Racial and ethnic disparities of sudden unexpected infant death in large US cities: a descriptive epidemiological study

Identifying infants at risk of sudden unexpected death with an automated predictive risk model

BACKGROUND/OBJECTIVE

Sudden unexpected infant death (SUID) is a common cause of infant death. We evaluated whether a predictive risk model (PRM) - Hello Baby - which was developed to stratify children by risk of entry into foster care could also identify infants at highest risk of SUID and non-fatal unsafe sleep events.

PARTICIPANTS AND SETTING

Cases: Infants with SUID or an unsafe sleep event over 5½ years in a single county.

CONTROLS

All births in the same county.

METHODS

Retrospective case-control study. Demographic and clinical data were collected and a Hello Baby PRM score was assigned. Descriptive statistics and the predictive value of a PRM score of 20 were calculated.

RESULTS

Infants with SUID (n = 62) or an unsafe sleep event (n = 37) (cases) were compared with 23,366 births (controls). Cases and controls were similar for all demographic and clinical data except that infants with unsafe sleep events were older. Median PRM score for cases was higher than controls (17.5 vs. 10, p < 0.001); 50 % of cases had a PRM score 17-20 vs. 16 % of controls (p < 0.001).

CONCLUSIONS

The Hello Baby PRM can identify newborns at high risk of SUID and non-fatal unsafe sleep events. The ability to identify high-risk newborns prior to a negative outcome allows for individualized evaluation of high-risk families for modifiable risk factors which are potentially amenable to intervention. This approach is limited by the fact that not all counties can calculate a PRM or similar score automatically.

Multiomic Analysis of Neuroinflammation and Occult Infection in Sudden Infant Death Syndrome

Importance

Antemortem infection is a risk factor for sudden infant death syndrome (SIDS)-the leading postneonatal cause of infant mortality in the developed world. Manifestations of infection and inflammation are not always apparent in clinical settings or by standard autopsy; thus, enhanced resolution approaches are needed.

Objective

To ascertain whether a subset of SIDS cases is associated with neuroinflammation and occult infection.

Design, Setting, and Participants

In this case-control study, postmortem fluids from SIDS cases and controls collected between July 2011 and November 2018 were screened for elevated inflammatory markers, specifically cerebrospinal fluid (CSF) neopterin and CSF and serum cytokines. CSF, liver, and brain tissue from SIDS cases with elevated CSF neopterin were subjected to metagenomic next-generation sequencing (mNGS) to probe for infectious pathogens. Brainstem tissue from a subset of these cases was analyzed by single-nucleus RNA sequencing (snRNAseq) to measure cell type-specific gene expression associated with neuroinflammation and infection. All tissue and fluid analyses were performed from April 2019 to January 2023 in a pathology research laboratory. Included was autopsy material from infants dying of SIDS and age-matched controls dying of known causes.

Exposures

There were no interventions or exposures.

Main Outcomes and Measures

CSF neopterin levels were measured by high-performance liquid chromatography. Cytokines were measured by multiplex fluorometric assay. mNGS was performed on liver, CSF, brain, and brainstem tissue. snRNAseq was performed on brainstem tissue.

Results

A cohort of 71 SIDS cases (mean [SD] age, 55.2 [11.4] postconceptional weeks; 42 male [59.2%]) and 20 controls (mean [SD] age, 63.2 [16.9] postconceptional weeks; 11 male [55.0%]) had CSF and/or serum available. CSF neopterin was screened in 64 SIDS cases and 15 controls, with no exclusions. Tissues from 6 SIDS cases were further analyzed. For CSF neopterin measures, SIDS samples were from infants with mean (SD) age of 54.5 (11.3) postconceptional weeks (38 male [59.4%]) and control samples were from infants with mean (SD) age of 61.5 (17.4) postconceptional weeks (7 male [46.7%]). A total of 6 SIDS cases (9.3%) with high CSF neopterin were identified, suggestive of neuroinflammation. mNGS detected human parechovirus 3 (HPeV3) in tissue and CSF from 1 of these 6 cases. snRNAseq of HPeV3-positive brainstem tissue (medulla) revealed dramatic enrichment of transcripts for genes with predominately inflammatory functions compared with 3 age-matched SIDS cases with normal CSF neopterin levels.

Conclusions and Relevance

Next-generation molecular tools in autopsy tissue provide novel insight into pathogens that go unrecognized by normal autopsy methodology, including in infants dying suddenly and unexpectedly.

