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Racial disparity and modifiable risk factors among infants dying suddenly and unexpectedly
Benjamin Unger1, James S Kemp, Davida Wilkins
1Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri 63110, USA.
Insights
Racial disparities in infant death rates persist, with African American infants experiencing higher risks from unsafe sleep practices like bedsharing. Public health messaging needs to equally emphasize safe sleep surfaces and alternatives to bedsharing to reduce these disparities.
Area of Science:
- Pediatric Public Health
- Epidemiology
- Sleep Medicine
Background:
- Racial disparities in Sudden Infant Death Syndrome (SIDS) rates have widened despite the
- Back to Sleep
- campaign.
- Unsafe sleep practices, including prone positioning, unsafe surfaces, and bedsharing, increase sudden infant death risk.
- Higher death rates from SIDS, accidental suffocation (AS), and undetermined (UD) causes are observed in African American (AA) infants compared to non-AA infants.
Purpose of the Study:
- To compare SIDS, AS, and UD death rates between AA and non-AA infants.
- To investigate the prevalence of unsafe sleep practices at the time of death in relation to race.
- To inform targeted public health interventions aimed at reducing racial disparities in infant mortality.
Main Methods:
- Population-based retrospective study of infant deaths (SIDS, AS, UD) in St. Louis City and County from 1994-1997.
- Inclusion criteria: infants under 2 years old.
- Data sources: death-scene information and medical examiner investigations; birth data used for rate denominators.
Main Results:
- AA infants had significantly higher SIDS and AS death rates compared to non-AA infants.
- Bedsharing and use of nonstandard sleep surfaces were more prevalent in deaths of AA infants.
- Infants bedsharing were more likely to be found in non-prone positions (back or side), but this position was less protective during bedsharing.
Conclusions:
- High prevalence of nonstandard sleep surfaces and bedsharing may contribute to increased infant death rates among AA infants.
- Racial disparities in infant sleep position are not the primary driver of the overall disparity in death rates.
- Public health campaigns for the AA community should equally emphasize safe sleep alternatives to bedsharing alongside avoiding prone sleep positions.
Background:
Racial disparity in rates of death attributable to sudden infant death syndrome (SIDS) has been observed for many years. Despite decreased SIDS death rates following the "Back to Sleep" intervention in 1994, this disparity in death rates has increased. The prone sleep position, unsafe sleep surfaces, and sharing a sleep surface with others (bedsharing) increase the risk of sudden infant death. The race-specific prevalence of these modifiable risk factors in sudden unexpected infant deaths-including SIDS, accidental suffocation (AS), and cause of death undetermined (UD)-has not been investigated in a population-based study. Death rates attributable to AS and UD are also higher in African Americans (AAs) than in other races (non-AA). The potential contribution of unsafe sleep practices to this overall disparity in death rates is uncertain.
Objective:
The objective of this study was to compare death rates attributable to SIDS and related causes of death (AS and UD) in AA and non-AA infants and the prevalence of unsafe sleep practices at time of death. Our hypothesis was that there is a large racial disparity in these modifiable risk factors at the time of death, and that public awareness of this could lead to improved intervention strategies to reduce the disparity in death rates.
Methods:
In this population-based study, we retrospectively reviewed death-scene information and medical examiners' investigations of deaths in St Louis City and County between January 1, 1994, and December 31, 1997. The deaths of all infants <2 years old with the diagnoses of SIDS, AS, or UD were included. Sleep surfaces other than those specifically designed and approved for infant use were termed nonstandard (adult beds, sofas, etc). Denominators for our rate estimates were the number of births (AA and non-AA) in St Louis City and County during the study period.
Results:
The deaths of 119 infants were studied (81 AA and 38 non-AA). SIDS rates were much higher in AA than non-AA infants (2.08 vs 0.65 per 1000 live births), as was the rate of AS (0.47 vs 0.06). There was a trend for increased deaths diagnosed as UD in AA infants (0.36 vs 0.06). Bedsharing deaths were nearly twice as common in AAs (67.1% vs 35.1% of deaths), as were deaths on nonstandard sleep surfaces (79.0% vs 46.0%). Forty-nine percent (49.1%) of all infants who died while bedsharing were found on their backs or sides compared with 20.4% of infants who were not bedsharing. Overall, the fraction of infants found in these nonprone positions was not different for AA infants and non-AA infants (43.3% vs 38.5%). In AA and non-AA infants, factors that greatly increase the risk of bedsharing, such as sofa sharing or all-night bedsharing, were present in all or many bedsharing deaths.
Conclusion:
Among AA infants dying suddenly and unexpectedly, the high prevalence of nonstandard bed use and bedsharing may underlie, in part, their increased death rates. Public health messages tailored for the AA community have stressed first and foremost using nonprone sleep positions. The observation that there was no difference between AA and non-AA infants in position found at death suggests that racial disparity in sleep position is not the most important contributor to racial disparity in death rates. The finding that more infants died on their back or side while bedsharing than otherwise suggests that these sleep positions are less protective when associated with bedsharing. We conclude that public health information tailored for the AA community should give equal emphasis to risks and alternatives to bedsharing as to avoidance of the prone position.