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Characteristics of Infant Deaths during Sleep While Under Nonparental Supervision
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Characteristics of Infant Deaths during Sleep While Under Nonparental Supervision Elena Lagon, BS1, Rachel Y. Moon, MD2, and Jeffrey D. Colvin, MD, JD3 Objective To compare risk factors for infant sleep-related deaths under the supervision of parents and nonparents. Study design We conducted a secondary analysis of sleep-related infant deaths from 2004 to 2014 in the National Center for Fatality Review and Prevention Child Death Review Case Reporting System. The main exposure was supervisor at time of death. Primary outcomes included sleep position, location, and objects in the environment. Risk factors for parental vs nonparental supervisor were compared using c2 and multivariable logistic regression models. Risk factors associated with different nonparental supervisors were analyzed using c2. Results Of the 10 490 deaths, 1375 (13.1%) occurred under nonparental supervision. Infants who died under nonparental supervision had higher adjusted odds of dying outside the home (OR 12.87, 95% CI 11.31-14.65), being placed prone (OR 1.61, 95% CI 1.39-1.86) or on their side (OR 1.35, 95% CI 1.12-1.62), or being found prone (OR 1.74, 95% CI 1.50-2.02). Among infants who died under nonparental supervision, those supervised by relatives or friends were more often placed on an adult bed or couch for sleep and bed sharing (P < .0001), and to have objects in the sleep environment (P = .01). Conclusions Infants who died of sleep-related causes under nonparental supervision were more likely to have been placed nonsupine. Among nonparental supervisors, relatives and friends were more likely to use unsafe sleep environments, such as locations other than a crib or bassinet and bed sharing. Pediatricians should educate parents that all caregivers must always follow safe sleep practices. (J Pediatr 2018;■■:■■-■■).
S
udden unexpected infant death (SUID) is a term used to encompass the diagnoses of sudden infant death syndrome (SIDS), asphyxia (including accidental suffocation and strangulation in bed), and ill-defined deaths during the first 12 months of life.1 In 1994, a coalition including the American Academy of Pediatrics and US Public Health Service initiated the well-known public education campaign “Back to Sleep,” which was associated with a notable decline in SIDS rates.1 However, although SIDS rates have declined, rates of accidental suffocation and strangulation in bed and ill-defined deaths have increased (indicating a possible diagnostic shift), resulting in a plateauing of overall SUID rates since 2000.2-4 Approximately 3500 infants died from SUID in 2014.5 The etiology of SIDS and other sleep-related deaths is believed to be multifactorial, with biological, developmental, and environmental determinants.6 Efforts to reduce the risk of sleep-related infant deaths have targeted modifiable environmental risk factors, and the most recent (2016) American Academy of Pediatrics safe sleep recommendations include supine positioning, use of a crib or bassinet with a firm sleep surface, breastfeeding, room sharing without bed sharing, avoidance of soft bedding and overheating, and prevention of parental alcohol, tobacco, and illicit drug use.1,7 Although most safe sleep information targets parents and the home environment, prior research demonstrated that a large percentage of these deaths can occur outside the home as well. Approximately 20% of SIDS deaths in the 1990s occurred in a childcare setting (including in-home babysitters and nannies).8 We also found that approximately 20% of SUID occurs out of the home.9 However, no studies have examined environmental risk factors associated with nonparental supervisors across a wide range of contexts beyond child care and across both in-home and out-of-home locations. For this study, we sought to compare risk factors for infant sleep-related deaths under the supervision of From the 1; 2Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA; and parents and nonparents. 3
Methods For this retrospective cross-sectional study, we received a deidentified dataset from the National Center for Fatality Review and Prevention’s Child Death Review Case Reporting System of infant deaths (ages 0-364 days) from 45 states occurring during
Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO R.M. served as a paid expert witness in cases of sleeprelated infant death occurring while under nonparental supervision. The other authors declare no conflicts of interest. Data Statement: The data is unavailable to be accessed because it is confidential. Researchers interested in access to the data should contact the National Center for Fatality Review and Prevention. Portions of this study were presented at the Pediatric Academic Societies annual meeting, May 6-9, 2017, San Francisco, California.
SIDS SUID
Sudden infant death syndrome Sudden unexpected infant death
0022-3476/$ - see front matter. © 2018 Elsevier Inc. All rights reserved. https://doi.org10.1016/j.jpeds.2018.01.051
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THE JOURNAL OF PEDIATRICS • www.jpeds.com sleep or in the sleep environment during the period 20042014. The Child Death Review Case Reporting System has been previously described10,11 and contains infant, caregiver, and supervisor demographic information, as well as information about known risk factors, including sleep environmental risk factors such as sleep position, objects in the sleep environment, location (eg, crib), and setting (eg, child’s home, relative’s home). Appendix 1 includes the 2005 Case Report form and Appendix 2 includes the 2011 Case Report form. All children less than 365 days of age were included if their deaths occurred during sleep or in the sleep environment (excluding medical causes and intentional trauma). Cases with missing data on the supervisor at the incident or the primary caregiver of the infant were excluded. Among the 13 471 deaths contained in the data set, 1230 (9.1%) were excluded because they were not sleep-related and 1750 (13.0%) were excluded because the case was missing either caregiver or supervisor data. This study was deemed exempt by the institutional review board of the University of Virginia. An incident was coded as having a “parental supervisor” if the biological, adoptive, step, or foster parent, or the mother or father’s partner were present, and a “nonparental supervisor” if a relative, friend, babysitter, childcare worker, hospital or institutional staff member, or “other” individual was the supervisor at the time of death. Supervisor at the time of death was further categorized as parent, relative (grandparent, sibling, or other relative), friend/acquaintance, childcare provider, babysitter, or other. The sleep positions in which infants were placed and found were categorized as supine, side, or prone. We categorized the incident sleep place as follows: crib (including bassinet or playpen); car seat/stroller; adult bed or on an adult person; couch or sofa; other (floor, futon, pillow, and bean bag); and unknown. Sleeping on an adult bed and sleeping on an adult person were grouped together because both situations represent the risk of suffocation due to adult roll-over. If an infant was sleeping on an adult and the adult was on a sofa or other piece of furniture, the incident sleep place was categorized as “on an adult.” Additional risk factors included bed sharing with an adult or other child, and the presence of objects, such as pillows, quilts, or toys, in the sleep environment. Infant demographic characteristics included age, sex, and race/ethnicity. As our prior studies have demonstrated differences in the importance of risk factors depending on age,10 infant age at death was classified as 0-3 months, 4-6 months, and 7 months-364 days. Race/ethnicity was classified as nonHispanic white, non-Hispanic black, Hispanic, and other. Incident location was categorized as child’s home, relative/ friend’s home, foster home, daycare/babysitter’s, and travelling/ temporary. The travelling/temporary category included sidewalks, driveways, roadways, trains, buses, parking areas, parks, sporting areas, other recreation areas, stores, restaurants, and similar locations. Statistical Analyses Data were analyzed using SPSS (IBM Corporation, Armonk, New York) and SAS (SAS Institute, Cary, North Carolina). We
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performed multiple imputation by using the Markov Monte Carlo method to impute missing data for variables used in the analyses12,13 (information on the proportions of missing data is included in Tables I and II; the maximum missing data per variable was 3.6%). Multiple imputation has been previously used for analyses of the Child Death Review Case Reporting System database.10,14 Multiple imputation predicts values for incomplete variables by using regression equations from complete variables. This minimizes assumptions that the subset of cases with complete data are representative of the entire sample population. Multiple imputation is used so that biases resulting from missing data are reduced; it provides better, nearly unbiased estimates than other methods of handling missing data.12,13 All subsequent analyses were conducted with pooled imputed data. Risk factors and demographic characteristics were compared for these 2 groups using the c2 test and multiple variable logistic regression analyses (controlling for age, sex, and race/ethnicity). In addition, risk factors were compared across specific nonparental supervisor types (relative, friend/ acquaintance, childcare provider, etc) using the c2 test.
Results A total of 10 490 sleep-related deaths met inclusion criteria. Of these deaths, 1375 (13.1%) occurred when a parent was not present (Table I). Infants who died under nonparental supervision were more likely to be older (44.9% aged 4 months and older under nonparental supervision vs 31.1% under parental supervision, P < .0001). There were no sex or racial/ethnic differences. Deaths under nonparental supervision were more likely than those under parental supervision to occur at a relative or friend’s home (29.7% vs 10%, P < .0001). In contrast, 86.3% of deaths under parental supervision occurred in the infant’s home (P < .0001). Of deaths occurring under nonparental supervision, more than two-thirds (67.3%) of deaths occurred outside of the child’s home, with approximately one-half (34.0%) of these occurring in a daycare center or babysitter’s home. Of deaths occurring under nonparental supervision, non-Hispanic white infants had a higher percentage while under the supervision of a licensed childcare provider (66.6%) or babysitter (57.2%) compared with non-Hispanic black infants (9.7% and 15.4%, respectively) and Hispanic infants (16.2% and 20.9%, respectively, P < .0001). Sleep Environment Risk Factors: Bivariate Analyses Sleep environment risk factors for deaths occurring under parental vs nonparental supervision were compared (Table II). With regards to sleep location, a higher proportion of deaths under parental supervision occurred in an adult bed or on an adult (55.0% vs 41.3%, P < .0001), and deaths under nonparental supervision were more likely to occur in a crib, bassinet, or playpen (40.3% vs 25.8%, P < .0001). Infants who died under parental supervision were twice as likely to be bed
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Table I. Incident location and demographic characteristics of infants with sleep-related death Total (n = 10 490) Characteristics* Age at death 0-3 mo 4-6 mo 7 mo-364 d Sex Male Female Race/ethnicity Hispanic Non-Hispanic white Non-Hispanic black Other Incident location Child's home Relative/friend's home Foster home Daycare/babysitter's Traveling/temporary Others
Parental primary caregiver present at incident (n = 9115)
Parental primary caregiver not present at incident (n = 1375)
N
%
N
%
N
%
7042 2441 1007
67.1 23.3 9.6
6284 2014 817
68.9 22.1 9.0
758 427 190
55.1 31.1 13.8
6124 4366
58.4 41.6
5310 3805
58.3 41.7
814 561
59.2 40.8
1849 4666 3344 631
17.6 44.5 31.9 6.0
1604 4027 2943 541
17.6 44.2 32.3 5.9
245 639 401 90
17.8 46.5 29.1 6.6
8313 1318 111 480 122 146
79.2 12.6 1.1 4.6 1.2 1.4
7863 910 83 12 117 129
86.3 10.0 0.9 0.1 1.3 1.4
449 408 28 468 5 17
32.7 29.7 2.1 34.0 0.4 1.2
P value† <.0001
.49
.12
<.0001
*Missing data was imputed for the following variables: sex (0.3%), race/ethnicity (2.3%), and incident location (1.1%). †P values reflect c2 tests comparing parental supervisor and nonparental supervisor groups for each demographic characteristic.
