Sudden Unexpected Deaths in Infancy (SUDI). Can Child Welfare Make a Difference?
By Karen Bridgman-Acker

Every parent‘s worst nightmare and the worst case scenario for a child protection worker providing service to families, is the death of a child. One death from any cause is one too many; deaths which are potentially preventable leave many unanswered questions and unresolved feelings for the involved caregivers and professionals.

The following case scenarios were created as compilations of non-identifying information gleaned from sample cases of infant deaths; the details are representative of real cases, but are not exact replications of actual events.

Case #1: A father was sleeping on the parental bed with his 3 month old daughter beside him, on his arm; the mother slept against the wall. Around 5:00 a.m. the father got up to use the washroom and noticed the baby was cold to the touch. The mother tried to resuscitate her and could not. There was no phone in the apartment. The mother and father admitted to drinking beer and smoking some marijuana during the evening. Both parents have histories of child welfare involvement and known problems with substance abuse, although they reported making efforts in the recent past to reduce their use. The death was classified as:
Cause of Death: No definitive anatomic or toxicological cause of death identified. Sudden Unexpected Death in Infancy (SUDI) in the presence of bed-sharing with both parents in an unsafe sleeping environment (adult bed)
Manner of Death: Undetermined

Case #2: A 2-month-old boy was found in bed with his mother, who had fallen asleep while breast-feeding, around 7:30 am one morning not breathing. CPR was attempted and he was taken to the hospital; he was pronounced dead at the hospital. There was no evidence of alcohol, tobacco or other substance use in the home. There was no crib in the home. The Children‘s Aid Society had recently closed the file after a brief investigation which did not verify reported concerns of inadequate supervision. This death was classified as:
Cause of Death: No definitive anatomic or toxicological cause of death identified. Sudden Unexpected Death in Infancy (SUDI) in the presence of bed sharing with the mother
Manner of Death: Undetermined

Sudden Unexpected Deaths in Infancy (SUDI) with no identified anatomic or toxicological cause of death, but where an unsafe sleeping environment is found to be a contributing factor, are potentially preventable. With information, education and planning, parents and professionals can create safer sleeping environments for infants and thereby prevent future deaths of otherwise healthy babies from this risky practice. We can make a difference.

Data compiled by the Office of the Chief Coroner of Ontario, shows that each year in this province 25-30 babies less than 1 year of age die while sharing a sleep surface with an adult (see chart below which includes deaths classified as accidental asphyxia due to"overlay"). All deaths due to natural disease in the presence of bed-sharing have been excluded. These numbers do not include other "unsafe sleeping" environments (cluttered cribs, couches, adult beds etc.). Annually, several more infants do not survive in such unsafe sleeping environments.

OCCO DATA on Sudden Unexpected Deaths in Infancy (SUDI)
With Bed-Sharing as a Significant Contributing Factor* 2004-2007

* No definitive anatomic or toxicological cause of death in an infant sharing a sleep surface with an adult(s).
** 2007 statistics are preliminary.

Case #3: One morning, after the father left for work, the mother checked on their 5 month old baby and found him unresponsive. While the baby‘s crib was new with a firm mattress, it contained blankets, clothing, stuffed toys and several used baby bottles. There were cats in the home, which was described, as dirty and untidy. This death was classified as:
Cause of Death: No definitive anatomic or toxicologic cause of death identified. Sudden Unexpected Death in Infancy (SUDI) in an unsafe sleeping environment (cluttered crib – blankets, sleeper and baby bottles).
Manner of Death: Undetermined

The file was an open protection file at a Children‘s Aid Society at the time of death due to ongoing concerns related to neglect.

The Paediatric Death Review Committee (PDRC) of the Office of the Chief Coroner for Ontario (OCCO) reviews the deaths of children between the ages of 0 and 18. The Deaths Under Five Committee (DU5C) reviews the deaths of children under the age of five. A main purpose of these Committees is to make recommendations to prevent future deaths of children in similar circumstances.

The OCCO, through the comprehensive review process of the DU5C, has identified trends over recent years which feature bed-sharing as a significant factor in Sudden Unexpected Death in Infancy (SUDI).

In many jurisdictions, including Ontario, the terms SUD (Sudden Unexpected Death) or SUDI (Sudden Unexpected Death in Infancy) are used in deaths previously considered to be SIDS. SIDS, which is a diag-nosis of exclusion, is reserved for deaths of infants where there are no positive findings after a complete investigation has been conducted. Increasingly, the findings of "unsafe sleeping environment" and "bed-sharing" are being recognized as positive findings in the investigation leading to the manner of death being classified as ‗undetermined‘. This change is causing a shift in the mortality data globally, which can cause confusion.

