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The death of a child in the first year of life is an unimaginable tragedy. Alabama has the second highest infant mortality in the nation, with more than nine in 1000 newborns dying before their first birthday.

Some of these children die because of extreme prematurity, others because of birth defects. Unsafe sleeping practices, however, are the cause of at least twenty-four percent of these deaths – deaths that are completely preventable. Every single loss of a baby is a tragedy both for a family and for our state. It is especially shocking when the baby is healthy and thriving the day before death.

I have been a pediatrician in Alabama for thirty-eight years. I count it as a personal loss every time I hear of another infant dying as a result of sleeping with an adult, on a sofa, in a lounge chair, in a baby bouncer, face down against a bumper pad, or surrounded by soft bedding. Years ago, a personal friend of mine lost her baby while sleeping on a waterbed.

I have worked on policies in my local hospital to teach new parents about safe sleeping. I have handed out an untold number of pamphlets designed for new moms, dads, grandparents, Latino parents, and African-American parents. I have placed posters in my community and attended many state meetings to discuss the problem. In desperation, I even once told a new mother that if she is going to sleep with her baby, she will have to find another doctor. I can’t deal with another senseless death.

More that twenty-five years of experience and research has led to the development of the “ABCs” of safe sleeping: Alone, on the Back, and in a Crib. Every leadership group I have worked with over the years continues to blame lack of education or cultural issues as drivers of this continued loss of life.

Recently, however, I had an “ah-ha” moment. This is not an education issue. This is not a cultural issue. This is a matter of the heart; not the head.

The revelation hit me after attending my county’s child death review meeting, followed a week later by the Fetal and Infant Mortality review for Southwest Alabama. The fact is, mothers who sleep with their babies are much more likely to have suffered from adverse childhood experiences (ACEs).

An ongoing research study conducted by Kaiser Permanente and the Center for Disease Control shows that adult illnesses (such as heart disease, liver disease, diabetes, tobacco use, substance abuse, suicide, asthma, autoimmune diseases, and even early death) are directly linked to what happens during childhood. The study surveys ten types of childhood trauma, including neglect, physical/emotional/sexual abuse, absence of a parent through divorce/death/abandonment, a family member diagnosed with a mental illness, domestic violence, incarceration of a parent/guardian, and drug/alcohol abuse in the family.

If a child suffers four or more adverse experiences, he is  32 times more likely to have learning and behavioral problems in school. As an adult, a person with four or more ACEs has a marked increase in chronic pulmonary disease, hepatitis, depression and suicide as well as many other physical and mental illnesses. (It is also worth noting that the research suggests that having a caring adult who loves the child unconditionally can buffer the effects of ACEs and lead to resilience.)

After our county Child Death Review meeting, the Forensic interviewer from our Child Advocacy Center shared that three of the mothers who slept with their babies had in previous years been victims of child sexual abuse. One had also experienced the suicide of the offending relative. A fourth one suffered from mental illness and drug abuse. At least three of these mothers had been found sleeping with their infants while still in the hospital after delivery. They received extensive education on safe sleeping and even signed a form saying they understood.

The following week, at the Fetal and Infant Mortality Review meeting for SW Alabama, social histories of the mothers who lost a child while sleeping together revealed that one had been a foster child, one had suffered severe child abuse, and another had been raped twice.

My first thought was that perhaps these mothers felt the need to protect the baby by holding them close – as much and as often as possible. But one of the experienced nurses on the team suggested that these moms have a deep desire for someone to love them in return. Their emotional needs drive them to crave a physical closeness to their child.  It is not that that they intentionally disregarded recommended safe sleeping practices. It has everything to do with what happened to them earlier in life that drives this need for touch.

Smart people with this information can design new ways to prevent these senseless deaths. Give the ACEs questionnaire to expectant moms. Identify those at risk. Refer them to a nurse-family partnership program. Discuss ways to have that closeness without bed-sharing. I feel sure there are other ways to intervene. Together let’s look for the answers.

