Photos Shared on Facebook in the Context of Safe Sleep Recommendations: Content Analysis of Images

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.

Sleeping Safe and Sound: A Multidisciplinary Hospital-wide Infant Safe Sleep Quality Improvement Initiative

INTRODUCTION

Promoting safe sleep to decrease sudden unexpected infant death is challenging in the hospital setting.

LOCAL PROBLEM

Concern for adherence to safe sleep practice across inpatient units at a large pediatric hospital.

METHODS

Used quality improvement methodologies to promote safe sleep across all units.

INTERVENTIONS

Development of a multidisciplinary expert group, hospital-wide guidelines, targeted interventions, and bedside audits to track progress.

RESULTS

Adherence to safe sleep practices improved from 9% to 53%. Objects in the crib were a major barrier to maintaining a safe sleep environment. Safe sleep practices were less likely to be observed in infants with increased medical complexity (p = .027).

CONCLUSIONS

Quality improvement methodology improved adherence to infant safe sleep guidelines across multiple units. Medically complex infants continue to be a challenge to safe sleep. Therefore, ongoing education for staff and further research into best practices for the most complex infant populations are necessary.

Practices and Awareness Regarding an Infant's Sleep Environment among Japanese Caregivers: A Cross-Sectional Survey

Preventing sudden, unexpected infant death related to sleep, especially suffocation and sudden infant death syndrome, remains challenging globally. To evaluate factors associated with an unsafe sleep environment (SE) for infants in Japan, this cross-sectional study investigated the current status of practices and awareness among caregivers about a safe SE. Two hundred and fifty-four caregivers of infants in Yamaguchi Prefecture participated. Among the caregivers, 96.0% could not thoroughly practice a safe SE, although 65.0% had knowledge about a safe SE. More unsafe SE practices were significantly associated with 8- to 11-month-old infants than with 0- to 3-month-old infants, using the same practice as for an older child than with accessing information or a familiar person than with mass media as the most useful source of information. The differences in having knowledge were not associated with their practice. Many caregivers obtained information about an infant's SE from mass media and a familiar person. They preferred education via a face-to-face method by medical experts to raise awareness about a safe SE. Thus, efforts need to be developed in Japan in which experts who directly attend to caregivers can truly educate them to ensure that caregivers are continuously aware of the importance of an SE.

What More Can We Do to Prevent Infants From Dying While They Sleep?

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.

Racial and Ethnic Disparities in Sudden Unexpected Infant Death Among US Infants Born Preterm

OBJECTIVE

To investigate among US infants born at <37 weeks gestation (a) racial and ethnic disparities in sudden unexpected infant death (SUID) and (b) state variation in SUID rates and non-Hispanic Black (NHB)-non-Hispanic White (NHW) SUID disparity ratio.

METHODS

In this retrospective cohort analysis of linked birth and death certificates from 50 states from 2005 to 2014, SUID was defined by the following International Classification of Diseases, 9th or 10th edition, codes listed on death certificates: (7980, R95 or Recode 135; ASSB: E913, W75 or Recode 146; Unknown: 7999 R99 or Recode 134). Multivariable models were used to assess the independent association between maternal race and ethnicity and SUID, adjusting for several maternal and infant characteristics. The NHB-NHW SUID disparity ratios were calculated for each state.

RESULTS

Among 4 086 504 preterm infants born during the study period, 8096 infants (0.2% or 2.0 per 1000 live births) experienced SUID. State variation in SUID ranged from the lowest rate of 0.82 per 1000 live births in Vermont to the highest rate of 3.87 per 1000 live births in Mississippi. Unadjusted SUID rates across racial and ethnic groups varied from 0.69 (Asian/Pacific Islander) to 3.51 (NHB) per 1000 live births. In the adjusted analysis, compared with NHW infants, NHB and Alaska Native/American Indian preterm infants had greater odds of SUID (aOR, 1.5;[95% CI, 1.42-1.59] and aOR, 1.44 [95% CI, 1.21-1.72]) with varying magnitude of SUID rates and NHB-NHW disparities across states.

CONCLUSIONS

Significant racial and ethnic disparities in SUID among preterm infants exist with variation across US states. Additional research to identify the drivers of these disparities within and across states is needed.

Maternal, infant, and environmental risk factors for sudden unexpected infant deaths: results from a large, administrative cohort

OBJECTIVES

Many studies of sudden unexpected infant death (SUID) have focused on individual domains of risk factors (maternal, infant, and environmental), resulting in limited capture of this multifactorial outcome. The objective of this study was to examine the geographic distribution of SUID in San Diego County, and assess maternal, infant, and environmental risk factors from a large, administrative research platform.

