Recommendations for safe sleeping environments for infants and children

The epidemiology of crib-related head injuries: A ten-year nationwide analysis

INTRODUCTION

Falls from cribs resulting in head injury are understudied and poorly characterized. The purpose of this study was to advance current understanding of the prevalence, descriptive characteristics of injury victims, and the types of crib fall-related head injuries (CFHI) using queried patient cases from the National Electronic Injury Surveillance System (NEISS) database.

METHODS

Using the US Consumer Product Safety Commission's System NEISS database, we queried all CFHIs among children from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of the incident, diagnoses, ED disposition, and sequelae were analyzed. The number of CFHI from all US EDs during each year was also collected from the database.

RESULTS

There were an estimated 54,799 (95% CI: 30,228-79,369) total visits to EDs for CFHIs between 2012 and 2021, with a decrease in incidence of approximately 20% during the onset of the COVID-19 pandemic (2019: 5616 cases, 2020: 4459 cases). The annual incidence of injuries showed no significant trend over the 10-year study period. An available subset of 1782 cases of head injuries from approximately 100 EDs was analyzed, and 1442 cases were included in final analysis. Injuries were sorted into three primary categories: unspecified closed head injury (e.g., closed head injury, blunt head trauma, or traumatic brain injury), concussion, or open head injury and skull fracture. Unspecified closed head injuries were the most common of all head injuries (95.4%, 1376/1442). Open head injuries (14/1442, 0.97%) and concussions 3.6% (52/1442, 3.6%) were rare. Most injuries involved children under the age of 1 (42.6%) compared to children who were 1, 2, 3, or 4-years old. About a fourth of patients had other diagnoses in addition to their primary injury including scalp/forehead hematomas, emesis, and contusions. Female patients were more likely to present with other diagnoses in addition to their primary head injury (Difference: 12.3%, 95% CI: 9.87%-15.4%, p < .0001).

CONCLUSION

Despite minimum rail height requirements set by the Consumer Safety Product Commission (CPSC), head injuries associated with crib falls are prevalent in the United States. However, most injuries were minor with a vast majority of patients being released following examination and treatment.

Asia-Pacific consensus statement on integrated 24-hour activity guidelines for the early years

Background

Early childhood is a vital period for development and growth. Promoting beneficial lifestyle behaviours in early childhood can help optimise children's health, development and learning, shape their behaviours in adulthood and offer the best protection against future non-communicable diseases (NCDs). In the Asia-Pacific region, NCDs are significant causes of healthcare burden and mortality. Furthermore, there is also a high prevalence of adverse metabolic risk factors and unhealthy lifestyle behaviours among these children.

Method

Representatives from 19 Asia-Pacific nations and/or jurisdictions developed a consensus statement on integrated 24-hour activity guidelines for the early years using the GRADE-ADOLOPMENT framework.

Findings

These guidelines apply to all infants, toddlers and pre-schoolers below 5 years of age. The guidelines aim to provide a holistic and practical approach to lifestyle activities by framing physical activity, sedentary behaviour and sleep within a 24-hour period. Dietary patterns were included as they play an integral role in metabolic health and energy balance.

Interpretation

Aligned with the World Health Organization's Global Action Plan for the Prevention and Control of NCDs through health promotion interventions in early life, through cultivating healthy lifestyle behaviours in the children's early years, we aim to provide children with the best start in life and reduce the burden of future NCDs in the Asia-Pacific region.

Funding

Funded by Integrated platform for research in advancing metabolic health outcomes of women and children.

Factors Associated with Safe Infant Sleep Practices in Saudi Arabia

Purpose

To assess mothers’ approaches to infant sleep practices.

Patients and Methods

A cross-sectional survey study was conducted on mothers with babies aged below five months who were attending paediatric clinics between November 1st, 2020, and January 5th, 2021, in Riyadh, Saudi Arabia.

Results

A total of 522 mothers participated in this study. A total of 38.9% practised exclusive formula feeding. A total of 61.9% of the participants practised the supine position. The majority (93.3%) of the mothers shared a room with their babies, while 34.7% shared a bed. Only 6.9% did not use any soft bedding. Age was a significant predictor associated with participant practices regarding sleeping and feeding positions (p < 0.05). Having two or more children was associated with improper sleeping practices (p < 0.05). Being non-Saudi and having a university degree or higher were associated with having a higher risk of unsafe practices regarding bed-sharing (p < 0.05). On the other hand, being contacted by a doctor, nurse, or other healthcare worker about safe sleep practices were an important factor that influenced safe practices regarding feeding (p < 0.05). Receiving care at a private hospital was associated with safer practices regarding sleeping position and bed-sharing (p < 0.05).

