Trends in Infant Bedding Use: National Infant Sleep Position Study, 1993–2010 Carrie K
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Trends in Infant Bedding Use: National Infant Sleep Position Study, 1993–2010 Carrie K. Shapiro-Mendoza, PhD, MPHa, Eve R. Colson, MD, MHPEb, Marian Willinger, PhDc, Denis V. Rybin, MSd, Lena Camperlengo, DrPHa, Michael J. Corwin, MDe abstract BACKGROUND: Use of potentially hazardous bedding, as defined by the American Academy of Pediatrics (eg, pillows, quilts, comforters, loose bedding), is a modifiable risk factor for sudden infant death syndrome and unintentional sleep-related suffocation. The proportion of US infants sleeping with these types of bedding is unknown. METHODS: To investigate the US prevalence of and trends in bedding use, we analyzed 1993–2010 data from the National Infant Sleep Position study. Infants reported as being usually placed to sleep with blankets, quilts, pillows, and other similar materials under or covering them in the last 2 weeks were classified as bedding users. Logistic regression was used to describe characteristics associated with bedding use. RESULTS: From 1993 to 2010, bedding use declined but remained a widespread practice (moving average of 85.9% in 1993–1995 to 54.7% in 2008–2010). Prevalence was highest for infants of teen-aged mothers (83.5%) and lowest for infants born at term (55.6%). Bedding use was also frequently reported among infants sleeping in adult beds, on their sides, and on a shared surface. The rate of decline in bedding use was markedly less from 2001–2010 compared with 1993–2000. For 2007 to 2010, the strongest predictors (adjusted odds ratio: $1.5) of bedding use were young maternal age, non-white race and ethnicity, and not being college educated. CONCLUSIONS: Bedding use for infant sleep remains common despite recommendations against this practice. Understanding trends in bedding use is important for tailoring safe sleep interventions. WHAT’S KNOWN ON THIS SUBJECT: The American aDivision of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; bDepartment of Academy of Pediatrics has identified bedding Pediatrics, Yale School of Medicine, New Haven, Connecticut; cPregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; dData such as pillows, blankets, and quilts as Coordinating Center, Boston University School of Public Health, Boston, Massachusetts; and eDepartment of potentially hazardous for the infant sleep Pediatrics, Boston University School of Medicine, and Slone Epidemiology Center, Boston University, Boston, Massachusetts environment. Bedding use is a modifiable risk factor for sudden infant death syndrome and Dr Shapiro-Mendoza led the conceptualization and design of the study, analyzed and interpreted the unintentional sleep-related suffocation. data, drafted the initial manuscript, and revised the manuscript; Drs Colson, Willinger, and Camperlengo conceptualized and designed the study, participated in interpretation of the data, WHAT THIS STUDY ADDS: Reported bedding use and critically reviewed the manuscript for important intellectual content; Mr Rybin conceptualized and designed the study, analyzed the data, participated in interpretation of the data, and critically over or under the infant for infant sleep reviewed the manuscript for important intellectual content; and Dr Corwin obtained study funding, substantially declined from 1993 to 2010. coordinated and supervised data collection, conceptualized and designed the study, participated in However, about one-half of US infants are still analysis and interpretation of the data, and critically reviewed the manuscript for important fi placed to sleep with potentially hazardous intellectual content. All authors approved the nal manuscript as submitted. bedding despite recommendations against this This work was presented in abstract form at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research (SPER) on June 26, 2012 in Minneapolis, Minnesota and at the practice. International Conference on Stillbirth, SIDS and Infant Survival on October 6, 2012 in Baltimore, Maryland. Downloaded from www.aappublications.org/news by guest on October 1, 2021 ARTICLE PEDIATRICS Volume 135, number 1, January 2015 Rates of sudden infant death In 2000, the AAP more strongly could not be calculated because the syndrome (SIDS), the leading cause of recommended against the use of eligibility status for those refusing the postneonatal mortality, have declined bedding.16 The proportion of US interview was unknown. However, slowly in the United States since infants who are placed to sleep with assuming those who refused had the 2000, from 66.3 to 52.7 per 100 000 bedding such as pillows, blankets, same eligibility proportion as those live births in 2010.1 Concurrently, and quilts is