Factors associated with the transition to nonprone sleep positions of infants in the United States: the National Infant Sleep Position Study

Risk of Sudden Infant Death Syndrome Among Siblings of Children Who Died of Sudden Infant Death Syndrome in Denmark

IMPORTANCE

Sudden infant death syndrome (SIDS) remains a leading cause of death during the first year of life. The etiology of SIDS is complex and remains largely unknown.

OBJECTIVE

To evaluate whether siblings of children who died of SIDS have a higher risk of SIDS compared with the general pediatric population.

DESIGN, SETTING, AND PARTICIPANTS

This register-based cohort study used Danish nationwide registers. Participants were all infants (<1 year) in Denmark between January 1, 1978, and December 31, 2016, including siblings of children who died of SIDS. Siblings were followed up from the index cases' date of SIDS, date of birth, or immigration, whichever came first, and until age 1 year, emigration, developing SIDS, death, or study end. The median (IQR) follow-up was 1 (1-1) year. Data analysis was conducted from January 2017 to October 2022.

MAIN OUTCOMES AND MEASURES

Standardized incidence ratios (SIRs) of SIDS were calculated with Poisson regression models relative to the general population.

RESULTS

In a population of 2 666 834 consecutive births (1 395 199 [52%] male), 1540 infants died of SIDS (median [IQR] age at SIDS, 3 [2-4] months) during a 39-year study period. A total of 2384 younger siblings (cases) to index cases (first sibling with SIDS) were identified. A higher rate of SIDS was observed among siblings compared with the general population, with SIRs of 4.27 (95% CI, 2.13-8.53) after adjustment for sex, age, and calendar year and of 3.50 (95% CI, 1.75-7.01) after further adjustment for mother's age (<29 years vs ≥29 years) and education (high school vs after high school).

CONCLUSIONS AND RELEVANCE

In this nationwide study, having a sibling who died of SIDS was associated with a 4-fold higher risk of SIDS compared with the general population. Shared genetic and/or environmental factors may contribute to the observed clustering of SIDS. The family history of SIDS should be considered when assessing SIDS risk in clinical settings. A multidisciplinary genetic evaluation of families with SIDS could provide additional evidence.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

A systematic review of the burden and risk factors of sudden infant death syndrome (SIDS) in Africa

Background

While sudden infant death syndrome (SIDS) has long been recognized as a leading preventable cause of infant mortality in high-income countries, little is known about the burden of SIDS in Africa. To address this knowledge gap, we conducted the first systematic review of SIDS-related publications in Africa. Our objective was to assess the prevalence of SIDS and its risk factors in Africa.

Methods

We systematically searched PubMed, Embase, Web of Science, Cochrane, and Google Scholar to identify studies published until December 26, 2020. Review authors screened titles and abstracts, and selected articles independently for full-text review. Risk of bias was assessed using the Newcastle Ottawa Scale (NOS) or a modification. Data on the proportion of infants who died of SIDS and reported prevalence of any risk factors were extracted using customized data extraction forms in Covidence.

Results

Our analysis rested on 32 peer-reviewed articles. Nine studies presented prevalence estimates on bedsharing and prone sleeping, suggesting near-universal bedsharing of infants with parents (range, 60 to 91.8%) and frequent use of the prone sleeping position (range, 26.7 to 63.8%). Eleven studies reported on the prevalence of SIDS, suggesting high rates of SIDS in Africa. The prevalence of SIDS ranged from 3.7 per 1000 live births in South Africa, 2.5 per 1000 live births in Niger, and 0.2 per 1000 live births in Zimbabwe. SIDS and other sudden infant deaths accounted for between 2.5 to 21% of infant deaths in South Africa and 11.3% in Zambia.

Conclusions

Africa may have the highest global rate of SIDS with a high burden of associated risk factors. However, majority of the studies were from South Africa which limits generalizability of our findings to the entire continent. There is an urgent need for higher quality studies outside of South Africa to fill this knowledge gap.

Protocol registration

Prospero Registration Number: CRD42021257261

State-level trends in sudden unexpected infant death and immunization in the United States: an ecological study

Background

Sudden unexpected infant death (SUID) continues to be a major contributor to infant mortality in the United States. The objective was to analyze time trends in SUID and their association with immunization coverage.

Methods

The number of deaths and live births per year and per state (1992–2015) was obtained from the Centers for Disease Control and Prevention (CDC). We calculated infant mortality rates (i.e., deaths below one year of age) per 1000 live births for SUID. We obtained data on immunization in children aged 19–35 months with three doses or more of diphtheria-tetanus-pertussis (3+ DTP), polio (3+ Polio), and Haemophilus influenzae type b (3+ Hib) as well as four doses or more of DTP (4+ DTP) from the National Immunization Survey, and data on infant sleep position from the Pregnancy Risk Assessment Monitoring System (PRAMS) Study. Data on poverty and race were derived from the Current Population and American Community Surveys of the U.S. Census Bureau. We calculated mean SUID mortality rates with 95% confidence interval (CI) as well as the annual percentage change using breakpoint analysis. We used Poisson regression with random effects to examine the dependence of SUID rates on immunization coverage, adjusting for sleep position and poverty (1996–2015). In a second model, we additionally adjusted for race (2000–2015).

Results

Overall, SUID mortality decreased in the United States. The mean annual percent change was − 9.6 (95% CI = − 10.5, − 8.6) between 1992 and 1996, and − 0.3 (95% CI = − 0.4, − 0.1) from 1996 onwards. The adjusted rate ratios for SUID mortality were 0.91 (95% CI = 0.80, 1.03) per 10% increase for 3+ DTP, 0.88 (95% CI = 0.83, 0.95) for 4+ DTP, 1.00 (95% CI = 0.90, 1.10) for 3+ polio, and 0.95 (95% CI = 0.89, 1.02) for 3+ Hib. After additionally adjusting for race, the rate ratios were 0.76 (95% CI = 0.67, 0.85) for 3+ DTP, 0.83 (95% CI = 0.78, 0.89) for 4+ DTP, 0.81 (95% CI = 0.73, 0.90) for 3+ polio, and 0.94 (95% CI = 0.88, 1.00) for 3+ Hib.

Conclusions

SUID mortality is decreasing, and inversely related to immunization coverage. However, since 1996, the decline has slowed down.

Revisiting the Neuropathology of Sudden Infant Death Syndrome (SIDS)

Background: Sudden infant death syndrome (SIDS) is one of the leading causes of infant mortality in the United States (US). The extent to which SIDS manifests with an underlying neuropathological mechanism is highly controversial. SIDS correlates with markers of poor prenatal and postnatal care, generally rooted in the lack of access and quality of healthcare endemic to select racial and ethnic groups, and thus can be viewed in the context of health disparities. However, some evidence suggests that at least a subset of SIDS cases may result from a neuropathological mechanism. To explain these issues, a triple-risk hypothesis has been proposed, whereby an underlying biological abnormality in an infant facing an extrinsic risk during a critical developmental period SIDS is hypothesized to occur. Each SIDS decedent is thus thought to have a unique combination of these risk factors leading to their death. This article reviews the neuropathological literature of SIDS and uses machine learning tools to identify distinct subtypes of SIDS decedents based on epidemiological data.

Methods: We analyzed US Period Linked Birth/Infant Mortality Files from 1990 to 2017 (excluding 1992–1994). Using t-SNE, an unsupervised machine learning dimensionality reduction algorithm, we identified clusters of SIDS decedents. Following identification of these groups, we identified changes in the rates of SIDS at the state level and across three countries.

