Decline in SUIDs, sleep-related infant deaths differ by race, ethnicity

While the rate of SUID has declined for all racial and ethnic groups since the start of the Back to Sleep Campaign in 1994, with each group exhibiting a unique trend in its decline, Parks et al. found that the pattern of disparity remains essentially intact: American Indian/Alaska Native and non-Hispanic black infants are at highest risk.

The researchers comment that the reasons for these variations are multifactorial and reflect biological as well as behavioral risk factors. With respect to the latter, more exposure to household smoke, less use of supine sleep, more bed sharing, more use of hazardous bedding, and less breastfeeding are examples of behaviors associated with a greater risk of SUID and more commonly found in the racial and ethnic groups exhibiting higher SUID rates.

The pediatrician is in a position to improve these practices through early and recurring discussions with parents. By identifying not only what a parent does or is planning to do, but also why those choices are being made, the pediatrician can learn about and address some of the barriers — cultural, social or personal — that underlie these choices and thus be better able to influence not only parental knowledge but also parental behavior.

Ideally, pediatricians should include grandparents in their safe sleep discussions. They play an important child-rearing role in many cultures but often lack access to current evidence-based guidelines on safe infant sleep. For example, they are more likely to perceive supine positioning, which contradicts what previous generations were told, as counter-intuitive with respect to the risk of aspiration. Although this study identifies racial and ethnic disparities in SUID rates, and therefore points to where intervention is most needed, no population group is without risk; therefore, all groups merit these discussions.

Barbara M. Ostfeld, PhD
Professor, Department of Pediatrics
Rutgers Robert Wood Johnson Medical School

Thomas Hegyi, MD
Professor and Vice-chair of Pediatrics
Rutgers Robert Wood Johnson Medical School

Catherine Y. Spong, MD

The recent study by Parks et al reveals new information on sudden unexpected infant deaths, one of the leading causes of infant deaths and the leading cause of post-neonatal deaths. This study highlight the important role of health care providers in reducing infant risk and the persistence of disparities in outcomes. Given that sudden unexpected infant deaths account for over 35% of post-neonatal deaths, interventions have the potential for significant public health benefit.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), along with its partners, has led efforts on safe infant sleep education since the 1990s. Beginning as the Back to Sleep campaign in 1994 and expanding to the Safe to Sleep campaign in 2012, these programs have helped raise awareness about ways to reduce the risk of sudden infant death syndrome (SIDS) and other sleep-related causes of infant death, such as suffocation. We have been fortunate to see the U.S. SIDS rates decrease by more than 60% since these efforts began.

Statistics suggest that the first 6 months after birth, when infants are forming their sleeping habits, are the most important in terms of following safe sleep recommendations to reduce SIDS risk. Research shows that 90% of SIDS deaths occur in infants younger than 6 months of age, with a peak between 1 and 4 months of age. However, because SIDS can occur at any time during an infant’s first year, parents and caregivers should continue to follow—and health care providers should continue to advise about—safe sleep practices until the infant’s first birthday.

Such conversations are most effective when caregivers can discuss sleep arrangements or situations honestly and receive appropriate feedback to help them create the safest sleep environment possible for their baby. Research confirms that advice from health care providers makes a difference in parent and caregiver decisions about sleep position and sleep environment. Helping expectant parents anticipate challenges to safe sleep and encouraging them to plan for sleep-deprived moments may help foster a more collaborative and problem-solving relationship with their provider.

Parks et al raise the importance of tailoring risk-reduction strategies to address the specific cultural makeup of racial/ethnic communities. Disparities in SIDS rates have persisted despite an overall reduction in SIDS rates. We are learning what works and what doesn’t in terms of spreading safe sleep messages in different communities. For instance, NICHD research shows that education programs in African-American communities have a major positive impact and that such efforts are effective for achieving high rates of back-sleeping among African-American infants.

We have identified that different strategies may be beneficial in different communities and groups; for example, our efforts in Mississippi were most beneficial when engaging in communities and local churches. In addition, we have targeted communications to other family caregivers, such as grandparents who may not be aware of the latest data but whose opinions hold considerable weight in communities.

Additional evidence shows that in American Indian/Alaska Native communities, infants are less likely to die of SIDS if their mothers were visited by a public health nurse before and after giving birth. Supporting communities in using these tactics is an ongoing effort not only for NICHD’s Safe to Sleep® campaign, but also for health care providers across the country.

Although we have made substantial progress over the last decades in reducing sleep-related infant deaths, Parks and colleagues remind us that gaps remain. Their work adds to the ongoing basic, epidemiologic, and clinical work to uncover the causes, mechanisms, and associated factors. As a mother, researcher, and practicing OB/GYN, I want a safe sleep environment for all children — this research helps to further that important cause.