Introduction: There have been dramatic improvements in reducing infant sleep-related
deaths since the 1990s, when recommendations were introduced to place infants on their
backs for sleep. However, there are still approximately 3,500 sleep-related deaths
among infants each year in the United States, including those from sudden infant death
syndrome, accidental suffocation and strangulation in bed, and unknown causes. Unsafe
sleep practices, including placing infants in a nonsupine (on side or on stomach)
sleep position, bed sharing, and using soft bedding in the sleep environment (e.g.,
blankets, pillows, and soft objects) are modifiable risk factors for sleep-related
infant deaths.
Methods: CDC analyzed 2009–2015 Pregnancy Risk Assessment Monitoring System (PRAMS)
data to describe infant sleep practices. PRAMS, a state-specific and population-based
surveillance system, monitors self-reported behaviors and experiences before, during,
and shortly after pregnancy among women with a recent live birth. CDC examined 2015
data on nonsupine sleep positioning, bed sharing, and soft bedding use by state and
selected maternal characteristics, as well as linear trends in nonsupine sleep positioning
from 2009 to 2015.
Results: In 2015, 21.6% of respondents from 32 states and New York City reported placing
their infant in a nonsupine sleep position; this proportion ranged from 12.2% in Wisconsin
to 33.8% in Louisiana. Infant nonsupine sleep positioning was highest among respondents
who were non-Hispanic blacks. Nonsupine sleep positioning prevalence was higher among
respondents aged <25 years compared with ≥25 years, those who had completed ≤12 years
compared with >12 years of education, and those who participated in the Special Supplemental
Nutrition Program for Women, Infants, and Children during pregnancy. Based on trend
data from 15 states, placement of infants in a nonsupine sleep position decreased
significantly from 27.2% in 2009 to 19.4% in 2015. In 2015, over half of respondents
(61.4%) from 14 states reported bed sharing with their infant, and 38.5% from 13 states
and New York City reported using any soft bedding, most commonly bumper pads and thick
blankets.
Conclusions and Implications for Public Health Practice: Improved implementation of
the safe sleep practices recommended by the American Academy of Pediatrics could help
reduce sleep-related infant mortality. Evidence-based interventions could increase
use of safe sleep practices, particularly within populations whose infants might be
at higher risk for sleep-related deaths.
Introduction
Approximately 3,500 sleep-related deaths among infants are reported each year in the
United States, including those from sudden infant death syndrome (SIDS), accidental
suffocation and strangulation in bed, and unknown causes (
1
). Significant sociodemographic and geographic disparities in sleep-related infant
deaths exist (
2
,
3
). To reduce risk factors for sleep-related infant mortality, recommendations from
the American Academy of Pediatrics (AAP) for safe sleep include 1) placing the infant
in the supine sleep position (placing the infant on his or her back) on a firm sleep
surface such as a mattress in a safety-approved crib or bassinet, 2) having infant
and caregivers share a room, but not the same sleeping surface, and 3) avoiding the
use of soft bedding (e.g., blankets, pillows, and soft objects) in the infant sleep
environment (
4
). Additional recommendations to reduce the risk for sleep-related infant deaths include
breastfeeding, providing routinely recommended immunizations, and avoiding prenatal
and postnatal exposure to tobacco smoke, alcohol, and illicit drugs (
4
).
Although the individual effect of each recommendation on sleep-related infant mortality
is unclear, sharp declines in SIDS and other sleep-related mortality in the 1990s
have been attributed to an increase in safe sleep practices such as supine sleep.
However, since the late 1990s declines in infant sleep-related deaths (
4
) and nonsupine sleep positioning (on side or stomach) (
5
) have been less pronounced. The rate of infant sleep-related deaths declined from
154.6 deaths per 100,000 live births in 1990 to 93.9 per 100,000 live births in 1999;
in 2015, the rate of infant sleep-related deaths was 92.6 deaths per 100,000 live
births (
6
). Previous research indicates implementation of safe sleep recommendations by infant
caregivers remains suboptimal. In the Study of Attitudes and Factors Effecting Infant
Care, which interviewed mothers 2–6 months postpartum during 2011–2014, 22% said they
had placed their infant in a nonsupine sleep position (
7
), and 21% shared a bed with their infant at least once during the 2 weeks before
being interviewed (
8
). In addition, in the National Infant Sleep Position Study, a household telephone
survey that sampled nighttime caregivers during 2007–2010, more than half (54%) placed
their infant to sleep with soft bedding during the 2 weeks before the interview (
9
).