Results: Through t-SNE and distance based statistical analysis, we identified three groups of SIDS decedents, each with a unique peak age of death. Within the US, SIDS is geographically heterogeneous. Following this, we found low birth weight and normal birth weight SIDS rates have not been equally impacted by implementation of clinical guidelines. We show that across countries with different levels of cultural heterogeneity, reduction in SIDS rates has also been distinct between decedents with low vs. normal birth weight.

Conclusions: Different epidemiological and extrinsic risk factors exist based on the three unique SIDS groups we identified with t-SNE and distance based statistical measurements. Clinical guidelines have not equally impacted the groups, and normal birth weight infants comprise more of the cases of SIDS even though low birth weight infants have a higher SIDS rate.

International time trends in sudden unexpected infant death, 1969-2012

Background

Sudden unexpected infant death (SUID) - including sudden infant death syndrome (SIDS) - continues to be a major contributor to infant mortality worldwide. Our objective was to analyse time trends and to identify country-clusters.

Methods

The National Statistical Offices of 52 countries provided the number of deaths and live births (1969–2012). We calculated infant mortality rates per 1000 live births for SUID, SIDS, and all-cause mortality. Overall, 29 countries provided sufficient data for time course analyses of SUID. To sensitively model change over time, we smoothed the curves of mortality rates (1980–2010). We performed a hierarchical cluster analysis to identify clusters of time trends for SUID and SIDS, including all-cause infant mortality.

Results

All-cause infant mortality declined from 28.5 to 4.8 per 1000 live births (mean 12.4; 95% confidence interval 12.0–12.9) between 1969 and 2012. The cluster analysis revealed four country-clusters. Clusters 1 and 2 mostly contained countries showing the typical peak of SUID mortality during the 1980s. Cluster 1 had higher SUID mortality compared to cluster 2. All-cause infant mortality was low in both clusters but higher in cluster 1 compared to cluster 2. Clusters 3 and 4 had low rates of SUID without a peak during the 1980s. Cluster 3 had the highest all-cause infant mortality of all clusters. Cluster 4 had an intermediate all-cause infant mortality. The time trends of SUID and SIDS mortality were similar.

Conclusions

The country-specific time trends in SUID varied considerably. The identification of country-clusters may promote research into how changes in sleep position, smoking, immunisation, or other factors are related to our findings.

Tummy Time and Infant Health Outcomes: A Systematic Review

CONTEXT

The World Health Organization recommends tummy time for infants because of the benefits of improved motor development and reduced likelihood of plagiocephaly. Because of poor uptake of these recommendations, the association of tummy time with other health outcomes requires further investigation.

OBJECTIVE

To review existing evidence regarding the association of tummy time with a broad and specific range of infant health outcomes.

DATA SOURCES

Electronic databases were searched between June 2018 and April 2019.

STUDY SELECTION

Peer-reviewed English-language articles were included if they investigated a population of healthy infants (0 to 12 months), using an observational or experimental study design containing an objective or subjective measure of tummy time which examined the association with a health outcome (adiposity, motor development, psychosocial health, cognitive development, fitness, cardiometabolic health, or risks/harms).

DATA EXTRACTION

Two reviewers independently extracted data and assessed their quality.

RESULTS

Sixteen articles representing 4237 participants from 8 countries were included. Tummy time was positively associated with gross motor and total development, a reduction in the BMI-z score, prevention of brachycephaly, and the ability to move while prone, supine, crawling, and rolling. An indeterminate association was found for social and cognitive domains, plagiocephaly, walking, standing, and sitting. No association was found for fine motor development and communication.

LIMITATIONS

Most studies were observational in design and lacked the robustness of a randomized controlled trial. High selection and performance bias were also present.

CONCLUSIONS

These findings guide the prioritization of interventions aimed at assisting parents meet the global and national physical activity guidelines.

'InUTERO': The effectiveness of an educational half day stillbirth awareness workshop for maternity care providers

BACKGROUND

There is a disconnect between what maternity care providers consider should be done and what they actually do with respect to talking with their pregnant clients about reducing their risk of stillbirth. This suggests that they would benefit from receiving up-to-date knowledge about stillbirth, alongside education that provides them with strategies for talking about stillbirth with pregnant women.

OBJECTIVES

To gain an understanding of maternity care provider (obstetricians and midwives) knowledge of stillbirth and determine whether delivering a half day workshop improves knowledge and results in intention to change practice.

DESIGN

A pre-post intervention study.

SETTING

Maternity care providers (Obstetricians, Midwives) working in the northern areas of Tasmania, Australia were asked, via questionnaire, about their knowledge of stillbirth both before and after attending a half-day workshop.

PARTICIPANTS

Maternity care providers (n = 51) attended the workshop and 30 (59%) completed both the pre-workshop and post-workshop surveys.

METHODS

A four hour interactive workshop grounded in understanding the stillbirth experience. Participants were given up-to-date information about stillbirth risks and current prevention research as well as provided with an actionable step wise approach to talking about stillbirth prevention in pregnancy.

RESULTS

Stillbirth knowledge scores (total of 8-points) significantly increased following the workshop (pre: mean = 2.9 ± 1.5; post: mean = 4.7 ± 1.4 points, t ₂₉ = 7.9, <0.001). Before the workshop, only 20% of participants responded that they "always" or usually" discussed the possibility stillbirth occurring with pregnant women in their care whereas, after the workshop, nearly all (88%) indicated that they planned to "always" discuss stillbirth with their pregnant clients.

CONCLUSIONS

Attending a stillbirth awareness for prevention education workshop resulted in significant knowledge improvement and self-reported intention to change practice in a group of Australian maternity care providers. While these results are promising, further study is needed to determine the presence and extent of actual practice change following such education.

Prevalence and Factors Associated With Safe Infant Sleep Practices

OBJECTIVES

To examine prevalence of safe infant sleep practices and variation by sociodemographic, behavioral, and health care characteristics, including provider advice.

METHODS

Using 2016 Pregnancy Risk Assessment Monitoring System data from 29 states, we examined maternal report of 4 safe sleep practices indicating how their infant usually slept: (1) back sleep position, (2) separate approved sleep surface, (3) room-sharing without bed-sharing, and (4) no soft objects or loose bedding as well as receipt of health care provider advice corresponding to each sleep practice.

RESULTS

Most mothers reported usually placing their infants to sleep on their backs (78.0%), followed by room-sharing without bed-sharing (57.1%). Fewer reported avoiding soft bedding (42.4%) and using a separate approved sleep surface (31.8%). Reported receipt of provider advice ranged from 48.8% (room-sharing without bed-sharing) to 92.6% (back sleep position). Differences by sociodemographic, behavioral, and health care characteristics were larger for safe sleep practices (∼10-20 percentage points) than receipt of advice (∼5-10 percentage points). Receipt of provider advice was associated with increased use of safe sleep practices, ranging from 12% for room-sharing without bed-sharing (adjusted prevalence ratio: 1.12; 95% confidence interval: 1.09-1.16) to 28% for back sleep position (adjusted prevalence ratio: 1.28; 95% confidence interval: 1.21-1.35). State-level differences in safe sleep practices spanned 20 to 25 percentage points and did not change substantially after adjustment for available characteristics.

CONCLUSIONS

Safe infant sleep practices, especially those other than back sleep position, are suboptimal, with demographic and state-level differences indicating improvement opportunities. Receipt of provider advice is an important modifiable factor to improve infant sleep practices.

