Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI research group

The role of alcohol in infant cosleeping deaths

The well-established epidemiological and neuropathological differences between infants who die alone compared to those in shared sleeping environments indicate that these cohorts have differences. Risk factors in both situations depend on both exogenous and endogenous factors. Although parental consumption of alcohol continues to be cited as a risk factor for sudden infant death syndrome (SIDS) it is difficult to understand how a substance which impairs parental consciousness rather than infant arousal could contribute to SIDS. Surely a more logical mechanism to explain these deaths would be suffocation by a sedated adult rather than evoking predisposing factors for SIDS.

Characteristics of Sudden Unexpected Infant Deaths on Shared and Nonshared Sleep Surfaces

OBJECTIVES

Describe characteristics of sudden unexpected infant deaths (SUID) occurring on shared or nonshared sleep surfaces.

METHODS

We examined SUID among residents of 23 US jurisdictions who died during 2011 to 2020. We calculated frequencies and percentages of demographic, sleep environment, and other characteristics by sleep surface sharing status and reported differences of at least 5% between surface sharing and nonsharing infants.

RESULTS

Of 7595 SUID cases, 59.5% were sleep surface sharing when they died. Compared with nonsharing infants, sharing infants were more often aged 0 to 3 months, non-Hispanic Black, publicly insured, found supine, found in an adult bed or chair/couch, had a higher number of unsafe sleep factors present, were exposed to maternal cigarette smoking prenatally, were supervised by a parent at the time of death, or had a supervisor who was impaired by drugs or alcohol at the time of death. At least 76% of all SUID had multiple unsafe sleep factors present. Among surface-sharing SUID, most were sharing with adults only (68.2%), in an adult bed (75.9%), and with 1 other person (51.6%). Surface sharing was more common among multiples than singletons.

CONCLUSIONS

Among SUID, surface sharing and nonsharing infants varied by age at death, race and ethnicity, insurance type, presence of unsafe sleep factors, prenatal smoke exposure, and supervisor impairment. Most SUID, regardless of sleep location, had multiple unsafe sleep factors present, demonstrating the need for comprehensive safe sleep counseling for every family at every encounter.

The National Association of Medical Examiners Position Paper on the Investigation and Certification of Pediatric Deaths From Environmental Neglect

ABSTRACT

Pediatric deaths that occur because of environmental neglect often involve 4 common scenarios: (1) hyperthermia due to environmental exposure, (2) ingestion of an accessible drug or poison, (3) unwitnessed/unsupervised drownings, and (4) unsafe sleep practices. Given the same fact pattern, the manner of death will vary from accident to homicide to undetermined based on local custom and/or the certifier's training and experience. Medical examiner/coroner death certifications are administrative public health determinations made for vital statistical purposes. Because the manner of death is an opinion, it is understandable that manner determinations may vary among practitioners. No prosecutor, judge, or jury is bound by the opinions expressed on the death certificate. This position paper does not dictate how these deaths should be certified. Rather, it describes the challenges of the investigations and manner determinations in these deaths. It provides specific criteria that may improve consistency of certification. Because pediatric deaths often are of public interest, this paper provides the medical examiner/coroner with a professional overview of such manner determination issues to assist various stakeholders in understanding these challenges and variations.

Changes in background characteristics and risk factors among SIDS infants in England: cohort comparisons from 1993 to 2020

OBJECTIVES

Using the National Child Mortality Database, this work aims to investigate background characteristics and risk factors in the sleeping environment associated with sudden infant death syndrome (SIDS) and compare the prevalence with previous English SIDS case-control studies.

DESIGN

Cohort of SIDS in 2020 compared with a combined analysis of two case-control studies conducted in 1993-1996 and 2003-2006.

SETTING

England, UK PARTICIPANTS: 138 SIDS deaths in 2020 compared with 402 SIDS deaths and 1387 age-equivalent surviving controls, combined from previous studies.

RESULTS

The increased vulnerability of SIDS infants identified in previous studies has become more marked. The infants who died in 2020 were younger (median=66 days (IQR: 34-118) vs 86 days (IQR: 52-148), p=0.003) with an increased prevalence of low birth weight (30.5% vs 21.6%, p=0.04) and preterm births (29.6% vs 19.3%, p=0.012). The excess of socioeconomically deprived families, male infants and high levels of maternal smoking during pregnancy were still evident. Among recent deaths, fewer infants were put down or found on their side; however, there was no significant change in the proportion of infants who were put down (15.6% vs 14.6%, p=0.81) and found prone (40.4% vs 35.3%, p=0.37), despite population wide risk reduction advice over three decades. The proportional increase observed in 2003-2006 of half the deaths occurring while sleeping next to an adult was maintained in 2020, and for the vast majority (90%), this was in hazardous circumstances (adult had consumed alcohol, smoked, slept on a sofa, or the infant was premature or low birth weight and less than 3 months old). More deaths also occurred when there was a disruption in infant care routine compared with previous observations (52.6% vs 20.7%, p<0.001).

CONCLUSIONS

A more targeted approach is needed with vulnerable families emphasising the importance of sleeping infants on their back and proactive planning infant sleep when there are disruptions to the normal routine, in particular to avoid hazardous co-sleeping.

Current SIDS research: time to resolve conflicting research hypotheses and collaborate

From the earliest publications on cot death or sudden infant death syndrome (SIDS) through to this day, clinical pathology and epidemiology have strongly featured infection as a constant association. Despite mounting evidence of the role of viruses and common toxigenic bacteria in the pathogenesis of SIDS, a growing school of thought featuring a paradigm based on the triple risk hypothesis that encompasses vulnerability through deranged homoeostatic control of arousal and/or cardiorespiratory function has become the mainstream view and now dominates SIDS research. The mainstream hypothesis rarely acknowledges the role of infection despite its notional potential role as a cofactor in the triple hit idea. Decades of mainstream research that has focussed on central nervous system homoeostatic mechanisms of arousal, cardiorespiratory control and abnormal neurotransmission has not been able to provide consistent answers to the SIDS enigma. This paper examines the disparity between these two schools of thought and calls for a collaborative approach. IMPACT: The popular research hypothesis explaining sudden infant death syndrome features the triple risk hypothesis with central nervous system homoeostatic mechanisms controlling arousal and cardiorespiratory function. Intense investigation has not yielded convincing results. There is a necessity to consider other plausible hypotheses (e.g., common bacterial toxin hypothesis). The review scrutinises the triple risk hypothesis and CNS control of cardiorespiratory function and arousal and reveals its flaws. Infection-based hypotheses with their strong SIDS risk factor associations are reviewed in a new context.

