using coronial records to understand deaths of infants through co-sleeping

Using Coronial Records to Understand Deaths of Infants

Through Co-sleeping

Joe Clarke4, Catherine Coyle2, Sharon Beattie5, Cathy MacPherson4, Una Turbitt2, Brid Farrell2, Anne Lazenbatt1, Lisa Bunting1, John Devaney4, David Hayes1, 1Queen's University Belfast, Belfast, UK, 2Public Health Agency Northern Ireland, Belfast, UK, 3Southern Health & Social Care Trust, Armagh, UK, 4South Eastern Health & Social Care Trust, 5Safeguarding Board for Northern Ireland, Belfast, UK

Research Study • Partnership approach

• Research strands: – a scoping review of the international literature on co-

sleeping and infant death

– a retrospective review of deaths of infants of relevant causes (aged 0-2 years) (n=45)

– Qualitative research involving interviews with international experts and focus groups with professionals and parents

Source: NI Statistics and Research Agency (NISRA)

23,000

23,500

24,000

24,500

25,000

25,500

0

20

40

60

80

100

120

140

160

2007 2008 2009 2010 2011 2012 2013

Population < 1 Year and Infant Deaths by Year

Mid Year Population 0-1Years

No of Deaths to those <1year

THE LITERATURE

Objectives

• Definitions

• Contribution of co-sleeping to sudden infant deaths – the literature

• Limitations of the evidence base

Definitions – SUDI/SIDS

• SUDI = all sudden deaths of infants

• After full investigations; explained and unexplained

• SIDS = unexplained classification of infant death

Triple-Risk Hypothesis

1.A vulnerable infant;

2.A vulnerable time of development;

3.External stressors.

Definitions – Co-Sleeping/Bed-Sharing

UNICEF:

• Bed-sharing: Bringing baby onto a sleep surface when co-sleeping is possible, whether intended or not

• Co-sleeping: Mother +/-partner or other person, being asleep on the same sleep surface as the baby

Evidence of Increased Risk? • Consistent evidence on factors which increase

the risk of infant death while bed-sharing:

– Smoking

– Ingestion of alcohol

– Consumption of drugs

– LBW or premature infant

– Age under 12 weeks

• Lack of evidence supporting bed-sharing and a reduction in risk of SIDS

Evidence of Increased Risk? • Sofa-sharing appears to be increasingly

implicated in unexplained infant deaths

• Often excluded / not examined

• Co-sleeping with an adult on a sofa or chair was

x18 higher risk than those who did not co-sleep,

adjusting for other factors

– Increased risk regardless of age

Breastfeeding and Bed Sharing

• Link between the two behaviours, probably bi-directional

• Breastfeeding associated with a reduction in risk of SIDS

• Impact of breastfeeding on risk of SIDS among infants who are bed-sharing is not clear-cut

What is the Risk of Co-Sleeping in the Absence of other Risk Factors?

• Conflicting results from recent studies:

– Carpenter 2013 – breast-fed babies with no other risk factors who co-sleep have an increased risk of death (OR=2.7). Risk highest in first 3 months

– Blair 2014 – examination of the same question resulted in no evidence of increased risk; no increased risk for bed-sharing in absence of sofa-sharing, alcohol and smoking

• Methodological differences

NICE Guidance Postnatal Care CG37

• Updated December 2014 on basis of recent evidence

• No inference of causation but association highlighted in the guidance

• Factors in recommendations: smoking, alcohol, drug use, premature or LBW infants

Limitations of Evidence Base

• Case-control studies; methodological limitations such as establishing causation

• Inconsistency in data recording

• Definitions of behaviours and practices

• Lack of data about fathers bed-sharing

Summary •Co-sleeping varies by culture and country and is known to be a common practice in the UK

•Evidence shows an increased risk of SIDS among infants who are bed-sharing especially in the presence of other factors

•There are limitations in the evidence of the inter-relationships with factors such as breastfeeding

Public Health Messages?

• Need to recognise that some parents will bed-share with infants

• Need to be provided with advice about risk

• ‘one size fits all’ information is unlikely to be effective

Discourage Completely

Encourage Completely

CASE REVIEW

Objectives

• In low risk healthy infants under three months of age it is predicted that over 80% of deaths would have been prevented had co-sleeping not occurred.

• In Northern Ireland a small number of child deaths of undetermined cause within a one year period emphasised the need to understand what the sleeping practices and culture are in N Ireland.

• This study seeks to understand this phenomenon within the Northern Ireland.