The Impact of Health Messages on Maternal Decisions About Infant Sleep Position: A Randomized Controlled Trial

Sudden infant death syndrome (SIDS) rates in African-Americans are more than twice national rates, and historically, African-American parents are more likely than other groups to place infants prone, even when they are aware of supine sleep recommendations. Prior studies have shown African-Americans have low self-efficacy against SIDS but high self-efficacy against suffocation. This study aimed to determine the impact of a specific health message about suffocation prevention on African-American parental decisions regarding infant sleep position. We conducted a randomized controlled trial of 1194 African-American mothers, who were randomized to receive standard messages about safe sleep practices to reduce the risk of SIDS, or enhanced messages about safe sleep practices to prevent SIDS and suffocation. Mothers were interviewed about knowledge and attitude, self-efficacy and current infant care practices when infants were 2-3 weeks, 2-3 months and 5-6 months old. Analyses of covariance were conducted to estimate the change in knowledge, attitudes and practice in each group, and chi square tests were used to compare sleep position with each variable. Over the first 6 months, the proportion of African-American infants placed supine gradually decreased and was unchanged by enhanced education about SIDS, suffocation risk and sleep safety. While initially high self-efficacy against SIDS and suffocation correlated with supine positioning, by 5-6 months self-efficacy did not correspond to sleep position in either group.

Implications of Mothers' Social Networks for Risky Infant Sleep Practices

OBJECTIVE

To describe the structure of networks in a cohort of mothers and to analyze associations of social network characteristics and norms with infant sleep practices.

STUDY DESIGN

We recruited a prospective cohort of mothers with infants <6 months of age from January 2015 to December 2016. Mothers completed a survey about their personal social networks and infant care practices. Latent class analysis identified unobserved network types. Binary statistics and path analysis were performed.

RESULTS

Overall, 402 mothers were surveyed. Latent class analysis identified 2 a priori unknown social network types: "exclusive" (restricted) and "expansive." Mothers who were black, younger, unmarried, less educated, and of lower socioeconomic status were more likely to have exclusive networks than expansive networks. Mothers with exclusive networks were more likely to be exposed to the norm of soft bedding (P = .002). Exposure to norms of non-supine infant placement, bedsharing, and soft bedding use within one's network was associated with engaging in these practices (P < .0001 for each). First-time mothers were more likely to pay attention to a non-supine norm and place infants in a non-supine position. Black mothers and first-time mothers were more likely to pay attention to the norm and use soft bedding.

CONCLUSIONS

Both the type of networks mothers have and the norms regarding infant sleep practices that circulate within these networks differed by race. Network norms were strongly associated with infant sleep practices and may partially explain the racial disparity therein.

National and State Trends in Sudden Unexpected Infant Death: 1990-2015

BACKGROUND

Sharp declines in sudden unexpected infant death (SUID) in the 1990s and a diagnostic shift from sudden infant death syndrome (SIDS) to unknown cause and accidental suffocation and strangulation in bed (ASSB) in 1999-2001 have been documented. We examined trends in SUID and SIDS, unknown cause, and ASSB from 1990 to 2015 and compared state-specific SUID rates to identify significant trends that may be used to inform SUID prevention efforts.

METHODS

We used data from US mortality files to evaluate national and state-specific SUID rates (deaths per 100 000 live births) for 1990-2015. SUID included infants with an underlying cause of death, SIDS, unknown cause, or ASSB. To examine overall US rates for SUID and SUID subtypes, we calculated the percent change by fitting Poisson regression models. We report state differences in SUID and compared state-specific rates from 2000-2002 to 2013-2015 by calculating the percent change.

RESULTS

SUID rates declined from 154.6 per 100 000 live births in 1990 to 92.4 in 2015, declining 44.6% from 1990 to 1998 and 7% from 1999 to 2015. From 1999 to 2015, SIDS rates decreased 35.8%, ASSB rates increased 183.8%, and there was no significant change in unknown cause rates. SUID trends among states varied widely from 41.5 to 184.3 in 2000-2002 and from 33.2 to 202.2 in 2013-2015.

CONCLUSIONS

Reductions in SUID rates since 1999 have been minimal, and wide variations in state-specific rates remain. States with significant declines in SUID rates might have SUID risk-reduction programs that could serve as models for other states.

Health Messaging and African-American Infant Sleep Location: A Randomized Controlled Trial

Infant-parent bedsharing increases the risk of SIDS and other sleep-related deaths. Despite AAP recommendations to avoid bedsharing, public health efforts have been unsuccessful in changing behaviors. African-American infants are more than twice as likely to die from SIDS and other sleep-related deaths, and are also twice as likely to bedshare with their parents. Further, African-American parents have a high degree of self-efficacy with regards to preventing infant suffocation, but low self-efficacy with regards to SIDS risk reduction. It is unclear whether messages emphasizing suffocation prevention will decrease bedsharing. To evaluate the impact of specific health messages on African-American parental decisions regarding infant sleep location. We conducted a randomized, controlled trial of African-American mothers of infants. The control group received standard messaging emphasizing AAP-recommended safe sleep practices, including avoidance of bedsharing, for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices, including avoidance of bedsharing, for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth. 1194 mothers were enrolled in the study, and 637 completed all interviews. Bedsharing, both usually (aOR 1.005 [95 % CI 1.003, 1.006]) and last night (aOR 1.004 [95 % CI 1.002, 1.007]) increased slightly but statistically significantly with infant age (p < 0.001). Receipt of the enhanced message did not impact on sleep location. Maternal belief that bedsharing increased the risk of SIDS or suffocation declined over 6 months (p < 0.001) and did not differ by group assignment. African-American mothers who received an enhanced message about SIDS risk reduction and suffocation prevention were no less likely to bedshare with their infants.

CLINICAL TRIALS REGISTRATION

Clinical Trials.gov identifier NCT01361880.

Sudden infant death syndrome and inherited cardiac conditions

Sudden infant death syndrome (SIDS) is the leading cause of post-neonatal infant mortality in developed countries, characterized by the death of infants for no obvious reason and without prior warning. The complex interaction of multiple factors in the pathogenesis of SIDS is illustrated by the 'triple risk hypothesis', which proposed that SIDS results from a convergence of three overlapping risk factors: a critical developmental period, an exogenous stressor, and underlying genetic and/or nongenetic vulnerability in the infant. Rare variants in genes associated with inherited arrhythmia syndromes and cardiomyopathies have been proposed as the substrate for an infant's critical vulnerability in a small subset of SIDS cases. Given the potential risk of inherited cardiac disease, current guidelines recommend post-mortem genetic testing (molecular autopsy) and cardiological investigation of the surviving family, complemented by targeted genetic testing if appropriate. In this Review, we highlight the latest developments in understanding the spectrum and prevalence of cardiac-mediated SIDS, and discuss the clinical implications of SIDS in the surviving family and the general population.

Why Should We Direct Our Efforts Toward Evidence-Based Knowledge Creation?

In the field of exotic animal medicine, there is much work to do, more than in human medicine and in companion animal medicine. The work in this field should be directed toward an evidence-based knowledge accumulation. Sound evidence supporting tests and treatments will ensure better health care for exotic animal patients.

Racial and Ethnic Trends in Sudden Unexpected Infant Deaths: United States, 1995-2013

BACKGROUND AND OBJECTIVES

Immediately after the 1994 Back-to-Sleep campaign, sudden unexpected infant death (SUID) rates decreased dramatically, but they have remained relatively stable (93.4 per 100 000 live births) since 2000. In this study, we examined trends in SUID rates and disparities by race/ethnicity since the Back-to-Sleep campaign.