Sudden Infant Death Syndrome: Risk Factors and Newer Risk Reduction Strategies

Sudden infant death syndrome (SIDS) continues to be one of the top causes of infant death in the U.S. Despite significant public health initiatives focused on high-risk populations to enhance sleep environments and techniques. The SIDS rate has remained stable in recent years. Risk factors and newer risk reduction strategies for SIDS are the focus of this review article. We conducted a comprehensive literature search on Medline, Cochrane, Embase, and Google Scholar until July 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "SIDS," "Sudden Infant Death" and "SUID". We explored the literature on SIDS for its epidemiology, pathophysiology, the role of various etiologies and their influence, associated complications leading to SIDS, and preventive and treatment modalities. Despite a more than 50% drop-in rates since the start of the "Back to Sleep" campaign in 1994, sudden infant death syndrome (SIDS) continues to be the top cause of post-neonatal mortality in the United States, despite continued educational initiatives that support safe sleep and other risk reduction strategies. The new American Academy of Pediatrics guidelines for lowering the risk of SIDS include a lot of emphasis on sleeping habits, bedding, and environment but also include elements that are frequently ignored (i.e., prenatal care, smoking, alcohol and drug use, and childhood vaccinations). This study highlights these less-frequently discussed aspects and identifies treatments that have produced beneficial behavioral shifts that benefit newborns as well as their mothers' health and wellbeing.

Risk Factors for Suffocation and Unexplained Causes of Infant Deaths

BACKGROUND

Observational studies have improved our understanding of the risk factors for sudden infant death syndrome, but separate examination of risk for sleep-related suffocation and unexplained infant deaths has been limited. We examined the association between unsafe infant sleep practices and sudden infant deaths (sleep-related suffocation and unexplained causes including sudden infant death syndrome).

METHODS

We conducted a population-based case-control study using 2016 to 2017 Centers for Disease Control and Prevention data. Controls were liveborn infants from the Pregnancy Risk Assessment Monitoring System; cases were from the Sudden Unexpected Infant Death Case Registry. We calculated risk factor prevalence among cases and controls and crude and adjusted odds ratios.

RESULTS

We included 112 sleep-related suffocation cases with 448 age-matched controls and 300 unexplained infant death cases with 1200 age-matched controls. Adjusted odds for sleep-related suffocation ranged from 18.7 (95% confidence interval [CI]: 6.8-51.3) among infants not sharing a room with their mother or caregiver to 1.9 (95% CI: 0.9-4.1) among infants with nonsupine sleep positioning. Adjusted odds for unexplained death ranged from 7.6 (95% CI: 4.7-12.2) among infants not sharing a room with their mother or caregiver to 1.6 (95% CI: 1.1-2.4) among nonsupine positioned infants.

COCLUSIONS

We confirmed previously identified risk factors for unexplained infant death and independently estimated risk factors for sleep-related suffocation. Significance of associations for suffocation followed similar patterns but was of larger magnitude. This information can be used to improve messaging about safe infant sleep.

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.

Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

Each year in the United States, ∼3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Classification of Diseases, 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 has 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. Additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is also included. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report.

Using complexity science to understand the role of co-sleeping (bedsharing) in mother-infant co-regulatory processes

Human infants spend most of their time sleeping, but over the first few years of life their sleep becomes regulated to coincide more closely with adult sleep (Galland et al., 2012; Paavonen et al., 2020). Evidence shows that co-sleeping played a role in the evolution of infant sleep regulation, as it is part of an ancient behavioral complex representing the biopsychosocial microenvironment in which human infants co-evolved with their mothers through millions of years of human history (Ball, 2003; McKenna 1986, 1990). This paper is a conceptual, interdisciplinary, integration of the literature on mother-infant co-sleeping and other mother-infant co-regulatory processes from an evolutionary (biological) perspective, using complexity science. Viewing the mother-infant dyad as a "complex adaptive system" (CAS) shows how the CAS fits assumptions of regulatory processes and reveals the role of the CAS in the ontogeny of mother-infant co-regulation of physiological (thermoregulation, breathing, circadian rhythm coordination, nighttime synchrony, and heart rate variability) and socioemotional (attachment and cortisol activity) development.

Hyperthermia and Heat Stress as Risk Factors for Sudden Infant Death Syndrome: A Narrative Review

BACKGROUND AND OBJECTIVES

Heat stress and hyperthermia are common findings in sudden infant death syndrome (SIDS) victims. It has been suggested that thermal stress can increase the risk of SIDS directly via lethal hyperthermia or indirectly by altering autonomic functions. Major changes in sleep, thermoregulation, cardiovascular function, and the emergence of circadian functions occur at the age at which the risk of SIDS peaks-explaining the greater vulnerability at this stage of development. Here, we review the literature data on (i) heat stress and hyperthermia as direct risk factors for SIDS, and (ii) the indirect effects of thermal loads on vital physiological functions.

RESULTS

Various situations leading to thermal stress (i.e., outdoors temperatures, thermal insulation from clothing and bedding, the prone position, bed-sharing, and head covering) have been analyzed. Hyperthermia mainly results from excessive clothing and bedding insulation with regard to the ambient thermal conditions. The appropriate amount of clothing and bedding thermal insulation for homeothermia requires further research. The prone position and bed-sharing do not have major thermal impacts; the elevated risk of SIDS in these situations cannot be explained solely by thermal factors. Special attention should be given to brain overheating because of the head's major role in body heat losses, heat production, and autonomic functions. Thermal stress can alter cardiovascular and respiratory functions, which in turn can lead to life-threatening events (e.g., bradycardia, apnea with blood desaturation, and glottal closure). Unfortunately, thermal load impairs the responses to these challenges by reducing chemosensitivity, arousability, and autoresuscitation. As a result, thermal load (even when not lethal directly) can interact detrimentally with vital physiological functions.