Conclusion

We observed high-risk sleeping practices among Saudi mothers. This includes using soft bedding and unsafe sleeping positions. The importance of this study lies in the future implementation of this result through public health measures aimed at at-risk populations.

Verbal Autopsies for Out-of-Hospital Infant Deaths in Zambia

OBJECTIVES

In Zambia, a significant number of infants die in the community. It is hypothesized that delays in care contribute to many of these so-called "brought in dead" infants.

METHODS

We analyzed free-text narratives from verbal autopsies, in which families narrate the final series of events leading to each infant's death. Using the 3-delays model framework and working iteratively to achieve consensus, we coded each narrative using NVivo software to identify, characterize, and quantify the contribution of delays and other factors to the fatal outcome.

RESULTS

Verbal autopsies were collected from 230 families of brought in dead infants younger than 6 months of age. As many as 82.8% of infants had 1 or more delays in care. The most-common delay was in the family's decision to seek care (54.8%), even as severe symptoms were frequently described. Similarly, 27.8% of infants died en route to a health care facility. Delays in receiving adequate care, including infants dying while waiting in line at a clinic or during referral from a clinic to a hospital, occurred in 24.7% of infants. A third of infants had been previously evaluated by a clinician in the days before their death.

CONCLUSIONS

Delays in care were the rule rather than the exception in this population of Zambian infants. Accessing care requires families to navigate significant logistic barriers, and balance complex forces in deciding to seek care. Strategies to avoid such delays could save many infants lives.

Parent-child bed-sharing: The good, the bad, and the burden of evidence

The practice of parent and child sharing a sleeping surface, or 'bed-sharing', is one of the most controversial topics in parenting research. The lay literature has popularized and polarized this debate, offering on one hand claims of dangers, and on the other, of benefits - both physical and psychological - associated with bed-sharing. To address the scientific evidence behind such claims, we systematically reviewed 659 published papers (peer-reviewed, editorial pieces, and commentaries) on the topic of parent-child bed-sharing. Our review offers a narrative walkthrough of the many subdomains of bed-sharing research, including its many correlates (e.g., socioeconomic and cultural factors) and purported risks or outcomes (e.g., sudden infant death syndrome, sleep problems). We found general design limitations and a lack of convincing evidence in the literature, which preclude making strong generalizations. A heat-map based on 98 eligible studies aids the reader to visualize world-wide prevalence in bed-sharing and highlights the need for further research in societies where bed-sharing is the norm. We urge for multiple subfields - anthropology, psychology/psychiatry, and pediatrics - to come together with the aim of understanding infant sleep and how nightly proximity to the parents influences children's social, emotional, and physical development.

Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach

OBJECTIVES

To assess whether clutter (comforters, blankets, pillows, toys) caused bumper deaths and provide an analysis of bumper-related incidents/injuries and their causal mechanisms.

STUDY DESIGN

Bumper-related deaths (January 1, 1985, to October 31, 2012) and incidents/injuries (January 1, 1990, to October 31, 2012) were identified from the US Consumer Product Safety Commission (CPSC) databases and classified by mechanism. Statistical analyses include mean age, 95% CIs, χ(2) test for trend, and ANOVA with a paired-comparisons information-criterion post hoc test for age differences among injury mechanisms.

RESULTS

There were 3 times more bumper deaths reported in the last 7 years than the 3 previous time periods (χ(2)(3) = 13.5, P ≤ .01). This could be attributable to increased reporting by the states, diagnostic shift, or both, or possibly a true increase in deaths. Bumpers caused 48 suffocations, 67% by a bumper alone, not clutter, and 33% by wedgings between a bumper and another object. The number of CPSC-reported deaths was compared with those from the National Center for the Review and Prevention of Child Deaths, 2008-2011; the latter reported substantially more deaths than CPSC, increasing the total to 77 deaths. Injury mechanisms showed significant differences by age (F4,120 = 3.2, P < .001) and were caused by design, construction, and quality control problems. Eleven injuries were apparent life-threatening events.

CONCLUSION

The effectiveness of public health recommendations, industry voluntary standard requirements, and the benefits of crib bumper use were not supported by the data. Study limitations include an undercount of CPSC-reported deaths, lack of denominator information, and voluntary incident reports.

