New Study on SUIDs & Surface Sharing: How Guidance Must Change
Image attribution: JP Valery @jpvalery
Introduction:
A study was released on Feb 20, 2024 in Pediatrics titled “Characteristics of Sudden Unexpected Infant Deaths (SUID) on Shared and Nonshared Sleep Surfaces.” The goal was to look at the difference between surface sharing (infant with at least 1 other person in a bed, crib, couch, etc.) or not across a variety of factors that influence sudden infant losses during sleep.
Annually, there are around 3,400 SUIDs in the United States. SUIDs include all infants under 1 yr old who die suddenly & unexpectedly in which the cause was not obvious before investigation. This includes Sudden Infant Death Syndrome (SIDS), known causes (such as accidental suffocation & strangulation in bed), & all other ill-defined & unknown causes; however, this would not include pre-existing medical conditions or incidents of abuse, for example.
Study Methods:
Researchers collected & reviewed 7,515 SUID data from 23 states/regions in the US who died of SUID during a 9 year period (2011 to 2020) using CDC SUID Case Registry.
They calculated the number of times events occurred (frequencies) & created percentages across topics of interest, including: demographics (infant age, sex, race, ethnicity, caregiver age, maternal smoking status, insurance type…), sleep environment (position, location, soft bedding…), as well as other characteristics by sleep surface sharing status (surface sharing with adult, other child, pet, or none). Chi-square (testing if two things are likely related or not) was used to analyze the differences between surface sharing & nonsharing infants – of which only those with over 5% difference were shared (this is not a p-value).
Findings:
Sleep Surface & Surface Sharing:
59.5% of infants were surface sharing & 40.5% were not at the time of death
Of the infants surface sharing above, 75.7% of them were found in an adult bed, with 68.3% of them having soft bedding
Almost all surface sharing losses had multiple unsafe sleep factors present BEYOND the surface itself
Bedding & Surface Sharing:
Soft bedding was the most common rationale for suffocation among sharing (47.7%) & nonsharing infants (80.1%)
Supervision & Surface Sharing:
87.2% of infants who were sharing a surface were supervised by a parent at time of death, compared to 72.5% of nonsharing infants
Impairment & Surface Sharing:
16.3% of infants found surface sharing had a supervisor who was impaired by drugs or alcohol, compared to 4.7% of nonsharing infants
Insurance & Surface Sharing:
Both sharing (75.1%) & nonsharing (64.3%) losses were more likely to have public insurance
Race & Surface Sharing:
Sharing infant losses were most commonly non-Hispanic Black (42.2%) & nonsharing infant losses were most commonly non-Hispanic white (46.2%)
Interpretation:
Investigators found that infants sharing a sleep surface were more often:
younger (0 to 3 months old),
non-Hispanic Black,
on public insurance,
found on their backs (supine),
in an adult bed or chair/couch,
with a greater number of unsafe sleep factors (on top of sharing a sleep surface),
were exposed to maternal cigarette smoking in utero,
were with a parent at time of death, or
were supervised by an impaired (drugs or alcohol) person at time of death.
They took time to review factors associated with surface sharing among living infants & those who were lost due to SUID in this investigation, which were largely similar. When looking at factors associated with living infants who surface share, poverty tends to be one of the largest factors, as well the following: “non-Hispanic Black or racial or ethnic minorities, lower parental education, teenage motherhood, lower income, breastfeeding, maternal smoking, and residential mobility (ie, moved at least once since birth).”
Lastly, investigators purported “although some characteristics were more common among surface sharing or nonsharing infants… most SUID had at least 1 unsafe factor in their sleep environment regardless of surface sharing status. Surface sharing in the absence of other unsafe sleep factors was rare. Furthermore, nonsharing infants were commonly in both an unsafe sleep position and with soft bedding in their sleep environment. Thus, surface-sharing in and of itself may not be what caregiver education should focus on. These results support efforts to provide comprehensive safe sleep messaging and not focus solely on not surface sharing, for all families at every encounter.”
Investigators acknowledged there were limitations to the study, such as:
lack of complete national data that lends question to generalizability,
potential data accuracy concerns due to the nature of SUID investigations,
data collection methods & bias can influence CDC Registry information due to a lack of standards for assessments (e.g. racial or socioeconomic status biases), &
risk calculations were not possible due to a lack of comprehensive data on live infants as a comparison group.
Thoughts:
This study confirms that safer sleep education for families must change. What we are doing in the US is NOT working. There are many reasons why folks bedshare (or share other surfaces) — whether it be intentionally or accidentally — therefore, reducing the hazards & risks associated with bedsharing can very likely save lives.
However, it is clear that the true focus for reducing SUIDs must be placed on systemic changes.
Investigators accurately noted that race is a social construct, but was important to investigate — & they found that infant SUIDs sharing a sleep space were most commonly non-Hispanic Black (42.2%). It is clear that systemic racism has disenfranchised this community, which are devastating to health outcomes.
Next, let’s revisit the fact that 75.1% of infants found sharing a sleep surface were publicly insured. In order to qualify for public insurance, you must meet certain criteria, usually income, resources, disability status, refugee status, &/or other special circumstances.
Taking these points into account is crucial, because we already know that 80% of our health outcomes are due to factors OTHER THAN clinical health care (our environment, our health behaviors, & socioeconomic factors such as income, education, or community safety) - these are called social drivers (determinants) of health (SDOH).
We all know that the United States does not equitably address SDOHs — consistently defunding education, denying dignified wage laws, & not allocating tax dollars back into community social supports that would help the most marginalized thrive. By helping those with the least thrive, we all reap the benefits.
In my professional opinion, healthcare providers must focus on cultivating a trusting environment with caregivers in order to have honest conversations about how to keep infants as safe as possible while sleeping. These conversations must not place shame on parents for surface sharing; however, placing an emphasis on a sleep surface that is a firm, flat mattress) & include discourse on the reasons some patients may be bedsharing (e.g. they may want a crib but cannot afford them). It is also critical that hospitals, clinics, & other pediatric care offices work with community to create resources to connect patients with supports that address SDOHs. Those early trust-building conversations will help patients be more receptive to community support referrals.
We need to stop blaming parents for systems failures. We need to support parents.
Reference:
Alexa B. Erck Lambert, Carrie K. Shapiro-Mendoza, Sharyn E. Parks, Carri Cottengim, Meghan Faulkner, Fern R. Hauck; Characteristics of Sudden Unexpected Infant Deaths on Shared and Nonshared Sleep Surfaces. Pediatrics March 2024; 153 (3): e2023061984. 10.1542/peds.2023-061984
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