tag:theconversation.com,2011:/us/topics/infant-death-21850/articlesinfant death – The Conversation2024-02-21T13:13:43Ztag:theconversation.com,2011:article/2223022024-02-21T13:13:43Z2024-02-21T13:13:43Z80% of premature baby deaths happen in poorer countries. Five simple measures that can help save them<p>Worldwide in 2020 a baby died every <a href="https://sasog.co.za/wp-content/uploads/2023/05/Born-Too-Soon-2023.pdf">40 seconds</a> because of complications of prematurity. Preterm birth is the <a href="https://www.who.int/news-room/fact-sheets/detail/preterm-birth">leading cause of death</a> among children under 5 years old. </p>
<p>The burden of preterm birth is <a href="https://sasog.co.za/wp-content/uploads/2023/05/Born-Too-Soon-2023.pdf">heavier in in low- and middle-income countries</a>, where around 80% occur. The countries with the highest recorded preterm rates in Africa are Malawi, South Africa, Ethiopia, the Democratic Republic of Congo and Botswana. In Ethiopia <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00878-4.pdf">12.9%</a> of babies were born preterm in 2020. In Nigeria the figure was <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00878-4.pdf">9.9%</a>.</p>
<p>Preterm birth occurs when a baby is born before 37 weeks’ gestation. Preterm babies are more at <a href="https://pubmed.ncbi.nlm.nih.gov/18207020/">risk</a> of severe neurological problems, like cerebral palsy, poor lung function and long-term problems with their guts. But around 95% of babies born preterm are born <a href="https://sasog.co.za/wp-content/uploads/2023/05/Born-Too-Soon-2023.pdf">after 28 weeks</a>. They often survive with relatively less complex medical interventions. </p>
<p>Given the scale of the problem, the preterm birth committee of the <a href="https://www.figo.org/">International Federation of Gynaecology and Obstetrics</a> selected five key interventions known to save lives. </p>
<p>We co-authored a recent <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.15269">paper</a> in which we discussed the five measures. There are many other interventions that may improve outcomes at the time of labour and after preterm birth. But the five selected are clinically effective and relatively inexpensive options that can be practised in most settings.</p>
<h2>Five interventions</h2>
<p>The five interventions are:</p>
<p>1.) Giving a <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.15269">course of steroids</a> before the baby is born. This triggers changes in the baby’s lungs, allowing them to expand, and so makes breathing easier. Additionally, it reduces the risk of brain bleeds, bowel complications and death. </p>
<p>A study run by the World Health Organization in low- and middle-income countries estimated <a href="https://www.emro.who.int/child-adolescent-health/newborn-health/prematurity.html">370,000 babies</a> could be saved each year if steroids were administered. </p>
<p>The drug is on the WHO <a href="https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2023.03">List of Essential Medications</a>. It is relatively easy to administer and carries a low risk of causing the mother any problems. It is also heat stable and does not require refrigeration, which is very important for environments where electricity is in short supply. </p>
<p>2.) Mothers can be given <a href="https://www.ncbi.nlm.nih.gov/books/NBK554553/">magnesium sulphate</a> soon before delivery. This is known to <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004661.pub3/full">stabilise cell membranes</a> in the baby. This protects neurons and therefore reduces brain damage. Magnesium sulphate given to a mother in preterm labour can be <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004661.pub3/full">lifesaving</a>.</p>
<p>This drug is also on the WHO <a href="https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2023.03">List of Essential Medications</a> and appropriate for low income environments.</p>
<p>3.) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641757/">Delayed cord clamping</a> for at least a minute postnatally at delivery. </p>
<p>When a baby is born their umbilical cord is clamped and then cut. However, a delay of around a minute before clamping is associated with a <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.15269">reduction in neonatal death</a>. It also reduces the need for medications to support blood pressure in the baby – something that cannot be offered outside highly specialist medical facilities. </p>
<p>4.) Encouraging breast feeding within one hour of delivery.</p>
<p>Breastfeeding is particularly beneficial for premature babies, reducing the risks of serious complications of prematurity like severe infection or a serious bowel condition called <a href="https://www.ncbi.nlm.nih.gov/books/NBK513357/">necrotising enterocolitis</a> that often requires surgery as a lifesaving measure. </p>
<p>5.) Strongly encouraging immediate “kangaroo care”. </p>