Parents' perception of stroller use in young children: a qualitative study

BACKGROUND

Despite their wide usage, it has recently been suggested that stroller use may reduce physical activity levels of young children. However, there have been no studies on stroller use as it relates to physical activity outcomes. The objectives of this study were to understand the context of stroller use for young children and parents' perceptions of the relationship between stroller use and their children's physical activity.

METHODS

Parents of children 1 to 5 years of age were recruited through two sites of TARGet Kids!, a primary-care, practice-based research network in Toronto, Canada. Fourteen semi-structured interviews were conducted. Interviews were audio recorded and transcribed verbatim and two independent reviewers conducted thematic analysis. A number of strategies were employed to ensure the trustworthiness of the data.

RESULTS

Parents discussed reasons for stroller use (i.e., transportation; storage; leisure; supervision/confinement; parent physical activity; and sleep), factors that influence the decision to use a stroller (i.e., caregiver choice; convenience, timing, distance; family lifestyle; and child preference), and perceived impact of stroller use on physical activity (i.e., most parents did not recognize a connection between stroller use and physical activity).

CONCLUSION

This study provides a context for researchers and policy makers to consider when developing stroller related physical activity guidelines for young children.

Excessive crying at 3 months of age and behavioural problems at 4 years age: a prospective cohort study

Background

Excessive crying in early infancy has been associated with behavioural problems among preschool children from high income countries but studies in low income and middle income countries are scarce.

Methods

The 2004 Pelotas Birth Cohort is a population-based study planned to enrol all live births occurring in Pelotas that year and comprises 4231 children who so far have been followed up at 3, 12, 24, 48 and 72 months of age. Several familial, maternal and child characteristics were gathered in every follow-up. At the 3-month follow-up, infants whose mothers perceived them as crying more than others of the same age were classified as ‘crying babies’. Child behavioural problems were assessed through the Child Behavior Checklist (CBCL) applied to the mother at the 48-month follow-up. Crude and adjusted ORs with 95% CIs were calculated by logistic regression.

Results

Prevalence of excessive crying at 3 months was 11.9% (10.9% to 13.0%). Among children with excessive crying at 3 months the proportion in the clinical range for CBCL total, internalising and externalising problems at 4 years of age was 31.2%, 12.9% and 37.5%, respectively, against 20.6%, 6.8% and 29.6%, respectively, among non-crying babies. After controlling for confounders crying babies presented increased risk of being in clinical range of CBCL total (OR=1.34; 1.03 to 1.74), internalising (OR=1.55; 1.09 to 2.21) and externalising problems (OR=1.29; 1.01 to 1.64) than infants without excessive crying.

Conclusions

Excessive crying in early infancy may represent one important risk factor for developing behavioural problems in later phases of early childhood.

Guidelines for feeding very low birth weight infants

Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.

Improper use of child restraint seats as a sleeping environment: Two cases of childhood death

A child restraint seat (CRS) is designed to keep infants safe inside motor vehicles while in motion. However, there have been a growing number of reports of injuries sustained as a result of CRS use outside the vehicle. These injuries commonly result from a fall from an elevated surface or an overturning of the CRS. The incidence of death from these events, however, is not well documented. The present report retrospectively analyzed the British Columbia Coroner Service Database to identify deaths involving CRS use outside the vehicle. Two such fatalities were identified. In both instances, infants had been placed in a CRS overnight and, in both cases, the CRS was found overturned, resulting in asphyxiation. The history and pathological findings of both cases are summarized.

Causes and risk factors for infant mortality in Nunavut, Canada 1999-2011

BACKGROUND

The northern territory Nunavut has Canada's largest jurisdictional land mass with 33,322 inhabitants, of which 85% self-identify as Inuit. Nunavut has rates of infant mortality, postneonatal mortality and hospitalisation of infants for respiratory infections that greatly exceed those for the rest of Canada. The infant mortality rate in Nunavut is 3 times the national average, and twice that of the neighbouring territory, the Northwest Territories. Nunavut has the largest Inuit population in Canada, a population which has been identified as having high rates of Sudden Infant Death Syndrome (SIDS) and infant deaths due to infections.

METHODS

To determine the causes and potential risk factors of infant mortality in Nunavut, we reviewed all infant deaths (<1 yr) documented by the Nunavut Chief Coroner's Office and the Nunavut Bureau of Statistics (n=117; 1999-2011). Rates were compared to published data for Canada.

