5 Safe Sleep, Sound Futures: Breaking the Silence on Sudden Infant Death Syndrome (SIDS)

This chapter is based on the Social Ecological Model.

Sudden infant death syndrome (SIDS) is the leading cause of death in infants aged 1-12 months, and the exact cause of SIDS is unknown (Baeis et al., 2015). Factors linked to SIDS are bed-sharing, maternal smoking during pregnancy, overheating, lack of prenatal care, premature birth, low birth weight, and male gender (Hymel, 2006). Populations at two to three times higher risk for SIDS are Native Americans, Alaska Natives, and Black Americans (Hymel, 2006). Studies have also found that there is a link between the socioeconomic and educational status of parents and the development of SIDS risk factors. (Baeis et al., 2015)

The first attempt to combat SIDS was the “Back to Sleep” campaign. Launched in 1992, advocates encouraged parents to put their infants on their backs to go to sleep. Since the campaign was launched, SIDS rates have dropped by almost 50% as of 2003, with 89.7 deaths per 100,000 live births (CDC, 2024). However, since then, rates have been climbing, and there are 100.90 deaths per 100,000 live births as of 2022 (CDC, 2024). Although the original Back to Sleep campaign was successful, health advocates can continue to promote other interventions to decrease the incidence of SIDs at all levels of the social ecological model.

The image on the left represents an infant in an unsafe sleeping position. He is prone (on the stomach) and surrounded by blankets and suffocation hazards. The image on the right shows a baby in a safe sleeping position, supine (on the back) with no fluffy blankets or suffocation hazards.

Individual

Maternal smoking is one of the largest modifiable risk factors for SIDS, as it accounts for approximately 34% of SIDS cases each year (Scherman et al., 2018). Smoking during and after pregnancy doubles the risk of SIDS for infants because of how it alters their heart and lung function (Markowitz, 2008).

Some parents are unaware of the effects of smoking and its correlation to SIDS. Teaching middle and high school students about the harms of smoking in pregnancy would assist in reducing the number of SIDS cases (Moon, 2011). Pregnant smokers are more likely to be low-income and have low levels of education, so introducing this education during school years would help target at-risk families while they are young (Scherman et al., 2018).

Another way to reduce maternal smoking rates would be to increase the amount of cessation smoking programs for pregnant women. Pregnancy may be an additional stressor for some women, especially if unplanned and if they are living in an already stressful environment. Women in these environments are 15% less likely to quit compared to those with planned pregnancies (Scherman et al., 2018). Therefore, advocates need to target and create accessible cessation programs for any smoker to reduce SIDS cases.

Relationship

Unfortunately, 17% of SIDS cases occur when the child is in the care of a relative (Chesser et al., 2019). Grandparents may be uneducated on the new guidelines, as the Safe Sleep Guidelines were not established until 1994 (Moon and Omron, 2002). Because of this, many grandparents feel reluctant to adhere to these new measures, as it often goes against what they were taught when raising their child.  A study found grandparents only placed the infant on their back 58% of the time (Chesser et al., 2019). Many parents report receiving advice on sleeping positions from their relatives and struggle to decide whether to trust their experienced parents or their healthcare providers (Hwang et al., 2020). This discrepancy in beliefs requires that new parents who follow healthcare advice need to educate their relatives about safe sleeping positions.

Community

Hospital Setting

Even though hospitals reach almost every parent across the nation after the birth of their infant, not all hospitals give parents access to safe sleep information. A study found that more than half of medical providers did not model safe sleep practices within the hospital setting (Miller et al., 2018).

However, Georgia hospitals have implemented a program titled “Georgia Safe to Sleep Hospital Initiative” that gives accurate safe sleep information to healthcare providers and guides hospitals to create a safe sleep policy (Miller et al., 2018). Program feedback has been extremely positive, as over 91.4% of hospitals have provided safe sleep training to staff, and 87.3% have a safe sleep policy in place compared to the 44.3% prior (Miller et al., 2018).