sharing at the time of death (60.0% vs 29.3%, P < .0001). However, infants under nonparental supervision were both less likely to be placed supine to sleep (39.3% vs 43.4%, P < .0001) and more likely to be found in the prone position (51.0% vs 37.6%, P < .0001), and also more likely to have objects in the sleep environment (36.1% vs 33.1%, P = .03).
We then examined risk factors specifically for the different categories of nonparental supervisors (eg, relatives, friends, babysitters, childcare providers) (Table III). Deaths under the care of relatives and friends were most likely to occur while infants were held or placed on an adult bed (53.4% and 47.1%, respectively) compared with deaths that occurred under the
Table II. Sleep environment risk factors occurring under parental and nonparental supervision Total (n = 10 490) Characteristics* Incident sleep place Crib/bassinet/playpen Car seat/stroller Adult bed/person Couch/chair Other Position placed On back On stomach On side Unknown Position found On back On stomach On side Unknown Bed sharing No Yes Object(s) in sleep environment No Yes
Parental primary caregiver present at incident (n = 9115)
Parental primary caregiver not present at incident (n = 1375)
N
%
N
%
N
%
2905 353 5582 1368 282
27.7 3.4 53.2 13.0 2.7
2350 298 5013 1230 224
25.8 3.3 55.0 13.5 2.5
555 56 568 138 58
40.3 4.1 41.3 10.0 4.2
4494 2363 1360 2273
42.8 22.5 13.0 21.7
3954 1958 1166 2037
43.4 21.5 12.8 22.3
541 405 194 236
39.3 29.4 14.1 17.1
3001 4128 1288 2074
28.6 39.4 12.3 19.8
2691 3427 1139 1857
29.5 37.6 12.5 20.4
310 701 148 216
22.5 51.0 10.8 15.7
4615 5875
44.0 56.0
3642 5473
40.0 60.0
972 403
70.7 29.3
6975 3515
66.5 33.5
6096 3019
66.9 33.1
879 496
63.9 36.1
P value <.0001
<.0001
<.0001
<.0001 .03
*Missing data was imputed for the following variables: sleep surface (3.1%), position placed (3.6%), position found (3.6%), and bed sharing (0.1%).
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Table III. Characteristics of sleep-related infant deaths stratified by nonparental supervisor Total (n = 1375) Characteristics Incident sleep place Crib/bassinet/playpen Car seat/stroller Adult bed/person Couch/chair Other Position placed On back On stomach On side Unknown Position found On back On stomach On side Unknown Bed sharing No Yes Object(s) in sleep environment No Yes
Relative (n = 673)
Friend (n = 85)
Childcare provider (n = 149)
Babysitter (n = 418)
Other (n = 50)
N
%
N
%
N
%
N
%
N
%
N
%
555 56 568 138 58
40.3 4.1 41.3 10.0 4.2
198 13 359 83 19
29.4 2.0 53.4 12.4 2.9
23 3 40 13 6
27.1 3.5 47.1 15.3 7.1
205 27 127 33 25
49.1 6.5 30.4 7.9 6.0
108 11 20 3 6
72.5 7.5 13.7 2.1 4.2
21 1 22 5 2
41.6 2.0 43.2 10.0 3.2
541 405 194 236
39.3 29.4 14.1 17.1
258 198 91 125
38.4 29.5 13.5 18.6
33 29 7 16
38.6 34.4 8.2 18.8
158 138 66 57
37.8 32.9 15.7 13.6
81 32 23 13
54.1 21.7 15.3 8.9
11 7 7 25
22.0 14.4 14.4 49.2
310 701 148 216
22.5 51.0 10.8 15.7
159 339 74 101
23.6 50.4 11.0 15.0
19 49 7 10
21.9 58.1 8.7 11.3
73 234 45 66
17.4 56.0 10.9 15.7
53 68 12 15
35.8 45.6 8.3 10.2
6 10 9 25
12.0 19.2 18.8 50.0
972 403
70.7 29.3
381 292
56.6 43.4
43 42
50.6 49.4
371 47
88.8 11.2
146 3
98.0 2.0
31 19
62.4 37.6
879 496
63.9 36.1
414 259
61.5 38.5
48 37
56.5 43.5
271 147
64.8 35.2
106 43
71.1 28.9
40 10
80.0 20.0
P value <.0001
<.0001
<.0001
<.0001 .01
supervision of a babysitter (30.4%) or childcare provider (13.7%, P < .0001). Almost one-half of the infants under relative (43.4%) or friend (49.4%) supervision died while bed sharing (P < .0001). A higher percentage of babysitters and childcare providers placed the infant in a crib (49.1% and 72.5%, respectively) than did relatives (29.4%) and friends (27.1%, P < .0001). With regards to sleep position, a higher percentage of licensed childcare providers placed infants who died under their care in the supine position to sleep (54.1%) compared with 38.4% of relatives, 38.6% of friends, and 37.8% of babysitters (P < .0001). Multiple Variable Logistic Regression Models for Sleep Environment Risk Factors After adjusting for age at death, race/ethnicity, and sex, infants who died under nonparental supervision had almost 13 times higher odds of having died outside of their home (aOR 12.87, 95% CI 11.31-14.65) compared with infants who died while supervised by a parent (Table IV). Infants who died while supervised by a nonparent had 61% higher odds of being placed prone (aOR 1.61, 95% CI 1.39-1.86), 35% higher odds of being placed on their side (aOR 1.35, 95% CI 1.12-1.62), and 74% higher odds of being found prone (aOR 1.74, 95% CI 1.502.02). However, infants under nonparental supervision were 71% less likely to be bed sharing (aOR 0.29, 95% CI 0.260.33). Finally, infants who died under nonparental supervision were also one-half as likely to have been placed to sleep on a couch or chair (aOR 0.50, 95% CI 0.40-0.62) or on an
Table IV. Crude and aOR of supervision by a nonparental supervisor at the time of death compared with supervision by a parental caregiver occurring in the presence of a sleep
Characteristics Location Not child's home Child's home Incident sleep place Car seat/stroller Adult bed/person Couch/chair Other Crib/bassinet/playpen Position placed On stomach On side Unknown/undetermined On back Position found On stomach On side Unknown/undetermined On back Bed sharing Yes No Object(s) in sleep environment Yes No
Parental caregiver not present — crude OR (95% CI)
Parental caregiver not present aOR (95% CI)*
12.94 (11.38, 14.71) Reference
12.87 (11.31, 14.65) Reference
0.8 (0.6, 1.1) 0.5 (0.4, 0.6) 0.5 (0.4, 0.6) 1.1 (0.8, 1.5) Reference
0.82 (0.60, 1.12) 0.50 (0.44, 0.58) 0.50 (0.40, 0.62) 1.12 (0.81, 1.53) Reference
1.51 (1.31, 1.74) 1.22 (1.02, 1.46) 0.85 (0.72, 0.996) Reference
1.61 (1.39, 1.86) 1.35 (1.12, 1.62) 0.84 (0.71, 0.99) Reference
1.78 (1.54, 2.06) 1.13 (0.92, 1.40) 1.01 (0.84, 1.22) Reference
1.74 (1.50, 2.02) 1.14 (0.92, 1.41) 1.00 (0.83, 1.20) Reference
0.28 (0.24, 0.31) Reference
0.29 (0.26, 0.33) Reference
1.14 (1.01, 1.28) Reference
1.11 (1.05, 1.18) Reference
*Adjusted for age at death, sex, and race/ethnicity. Reference is parental caregiver present.
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adult bed/person (aOR 0.50, 95% CI 0.44-0.58). The same multiple variable logistic regression models were also conducted for each age category (Table V; available at www.jpeds.com).
