CASE STUDY by 1 Rebekah Beyers , MD , FAAP ; 2 Dawn Porter , MS , CHES ;
3
Samantha H . Mullins , MPH ; 4 Courtney Cox , MD ; 4 Abdallah Dalabih , MD , MBA
1
Department of Pediatrics , Community Clinic , Springdale , Ark .,
2
Intentional Injury Prevention Specialist , Arkansas Children ’ s Hospital , Little Rock , Ark .
3
Director , Injury Prevention Center , Arkansas Children ’ s Hospital , Little Rock , Ark .,
4
Department of Pediatrics , Pediatric Critical Care , UAMS , Little Rock , Ark .
Case Studies of Sudden Unexpected Infant Death in Breastfed Infants in an Unsafe Sleep Environment in Arkansas
Abstract
Breastfeeding is a protective factor against sudden unexpected infant death ( SUID ). We present a retrospective review of four cases of infant mortality obtained from the Arkansas Infant and Child Death Review database . These cases involved infants aged 14 days to 2 months who were breastfeeding when their mothers fell asleep , resulting in infant death . In this study , we report that an unsafe sleep environment contributed to infant death in all four cases , despite the protection provided by breastfeeding . Evidence of SUID among infants that were breastfed in unsafe sleep environments may help to provide additional education regarding prevention of SUID .
Introduction
The term Sudden Unexpected Infant Death ( SUID ) includes the death of any infant under 1 year of age that has no definitive cause before investigation . SUID encompasses death due to unsafe sleep environment , asphyxiation , suffocation , and Sudden Infant Death Syndrome
The ICDR Annual Report showed a 40 % increase in asphyxia-related deaths in children less than one year of age between 2016 and 2017 , and all the deaths were determined to be sleep-related .
( SIDS ). 1 Arkansas currently ranks third in the nation for infant mortality . 2 In 2017 , there were 60 deaths among children in Arkansas related to unsafe sleep practices . 3
While infant mortality is multifactorial , certain factors including breastfeeding have been shown to have protective benefits or reduce the risk of SUID . 4 Placing infants to sleep in a supine position , alone , on a firm surface such as a crib or bassinet , with no soft bedding , also has a strong association with prevention of SUID . 4
Methods
The Arkansas Infant and Child Death Review and Prevention Program ( ICDR ) reviews unexpected deaths in children under 18 years of age in the state of Arkansas . Data collected in a SUID case review includes information from coroners ’ reports , Sudden Unexplained Infant Death Investigation ( SUIDI ) reports , doll re-enactment photos , and hospital records . Data collected from case reviews are entered into a closed-access database . De-identified data was extracted from the database and summarized for each case ( Table 1 ).
This brief report was deemed exempt by the UAMS Institutional Review Board .
Results
All four infants in the reported cases were breastfed and co-sleeping with mother at the time of death . Two cases indicate the infant was co-sleeping with mother on a couch , while two cases indicate co-sleeping occurred in an adult bed . Additionally , in two cases the mother was noted to be obese , and in one case the mother was noted to be under the influence of alcohol . Among all four cases , three infants were exclusively breastfed and one infant was both bottle and breastfed . In two cases , the mothers were discovered to be on top of the infant . In one case , the mother ’ s breast was found to be obstructing the infant ’ s nose and mouth , and in one case , the infant was found face down in a pregnancy pillow .
Discussion
A marked decline in sudden infant death was seen in the U . S . from 1990 to 1998 following the implementation of the AAP Back to Sleep campaign and SIDS prevention guidelines . 4 , 5 However , since 2005 , death due to asphyxiation and suffocation , as well as undefined deaths , have steadily increased . 6 The ICDR Annual Report showed a 40 % increase in asphyxia-related deaths in children less than one year of age between 2016 and 2017 , and all the deaths were determined to be sleep-related . 3 It is apparent that co-sleeping continues to be common and increasing in popularity . A study by Colson , Willinger , and Rybin found that bed-sharing actually increased in prevalence between 2001 and 2010 . 7 Advantages to co-sleeping have been noted ; mothers that engaged in co-sleeping with their infant at age one-month were two times more likely to still be breastfeeding at age 4 months than mothers who did not co-sleep . 8
While there is a significant body of work surrounding safe sleep environments and its impact on infant mortality , there is still a knowledge gap in regard to the incidence of SUID or asphyxiation in infants with the combination of both protective and risk factors . Evidence does indicate that smoke exposure , co-sleeping on sofas , and co-sleeping with an impaired caregiver are associated with the
158 • The Journal of the Arkansas Medical Society www . ArkMed . org