1. Challenges to Public Health Responses to Safe Infant Sleep Practices Lauren Smith, MD, MPH May 2012

2. 2 Disclosure I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3. 3 Overview SIDS policy recommendations SIDS epidemiology SIDS disparities Safe sleep controversies DPH efforts

4. 4 SIDS Deaths, by Age The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116:1245–1255

5. 5 Milestones of the Back-to-Sleep Campaign 1992 – AAP issues statement that all healthy full term infants should be placed in non-prone positions to reduce the risk of SIDS. 1994 – The Back to Sleep Campaign launched 1998 – The back sleeping campaign reduces SIDS deaths by 30 - 50 %. 2000 -- AAP statement - supine position poses lowest risk; side position less than prone 2005 – The AAP issues revised policy – supine only 2011 – The AAP updates its policy

6. 6 Healthy People 2020 & 2011 AAP Safe Sleep Recommendations Healthy People 2020 goal – 75.9% back sleeping for infants < 8 months More detailed recommendations from AAP –Back only sleep position –Firm sleep surface –No soft objects, loose bedding or bumpers –Separate but close sleep environment –Encourage breastfeeding –Avoid smoking during pregnancy –Keep infants up to date on immunizations –Offer pacifier during sleep –Avoid commercial devices claiming to decrease SIDS

7. SIDS Epidemiology

8. 8 U.S. Trends in SIDS Rates and Prevalence of Prone Sleep by Race American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116:1245–1255

9. 9 SIDS rate per 1000 live births

10. 10 Trends in Sleep Position, PRAMS, MA 2007-2010 Source: MA Pregnancy Risk Assessment Monitoring System

11. 11 Trends in Sleep Location, PRAMS, MA 2007-2010 Source: MA Pregnancy Risk Assessment Monitoring System

12. 12 Trend in MA SUID Deaths, 2004-2009 Source: Registry of Vital Records and Statistics, MA Department of Public Health Includes deaths with underlying cause of death coded as SIDS, Unexplained/Undetermined, Accidental Suffocation in Bed or Unspecified Threat to Breathing.

13. Disparities in SIDS Epidemiology

14. 14 Uneven Adoption of the Message Significant racial disparities persist in SIDS and prone sleeping, despite overall decreases

15. 15 Racial Differences in Non-Supine Sleep Position: A Widening Gap

16. 16 Different Timing & Level of Plateaus 45%

17. 17 The High Cost of Failed Public Health Messaging 719 excess lives lost E. Colson, Pediatrics, 2010

18. 18 Prevalence in Back Sleeping By Race/Ethnicity, MA, 2009-2010 Source: MA Pregnancy Risk Assessment Monitoring System

19. 19 Sleep Location By Race/Ethnicity, MA, 2009-2010 Source: MA Pregnancy Risk Assessment Monitoring System

20. 20 Disparities in MA SUID Deaths, 2004-2009 Source: Registry of Vital Records and Statistics, MA Department of Public Health Includes deaths with underlying cause of death coded as SIDS, Unexplained/Undetermined, Accidental Suffocation in Bed or Unspecified Threat to Breathing.

21. Barriers to Adopting Safe Sleep Practices

22. 22 Barriers to Following Recommendations: Importance of Message and Messenger Lack of or wrong advice Lack of trust in providers Concerns about safety –Worried about choking Concerns about comfort –Babies sleep better prone Lack of knowledge –Sleeping with mother or adult is best way to prevent SIDS Colson ER, Levenson S, Rybin D, et al. Barriers to following the supine sleep recommendation among mothers at four centers for the Women, Infants, and Children Program. Pediatrics.2006;118(2):e243-e250.

23. 23 Understanding Influence of the Messenger Although physicians are expected to provide these recommendations, it is not clear –- How mothers of young infants rate physician qualification to give advice in the 3 AAP targeted areas of sleep position, bed sharing and pacifier use If maternal ratings of physician qualification are associated with the recommended maternal behavior in these 3 areas. Smith LA, Colson E, Rybin D,, Colton T, Margolis A, Lister G, Corwin MJ. Parental Assessment of Physician Qualification to Give Advice on AAP Recommended Infant Sleep Practices Related to SIDS. Academic Pediatrics, 2010;10 (6):383-388

24. 24 Methods Convenience sample of 1580 mothers of infants less than 8 months of age WIC centers in –Birmingham, AL –Clarksdale and Jackson, MS –Dallas, TX –Detroit, MI –New Haven, CT In-person, semi-structured interviews conducted June-December 2006 and 2007

25. 25 Primary Outcome Variables Usually placed supine for sleep Usually does not share bed with adult during sleep Usually use pacifier during sleep

26. 26 Independent Variables Maternal rating of physician qualification Doctors give advice to parents about different topics. How qualified do you think your babys doctor is to give you advice on …. –3 AAP targeted behaviors: sleep position, bed sharing, pacifier use –3 other domains: feeding practices, vaccinations, fever control –Rating scale,1-5: High (4 or 5), Low ( 3)

27. 27 Independent Variables Nature of physician advice –Concordant w/ recommendations –Contrary to recommendations –No advice

28. 28 Demographic Characteristics N = 1580 % Race/ethnicity of mother African-American Latino White 74 14 8 High school education or less63 Mean maternal age in years (SD)24 (6) Infant age 0-1 month 2-3 month 4-8 month 43 18 42 First child45