METHODS

We used 1995-2013 US period-linked birth-infant death data to evaluate SUID rates per 100 000 live births by non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander racial/ethnic groupings. To examine racial/ethnic disparities, we calculated rate ratios with NHWs as the referent group. Unadjusted linear regression was used to evaluate trends (P < .05) in rates and rate ratios. The distribution and rates of SUID by demographic and birth characteristics were compared for 1995-1997 and 2011-2013, and χ2 tests were used to evaluate significance.

RESULTS

From 1995 to 2013, SUID rates were consistently highest for American Indian/Alaska Natives, followed by NHBs. The rate for NHBs decreased significantly, whereas the rate for NHWs also declined, but not significantly. As a result, the disparity between NHWs and NHBs narrowed slightly. The SUID rates for Hispanics and Asian/Pacific Islanders were lower than the rates for NHWs and showed a significant decrease, resulting in an increase in their advantage over NHWs.

CONCLUSIONS

Each racial/ethnic group showed a unique trend in SUID rates since the Back-to-Sleep campaign. When implementing risk-reduction strategies, it is important to consider these trends in targeting populations for prevention and developing culturally appropriate approaches for racial/ethnic communities.

Differences in Infant Care Practices and Smoking among Hispanic Mothers Living in the United States

OBJECTIVE

To assess the association between maternal birth country and adherence to the American Academy of Pediatrics safe sleep recommendations in a national sample of Hispanic mothers, given that data assessing the heterogeneity of infant care practices among Hispanics are lacking.

STUDY DESIGN

We used a stratified, 2-stage, clustered design to obtain a nationally representative sample of mothers from 32 US intrapartum hospitals. A total of 907 completed follow-up surveys (administered 2-6 months postpartum) were received from mothers who self-identified as Hispanic/Latina, forming our sample, which we divided into 4 subpopulations by birth country (US, Mexico, Central/South America, and Caribbean). Prevalence estimates and aORs were determined for infant sleep position, location, breastfeeding, and maternal smoking.

RESULTS

When compared with US-born mothers, we found that mothers born in the Caribbean (aOR 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. Caribbean-born mothers were significantly less likely to place infants to sleep supine (aOR 0.41). Mothers born in Mexico (aOR 1.67) and Central/South America (aOR 2.57) were significantly more likely to exclusively breastfeed; Caribbean-born mothers (aOR 0.13) were significantly less likely to do so. Foreign-born mothers were significantly less likely to smoke before and during pregnancy.

CONCLUSIONS

Among US Hispanics, adherence to American Academy of Pediatrics safe sleep recommendations varies widely by maternal birth country. These data illustrate the importance of examining behavioral heterogeneity among ethnic groups and have potential relevance for developing targeted interventions for safe infant sleep.

Zygomatic bone shape in intentional cranial deformations: a model for the study of the interactions between skull growth and facial morphology

Intentional cranial deformations (ICD) were obtained by exerting external mechanical constraints on the skull vault during the first years of life to permanently modify head shape. The repercussions of ICD on the face are not well described in the midfacial region. Here we assessed the shape of the zygomatic bone in different types of ICDs. We considered 14 non-deformed skulls, 19 skulls with antero-posterior deformation, nine skulls with circumferential deformation and seven skulls with Toulouse deformation. The shape of the zygomatic bone was assessed using a statistical shape model after mesh registration. Euclidian distances between mean models and Mahalanobis distances after canonical variate analysis were computed. Classification accuracy was computed using a cross-validation approach. Different ICDs cause specific zygomatic shape modifications corresponding to different degrees of retrusion but the shape of the zygomatic bone alone is not a sufficient parameter for classifying populations into ICD groups defined by deformation types. We illustrate the fact that external mechanical constraints on the skull vault influence midfacial growth. ICDs are a model for the study of the influence of epigenetic factors on craniofacial growth and can help to understand the facial effects of congenital skull malformations such as single or multi-suture synostoses, or of external orthopedic devices such as helmets used to correct deformational plagiocephaly.

SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment

Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. After an initial decrease in the 1990s, the overall sleep-related infant death rate has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," which is included in this issue.

Child Health Disparities in the 21st Century

The topic of persistent child health disparities remains a priority for policymakers and a concern for pediatric clinicians. Health disparities are defined as differences in adverse health outcomes for specific health indicators that exist across sub-groups of the population, frequently between minority and majority populations. This review will highlight the gains that have been made since the 1990s as well as describe disparities that have persisted or have worsened into the 21st century. It will also examine the most potent social determinants and their impact on the major disparities in mortality, preventive care, chronic disease, mental health, educational outcomes, and exposure to selected environmental toxins. Each section concludes with a description of interventions and innovations that have been successful in reducing child health disparities.

Supine sleep positioning in preterm and term infants after hospital discharge from 2000 to 2011

OBJECTIVE

Supine sleep positioning (SSP) has been shown to reduce the risk of sudden infant death syndrome (SIDS) and preterm infants are at higher risk for SIDS. Population-based estimates of SSP are lacking for the preterm population. The objectives of this study are: (1) compare the prevalence of SSP after hospital discharge for preterm and term infants in the United States; and (2) assess racial/ethnic disparities in SSP for preterm and term infants.

STUDY DESIGN

We analyzed the 2000 to 2011 data from the Pregnancy Risk Assessment Monitoring System of Centers for Disease Control and Prevention from 35 states. We measured prevalence of SSP by preterm and term gestational age (GA) categories. We calculated adjusted prevalence ratios (APR) to evaluate the likelihood of SSP for each GA category compared with term infants and the likelihood of SSP for non-Hispanic black (NHB) and Hispanic infants compared with non-Hispanic white (NHW) infants.

RESULTS

Prevalence of SSP varied by GA: ⩽27, 59.7%; 28 0/7 to 33 6/7, 63.7%; 34 0/7 to 36 6/7 (late preterm), 63.6%; and 37 0/7 to 42 6/7 (term) weeks, 66.8% (P<0.001). In the adjusted analyses, late preterm infants were slightly less likely to be placed in SSP compared with term infants (APR: 0.96, confidence interval: 0.95 to 0.98). There were racial/ethnic disparities in SSP for all GA categories when NHB and Hispanic infants were compared with NHW infants.

CONCLUSIONS

All infants had suboptimal adherence to SSP indicating a continued need to better engage families about SSP. Parents of late preterm infants and families of NHB and Hispanic infants will also require greater attention given their decreased likelihood of SSP.

Hypothesis on supine sleep, sudden infant death syndrome reduction and association with increasing autism incidence

AIM: To identify a hypothesis on: Supine sleep, sudden infant death syndrome (SIDS) reduction and association with increasing autism incidence.

METHODS: Literature was searched for autism spectrum disorder incidence time trends, with correlation of change-points matching supine sleep campaigns. A mechanistic model expanding the hypothesis was constructed based on further review of epidemiological and other literature on autism.

RESULTS: In five countries (Denmark, United Kingdom, Australia, Israel, United States) with published time trends of autism, change-points coinciding with supine sleep campaigns were identified. The model proposes that supine sleep does not directly cause autism, but increases the likelihood of expression of a subset of autistic criteria in individuals with genetic susceptibility, thereby specifically increasing the incidence of autism without intellectual disability.

CONCLUSION: Supine sleep is likely a physiological stressor, that does reduce SIDS, but at the cost of impact on emotional and social development in the population, a portion of which will be susceptible to, and consequently express autism. A re-evaluation of all benefits and harms of supine sleep is warranted. If the SIDS mechanism proposed and autism model presented can be verified, the research agenda may be better directed, in order to further decrease SIDS, and reduce autism incidence.

