In their analysis of national and state trends in US sudden unexpected infant death (SUID) rates in this month’s issue of Pediatrics, Erck Lambert et al1 demonstrate that declines in SUID rates have plateaued for the past 2 decades. The state-by-state data in which large disparities in SUID rates are shown should both raise alarm in the 22 states where rates are increasing and bring light to prevention efforts in the 9 states with the largest declines.

Widespread education about safe sleep environments (eg, the Back to Sleep campaign) was associated with large decreases in SUID rates between 1990 and 2002. However, the effectiveness of such campaigns may have peaked as they have encountered cultural barriers, Internet misinformation, and countercampaigns. In light of this, how should we, as health care and public health professionals, proceed?

First, we should recognize that among developed countries, the United States has the highest SUID rate. In a recent international comparison, researchers found that among 8 developed countries, the United States had the highest mean 2002–2010 postneonatal mortality rates (of which SUID comprises the majority) at 2.25 per 1000 live births, ∼70% higher than the other countries; only New Zealand, at 2.14 per 1000 live births, came close.2 To understand these differences, we must begin to look at variations in national policies. Of these countries, the United States is the only one that does not provide universal health care,3 home visitors in the neonatal period,4 and universal paid maternity leave.5 All of these are important protective factors for infant mortality.6,8 Additionally, these policies may have positive downstream effects on parental practices. The education received during prenatal care and by home visitors establishes a social norm for safe sleep. Parents are continually encouraged (and assisted in their efforts) by home visitors to breastfeed and to place the infant supine. Many healthy infant care practices (eg, breastfeeding, supine sleep position, safe infant sleep location) cease when the mother returns to work because of poor work support, new caregivers,9,10 or the need for increased parental sleep.11,14 In the United States, most mothers must return to work when the infant is 1 to 4 months of age, which coincides with the highest risk period for SUID.15 

It is unlikely that, in the current political climate, universal changes in health care, home visitor programs, and parental leave policies on the national scale will occur. Thus, we should look at changes that we can make locally. Although Erck Lambert et al1 point out that it may be difficult to discern what changes may have been responsible for the state-by-state variability in SUID trends, and although most areas have not committed funding to conduct rigorous trials, there may still be lessons that can be applied to further prevent SUIDs in this country.

Surveying parental practices and turning to evidence-based strategies are important places to begin. For instance, maternal smoking has been found in >50 studies to increase SUID risk.16 The 5 states with the highest and rising SUID rates in Erck Lambert et al’s1 study have tobacco use rates in the top 2 quintiles (>18.6%),17 whereas only 1 of the 9 states with the most dramatic falls in SUID rates had similarly high tobacco use rates.17 Researchers in several studies have looked at financial incentives as a way to encourage smoking cessation,18 including in a randomized controlled trial in Scotland, where 24% of pregnant women reported being a smoker. In this trial, in addition to providing stop-smoking support services, pregnant women were provided a financial incentive of up to 400 British pounds (∼$530) throughout their pregnancy to remain smoke free. Women receiving incentives had almost 4 times higher odds (adjusted odds ratio 3.88, 95% confidence interval 2.10–7.16) of remaining smoke free throughout pregnancy.19 Health districts in New Zealand and Scotland are funding financial incentives to help smokers quit (E.A. Mitchell, DCH, DSc (Med) and D. Tappin MBBS, MD, MSc, personal communication). Given estimates that one-third of sudden infant death syndrome deaths could be prevented if all maternal smoking during pregnancy was eliminated,16,20 implementation of similar programs could help significantly lower SUID rates.

As Erck Lambert et al1 noted, the opioid crisis in the United States may also be a new and yet poorly defined variable in the SUID environment. In one prospective cohort study, researchers found that infants exposed to methadone, heroin, or methadone and heroin had 3.6-, 2.3-, and 3.2-fold increases in SUID, respectively.21 Researchers in another study found a 15-fold increased sudden infant death syndrome rate for opiate-exposed infants.22 It remains unclear if the risk to infants is from the exposure itself, disparate infant care practices, or the increased risk that an impaired caregiver poses. As more infants are born to mothers actively using opiates, it is important for us to further examine these risks so they can be targeted in risk reduction.

In additional to substance and cigarette use, regional comparisons are important because there is still much work to be done with regard to improving sleep practices. US nonsupine sleep position rates are ∼25%,14,23 whereas rates in other developed countries have consistently been <5%.24,30 US bed-sharing rates continue to increase,13 and rates of soft bedding use are consistently at 50%.31 Qualitative studies have revealed that parents make their infant care decisions largely on the basis of what they perceive will keep their infant both safe and comfortable.32,34 Thus, they place infants prone because they believe that supine positioning will increase the risk of aspiration or because the infant will sleep longer.32 They bed-share because they believe that this is the best way to monitor their infant while they are asleep and thus the best way to keep their infant safe.33 They use soft bedding because they believe that the infant will be more comfortable or because they are concerned about the infant becoming injured against the hard, uncushioned crib sides.34 For behavior change to occur, health care and public health professionals will need to understand and address parental concerns about safety and comfort.

