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Pretorius K, Kang S, Choi E. Photos Shared on Facebook in the Context of Safe Sleep Recommendations: Content Analysis of Images. JMIR Pediatr Parent 2024; 7:e54610. [PMID: 38659146 PMCID: PMC11063578 DOI: 10.2196/54610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/29/2024] [Accepted: 03/14/2024] [Indexed: 04/26/2024] Open
Abstract
Background Sudden unexpected infant death (SUID) remains a leading cause of infant mortality; therefore, understanding parental practices of infant sleep at home is essential. Since social media analyses yield invaluable patient perspectives, understanding sleep practices in the context of safe sleep recommendations via a Facebook mothers' group is instrumental for policy makers, health care providers, and researchers. Objective This study aimed to identify photos shared by mothers discussing SUID and safe sleep online and assess their consistency with infant sleep guidelines per the American Academy of Pediatrics (AAP). We hypothesized the photos would not be consistent with guidelines based on prior research and increasing rates of accidental suffocation and strangulation in bed. Methods Data were extracted from a Facebook mothers' group in May 2019. After trialing various search terms, searching for the term "SIDS" on the selected Facebook group resulted in the most relevant discussions on SUID and safe sleep. The resulting data, including 20 posts and 912 comments among 512 mothers, were extracted and underwent qualitative descriptive content analysis. In completing the extraction and subsequent analysis, 24 shared personal photos were identified among the discussions. Of the photos, 14 pertained to the infant sleep environment. Photos of the infant sleep environment were then assessed for consistency with safe sleep guidelines per the AAP standards by 2 separate reviewers. Results Of the shared photos relating to the infant sleep environment, 86% (12/14) were not consistent with AAP safe sleep guidelines. Specific inconsistencies included prone sleeping, foreign objects in the sleeping environment, and use of infant sleeping devices. Use of infant monitoring devices was also identified. Conclusions This study is unique because the photos originated from the home setting, were in the context of SUID and safe sleep, and were obtained without researcher interference. Despite study limitations, the commonality of prone sleeping, foreign objects, and the use of both infant sleep and monitoring devices (ie, overall inconsistency regarding AAP safe sleep guidelines) sets the stage for future investigation regarding parental barriers to practicing safe infant sleep and has implications for policy makers, clinicians, and researchers.
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Affiliation(s)
- Kelly Pretorius
- School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Sookja Kang
- School of Nursing, The University of Texas at Austin, Austin, TX, United States
| | - Eunju Choi
- School of Nursing, MD Anderson Cancer Center, The University of Texas, Houston, TX, United States
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Bourneuf AL, Pabic EL, de Visme S, Levieux K, Pladys P. Risk factors for unexpected infant death among very premature infants in France. Arch Pediatr 2024; 31:195-201. [PMID: 38538469 DOI: 10.1016/j.arcped.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/08/2023] [Accepted: 12/10/2023] [Indexed: 04/07/2024]
Abstract
BACKGROUND Prematurity is one of the risk factors for sudden unexpected infant death (SUID), a phenomenon that remains poorly explained. MATERIALS AND METHODS The analysis of specific factors associated with SUID among very premature infants (VPI) was performed through a retrospective review of data collected in the French SUID registry from May 2015 to December 2018. The factors associated with SUID among VPI were compared with those observed among full-term infants (FTI). Results are expressed as means (standard deviation [SD]) or medians (interquartile range [IQR)]. RESULTS During the study period, 719 cases of SUID were included in the registry, 36 (incidence: 0.60 ‰) of which involved VPI (gestational age: 29.2 [2] weeks, 1157 [364]) g] and 313 (0.18 ‰) involved FTI (gestational age: 40 [0.8] weeks, 3298 [452] g). The infants' postnatal age at the time of death was similar in the two groups: 15.5 (12.2-21.8) vs. 14.5 (7.1-23.4) weeks. We observed low breastfeeding rates and a high proportion of fathers with no occupation or unemployment status among the VPI compared to the FTI group (31% vs. 55 %, p = 0.01 and 32% vs. 13 %, p = 0.05, respectively). Among the VPI, only 52 % were in supine position, and 29 % were lying prone at the time of the SUID (compared to 63 % and 17 %, respectively, in the FTI group). CONCLUSION This study confirms prematurity as a risk factor for SUID with no difference in the SUID-specific risk factors studied except for breastfeeding and socioeconomic status of the fathers. VPI and FTI died at similar chronological ages with a high proportion of infants dying in prone position. These results argue for reinforcement of prevention strategies in cases of prematurity.
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Affiliation(s)
| | - Estelle Le Pabic
- CHU Rennes, Inserm, CIC 1414 (Clinical Investigation Center), F-35000 Rennes, France
| | | | - Karine Levieux
- Inserm CIC 1413, Nantes University Hospital, Nantes, France; Pediatric Emergency Care Unit, Nantes University Hospital, Nantes, France
| | - Patrick Pladys
- Department of Child and Adolescent Medicine, CHU de Rennes, Rennes, France; Research and Innovation Department, Paediatric Department, University Hospital of Rennes, Rennes, France
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Pries AM, Ruskamp JM, Edelenbos E, Fuijkschot J, Semmekrot B, Verbruggen KT, van de Putte E, Puiman PJ. A Systematic Approach to Evaluate Sudden Unexplained Death in Children. J Pediatr 2024; 264:113780. [PMID: 37852434 DOI: 10.1016/j.jpeds.2023.113780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE To evaluate in the Netherlands the national outcomes in providing cause of and insights into sudden and unexplained child deaths among children via the Postmortem Evaluation of Sudden Unexplained Death in Youth (PESUDY) procedure. STUDY DESIGN Children aged 0-18 years in the Netherlands who died suddenly were included in the PESUDY procedure if their death was unexplained and their parents gave consent. The PESUDY procedure consists of pediatric and forensic examination, biochemical, and microbiological tests; radiologic imaging; autopsy; and multidisciplinary discussion. Data on history, modifiable factors, previous symptoms, performed diagnostics, and cause of death were collected between October 2016 and December 2021. RESULTS In total, 212 cases (median age 11 months, 56% boys, 33% comorbidity) were included. Microbiological, toxicological, and metabolic testing was performed in 93%, 34%, and 32% of cases. In 95% a computed tomography scan or magnetic resonance imaging was done and in 62% an autopsy was performed. The cause of death was explained in 58% of cases and a plausible cause was identified in an additional 13%. Most children died from infectious diseases. Noninfectious cardiac causes were the second leading cause of death found. Modifiable factors were identified in 24% of non-sudden infant death syndrome/unclassified sudden infant death cases and mostly involved overlooked alarming symptoms. CONCLUSIONS The PESUDY procedure is valuable and effective for determining the cause of death in children with sudden unexplained deaths and for providing answers to grieving parents and involved health care professionals.
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Affiliation(s)
- Annelotte Maretta Pries
- Department of General Paediatrics, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jopje Marlies Ruskamp
- Department of Paediatrics, University Medical Center Utrecht Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Esther Edelenbos
- Department of Paediatrics, Amsterdam University Medical Center Emma Children's Hospital, Amsterdam, The Netherlands
| | - Joris Fuijkschot
- Department of Paediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Ben Semmekrot
- Department of Paediatrics, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Krijn Teunis Verbruggen
- Department of Paediatrics, University Medical Center Groningen Beatrix Children's Hospital, Groningen, The Netherlands
| | - Elise van de Putte
- Department of Paediatrics, University Medical Center Utrecht Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Patrycja Jolanta Puiman
- Department of General Paediatrics, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands.
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Hitchcock SC. What More Can We Do to Prevent Infants From Dying While They Sleep? Nurs Womens Health 2023; 27:448-456. [PMID: 37918814 DOI: 10.1016/j.nwh.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/04/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023]
Abstract
Sleep-related infant deaths, now called sudden unexpected infant deaths, are not declining, and the United States continues to have greater rates than most other developed nations. Health disparities are significant, with death rates greater in certain vulnerable groups, including non-Hispanic Black infants. Nurses play a crucial role in educating, role-modeling, and problem-solving with parents. Thus, it is critical for nurses to stay current with the science, prevention recommendations, and societal decisions and debates surrounding this topic. This article provides a summary of the updated safe sleep recommendations released by the American Academy of Pediatrics in 2022 as well as discussions on current trends, thoughts, and controversies related to how safe sleep education is provided to parents.
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Ahlers-Schmidt CR, Okut H, Jacobson LT, Hervey A, Schunn C, Torres M, Kuhlmann Z. Characteristics Associated with Sudden Unexpected Infant Death in a Rural Hispanic Population: A Case-Control Study. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01854-5. [PMID: 37947954 DOI: 10.1007/s40615-023-01854-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
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.
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Affiliation(s)
- Carolyn R Ahlers-Schmidt
- Center for Research for Infant Birth and Survival, University of Kansas School of Medicine-Wichita, 3243 E. Murdock, Suite 604, Wichita, KS, 67208, USA.