 

Marsha D. Raulerson MEd.  MD  FAAP

Pediatrician, Teacher and Child Advocate

Brewton, Alabama

 

 

Child Abuse Prevention Month is right around the corner.  The Alabama Department of Child Abuse and Neglect Prevention, the “Children’s Trust Fund”, encourages grantees to expend additional effort to raise awareness of child abuse prevention during the month April.  We have included a copy of the 2018 Child Abuse Prevention Month Toolkit (https://ctf.alabama.gov/event/april/) to assist in planning for the month. Click here to access it. 

Even though the month of April is ceremoniously emphasized to raise awareness, it is important to remember that this is a year-round effort.  To celebrate your constant commitment to protect Alabama’s children, please plan to join us on April 6, 2018 in Montgomery at what time? for our annual planting of the pinwheel garden.

Thinking ahead for April activities, we are very excited to offer copies of the Resilience movie. If you’re not familiar with this movie, you can learn more and watch a preview here. Our agency recently purchased the rights to provide showings of the film throughout the state. Anyone interested in showing the film in their community can contact Bailey McKell Waller at bailey.waller@copperwingd1.sg-host.com to get more information on hosting a Resilience showing. This will be an excellent event to plan in April but can be done throughout the year.

The work we do as an agency and network of community providers has never been more important.  The Annie E. Casey Foundation (2018) recently estimated 22% of all children have experienced 2 or more Adverse Childhood Experiences (ACEs) in their lifetime.  In Alabama, we see an increase to 28% of surveyed children have 2 or more ACEs.  In general, states in the South and Southwest exceed the national average.  Poverty, household substance abuse, divorce, and household mental illness remain four of the most common ACEs among Alabama’s children (Sacks, Murphey, & Moore, 2014).

We look forward to hearing about your wonderful events and how you have implemented strategies to combat child abuse and neglect and build more resilient communities.

 

The Annie E. Casey Foundation. (2018, February 10). More than one in five U.S. kids has had multiple adverse experiences. Retrieved from http://datacenter.kidscount.org/updates/show/188-more-than-one-in-five-us-kids-has-had-multiple-adverse-experiences

Kann L, McManus T, Harris WA, et al. (2016). Youth Risk Behavior Surveillance — United States, 2015. MMWR Surveill Summ. 65(No. SS-6):1–174. doi: http://dx.doi.org/10.15585/mmwr.ss6506a1

Sacks, V., Murphey, D., & Moore, K. (2014, July).  Adverse childhood experiences: National and state=level prevalence. Child Trends. Retrieved from https://www.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-childhood-experiences_FINAL.pdf

On October 26, 2017, President Donald J. Trump proclaimed the opioid epidemic a Nationwide Public Health Emergency.  However, some may be unaware that Alabama already started to wage its own fight against opioid abuse and addiction.  On August 15, 2017, Governor Kay Ivey established the Alabama Opioid Overdose and Addiction Council to explore the causes and develop a strategic plan to address the overuse and abuse of prescription and non-prescription opiates in the state which was released on January 24, 2018.  Additionally, PBS premiered its special report Understanding the Opioid Epidemic on January 17, 2018.  The spotlight on the opioid use and abuse has fallen clearly on the state of Alabama in the past 12 months. Alabamians have the highest opioid prescription usage rate in the country.  So, what are the consequences and what can be done to stem the tide when enough prescription opioids were produced in 2013 to give every adult a 30-day supply?

According to the CDC, there were approximately 62 deaths per day involving prescription opioids in 2015 which represents an increase from 2014 (CDC, 2017).  One third or over 92,000 children entered U.S foster care in FY2016 in part due to parental substance abuse.  2% of children entered foster care in FY2016 due to their own substance abuse.  These figures account for multiple causes of child removal.  Neglect accounts for over 60% of child removals in FY2016 and shares a similar catchment of removal issues as parental substance users (Children’s Bureau, 2017).

Parental alcohol or substance abuse is the fastest growing contributing factor for child removal in the United States from 2000-2015 (National Center on Substance Abuse and Child Welfare, n.d.).  In Alabama, AFCARS data suggests 36.7% of children enter foster care as a result of parental substance abuse.  An estimated 5% of children are born with prenatal exposure to illicit drugs which include opioids.  Additionally, the greatest number of children entering care were less than one year old at the time of removal.  When considering these factors together, one might conclude that substance abuse literally fractures safe living environments especially among the most vulnerable children in our population.

