor Vehicle Safety Standard 118 to require that power windows in motor vehicles not in excess of 10,000 pounds have switches that raise the window only when the switch is pulled up or out. The Secretary shall issue a final rule implementing this section by April 1, 2007.*

**Notes:**
Q.   The new case reporting system described by Teri seems to have great potential to better inform us on the circumstances of child deaths.  Mary, have we been able to use any multi-State data from Child Death Review teams as evidence for national initiatives so far?

A. We have three good examples - even though the multi-State standardized data tool is still in the testing phase.  This slide addresses two of these examples:  Prior to the tool development, States teams have been asked to provide data about the circumstances of childhood drowning and about the deaths of children due to inadvertent pressure on car power window levers. 

Twenty-seven States responded to a request from Safe Kids to provide data on circumstances involved in child-hood drowning for a National Drowning Prevention Campaign.  The results are published in the report shown here and were used widely in media efforts during the summer of 2004 to raise awareness among caretakers about drowning safety for young children. 

The Kids and Cars organization asked CDR teams for any evidence they could provide about the number of children who died as a result of strangulation by car windows due to inappropriate engineering of the power window levers.  The Kids and Cars organization obtained information on a number of these strangulation deaths from data supplied by CDR teams.  Almost all of the deaths  occurred when children inadvertently  pushed down on the levers while leaning out winders.   The organization effectively lobbied to the National Highway Safety and Transportation Agency and to Congress for regulations to change the design of these  levers.  New requirements were placed in the 2005 Omnibus Transportation Law to change the manufacturing of power window levers, so that they only close windows when the level is pulled up.   

In both cases, the information about circumstances leading to the deaths was not easily available from any other reporting source, including death certificates.

## Safe Sleeping for Infants

**Notes:**
Q.  Mary, we have resource information appended to the end of the presentation for people who would like to read the reports and understand the data on circumstances that death review teams provide.  Links to Safe Kids and the Kids and Cars Organizations are shown for further information.  Your third example is focused on infant sleep-related deaths.  How has CDR data helped shape our understanding of these deaths?

CDR data on the circumstances related to infant sleep environments has been very important to our understanding of sudden and unexpected infant deaths.  This data is now being looked at a national level.  At the National SIDS conference last September, the National SIDS Alliance sponsored a pre-conference workshop on Safe Sleep Environments for Infants.  With just a few weeks of lead time, I was asked if the bureau could provide evidence on circumstances around sleep-related deaths.  We looked for data from existing research, death scene reenactments, and any other available sources.  The best data source seems to be emerging from work by CDR teams.  This data provided much more extensive information on the deaths than provided through death certificates.

## Why Not Use Causes Shown on U.S. Infant Death Certificates?

- Inconsistent investigations and cause classification of sleep-related deaths among more than 2000 medical examiner and coroner systems
- Cause classification uses International Classification of Disease (ICD)
- ICD sleep-related death data are incomplete, inaccurate, and not specific enough
- Death scene reenactments are informative

**Notes:**
Q.  What are the limitations of gathering this data from Death Certificates?  

Death certificates do not identify circumstances as sleep-related or occurring in sleep-related environments.  These death's may be classified as SIDS, accidental suffocations, undetermined causes and in rare cases homicides.  Many of these deaths  have been shown by CDR teams and other researchers to be due to or associated with unsafe sleeping arrangements.  Many medical examiners and coroners are working with CDR teams to enhance information available for their final determinations.  Deaths associated with unsafe conditions may be officially classified as ‘natural’ or traumatic or due to undetermined causes.  Medical examiners and coroners  have begun to address their lack of certainty about sudden unexpected infant deaths, whether classified as SIDS, suffocations, or complications of pre-existing medical conditions by shifting uncertain diagnoses away from SIDS to other causes.  Further description of changing classification practices may be found in the papers by Malloy and Krous in this DataSpeak’s references. 