Messaging Affects the Behavior of African American Parents with Regards to Soft Bedding in the Infant Sleep Environment: A Randomized Controlled Trial

OBJECTIVE

To evaluate the impact of specific health messages on the decisions of African American parents regarding soft bedding use, specifically related to the high degree of self-efficacy that African American parents have with regards to preventing infant suffocation vs low self-efficacy with regards to sudden infant death syndrome (SIDS) risk reduction.

STUDY DESIGN

We conducted a randomized, controlled clinical trial of African American mothers of infants. The control group received standard messaging emphasizing safe sleep practices recommended by the American Academy of Pediatrics for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth.

RESULTS

Of 1194 mothers enrolled, 637 completed all interviews. The use of soft bedding both in the past week and last night declined with age (P < .001). Infants in the enhanced group had a lower rate of use of soft bedding in the past week (P = .006) and last night (P = .013). Mothers who received the enhanced message were more likely to state that they avoided soft bedding to protect their infant from suffocation.

CONCLUSIONS

African American mothers who receive an enhanced message about SIDS risk reduction and suffocation prevention are less likely to use soft bedding in their infant's sleep environment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01361880.

Reasons for Pacifier Use and Non-Use in African-Americans: Does Knowledge of Reduced SIDS Risk Change Parents' Minds?

To investigate African-American parental reasons for pacifier use or non-use, and whether knowledge of the association with decreased SIDS risk changes decisions about pacifier use. We conducted focus groups and individual interviews with mothers. Grounded theory methodology was used. 83 mothers participated; 72.3 % of infants used pacifiers. Reasons for pacifier use included comfort/soothing, safety/SIDS, and preference over digit-sucking. Reasons for pacifier non-use included infant refusal, fear of attachment, nipple confusion, and germs. Many parents were unaware that pacifier use reduces SIDS risk; however, most parents of non-users did not think that this knowledge would have changed their decision. Reasons included skepticism about the pacifier-SIDS link. Many reasons underlie African-American parental decisions about pacifier use. Providers should provide information about the benefits of pacifiers. Establishing for parents any plausible link between the protective mechanism of pacifiers and SIDS pathophysiology may be important in promoting pacifier use.

Evaluation of bedtime basics for babies: a national crib distribution program to reduce the risk of sleep-related sudden infant deaths

Rates of sleep-related infant deaths have remained stagnant in recent years. Although most parents are aware of safe sleep recommendations, barriers to adherence, including lack of access to a safe crib, remain. The objective of this study was to describe parental knowledge and practices regarding infant sleep position, bedsharing, pacifier use, and feeding practices before and after receipt of a free crib and safe sleep education. Bedtime Basics for Babies (BBB) enrolled high-risk families in Washington, Indiana, and Washington, DC and provided them with cribs and safe sleep education. Parents completed surveys before ("prenatal" and "postnatal") and 1-3 months after crib receipt ("follow-up"). Descriptive and bivariate analyses were completed. 3,303 prenatal, 1,483 postnatal, and 1,729 follow-up surveys were collected. Parental knowledge of recommended infant sleep position improved from 76% (prenatal) and 77% (postnatal) to 94% after crib receipt (p < 0.001). Intended use of supine positioning increased from 84% (prenatal) and 80% (postnatal) to 87% after the intervention (p < 0.001). Although only 8% of parents intended to bedshare when asked prenatally, 38% of parents receiving the crib after the infant's birth reported that they had bedshared the night before. This decreased to 16% after the intervention. Ninety percent reported that the baby slept in a crib after the intervention, compared with 51% postnatally (p < 0.01). BBB was successful in changing knowledge and practices in the majority of high-risk participants with regards to placing the infant supine in a crib for sleep. Crib distribution and safe sleep education positively influence knowledge and practices about safe sleep.

Interventions to Improve Safe Sleep Among Hospitalized Infants at Eight Children's Hospitals

BACKGROUND AND OBJECTIVES

Within hospital pediatric units, there is a lack of consistent application or modeling of the American Academy of Pediatrics recommendations for safe infant sleep. The purpose of this study was to improve safe sleep practices for infants in nonneonatal pediatric units with implementation of specific interventions.

METHODS

This multi-institutional study was conducted by using baseline observations collected for sleep location, position, and environment (collectively, "safe sleep") of infants admitted to pediatric units. Interventions consisted of: (1) staff education, including a commitment to promote safe sleep; (2) implementing site-generated safe sleep policies; (3) designating supply storage in patient rooms; and/or (4) caregiver education. Postintervention observations of safe sleep were collected. Eight hospitals participated from the Inpatient FOCUS Group of the Children's Hospital Association. Each site received institutional review board approval/exemption.

RESULTS

Safe sleep was observed for 4.9% of 264 infants at baseline and 31.2% of 234 infants postintervention (P<.001). Extra blankets, the most common of unsafe items, were present in 77% of cribs at baseline and 44% postintervention. However, the mean number of unsafe items observed in each sleeping environment was reduced by >50% (P=.001).

CONCLUSIONS

Implementation of site-specific interventions seems to improve overall safe sleep in inpatient pediatric units, although continued improvement is needed. Specifically, extra items are persistently left in the sleeping environment. Moving forward, hospitals should evaluate their compliance with American Academy of Pediatrics recommendations and embrace initiatives to improve modeling of safe sleep.

Overall Postneonatal Mortality and Rates of SIDS

BACKGROUND

Reductions in sudden infant death syndrome (SIDS) are commonly attributed to modifications in infant sleep environments. Approaches to diagnosis in sudden infant death, death scene investigations, the prevalence of intrinsic risk factors for SIDS, and the potential influence of treatment-related factors on infant vulnerability have also changed. Understanding all contributory factors may help reduce residual SIDS rates.

METHODS

We analyzed US Mortality Multiple Causes Records for 1983 to 2012 to compare SIDS postneonatal mortality rates with a projection applying non-SIDS mortality changes, using those changes as a proxy measure for alterations in intrinsic risk. Composites of neglect-related, unknown, and circumstantial respiratory diagnoses were measured, as was a cumulative composite of unexplained infant death diagnoses. Cluster analysis with leading causes of postneonatal mortality and SIDS mortality rates for low birth weight infants were also examined.

RESULTS

SIDS and non-SIDS postneonatal mortality rates were concordant over time. Important variance was seen 1994 to 1996, coinciding with Back-to-Sleep initiation. Other variance, eliminated in the cumulative composite, appeared related to differences in diagnostic practices. Changes in SIDS rates resembled changes in mortality from congenital malformations, respiratory distress of the newborn, and diseases of the circulatory system. SIDS rates for low birth weight infants followed broader postneonatal trends.

CONCLUSIONS

SIDS mortality followed trends in overall postneonatal mortality, including effects of changes in the infant sleep environment and diagnostic classification. Preventing asphyxia risk in the sleep environment must be coupled with efforts to understand intrinsic biological pathways, some potentially associated with other categories of infant and perinatal mortality.

Maternal Report of Advice Received for Infant Care

BACKGROUND

Advice has been associated with increased adherence to recommended infant care practices, and may represent a modifiable factor to promote infant health.

METHODS

A stratified, 2-stage, clustered design, with oversampling of black and Hispanic mothers, was used to survey a nationally representative sample of 1031 mothers of infants aged 2 to 6 months. Survey questions assessed advice received from doctors, birth hospital nurses, family, and media regarding immunization, breastfeeding, sleep position, sleep location, and pacifier use. Weighted frequencies of no advice and advice consistent with recommendations were calculated to obtain prevalence estimates. Multivariable logistic regression analyses were performed to assess factors associated with receipt of recommendation consistent advice.

