DefinitionSudden unexpected infant deaths are those involving an infant less than 1 year of age that occur suddenly and unexpectedly, and whose cause of death is not immediately obvious before investigation. Following an autopsy, death scene investigation, and review of medical history, a small portion of these deaths turn out to be due to an undetected medical cause. However, the majority of these deaths are finalized with one of the following '''ICD-10 codes: R95''' (Sudden Infant Death Syndrome or SIDS), '''R99''' (ill-defined and unknown cause), or '''W75''' (accidental suffocation and strangulation in bed). By definition, SIDS is a sudden death of an infant that remains unexplained following a thorough investigation involving an autopsy, death scene investigation and review of the clinical history. However, while causes remain unknown, the conditions that elevate risk and the actions needed to reduce those risks have been identified.
NumeratorNumber of deaths in the first year of life with Sudden Unexpected Infant Death (SUID) as the underlying cause of death
DenominatorTotal number of live births in the same year
Why Is This Important?Despite declines, SIDS remains one of the top five leading causes of infant mortality. However, even after a thorough investigation, it can be difficult to distinguish SIDS from other sleep-related infant deaths such as suffocation by soft bedding. This is because these deaths are often unwitnessed, and there are no tests to tell SIDS apart from suffocation or those classified as due to an ill-defined and unknown cause. To complicate matters, people who investigate SUIDs may report cause of death in different ways. [https://www.cdc.gov/sids/AboutSUIDandSIDS.htm ^1^] Thus, a decline in SIDS may reflect a shift to one of the other codes comprising SUID rather than a true decline. Therefore, SIDS and the other sleep-related infant deaths, which share common risk factors, are grouped and assessed as a whole as Sudden Unexpected Infant Death (SUID) and, together, are the focus of the evidence-based safe sleep guidelines of the American Academy of Pediatrics in its goal of reducing all sleep-related infant deaths.
Healthy People Objective: Sudden unexpected infant deaths (includes SIDS, Unknown Cause, and Accidental Suffocation and Strangulation in Bed)U.S. Target: 0.84 infant deaths per 1,000 live births
How Are We Doing?The SUID rate in New Jersey has remained between 0.5 and 0.7 deaths per 1,000 live births since 2000, well below the national rate.
Through the state-mandated work of the [http://www.rwjms.rutgers.edu/sids/ SIDS Center of New Jersey] (SCNJ), New Jersey began disseminating safe sleep and other risk reduction information in 1992 based on the publication of the first American Academy of Pediatrics (AAP) guidelines and in advance of the 1994 onset of the National Institute of Child Health and Human Development's "Back to Sleep" campaign. By 1998, New Jersey's rate had fallen to one the lowest in the nation. Research by the SCNJ contributed to updates of the AAP guidelines.
While safe infant sleep practices, such as supine placement, reduce the risk of SUID, other factors also play an important role in affecting SUID rates.^2-4^ Adverse social and health determinants such as poverty, poor access to healthcare, smoking, and preterm birth are examples of risk factors that contribute to an infant's vulnerability to SUID. Elimination of smoking during pregnancy would potentially reduce SUID by 22%.^5^ The SUID rate for infants exposed to maternal smoking during pregnancy was 3.5 per 1000 live births in 2017-2019, compared to 0.4 for infants of nonsmoking mothers. Prematurity also is a major risk factor. Infants born between 24 and 27 weeks of gestation have over three times the risk for SUID compared to full term infants.^6^ In 2017-2019, 25% of SUIDs were preterm, in contrast to 9.5% of all births. Racial disparity in adverse social and health determinants, including those potentially impacted by implicit bias and racism, is associated with disparity in SUID rates.^7^ Racial disparities are also evident in inadequate prenatal care which is associated with a higher SUID rate.^4 ^
Elimination of adverse social determinants plays a role in reducing the impact of some risks. For example, in New Jersey, Asian Indians bed share the most, which is a risk elevating behavior, but they have the lowest rate of SUID.^3^ This paradoxical finding may reflect compensatory conditions in this group such as a high level of supine sleep but also less poverty, smoking, and alcohol use. Maternal fatigue makes bed sharing especially dangerous. Thus, the cultural practice among Asian Indians of closely involving grandparents in early child care may reduce maternal fatigue in this population. However, even in this low- risk population group, reduced bed sharing further reduces risk, underscoring the importance of following safe sleep guidelines.
