Successful injury prevention efforts depend on high quality data to better understand the circumstances of the injury/fatality events. Child Fatality Review in Georgia is a great source for these data, and the local Child Fatality Review committees are key in implementing prevention efforts. This workshop will offer data from reviewed child deaths, reported trends over time, and present opportunities for targeted prevention efforts.

1. 2nd Annual Conference
September 4, 2013

2. Child Fatality Review in Georgia
Reported Trends and Prevention
Opportunities

3. Child Fatality Review:
What We Do
• To serve Georgia’s children by:
– promoting more accurate identification and reporting of child
fatalities,
– evaluating the prevalence and circumstances of both child abuse
cases and child fatality investigations, and
– monitoring the implementation and impact of the statewide
child injury prevention plan in order to prevent and reduce
incidents of child abuse and fatalities in the state
• The most important reason to review child fatalities in
Georgia is to identify factors that can improve the health
and safety of children, and to prevent other children from
dying

4. Reviewed Deaths, 2005-2011
623
594
681
571
518
594
495
0
100
200
300
400
500
600
700
800
2005 2006 2007 2008 2009 2010 2011

5. All Reviewed, 2011 (N=495)
2
3
5
5
8
8
15
16
19
28
59
85
87
155
0 50 100 150 200
Other (Weather-related)0.4%
Unintentional Firearm 0.6%
Exposure 1.0%
Fall/Crush 1.0%
Asphyxia/Suffocation 1.6%
Poison 1.6%
Fire 3.0%
Undetermined 3.2%
Suicide 3.8%
Drowning 5.7%
Homicide 11.9%
Medical 17.2%
Motor Vehicle-Related 17.6%
Sleep-Related Infant Deaths…

6. CFR Definition of “preventable”
• The definition of “preventable” for CFR in Georgia
states that a child’s death is preventable if the
community or an individual could reasonably
have done something AT ANY POINT PRIOR TO
THE DEATH that COULD have changed the
circumstances that led to the death.
• We often think that injury events are random
"accidents.” However, most injuries to children
are predictable, understandable, and therefore
preventable.

7. Preventability, Reviewed Deaths, 2011
CAUSE Missing/Blank No, Probably
Not
Yes, Probably Team could
not determine
%
Preventable*
All
Unintentional 2 18 134 10 88.2%
SIDS -- 6 -- 2 n/a
Sleep-Related
Asphyxia 1 2 21 4 91.3%
SUID 6 15 61 26 80.3%
Homicide 4 5 48 3 90.6%
Suicide -- 3 16 -- 84.2%
Undetermined -- 4 3 7 n/a
Medical 9 49 17 19 25.8%

8. 2011 Prevention Recommendations
• Committees can choose multiple
recommendation areas in each death, because
there are many ways that prevention efforts can
be delivered to parents, caregivers, communities,
providers, and policymakers.
• In 2011, there were 104 deaths (21%) where the
committees made a prevention recommendation
for at least one area (e.g. education, law/policy,
environment, etc). In 391 cases, the committee
did not recommend any preventive action.

9. 2011 Prevention Recommendations
• Of the 227 “education” recommendations, committees
most often suggested media campaigns, school
programs, parent education, and community safety
projects
• Of the 12 “law” recommendations, committees most
often identified enforcing existing laws and ordinances
• Of the six “agency” recommendations, committees
most often identified revising policies, creating new
programs, and expanding services

10. Important Terms
• SIDS – Sudden Infant Death Syndrome
• SUID – Sudden Unexplained Infant Death
• Sleep-related Asphyxia
• Accidental Suffocation or Strangulation in Bed
(ASSB)
• Unknown/Undetermined

11. SIDS
• sudden death of an infant under one year of
age which remains unexplained after a
thorough case investigation, including
performance of a complete autopsy,
examination of the death scene, and review of
the clinical history

12. Safe Sleep Environment

13. SUID
• Infant deaths reported to medical examiners
and coroners that:
– Occur suddenly and unexpectedly
– Have no obvious cause (and/or manner) of death
prior to investigation
– After investigation, risk factors are identified that
COULD HAVE contributed to the death, but are
not conclusive to have CAUSED the death

14. Safe or Unsafe?

15. Common Patterns
• Most sleep-related deaths occur when the infant is
between two and four months of age
• More sleep-related deaths occur in the colder months
• More males die from sleep-related deaths than females
• African-American infants have a 2-3 times greater risk of
dying from unsafe sleep than Caucasian infants
• Back sleeping is the safest sleep position for infants under
one year of age
• About 75% of infants who die suddenly and unexpectedly
die while they are sleeping in the same place
(couch, futon, or bed) as another person
• SIDS is not the same as suffocation/asphyxia, but both can
happen when the infant is asleep