STUDY DESIGN

Births in California between 2005 and 2017 were linked to hospital discharge summaries and death files. From this retrospective birth cohort, cases of SUID were identified from infant death files in San Diego County. We estimated adjusted hazard ratios (aHRs) for infant, maternal, and environmental factors and SUID in multivariable Cox regression analysis. Models were adjusted for maternal sociodemographic characteristics and prenatal nicotine exposure.

RESULTS

There were 211 (44/100,000 live births; absolute risk 0.04%) infants with a SUID among 484,905 live births. There was heterogeneity in geographic distribution of cases. Multiparity (0.05%; aHR 1.4, 95% confidence interval (CI) 1.1, 1.9), maternal depression (0.11%; aHR 1.8, 95% CI 1.0, 3.4), substance-related diagnoses (0.27%; aHR 2.3, 95% CI 1.3, 3.8), cannabis-related diagnosis (0.35%; aHR 2.7, 95% CI 1.5, 5.0), prenatal nicotine use (0.23%; aHR 2.5, 95% CI 1.5, 4.2), preexisting hypertension (0.11%; aHR 2.3, 95% CI 1.2, 4.3), preterm delivery (0.09%; aHR 2.1, 95% CI 1.5, 3.0), infant with a major malformation (0.09%; aHR 2.0, 95% CI 1.1, 3.6), respiratory distress syndrome (0.12%; aHR 2.6, 95% CI 1.5, 4.6), and select environmental factors were all associated with SUID.

CONCLUSIONS

Multiple risk factors were confirmed and expanded upon, and the geographic distribution for SUID in San Diego County was identified. Through this approach, prevention efforts can be targeted to geographies that would benefit the most.

Challenges and Opportunities of Using a National Database to Evaluate Racial/Ethnic Disparities and Breastfeeding Effects on Sudden Unexpected Infant Death

Background: Sudden unexpected infant death (SUID) rates remain higher in American Indian/Alaska Native (AI/AN) and non-Hispanic Black (NHB) infants than other demographic groups. Racial disparities are also evident in breastfeeding, which is associated with reduced risk of SUID. Objective: To assess the relationship between racial/ethnic disparities in SUID and breastfeeding beyond the newborn period using U.S. nationally reported public databases. Methods: Data were extracted from Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) and the National Immunization Surveys (NISs) 2009-2017. WONDER data were restricted to full-term infants and sorted by death year, race/ethnicity, and other characteristics. NIS breastfeeding data included ever breastfed, breastfed at 6 months, and exclusive breastfeeding at 3 and 6 months. Breastfeeding rates and mortality data were aggregated based on race/ethnicity, and mortality rates were analyzed by weighted (number of births) multivariable linear regression. Results: SUID rates were highest among NHB and AI/AN infants who also had the lowest breastfeeding rates. When breastfeeding and race/ethnicity were included in the analyses, race/ethnicity confounded the relationship between breastfeeding and SUID. When race was excluded, ever breastfeeding and any breastfeeding at 6 months were associated with significantly decreased SUID rates. Conclusion: Race/ethnicity confounded the relationship between breastfeeding and SUID. Analysis was limited because individual SUID rates were available for maternal/birth characteristics but not for breastfeeding. Our study showed a need for adding additional data points to other national databases to better understand the role that breastfeeding plays in the racial/ethnic disparities in SUID.

Emergency Department Visits Before Sudden Unexpected Infant Death: A Touchpoint for Unsafe Sleep Reduction

OBJECTIVES

Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death.

METHODS

We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID.

RESULTS

Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3.

CONCLUSIONS

Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts.

A ten-year retrospective case review of risk factors associated with sleep-related infant deaths

AIM

The study aimed to identify risk factors associated with sleep-related deaths of infants (0-24 months) in the province of Manitoba, Canada, between January 2009 and December 2018.

METHODS

A systematic retrospective case review of autopsies and administrative records in Manitoba between 2009 and 2018.

RESULTS

A total of 145 infants died in cases where unsafe sleep environments were known to have contributed to or resulted in their death and where no explained medical causes were identified. Where data complete, all infants had at least one known risk factor for sleep-related deaths, and 96% had multiple. The most common risk factors increased over time and included objects in the sleeping environment (90% of cases), not approved sleep surfaces (77%) and bedsharing (50%). Indigenous infants, infants of young mothers and infants in low-income neighbourhoods are overrepresented. Risk factors for Indigenous infants differed from cases involving non-Indigenous infants.