CONCLUSIONS

With the exception of excessive thermal insulation (which can lead to lethal hyperthermia), the major risk factors for SIDS appears to be associated with impairments of vital physiological functions when the infant is exposed to thermal stress.

Renewed Attention Needed for Prevention of Sudden Unexpected Death in Infancy in the Netherlands

Background: The incidence of sudden unexpected death in infancy (SUDI), which includes sudden infant death syndrome (SIDS), has declined in developed countries since the 1980s, including the Netherlands. To identify improvement opportunities in SUDI prevention, we monitored the adherence of parents to the prevention advice on infant care habits over the past 20 years, especially in relation to the SUDI incidence over time. Potential changes in parental adherence between the latest surveys are of specific interest, as these indicate where current focus is needed. Methods: Description of the prevalence of infant care factors related to the risk of SUDI, assessed from five Dutch national surveys from 1999 to 2017 among parents of infants under 12 months, and analysis of the potential differences in these prevalences between the two latest surveys in 2010/11 and 2017 with a z-test. Results: Supine sleeping position decreased from the highest prevalence of 92% in 2010/11, to 83% in 2017. Sleep sack use has increased to 55%, the highest prevalence up to now. Avoiding a duvet has remained reasonably stable since 2002/03 and now 95% of parents do not use a duvet. The prevalence of room-sharing, without sharing the bed, increased from 14% in 1999 to the highest prevalence in 2017 (31%). However, also bed-sharing almost doubled from 5.6% in 2010/11 to 10% in 2017. Breastfeeding decreased between 1999 and 2010/11, but increased from 34% in 2010/11 to 42% in 2017. An increased prevalence of mothers who abstained from smoking during pregnancy, as well as both parents not smoking, was observed, although mostly higher educated parents showed this beneficial behavior. Discussion and Conclusion: Much has already been achieved first by decreasing prone sleeping since the 80's, and subsequently promoting supine as the safest sleep position. The decrease in duvet use and smoking, and an increase in breastfeeding have also had impact. Indications of a recent decreased prevalence of the supine sleeping position and higher prevalence of bed-sharing might relate to the slightly increasing SUDI incidence in the Netherlands. Renewed attention for prevention of SUDI and specific advice targeting high-risk groups is needed. Modern, picture driven information via internet is recommended.

Knowledge Assessment of Correct Infant Sleep Practices and Sudden Infant Death Syndrome Among Mothers

INTRODUCTION

Sudden infant death syndrome (SIDS) is characterized as the sudden unexpected death of a healthy infant below the age of 12 months with an unknown cause even after careful death scene assessment. The aim of this study is to estimate the percentage of proper sleep practices among infants and assess the knowledge and awareness of SIDS and its associated risk factors among Saudi and non-Saudi mothers.

METHODS

This cross-sectional study was done in Riyadh, Saudi Arabia. The data were collected using an anonymous, self-administered questionnaire that consisted of 36 items that were divided into demographic data of the parents and child, observations of the child's sleep practice, and knowledge and awareness of SIDS and its associated risk factors.

RESULTS

A total of 667 participants completed the questionnaire. The mean age of the mothers was 31.44 + 7.55. As for the nationality, 527 (79%) were Saudi and 140 (21%) were non-Saudi. The majority had bachelors' degrees 407 (61%). Sleep practices assessment demonstrated that 391 (58.6%) of infants were sleeping in the supine position. A total of 329 (49.3%) participants reported hearing about SIDS from social media and websites as being the major source of information. SIDS acknowledgment was higher in non-Saudi mothers compared to Saudis.

CONCLUSION

The results provide informative descriptive data on childcare practices in Saudi Arabia. Considerable variation was noted and the results from this study are intended to have a better understanding of the prevalence of childcare practices and knowledge of SIDS risk factors in Saudi and non-Saudi mothers.

Factors Associated with Safe Infant Sleep Practices in Saudi Arabia

Purpose

To assess mothers’ approaches to infant sleep practices.

Patients and Methods

A cross-sectional survey study was conducted on mothers with babies aged below five months who were attending paediatric clinics between November 1st, 2020, and January 5th, 2021, in Riyadh, Saudi Arabia.

Results

A total of 522 mothers participated in this study. A total of 38.9% practised exclusive formula feeding. A total of 61.9% of the participants practised the supine position. The majority (93.3%) of the mothers shared a room with their babies, while 34.7% shared a bed. Only 6.9% did not use any soft bedding. Age was a significant predictor associated with participant practices regarding sleeping and feeding positions (p < 0.05). Having two or more children was associated with improper sleeping practices (p < 0.05). Being non-Saudi and having a university degree or higher were associated with having a higher risk of unsafe practices regarding bed-sharing (p < 0.05). On the other hand, being contacted by a doctor, nurse, or other healthcare worker about safe sleep practices were an important factor that influenced safe practices regarding feeding (p < 0.05). Receiving care at a private hospital was associated with safer practices regarding sleeping position and bed-sharing (p < 0.05).

Conclusion

We observed high-risk sleeping practices among Saudi mothers. This includes using soft bedding and unsafe sleeping positions. The importance of this study lies in the future implementation of this result through public health measures aimed at at-risk populations.

A firm recommendation: measuring the softness of infant sleep surfaces

Background

Approximately 3600 sudden unexpected infant deaths (SUID) occur annually in the United States, and a quarter of SUIDs are caused by unintentional suffocation and strangulation in bed, with soft bedding use being a significant risk factor. Therefore, The American Academy of Pediatrics (AAP) recommends infants sleep on a “firm” surface, though neither an objective definition nor national standard has been established. The purpose of this study is to report on the performance of a device that measures mattress softness and to provide quantitative values of softness for various infant sleep surfaces.

Methods

In collaboration with the authors and a national child product safety organization (Kids in Danger), University of Michigan engineering students designed and validated a device that measures the vertical depression (softness) of a simulated 2-month-old’s head on a sleep surface. A total of 17 infant sleep surfaces − 14 household surfaces and 3 hospital mattresses - were measured between April 2019 and January 2020. The average softness of each surface was calculated. Surfaces were also measured with soft bedding, which included an infant fleece blanket, and firm and soft pillows.