<p><a href="https://www.who.int/publications/i/item/9241590351">Kangaroo care</a> involves a baby being placed skin-to-skin on the chest of its mother or another family member for extended periods of time – at least eight hours a day, but for as long as possible. </p>
<p>Premature babies are very prone to getting very cold. Kangaroo care <a href="https://pubmed.ncbi.nlm.nih.gov/34038632">reduces the risk</a> of death. This has been found to be the case even if there aren’t other options to stabilise the baby. </p>
<p>Kangaroo care also reduces the <a href="https://pubmed.ncbi.nlm.nih.gov/37277198/">risk of infection</a> and improves rates of breastfeeding. </p>
<p>Beyond the benefits for the baby, both kangaroo care and breastfeeding play an important part in involving parents in the care of their infant, and in reducing rates of <a href="https://pubmed.ncbi.nlm.nih.gov/37265678/">maternal postnatal depression</a>. </p>
<p>The risk of postnatal depression is known to be higher following a preterm birth. </p>
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Read more:
<a href="https://theconversation.com/every-2-seconds-in-the-world-a-baby-is-born-prematurely-report-identifies-biggest-challenges-for-their-survival-207034">Every 2 seconds in the world a baby is born prematurely – report identifies biggest challenges for their survival</a>
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<h2>Looking to the future</h2>
<p>All these interventions have a track record of being effective in low- and middle-income settings. But there has been no coordinated effort to make them better known worldwide. </p>
<p>Using multimedia and other training methods, the <a href="https://www.figo.org/news/new-ijgo-publication-effective-and-simple-interventions-improve-outcomes-preterm-infants">FIGO PremPrep-5 initiative</a> provides initial training to national obstetrics and gynaecology societies so that they can pass on the skills to other professionals.</p>
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<figcaption><span class="caption">Five simple ways to prevent preterm deaths.</span></figcaption>
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<a href="https://theconversation.com/the-number-of-premature-baby-deaths-is-still-too-high-what-can-be-done-about-it-67534">The number of premature baby deaths is still too high. What can be done about it</a>
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<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Preterm babies born after 28 weeks can often survive with relatively simple medical care. Here is how.Andrew Shennan, Professor of Obstetrics at King’s College London and chair of the FIGO Preterm Birth Committee (2012-23)., King's College LondonMegan Hall, Clinical Research Fellow, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1909712022-09-27T02:13:45Z2022-09-27T02:13:45ZBaby sling safety is under the spotlight – a 5-point checklist can keep infants safe<figure><img src="https://images.theconversation.com/files/486461/original/file-20220926-23-ishjth.jpg?ixlib=rb-1.1.0&rect=36%2C22%2C4861%2C3223&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.cancercouncil.com.au/cancer-prevention/smoking/electronic-cigarettes/generation-vape/">Shutterstock</a></span></figcaption></figure><p>Carrying babies in a soft fabric sling or carrier close to their parent or caregiver has been practised throughout the world for centuries. However, the recent <a href="https://www.smh.com.au/national/nsw/inquest-examines-role-cloth-baby-sling-played-in-death-of-three-week-old-boy-20220919-p5bj82.html">inquest</a> into the death of a three-week old baby boy in New South Wales has highlighted the potential risks of this valued aspect of infant care. </p>
<p>At least <a href="https://research.usc.edu.au/esploro/outputs/conferencePresentation/Keeping-baby-close-and-safe-Awareness/99603943802621">five babies across three Australian states</a> have died during use of an infant sling or baby carrier since 2004. Case reports from <a href="https://www.mja.com.au/journal/2011/195/6/infant-deaths-associated-baby-slings">Australia</a>, <a href="https://rednose.org.au/downloads/RN0215_20_infostatements_Slings.pdf">France, Japan</a> and the <a href="https://www.cpsc.gov/Newsroom/News-Releases/2010/Infant-Deaths-Prompt-CPSC-Warning-About-Sling-Carriers-for-Babies">United States</a> have also highlighted the risk of injuries and deaths associated with slings and carriers. </p>
<p>Although rare, these tragic deaths may have been preventable. There are protective strategies parents and caregivers can use to reduce the risk of accidents and fatalities.</p>
<h2>‘Wearing’ your baby</h2>
<p>Baby slings and carriers allow parents to “wear” their baby. First used in <a href="https://www.sciencedirect.com/science/article/abs/pii/S016363831830256X">traditional societies</a>, baby-wearing has <a href="https://doi.org/10.1080/17450101.2018.1533682">increased</a> in western societies in recent decades.
