In an article and accompanying video abstract being early released this week in Pediatrics, Dr. Stephanie Anne Deutsch and colleagues from Nemours Children’s Health aimed to examine and compare characteristics of sleep-related sudden unexplained infant death (SUID) among infants born with prenatal substance exposure (PSE) versus those who were not exposed, in order to identify targeted opportunities for SUID prevention among infants with PSE. (10.1542/peds.2024-067372)
Literature cited by the authors strongly suggests that PSE is a unique risk factor for SUID, either directly through caregiver impairment leading to poor sleep space choices or indirectly in association with numerous social drivers of health and family vulnerabilities.
In this study, the authors used the National Sudden Death in the Young Registry and included infant deaths in 2015–2020 that were described as “related to sleeping or the sleep environment.” They then dichotomized the deaths by response to the question “Was the infant/fetus delivered drug exposed?” to compare exposed versus non-exposed infants. Multiple infant and maternal demographic and social factors were compared.
In brief, of the total 2010 infants, about half (1045, 52%) of deaths involved sharing a bed, and 283 infants (14% of this cohort) had PSE. “Supervisors” (the responsible caregivers) were more likely to be impaired among exposed versus non-exposed infants (n=97, 34% and n=279, 16%, respectively), and in fact, one quarter (70, 25%) of deaths of infants with PSE involved both an impaired supervisor and bedsharing. Statistically significant associations between PSE and social drivers of poor health and social vulnerability (intimate partner violence, infant maltreatment, and out of home placement) were identified.
The insightful commentary (10.1542/peds.2024-068360) by Drs. Davida Schiff, Barbara Chaiyachati, and Margaret Parker thoughtfully addresses the challenges and nuances of the research described, which include:
- SUID is uncommon (93/100,000 births),
- The literature regarding modifiable preventive factors is sparse, and
- Without a non-SUID control group it is difficult to know if PSE is an independent risk factor for SUID.
Additionally:
- The variable of most interest regarding PSE “lumps” medicinal and recreational substances into a single item, so attribution of specific effects or understanding of biological mechanisms is not possible.
- Nicotine exposure confounds the analysis, since mothers of infants with, as compared to without, PSE are significantly more likely to smoke cigarettes.
- Missing data (both infants not registered as well as missing information for those included) in the registry is a meaningful limitation.
But despite these challenges, Drs. Schiff, Chaiyachati, and Parker laud the work of Drs. Deutsch and colleagues, which contributes not just to a body of evolving research on this important topic, but to a supportive, non-punitive and person-centered approach to SUID risk reduction for mothers of infants with PSE.
Until more robust upstream approaches emerge, we can begin this work, in collaboration with our obstetrical colleagues, public health nurses, and community health workers, by providing brief, targeted, and nonjudgmental messaging about safe sleep for expectant and delivered parents with substance use disorder.
