Vital Signs

Trends and Disparities in Infant Safe Sleep Practices — United States, 2009–2015

Jennifer M. Bombard, MSPH; Katherine Kortsmit, PhD; Lee Warner, PhD; Carrie K. Shapiro-Mendoza, PhD; Shanna Cox, MSPH; Charlan D. Kroelinger, PhD; Sharyn E. Parks, PhD; Deborah L. Dee, PhD; Denise V. D'Angelo, MPH; Ruben A. Smith, PhD; Kim Burley; Brian Morrow, MA; Christine K. Olson, MD; Holly B. Shulman, MA; Leslie Harrison, MPH; Carri Cottengim, MA; Wanda D. Barfield, MD

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(1):39-46. 

In This Article

Abstract and Introduction

Abstract

Introduction: There have been dramatic improvements in reducing infant sleep-related deaths since the 1990s, when recommendations were introduced to place infants on their backs for sleep. However, there are still approximately 3,500 sleep-related deaths among infants each year in the United States, including those from sudden infant death syndrome, accidental suffocation and strangulation in bed, and unknown causes. Unsafe sleep practices, including placing infants in a nonsupine (on side or on stomach) sleep position, bed sharing, and using soft bedding in the sleep environment (e.g., blankets, pillows, and soft objects) are modifiable risk factors for sleep-related infant deaths.

Methods: CDC analyzed 2009–2015 Pregnancy Risk Assessment Monitoring System (PRAMS) data to describe infant sleep practices. PRAMS, a state-specific and population-based surveillance system, monitors self-reported behaviors and experiences before, during, and shortly after pregnancy among women with a recent live birth. CDC examined 2015 data on nonsupine sleep positioning, bed sharing, and soft bedding use by state and selected maternal characteristics, as well as linear trends in nonsupine sleep positioning from 2009 to 2015.

Results: In 2015, 21.6% of respondents from 32 states and New York City reported placing their infant in a nonsupine sleep position; this proportion ranged from 12.2% in Wisconsin to 33.8% in Louisiana. Infant nonsupine sleep positioning was highest among respondents who were non-Hispanic blacks. Nonsupine sleep positioning prevalence was higher among respondents aged <25 years compared with ≥25 years, those who had completed ≤12 years compared with >12 years of education, and those who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children during pregnancy. Based on trend data from 15 states, placement of infants in a nonsupine sleep position decreased significantly from 27.2% in 2009 to 19.4% in 2015. In 2015, over half of respondents (61.4%) from 14 states reported bed sharing with their infant, and 38.5% from 13 states and New York City reported using any soft bedding, most commonly bumper pads and thick blankets.

Conclusions and Implications for Public Health Practice: Improved implementation of the safe sleep practices recommended by the American Academy of Pediatrics could help reduce sleep-related infant mortality. Evidence-based interventions could increase use of safe sleep practices, particularly within populations whose infants might be at higher risk for sleep-related deaths.

Introduction

Approximately 3,500 sleep-related deaths among infants are reported each year in the United States, including those from sudden infant death syndrome (SIDS), accidental suffocation and strangulation in bed, and unknown causes.[1] Significant sociodemographic and geographic disparities in sleep-related infant deaths exist.[2,3] To reduce risk factors for sleep-related infant mortality, recommendations from the American Academy of Pediatrics (AAP) for safe sleep include 1) placing the infant in the supine sleep position (placing the infant on his or her back) on a firm sleep surface such as a mattress in a safety-approved crib or bassinet, 2) having infant and caregivers share a room, but not the same sleeping surface, and 3) avoiding the use of soft bedding (e.g., blankets, pillows, and soft objects) in the infant sleep environment.[4] Additional recommendations to reduce the risk for sleep-related infant deaths include breastfeeding, providing routinely recommended immunizations, and avoiding prenatal and postnatal exposure to tobacco smoke, alcohol, and illicit drugs.[4]

Although the individual effect of each recommendation on sleep-related infant mortality is unclear, sharp declines in SIDS and other sleep-related mortality in the 1990s have been attributed to an increase in safe sleep practices such as supine sleep. However, since the late 1990s declines in infant sleep-related deaths[4] and nonsupine sleep positioning (on side or stomach)[5] have been less pronounced. The rate of infant sleep-related deaths declined from 154.6 deaths per 100,000 live births in 1990 to 93.9 per 100,000 live births in 1999; in 2015, the rate of infant sleep-related deaths was 92.6 deaths per 100,000 live births.[6] Previous research indicates implementation of safe sleep recommendations by infant caregivers remains suboptimal. In the Study of Attitudes and Factors Effecting Infant Care, which interviewed mothers 2–6 months postpartum during 2011–2014, 22% said they had placed their infant in a nonsupine sleep position,[7] and 21% shared a bed with their infant at least once during the 2 weeks before being interviewed.[8] In addition, in the National Infant Sleep Position Study, a household telephone survey that sampled nighttime caregivers during 2007–2010, more than half (54%) placed their infant to sleep with soft bedding during the 2 weeks before the interview.[9]

CDC used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to examine the prevalence of unsafe infant sleep practices. Ongoing surveillance efforts can identify populations at risk for unsafe sleep practices and help evaluate policies and programs to improve safe sleep practices. Health care providers and state-based and community-based programs can identify barriers to safe sleep practices and provide culturally appropriate counseling and messaging to improve infant sleep practices.

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