whakawhetu sudi
The SIDS/SUDI story: our role in General Practice?
David Tipene-Leach General Practitioner
New Zealand IMR falls from 2009
New Zealand IMR falls from 2009
Māori IMR falls by a third
Sudden infant death syndrome • Baby below 1 year age died in sleep • Where cause of death is unknown Even after a post-mortem And a full medical history
1980’s: highest SIDS rate in world SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
Māori SIDS twice as high
1980’s Māori SIDS twice as high SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
12
Deaths per 1000 births
10
8.5
8 6
4.0
4 2 0
1980 - 1990
Non-Maori SIDS rate
NZ Cot Death Study (1988-1990) ‘Modifiable’ risk factors Prone sleep position Maternal cigarette smoking Not breast feeding Bed sharing
OR 4.48 OR 1.79 OR 1.89 OR 2.02
NZ Cot Death Study (1988-1990) ‘Non-modifiable’ RF’s • Low socio-economic status
Poor
• young maternal school leaving age young and unmarried motherhood greater number of previous pregnancies
Young
• little or late antenatal care non-attendance at antenatal classes • LBW prematurity
Poor access to care Bad maternal outcomes
1991 Cot Death Prevention campaign SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
Observation of decreasing SIDS deaths
Cot Death Prevention campaign SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
National and non-Māori SIDS are decreasing
Cot Death Prevention campaign SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
What happened to the Māori rates?
Cot death prevention campaign Reduction of SIDS: Rates 1986-1992 NZ:
3.6 to 1.6
Maori:
7.4 to 6.9
The disparity in rates has gone from 2x to 5x
(Mitchell et al 1994)
Māori SIDS Prevention Team South Auckland 19931994 Public Health Commission
Prevention/health promotion Workforce development
Māori SIDS Prevention Team SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate 12
Deaths per 1000 births
10 8 6 4 2 0
Maori SIDS rate
Non-Maori SIDS rate
Māori SIDS Prevention Team SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
Decrease in Māori SIDS rate
But what happened next? SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
2002-2010
Sudden unexpected death in infancy In later years as SIDS deaths fell and More ‘possible overlaying’ was seen Diagnosis became much more difficult And so … SUDI includes “accidental suffocation”
SUDI in NZ: (2002-2008) Highest rate in the Western world Rates have plateau’ed Huge disparities – Māori 2.3/1000 – Pacific 1.3/1000 – n-M,n-P 0.5/1000 Child and Youth Mortality Review Committee; 2009.
What did we know about SUDI? Unsafe sleeping places • Car seats and sofas • Co-sleeping compromised adults • Co-sleeping with children
What did we know about SUDI? Unsafe sleeping practices • • • • •
Sleeping prone Pillows/bumpers Blankets over head Non return to SSE after feeding Change of routine: sleeping place and/or car
What did we know about SUDI? Bedsharing and smoking in pregnancy • • • •
Scragg and Mitchell BMJ 1993 Scragg and Mitchell NZMJ 1996 Mitchell and Milerad R.Env.Hlth 2006 Mitchell Acta Paed Scan 2009
What did we know about SUDI? RF’s – Bedsharing
Māori
non-M
20(+45)%
20(+7)%
– Smok/preg
51%
7%
– BS + Smoke
21%
1%
1 Tipene-Leach
et al 2010
2Hutchison
et al 2006
What did we know about SUDI? of the 50-80 SUDI infants a year Over 60% are Māori Nearly all are smokers and Over half are bed-sharers
What did we know about SUDI? Looking for a new intervention Deal with smoking – hard to fix problem Deal with bedsharing – resistance by Māori
Bedsharing where there was smoking in pregnancy
Looking for a new intervention Modification of interacting risks “The removal of one of two interacting risk factors will remove the risk associated with the interacting pair”
Looking for a new intervention Can bedsharing be more safe? in the international recommendations ‘Separate sleeping surface’ and eliminating unsafe factors ‘Safe Sleeping Environment’
Looking for a new intervention
Independent of smoking
•
.
Separate sleeping surface Safe sleeping environments
Looking for a new intervention
Independent of smoking
•
.
Separate sleeping surface Safe sleeping environments
Looking for a new intervention
Independent of smoking
•
.
Separate sleeping surface Safe sleeping environments
The wahakura – a new intervention Safe sleep rules • • • • • • • •
back position face clear smoke free adult free firm mattress loose blankets/pillows/bumper and toy free not over wrapped or over heated remind every caregiver of rules
The wahakura – a new intervention
The wahakura – a new intervention .
Need evidence for wahakura Hard/expensive to access Need more available alternatives to wahakura
Alternatives .