As with almost all infant care practices, there are <a href="https://rednose.org.au/downloads/RN0215_20_infostatements_Slings.pdf">benefits and risks</a>. </p>
<p>Baby-wearing is <a href="https://doi.org/10.1080/17450101.2018.1533682">convenient</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/31877392/">helps to</a> soothe and calm baby, and allows parents to pick up on infant feeding cues. It has been associated with improved <a href="https://pubmed.ncbi.nlm.nih.gov/31877392/">maternal-infant bonding</a>, increased <a href="https://pubmed.ncbi.nlm.nih.gov/22734604/">breastfeeding duration</a> and better <a href="https://pubmed.ncbi.nlm.nih.gov/32178849/">infant neck muscle development</a>. </p>
<p>However, <a href="https://www.accc.gov.au/system/files/874_Safety%20Alert_Baby%20slings_FA.pdf">adverse outcomes</a> from incorrect use include hip dysplasia, falls, burns and suffocation. </p>
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<h2>Commonly used but not well-understood</h2>
<p>In Australia, baby-wearing is very common. A <a href="https://research.usc.edu.au/esploro/outputs/conferencePresentation/Keeping-baby-close-and-safe-Awareness/99603943802621">study</a> conducted in Queensland with over 3,300 parents with babies aged 3–4 months, found 87% of parents had used a sling or baby carrier in the first three months of their baby’s life. Over one third had used a sling or carrier for <a href="https://doi.org/10.1186/s12887-020-1917-5">baby to sleep in</a>. </p>
<p>But while 65% of parents said they had read about how to use slings, less than one in five had heard of about internationally agreed upon <a href="https://raisingchildren.net.au/newborns/safety/equipment-furniture/baby-carrier-sling-safety">sling safety advice</a>, known as the <a href="https://rednose.org.au/downloads/RN0215_20_infostatements_Slings.pdf">TICKS rules</a>. </p>
<p>A variety of designs were being used by those studied, including front fabric wrap or structured baby carrier styles, over the shoulder styles, ring slings, and traditional slings. Several of these styles are not recommended for babies under four months.</p>
<p>These <a href="https://research.usc.edu.au/esploro/outputs/conferencePresentation/Keeping-baby-close-and-safe-Awareness/99603943802621">findings</a> highlighted that many parents may not be aware of potential dangers from use of infant products that do not match their baby’s growth and development.</p>
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Read more:
<a href="https://theconversation.com/why-is-newborn-baby-skin-to-skin-contact-with-dads-and-non-birthing-parents-important-heres-what-the-science-says-188927">Why is newborn baby skin-to-skin contact with dads and non-birthing parents important? Here's what the science says</a>
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<h2>Babies breathe differently</h2>
<p>Suffocation is the <a href="https://www.accc.gov.au/system/files/874_Safety%20Alert_Baby%20slings_FA.pdf">likely cause</a> in most deaths associated with slings and baby carriers. To understand the risks, we need to understand babies’ bodies and how they usually develop. </p>
<p>In particular, we need to know <a href="https://www.healthline.com/health/newborn-breathing">how babies breathe</a> and how the environment they are in can make breathing difficult. Typically, this interaction is dynamic – it changes as a baby grows and develops. </p>
<p>It’s important to note babies can have <a href="https://extension.okstate.edu/fact-sheets/protecting-infants-and-toddlers-from-positional-asphyxia-car-seats-and-sling-carriers.html">difficulty with breathing</a> without making any noise or movement. </p>
<p>Compared to older children, <a href="https://www.rch.org.au/trauma-service/manual/airway-management/">babies</a> have smaller and more easily compressed airways. And they have a large, heavy head relative to their body size, with a <a href="https://www.stanfordchildrens.org/en/topic/default?id=anatomy-of-the-newborn-skull-90-P01840">protruding occiput</a> (that bony bump on the back of their head) that tips the head forward even when lying on their back. </p>
<p>Babies prefer to breathe through their noses. They have <a href="https://www.productsafety.gov.au/about-us/publications/best-practice-guide-for-the-design-of-safe-infant-sleeping-environments">less respiratory stamina</a> (their ability to respond to reduced oxygen) and less ability to control their temperature, particularly if their head is covered.</p>