Discussion Although the environmental risk factors of SUID have been well documented, prior studies have not compared risk factors of sleep-related deaths under the supervision of parental and nonparental supervisors. Among the 10 490 deaths studied, those that occurred under nonparental supervision were associated with different risk factors than those under parental supervision. Infants who died under nonparental supervision were more likely to be placed and found prone, and infants under parental supervision were more likely to be bed sharing. Among nonparental supervisors, childcare providers were least likely to have placed infants prone, and friends and relatives were more likely to bed share. Side or prone sleep position remains an important risk factor associated with SIDS. Prone sleeping can increase the risk of rebreathing expired gases15 and overheating,16 and compromises cerebral oxygenation,17 autonomic control of the cardiovascular system,18 and arousal.19 Our findings suggest that nonparental supervisors are more likely to place infants prone or on their side. This may be due to a lack of communication about safe sleep position between parents and their relatives, babysitters, or friends. This finding is consistent with recent findings that infants who died from sleep-related deaths outside the home were more likely to have been placed prone and to be in a sleep location other than a crib.9 There is a common misperception that infants are less comfortable or may choke when supine, and supervisors may, therefore, be more likely to place the infant prone.20-23 Parents should, therefore, communicate their wishes regarding safe sleep practices to the other supervisors of their infant, as misinformed beliefs like these may have tragic results. Although past studies have demonstrated that many childcare providers place infants prone for sleeping,24 we found that childcare providers were the most likely of the nonparental supervisors to place infants in the supine position and in cribs. It is likely that this is the result of both educational efforts by the Back to Sleep campaign that have focused specifically on childcare providers25 and on state regulations regarding sleep environment.26 However, babysitters, who are not subject to these regulations, had rates of nonsupine placement that were similarly high to relative and friend caregivers. In addition, childcare providers and babysitters were most likely to have placed babies in car seats and strollers for sleep, possibly because of lack of space for multiple children to sleep. Given that infants are often placed awake in car seats to facilitate care,27 we speculate that this also occurs in childcare settings, and that infants fall asleep in these devices. Bed sharing is an important risk factor for SIDS; in particular, infants who died when they were younger than 4 months of age had a higher prevalence of bed sharing than infants who died at 4-12 months of age.10 Our findings suggest that parents are more likely than nonparents to bed share, and to hold their
infant or place them on an adult bed for sleep. It is possible that parents choose to keep their infant nearby to allow easy monitoring,28 or that fatigued parents may fall asleep with their child in the adult bed. In addition, friends and relatives were more likely than other nonparental supervisors to bed share or hold infants who died, possibly because of a closer familiarity with the child than babysitters or childcare providers may have. The newest American Academy of Pediatrics policy statement7 recommends room sharing with infants without bed sharing, which would provide the ability to easily monitor the infant. This is a suggestion that pediatricians should share with parents and nonparental supervisors. Census data from 2011 indicates that infants are twice as likely to be cared for by grandparents than by a childcare provider.29 Given the findings of this study, priority should be placed on educating relatives about safe sleep. Our findings suggest that relatives and friends are the nonparental supervisors most likely to place infants on an adult bed or couch or to hold them. They are also the most likely to place objects in the sleep environment. Parents should ensure that all individuals who care for their child are educated about safe sleep, so that these risk factors can be avoided. Public health messaging about safe sleep practices should also consider targeting relatives and friends. This study has limitations. The Child Death Review Case Reporting System may not include all child deaths within each state, and it does not necessarily constitute a representative sample of all infant sleep-related deaths from the contributing states. In addition, the limitations of the Case Reporting System reflect limitations of the child death review process: data are often incomplete, and witness accounts may be inaccurate. For certain variables, if the child death review team did not affirmatively mark that a condition was present at the time of death (ie, an object was found in the sleep environment), the variable choice defaulted to “unspecified.” We interpreted “unspecified” as meaning that the condition (ie, an object) was not present. This assumption relies on accurate completion of the death review report by the death review teams. If a death review team did not accurately complete a form, it would underestimate the presence of risk factors. It is unclear how this potential underestimation may have been more or less frequent for deaths occurring in the presence of nonparental supervisors. Reporting of risk factors may also have underestimated the actual prevalence, as there may have been social desirability bias. Further, we excluded deaths that were missing supervisor or caregiver data. It is possible that this data was systematically missing (rather than missing at random), and it is unclear if this may have created bias. Similarly, imputation of missing data assumes that the data are missing randomly. The high proportion of missing data for certain variables (eg, child health insurance and maternal education) precluded inclusion of these variables in the analysis. It is possible that inclusion of these variables in adjusted analyses could alter our results. However, our findings highlight the influence of parental presence or nonpresence on infant sleep environment risk factors, which we hope may be used to tailor resources about safe sleep for specific caregiver populations.
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THE JOURNAL OF PEDIATRICS • www.jpeds.com Certain well-established sleep environment risk factors, such as nonsupine sleep position, were more commonly present in sleep-related infant deaths that occurred under the care of nonparental supervisors, and others, such as bed sharing, were more commonly present in deaths occurring under the care of parental supervisors. Further declines in rates of sleeprelated infant deaths will require safe sleep education adherent to the recommendations of the American Academy of Pediatrics, not only of parents, but also of nonparental supervisors, such as relatives, babysitters, and childcare providers. ■ Acknowledgments available at www.jpeds.com Submitted for publication Oct 16, 2017; last revision received Dec 18, 2017; accepted Jan 18, 2018
References 1. Moon RY. Task Force on Sudden Infant Death Syndrome, SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics 2016;138:e20162940. 2. Mathews TJ, MacDorman MF, Thoma ME. Infant mortality statistics from the 2013 period linked birth/infant death data set. Natl Vital Stat Rep 2015;64. 3. Shapiro-Mendoza CK, Tomashek KM, Anderson RN, Wingo J. Recent national trends in sudden, unexpected infant deaths: more evidence supporting a change in classification or reporting. Am J Epidemiol 2006;163:762-9. 4. Malloy MH, MacDorman M. Changes in the classification of sudden unexpected infant deaths: United States, 1992-2001. Pediatrics 2005;115:124753. 5. United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis and Epidemiology (OAE), Division of Vital Statistics (DVS). Linked birth / infant death records on CDC WONDER online database. http://wonder.cdc.gov/lbd.html. Accessed July 11, 2017. 6. Filiano JJ, Kinney HC. A perspective on neuropathologic findings in victims of the sudden infant death syndrome: the triple-risk model. Biol Neonate 1994;65:194-7. 7. Moon RY. Task Force on Sudden Infant Death Syndrome, SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics 2016;138:e20162938. 8. Moon RY, Patel KM, Shaefer SJ. Sudden infant death syndrome in childcare settings. Pediatrics 2000;106:295-300. 9. Kassa H, Moon RY, Colvin JD. Risk factors for sleep-related infant deaths in in-home and out-of-home settings. Pediatrics 2016;138:e20161124. 10. Colvin JD, Collie-Akers V, Schunn C, Moon RY. Sleep environment risks for younger and older infants. Pediatrics 2014;134:e406-12.
Volume ■■ 11. Covington TM. The US national child death review case reporting system. Inj Prev 2011;17(Suppl 1):i34-7. 12. Howell DC. The treatment of missing data. SAGE handbook of social science methodology. London: SAGE; 2008. p. 1-44. 13. Baraldi AN, Enders CK. An introduction to modern missing data analyses. J Sch Psychol 2010;48:5-37. 14. Rechtman LR, Colvin JD, Blair PS, Moon RY. Sofas and infant mortality. Pediatrics 2014;134:e1293-300. 15. Kanetake J, Aoki Y, Funayama M. Evaluation of rebreathing potential on bedding for infant use. Pediatr Int 2003;45:284-9. 16. Ammari A, Schulze KF, Ohira-Kist K, Kashyap S, Fifer WP, Myers MM, et al. Effects of body position on thermal, cardiorespiratory and metabolic activity in low birth weight infants. Early Hum Dev 2009;85:497501. 17. Wong FY, Witcombe NB, Yiallourou SR, Yorkston S, Dymowski AR, Krishnan L, et al. Cerebral oxygenation is depressed during sleep in healthy term infants when they sleep prone. Pediatrics 2011;127:e558-65. 18. Yiallourou SR, Walker AM, Horne RS. Prone sleeping impairs circulatory control during sleep in healthy term infants: implications for SIDS. Sleep 2008;31:1139-46. 19. Horne RS, Ferens D, Watts AM, Vitkovic J, Lacey B, Andrew S, et al. Effects of maternal tobacco smoking, sleeping position, and sleep state on arousal in healthy term infants. Arch Dis Child Fetal Neonatal Ed 2002;87:F1005. 20. Aitken ME, Rose A, Mullins SH, Miller BK, Nick T, Rettiganti M, et al. Grandmothers’ beliefs and practices in infant safe sleep. Matern Child Health J 2016;20:1464-71. 21. Oden R, Joyner BL, Ajao TI, Moon R. Factors influencing AfricanAmerican mothers’ decisions about sleep position: a qualitative study. J Natl Med Assoc 2010;102:870-80. 22. Colson ER, Levenson S, Rybin D, Calianos C, Margolis A, Colton T, et al. Barriers to following the supine sleep recommendation among mothers at four centers for the Women, Infants, and Children Program. Pediatrics 2006;118:e243-50. 23. Colson ER, McCabe LK, Fox K, Levenson S, Colton T, Lister G, et al. Barriers to following the back-to-sleep recommendations: insights from focus groups with inner-city caregivers. Ambul Pediatr 2005;5:349-54. 24. Gershon NB, Moon RY. Infant sleep position in licensed childcare centers. Pediatrics 1997;100:75-8. 25. Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project. Pediatrics 2008;122:788-98. 26. Moon RY, Kotch L, Aird L. State childcare regulations regarding infant sleep environment since the Healthy Child Care America-Back to Sleep campaign. Pediatrics 2006;118:73-83. 27. Callahan CW, Sisler C. Use of seating devices in infants too young to sit. Arch Pediatr Adolesc Med 1997;151:233-5. 28. Moon RY, Oden RP, Joyner BL, Ajao TI. Qualitative analysis of beliefs and perceptions about sudden infant death syndrome (SIDS) among African-American mothers: implications for safe sleep recommendations. J Pediatr 2010;157:92-7, e2. 29. Laughlin L. Who’s minding the kids? Child care arrangements: Spring 2011. Washington (DC): U.S. Census Bureau; 2013.
