June/July E-zine

The Georgia SIDS Project E-Zine is an on-line educational update offered monthly by the Georgia Sudden Infant Death Information, Referral and Support Project, an affiliate of First Candle/SIDS Alliance. To comment on this issue, request additional information, refer families in need of support, make a donation or be added or removed from the list please contact us at gasids@mindspring.com or call 678-342-3360 or through Powerline at 1-800-822-2539.

This publication is made available through the generous donation of friends and supporters of our program.

Volume 2 - Issue Number 6, June/July 2006

1. The U.S. Senate poised this week to fund pilot “Cribs” Campaign - Join your voice to encourage the passage of these funds for the pilot in Georgia

2. Georgia SIDS Project funding for bereavement services no longer underwritten by Georgia Division of Public Health

3. SIDS Standardization of Investigation and classification protocols recommendations by international group of researchers

4. Experience of miscarriage in the UK: Qualitative findings from the National Women's Health Study in Britian.

5. Home Visiting As A Promising Strategy To Improve Birth Outcomes Among MCH Populations reviewed

6. Effect of "This Side Up" T-shirts on Infant Sleep Position – what educational approaches work and for whom?

7. AAP updates recommendations on distinguishing sudden infant death syndrome from child abuse fatalities

8. DFACS referrals in cases of sudden infant death: A 10-year, population-based analysis in California

9. New study looks at effect of prone and supine position on sleep, apneas, and arousal in preterm infants

10. State child care regulations reviewed regarding infant sleep environment since start of Back to Sleep campaign

11. Report Investigates Problems And Solutions in Medicaid and other public insurance for children and families

12. Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa patients: Retrospective controlled study.

13. Legislation supports post partum Depression Care and Research

14. Hospital patient volume and neonatal mortality among very low birth weight infants.

15. Predictors of preterm birth – Scientific Literature Review.

16. Higher Mortality Rate Among Infants of US-Born Mothers Compared to Foreign-Born Mothers in New York City.

17. Exposures to air pollutants during pregnancy and preterm delivery

18. International groups reviews pacifier recommendations

1. First Candle, in conjunction with the Georgia SIDS Project is asking your help to support funding for a Georgia Cribs Pilot Project. The Senate will be determining funding priorities this week. We have a model letter (please modify with your local information) for you to send. Our senators will respond but only if they hear from you. We hope that the pilot will turn into a program much like our car seat programs – where families are asked if they have a crib before discharge – and encouraged to have a safe place for their baby to sleep before they go home. This pilot project would occur in a number of states, and is structured to not only provide cribs to needy families – but also help us learn more about infant sleep safety. Please take a minute to e-mail this, or your own letter to our Senators in support of the pilot! Go to www.sidsga.org to a copy of the model letter and information on how to make your voice heard.

2. The Georgia SIDS Project will no longer be receiving state funding to support our bereavement support services for families experiencing an infant or early childhood death from Georgia Division of Public Health for fiscal year 2007 (beginning 7/1/06). These services will continue, but will need to be underwritten by private donations or from other sources. Last year, as part of our contract Georgia SIDS was able to contact and provide resources for 211 families. Support information continues to be available through our peer support program, and on our website at www.sidsga.org which lists current web-based, national, state and local support programs. Referred parents will continue to receive support literature, the resource list and information about our peer support program. Donations to support this work are more important than ever… we appreciate any support you may be able to offer.

3. Sudden infant death syndrome (SIDS)-Standardized investigations and classification: Recommendations.

Bajanowski T, Vege A, Byard RW, Krous HF, et al. Forensic Sci Int. 2006 Jun 23; SIDS still accounts for considerable numbers of unexpected infant deaths in many countries. While numerous theories have been advanced to explain these events, it is increasingly clear that this group of infant deaths results from the complex interaction of a variety of heritable and idiosyncratic endogenous factors interacting with exogenous factors. This has been elegantly summarized in the "triple risk" model. Contradictions and lack of consistencies in the literature have arisen from diverse autopsy approaches, variable applications of diagnostic criteria and inconsistent use of definitions. An approach to sudden infant death is outlined with discussion of appropriate tissue sampling, ancillary investigations and use of controls in research projects. Standardization of infant death investigations with the application of uniform definitions and protocols will ensure optimal investigation of individual cases and enable international comparisons of trends. The authors of the article are from a diverse number of countries, working to create consistent definitions and data collection protocols.