CONCLUSION

A high proportion of sleep-related infant deaths were associated with not approved sleep surfaces and bedsharing, especially for infants under one year. Families in low-income neighbourhoods, Indigenous families and families with young mothers were disproportionately affected by sleep-related infant deaths. There is a need to enhance messaging and smoking cessation messaging in Indigenous communities to prevent sleep-related deaths.

When there is no air, the cradle will fall: A narrative review of tobacco-related content across infant safe sleep interventions

Sudden Unexpected Infant Death (SUID) from sleep-related causes is a leading cause of infant mortality worldwide. Sudden Infant Death Syndrome (SIDS) is one of the primary causes of SUID attributed to one or more environmental or behavioral determinants surrounding safe sleep practices among infants. The focus of many interventions on mitigating sleep-related infant deaths have addressed visible determinants pertaining to bed sharing, safe sleep surfaces, and removal of blankets, toys and other choking or strangulation hazards. Tobacco reduction and cessation have not been at the heart of any infant safe sleep interventions although addressing tobacco exposure is one of the primary safe sleep recommendations of the American Academy of Pediatrics. To date, there has not been a comprehensive review published on tobacco-related components across safe sleep interventions to reduce the risk of SIDS and SUID as the basis to contribute towards decreasing the rate of infant mortality. This review synthesizes the best practices, strategies, education, and additional interventions centered on addressing tobacco exposure as a risk factor for sleep-related infant deaths. Ten peer-reviewed studies were identified between 1995 and 2021 and integrated into this narrative review. There were three cross-sectional studies, three campaigns, one multi-center case control study, two randomized controlled trials, and two group comparison studies. Strengths and limitations of each approach are delineated followed by recommendations for future campaign, research, program, and practice endeavors to account for the totality of pertinent modifiable risk factors that contribute towards heightened infant mortality from sleep-related causes.

Prematurity, the diagnosis of bronchopulmonary dysplasia, and maturation of ventilatory control

Infants born before 32 weeks gestational age and receiving respiratory support at 36 weeks postmenstrual age (PMA) are diagnosed with bronchopulmonary dysplasia (BPD). This label suggests that their need for supplemental oxygen (O₂ ) is primarily due to acquired dysplasia of airways and airspaces, and that the supplemental O₂ is treating residual parenchymal lung disease. However, emerging evidence suggests that immature ventilatory control may also contribute to the need for supplemental O₂ at 36 weeks PMA. In all newborns, maturation of ventilatory control continues ex utero and is a plastic process. Among premature infants, supplemental O₂ mitigates the hypoxemic effects of delayed maturation of ventilatory control, as well as reduces the duration and frequency of periodic breathing events. Nevertheless, prematurity is associated with altered and occasionally aberrant maturation of ventilatory control. Infants born prematurely, with or without a diagnosis of BPD, are more prone to long-lasting effects of dysfunctional ventilatory control. This review addresses normal and abnormal maturation of ventilatory control and suggests how aberrant maturation complicates assigning the diagnosis of BPD. Greater awareness of the interaction between parenchymal lung disease and delayed maturation of ventilatory control is essential to understanding why a given premature infant requires and is benefitting from supplemental O₂ at 36 weeks PMA.

Explaining Sudden Unexpected Infant Deaths, 2011-2017

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.

Circadian variation in sudden unexpected infant death in the United States

Aim

To determine which factors are associated with sudden unexpected infant death (SUID) by time of day.

Methods

Data were analysed from the National Fatality Review Case Reporting System (2006‐2015). Out of 20 005 SUID deaths in 37 states, 12 191 (60.9%) deaths had a recorded nearest hour of discovery of the infant. We compared distribution patterns between time of death and 118 variables to determine which were significantly correlated with SUID time of death using advanced statistical modelling techniques.

Results

The 12‐hour time periods that were most different were 10:00 to 21:00 (daytime) and 22:00 to 09:00 (nighttime). The main features that were associated with nighttime SUID were bed sharing, younger infants, non‐white infants, placed supine to sleep and found supine, and caregiver was the parent. Daytime SUID was associated with older infants, day care, white infants, sleeping in an adult bed and prone sleep position. Factors not associated with time of death were sex of the infant, smoking and breastfeeding.

Conclusion

Sudden unexpected infant death deaths that occur at night are associated with a separate set of risk factors compared to deaths that occur during the day. However, to minimise risk, it is important to practice safe sleep guidelines during both nighttime and daytime sleep.