Waikawa Simple quick weaving method
Alternatives The Pepi-Pod More easily available plastic box
Change for our Children, Christchurch
Evidence The Wahakura Qualitative Study Beliefs and opinions about the wahakura How the wahakura is used in normal practice Whether the safe sleep rules are understood
Evidence Kahungunu Safe Sleep Study (KISS) Randomised controlled trial To determine the safety and other benefits, or harm, of using a wahakura compared to a bassinet
Evidence KISS: Risks and benefits of a sleep environment
Risks
Thermal Hypoxia Head covering
Benefits
Sleep improvement Mother infant interaction ‘Attachment’
No difference in the environments (risks) Extended breastfeeding in the wahakura group Wahakura to be a ‘safe’ sleep environment
Evidence 2014 BMC Paeds Methodology and recruitment for a randomised controlled trial to evaluate the safety of wahakura for infant bedsharing 2014 NZMJ The wahakura: A qualitative study of the flax bassinet as a sleep location for New Zealand Māori infants
Evidence 2015 Paediatrics (in review) Safe infant sleep: a randomised controlled trial to compare an indigenous sleep device with a portable bassinet. 2015 (in preparation) A randomised controlled trial using overnight sleep studies in the home to evaluate an indigenous infant sleep device.
DHB Safe sleep projects • Audit of SS Env & SS Practice • Provision of SS Env • Proliferation of SS Messages • Including South Auckland
So whats out there for us in GP-land? Supply Wahakura and Pepi-Pods DHB projects
Evidence WQS, KISS, Haumaru Moe
Community Whakawhetū DHBs and MOH
So whats out there for us in GP-land? Risk factors Smoking in pregnancy Breastfeeding support Back sleeping Exhortation about alcohol Safe Sleep device
So whats out there for us in GP-land? Whakawhetu SUDI calculator Ed Mitchell Developing an App Individual baby risk “Change of behaviour’ Being pilotted in S Auckland
So whats out there for us in GP-land? Whakawhetu SUDI online training www.learnonline.health.nz www.whakawhetu.co.nz CME points
So whats out there for us in GP-land? Whakawhetu
‘Weave off’, SS picnics, wananga, buggy walk, maternity fashion show
Great news to finish with SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate 12
Deaths per 1000 births
10 8 6 4 2 0
Maori SIDS rate
Non-Maori SIDS rate
Great news to finish with
The SIDS/SUDI story: our role in General Practice
David Tipene-Leach General Practitioner
David Tipene-Leach General Practitioner
New Zealand IMR falls from 2009
New Zealand IMR falls from 2009
Māori IMR falls by a third
Sudden infant death syndrome • Baby below 1 year age died in sleep • Where cause of death is unknown Even after a post-mortem And a full medical history
1980’s: highest SIDS rate in world SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
Māori SIDS twice as high
1980’s Māori SIDS twice as high SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
12
Deaths per 1000 births
10
8.5
8 6
4.0
4 2 0
1980 - 1990
Non-Maori SIDS rate
NZ Cot Death Study (1988-1990) ‘Modifiable’ risk factors Prone sleep position Maternal cigarette smoking Not breast feeding Bed sharing
OR 4.48 OR 1.79 OR 1.89 OR 2.02
NZ Cot Death Study (1988-1990) ‘Non-modifiable’ RF’s • Low socio-economic status
Poor
• young maternal school leaving age young and unmarried motherhood greater number of previous pregnancies
Young
• little or late antenatal care non-attendance at antenatal classes • LBW prematurity
Poor access to care Bad maternal outcomes
1991 Cot Death Prevention campaign SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
Observation of decreasing SIDS deaths
Cot Death Prevention campaign SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
National and non-Māori SIDS are decreasing
Cot Death Prevention campaign SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
What happened to the Māori rates?
Cot death prevention campaign Reduction of SIDS: Rates 1986-1992 NZ:
3.6 to 1.6
Maori:
7.4 to 6.9
The disparity in rates has gone from 2x to 5x
(Mitchell et al 1994)
Māori SIDS Prevention Team South Auckland 19931994 Public Health Commission
Prevention/health promotion Workforce development
Māori SIDS Prevention Team SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate 12
Deaths per 1000 births
10 8 6 4 2 0
Maori SIDS rate
Non-Maori SIDS rate
Māori SIDS Prevention Team SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
Decrease in Māori SIDS rate
But what happened next? SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate
Maori SIDS rate
Non-Maori SIDS rate
12
Deaths per 1000 births
10 8 6 4 2 0
2002-2010
Sudden unexpected death in infancy In later years as SIDS deaths fell and More ‘possible overlaying’ was seen Diagnosis became much more difficult And so … SUDI includes “accidental suffocation”
SUDI in NZ: (2002-2008) Highest rate in the Western world Rates have plateau’ed Huge disparities – Māori 2.3/1000 – Pacific 1.3/1000 – n-M,n-P 0.5/1000 Child and Youth Mortality Review Committee; 2009.
