Infant sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002

Higher awakening threshold of preterm infants in prone position may be a risk factor for SIDS

AIM

The supine sleeping position in the prevention of sudden infant death syndrome in preterm infants is poorly understood. We aimed to investigate the effect of sleep posture on cardiorespiratory parameters and movement patterns in preterm infants close to discharge.

METHODS

This observational study included neonates born in 2022 at the University Hospital Schleswig-Holstein, Lübeck, Germany. Motion sensor data, heart rate, respiratory rate and oxygen saturation were recorded for infants with postconceptional age 35-37 weeks during sleep in the prone and supine positions.

RESULTS

We recorded data from 50 infants, born at 31 (24-35) weeks of gestation (mean(range)), aged 5.2 ± 3.7 weeks (mean ± SD), of whom 48% were female. Five typical movement patterns were identified. In the prone position, the percentage of calm, regular breathing was higher and active movement was less frequent when compared to the supine position. The percentage of calm irregular breathing, number of apnoeas, bradycardias, desaturations and vital sign changes were not influenced by position.

CONCLUSION

The prone position seems to be associated with a higher arousal threshold. The supine position appears advantageous for escape from life-threatening situations such as sudden infant death syndrome.

Inconsistency Between Pictures on Baby Diaper Packaging in Europe and Safe Infant Sleep Recommendations

OBJECTIVE

To describe the level of inconsistency between pictures on baby diaper packaging and safe infant sleep recommendations (SISRs) in Europe.

STUDY DESIGN

We attempted to identify all packaging of baby diapers sold in 11 European countries for infants weighing less than 5 kg through internet searches from July 2022 through February 2023. For each type of package, we extracted whether there was a picture depicting a baby, whether the baby was sleeping, and whether the picture of the sleeping baby was inconsistent with ≥1 of 3 SISRs: (i) nonsupine sleeping position, (ii) soft objects or loose bedding, or (iii) sharing a sleep surface with another person. Data were aggregated at the country level, and a random-effects meta-analysis of proportions was used to obtain summary estimates. The outcome was the summary estimate of the proportion of pictures that were inconsistent with SISRs.

RESULTS

We identified 631 baby diaper packaging types of which 49% (95% CI: 42-57; n = 311) displayed a picture of a sleeping baby. Among those 311 packages, 79% (95% CI 73-84) were inconsistent with ≥1 SISR, including a nonsupine sleeping position, 45% (95% CI 39-51), soft objects or loose bedding such as pillows or blankets, 51% (95% CI 46-57), and sharing a sleep surface with another person, 10% (95% CI 4-18).

CONCLUSIONS

Pictures on baby diaper packaging in Europe are often inconsistent with SISRs. The prevention of sudden unexpected death in infancy requires action from manufacturers and legislators to stop parents' exposure to misleading images that may lead to dangerous practices.

How to review and assess a systematic review and meta-analysis article: a methodological study (secondary publication)

Systematic reviews and meta-analyses have become central in many research fields, particularly medicine. They offer the highest level of evidence in evidence-based medicine and support the development and revision of clinical practice guidelines, which offer recommendations for clinicians caring for patients with specific diseases and conditions. This review summarizes the concepts of systematic reviews and meta-analyses and provides guidance on reviewing and assessing such papers. A systematic review refers to a review of a research question that uses explicit and systematic methods to identify, select, and critically appraise relevant research. In contrast, a meta-analysis is a quantitative statistical analysis that combines individual results on the same research question to estimate the common or mean effect. Conducting a meta-analysis involves defining a research topic, selecting a study design, searching literature in electronic databases, selecting relevant studies, and conducting the analysis. One can assess the findings of a meta-analysis by interpreting a forest plot and a funnel plot and by examining heterogeneity. When reviewing systematic reviews and meta-analyses, several essential points must be considered, including the originality and significance of the work, the comprehensiveness of the database search, the selection of studies based on inclusion and exclusion criteria, subgroup analyses by various factors, and the interpretation of the results based on the levels of evidence. This review will provide readers with helpful guidance to help them read, understand, and evaluate these articles.

Qualitative assessment of infant sleep practices and other risk factors of sudden infant death syndrome (SIDS) among mothers in Lusaka, Zambia

BACKGROUND

There is very little information on the beliefs and perceptions of mothers about SIDS and its related risk factors in Africa. To better understand parental decisions about infant sleep practices and other risk factors for SIDS, we conducted focus group discussions (FGDs) with mothers of infants in Lusaka, Zambia.

METHODS

FGDs involved 35 purposively sampled mothers aged 18-49 years. FGDs were conducted using a semi-structured interview guide in the local language, Nyanja. These were translated, transcribed verbatim into English, and then coded and analyzed using thematic analysis in NVivo 12.

RESULTS

Six FGDs were conducted with 35 mothers in April-May 2021 across two study sites. FGD Participants were generally aware of sudden unexplained infant deaths, with several describing stories of apparent SIDS in the community. The side sleeping position was preferred and perceived to be safer for the infant with most believing the supine position posed an aspiration or choking risk to the infant. Bedsharing was also preferred and perceived to be convenient for breastfeeding and monitoring of the infant. Experienced family members such as grandmothers and mothers-in-law, and health care workers were frequently cited as sources of information on infant sleep position. A heightened awareness of the infant's sleeping environment was suggested as a mechanism to prevent SIDS and smothering.

CONCLUSIONS

Decisions about bedsharing and infant sleep position were guided by maternal beliefs and perceptions about what is convenient for breastfeeding and safer for the infant. These concerns are vital to designing tailored interventions to address sleep-related sudden infant losses in Zambia. Public health campaigns with tailored messages that address these concerns are likely to be effective at ensuring optimal uptake of safe sleep recommendations.

Obstructive sleep apnea is position dependent in young infants

BACKGROUND

Obstructive sleep apnea in infants with Pierre Robin sequence is sleep-position dependent. The influence of sleep position on obstructive events is not established in other infants.

METHODS

We re-evaluated ten-year pediatric sleep center data in infants aged less than six months, with polysomnography performed in different sleep positions. We excluded infants with syndromes, genetic defects, or structural anomalies.

