Despite the efforts of pediatric healthcare professionals to educate families on the risks of unsafe sleep practices, and to encourage adherence to safe sleep guidelines, sleep-related sudden unexpected infant deaths (SUID) remain stuck at around 3,400 cases each year. SUID, as I explained in more detail in a 2021 post, includes SIDS, accidental suffocation and strangulation in bed (ASSB), and unknown causes. In that post, which discussed data from 2011 through 2017, I pointed out the frustrating fact that most SUID cases occurred in the setting of modifiable environmental risk factors:
After analyzing the data, the authors determined key implications for pediatric healthcare professionals. Because more than 70% of SUID cases involved unsafe sleep environments, it is crucial that we figure out why caregivers aren’t following our recommendations. It is imperative that we develop more effective ways to educate these caregivers and help them adhere to the guidelines
https://sciencebasedmedicine.org/cdc-data-reveals-frustrating-infant-death-statistics/
A study looking at CDC data from 2015 through 2020, which I also covered last year, found additional concerns. in 2020, there was a 15% increase in SIDS cases despite improvements in overall infant mortality in general. The increase in cases of SIDS, as I explain in that post, appeared to be real and to involve a specific group of infants:
What really stood out in the 2020 numbers was that every group had SUID rates that were either lower or stable except for Black infants. This group saw an increase of 11%, from 189.9 to 214 cases per 100,000 live births. So if the increase in SIDS cases is real, and I think it is, it isn’t a stretch to imagine that most of those additional deaths involved Black infants.
https://sciencebasedmedicine.org/was-the-sars-cov-2-pandemic-to-blame-for-an-increase-in-unexpected-infant-deaths-in-2020/
The factors behind the increase in SUID cases in black infants almost certainly involved pandemic-related socioeconomic stressors that negatively impacted the day to day lives of their caregivers. Essentially, financial as well as physical and mental health challenges in the hardest hit communities likely resulted in decreased adherence to safe sleep recommendations. Hopefully subsequent years will have seen a return to “normal”, which again is still bad for babies of color, but that data isn’t available yet.
What I want to write about today is a new study in Pediatrics which provides further confirmation that we need to work much harder to convince families to follow safe sleep recommendations, and to help establish an environment where following those recommendations is easier. In the study, researchers set out to gather data involving the “characteristics and circumstances” of SUID cases in order to determine differences and similarities between cases where infants were sharing or not sharing a sleep surface with a caregiver. Surface sharing significantly increases the risk of all forms of SUID, and specifically SIDS by nearly 300%, which is why pediatricians so strongly recommend against it. Despite the fact that half of all SUID cases occur on a shared sleep surface, it remains a common practice with roughly a third of infants sharing a caregiver’s sleep surface for significant periods of time.
Using data from the CDC SUID Case Registry, which contains child death review program information (death certificates, autopsy reports, medical records), the researchers looked at surface sharing status, found location of the dead infant and person(s) sharing the surface, infant demographic data, birth characteristics, sleep environment, and potential suffocation mechanisms. In total, 7,595 SUID cases occurring from 2011 to 2020 and from 23 different U.S. jurisdictions were evaluated. Gathering this kind of data, according to the study authors, could drive future research and help us to better educate families.
60% of the SUID cases involved sleep surface sharing, which was a bit higher than expected. Also keep in mind that this particular datapoint is self-reported and very likely an underestimation of the true association. Most (73%) of the co-sleeping infants were 0 to 3 months compared to 57% of nonsharing infants. Most cases of SUID occur in younger infants, so this tracks. The largest group of infants sharing a sleep surface were non-Hispanic Black at 42%. Non-Hispanic White infants made up the largest nonsharing group at 46%. Sharing a sleep surface was more common with publicly insured infants.
46% of infants who died while sharing a sleep surface were found in a riskier face down or side position compared to 61% of nonsharing SUID cases. Nonsharing significantly lowers the risk of SUID, but it is not the only potential problem. This is an example of how data like this might help us to better educate families. Some caregivers might have a false sense of security and bend the rules a bit when placing a baby to sleep in a bassinet rather than co-sleeping. A baby is safest when all the recommendations are followed.
Another finding of concern is the clumping of risk factors in surface sharing scenarios. A third of bed sharing infants died in soft/loose bedding, sleeping on an adult bed, and face down or in the side position. 21% of nonsharing infants had all three risk factors, which is also shockingly high. 76% of these cases overall involved more than one SUID risk factor. Finally, infants sharing a sleep surface were more likely to have been exposed to maternal cigarette smoking during pregnancy, which is actually more of a risk factor than postnatal exposure.
The findings in this study were consistent with previous analyses when it comes to the clear dangers of sharing a sleep surface. We need to find a way to effectively communicate this risk to caregivers, but communication is only part of the issue. Many caregivers who decide to co-sleep likely know that it is riskier but have no other options. One example mentioned in the paper is that some families may not have a crib. There are often resources that hospitals can access to help in these situations.
These bed sharing families are more likely to have younger infants, to be black, and to rely on public health insurance. The first several weeks of parenting a new baby can be a time of great physical and emotional, and perhaps also economic stress, with the potential for sleep deprivation among many other issues. Focusing on easing the burden of caring for a young infant with a biopsychosocial approach might result in less sleep surface sharing.
Counseling of infant caregivers on the safe sleep is a challenge. It needs to be comprehensive. Heavy focus on only one aspect, even if it as important as providing a separate sleeping surface for an infant, might not always be the right approach. Though we don’t like to think about it, some families are going to bed share no matter what we say and there are ways to make it as safe as possible. Establishing an open and non-judgmental dialogue with caregivers can allow for honest disclosure and an ability to help reduce risk without endorsing practices that aren’t in line with AAP guidelines.