Methodology

• A retrospective review of all paediatric deaths of infants (aged 0-2 years) referred to the Coroner's Office for Northern Ireland between January 2007 and December 2013 where the death was certified as SUDI / Unascertained / Wedging / SIDS / Co-Sleeping / Overlaying or any combination of these causes (n=45)

Results (Demographics)

Sex

– 33.33% Female

– 66.67% Male

Age

Ethnicity 91% white ethnicity 9% Irish Traveller

Results (Age)

• The literature reports that 90% deaths have occurred by age 6 months

• Using age in weeks (and 4 weeks approximately corresponding to one month) cases were broken down into age bands by months

• 75% deaths occurred by age 6 months

Results (Age)

Age in Weeks Age in Months

Frequency Percent

0 – 8 0-2 Months

2-4 Months

4-6 Months

> 6 Months

Total

14 31.8

9 – 16 12 27.3

17 – 24 7 15.9

≥ 25 11 25.0

44 100.0

Results (Maternal History)

• Average age of Mother at time of death = 26.27 years (n=41) (range: 17-41 years)

• ⅓ of mothers do have a significant past medical history, most commonly depression

• 71% smoked during pregnancy (n=42) – NI smoking prevalence is 22% overall and 15% among

pregnant women

• 8 out of 10 mothers took alcohol before pregnancy, limited info on alcohol antenatally

• Under 20% had pregnancy complications, the most common of which was preterm delivery

Results (Delivery and birth)

• Mean gestation at birth was 38.47 weeks (n=45)

• Median Gestation at birth was 40 weeks

• All singleton, hospital births

• ¾ by NVD

Results (Infant health)

• GOR most common diagnosis

• All infants were UTD with vaccinations and had no history of ALTEs

• 11% breastfed at time of death; very few on artificial feeding had a history of breastfeeding

Results (Social History)

• All cases lived at home with their mother, over 75% were co-habiting or married

• Half of mothers did not work

• Drug use and substance misuse not commonly reported among mothers

• Most cases 2nd caregiver was their father (93%)

• Mean age of father was 28 years (n=31)

Results (Social History)

• 74% of fathers were smokers at time of birth (34%)

• 33% of fathers used drugs recreationally (n=33)

• 20% of fathers have a history of substance abuse (n=30)

• Just under 1/3 cases were in contact with social services for a range of reasons

• <10% reported domestic violence

• 7% cases were on the child protection register (n=45)

Results (Circumstances of death)

31.11%

11.11%

8.89%

15.56%

11.11%

6.67%

15.56%

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

% of Cases by Day of Death


4

6

5

4

2

3

4

9

1

3 3

1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Cases by Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec


Time found Percentage

Midnight - 6am 11.11%

6am - 10am 48.89%

10am - 12pm 31.11%

> 12 Noon < Midnight 8.89%

Grand Total 100.00%

Room found Percentage

A bedroom not at Home 13.33%

Living Room 20.00%

Living room not at home 2.22%

Own room 8.89%

Parent or Parents' Room 55.56%

Grand Total 100.00%

Row Labels Count of Location found within room

Beside bed 2.22%

Cot 20.00%

In car seat 2.22%

On Bed 51.11%

On Chair 2.22%

On Sofa 17.78%

Travel Cot 4.44%

Grand Total 100.00%


Position found Percentage

Arms of Parent 11.63%

On side 18.60%

Prone 27.91%

Prone and on

knees 2.33%

Supine 34.88%

Wedging 4.65%

Grand Total 100.00%

Position put to sleep Percentage

Arms / Body of

Parent 22.50%

On side 12.50%

Prone 5.00%

Supine 60.00%

Grand Total 100.00%


• 71.1% cases were co-sleeping (n=45)

• For the 32/45 cases who were co-sleeping

– 59% were co-sleeping with one other person

– 41% were co-sleeping with 2 people


• In 2% cases were covers found over the child’s head (n=45)

• 16% cases the child was away from home (n=45)

• 24% cases it was a family occasion (n=45)

• 52% cases alcohol was taken by caregivers (n=44)

• 59% cases who were co-sleeping the co-sleeper had

taken alcohol (n=32)


Location of co-sleeping Percentage

Chair 3.13%

Mattress 68.75%

Mother's arms 3.13%

Sofa 25.00%

Grand Total 100.00%

Results (Co-sleeping)

• 44% of cases were aged 12 weeks and younger

• Of those cases ≤ 12 weeks 95% were co-sleeping compared with 52% of those over age of 12 weeks.

Results (Child health in 72 hours prior to death)

• 1/3 cases had symptoms in 72 hours before death (n=45), most commonly cough and coryza

• 6/15 seen by a healthcare professional and 50% prescribed medication

• 18% reported problems with feeding within this time period (n=45)

Results (Post-mortem results)

• 89% had abnormal PM results (40/45) [Totals below will add up to more than 40 as some cases have more than one abnormal result] – 38/40 had abnormal bacteriology results – 10/40 had abnormal skeletal survey – 5/40 had abnormal virology results – 4/40 had abnormal toxicology results – 1/40 had abnormal genetics results – 3/40 had raised WCC or abnormal haematology – 5/40 had at least 3 types of abnormal results – 11/40 had 2 types of abnormal results – 24/40 had 1 type of abnormal result


Through Co-sleeping

Questions?

Summary

• 71.1% cases were co-sleeping

• 59% cases who were co-sleeping the co-sleeper had taken alcohol


Through Co-sleeping

Thanks!

using coronial records to understand deaths of infants through co-sleeping

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