Challenges to Public Health Responses to Safe Infant Sleep

Practices

Lauren Smith, MD, MPHMay 2012

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Disclosure

• I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

• I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

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Overview

• SIDS policy recommendations

• SIDS epidemiology• SIDS disparities• Safe sleep

controversies• DPH efforts

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SIDS Deaths, by Age

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9 10 11

Age at death in months

% o

f SID

S d

eath

s

The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116:1245–1255

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Milestones of the Back-to-Sleep Campaign

• 1992 – AAP issues statement that all healthy full term infants should be placed in non-prone positions to reduce the risk of SIDS.

• 1994 – The “Back to Sleep Campaign launched

• 1998 – The back sleeping campaign reduces SIDS deaths by 30 - 50 %.

• 2000 -- AAP statement - supine position poses lowest risk; side position less than prone

• 2005 – The AAP issues revised policy – supine only

• 2011 – The AAP updates its policy

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Healthy People 2020 & 2011 AAP Safe Sleep Recommendations

• Healthy People 2020 goal – 75.9% back sleeping for infants < 8 months

• More detailed recommendations from AAP– Back only sleep position– Firm sleep surface– No soft objects, loose bedding or bumpers– Separate but close sleep environment– Encourage breastfeeding– Avoid smoking during pregnancy– Keep infants up to date on immunizations– Offer pacifier during sleep– Avoid commercial devices claiming to decrease

SIDS

SIDS Epidemiology

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U.S. Trends in SIDS Rates and Prevalence of Prone Sleep by Race

American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116:1245–1255

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SIDS rate per 1000 live births

0

0.5

1

1.5

2

2.5

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

SID

S r

ate

Blacks

Whites

All

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Trends in Sleep Position, PRAMS, MA 2007-2010

77.478.576.274.1

0

20

40

60

80

100

2007 2008 2009 2010

Pre

vale

nce

of

slee

p p

osi

tio

n

Back Side Stomach > 1 Position

Source: MA Pregnancy Risk Assessment Monitoring System

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Trends in Sleep Location, PRAMS, MA 2007-2010

83.980.481.880.7

1214.714.715.5

0

20

40

60

80

100

2007 2008 2009 2010

Pre

vale

nce

of

slee

p l

oca

tio

n

Crib/Bassinet Adult bed w/ another Carseat

Source: MA Pregnancy Risk Assessment Monitoring System

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Trend in MA SUID Deaths, 2004-2009

40

35

40

46

38

58

0

10

20

30

40

50

60

70

2004 2005 2006 2007 2008 2009

Nu

mb

er o

f S

UID

Dea

ths

per

Yea

r

Source: Registry of Vital Records and Statistics, MA Department of Public HealthIncludes deaths with underlying cause of death coded as SIDS, Unexplained/Undetermined, Accidental Suffocation in Bed or Unspecified Threat to Breathing.

Disparities in SIDS Epidemiology

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Uneven Adoption of the Message

• Significant racial disparities persist in SIDS and prone sleeping, despite overall decreases

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Racial Differences in Non-Supine Sleep Position: A Widening Gap

0

25

50

75

100

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

No

n-S

up

ine

Pre

vale

nce

(%

)

Whites Blacks

16

Different Timing & Level of Plateaus

0

25

50

75

100

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

No

n-S

up

ine

Pre

vale

nce

(%

)

Whites Blacks

45%

45%

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The High Cost of Failed Public Health Messaging

0

500

1000

1500

2000

2500

3000

3500

4000

1997 1998 1999 2000 2001

Cu

mu

lati

ve

No

. o

f S

IDS

De

ath

s a

mo

ng

A

fric

an

Am

eri

ca

ns

Cumulative Actual African-American SIDS Deaths

Cumulative Calculated African-American SIDS Deaths at Pooled 2002 - 2004 African-American SIDS Rate

719 excesslives lost

E. Colson, Pediatrics, 2010

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Prevalence in Back Sleeping By Race/Ethnicity, MA, 2009-2010

82.8

5965.8

82.277.1

0

10

20

30

40

50

60

70

80

90

100

White, NH Black, NH Hispanic Asian, NH Other

Per

cen

t o

f B

ack

Sle

ep

Source: MA Pregnancy Risk Assessment Monitoring System

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Sleep Location By Race/Ethnicity, MA, 2009-2010