Sudden Unexpected Postnatal Collapse Resulting in Newborn Death in the United States

BACKGROUND

The sudden collapse of an apparently healthy newborn, or sudden unexpected postnatal collapse (SUPC) is fatal in about half of cases. Epidemiological characteristics of sudden unexpected infant death (SUID) in the first week of life differ from those in the postperinatal age group (7-365 days).

AIM

To describe the characteristics of SUPC resulting in neonatal death.

METHODS

We analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2003-2013: 41,125,233 births and 37,624 SUIDs). SUPC was defined as infants born ≥35 weeks gestational age, with a 5-minute Apgar score of ≥7, who died suddenly and unexpectedly in the first week of life.

RESULTS

Of the 37,624 deaths categorized as SUID during the study period, 616 met the SUPC criteria (1.5/100,000 live births). Eleven percent occurred on the first day of life and nearly three quarters occurred during postnatal days 3-6. SUPC deaths differed statistically from SUID deaths occurring 7-364 days of age, in particular for sex, marital status, and live birth order.

IMPLICATIONS

These data support the need for adequate nurse staffing during the immediate recovery period and for the entire postpartum stay as well as nurse rounding for new mothers in the hospital setting.

A Common 3'UTR Variant of the PHOX2B Gene Is Associated With Infant Life-Threatening and Sudden Death Events in the Italian Population

Heterozygous mutations in the Paired like homeobox 2b (PHOX2B) gene are causative of congenital central hypoventilation syndrome (CCHS), a rare monogenic disorder belonging to the family of neurocristopathies and due to a defective development of the autonomic nervous system. Most patients manifest sudden symptoms within 1 year of birth, mainly represented by central apnea and cyanosis episodes. The sudden appearance of hypoxic manifestations in CCHS and their occurrence during sleep resemble two other unexplained perinatal disorders, apparent life-threatening event (ALTE) and sudden and unexpected infant death (SUID), among which the vast majority is represented by sudden infant death syndrome (SIDS). Differently from CCHS, characterized by Mendelian autosomal dominant inheritance, ALTE and SIDS are complex traits, where common genetic variants, together with external factors, may exert an additive effect with symptoms likely manifesting only over a “threshold.” Given the similarities observed among the three abovementioned perinatal disorders, in this work, we have analyzed the frequency of PHOX2B common variants in two groups of Italian idiopathic ALTE (IALTE) and SUIDs/SIDS patients. Here, we report that the c^*161G>A (rs114290493) SNP of the 3′UTR PHOX2B (i) became overrepresented in the two sets of patients compared to population matched healthy controls, and (ii) associated with decreased PHOX2B gene expression, likely mediated by miR-204, a microRNA already known to bind the 3′UTR of the PHOX2B gene. Overall, these results suggest that, at least in the Italian population, the SNP c^*161G>A (rs114290493) does contribute, presumably in association with others mutations or polymorphisms, to confer susceptibility to sudden unexplained perinatal life-threatening or fatal disorders by increasing the effect of miR-204 in inducing PHOX2B expression down-regulation. However, these are preliminary observations that need to be confirmed on larger cohorts to achieve a clinical relevance.

Nurses Leading Safe Infant Sleep Initiatives in the Hospital Setting

Every day, 10 otherwise healthy infants die from sleep-related deaths in the United States. These deaths, termed sudden unexpected infant death, remain the leading cause of post-neonatal death in the United States despite known modifiable risk factors and prevention recommendations. In birthing hospitals, many parents report being given incorrect and sometimes no information about infant sleep safety, which creates immediate and long-term safety concerns. In this article, we provide an overview of sudden unexpected infant death, including sudden unexpected postnatal collapse, and the latest safe sleep recommendations from the American Academy of Pediatrics. We also offer practical guidelines for nurses-those working at the bedside and those in leadership positions-who may be seeking to improve the quality of infant sleep practices in their organizations.