Results

The average softness for the 14 household sleep surfaces ranged from 7.4–36.9 mm. The 2019 cribette playard and the 2018 infant spring had similar softness (21 mm) as the 2018 and 2019 adult foam and 2015 sofa. An infant’s fleece blanket folded once added an additional 2.3–6.5 mm of softness, folded twice added 4.8–11.6 mm, and folded three times added 11–21.8 mm. Using a firm pillow added 4.0–20.9 mm of softness while using a soft pillow added 24.5–46.4 mm. The softness for the 3 hospital sleep surfaces ranged from 14 to 36.9 mm, with the infant bassinet being the firmest and the pediatrics mattress being the softest.

Conclusions

We found a wide range of softness among sleep surfaces, with some infant mattresses as soft as some adult mattresses. Adding blankets and pillows to mattresses measurably increased softness. Quantifying sleep surface softness will advance our understanding of how softness relates to SUID risk. We hope this new information will further inform safe infant sleep recommendations and improve mattress safety standards nationally.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00325-x.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Sudden Infant Death Syndrome: Beyond Risk Factors

Sudden infant death syndrome (SIDS) is defined as "the sudden death of an infant under 1 year of age which remains unexplained after thorough investigation including a complete autopsy, death scene investigation, and detailed clinical and pathological review". A significant decrease of SIDS deaths occurred in the last decades in most countries after the beginning of national campaigns, mainly as a consequence of the implementation of risk reduction action mostly concentrating on the improvement of sleep conditions. Nevertheless, infant mortality from SIDS still remains unacceptably high. There is an urgent need to get insight into previously unexplored aspects of the brain system with a special focus on high-risk groups. SIDS pathogenesis is associated with a multifactorial condition that comprehends genetic, environmental and sociocultural factors. Effective prevention of SIDS requires multiple interventions from different fields. Developing brain susceptibility, intrinsic vulnerability and early identification of infants with high risk of SIDS represents a challenge. Progress in SIDS research appears to be fundamental to the ultimate aim of eradicating SIDS deaths. A complex model that combines different risk factor data from biomarkers and omic analysis may represent a tool to identify a SIDS risk profile in newborn settings. If high risk is detected, the infant may be referred for further investigations and follow ups. This review aims to illustrate the most recent discoveries from different fields, analyzing the neuroanatomical, genetic, metabolic, proteomic, environmental and sociocultural aspects related to SIDS.

The effects of bed sharing on sleep: From partners to pets

BACKGROUND

Bed sharing is common practice across the global population. However, the vast majority of research on bed sharing has focused solely on mother-infant bed sharing.

METHODS

Here, we provide a holistic review of research on bed sharing. Articles investigating the relationship between bed sharing and sleep were identified in 4 dyad categories: (1) parent and child, (2) couples, (3) siblings, and (4) pet owners and pets. Of interest was whether sleep-promoting factors such as psychological comfort were generalizable across bed-sharing dyads; alternatively, sleep-demoting factors such as movement or heat may be commonalities.

RESULTS

We found that, across dyad types, in general, subjective reports of sleep quality were better when bed sharing despite generally worse objective measures of sleep.

CONCLUSIONS

Understanding bed sharing is important to treating sleep disturbances, given the prevalence of shared beds. This scoping review points to critical gaps in our understanding of bed sharing that motivate future research.

Sleep Pattern and Problems in Young Children Visiting Outpatient Department of a Tertiary Level Hospital in Kathmandu, Nepal

Background

Sleep is an important parameter of a child's growth and development. The pattern and duration of sleep varies with age. Sleep problems are a common occurrence during childhood days, and these problems that establish in childhood are presumed to continue later in life. Many times, parental concerns regarding their child's sleep problems like difficulty in putting to sleep, frequent night time awakening, and waking up early are overlooked during their visits to the hospital.

Objective

The aim of this study was to find out the sleep patterns and problems of children aged six to thirty-six months. Methodology. A cross-sectional study was conducted at the pediatric outpatient department of Kathmandu Medical College Teaching Hospital from October, 2019 till March, 2020. Two hundred and forty-nine respondents were chosen purposively and were given questionnaires to be filled out. Research instrument was a standard, Nepali version of a structured questionnaire called Brief Infant Sleep Questionnaire (BISQ) which contained questions related to sleep parameters and sleep problems existing among young children of 6-36 months. Mean, standard deviation, frequencies, and Kruskal Wallis test were used for statistical analysis.

Results

The mean duration of total sleep was 12.12 ± 2.00 hours, while that of night sleep was 9.22 ± 1.19 hours and mean daytime nap was 2.90 ± 1.66 hours. Most of the children (96%) coslept with their parents, and 55% of the children had feeding as a bedtime ritual. Overall, 19.6% of the children had sleep problems as identified by BISQ although only 5.6% of the parents perceived that their children had it.

Conclusions

Sleep problems were present among young Nepalese children included in our study, and sleep assessment should be a part of every health checkup for children.

Sudden Infant Death Syndrome: What Healthcare Professionals and Parents Know About How to Prevent it in Portugal

Background: Sudden Infant Death Syndrome (SIDS) is defined as the death of an infant of less than 1 year, that is unexpected and unexplained after an extensive investigation. Risk factors related to SIDS have been identified, and most of them concern the infant's sleep position and environment. Objective: Our objective was to conduct a survey with parents and healthcare professionals at the Centro Hospitalar Universitário São João (CHUSJ), in order to assess their knowledge of SIDS and its risk factors. Materials and Methods: This study used two structured self-administered questionnaires aimed at evaluating the knowledge of parents and healthcare professionals about SIDS prevention. Results: Overall, 100% of healthcare professionals and 67.7% of parents were aware of SIDS. Besides, 82.3% of healthcare professionals and 47.5% of parents recognized the supine position as the safest to prevent SIDS. For each of the 13 questions in the questionnaire about SIDS risk factors, the majority of healthcare professionals identified the correct answer whereas among parents, only seven questions were correctly answered by the majority of respondents. Discussion and Conclusion: Healthcare professionals are not as well informed about SIDS as they should be and have little confidence in discussing SIDS-related issues. Therefore, this study highlights the paramount importance of ensuring that their training on this topic is up-to-date, especially due to their crucial role of (partial) gatekeepers of this information for parents, and that providing them with appropriate support could likely contribute to a substantial decrease in the number of SIDS cases.