<p>The anatomy and physiology of babies younger than 12 months means they are <a href="https://www.productsafety.gov.au/about-us/publications/best-practice-guide-for-the-design-of-safe-infant-sleeping-environments">vulnerable to suffocation</a> in several specific ways.</p>
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<h2>4 ways a baby’s airway can be at risk</h2>
<p>We need to think about the baby’s airway <a href="https://www.changeforourchildren.nz/safe_start_programme/through_the_tubes">as a tube</a>. It needs to remain open for oxygen to get to the lungs. Everyone who cares for young babies needs to be aware this tube may be </p>
<ul>
<li>covered</li>
<li>pinched off</li>
<li>bent </li>
<li>pressed on. </li>
</ul>
<p>Any of these actions increase the risk of suffocation. </p>
<p>Babies under four months of age often lack the strength to move their heads to keep their airways clear. So if baby’s face is covered or pinched off by fabric or the wearer’s body, rapid suffocation can occur. </p>
<p>If baby is lying with a curved back in a C-position – such as in a baby capsule, sling or carrier – and the head is able to tip forward to chin-on-chest, their airway may bend. This too can result in reduced oxygen and slow suffocation. </p>
<p>Finally, if there is pressure on baby’s chest, such as when a carrier or sling is too tight around baby’s body, the infant might not be able to expand their chest to take deep enough breaths. </p>
<p>Babies born preterm, of low birth weight or those who are unwell need <a href="https://raisingchildren.net.au/newborns/safety/equipment-furniture/baby-carrier-sling-safety">extra consideration</a> and support to maintain a clear airway, compared to full term babies.</p>
<h2>The 5-point checklist: TICKS</h2>
<p>The <a href="https://babyslingsafety.co.uk/">TICKS checklist</a> extends the idea of the airway as a tube that needs protecting. It is applicable to various circumstances such as infant car seats, bouncers and rockers, as well as slings and baby carriers. The five points promote safe baby-wearing by emphasising caregiver observation and optimal infant positioning to reduce suffocation risk. The baby should be positioned in a way that is</p>
<ul>
<li>tight (firm enough to position baby high and upright with head support)</li>
<li>in view at all times</li>
<li>close enough to kiss</li>
<li>keeps their chin off chest</li>
<li>supports their back.</li>
</ul>
<p><a href="https://www.babyproductsafety.gov.au/move-safe/baby-slings-and-carriers">Product Safety Australia</a>, <a href="https://raisingchildren.net.au/newborns/safety/equipment-furniture/baby-carrier-sling-safety">Raising Children’s Network</a>, and <a href="https://rednose.org.au/downloads/RN0215_20_infostatements_Slings.pdf">Red Nose</a> have also published advice for parents who are considering slings or carriers for their baby. </p>
<p>Currently there are <a href="https://rednose.org.au/downloads/RN0215_20_infostatements_Slings.pdf">no Australian standards</a> for the manufacture of baby carriers and slings, despite slings developed in other countries being available for purchase in Australia. </p>
<p>Raising public awareness about safety and the TICKS checklist, together with recommendations for selecting and using slings and carriers appropriate for baby’s age and development, will help parents harness the benefits of using slings and carriers to keep their babies close and safe. </p>
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<p class="fine-print"><em><span>Jeanine Young is affiliated with the Queensland Child Death Review Board. Jeanine is also a volunteer Board Member. for Little Sparklers, a parent consumer and advocacy group. Jeanine was an active member of the Red Nose National Scientifid Advisory Group from 2004- June 2021 and the author of the Red Nose Information Statement: Slings, Baby Carriers and Backpacks.</span></em></p>Although rare, deaths of babies in slings are potentially preventable. Caregivers should visualise the baby’s airway as tube that is vulnerable and needs protection.Jeanine Young, Professor of Nursing & Deputy Head of School - Research, University of the Sunshine Coast, University of the Sunshine CoastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1057232018-11-20T11:35:29Z2018-11-20T11:35:29ZPreventing infant deaths: The ABCs of safe baby sleep<figure><img src="https://images.theconversation.com/files/242494/original/file-20181026-7056-t9kw9c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Babies should sleep on their backs, as this one is doing. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-asian-boy-baby-sleeping-on-1173691807?src=h6o9syy70fOaoqD1H35qgg-1-5">lsarapic/Shutterstock.com</a></span></figcaption></figure><p>I recently read an X-ray study of an infant who died while sleeping with a parent. I am a pediatric radiologist, and in cases where an infant has died unexpectedly, we often obtain X-ray images to make sure that the infant does not have skeletal fractures or other signs of injury that might suggest that he or she was the victim of child abuse. Most of the time we find no such evidence.</p>
<p>Yet every infant death is heart-wrenching, above all for the parents who wake up to discover their infant limp and lifeless.</p>
<p>Each year, about 3,600 U.S. children under the age of 1 year <a href="https://www.cdc.gov/sids/data.htm">die</a> suddenly and unexpectedly. Such deaths are <a href="https://www1.nichd.nih.gov/sts/news/downloadable/Pages/infographic_byage.aspx">especially common</a> in babies between 1 and 4 months of age, perhaps because younger infants are less capable of repositioning themselves and crying out for help. For reasons that are unclear, such deaths are also <a href="https://www1.nichd.nih.gov/sts/about/SIDS/Pages/fastfacts.aspx">slightly more common</a> among boys than girls.</p>
<p>While all infant deaths are not preventable, many are. A <a href="https://www.charlotteobserver.com/news/special-reports/nc-medical-examiners/article9165191.html">2010 investigation</a> of hundreds of deaths in North Carolina showed that as many as two-thirds may have been attributable to ill-advised sleep practices, such as the use of unsafe bedding and sleeping with adults. Many are thought to be due to suffocation, when the baby’s airway becomes blocked or when a larger person rolls over and prevents the baby’s chest from expanding during breathing.</p>
<h2>The ABCs of safe sleep</h2>
<p>Efforts to prevent such deaths have led the American Academy of Pediatrics to formulate a <a href="http://pediatrics.aappublications.org/content/138/5/e20162938">policy</a> on safe infant sleep, key points of which can be summarized as the ABCs of safe sleep:</p>
<p>A – Alone. This does not mean that babies should be put to bed in a room separate from parents. It does, however, mean that infants should not sleep in the same bed. The reason for this is that parents may move during sleep in ways that interfere with babies’ breathing or even crush them. Inadvertently dozing off while breastfeeding or cuddling an infant is just as hazardous as intentionally co-sleeping.</p>
<p>B – Back. Babies should always be put to sleep on their backs. There is nothing wrong with placing healthy babies on their tummies to play, but on the back appears to be the safest position for sleeping. One possible explanation is the fact that babies lying on their bellies are more likely to rebreathe the air they exhale, causing blood levels of carbon dioxide to rise as oxygen falls. This recommendation applies throughout the first year, but it is especially important in the first six months after birth.</p>
<p>The American Academy of Pediatrics <a href="http://pediatrics.aappublications.org/content/138/5/e20162938">policy</a> on safe sleep explicitly contradicts the outdated view that back-sleeping increases the risk of choking. While it is true that many infants experience <a href="https://medlineplus.gov/ency/article/001134.htm">gastroesophageal reflux</a>, familiar to parents as “spitting up,” healthy babies protect themselves against aspiration. Parents should also avoid raising the head of the crib. It doesn’t reduce the risk of reflux and can cause babies to slide into a dangerous position.</p>