4. Experience of miscarriage in the UK: Qualitative findings from the National Women's Health Study.

Simmons RK, et al Soc Sci Med. 2006 Jun 14; Miscarriage is the most common adverse outcome in pregnancy. For many women it is a traumatic experience. Previous research has identified shortcomings in the emotional and social support provided for miscarriage sufferers but personal accounts of pregnancy loss remain relatively under-explored. The UK National Women's Health Study (NWHS) is a nationally representative survey of women's reproductive histories. It provided an opportunity to study accounts of miscarriage written in response to an invitation for further comments on the survey questionnaire. In conjunction with quantitative findings from the NWHS, we thematically analyzed 172 detailed narratives that facilitated qualitative exploration of a characteristically private event. Analysis of the narratives suggested that few women who had planned their pregnancy were satisfied with fatalistic explanations of miscarriage. Those who were not given medical explanations for their loss engaged in complex searches for meaning, often linked to accounts of their moral deservedness as mothers. The narratives highlighted tensions between biomedical and lay understandings of pregnancy loss. There were reports of inappropriate medicalization and a perceived lack of emotional support, but also a desire for medical validation of the reality of miscarriage and investigations to identify medical causes. Professionals' reported behavior played a key role in women's accounts. These findings remind providers that: women do not experience miscarriage as a routine complication; medicalization is both resisted and desired; and, for some women, more support and information is needed to assist their search for meaning.

5. Brief Presents Home Visiting As A Promising Strategy To Improve Birth Outcomes Among MCH Populations Bringing Home Better Birth Outcomes examines home visiting as a strategy employed by state health agencies to deliver public health interventions aimed at improving birth outcomes. The issue brief, published by the Association of State and Territorial Health Officers (ASTHO) with support from The MCH Bureau, was written in follow-up to ASTHO's Strides Among States to Improve Birth Outcomes: A Compendium of Programs, in which several featured states reported using home-visiting programs to reduce infant mortality and disparities in birth outcomes. Topics include an overview of home-visiting programs; a discussion of goals, target populations, common service components, outcomes, and financing of state-level programs; and examples of programs from Georgia, Maine, Montana, Oklahoma, and Puerto Rico. Home-visiting resources, including state programs featured in the brief, nationally organized home-visiting models, and publications on home visiting, are also provided. The brief is intended for use by states to address the challenges of reducing infant mortality and preterm birth, maternal and infant morbidity, and disparities in birth and pregnancy outcomes. The brief is available at http://www.astho.org/pubs/HomeVisitingBriefFinal.pdf.

6. Effect of "This Side Up" T-shirts on Infant Sleep Position. Barnes-Josiah D Let al Matern Child Health J. 2006 Jul 1; Objective of this study was to assess the impact of "This Side Up" T-shirts on parental practices in Nebraska. A random sample of 3,210 Nebraska women who gave birth in 2004, stratified by race/ethnicity, was mailed a brief questionnaire on their receipt of a T-shirt and SIDS risk reduction materials at their birthing hospital, and on infant sleep position. Response rates were low (25.9%), ranging from 10.6% for Native American mothers to 46.4% for White mothers. Half (52.0%) had received a T-shirt and 71.6% had received SIDS information. Two-thirds (64.0%) reported that their infants slept on their backs; African-American and Hispanic infants were significantly less likely to back sleep. In univariate logistic regression models, African-American race, Hispanic ethnicity and maternal age 30-39 were significant negative predictors of back sleeping; White race and having received a SIDS brochure were positive predictors. In the fully controlled model African American and Asian race and Hispanic ethnicity were negative predictors of back sleeping; neither receiving SIDS information nor the infant T-shirt was significant. Effects of maternal age and a SIDS informational brochure appeared in models stratified by race/ethnicity. Therefore, receiving an infant T-shirt was not related to how mothers placed their infants to sleep. Additional research is needed on effective methods of delivering targeted counseling and promoting safe sleep practices among families, particularly among racial and ethnic subgroups.

7. Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics 2006 Jul;118(1):421-7
Fatal child abuse has been mistaken for sudden infant death syndrome. When a healthy infant younger than 1 year dies suddenly and unexpectedly, the cause of death may be certified as SIDS. SIDS is more common than infanticide. Parents of sudden infant death syndrome victims typically are anxious to provide unlimited information to professionals involved in death investigation or research. They also want and deserve to be approached in a non-accusatory manner. This clinical report provides professionals with information and suggestions for procedures to help avoid stigmatizing families of sudden infant death syndrome victims while allowing accumulation of appropriate evidence in potential cases of infanticide. The article updates recommendations in the 2001 American Academy of Pediatrics policy statement of the same name. For the new policy go to: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;118/1/421.pdf

8. Child protective services referrals in cases of sudden infant death: A 10-year, population-based analysis in San Diego county, California. Krous HF, et al. Child Maltreat. 2006 Aug; 11The potential diagnostic significance of prior family referral to Child Protective Services (CPS) in cases of sudden infant death is unknown. Therefore, the authors retrospectively searched for CPS data for the 5-year referral history on all 533 families whose infants died suddenly from Sudden Infant Death Syndrome (SIDS), other natural diseases, accidents, or inflicted injuries and underwent postmortem examination by the medical examiner during a 10-year period. No family had more than one infant death. At least 27% of the families in each group had at least one CPS referral. The data suggest that a family's referral to CPS prior to their sudden death of their infant does not increase the likelihood that it was caused by inflicted injuries, and prior referral should not preclude a diagnosis of SIDS. The authors recommend future prospective studies that include refined exposure histories and that are large enough to have sufficient statistical power to compare family CPS referrals and outcomes in groups of infants who died suddenly with a matched group of living infants.

9. Effect of prone and supine position on sleep, apneas, and arousal in preterm infants. Pediatrics 2006 Jul;
Objective: Prematurely born compared with term born infants are at increased risk of sudden infant death syndrome, particularly if slept prone. The purpose of this work was to test the hypothesis that preterm infants with or without bronchopulmonary dysplasia being prepared for neonatal unit discharge would sleep longer and have less arousals and more central apneas in the prone position. This was a prospective observational study in a tertiary NICU. Twenty-four infants (14 with bronchopulmonary dysplasia) with a median gestational age of 27 weeks were studied at a median postconceptional age of 37 weeks. Video polysomnographic recordings of 2-channel electroencephalogram, 2-channel electro-oculogram, nasal airflow, chest and abdominal wall movements, limb movements, electrocardiogram, and oxygen saturation were made in the supine and prone positions, each position maintained for 3 hours. The duration of sleep, sleep efficiency (total sleep time/total recording time), and number and type of apneas, arousals, and awakenings were recorded. Results: Overall, in the prone position, infants slept longer, had greater sleep efficiency (89.5% vs 72.5%), and had more central apneas (median: 5.6 vs 2.2), but fewer obstructive apneas (0.5 vs 0.9). The infants had more awakenings (9.7 vs 3.5) and arousals per hour (13.6 vs 9.0) when supine. There were similar findings in the bronchopulmonary dysplasia infants. The study concluded very prematurely born infants studied before neonatal unit discharge sleep more efficiently with fewer arousals and more central apneas in the prone position, emphasizing the importance of recommending supine sleeping after neonatal unit discharge for prematurely born infants.

10. State child care regulations regarding infant sleep environment since the Healthy Child Care America-Back to Sleep campaign. Moon RY, Kotch L, Aird L. Pediatrics. 2006 Jul; Despite overall decreases in SIDS deaths and prone sleeping, the proportion of SIDS deaths that occurs in child care settings has remained constant at approximately 20%. In 2003, the American Academy of Pediatrics' Healthy Child Care America program launched its own Back to Sleep campaign to promote the Back to Sleep message for those who care for young children. The purpose of this study was to evaluate the effectiveness of the first 2 years of the Healthy Child Care America-Back to Sleep campaign in improving child care regulations by assessing the inclusion of the elements of a safe sleep environment in the individual state regulations for child care centers and family child care homes. We examined regulations available in October 2005 for licensed child care centers and family child care homes in the 50 states and the District of Columbia for specific regulations pertaining to (1) sudden infant death syndrome risk-reduction training for child care providers, (2) infant sleep position, (3) crib safety, (4) bedding safety, (5) smoking, and (6) provision of information about sleep positioning policies and arrangements to parents before the infant is enrolled in child care. The study found since 2003, when the campaign began, 60 of the 101 state regulations for either child care centers or FCCHs have been revised. More than half of these regulations written since 2003 mandate a nonprone sleep position and restrictions on soft bedding in the crib, and the change in these regulations since 2003 is statistically significant. However, of the 101 existing state regulations, only 49 require that infants sleep non-prone, 18 mandate sudden infant death syndrome training for child care providers, 81 have > or = 1 crib safety standard, and 43 restrict soft bedding in the crib. Only 4 regulations require that parents be provided with sleep policy information. The initial 2 years of the Healthy Child Care America Back to Sleep campaign have been successful in promoting safe infant sleep regulations. Efforts must continue so that safe sleep regulations exist in all jurisdictions. Georgia regulations do require infants to be placed on their backs to sleep unless there is a medical order for an alternative position. They also require cribs to meet safety standards, and the removal soft objects from the sleep environment. There is no SIDS prevention training requirement and no requirement for parents to receive sleep policy information.