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.

The influence of bed-sharing on infant physiology, breastfeeding and behaviour: A systematic review

This review aimed to better understand the underlying physiology of the risks and benefits of bed-sharing. Eight databases were searched using terms relating to adult-infant/baby, bed-sharing/co-sleeping combined with outcome terms for physiology, sleep, cardiovascular, respiratory, temperature and behaviour. Of 836 papers identified, 59 papers representing 48 cohorts met inclusion criteria. Objective data using various methodologies were available in 27 papers and subjective data in 32 papers. Diverse measures were reported using variable definitions of bed-sharing. Identified physiological and behavioural differences between bed-sharing and cot-sleeping included increased behavioural arousals, warmer in-bed temperatures and increased breastfeeding duration in bedshare infants as well as differences in infant overnight sleep architecture, cardiorespiratory control and cortisol responses to stress. We concluded that many differences are context-specific, and dependent on the subjective view of the parents and their cultural values. Objective risk arises if the infant is unable to mount an appropriate physiological or behavioural response to their micro-environment. More studies in the bed-sharing setting are needed to identify infant risk, the potential benefits of a safer environment, and how bed-sharing interacts with infant care practices other than sleep.

Stock Photographs Do Not Comply With Infant Safe Sleep Guidelines

We evaluated images in popular stock photography websites for adherence with American Academy of Pediatrics (AAP) guidelines for safe infant sleep practices. Three top stock photo websites were used to collect photographs generated from key phrases. All images depicting an infant sleep environment were analyzed for consistency with AAP guidelines. Descriptive statistics, chi-square and z test of proportions, were conducted. A total of 1233 of 1947 stock photographs showed sleeping infants on a flat surface. In all, 627 (50.8%) photographs showed the infant in the supine position and 79 (5%) of all infant sleep environments were adherent with AAP recommendations. Bedding inconsistent with safe sleep recommendations was identified in 1133 images (71.3%), with blankets noted in 49.5%. Images depicting sleeping infants on stock photography sites do not routinely adhere to AAP recommendations. Media messages inconsistent with health care messages create confusion and misinformation about infant sleep safety and may lead inadvertently to unsafe practices.

Physiological stability in an indigenous sleep device: a randomised controlled trial

OBJECTIVE

To compare overnight oxygen saturation, heart rate and the thermal environment of infants sleeping in an indigenous sleep device (wahakura) or bassinet to identify potential risks and benefits.

DESIGN

Randomised controlled trial.

SETTING

Family homes in low socio-economic areas in New Zealand.

PATIENTS

200 mainly Māori mothers and their infants.

INTERVENTIONS

Participants received a wahakura or bassinet from birth.

MAIN OUTCOME MEASURES

Overnight oximetry, heart rate and temperature at 1 month.

RESULTS

Intention-to-treat analysis for 83 bassinet and 84 wahakura infants showed no significant differences between groups for the mean time oxygen saturation (SpO₂) was less than 94% (0.54 min, 95% CI -1.36 to 2.45) or less than 90% (0.22 min, 95% CI -0.56 to 1.00), the mean number of SpO₂ dips per hour >5% (-0.19, 95% CI -3.07 to 2.69) or >10% (-0.41, 95% CI -1.63 to 0.81), mean heart rate (1.99 beats/min, 95% CI -1.02 to 4.99), or time shin temperature >36°C (risk ratio (RR): 0.63, 95% CI 0.13 to 2.99) or <34°C (RR: 0.89, 95% CI 0.61 to 1.30). A per-protocol analysis of 45 bassinet and 26 wahakura infants and an as-used analysis of 104 infants in a bassinet and 48 in a wahakura found no significant differences between groups for all outcome measures.

CONCLUSIONS

This indigenous sleep device is at least as safe as the currently recommended bassinet, which supports its use as a sleep environment that offers an alternative way of bed-sharing.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN12610000993099.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES

To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

SELECTION CRITERIA

We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

MAIN RESULTS

Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS

A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.

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.

Impact of a Randomized Controlled Trial to Reduce Bedsharing on Breastfeeding Rates and Duration for African-American Infants

Bedsharing is associated with both increased breastfeeding and increased risk of sudden and unexpected infant deaths. The objective was to determine impact of sleep location and counseling about sleep location on breastfeeding exclusivity and duration in African-Americans. 1194 mothers of newborns were randomized to receive messaging emphasizing either safe sleep practices to reduce SIDS risk or safe sleep practices to prevent SIDS/suffocation. Mothers completed four interviews in the 6 months after delivery. The most common sleep arrangement was roomsharing without bedsharing ("roomsharing"). Duration of any breastfeeding was 6.1 and 5.3 weeks for infants who usually bedshared or roomshared, respectively (p = 0.01). Duration of exclusive breastfeeding was 3.0 and 1.6 weeks for infants who usually bedshared or roomshared, respectively (p < 0.001). Group assignment did not affect breastfeeding duration. The most common sleep arrangement for African-American infants <6 months was roomsharing. An intervention designed to discourage bedsharing did not impact breastfeeding duration.

Mother-Infant Room-Sharing and Sleep Outcomes in the INSIGHT Study

OBJECTIVES

The American Academy of Pediatrics recommends infant-parent room-sharing until age 1. We assessed the association between room-sharing and sleep outcomes.

METHODS

The Intervention Nurses Start Infants Growing on Healthy Trajectories study is an obesity prevention trial comparing a responsive parenting intervention with a safety control among primiparous mother-infant dyads. Mothers completed the Brief Infant Sleep Questionnaire at 4, 9, 12, and 30 months. Reported sleep duration and overnight behaviors, adjusted for intervention group, were compared among early independent sleepers (own room <4 months), later independent sleepers (own room between 4 and 9 months), and room-sharers at 9 months.