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ORIGINAL ARTICLES Acknowledgments
We thank the National Center for Fatality Review and Prevention for giving us permission to use its dataset for analyses as well as answering our questions in regards to the collected data. This dataset was provided by the National Center Fatality Review & Prevention which is funded in part by Grant Number UG7MC28482 from the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), and in part by the US Centers for Disease Control
and Prevention Division of Reproductive Health. The contents are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Fatality Review and Prevention, U.S. Department of Health and Human Services, or the participating states. Forty-five states contributed data, including Alabama, Arkansas, Arizona, California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Iowa, Idaho, Indiana, Maryland, Michigan, Missouri, Mississippi, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas, Virginia, Washington, Wisconsin, and West Virginia.
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Table V. aOR by age category of supervision by a nonparental supervisor at the time of death compared with supervision by a parental caregiver Characteristics Location Not child's home Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Child's home Incident sleep place Car seat/stroller Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Adult bed/person Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Couch/chair Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Other Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Crib/bassinet/playpen Position placed On stomach Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On side Nonparental Parental Male Female
0-3 mo at death aOR (95% CI)
4-6 mo at death aOR (95% CI)
7 mo-364 d of age at death aOR (95% CI)
11.7 (9.9, 13.8) Reference 0.8 (0.7, 0.9) Reference 0.9 (0.6, 1.2) 1.0 (0.8, 1.4) 0.9 (0.7, 1.2) Reference Reference
15.9 (12.4, 20.3) Reference 1.1 (0.8, 1.3) Reference 0.9 (0.5, 1.4) 1.1 (0.7, 1.7) 1.0 (0.6, 1.6) Reference Reference
12.9 (8.9, 18.6) Reference 1.0 (0.7, 1.4) Reference 1.7 (0.8, 3.7) 1.5 (0.7, 3.1) 1.3 (0.6, 2.8) Reference Reference
0.6 (0.4, 1.0) Reference 0.8 (0.6, 1.1) Reference 1.0 (0.5, 2.3) 1.4 (0.6, 2.9) 1.9 (0.9, 4.1) Reference
1.0 (0.6, 1.7) Reference 1.0 (0.6, 1.5) Reference 0.9 (0.4, 2.1) 0.5 (0.2, 1.2) 0.6 (0.2, 1.5) Reference
1.4 (0.5, 3.4) Reference 0.8 (0.4, 1.9) Reference 2.1 (0.4, 10.7) 0.7 (0.2, 3.5) 0.2 (0.0, 2.7) Reference
0.4 (0.3, 0.5) Reference 0.9 (0.8, 1.0) Reference 1.0 (0.7, 1.3) 0.8 (0.6, 1.0) 1.1 (0.9, 1.5) Reference
0.6 (0.5, 0.8) Reference 0.8 (0.7, 1.0) Reference 0.9 (0.6, 1.4) 0.5 (0.3, 0.7) 1.4 (0.9, 2.1) Reference
0.8 (0.6, 1.2) Reference 0.9 (0.6, 1.2) Reference 1.2 (0.6, 2.3) 0.7 (0.4, 1.2) 2.0 (1.0, 3.7) Reference
0.4 (0.3, 0.6) Reference 1.0 (0.9, 1.2) Reference 0.9 (0.6, 1.4) 1.6 (1.0, 2.4) 1.7 (1.1, 2.6) Reference
0.5 (0.3, 0.8) Reference 0.6 (0.5, 0.8) Reference 0.7 (0.3, 1.4) 0.9 (0.5, 1.6) 2.0 (1.1, 3.9) Reference
0.8 (0.5, 1.5) Reference 0.9 (0.6, 1.4) Reference 1.7 (0.6, 5.1) 1.4 (0.5, 3.9) 2.8 (1.0, 8.0) Reference
0.9 (0.6, 1.4) Reference 0.8 (0.6, 1.1) Reference 9.0 (0.4, 1.8) 0.7 (0.3, 1.3) 0.8 (0.4, 1.6) Reference Reference
1.2 (0.7, 2.1) Reference 1.2 (0.7, 2.0) Reference 0.8 (0.3, 2.7) 0.4 (0.2, 1.1) 1.1 (0.4, 2.9) Reference Reference
2.3 (1.0, 5.5) Reference 1.3 (0.6, 3.0) Reference 0.7 (0.2, 2.6) 0.3 (0.1, 1.1) 0.7 (0.2, 2.8) Reference Reference
2.0 (1.6, 2.4) Reference 1.2 (1.0, 1.4) Reference 1.0 (0.7, 1.4) 1.2 (0.9, 1.6) 1.9 (1.4, 2.5) Reference
1.2 (0.9, 1.5) Reference 1.2 (1.0, 1.5) Reference 0.7 (0.4, 1.2) 1.1 (0.7, 1.7) 1.8 (1.1, 2.7) Reference
1.3 (0.8, 1.9) Reference 1.1 (0.8, 1.5) Reference 1.2 (0.6, 2.8) 1.1 (0.6, 2.4) 2.4 (1.2, 5.0) Reference
1.6 (1.3, 2.0) Reference 1.1 (0.9, 1.3) Reference
0.9 (0.6, 1.3) Reference 0.9 (0.7, 1.3) Reference
1.2 (0.7, 2.3) Reference 0.8 (0.5, 1.3) Reference (continued)
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Table V. Continued Characteristics Hispanic Non-Hispanic white Non-Hispanic black Other Unknown Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On back Position found On stomach Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On side Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Unknown Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On back Bed sharing Yes Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other No Object(s) in sleep environment Yes Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other No
0-3 mo at death aOR (95% CI)
4-6 mo at death aOR (95% CI)
7 mo-364 d of age at death aOR (95% CI)
1.4 (1.0, 2.0) 1.0 (0.7, 1.5) 1.4 (1.0, 1.9) Reference
1.9 (0.9, 4.0) 1.9 (0.9, 4.0) 2.3 (1.1, 4.8) Reference
2.1 (0.6, 7.7) 2.1 (0.6, 7.3) 2.1 (0.6, 7.5) Reference
0.9 (0.7, 1.1) Reference 1.1 (0.9, 1.2) Reference 1.0 (0.8, 1.4) 1.2 (0.9, 1.6) 1.1 (0.8, 1.5) Reference Reference
0.8 (0.6, 1.0) Reference 1.2 (0.9, 1.4) Reference 0.8 (0.5, 1.4) 1.2 (0.8, 1.9) 1.2 (0.7, 1.8) Reference Reference
0.9 (0.6, 1.3) Reference 1.2 (0.8, 1.6) Reference 2.2 (1.1, 4.7) 2.2 (1.1, 4.4) 2.1 (1.0, 4.4) Reference Reference
2.3 (1.9, 2.8) Reference 1.3 (1.1, 1.5) Reference 1.1 (0.8, 1.5) 1.2 (0.9, 1.6) 1.5 (1.2, 2.0) Reference
1.2 (0.9, 1.5) Reference 1.5 (1.3, 1.9) Reference 0.8 (0.5, 1.2) 1.1 (0.8, 1.7) 1.0 (0.7, 1.5) Reference
1.4 (0.9, 2.0) Reference 1.3 (1.0, 1.8) Reference 0.7 (0.3, 1.5) 0.8 (0.4, 1.5) 1.0 (0.5, 2.1) Reference
1.3 (1.0, 1.7) Reference 1.0 (0.9, 1.2) Reference 1.4 (0.9, 2.1) 1.5 (1.0, 2.1) 1.4 (1.0, 2.1) Reference
1.0 (0.7, 1.5) Reference 1.1 (0.8, 1.5) Reference 0.7 (0.46, 1.3) 1.1 (0.6, 1.9) 0.9 (0.5, 1.7) Reference
0.9 (0.5, 1.6) Reference 0.9 (0.6, 1.4) Reference 0.6 (0.2, 1.5) 0.5 (0.2, 1.2) 0.7 (0.3, 1.6) Reference
1.2 (0.9, 1.6) Reference 1.1 (1.0, 1.3) Reference 1.1 (0.8, 1.5) 1.4 (1.1, 1.9) 1.1 (0.8, 1.5) Reference Reference
0.7 (0.5, 1.0) Reference 1.2 (0.9, 1.5) Reference 0.7 (0.4, 1.3) 1.2 (0.7, 2.1) 0.9 (0.5, 1.5) Reference Reference
0.9 (0.5, 1.5) Reference 0.9 (0.6, 1.3) Reference 0.8 (0.3, 2.0) 1.1 (0.5, 2.6) 1.5 (0.6, 3.7) Reference Reference
0.2 (0.2, 0.3) Reference 0.9 (0.8, 0.9) Reference 1.0 (0.8, 1.3) 0.9 (0.7, 1.2) 1.3 (1.0, 1.6) Reference Reference
0.4 (0.3, 0.5) Reference 0.8 (0.7, 1.0) Reference 0.9 (0.6, 1.4) 0.8 (0.6, 1.2) 2.0 (1.4, 2.9) Reference Reference
0.4 (0.3, 0.5) Reference 0.7 (0.6, 1.0) Reference 0.8 (0.5, 1.5) 0.8 (0.5, 1.4) 2.1 (1.2, 3.7) Reference Reference
1.3 (1.1, 1.5) Reference 1.0 (0.9, 1.1) Reference 0.9 (0.7, 1.1) 0.8 (0.6, 1.0) 0.9 (0.7, 1.1) Reference Reference
0.8 (0.7, 0.9) Reference 1.1 (0.9, 1.3) Reference 1.2 (0.8, 1.8) 1.1 (0.7, 1.5) 1.0 (0.7, 1.4) Reference Reference
1.1 (0.8, 1.6) Reference 1.3 (1.0, 1.7) Reference 1.3 (0.7, 2.4) 1.5 (0.8, 2.6) 1.4 (0.8, 2.6) Reference Reference
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Characteristics of Infant Deaths during Sleep While Under Nonparental Supervision Elena Lagon, BS1, Rachel Y. Moon, MD2, and Jeffrey D. Colvin, MD, JD3 Objective To compare risk factors for infant sleep-related deaths under the supervision of parents and nonparents. Study design We conducted a secondary analysis of sleep-related infant deaths from 2004 to 2014 in the National Center for Fatality Review and Prevention Child Death Review Case Reporting System. The main exposure was supervisor at time of death. Primary outcomes included sleep position, location, and objects in the environment. Risk factors for parental vs nonparental supervisor were compared using c2 and multivariable logistic regression models. Risk factors associated with different nonparental supervisors were analyzed using c2. Results Of the 10 490 deaths, 1375 (13.1%) occurred under nonparental supervision. Infants who died under nonparental supervision had higher adjusted odds of dying outside the home (OR 12.87, 95% CI 11.31-14.65), being placed prone (OR 1.61, 95% CI 1.39-1.86) or on their side (OR 1.35, 95% CI 1.12-1.62), or being found prone (OR 1.74, 95% CI 1.50-2.02). Among infants who died under nonparental supervision, those supervised by relatives or friends were more often placed on an adult bed or couch for sleep and bed sharing (P < .0001), and to have objects in the sleep environment (P = .01). Conclusions Infants who died of sleep-related causes under nonparental supervision were more likely to have been placed nonsupine. Among nonparental supervisors, relatives and friends were more likely to use unsafe sleep environments, such as locations other than a crib or bassinet and bed sharing. Pediatricians should educate parents that all caregivers must always follow safe sleep practices. (J Pediatr 2018;■■:■■-■■).