Characteristics Associated with Sudden Unexpected Infant Death in a Rural Hispanic Population: A Case-Control Study

INTRODUCTION

Sudden unexpected infant death (SUID) is the leading cause of death among U.S. infants aged 28 days to 1 year. In Kansas, Hispanic infant mortality is nearly 50% higher than non-Hispanic White. Further, the SUID rate did not change between 2005-2018, while rates for non-Hispanic Black and White infants decreased significantly. This study sought to identify characteristics and behaviors of Hispanic birthing persons related to SUID.

METHODS

Linked Kansas birth/death vital statistics data (2005-2018) identified Hispanic birthing persons with a singleton birth who experienced SUID. To reduce confounding effects, greedy nearest neighbor matching paired each SUID case sequentially with the four nearest controls based on age, race, payor source and parity. Matching procedures, likelihood-ratio χ2, Fisher exact test and multiple logistic regression model with Firth's penalized maximum likelihood estimation were computed.

RESULTS

Of 86,052 Hispanic singleton births, 66 involved SUID and were matched with 264 controls. No differences were related to marital status, population density of residence, education level, language spoken, prenatal BMI, weight gained during pregnancy, adequacy of prenatal care, enrollment in WIC, or state immunization registry participation (all p>0.05). However, tobacco use during pregnancy contributed to a three times greater risk of SUID (OR=3.208; 95% CI=1.438 to 7.154). Multivariable models for behavioral variables revealed low predictive accuracy with area under the ROC curve=0.6303.

CONCLUSION

This study suggests SUID deaths to rural Hispanic families are likely multifaceted. Study results inform educational programs on the importance of addressing tobacco cessation in SUID risk reduction interventions for Hispanic families.

Sociodemographic factors associated with paediatric out-of-hospital cardiac arrest: A systematic review

BACKGROUND

Paediatric out-of-hospital cardiac arrest (POHCA) is associated with poor survival and severe neurological sequelae. We conducted a systematic review on the impact of sociodemographic factors across different stages of POHCA.

METHODS

We searched MEDLINE, EMBASE, and Web of Science from database inception to October 2022. We included studies examining the association between sociodemographic factors (i.e., race, ethnicity, migrant status and socioeconomic status [SES]) and POHCA risk, bystander cardiopulmonary resuscitation (CPR) provision, bystander automated external defibrillator (AED) application, survival (at or 30-days post-discharge), and neurological outcome. We synthesized the data qualitatively.

RESULTS

We screened 11,097 citations and included 18 articles (arising from 15 studies). There were 4 articles reporting on POHCA risk, 5 on bystander CPR provision, 3 on bystander AED application, 13 on survival, and 6 on neurological outcome. In all studies on POHCA risk, significant differences were found across racial groups, with minority populations being disproportionately impacted. There were no articles reporting on the association between SES and POHCA risk. Bystander CPR provision was consistently associated with race and ethnicity, with disparities impacting Black and Hispanic children. The association between bystander CPR provision and SES was variable. There was little evidence of socioeconomic or racial disparities in studies on bystander AED application, survival, and neurological outcome, particularly across adjusted analyses.

CONCLUSIONS

Race and ethnicity are likely associated with POHCA risk and bystander CPR provision. These findings highlight the importance of prioritizing at-risk groups in POHCA prevention and intervention efforts. Further research is needed to understand underlying mechanisms.

Pre- and postnatal safe sleep knowledge and planned as compared to actual infant sleep practices

BACKGROUND

Our objectives were to compare safe sleep knowledge, attitudes and planned vs. actual infant sleep practices among expectant mothers before and after their infant's birth and to determine whether differences (if present) were associated with any demographic variables.

METHODS

Study participants were surveyed at their 28-week prenatal and 6-week postpartum obstetric clinic visits from November 2019-February 2021. Due to COVID-19 pandemic cancellation of in-person postpartum visits, many participants received text messaging encouraging them to take the follow-up survey online. Frequency and comparative analyses were performed.

RESULTS

355 women (44%) completed both pre- and postnatal surveys. Many participants increased their safe sleep knowledge during the study. For example, of those who were unsure or thought it safe for a baby to sleep in a baby swing/bouncy seat, two-thirds (67/102, 66%) stated it was unsafe on the postnatal survey. In addition, many who were unsure or planned sleep practices considered unsafe prenatally reported utilizing safe sleep practices on their postnatal survey. For example, of those unsure or planning to use a crib bumper (17% of the total), almost all (88%) were not using one postnatally. Conversely, some participants who reported they would be following safe sleep practices prenatally were not doing so postpartum. For example, 13% of those stating they would place their child on their back reported using another sleep position on the postnatal survey. Certain demographics had higher proportions reporting this reversal for specific safe sleep practices. For example, non-Hispanic Whites (19%) as compared to other races/ethnicities (5%) and those with incomes ≥ $75,000 (21%) as compared with those with less income (9%) had higher proportions stating their infant would sleep in the same room but then reported postnatally they were sleeping in a different room, p = 0.0094 and p = 0.0138, respectively.