RESULTS

At 4 months, reported overnight sleep duration was similar between groups, but compared with room-sharers, early independent sleepers had better sleep consolidation (longest stretch: 46 more minutes, P = .02). At 9 months, early independent sleepers slept 40 more minutes nightly than room-sharers and 26 more minutes than later independent sleepers (P = .008). The longest stretch for early independent sleepers was 100 and 45 minutes more than room-sharers and later independent sleepers, respectively (P = .01). At 30 months, infants sleeping independently by 9 months slept >45 more minutes nightly than those room-sharing at 9 months (P = .004). Room-sharers had 4 times the odds of transitioning to bed-sharing overnight at both 4 and 9 months (P < .01 for both).

CONCLUSIONS

Room-sharing at ages 4 and 9 months is associated with less nighttime sleep in both the short and long-term, reduced sleep consolidation, and unsafe sleep practices previously associated with sleep-related death.

Wahakura Versus Bassinet for Safe Infant Sleep: A Randomized Trial

OBJECTIVES

To compare an indigenous sleep device (wahakura) for infants at high risk for sudden unexpected death with a bassinet, for measures of infant sleep position, head covering, breastfeeding, bed-sharing, and maternal sleep and fatigue.

METHODS

A total of 200 mainly Māori pregnant women were recruited from deprived areas of New Zealand. They were randomized to receive a bassinet or wahakura and asked to sleep the infant in this device from birth. Questionnaires at 1, 3, and 6 months and an overnight infrared video in the home at 1 month were completed.

RESULTS

An intention-to-treat and an "as-used" analysis of questionnaires showed no group differences at 1, 3, and 6 months in infant-adult direct bed-sharing (7% vs 12%, P = .24 at 1 month), and at the 6-month interview, the wahakura group reported twice the level of full breastfeeding (22.5% vs 10.7%, P = .04). Maternal sleep and fatigue were not significantly different between groups. Video identified no increase in head covering, prone/side sleep position, or bed-sharing in the wahakura group, either from intention-to-treat analysis, or when analyzed for actual sleep location.

CONCLUSION

There were no significant differences in infant risk behaviors in wahakura compared with bassinets and there were other advantages, including an increase in sustained breastfeeding. This suggests wahakura are relatively safe and can be promoted as an alternative to infant-adult bed-sharing. Policies that encourage utilization are likely to be helpful in high-risk populations.

Sleep-Related Infant Deaths in Victoria: A Retrospective Case Series Study

BACKGROUND

There is general agreement that in some circumstances, sharing a sleep surface of any kind with an infant increases the risk of sudden unexpected death in infancy. There is a paucity of research conducted in Australia examining this issue. This study examines the frequency and distribution of sleep-related infant deaths in a defined population, and reports the proportion that occurred in the context of bed-sharing.

METHODS

A retrospective population-based case series study was conducted of infants (≤365 days) who died in a sleeping context during the period 1 January 2008 to 31 December 2010 in the state of Victoria, Australia. Information about the infant, caregiver, sleeping environment and bed-sharing was collected from a review of the coroner's death investigation record.

RESULTS

During the 3-year study period, 72 infant deaths occurred in a sleeping context. Of these, 33 (45.8 %) occurred in the context of bed-sharing: n = 7 in 2008; n = 11 in 2009; and n = 15 in 2010. Further analysis of the 33 deaths occurring in the context of bed-sharing showed that in this group, bed-sharing was largely intentional, habitual and most often involved the mother as one of the parties.

CONCLUSIONS

Given the case series nature of the study design, a causal relationship between bed-sharing and infant death could not be inferred. However the fact that nearly half of all sleep-related deaths occurred in the context of bed-sharing, provides strong support for the need to undertake definitive analytic studies in Australia so that evidence-based advice can be provided to families regarding the safety of bed-sharing practices.

Comparison of Infant Sleep Practices in African-American and US Hispanic Families: Implications for Sleep-Related Infant Death

African-American and Hispanic families share similar socioeconomic profiles. Hispanic rates of sleep-related infant death are four times lower than African-American rates. We conducted a cross-sectional, multi-modal (surveys, qualitative interviews) study to compare infant care practices that impact risk for sleep-related infant death in African-American and Hispanic families. We surveyed 422 African-American and 90 Hispanic mothers. Eighty-three African-American and six Hispanic mothers participated in qualitative interviews. African-American infants were more likely to be placed prone (p < 0.001), share the bed with the parent (p < 0.001), and to be exposed to smoke (p < 0.001). Hispanic women were more likely to breastfeed (p < .001), while African-American women were more knowledgeable about SIDS. Qualitative interviews indicate that, although African-American and Hispanic parents had similar concerns, behaviors differed. Although the rationale for infant care decisions was similar for African-American and Hispanic families, practices differed. This may help to explain the racial/ethnic disparity seen in sleep-related infant deaths.

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.

Effectiveness of the 'Back-to-Sleep' campaigns among healthcare professionals in the past 20 years: a systematic review

OBJECTIVES

From the late 1980s 'Back-to-Sleep' (BTS) campaigns were run in most developed countries to increase awareness of the supine position's protective effect against sleep-related infant deaths. Once the media awareness-raising action associated with these campaigns ended, healthcare professionals' role became crucial. The goal of this paper is to determine if healthcare professionals' knowledge and parent advice consistent with evidence-based infant sleep recommendations have changed over the past 20 years.

SETTING

All studies investigating healthcare professionals' knowledge and/or advice to parents were included in a systematic review. The search was performed in PubMed and in MEDLINE, and 21 studies were identified.

RESULTS

The correctness of healthcare professionals' knowledge and parent advice about the supine sleeping position increased over the past 20 years. However, the percentage of those aware that parents should avoid putting their babies to sleep in a prone position is decreasing over time: from about 97% in the 1990s to about 90% at the end of the 2000s.

CONCLUSIONS

The effectiveness of the BTS campaigns in publicising the benefits of the supine position is confirmed by this paper. More and more healthcare professionals know that it is the best position to reduce the risk of sleep-related deaths and they recommend it exclusively. However, the decrease in the knowledge about non-prone positions suggests that the campaigns may not have focused enough on the dangers of the prone position.

Infant Sleep Location and Breastfeeding Practices in the United States, 2011-2014

OBJECTIVE

To describe the prevalence of breastfeeding and sleep location practices among US mothers and the factors associated with these behaviors, including advice received regarding these practices.

METHODS

A nationally representative sample of 3218 mothers who spoke English or Spanish were enrolled at a sample of 32 US birth hospitals between January 2011 and March 2014.

