Rachel Y. Moon

Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis

CONTEXT: Swaddling is a traditional practice of wrapping infants to promote calming and sleep. Although the benefits and risks of swaddling in general have been studied, the practice in relation to sudden infant death syndrome remains unclear. OBJECTIVE: The goal of this study was to conduct an individual-level meta-analysis of sudden infant death syndrome risk for infants swaddled for sleep. DATA SOURCES: Additional data on sleeping position and age were provided by authors of included studies. STUDY SELECTION: Observational studies that measured swaddling for the last or reference sleep were included. DATA EXTRACTION: Of 283 articles screened, 4 studies met the inclusion criteria. RESULTS: There was significant heterogeneity among studies (I2 = 65.5%; P = .03), and a random effects model was therefore used for analysis. The overall age-adjusted pooled odds ratio (OR) for swaddling in all 4 studies was 1.58 (95% confidence interval [CI], 0.97–2.58). Removing the most recent study conducted in the United Kingdom reduced the heterogeneity (I2 = 28.2%; P = .25) and provided a pooled OR (using a fixed effects model) of 1.38 (95% CI, 1.05–1.80). Swaddling risk varied according to position placed for sleep; the risk was highest for prone sleeping (OR, 12.99 [95% CI, 4.14–40.77]), followed by side sleeping (OR, 3.16 [95% CI, 2.08–4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27–2.93]). Limited evidence suggested swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months. LIMITATIONS: Heterogeneity among the few studies available, imprecise definitions of swaddling, and difficulties controlling for further known risks make interpretation difficult. CONCLUSIONS: Current advice to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration should be given to an age after which swaddling should be discouraged.

Risk Factors, Protective Factors, and Current Recommendations to Reduce Sudden Infant Death Syndrome: A Review.

Importance Sudden infant death syndrome remains the leading cause of death in infants aged 1 month to 1 year in the United States. Observations While its exact cause is unknown, sudden infant death syndrome is believed to be multifactorial, ie, occurs in infants with underlying biological vulnerability who experience an exogenous stressor, such as prone/side sleeping or soft bedding, during a critical developmental period. Much genetic and physiologic evidence points to impaired arousal responses to hypercarbia and hypoxia, which ultimately leads to asphyxia. Known risk factors for infants include prone and side sleeping, soft bedding, bed sharing, inappropriate sleep surfaces (including sofas), exposure to tobacco smoke, and prematurity; protective factors include breastfeeding, pacifier use, room sharing, and immunizations. Conclusions and Relevance Despite our improved understanding of the physiologic mechanisms that cause sudden infant death, the mainstay of risk reduction continues to be a safe sleep environment, as most infants who die suddenly and unexpectedly do so in unsafe sleep environments.

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

Maternal Attitudes and Other Factors Associated with Infant Vaccination Status in the United States, 2011-2014

Objective To assess the role of maternal attitudes and other factors associated with infant vaccination status. Study design Data on reported vaccination status were analyzed from a nationally representative prospective survey of mothers of 2‐ to 6‐month‐old infants. Weighted univariate and multiple logistic regression analyses were conducted. Latent profile analysis of mothers reporting nonimmunized infants identified distinct groups, Results Of 3268 mothers, 2820 (weighted 86.2%), 311 (9.1%), and 137 (4.7%), respectively, reported their infant had received all, some, or no recommended vaccinations for age. Younger infants and infants with younger mothers were more likely to have received no vaccinations. Mothers with neutral and negative attitudes toward vaccination were >3 (aOR 3.66, 95% CI 1.80‐7.46) and 43 times (aOR 43.23, 95% CI 20.28‐92.16), respectively, more likely than mothers with positive attitudes to report their infants had received no vaccinations. Two subgroups of mothers reporting that their infants had received no vaccinations were identified: group A (52.5%) had less than positive attitudes and less than positive subjective norms about vaccination (ie, perceived social pressure from others); group B (47.5%) had positive attitudes and positive subjective norms. Group A mothers were more likely to be white (76.1% vs 48.3%, P = .002), more educated (43.5% vs 35.4% college or higher, P = .02), and to exclusively breastfeed (74.9% vs. 27.3%, P < .001). Conclusions Although access barriers can result in nonvaccination, less than positive maternal attitude toward vaccination was the strongest predictor. Strategies to improve vaccination rates must focus on both improved access and better understanding of factors underlying maternal attitudes.