In 2017, New Jersey surpassed its Healthy NJ 2020 target for supine placement. A 6% increase between 2016 and 2017 represented the largest year to year improvement. In 2020 the practice declined slightly to 73.7%. Both White and Black infants surpassed their targets, and Hispanic infants approximated theirs. Mothers who placed infants on the side or stomach rather than supine most of the time were more likely to be Black or Hispanic, age 24 years or younger, a WIC recipient, and lacking insurance or receiving Medicaid, reinforcing poverty as a risk factor.
How Do We Compare With the U.S.?In 2016-2018, New Jersey's SUID rate of 0.59 deaths per 1,000 live births was well below the national rate of 0.92. New Jersey's rate declined again in 2017-2019, but national data for this era are not yet available. However, for 2018, the most recent year available for both state and national SUID data, New Jersey's rate of 0.51 again fell well below the national rate of 0.91 and was 3rd lowest among the 46 states meeting statistical criteria for confidentiality constraints. New Jersey's SUID rates for infants of White, Black, or Hispanic mothers were also below U.S. rates for these groups. In 2016-2018, for the U.S. and New Jersey, respectively, the White non-Hispanic rates were 0.85 vs. 0.43, the Black non-Hispanic rates were 1.91 vs. 1.73, and the Hispanic rates were 0.55 vs. 0.43. However, as with fetal demise, stillbirth, and infant deaths from any cause, the rate of SUID among infants of Black mothers was higher than for other racial/ethnic groups both in the U.S. and within states.
What Is Being Done?In 1994, the "Back to Sleep" campaign was enacted encouraging parents to place babies on their backs to sleep. This practice has been termed one of the seven most important research findings in pediatrics in the past 40 years and is associated with a reduction in Sudden Unexpected Infant Death (SUID). This campaign promoted the evidence-based, risk-reducing recommendations the AAP began issuing in 1992. Now termed the "[https://safetosleep.nichd.nih.gov/ Safe to Sleep]" campaign, the [https://pediatrics.aappublications.org/content/138/5/e20162938 guidelines] have expanded to address other risk factors for SUID and are described in the Evidence-based Practices section below.
The SIDS Center of New Jersey (SCNJ) carries out the state's mandate to provide bereavement support, study risk factors, and provide multilingual and culturally, racially, and ethnically-sensitive risk-reducing education. Its research has contributed to the safe sleep guidelines of the AAP. The SCNJ collaborates with and serves the educational needs of health care, social service and child care providers; health care systems; home visiting programs; community groups; schools; and others in promoting safe infant sleep. It addresses barriers to compliance and participates in national initiatives. Its programs, educational flyers, videos, tool kits, webinars, and presentations can be accessed via its [http://www.rwjms.rutgers.edu/sids/ website] and [https://www.facebook.com/SIDSCenterNJ/ social media].
The SCNJ's newest initiatives include SIDS Info, a [https://www.facebook.com/SIDSCenterNJ/photos/a.113251280667566/139840824675278/ free mobile phone app] for safe sleep, in English and Spanish, which includes graphics and voice-overs to overcome any literacy challenges. The app received a Public Health Innovation Award from the New Jersey Department of Health and has been included as a resource by the NICHD Safe to Sleep Campaign and the Association of Maternal and Child Health Programs. It can be accessed by searching for "SIDS Info" in the app store associated with one's cell phone.