RESULTS

Exclusive breastfeeding was reported by 30.5% of mothers, while an additional 29.5% reported partial breastfeeding. The majority of mothers, 65.5%, reported usually room sharing without bed sharing, while 20.7% reported bed sharing. Compared to mothers who room shared without bed sharing, mothers who bed shared were more likely to report exclusive breastfeeding (adjusted odds ratio 2.46, 95% confidence interval 1.76, 3.45) or partial breastfeeding (adjusted odds ratio 1.75, 95% confidence interval 1.33, 2.31). The majority of mothers reported usually room sharing without bed sharing regardless of feeding practices, including 58.2% of exclusively breastfeeding mothers and 70.0% of nonbreastfeeding mothers. Receiving advice regarding sleep location or breastfeeding increased adherence to recommendations in a dose response manner (the adjusted odds of room sharing without bed sharing and exclusive breastfeeding increased as the relevant advice score increased); however, receiving advice regarding sleep location did not affect feeding practices.

CONCLUSIONS

Many mothers have not adopted the recommended infant sleep location or feeding practices. Receiving advice from multiple sources appears to promote adherence in a dose response manner. Many women are able to both breastfeed and room share without bed sharing, and advice to adhere to both of these recommendations did not decrease breastfeeding rates.

Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis

CONTEXT

Swaddling is a traditional practice of wrapping infants to promote calming and sleep. Although the benefits and risks of swaddling in general have been studied, the practice in relation to sudden infant death syndrome remains unclear.

OBJECTIVE

The goal of this study was to conduct an individual-level meta-analysis of sudden infant death syndrome risk for infants swaddled for sleep.

DATA SOURCES

Additional data on sleeping position and age were provided by authors of included studies.

STUDY SELECTION

Observational studies that measured swaddling for the last or reference sleep were included.

DATA EXTRACTION

Of 283 articles screened, 4 studies met the inclusion criteria.

RESULTS

There was significant heterogeneity among studies (I(2) = 65.5%; P = .03), and a random effects model was therefore used for analysis. The overall age-adjusted pooled odds ratio (OR) for swaddling in all 4 studies was 1.58 (95% confidence interval [CI], 0.97-2.58). Removing the most recent study conducted in the United Kingdom reduced the heterogeneity (I(2) = 28.2%; P = .25) and provided a pooled OR (using a fixed effects model) of 1.38 (95% CI, 1.05-1.80). Swaddling risk varied according to position placed for sleep; the risk was highest for prone sleeping (OR, 12.99 [95% CI, 4.14-40.77]), followed by side sleeping (OR, 3.16 [95% CI, 2.08-4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27-2.93]). Limited evidence suggested swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months.

LIMITATIONS

Heterogeneity among the few studies available, imprecise definitions of swaddling, and difficulties controlling for further known risks make interpretation difficult.

CONCLUSIONS

Current advice to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration should be given to an age after which swaddling should be discouraged.

Parent-child bed-sharing: The good, the bad, and the burden of evidence

The practice of parent and child sharing a sleeping surface, or 'bed-sharing', is one of the most controversial topics in parenting research. The lay literature has popularized and polarized this debate, offering on one hand claims of dangers, and on the other, of benefits - both physical and psychological - associated with bed-sharing. To address the scientific evidence behind such claims, we systematically reviewed 659 published papers (peer-reviewed, editorial pieces, and commentaries) on the topic of parent-child bed-sharing. Our review offers a narrative walkthrough of the many subdomains of bed-sharing research, including its many correlates (e.g., socioeconomic and cultural factors) and purported risks or outcomes (e.g., sudden infant death syndrome, sleep problems). We found general design limitations and a lack of convincing evidence in the literature, which preclude making strong generalizations. A heat-map based on 98 eligible studies aids the reader to visualize world-wide prevalence in bed-sharing and highlights the need for further research in societies where bed-sharing is the norm. We urge for multiple subfields - anthropology, psychology/psychiatry, and pediatrics - to come together with the aim of understanding infant sleep and how nightly proximity to the parents influences children's social, emotional, and physical development.

Reasons for mother-infant bed-sharing: a systematic narrative synthesis of the literature and implications for future research

Mother-infant bed-sharing has been a common practice for centuries. Understanding the reasons parents choose to bed-share can help tailor safe sleep education. The purpose of this article was to systematically review the international literature on: (1) reasons parents bed-share, (2) the cultural context of bed-sharing, and (3) implications for interventions and future research. The search occurred August-September 2013 via PubMed, CINAHL, and Psyc INFO using the terms: "infant," "sleep," "bed shar*," "co sleep*," "sleep location," "sleep practices," and "sleep arrangements," alone or in combination. Google Scholar was searched using: "bed share," "bed sharing," "co sleep," and "co sleeping." Inclusion criteria were: (1) referenced bed-sharing with infants 12 months or younger; (2) provided reasons for bed-sharing; and (3) published between 1990 and 2013. Studies were excluded if they focused on disorders such as epilepsy, breathing disorders, or among multi-gestational infants. Narrative synthesis was used to summarize findings. Thirty-four studies met inclusion criteria. The main themes around bed-sharing based on this synthesis included: (1) breastfeeding, (2) comforting, (3) better/more sleep, (4) monitoring, (5) bonding/attachment, (6) environmental, (7) crying, (8) tradition, (9) disagree with danger, and (10) maternal instinct. Findings suggest that future research should examine parents' decision-making process on infant sleep location, including how they weigh personal reasons and sources of advice. Public health interventions should incorporate the particular reasons of the population they are targeting. Clinicians should discuss infant sleep environment with each family, along with their motivations for choosing this environment, and work within that framework to address the safety of the sleep environment.

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.

