The Context and Circumstances of Unintentional Suffocation in Place of Sleep in New Zealand

Hayman R.M, Dalziel SR, Baker N.J de C

New Zealand Child and Youth Mortality Review Committee

1Nick Baker 7Nick Baker

• From National Mortality Collection – Suffocation is 2nd commonest cause of injury death

• after transport• therefore needed detailed review of suffocation using

national & local information collection

• Focus on part of the results relevant to < 1 yr

• One National Committee• 20 local death review groups• Based on 20 DHBs – “Health States”

Accidental suffocation in place of sleep - 0 days to 23 mths NZ 2002-2009 (n=152)

0

5

10

15

20

25

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Male

Female

Number of deaths

Age in months

Figure 3a. Mortality from accidental suffocation and strangulation in bed in children and young people aged 0 days to 24 months by age (in months) and gender, New Zealand 2002-2009 (n=121)

Source: CYMRC and PMMRC Cases by ICD-10-AM Underlying Cause of Death as assigned in National Mortality Collection .

Methods• Broad ICD 10 Search by 14 codes

– Unintentional death by suffocation– Eight years 2002 – 2009 inc

• 621 cases – for inclusion 3 independent reviewers sought evidence of

• death in place of sleep• external compression of the neck or chest or• oro-nasal compression or• blockage of airway with object other than vomit

• 50 meet criteria = categorical suffocation in place of sleep• Subjected to detailed review

– location, means & circumstance of death– using mortality data systems, local review, coronial records

Age Distribution

• Forty-eight (96.0%) under 12 months of age • For under ones average age of death was 3.4 mths.

– range 3 days - 10 months• Twenty one (42%) under one month

Unintentional Suffocation in Place of Sleep by Ethnicity

Ethnic group Total

2002–2009 rate

per 100,000

Rate ratio RR Confidence interval (95%)

European 10 0.15 1.00 -

Māori 32 1.21 8.22 4.04 - 16.73

Pacific 7 0.67 4.56 1.74 - 11.98

Asian 1 0.08 0.52 0.07 - 4.07

Subtotal 50 0.42

Rate data based on total population under age 25

Location of Death

• Bed and mattress arrangements n = 32 (64%)– mattresses on floor, bunk beds, beds pulled together, bean

bag, tri-pillow, mixtures, single mattress two people

• Couch or chair n = 9 (18%)• Cot n = 7 (14%) – six faulty cots

– gaps round mattresses– faulty cots sides

• slipped through and trapped• wedged in gap by sagging cot side

Means of Death• Overlaying n = 30 (60.0%)

• whole or part of a body, limb or breast, can cover the face, flex the neck or apply pressure to the chest or abdomen

– by mother/father in a co-sleeping situation n = 25 (50%)– by sibling in a co-sleeping situation n = 4 (8%)

• Wedging n = 20 (40.0%) – entrapment between a hard sleeping surface and

bedding n=10 (20%) e.g. mattress and cot/bed/couch– sleeping surface and wall n = 5 (10%)– couch/cushions/chair n = 5 (10%)

Circumstances of Death• domestic chaos, mobile families

– safe sleep not a high priority• cannot find baby after death!

• apparent lack of knowledge about risks and safety– “stunned amazement” that baby was at risk

• shared sleep surface n = 34 (68%)• Illness at time of death n = 8 (16%)• pillows, bean bag, “complex” bedding• unaccustomed caregivers

Why was infant in “harms way”?

• routine n = 13 (26%)• breast feeding n = 8 (16%)

– overlain by mother arm pit, under breast, face covering• bottle feed n = 3 (6%)• makeshift sleeping arrangements n = 8 (16%)

– social gatherings, renovations, holiday– snugly kills

• moved to unsafe space to settle n = 3 (6%)• nowhere else to sleep – too cold, overcrowded,• alcohol impaired caregiver n = 4 (8%)

– But data not collected systematically!

SUDI Spectrum in NZ

Environmental Factors

10 10 10 10 10 10

SIDS SuffocationVulnerability and Environment Conspire Together

Infants under one who die without enough distress to alert caregivers

• Vulnerability or Disease – smoking especially before birth, preterm, growth retarded, infections, weak, floppy, other diseases• Environmental factors – face covering, tummy sleeping, chest compression, neck compression, airway blockage, over heating

Vulnerability or Disease

Suffocation in Place of Sleep - Real and Preventable

• “Get suffocation out of no-man's-land”– As part of SUDI missed by injury prevention workforce– Can be hidden in SIDS/unascertained as unpalatable

• Engage injury prevention workforce– By far the commonest cause of injury death under one– Work needed on consumer product safety

Mortality (%) in infants aged 28 days to < 1 yr New Zealand 2006–2010 (n=683 deaths)

Congenital anomalies 18.2%

Certain conditions originating in the perinatal

period 11.4%

Diseases of the respiratory system 8.5%

Infectious and parasitic disease 6.1%

Diseases of the nervous system 3.0%

Missing data 1.7%Other Medical 7.4% Assault 1.1%

Unintentional injury 2.9%

R95 Sudden infant death syndrome 18.7%

W75 Accidental suffocation

and strangulationin bed 15.9%

R99 Other ill-defined and unspecified causes 4.9%

Other 0.3%

SUDI 39.8%

R95 SIDS 18.7%

W75 Accidental

suffocation in place of sleep

15.9%

Consistent and Persistent Safe Sleep Practices

• Maori community driven solutions – culturally appropriate, appealing, possible, easy

• Safe sleep for infants reprioritised– Model and support good practice at every opportunity

• Especially during health care – staff, training skills• Policy, audit, record keeping

– Antenatal preparation– Enable safe sleep – make doing the right thing easy

– “we did it with car seats”• Wahakura, Pepi-pods

– Whole of society priority• Health curriculum in schools to great grand parents!

• Every baby needs a sober caregiver

Unbroken Journey of Safe Sleep Support

Antenatal – Natal – Postnatal - Infant1. Needs Assessment

– infant, mum, wider environment– wishes– reality of life

2. Planning – with family3. Action

– every baby has a place to sleep• Free of people who might overlay the infant• Free of gaps that could trap or wedge• Firm• Flat• Free from objects that might cover the face

– and it is used!

Record Keeping

Conclusions

• The unexpected nature of SUDI can lead to the acceptance that these deaths “just happen” and families feeling disempowered.

• A substantial proportion of SUDI is preventable through addressing suffocation risks

• Families have the right to be– empowered by knowledge of the circumstances in

which suffocation occurs– supported in having safe environments for infant sleep.

Acknowledgements• Dr Rebecca Hayman• Dr Stuart Dalziel• Otago University Mortality Data group• The PMMRC

• Local & National CYMRC Coordinators • Local Groups and Chairs• 500 plus Agents – Police, CYF, Plunket, St Johns, MOE, NGOs

• DHBs• Coroners• HQSC secretariat

• Wedging refers to an infant who was found with face, neck or chest trapped in a manner that would impede breathing and compromise the airway. Wedging had to occur between two sleeping surfaces, such as a mattress and a cot.

• Overlay refers to the situation where a co-sleeping partner has caused suffocation.

• Suffocation in place of sleep includes situations where the whole or part of a body, such as a limb or breast, can cover the face, flex the neck or apply pressure to the chest or abdomen of an infant making it harder to breath. Infants have few mechanisms to protect their own airway because of soft flexible tissues so even slight pressure on the nose or face or neck flexing can lead to suffocation.