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, 3243 E. Murdock, Suite 604, Wichita, KS, 67208, USA.
| | - Hayrettin Okut
- Office of Research, University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS, 67214, USA
| | - Lisette T Jacobson
- Department of Population Health, University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS, 67214, USA
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS, 67214, USA
| | - Ashley Hervey
- Center for Research for Infant Birth and Survival, University of Kansas School of Medicine-Wichita, 3243 E. Murdock, Suite 604, Wichita, KS, 67208, USA
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, 3243 E. Murdock, Suite 604, Wichita, KS, 67208, USA
| | - Christy Schunn
- Kansas Infant Death and SIDS (KIDS) Network, 300 W. Douglas, Suite 145, Wichita, KS, 67202, USA
| | - Maria Torres
- Kansas Infant Death and SIDS (KIDS) Network, 300 W. Douglas, Suite 145, Wichita, KS, 67202, USA
| | - Zachary Kuhlmann
- Department of Obstetrics and Gynecology, University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS, 67214, USA
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Nazaruk D, Palacios AM, Chopak-Foss J, Mayo-Gamble TL, Marshall NA. Parental Knowledge and Perceptions on Prevention of Sudden Unexpected Infant Death and Infant Care. Children (Basel) 2023; 10:1550. [PMID: 37761510 PMCID: PMC10529227 DOI: 10.3390/children10091550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/28/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023]
Abstract
(1) Background: The study's purpose was to explore the knowledge, perceptions, and confidence of mothers about infant care to reduce the risk of sudden unexpected infant death. (2) Methods: A purposeful sampling method was used to recruit 15 first-time mothers from Georgia with infants under 1 year of age. The researchers utilized the Socio-ecological model to report the results. Participants also provided recommendations on how to improve infant care and reduce the risk of SUID. (3) Results: The confidence level of infant care among most participants was low but increased over time. Mothers' knowledge level about the prevention of SUID was high, but poor emotional health could hurt their parental abilities. Most participants recognized medical providers as the main source of reliable information. However, a lack of emotional and physical support was reported by mothers. (4) Conclusions: Results suggested that a more holistic approach to infant care is needed. The healthcare system and communities should provide more physical, social, and mental support to first-time mothers, a consolidated approach to care before and after birth, and easy access to services at all stages of the process to reduce the risk of SUID.
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Affiliation(s)
- Dziyana Nazaruk
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Sothern University, 11935 Abercorn Street, Savannah, GA 31419, USA
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Galambos C, Bush D, Abman SH, Caplan M. Prominent Intrapulmonary Shunt Vessels and Altered Lung Development in Infants With Sudden Unexplained Infant Death. J Pediatr 2023; 255:214-219.e1. [PMID: 36336004 DOI: 10.1016/j.jpeds.2022.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/29/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
The purpose of this study was to evaluate intrapulmonary arteriovenous shunts in patients with and without sudden unexplained infant death. We identified open intrapulmonary bronchopulmonary anastomoses as potential pathways for right-to-left shunt in a subset of infants with sudden unexplained infant death.
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Affiliation(s)
- Csaba Galambos
- Department of Pathology and Laboratory Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Douglas Bush
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Lazarus SG, Miller T, Hudson PJ, McFadden T, Baas G, Kendi S. Racial and incident discrepancies in news media reporting of sudden unexpected infant death ( SUID). Inj Epidemiol 2022; 9:39. [PMID: 36544220 PMCID: PMC9768877 DOI: 10.1186/s40621-022-00398-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Regardless of injury prevention and outreach efforts, there continue to be low rates of adherence with the American Academy of Pediatrics (AAP) safe sleep recommendations. Media is an important tool for parental education and may influence risk perception and caregiver choices. Due to media reports potentially serving as an opportunity for shaping social norms, caregiver education and injury prevention, an evaluation was undertaken to evaluate Georgia local news reporting of sudden unexpected infant death (SUID) as compared to drownings, homicides, and firearm injuries. Our objective was to evaluate incident and racial discrepancies in Georgia news media reporting of SUID as compared to other pediatric injury deaths. RESULTS Despite its high incidence, SUID was far less commonly mentioned in the news media, with only 1.9% (10/525) mentioned as compared to 8.1% of drownings (17/211), 11.4% (74/649) of MVC's, 14.7% (59/402) of homicides between ages 1-18, 20% (11/55) of fire-related deaths and 25% (15/59) of homicides under age one (infant homicides). Across SUID and homicide, deaths of White infants were reported in the news media at 2.5 times the rate of Black infants. CONCLUSION Despite SUID being a leading cause of infant death, it is infrequently mentioned in the news media. When mentioned, the news media are more likely to highlight the deaths of White infants as compared to Black infants, though the incidence rate of SUID is higher in Black infants as compared to White.
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Affiliation(s)
- Sarah Gard Lazarus
- Pediatric Emergency Medicine Associates, Atlanta, GA USA ,grid.428158.20000 0004 0371 6071Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Terri Miller
- grid.420388.50000 0004 4692 4364Georgia Department of Public Health, Atlanta, GA USA
| | - Philip J. Hudson
- grid.420388.50000 0004 4692 4364Georgia Department of Public Health, Atlanta, GA USA
| | - Terri McFadden
- grid.189967.80000 0001 0941 6502Emory University Department of Pediatrics, Atlanta, GA USA
| | - Gretchen Baas
- grid.189967.80000 0001 0941 6502Rollins School of Public Health, Atlanta, GA USA
| | - Sadiqa Kendi
- grid.239560.b0000 0004 0482 1586Children’s National Hospital, Washington, DC USA
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Boyer BT, Lowell GS, Roehler DR, Quinlan KP. Racial and ethnic disparities of sudden unexpected infant death in large US cities: a descriptive epidemiological study. Inj Epidemiol 2022; 9:12. [PMID: 35337375 PMCID: PMC8957171 DOI: 10.1186/s40621-022-00377-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background Sudden unexpected infant death (SUID) accounts for ~ 3400 deaths per year in the USA, and minimal progress has been made in reducing SUID over the past two decades. SUID is the sudden death of an infant that has occurred as a result of accidental suffocation in a sleeping environment, SIDS (sudden infant death syndrome), or from an unknown cause of death. Nationally, non-Hispanic Black (NHB) infants have twice the risk of SUID compared to non-Hispanic White (NHW) infants. In Chicago, this disparity is greatly magnified. To explore whether this disparity is similarly seen in other large cities, we analyzed SUIDs by race and ethnicity for a seven-year period from the 10 most populous US cities. SUID case counts by race and ethnicity were obtained for 2011–2017 from the 10 most populous US cities based on 2010 census data. For each city, we calculated average annual SUID rates (per 1000 live births) by race and ethnicity, allowing calculation of disparity rate ratios. Findings Nationally, from 2011 through 2017, there were 0.891 SUIDs per 1000 live births, with a rate of 0.847 for NHWs, 1.795 for NHBs, and 0.522 for Hispanics. In most study cities, the NHB and Hispanic SUID rates were higher than the corresponding national rate. Hispanic SUID rates were higher than NHW rates in 9 of the 10 largest cities. In every study city, the NHW SUID rate was lower than the national NHW rate. In Chicago, NHB infants had a SUID rate 12.735 times that of NHW infants. Conclusion With few exceptions, the 10 largest US cities had higher NHB and Hispanic SUID rates, but lower NHW SUID rates, compared to the corresponding rates at the national level. Unlike the national pattern, Hispanic SUID rates were higher than NHW rates in 9 of the 10 largest cities. Prevention is currently hampered by the lack of detailed, accurate, and timely information regarding the circumstances of these tragic deaths. A national SUID surveillance system would allow greater understanding of the factors that lead to this disproportionately distributed and enduring cause of infant death.
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Affiliation(s)
| | - Gina S Lowell
- Department of Pediatrics, Rush University Medical Center, 1725 W Harrison St Suite 710, Chicago, IL, 60612, USA
| | - Douglas R Roehler
- Department of Pediatrics, Rush University Medical Center, 1725 W Harrison St Suite 710, Chicago, IL, 60612, USA
| | - Kyran P Quinlan
- Department of Pediatrics, Rush University Medical Center, 1725 W Harrison St Suite 710, Chicago, IL, 60612, USA
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Snippen JR, Cheyney M, Drake SA. Barriers to consistent and reliable investigation of sudden unexpected infant death: Perspectives from law enforcement. J Forensic Sci 2022; 67:1084-1091. [PMID: 35037699 DOI: 10.1111/1556-4029.14982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/22/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022]
Abstract
Despite persistent efforts to advance infant death investigation, most sudden unexpected infant deaths (SUIDs) remain unexplained. Law enforcement officials contribute to SUID investigations throughout the United States, but their impacts on these investigations have not been adequately examined. In this exploratory study, 26 law enforcement officials were interviewed about their experiences and perspectives with SUID investigations. Thematic analysis of qualitative data revealed three specific difficulties law enforcement encounter during SUID investigations: (1) inadequate preparation; (2) overwhelming emotions; and (3) a victim-suspect dilemma. Findings indicate that these barriers may inhibit consistent and reliable investigation of infant death and, therefore, may impede the cause and manner of death determinations. Participants' narratives also offered insights into potential solutions, including expanded SUID training for law enforcement and use of checklists, such as the Sudden Unexpected Infant Death Investigation Reporting Form. The impacts of overwhelming emotions confronted during SUID investigation warrant further study. The victim-suspect dilemma stems from the inability of law enforcement to conclusively eliminate the possibility of homicide. This dilemma may be resolved through a clear distinction between interactions with potential evidence and interactions with the family. Law enforcement must be trained to treat all SUID families in a compassionate and non-accusatory manner, while investigating all SUID with careful attention to detail that is essential in any potential homicide investigation. A consistent, meticulous, and compassionate approach to SUID investigations will improve the reliability of information obtained and offer the best opportunity for providing answers to grieving parents.