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<img alt="" src="https://images.theconversation.com/files/242497/original/file-20181026-7074-1wv4cg4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242497/original/file-20181026-7074-1wv4cg4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242497/original/file-20181026-7074-1wv4cg4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242497/original/file-20181026-7074-1wv4cg4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242497/original/file-20181026-7074-1wv4cg4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242497/original/file-20181026-7074-1wv4cg4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242497/original/file-20181026-7074-1wv4cg4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Babies should always sleep in a crib or bassinet, and never in a bed with a parent.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/adorable-newborn-baby-sleeping-swaddled-white-307435160?src=9Ibf9zp2mi4pAUUlqSfWwQ-1-32">FamVeld/Shutterstock.com</a></span>
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<p>C – Crib. Cribs and bassinets that meet current safety standards are the safest places for babies to sleep, while chairs and sofas should be avoided. A firm surface prevents the baby’s face from becoming caught in a fold or indentation. Likewise, the crib should be empty of loose bedding, pillows, bumpers and toys, any one of which could cause entrapment and suffocation. Too many coverings can also increase the risk that a baby will overheat, an important consideration because <a href="https://www.chop.edu/conditions-diseases/warmth-and-temperature-regulation">temperature regulation</a> is not fully developed in infants. </p>
<p>Of course, there are other steps parents can take to ensure that their babies sleep safely. One is to prevent exposure to <a href="https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx">cigarette smoke,</a> which appears to increase the risk of sudden infant death. Unsurprisingly, parental intoxication and illicit drug use also appear to place babies at greater risk. Another key factor is making sure that others who care for the baby, such as family members and daycare workers, understand the importance of adhering to the ABCs of safe sleep.</p>
<p>It is important to avoid stigmatizing parents who have lost an infant. In many cases, like the baby whose X-rays I read, we never know for sure what caused the death. Yet there are simple steps every parent can take to enhance the safety of sleeping infants, and it all begins with education. My colleagues and I hope that by educating parents about the ABCs of safe sleep, we may be able to prevent hundreds – perhaps even thousands – of infant deaths every year.</p><img src="https://counter.theconversation.com/content/105723/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Gunderman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hundreds – perhaps thousands – of infant deaths every year are preventable if parents make sure babies sleep in their own cribs, on their backs.Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/625002016-07-17T20:09:18Z2016-07-17T20:09:18ZA snapshot of children’s health in Australia<figure><img src="https://images.theconversation.com/files/130637/original/image-20160715-2110-in0zi4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The overall infant mortality rate more than halved between 1986 and 2014. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>Today, we start our series looking at health conditions in children. Later in the week, we’ll have articles about childhood migraines, bed-wetting in older kids, and nightmares and night terrors.</em></p>
<p><em>The infographic below provides a snapshot of children’s health in Australia, from mortality and chronic conditions to the risk factors adversely affecting our children’s health.</em> </p>
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This infographic provides a snapshot of children’s health in Australia, from mortality and chronic conditions to the risk factors adversely affecting our children’s health.Alexandra Hansen, Deputy Editor and Chief of Staff, The Conversation AUNZEmil Jeyaratnam, Data + Interactives Editor, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/494352015-10-21T23:51:34Z2015-10-21T23:51:34ZBetter care and communication can cut stillbirth rates and avoid unnecessary trauma<figure><img src="https://images.theconversation.com/files/99128/original/image-20151021-15451-1izl8gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The death of an unborn baby is a devastating and traumatic event</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>An unusually high number of stillbirths and infant deaths at a Victorian regional hospital has stirred up a grim topic often hidden from public view. <a href="http://www.abc.net.au/news/2015-10-20/bacchus-marsh-hospital-midwives-reading-ultrasound-manual/6868426">A review of ten of these deaths</a> occurring in 2013 and 2014 found that seven may have been avoidable.</p>