Adverse social and health determinants also elevate an infant's vulnerability, and disparities in these factors increase disparities in rates. The SCNJ participates in public health initiatives to address these disparities, such as Nurture NJ and the New Jersey Perinatal Quality Collaborative Health Disparities Work Group. The SCNJ also collaborates with other relevant New Jersey public programs such as the New Jersey Chapter of the AAP, the Maternal and Child Health Consortia, and New Jersey's home visiting programs.
Racial disparities in SUID rates reflect disparities in such adverse social and health determinants as economic resources, access to healthcare, access to healthy food, lifespan health, smoking, prematurity, neighborhood crime as well as disparities in safe sleep practices. Implicit bias and racism play a role in elevating adverse social and health determinants.^4,7^ The SCNJ partnered with other organizations to present a Black Infant Mortality Conference in June 2017 to raise awareness of social and health determinants and provided testimony to the NJ State Senate Health Committee to bring greater awareness of the disparities in social determinants that can affect infant mortality and to facilitate efforts to address these and the impact of implicit bias. In addition to working with other public health programs addressing these challenges, the SCNJ also develops new initiatives that bring risk reduction awareness to high risk communities from trusted communicators. An example is the Student Safe Sleep Ambassador program whereby students in high infant mortality communities learn about safe sleep and bring safe sleep information to their communities.^8^
Evidence-based PracticesThe most recent safe infant sleep [https://pediatrics.aappublications.org/content/138/5/e20162938 guidelines] and [https://pediatrics.aappublications.org/content/138/5/e20162940.long technical notes] were published by the American Academy of Pediatrics (AAP) in 2016 and include research conducted by the SIDS Center of New Jersey. The campaign describes the safest sleep environment for infants from birth to 12 months of age. In addition to placing infants on their backs to sleep, the guidelines recommend avoidance of an infant sharing a bed with a sleeping adult or child; avoidance of a sofa or chair for infant sleep; removal of loose bedding, pillows, quilts, soft objects, and bumpers from the infant's sleep area; use of a firm, flat mattress that fits the crib space, is intended for the product, and is covered only with a tightly fitted sheet; avoidance of overheating the infant; and avoidance of exposure to tobacco smoke. In place of bed sharing, room sharing with the baby is advised so that the parent can be close by the infant. Breastfeeding is also recommended. While parents may bring the infant into bed for feeding and comforting, the AAP recommends that the infant be returned to the near-by crib, bassinet, portable crib, or play yard that meets current safety standards once the parent is ready to sleep. In case the parent falls briefly asleep, removal of the adult pillows and other soft bedding is recommended in advance of bringing the baby into the bed for feeding. Crib, bassinet and portable crib standards can be obtained from the [https://www.cpsc.gov/SafeSleep Consumer Product Safety Commission] (800-638-2772). The AAP does not designate swaddling as a strategy to reduce the risk of SUID. However, if the parent chooses to swaddle, the AAP recommends that it be discontinued well in advance of the baby being able to roll over, that baby must be on the back, that baby should not be overheated, and that the swaddle should not cover baby's face. Additional information can be accessed from the AAP's [https://pediatrics.aappublications.org/content/138/5/e20162938 guidelines] and technical report and the SCNJ's website [http://www.rwjms.rutgers.edu/sids/]. Parents should consider offering a pacifier but should wait one month if breastfeeding and should avoid the use of clips or strings to attach a pacifier to the infant's clothing as these pose a strangulation risk. Tummy time when the infant is awake and supervised is also recommended to facilitate motor development. The AAP urges all caregivers to discuss these [https://pediatrics.aappublications.org/content/138/5/e20162938 guidelines] and any challenges to achieving them with their infant's health care providers.
Health Program Information[[br]]
*[http://www.rwjms.rutgers.edu/sids/ SIDS Center of New Jersey]
*[https://safetosleep.nichd.nih.gov/ National Institutes of Health "Safe to Sleep" campaign]
*[https://www.nj.gov/health/fhs/maternalchild/sidsfasd/sids/index.shtml NJDOH SIDS information]
*[http://njsafesleep.com/main/ NJ Department of Children and Families]