Why Is This Important?

Sudden Infant Death Syndrome (SIDS) is the third leading cause of infant mortality in New Jersey and the U.S. It can be difficult to distinguish SIDS from other sleep-related infant deaths, such as suffocation by soft bedding, even after a thorough investigation, because these deaths are often unwitnessed, and there are no tests to tell SIDS apart from suffocation or deaths classified as due to an ill-defined and unknown cause. Additionally, people who investigate such deaths may report cause of death in different ways. [https://www.cdc.gov/sids/about/index.htm ^1^] 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)'''.

Definition

Death of an infant before his or her first birthday that occurs suddenly and unexpectedly, and whose cause of death cannot be determined after an autopsy, death scene investigation, and review of medical history. Underlying cause of death ICD-10 codes: *R95 -- Sudden Infant Death Syndrome (SIDS), *R99 -- ill-defined and unknown cause, *W75 -- accidental suffocation and strangulation in bed

Data Sources

• Birth Certificate Database, Office of Vital Statistics and Registry, New Jersey Department of Health
  (https://www.nj.gov/health/vital/)
• Linked Infant Death-Birth Database, Center for Health Statistics, New Jersey Department of Health
  (https://www.nj.gov/health/chs/)
• Linked Birth/Infant Death Records, CDC WONDER On-line Database, Centers for Disease Control and Prevention
  (https://wonder.cdc.gov/lbd.html)

How the Measure is Calculated

How Are We Doing?

The SUID rate in New Jersey has remained between 0.48 and 0.68 deaths per 1,000 live births since 2000, well below the national rate. 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 3.1 per 1000 live births in 2019-2021, 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 2019-2021, 19% of SUIDs were preterm (< 37 weeks gestation), in contrast to 9.3% 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, under age 25, a WIC recipient, and lacking insurance or receiving Medicaid, reinforcing poverty as a risk factor.

How Do We Compare With the U.S.?

In 2019-2021, New Jersey's SUID rate of 0.56 deaths per 1,000 live births was well below the national rate of 0.94. New Jersey's SUID rates for infants of White, Black, or Hispanic mothers were also below U.S. rates for these groups. In 2019-2021, for the U.S. and New Jersey, respectively, the White non-Hispanic rates were 0.8 vs. 0.4, the Black non-Hispanic rates were 2.1 vs. 1.7, and the Hispanic rates were 0.9 vs. 0.2. However, as with fetal deaths as well as 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?

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. 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. 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 [https://nurturenj.nj.gov/ Nurture NJ] and the [https://www.njha.com/maternal-child-health/patient-safety/ 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 Practices

The 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 (SCNJ). The "[https://safetosleep.nichd.nih.gov/ Safe to Sleep]" 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 [http://www.rwjms.rutgers.edu/sids/ SCNJ's website]. 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.

Available Services

[[br]]'''Sudden Infant Death Syndrome Center of New Jersey (SCNJ)'''[[br]] The [http://www.rwjms.rutgers.edu/sids/ SIDS Center of New Jersey] (SCNJ) conducts research, offers risk reduction education and resources, and provides bereavement support. Visit the SCNJ website or email the SCNJ to obtain additional information and services, such as hospital Safe Sleep Tool Kits; the American Academy of Pediatrics safe infant sleep guidelines; and SIDS Center safe sleep flyers, videos, information on its free mobile phone app, and related material. Educational materials are provided in English, Spanish, Arabic, Haitian Creole, and Hindi. Materials in other languages are available by request. In addressing the major risk of household smoke exposure, the SCNJ collaborated with [http://momsquit.com/ Mom's Quit Connection] to extend the penetration of knowledge and interventions. The SCNJ also targets specific groups of caregivers, such as grandparents, and works with faith-based communities to reach caregivers at community levels. Call or email SCNJ to arrange education programs. Hotline: 800-545-7437 / Office line: 732-249-2160 / E-mail: scnj@rwjms.rutgers.edu

More Resources

NJ Department of Children and Families: *[http://njsafesleep.com/main/ Safe Sleep for Infants] *[https://www.nj.gov/dcf/news/reportsnewsletters/taskforce/fatality_reports.html Child Fatality and Near Fatality Review Board Annual Reports] [[br]] Other: *[http://www.healthychildren.org/english/ages-stages/baby/sleep/Pages/default.aspx American Academy of Pediatrics] *[https://www.cpsc.gov/SafeSleep Consumer Product Safety Commission Crib Information Center] *[https://safetosleep.nichd.nih.gov/ National Institutes of Health "Safe to Sleep" public health education campaign] *[http://www.rwjms.rutgers.edu/sids/ SIDS Center of New Jersey]

Health Program Information

NJDOH [https://www.nj.gov/health/fhs/maternalchild/sidsfasd/sids/index.shtml SIDS information]

Footnote References

[[br]] # CDC: [https://www.cdc.gov/sids/about/index.htm About SUID and SIDS] # Ostfeld BM, Hegyi T. Public health indicators of safe infant sleep do not correlate with rate of SUID. Pediatric Academic Societies-Society for Pediatric Research. May 9, 2017, San Diego, CA. # Ostfeld BM, Gaur S. Hegyi T. Safe Infant Sleep and Sudden Unexpected Infant Deaths in New Jersey Asian Indians. [https://njaap.org/ NJ Pediatrics]. Summer 2018. # Nijagal MA, Patel D, Lyles C, Liao J, Chehab L, Williams S, Sammann A. Using human centered design to identify opportunities for reducing inequities in perinatal care. BMC Health Serv Res. 2021 Jul 20;21(1):714. doi: 10.1186/s12913-021-06609-8. PMID: 34284758; PMCID: PMC8293556. # Anderson TM, Lavista-Ferres JM, Ren SU, Moon RY et al. [https://pediatrics.aappublications.org/content/143/4/e20183325 Maternal smoking before and during pregnancy and the risk of Sudden Unexpected Infant Death]. Pediatrics 2019;143:e20183325 # Ostfeld BM, Schwartz-Soicher O, Reichman NE, Teitler JO, Hegyi T. [https://pediatrics.aappublications.org/content/140/1/e20163334 Prematurity and Sudden Unexpected Infant Deaths in the United States]. Pediatrics 2017;140:e20163334. # Capp AI. "They Make You Feel Less of a Human Being": Understanding and Responding to Milwaukee's Racial Disparity in Infant Mortality. Matern Child Health J. 2021 Nov 25. doi: 10.1007/s10995-021-03281-6. Epub ahead of print. PMID: 34822032. # Ostfeld BM, Lansang D, Hegyi T. A Student-Based Initiative to Reduce the Risk of Sudden Unexpected Infant Death. NJ Pediatrics 2020;45:20-21.