<p>The death of an unborn baby is a devastating and traumatic event, with long-lasting <a href="http://www.biomedcentral.com/1471-2393/15/188/">psychological, social and economic impacts</a> on parents, families and society. In Australia, around <a href="http://www.aihw.gov.au/publication-detail/?id=60129550033">2,225</a> stillbirths occur each year.</p>
<p>The majority of these deaths are not fully, diagnostically investigated, while some remain unexplained despite thorough investigation. Although there are beliefs stillbirth is “nature’s way” and therefore “meant to be”, <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=stillbirths+the+vision+for+2020">many stillbirths are preventable</a> with improved health and quality care. </p>
<h2>Causes and risk factors</h2>
<p>In Australia, <a href="http://www.health.vic.gov.au/ccopmm/about/mortality.htm">stillbirth is defined</a> as the death of a baby of at least 20 weeks’ gestation or 400 grams in weight. Most stillbirths occur in the antenatal period.</p>
<p><a href="http://www.aihw.gov.au/publication-detail/?id=60129550033">Causes of death</a> can include infection, the mother’s health, haemorrhage, spontaneous preterm birth and congenital abnormality. </p>
<p>In high-income countries, no definitive cause is found in around <a href="http://www.ncbi.nlm.nih.gov/pubmed/21496907">30%</a> of stillbirth cases. But <a href="http://www.ncbi.nlm.nih.gov/pubmed/21496916">mothers most at risk</a> include those who are older, smokers, those with obesity and diabetes, and women with a past history of stillbirth. </p>
<p>Problems with the placenta that restrict blood and nutrient flow from the mother to the baby, called <a href="http://www.ncbi.nlm.nih.gov/pubmed/24953162">placental insufficiency</a>, are strongly linked with stillbirth. Fetal growth restriction, twin or multiple pregnancy, ethnicity and social disadvantage, can also play a part.</p>
<p>However, many women who have a stillborn baby have no identifiable risk factors. And in a some cases, substandard care can be to blame.</p>
<h2>Substandard care</h2>
<p>Substandard care appears to more commonly contribute to stillbirths during labour and birth. A Dutch <a href="http://www.sciencedirect.com/science/article/pii/S0301211599001359">study showed inadequate care</a> may have played a part in around 30% of stillbirths. </p>
<p>A 2010 <a href="http://www.pi.nhs.uk/pnm/clinicaloutcomereviews/index.htm">confidential enquiry</a> in the United Kingdom found the majority of reviewed infant deaths at birth had “contributing factors”, some of which may have lead directly to the death of the baby. While in New Zealand, adequate care <a href="http://www.hqsc.govt.nz/publications-and-resources/publication/2123/">could have prevented</a> 19% of stillbirths in 2013. </p>
<p>Concerns about care in the UK report included failures to identify signs of poor health (such as poor growth of the baby), misinterpretation of the fetal heart rate, failure to consult senior staff, and poor communication between care providers or with the mother.</p>
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<span class="caption">Not following clinical guidelines can contribute to stillbirths and infant deaths.</span>
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<p>Failure to follow clinical practice guidelines and poor communication is <a href="http://www.ncbi.nlm.nih.gov/pubmed/2149690">most common</a> in substandard care. Low antenatal care attendance and poor management of the mother’s health conditions, such as diabetes, are also instances of inadequate care.</p>
<h2>Coronial inquests</h2>
<p>There are a number of ways to investigate the causes of stillbirth. As the gold standard, it is <a href="http://www.ncbi.nlm.nih.gov/pubmed/21496907">recommended</a> all parents be offered an autopsy of the baby and examination of placental tissue to look for abnormalities that may weaken placental function.</p>
<p>But <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2012.03357.x/full">some parents don’t consent to an autopsy</a>, while others are not approached at all about the possibility. Some are not appropriately counselled to help them make an informed decision about whether to have the autopsy.</p>