84.2

10.4

72.2

25.1

84.1

12.9

71.9

25.6

79.1

14.2

0

10

20

30

40

50

60

70

80

90

100

Crib/bassinet Adult bed w/ another person

Pre

vale

nce

of

slee

pin

g lo

cati

on

White, NH Black, NH Hispanic Asian, NH Other

Source: MA Pregnancy Risk Assessment Monitoring System

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Disparities in MA SUID Deaths, 2004-2009

16.6

141.2

78.2

43.255.8

0

20

40

60

80

100

120

140

160

Asian Black, NH Hispanic White, NH Total

Avg

. A

nn

ual

SU

ID R

ate

per

100

,000

Source: Registry of Vital Records and Statistics, MA Department of Public HealthIncludes deaths with underlying cause of death coded as SIDS, Unexplained/Undetermined, Accidental Suffocation in Bed or Unspecified Threat to Breathing.

Barriers to Adopting Safe Sleep Practices

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Barriers to Following Recommendations:Importance of Message and Messenger

• Lack of or wrong advice• Lack of trust in providers• Concerns about safety

– Worried about choking• Concerns about comfort

– Babies sleep better prone• Lack of knowledge

– Sleeping with mother or adult is best way to prevent SIDS

Colson ER, Levenson S, Rybin D, et al. Barriers to following the supine sleep recommendation among mothers at four centers for the Women, Infants, and Children Program. Pediatrics.2006;118(2):e243-e250.

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Understanding Influence of the Messenger

Although physicians are expected to provide these recommendations, it is not clear –-

• How mothers of young infants rate physician qualification to give advice in the 3 AAP targeted areas of sleep position, bed sharing and pacifier use

• If maternal ratings of physician qualification are associated with the recommended maternal behavior in these 3 areas.

Smith LA, Colson E, Rybin D, , Colton T, Margolis A, Lister G, Corwin MJ. Parental Assessment of Physician Qualification to Give Advice on AAP Recommended Infant Sleep Practices Related to SIDS. Academic Pediatrics, 2010;10 (6):383-388

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Methods

• Convenience sample of 1580 mothers of infants less than 8 months of age

• WIC centers in – Birmingham, AL– Clarksdale and Jackson, MS– Dallas, TX– Detroit, MI– New Haven, CT

• In-person, semi-structured interviews conducted June-December 2006 and 2007

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Primary Outcome Variables

• Usually placed supine for sleep

• Usually does not share bed with adult during sleep

• Usually use pacifier during sleep

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Independent Variables

Maternal rating of physician qualification

“Doctors give advice to parents about different topics. How qualified do you think your baby’s doctor is to give you advice on ….”

– 3 AAP targeted behaviors: sleep position, bed sharing, pacifier use

– 3 other domains: feeding practices, vaccinations, fever control

– Rating scale,1-5: High (4 or 5), Low ( ≤ 3)

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Independent Variables

• Nature of physician advice– Concordant w/ recommendations– Contrary to recommendations– No advice

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Demographic Characteristics

N = 1580

%Race/ethnicity of mother

African-American

Latino

White

74

14

8

High school education or less 63

Mean maternal age in years (SD) 24 (6)

Infant age

0-1 month

2-3 month

4-8 month

43

18

42

First child 45

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Maternal Rating of Physician Qualification

Topic Area High Rating

Percent

(N = 1580)

What to do when your baby has a fever 96 %

Whether and when to give vaccinations 95 %

What and how to feed your baby 82 %

What position your baby should be in for sleep

79 %

Whether your baby should share a bed with you or another adult

67 %

Whether your baby should use a pacifier 57 %

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Association of High Maternal Rating of Physician Qualification with Target

Behaviors

AAP Recommended Sleep Behavior

Unadjusted ORs

(95% CI)

Adjusted ORs*

(95% CI)

Supine only sleep position 2.3

(1.6 – 2.9)

2.0

(1.5 – 2.6)

Usually no bed sharing with adult

1.9

(1.5 – 2.3)

1.5

(1.2 – 2.0)

Usually use pacifier when sleeping

1.3

(1.0 – 1.6)

1.3

(1.0 – 1.6)* Adjusted for year, site, maternal race, age, education, infant age, doctor input, trusted source of advice.

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Nature of Physician Advice on 3 AAP Recommended Behaviors

37

14

54

77

15 10 9

57

28

0%

20%

40%

60%

80%

100%

Supine onlysleep

No bedsharing

Pacifierduring sleep

Contraryadvice

No advice

Concordantadvice

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Limitations

• Data were collected from 6 geographic sites which may limit generalizability.

• We rely on parental report of the nature of physician advice and sleep behaviors.