Adding a national program that models the Georgia initiative in all hospitals could reduce SIDS rates. If SIDS education is a mandatory practice, all parents would be informed, especially those who are unfamiliar with the guidelines. By having a captive audience at the hospital, at-risk populations will be instructed on the safe sleep information, which may not have been available due to a lack of educational opportunities.

Childcare Setting

Around 20% of SIDS cases occur in a childcare setting as providers are not always adhering to safe sleep practices (Moon, 2005). Some childcare providers place infants in a prone position because they are uneducated about safe sleep practices, have misconceptions about infant comfort, or follow the unsafe parental preference given to them (Moon et al., 2016b).

Currently, 43 states regulate infant sleep position, and 17 states require SIDS training at licensed childcare centers (Moon et al., 2016b). But, all of these regulations vary, and waivers can be given in order to override protocols (Moon et al., 2016b). To reduce the number of cases, tighter regulation is needed nationwide, as all 50 states should regulate sleeping positions and require SIDS training for licensed providers.

Community Setting

Black Americans are less likely to adhere to safe sleep practices compared to White Americans, which doubles the risk of SIDS event (Moon et al., 2016a). Studies have found that cultural beliefs of Black Americans play a large role in their attitudes towards safe sleep practices overall (Zoucha et al., 2015).

Black Americans are also more likely to follow the words of mothers or grandmothers in the local community on how to put their infant to sleep. Older generations have been found to believe that SIDS is random, associate cribs with “crib death”, and push for co-sleeping methods (Zoucha et al., 2015). Unfortunately, all of these practices increase the risk of SIDS. At-risk families may be more likely to follow this advice, especially if they lack access to education about SIDS from other sources.

In order to combat the lack of safe sleep practices within the Black community, the use of nurses to educate the community would be effective in reducing the rates of SIDS. In a study in the United States that explored cultural influences on safe sleep practices of Black Americans, participants expressed more interest in working with nurses as they trusted them as medical providers the most (Zoucha et al., 2015). Incorporating community educational opportunities with nurses could change the communities’ attitudes toward safe sleep practices (Zoucha et al., 2015).

Societal

Creating a safe sleeping environment is one of the most effective ways to prevent SIDS; however, at-risk families may struggle to be able to provide this for their children. Families whose living conditions require sharing of beds may have trouble following the guidelines of not sleeping with an infant. As a result, low-income mothers are 1.7 times more likely to bed share than high-income mothers (Covington et al., 2018). To combat this issue, the Georgia Department of Public Health began a program to educate low-income parents on safe sleep practices, and provide them with portable cribs (Salm Ward et al., 2018). Not only does this teach the importance of prioritizing safe sleep, but by providing them with portable cribs, it ensures that they are able to comply with the recommendations despite their economic status.

Statewide policies like the program mentioned above exist, but we still need to progress at the federal level. After the Boppy Newborn Lounger caused the deaths of eight infants in 2021, the U.S. Consumer Product Safety Commission (CPSC) issued a recall of these specific loungers (Khimm & Chuck, 2023). However, when CPSC members attempted to force manufacturers of other companies to redesign loungers similar to the Boppy Lounger, the plan was shut down by the head commissioners (Khimm & Chuck, 2023). Due to this lack of regulation, these questionable items are still on the market and advertised as safe, which could potentially lead to SIDS (Khimm & Chuck, 2023). If a parent is unaware of the recalls or safety concerns, they cannot protect their baby.

