Analysis of police records shows key risk factors behind unexpected infant deaths
Sudden unexpected death in infancy is not only one of the most tragic fates to befall a family, it may also be one of the most preventable. Traditionally it has been regarded as a universal public health issue. That is now starting to change amid the growth of a body of opinion that messages about safe sleeping should be targeted at groups of parents known to be at increased risk, with social workers taking a major role.
Joyce Epstein, director of the Foundation for the Study of Infant Deaths (FSID) says that when resources are stretched "we need to rely on every agency to reinforce these messages". She admits that the FSID has only now become aware that foster parents of infants, for example, are not given the public health leaflets about safe sleeping which are given to all birth parents. "We don't even know how aware social workers are of these public health messages and the risk factors." As a result the FSID is setting up an online resource for foster parents and social workers.
Some in the sector also say that cot death should be considered as a child protection issue. They cite a five-year analysis from the Metropolitan Police's Project Indigo investigations, exclusively revealed to Community Care, into sudden, unexplained deaths of infants (Sudis), which has identified previously unknown indicators of elevated risk.
These include parents with criminal convictions and, within such households, histories of substance misuse, deprivation and theft, lead to higher risk of death.
Sally Parma, head of safeguarding and chair of the child death overview panel at Enfield Council, says she is very clear that the syndrome is a safeguarding issue and social workers should be more involved.
"We know that deprivation is a risk factor and these are the families that social workers are already visiting. If there's an infant in a family a social worker should not be afraid to ask: 'Where is baby sleeping? Show me where baby slept last night'."
Complex findings
The Project Indigo analysis is interesting because it has raised risk factors that would not necessarily be documented in studies with a more health-based focus. However, Epstein warns that they need to be interpreted with caution because it is not a controlled study and the reasons behind the findings about parents with criminal convictions, in particular, are likely to be complex.
Detective chief inspector Dick Henson, of the Child Abuse Investigation Command, agrees. "It would be wrong to draw any conclusions from it yet because it's an emerging finding. It could be linked to any number of things such as upbringing and deprivation and even because there is a higher proportion of those in this population who smoke. What we are saying is that if a family ticks a number of these risk factor boxes then that is the time when professionals should be thinking about targeting support to them in this area."
Henson is hoping to convene a conference next year to present more detailed analysis of the Project Indigo figures and to promote long-term, multi-agency work on preventative strategies in London.
He wants the findings to be added to a risk factor matrix which would not only "help to prioritise strategic level pro-active work in relation to the most at-risk communities, but would also help to better focus support to individual households when they are themselves at their most vulnerable".
Epstein agrees that at a time of scarce resources the only option is to have more targeted messages and move away from universal public health messages. "The FSID's strategic policy now is to focus on those vulnerable populations whose babies are dying. We're not going to entirely forget the more public messages but the reality is that these groups are labelled "hard-to-reach" for a reason. It makes sense to channel our resources into trying to reach them."
However, while Parma agrees to a certain extent, she warns that local results can vary. In Enfield they did their own analysis of nine cot deaths which occurred within one year (2008-9) and found the tragedies cut across society.
"Our findings did not reflect some of the findings nationally, such as young mothers being most at risk nor that those living in the poorest areas were most at risk. We only had one teenage mother. Some of the others included the child of a nurse and the child of a barrister, for example."
Co-sleeping
However, the one risk factor that featured in every single case was co-sleeping. "There are always lots of contributing factors but none of those babies were sleeping in their own cot," Parma says.
Henson agrees that co-sleeping is a significant factor in all the Project Indigo findings.
"But we don't tell people not to co-sleep because there are some ethnic groups who co-sleep almost universally and never have any incidents," he adds. "It is the addition of other factors such as being intoxicated, overtired and on a sofa that magnify the risk."
The issue of co-sleeping often comes up against the all-powerful breast-feeding lobby as well, Parma notes. Many breast-feeding advocates promote mothers taking their babies into bed to breast feed. But if parents are tired the danger is that they fall asleep while the child is in bed with them and the child suffocates in the bedding or under pillows unnoticed.
Whatever the differences of opinion over targeting and risk factors it seems inescapable that social workers should take on a greater role in this area.
Epstein adds that "there are few areas in child protection and child deaths which are so preventable as cotdeath and therefore is the one area where professionals can really make a difference".