While it may be easy to focus efforts on treating parents for opioid abuse, providers must consider how modeling from parents influences the substance use of their children.  According to a SAMSHA (2017) report, 11.8 million people age 12 and older misused opioids in the past year including almost 900,000 adolescents.  Oxycodone, hydrocodone, and codeine represented the most commonly misused pain relievers (SAMSHA, 2017). Pain relief, relaxation, and euphoric effects were the most commonly reported reasons for opioid misuse.  Lastly, individuals 12 and older report that they obtain their opioids through friends or relatives (53.0%) or from a doctor (35.4%) (SAMSHA, 2017). Parents must understand their impact as a role in modeling safe medication practices including assessing the reasons for one’s use and the necessity of medications in their household.  Additionally, parents must understand their child’s social life in an increasingly social media-driven era.

Warning signs of opioid use can vary from physical symptoms (injection marks, confusion, slowed breathing, drowsiness, and constricted pupils), to emotional symptoms (elation or euphoria, changing moods), to environmental issues or drug-seeking behaviors (doctor shopping, excessive prescription bottles, financial issues, and social withdrawal), and withdrawal symptoms (fatigue, anxiety, insomnia, sweating, nausea, vomiting, etc.) (Patterson, n.d.).  For a service provider assisting families, you should be aware of sudden drops in attendance of program participants, changes in living circumstances, shifts in behavior or mood, and reports of parenting issues from child clients. While substance abuse should be addressed, it often contributes to a variety of other social issues that affect the well-being of Alabama’s children.  As mandated reporters, we have an obligation to consider these issues and report our suspicions of child, parent, or caregiver substance abuse.

There are treatment options available even for pregnant mothers.  If you have concerns for an individual regarding their substance or you may need to seek help yourself, please contact the National Helpline at any time at 1-800-662-HELP (4357).  Additionally, you can assist a client with a warm handoff to a treatment center by visiting SAMSHA’s opioid treatment program directory or buprenorphine treatment practitioner locator provided below:

Opioid Treatment Program Directory:  https://dpt2.samhsa.gov/treatment/directory.aspx

Buprenorphine Practitioners:  https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator?field_bup_physician_us_state_value=AL

Additionally, you can inform individuals and their families of the availability of naloxone in Alabama pharmacies to counteract opioid overdoses if administered in a timely manner.  And in the coming months, please look out for the Alabama Opioid Task Force’s unveiling of two websites designed to offer support and treatment for individuals with opioid abuse issues:

www.additictionisdisease.org and www.livethelabel.org

 

References

Alabama Opioid Overdose and Addiction Council. (2017).  State of Alabama Opioid Action Plan.  [PDF format]. Retrieved from http://www.mh.alabama.gov

CDC, National Center for Health Statistics. (2017). Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA. Available at http://wonder.cdc.gov.

Children’s Bureau. (2017). The AFCARS Report.  [PDF format]. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families:  Washington, D.C. Retrieved from https://www.acf.hhs.gov/sites/default/files/cb/afcarsreport24.pdf

Combatting the National Drug Demand and Opioid Crisis.  82 Fed. Reg. 50305.  (October 26, 2017). Retrieved from https://www.federalregister.gov/documents/2017/10/31/2017-23787/combatting-the-national-drug-demand-and-opioid-crisis

Grant, J. (2018). Understanding the Opioid Epidemic. [Television broadcast]. In. J. Grant (Producer). Toronto: WNED-TV.

National Center on Substance Abuse and Child Welfare. (n.d.). Child welfare and treatment statistics. Retrieved from https://ncsacw.samhsa.gov/resources/child-welfare-and-treatment-statistics.aspx

Patterson, E. (n.d.) Opiate abuse. Retrieved from https://drugabuse.com/library/opiate-abuse/

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/

Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH, Series H-48, HHS Publication No. (SMA) 14-4863. [PDF format]. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf

U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, Children’s Bureau. (2000-2016). The Adoption and Foster Care Analysis and Reporting System (AFCARS) Data Set.