Effect of Education and Cardboard Bassinet Distribution on Newborn Bed-Sharing

Objective. This study sought to determine if infant sleep education plus a cardboard bassinet reduced bed-sharing, a risk factor for sudden infant death syndrome (SIDS) and sleep-related deaths (SRD), in the first week of life. Methods. Women delivered between 1/1/2015-11/15/2016 were interviewed by phone within 72 hours of discharge. Control 1 delivered through 10/31/2015 (previously reported); Control 2: 11/1/2015-2/7/2016; Intervention 1 received inpatient safe sleep education and delivered between 2/8/2016-5/4/2016; Intervention 2 also received a cardboard bassinet and delivered after 5/4/2016. Subjects self-reported bed-sharing, newborn sleep position, feeding method, and sleep environment; demographic data was obtained from medical records. Bayesian methodology compared bed-sharing rates between aggregated control and intervention groups; results were expressed as posterior rates, rate ratios, and 95% credible intervals (CredInt); the posterior probability that the rate ratio was > 1(Bayesian probability) was determined by calculation and simulation. Results. 5187 eligible subjects, 2763 (53%) completed the survey (Control 1: n=1264; Control 2: n=423; Intervention 1: n=391; Intervention 2: n=685). Bed-sharing rates: Control: 6.3% (5.2,7.4); Intervention: 4.7% (3.5,5.9). Rate ratio (Control/Intervention) was 1.36 (0.95,1.83) and the Bayesian probability that the rate ratio >1 was .96 and .97 by calculation and simulation, respectively. Bed-sharing rates for exclusively breastfed infants: Control: 11% (7.4, 14.6); Intervention: 5.9% (2.7, 9.2); Rate ratio was 2.00 (1.01, 3.15) and the Bayesian probability that the rate ratio >1 was .993. Conclusions. Infant sleep education plus a cardboard bassinet reduced the rate of bed-sharing in the first week of life, particularly among exclusively breastfeeding dyads.

Sudden Infant Death Syndrome and Safe Sleep on Twitter: Analysis of Influences and Themes to Guide Health Promotion Efforts

BACKGROUND

In the United States, sudden infant death syndrome (SIDS) is the leading cause of death in infants aged 1 month to 1 year. Approximately 3500 infants die from SIDS and sleep-related reasons on a yearly basis. Unintentional sleep-related deaths and bed sharing, a known risk factor for SIDS, are on the rise. Furthermore, ethnic disparities exist among those most affected by SIDS. Despite public health campaigns, infant mortality persists. Given the popularity of social media, understanding social media conversations around SIDS and safe sleep may assist the medical and public health communities with information needed to spread, reinforce, or counteract false information regarding SIDS and safe sleep.

OBJECTIVE

The objective of our study was to investigate the social media conversation around SIDS and safe sleep to understand the possible influences and guide health promotion efforts and public health research as well as enable health professionals to engage in directed communication regarding this topic.

METHODS

We used textual analytics to identify topics and extract meanings contained in unstructured textual data. Twitter messages were captured during September, October, and November in 2017. Tweets and retweets were collected using NUVI software in conjunction with Twitter's search API using the keywords: "sids," "infant death syndrome," "sudden infant death syndrome," and "safe sleep." This returned a total of 41,358 messages, which were analyzed using text mining and social media monitoring software.

RESULTS

Multiple themes were identified, including recommendations for safe sleep to prevent SIDS, safe sleep devices, the potential causes of SIDS, and how breastfeeding reduces SIDS. Compared with September and November, more personal and specific stories of infant loss were demonstrated in October (Pregnancy and Infant Loss Awareness Month). The top influencers were news organizations, universities, and health-related organizations.

CONCLUSIONS

We identified valuable topics discussed and shared on Twitter regarding SIDS and safe sleep. The study results highlight the contradicting information a subset of the population is exposed to regarding SIDS and the continued controversy over vaccines. In addition, this analysis emphasizes the lack of public health organizations' presence on Twitter compared with the influence of universities and news media organizations. The results also demonstrate the prevalence of safe sleep products that are embedded in safe sleep messaging. These findings can assist providers in speaking about relevant topics when engaging in conversations about the prevention of SIDS and the promotion of safe sleep. Furthermore, public health agencies and advocates should utilize social media and Twitter to better communicate accurate health information as well as continue to combat the spread of false information.

Characteristics of Infant Deaths during Sleep While Under Nonparental Supervision

OBJECTIVE

To compare risk factors for infant sleep-related deaths under the supervision of parents and nonparents.

STUDY DESIGN

We conducted a secondary analysis of sleep-related infant deaths from 2004 to 2014 in the National Center for Fatality Review and Prevention Child Death Review Case Reporting System. The main exposure was supervisor at time of death. Primary outcomes included sleep position, location, and objects in the environment. Risk factors for parental vs nonparental supervisor were compared using χ² and multivariable logistic regression models. Risk factors associated with different nonparental supervisors were analyzed using χ².