RESULTS

Comparison of breathing between supine and side sleeping positions was performed for 72 infants at the median corrected age of 4 weeks (interquartile range (IQR) 2-8 weeks). Of the infants, 74% were male, 35% were born prematurely, and 35% underwent study because of a life-threatening event or for being a SIDS sibling. Upper airway obstruction was more frequent (obstructive apnea-hypopnea index (OAHI), p < 0.001), 95th-percentile end-tidal carbon dioxide levels were higher (p = 0.004), and the work of breathing was heavier (p = 0.002) in the supine than in the side position. Median OAHI in the supine position was 8 h-1 (IQR 4-20 h-1), and in the side position was 4 h-1 (IQR 0-10 h-1).

CONCLUSIONS

Obstructive upper airway events in young infants are more frequent when supine than when sleeping on the side.

IMPACT

The effect of sleep position on obstructive sleep apnea is not well established in infants other than in those with Pierre Robin sequence. A tendency for upper airway obstruction is position dependent in most infants aged less than 6 months. Upper airway obstruction is more common, end-tidal carbon dioxide 95th-percentile values higher, and breathing more laborious in the supine than in the side-sleeping position. Upper airway obstruction and obstructive events have high REM sleep predominance. As part of obstructive sleep apnea treatment in young infants, side-sleeping positioning may prove useful.

Obstructive sleep apnea in young infants: Sleep position dependence and spontaneous improvement

OBJECTIVES

The natural evolution of obstructive sleep apnea (OSA) in young infants is not established.

METHODS

We re-evaluated 10-year pediatric sleep center infant polysomnography (PSG) data, excluding infants with syndromes, genetic defects, structural anomalies or periodic breathing > 5% of sleep time.

RESULTS

Obstructive events > 1 h^-1 were evident in 255 infants, of which 91 were eligible for the study. Of the 38 infants in a follow-up study, 30 (79%) were male, 15 (40%) were born prematurely, 25 (66%) had observed apneas, and 13 (33%) had experienced a brief, unexplained event or had a sibling of the infant died suddenly. The first PSG was performed at a median corrected age of 4 weeks (interquartile range [IQR] 2-7) and the second at 11 weeks (IQR 9-14). The obstructive apnea and hypopnea index (OAHI) was greater in the supine compared to side-sleeping position in both recordings (p < 0.001), whereas OAHI dropped from 10 h^-1 (IQR 6-24) in the first PSG to 3 h^-1 (IQR 1-9) in the second PSG (p < 0.001). OSA alleviation was also observable as a decrease in the number of oxygen desaturations (p < 0.001), as a decrease in transcutaneous (p = 0.001) and end-tidal carbon dioxide (p = 0.01) 95th percentile levels, and work of breathing (p = 0.002). Seven infants had a third PSG to verify a satisfactory improvement of OSA.

CONCLUSIONS

OSA in young infants without a clear syndrome or structural anomaly is sleep position dependent and shows improvement during the following few months.

The provision of the baby box was associated with safe sleep practices in a low-resource community: a randomized control trial in Ecuador

BACKGROUND

Sudden Unexpected Infant Deaths (SUID) can occur between 1 month and 1 year of age and are inequitably distributed with a greater burden in populations with numerous health disparities. Modifying the infant sleep environment to promote safe sleep is the most effective risk reduction strategy to reduce SUID. The provision of baby boxes with a mattress and infant supplies has been part of a larger anti-poverty social justice maternity package for decades in Finland. While infant mortality rates have generally improved after the maternity package was introduced, little is known about whether the provision of the baby box increased safe sleep practices. The purpose of the study was to evaluate whether the provision of a Finnish-style baby box reinforced safe infant sleep practice in the home in a low-resource community in Ecuador.

METHODS

In this longitudinal randomized controlled trial all participants received the same safe sleep education in their third trimester of pregnancy (n = 100). This was followed by randomization into two groups; the control received a diaper bag and newborn gifts, and the intervention group received a baby box and the same gifts at each timepoint. Four infant sleep practices (room sharing, bed sharing/co-sleeping, position, and soft items in the sleep environment) were assessed at 1 month and 1 months post-delivery during a home visit where safe sleep education was also reinforced with both groups.

RESULTS

Those in the baby box group were 2.5 times more likely to report safe sleep practices compared with mothers in the diaper bag group at 1 month (odds ratio [OR] = 2.45 and 95% confidence interval [CI]: 1.03-5.86; χ² = 4.1, p = .043). The group difference was also present at 6-months post-birth: those in the baby box group were 2.9 times more likely to report safe sleep practices compared with those in the diaper bag group (OR = 2.86 and 95% CI: 1.16-7.05; χ² = 5.2, p = .022).

CONCLUSIONS

While not all participants used the box regularly, the mothers who received the box were more likely to practice safe sleep at 1 month and 6 months. This suggests the baby box may have served as an important prompt towards safer infant sleep practice.

TRIAL REGISTRATION

(Clinical Trial Registry, per clinicaltrials.gov : not applicable under 42 CFR 11.22(b) as the study Facility Location was not in the United States (took place in Ecuador), does not involve FDA IND or IDE, and does not involve a drug, biological or device product that is manufactured in and exported from the US for study in another country. The University of San Francisco Quito, Research Ethics Committee in Human Beings approved the study, #2017- 127 M. The University of Kentucky Office of Research Integrity also approved the study, IRB # 42965).

Rehabilitation Evidence-Based Decision-Making: The READ Model

Evidence-based practice is the foundation of rehabilitation for maximizing client outcomes. However, an unacceptably high number of ineffective or outdated interventions are still implemented, leading to sub-optimal outcomes for clients. This paper proposes the Rehabilitation Evidence bAsed Decision-Making (READ) Model, a decision-making algorithm for evidence-based decision-making in rehabilitation settings. The READ Model outlines a step-by-step layered process for healthcare professionals to collaboratively set goals, and to select appropriate interventions. The READ Model acknowledges the important multi-layered contributions of client's preferences and values, family supports available, and external environmental factors such as funding, availability of services and access. Healthcare professionals can apply the READ Model to choose interventions that are evidence-based, with an appropriate mode, dose, and with regular review, in order to achieve client's goals. Two case studies are used to demonstrate application of the READ Model: cerebral palsy and autism spectrum disorder. The READ Model applies the four central principles of evidence-based practice and can be applied across multiple rehabilitation settings.

Effect of sleep position in term healthy newborns on sudden infant death syndrome and other infant outcomes: A systematic review

Background

Though recommended by numerous guidelines, adherence to supine sleep position during the first year of life is variable across the globe.