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Abstract
UNLABELLED This Viewpoint paper presents a timely and constructive critique of mainstream SIDS research. It is concerning that twenty-first century medical science has not provided an answer to the tragic enigma of SIDS. The paper helps explain why this is so and illustrates possible shortcomings in the investigation of Sudden Infant Death Syndrome/Sudden Unexplained Infant Death (SIDS/SUID) by mainstream researchers. Mainstream findings are often based on questionable and dogmatic assumptions that return to founding notions such as the Triple Risk Hypothesis and the contention that the mechanisms underlying SIDS/SUID are heterogeneous in nature. The paper illustrates how the pathological findings in SIDS have been under-investigated (or ignored) and that key epidemiological risk factors have slipped from memory. This apparent amnesia has resulted in failure to use these established SIDS facts to substantiate the significance of various neuropathological, neurochemical, or other research findings. These unsupported findings and their derivative hypotheses are therefore ill-founded and lack scientific rigor. CONCLUSION The deficits of SIDS "science" revealed in this paper explain why the SIDS enigma has not yet been solved. To make progress in understanding SIDS, it is important that researchers, as scientists, uphold standards of research. Encouragement for new directions of research is offered.
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Affiliation(s)
- Paul Nathan Goldwater
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
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Williams AF, Bryan AF, Tomasek K, Fulmer CA, Gregory K, Bozeman C, Li F, Absi TS, Su YR, Kannankeril PJ. Developmental changes in cardiac expression of KCNQ1 and SCN5A spliceoforms: Implications for sudden unexpected infant death. Heart Rhythm 2021:S1547-5271(21)02421-8. [PMID: 34843966 DOI: 10.1016/j.hrthm.2021.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/27/2021] [Accepted: 11/19/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Sudden unexpected infant death (SUID) occurs unpredictably and remains unexplained after scene investigation and autopsy. Approximately 1 in 7 cases of SUID can be related to a cardiac cause, and developmental regulation of cardiac ion channel genes may contribute to SUID. OBJECTIVE The goal of this study was to investigate the developmental changes in the spliceoforms of SCN5A and KCNQ1, 2 genes implicated in SUID. METHODS Using reverse transcription quantitative real-time polymerase chain reaction, we quantified expression of SCN5A (adult and fetal) and KCNQ1 (KCNQ1a and b) spliceoforms in 153 human cardiac tissue samples from decedents that succumbed to SUID ("unexplained") and other known causes of death ("explained noncardiac"). RESULTS There is a stepwise increase in the adult/fetal SCN5A spliceoform ratio from <2 months (4.55 ± 0.36; n = 51) through infancy and into adulthood (17.41 ± 3.33; n = 5). For KCNQ1, there is a decrease in the ratio of KCNQ1b to KCNQ1a between the <2-month (0.37 ± 0.02; n = 46) and the 2- to 4-month (0.28 ± 0.02; n = 52) age groups. When broken down by sex, race, or cause of death, there were no differences in SCN5A or KCNQ1 spliceoform expression, except for a higher ratio of KCNQ1b to KCNQ1a at 5-12 months of age for SUID females (0.40 ± 0.04; n = 9) than for males (0.25 ± 0.03; n = 6) and at <2 months of age for SUID white (0.42 ± 0.03; n = 19) than for black (0.33 ± 0.05; n = 9) infants. CONCLUSION This study documents the developmental changes in SCN5A and KCNQ1 spliceoforms in humans. Our data suggest that spliceoform expression ratios change significantly throughout the first year of life.
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Gillani SH, Lowell GS, Quinlan KP. A firm recommendation: measuring the softness of infant sleep surfaces. Inj Epidemiol 2021; 8:30. [PMID: 34517913 PMCID: PMC8436463 DOI: 10.1186/s40621-021-00325-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/15/2021] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Sheena H Gillani
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL, 60064, USA.
| | - Gina S Lowell
- Department of Pediatrics, Rush University Children's Hospital, 1653 W. Congress Pkwy, Chicago, IL, 60612, USA
| | - Kyran P Quinlan
- Department of Pediatrics, Rush University Children's Hospital, 1653 W. Congress Pkwy, Chicago, IL, 60612, USA
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Feld H, Ceballos Osorio J, Bahamonde M, Young T, Boada P, Rayens MK. Poverty and Paternal Education Associated With Infant Safe Sleep Intentions in a Peri-Urban Community in Ecuador. Glob Pediatr Health 2021; 8:2333794X211044112. [PMID: 34485625 PMCID: PMC8411618 DOI: 10.1177/2333794x211044112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Ecuador's annual mortality rate from SIDS is 0.4 per 100 000 people, 4 times higher than neighboring countries Peru, Bolivia, and Brazil. Modifying the infant sleep environment toward safe practice has been demonstrated to be the most effective risk reduction strategy in reducing mortality from SIDS and little is known about sleep practices in Ecuador. The purpose of this study is to describe baseline infant sleep intentions of pregnant women in a peri-urban, low resource community in Ecuador. We also aim to identify demographic and psychosocial factors associated with suboptimal sleep practices in this context to develop long-term strategies to identify infants with high risk for SIDS/SUID. A cross-sectional study design was employed with 100 women in their third trimester of pregnancy. The majority of women were partnered (82%), both parents had approximately 8 years of education, and over half reported that their incomes met or exceeded their basic needs (55%). Significant predictors of safer sleep intention included years of paternal education (P = .019) and income meeting their basic needs (P = .0049). For each additional year of paternal education, families were 23% more likely to report safer intended infant sleep practices. Compared to those whose income did not allow for basic needs, those who had sufficient income to meet (or exceed) basic needs were 425% more likely to report safer intended sleep practices. Targeted interventions to high-risk populations may reduce the burden of SIDS/SUID in this community.
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Affiliation(s)
| | | | | | | | - Pablo Boada
- Fundación Hombro a Hombro, Quito, Pichincha, Ecuador
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15
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Abstract
Sudden unexpected infant death is a leading cause of death in infancy. Both safe sleep practices and breastfeeding can help decrease the risk, although the current practice of educating parents about the recommendations has not resulted in universal adherence. Prenatal counseling provides opportunities to discuss recommendations as well as troubleshoot common barriers to breastfeeding and safe infant sleep with goals to gradually change attitudes, address social norms, and prepare new parents. A conversational, motivational approach to discussions about the importance of safe sleep and continued breastfeeding, with explanations as to the reasoning behind these recommendations, can help parents incorporate optimal practices into their lifestyles in a way that is sustainable for adherence.
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Affiliation(s)
- Ann Kellams
- Department of Pediatrics, University of Virginia, PO Box 800386, Charlottesville, VA 22908, USA.
| | - Lori Feldman-Winter
- Children's Regional Hospital at Cooper University Healthcare, Cooper Medical School of Rowan University, Three Cooper Plaza Suite 200, Camden, NJ 08103, USA
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16
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Abstract
BACKGROUND Sudden unexpected infant death (SUID) represents a broad group of explained and unexplained infant deaths (<1 year old). Explaining why SUID occurs is critical to understanding etiology and prevention. Death certificate data cannot differentiate explained from unexplained SUID cases nor describe the surrounding circumstances. We report SUID rates by explained and unexplained categories and describe demographics and history of recent injury or illness using the Centers for Disease Control and Prevention SUID Case Registry. METHODS The registry is a population-based surveillance system built on Child Death Review programs. Data are derived from multiple sources, including death certificates, scene investigations, and autopsy reports. Cases included SUIDs reported by states or jurisdictions participating in the registry during 2011-2017. Cases were classified into explained and unexplained categories by using the registry's classification system. Frequencies, percentages, and mortality rates per 100 000 live births were calculated. RESULTS Of the 4929 SUID cases, 82% were categorized as unexplained. Among all cases, 73% had complete case information. Most SUIDs (72%) occurred in an unsafe sleep environment. The SUID mortality rate was 97.3 per 100 000 live births. Among explained and possible suffocation deaths, ∼75% resulted from airway obstruction attributed to soft bedding. CONCLUSIONS Unsafe sleep factors were common in explained and unexplained SUID cases, but deaths could only be classified as explained suffocation for ∼20% of cases. Further analysis of unexplained deaths, including continued improvements to death scene investigation and documentation, may generate hypotheses for physiologic and genetic research, advance our understanding of gaps in SUID investigation, and enhance our understanding of infants at highest risk.