11. Report Investigates Problems And Solutions In Public Health Insurance Coverage For Children And Families Instability of Public Health Insurance Coverage for Children and Their Families: Causes, Consequences, and Remedies examines the problem of coverage instability within public health insurance programs and looks at strategies that can make coverage more stable for children and families. The report, published by the Commonwealth Fund, draws from findings from a variety of sources, including an in-depth examination of the experiences of four states (Louisiana, Rhode Island, Virginia, and Washington) in averting coverage instability by adopting key policies and procedures. In particular, the report focuses on the phenomenon of "churning," which occurs when individuals lose and regain coverage within a short period of time. Intended for use by state and local agencies in maintaining or improving participation rates among eligible children and families, the report is available at: http://snipurl.com/PublicInsur

12. Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: Retrospective controlled study. Morgan JF , Lacey JH, Chung E.Psychosom Med. 2006 May-Jun; Bulimia nervosa is common and treatable. An association between bulimia and obstetric complications has been suggested, but sample size and absence of control have limited previous studies. Our aim was to determine if active bulimia nervosa affects obstetric outcome. This was a retrospective case-control comparison of obstetric complications in first time pregnancy women previously treated for bulimia in a specialist eating disorder service. A cohort of 122 women with active bulimia during pregnancy was contrasted against 82 with quiescent bulimia, using structured interviews comprising the Eating Disorders Examination, Structured Clinical Interview for DSM-III-R, and systematic questions addressing obstetric complications. Odds ratios (ORs) for postnatal depression, miscarriage, and preterm delivery were 2.8 (95% confidence interval [CI], 1.2-6.2), 2.6 (95% CI, 1.2-5.6) and 3.3 (95% CI, 1.3-8.8) respectively. Risk of unplanned pregnancy was markedly elevated (OR, 30.0; 95% CI, 12.8-68.7). Risk estimates were not explained by differences in adiposity, demographics, alcohol/substance/laxative misuse, smoking, or year of birth, but relative contributions of bulimic behaviors were not discerned. Active bulimia during pregnancy is associated with postnatal depression, miscarriage, and preterm delivery. Bulimia may be a treatable cause of adverse obstetric outcome.

13. Legislation support post partum Depression Care and Research. Several leading organizations in maternal-child health have endorsed new federal legislation known as The M.O.T.H.E.R.S. Act (The Mom's Opportunity to Access Help, Education, Research and Support for Postpartum Depression), which was introduced earlier this month by Sens. Robert Menendez (D-NJ) and Richard Durbin (D-Ill). If adopted by Congress, the bill will ensure that new moms and their families are educated about postpartum depression, screened for symptoms and provided with essential services. In addition, this legislation incorporates a House bill, the Melanie Stokes Postpartum Depression Research and Care Act, which would expand and intensify research at the NIH with respect to PPD and psychosis, including increased discovery of treatments, diagnostic tools and educational materials for providers. The M.O.T.H.E.R.S. Act is endorsed by Postpartum Support International (PSI), the American College of Nurse-Midwives (ACNM), the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), the National Mental Health Association (NMHA), the National Alliance for the Mentally Ill (NAMI) and others. For more details about this bill and how you can lend support, go to http://menendez.senate.gov/newsroom/record.cfm?id=257314&&.