CDC used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to examine
the prevalence of unsafe infant sleep practices. Ongoing surveillance efforts can
identify populations at risk for unsafe sleep practices and help evaluate policies
and programs to improve safe sleep practices. Health care providers and state-based
and community-based programs can identify barriers to safe sleep practices and provide
culturally appropriate counseling and messaging to improve infant sleep practices.
Methods
Data source. PRAMS (
10
) collects state-specific, population-based data on self-reported maternal behaviors
and experiences before, during, and shortly after pregnancy. In each participating
state, a stratified random sample of women with a recent live birth is selected from
birth certificate files, and women are surveyed 2–6 months postpartum using a standardized
protocol and questionnaire. PRAMS data for each site are weighted for sampling design,
nonresponse, and noncoverage to produce a data set representative of the state’s birth
population. PRAMS sites were included in this report if their weighted response rate
was ≥65% for years 2009–2011, ≥60% for 2012–2014, and ≥55% for 2015.
PRAMS sites included the question, “In which position do you most often lay your baby
down to sleep now?” (check one answer): “on side; on back; on stomach.” Respondents
who selected “on side” or “on stomach” were classified as placing their infant in
a nonsupine sleep position.* Analyses on nonsupine sleep positioning were conducted
using 2015 data from 32 PRAMS states
†
and New York City. To explore trends in nonsupine sleep position, CDC analyzed PRAMS
data from 2009–2015 in 15 states.
§
Analyses of bed sharing used 2015 data from 14 states
¶
that included the optional question on their state-specific PRAMS survey: “How often
does your new baby sleep in the same bed with you or anyone else?” Respondents who
indicated “always,” “often,” “sometimes,” or “rarely” were classified as having bed
shared and were compared with respondents who indicated “never.” Bed sharing was also
categorized as: “rarely or sometimes,” and “often or always.” Analyses of soft bedding
used 2015 data from 13 states** and New York City that included the following optional
question on their state-specific survey: “Listed below are some things that describe
how your new baby usually sleeps.” Respondents were asked to select “yes” or “no”
for the following soft bedding items: “pillows,” “thick or plush blankets,” “bumper
pads,” “stuffed toys” and “infant positioner.” Respondents who selected “yes” to one
or more items were defined as using any soft bedding.
Statistical analysis. The weighted prevalence and 95% confidence intervals of unsafe
sleep practices were calculated overall and by state for 2015. Chi-square tests and
95% confidence intervals
††
were used to determine differences in unsafe sleep practices by maternal characteristic
(i.e., race/ethnicity, age, education level, and participation in the Special Supplemental
Nutrition Program for Women, Infants, and Children (WIC) program during pregnancy),
gestational age at birth (i.e., preterm, <37 weeks’ gestation, compared with term,
≥37 weeks’ gestation) and any breastfeeding at 8 weeks postpartum. CDC tested for
linear trends in nonsupine sleep position overall and by maternal characteristics
and state, from 2009 to 2015, using logistic regression. Analyses accounted for the
complex survey sampling design of PRAMS.
Results
In 2015, the overall prevalence of nonsupine sleep positioning was 21.6%, ranging
from 12.2% in Wisconsin to 33.8% in Louisiana (Table 1). Nonsupine sleep positioning
varied by maternal characteristics, and was highest among respondents who were non-Hispanic
blacks. Nonsupine sleep positioning prevalence was higher among respondents aged <25
years compared with ≥25 years and those who had completed ≤12 years compared with
>12 years of education, and who were WIC participants. Among the 15 states examined
during 2009–2015, nonsupine sleep positioning decreased significantly from 27.2% in
2009 to 19.4% in 2015 overall (p<0.001) (Supplementary Table https://stacks.cdc.gov/view/cdc/50001
) and in 13 of 15 states (except for Maryland and Washington). Nonsupine sleep positioning
decreased significantly among all age, education, WIC participation and most race/ethnicity
groups except among respondents who were American Indians/Alaska Natives (Figure).