RESULTS

Of the 10 490 deaths, 1375 (13.1%) occurred under nonparental supervision. Infants who died under nonparental supervision had higher adjusted odds of dying outside the home (OR 12.87, 95% CI 11.31-14.65), being placed prone (OR 1.61, 95% CI 1.39-1.86) or on their side (OR 1.35, 95% CI 1.12-1.62), or being found prone (OR 1.74, 95% CI 1.50-2.02). Among infants who died under nonparental supervision, those supervised by relatives or friends were more often placed on an adult bed or couch for sleep and bed sharing (P < .0001), and to have objects in the sleep environment (P = .01).

CONCLUSIONS

Infants who died of sleep-related causes under nonparental supervision were more likely to have been placed nonsupine. Among nonparental supervisors, relatives and friends were more likely to use unsafe sleep environments, such as locations other than a crib or bassinet and bed sharing. Pediatricians should educate parents that all caregivers must always follow safe sleep practices.

Trends in the Incidence of Sudden Unexpected Infant Death in the Newborn: 1995-2014

OBJECTIVE

To evaluate the epidemiology of sudden unexpected infant death (SUID) over a 20-year period in the US, to assess the potential frequency of sudden unexpected postnatal collapse in the early days of life, and to determine if SUID rates in the neonatal period (0-27 days) have changed in parallel with rates in the postneonatal periods, including the percentages attributed to codes that include accidental suffocation.

STUDY DESIGN

Data from the US Centers for Disease Control and Prevention Linked Birth/Infant Death Records for 1995-2014 were analyzed for the first hour, day, week, and month of life. A comparison of neonatal and postneonatal data related to SUID, including accidental suffocation, was carried out.

RESULTS

Death records for 1995-2014 indicate that, although SUID rates in the postneonatal period have declined subsequent to the 1992 American Academy of Pediatrics sleep position policy change, newborn SUIDs have failed to decrease, and the percentage of SUIDs attributed to unsafe sleep conditions has increased significantly in both periods; 29.2% of the neonatal cases occurred within the first 6 days of life.

CONCLUSIONS

The frequency of SUIDs during the neonatal period warrants ongoing attention to all circumstances contributing to this category of deaths. The development of a standardized definition of sudden unexpected postnatal collapse and a national registry of these events is recommended. Ongoing research on the effects of early neonatal practices on postneonatal SUID should also be encouraged.

The French prospective multisite registry on sudden unexpected infant death (OMIN): rationale and study protocol

INTRODUCTION

Even after 'back-to-sleep' campaigns, sudden unexpected infant death (SUID) continues to be the leading cause of death for infants 1 month to 1 year old in developed countries, with devastating social, psychological and legal implications for families. To sustainably tackle this problem and decrease the number of SUIDs, a French SUID registry was initiated in 2015 to (1) inform prevention with standardised data, (2) understand the mechanisms leading to SUID and the contribution of the already known or newly suggested risk factors and (3) gather a multidisciplinary group of experts to coordinate and develop innovative and urgent research in the SUID area.

METHODS AND ANALYSIS

This observational multisite prospective observatory includes all cases of sudden unexpected deaths in children younger than 2 years occurring in the French territory covered by the 35 participating French referral centres. From these cases, various data concerning sociodemographic conditions, death scene, personal and family medical history, parental behaviours, sleep environment, clinical examinations, biological and imagery investigations and autopsy are systematically collected. These data will be complemented as of 2018 with a biobank of diverse biological samples (blood, hair, urine, faeces and cerebrospinal fluid), with other administrative health-related data (health claim reimbursements and hospital admissions) and socioenvironmental data. Insights from exploratory descriptive statistics and thematic analysis will be combined for the design of targeted strategies to effectively reduce preventable infant deaths.

ETHICS AND DISSEMINATION

The French sudden unexpected infant death registry (Observatoire National des Morts Inattendues du Nourrisson registry;OMIN) was approved in 2015 by the French Data Protection Authority in clinical research (Commission Nationale de l'Informatique et des Libertés: number 915273) and by an independent ethics committee (Groupe Nantais d'Ethique dans le Domaine de la Santé: number 2015-01-27). Results will be discussed with associations of families affected by SUID, caregivers, funders of the registry, medical societies and researchers and will be submitted to international peer-reviewed journals and presented at international conferences.

Stock Photographs Do Not Comply With Infant Safe Sleep Guidelines

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

Barriers to and Interventions that Increase Nurses' and Parents' Compliance With Safe Sleep Recommendations for Preterm Infants

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.

Types of Objects in the Sleep Environment Associated With Infant Suffocation and Strangulation

OBJECTIVE

To investigate the circumstances of death and types and roles of objects present in the sleep environment at the time of death for infants who died from suffocation or strangulation during sleep.

