March 1, 2018

CDC Finds That Infant Safe Sleep Practices Often Not Followed, Increasing Risk of Infant Death

Health Letter, March 2018

By Michael Carome, M.D.

For parents, the death of a child is a devastating tragedy — particularly when a healthy baby suddenly dies while sleeping in what is presumed to be the safe environment of a crib. Approximately 3,500 infants die each year in the U.S. from sleep-related events, including sudden infant death syndrome (SIDS) and accidental suffocation and strangulation in bed.[1]

A Centers for Disease Control and Prevention (CDC) study published in January in the agency’s journal, Morbidity and Mortality Weekly Reports, revealed that a significant proportion of infant caregivers fail to follow recommended infant safe sleep practices, even though such failures increase the risk of SIDS and accidental suffocation and strangulation in bed.[2] The CDC’s findings signal the ongoing need for more aggressive and more effective education to teach parents how to keep their infants safe during sleep.

Reducing the risk of sleep-related infant deaths

In the early-to-mid-1990s, the incidence of SIDS in the U.S. declined sharply.[3] This decline coincided with two events. First, in 1992, the American Academy of Pediatrics (AAP) formally recommended that healthy infants be placed for sleep on their backs or sides, rather than in the prone position (lying on stomach), in order to prevent SIDS.[4] Then, in 1994, the National Institute of Child Health and Human Development (now the Eunice Kennedy Shriver National Institute of Child Health and Human Development), in conjunction with the AAP and other organizations, initiated the “Back to Sleep” campaign, which urged parents to place infants on their backs (supine position) for sleep.[5]

The AAP updated its recommendation on infant sleeping positions in 1996 and indicated that placing infants wholly on their back presents the lowest risk of SIDS and is the preferred sleep position, although placement on the side also significantly lowers the risk.[6]

The AAP also recommended in 1996, and again in 2000 with greater detail, that soft surfaces and objects, such as pillows or quilts, not be placed in an infant’s sleeping environment.[7] Soft objects and loose bedding can obstruct the infant airway and pose a risk of suffocation or strangulation.

The AAP further cautioned in 2000 that bed-sharing or co-sleeping may be hazardous to infants.[8] In 2016, the group recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface (see the text box below for additional 2016 updated recommendations from the AAP for a safe infant sleeping environment).[9]

The American Academy of Pediatrics’ 2016 Updated Recommendations for a Safe Infant Sleeping Environment

The American Academy of Pediatrics recommends the following infant sleep practices, among others things, to reduce the risk of SIDS and sleep-related suffocation, asphyxia and entrapment among infants in the general population: To reduce the risk of SIDS, infants should be placed for sleep in the supine position (wholly on the back) for every sleep period by every caregiver until 1 year of age. Side sleeping is not safe and is not advised. The supine sleep position does not increase the risk of choking or aspiration in infants, even in those with gastroesophageal reflux. Once an infant can roll from supine to prone (lying on stomach) and from prone to supine, the infant may remain in the sleep position that he or she assumes. Infants should be placed on a firm sleep surface (for example, a mattress in a safety-approved crib) covered by a fitted sheet with no other bedding or soft objects to reduce the risk of SIDS and suffocation. A crib, bassinet, portable crib or play yard that conforms to the safety standards of the Consumer Product Safety Commission is recommended. Sitting devices, such as car seats, strollers, swings, infant carriers and infant slings, are not recommended for routine sleep in the hospital or at home, particularly for young infants. Infants should sleep in the parents’ room, close to the parents’ bed, but on a separate surface. The infant’s crib, portable crib, play yard or bassinet should be placed in the parents’ bedroom, ideally for the first year of life, but at least for the first 6 months. Infants who are brought into the bed for feeding or comforting should be returned to their own crib or bassinet when the parent is ready to go back to sleep. Couches and armchairs are extremely dangerous places for infants. Keep soft objects, such as pillows, pillow-like toys, quilts, comforters, sheepskins and loose bedding — such as blankets and nonfitted sheets — away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment and strangulation. Bumper pads are not recommended; they have been implicated in deaths attributable to suffocation, entrapment and strangulation and, with new safety standards for crib slats, are not necessary for safety against head entrapment.

The CDC study [10]

CDC researchers analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to determine the prevalence of unsafe infant sleep practices. PRAMS, which was developed in 1987, is a surveillance project conducted by the CDC and state health departments that involves collecting information about maternal attitudes and experiences before, during and shortly after pregnancy.[11] States participating in the project each year ask a random sample of women who recently gave birth to complete a standardized questionnaire two to six months after delivery.

One key question in the PRAMS questionnaire is:

In which position do you most often lay your baby down to sleep now? (check one answer): on side; on back; on stomach.

Mothers who selected “on side” or “on stomach” were classified as placing their infant in the nonsupine sleep position. In 2015, data from 32 states and New York City revealed an overall prevalence of nonsupine infant sleep position of 22 percent. The prevalence by state ranged from 12 percent in Wisconsin to 34 percent in Louisiana. The researchers also analyzed questionnaire data from 15 states from 2009 to 2015 and found that over this time span, the rate of nonsupine infant sleep position decreased significantly from 27 percent to 19 percent.

The CDC researchers also analyzed responses to optional questions included in the 2015 PRAMS questionnaire regarding how often the mother’s new baby sleeps in the same bed with the mother or anyone else and whether the new baby sleeps with any of the following soft bedding items: pillows, thick or plush blankets, bumper pads, stuffed toys and infant positioners. They found that in 2015, more than 60 percent of mothers from 14 states reported any bed sharing with their infant, with 37 percent reporting “rarely or sometimes” and 24 percent responding “often or always” bed sharing. Furthermore, 39 percent of mothers from 13 states and New York City reported using at least one type of soft bedding for their infants.

This important CDC study demonstrates that mothers of infants commonly do not adhere to the long-standing AAP recommendations for safe sleeping practices for their infants. The takeaway message from this study is clear: Health care professionals and public health agencies need to redouble their efforts to educate parents and other caregivers regarding the AAP’s recommendations for keeping infants safe when they sleep.

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References

[1] Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics 2016;138(5):e20162940.

[2] Bombard JM, Kortsmit K, Warner L, et al. Vital signs: Trends and disparities in infant safe sleep practices — United States, 2009–2015. MMWR. 2018 January 9;67(early release):1-7.

[3] Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics 2016;138(5):e20162940.

[4] American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89(6):1120-1126.

[5] Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics 2016;138(5):e20162940.

[6] American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and sudden infant death syndrome (SIDS): Update. Pediatrics. 1996;98(6):1216-1218.

[7] American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650-656.

[8] American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics. 2000;105(3):650-656.

[9] Moon RY. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics 2016;138(5):e20162940.

[10] Bombard JM, Kortsmit K, Warner L, et al. Vital signs: Trends and disparities in infant safe sleep practices — United States, 2009–2015. MMWR. 2018 January 9;67(early release):1-7. [

[11] Centers for Disease Control and Prevention. What is PRAMS? August 30, 2017. https://www.cdc.gov/prams/index.htm. Accessed January 19, 2018.