In Ontario, the DU5C considers the sleep environment in all deaths of children, particularly those under the age of one year. Unsafe sleeping environments include surfaces not designed for infant sleep, such as adult beds, couches, armchairs and infant swings. However any sleep surface that is cluttered with pillows, blankets, toys, duvets and other objects is deemed to be an unsafe sleeping environment.

The terms "co-sleeping" and "bed-sharing" are often used interchangeable by professionals and in the literature. The Office of the Chief Coroner‘s death review committees have committed to using "bed-sharing" to mean an infant sharing the same sleep surface with someone else (usually an adult, but occasionally a sibling). The term "co-sleeping" is used to describe an infant sharing the same room with the caregiver(s). Room-sharing but not bed-sharing is the preferred arrangement for safe sleeping.

Example of safe room-sharing/sleeping environment

(Graphic courtesy of the Canadian Foundation for the Study of Infant Deaths)

The number of infant deaths reviewed by the committees where unsafe sleeping practices, including bed-sharing, were factors, is a growing concern. While there is no precise way of knowing how many parents share a bed with their infants without incident, the frequency with which death occurs can be considered a public safety issue.

As part of the 2006 Joint Directive for Reporting and Reviewing Child Deaths between the Ministry of Children and Youth Services and the Office of the Chief Coroner, the PDRC tracks and analyzes the deaths of all children who were being serviced by a Children‘s Aid Society within the 12 months preceding the death. While unsafe sleeping related deaths occur across the province regardless of child welfare involvement, the committee notes that 40 percent of the 42 cases reviewed last year were deaths of infants in unsafe sleeping and bed-sharing situations. This suggests an important potential point of intervention for the prevention of future deaths for the child welfare field.

In June 2009, the PDRC and DU5C released its most recent annual report; some of the SUDI data presented included:

A total of 96 cases were reviewed by the DU5C last year

• 40 of 96 deaths were classified as Undetermined
• 33 (75%) of the Undetermined cases involved unsafe sleeping environments
• 19 (58%) of these unsafe sleeping related cases involved bed-sharing
• 11 of the infants were female; 22 were male
• 31 of the infants were 7 months of age or younger and 2 were 10 months old, stressing the increased risk of sharing a sleep surface with very young babies.

In the 19 unsafe sleeping related deaths with bed-sharing, all involved one or two adults and in one case another child was also in the bed. Fourteen babies died on unsafe sleep surfaces not involving bed-sharing (see graphs below showing sleep surfaces in these cases).

Comprehensive post-mortem examination, investigation and review did not identify anatomic or toxicologic causes of death. These deaths may have resulted from respiratory interference due to airway obstruction and/or compression of the torso.

The OCCO has been involved in several initiatives where the goal has been to bring appropriate stake-holders to the table to facilitate agreement on, and hopefully delivery of, a clear and consistent message to parents, as well as service and health care providers, about the risks of unsafe sleeping and bed-sharing. Due to acknowledged controversy in this area, further research is warranted and is ongoing.

Parents and caregivers are consistently being given conflicting information and advice by friends, family and even health care providers regarding safe sleeping practices at a very vulnerable and often stressful time in their lives. Child protection workers are in a position to help clarify the messages for parents with whom they are working. Children‘s Aid Society staff have the opportunity to educate and inform parents directly and early on about the risks of unsafe sleeping environments for infants. It is imperative that accurate and consistent messages be provided to new mothers regarding safe sleeping practices during pregnancy, while in hospital, when being discharged home and when being visited in their homes by social workers, family home visitors and public health nurses.

With increasing frequency, Children‘s Aid Societies are developing policies and practices which support a consistent message for parents of infants about safe sleeping. The challenge is to obtain the same measure of commitment from the health care professions to do the same.

Earlier this year, suggestions were made by the OCCO to the Canadian Paediatric Society for changes to its position on Safe Sleeping Practices. The suggested changes are as follows:

• Sleeping with an infant is dangerous.
• The sharing of a bed with an infant by an adult or another child may lead to the accidental death of the infant due to airway obstruction.
• Letting the infant sleep alone on any type of couch, recliner or cushioned chair is dangerous.
• These situations place infants at substantial risk of accidental death due to airway obstruction.
• Any makeshift bed is dangerous.
• All infants should only be placed for sleep on appropriately approved surfaces such as in cribs.

In October 2008, Ms. Karen Bridgman-Acker participated in a round table discussion co-hosted by the Public Health Agency of Canada and the Canadian Foundation for the Study of Infant Deaths. Numerous people with expertise in the areas of Sudden Infant Death Syndrome (SIDS), Sudden Infant Death of Infants (SUDI) and paediatrics joined together to re-vise the 1999 "Back to Sleep" brochure distributed by the Public Health Agency of Canada. Evidence-based information is being used to update this brochure entitled "Safe Sleep for Your Baby" which should be released in March 2010. The report of this Roundtable Session is available at: http://www.phac-aspc.gc.ca

A document entitled: "The Practice of Bed-sharing: A Systemic Literature Review and Policy Review" by Wendy Trifunov (2009) recommends further research, but concludes that while "bed-sharing has been known to increase the duration and frequency of breast feeding and augment the opportunity for bonding…these benefits are outweighed by the risk attributed to bed-sharing".