RESULTS

Although doctors were the most prevalent source of reported advice, ∼20% of mothers reported no doctor advice for breastfeeding or sleep position, and more than 50% reported no advice regarding sleep location or pacifier use. Reported advice from nurses was generally similar to doctors. The prevalence of any advice from family or media was 20% to 56% for nearly all care practices, and advice given was often inconsistent with recommendations. The only factors that were consistently associated with receipt of recommendation consistent advice were race/ethnicity and parity; black and Hispanic mothers and first-time mothers were more likely to report recommendation consistent advice.

CONCLUSIONS

Mothers commonly report receiving either no advice or recommendation inconsistent advice from each of the 4 sources we studied. By identifying care practices with low prevalence of recommendation consistent advice from potentially important advisors, our findings highlight opportunities for future intervention.

Tobacco Control Policies and Sudden Infant Death Syndrome in Developed Nations

This paper estimates the effects of higher cigarette prices and smoke-free policies on the prevalence of Sudden Infant Death Syndrome (SIDS). Using a panel of developed countries over a 20 year period, we find that higher cigarette prices are associated with reductions in the prevalence of SIDS. However, we find no evidence that smoke-free policies are associated with declines in SIDS.

Uvular malformation in the presence of deformational plagiocephaly

BACKGROUND

Deformational plagiocephaly is cranial asymmetry caused by external forces on the skull. Deformational plagiocephaly is seen in 5% to 48% of healthy newborns. Incomplete uvular fusion, in contrast, is one of many uvular malformations. The incidence of all degrees of incomplete uvular fusion is approximately 1% in healthy children. Bifid uvula is a malformation that is often considered a microform cleft palate or a marker for submucous cleft palate.

METHODS

This is a retrospective study of patients with deformational plagiocephaly seen at the Upstate Cleft and Craniofacial Center between January 1, 2006, and September 30, 2011. Patients were identified by the International Classification of Diseases, Ninth Revision code for plagiocephaly. Seventy-nine patients were excluded with craniosynostosis and syndromic diagnoses. One hundred forty-six patients with deformational plagiocephaly were included in the study. Data were collected for sex, age at presentation, parity, multiple births, delivery, oligohydramnios, cephalohematoma, uterine abnormalities, fetal position, and intrauterine growth restriction. Clinical findings were collected including location of cranial flattening and uvular malformations.

RESULTS

Twenty-four of 146 patients with deformational plagiocephaly had incomplete fusion of the uvula ranging from complete bifid uvula to a notched uvular tip (16.4%). This association was statistically significant (odds ratio, 18; 95% confidence interval, 11.1-28.9). Most patients (62.3%) were male. We recorded primiparity (44.5%), multiple births (17.1%), vacuum-assisted delivery (6.2%), cesarean section (36.3%), oligohydramnios (4.1%), uterine abnormalities (2.1%), abnormal fetal position (3.4%), and intrauterine growth restriction (1.4%). Ten of the 24 patients with plagiocephaly and uvular malformation were seen for an initial consultation only in our chart system. Of the remaining 14 patients with follow-up, none had recorded signs or symptoms of velopharyngeal insufficiency.

CONCLUSIONS

The incidence of incomplete uvular fusion in infants with deformational plagiocephaly is 16.4%, which is significantly higher than the approximate 1% incidence reported in the general population. This is the first report of uvular malformation in the presence of deformational plagiocephaly.

Association between sudden infant death syndrome and diphtheria-tetanus-pertussis immunisation: an ecological study

BACKGROUND

Sudden infant death syndrome (SIDS) continues to be one of the main causes of infant mortality in the United States. The objective of this study was to analyse the association between diphtheria-tetanus-pertussis (DTP) immunisation and SIDS over time.

METHODS

The Centers for Disease Control and Prevention provided the number of cases of SIDS and live births per year (1968-2009), allowing the calculation of SIDS mortality rates. Immunisation coverage was based on (1) the United States Immunization Survey (1968-1985), (2) the National Health Interview Survey (1991-1993), and (3) the National Immunization Survey (1994-2009). We used sleep position data from the National Infant Sleep Position Survey. To determine the time points at which significant changes occurred and to estimate the annual percentage change in mortality rates, we performed joinpoint regression analyses. We fitted a Poisson regression model to determine the association between SIDS mortality rates and DTP immunisation coverage (1975-2009).

RESULTS

SIDS mortality rates increased significantly from 1968 to 1971 (+27% annually), from 1971 to 1974 (+47%), and from 1974 to 1979 (+3%). They decreased from 1979 to 1991 (-1%) and from 1991 to 2001 (-8%). After 2001, mortality rates remained constant. DTP immunisation coverage was inversely associated with SIDS mortality rates. We observed an incidence rate ratio of 0.92 (95% confidence interval: 0.87 to 0.97) per 10% increase in DTP immunisation coverage after adjusting for infant sleep position.

CONCLUSIONS

Increased DTP immunisation coverage is associated with decreased SIDS mortality. Current recommendations on timely DTP immunisation should be emphasised to prevent not only specific infectious diseases but also potentially SIDS.

Socioeconomic position and factors associated with use of a nonsupine infant sleep position: findings from the Canadian Maternity Experiences Survey

OBJECTIVES

With a focus on socioeconomic position, we examined the association between maternal education and nonsupine infant sleep position, and examined patterns of effect modification with additional sociodemographic, maternal, infant, and health services predictors.

METHODS

Data were from the Maternity Experiences Survey, a national population-based sample of 76 178 new Canadian mothers (unweighted n = 6421) aged 15 years or older interviewed in 2006-2007. Using logistic regression, we developed multivariate models for 3 maternal education strata.

RESULTS

Level of maternal education was significantly and inversely related to nonsupine infant sleep position. Stratified analyses revealed different predictive factors for nonsupine infant sleep position across strata of maternal education. Postpartum home visits were not associated with use of this sleep position among new mothers with less than high school completion. Adequacy of postpartum information regarding sudden infant death syndrome was not associated with nonsupine infant sleep position in any of the educational strata.

CONCLUSIONS

These findings suggest a need to revisit Back to Sleep health promotion strategies and to ensure that these interventions are tailored to match the information needs of all families, including mothers with lower levels of formal education.

Black-white differences in maternal age, maternal birth cohort, and period effects on infant mortality in the US (1983-2002)

We investigate three interrelated sources of change in infant mortality rates over a 20year period using the National Center for Health Statistics (NCHS) linked birth and infant death cohort files. The effects of maternal age, maternal birth cohort, and time period of childbirth on infant mortality are estimated using a modified age/period/cohort (APC) model that identifies age, period, cohort effects. We document black-white differences in the patterning of these effects and find that maternal age effects follow the predictable U-shaped pattern, net of period and cohort, but with a less steep gradient in the black population. The largest relative maternal age-specific disparity in IMR occurs among older African American mothers. Cohort effects, while considerably smaller than age and period effects, present an interesting pattern of a modest decline in IMR among later cohorts of African American mothers coupled with an increasing IMR among the same cohorts of non-Hispanic whites. However, period effects dominate the time trends, implying that period-related technologies overwhelmingly shape US infant survival in today's population. These general findings are mirrored in APC analyses carried out for several leading underlying causes of infant mortality.