16. Month of Death for Reviewed Sleep-
Related Deaths, 2006-2011 (N=1,094)
106
94 97 100
93
76 80 84 82 79
105
98
0
20
40
60
80
100
120

17. Sleep-Related Deaths by
Location, 2011 (N=155)
1
2
2
3
4
5
14
19
25
80
0 20 40 60 80 100
Stroller
Floor
Carseat
Chair
Playpen
Other
Bassinette
Couch
Crib
Adult bed

18. 61%
39%
Sharing
Alone
2011 Sleep-Related Deaths by
Bedsharing status (N=152)

19. Common Issues with Bedsharing
• “I’m gone all day at work and I want her close
to me at night so I can cuddle with her in bed”
• “I want to keep breastfeeding whenever she
needs me, but I don’t want to get up and walk
back and forth to her crib all night either”
**https://www.childwelfare.gov/pubs/guide2013/bonding.pdf**

20. “ Cribs for Kids” Pack and Play

21. Cribs for Kids “Safe Sleep Survival Kit”
-Graco pack and play
-crib sheet with safe sleep message
-Halo sleep sack
-newborn pacifier
-safe sleep magnet

22. Position Placed to Sleep, when
known, 2009-2011 (N=432)
212
144
76
94
0 50 100 150 200 250
Placed on Back (Supine)
Placed on Stomach (Prone)
Placed on Side
Unknown

23. Upper Respiratory Anatomy: Baby in
Back Sleeping Position

24. Upper Respiratory Anatomy: Baby in
Stomach Sleeping Position

25. Sleep Position Source: NICHD Household Survey
SIDS Rate Source: National Center for Health Statistics, CDC
National SIDS Rate and Sleep Position,
1988-2008
1.4 1.39
1.3 1.3
1.2 1.17
1.03
0.87
0.74
0.77
0.720.670.620.560.570.530.560.540.550.570.55
13
17
26.9
38.635.3 53.1
55.7
64.466.6
71.671.172.870.172.275.7
70.372.1
0
50
100
0
0.5
1
1.5
PercentBackSleeping
SIDSRate
Year
Pre-AAP recommendation Post-AAP BTS Campaign

26. MODIFIABLE RISK FACTORS
• What are some “modifiable risk factors” for
sleep-related deaths?
– What are some things we can change –
environment, engineering, behaviors – that might
reduce the chances of an infant dying during
sleep?

27. American Academy of Pediatrics (AAP)
• AAP’s new safe sleep recommendations were published
in November 2011
• Recommendations target the creation of a safe sleeping
environment for infants to prevent infant sleep death
from a variety of causes
• The recommendations are divided into 3 levels.
– Level A – based on good, consistent scientific evidence
– Level B – based on limited, inconsistent scientific
evidence
– Level C – based on consensus and expert opinion

28. 2011 AAP Recommendations:
Level A (based on consistent scientific evidence)
–Always place baby on back for every sleep
time
–Use a firm sleep surface covered with fitted
sheet
–Room sharing without bed sharing
–Keep soft objects and loose bedding out of
baby’s sleep area, including bumpers
–Pregnant women should receive regular
prenatal care

29. 2011 AAP Recommendations:
Level B (based on inconsistent scientific evidence)
• Avoid smoking exposure during pregnancy
and after birth
• Avoid alcohol and illicit drug use during
pregnancy and after birth
• Breastfeed baby
• Consider giving a pacifier at nap time and bed
time
• Avoid overheating

30. 2011 AAP Recommendations:
Level C (based on consensus and expert opinion)
• Infants should get well-baby check-ups and
vaccines
• Avoid commercial devices marketed to reduce
SIDS
• Do not use home breathing and heart
monitors to reduce SIDS
• Give supervised tummy time
AAP Pediatrics, Vol. 128, # 5, November 2011

31. New Safe to Sleep Campaign Logo
(**changed from “Back to Sleep”**)
English
Spanish

32. Safe to Sleep Campaign Materials
The expanded “Safe to Sleep” campaign builds on the success and reach of the “Back
to Sleep” campaign.
In addition to strategies for reducing the risk of SIDS, “Safe to Sleep” also describes
actions that parents and caregivers can take to reduce the risk of other sleep-related
causes of infant death, such as suffocation.