29. 29 Maternal Rating of Physician Qualification Topic AreaHigh Rating Percent (N = 1580) What to do when your baby has a fever 96 % Whether and when to give vaccinations 95 % What and how to feed your baby 82 % What position your baby should be in for sleep 79 % Whether your baby should share a bed with you or another adult 67 % Whether your baby should use a pacifier 57 %

30. 30 Association of High Maternal Rating of Physician Qualification with Target Behaviors AAP Recommended Sleep Behavior Unadjusted ORs (95% CI) Adjusted ORs* (95% CI) Supine only sleep position2.3 (1.6 – 2.9) 2.0 (1.5 – 2.6) Usually no bed sharing with adult 1.9 (1.5 – 2.3) 1.5 (1.2 – 2.0) Usually use pacifier when sleeping 1.3 (1.0 – 1.6) 1.3 (1.0 – 1.6) * Adjusted for year, site, maternal race, age, education, infant age, doctor input, trusted source of advice.

31. 31 Nature of Physician Advice on 3 AAP Recommended Behaviors

32. 32 Limitations Data were collected from 6 geographic sites which may limit generalizability. We rely on parental report of the nature of physician advice and sleep behaviors.

33. 33 Conclusion Low income, minority mothers rate physician qualification to give advice lower in the 3 AAP targeted safe sleep topics than in 3 more medical topics. Many mothers in this potentially vulnerable group report receiving no or non-AAP recommended advice, especially regarding pacifier use. High qualification ratings and the receipt of AAP- consistent advice from doctors are related to higher rates of recommended behavior.

34. 34 Implications Focus on populations with low rates of acceptance of recommendations AAP may need to consider alternative methods, in addition to relying on physician education, to encourage adoption of recommended behaviors to prevent SIDS. Focus on message and messenger

35. Safe Sleep Controversies

36. 36 What to do about bedsharing? Increase in infant deaths in setting of bedsharing in MA –More cases referred to DCF Renewed focus on issue after controversial case in Milwaukee

37. 37 Bedsharing Controversy Why babies should never sleep alone: A review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding At very least, we hope that the studies and data described in this paper, which show that co-sleeping at least in the form of roomsharing especially with an actively breast feeding mother saves lives, is a powerful reason why the simplistic, scientifically inaccurate and misleading statement never sleep with your baby needs to be rescinded, wherever and whenever it is published. J McKenna, T McDade 2005

38. 38 Why Mothers Chose Bedsharing? Inner-City Caregivers Perspective on Bedsharing with their Infants Parents expressed divergent views about the safety of bed sharing: 1)ambivalence regarding balancing risks of overlaying and suffocation with benefits of bed sharing, or 2) assertion that bed sharing poses no risks for their child. Common to all groups was the finding that clinicians advice against bed sharing did not influence parents decision, but advice to increase safety when bed sharing would be appreciated. J Chianese, et al, 2009

39. 39

40. 40

41. 41 Some Public Health Messaging

42. 42 Baltimore City Effort: ABC Bmore for Healthy Babies: Every baby counts on you Uses testimonials from parents whose infants have died in bedsharing situations Focus on 3 part ABC message –Alone –Back –Crib

43. Evolution of DPH Efforts

44. 44 Safe Sleep Policy Recommendation –The safest place for an infant to sleep is on his or her back in the same room with a parent or caregiver and in a separate sleep space such as a crib or bassinet. Recommended sleep position Recommended sleep environment Bedsharing precautions MA Department of Public Health Safe Sleep Policy, 2009

45. 45 Prior MA DPH Bedsharing Recommendations: Risk Reduction Approach Some parents may decide to sleep in the same bed with their infant despite the MDPH safe sleep policy recommendation that an infant sleep in a separate space. If a parent chooses to bed share, the MDPH offers the following precautions to reduce the risk of SIDS or an adult rolling over on an infant. The MDPH recommends that an adult never sleep with an infant if the adult is: On soft bedding such as a sofa, couch, futon, cushioned chair, recliner, pillow, or water bed; Using medications that cause drowsiness; Using any amount of alcohol or drugs (prescription or illicit) ; Sick; Unusually tired; Severely overweight or obese; or A smoker.

46. 46 New AAP Guidelines Approach to Bedsharing There are specific circumstances in which bed-sharing is particularly hazardous, and it should be stressed to parents that they avoid the following situations at all times: –When parent smokes –When parent uses alcohol, drugs or medications –When infant < 3 months –On waterbeds, sofas, armchairs –With soft bedding, pillows, blankets –With multiple people in the bed

47. 47 Are risk reduction messages confusing? Risk reduction vs. strict prohibition – which is more effective and for whom? –Possibility that choice could exacerbate disparities What does it mean to acknowledge possibility of non-recommended behavior –If you are not going to use a car seat, at least put your toddler in seatbelt –If you are going to drink during pregnancy, at least wait until the 3 rd trimester when all of the organs are formed

48. 48 Safe Sleep Challenges No cost, effective intervention – should be easy to adopt, but … Skepticism regarding mechanism Alternative strongly held beliefs on sleep position and environment –Concern about safety – preventing choking –Co-sleeping is protective for baby –Better/longer sleep for mother and baby –Facilitating breastfeeding Discounting doctors advice – sleep isnt their domain

49. 49 Whats Next? Issue new DPH Safe Sleep Policy Communication campaign with State Child Fatality Review Team partners and others Redesign public health messaging to target persistently vulnerable groups –Fear vs. positive messages Reinforce key points in all DPH programs, policies, outreach, contracts

50. 50