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Affiliation(s)
- Sharyn E Parks
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia;
| | | | - Fern R Hauck
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia; and
| | - Carri R Cottengim
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meghan Faulkner
- Center for National Prevention Initiatives, Michigan Public Health Institute, Okemos, Michigan
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17
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Keywan C, Poduri AH, Goldstein RD, Holm IA. Genetic Factors Underlying Sudden Infant Death Syndrome. Appl Clin Genet 2021; 14:61-76. [PMID: 33623412 PMCID: PMC7894824 DOI: 10.2147/tacg.s239478] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/24/2021] [Indexed: 12/28/2022]
Abstract
Sudden Infant Death syndrome (SIDS) is a diagnosis of exclusion. Decades of research have made steady gains in understanding plausible mechanisms of terminal events. Current evidence suggests SIDS includes heterogeneous biological conditions, such as metabolic, cardiac, neurologic, respiratory, and infectious conditions. Here we review genetic studies that address each of these areas in SIDS cases and cohorts, providing a broad view of the genetic underpinnings of this devastating phenomenon. The current literature has established a role for monogenic genetic causes of SIDS mortality in a subset of cases. To expand upon our current knowledge of disease-causing genetic variants in SIDS cohorts and their mechanisms, future genetic studies may employ functional assessments of implicated variants, broader genetic tests, and the inclusion of parental genetic data and family history information.
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Affiliation(s)
- Christine Keywan
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Annapurna H Poduri
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Richard D Goldstein
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Ingrid A Holm
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of Genetics and Genomics, Department of Pediatrics, and Manton Center for Orphan Diseases Research, Boston Children's Hospital, Boston, MA, USA
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18
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Allen K, Anderson TM, Chajewska U, Ramirez J, Mitchell EA. Factors associated with age of death in sudden unexpected infant death. Acta Paediatr 2021; 110:174-183. [PMID: 32304589 PMCID: PMC7574313 DOI: 10.1111/apa.15308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/03/2020] [Accepted: 04/14/2020] [Indexed: 12/28/2022]
Abstract
Aim This study aimed to systematically analyse the pregnancy, birth and demographic‐related factors associated with age of death in sudden unexpected infant death (SUID). Methods Data were analysed from the Centers for Disease Control and Prevention's Cohort Linked Birth/Infant Death data set (2011‐2013; 11 737 930 live births). SUID was defined as deaths from sudden infant death syndrome, ill‐defined causes, or accidental suffocation and strangulation in bed. There were 9668 SUID cases (7‐364 days; gestation >28 weeks; 0.82/1000 live births). The odds of death at different ages were compared to determine which variables significantly affect the SUID age of death. Results Forty‐three features indicated a significant change in age of death with two main patterns: (a) younger chronologic age at death was associated with maternal smoking and factors associated with lower socio‐economic status, and (b) older age was associated with low birthweight, prematurity and admission to the neonatal intensive care unit. However, when age was corrected for gestation, these factors were associated with younger age. Conclusion Factors that varied with age of death are well‐documented risk factors for SUID. The majority of these risk factors were associated with younger age at death after allowing for gestational age at birth.
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Affiliation(s)
| | | | | | - Jan‐Marino Ramirez
- Seattle Children’s Research Institute Seattle WA USA
- Departments of Neurological Surgery and Pediatrics University of Washington School of Medicine Seattle WA USA
| | - Edwin A. Mitchell
- Department of Paediatrics: Child and Youth Health University of Auckland Auckland New Zealand
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19
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Higgins ST, Slade EP, Shepard DS. Decreasing smoking during pregnancy: Potential economic benefit of reducing sudden unexpected infant death. Prev Med 2020; 140:106238. [PMID: 32818512 PMCID: PMC7429512 DOI: 10.1016/j.ypmed.2020.106238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 12/21/2022]
Abstract
Sudden Unexpected Infant Death (SUID) remains the leading cause of death among U.S. infants age 1-12 months. Extensive epidemiological evidence documents maternal prenatal cigarette smoking as a major risk factor for SUID, but leaves unclear whether quitting reduces risk. This Commentary draws attention to a report by Anderson et al. (Pediatrics. 2019, 143[4]) that represents a breakthrough on this question and uses their data on SUID risk reduction to delineate potential economic benefits. Using a five-year (2007-11) U.S. CDC Birth Cohort Linked Birth/Infant Death dataset, Anderson et al. demonstrated that compared to those who continued smoking, women who quit or reduced smoking by third trimester decreased the adjusted odds of SUID risk by 23% (95% CI, 13%-33%) and 12% (95% CI, 2%-21%), respectively. We applied these reductions to the U.S. Department of Health and Human Services' recommended value of a statistical life in 2020 ($10.1 million). Compared to continued smoking during pregnancy, the economic benefits per woman of quitting or reducing smoking are $4700 (95% CI $2700-$6800) and $2500 (95% CI, $400-$4300), respectively. While the U.S. obtained aggregate annual economic benefits of $0.58 (95% CI, 0.35-0.82) billion from pregnant women who quit or reduced smoking, it missed an additional $1.16 (95%CI 0.71-1.60) billion from the women who continued smoking. Delineating the health and economic impacts of decreasing smoking during pregnancy using large epidemiological studies like Anderson et al. is critically important for conducting meaningful economic analyses of the benefits-costs of developing more effective interventions for decreasing smoking during pregnancy.
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Affiliation(s)
- Stephen T Higgins
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Department of Psychological Science, University of Vermont, United States of America.
| | - Eric P Slade
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Johns Hopkins University School of Nursing, United States of America
| | - Donald S Shepard
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Heller School for Social Policy and Management, Brandeis University, United States of America
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20
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Canty EA, Fogel BN, Batra EK, Schaefer EW, Beiler JS, Paul IM. Improving infant sleep safety via electronic health record communication: a randomized controlled trial. BMC Pediatr 2020; 20:468. [PMID: 33032546 PMCID: PMC7542743 DOI: 10.1186/s12887-020-02369-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND With increased use of telehealth, interventions to improve infant sleep environments have not been explored. This study sought to assess the feasibility and efficacy of using electronic health record patient portals to transmit photographs of infant sleep between mothers and healthcare professionals as part of an intervention to promote sleep environments consistent with AAP guidelines. METHODS One hundred eighty-four mother-newborn dyads consented to participate in a randomized trial requiring patient portal registration within 1 month of delivery. We first assessed feasibility as measured by a) the proportion of consented mothers enrolling in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Intervention group mothers were prompted at 1 and 2 months; controls were prompted only at 2 months. Efficacy was determined via research assistant review of submitted photographs. These assistants were trained to detect sudden unexplained infant death risk factors utilizing AAP guidelines. Standardized feedback was returned to mothers through the patient portal. We used Fisher's Exact test to assess group differences in guideline adherence at 2 months. RESULTS One hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25-52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28-46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI - 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface. CONCLUSIONS Utilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices. TRIAL REGISTRATION Name: Improving Infant Sleep Safety With the Electronic Health Record; Clinicaltrials.gov: NCT03662048 ; Date of Registration: September 7, 2018; Data Sharing Statement: None.
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Affiliation(s)
- Ethan A. Canty
- grid.5288.70000 0000 9758 5690Department of Pediatrics, Oregon Health & Science University, Portland, OR USA
| | - Benjamin N. Fogel
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State College of Medicine, HS83, 500 University Drive, Hershey, PA 17033 USA
| | - Erich K. Batra
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State College of Medicine, HS83, 500 University Drive, Hershey, PA 17033 USA ,grid.240473.60000 0004 0543 9901Family and Community Medicine, Penn State College of Medicine, Hershey, PA USA
| | - Eric W. Schaefer
- grid.240473.60000 0004 0543 9901Public Health Sciences, Penn State College of Medicine, Hershey, PA USA
| | - Jessica S. Beiler
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State College of Medicine, HS83, 500 University Drive, Hershey, PA 17033 USA
| | - Ian M. Paul
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State College of Medicine, HS83, 500 University Drive, Hershey, PA 17033 USA ,grid.240473.60000 0004 0543 9901Public Health Sciences, Penn State College of Medicine, Hershey, PA USA
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21
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Mitchell EA, Yan X, Ren SY, Anderson TM, Ramirez JM, Lavista Ferres JM, Johnston R. Geographic Variation in Sudden Unexpected Infant Death in the United States. J Pediatr 2020; 220:49-55.e2. [PMID: 32061407 PMCID: PMC7995635 DOI: 10.1016/j.jpeds.2020.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 12/04/2019] [Accepted: 01/06/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess the geographic variation of sudden unexpected infant death (SUID) and test if variation in geographic factors, such as state, latitude, and longitude, play a role in SUID risk across the US. STUDY DESIGN We analyzed the Centers for Disease Control and Prevention's Cohort Linked Birth/Infant Death dataset (2005-2010; 22 882 SUID cases, 25 305 837 live births, rate 0.90/1000). SUID was defined as infant deaths (ages 7-364 days) that included sudden infant death syndrome, ill-defined and unknown cause of mortality, and accidental suffocation and strangulation in bed. SUID geographic variation was analyzed using 2 statistical models, logistic regression and generalized additive model (GAM). RESULTS Both models produced similar results. Without adjustment, there was marked geographic variation in SUID rates, but the variation decreased after adjusting for covariates including known risk factors for SUID. After adjustment, nine states demonstrated significantly higher or lower SUID mortality than the national average. Geographic contribution to SUID risk in terms of latitude and longitude were also attenuated after adjustment for covariates. CONCLUSION Understanding why some states have lower SUID rates may enhance SUID prevention strategies.