Cardiac ion channelopathies and the sudden infant death syndrome

The sudden infant death syndrome (SIDS) causes the sudden death of an apparently healthy infant, which remains unexplained despite a thorough investigation, including the performance of a complete autopsy. The triple risk model for the pathogenesis of SIDS points to the coincidence of a vulnerable infant, a critical developmental period, and an exogenous stressor. Primary electrical diseases of the heart, which may cause lethal arrhythmias as a result of dysfunctioning cardiac ion channels (“cardiac ion channelopathies”) and are not detectable during a standard postmortem examination, may create the vulnerable infant and thus contribute to SIDS. Evidence comes from clinical correlations between the long QT syndrome and SIDS as well as genetic analyses in cohorts of SIDS victims (“molecular autopsy”), which have revealed a large number of mutations in ion channel-related genes linked to inheritable arrhythmogenic syndromes, in particular the long QT syndrome, the short QT syndrome, the Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia. Combining data from population-based cohort studies, it can be concluded that at least one out of five SIDS victims carries a mutation in a cardiac ion channel-related gene and that the majority of these mutations are of a known malignant phenotype.

Supine and prone infant positioning: a winning combination

Since 1992, the optimal sleeping position for infants in the United States has been supine. This position has been shown to greatly reduce the rate of Sudden Infant Death Syndrome (Skadberg, Morild, & Markestad, 1998). However, the supine position may lead to other unintended consequences or complications. Through a review of literature, this article explores some of the complications associated with the "Back to Sleep" campaign in the U.S. and discusses educational strategies for perinatal educators.

Bed- and sofa-sharing practices in a UK biethnic population

OBJECTIVE

To describe the prevalence and associations of bed- and sofa-sharing in a biethnic UK birth cohort.

METHODS

We surveyed 3082 participants in the Born in Bradford birth cohort study by using a telephone interview when infants were aged 2 to 4 months. We asked families about sleep surface sharing behaviors, and other sudden unexpected death in infancy (SUDI)-related behaviors.

RESULTS

There were 15.5% of families that had ever bed-shared, 7.2% of families regularly bed-shared, and 9.4% of families had ever sofa-shared with their infants; 1.4% reported both. Regular bed-sharers were more commonly Pakistani (adjusted odds ratio [aOR] = 3.02, 95% confidence interval [CI] 1.96-4.66), had further or higher educational qualifications (aOR = 1.62, 95% CI 1.03-2.57), or breastfed for at least 8 weeks (aOR = 3.06, 95% CI 2.00-4.66). The association between breastfeeding and bed-sharing was greater among white British than Pakistani families. Sofa-sharing occurred in association with smoking (aOR = 1.79, 95% CI 1.14-2.80) and breastfeeding for more than 8 weeks (aOR = 1.76, 95% CI 1.19-2.58), and was less likely in Pakistani families (aOR = 0.21, 95% CI 0.14-0.31), or single-parent families (aOR = 0.50, 95% CI 0.29-0.87).

CONCLUSIONS

The data confirm that bed-sharing and sofa-sharing are distinct practices, which should not be combined in studies of unexpected infant deaths as a single exposure. The determinants of sleep-surface sharing differ between the UK Pakistani and UK majority communities, and from those of US minority communities. Caution is needed in generalizing SUDI/SIDS risk factors across populations with differing risk factor profiles, and care should be taken in adopting SUDI/SIDS reduction guidelines from other contexts.

Temporal trends in sudden infant death syndrome in Canada from 1991 to 2005: contribution of changes in cause of death assignment practices and in maternal and infant characteristics

The rate of sudden infant death syndrome (SIDS) declined significantly in Canada and the US between the late 1980s and the early 2000s. In the US, this decline was shown to be due in part to a shift in diagnosis, as deaths from accidental suffocation and strangulation in bed and from other ill-defined and unspecified cause increased concurrently. This study was undertaken to determine whether there was such a shift in diagnosis from SIDS to other causes of death in Canada, and to quantify the true temporal decrease in SIDS. Cause-specific infant death rates were compared across three periods: 1991-95, 1996-2000 and 2001-05 using the Canadian linked livebirth-infant death file. The temporal decline in SIDS was estimated after adjustment for maternal and infant characteristics such as maternal age and small-for-gestational age using logistic regression. Deaths from SIDS decreased from 78.4 [95% confidence interval (CI) 73.4, 83.4] per 100 000 livebirths in 1991-95, to 48.5 [95% CI 44.3, 52.7] in 1996-2000 and to 34.6 [95% CI 31.0, 38.3] in 2001-05. Mortality rates from other ill-defined and unspecified causes and accidental suffocation and strangulation in bed remained stable. The temporal decline in SIDS between 1991-95 and 2001-05 did not change substantially after adjustment for maternal and infant factors. It is unlikely that the temporal decline of SIDS in Canada was due to changes in cause-of-death assignment practices or in maternal and infant characteristics.

Infant care practices related to sudden infant death syndrome in South Asian and White British families in the UK

In the UK, infants of South Asian parents have a lower rate of sudden infant death syndrome (SIDS) than White British infants. Infant care and life style behaviours are strongly associated with SIDS risk. This paper describes and explores variability in infant care between White British and South Asian families (of Bangladeshi, Indian or Pakistani origin) in Bradford, UK (the vast majority of which were Pakistani) and identifies areas for targeted SIDS intervention. A cross-sectional telephone interview study was conducted involving 2560 families with 2- to 4-month-old singleton infants enrolled in the Born in Bradford cohort study. Outcome measures were prevalence of self-reported practices in infant sleeping environment, sharing sleep surfaces, breast feeding, use of dummy or pacifier, and life style behaviours. We found that, compared with White British infants, Pakistani infants were more likely to: sleep in an adult bed (OR = 8.48 [95% CI 2.92, 24.63]); be positioned on their side for sleep (OR = 4.42 [2.85, 6.86]); have a pillow in their sleep environment (OR = 9.85 [6.39, 15.19]); sleep under a duvet (OR = 3.24 [2.39, 4.40]); be swaddled for sleep (OR = 1.49 [1.13, 1.97]); ever bed-share (OR = 2.13 [1.59, 2.86]); regularly bed-share (OR = 3.57 [2.23, 5.72]); ever been breast-fed (OR = 2.00 [1.58, 2.53]); and breast-fed for 8+ weeks (OR = 1.65 [1.31, 2.07]). Additionally, Pakistani infants were less likely to: sleep in a room alone (OR = 0.05 [0.03, 0.09]); use feet-to-foot position (OR = 0.36 [0.26, 0.50]); sleep with a soft toy (OR = 0.52 [0.40, 0.68]); use an infant sleeping bag (OR = 0.20 [0.16, 0.26]); ever sofa-share (OR = 0.22 [0.15, 0.34]); be receiving solid foods (OR = 0.22 [0.17, 0.30]); or use a dummy at night (OR = 0.40 [0.33, 0.50]). Pakistani infants were also less likely to be exposed to maternal smoking (OR = 0.07 [0.04, 0.12]) and to alcohol consumption by either parent. No difference was found in the prevalence of prone sleeping (OR = 1.04 [0.53, 2.01]). Night-time infant care therefore differed significantly between South Asian and White British families. South Asian infant care practices were more likely to protect infants from the most important SIDS risks such as smoking, alcohol consumption, sofa-sharing and solitary sleep. These differences may explain the lower rate of SIDS in this population.

SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment

Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death occurring during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in this technical report. The recommendations are published in the accompanying "Policy Statement--Sudden Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).