33. Safe to Sleep Campaign Materials

34. Safe To Sleep Campaign
The campaign’s main messages are:
1. Babies sleep safest on their backs.
2. Create a separate sleep area for your baby.
3. Sleep surface matters. Use a firm
surface, covered by a fitted sheet. Remove all
bumpers, loose bedding, soft objects and toys.
** http://www.nichd.nih.gov/SIDS**

35. MOTOR VEHICLE RELATED DEATHS

36. Motor Vehicle-related deaths by
Position, 2011 (N=87)
26
21
17
12
6
3
2
0
5
10
15
20
25
30
Back Seat
Passenger
Pedestrian Driver Front Seat
Passenger
Passenger
- Unknown
position
Other Bicyclist

37. Motor Vehicle-Related
Deaths
•Of 15-17 year old MV-
related deaths:
•46% of those were
operating the vehicle
•29% were passengers
•Less than 20% of those
driving were under
influence (DUI)
5%
17%
13%
18%
46%
Percentage of Deaths by Age, Motor
Vehicle
2004-2008
Infants
1-4 years
5-9 years
10-14 years
15-17 years

38. Common Patterns
• Child restraint systems (i.e. car seats) are often used
incorrectly – studies suggest up to 80%
• Restraint use among young children often depends upon
the driver’s seat belt use. Almost 40% of children riding
with unbelted drivers are also not restrained appropriately
• Approximately 39% of backover deaths occurred at home in
the driveway, an apartment parking lot or in a townhome
complex
• Sports utility vehicles and trucks are involved in more
backovers than cars
• Of reviewed toddler Motor Vehicle-related deaths in
Georgia, 42% of victims were pedestrians
– Driveways
– Playing in yard, darting out
– Walking in roadways

39. MODIFIABLE RISK FACTORS
• What are some “modifiable risk factors” for
motor vehicle deaths?
– What are some things we can change –
environment, engineering, behaviors – that might
reduce the chances of someone being hurt or
killed by a vehicle?

40. Prevention Together
• Rules aimed at helping drivers avoid unintentionally backing over
children, already overdue, are being delayed again following
complaints from automakers that requiring rearview video cameras
systems on new cars and trucks would be too expensive.
• The new rear visibility standard was required by a law that Congress
passed in 2008 in response to dozens of accidents in which children
were backed over. At issue in particular were blind zones in large sport
utility vehicles and pickups.
• More than a year ago, the National Highway Traffic Safety
Administration proposed requiring improved driver rear visibility in
new vehicles, a standard that in most cases would necessitate rear-
mounted video cameras with in-vehicle display screens. The
regulations were to be phased in, applying to all cars and light trucks by
the 2014 model year.

41. MEDICAL DEATHS

42. Medical Deaths by Age of
Decedent, 2011 (N=85)
AGE NUMBER PERCENT
Infant 31 35.6
1 to 4 16 18.4
5 to 9 10 11.5
10 to 14 12 13.8
15 to 17 16 18.4

43. 2010 Reviewed Medical Deaths,
All Ages
1
1
3
4
4
5
8
8
15
20
30
0 5 10 15 20 25 30 35
Malnutrition/dehydration
Unknown
Asthma
Neurological/seizure disorder
Prematurity
Undetermined medical cause
Congenital anomaly
Other infection
Pneumonia
Cardiovascular
Other medical condition

44. MODIFIABLE RISK FACTORS
• What are some “modifiable risk factors” for
medical deaths?
– What are some things we can change –
environment, engineering, behaviors – that might
reduce the chances of someone dying from an
illness or disease?

45. Prevention Together
• The Urban Health Program in the department of pediatrics at Emory
University School of Medicine recently announced funding for 18
planning grants throughout Georgia, to stimulate
development, collaboration, and community discussion to expand the
number of school-based health centers. The grants are funded by a $3
million gift from the Zeist Foundation aimed to help improve
outcomes for at-risk children in metro Atlanta and throughout the
state over the next five years.
– There are 2,000 school-based health clinics in the nation. School-based
health centers are located in schools or on school grounds, and they
employ a multidisciplinary team of providers to care for children. They
also provide clinical services through a qualified health provider such as a
hospital, health department, or medical practices. Florida has
245, California has 160, Louisiana has 64, Mississippi has 31, and Georgia
has only two in the entire state.
– The 2009 Kids Count Data Book ranked Georgia children 42nd in the
nation for well being. More than 300,000 of the state’s children are
uninsured with very limited access to routine healthcare.