§§
TABLE 1
Prevalence of nonsupine (on side or stomach) sleep positioning, by maternal characteristics,
gestational age at birth, and breastfeeding at 8 weeks postpartum — Pregnancy Risk
Assessment Monitoring System, 32 states and New York City, 2015
Characteristic
Nonsupine sleep positioning % (95% CI)*
Chi-square p-value
Total
21.6 (20.9–22.4)
—
Maternal race/ethnicity
<0.001
White, non-Hispanic
16.1 (15.3–16.9)
Black, non-Hispanic
37.6 (35.8–39.3)
Hispanic
26.5 (24.3–28.9)
Asian or Pacific Islander, non-Hispanic
20.8 (18.2–23.6)
American Indian or Alaska Native, non-Hispanic
19.8 (13.8–27.6)
Maternal age group (yrs)
<0.001
<20
29.9 (26.4–33.5)
20–24
27.9 (26.0–29.8)
25–34
19.4 (18.6–20.3)
≥35
18.5 (16.8–20.3)
Maternal education (yrs)
<0.001
<12
27.9 (25.5–30.5)
12
26.0 (24.3–27.7)
>12
18.4 (17.6–19.2)
WIC participation during pregnancy
<0.001
No
16.7 (15.9–17.6)
Yes
28.0 (26.7–29.3)
Infant gestation (wks)
0.240
Term (≥37)
21.5 (20.7–22.3)
Preterm (<37)
22.9 (20.8–25.2)
Any breastfeeding at 8 wks
<0.001
No
24.0 (22.7–25.4)
Yes
20.4 (19.5–21.3)
State/City
<0.001
Alabama
28.7 (25.7–32.0)
Alaska
23.0 (20.1–26.2)
Arkansas
29.3 (25.3–33.6)
Colorado
12.3 (10.3–14.6)
Connecticut
22.7 (19.7–26.1)
Delaware
18.7 (16.1–21.5)
Hawaii
18.5 (15.8–21.5)
Illinois
19.1 (17.0–21.4)
Iowa
14.2 (11.5–17.5)
Louisiana
33.8 (30.9–36.8)
Maryland
25.4 (22.7–28.3)
Massachusetts
14.2 (12.1–16.5)
Michigan
18.6 (16.3–21.1)
Missouri
20.6 (17.9–23.5)
Nebraska
15.9 (13.8–18.2)
New Hampshire
13.1 (10.1–16.7)
New Jersey
29.5 (26.8–32.3)
New Mexico
21.7 (19.5–24.0)
New York City
31.1 (28.6–33.8)
New York (outside of New York City)
20.9 (17.6–24.6)
Ohio
14.5 (12.1–17.3)
Oklahoma
18.8 (16.0–21.9)
Oregon
17.9 (15.1–21.2)
Pennsylvania
16.0 (13.6–18.7)
Tennessee
17.0 (14.1–20.4)
Texas
28.8 (25.7–32.0)
Utah
16.4 (14.1–18.9)
Vermont
15.3 (13.0–18.0)
Virginia
22.0 (18.2–26.2)
Washington
17.5 (15.1–20.2)
West Virginia
16.3 (13.7–19.3)
Wisconsin
12.2 (9.8–15.1)
Wyoming
12.5 (9.6–16.2)
Abbreviations: CI = confidence interval; WIC = Special Supplemental Nutrition Program
for Women, Infants, and Children.
* Weighted percentage.
FIGURE
Trends in prevalence of nonsupine (on side or stomach) sleep positioning of infants,
by mother’s race/ethnicity — 15 states,* Pregnancy Risk Assessment Monitoring System,
2009–2015
* Delaware, Hawaii, Illinois, Maryland, Massachusetts, Missouri, Nebraska, New Jersey,
Oklahoma, Pennsylvania, Utah, Vermont, Washington, West Virginia and Wyoming.
The figure above is a line graph indicating the percentage of infants placed in nonsupine
sleep positioning, by the mother’s race/ethnicity, in 15 states during 2009–2015.
In 2015, more than half (61.4%) of respondents reported any bed sharing with their
infant, with 37.0% reporting “rarely or sometimes” and 24.4% responding “often or
always” bed sharing (Table 2). Self-report of any bed sharing varied by state, ranging
from 49.0% in West Virginia to 78.9% in Alaska. The prevalence of bed sharing varied
by maternal characteristics, gestational age at birth, and breastfeeding at 8 weeks
postpartum. Bed sharing prevalence was higher among respondents who were American
Indians/Alaska Natives, non-Hispanic blacks, or Asians/Pacific Islanders compared
with non-Hispanic whites or Hispanics, aged <25 years compared with ≥25 years, who
had completed ≤12 years compared with >12 years of education, who were WIC participants,
and who reported any breastfeeding at 8 weeks postpartum (Table 2).