RESULTS

Sudden death in infancy (SIDS/SUDI; 48%) and infection (21%) were the leading causes of infant death, with rates significantly higher than for Canada (2003-2007). Of SIDS/SUDI cases with information on sleep position (n=42) and bed-sharing (n=47), 29 (69%) were sleeping non-supine and 33 (70%) were bed-sharing. Of those bed-sharing, 23 (70%) had two or more additional risk factors present, usually non-supine sleep position. CPT1A P479L homozygosity, which has been previously associated with infant mortality in Alaska Native and British Columbia First Nations populations, was associated with unexpected infant death (SIDS/SUDI, infection) throughout Nunavut (OR:3.43, 95% CI:1.30-11.47).

CONCLUSION

Unexpected infant deaths comprise the majority of infant deaths in Nunavut. Although the CPT1A P479L variant was associated with unexpected infant death in Nunavut as a whole, the association was less apparent when population stratification was considered. Strategies to promote safe sleep practices and further understand other potential risk factors for infant mortality (P479L variant, respiratory illness) are underway with local partners.

Bed-sharing and risk of hospitalisation due to pneumonia and diarrhoea in infancy: the 2004 Pelotas Birth Cohort

OBJECTIVE

To investigate the association between bed-sharing with the mother at 3 months of age and incidence of hospitalisation due to pneumonia and diarrhoea between 3 and 12 months.

METHODS

The 2004 Pelotas Birth Cohort included all live births to mothers living in Pelotas, Brazil, in 2004. Information on bed-sharing was obtained at the 3-month follow-up visit, and on hospitalisations at the 12-month visit, both based on mothers' reports. Only singleton infants with complete information on hospitalisation were analysed.

RESULTS

3906 infants were included. The bed-sharing prevalence at 3 months was 46.4% (95% CI 44.9 to 48.0%). The incidence of pneumonia admissions between 3 and 12 months was 3.6% (95% CI 3.3 to 4.2%) and diarrhoea, 0.9% (95% CI 0.6 to 1.2%). In crude analyses, bed-sharing with the mother was associated with higher incidence of hospitalisation due to both pneumonia and diarrhoea. There was interaction between bed-sharing and duration of breastfeeding regarding the chance of admission due to pneumonia. Among infants breastfed for 3 months or less, the chance of hospitalisation due to pneumonia among bed-sharers was almost twice as high as among non-bed-sharers (adjusted OR 1.96; 95% CI 1.08 to 3.55). There was no association between bed-sharing and hospitalisation due to pneumonia among infants breastfed for longer than 3 months in crude or adjusted analyses. The association between bed-sharing and admissions due to diarrhoea lost statistical significance after allowing for confounders.

CONCLUSIONS

The effect of bed-sharing in infancy on the risk of hospitalisation due to pneumonia depends on breastfeeding, such that weaned children present higher risk.

Respiratory disease in Canadian First Nations and Inuit children

First Nations and Inuit Children are disproportionately affected by respiratory infections such as viral bronchiolitis, pneumonia and tuberculosis. Rates of long-term lung disease following severe respiratory infections early in life, such as bronchiectasis, are also elevated. In contrast, rates of asthma may be somewhat less than in other Canadian children, although rates of poor asthma control are increased. Causes for the high rates of infections include poverty, overcrowding, housing in need of major repairs and better ventilation, and increased exposure to environmental tobacco smoke. Improving these issues will require addressing the social origins of health in First Nations and Inuit communities, including poverty and employment, building more and improving existing housing, and will likely require developing enhanced immunization and surveillance strategies.

Maternal caffeine consumption and infant nighttime waking: prospective cohort study

OBJECTIVE

Coffee and other caffeinated beverages are commonly consumed in pregnancy. In adults, caffeine may interfere with sleep onset and have a dose-response effect similar to those seen during insomnia. In infancy, nighttime waking is a common event. With this study, we aimed to investigate if maternal caffeine consumption during pregnancy and lactation leads to frequent nocturnal awakening among infants at 3 months of age.

METHODS

All children born in the city of Pelotas, Brazil, during 2004 were enrolled on a cohort study. Mothers were interviewed at delivery and after 3 months to obtain information on caffeine drinking consumption, sociodemographic, reproductive, and behavioral characteristics. Infant sleeping pattern in the previous 15 days was obtained from a subsample. Night waking was defined as an episode of infant arousal that woke the parents during nighttime. Multivariable analysis was performed by using Poisson regression.