S
udden unexpected infant death (SUID) is a term used to encompass the diagnoses of sudden infant death syndrome (SIDS), asphyxia (including accidental suffocation and strangulation in bed), and ill-defined deaths during the first 12 months of life.1 In 1994, a coalition including the American Academy of Pediatrics and US Public Health Service initiated the well-known public education campaign “Back to Sleep,” which was associated with a notable decline in SIDS rates.1 However, although SIDS rates have declined, rates of accidental suffocation and strangulation in bed and ill-defined deaths have increased (indicating a possible diagnostic shift), resulting in a plateauing of overall SUID rates since 2000.2-4 Approximately 3500 infants died from SUID in 2014.5 The etiology of SIDS and other sleep-related deaths is believed to be multifactorial, with biological, developmental, and environmental determinants.6 Efforts to reduce the risk of sleep-related infant deaths have targeted modifiable environmental risk factors, and the most recent (2016) American Academy of Pediatrics safe sleep recommendations include supine positioning, use of a crib or bassinet with a firm sleep surface, breastfeeding, room sharing without bed sharing, avoidance of soft bedding and overheating, and prevention of parental alcohol, tobacco, and illicit drug use.1,7 Although most safe sleep information targets parents and the home environment, prior research demonstrated that a large percentage of these deaths can occur outside the home as well. Approximately 20% of SIDS deaths in the 1990s occurred in a childcare setting (including in-home babysitters and nannies).8 We also found that approximately 20% of SUID occurs out of the home.9 However, no studies have examined environmental risk factors associated with nonparental supervisors across a wide range of contexts beyond child care and across both in-home and out-of-home locations. For this study, we sought to compare risk factors for infant sleep-related deaths under the supervision of From the 1; 2Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA; and parents and nonparents. 3
Methods For this retrospective cross-sectional study, we received a deidentified dataset from the National Center for Fatality Review and Prevention’s Child Death Review Case Reporting System of infant deaths (ages 0-364 days) from 45 states occurring during
Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO R.M. served as a paid expert witness in cases of sleeprelated infant death occurring while under nonparental supervision. The other authors declare no conflicts of interest. Data Statement: The data is unavailable to be accessed because it is confidential. Researchers interested in access to the data should contact the National Center for Fatality Review and Prevention. Portions of this study were presented at the Pediatric Academic Societies annual meeting, May 6-9, 2017, San Francisco, California.
SIDS SUID
Sudden infant death syndrome Sudden unexpected infant death
0022-3476/$ - see front matter. © 2018 Elsevier Inc. All rights reserved. https://doi.org10.1016/j.jpeds.2018.01.051
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THE JOURNAL OF PEDIATRICS • www.jpeds.com sleep or in the sleep environment during the period 20042014. The Child Death Review Case Reporting System has been previously described10,11 and contains infant, caregiver, and supervisor demographic information, as well as information about known risk factors, including sleep environmental risk factors such as sleep position, objects in the sleep environment, location (eg, crib), and setting (eg, child’s home, relative’s home). Appendix 1 includes the 2005 Case Report form and Appendix 2 includes the 2011 Case Report form. All children less than 365 days of age were included if their deaths occurred during sleep or in the sleep environment (excluding medical causes and intentional trauma). Cases with missing data on the supervisor at the incident or the primary caregiver of the infant were excluded. Among the 13 471 deaths contained in the data set, 1230 (9.1%) were excluded because they were not sleep-related and 1750 (13.0%) were excluded because the case was missing either caregiver or supervisor data. This study was deemed exempt by the institutional review board of the University of Virginia. An incident was coded as having a “parental supervisor” if the biological, adoptive, step, or foster parent, or the mother or father’s partner were present, and a “nonparental supervisor” if a relative, friend, babysitter, childcare worker, hospital or institutional staff member, or “other” individual was the supervisor at the time of death. Supervisor at the time of death was further categorized as parent, relative (grandparent, sibling, or other relative), friend/acquaintance, childcare provider, babysitter, or other. The sleep positions in which infants were placed and found were categorized as supine, side, or prone. We categorized the incident sleep place as follows: crib (including bassinet or playpen); car seat/stroller; adult bed or on an adult person; couch or sofa; other (floor, futon, pillow, and bean bag); and unknown. Sleeping on an adult bed and sleeping on an adult person were grouped together because both situations represent the risk of suffocation due to adult roll-over. If an infant was sleeping on an adult and the adult was on a sofa or other piece of furniture, the incident sleep place was categorized as “on an adult.” Additional risk factors included bed sharing with an adult or other child, and the presence of objects, such as pillows, quilts, or toys, in the sleep environment. Infant demographic characteristics included age, sex, and race/ethnicity. As our prior studies have demonstrated differences in the importance of risk factors depending on age,10 infant age at death was classified as 0-3 months, 4-6 months, and 7 months-364 days. Race/ethnicity was classified as nonHispanic white, non-Hispanic black, Hispanic, and other. Incident location was categorized as child’s home, relative/ friend’s home, foster home, daycare/babysitter’s, and travelling/ temporary. The travelling/temporary category included sidewalks, driveways, roadways, trains, buses, parking areas, parks, sporting areas, other recreation areas, stores, restaurants, and similar locations. Statistical Analyses Data were analyzed using SPSS (IBM Corporation, Armonk, New York) and SAS (SAS Institute, Cary, North Carolina). We
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performed multiple imputation by using the Markov Monte Carlo method to impute missing data for variables used in the analyses12,13 (information on the proportions of missing data is included in Tables I and II; the maximum missing data per variable was 3.6%). Multiple imputation has been previously used for analyses of the Child Death Review Case Reporting System database.10,14 Multiple imputation predicts values for incomplete variables by using regression equations from complete variables. This minimizes assumptions that the subset of cases with complete data are representative of the entire sample population. Multiple imputation is used so that biases resulting from missing data are reduced; it provides better, nearly unbiased estimates than other methods of handling missing data.12,13 All subsequent analyses were conducted with pooled imputed data. Risk factors and demographic characteristics were compared for these 2 groups using the c2 test and multiple variable logistic regression analyses (controlling for age, sex, and race/ethnicity). In addition, risk factors were compared across specific nonparental supervisor types (relative, friend/ acquaintance, childcare provider, etc) using the c2 test.
Results A total of 10 490 sleep-related deaths met inclusion criteria. Of these deaths, 1375 (13.1%) occurred when a parent was not present (Table I). Infants who died under nonparental supervision were more likely to be older (44.9% aged 4 months and older under nonparental supervision vs 31.1% under parental supervision, P < .0001). There were no sex or racial/ethnic differences. Deaths under nonparental supervision were more likely than those under parental supervision to occur at a relative or friend’s home (29.7% vs 10%, P < .0001). In contrast, 86.3% of deaths under parental supervision occurred in the infant’s home (P < .0001). Of deaths occurring under nonparental supervision, more than two-thirds (67.3%) of deaths occurred outside of the child’s home, with approximately one-half (34.0%) of these occurring in a daycare center or babysitter’s home. Of deaths occurring under nonparental supervision, non-Hispanic white infants had a higher percentage while under the supervision of a licensed childcare provider (66.6%) or babysitter (57.2%) compared with non-Hispanic black infants (9.7% and 15.4%, respectively) and Hispanic infants (16.2% and 20.9%, respectively, P < .0001). Sleep Environment Risk Factors: Bivariate Analyses Sleep environment risk factors for deaths occurring under parental vs nonparental supervision were compared (Table II). With regards to sleep location, a higher proportion of deaths under parental supervision occurred in an adult bed or on an adult (55.0% vs 41.3%, P < .0001), and deaths under nonparental supervision were more likely to occur in a crib, bassinet, or playpen (40.3% vs 25.8%, P < .0001). Infants who died under parental supervision were twice as likely to be bed
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Table I. Incident location and demographic characteristics of infants with sleep-related death Total (n = 10 490) Characteristics* Age at death 0-3 mo 4-6 mo 7 mo-364 d Sex Male Female Race/ethnicity Hispanic Non-Hispanic white Non-Hispanic black Other Incident location Child's home Relative/friend's home Foster home Daycare/babysitter's Traveling/temporary Others
Parental primary caregiver present at incident (n = 9115)
Parental primary caregiver not present at incident (n = 1375)
N
%
N
%
N
%
7042 2441 1007
67.1 23.3 9.6
6284 2014 817
68.9 22.1 9.0
758 427 190
55.1 31.1 13.8
6124 4366
58.4 41.6
5310 3805
58.3 41.7
814 561
59.2 40.8
1849 4666 3344 631
17.6 44.5 31.9 6.0
1604 4027 2943 541
17.6 44.2 32.3 5.9
245 639 401 90
17.8 46.5 29.1 6.6
8313 1318 111 480 122 146
79.2 12.6 1.1 4.6 1.2 1.4
7863 910 83 12 117 129
86.3 10.0 0.9 0.1 1.3 1.4
449 408 28 468 5 17
32.7 29.7 2.1 34.0 0.4 1.2
P value† <.0001
.49
.12
<.0001
*Missing data was imputed for the following variables: sex (0.3%), race/ethnicity (2.3%), and incident location (1.1%). †P values reflect c2 tests comparing parental supervisor and nonparental supervisor groups for each demographic characteristic.