Methods

This systematic review of randomized trials and observational studies assessed the effect of the supine compared to non-supine (prone or side) sleep position on healthy newborns. Key outcomes were neonatal mortality, sudden infant death syndrome (SIDS), sudden unexpected death in infancy (SUDI), acute life-threatening event (ALTE), neurodevelopment, and positional plagiocephaly. We searched MEDLINE via PubMed, Cochrane CENTRAL, EMBASE, and CINAHL (updated till November 2021). Two authors separately evaluated the risk of bias, extracted data, and synthesised effect estimates using relative risk (RR) or odds ratio (OR). The GRADE approach was used to assess the certainty of evidence.

Results

We included 54 studies (43 observational studies and 11 intervention trials) involving 474 672 participants. A single study meeting the inclusion criteria suggested that the supine sleep position might reduce the risk of SUDI (0-1 year; OR = 0.39, 95% confidence interval (CI) = 0.23-0.65; 384 infants), compared to non-supine position. Supine sleep position might reduce the risk of SIDS (0-1 year; OR = 0.51, 95% CI = 0.42-0.61; 26 studies, 59332 infants) and unexplained SIDS/severe ALTE (neonatal period; OR = 0.16, 95% CI = 0.03-0.82; 1 study, 119 newborns), but the evidence was very uncertain. Supine sleep position probably increased the odds of being 0.5 standard deviation (SD) below mean on Gross Motor Scale at 6 months (OR = 1.67, 95% CI = 1.22-2.27; 1 study, 2097 participants), but might have little to no effect at 18 months of age (OR = 1.16, 95% CI = 0.96, 1.43; 1 study, 1919 participants). An increase in positional plagiocephaly at 2-7 months of age with supine sleep position is possible (OR = 2.77, 95% CI = 2.06-3.72; 6 studies, 1774 participants).

Conclusions

Low- to very low-certainty evidence suggests that supine sleep position may reduce the risk of SUDI (0-1 year) and SIDS (0-1 year). Limited evidence suggests that supine sleeping probably delays short-term ‘gross motor’ development at 6 months, but the effect on long-term neurodevelopment at 18 months may be negligible.

The role of monoaminergic neurons in modulating respiration during sleep and the connection with SUDEP

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death among epilepsy patients, occurring even more frequently in cases with anti-epileptic drug resistance. Despite some advancements in characterizing SUDEP, the underlying mechanism remains incompletely understood. This review summarizes the latest advances in our understanding of the pathogenic mechanisms of SUDEP, in order to identify possible targets for the development of new strategies to prevent SUDEP. Based on our previous research along with the current literature, we focus on the role of sleep-disordered breathing (SDB) and its related neural mechanisms to consider the possible roles of monoaminergic neurons in the modulation of respiration during sleep and the occurrence of SUDEP. Overall, this review suggests that targeting the monoaminergic neurons is a promising approach to preventing SUDEP. The proposed roles of SDB and related monoaminergic neural mechanisms in SUDEP provide new insights for explaining the pathogenesis of SUDEP.

Sudden Unexpected Death in Infancy [SUDI]: What the clinician, pathologist, coroner and researchers want to know

The loss of an apparently healthy infant is confronting for any family, puzzling for a clinician and challenging for the pathologist charged with the task of demonstrating a cause for death. The term "cot death" evolved to "sudden infant death syndrome" [SIDS] and now "sudden unexpected death in infancy [SUDI]" as the epidemiology and pathology of infant death changed. Community interventions were successful in changing sleep practices for young babies. The current research focus is on understanding genetic predispositions to unexpected death in early childhood. Whilst much has been achieved in reducing the infant mortality rate from SUDI by between 50%, and 80% in some countries, over the last 30 years, there remain challenges for improving rates of accurate diagnosis and reaching out to more vulnerable families with clearly modifiable risk factors for SUDI. These challenges directly involve the clinician through taking a systematic and detailed history and better standardised death scene evaluations with specifically accredited assessors. Better knowledge regarding circumstances of SUDI cases will help Coroners and researchers provide answers for grieving families now, and in the future contribute to further reductions in the rate of SUDI in communities across the world.

A systematic review of the burden and risk factors of sudden infant death syndrome (SIDS) in Africa

Background

While sudden infant death syndrome (SIDS) has long been recognized as a leading preventable cause of infant mortality in high-income countries, little is known about the burden of SIDS in Africa. To address this knowledge gap, we conducted the first systematic review of SIDS-related publications in Africa. Our objective was to assess the prevalence of SIDS and its risk factors in Africa.

Methods

We systematically searched PubMed, Embase, Web of Science, Cochrane, and Google Scholar to identify studies published until December 26, 2020. Review authors screened titles and abstracts, and selected articles independently for full-text review. Risk of bias was assessed using the Newcastle Ottawa Scale (NOS) or a modification. Data on the proportion of infants who died of SIDS and reported prevalence of any risk factors were extracted using customized data extraction forms in Covidence.

Results

Our analysis rested on 32 peer-reviewed articles. Nine studies presented prevalence estimates on bedsharing and prone sleeping, suggesting near-universal bedsharing of infants with parents (range, 60 to 91.8%) and frequent use of the prone sleeping position (range, 26.7 to 63.8%). Eleven studies reported on the prevalence of SIDS, suggesting high rates of SIDS in Africa. The prevalence of SIDS ranged from 3.7 per 1000 live births in South Africa, 2.5 per 1000 live births in Niger, and 0.2 per 1000 live births in Zimbabwe. SIDS and other sudden infant deaths accounted for between 2.5 to 21% of infant deaths in South Africa and 11.3% in Zambia.

Conclusions

Africa may have the highest global rate of SIDS with a high burden of associated risk factors. However, majority of the studies were from South Africa which limits generalizability of our findings to the entire continent. There is an urgent need for higher quality studies outside of South Africa to fill this knowledge gap.