CONCLUSIONS

We observed increases in safe sleep knowledge and that some participants followed safer sleep practices than they had planned. However, there were also participants who planned to use safe sleep practices prenatally who were not doing so after their baby's birth. Our study identified demographics for which targeted safe sleep education and more effective interventions may be needed.

Unexplained and Unexpected Pediatric Deaths: Forensic Review and New Perspectives

Unexplained and unexpected pediatric deaths are a major challenge in global healthcare. The role of the forensic pathologist is crucial in determining the cause and manner of death in these cases, although to date, there are many limitations in post-mortem diagnosis. The role of the autopsy and related forensic investigations become a fundamental tool to investigate and give an explanation for an unacceptable event, considering the young age of the victims. From this point of view, even today, it is necessary that this phenomenon is correctly recorded through standardized systems and universally accepted methods. Furthermore, it is essential that scientific research on this topic is increased through the implementation of universally accepted operating protocols recognizing real risk factors in order to prevent such events. The purpose of the study is to offer a review of the state of the art about unexplained pediatric death and, above all, to propose an international reporting platform, extending proper investigations not only to judicial cases but also to all the other cases of unexpected pediatric death.

Fathers, Breastfeeding, and Infant Sleep Practices: Findings From a State-Representative Survey

OBJECTIVES

To assess infant breastfeeding initiation and any breastfeeding at 8 weeks and safe sleep practices (back sleep position, approved sleep surface, and no soft objects or loose bedding ["soft bedding"]) by select paternal characteristics among a state-representative sample of fathers with new infants.

METHODS

Pregnancy Risk Assessment Monitoring System (PRAMS) for Dads, a novel population-based cross-sectional study, surveyed fathers in Georgia 2-6 months after their infant's birth. Fathers were eligible if the infant's mother was sampled for maternal PRAMS from October 2018 to July 2019.

RESULTS

Of 250 respondents, 86.1% reported their infants ever breastfed and 63.4% reported breastfeeding at 8 weeks. Initiation and breastfeeding at 8 weeks were more likely to be reported by fathers who reported wanting their infant's mother to breastfeed than those who did not want her to breastfeed or had no opinion (adjusted prevalence ratio [aPR] = 1.39; 95% confidence interval [CI], 1.15-1.68; aPR = 2.33; 95% CI, 1.59-3.42, respectively) and fathers who were college graduates than those with ≤high school diploma (aPR = 1.25; 95% CI, 1.06-1.46; aPR = 1.44; 95% CI, 1.08-1.91, respectively). Although about four-fifths (81.1%) of fathers reported usually placing their infants to sleep on their back, fewer fathers report avoiding soft bedding (44.1%) or using an approved sleep surface (31.9%). Non-Hispanic Black fathers were less likely to report back sleep position (aPR = 0.70; 95% CI, 0.54-0.90) and no soft bedding (aPR = 0.52; 95% CI, 0.30-0.89) than non-Hispanic white fathers.

CONCLUSIONS

Fathers reported suboptimal infant breastfeeding rates and safe sleep practices overall and by paternal characteristics, suggesting opportunities to include fathers in promotion of breastfeeding and infant safe sleep.

Racial differences in the impact of maternal smoking on sudden unexpected infant death

BACKGROUND

Prenatal smoking increases the risk of Sudden Unexpected Infant Death (SUID). Whether exposure patterns and associations differ by race requires further study.

OBJECTIVES

Determine if patterns of exposure and associations between SUID and maternal smoking before and during pregnancy differ by race.

METHODS

Using U.S. National Center for Health Statistics linked birth/infant death files 2012-2013, we documented SUID by smoking duration and race. Maternal smoking history: never, pre-pregnancy only, and pre-pregnancy plus first, first, second, or all trimesters.

RESULTS

Smoking was more common in non-Hispanic White (NHW) than non-Hispanic Black (NHB) mothers and more evident for both in SUID cases. The most common exposure duration is from before and throughout pregnancy (SUID: 78.3% NHW, 66.9% NHB; Survivors: 60.22% and 53.96%, respectively). NHB vs. NHW SUID rates per 1000 live births were 1.07 vs. 0.34 for non-smokers and 3.06 and 1.79 for smokers, ORs trended upward for both with increasing smoking duration.

CONCLUSION

Fewer NHB mothers smoked, but both NHB and NHW groups exhibited a dose-response relationship between smoking duration and SUID. The most common duration was from before to the end of pregnancy, suggesting difficulty in quitting and a need for effective interventions.