sharing at the time of death (60.0% vs 29.3%, P < .0001). However, infants under nonparental supervision were both less likely to be placed supine to sleep (39.3% vs 43.4%, P < .0001) and more likely to be found in the prone position (51.0% vs 37.6%, P < .0001), and also more likely to have objects in the sleep environment (36.1% vs 33.1%, P = .03).
We then examined risk factors specifically for the different categories of nonparental supervisors (eg, relatives, friends, babysitters, childcare providers) (Table III). Deaths under the care of relatives and friends were most likely to occur while infants were held or placed on an adult bed (53.4% and 47.1%, respectively) compared with deaths that occurred under the
Table II. Sleep environment risk factors occurring under parental and nonparental supervision Total (n = 10 490) Characteristics* Incident sleep place Crib/bassinet/playpen Car seat/stroller Adult bed/person Couch/chair Other Position placed On back On stomach On side Unknown Position found On back On stomach On side Unknown Bed sharing No Yes Object(s) in sleep environment No Yes
Parental primary caregiver present at incident (n = 9115)
Parental primary caregiver not present at incident (n = 1375)
N
%
N
%
N
%
2905 353 5582 1368 282
27.7 3.4 53.2 13.0 2.7
2350 298 5013 1230 224
25.8 3.3 55.0 13.5 2.5
555 56 568 138 58
40.3 4.1 41.3 10.0 4.2
4494 2363 1360 2273
42.8 22.5 13.0 21.7
3954 1958 1166 2037
43.4 21.5 12.8 22.3
541 405 194 236
39.3 29.4 14.1 17.1
3001 4128 1288 2074
28.6 39.4 12.3 19.8
2691 3427 1139 1857
29.5 37.6 12.5 20.4
310 701 148 216
22.5 51.0 10.8 15.7
4615 5875
44.0 56.0
3642 5473
40.0 60.0
972 403
70.7 29.3
6975 3515
66.5 33.5
6096 3019
66.9 33.1
879 496
63.9 36.1
P value <.0001
<.0001
<.0001
<.0001 .03
*Missing data was imputed for the following variables: sleep surface (3.1%), position placed (3.6%), position found (3.6%), and bed sharing (0.1%).
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Table III. Characteristics of sleep-related infant deaths stratified by nonparental supervisor Total (n = 1375) Characteristics Incident sleep place Crib/bassinet/playpen Car seat/stroller Adult bed/person Couch/chair Other Position placed On back On stomach On side Unknown Position found On back On stomach On side Unknown Bed sharing No Yes Object(s) in sleep environment No Yes
Relative (n = 673)
Friend (n = 85)
Childcare provider (n = 149)
Babysitter (n = 418)
Other (n = 50)
N
%
N
%
N
%
N
%
N
%
N
%
555 56 568 138 58
40.3 4.1 41.3 10.0 4.2
198 13 359 83 19
29.4 2.0 53.4 12.4 2.9
23 3 40 13 6
27.1 3.5 47.1 15.3 7.1
205 27 127 33 25
49.1 6.5 30.4 7.9 6.0
108 11 20 3 6
72.5 7.5 13.7 2.1 4.2
21 1 22 5 2
41.6 2.0 43.2 10.0 3.2
541 405 194 236
39.3 29.4 14.1 17.1
258 198 91 125
38.4 29.5 13.5 18.6
33 29 7 16
38.6 34.4 8.2 18.8
158 138 66 57
37.8 32.9 15.7 13.6
81 32 23 13
54.1 21.7 15.3 8.9
11 7 7 25
22.0 14.4 14.4 49.2
310 701 148 216
22.5 51.0 10.8 15.7
159 339 74 101
23.6 50.4 11.0 15.0
19 49 7 10
21.9 58.1 8.7 11.3
73 234 45 66
17.4 56.0 10.9 15.7
53 68 12 15
35.8 45.6 8.3 10.2
6 10 9 25
12.0 19.2 18.8 50.0
972 403
70.7 29.3
381 292
56.6 43.4
43 42
50.6 49.4
371 47
88.8 11.2
146 3
98.0 2.0
31 19
62.4 37.6
879 496
63.9 36.1
414 259
61.5 38.5
48 37
56.5 43.5
271 147
64.8 35.2
106 43
71.1 28.9
40 10
80.0 20.0
P value <.0001
<.0001
<.0001
<.0001 .01
supervision of a babysitter (30.4%) or childcare provider (13.7%, P < .0001). Almost one-half of the infants under relative (43.4%) or friend (49.4%) supervision died while bed sharing (P < .0001). A higher percentage of babysitters and childcare providers placed the infant in a crib (49.1% and 72.5%, respectively) than did relatives (29.4%) and friends (27.1%, P < .0001). With regards to sleep position, a higher percentage of licensed childcare providers placed infants who died under their care in the supine position to sleep (54.1%) compared with 38.4% of relatives, 38.6% of friends, and 37.8% of babysitters (P < .0001). Multiple Variable Logistic Regression Models for Sleep Environment Risk Factors After adjusting for age at death, race/ethnicity, and sex, infants who died under nonparental supervision had almost 13 times higher odds of having died outside of their home (aOR 12.87, 95% CI 11.31-14.65) compared with infants who died while supervised by a parent (Table IV). Infants who died while supervised by a nonparent had 61% higher odds of being placed prone (aOR 1.61, 95% CI 1.39-1.86), 35% higher odds of being placed on their side (aOR 1.35, 95% CI 1.12-1.62), and 74% higher odds of being found prone (aOR 1.74, 95% CI 1.502.02). However, infants under nonparental supervision were 71% less likely to be bed sharing (aOR 0.29, 95% CI 0.260.33). Finally, infants who died under nonparental supervision were also one-half as likely to have been placed to sleep on a couch or chair (aOR 0.50, 95% CI 0.40-0.62) or on an
Table IV. Crude and aOR of supervision by a nonparental supervisor at the time of death compared with supervision by a parental caregiver occurring in the presence of a sleep
Characteristics Location Not child's home Child's home Incident sleep place Car seat/stroller Adult bed/person Couch/chair Other Crib/bassinet/playpen Position placed On stomach On side Unknown/undetermined On back Position found On stomach On side Unknown/undetermined On back Bed sharing Yes No Object(s) in sleep environment Yes No
Parental caregiver not present — crude OR (95% CI)
Parental caregiver not present aOR (95% CI)*
12.94 (11.38, 14.71) Reference
12.87 (11.31, 14.65) Reference
0.8 (0.6, 1.1) 0.5 (0.4, 0.6) 0.5 (0.4, 0.6) 1.1 (0.8, 1.5) Reference
0.82 (0.60, 1.12) 0.50 (0.44, 0.58) 0.50 (0.40, 0.62) 1.12 (0.81, 1.53) Reference
1.51 (1.31, 1.74) 1.22 (1.02, 1.46) 0.85 (0.72, 0.996) Reference
1.61 (1.39, 1.86) 1.35 (1.12, 1.62) 0.84 (0.71, 0.99) Reference
1.78 (1.54, 2.06) 1.13 (0.92, 1.40) 1.01 (0.84, 1.22) Reference
1.74 (1.50, 2.02) 1.14 (0.92, 1.41) 1.00 (0.83, 1.20) Reference
0.28 (0.24, 0.31) Reference
0.29 (0.26, 0.33) Reference
1.14 (1.01, 1.28) Reference
1.11 (1.05, 1.18) Reference
*Adjusted for age at death, sex, and race/ethnicity. Reference is parental caregiver present.
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adult bed/person (aOR 0.50, 95% CI 0.44-0.58). The same multiple variable logistic regression models were also conducted for each age category (Table V; available at www.jpeds.com).