It will also be critical for us to change the way that we communicate with parents and family members. Given widespread access to the Internet, where there is a false equivalency between evidence-based recommendations and unsubstantiated statements about the safety of not following safe sleep recommendations, health care and public health professionals must be smarter with health messaging. We need to learn to communicate with parents using tools and applications that they already turn to on their mobile phones. One randomized controlled trial revealed that mobile messaging using text messages or e-mails with embedded videos was effective at improving safe sleep practices.35 However, we also need to understand what types of messages work, and this will require partnering with experts in advertising and technology. We need to better use search engine algorithms so that we can increase the likelihood that when parents search “should my baby sleep on the stomach?” they will land on a Web site that provides evidence-based information.

As we approach the Healthy People 2020 goals, it is important for us to take stock and examine both our successes and failures. Although the SUID rate has continued to slowly trend downward nationally, ∼3700 infants still die annually, and in many regions of the country the rate continues to rise. However, there are also regions that have had significant successes in decreasing their SUID rates. In the absence of a dramatic change in our health care delivery system that would enable more emphasis on public safety and prevention to improve infant mortality rates, we must commit to learning from local successes and applying them more broadly.

     
  • SUID

    sudden unexpected infant death

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-3519.

1
Erck Lambert
AB
,
Parks
SE
,
Shapiro-Mendoza
CA
.
National and state trends in sudden unexpected infant death: 1990–2015.
Pediatrics
.
2018
;
141
(
3
):
e20173519
2
Taylor
BJ
,
Garstang
J
,
Engelberts
A
, et al
.
International comparison of sudden unexpected death in infancy rates using a newly proposed set of cause-of-death codes.
Arch Dis Child
.
2015
;
100
(
11
):
1018
1023
[PubMed]
3
Roy
A
. Conservative think tank: 10 countries with universal healthcare have freer economies than the U.S. 2015. Available at: https://www.forbes.com/sites/theapothecary/2015/01/27/conservative-think-tank-10-countries-with-universal-health-care-are-economically-freer-than-the-u-s/#7b5dec45137e. Accessed December 8, 2017
4
Council on Community Pediatrics
.
The role of preschool home-visiting programs in improving children’s developmental and health outcomes.
Pediatrics
.
2009
;
123
(
2
):
598
603
[PubMed]
5
Livingston
G
. Among 41 nations, U.S. is the outlier when it comes to paid parental leave. 2016. Available at: www.pewresearch.org/fact-tank/2016/09/26/u-s-lacks-mandated-paid-parental-leave/. Accessed November 28, 2017
6
Donovan
EF
,
Ammerman
RT
,
Besl
J
, et al
.
Intensive home visiting is associated with decreased risk of infant death.
Pediatrics
.
2007
;
119
(
6
):
1145
1151
[PubMed]
7
Poma
PA
.
Effect of prenatal care on infant mortality rates according to birth-death certificate files.
J Natl Med Assoc
.
1999
;
91
(
9
):
515
520
[PubMed]
8
Nandi
A
,
Hajizadeh
M
,
Harper
S
,
Koski
A
,
Strumpf
EC
,
Heymann
J
.
Increased duration of paid maternity leave lowers infant mortality in low- and middle-income countries: a quasi-experimental study.
PLoS Med
.
2016
;
13
(
3
):
e1001985
[PubMed]
9
Moon
RY
,
Patel
KM
,
Shaefer
SJ
.
Sudden infant death syndrome in child care settings.
Pediatrics
.
2000
;
106
(
2, pt 1
):
295
300
[PubMed]
10
Moon
RY
,
Sprague
BM
,
Patel
KM
.
Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001.
Pediatrics
.
2005
;
116
(
4
):
972
977
[PubMed]
11
Ahluwalia
IB
,
Morrow
B
,
Hsia
J
.
Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System.
Pediatrics
.
2005
;
116
(
6
):
1408
1412
[PubMed]
12
Baker
M
,
Milligan
K
.
Maternal employment, breastfeeding, and health: evidence from maternity leave mandates.
J Health Econ
.
2008
;
27
(
4
):
871
887
[PubMed]
13
Colson
ER
,
Willinger
M
,
Rybin
D
, et al
.
Trends and factors associated with infant bed sharing, 1993-2010: the National Infant Sleep Position Study.
JAMA Pediatr
.
2013
;
167
(
11
):
1032
1037
[PubMed]