46. HOMICIDE DEATHS

47. Demographics (Age) of Reviewed Homicide
Deaths, 2011 (N=60)
Infant
14
24%
1 to 4
17
28%
5 to 9
6
10%
10 to 14
9
15%
15 to 17
14
23%

48. Reviewed Homicide Deaths, by
Mechanism, 2011 (N = 60)
7
1
1
1
2
3
3
7
14
21
0 5 10 15 20 25
Unknown
Choking
Deprivation
Exposure
Drowning
Fire
Poison
Knife
Blunt Force Trauma
Firearm
Number of Deaths

49. MODIFIABLE RISK FACTORS
• What are some “modifiable risk factors” for
homicide deaths?
– What are some things we can change –
environment, engineering, behaviors – that might
reduce the chances of someone being hurt or
killed by someone else?

50. Prevention Together
• Chicago’s CeaseFire uses a public health model to stop
shootings and killings. CeaseFire is a
unique, interdisciplinary, public health approach to violence
prevention. Violence is a learned behavior that can be
prevented using disease control methods. Using proven
public health techniques, the model prevents violence
through a three-prong approach:
– Identification & detection
– Interruption, Intervention, & risk reduction
– Changing behavior and norms
• The award-winning film “The Interrupters” (released in
2012) shows how three CeaseFire workers are changing
their community landscape and reducing violence and
homicide. Watch it free on Frontline (www.pbs.org)

51. SUICIDE DEATHS

52. Demographics (Race/Gender) of Reviewed
Suicide Deaths, 2011 (N=19)
White Male
12
White Female
2
African-
American Male
2
African-
American
Female
2
Asian Male
1

53. Reported Risk Factors, 2011
(**multiple risk factors could be selected for each individual case**)
7 7
5 5
4 4 4
3
2
0
1
2
3
4
5
6
7
8

54. MODIFIABLE RISK FACTORS
• What are some “modifiable risk factors” for
suicide deaths?
– What are some things we can change –
environment, engineering, behaviors – that might
reduce the chances of someone trying to hurt or
kill themselves?

55. Prevention Together
• The Sources of Strength (SOS) Program is
provided as part of the Garrett Lee Smith
grant youth suicide prevention activities out of
the Georgia Department of Behavioral Health
and Developmental Disabilities (DBHDD).

56. Sources of Strength (SOS)
• Comparing the Department of Education (DOE) Student
Health Surveys for the Middle Schools in Houston and
Emanuel Counties that have Sources of Strength Teams
(three schools/ 750 students sampled) with those that
don't (seven schools/ 2,300 students sampled) after
implementing the program:
– The schools that have SOS showed a decrease in the number of
students reporting that they have seriously considered suicide
in the past year by 42% compared to an 8% decrease in the
schools without SOS
– In the schools that have SOS, self-reports of annual suicide
attempts showed a 21% drop compared to a 16% drop in those
schools without SOS

57. Sources of Strength (SOS)
• After three months of participation in SOS, 88
Middle School and High School students
completed follow-up surveys indicating that:
– 99% believed there was an adult at school that could
be trusted to help suicidal students (an increase from
83%)
– 98% would tell an adult about a suicidal friend even if
asked to keep it secret (an increase from 88%)
– 74% would go to an adult at school if they had a
problem (an increase from 64%)

58. Prevention Strategies in Georgia
• Promoting Protective Factors
– Protective factors are conditions that buffer a person
from exposure to risk by either reducing the impact of the
risks or changing the way that one respond to risks
• Reducing Risk Factors
– Risk factors are conditions that increase the likelihood of
a person becoming involved in problem behavior or
developing a disease or injury (e.g., smoking increases
the chance of developing lung cancer)

59. Richmond County – Fatality Trends
• 131 child deaths reported to CFR since 2006
– 34 child deaths from 2010-2011
– of those, 16 were infants (47%)
– the most frequent causes overall were:
• homicides (N=9)
• sleep-related (SIDS/SUID/asphyxia) (N=12)

60. Richmond County- Prevention Efforts
• Augusta Safe Kids provides outreach and
education to Richmond and neighboring counties
for safe sleep, motor vehicle, drowning, and
other child injury/death issues
• Applying for grants that will support their “Cribs
for Kids” education programs
• Presented local safe sleep educational activities
at the National Cribs for Kids Conference in June
2013 (Pittsburgh, PA)

61. Floyd County – Fatality Trends
• Floyd County CFR reported on 63 child deaths
since 2006
• 18 child deaths in 2010-2011 (10 were infants
– 56%)
– Of those 18, six were determined to be “probably
preventable”