Discussion Although the environmental risk factors of SUID have been well documented, prior studies have not compared risk factors of sleep-related deaths under the supervision of parental and nonparental supervisors. Among the 10 490 deaths studied, those that occurred under nonparental supervision were associated with different risk factors than those under parental supervision. Infants who died under nonparental supervision were more likely to be placed and found prone, and infants under parental supervision were more likely to be bed sharing. Among nonparental supervisors, childcare providers were least likely to have placed infants prone, and friends and relatives were more likely to bed share. Side or prone sleep position remains an important risk factor associated with SIDS. Prone sleeping can increase the risk of rebreathing expired gases15 and overheating,16 and compromises cerebral oxygenation,17 autonomic control of the cardiovascular system,18 and arousal.19 Our findings suggest that nonparental supervisors are more likely to place infants prone or on their side. This may be due to a lack of communication about safe sleep position between parents and their relatives, babysitters, or friends. This finding is consistent with recent findings that infants who died from sleep-related deaths outside the home were more likely to have been placed prone and to be in a sleep location other than a crib.9 There is a common misperception that infants are less comfortable or may choke when supine, and supervisors may, therefore, be more likely to place the infant prone.20-23 Parents should, therefore, communicate their wishes regarding safe sleep practices to the other supervisors of their infant, as misinformed beliefs like these may have tragic results. Although past studies have demonstrated that many childcare providers place infants prone for sleeping,24 we found that childcare providers were the most likely of the nonparental supervisors to place infants in the supine position and in cribs. It is likely that this is the result of both educational efforts by the Back to Sleep campaign that have focused specifically on childcare providers25 and on state regulations regarding sleep environment.26 However, babysitters, who are not subject to these regulations, had rates of nonsupine placement that were similarly high to relative and friend caregivers. In addition, childcare providers and babysitters were most likely to have placed babies in car seats and strollers for sleep, possibly because of lack of space for multiple children to sleep. Given that infants are often placed awake in car seats to facilitate care,27 we speculate that this also occurs in childcare settings, and that infants fall asleep in these devices. Bed sharing is an important risk factor for SIDS; in particular, infants who died when they were younger than 4 months of age had a higher prevalence of bed sharing than infants who died at 4-12 months of age.10 Our findings suggest that parents are more likely than nonparents to bed share, and to hold their
infant or place them on an adult bed for sleep. It is possible that parents choose to keep their infant nearby to allow easy monitoring,28 or that fatigued parents may fall asleep with their child in the adult bed. In addition, friends and relatives were more likely than other nonparental supervisors to bed share or hold infants who died, possibly because of a closer familiarity with the child than babysitters or childcare providers may have. The newest American Academy of Pediatrics policy statement7 recommends room sharing with infants without bed sharing, which would provide the ability to easily monitor the infant. This is a suggestion that pediatricians should share with parents and nonparental supervisors. Census data from 2011 indicates that infants are twice as likely to be cared for by grandparents than by a childcare provider.29 Given the findings of this study, priority should be placed on educating relatives about safe sleep. Our findings suggest that relatives and friends are the nonparental supervisors most likely to place infants on an adult bed or couch or to hold them. They are also the most likely to place objects in the sleep environment. Parents should ensure that all individuals who care for their child are educated about safe sleep, so that these risk factors can be avoided. Public health messaging about safe sleep practices should also consider targeting relatives and friends. This study has limitations. The Child Death Review Case Reporting System may not include all child deaths within each state, and it does not necessarily constitute a representative sample of all infant sleep-related deaths from the contributing states. In addition, the limitations of the Case Reporting System reflect limitations of the child death review process: data are often incomplete, and witness accounts may be inaccurate. For certain variables, if the child death review team did not affirmatively mark that a condition was present at the time of death (ie, an object was found in the sleep environment), the variable choice defaulted to “unspecified.” We interpreted “unspecified” as meaning that the condition (ie, an object) was not present. This assumption relies on accurate completion of the death review report by the death review teams. If a death review team did not accurately complete a form, it would underestimate the presence of risk factors. It is unclear how this potential underestimation may have been more or less frequent for deaths occurring in the presence of nonparental supervisors. Reporting of risk factors may also have underestimated the actual prevalence, as there may have been social desirability bias. Further, we excluded deaths that were missing supervisor or caregiver data. It is possible that this data was systematically missing (rather than missing at random), and it is unclear if this may have created bias. Similarly, imputation of missing data assumes that the data are missing randomly. The high proportion of missing data for certain variables (eg, child health insurance and maternal education) precluded inclusion of these variables in the analysis. It is possible that inclusion of these variables in adjusted analyses could alter our results. However, our findings highlight the influence of parental presence or nonpresence on infant sleep environment risk factors, which we hope may be used to tailor resources about safe sleep for specific caregiver populations.
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THE JOURNAL OF PEDIATRICS • www.jpeds.com Certain well-established sleep environment risk factors, such as nonsupine sleep position, were more commonly present in sleep-related infant deaths that occurred under the care of nonparental supervisors, and others, such as bed sharing, were more commonly present in deaths occurring under the care of parental supervisors. Further declines in rates of sleeprelated infant deaths will require safe sleep education adherent to the recommendations of the American Academy of Pediatrics, not only of parents, but also of nonparental supervisors, such as relatives, babysitters, and childcare providers. ■ Acknowledgments available at www.jpeds.com Submitted for publication Oct 16, 2017; last revision received Dec 18, 2017; accepted Jan 18, 2018
References 1. Moon RY. Task Force on Sudden Infant Death Syndrome, SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics 2016;138:e20162940. 2. Mathews TJ, MacDorman MF, Thoma ME. Infant mortality statistics from the 2013 period linked birth/infant death data set. Natl Vital Stat Rep 2015;64. 3. Shapiro-Mendoza CK, Tomashek KM, Anderson RN, Wingo J. Recent national trends in sudden, unexpected infant deaths: more evidence supporting a change in classification or reporting. Am J Epidemiol 2006;163:762-9. 4. Malloy MH, MacDorman M. Changes in the classification of sudden unexpected infant deaths: United States, 1992-2001. Pediatrics 2005;115:124753. 5. United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis and Epidemiology (OAE), Division of Vital Statistics (DVS). Linked birth / infant death records on CDC WONDER online database. http://wonder.cdc.gov/lbd.html. Accessed July 11, 2017. 6. Filiano JJ, Kinney HC. A perspective on neuropathologic findings in victims of the sudden infant death syndrome: the triple-risk model. Biol Neonate 1994;65:194-7. 7. Moon RY. Task Force on Sudden Infant Death Syndrome, SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics 2016;138:e20162938. 8. Moon RY, Patel KM, Shaefer SJ. Sudden infant death syndrome in childcare settings. Pediatrics 2000;106:295-300. 9. Kassa H, Moon RY, Colvin JD. Risk factors for sleep-related infant deaths in in-home and out-of-home settings. Pediatrics 2016;138:e20161124. 10. Colvin JD, Collie-Akers V, Schunn C, Moon RY. Sleep environment risks for younger and older infants. Pediatrics 2014;134:e406-12.
Volume ■■ 11. Covington TM. The US national child death review case reporting system. Inj Prev 2011;17(Suppl 1):i34-7. 12. Howell DC. The treatment of missing data. SAGE handbook of social science methodology. London: SAGE; 2008. p. 1-44. 13. Baraldi AN, Enders CK. An introduction to modern missing data analyses. J Sch Psychol 2010;48:5-37. 14. Rechtman LR, Colvin JD, Blair PS, Moon RY. Sofas and infant mortality. Pediatrics 2014;134:e1293-300. 15. Kanetake J, Aoki Y, Funayama M. Evaluation of rebreathing potential on bedding for infant use. Pediatr Int 2003;45:284-9. 16. Ammari A, Schulze KF, Ohira-Kist K, Kashyap S, Fifer WP, Myers MM, et al. Effects of body position on thermal, cardiorespiratory and metabolic activity in low birth weight infants. Early Hum Dev 2009;85:497501. 17. Wong FY, Witcombe NB, Yiallourou SR, Yorkston S, Dymowski AR, Krishnan L, et al. Cerebral oxygenation is depressed during sleep in healthy term infants when they sleep prone. Pediatrics 2011;127:e558-65. 18. Yiallourou SR, Walker AM, Horne RS. Prone sleeping impairs circulatory control during sleep in healthy term infants: implications for SIDS. Sleep 2008;31:1139-46. 19. Horne RS, Ferens D, Watts AM, Vitkovic J, Lacey B, Andrew S, et al. Effects of maternal tobacco smoking, sleeping position, and sleep state on arousal in healthy term infants. Arch Dis Child Fetal Neonatal Ed 2002;87:F1005. 20. Aitken ME, Rose A, Mullins SH, Miller BK, Nick T, Rettiganti M, et al. Grandmothers’ beliefs and practices in infant safe sleep. Matern Child Health J 2016;20:1464-71. 21. Oden R, Joyner BL, Ajao TI, Moon R. Factors influencing AfricanAmerican mothers’ decisions about sleep position: a qualitative study. J Natl Med Assoc 2010;102:870-80. 22. Colson ER, Levenson S, Rybin D, Calianos C, Margolis A, Colton T, et al. Barriers to following the supine sleep recommendation among mothers at four centers for the Women, Infants, and Children Program. Pediatrics 2006;118:e243-50. 23. Colson ER, McCabe LK, Fox K, Levenson S, Colton T, Lister G, et al. Barriers to following the back-to-sleep recommendations: insights from focus groups with inner-city caregivers. Ambul Pediatr 2005;5:349-54. 24. Gershon NB, Moon RY. Infant sleep position in licensed childcare centers. Pediatrics 1997;100:75-8. 25. Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project. Pediatrics 2008;122:788-98. 26. Moon RY, Kotch L, Aird L. State childcare regulations regarding infant sleep environment since the Healthy Child Care America-Back to Sleep campaign. Pediatrics 2006;118:73-83. 27. Callahan CW, Sisler C. Use of seating devices in infants too young to sit. Arch Pediatr Adolesc Med 1997;151:233-5. 28. Moon RY, Oden RP, Joyner BL, Ajao TI. Qualitative analysis of beliefs and perceptions about sudden infant death syndrome (SIDS) among African-American mothers: implications for safe sleep recommendations. J Pediatr 2010;157:92-7, e2. 29. Laughlin L. Who’s minding the kids? Child care arrangements: Spring 2011. Washington (DC): U.S. Census Bureau; 2013.