What did we know about SUDI? Unsafe sleeping places • Car seats and sofas • Co-sleeping compromised adults • Co-sleeping with children
What did we know about SUDI? Unsafe sleeping practices • • • • •
Sleeping prone Pillows/bumpers Blankets over head Non return to SSE after feeding Change of routine: sleeping place and/or car
What did we know about SUDI? Bedsharing and smoking in pregnancy • • • •
Scragg and Mitchell BMJ 1993 Scragg and Mitchell NZMJ 1996 Mitchell and Milerad R.Env.Hlth 2006 Mitchell Acta Paed Scan 2009
What did we know about SUDI? RF’s – Bedsharing
Māori
non-M
20(+45)%
20(+7)%
– Smok/preg
51%
7%
– BS + Smoke
21%
1%
1 Tipene-Leach
et al 2010
2Hutchison
et al 2006
What did we know about SUDI? of the 50-80 SUDI infants a year Over 60% are Māori Nearly all are smokers and Over half are bed-sharers
What did we know about SUDI? Looking for a new intervention Deal with smoking – hard to fix problem Deal with bedsharing – resistance by Māori
Bedsharing where there was smoking in pregnancy
Looking for a new intervention Modification of interacting risks “The removal of one of two interacting risk factors will remove the risk associated with the interacting pair”
Looking for a new intervention Can bedsharing be more safe? in the international recommendations ‘Separate sleeping surface’ and eliminating unsafe factors ‘Safe Sleeping Environment’
Looking for a new intervention
Independent of smoking
•
.
Separate sleeping surface Safe sleeping environments
Looking for a new intervention
Independent of smoking
•
.
Separate sleeping surface Safe sleeping environments
Looking for a new intervention
Independent of smoking
•
.
Separate sleeping surface Safe sleeping environments
The wahakura – a new intervention Safe sleep rules • • • • • • • •
back position face clear smoke free adult free firm mattress loose blankets/pillows/bumper and toy free not over wrapped or over heated remind every caregiver of rules
The wahakura – a new intervention
The wahakura – a new intervention .
Need evidence for wahakura Hard/expensive to access Need more available alternatives to wahakura
Alternatives .
Waikawa Simple quick weaving method
Alternatives The Pepi-Pod More easily available plastic box
Change for our Children, Christchurch
Evidence The Wahakura Qualitative Study Beliefs and opinions about the wahakura How the wahakura is used in normal practice Whether the safe sleep rules are understood
Evidence Kahungunu Safe Sleep Study (KISS) Randomised controlled trial To determine the safety and other benefits, or harm, of using a wahakura compared to a bassinet
Evidence KISS: Risks and benefits of a sleep environment
Risks
Thermal Hypoxia Head covering
Benefits
Sleep improvement Mother infant interaction ‘Attachment’
No difference in the environments (risks) Extended breastfeeding in the wahakura group Wahakura to be a ‘safe’ sleep environment
Evidence 2014 BMC Paeds Methodology and recruitment for a randomised controlled trial to evaluate the safety of wahakura for infant bedsharing 2014 NZMJ The wahakura: A qualitative study of the flax bassinet as a sleep location for New Zealand Māori infants
Evidence 2015 Paediatrics (in review) Safe infant sleep: a randomised controlled trial to compare an indigenous sleep device with a portable bassinet. 2015 (in preparation) A randomised controlled trial using overnight sleep studies in the home to evaluate an indigenous infant sleep device.
DHB Safe sleep projects • Audit of SS Env & SS Practice • Provision of SS Env • Proliferation of SS Messages • Including South Auckland
So whats out there for us in GP-land? Supply Wahakura and Pepi-Pods DHB projects
Evidence WQS, KISS, Haumaru Moe
Community Whakawhetū DHBs and MOH
So whats out there for us in GP-land? Risk factors Smoking in pregnancy Breastfeeding support Back sleeping Exhortation about alcohol Safe Sleep device
So whats out there for us in GP-land? Whakawhetu SUDI calculator Ed Mitchell Developing an App Individual baby risk “Change of behaviour’ Being pilotted in S Auckland
So whats out there for us in GP-land? Whakawhetu SUDI online training www.learnonline.health.nz www.whakawhetu.co.nz CME points
So whats out there for us in GP-land? Whakawhetu
‘Weave off’, SS picnics, wananga, buggy walk, maternity fashion show
Great news to finish with SIDS/SUDI Rate NZ 1978 - 2012 SIDS rate 12
Deaths per 1000 births
10 8 6 4 2 0
Maori SIDS rate
Non-Maori SIDS rate
Great news to finish with
The SIDS/SUDI story: our role in General Practice
David Tipene-Leach General Practitioner
