Kawai O. Tanabe

Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis

CONTEXT: Benefits of breastfeeding include lower risk of postneonatal mortality. However, it is unclear whether breastfeeding specifically lowers sudden infant death syndrome (SIDS) risk, because study results have been conflicting. OBJECTIVE: To perform a meta-analysis to measure the association between breastfeeding and SIDS. METHODS: We identified 288 studies with data on breastfeeding and SIDS through a Medline search (1966–2009), review articles, and meta-analyses. Twenty-four original case-control studies were identified that provided data on the relationship between breastfeeding and SIDS risk. Two teams of 2 reviewers evaluated study quality according to preset criteria; 6 studies were excluded, which resulted in 18 studies for analysis. Univariable and multivariable odds ratios were extracted. A summary odds ratio (SOR) was calculated for the odds ratios by using the fixed-effect and random-effect inverse-variance methods of meta-analysis. The Breslow-Day test for heterogeneity was performed. RESULTS: For infants who received any amount of breast milk for any duration, the univariable SOR was 0.40 (95% confidence interval [CI]: 0.35–0.44), and the multivariable SOR was 0.55 (95% CI: 0.44–0.69). For any breastfeeding at 2 months of age or older, the univariable SOR was 0.38 (95% CI: 0.27–0.54). The univariable SOR for exclusive breastfeeding of any duration was 0.27 (95% CI: 0.24–0.31). CONCLUSIONS: Breastfeeding is protective against SIDS, and this effect is stronger when breastfeeding is exclusive. The recommendation to breastfeed infants should be included with other SIDS risk-reduction messages to both reduce the risk of SIDS and promote breastfeeding for its many other infant and maternal health benefits.

International trends in sudden infant death syndrome: stabilization of rates requires further action

Sudden infant death syndrome (SIDS) is the leading cause of death among infants between 1 month and 1 year of age in the developed world. In the United States, SIDS accounts for 22% of all postneonatal deaths.1 Many countries have launched educational campaigns in an effort to prevent SIDS, focusing on the modifiable factors that had been shown previously to be associated with SIDS.2 Although campaigns vary in the content of their other messages, the leading message of every campaign has been avoidance of the prone position for sleeping infants. Dramatic declines in SIDS have been attributed to these campaigns, which were found to be primarily a result of decreases in prone-sleeping rates.3–9 Other recommendations, such as those advising mothers not to smoke during pregnancy, were followed less widely.3,7 The majority of campaigns were initiated in the late 1980s to early 1990s. In the United States, the American Academy of Pediatrics recommended the nonprone sleeping position for infants in 1992.10 The national Back to Sleep campaign began 2 years later and emphasized the same recommendation.11 In 2000, on the basis of new epidemiologic evidence, the American Academy of Pediatrics recommended back sleeping as the preferred position.7 In the United States, prone-sleeping rates have declined 81%, from 70% in 1992 to 13% in 2005, and supine-sleeping rates have increased from 13% to 72% over that period.12 The US rate of SIDS has declined 55% (from 1.20 in 1000 live births in 199213 to 0.54 in 1000 live births in 2005).14 Previously, SIDS rates were found to differ by country, as had reductions in rates.15 The purpose of this report is to compare more-recent international data on SIDS and postneonatal infant mortality rates to examine trends, discuss … Address correspondence to Fern R. Hauck, MD, MS, University of Virginia School of Medicine, Department of Family Medicine, PO Box 800729, Charlottesville, VA 22908-0729. E-mail: frh8e{at}virginia.edu

Racial and Ethnic Disparities in Infant Mortality

Racial and ethnic disparities in infant mortality in the United States seem to defy all attempts at elimination. Despite national priorities to eliminate these disparities, black infants are 2.5 times more likely to die in infancy compared with non-Hispanic white infants. This disparity is largely related to the greater incidence among black infants of prematurity and low birth weight, congenital malformations, sudden infant death syndrome, and unintentional injuries. This greater incidence, in turn, is related to a complex interaction of behavioral, social, political, genetic, medical, and health care access factors. Thus, to influence the persistent racial disparity in infant mortality, a highly integrated approach is needed, with interventions adapted along a continuum from childhood through the periods of young adulthood, pregnancy, postpartum and beyond. The content and methodologies of these interventions need to be adapted to the underlying behaviors, social influences, and technology and access issues they are meant to address.

Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis

This study used individual-level data from international studies to assess the associations between duration of any breastfeeding versus exclusive breastfeeding and SIDS. CONTEXT: Sudden infant death syndrome (SIDS) is a leading cause of postneonatal infant mortality. Our previous meta-analyses showed that any breastfeeding is protective against SIDS with exclusive breastfeeding conferring a stronger effect.The duration of breastfeeding required to confer a protective effect is unknown. OBJECTIVE: To assess the associations between breastfeeding duration and SIDS. DATA SOURCES: Individual-level data from 8 case-control studies. STUDY SELECTION: Case-control SIDS studies with breastfeeding data. DATA EXTRACTION: Breastfeeding variables, demographic factors, and other potential confounders were identified. Individual-study and pooled analyses were performed. RESULTS: A total of 2267 SIDS cases and 6837 control infants were included. In multivariable pooled analysis, breastfeeding for <2 months was not protective (adjusted odds ratio [aOR]: 0.91, 95% confidence interval [CI]: 0.68–1.22). Any breastfeeding ≥2 months was protective, with greater protection seen with increased duration (2–4 months: aOR: 0.60, 95% CI: 0.44–0.82; 4–6 months: aOR: 0.40, 95% CI: 0.26–0.63; and >6 months: aOR: 0.36, 95% CI: 0.22–0.61). Although exclusive breastfeeding for <2 months was not protective (aOR: 0.82, 95% CI: 0.59–1.14), longer periods were protective (2–4 months: aOR: 0.61, 95% CI: 0.42–0.87; 4–6 months: aOR: 0.46, 95% CI: 0.29–0.74). LIMITATIONS: The variables collected in each study varied slightly, limiting our ability to include all studies in the analysis and control for all confounders. CONCLUSIONS: Breastfeeding duration of at least 2 months was associated with half the risk of SIDS. Breastfeeding does not need to be exclusive to confer this protection.

The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices: A Randomized Clinical Trial.

Importance Inadequate adherence to recommendations known to reduce the risk of sudden unexpected infant death has contributed to a slowing in the decline of these deaths. Objective To assess the effectiveness of 2 interventions separately and combined to promote infant safe sleep practices compared with control interventions. Design, Setting, and Participants Four-group cluster randomized clinical trial of mothers of healthy term newborns who were recruited between March 2015 and May 2016 at 16 US hospitals with more than 100 births annually. Data collection ended in October 2016. Interventions All participants were beneficiaries of a nursing quality improvement campaign in infant safe sleep practices (intervention) or breastfeeding (control), and then received a 60-day mobile health program, in which mothers received frequent emails or text messages containing short videos with educational content about infant safe sleep practices (intervention) or breastfeeding (control) and queries about infant care practices. Main Outcomes and Measures The primary outcome was maternal self-reported adherence to 4 infant safe sleep practices of sleep position (supine), sleep location (room sharing without bed sharing), soft bedding use (none), and pacifier use (any); data were collected by maternal survey when the infant was aged 60 to 240 days. Results Of the 1600 mothers who were randomized to 1 of 4 groups (400 per group), 1263 completed the survey (78.9%). The mean (SD) maternal age was 28.1 years (5.8 years) and 32.8% of respondents were non-Hispanic white, 32.3% Hispanic, 27.2% non-Hispanic black, and 7.7% other race/ethnicity. The mean (SD) infant age was 11.2 weeks (4.4 weeks) and 51.2% were female. In the adjusted analyses, mothers receiving the safe sleep mobile health intervention had higher prevalence of placing their infants supine compared with mothers receiving the control mobile health intervention (89.1% vs 80.2%, respectively; adjusted risk difference, 8.9% [95% CI, 5.3%-11.7%]), room sharing without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4% [95% CI, 9.3%-15.1%]), no soft bedding use (79.4% vs 67.6%; adjusted risk difference, 11.8% [95% CI, 8.1%-15.2%]), and any pacifier use (68.5% vs 59.8%; adjusted risk difference, 8.7% [95% CI, 3.9%-13.1%]). The independent effect of the nursing quality improvement intervention was not significant for all outcomes. Interactions between the 2 interventions were only significant for the supine sleep position. Conclusions and Relevance Among mothers of healthy term newborns, a mobile health intervention, but not a nursing quality improvement intervention, improved adherence to infant safe sleep practices compared with control interventions. Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied. Trial Registration clinicaltrials.gov Identifier: NCT01713868

A United States Perspective

Sudden infant death syndrome (SIDS) rates have declined significantly in the United States (US) as a result of the “Back to Sleep” campaign. Despite this and many state and local risk reduction campaigns, rates still remain high in the African American and American Indian/Alaska Native populations. The American Academy of Pediatrics (AAP) recently released (2016) updated guidelines and recommendations for a safe sleep environment (12). However, certain recommendations, especially the advice against infant bed sharing, continue to be controversial and are not followed by some groups. Further research on the reasons for non-adherence and identification of culturally acceptable and safe alternatives that address parental concerns are needed to help in targeting educational interventions in high-risk populations. In this chapter, we will address SIDS from a US perspective, covering rates and trends, interventions to reduce risk, the bed-sharing controversy, and current laws and regulations in the US.