TABLE 2
Prevalence of bed sharing, by maternal characteristics, gestational age at birth,
and breastfeeding at 8 weeks postpartum — Pregnancy Risk Assessment Monitoring System,
14 states, 2015
Characteristic
Any*
Rarely or sometimes
Often or always
Never
Chi–square
p–value
% (95% CI)†
% (95% CI)†
% (95% CI)†
% (95% CI)†
Never versus Any
Total
61.4 (59.9–62.8)
37.0 (35.6–38.5)
24.4 (23.1–25.7)
38.6 (37.2–40.1)
—
Maternal race/ethnicity
<0.001
White, non-Hispanic
52.7 (50.9–54.4)
35.2 (33.5–37.0)
17.5 (16.1–18.9)
47.3 (45.6–49.1)
Black, non-Hispanic
76.5 (74.2–78.7)
41.2 (38.5–43.9)
35.3 (32.7–38.0)
23.5 (21.3–25.8)
Hispanic
66.7 (62.9–70.3)
38.0 (34.3–41.9)
28.7 (25.2–32.4)
33.3 (29.7–37.1)
Asian or Pacific Islander, non-Hispanic
76.8 (72.0–80.9)
39.8 (34.7–45.2)
37.0 (31.8–42.4)
23.2 (19.1–28.0)
American Indian or Alaska Native, non-Hispanic
83.9 (75.3–89.9)
27.8 (20.1–37.0)
56.1 (44.3–67.3)
16.1 (10.1–24.7)
Maternal age group (yrs)
<0.001
<20
76.8 (71.1–81.7)
40.5 (34.3–47.2)
36.3 (30.0–43.1)
23.2 (18.3–28.9)
20–24
68.5 (65.2–71.7)
40.5 (37.1–44.0)
28.0 (24.9–31.3)
31.5 (28.3–34.8)
25–34
58.1 (56.3–59.9)
36.3 (34.5–38.2)
21.8 (20.3–23.4)
41.9 (40.1–43.7)
≥35
57.1 (53.6–60.6)
33.5 (30.3–36.9)
23.6 (20.5–27.0)
42.9 (39.4–46.4)
Maternal education level (yrs)
0.001
<12
65.2 (60.7–69.4)
34.4 (30.2–38.9)
30.8 (26.5–35.5)
34.8 (30.6–39.3)
12
64.6 (61.5–67.5)
39.9 (36.8–42.9)
24.7 (22.1–27.6)
35.4 (32.5–38.5)
>12
58.8 (57.1–60.5)
36.3 (34.6–38.0)
22.5 (21.1–24.0)
41.2 (39.5–42.9)
WIC participation during pregnancy
<0.001
No
57.5 (55.7–59.3)
35.4 (33.7–37.2)
22.1 (20.5–23.7)
42.5 (40.7–44.3)
Yes
66.2 (63.9–68.5)
39.0 (36.6–41.4)
27.2 (25.1–29.5)
33.8 (31.5–36.1)
Infant gestation (wks)
0.023
Term (≥37)
61.8 (60.3–63.3)
37.0 (35.5–38.5)
24.8 (23.4–26.2)
38.2 (36.7–39.7)
Preterm (<37)
56.4 (52.1–60.7)
37.5 (33.3–41.9)
18.9 (15.9–22.3)
43.6 (39.3–47.9)
Any breastfeeding at 8 wks
<0.001
No
56.9 (54.3–59.4)
36.6 (34.0–39.1)
20.3 (18.3–22.5)
43.1 (40.6–45.7)
Yes
63.8 (62.1–65.5)
37.4 (35.6–39.1)
26.4 (24.8–28.1)
36.2 (34.5–37.9)
State
<0.001
Alaska
78.9 (75.7–81.7)
33.0 (29.7–36.4)
45.9 (42.4–49.4)
21.1 (18.3–24.3)
Connecticut
52.9 (48.9–56.9)
33.8 (30.2–37.6)
19.1 (16.3–22.3)
47.1 (43.1–51.1)
Delaware
52.8 (49.5–56.2)
34.4 (31.3–37.7)
18.4 (15.9–21.1)
47.2 (43.8–50.5)
Louisiana
63.6 (60.5–66.7)
35.5 (32.5–38.7)
28.1 (25.4–31.0)
36.4 (33.3–39.5)
Nebraska
54.4 (51.2–57.6)
35.2 (32.2–38.4)
19.2 (16.9–21.7)
45.6 (42.4–48.8)
New Jersey
57.7 (54.6–60.8)
37.9 (34.9–41.1)
19.8 (17.5–22.3)
42.3 (39.2–45.4)
Pennsylvania
50.9 (47.4–54.3)
37.4 (34.1–40.7)
13.5 (11.3–16.1)
49.1 (45.7–52.6)
Tennessee
58.3 (54.0–62.4)