In summary, the safest and most effective way to re-duce risk and prevent harm to a newborn is to place the infant in the parents‘ room in an approved crib. This proximity likely facilitates breastfeeding and bonding. Bed-sharing with an infant, however, carries a risk of death and this outweighs any benefit. Sharing a soft sleep surface on an inappropriate sleep environment such as an adult bed, couch, futon, air mattress or armchair is dangerous and carries an even higher risk.

Working together to provide clear and consistent messages to caregivers about the importance of safe sleeping environments for babies is one way to pre-vent the unnecessary deaths of vulnerable infants. We just might be able to save the lives of at least 25 babies each year; now that would make a difference.
How can child protection workers make a difference?

"DO‘s and DON‘Ts"

To reduce the chances that a baby will die from SUDI (Sudden Unexpected Death in Infancy)

DO inform parents of the following:

DO place babies down for sleep only on their backs until they are one year of age.

DO put them on a firm mattress in an un-cluttered crib.

DO have babies sleep in the same room with the parent(s) but NOT on the same sleep surface!

DO keep the baby's room temperature cool (about 65 degrees) when he or she is sleeping.

DO feed, hold and cuddle the baby to enhance bonding and breast feeding, while awake.

DO use only cribs, playpens, bassinettes and other baby equipment that meet Health Canada Standards.

DO tell other caregivers of the baby (parents, aunts, uncles, babysitters, etc.) to follow these simple rules, too!

DON'T smoke around babies or let anyone else smoke around them.

DON'T let babies share a sleep surface with another child or with an adult.

DON'T put babies in an adult bed or on a sofa to sleep!

DON'T leave babies sleeping for extended periods of time in car seats.

DON'T use baby equipment not designed for infant sleep for permanent sleeping arrangements (i.e. car seats, playpens, swings etc.)

DON'T use pillows, bumper pads, blankets, duvets, or quilts (especially adult bedcovers) over or under babies.

DON'T overdress or overheat the baby, especially if he or she is ill.

DO the following in your professional role:

DO encourage the baby's mother not to smoke while she is pregnant or afterward around her baby and not to take the baby into smoke-filled environments.

DO encourage the baby's mother to breast-feed the child. If mother is a heavy smoker and breastfeeds, please ask her to talk with her doctor. If the mother is tired, as many are, encourage her to breast feed and hold the baby where she is least likely to fall asleep.

DO encourage the baby's parents to seek medical care for the baby when he or she becomes ill.

DO check the baby‘s sleep environment whenever visiting the home.

DO develop policies, practices and materials on Safe Sleep Practices for Infants.

DO participate in training for high risk infants.

DO share these messages with parents, colleagues and community partners.

References

Canadian Foundation for the Study of Infant Deaths (http://www.sidscanada.org).

Canadian Paediatric Society. (2004). Recommendations for Safe Sleeping Environments for Infants and Children. Paedi-atrics & Child Health, 9, 9, 659-663.

Office of the Chief Coroner, Province of Ontario. (June 2007). Report of the Paediatric Death Review Committee and Deaths Under Five Committee. Ontario, Canada.

Office of the Chief Coroner, Province of Ontario. (June 2008). Report of the Paediatric Death Review Committee and Deaths Under Five Committee. Ontario, Canada.

Office of the Chief Coroner, Province of Ontario. (June 2009). Report of the Paediatric Death Review Committee and Deaths Under Five Committee. Ontario, Canada.

Public Health Agency of Canada (http://www.phac-aspc.gc.ca).

Trifunov, W. (May 15, 2009). The Practice of Bed Sharing: A Systematic Literature and Policy Review. Unpublished paper available through Division of Childhood and Adolescence, Public Health Agency of Canada.

About the Author

Karen Bridgman-Acker is a social worker and child welfare specialist who works at the Office of Chief Coroner for Ontario. She is seconded from the Catholic Children‘s Aid Society of Hamilton and co-coordinates the child welfare case reviews for the Paediatric Death Review Committee and acts as the liaison for child welfare agencies and the coroner‘s office. She is a member of the Paediatric Death Re-view Committee, the Deaths Under Five Committee and the Domestic Violence Death Review Committee at the OCCO.

She would like to acknowledge the contributions of Ms. Doris Hildebrandt and Dr. Bert Lauwers of the OCCO to this paper and to the ongoing study of this issue.

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