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

BACKGROUND: Our objectives were to compare safe sleep knowledge, attitudes and planned vs. actual infant sleep practices among expectant mothers before and after their infant's birth and to determine whether differences (if present) were associated with any demographic variables. METHODS: Study participants were surveyed at their 28-week prenatal and 6-week postpartum obstetric clinic visits from November 2019-February 2021. Due to COVID-19 pandemic cancellation of in-person postpartum visits, many participants received text messaging encouraging them to take the follow-up survey online. Frequency and comparative analyses were performed. RESULTS: 355 women (44%) completed both pre- and postnatal surveys. Many participants increased their safe sleep knowledge during the study. For example, of those who were unsure or thought it safe for a baby to sleep in a baby swing/bouncy seat, two-thirds (67/102, 66%) stated it was unsafe on the postnatal survey. In addition, many who were unsure or planned sleep practices considered unsafe prenatally reported utilizing safe sleep practices on their postnatal survey. For example, of those unsure or planning to use a crib bumper (17% of the total), almost all (88%) were not using one postnatally. Conversely, some participants who reported they would be following safe sleep practices prenatally were not doing so postpartum. For example, 13% of those stating they would place their child on their back reported using another sleep position on the postnatal survey. Certain demographics had higher proportions reporting this reversal for specific safe sleep practices. For example, non-Hispanic Whites (19%) as compared to other races/ethnicities (5%) and those with incomes ≥ $75,000 (21%) as compared with those with less income (9%) had higher proportions stating their infant would sleep in the same room but then reported postnatally they were sleeping in a different room, p = 0.0094 and p = 0.0138, respectively. CONCLUSIONS: We observed increases in safe sleep knowledge and that some participants followed safer sleep practices than they had planned. However, there were also participants who planned to use safe sleep practices prenatally who were not doing so after their baby's birth. Our study identified demographics for which targeted safe sleep education and more effective interventions may be needed.

Death-scene investigations contribute to legal protection in unexpected child deaths in Norway.

AIM: This study reviewed cases of sudden unexpected child deaths in Norway to determine the significance of death-scene investigations (DSIs) in establishing cause and manner of death, and thereby it is relevance to legal protection. METHODS: Data from forensic autopsy reports and DSIs were collected and analysed for cases of unexpected deaths in children below 4 years of age in Norway during 2010-2016. RESULTS: Out of 141 cases, the death scene was investigated as a voluntary procedure in 75 cases and by the police in 41 cases. The cause of death remained unexplained in 81/141 (57%) of the cases, of which 46/141 (33%) met the criteria for sudden infant death syndrome (SIDS) or sudden unexplained death in early childhood (SUDC). The manner of death was determined in 102/141 (72%). Voluntary DSI increased the ability to rule out accidental suffocation, facilitated evaluations of environmental risk factors and enabled detection of possible neglect. CONCLUSION: Death-scene investigations illuminate uncertainty about the cause of death, especially in grey-area cases where accidental suffocation, neglect or abuse is suspected. Knowledge about the course of events and the cause of death enhances both the child's and the caregiver's legal protection. Death-scene investigations should therefore be mandatory.

Inconsistent classification of unexplained sudden deaths in infants and children hinders surveillance, prevention and research: recommendations from The 3rd International Congress on Sudden Infant and Child Death.

This report details the proceedings and conclusions from the 3rd International Congress on Unexplained Deaths in Infants and Children, held November 26-27, 2018 at the Radcliffe Institute at Harvard University. The Congress was motivated by the increasing rejection of the diagnosis Sudden Infant Death Syndrome (SIDS) in the medical examiner community, leading to falsely depressed reported SIDS rates and undermining the validity and reliability of the diagnosis, which remains a leading cause of infant and child mortality. We describe the diagnostic shift away from SIDS and the practical issues contributing to it. The Congress was attended by major figures and opinion leaders in this area from countries significantly engaged in this problem. Four categories (International Classification of Diseases (ICD)-11 categories of MH11, MH12, MH14, PB00-PB0Z) were recommended for classification, and explicit definitions and guidance were provided for death certifiers. SIDS was reframed as unexplained sudden death in infancy or SIDS/MH11 to emphasize that either term signifies the lack of explanation following a rigorous investigation. A distinct category for children over the age of 1 was recommended (MH12). Definitions and exclusions were provided for the alternative categories of accidental asphyxia and undetermined. As recommended, unexplained sudden death in infancy or SIDS on a death certificate will code a unique, trackable entity, accurately reflecting the inability to determine a definitive explanation, while satisfying surveillance needs and reliable identification for research efforts. The conclusions will be submitted to the World Health Organization for inclusion in the upcoming ICD-11.