Risk Factors for Sleep-Related Infant Deaths in In-Home and Out-of-Home Settings

BACKGROUND AND OBJECTIVE: Multiple environmental risk factors are associated with sleep-related infant deaths. Little is known about differences in risk factors for deaths occurring in-home and out-of-home. We sought to compare risk factors for in-home and out-of-home infant deaths. METHODS: We conducted a cross-sectional analysis of sleep-related infant deaths from 2004 to 2014 in the National Child Fatality Review and Prevention database. The main exposure was setting (in-home versus out-of-home) at time of death. Primary outcomes were known risk factors: sleep position, sleep location (eg, crib), objects in the environment, and bed sharing. Risk factors for in-home versus out-of-home deaths were compared using the χ2 test and multivariate logistic regressions. RESULTS: A total of 11 717 deaths were analyzed. Infants who died out-of-home were more likely to be in a stroller/car seat (adjusted odds ratio, 2.6; 95% confidence interval, 2.1–3.4; P < .001) and other locations (adjusted odds ratio, 1.9; 95% confidence interval, 1.5–2.3; P < .001), and placed prone (adjusted odds ratio, 1.2; 95% confidence interval, 1.1–1.3; P <0.01). Bed sharing was less common out-of-home (adjusted odds ratio, 0.7; 95% confidence interval, 0.6–0.7; P < .001). There were no differences in sleeping on a couch/ chair, or objects in the sleep environment. CONCLUSIONS: Sleep-related infant deaths in the out-of-home setting have higher odds of having certain risk factors, such as prone placement for sleep and location in a stroller/car seat, rather than in a crib/bassinet. Caregivers should be educated on the importance of placing infants to sleep supine in cribs/bassinets to protect against sleep-related deaths, both in and out of the home.

Differences in Infant Care Practices and Smoking among Hispanic Mothers Living in the United States.

Objective To assess the association between maternal birth country and adherence to the American Academy of Pediatrics safe sleep recommendations in a national sample of Hispanic mothers, given that data assessing the heterogeneity of infant care practices among Hispanics are lacking. Study design We used a stratified, 2‐stage, clustered design to obtain a nationally representative sample of mothers from 32 US intrapartum hospitals. A total of 907 completed follow‐up surveys (administered 2‐6 months postpartum) were received from mothers who self‐identified as Hispanic/Latina, forming our sample, which we divided into 4 subpopulations by birth country (US, Mexico, Central/South America, and Caribbean). Prevalence estimates and aORs were determined for infant sleep position, location, breastfeeding, and maternal smoking. Results When compared with US‐born mothers, we found that mothers born in the Caribbean (aOR 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. Caribbean‐born mothers were significantly less likely to place infants to sleep supine (aOR 0.41). Mothers born in Mexico (aOR 1.67) and Central/South America (aOR 2.57) were significantly more likely to exclusively breastfeed; Caribbean‐born mothers (aOR 0.13) were significantly less likely to do so. Foreign‐born mothers were significantly less likely to smoke before and during pregnancy. Conclusions Among US Hispanics, adherence to American Academy of Pediatrics safe sleep recommendations varies widely by maternal birth country. These data illustrate the importance of examining behavioral heterogeneity among ethnic groups and have potential relevance for developing targeted interventions for safe infant sleep.

Reasons for Infant Feeding Decisions in Low-Income Families in Washington, DC.