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Affiliation(s)
- Edwin A Mitchell
- Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Xiaohan Yan
- AI For Good Research Lab, Microsoft, Redmond, WA
| | | | - Tatiana M Anderson
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | - Jan-Marino Ramirez
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA; Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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22
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Bartick M, Boisvert ME, Philipp BL, Feldman-Winter L. Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after Birth. J Pediatr 2020; 218:11-15. [PMID: 31753326 DOI: 10.1016/j.jpeds.2019.09.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/28/2019] [Accepted: 09/25/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if implementation of skin-to-skin care and the Baby-Friendly Hospital Initiative (BFHI) contributes to sudden unexpected infant death (SUID) and asphyxia in the first 6 days after birth. STUDY DESIGN Survey data were used to determine a correlation between BFHI and deaths from SUID and asphyxia among infants <7 days in the US and Massachusetts. Using data from the Centers for Disease Control and Prevention, implementation of BFHI was tracked from 2004-2016 and skin-to-skin care was tracked from 2007-2015. Using data from Centers for Disease Control and Prevention WONDER and the Massachusetts Department of Public Health, SUID and asphyxia were tracked from 2004-2016. RESULTS Nationally, births in Baby-Friendly facilities rose from 1.8% to 18.3% and the percentage of facilities in which most dyads experienced skin-to-skin care rose from 40% to 83%. SUID prevalence among infants <7 days was rare (0.72% of neonatal deaths) and decreased significantly from 2004-2009 compared with 2010-2016, from 0.033 per 1000 live births to 0.028, OR 0.85 (95% CI 0.77, 0.94). In Massachusetts, births in Baby-Friendly facilities rose from 2.8% to 13.9% and skin-to-skin care rose from 50% to 97.8%. SUID prevalence decreased from 2010-2016 compared with 2004-2009: OR 0.32 (95% CI 0.13, 0.82), with 0 asphyxia deaths during the 13-year period. CONCLUSION Increasing rates of breastfeeding initiatives and skin-to-skin care are temporally associated with decreasing SUID prevalence in the first 6 days after birth in the US and Massachusetts.
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Affiliation(s)
- Melissa Bartick
- Department of Medicine, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA.
| | | | - Barbara L Philipp
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | - Lori Feldman-Winter
- Department of Pediatrics, Cooper Medical School of Rowan University, Camden, NJ
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Cottengim C, Parks S, Rhoda D, Andrew T, Nolte KB, Fudenberg J, Sens MA, Brustrom J, Payn B, Shapiro-Mendoza CK. Protocols, practices, and needs for investigating sudden unexpected infant deaths. Forensic Sci Med Pathol 2019; 16:91-98. [PMID: 31741206 DOI: 10.1007/s12024-019-00196-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 12/01/2022]
Abstract
Understanding case identification practices, protocols, and training needs of medical examiners and coroners (MEC) may inform efforts to improve cause-of-death certification. We surveyed a U.S.-representative sample of MECs and described investigation practices and protocols used in certifying sudden unexpected infant deaths (SUID). We also identified MEC training and resource needs. Of the 377 respondents, use of the SUID Investigation Reporting Form or an equivalent was 89% for large, 87% for medium, and 52% for small jurisdictions. Routine completion of infant medical history, witness interviews, autopsy, photos or videos, and family social history for infant death investigations was ≥80%, but routine scene re-creation with a doll was 30% in small, 64% in medium, and 59% in large offices. Seventy percent of MECs reported infant death investigation training needs. Increased training and use of standardized practices may improve SUID cause-of-death certification, allowing us to better understand SUID.
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Affiliation(s)
- Carri Cottengim
- Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, N.E. MS S107-2, Chamblee, GA, 30341, USA.
| | - Sharyn Parks
- Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, N.E. MS S107-2, Chamblee, GA, 30341, USA
| | - Dale Rhoda
- Biostat Global Consulting, Worthington, OH, formerly at Battelle, Columbus, OH, USA
| | - Tom Andrew
- Office of Chief Medical Examiner, Concord, NH, USA
| | - Kurt B Nolte
- Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - John Fudenberg
- Clark County Office of the Coroner/Medical Examiner, Las Vegas, NV, USA
| | - Mary Ann Sens
- Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | | | - Betsy Payn
- University of Washington, Seattle, WA, USA
| | - Carrie K Shapiro-Mendoza
- Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, N.E. MS S107-2, Chamblee, GA, 30341, USA
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24
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Dalvie N, Nguyen V, Colson E, Loyal J. Mothers' Perceptions of the Cardboard Box as a Potential Sleep Space. Acad Pediatr 2019; 19:787-792. [PMID: 30807848 DOI: 10.1016/j.acap.2019.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Due to increasing popularity, our hospital began considering distributing cardboard boxes combined with safe sleep education to new mothers. As a first step in studying the impact of this intervention on bedsharing in our community, we sought to understand mothers' perceptions of the cardboard box. METHODS We recruited primarily low-income, English- or Spanish-speaking mothers of infants aged 2 to 16 weeks during routine primary care visits. Participants responding to a cross-sectional survey about infant sleep practices were invited to participate in in-depth interviews about the cardboard box. We used a grounded theory approach and the constant comparative method until saturation was reached. RESULTS Of 120 participants in the survey, 50 (42%) participated in the qualitative study. Participants were mothers of infants aged ≤4 weeks (46%), 4 to 8 weeks (32%), and 16 weeks (22%). Of 50 participants, 52% said they would use the cardboard box for their infant to sleep in, if provided, compared with 42% who said they would not and 6% were unsure. Three themes emerged from the data: (1) safety of the cardboard box; (2) appearance, and (3) variation in planned use. Some participants planned to place the cardboard box in their bed. CONCLUSIONS Participants in our study were divided about whether they would use the cardboard box for their infant to sleep in. If distributed, hospital staff should advise families to not place the cardboard box in their bed. Next steps include determining bedsharing frequency among parents who choose to use the cardboard box for their infant.
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Affiliation(s)
- Nisha Dalvie
- Department of Pediatrics, Yale University School of Medicine, (N Dalvie and J Loyal) New Haven, Conn
| | - Victoria Nguyen
- Department of Pediatrics (V Nguyen), Rutgers New Jersey Medical School, Newark
| | - Eve Colson
- Department of Pediatrics (E Colson), Washington University School of Medicine, St Louis, Mo
| | - Jaspreet Loyal
- Department of Pediatrics, Yale University School of Medicine, (N Dalvie and J Loyal) New Haven, Conn.
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Randall B, Thompson P, Wilson A. Racial differences within subsets of Sudden Unexpected Infant Death ( SUID) with an emphasis on asphyxia. J Forensic Leg Med 2019; 62:52-55. [PMID: 30658266 DOI: 10.1016/j.jflm.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 12/04/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Sudden Unexpected Infant Deaths (SUID) is defined as a combination of Sudden Infant Death Syndrome (SIDS), Unknown Cause of Death (UCD) and Accidental Suffocation and Strangulation in Bed (ASSB). Overall rates from 2000 to 2015 have been trending down. Racial differences in occurrence are seen. STUDY DESIGN AND SETTING Using the CDC Wonder Database, the total rates of SUID and its subsets were examined. RESULTS Non-Caucasian infant death rates for the total SUID group, and the SIDS component, are trending downward significantly faster than for Caucasians. UCD trends in rates show an apparent small, non-significant, decline for non-Caucasians, and are unchanged for Caucasians. ASSB rates are trending upward slightly more rapidly (not significantly) for non-Caucasians than Caucasians. CONCLUSION The trend showing ASSB trending upward more in non-Caucasians than Caucasians may suggest: 1) A racial difference that certifiers are more willing to certify SIDS than ASSB in Caucasians, and/or 2) Certifiers are biased towards certifying more ASSB than SIDS in non-Caucasians, and/or 3) Asphyxia risks may be increasing more in non-Caucasian SUIDs. Option #1 would require educational efforts to recognize the asphyxia risks in Caucasians. Option #2 would require documentation of racial bias in infant death certification followed by efforts to reduce the bias. Option #3 would require focused targeting of non-Caucasian populations to reduce asphyxia risks. Potentially all three scenarios could co-exist.
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Affiliation(s)
- Brad Randall
- Department of Pathology, Sanford School of Medicine, University of South Dakota, 812 Covel Ave, Sioux Falls, SD, 57104, USA.
| | - Paul Thompson
- Department of Pediatrics and Internal Medicine, Sanford School of Medicine, University of South Dakota, 812 Covel Ave, Sioux Falls, SD, 57104, USA
| | - Ann Wilson
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, 812 Covel Ave, Sioux Falls, SD, 57104, USA
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Bartick M, Tomori C. Sudden infant death and social justice: A syndemics approach. Matern Child Nutr 2019; 15:e12652. [PMID: 30136404 PMCID: PMC7198924 DOI: 10.1111/mcn.12652] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/01/2018] [Accepted: 06/21/2018] [Indexed: 01/31/2023]
Abstract
Sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS) prevention has focused on modifying individual behavioural risk factors, especially bedsharing. Yet these deaths are most common among poor and marginalized people in wealthy countries, including U.S. Blacks, American Indians/Alaskan Natives, New Zealand Māori, Australian Aborigines, indigenous Canadians, and low-income British people. The United States now has the world's highest prevalence of SUID/SIDS, where even Whites' SIDS prevalence now approaches that of the Māori. Using public databases and the literature, we examine SUID/SIDS prevalence and the following risk factors in selected world populations: maternal smoking, preterm birth, alcohol use, poor prenatal care, sleep position, bedsharing, and formula feeding. Our findings suggest that risk factors cluster in high-prevalence populations, many are linked to poverty and discrimination and have independent effects on perinatal outcomes. Moreover, populations with the world's lowest rates of SUID/SIDS have low income-inequality or high relative wealth, yet have high to moderate rates of bedsharing. Employing syndemics theory, we suggest that disproportionately high prevalence of SUID/SIDS is primarily the result of socially driven, co-occurring epidemics that may act synergistically to amplify risk. SUID must be examined through the lens of structural inequity and the legacy of historical trauma. Emphasis on bedsharing may divert attention from risk reduction from structural interventions, breastfeeding, prenatal care, and tobacco cessation. Medical organizations play an important role in advocating for policies that address the root causes of infant mortality via poverty and discrimination interventions, tobacco control, and culturally appropriate support to families.
