Increasing Disparities in Sudden Unexpected Infant Deaths Reflect Societal Failures

The coronavirus disease 2019 (COVID-19) pandemic and the subsequent preventive measures (physical distancing, mask use, and staying at home) have been associated with changes in the rates of many health outcomes. Some of these, such as a steep decline in viral illnesses,¹  are not surprising. Others, such as an increase in fatal motor vehicle accidents,²  may be more unanticipated, as a complicated interaction of factors and root causes may be at play.

In their analysis comparing sudden infant death syndrome (SIDS) and sudden unexpected infant death (SUID) rates before and during the COVID-19 pandemic, Shapiro-Mendoza and colleagues from the US Centers for Disease Control and Prevention noted that, although overall US infant mortality continued its steady decline through 2020, the overall rate of SUID (which includes SIDS, accidental suffocation and strangulation in bed, and ill-defined cause of death) did not; it remained unchanged from 2015 to 2020.³  Additionally, in 2020 there was a rise in SIDS rates and an increase in the SUID rate for those who identified as being non-Hispanic Black.

We agree with the authors that, given that the overall SUID rate over this same period is stable, the variations in SIDS rates likely reflect shifting diagnostic criteria rather than a true rise. However, these diagnostic shifts highlight the need for increased uniformity in SUID investigations and cause of death certification. Without standardization of certification of deaths, it becomes almost impossible to track true trends in the subcategories of SUID, which in turn limits our ability to better understand the pathophysiology of these deaths and to develop targeted educational interventions.

More concerning from these data are the overall rise in SUID deaths between 2019 and 2020 among infants born to non-Hispanic Black families. As the authors note, this rise further increases the already existing disparities in these deaths, with the rate among infants born to non-Hispanic Black families now 2.3-fold higher than the general population and 2.8-fold higher than infants born to non-Hispanic white families. Although there were also disparities in COVID-19 infection rates,⁴  since few SUIDs were associated with a COVID-19 diagnosis, infection with the virus per se does not explain the increased rate. Rather, these disparities are likely multifactorial, reflecting poverty levels, lack of access to prenatal and well-child care, and education regarding safe sleep and other practices, including the feeding of human milk, which can reduce the risk of SUID, and social norms related to these practices that vary between communities. Although small-scale intervention studies to provide education to new parents have shown promise in their ability to decrease these disparities,⁵  as with most inequities, to make a truly large difference in the rates of sleep-related deaths, as a society we need to address the underlying causes. Although Shapiro-Mendoza’s paper does not stratify data by socioeconomic characteristics, non-Hispanic Black Americans are more than twice as likely as non-Hispanic white Americans to live in poverty,⁶  and among families with children, homelessness is 50% more likely among those who identify as non-Hispanic Black.⁷  Our societal failures to address these issues not only result in limited access to health care and education, but also in many families not having a stable, safe place for their infants to sleep.

In contrast to many middle- and high-income countries, the United States lacks large-scale support for families, including but not limited to lactation assistance to increase human milk feeding rates, home visiting programs to support families in their home and help identify and address unsafe sleep conditions, and support for maternal mental health, particularly in the postpartum period. Our lack of guaranteed paid family leave means that parents may be forced to stop human milk feeding before they would like, parents are more desperate for nighttime sleep and thus, may turn to less safe sleep practices, and infants are often cared for by a variety of caregivers, not all of whom are adequately educated on safe sleep practices. Additionally, during the pandemic, many of the limited resources available to families, such as physician offices, Special Supplemental Nutrition Program for Women Infants and Children, home visiting programs, and mental health organizations stopped or drastically curtailed in-person visits. This may have decreased the quality and quantity of support and eliminated in-person modeling of best practices for these families. All of these factors potentially contributed to the increased rate of SUID seen in 2020 for non-Hispanic Black infants.

These latest data about the SUID rates during the first year of the COVID-19 pandemic reflect our societal failures. The United States has one of the highest SUID rates for all middle- and high-income countries that track these deaths,⁸  and the findings regarding increasing disparities sound the alarm about the need for interventions that look beyond individual counseling and toward community- and society-level solutions. All infants deserve a better start in life than we in the United States are providing to them now.