References

Baeis, M. G., Miladinia, M., Talayian, M., Vahedi, M., Vafayi, S., & Tashvighi, M. (2015). Prevalence and the relationship between characteristics and parental conditions with risk factors for sudden infant death syndrome (SIDS). International Journal of Pediatrics, 3(6), 1135–1143. https://doi.org/10.22038/ijp.2015.5933

Centers for Disease Control and Prevention. (2024). Trends in SUID rates by cause of death, 1990—2022. https://www.cdc.gov/sudden-infant-death/data-research/data/sids-deaths-by-cause.html

Chesser, A. K., Ahlers-Schmidt, C. R., & Schunn, C. (2019). Grandparent knowledge of infant safe sleep. Global Pediatric Health, 6. https://doi.org/10.1177/2333794×19852008

Covington, L. B., Armstrong, B., & Black, M. M. (2018). Perceived toddler sleep problems, co-sleeping, and maternal sleep and mental health.  Journal of Developmental & Behavioral Pediatrics, 39(3), 238–245. https://doi.org/10.1097/dbp.0000000000000535

Hwang, S. S., Parker, M. G., Colvin, B. N., Forbes, E. S., Brown, K., & Colson, E. R. (2020). Understanding the barriers and facilitators to safe infant sleep for mothers of preterm infants. Journal of Perinatology, 41(8), 1992–1999. https://doi.org/10.1038/s41372-020-00896-5

Hymel, K. P. (2006). Distinguishing sudden infant death syndrome from child abuse fatalities. American Academy of Pediatrics, 118(1). https://doi.org/https://doi.org/10.1542/peds.2006-1245

Khimm, S., & Chuck, E. (2023). Federal staff recommends first safety rules for infant rockers after deaths stretching over a decade. NBC News. https://www.nbcnews.com/news/us-news/infant-rockers-deaths-consumer-product-safety-commission-rcna103589

Markowitz, S. (2008). The effectiveness of cigarette regulations in reducing cases of sudden infant death syndrome. Journal of Health Economics, 27(1), 106–133. https://doi.org/10.1016/j.jhealeco.2007.03.006

Miller, T. J., Salm Ward, T. C., McClellan, M. M., Dawson, L., Ford, K., Polatty, L., Walcott, R. L., & Corso, P. S. (2018). Implementing a statewide safe to sleep hospital initiative: Lessons learned. Journal of Community Health, 43(4), 768–774. https://doi.org/10.1007/s10900-018-0483-3

Moon, R. Y., & Omron, R. (2002). Determinants of infant sleep position in an urban population. Clinical Pediatrics, 41(8), 569–573. https://doi.org/10.1177/000992280204100803

Moon, R. (2011). SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics, 128(5), 1030–1039. https://doi.org/10.1542/peds.2011-2284

Moon, R. (2005). Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001. Pediatrics 116(4), 972–977. https://doi.org/10.1542/peds.2005-0924

Moon, R., Mathews, A., Joyner, B. L., Oden, R. P., He, J., & McCarter, R. (2016a). Health messaging and African–American infant sleep location: A randomized controlled trial. Journal of Community Health, 42(1), 1–9. https://doi.org/10.1007/s10900-016-0227-1

Moon, R., Hauck, F., & Colson, E. (2016b). Safe infant sleep interventions: What is the evidence for successful behavior change? Current Pediatric Reviews, 12(1), 67–75. https://doi.org/10.2174/1573396311666151026110148

Salm Ward, T. C., McClellan, M. M., Miller, T. J., & Brown, S. (2018). Evaluation of a crib distribution and safe sleep educational program to reduce risk of sleep-related infant death. Journal of Community Health, 43(5), 848–855. https://doi.org/10.1007/s10900-018-0493-1

Scherman, A., Tolosa, J. E., & McEvoy, C. (2018). Smoking cessation in pregnancy: A continuing challenge in the United States. Therapeutic Advances in Drug Safety, 9(8), 457–474. https://doi.org/10.1177/2042098618775366

Zoucha, R., Walters, C. A., Colbert, A. M., Carlins, E., & Smith, E. (2015). Exploring safe sleep and SIDS risk perception in an African-American community: Focused ethnography. Public Health Nursing, 33(3), 206–213. https://doi.org/10.1111/phn.12235