62. Floyd County - Prevention Efforts
• The Floyd County CFR Team addressed infant sleep-related deaths in
2012, with support from a grant/donation that was received through
a former 501 organization in Rome called TASK – the Alliance to
Support Kids
• The prevention effort was to provide co-sleepers and cuddle nests to
mothers that rated on their scale as “in need” of them and would
possibly sleep in the same bed with their infant
– The funds allowed for service of up to 200 families, and the company
even gave extra due to the team’s passion and concern with this issue
• The team has given the co-sleepers through the Floyd County Family
Resource Center, Floyd Medical Center-Pediatrics and through TASK
during the calendar year of 2012
– The team will monitor sleep-related deaths in 2013 to see if there is any
drop in bed sharing deaths

63. Gwinnett County – Fatality Trends
• 241 deaths reported to CFR since 2006
– 67 reported from 2010-2011
– Of those 67, 19 were infants (28%)
• Of those 67 deaths reported, 31 were
unintentional injuries:
– 19 motor vehicle deaths (28%)
– eight drowning deaths (12%)
– two fire deaths (3%)

64. Gwinnett County – Prevention Efforts
• In 2012, the Gwinnett CFR team looked at their data and evaluated
the areas that needed the most attention on prevention. From that
review, they noted the areas were: safe sleep, motor vehicle
deaths, and suicide prevention.
– The team members attended training webinars to better understand
suicide and are looking to get prevention programs implemented in
the near future.
– They also addressed the need to reduce motor vehicle deaths and will
be working with local law enforcement and the schools to get
prevention methods in place.
– Gwinnett has also created new educational literature regarding infant
safe sleep habits.
• They have used their partnership with Safe Kids Gwinnett to help
get the information about Safe Sleep out to the community through
the DA's Office, Law Enforcement, and in local hospitals and
shelters.

65. Brooks County – Fatality Trends
• Brooks County CFR has reported on six child
deaths since 2007
• The most recent CFR report was in 2010 (a
sleep-related infant death case)

66. Brooks County - Prevention Efforts
• In December 2012, the CFR team decided to continue with their current
programs of educating the community on infant death prevention with the
most up-to-date educational materials available
• The VWAP and DFCS Director are members of the Brooks County Family
Connections strategic planning committee
– Family Connections is the organization where all of the community
agencies, groups and programs partner together to provide educational
programs to improve quality of life for the children in Brooks County
• The BCFC Strategic Planning Committee is currently working on plans for
Teen Maze to be held the last week in October.
– This event will cover several other educational programs for child death
prevention (i.e.: texting and driving, drinking and driving, teen pregnancy, dating
violence, etc)
• They will continue to work closely with all of their community organizations
to support any additional programs as requested for child death prevention

67. Cherokee County – Fatality Trends
• 67 deaths reported to CFR since 2006
– 22 deaths from 2010-2011
– Of those 22, 6 were infants (27%)
• Most common causes of deaths reported:
– Medical issues (5; 23%)
– Motor vehicle (4; 18%)
– Suicide (3; 14%)

68. Cherokee County – Prevention Efforts
• In August 2012, the Cherokee County CFR committee participated in
the Night Out Against Crime Community Prevention night sponsored
by the Woodstock Police Department.
• The majority of their table was dedicated to sleep-related infant
death prevention and abusive head trauma prevention.
– They had free education materials on safe infant sleep and information
on the number of sleep-rated deaths in our county over the past seven
years.
– There was a laptop continuously playing Dr. Randall Alexander’s
“Abusive Head Trauma” video that explains what AHT is and the internal
effects on a baby. They had free educational materials on shaken baby
syndrome and dealing appropriately with a crying baby.
– They also provided free materials on teen suicide, online
predators, teen depression, bullying, teenage dating violence, and
general child abuse prevention.
• In 2012, we also made these free materials available in the lobby of
the Office of the District Attorney, and in January 2013, we expanded
to place these free materials in the Juvenile Court Offices.

69. Thank You!
Arleymah Gray, MPH
Child Fatality Prevention Specialist
Georgia Office of the Child Advocate
agray@oca.ga.gov
404-232-1310

70. This project was supported in part by the Governor’s Office for
Children and Families through the U.S. Department of Health and
Human Services, Administration for Children and
Families, Community Based Child Abuse Prevention and Treatment
Act (CFDA 93.590). Points of view or opinions stated in this
document are those of the author(s) and do not necessarily represent
the official position or policies of the Governor’s Office for Children
and Families or the U.S. Department of Health and Human
Services, Administration for Children and Families, Community Based
Child Abuse Prevention and Treatment Act (CFDA 93.590).