## Death Scene Reenactment

**1**

**2**

**Notes:**
Mary, what kind of sleep-related factors have been shown to be associated with infant deaths?

Additional evidence from the literature about SIDS and sudden unexpected infant deaths indicate that unsafe sleeping environments may increase risks among infants whose protective repositioning movements may already be compromised due to relative stage of physical maturity, including prematurity factors, metabolic disorders, other birth-related developmental issues, maternal smoking both pre- and postnatally, and respiratory-cardiovascular conditions.  A review paper by Dr. Fern Hauck, describing what we know about these factors from research studies, is included in the resources referenced at the end of our presentation today.  As noted by Dr. Hauck, many SIDS cases may not involve unsafe sleeping conditions, but the existing evidence on sleep circumstances and individual infant conditions usually does not allow us to address either the co-occurrence or presence of the different factors.

Vivid evidence comes from death scene re-enactments that have been performed in a few States and shared with child death reviews.  The following pictures simulate actual cases where a doll was used to show how the person who first discovered the infant saw the circumstances.  

The first two re-enactments demonstrate cases where an infant was sleeping on an adult mattress with a parent or parents.  These are simulated reenactments of actual cases reviewed by a team.  The infants were unable to breath because of their position nestled very tightly next to the mother in the first photo and because the father lay a heavy arm over the infant in the second.  While obesity, drugs, or alcohol are sometimes thought to be factors, it can be hard for very tired parents, who are not otherwise compromised, to control their body movements after they fall asleep.  Sometimes infants become lodged into bedding and pillows on an adult mattress, restricting their ability to breathe deeply and continuously as shown in the third photo.

## 3

**3**

**4**

**Notes:**
The next reenactment shows an infant who feel asleep on the mother’s chest after nursing.  When the mother fell asleep and relaxed, the infant rolled to the inside of the couch, suffocating due to inability to reposition itself.

The final picture demonstrates an infant for whom all the appropriate precautions were taken:  sleeping on its back, separated from the adults’ sleeping surfaces, in a bassinet with no bumpers and open air passage on the side surfaces.  Unfortunately, a blanket was left in the bassinet near the young infant’s head resulting in obstruction to breathing.

These reenactments are consistent with precautions suggested by the National Back to Sleep Campaign to prevent SIDS. 

## State Reviews of Sleep-Related Deaths by Manner/Cause

| Manner/Cause | No. of States |
| --- | --- |
| SIDS | 12 |
| Suffocation/strangulation | 11 |
| Medical conditions | 5 |
| Undetermined for cause or intent | 8 |
| Other (selected) | 7 |

**Notes:**
Q.   Mary, what evidence were the Child Death Review teams able to provide for the Safe Sleeping Environment workshop?

A.  With only about 3 weeks lead time before the Safe Sleep Environment workshop, we asked State CDR teams if they could provide answers to selected questions.  The questions were based on sleep-related risk factors previously identified by experts for testing and reports using the National CDR Center standardized multi-State data tool.  We defined sleep-related deaths as those occurring while an infant was sleeping or in a sleeping environment.  

12 States sent us the information they had on sleep-related deaths either occurring or reviewed in 2001 through 2003.  

Information on sleep-factors varied due to CDR review criteria or completeness of records.  Most teams review all infant deaths classified on death certificates as due to SIDS, suffocation/strangulation, other trauma, and deaths undetermined for cause or intent.  Fewer review other medical conditions.  
Deaths classified as due to SIDS were most likely to be reviewed for sleep-related conditions, resulting in some under-reporting bias for sleep-related deaths classified elsewhere.  But for purposes of obtaining information on unsafe sleeping circumstances for the workshop, distributions of risk facts were very informative.

About 6,400 infant deaths were reviewed, with 1/3rd considered to be sleep-related based on the selected review criteria.  Nine States had sleep-related details, predominately from SIDS case reviews.  Type of sleep-related information varied by State, with fewer States able to report on the relationship of the caretaker at the time of death or on the presence of multiple risk factors.  As mentioned before, the standardized sleep-related information for the data tool is not widely used among States yet.