Racial and ethnic disparities in infant mortality

Racial and ethnic disparities in infant mortality in the United States seem to defy all attempts at elimination. Despite national priorities to eliminate these disparities, black infants are 2.5 times more likely to die in infancy compared with non-Hispanic white infants. This disparity is largely related to the greater incidence among black infants of prematurity and low birth weight, congenital malformations, sudden infant death syndrome, and unintentional injuries. This greater incidence, in turn, is related to a complex interaction of behavioral, social, political, genetic, medical, and health care access factors. Thus, to influence the persistent racial disparity in infant mortality, a highly integrated approach is needed, with interventions adapted along a continuum from childhood through the periods of young adulthood, pregnancy, postpartum and beyond. The content and methodologies of these interventions need to be adapted to the underlying behaviors, social influences, and technology and access issues they are meant to address.

Treatment of Plagiocephaly with Helmet Molding Therapy: Do Actual Results Mimic Perception?

Purpose

Actual and perceived improvements from helmet molding therapy for deformational plagiocephaly are demonstrated here. Effective communication of these data by craniofacial teams can help avoid unrealistic expectations and inform parents of expected outcomes.

Methods

Parents of 61 patients with plagiocephaly were asked to rate their children's head shape and ear position before and after helmet therapy (a score of 1 being abnormal and 10 being normal). Topographic laser head scans for an aged-matched cohort of 91 patients with deformational plagiocephaly were acquired. Cephalic ratio, overall symmetry ratio, radial symmetry index, ear offset, and left and right oblique were recorded before and after molding. The cranial vault asymmetry index (CVSI) score was calculated.

Results

Parent ratings before and after molding, respectively, were head shape 2.99 ± 1.50 (mean ± SD) versus 7.88 ± 1.64 (p < .0001) and ear position 3.75 ± 2.5 versus 7.73 ± 2.34 (p < 0.0001). Measurements before and after molding were cephalic ratio 0.89 ± 0.07 versus 0.87 ± 0.08 (p < .0001), overall symmetry index 0.87 ± 0.05 versus 0.90 ± 0.04 (p < .0001), radial symmetry index 59.9 ± 26.9 mm versus 46.3 ± 25.1 mm (p < .0001), CVSI 7.2 ± 3.75 versus 4.8 ± 2.8 (p < .0001), and ear offset 5.7 versus 5.5 mm (p = .58).

Conclusions

Helmet molding produces reproducible changes in head shape. Despite relatively small actual changes on topographic laser imaging, parents perceive a large correction in head shape and ear position following helmet molding. Craniofacial teams can use these data and head scans before helmet molding to provide parents with realistic expectations for the outcome of their child's helmet molding therapy.

Sleeping position and health status of children at six-, eighteen- and thirty-six-month development

Using structural equation modeling to investigate the multiple pathways of sleeping position and children's early development at six-, eighteen- and thirty-six-month children, with parental demographics and child health status controlled. The participants consisted of 1783 six-month children, who were assessed using the Taiwan Birth Cohort Study Instrument. After follow-up, 1620 eighteen-month and 1630 thirty-six-month children participated in the second and third assessments, respectively. With potential confounding factors controlled, children at six-month of mothers with a lower level of education tended to sleep supine (β=-0.08, p=0.001). Compared to those sleeping in the prone and side positions, infants in the supine had slower gross and fine motor development (β=-0.11, p<.001; β=-0.12, p=0.030); however, the effect of sleeping position on the children's development dissipated at eighteen- and thirty-six-month. Sleeping position had effect on children's development at six-month; however, this effect was transient. Instead, chronic illness and maternal level of education had a more persistent effect on children's development.

Where should my baby sleep: a qualitative study of African American infant sleep location decisions

BACKGROUND

African American infants are of higher risk for sudden infant death syndrome (SIDS) and accidental suffocation than other infants and are up to 4 times more likely to bedshare with their parents.

OBJECTIVE

To investigate, using qualitative methods, factors influencing African American parents' decisions regarding infant sleep location (room location and sleep surface).

METHODS

Eighty-three mothers participated in focus groups or individual interviews. Questions probed reasons for infant sleep location decisions and influences on decision making.

RESULTS

Most of the mothers in this study slept in the same room as their infant. Reasons for roomsharing included space, convenience, and safety. Mothers largely decided on infant sleep surface because of space for/availability of crib, comfort, convenience, and safety. Both roomsharing and bedsharing were often chosen to make feeding and checking on the infant more convenient. Mothers who chose not to bedshare cited privacy, concern that the infant would become attached to the parents' bed, and fears about suffocation. Mothers who chose to bedshare often cited the ability to maintain vigilance while asleep. Low-income mothers also used bedsharing as a defense against environmental dangers.

CONCLUSION

African American mothers in this study viewed both roomsharing and bedsharing as strategies to keep their infants safe. Efforts to encourage roomsharing without bed-sharing must address parental concerns about space for/ availability of a crib, convenience, infant and parent comfort, and infant safety.

Bed sharing among black infants and sudden infant death syndrome: interactions with other known risk factors

OBJECTIVE

Bed sharing has been associated with sudden infant death syndrome (SIDS) and may contribute to the racial disparity seen in infant mortality. It is unclear how bed sharing interacts with other factors to impact SIDS risk. We aimed to measure the effects of bed sharing on risk of SIDS in blacks and to determine whether the risk is modified by other characteristics of the sleep environment.

METHODS

Characteristics of 195 black infants who died of SIDS were compared with matched controls. The moderating influence of known SIDS risk factors on the effect of bed sharing on risk of SIDS was examined using logistic regression.

RESULTS

Almost half (47.4%) of the study population bed shared during the last/reference sleep (58% cases and 37% controls). Bed sharing was associated with 2 times greater risk of SIDS compared with not bed sharing. The deleterious effect of bed sharing was more pronounced with a soft sleep surface, pillow use, maternal smoking, and younger infant age. However, bed sharing was still associated with an increased risk of SIDS, even when the infant was not using a pillow or sleeping on a firm surface. The strongest predictors of SIDS among bed-sharing infants were soft sleep surface, nonuse of a pacifier, and maternal smoking during pregnancy.

CONCLUSIONS

Bed sharing is a common practice among black infants. It is associated with a clear and strong increased risk of SIDS, which is even greater when combined with other known risk factors for SIDS. This practice likely contributes to the excess incidence of SIDS among blacks, and culturally competent education methods must be developed to target this high-risk group.

Disparities in sleep position awareness and compliance

OBJECTIVES

To identify demographic predictors of caregivers who are more likely to position their infants prone for sleep; to determine caregivers' primary information sources regarding sleep position recommendations; and to determine the primary influence on choice of infant sleep position among caregivers who still place their infants in an at-risk sleep position when informed of the recommendations.

METHODS

Survey of caregivers of 205 infants from birth to 24 months at 2 rural and 2 urban private pediatric practices in Southwest Tennessee.

RESULTS

Income was a significant predictor (P < 0.05) of caregivers' awareness of sleep position recommendations. Awareness rates were 74% among respondents with an income of less than $20,000 and 98% among those earning above $80,000. The primary source of sleep position recommendations for lower income and African American respondents was hospital staff; higher income and European Americans reported printed materials as the primary source. Among respondents who were aware of the recommendations but noncompliant, 60% reported infant preference as the primary influence on choice of sleep position.

CONCLUSIONS

Based on this study, particular emphasis needs to be placed on reaching out to lower income groups to disseminate the American Academy of Pediatrics (AAP) sleep positioning recommendations. The importance of positioning infants supine for sleep must be stressed before mother and baby are discharged from the hospital. Caregivers need to understand that many infants prefer to sleep on their stomachs, but there are ways to help babies adapt to supine sleeping.