14
Colson
ER
,
Rybin
D
,
Smith
LA
,
Colton
T
,
Lister
G
,
Corwin
MJ
.
Trends and factors associated with infant sleeping position: the national infant sleep position study, 1993-2007.
Arch Pediatr Adolesc Med
.
2009
;
163
(
12
):
1122
1128
[PubMed]
15
Shapiro-Mendoza
CK
,
Tomashek
KM
,
Anderson
RN
,
Wingo
J
.
Recent national trends in sudden, unexpected infant deaths: more evidence supporting a change in classification or reporting.
Am J Epidemiol
.
2006
;
163
(
8
):
762
769
[PubMed]
16
Mitchell
EA
,
Milerad
J
.
Smoking and the sudden infant death syndrome.
Rev Environ Health
.
2006
;
21
(
2
):
81
103
[PubMed]
17
Centers for Disease Control and Prevention
. Current cigarette use among adults (Behavior Risk Factor Surveillance System) 2016. Available at: https://www.cdc.gov/statesystem/cigaretteuseadult.html. Accessed December 6, 2017
18
Cahill
K
,
Hartmann-Boyce
J
,
Perera
R
.
Incentives for smoking cessation.
Cochrane Database Syst Rev
.
2015
;(
5
):
CD004307
[PubMed]
19
Tappin
D
,
Bauld
L
,
Purves
D
, et al;
Cessation in Pregnancy Incentives Trial Team
.
Financial incentives for smoking cessation in pregnancy: randomised controlled trial.
BMJ
.
2015
;
350
:
h134
[PubMed]
20
Dietz
PM
,
England
LJ
,
Shapiro-Mendoza
CK
,
Tong
VT
,
Farr
SL
,
Callaghan
WM
.
Infant morbidity and mortality attributable to prenatal smoking in the U.S.
Am J Prev Med
.
2010
;
39
(
1
):
45
52
[PubMed]
21
Kandall
SR
,
Gaines
J
,
Habel
L
,
Davidson
G
,
Jessop
D
.
Relationship of maternal substance abuse to subsequent sudden infant death syndrome in offspring.
J Pediatr
.
1993
;
123
(
1
):
120
126
[PubMed]
22
Ward
SL
,
Bautista
D
,
Chan
L
, et al
.
Sudden infant death syndrome in infants of substance-abusing mothers.
J Pediatr
.
1990
;
117
(
6
):
876
881
[PubMed]
23
Colson
ER
,
Geller
NL
,
Heeren
T
,
Corwin
MJ
.
Factors associated with choice of infant sleep position.
Pediatrics
.
2017
;
140
(
3
):
e20170596
[PubMed]
24
Alm
B
,
Möllborg
P
,
Erdes
L
, et al
.
SIDS risk factors and factors associated with prone sleeping in Sweden.
Arch Dis Child
.
2006
;
91
(
11
):
915
919
[PubMed]
25
Ball
HL
,
Moya
E
,
Fairley
L
,
Westman
J
,
Oddie
S
,
Wright
J
.
Infant care practices related to sudden infant death syndrome in South Asian and White British families in the UK.
Paediatr Perinat Epidemiol
.
2012
;
26
(
1
):
3
12
[PubMed]
26
van Sleuwen
BE
,
L’Hoir
MP
,
Engelberts
AC
,
Westers
P
,
Schulpen
TW
.
Infant care practices related to cot death in Turkish and Moroccan families in the Netherlands.
Arch Dis Child
.
2003
;
88
(
9
):
784
788
[PubMed]
27
Hutchison
BL
,
Thompson
JM
,
Mitchell
EA
.
Infant care practices related to sudden unexpected death in infancy: a 2013 survey.
N Z Med J
.
2015
;
128
(
1408
):
15
22
[PubMed]
28
Vennemann
MM
,
Findeisen
M
,
Butterfass-Bahloul
T
, et al;
GeSID Group
.
Modifiable risk factors for SIDS in Germany: results of GeSID.
Acta Paediatr
.
2005
;
94
(
6
):
655
660
[PubMed]
29
Hirabayashi
M
,
Yoshinaga
M
,
Nomura
Y
, et al
.
Environmental risk factors for sudden infant death syndrome in Japan.
Eur J Pediatr
.
2016
;
175
(
12
):
1921
1926
[PubMed]
30
Nelson
EAS
,
Taylor
BJ
.
International Child Care Practices Study: infant sleep position and parental smoking.
Early Hum Dev
.
2001
;
64
(
1
):
7
20
[PubMed]
31
Shapiro-Mendoza
CK
,
Colson
ER
,
Willinger
M
,
Rybin
DV
,
Camperlengo
L
,
Corwin
MJ
.
Trends in infant bedding use: National Infant Sleep Position study, 1993-2010.
Pediatrics
.
2015
;
135
(
1
):
10
17
[PubMed]
32
Oden
RP
,
Joyner
BL
,
Ajao
TI
,
Moon
RY
.
Factors influencing African American mothers’ decisions about sleep position: a qualitative study.
J Natl Med Assoc
.
2010
;
102
(
10
):
870
872, 875–880
[PubMed]
33
Joyner
BL
,
Oden
RP
,
Ajao
TI
,
Moon
RY
.
Where should my baby sleep: a qualitative study of African American infant sleep location decisions.
J Natl Med Assoc
.
2010
;
102
(
10
):
881
889
[PubMed]
34
Ajao
TI
,
Oden
RP
,
Joyner
BL
,
Moon
RY
.
Decisions of black parents about infant bedding and sleep surfaces: a qualitative study.
Pediatrics
.
2011
;
128
(
3
):
494
502
[PubMed]
35
Moon
RY
,
Hauck
FR
,
Colson
ER
, et al
.
The effect of nursing quality improvement and mobile health interventions on infant sleep practices: a randomized clinical trial.
JAMA
.
2017
;
318
(
4
):
351
359
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.