Background: Breastfeeding rates for low-income, African American infants remain low. Objective: This study aimed to determine the barriers, support, and influences for infant feeding decisions among women enrolled in the Washington, DC, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) after revisions in the WIC package to include more food vouchers for breastfeeding mothers and their infants and improvement of in-hospital breastfeeding support. Methods: We surveyed 100 women, using a 42-item verbally administered survey that asked about demographics, infant feeding method, and influences and support for feeding decisions. Results: The majority of participants (76%) initiated breastfeeding; 31% exclusively breastfed in the hospital. Participants were more likely to breastfeed if they had some college education, were unemployed or employed full-time, had only one child, and had been breastfed themselves as infants. Barriers to prolonged breastfeeding included limited support after hospital discharge, pain, and perceived insufficient milk supply. Participants in this study had higher breastfeeding initiation and in-hospital exclusivity rates after improvement of in-hospital breastfeeding support. Conclusion: Clients of WIC initiated breastfeeding at a high rate but either supplemented with formula or stopped breastfeeding for reasons that could be remedied by improved prenatal education, encouragement of exclusive breastfeeding in the hospital, and more outpatient support.

Learning From National and State Trends in Sudden Unexpected Infant Death

* Abbreviation: SUID — : sudden unexpected infant death In their analysis of national and state trends in US sudden unexpected infant death (SUID) rates in this month’s issue of Pediatrics , Erck Lambert et al1 demonstrate that declines in SUID rates have plateaued for the past 2 decades. The state-by-state data in which large disparities in SUID rates are shown should both raise alarm in the 22 states where rates are increasing and bring light to prevention efforts in the 9 states with the largest declines. Widespread education about safe sleep environments (eg, the Back to Sleep campaign) was associated with large decreases in SUID rates between 1990 and 2002. However, the effectiveness of such campaigns may have peaked as they have encountered cultural barriers, Internet misinformation, and countercampaigns. In light of this, how should we, as health care and public health professionals, proceed? First, we should recognize that among developed countries, the United States has the highest SUID rate. In a recent international comparison, researchers found that among 8 developed countries, the United States had the highest mean 2002–2010 postneonatal mortality rates (of which SUID comprises the majority) at 2.25 per 1000 live births, ∼70% higher than the other countries; only New Zealand, at 2.14 per 1000 live births, came close.2 To understand these differences, we must begin to look at variations in national policies. Of these countries, the United States is the only one that does not provide universal health care,3 home visitors in the neonatal period,4 and universal paid maternity leave.5 All of these are important protective factors for infant mortality.6–8 Additionally, these policies may have positive downstream effects on parental practices. The … Address correspondence to Rachel Y. Moon, MD, Division of General Pediatrics, University of Virginia, PO Box 800386, Charlottesville, VA 22908. E-mail: rym4z{at}virginia.edu

Proposed guidelines for skin-to-skin care and rooming-in should be more inclusive

Dear Editor, We read with interest the recent commentary “The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. A critical review of the literature” published in the Journal of Perinatology [1]. Table 2, created by Gomez-Pomar and Blubaugh, provides a potential order set for “safe skin-to-skin care,” reportedly based on recommendations provided by the AAP [2] and Davanzo [3]. However, the guidance provided is unnecessarily restrictive and is inconsistent with recommendations endorsed by the American Heart Association/American Academy of Pediatrics/International Liaison Committee on Resuscitation (AHA/AAP/ILCOR) neonatal resuscitative guidelines [4]. There is no evidence that near-term newborns (37–38 weeks gestation), or those with no prenatal care, maternal fever, history of drug exposure, prolonged rupture of membranes, non-life-threatening congenital anomalies, infants <2500 g, or suspicion of chorioamnionitis require stabilization on a warmer bed. These newborns may be stabilized and assessed on the mother while in skin-to-skin care (SSC). Infants with meconium staining with normal respiratory effort, good tone, and heart rate >100 may also be placed immediately in SSC. Furthermore, late preterm newborns (≥35 weeks gestation) may have SSC if stable, with good tone, normal heart rate, respiratory effort, and Apgar score of ≥7 at 5 min. In the event of positive pressure ventilation, SSC should be postponed until the infant is stabilized, but is not precluded [5]. Suggestions for monitoring during SSC included in Table 2 are also overly conservative and may be impractical. The AAP Clinical Report [2] and others [6] recommend the following guidance for monitoring: ● Continuous observational monitoring: staff member at the bedside of the dyad, preferably for the first 2 h, until transitioned to the mother–infant unit; the first 2 h after birth poses the highest risk for sudden unexpected postnatal collapse (SUPC).