METHODS

This study analyzed 1736 reported incidents of accidental suffocation and strangulation in bed (ASSB) of infants younger than 1 year of age. These fatalities occurred from 2000 through 2012 and were reported to the United States Consumer Product Safety Commission.

RESULTS

The mean age of ASSB death was 3.76 months (SD, 2.51). Infants younger than 5 months accounted for 67.3% (1168 of 1736) of all reported fatalities and 58.3% (1009 of 1731) were male. Deceased infants were often found in a crib or bassinet (30.6%; 383 of 1253) or in the prone orientation (84.9%; 595 of 701). The most common objects associated with infant ASSB were pillows (24.5%; 425 of 1736), mattresses (21.0%; 364 of 1736), blankets (13.1%; 228 of 1736), and walls (11.5%; 199 of 1736). Wedged (43.3%; 616 of 1424) or positioned on top of an object (25.9%; 369 of 1424) were the most common positions associated with death. Infants were often found wedged between a mattress and wall (30.2%; 181 of 599) or oriented face-down or prone on top of a pillow (52.2%; 187 of 358). Sleep surface sharing was associated with 6.5% (112 of 1736) of ASSB deaths.

CONCLUSIONS

Pillows and blankets are objects in sleep environments frequently associated with unintentional suffocation and strangulation of infants. Increased efforts should be made to remove these and other objects from sleep environments of infants.

An Update on Safe Infant Sleep

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.

Understanding the Risks Sitting and Carrying Devices Pose to Safe Infant Sleep

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.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Factors Associated With Infant Bed-Sharing

Objective: Bed-sharing is associated with sudden infant death syndrome and accidental suffocation and strangulation in bed. The purpose of this study was to identify risk factors for newborn bed-sharing. Methods: Postpartum mothers from a university maternity service were contacted by phone to complete a survey. Demographic and environmental data were collected; newborn bed-sharing and sleep environment were self-reported. Results: A total of 1261 mothers completed surveys; bed-sharing was reported by 79 mothers (6.3%). Multivariate logistic regression identified referral to a nurse (odds ratio [OR] = 10; 95% confidence interval [CI] = 4.5-30) and sleep location "other" than a crib, bassinet, or Pack and Play (OR = 7.1; 95% CI = 1.9-25.9) as factors associated with an increased risk of bed-sharing; formula feeding (OR = 0.4; 95% CI = 0.20-0.77) and crib sleeping (OR = 0.49; 95% CI = 0.26-0.86) reduced this risk. Conclusion: Infants with no identifiable places to sleep, significant health issues, and who are breastfed are more likely to bed-share. Interventional studies should be directed at these factors.

Unexpected Death of a Child with Complex Febrile Seizures-Pathophysiology Similar to Sudden Unexpected Death in Epilepsy?

Febrile seizures are usually considered relatively benign. Although some cases of sudden unexplained death in childhood have a history of febrile seizures, no documented case of febrile seizure-induced death has been reported. Here, we describe a child with complex febrile seizures who died suddenly and unexpectedly after a suspected seizure while in bed at night during the beginning phases of sleep. She was resuscitated and pronounced brain dead 2 days later at our regional medical center. Autopsy revealed multiorgan effects of hypoperfusion and did not reveal an underlying (precipitating) disease, injury, or toxicological cause of death. Although a seizure was not witnessed, it was suspected as the underlying cause of death based on the medical examiner and forensic pathologist (author Marcus Nashelsky) investigation, the post-resuscitation clinical findings, and multiple aspects of the clinical history. The child had a history of complex febrile seizures that had previously caused apnea and oxygen desaturation. She had two febrile seizures earlier on the same day of the fatal event. Interestingly, her mother also experienced a febrile seizure as a child, which led to respiratory arrest requiring cardiorespiratory resuscitation. This case suggests that in a child with complex febrile seizures, a seizure can induce death in a manner that is consistent with the majority of cases of sudden unexpected death in epilepsy (SUDEP). Further work is needed to better understand how and why certain individuals, with a history of epilepsy or not, die suddenly and unexpectedly from seizures. This will only occur through better understanding of the pathophysiologic mechanisms underlying epileptic and febrile seizures and death from seizures including SUDEP.

Sudden unexpected infant death in Jordan and the home environment

BACKGROUND

The aim of this study was to evaluate maternal common practice for infant sleep care and the home environment, in order to explore the major risk factors associated with sudden unexpected infant death in Jordan.