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Conclusion

• Low income, minority mothers rate physician qualification to give advice lower in the 3 AAP targeted safe sleep topics than in 3 more “medical” topics.

• Many mothers in this potentially vulnerable group report receiving no or non-AAP recommended advice, especially regarding pacifier use.

• High qualification ratings and the receipt of AAP-consistent advice from doctors are related to higher rates of recommended behavior.

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Implications

• Focus on populations with low rates of acceptance of recommendations

• AAP may need to consider alternative methods, in addition to relying on physician education, to encourage adoption of recommended behaviors to prevent SIDS.

• Focus on message and messenger

Safe Sleep Controversies

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What to do about bedsharing?

• Increase in infant deaths in setting of bedsharing in MA – More cases referred to

DCF

• Renewed focus on issue after controversial case in Milwaukee

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Bedsharing Controversy

Why babies should never sleep alone: A reviewof the co-sleeping controversy in relation to SIDS,bedsharing and breast feeding

“At very least, we hope that the studies and data described in this paper, which show that co-sleeping at least in the form of roomsharing especially with an actively breast feeding mother saves lives, is a powerful reason why the simplistic, scientifically inaccurate and misleading statement ‘never sleep with your baby’ needs to be rescinded, wherever and whenever it is published.”

J McKenna, T McDade 2005

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Why Mothers Chose Bedsharing?

Inner-City Caregivers’ Perspective on Bedsharing with their Infants

“Parents expressed divergent views about the safety of bed sharing: 1)ambivalence regarding balancing risks of overlaying and suffocation with benefits of bed sharing, or 2) assertion that bed sharing poses no risks for their child. Common to all groups was the finding that clinicians’ advice against bed sharing did not influence parents’ decision, but advice to increase safety when bed sharing would be appreciated.”

J Chianese, et al, 2009

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40

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Some Public Health Messaging

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Baltimore City Effort: ABC

• “B’more for Healthy Babies: Every baby counts on you”

• Uses testimonials from parents whose infants have died in bedsharing situations

• Focus on 3 part “ABC” message– Alone– Back– Crib

Evolution of DPH Efforts

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• Safe Sleep Policy Recommendation– The safest place for an infant to sleep is on

his or her back in the same room with a parent or caregiver and in a separate sleep space such as a crib or bassinet.

• Recommended sleep position• Recommended sleep environment• Bedsharing precautions

MA Department of Public HealthSafe Sleep Policy, 2009

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Prior MA DPH Bedsharing Recommendations:

Risk Reduction Approach Some parents may decide to sleep in the same bed with their

infant despite the MDPH safe sleep policy recommendation that an infant sleep in a separate space. If a parent chooses to bed share, the MDPH offers the following precautions to reduce the risk of SIDS or an adult rolling over on an infant.

The MDPH recommends that an adult never sleep with an infant if the adult is:

• On soft bedding such as a sofa, couch, futon, cushioned chair, recliner, pillow, or water bed;

• Using medications that cause drowsiness;• Using any amount of alcohol or drugs (prescription or illicit) ;• Sick;• Unusually tired;• Severely overweight or obese; or• A smoker.

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New AAP Guidelines Approach to Bedsharing

There are specific circumstances in which bed-sharing is particularly hazardous, and it should be stressed to parents that they avoid the following situations at all times:– When parent smokes– When parent uses alcohol, drugs or medications– When infant < 3 months– On waterbeds, sofas, armchairs– With soft bedding, pillows, blankets– With multiple people in the bed

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Are risk reduction messages confusing?

• Risk reduction vs. strict prohibition – which is more effective and for whom?– Possibility that choice could exacerbate disparities

• What does it mean to acknowledge possibility of non-recommended behavior– “If you are not going to use a car seat, at least put

your toddler in seatbelt”– “If you are going to drink during pregnancy, at

least wait until the 3rd trimester when all of the organs are formed”

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Safe Sleep Challenges

No cost, effective intervention – should be easy to adopt, but …

• Skepticism regarding mechanism• Alternative strongly held beliefs on

sleep position and environment– Concern about safety – preventing

choking– Co-sleeping is protective for baby– Better/longer sleep for mother and

baby– Facilitating breastfeeding

• Discounting doctor’s advice – sleep isn’t their domain

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What’s Next?

• Issue new DPH Safe Sleep Policy• Communication campaign with

State Child Fatality Review Team partners and others

• Redesign public health messaging to target persistently vulnerable groups– Fear vs. positive messages

• Reinforce key points in all DPH programs, policies, outreach, contracts

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