The Pediatrician’s Role in Eliminating Racial and Ethnic Disparities in Sleep-Related Infant Deaths

The infant mortality rate in the United States ranks 33rd among countries belonging to the Organization for Economic Cooperation and Development,¹  and there are persistent racial and ethnic disparities, with non-Hispanic black infants dying at a rate 2 to 3 times that of non-Hispanic white infants.²  In this issue of Pediatrics, Hirai et al³  provide insight into racial and ethnic differences in infant sleep practices that have important implications for racial and ethnic disparities for sleep-related infant deaths, including sudden infant death syndrome and accidental suffocation and strangulation in bed, which are the third leading cause of infant mortality in the United States.

Hirai et al³  leveraged recently added questions to the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System (PRAMS) to examine differences in sleep position, items in the sleep environment, bed-sharing, and room-sharing by race and ethnicity. Forty-seven states currently partner with the Centers for Disease Control and Prevention to administer the PRAMS survey to a randomly selected subpopulation of women in their state who have recently delivered. PRAMS previously only included questions on the infant’s sleep position. States began to include questions about bed-sharing and items in the sleep environment in 2009. In 2016, those questions, along with additional survey items about room-sharing and safe sleep anticipatory guidance from health care providers, were included for all participating states. This allowed the authors to more comprehensively examine the sleep environment of a representative population of infants from a majority of states.

They found a mixture of good and bad news. First, the bad news: one-third of non-Hispanic black infants were not usually placed on their back to sleep; 75% were not solely placed to sleep in a crib, bassinet, or portable crib; and two-thirds had soft objects in the sleep environment. The authors also found that many mothers reported that they never received the full range of safe sleep anticipatory guidance from their health care provider. Approximately 15% of mothers reported never being told to place their infant in a crib, bassinet, or portable crib to sleep and remove all soft objects from the sleep environment; fewer than 50% were advised to room share without bed-sharing. Even if this anticipatory guidance was given but not remembered by the mothers, these numbers should certainly alert our profession to the need to repeatedly discuss safe sleep. Because there are multiple opportunities to discuss safe sleep in the newborn nursery and at the frequent well-child visits and weight checks in early infancy, this is one area in which we can make a difference in infant mortality.

The authors also had good news. They found that parents listen to their health care providers’ advice on safe sleep for their infant. Consistent with previous, smaller studies,^4–7  mothers who received safe sleep anticipatory guidance from their health care provider were 10% to 30% more likely to place their infant on their back for sleep; place their infant in a crib, bassinet, or portable playpen; room share without bed-sharing; and have no soft objects in the sleep environment. This makes the provision of repeated safe sleep anticipatory guidance all the more important. The most effective guidance will also likely specifically address the primary drivers of parent behavior: perceptions of infant comfort and safety, the mistaken belief that their infant is not at risk, and misplaced confidence in parental vigilance to prevent a sleep-related death.^4,5,8–12  Unfortunately, when parents receive inconsistent advice from health care providers, they are more likely to disregard the guidance of all health care providers, instead relying on the advice of friends and family.^7,11  This is particularly important because sleep-deprived parents may make decisions about infant sleep position, location, and bedding simply on the basis of their desire for the infant to sleep longer.^4,5,8–12  Thus, consistent, evidence-based infant sleep recommendations from all health care providers will be important in eliminating disparities in sleep practices and sleep-related infant mortality.

However, although evidence-based guidance on infant safe sleep from health care providers is essential in eliminating these disparities, it likely will not be sufficient. In previous research, it has been found that the influence of family and friends and the overall weight of social norms are incredibly important.^7,13,14  To overcome those influences, repeated, consistent messaging after the infant leaves the hospital and clinic will be needed.¹⁵  Furthermore, racial and ethnic health disparities cannot be separated from socioeconomic health disparities in infant mortality. This will require the voices of pediatricians outside of the examination room, as well. The advocacy of pediatricians is essential to advance policies, such as paid parental leave and home visiting programs, to support families with infants so that parents and other child care providers get the support, respite, and consistent health messaging needed to eliminate racial and ethnic disparities in infant sleep-related deaths in the United States.

PRAMS

Pregnancy Risk Assessment Monitoring System