unknown. who participated, the average infant mortality related to Understanding caregiver behavior response rate would be 71% (ranging unintentional sleep-related related to infant sleep practices and from 78% in 1993 to 46% in 2010). suffocation, the leading cause of how it has changed can inform the infant mortality from injury, has refinement and promotion of Main Outcome and Measures increased more than twofold, from interventions aimed at reducing The main outcome for this analysis 7.0 per 100 000 live births in 2000 to unsafe practices. In the present study, was reported usual use of certain 15.9 per 100 000 live births in 2010. we used data from the NISP (National types of bedding under the infant or Blankets, quilts, and pillows are Infant Sleep Position) Study17,18 to covering the infant while sleeping in examples of bedding that can be estimate the prevalence of reported the last 2 weeks. Caregivers were potentially hazardous to infants if use of certain types of bedding and asked, “During the past 2 weeks, under or around them during sleep. examine trends from 1993 to 2010 which of the following items were Soft objects and loose bedding such (overall and according to race/ usually under [infant] while [he/she] as these items can obstruct the infant ethnicity). We also investigated slept? Please answer yes or no to each airway and pose a suffocation risk. In characteristics associated with one.” Based on the guidelines from addition, this type of bedding is bedding use from 2007 to 2010. the AAP,2 affirmative responses for a recognized risk factor for SIDS. blanket, bean bag, waterbed, rug, Because of these risks, the American METHODS sheepskin, cushion, sleeping bag, or Academy of Pediatrics (AAP) pillow were classified as having used recommends that soft objects and The NISP Study bedding under the infant. Caregivers loose bedding be removed from the The NISP methods have been were also asked, “During the past 2 2,3 infant sleep area. A US study reported previously.17,18 Briefly, NISP weeks, which of the following were showed that certain types of bedding was an annual, cross-sectional usually used to cover [infant] when increased the odds for SIDS telephone survey conducted from [he/she] slept at night? Please answer fi 4 fi approximately vefold. This nding 1993 to 2010. A random sample of yes or no to each one.” Affirmative is consistent with studies from the households in the continental United responses to sheet, blanket, quilt/ United States, Europe, New Zealand, States with infants aged ,8 months comforter, sheepskin, pillow, or other and Australia in which adjusted odds was chosen from a purchased list were classified as bedding over the ratios (aORs) for SIDS and the use of containing public information from infant or used to cover the infant. these types of bedding ranged from birth records, infant photography Caregivers who answered “blanket” 5–13 3.1 to 6.7. companies, and formula companies. were also asked if the blanket was Recommendations about the During a telephone interview, thicker than a receiving blanket. If the avoidance of bedding in the sleep nighttime caregivers answered caregiver responded that any of these environment were first issued in questions about infant sleeping items were used (excluding sheets 1996 when the AAP advised that practices (eg, sleep position, location and blankets not thicker than infants be placed to sleep in for sleep, use of potentially hazardous a receiving blanket), the infant was environments free of soft surfaces bedding) and sociodemographic classified as having used bedding as and gas-trapping objects.14 In April characteristics. Most respondents a cover. Our definition excluded thin 1999, the Consumer Product Safety (80%) were mothers. Given the blankets because the AAP had not Commission, the National Institute of increased risk of sleep-related infant recommended the removal of thin Child Health and Human deaths in certain racial and ethnic blankets during the study period. Development, and the AAP Task groups,2,4 all respondents were asked Force issued a safety alert to self-report maternal race and Statistical Analysis recommending that infants “be placed ethnicity. The NISP sample For each year, the prevalence of to sleep on their backs on a firm, underrepresented mothers of black bedding use in the sleeping tight-fitting mattress in a crib that race and Hispanic ethnicity, environment was calculated. We meets current safety standards and teenagers, and those with less than further examined the frequency of that pillows, quilts, comforters, a high school education.17 Annual use according to type, race and sheepskins and other pillow-like soft sample size ranged from 1012 to ethnicity, and survey year. Trends for products be removed from the crib.”15 1188,