Protocol registration

Prospero Registration Number: CRD42021257261

Memory-Efficient AI Algorithm for Infant Sleeping Death Syndrome Detection in Smart Buildings

Artificial intelligence (AI) is fundamentally transforming smart buildings by increasing energy efficiency and operational productivity, improving life experience, and providing better healthcare services. Sudden Infant Death Syndrome (SIDS) is an unexpected and unexplained death of infants under one year old. Previous research reports that sleeping on the back can significantly reduce the risk of SIDS. Existing sensor-based wearable or touchable monitors have serious drawbacks such as inconvenience and false alarm, so they are not attractive in monitoring infant sleeping postures. Several recent studies use a camera, portable electronics, and AI algorithm to monitor the sleep postures of infants. However, there are two major bottlenecks that prevent AI from detecting potential baby sleeping hazards in smart buildings. In order to overcome these bottlenecks, in this work, we create a complete dataset containing 10,240 day and night vision samples, and use post-training weight quantization to solve the huge memory demand problem. Experimental results verify the effectiveness and benefits of our proposed idea. Compared with the state-of-the-art AI algorithms in the literature, the proposed method reduces memory footprint by at least 89%, while achieving a similar high detection accuracy of about 90%. Our proposed AI algorithm only requires 6.4 MB of memory space, while other existing AI algorithms for sleep posture detection require 58.2 MB to 275 MB of memory space. This comparison shows that the memory is reduced by at least 9 times without sacrificing the detection accuracy. Therefore, our proposed memory-efficient AI algorithm has great potential to be deployed and to run on edge devices, such as micro-controllers and Raspberry Pi, which have low memory footprint, limited power budget, and constrained computing resources.

Poverty and Paternal Education Associated With Infant Safe Sleep Intentions in a Peri-Urban Community in Ecuador

Ecuador's annual mortality rate from SIDS is 0.4 per 100 000 people, 4 times higher than neighboring countries Peru, Bolivia, and Brazil. Modifying the infant sleep environment toward safe practice has been demonstrated to be the most effective risk reduction strategy in reducing mortality from SIDS and little is known about sleep practices in Ecuador. The purpose of this study is to describe baseline infant sleep intentions of pregnant women in a peri-urban, low resource community in Ecuador. We also aim to identify demographic and psychosocial factors associated with suboptimal sleep practices in this context to develop long-term strategies to identify infants with high risk for SIDS/SUID. A cross-sectional study design was employed with 100 women in their third trimester of pregnancy. The majority of women were partnered (82%), both parents had approximately 8 years of education, and over half reported that their incomes met or exceeded their basic needs (55%). Significant predictors of safer sleep intention included years of paternal education (P = .019) and income meeting their basic needs (P = .0049). For each additional year of paternal education, families were 23% more likely to report safer intended infant sleep practices. Compared to those whose income did not allow for basic needs, those who had sufficient income to meet (or exceed) basic needs were 425% more likely to report safer intended sleep practices. Targeted interventions to high-risk populations may reduce the burden of SIDS/SUID in this community.

State-level trends in sudden unexpected infant death and immunization in the United States: an ecological study

Background

Sudden unexpected infant death (SUID) continues to be a major contributor to infant mortality in the United States. The objective was to analyze time trends in SUID and their association with immunization coverage.

Methods

The number of deaths and live births per year and per state (1992–2015) was obtained from the Centers for Disease Control and Prevention (CDC). We calculated infant mortality rates (i.e., deaths below one year of age) per 1000 live births for SUID. We obtained data on immunization in children aged 19–35 months with three doses or more of diphtheria-tetanus-pertussis (3+ DTP), polio (3+ Polio), and Haemophilus influenzae type b (3+ Hib) as well as four doses or more of DTP (4+ DTP) from the National Immunization Survey, and data on infant sleep position from the Pregnancy Risk Assessment Monitoring System (PRAMS) Study. Data on poverty and race were derived from the Current Population and American Community Surveys of the U.S. Census Bureau. We calculated mean SUID mortality rates with 95% confidence interval (CI) as well as the annual percentage change using breakpoint analysis. We used Poisson regression with random effects to examine the dependence of SUID rates on immunization coverage, adjusting for sleep position and poverty (1996–2015). In a second model, we additionally adjusted for race (2000–2015).

Results

Overall, SUID mortality decreased in the United States. The mean annual percent change was − 9.6 (95% CI = − 10.5, − 8.6) between 1992 and 1996, and − 0.3 (95% CI = − 0.4, − 0.1) from 1996 onwards. The adjusted rate ratios for SUID mortality were 0.91 (95% CI = 0.80, 1.03) per 10% increase for 3+ DTP, 0.88 (95% CI = 0.83, 0.95) for 4+ DTP, 1.00 (95% CI = 0.90, 1.10) for 3+ polio, and 0.95 (95% CI = 0.89, 1.02) for 3+ Hib. After additionally adjusting for race, the rate ratios were 0.76 (95% CI = 0.67, 0.85) for 3+ DTP, 0.83 (95% CI = 0.78, 0.89) for 4+ DTP, 0.81 (95% CI = 0.73, 0.90) for 3+ polio, and 0.94 (95% CI = 0.88, 1.00) for 3+ Hib.

Conclusions

SUID mortality is decreasing, and inversely related to immunization coverage. However, since 1996, the decline has slowed down.

International time trends in sudden unexpected infant death, 1969-2012

Background

Sudden unexpected infant death (SUID) - including sudden infant death syndrome (SIDS) - continues to be a major contributor to infant mortality worldwide. Our objective was to analyse time trends and to identify country-clusters.

Methods

The National Statistical Offices of 52 countries provided the number of deaths and live births (1969–2012). We calculated infant mortality rates per 1000 live births for SUID, SIDS, and all-cause mortality. Overall, 29 countries provided sufficient data for time course analyses of SUID. To sensitively model change over time, we smoothed the curves of mortality rates (1980–2010). We performed a hierarchical cluster analysis to identify clusters of time trends for SUID and SIDS, including all-cause infant mortality.

Results

All-cause infant mortality declined from 28.5 to 4.8 per 1000 live births (mean 12.4; 95% confidence interval 12.0–12.9) between 1969 and 2012. The cluster analysis revealed four country-clusters. Clusters 1 and 2 mostly contained countries showing the typical peak of SUID mortality during the 1980s. Cluster 1 had higher SUID mortality compared to cluster 2. All-cause infant mortality was low in both clusters but higher in cluster 1 compared to cluster 2. Clusters 3 and 4 had low rates of SUID without a peak during the 1980s. Cluster 3 had the highest all-cause infant mortality of all clusters. Cluster 4 had an intermediate all-cause infant mortality. The time trends of SUID and SIDS mortality were similar.

Conclusions

The country-specific time trends in SUID varied considerably. The identification of country-clusters may promote research into how changes in sleep position, smoking, immunisation, or other factors are related to our findings.

The use of post-mortem lividity to determine sleep position in sudden unexpected deaths in infancy

AIM

To compare parental reports of position found in sudden unexpected deaths in infancy (SUDI) to autopsy reports of lividity and to more accurately classify infant sleep position.