37.2 (33.2–41.4)
21.1 (17.7–24.8)
41.7 (37.6–46.0)
Texas
67.0 (63.6–70.1)
36.9 (33.6–40.3)
30.1 (27.0–33.3)
33.0 (29.9–36.4)
Vermont
63.1 (59.8–66.3)
39.2 (35.9–42.5)
23.9 (21.2–26.9)
36.9 (33.7–40.2)
Virginia
63.9 (59.2–68.3)
40.6 (35.9–45.3)
23.3 (19.5–27.6)
36.1 (31.7–40.8)
Washington
68.1 (64.7–71.2)
35.2 (32.0–38.6)
32.9 (29.7–36.1)
31.9 (28.8–35.3)
West Virginia
49.0 (45.2–52.8)
32.8 (29.3–36.4)
16.2 (13.6–19.3)
51.0 (47.2–54.8)
Wisconsin
51.8 (47.6–56.0)
38.7 (34.7–42.9)
13.1 (10.6–16.0)
48.2 (44.0–52.4)
Abbreviations: CI = confidence interval, WIC = Special Supplemental Nutrition Program
for Women, Infants, and Children.
* “Any” is the sum of “Rarely or sometimes” and “Often or always.”
† Weighted percentage.
Use of at least one type of soft bedding was reported by 38.5% of respondents, ranging
from 28.7% in Illinois to 52.6% in New York City (Table 3). The most frequently reported
types of soft bedding were bumper pads (19.1%) and plush or thick blankets (17.5%),
followed by pillows (7.1%), infant positioners (6.2%), and stuffed toys (3.1%). Use
of at least one type of soft bedding varied by maternal characteristics and breastfeeding
at 8 weeks postpartum. The prevalence of soft bedding use was higher among respondents
who were Asians/Pacific Islanders or Hispanics compared with members of other race/ethnicity
groups, aged <25 years compared with ≥25 years, who had completed ≤12 compared with
>12 years of education, who were WIC participants, and who were not breastfeeding
at 8 weeks postpartum (Table 3).
TABLE 3
Prevalence of soft bedding* use, by maternal characteristics, gestational age at birth,
and breastfeeding at 8 weeks postpartum — Pregnancy Risk Assessment Monitoring System,
13 states and New York City, 2015
Characteristic
Pillows
Blankets
Bumper pads
Toys
Positioner
Any soft bedding*
Chi-square
p-value
% (95% CI)†
% (95% CI)†
% (95% CI)†
% (95% CI)†
% (95% CI)†
% (95% CI)†
Total
7.1 (6.6–7.6)
17.5 (16.8–18.3)
19.1 (18.3–19.9)
3.1 (2.8–3.5)
6.2 (5.7–6.7)
38.5 (37.5–39.5)
—
Maternal race/ethnicity
<0.001
White, non-Hispanic
4.3 (3.8–4.9)
14.7 (13.7–15.7)
16.4 (15.4–17.5)
2.5 (2.1–3.0)
5.7 (5.1–6.4)
32.9 (31.6–34.2)
Black, non-Hispanic
9.9 (8.6–11.5)
22.0 (20.1–24.1)
14.9 (13.2–16.7)
3.8 (2.9–4.9)
7.4 (6.2–8.7)
40.5 (38.2–42.8)
Hispanic
9.1 (7.7–10.7)
19.3 (17.3–21.4)
35.1 (32.6–37.8)
3.0 (2.2–4.0)
6.2 (5.1–7.5)
52.9 (50.2–55.5)
Asian or Pacific Islander, non-Hispanic
21.1 (18.0–24.7)
31.1 (27.4–35.0)
18.2 (15.2–21.6)
7.3 (5.4–9.8)
9.5 (7.2–12.4)
54.7 (50.6–58.7)
American Indian or Alaska Native, non-Hispanic
12.4 (7.3–20.5)
15.1 (9.5–23.0)
12.8 (6.6–23.4)
