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Infant Deaths Occurring in the Sleep Environment. Federal/State Partnership Meeting October 18, 2005 Mary D. Overpeck, DrPH U.S. Department of Health and Human Services Health Resources and Services Administration, Maternal and Child Health Bureau. Contributors. Sara Rich, MPA*

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infant deaths occurring in the sleep environment

Infant Deaths Occurring in the Sleep Environment

Federal/State Partnership Meeting

October 18, 2005

Mary D. Overpeck, DrPH

U.S. Department of Health and Human Services

Health Resources and Services Administration,

Maternal and Child Health Bureau

  • Sara Rich, MPA*
  • Teri Covington, MPH*
  • Monique Shepard, PhD**
  • Douglas Hill, PhD**
  • Child Death Review Teams across US

*National MCH Center for Child Death Review

**Children’s Safety Network, Pacific Institute for Research & Evaluation

data needed for evidence
Data needed for Evidence
  • Sudden Infant Death Syndrome (SIDS) workshop appeal for evidence related to potential for a National Crib Campaign to reduce sleep-related infant deaths
  • Identifiable risk factor data was needed to:
    • Assess factors pertinent for targeting appropriate audiences for crib campaigns
    • Assesspotential for success in reducing deaths.
why not use u s infant mortality rates
Why not use U.S. Infant Mortality Rates?
  • Rates based on death certification by over 2000 medical examiner and coroner systems
  • Inconsistent investigations and cause classification of sleep-related deaths
  • Cause classification from death certificates uses International Classification of Disease (ICD)
  • ICD sleep-related death data are incomplete, inaccurate and not specific enough
diagnostic shifts on death certificates
Diagnostic Shifts on Death Certificates
  • More jurisdictions requiring mandatory autopsies of unexpected infant deaths
  • Medical certifiers are shifting designations to categories other than SIDS
  • Recognition of multiple mechanisms
  • Mechanisms may involve infections, metabolic problems together with some

form of suffocation or strangulation

ambiguity in sids as cause of death
Ambiguity in SIDS as Cause of Death
  • Sudden Infant Death Syndrome (SIDS)
    • Unexplained cause after thorough autopsy and death scene investigation
  • Sudden Unexpected Infant Death (SUID/SUDI)
    • Mentioned as option to SIDS in ICD-10 since 1999
    • Recognizes diagnostic shift away from SIDS to undetermined or unknown cause and suffocations
  • SIDS & SUID/SUDI – Manner of death classified as ‘Natural’ events
  • Asphyxiation & Suffocations – Manner of death classified ‘Traumatic’ (Injury) events
nature of infant injury deaths as classified by cause mechanism
Nature of Infant Injury Deaths as Classified by Cause/Mechanism

Deaths per 100,000 live births

US, Certificates1999-2002

infant injury deaths us 1991 2002
Infant Injury Deaths US, 1991-2002

US, Certificates1999-2002

supportive investigations
Supportive Investigations
  • Manner and mechanisms of sleep-related deaths, including injuries:

- Infant Death Scene Investigation

- Scene re-enactments for infant deaths occurring in sleeping environment

- Child Death Review (CDR)

query for help to cdr teams
Query for Help to CDR Teams
  • Some CDR teams are participating in development of a data review tool
  • Tool includes standardized report format for sleep-related deaths
  • Other CDR teams review infants deaths and document sleep-related deaths
availability of more accurate sleep related information
Availability of More Accurate Sleep-Related Information
  • CDR may be able to provide information on items related to:
    • Sleep-related surfaces in use at death
    • Location where infant found dead
    • Primary caretaker at time of death
    • Multiple risk factors for sleep-related deaths
state cdr team contributors










South Carolina


State CDR Team Contributors
questions to cdr teams on sleep related deaths
Questions to CDR Teams on Sleep-Related Deaths
  • How many infant deaths were reviewed in your state in 2001-2003?
    • 6,359 deaths: varying review time periods or completeness of records among teams
  • Sleep-related deaths are those occurring while infant was sleeping or in a sleeping environment. Of those infant deaths reviewed, how many were sleep-related?
    • About 1/3rd were considered to be sleep-related
sleep related deaths questions responses
Sleep-Related Deaths:Questions & Responses
  • Of the deaths deemed sleep-related, what was the official cause of death by age?
  • CDR team responses affected by review criteria:
    • Most review all infant deaths from SIDS, suffocation/strangulation, other trauma, and deaths undetermined for cause or intent
    • Fewer review other medical conditions
age at death n 1 337 from 9 states
Age at DeathN = 1,337 from 9 States
  • About 1/3rd died during first month of life
  • Almost 40% died during 2nd and 3rd month
  • Almost 20% died during 4th and 5th month
  • Questions raised:
    • Are most deaths occurring before age when most infants are placed in cribs?
    • Are more dead infants found in bassinets and on other surfaces at younger ages?
sleep surface where infant was found n 1501 from 9 states
Bed mattress





Other Places

Don’t know








SleepSurface Where Infant was FoundN = 1501 from 9 States
where did the death occur n 1 184 from 7 states
Own home

Other homes, places *



Where did the Death Occur?N = 1,184 from 7 States

* Relative’s home and child care specified only by 3 states and type of child care setting not included

relationship of caretaker at time of death n 640 from 6 states
Biological parents

Both parents (20%)

Father (10%)

Mother (50%)

Other relative

Child care provider






Relationship of Caretaker at Time of DeathN = 640 from 6 States
co sleeping bedsharing
Co-Sleeping / Bedsharing? *
  • At least 46% of 1486 Deaths in 9 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 bedsharing rather than for ‘co-sleeping’

multiple risk factors for sleep related deaths various state reporting
Multiple Risk Factors* for Sleep-Related DeathsVarious State 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.

  • Death certificate information is not accurate for assessing number of SIDS or sleep-related deaths
  • CDR teams can provide new information on sleep-related deaths and risk factors
  • Infant death scene investigations and death scene reenactments are needed to assist death certifiers prior to determinations
conclusion crib related evidence
Conclusion: Crib-related Evidence
  • Data systems are not sufficient to evaluate:
    • How often cribs were available but not used
    • Reasons available cribs were not used
    • Locations of deaths when cribs were not available
    • Who we need to target for use of cribs, bassinets and safe alternative surfaces
where from here
Where From Here?
  • Identifiable risk factor data from death investigations and review teams are needed:
    • Assess factors pertinent for targeting appropriate audiences for crib campaigns
    • Assess campaign success in reducing deaths.
for further information
For Further Information
  • National MCH Center for Child Death Review (
  • Mary Overpeck (

Health Resources and Services Administration, Maternal and Child Health Bureau