Accidental Infant Suffocation and Strangulation in Bed: Disparities and Opportunities.

Objectives (a) Update previous descriptions of trends in ASSB; (b) determine if factors previously associated with ASSB are replicated by updated data; and (c) generate new hypotheses about the occurrence of ASSB and racial inequalities in ASSB mortality. Methods National Center for Health Statistics files (International Classification of Diseases, Tenth Edition) Code W75 to describe race-ethnicity-specific ASSB occurrence. Results (a) ASSB mortality continues to increase significantly; for 1999-2016, 4.4-fold for NHB girls (45.8 per 100,000 in 2016), 3.5-fold for NHB boys (53.8), 2.7-fold for NHW girls (15.8) and 4.0-fold for NHW boys (25.9); (b) F actors previously associated with ASSB (unmarried mothers and mothers with low educational attainment, low infant birth weight, low gestational age, lack of prenatal care, male infant, multiple birth, high birth order) continue to be associated with both overall ASSB and inequalities adversely affecting NHB; (c) (1) geographic differences and similarities in ASSB occurrence support hypotheses related to positive deviance; (2) lower ASSB mortality for births attended by midwives as contrasted to physicians generate hypotheses related to both medical infrastructure and maternal engagement; (3) high rates of ASSB among infants born to teenage mothers generate hypotheses related to the possibility that poor maternal health may be a barrier to ASSB prevention based on education, culture and tradition. Conclusions for Practice These descriptive data may generate new hypotheses and targets for interventions for reducing both ASSB mortality and racial inequalities. Analytic epidemiologic studies designed a priori to do so are required to address these hypotheses.

Reports of Injury Risks and Reasons for Choice of Sleep Environments for Infants and Toddlers.

OBJECTIVE: Compare mothers' reports of injuries for infants and toddlers sleeping with crib-bumpers/mesh-liners/no-barriers and reasons for these sleep environment choices. METHODS: A cross-sectional survey of mothers subscribing to a parenting magazine and using crib bumpers (n = 224), mesh liners (n = 262), and no barriers (n = 842). Analyses of four possible injuries (face-covered, climb-out/fall, slat-entrapment, hit-head) including multivariate logistic regression adjusted for missing data/demographics and Chi squared analyses of reasons for mothers' choices. RESULTS: Maternal reports of finding infants/toddlers with face covered had 3.5 times higher adjusted odds (aOR) for crib bumper versus mesh liner use. Breathing difficulties and wedgings were reported for infants/toddlers using crib bumpers but not mesh liners. Climb-outs/falls showed no significant difference in aORs for crib bumpers versus no-barriers and mesh liners versus no barriers. Reports of slat-entrapment were less likely for mothers using crib bumpers and mesh liners than using no barrier (aOR = .28 and .32). Reports of hit-heads were less likely for crib bumpers vs no barrier (aOR = .38) with no significant difference between mesh liners versus no barrier use. Mothers using crib bumpers and mesh liners felt their choice prevented slat-entrapment (89%, 91%); 93.5% of crib bumper users felt their choice prevented hit-heads. Significantly more mesh liner than crib bumper users chose them because "There is no suffocation risk" (64.1% vs. 40.6%), while 83.6% of no-barrier users chose them because "I was concerned about suffocation risk." CONCLUSIONS FOR PRACTICE: Mothers appeared to be more concerned about preventing minor risks than suffocation. Understanding reasons for mothers' use of barriers/no-barriers is important in tailoring counseling for mothers with infants/toddlers.

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.

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.

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.

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.

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.

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.

Knowledge, Attitudes, and Risk for Sudden Unexpected Infant Death in Children of Adolescent Mothers: A Qualitative Study.

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.

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.

A prospective study of sudden unexpected infant death after reported maltreatment.

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.