2.2 (1.3–3.6)
2.8 (1.8–4.5)
35.9 (26.4–46.6)
Maternal age group (yrs)
<0.001
<20
10.9 (8.3–14.1)
27.7 (23.6–32.2)
22.8 (19.0–27.1)
6.4 (4.4–9.2)
7.3 (5.2–10.2)
49.2 (44.6–53.9)
20–24
9.4 (8.1–10.8)
24.1 (22.1–26.3)
22.0 (20.0–24.1)
4.4 (3.5–5.6)
6.1 (5.1–7.2)
45.9 (43.5–48.2)
25–34
6.2 (5.6–6.9)
15.3 (14.3–16.2)
18.0 (17.0–19.0)
2.5 (2.1–3.0)
6.1 (5.5–6.8)
35.9 (34.6–37.2)
≥35
6.1 (5.1–7.4)
14.4 (12.8–16.2)
18.3 (16.5–20.3)
2.4 (1.8–3.3)
6.6 (5.5–7.9)
35.5 (33.2–37.9)
Maternal education level (yrs)
<0.001
<12
12.6 (10.8–14.6)
22.1 (19.7–24.6)
27.9 (25.2–30.7)
4.9 (3.8–6.4)
8.8 (7.3–10.6)
51.0 (48.0–53.9)
12
8.6 (7.6–9.9)
23.0 (21.2–24.9)
23.3 (21.5–25.2)
3.6 (2.8–4.4)
6.9 (5.9–8.0)
46.9 (44.7–49.1)
>12
5.4 (4.8–6.0)
14.6 (13.7–15.5)
15.7 (14.8–16.6)
2.6 (2.2–3.0)
5.5 (4.9–6.1)
32.9 (31.7–34.1)
WIC participation during pregnancy
<0.001
No
4.8 (4.3–5.4)
13.4 (12.5–14.4)
15.6 (14.6–16.6)
2.4 (2.0–2.9)
5.6 (5.0–6.2)
31.7 (30.5–33.0)
Yes
10.0 (9.1–10.9)
22.7 (21.4–24.0)
23.4 (22.0–24.8)
3.9 (3.3–4.6)
7.1 (6.4–8.0)
47.0 (45.5–48.6)
Infant gestation (wks)
0.410
Term (≥37)
7.0 (6.5–7.6)
17.5 (16.7–18.4)
19.3 (18.4–20.2)
3.2 (2.8–3.6)
6.1 (5.6–6.7)
38.6 (37.6–39.7)
Preterm (<37)
8.0 (6.6–9.7)
17.8 (15.8–20.1)
16.8 (14.8–19.0)
2.4 (1.6–3.5)
7.5 (6.2–9.1)
37.4 (34.8–40.1)
Any breastfeeding at 8 wks
<0.001
No
7.9 (7.0–8.8)
19.8 (18.4–21.2)
22.1 (20.7–23.6)
4.0 (3.4–4.8)
7.4 (6.5–8.3)
42.7 (41.0–44.4)
Yes
6.6 (6.0–7.3)
16.1 (15.1–17.0)
17.2 (16.3–18.2)
2.6 (2.2–3.0)
5.4 (4.9–6.0)
35.8 (34.6–37.0)
State/City
<0.001
Alaska
13.0 (10.8–15.6)
18.4 (15.8–21.3)
14.4 (12.0–17.2)
2.6 (1.7–3.8)
5.6 (4.1–7.6)
40.6 (37.2–44.2)
Illinois
5.9 (4.7–7.4)
12.2 (10.4–14.1)
15.6 (13.7–17.8)
1.7 (1.1–2.6)
3.8 (2.9–5.0)
28.7 (26.2–31.3)
Iowa
5.7 (3.9–8.2)
14.1 (11.1–17.8)
12.4 (9.7–15.7)
1.0 (0.4–2.6)
4.4 (2.9–6.5)
29.0 (25.0–33.3)
Louisiana
11.6 (9.7–13.8)
16.7 (14.5–19.3)
18.3 (15.9–21.0)
2.9 (2.0–4.1)
11.7 (9.9–13.9)
41.3 (38.2–44.6)
Maryland
6.1 (4.7–7.9)
19.2 (16.8–21.9)
12.1 (10.1–14.4)
3.5 (2.4–4.9)
6.4 (5.0–8.2)
35.7 (32.7–38.9)
Michigan
5.4 (4.1–7.2)
13.2 (11.1–15.6)
12.6 (10.5–15.0)
2.0 (1.3–3.2)
4.7 (3.4–6.4)
29.5 (26.6–32.6)
Missouri
7.3 (5.7–9.3)
19.6 (17.0–22.5)
17.1 (14.7–19.9)
3.0 (2.0–4.5)
5.7 (4.3–7.6)
37.9 (34.7–41.3)
New Jersey
9.0 (7.4–10.8)
25.2 (22.5–28.0)
28.2 (25.5–31.1)
4.8 (3.7–6.2)
6.0 (4.7–7.6)
51.8 (48.7–54.9)
New York (outside of New York City)
5.3 (3.7–7.6)
15.7 (12.8–19.1)
20.2 (16.9–23.9)
2.8 (1.7–4.7)
7.1 (5.2–9.6)
38.2 (34.2–42.5)
New York City
11.4 (9.7–13.3)
24.5 (22.1–27.0)
27.8 (25.3–30.5)
5.2 (4.0–6.7)
7.0 (5.7–8.6)
52.6 (49.7–55.4)
Pennsylvania
4.8 (3.5–6.5)
15.5 (13.2–18.2)
19.7 (17.0–22.7)