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Affiliation(s)
- Melissa Bartick
- Department of MedicineCambridge Health Alliance and Harvard Medical SchoolCambridgeMassachusetts
| | - Cecília Tomori
- Department of Anthropology, Parent–Infant Sleep LabDurham UniversityDurhamUK
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Naugler MR, DiCarlo K. Barriers to and Interventions that Increase Nurses' and Parents' Compliance With Safe Sleep Recommendations for Preterm Infants. Nurs Womens Health 2018; 22:24-39. [PMID: 29433698 DOI: 10.1016/j.nwh.2017.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/01/2017] [Indexed: 06/08/2023]
Abstract
The purpose of this integrative review was to identify interventions that increase compliance of nurses and of parents with safe sleep recommendations for premature infants. Ten studies were included in the final sample, including three studies with a prospective descriptive design, five quality improvement initiatives with an interventional research design, one secondary analysis, and one retrospective medical chart review. Study samples included neonatal nurses and parents of premature infants in NICUs and transitional care nurseries in Massachusetts, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas. Sample sizes ranged from 5 to 259 NICU parents and 86 to 658 neonatal nurses. The categories of interventions we identified include identifying barriers to compliance, changing hospital policy, and providing safe sleep education for nurses and parents. We conclude that hospitals should have current, evidence-based safe sleep policies with clear transition guidelines for premature infants and that consistent and comprehensive nursing and parental education related to safe sleep should include current American Academy of Pediatrics recommendations and should address potential barriers to compliance.
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Hutton JS, Gupta R, Gruber R, Berndsen J, DeWitt T, Ollberding NJ, Van Ginkel JB, Ammerman RT. Randomized Trial of a Children's Book Versus Brochures for Safe Sleep Knowledge and Adherence in a High-Risk Population. Acad Pediatr 2017; 17:879-886. [PMID: 28450082 DOI: 10.1016/j.acap.2017.04.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 04/14/2017] [Accepted: 04/15/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Sleep-related infant deaths have plateaued in the past decade, disproportionately affecting low socioeconomic status (SES) families. Printed materials are widely used for anticipatory guidance, yet none for safe sleep has been studied. We tested the efficacy of a specially designed children's book compared to brochures for safe sleep knowledge and adherence, which we hypothesized would be greater due to superior readability and engagement. METHODS This randomized controlled trial involved low-SES mothers (n = 282) enrolled in a home visiting program. Home visitors (n = 56) were randomly assigned to perform safe sleep teaching and assessments during 3 visits: third trimester, 1 week old, and 2 months old, exclusively utilizing a specially designed children's book or brochures, and surveys incorporating the American Academy of Pediatrics' safe sleep recommendations. Outcomes were safe sleep knowledge, adherence, and usefulness of materials, controlling for maternal health literacy. RESULTS Safe sleep knowledge increased across all time points with no overall group difference, though gains for sleep-evocative and general health items varied. Odds of bed sharing were higher and exclusive crib use lower for the brochure group (P < .05). Mothers and home visitors reported similar usefulness, though home visitors reported greater dialogue via the book and mothers in the book group reported more book sharing with their baby. CONCLUSIONS While a specially designed children's book and brochures were equally effective conveying aggregate safe sleep knowledge in low-SES mothers, adherence to exclusive crib use and avoiding bed sharing were greater in the book group, attributable to enhanced dialogue, readability and emotional engagement. Children's books are a promising mode of anticipatory guidance, warranting further investigation.
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Affiliation(s)
- John S Hutton
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Reading and Literacy Discovery Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Resmi Gupta
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rachel Gruber
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Berndsen
- Every Child Succeeds, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Thomas DeWitt
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Reading and Literacy Discovery Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Judith B Van Ginkel
- Every Child Succeeds, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert T Ammerman
- Every Child Succeeds, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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29
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Kuhlmann Z, Kuhlmann S, Schunn C, Klug BF, Greaves T, Foster M, Ahlers-Schmidt CR. Collaborating with obstetrical providers to promote infant safe sleep guidelines. Sleep Health 2017; 2:219-224. [PMID: 29073426 DOI: 10.1016/j.sleh.2016.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/15/2016] [Accepted: 06/21/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To partner with obstetrical providers to increase promotion of the American Academy of Pediatrics guidelines for infant safe sleep. Specifically, this study evaluates the effectiveness of the Safe Sleep Toolkit during obstetrical visits. Secondary objectives include improving provider and maternal knowledge of safe sleep. METHODS Obstetrical providers (n=11) and staff at an outpatient clinic were trained using the Safe Sleep Toolkit and encouraged to discuss infant safe sleep with pregnant women at their 28- or 36-week gestation appointment (n=111, 56 pre- and 55 post-intervention). Provider-reported time spent counseling women on safe sleep recommendations and safe sleep knowledge was measured before and after the intervention. Surveys were conducted with women assessing safe sleep knowledge, intention to follow guidelines, and whether safe sleep was discussed at the appointment. RESULTS Significantly more post-intervention women reported their provider had discussed safe sleep (78% vs 32%) (P<.001). Similarly, provider-reported discussion with women increased significantly for all safe sleep guidelines (82%-90% vs 8%-12%) (all P<.001). Maternal knowledge, especially surrounding unsafe sleep practices, improved significantly post-intervention. CONCLUSION Training obstetricians to use a toolkit to promote infant safe sleep guidelines increases the prenatal delivery of this information, and improves pregnant women's knowledge and intentions regarding safe infant sleep.
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Affiliation(s)
- Zachary Kuhlmann
- Department of Obstetrics & Gynecology, University of Kansas School of Medicine-Wichita, 1010 N. Kansas St., Wichita, KS 67214
| | - Stephanie Kuhlmann
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, 1010 N. Kansas St., Wichita, KS 67214
| | - Christy Schunn
- Kansas Infant Death and SIDS Network, Inc., 1148 S. Hillside, Suite 10, Wichita, KS 67211
| | - Benjamin F Klug
- Department of Obstetrics & Gynecology, University of Kansas School of Medicine-Wichita, 1010 N. Kansas St., Wichita, KS 67214
| | - Thomas Greaves
- Department of Obstetrics & Gynecology, University of Kansas School of Medicine-Wichita, 1010 N. Kansas St., Wichita, KS 67214
| | - Megan Foster
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, 1010 N. Kansas St., Wichita, KS 67214
| | - Carolyn R Ahlers-Schmidt
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, 1010 N. Kansas St., Wichita, KS 67214.
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30
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Aitken ME, Rose A, Mullins SH, Miller BK, Nick T, Rettiganti M, Nabaweesi R, Whiteside-Mansell L. Grandmothers' Beliefs and Practices in Infant Safe Sleep. Matern Child Health J 2017; 20:1464-71. [PMID: 26987862 DOI: 10.1007/s10995-016-1945-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background Sudden infant death syndrome (SIDS) and suffocation are leading causes of infant mortality. Supine sleep position and use of appropriate sleep surfaces reduce SIDS risk but are not universally practiced. Mothers' decisions about sleep position and environment may be influenced by guidance provided by infants' grandmothers and other caregivers. Methods A survey was conducted of a convenience sample of grandmothers aged 30-70 years who provide care at least weekly for an infant grandchild <6 months old. The survey was distributed through community partners of a university-based research team. Respondents received home safety items as compensation. Analyses focused on the relationship of grandmother demographic characteristics and beliefs on their reported practices related to infant sleep. Results Among the 239 grandmothers, 45 % reported placing infants to sleep supine on an appropriate sleep surface at the grandmother's house, while 58 % reported doing so when the infant was sleeping in the mother's house. After adjusting for other factors, respondents were less likely to adhere to recommended guidelines when they believed supine position increased choking risk (OR 0.34, 95 % CI 0.18-0.62) or believed infants are more comfortable or sleep longer when on their stomachs (OR 0.51, 95 % CI 0.28-0.93). Discussion Grandmothers do not universally observe evidence-based safe sleep practices, particularly if the infant is not sleeping in the home of the parent. Interventions for senior caregivers focused on perceived choking risk, infant comfort in the supine position, and other recent changes in recommended safety practices are warranted.