RESULTS

The subsample included 885 of the 4231 infants born in 2004. All but 1 mother consumed caffeine in pregnancy. Nearly 20% were heavy consumers (≥300 mg/day) during pregnancy and 14.3% at 3 months postpartum. Prevalence of frequent nighttime awakeners (>3 episodes per night) was 13.8% (95% confidence interval: 11.5%-16.0%). The highest prevalence ratio was observed among breastfed infants from mothers consuming ≥300 mg/day during the whole pregnancy and in the postpartum period (1.65; 95% confidence interval: 0.86-3.17) but at a nonsignificant level.

CONCLUSIONS

Caffeine consumption during pregnancy and by nursing mothers seems not to have consequences on sleep of infants at the age of 3 months.

Exploring the impact of osteopathic treatment on cranial asymmetries associated with nonsynostotic plagiocephaly in infants

OBJECTIVES

To document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who were to undergo a course of four osteopathic treatments (in addition to the standard positioning recommendations) as well as to determine the feasibility of using this methodology to conduct a randomized clinical trial investigating the impact of osteopathic intervention for infants with NSOP.

DESIGN

Pilot clinical standardization project using pre-post design in which 12 infants participated. Ten infants presented an initial Oblique Diameter Difference Index (ODDI) over 104% and five of them had an initial moderate to severe Cranial Vault Asymmetry (CVA) (over 12mm).

INTERVENTIONS

Infants received four osteopathic treatments at 2-week intervals.

MAIN OUTCOME MEASURES

Anthropometric, plagiocephalometric as well as qualitative measures were administered pre-intervention (T1), during the third treatment (T2) and two weeks after the fourth treatment (T3).

RESULTS

Participants showed a significant decrease in CVA (p=0.02), Skull Base Asymmetry (SBA) (p=0.01), Trans-Cranial Vault Asymmetry (TCVA) (p<0.003) between the first and third evaluations.

CONCLUSIONS

These clinical findings support the hypothesis that osteopathic treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP characteristics.

Update on well-baby and well-child care from 0 to 5 years: What's new in the Rourke Baby Record?

OBJECTIVE

To provide an overview of the 2009 edition of the Rourke Baby Record (RBR), which incorporates recent research in the literature relating to preventive health care for children aged 0 to 5 years.

QUALITY OF EVIDENCE

Recommendations are identified as supported by good, fair, or consensus evidence, according to the classification of the Canadian Task Force on Preventive Health Care.

MAIN MESSAGE

New information and recommendations are given for growth monitoring, nutrition, developmental surveillance, physical examination maneuvers, immunization schedules, and advice for parents. Anticipatory guidance updates relate to injury prevention, infant swaddling, literacy facilitation, nonparental child care, parenting skills programs, serum lead levels, over-the-counter cough and cold medications, pacifiers, antipyretics, insect repellents, and dental care and oral health. The 2009 RBR is available in English and French in both National and Ontario versions and is endorsed by the College of Family Physicians of Canada and the Canadian Paediatric Society.

CONCLUSION

The RBR website (www.rourkebabyrecord.ca) provides a practical tool for well-baby and well-child care, including background information, current evidence and literature review appraisal, an interactive walk-through of the guides with links to further information and evidence, and additional practical resources.

Bedsharing

On October 10, 2005, the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome made the recommendation that babies should not sleep in the same bed as adults. The purpose of this article is to present a more holistic approach to bedsharing based on the current research.

Sudden infant death syndrome

Sudden infant death syndrome (SIDS) continues to be the most common cause of postneonatal infant death. SIDS is a complex, multifactorial disorder, the cause of which is still not fully understood. However, much is known now about environmental risk factors, some of which are modifiable. These include maternal and antenatal risk factors such as smoking during pregnancy, as well as infant-related risk factors such as non-supine sleeping position and soft bedding. Emerging evidence also substantiates an expanding number of genetic risk factors. Interactions between environmental and genetic risk factors may be of critical importance in determining an infant's actual risk of SIDS. Although no practical way exists to identify which infants will die of SIDS, nor is there a safe and proven prevention strategy even if identification were feasible, reducing exposure to modifiable risk factors has helped to lower the incidence of SIDS. Current challenges include wider dissemination of guidelines to all people who care for infants, dissemination of guidelines in culturally appropriate ways, and surveillance of SIDS trends and other outcomes associated with implementation of these guidelines.

The relation between child death and child maltreatment

The death of a child is a sentinel event in a community, and a defining marker of a society's policies of safety and health. Child death as a result of abuse and neglect is a tragic outcome that occurs in all nations of the world. The true incidence of fatal child abuse and neglect is unknown. The most accurate incidence data of such deaths have been obtained from countries where multi-agency death review teams analyse the causes of child fatalities, as is done in the United States and Australia.