METHODS

Cases of SUDI in Queensland between 2010 and 2014 were reviewed to determine the position in which infants were reported to have been placed and found. This was compared to the distribution of post-mortem lividity at autopsy. Evidence of lividity present during early death scene investigation was also recorded.

RESULTS

There was a discordance between the position an infant was reported to have been found and the position of lividity at autopsy in 22/228 SUDI (9.6%). All infants had anterior lividity despite 13 reportedly found supine, three on their side and six in an unknown position. Using anterior lividity at autopsy to change the position found increased the proportion of prone infants from 37.7% to 47.4%. In 47.8% cases, anterior or lateral lividity reported at the scene was no longer present at autopsy.

CONCLUSION

Previously published odds ratios may have underestimated the risk of sudden infant death associated with prone sleep position. SUDI death scene investigation protocols should require photographic documentation of lividity prior to transporting an infant.

Unwanted effects of treatments for depression in children and adolescents: a mapping of systematic reviews

OBJECTIVES

To describe the results of a mapping review exploring the coverage of unwanted treatment effects in systematic reviews of the effects of various treatments for moderate to severe depression in children and adolescents.

SETTING

Any context or service providing treatment for depression, including interventions delivered in local communities and school settings, as well as services provided in primary or specialist care.

PARTICIPANTS

Children and young people with moderate to severe depression (<18 years).

INTERVENTIONS

Systematic reviews published in 2011 or later comparing the effects of any treatment for children and adolescents with moderate to severe depression meeting the Database of Abstracts of Reviews of Effects criteria. The systematic search was performed in April 2018 and updated in December 2018.

PRIMARY OUTCOMES

Any unwanted effects of treatments as defined in the systematic review.

RESULTS

We included 10 systematic reviews covering 19 treatment comparisons. Unwanted effects were assessed for seven of 19. Three comparisons were evaluations of pharmaceutical interventions or combination therapy, reporting effects on 'suicidal ideation' and 'suicide risk'. Two included therapy, reporting 'self-harm', and 'suicidal ideation', and two comparisons included transcranial magnetic stimulation and electroconvulsive treatment. Unwanted effects evaluated for these treatments were mostly symptoms of physical discomfort such as headache or cramps. For the remaining treatment comparisons evaluating psychological and psychosocial therapies, unwanted effects were not evaluated or found. A limitation of overviews of systematic reviews such as this mapping study is that data extraction is done based on the reporting of results by the review authors and not on the primary studies.

CONCLUSION

The unwanted effects of widely used treatments for children and young people with depression is unknown. This is a major barrier for evidence informed decision making about treatment choices for children and young people. We suggest that unwanted effects should be a reporting standard in all protocols describing evaluations of treatments, including primary studies as well as systematic reviews.

An Integrated Analysis of Maternal-Infant Sleep, Breastfeeding, and Sudden Infant Death Syndrome Research Supporting a Balanced Discourse

Breastfeeding and the place of sleep for the mother and the infant have been controversial internationally due to reported concerns regarding infant deaths despite the known benefits of exclusive and prolonged breastfeeding, which are increased by breastfeeding at night. The aims of this integrated analysis were to (a) review breastfeeding and maternal and infant sleep research literature via historical, epidemiological, anthropological, and methodological lenses; (b) use this information to determine where we are currently in safeguarding both infant lives and breastfeeding; and (c) postulate the direction that research might take from this point forward to improve our knowledge and inform our policy and practice. Despite well-meaning but unsuccessful campaigns in some countries to dissuade parents from sleeping with their babies, many breastfeeding mothers and caregivers do sleep with their infants whether intentionally or unintentionally. Taking cultural contexts and socio-ecological circumstances into consideration, data supports policies to counsel parents and caregivers on safe sleep practices, including bed-sharing in non-hazardous circumstances, particularly in the absence of parental smoking, recent parental alcohol consumption, or sleeping next to an adult on a sofa. Further research with appropriate methodology is needed to drill down on actual rates of infant deaths, paying close attention to the definitions of deaths, the circumstances of the deaths, and confounding factors, in order to ensure we have the best information with which to derive public health policy. Introduction and use of the concept of "breastsleeping" is a plausible way to remove the negative connotations of "co-sleeping" and redirect ongoing data-driven discussions and education of best practices of breastfeeding and sleep.

Making research central to good paediatric practice

There is evidence abroad of a cautious if not protective approach to research involving children and young people (CYP). We are sensitive to these views but believe they are based on a misconception that we must address together. In this introductory article we look at the complexities and risks of this research, how we must involving CYP and their families in the all aspects of research, how to seek valid consent and assent and how research findings should be reported. Considering how we should conduct this ongoing debate, we outline seven principles that we believe should underpin the necessary dialogue between all with legitimate interest. Our debate should be: (1) evidence informed: arguments should be supported by appropriate and reasonably accurate factual claims; (2) transparent about the grounds for decisions; (3) balanced: arguments should be met by contrary arguments; (4) conscientious: we must be willing to talk and listen, with civility and respect; (5) substantive: arguments should be considered sincerely on their merits, not on how they are made or by who is making them; (6) comprehensive: all points of view held by significant portions of the population should receive attention; and (7) with procedures for revising decisions in light of challenges, and it should be our responsibility to ensure we have met all of these.

Avoidable mortality from respiratory tract infection and sudden unexplained death in children with chronic conditions: a data linkage study

OBJECTIVE

To determine the risk of death from two potentially avoidable causes with different aetiologies: respiratory tract infection (RTI) and sudden unexplained death (SUD) in children with and without chronic conditions.

DESIGN

Whole-country, birth cohort study using linked administrative health databases from Scotland.

SETTING AND PARTICIPANTS

Children aged 2 months to less than 5 years in Scotland between 2000 and 2014.

MAIN OUTCOME MEASURES

Relative risk of death (expressed as the HR) related to RTIs or SUD, in children with and without chronic conditions. We separately analysed deaths at ages 2-11 months and at 1-4 years and adjusted for birth characteristics, socioeconomic status and vaccination uptake using Cox regression.