Of about 1,400 sleep-related deaths in these 9 States, 1/3rd died during first month of life; 40% in the 2nd & 3rd months; 20% in the 4th & 5th months.  This distribution is consistent with the developmental stages at which infants are most vulnerable to unsafe sleep arrangements.  Almost 80% of the sleep-related deaths occurred in the infant’s own home.

This first use of CDR team information in a preliminary survey provided strong evidence that separated sleeping surfaces could prevent deaths.  The consensus was that it is time to proceed at the national level with education and assistance in providing a safe sleep environment for infant.    As more CDR teams begin to use the standardized data tool to document sleep-related deaths for all infant cases, we will be able to provide much more robust evidence to prevent sudden unexpected infant deaths.

## Sleep Surface Where Infant Was Foundn = 1,501 from 9 States  

- Bed mattress
- Crib/bassinet
- Couch/chair
- Playpen
- Waterbed
- Other places
- Don’t know

- 39%
- 23%
- 15%
-   2%
- <1%
- 10%
- 10%

**Notes:**
What did your data tell you about the sleep surface where the infant was found and who was taking care of the infant at the time of death?

A.  Almost 80% of deaths occurred on adult bed mattresses, in cribs or bassinets, or couches & chairs.  About 40% occurred on bed mattresses, reinforcing the death scene reenactments of entanglement with sleeping adults and mattress bedding.  About one-quarter occurred in cribs & bassinets and 15% on couches or chairs.  

## Relationship of Caretaker at Time of Deathn = 640 from 6 States

| Biological parents | 81% |
| --- | --- |
| Other relative
 | 5% |
| Child care provider
 | 11% |
| Other
 | 3% |

**Notes:**
Over 80% of infants were being cared from by a biological parent at the time of death.  Child care providers were responsible in 11% of cases; other relatives, 5%.

## Co-sleeping/Bedsharing?* 

- Almost half of 1,486 deaths in nine States involved co-sleeping and/or bed sharing
- No or don’t know in remaining deaths
- If co-sleeping, sleeping with 1+ adults?
- About 80% of co-sleeping included adults

**********	****Some information collected only for the SIDS diagnosis and bed sharing rather than for “co-sleeping” *

**Notes:**
Bed sharing is a pretty controversial topic in the safe infant sleep debate.  Was bed sharing a factor in he deaths reviewed?

A.  Almost half of the cases involved co-sleeping or bed-sharing, the vast majority with an adult.  Some of these cases could have occurred on couches, accounting for the difference in deaths occurring on adults mattresses (39%) and co-sleeping (48%).

## Multiple Risk Factors* for Sleep-related Deaths Various States Reporting 

- Prone position:            35%   (8 States)
- Blankets/pillows/toys:  30%   (7 States)
- Sleeping with others:   48%   (9 States)

- *	*More than one factor may be present*

**Notes:**
So what did the teams find as major risk factors and what conclusions did you draw?

A.  Risks probably increase when more than one factor is present.  Prone sleeping position was a factor more than a third of the time in spite of the broad education provided nationally through the Back to Sleep Campaign.  Almost a third of cases included the presence of bedding and toys in the sleeping arrangements.  But the largest contributor was sleeping with others in almost half of the cases. 

## Conclusion: Safe Sleep Evidence

- Preliminary CDR survey  sufficient evidence that separated sleeping surfaces could prevent deaths
- Conference consensus  need to address safe sleeping arrangements, including use of bassinets, cribs, or co-sleepers
- Followup survey of CDR teams will address:
- Result differences based on case review criteria
- How often cribs/bassinets were available but not used
- Reasons available cribs/bassinets were not used
- Location of deaths when cribs/bassinets were not available

**Notes:**
This first use of CDR team information in a preliminary survey provided strong evidence that separated sleeping surfaces could prevent deaths.  The consensus was that it is time to proceed at the national level with education and assistance in providing a safe sleep environment for infant.    As more CDR teams begin to use the standardized CDR case reporting system, described by Teri, to document sleep-related deaths for all infant cases, we will be able to provide much more robust evidence to prevent sudden unexpected infant deaths.