3.8 (2.6–5.4)
5.8 (4.3–7.6)
36.7 (33.4–40.1)
Tennessee
6.5 (4.7–9.1)
19.7 (16.5–23.4)
20.2 (16.9–23.8)
2.4 (1.4–4.1)
7.9 (5.9–10.6)
41.4 (37.3–45.7)
West Virginia
6.2 (4.6–8.4)
16.0 (13.4–19.0)
22.2 (19.2–25.6)
3.5 (2.3–5.2)
7.8 (6.0–10.1)
41.5 (37.8–45.3)
Wyoming
6.8 (4.6–9.9)
20.6 (16.8–25.0)
20.4 (16.6–24.8)
3.4 (2.0–5.9)
8.9 (6.4–12.3)
41.1 (36.2–46.1)
Abbreviations: CI = confidence interval, WIC = Special Supplemental Nutrition Program
for Women, Infants, and Children.
* Soft bedding defined as infant being placed to sleep with any of the following items:
pillow, thick or plush blanket, bumper pads, stuffed toys, or an infant positioner.
† Weighted percentage.
Conclusions and Comment
Among all mothers responding, 21.6% reported placing their infant to sleep in a nonsupine
position, 61.4% shared their bed with their infant, and 38.5% reported using soft
bedding. The noted variation observed in nonsupine sleep positioning by maternal characteristics
is similar to several disparities observed in sleep-related death rates (
2
,
3
). Sleep-related infant deaths have been consistently highest among American Indian
or Alaska Native followed by non-Hispanic black mothers (
2
) and those who are aged <20 years and have less education (
3
). Unsafe sleep practices were most commonly reported by younger, less educated, and
racial/ethnic minority mothers, suggesting priority groups that might need to be reached
with clear, culturally appropriate messages.
While most states and subpopulations observed a significant decline over time in nonsupine
sleep positioning, these findings highlight the need to implement and evaluate interventions
to continue improving safe sleep practices. Evidence-based approaches to increase
use of safe sleep practices include developing health messages and educational tools
for caregivers and educating health and child care professionals on safe sleep practices
(
11
,
12
). For example, a recent randomized controlled trial among postpartum mothers found
a 60-day mobile health program significantly improved uptake of safe sleep practices.
The mobile health program included sending frequent emails or text messages with short
videos related to infant safe sleep practices (
13
). Other strategies include removing known barriers to safe sleep practices (e.g.,
providing free or reduced cost cribs for families), identifying and addressing cultural
and social practices that are unsafe (e.g., by holding safe-sleep baby showers), and
implementing legislative and regulatory supports (e.g., requiring SIDS risk reduction
training for licensed child care providers) (
11
).