RESULTS

The cohort comprised 761 172 children. Chronic conditions were recorded in 9.6% (n=72 901) of live births, 82.4% (n=173) of RTI-related deaths and 17.4% (n=49) of SUDs. Chronic conditions were very strongly associated with RTI mortality (2-11 months: HR 68.48, 95% CI (40.57 to 115.60), 1-4 years: HR 38.32, 95% CI (23.26 to 63.14)) and strongly associated with SUD (2-11 months: HR 2.42, 95% CI (1.67 to 3.63), 1-4 years: HR 2.53, 95% CI (1.36 to 4.71)).

CONCLUSIONS

The very strong association with chronic conditions suggests that RTI-related mortality may sometimes be a consequence of a terminal decline and not possible to defer or prevent in all cases. Recording whether death was expected on death certificates could indicate which RTI-related deaths might be avoidable through healthcare and public health measures.

The "architect analogy" of evidence-based practice: Reconsidering the role of clinical expertise and clinician experience in evidence-based health care

The role of expertise in evidence-based medicine (EBM) and practice (EBP) has long been debated. In the early years of the EBP movement, the role of expertise and experience were diminished in clinical decision-making. However, the concepts of EBP are evolving. A more nuanced view of the value of clinician expertise, based on experience and clinical judgement, has emerged. This article proposes that clinical expertise does not belong within the evidence hierarchy's decision-making pyramid as the lowest form of evidence, but rather alongside it, representing a complementary source of knowledge that supports the processes of EBP. An "Architect Analogy of EBP" is proposed as a new model by which to describe this relationship. In this analogy, the clinician's use of expertise is likened to the role of an architect, using evidence as building blocks in the construction of the client's edifice, representing the patients' health and wellbeing. Much as an architect carefully designs the edifice in consultation with the client's needs and preferences, choosing appropriate material (evidence), rejecting faulty material, and ensuring construction stays on course, the clinician must sort through a plethora of sometimes contradictory evidence, evaluate its merits and appropriateness for the patients' unique biopsychosocial circumstances and values, and monitor the effects of interventions on patients' health and wellbeing. The expertise of practitioners, as the architects of EBP, is an important supporting source of knowledge that facilitates the "Five Steps of EBP," informs and facilitates EBP, and supports patient-centred care.

Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings

The discontinuation of interventions that should be stopped, or de-implementation, has emerged as a novel line of inquiry within dissemination and implementation science. As this area grows in human services research, like public health and social work, theory is needed to help guide scientific endeavors. Given the infancy of de-implementation, this conceptual narrative provides a definition and criteria for determining if an intervention should be de-implemented. We identify three criteria for identifying interventions appropriate for de-implementation: (a) interventions that are not effective or harmful, (b) interventions that are not the most effective or efficient to provide, and (c) interventions that are no longer necessary. Detailed, well-documented examples illustrate each of the criteria. We describe de-implementation frameworks, but also demonstrate how other existing implementation frameworks might be applied to de-implementation research as a supplement. Finally, we conclude with a discussion of de-implementation in the context of other stages of implementation, like sustainability and adoption; next steps for de-implementation research, especially identifying interventions appropriate for de-implementation in a systematic manner; and highlight special ethical considerations to advance the field of de-implementation research.

Is the Right Research Being Conducted to Advance Knowledge about Breast Reconstruction? An Analysis of the Research Pipeline

BACKGROUND

It has been estimated that up to 85 percent of research is of limited value or wasted, in part because of the wrong research questions being addressed. In this study, the authors identified research gaps for breast reconstruction using guideline recommendations based on low-quality or no evidence. The authors then evaluated whether research was currently being conducted to fill these gaps.

METHODS

The authors extracted grade C and D options, which are based on limited evidence, from the American Society of Plastic Surgeon's clinical practice guideline for breast reconstruction. For each option, the authors created Participants, Intervention, Comparator, Outcome questions and search strings using a systematic process. Searches were conducted of ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform to locate new and ongoing studies. The authors also catalogued studies on breast reconstruction funded by the Plastic Surgery Foundation.

RESULTS

Of the 10 research gaps, only six were being addressed by new and ongoing research. Timing of reconstruction (immediate or delayed) and use of acellular dermal matrix were most frequently studied. Preoperative referral of a plastic surgeon before mastectomy, complications associated with preoperative breast size, effects of hormone therapy on postoperative outcomes, and methods for detecting local recurrence after mastectomy were not being addressed by new research. Studies funded by the Plastic Surgery Foundation showed a similar pattern.

CONCLUSIONS

Of the areas identified, some have received more attention than others. Gaps remain. The authors' results should spark interest in conducting research on these topics and, by so doing, strengthen the clinical practice guideline recommendations.

Ethnic variation in unexplained deaths in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-2012: national birth cohort study using routine data

BACKGROUND

Unexplained deaths in infancy comprise 'sudden infant death syndrome' (SIDS) and deaths without ascertained cause. They are typically sleep-related, perhaps triggered by unsafe sleep environments. Preterm birth may increase risk, and varies with ethnicity. We aimed to compare ethnic-specific rates of unexplained infant death, explore sociodemographic explanations for ethnic variation, and examine the role of preterm birth.

METHODS

We analysed routine data for 4.6 million live singleton births in England and Wales 2006-2012, including seven non-White ethnic groups ranging in size from 29 313 (Mixed Black-African-White) to 180 265 (Pakistani). We calculated rates, birth-year-adjusted ORs, and effects of further adjustments on the χ² for ethnic variation.

RESULTS

There were 1559 unexplained infant deaths. Crude rates per 1000 live singleton births were as follows: 0.1-0.2 for Indian, Bangladeshi, Pakistani, White Non-British, Black African; 0.4 for White British; 0.6-0.7 for Mixed Black-African-White, Mixed Black-Caribbean-White, Black Caribbean. Birth-year-adjusted ORs relative to White British ranged from 0.38 (95% CI 0.24 to 0.60) for Indian babies to 1.73 (1.21 to 2.47) for Black Caribbean (χ²(10 df)=113.6, p<0.0005). Combined adjustment for parents' marital/registration status and mother's country of birth (UK/non-UK) attenuated the ethnic variation. Adjustments for gestational age at birth, maternal age and area deprivation made little difference.

CONCLUSION

Substantial ethnic disparity in risk of unexplained infant death exists in England and Wales. Apparently not attributable to preterm birth or area deprivation, this may reflect cultural differences in infant care. Further research into infant-care practices in low-risk ethnic groups might enable more effective prevention of such deaths in the general population.

The effect of body position on esophageal reflexes in cats: a possible mechanism of SIDS?