Parent-infant bed-sharing behavior : Effects of feeding type and presence of father

An evolutionarily informed perspective on parent-infant sleep contact challenges recommendations regarding appropriate parent-infant sleep practices based on large epidemiological studies. In this study regularly bed-sharing parents and infants participated in an in-home video study of bed-sharing behavior. Ten formula-feeding and ten breast-feeding families were filmed for 3 nights (adjustment, dyadic, and triadic nights) for 8 hours per night. For breast-fed infants, mother-infant orientation, sleep position, frequency of feeding, arousal, and synchronous arousal were all consistent with previous sleep-lab studies of mother-infant bed-sharing behavior, but significant differences were found between formula and breast-fed infants. While breast-feeding mothers shared a bed with their infants in a characteristic manner that provided several safety benefits, formula-feeding mothers shared a bed in a more variable manner with consequences for infant safety. Paternal bed-sharing behavior introduced further variability. Epidemiological case-control studies examining bed-sharing risks and benefits do not normally control for behavioral variables that an evolutionary viewpoint would deem crucial. This study demonstrates how parental behavior affects the bed-sharing experience and indicates that cases and controls in epidemiological studies should be matched for behavioral, as well as sociodemographic, variables.

Bed-sharing and unexpected infant deaths: what is the relationship?

For much of human history infant survival has been largely predicated by close and continuous contact between the infant and the primary carer - almost always the mother. Many factors in post-industrial human society - notably tobacco smoking, alcohol intake and the use of recreational drugs- have been associated with increased risk to infants sleeping in close proximity to their mothers. This is particularly true for mothers who choose not to breastfeed. The question of the risks and possible benefits of bed-sharing for mothers who plan to breastfeed, do not smoke, do not drink alcohol or take recreational drugs, and are aware of how to ensure a safe infant sleep environment need to be quantified. In this paper we review the evidence from several epidemiological studies and identify the factors that make bedsharing more or less hazardous for the infant. This analysis is important in allowing us to give parents accurate and unbiased information on which to make their own choices about optimal night time care of their infants without demonising normal parental behaviour or practices.

Breastfeeding in African Americans may not depend on sleep arrangement: a mixed-methods study

BACKGROUND

Despite high bedsharing rates, breastfeeding rates are low among African Americans.

OBJECTIVE

Describe the association between breastfeeding and bedsharing; elucidate barriers to breastfeeding in African Americans.

METHODS

African American mothers with infants <6 months were recruited for this cross-sectional, mixed-methods study and completed an infant care practices survey. A subgroup participated in focus groups or individual interviews.

RESULTS

A total of 412 completed the survey; 83 participated in a focus group or interview. Lower socioeconomic status mothers were more likely to breastfeed exclusively or at all if they bedshared (P = .02 and P = .01, respectively). Bedsharing was not associated with breastfeeding among higher socioeconomic status mothers. Breast pain, lack of support, and maternal skepticism about breastfeeding benefits were barriers; the latter was a recurrent theme among nonbreastfeeding mothers.

CONCLUSIONS

While bedsharing is associated with breastfeeding in lower socioeconomic groups, it is not in higher socioeconomic African American groups. Skepticism about breastfeeding benefits may contribute to low breastfeeding rates in African Americans.

Sofas and infant mortality

OBJECTIVE

Sleeping on sofas increases the risk of sudden infant death syndrome and other sleep-related deaths. We sought to describe factors associated with infant deaths on sofas.

METHODS

We analyzed data for infant deaths on sofas from 24 states in 2004 to 2012 in the National Center for the Review and Prevention of Child Deaths Case Reporting System database. Demographic and environmental data for deaths on sofas were compared with data for sleep-related infant deaths in other locations, using bivariate and multivariable, multinomial logistic regression analyses.

RESULTS

A total of 1024 deaths on sofas made up 12.9% of sleep-related infant deaths. They were more likely than deaths in other locations to be classified as accidental suffocation or strangulation (adjusted odds ratio [aOR] 1.9; 95% confidence interval [CI], 1.6-2.3) or ill-defined cause of death (aOR 1.2; 95% CI, 1.0-1.5). Infants who died on sofas were less likely to be Hispanic (aOR 0.7; 95% CI, 0.6-0.9) compared with non-Hispanic white infants or to have objects in the environment (aOR 0.6; 95% CI, 0.5-0.7) and more likely to be sharing the surface with another person (aOR 2.4; 95% CI, 1.9-3.0), to be found on the side (aOR 1.9; 95% CI, 1.4-2.4), to be found in a new sleep location (aOR 6.5; 95% CI, 5.2-8.2), and to have had prenatal smoke exposure (aOR 1.4; 95% CI, 1.2-1.6). Data on recent parental alcohol and drug consumption were not available.

CONCLUSIONS

The sofa is an extremely hazardous sleep surface for infants. Deaths on sofas are associated with surface sharing, being found on the side, changing sleep location, and experiencing prenatal tobacco exposure, which are all risk factors for sudden infant death syndrome and sleep-related deaths.

An evidence-based safe sleep teaching program

This column describes the experience of the units practice council in developing an evidence-based practice teaching program focused on safe sleep for newborn infants.

Speaking out on safe sleep: evidence-based infant sleep recommendations

The American Academy of Pediatrics (AAP) issued recommendations in 2005 and 2011 to reduce sleep-related infant death, which advise against all bedsharing for sleep. These recommendations overemphasize the risks of bedsharing, and this overemphasis has serious unintended consequences. It may result in increased deaths on sofas as tired parents try to avoid feeding their infants in bed. Current evidence shows that other risks are far more potent, such as smoking, shared sleep on sofas, sleeping next to impaired caregivers, and formula feeding. The emphasis on separate sleep is diverting resources away from addressing these critical risk factors. Recommendations to avoid bedsharing may also interfere with breastfeeding. We examine both the evidence behind the AAP recommendations and the evidence omitted from those recommendations. We conclude that the only evidence-based universal advice to date is that sofas are hazardous places for adults to sleep with infants; that exposure to smoke, both prenatal and postnatal, increases the risk of death; and that sleeping next to an impaired caregiver increases the risk of death. No sleep environment is completely safe. Public health efforts must address the reality that tired parents must feed their infants at night somewhere and that sofas are highly risky places for parents to fall asleep with their infants, especially if parents are smokers or under the influence of alcohol or drugs. All messaging must be crafted and reevaluated to avoid unintended negative consequences, including impact on breastfeeding rates, or falling asleep in more dangerous situations than parental beds. We must realign our resources to focus on the greater risk factors, and that may include greater investment in smoking cessation and doing away with aggressive formula marketing. This includes eliminating conflicts of interest between formula marketing companies and organizations dedicated to the health of children.