The Impact and Importance of Safe Sleep
*this article was written by Dr. Tony GiaQuinta for the Fort Wayne Medicine Quarterly
It’s been 30 years since the American Academy of Pediatrics released new recommendations calling for a change in infant sleep practice. Discovering that infants sleep safest when alone, on their back, on a firm sleep surface (crib), the “ABCs” of safe sleep became a shining model of a successful public health campaign as infant sleep deaths declined for 10 straight years to record lows (1).
Unfortunately, over the last 20 years, sleep death rates haven’t budged, still accounting for 3500 infant deaths every year, and contributing to an infant mortality rate in Allen County that is among the nation’s worst (2).
Why the stagnation?
One might conclude that despite safe sleep practice, sudden unexpected infant deaths (SUIDS) will always be a lamentable and unpreventable contributor to infant mortality rates?
In fact, this is not the case.
As chair of the Allen County Child Death Review Team the past two years, I can tell you we have not reviewed a single case where after thorough investigation, a child died during sleep without unsafe risk factors. Not a single one.
For this reason, myself and most safe sleep experts agree that infant sleep deaths are largely preventable. Taken another way, these persistent infant deaths indicate the public heath arena, including the medical profession, is failing our most vulnerable and valuable.
The medical profession can do better. We can start by relying less on the verbose after-visit summaries that likely get tossed or buried, and instead make this a priority conversation instead of a spiel or mention.
I recommend inviting yourself into a conversation around safe sleep that asks about their sleep practices, while motivating the heart, maybe something like this:
“It is clear to me how much you love your baby. Look at all you have done to keep your baby healthy (here, I like pointing out how much weight their baby gained, excellent skin care, or as simple as placing socks to keep the feet warm)! As your doctor/nurse/provider, it’s important to me that you know the safest way for your baby to sleep. Can you tell me how you put your baby to sleep at night?”
When I use a conversational approach, I’m often surprised by the honest answers I get, unveiling the risk factors and other barriers that underlie our devastatingly high infant mortality rate.
These barriers are highlighted in a survey conducted by Healthier Mom’s and Babies Infant Mortality Study. Spoiler alert: parents rarely admitted they just didn’t know about the “ABCs” of safe sleep!
Instead, the survey revealed the honest answers I hear in clinic, such as how their baby sleeps better in their bed or on their tummy, and the stress of not getting sleep at night. I also hear stories of eviction threats if an infant is crying throughout the night, or using air mattresses due to bed-bug infestations.
Of course, understanding the ‘why’ is not enough to stop sleep related deaths. The more difficult but meaningful strategy is validating the ‘why’s’, and then finding practical solutions that address cultural, socioeconomic, and mental health disparities underlying variations in safe sleep practice.
In my practice, the most common ‘why’ for abandoning safe sleep practices is a fear that their baby can’t sleep soundly alone, on their back, in a crib. This results in a phenomenon called second sleep practice, described as when a caregiver intervenes with a crying baby, and when put back to sleep, is in a different position than the initial sleep position. Studies show this occurs in almost 40% of night-time awakenings, and almost always to a more ‘unsafe’ sleep position (3). Of course, night time awakenings are a struggle for every parent. So why are some parents willing to compromise their baby’s safety experimenting with different sleep positions?
To me, I wonder about avoidable stresses that tip the scales of anxiety and fatigue when a baby cries at night.
One public health strategy that other societies value (and, by the way, often have lower infant mortality rates) include longer maternal and paternal leave time, which boost the energy and focus necessary to care for infants, without fear of income loss or job security. Two partners switching out night time duties definitely relieves the stress of a sleepless night, especially if a parent (or both!) has a long days’ work looming.
And speaking of the value of two partners tag teaming night time duties, public efforts to provide accessible, long acting, reversible contraceptive access must be emphasized. Empowering women to have babies when they are ready and intended includes not only prepares financial and emotional readiness, but usually involves a committed partner ready to share in the energy and efforts required, especially at night.
In addition, I believe improving post-partum depression screening and access to treatment would give parents that extra emotional strength to cope with their baby’s cry at night. Along with this, medical providers can be well versed in sleep training curriculums (personally, a fan of the book, Babywise, but there are others) to offer strategies for getting the baby to sleep without compromising safety.
I’m excited and pleased that some of these strategies are exactly what Healthier Mom’s and Babies’ “The Future of Firsts” focuses on, amplifying the community based messaging around safe sleep by taking an individual approach with parents and caregivers, as well as addressing disparities in mental, preconception and interconception health: https://www.healthiermomsandbabies.org/report. It’s high time we mean what we say when we lament our devastatingly high infant mortality rates, and invest in real public health strategies that result in more first birthdays and a more secure commonwealth.
Be sure to join us and Dr. GiaQuinta at our Infant and Mortality Conference on Friday, February 23rd! Register here: healthiermomsandbabies.org/conference
This article can be found in the Fort Wayne Medicine Quarterly: https://www.fwms.org/fortwaynemedicinequarterly
Sources:
Moon RY. Sleep Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN. Pediatrics (2022) 150 (1): e2022057990.
https://www.cdc.gov/sids/data.htm
Bryan ME. Safe Sleep Behaviors and Factors Associated with Infant Second Sleep Practices. Pediatrics (2022) 149 (6): e2021053935.