BackgroundIt has been hypothesized that life-threatening events are caused by supraesophageal reflux (SER) of gastric contents that activates laryngeal chemoreflex-stimulated apnea. Placing infants supine decreases the risk of sudden infant death syndrome (SIDS). The aim of this study was to determine whether body position affects esophageal reflexes that control SER.MethodsWe instrumented the pharyngeal and esophageal muscles of decerebrate cats (N=14) to record EMG or manometry, and investigated the effects of body position on the esophago-upper esophageal sphincter (UES) contractile reflex (EUCR), esophago-UES relaxation reflex (EURR), esophagus-stimulated pharyngeal swallow response (EPSR), secondary peristalsis (SP), and pharyngeal swallow (PS). EPSR, EUCR, and SP were activated by balloon distension, EURR by air pulse, and PS by nasopharyngeal water injection. The esophagus was stimulated in the cervical, proximal thoracic, and distal thoracic regions. The threshold stimulus for activation of EUCR, EURR, and PS, and the chance of activation of EPSR and SP were quantified.ResultsWe found that only EPSR was significantly more sensitive in the supine vs. prone position regardless of the stimulus or the position of the stimulus in the esophagus.ConclusionWe hypothesize that the EPSR may contribute to the protection of infants from SIDS by placement in the supine position.

Cot Death: History of an Iatrogenic Disaster

Since antiquity, cot death has been explained as accidental suffocation, overlaying, or smothering. Parents were blamed for neglect or drunkenness. A cage called arcuccio was invented around 1570 to protect the sleeping infant. Up to the 19th century, accidents were registered as natural causes of death. From 1830, accidental suffocation became unacceptable for physicians and legislators, and "natural" explanations for the catastrophe were sought, with parents being consoled rather than blamed. Two assumed causes had serious consequences: thymus hyperplasia was irradiated, causing thyroid cancer, and the concept of central apnea was widely accepted, which led to home monitors and distracted from epidemiological evidence. Prone sleeping originated in the 1930s and from 1944, it was associated with cot death. However, from the 1960s, many authors recommended prone sleeping for infants, and many countries adopted the advice. A worldwide epidemic followed, peaking at 2‰ in England and Wales and 5‰ in New Zealand in the 1980s. Although epidemiological evidence was available by 1970, the first intervention was initiated in the Netherlands in 1989. Cot death disappeared almost entirely wherever prone sleeping was avoided. This strongly supports the assumption that prone sleeping has the greatest influence on the disorder, and that the epidemic resulted from wrong advice.

Why is a prone sleeping position dangerous for certain infants?

The prone (face down) sleeping position is known to be associated with a significantly increased risk of sudden and unexpected death in infancy (sudden infant death syndrome or SIDS), however, the reasons for this are unclear. Suggested mechanisms have involved suffocation from occlusion of the external airways by soft bedding/pillows or from flattening of the nose with backward displacement of the tongue, rebreathing of carbon dioxide, blunting of arousal responses with decreased cardiac responses to auditory stimulation, diaphragmatic splinting or fatigue, lowering of vasomotor tone with tachycardia, nasopharyngeal bacterial overgrowth, overheating, alteration of sleep patterns, compromise of cerebral blood flow and upper airway obstruction from distortion of nasal cartilages. Recent studies have, however, shown a significant reduction in substance P in the inferior portion of the olivo-cerebellar complex in SIDS infants which is crucial for the integration of motor and sensory information for the control of head and neck movement. This deficit may explain why some infants are not able to move their faces away from potentially dangerous sleeping environments.

Types of Objects in the Sleep Environment Associated With Infant Suffocation and Strangulation

OBJECTIVE

To investigate the circumstances of death and types and roles of objects present in the sleep environment at the time of death for infants who died from suffocation or strangulation during sleep.

METHODS

This study analyzed 1736 reported incidents of accidental suffocation and strangulation in bed (ASSB) of infants younger than 1 year of age. These fatalities occurred from 2000 through 2012 and were reported to the United States Consumer Product Safety Commission.

RESULTS

The mean age of ASSB death was 3.76 months (SD, 2.51). Infants younger than 5 months accounted for 67.3% (1168 of 1736) of all reported fatalities and 58.3% (1009 of 1731) were male. Deceased infants were often found in a crib or bassinet (30.6%; 383 of 1253) or in the prone orientation (84.9%; 595 of 701). The most common objects associated with infant ASSB were pillows (24.5%; 425 of 1736), mattresses (21.0%; 364 of 1736), blankets (13.1%; 228 of 1736), and walls (11.5%; 199 of 1736). Wedged (43.3%; 616 of 1424) or positioned on top of an object (25.9%; 369 of 1424) were the most common positions associated with death. Infants were often found wedged between a mattress and wall (30.2%; 181 of 599) or oriented face-down or prone on top of a pillow (52.2%; 187 of 358). Sleep surface sharing was associated with 6.5% (112 of 1736) of ASSB deaths.

CONCLUSIONS

Pillows and blankets are objects in sleep environments frequently associated with unintentional suffocation and strangulation of infants. Increased efforts should be made to remove these and other objects from sleep environments of infants.

Why Should We Direct Our Efforts Toward Evidence-Based Knowledge Creation?

In the field of exotic animal medicine, there is much work to do, more than in human medicine and in companion animal medicine. The work in this field should be directed toward an evidence-based knowledge accumulation. Sound evidence supporting tests and treatments will ensure better health care for exotic animal patients.

Progress in evidence-based medicine: a quarter century on

In response to limitations in the understanding and use of published evidence, evidence-based medicine (EBM) began as a movement in the early 1990s. EBM's initial focus was on educating clinicians in the understanding and use of published literature to optimise clinical care, including the science of systematic reviews. EBM progressed to recognise limitations of evidence alone, and has increasingly stressed the need to combine critical appraisal of the evidence with patient's values and preferences through shared decision making. In another progress, EBM incorporated and further developed the science of producing trustworthy clinical practice guidelines pioneered by investigators in the 1980s. EBM's enduring contributions to clinical medicine include placing the practice of medicine on a solid scientific basis, the development of more sophisticated hierarchies of evidence, the recognition of the crucial role of patient values and preferences in clinical decision making, and the development of the methodology for generating trustworthy recommendations.