14. Hospital volume and neonatal mortality among very low birth weight infants. Bartels DBet al Pediatrics. 2006 Jun;117(6):2206-2214. Very low birth weight infants (< 1500 g) are at increased mortality risk. Authors hypothesized that neonatal mortality would be higher in small NICUs (< 36 very low birth weight admissions per year) than in large NICUs, with adjustment for volume of the delivery unit. They analyzed population-based data from a quality assurance program Germany. Perinatal data for almost all very low birth weight infants born in 1991 to 1999 (n = 7745) were available. Analyses were restricted to infants born at 24 to 30 weeks (n = 4379). Data validation procedures, univariate data analyses, and logistic regression models based on general estimating equations were performed. Neonatal mortality among infants admitted to NICUs was 12.2% in small NICUs and 10.2% in large NICUs. The mortality rate in small NICUs was increased significantly. Compared with infants from large delivery hospitals (> 1000 births per year) and large NICUs, the adjusted odds ratio was 1.94 for neonates for whom both units were small, 1.75 for those from large delivery units but small neonatal units, and 1.16 for those for whom only the NICU was large. Stratification by gestational age revealed the greatest impact on mortality for infants of < 29 weeks. Results suggest that creating larger perinatal centers may improve perinatal health care. The volume of the NICU was associated more strongly with 28-day mortality than was the volume of the delivery hospital, and it had the largest impact on survival for infants of < 29 weeks.

15. Predictors of preterm birth. Krupa FG et al Int J Gynaecol Obstet. 2006 May 23; This was a systematic review to assess published scientific evidence on preterm birth predictors. An Internet search for predictors of preterm birth was performed and the evidence level of each method was evaluated. Authors found strong evidence that preterm birth can be predicted using vaginal sonography to evaluate cervical characteristics, fetal fibronectin in cervicovaginal secretions and interleukin-6 in amniotic fluid. There is consistent evidence that digital cervical examination is a weak predictor, and controversy regarding home uterine activity monitoring. There is scanty evidence about the predictive ability of maternal history and perceptions of symptoms since the study design fails to provide high evidence level. Cervical evaluation by vaginal sonography, fetal fibronectin and interleukin-6 are the best methods for predicting preterm birth

16. Higher Mortality Rate Among Infants of US-Born Mothers Compared to Foreign-Born Mothers in New York City. Liu KL, Laraque F.J Immigr Minor Health. 2006 Jul This study is to compare infant mortality rates (IMRs) between US- and foreign-born mothers in New York City. The linked live birth-infant death records from 1995 to 1998 were analyzed. Overall US-born mothers had a higher IMR than foreign-born mothers, though there were great variations in IMRs by country of maternal birth among foreign-born mothers. US-born mothers had higher IMRs compared to foreign-born mothers for several maternal/infant characteristics. Logistic regression analyses indicated that infants of foreign-born mothers were less likely to die from prematurity, Sudden Infant Death Syndrome and external causes, but were more likely to die of congenital anomalies than those of US-born mothers.

17. Exposures to air pollutants during pregnancy and preterm delivery. Leem JH, et al Environ Health Perspect. 2006 Jun; The association between preterm delivery (PTD) and exposure to air pollutants has recently become a major concern. We investigated this relationship in Incheon, Republic of Korea, using spatial and temporal modeling to better infer individual exposures. The birth cohort consisted of 52,113 singleton births in 2001-2002, and data included residential address, gestational age, sex, birth date and order, and parental age and education. We used a geographic information system and kriging methods to construct spatial and temporal exposure models. Associations between exposure and PTD were evaluated using univariate and multivariate log-binomial regressions. Given the gestational age, birth date, and the mother's residential address, we estimated each mother's potential exposure to air pollutants during critical periods of the pregnancy. The adjusted risk ratios for PTD in the highest quartiles of the first trimester exposure were 1.26 [95% confidence interval (CI), 1.11-1.44] for carbon monoxide, 1.27 (95% CI, 1.04-1.56) for particulate matter with aerodynamic diameter < or = 10 microm, 1.24 (95% CI, 1.09-1.41) for nitrogen dioxide, and 1.21 (95% CI, 1.04-1.42) for sulfur dioxide. The relationships between PTD and exposures to CO, NO2, and SO2 were dose dependent (p < 0.001, p < 0.02, p < 0.02, respectively) . In addition, the results of our study indicated a significant association between air pollution and PTD during the third trimester of pregnancy. In conclusion, our study showed that relatively low concentrations of air pollution under current air quality standards during pregnancy may contribute to an increased risk of PTD. A biologic mechanism through increased prostaglandin levels that are triggered by inflammatory mediators during exposure periods is discussed.

18. International groups reviews pacifier recommendations: South African and Australian groups look at pacifier use evidence in making recommendations. Results available at http://www.joannabriggs.edu.au/pubs/best_practice.php

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