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Affiliation(s)
- Mary E Aitken
- Department of Pediatrics, Center for Applied Research and Evaluation, University of Arkansas for Medical Sciences, Little Rock, AR, USA. .,Injury Prevention Center, Arkansas Children's Hospital Research Institute, Little Rock, AR, USA.
| | - Alison Rose
- Arkansas Children's Hospital, Little Rock, AR, USA
| | - S Hope Mullins
- Department of Pediatrics, Center for Applied Research and Evaluation, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Injury Prevention Center, Arkansas Children's Hospital Research Institute, Little Rock, AR, USA
| | - Beverly K Miller
- Department of Pediatrics, Center for Applied Research and Evaluation, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Injury Prevention Center, Arkansas Children's Hospital Research Institute, Little Rock, AR, USA
| | - Todd Nick
- Department of Pediatrics, Center for Applied Research and Evaluation, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mallikarjuna Rettiganti
- Department of Pediatrics, Center for Applied Research and Evaluation, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rosemary Nabaweesi
- Department of Pediatrics, Center for Applied Research and Evaluation, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Injury Prevention Center, Arkansas Children's Hospital Research Institute, Little Rock, AR, USA
| | - Leanne Whiteside-Mansell
- Department of Family and Community Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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31
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Altfeld S, Peacock N, Rowe HL, Massino J, Garland C, Smith S, Wishart M. Moving Beyond "Abstinence-Only" Messaging to Reduce Sleep-Related Infant Deaths. J Pediatr 2017; 189:207-212. [PMID: 28838726 DOI: 10.1016/j.jpeds.2017.06.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/24/2017] [Accepted: 06/28/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Susan Altfeld
- Center of Excellence in Maternal and Child Health, Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL.
| | - Nadine Peacock
- Center of Excellence in Maternal and Child Health, Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - Hillary L Rowe
- Department of Psychology, University of Illinois at Chicago, Chicago, IL
| | - Jill Massino
- Center of Excellence in Maternal and Child Health, Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - Caitlin Garland
- Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, IL
| | - Sherri Smith
- Center of Excellence in Maternal and Child Health, Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - Marisa Wishart
- Center of Excellence in Maternal and Child Health, Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL
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Abstract
In October 2016, the American Academy of Pediatrics published updated guidelines for safe infant sleep. Although there are no major changes to the recommendations, there are many small additions and clarifications important to the work of nurses. Topics addressed in this article include breastfeeding, skin-to-skin contact, swaddling, room-sharing, bed-sharing, new products, pacifiers, loose bedding, and sitting devices. It is important for nurses and other clinicians to model recommended behaviors with regard to safe infant sleep and to have conversations with parents and caregivers about safe infant sleep throughout the hospital stay.
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Whiteside-Mansell L, Nabaweesi R, Caballero AR, Mullins SH, Miller BK, Aitken ME. Assessment of Safe Sleep: Validation of the Parent Newborn Sleep Safety Survey. J Pediatr Nurs 2017; 35:30-35. [PMID: 28728766 PMCID: PMC5592828 DOI: 10.1016/j.pedn.2017.02.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/25/2017] [Accepted: 02/26/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Sudden Infant Death Syndrome (SIDS) and suffocation account for more than half of all Sudden Unexpected Infant Deaths (SUID). The American Academy of Pediatrics (AAP) recommendations describe the safest environments to protect infants. This study compared parent responses on the Newborn Sleep Safety Survey and observational assessments (N=72) of infant sleep environments in families thought to be at high-risk for non-compliance with AAP recommendations. DESIGN AND METHODS A naturalistic study of participants enrolled in two home visitation support programs was used. Observed risks ranged from 36.6% (never use pacifier) to 4.3% (never use firm mattress). RESULTS Results comparing report to observation demonstrated acceptable concordance. Five items had fair concordance (Kappa>.4), four showed moderate concordance (Kappa>.6), and one excellent concordance (Kappa>.8). Although direct observation of safety behaviors is the gold standard in the injury prevention field, direct observation is logistically difficult, time consuming, and costly. CONCLUSIONS Research and interventions aimed at a reduction of Sudden Infant Death Syndrome (SIDS) and suffocation require accurate assessment of the infant sleep environment. This study provides acceptable evidence for the use of the Newborn Sleep Safety Survey as an alternative to direct observation to assess parent adherence to recommendations. Limitations are discussed. PRACTICAL IMPLICATIONS This study provided evidence of the usefulness of the Newborn Sleep Safety Survey, a parent survey of infant sleep environments. This tool will provide medical and research professionals a reliable, inexpensive tool to evaluation of the quality of sleep environments using a standard definition.
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Affiliation(s)
- Leanne Whiteside-Mansell
- Department of Family and Community Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
| | - Rosemary Nabaweesi
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, and Injury Prevention Center, Arkansas Children's Hospital, Little Rock, AR, United States
| | | | - Samantha Hope Mullins
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, and Injury Prevention Center, Arkansas Children's Hospital, Little Rock, AR, United States
| | - Beverly Kaye Miller
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, and Injury Prevention Center, Arkansas Children's Hospital, Little Rock, AR, United States
| | - Mary Elizabeth Aitken
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, and Injury Prevention Center, Arkansas Children's Hospital, Little Rock, AR, United States
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34
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Rholdon R. Understanding the Risks Sitting and Carrying Devices Pose to Safe Infant Sleep. Nurs Womens Health 2017; 21:225-230. [PMID: 28599744 DOI: 10.1016/j.nwh.2017.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/30/2017] [Indexed: 11/25/2022]
Abstract
There have been various campaigns and recommendations to decrease the incidence of sudden unexpected infant death. Despite this, caregivers continue to place infants in unsafe sleeping environments. These environments, such as sitting devices, slings, carriers, and car seats, pose a significant risk to an infant's safety because of the risk from suffocation and cardiorespiratory instability. It is important for health care providers to understand the appropriate use of car seats, slings, and other sitting devices, to model appropriate behaviors, and to educate parents and caregivers. All parents, hospital staff, and other caregivers should understand the potential dangers associated with the inappropriate use of sitting devices for routine sleep.
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Folkerth RD, Nunez J, Georgievskaya Z, McGuone D. Neuropathologic Examination in Sudden Unexpected Deaths in Infancy and Childhood: Recommendations for Highest Diagnostic Yield and Cost-Effectiveness in Forensic Settings. Acad Forensic Pathol 2017; 7:182-199. [PMID: 31239973 PMCID: PMC6474536 DOI: 10.23907/2017.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/30/2017] [Accepted: 04/30/2017] [Indexed: 11/12/2022]
Abstract
In infants and toddlers (less than four years of age), determination of cause and manner of death often requires a complete autopsy. Few evidence-based guidelines exist regarding optimum nervous system sectioning in this population. Over a six-month interval and using a comprehensive section protocol, we categorized cases having neuropathological findings that were critical (Class A), contributory (Class B), or noncontributory (Class C) to the final cause and manner of death. We further evaluated which sections helped make this determination. Among 53 cases (44 infants, 9 toddlers; 26 girls, 27 boys), Class A neuropathology was noted in nine (16.9%). Seven infants had meningoencephalitis (2/7, 28.6%), craniospinal trauma (3/7, 42.8%), brainstem necrosis suggesting Leigh Disease (1/7, 14.3%), and hydrocephalus in Dandy-Walker malformation (1/7, 14.3%); two toddlers had inflicted craniospinal trauma (2/2, 100%). Class B factors were identified in 11/53 (20.8%), including recent hypoxic-ischemic lesions (2/11, 18.2%), meningitis or dural venous sinus thrombosis in systemic sepsis (2/11, 18.2%), multicystic encephalopathy following peripartum asphyxia (2/11, 18.2%), and microcephaly and delayed myelination (Cri-du-Chat Syndrome) (1/11, 9.09%). Class B also included three toddlers (3/11, 27.2%) with features of hippocampal dysgenesis, two in the setting of febrile seizures. Class C comprised normal brains (3/53, 5.7%), and those with findings of uncertain significance, such as white matter and brainstem gliosis (30/53, 56.6%). The sections most valuable for detection of relevant pathology, and thus recommended for routine sampling, were: 1) bilateral hippocampus; 2) cerebral cortex and leptomeninges; and 3) pons or medulla.
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Affiliation(s)
- Rebecca D. Folkerth
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
| | - Jacqueline Nunez
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
| | - Zhanna Georgievskaya
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
| | - Declan McGuone
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
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36
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Peacock NR, Altfeld S, Rosenthal AL, Garland CE, Massino JM, Smith SL, Rowe HL, Wagener SE. Qualitative Analysis of Infant Safe Sleep Public Campaign Messaging. Health Promot Pract 2017; 19:203-212. [PMID: 29161896 DOI: 10.1177/1524839917690339] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 1994 Back to Sleep public education campaign resulted in dramatic reductions in sleep-related infant deaths, but comparable progress in recent years has been elusive. We conducted qualitative analyses of recent safe sleep campaigns from 13 U.S. cities. Goals were to (a) determine whether the campaigns reflect the full range of American Academy of Pediatrics (AAP) 2011 safe sleep recommendations, (b) describe tone and framing of the messages (e.g., use of fear appeals), (c) describe targeting/tailoring of messages to priority populations, and (d) ascertain whether the campaigns have been evaluated for reach and/or effectiveness. Methods included computer-assisted analyses of campaign materials and key informant interviews. All campaigns included "ABC" (Alone, Back, Crib) messaging; many ignored other AAP recommendations such as breastfeeding, room-sharing, immunizations, and avoiding smoke exposure. Campaigns frequently targeted priority populations such as African Americans. Fear appeals were used in three quarters of the campaigns, and 60% of the fear-based campaigns used guilt/blame messaging. We did not find published evaluation data for any of the campaigns. More attention is needed in public education campaigns to the full range of AAP recommendations, and evaluations are needed to determine the impact of these interventions on knowledge, behavior, and health outcomes.