Infant pacifiers for reduction in risk of sudden infant death syndrome

BACKGROUND

Sudden infant death syndrome (SIDS) has been most recently defined as the sudden unexpected death of an infant less than one year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including the performance of a complete autopsy and a review of the circumstances of death and clinical history. Despite the success of several prevention campaigns, SIDS remains a leading cause of infant mortality. In 1994, a 'triple risk model' for SIDS was proposed that described SIDS as an event that results from the intersection of three factors: a vulnerable infant; a critical development period in homeostatic control (age related); and an exogenous stressor. The association between pacifier (dummy) use and reduced incidence of SIDS has been shown in epidemiological studies since the early 1990s. Pacifier use, given its low cost, might be a cost-effective intervention for SIDS prevention if it is confirmed effective in randomised controlled trials.

OBJECTIVES

To determine whether the use of pacifiers during sleep versus no pacifier during sleep reduces the risk of SIDS.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed, Embase, and CINAHL to 16 March 2016. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Published and unpublished controlled trials using random and quasi-random allocations of infants born at term and at preterm (less than 37 weeks' gestation) or with low birth weight (< 2500 g). Infants must have been randomised by one month' postmenstrual age. We planned to include studies reported only by abstracts, and cluster and cross-over randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed studies from searches. We found no eligible studies.

MAIN RESULTS

We identified no randomised controlled trials examining infant pacifiers for reduction in risk of SIDS.

AUTHORS' CONCLUSIONS

We found no randomised control trial evidence on which to support or refute the use of pacifiers for the prevention of SIDS.

Biomarkers-A General Review

A biomarker is a biological observation that substitutes for and ideally predicts a clinically relevant endpoint or intermediate outcome that is more difficult to observe. The use of clinical biomarkers is easier and less expensive than direct measurement of the final clinical endpoint, and biomarkers are usually measured over a shorter time span. They can be used in disease screening, diagnosis, characterization, and monitoring; as prognostic indicators; for developing individualized therapeutic interventions; for predicting and treating adverse drug reactions; for identifying cell types; and for pharmacodynamic and dose-response studies. To understand the value of a biomarker, it is necessary to know the pathophysiological relationship between the biomarker and the relevant clinical endpoint. Good biomarkers should be measurable with little or no variability, should have a sizeable signal to noise ratio, and should change promptly and reliably in response to changes in the condition or its therapy. © 2017 by John Wiley & Sons, Inc.

Clinical Practice Guidelines: A Primer on Development and Dissemination

Trustworthy clinical practice guidelines should be based on a systematic review of the literature, provide ratings of the quality of evidence and the strength of recommendations, consider patient values, and be developed by a multidisciplinary panel of experts. The quality of evidence reflects our certainty that the evidence warrants a particular action. Transforming evidence into a decision requires consideration of the quality of evidence, balance of benefits and harms, patients' values, available resources, feasibility of the intervention, acceptability by stakeholders, and effect on health equity. Empirical evidence shows that adherence to guidelines improves patient outcomes; however, adherence to guidelines is variable. Therefore, guidelines require active dissemination and innovative implementation strategies.

A proposed World Council on Epidemiology and Causation: summary of feedback and considerations in an international workshop

Rigorous evaluation of associations in epidemiology is essential, especially given big data, data mining, and hypothesis-free analyses. There is a precedent in making judgments on associations in the monographs of the International Agency for Research on Cancer; however, only the carcinogenic effects of exposures are examined. The idea of a World Council of Epidemiology and Causality to undertake rigorous, independent, comprehensive examination of associations has been debated, including in a workshop at the International Epidemiology Association's 20^th World Congress of Epidemiology, 2014. The objective of the workshop was both to, briefly, debate the idea and set out further questions and next steps. The principal conclusion from feedback including from the workshop is that the World Council of Epidemiology and Causality idea, notwithstanding challenges, has promise and deserves more debate. The preferred model is for a small independent body working closely with relevant partners with a distributed approach to tasks. Recommendations are contextualized in contemporary approaches in causal thinking in epidemiology.

Wrong guidelines: how to detect them and what to do in the case of flawed recommendations

Any evidence-based recommendation needs careful assessment of its methodological background as well as of its content trustworthiness, especially given that following it will not necessarily produce the intended clinical outcomes. There are no established instruments to evaluate guidelines for their content, while useful tools assessing the quality of methods followed are well recognised and adopted. We suggest a 'safety bundle' considering methodological aspects and content trustworthiness of guidelines, by adopting the GRADE method in a backward fashion. Sharing the critical analysis of the guidelines with patients, including any eventual uncertainty about them, is of key importance in order to avoid the possible adverse effects derived from following the wrong guidelines. Such critical approach is also helpful and beneficial in producing better care pathways, health policy decisions and more relevant and ethical research.

Environmental risk factors for sudden infant death syndrome in Japan

While the prevalence of sudden infant death syndrome (SIDS) has decreased worldwide, this decline has plateaued recently. Strategies are needed to resume the constant decrease of SIDS in Japan. A prospective electrocardiographic screening program for infants was performed between July 2010 and March 2011. Parents of 4319 infants were asked about environmental factors related to SIDS through questionnaires at a one-month medical checkup and one year. Parental awareness of prone position, smoke exposure, and breast feeding as environmental factors were 81.4 %, 69.0 %, and 47.8 %, respectively. The prevalence of laying infants exclusively in a supine position was 96.7 %. At the one-month medical checkup, smoking prevalence was 41.7 % in fathers and 2.1 % in mothers. Maternal smoking prevalence was significantly increased at one year after (p < 0.001). Multivariate regression analysis showed that risk factors for new or continued maternal smoking habits were maternal smoking habits at one month (p < 0.001), paternal smoking habits one year later (p < 0.001), and younger maternal age (p = 0.02).

CONCLUSION

Most parents already avoid laying infants in the prone position, and parental smoking is still a SIDS risk concern in Japan. Smoking cessation programs should be further implemented for parents to decrease risks of SIDS in Japan. What is Known: • The prevalence of sudden infant death syndrome (SIDS) has decreased worldwide, however, this decline has plateaued recently. What is New: • Most infants were laid sleeping in the supine position (96.7 %) and were fed breast milk or a mix of expressed milk and formula (92.7 %), and 2.1 % of mothers smoked at the one-month medical checkup. • Maternal smoking prevalence significantly increased from the one-month medical checkup to one year later, and smoking mothers were more likely to feed infants by formula rather than breast milk. • Independent risk factors for new or continued maternal smoking habits included younger maternal age, maternal smoking habits at one month, and paternal smoking habits one year later.