The idea that your baby could die in the middle of the night, for no apparent reason, is terrifying for parents. But if you live in a state like Alaska, Alabama, Arkansas, Kentucky or Louisiana, your child may be at an increased risk for what's known as sudden unexpected infant death (SUID), a term that encompasses sudden infant death syndrome (SIDS), as well as accidental suffocation and strangulation in bed (ASSB) and undetermined deaths.
There are about 3,500 infants in the US each year who die unexpectedly in their sleep. While US infant deaths declined sharply during the 1990s after an educational campaign called Back to Sleep (now known as the Safe to Sleep® campaign), there has been little research on the rates since 1999. Now, a new study published in the journal Paediatrics has found that SUID rates have largely stayed the same since 1999 and, in fact, there is now a wide variation in death rates from state to state.
The study compared SUID rates in 2000-2002 and 2013-2015, and found that states that showed the biggest declines were California, Colorado, the District of Columbia, Florida, Kansas, Missouri, New York, Oregon, Washington and Wisconsin. However, Alaska, Arkansas, Alabama, Kentucky and Louisiana had the highest SUID rates in 2013-2015, and saw significant increases since 2000-2002.
The reasons for the disparity between states are complicated because there are a lot of factors at play, says Rebecca Carlin, a pediatrician at Children's National Health System, who wrote an accompanying commentary about the study in Pediatrics. "We know from previous studies that there are variations in SUID rates based on demographics, that rates are higher in those with lower socioeconomic status and education levels, and that there is also racial variation in SUID rates, with America Indian/Alaskan Native and non-Hispanic African American infants having the highest rates, and Hispanic American and Asian American infants having the lowest rates," she says.
Smoking rates can also be a contributor to the state-by-state variation, says Carlin. More than 50 studies show that if a mother smokes, her infant is at a higher risk for SUID. All five of the states with the highest and increasing SUID rates also have some of the highest rates of smoking, whereas only one of the nine states with the biggest fall in SUID rates had as high a rate of tobacco use. Researchers are also looking to whether opioid use is a factor, notes Carlin, and one study found that infants exposed to methadone, heroin or both had significant increases in SUID.
There is also a wide range of strategies from state to state being used to reduce SUID, says the study's lead author Alexa Erck, an epidemiologist working in the maternal and infant health branch at the Centers for Disease Control and Prevention. Many strategies have been established to educate parents about safe sleep practices that prevent SUID, like putting babies to sleep on their backs, not sharing a bed with your baby and keeping loose bedding out of the crib. Some of those educational strategies include laws and regulations for childcare providers; Safe to Sleep campaigns; messaging through the Special Supplemental Nutrition Program for Women, Infants, and Children; home-visiting programs; and improvements in the quality of care at hospitals. These programs have had varying rates of success, but "we know from the states with large declines in their SUID rates that they can be successful in improving infant safety," says Carlin.
Looking at the differences in SUID rates between regions is important because it shows experts where more work is needed for improving sleep safety. In the US, putting babies to sleep in positions other than on the back is much more common than in other developed countries. Meanwhile, bed-sharing rates continue to increase and the use of soft bedding is also quite high.
Many parents decide how to care for their children largely based on what they perceive will keep their infant both safe and comfortable, says Carlin, so they put infants on their bellies because they think that it will be safer and lead to longer sleep periods. (New parents are tired, after all!) Many also believe bed-sharing is the best way to keep an eye on their babies at night, and that using soft-bedding is more comfortable for soft-skinned newborns. Healthcare and public health professionals in states with higher SUID rates need to address these perceptions.
The bottom line for both parents and physicians is that there's much room to improve, says Carlin. "As a new parent there are so many stressors and things to worry about that it is easy to do whatever you can to make your child fall asleep faster or sleep longer, thinking SUID will never happen to them," says Carlin. "But that is what the parent of every SUID victim thought when they put their child down to sleep."
To counter these beliefs, we need to invest in more programs to educate mothers on the risks of unsafe sleep practices and better support new parents so they are able to follow those recommendations.