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Affiliation(s)
- Nadine R Peacock
- 1 School of Public Health at the University of Illinois at Chicago, Chicago, IL, USA
| | - Susan Altfeld
- 1 School of Public Health at the University of Illinois at Chicago, Chicago, IL, USA
| | | | - Caitlin E Garland
- 1 School of Public Health at the University of Illinois at Chicago, Chicago, IL, USA
| | - Jill M Massino
- 1 School of Public Health at the University of Illinois at Chicago, Chicago, IL, USA
| | - Sherri L Smith
- 1 School of Public Health at the University of Illinois at Chicago, Chicago, IL, USA
| | - Hillary L Rowe
- 3 Department of Psychology at the University of Illinois at Chicago, Chicago, IL, USA
| | - Sarah E Wagener
- 4 Chapin Hall at the University of Chicago, Chicago, IL, USA
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Caraballo M, Shimasaki S, Johnston K, Tung G, Albright K, Halbower AC. Knowledge, Attitudes, and Risk for Sudden Unexpected Infant Death in Children of Adolescent Mothers: A Qualitative Study. J Pediatr 2016; 174:78-83.e2. [PMID: 27113377 DOI: 10.1016/j.jpeds.2016.03.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 02/29/2016] [Accepted: 03/10/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate practices, knowledge, attitudes, and beliefs regarding infant sleep among adolescent mothers, a demographic at high risk for sudden unexpected infant death, and to identify novel public health interventions targeting the particular reasons of this population. STUDY DESIGN Seven targeted focus groups including 43 adolescent mothers were conducted at high school daycare centers throughout Colorado. Focus groups were recorded, transcribed, validated, and then analyzed in NVivo 10. Validation included coding consistency statistics and expert review. RESULTS Most mothers knew many of the American Academy of Pediatrics recommendations for infant sleep. However, almost all teens reported bedsharing regularly and used loose blankets or soft bedding despite being informed of risks. Reasons for nonadherence to recommendations included beliefs that babies are safest and sleep more/better in bed with them, that bedsharing is a bonding opportunity, and that bedsharing is easier than using a separate sleep space. The most common justifications for blankets were infant comfort and concern that babies were cold. Participants' decision making was often influenced by their own mothers, with whom they often resided. Participants felt that their instincts trumped professional advice, even when in direct contradiction to safe sleep recommendations. CONCLUSIONS Among focus group participants, adherence with safe sleep practices was poor despite awareness of the American Academy of Pediatrics recommendations. Many mothers expressed beliefs and instincts that infants were safe in various unsafe sleep environments. Future study should investigate the efficacy of alternative educational strategies, including education of grandmothers, who have significant influence over adolescent mothers.
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Affiliation(s)
- Michelle Caraballo
- Pulmonary Section, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
| | - Suzuho Shimasaki
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Aurora, CO
| | | | - Gregory Tung
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Karen Albright
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Aurora, CO; The Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Ann C Halbower
- Pulmonary Section, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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Abstract
Cases of sudden unexpected infant death (SUID) leave many families devastated, especially in those without an identified cause of death. Here, we describe the case of an apparently healthy 15-day-old infant who died suddenly and unexpectedly. Through whole-exome sequencing, the infant was posthumously found to have 2 mutations in the CLCNKB gene, leading to a molecular diagnosis of Bartter syndrome type III, the likely cause of death. This case illustrates the potential utility of exome sequencing in cases of SUID to suggest a diagnosis, with important implications for families, allowing them to come to closure over the cause of death, informing their future reproductive decisions, and minimizing the risk of recurrence.
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Affiliation(s)
- Hector U Lopez
- 1 Columbia University College of Physicians & Surgeons, 630 West 168th Street, New York, NY 10032, USA
| | | | - Wendy K Chung
- 3 Department of Pediatrics and Medicine, Columbia University Medical Center, 1150 St Nicholas Avenue, Room 620, New York, NY 10032, USA
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Treadway NJ, Diop H, Lu E, Nelson K, Hackman H, Howland J. Using surveillance data to inform a SUID reduction strategy in Massachusetts. Inj Epidemiol 2014; 1:12. [PMID: 27747680 PMCID: PMC5005622 DOI: 10.1186/2197-1714-1-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/18/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Non-supine infant sleep positions put infants at risk for sudden unexpected infant death (SUID). Disparities in safe sleep practices are associated with maternal income and race/ethnicity. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a nutrition supplement program for low-income (≤185% Federal Poverty Level) pregnant and postpartum women. Currently in Massachusetts, approximately 40% of pregnant/postpartum women are WIC clients. To inform the development of a SUID intervention strategy, the Massachusetts Department of Public Health (MDPH) investigated the association between WIC status and infant safe sleep practices among postpartum Massachusetts mothers using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. METHODS PRAMS is an ongoing statewide health surveillance system of new mothers conducted by the MDPH in collaboration with the Centers for Disease Control and Prevention (CDC). PRAMS includes questions about infant sleep position and mothers' prenatal WIC status. Risk Ratio (RR) and 95 percent confidence intervals (CI) were calculated for infant supine sleep positioning by WIC enrollment, yearly and in aggregate (2007-2010). RESULTS/OUTCOMES The aggregate (2007-2010) weighted sample included 276,252 women (weighted n ≈ 69,063 women/year; mean survey response rate 69%). Compared to non-WIC mothers, WIC mothers were less likely to usually or always place their infants in supine sleeping positions [RR = 0.81 (95% CI: 0.80, 0.81)]. Overall, significant differences were found for each year (2007, 2008, 2009, 2010), and in aggregate (2007-2010) by WIC status. CONCLUSION Massachusetts WIC mothers more frequently placed their babies in non-supine positions than non-WIC mothers. While this relationship likely reflects the demographic factors associated with safe sleep practices (e.g., maternal income and race/ethnicity), the finding informed the deployment of an intervention strategy for SUID prevention. Given WIC's statewide infrastructure and the large proportion of pregnant/postpartum women in Massachusetts that are enrolled in WIC, a WIC-based safe sleep intervention may be an effective SUID reduction strategy with potential national application.
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Affiliation(s)
- Nicole J Treadway
- Boston Medical Center Injury Prevention Center, Boston, MA USA
- Department of Emergency Medicine, Boston University School of Medicine, One Boston Medical Center Place, Dowling 1, South, Boston, MA 02118 USA
| | - Hafsatou Diop
- Massachusetts Department of Public Health, 250 Washington Street, 02108 Boston, Massachusetts USA
| | - Emily Lu
- Massachusetts Department of Public Health, 250 Washington Street, 02108 Boston, Massachusetts USA
| | - Kerrie Nelson
- Boston University School of Public Health, 715 Albany Street, Talbot Building, 02118 Boston, MA USA
| | - Holly Hackman
- Massachusetts Department of Public Health, 250 Washington Street, 02108 Boston, Massachusetts USA
| | - Jonathan Howland
- Boston Medical Center Injury Prevention Center, Boston, MA USA
- Department of Emergency Medicine, Boston University School of Medicine, One Boston Medical Center Place, Dowling 1, South, Boston, MA 02118 USA
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40
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Putnam-Hornstein E, Schneiderman JU, Cleves MA, Magruder J, Krous HF. A prospective study of sudden unexpected infant death after reported maltreatment. J Pediatr 2014; 164:142-8. [PMID: 24139442 DOI: 10.1016/j.jpeds.2013.08.073] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/05/2013] [Accepted: 08/30/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine whether infants reported for maltreatment face a heightened risk of sudden infant death syndrome (SIDS) and other leading causes of sudden unexpected infant death (SUID). STUDY DESIGN Linked birth and infant death records for all children born in California between 1999 and 2006 were matched to administrative child protection data. Infants were prospectively followed from birth through death or 1 year of age. A report of maltreatment was modeled as a time-varying covariate; risk factors at birth were included as baseline covariates. Multivariable competing risk survival models were used to estimate the adjusted relative hazard of postneonatal SIDS and other SUID. RESULTS A previous maltreatment report emerged as a significant predictor of SIDS and other SUID. After adjusting for baseline risk factors, the rate of SIDS was more than 3 times as great among infants reported for possible maltreatment (hazard ratio: 3.22; 95% CI: 2.66, 3.89). CONCLUSION Infants reported to child protective services have a heightened risk of SIDS and other SUID. Targeted services and improved communication between child protective services and the pediatric health care community may enhance infant well-being and reduce risk of death.
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Affiliation(s)
- Emily Putnam-Hornstein
- University of Southern California, School of Social Work, Los Angeles, CA; University of California, Berkeley, California Child Welfare Indicators Project, Berkeley, CA.
| | | | - Mario A Cleves
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Joseph Magruder
- University of California, Berkeley, California Child Welfare Indicators Project, Berkeley, CA
| | - Henry F Krous
- Department of Pathology, Rady Children's Hospital-San Diego and Department of Pediatrics, School of Medicine, University of California, San Diego, La Jolla, CA
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