<p>Tests such as these are also limited in availability due to high costs as well as access to equipment and expertise. </p>
<p>Several rights and legal groups <a href="http://www.mauriceblackburn.com.au/about/media-centre/newsletters/medical-law/autumn-2012/legal-rights-of-infants-and-parents/">are advocating to incorporate</a> stillbirths into states’ Coroner’s Acts for their cause to be determined through a Coronial inquest.</p>
<p>But this is not the most appropriate way of investigating stillbirths, for a number of reasons. </p>
<p>First, the purpose of the Coroner is to determine whether the cause of a death is natural or caused by accident or injury. Because the majority of stillbirths aren’t a result of the latter, and have an obvious cause, they wouldn’t fulfil the requirement of this determination.</p>
<p>Further, a Coronial inquest would mean the autopsy would generally be performed by a forensic pathologist rather than a more suitable, skilled perinatal pathologist.</p>
<p>And most importantly, there are significant disadvantages for women and their families. The major limiting factor to autopsy being performed in the case of a stillbirth is parental consent, as many don’t wish their child to undergo this procedure. </p>
<p>The inquest – which would have the bereaved family separated from the child immediately after birth – would take the choice away from parents and surely add to their emotional turmoil. </p>
<p>And while autopsy is the gold standard test (along with placental pathology) there are alternatives to autopsy which are often helpful in understanding why the baby died.</p>
<h2>Recommended investigation</h2>
<p>The Perinatal Society of Australia and New Zealand <a href="http://www.stillbirthalliance.org.au/guideline1.htm">sets out recommendations</a> for maternity services to investigate and clinically audit stillbirths and neonatal deaths. </p>
<p>These audits should be conducted by the health service responsible, with an external expert panel doing an in-depth review. This review must be underpinned by comprehensive information about the death. </p>
<p>Victoria is currently introducing a state-wide perinatal autopsy service to ensure high-level advice on the appropriate investigations is given and appropriate support and counselling can be set in place for families. </p>
<p>For the cases of unexpected stillbirths in late pregnancy, there will be a requirement under the regulations of the Act that governs the <a href="http://www.health.vic.gov.au/ccopmm/">Consultative Council on Obstetric and Paediatric Mortality and Morbidity</a>, that these deaths are notified within 48 hours.</p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1034/j.1600-0412.2003.00224.x/abstract">Norway</a> introduced perinatal mortality audits such as these, which have been associated with improved care and less perinatal deaths.</p>
<p>In 2011 the <a href="http://www.thelancet.com/series/stillbirth">Lancet’s stillbirths series</a> urged all high-income countries to implement routine perinatal mortality audits, governed at the national level. Despite this call, only a handful of countries have such programs in operation.</p><img src="https://counter.theconversation.com/content/49435/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vicki Flenady receives funding from Stillbirth Foundation Australia, the NHMRC and Queensland Health.</span></em></p><p class="fine-print"><em><span>Aleena Wojcieszek has received funding from Stillbirth Foundation Australia. </span></em></p><p class="fine-print"><em><span>David Ellwood receives funding from NHMRC and Stillbirth Foundation Australia. He is a past-Chair of the International Stillbirth Alliance.</span></em></p>The death of a baby, whether born or unborn, is a devastating and traumatic event. More than 2,000 stillbirths occur every year in Australia. But a large number of them can be prevented.Vicki Flenady, Associate Professor, School of Medicine, School of Population Health, and School of Nursing and Midwifery, The University of QueenslandAleena Wojcieszek, Research Officer, Stillbirth Prevention Group, Mater Research Institute, The University of QueenslandDavid Ellwood, Professor of Obstetrics & Gynaecology, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.