METHODS

Data were collected via semi-structured questionnaire interview to investigate the sociodemographic features, infant sleep practices and home environments. The sample included 604 mothers with infants <1 year old. Descriptive statistics were generated.

RESULTS

Sleep practices were identified as leading factors in unexpected infant death. They included infant head covering (84%), heavy bedding with multiple quilts (81%) or blankets (67%), and co-bedding (66%). Environmental risk factors included high incidence of smoking, exposure to toxic solid fuel heaters during winter and inadequate room ventilation.

CONCLUSION

Factors leading to unexpected infant death were high in Jordan. Unsafe infant sleeping practices and poor environmental factors put infants at high risk of sudden death. Lack of awareness of risk factors increases the risk.

Improving infant sleep safety through a comprehensive hospital-based program

We evaluated a comprehensive hospital-based infant safe sleep education program on parental education and safe sleep behaviors in the home using a cross-sectional survey of new parents at hospital discharge (HD) and 4-month follow-up (F/U). Knowledge and practices of infant safe sleep were compared to the National Infant Sleep Position Study benchmark. There were 1092 HD and 490 F/U surveys. Supine sleep knowledge was 99.8% at HD; 94.8% of families planned to always use this position. At F/U, 97.3% retained supine knowledge, and 84.9% maintained this position exclusively (P < .01). Knowledge of crib as safest surface was 99.8% at HD and 99.5% F/U. Use in the parents' room fell to 91.9% (HD) and 68.2% (F/U). Compared to the National Infant Sleep Position Study, the F/U group was more likely to use supine positioning and a bassinette or crib. Reinforcing the infant sleep safety message through intensive hospital-based education improves parental compliance with sudden infant death syndrome risk reduction guidelines.

Trends in infant bedding use: National Infant Sleep Position study, 1993-2010

BACKGROUND

Use of potentially hazardous bedding, as defined by the American Academy of Pediatrics (eg, pillows, quilts, comforters, loose bedding), is a modifiable risk factor for sudden infant death syndrome and unintentional sleep-related suffocation. The proportion of US infants sleeping with these types of bedding is unknown.

METHODS

To investigate the US prevalence of and trends in bedding use, we analyzed 1993-2010 data from the National Infant Sleep Position study. Infants reported as being usually placed to sleep with blankets, quilts, pillows, and other similar materials under or covering them in the last 2 weeks were classified as bedding users. Logistic regression was used to describe characteristics associated with bedding use.

RESULTS

From 1993 to 2010, bedding use declined but remained a widespread practice (moving average of 85.9% in 1993-1995 to 54.7% in 2008-2010). Prevalence was highest for infants of teen-aged mothers (83.5%) and lowest for infants born at term (55.6%). Bedding use was also frequently reported among infants sleeping in adult beds, on their sides, and on a shared surface. The rate of decline in bedding use was markedly less from 2001-2010 compared with 1993-2000. For 2007 to 2010, the strongest predictors (adjusted odds ratio: ≥1.5) of bedding use were young maternal age, non-white race and ethnicity, and not being college educated.

CONCLUSIONS

Bedding use for infant sleep remains common despite recommendations against this practice. Understanding trends in bedding use is important for tailoring safe sleep interventions.

Classification system for the Sudden Unexpected Infant Death Case Registry and its application

Sudden unexpected infant deaths (SUID) accounted for 1 in 3 postneonatal deaths in 2010. Sudden infant death syndrome and accidental sleep-related suffocation are among the most frequently reported types of SUID. The causes of these SUID usually are not obvious before a medico-legal investigation and may remain unexplained even after investigation. Lack of consistent investigation practices and an autopsy marker make it difficult to distinguish sudden infant death syndrome from other SUID. Standardized categories might assist in differentiating SUID subtypes and allow for more accurate monitoring of the magnitude of SUID, as well as an enhanced ability to characterize the highest risk groups. To capture information about the extent to which cases are thoroughly investigated and how factors like unsafe sleep may contribute to deaths, CDC created a multistate SUID Case Registry in 2009. As part of the registry, the Centers for Disease Control and Prevention developed a classification system that recognizes the uncertainty about how suffocation or asphyxiation may contribute to death and that accounts for unknown and incomplete information about the death scene and autopsy. This report describes the classification system, including its definitions and decision-making algorithm, and applies the system to 436 US SUID cases that occurred in 2011 and were reported to the registry. These categories, although not replacing official cause-of-death determinations, allow local and state programs to track SUID subtypes, creating a valuable tool to identify gaps in investigation and inform SUID reduction strategies.