States and health care providers can play an important role in promoting implementation
of AAP safe sleep recommendations in a variety of settings. In the Study of Attitudes
and Factors Effecting Infant Care, 55% of caregivers reported receiving appropriate
advice, 25% received incorrect advice and 20% received no advice on safe sleep practices
from health care providers. Caregivers who received appropriate advice were significantly
less likely to place their infants to sleep in a nonsupine position than were those
who received inappropriate or no advice on safe sleep practices (
7
). In recent years, state public health agencies have worked with partners to implement
a variety of efforts to promote safe sleep, including communication campaigns, messaging
delivered during WIC program visits and home-visiting programs, policies in facilities
and clinics, and hospital-based quality improvement initiatives and collaboratives.
¶¶
States aiming to improve safe sleep practices can examine successful interventions
that have been implemented in other states. For example, the Massachusetts Perinatal-Neonatal
Quality Improvement Network implemented a safe sleep initiative in neonatal intensive
care units that improved safe sleep practices by modeling safe practices for parents
of medically stable premature infants in advance of infant discharge (
14
).*** The Tennessee Department of Health demonstrated that having a hospital policy
to correctly model safe sleep practices reduced the percentage of infants placed to
sleep in an unsafe environment (e.g., not on their back) while in the hospital by
nearly half (
15
). Finally, state participation in national initiatives, such as the National Action
Partnership to Promote Safe Sleep Improvement and Innovation Network
†††
and Collaborative Improvement and Innovation Network to reduce infant mortality,
§§§
can help facilitate and monitor the use of evidence-based strategies related to safe
sleep according to standardized metrics of success.
Continued surveillance of infant sleep practices in the United States is necessary
to monitor whether the prevalence of safe sleep practices is improving, especially
among populations where sleep-related infant mortality is disproportionately high.
The state-specific estimates derived from PRAMS can complement other data sources
used to assess initiatives to reduce sleep-related infant deaths. Of note, CDC also
supports 16 states and two jurisdictions through its Sudden Unexpected Infant Death
(SUID)
¶¶¶
Case Registry to monitor sleep-related deaths and related circumstances, including
the sleep environment. This surveillance effort, which captures 30% of all SUID cases
in the United States, focuses on improving data quality and completeness of SUID investigations
to inform strategies to reduce sleep-related deaths (
16
).****
The findings in this report are subject to at least three limitations. First, results
are limited to states that implemented PRAMS, met the required response rate threshold
for inclusion in data analysis, and included questions regarding safe sleep practices
on their state-specific PRAMS survey. Second, AAP recommends placing the infant to
sleep in the supine position every time; however, the PRAMS survey only asked respondents
the sleep position their infant was placed most often. Also, prior to 2016, PRAMS
collected data on the unsafe practice of bed sharing, but not on the AAP-recommended
practice of room sharing. Finally, PRAMS data are self-reported and might be subject
to both recall and social desirability biases.
Despite recommendations from AAP regarding safe sleep practices for infants, this
report demonstrates that placement of infants in a nonsupine sleep position, bed sharing
with infants, and use of soft bedding are commonly reported by mothers. Evidence-based
interventions that encourage infant safe sleep practices by caregivers, particularly
within populations where unsafe infant sleep practices are higher, could help reduce
sleep-related infant mortality.
Key Points
• Infant safe sleep practices recommended by the American Academy of Pediatrics (AAP),
including placing infants to sleep on their backs, room sharing but not bed sharing,
and keeping soft objects and loose bedding out of the infant’s sleep environment,
can help reduce sleep-related infant deaths; however, implementation of these recommendations
remains suboptimal.
• Approximately one in five mothers reported placing their infant to sleep on their
side or stomach. More than one half reported bed sharing with their infant, and more
than one third reported using soft bedding in the infant’s sleep environment. Unsafe
sleep practices varied by state, race/ethnicity, age, education, and participation
in the Special Supplemental Nutrition Program for Women, Infants, and Children.
• Health care providers and state-based and community-based programs can identify
barriers to safe sleep practices and provide culturally appropriate counseling and
messaging to improve infant safe sleep practices.
• Additional information is available at https://www.cdc.gov/vitalsigns/.