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We thank the National Center for Fatality Review and Prevention for giving us permission to use its dataset for analyses as well as answering our questions in regards to the collected data. This dataset was provided by the National Center Fatality Review & Prevention which is funded in part by Grant Number UG7MC28482 from the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), and in part by the US Centers for Disease Control
and Prevention Division of Reproductive Health. The contents are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Fatality Review and Prevention, U.S. Department of Health and Human Services, or the participating states. Forty-five states contributed data, including Alabama, Arkansas, Arizona, California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Iowa, Idaho, Indiana, Maryland, Michigan, Missouri, Mississippi, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas, Virginia, Washington, Wisconsin, and West Virginia.
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Table V. aOR by age category of supervision by a nonparental supervisor at the time of death compared with supervision by a parental caregiver Characteristics Location Not child's home Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Child's home Incident sleep place Car seat/stroller Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Adult bed/person Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Couch/chair Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Other Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Crib/bassinet/playpen Position placed On stomach Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On side Nonparental Parental Male Female
0-3 mo at death aOR (95% CI)
4-6 mo at death aOR (95% CI)
7 mo-364 d of age at death aOR (95% CI)
11.7 (9.9, 13.8) Reference 0.8 (0.7, 0.9) Reference 0.9 (0.6, 1.2) 1.0 (0.8, 1.4) 0.9 (0.7, 1.2) Reference Reference
15.9 (12.4, 20.3) Reference 1.1 (0.8, 1.3) Reference 0.9 (0.5, 1.4) 1.1 (0.7, 1.7) 1.0 (0.6, 1.6) Reference Reference
12.9 (8.9, 18.6) Reference 1.0 (0.7, 1.4) Reference 1.7 (0.8, 3.7) 1.5 (0.7, 3.1) 1.3 (0.6, 2.8) Reference Reference
0.6 (0.4, 1.0) Reference 0.8 (0.6, 1.1) Reference 1.0 (0.5, 2.3) 1.4 (0.6, 2.9) 1.9 (0.9, 4.1) Reference
1.0 (0.6, 1.7) Reference 1.0 (0.6, 1.5) Reference 0.9 (0.4, 2.1) 0.5 (0.2, 1.2) 0.6 (0.2, 1.5) Reference
1.4 (0.5, 3.4) Reference 0.8 (0.4, 1.9) Reference 2.1 (0.4, 10.7) 0.7 (0.2, 3.5) 0.2 (0.0, 2.7) Reference
0.4 (0.3, 0.5) Reference 0.9 (0.8, 1.0) Reference 1.0 (0.7, 1.3) 0.8 (0.6, 1.0) 1.1 (0.9, 1.5) Reference
0.6 (0.5, 0.8) Reference 0.8 (0.7, 1.0) Reference 0.9 (0.6, 1.4) 0.5 (0.3, 0.7) 1.4 (0.9, 2.1) Reference
0.8 (0.6, 1.2) Reference 0.9 (0.6, 1.2) Reference 1.2 (0.6, 2.3) 0.7 (0.4, 1.2) 2.0 (1.0, 3.7) Reference
0.4 (0.3, 0.6) Reference 1.0 (0.9, 1.2) Reference 0.9 (0.6, 1.4) 1.6 (1.0, 2.4) 1.7 (1.1, 2.6) Reference
0.5 (0.3, 0.8) Reference 0.6 (0.5, 0.8) Reference 0.7 (0.3, 1.4) 0.9 (0.5, 1.6) 2.0 (1.1, 3.9) Reference
0.8 (0.5, 1.5) Reference 0.9 (0.6, 1.4) Reference 1.7 (0.6, 5.1) 1.4 (0.5, 3.9) 2.8 (1.0, 8.0) Reference
0.9 (0.6, 1.4) Reference 0.8 (0.6, 1.1) Reference 9.0 (0.4, 1.8) 0.7 (0.3, 1.3) 0.8 (0.4, 1.6) Reference Reference
1.2 (0.7, 2.1) Reference 1.2 (0.7, 2.0) Reference 0.8 (0.3, 2.7) 0.4 (0.2, 1.1) 1.1 (0.4, 2.9) Reference Reference
2.3 (1.0, 5.5) Reference 1.3 (0.6, 3.0) Reference 0.7 (0.2, 2.6) 0.3 (0.1, 1.1) 0.7 (0.2, 2.8) Reference Reference
2.0 (1.6, 2.4) Reference 1.2 (1.0, 1.4) Reference 1.0 (0.7, 1.4) 1.2 (0.9, 1.6) 1.9 (1.4, 2.5) Reference
1.2 (0.9, 1.5) Reference 1.2 (1.0, 1.5) Reference 0.7 (0.4, 1.2) 1.1 (0.7, 1.7) 1.8 (1.1, 2.7) Reference
1.3 (0.8, 1.9) Reference 1.1 (0.8, 1.5) Reference 1.2 (0.6, 2.8) 1.1 (0.6, 2.4) 2.4 (1.2, 5.0) Reference
1.6 (1.3, 2.0) Reference 1.1 (0.9, 1.3) Reference
0.9 (0.6, 1.3) Reference 0.9 (0.7, 1.3) Reference
1.2 (0.7, 2.3) Reference 0.8 (0.5, 1.3) Reference (continued)
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Table V. Continued Characteristics Hispanic Non-Hispanic white Non-Hispanic black Other Unknown Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On back Position found On stomach Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On side Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other Unknown Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other On back Bed sharing Yes Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other No Object(s) in sleep environment Yes Nonparental Parental Male Female Hispanic Non-Hispanic white Non-Hispanic black Other No
0-3 mo at death aOR (95% CI)
4-6 mo at death aOR (95% CI)
7 mo-364 d of age at death aOR (95% CI)
1.4 (1.0, 2.0) 1.0 (0.7, 1.5) 1.4 (1.0, 1.9) Reference
1.9 (0.9, 4.0) 1.9 (0.9, 4.0) 2.3 (1.1, 4.8) Reference
2.1 (0.6, 7.7) 2.1 (0.6, 7.3) 2.1 (0.6, 7.5) Reference
0.9 (0.7, 1.1) Reference 1.1 (0.9, 1.2) Reference 1.0 (0.8, 1.4) 1.2 (0.9, 1.6) 1.1 (0.8, 1.5) Reference Reference
0.8 (0.6, 1.0) Reference 1.2 (0.9, 1.4) Reference 0.8 (0.5, 1.4) 1.2 (0.8, 1.9) 1.2 (0.7, 1.8) Reference Reference
0.9 (0.6, 1.3) Reference 1.2 (0.8, 1.6) Reference 2.2 (1.1, 4.7) 2.2 (1.1, 4.4) 2.1 (1.0, 4.4) Reference Reference
2.3 (1.9, 2.8) Reference 1.3 (1.1, 1.5) Reference 1.1 (0.8, 1.5) 1.2 (0.9, 1.6) 1.5 (1.2, 2.0) Reference
1.2 (0.9, 1.5) Reference 1.5 (1.3, 1.9) Reference 0.8 (0.5, 1.2) 1.1 (0.8, 1.7) 1.0 (0.7, 1.5) Reference
1.4 (0.9, 2.0) Reference 1.3 (1.0, 1.8) Reference 0.7 (0.3, 1.5) 0.8 (0.4, 1.5) 1.0 (0.5, 2.1) Reference
1.3 (1.0, 1.7) Reference 1.0 (0.9, 1.2) Reference 1.4 (0.9, 2.1) 1.5 (1.0, 2.1) 1.4 (1.0, 2.1) Reference
1.0 (0.7, 1.5) Reference 1.1 (0.8, 1.5) Reference 0.7 (0.46, 1.3) 1.1 (0.6, 1.9) 0.9 (0.5, 1.7) Reference
0.9 (0.5, 1.6) Reference 0.9 (0.6, 1.4) Reference 0.6 (0.2, 1.5) 0.5 (0.2, 1.2) 0.7 (0.3, 1.6) Reference
1.2 (0.9, 1.6) Reference 1.1 (1.0, 1.3) Reference 1.1 (0.8, 1.5) 1.4 (1.1, 1.9) 1.1 (0.8, 1.5) Reference Reference
0.7 (0.5, 1.0) Reference 1.2 (0.9, 1.5) Reference 0.7 (0.4, 1.3) 1.2 (0.7, 2.1) 0.9 (0.5, 1.5) Reference Reference
0.9 (0.5, 1.5) Reference 0.9 (0.6, 1.3) Reference 0.8 (0.3, 2.0) 1.1 (0.5, 2.6) 1.5 (0.6, 3.7) Reference Reference
0.2 (0.2, 0.3) Reference 0.9 (0.8, 0.9) Reference 1.0 (0.8, 1.3) 0.9 (0.7, 1.2) 1.3 (1.0, 1.6) Reference Reference
0.4 (0.3, 0.5) Reference 0.8 (0.7, 1.0) Reference 0.9 (0.6, 1.4) 0.8 (0.6, 1.2) 2.0 (1.4, 2.9) Reference Reference
0.4 (0.3, 0.5) Reference 0.7 (0.6, 1.0) Reference 0.8 (0.5, 1.5) 0.8 (0.5, 1.4) 2.1 (1.2, 3.7) Reference Reference
1.3 (1.1, 1.5) Reference 1.0 (0.9, 1.1) Reference 0.9 (0.7, 1.1) 0.8 (0.6, 1.0) 0.9 (0.7, 1.1) Reference Reference
0.8 (0.7, 0.9) Reference 1.1 (0.9, 1.3) Reference 1.2 (0.8, 1.8) 1.1 (0.7, 1.5) 1.0 (0.7, 1.4) Reference Reference
1.1 (0.8, 1.6) Reference 1.3 (1.0, 1.7) Reference 1.3 (0.7, 2.4) 1.5 (0.8, 2.6) 1.4 (0.8, 2.6) Reference Reference
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