Addressing Racial Disparities in Sudden Unexpected Infant Death (SUID)

Introduction: Sudden unexpected infant death (SUID) is the leading cause of neonatal mortality in the United States, and disproportionately affects children of color. The case we present aims to 1) discuss how well-known SUID risk factors are related to structural racism, 2) categorize barriers to safe sleeping recommendations, specifically how vulnerable housing status complicates implementation, and 3) offer strategies for providers to promote safe sleep and harm reduction in a family-centered way.

Case Description: The patient we present is an infant seen in the ED after being found apneic and unresponsive at home. Resuscitation efforts ultimately fail. The death is attributed to SUID after an investigation finds no other identifiable cause. Social history reveals that the family has been struggling with housing insecurity - both parents and three children were sharing a small room and did not have sufficient space for a crib. They had discussed these concerns with their primary pediatrician, who was in the process of mobilizing resources with outpatient social work when this event occurred.

Discussion: Safe sleep is a crucial part of early infancy counseling in the nursery and pediatrician’s office. Despite major campaigns to promote safe sleep, families of color are less likely to practice recommendations relating to supine positioning and co-sleeping. Qualitative data has suggested these are due to lack of patient-centered teaching around choking, comfort, and having more trust in recommendations from family compared to medical providers. In particular, for families with housing instability, many best practices concerning the built sleeping environment are unrealistic and cannot be implemented. Providers must recognize the history of structural racism that contributes to the overlap of housing instability, lack of trust, and other SUID risk factors in families of color. Studies regarding products for safer co-sleeping, as well as the UNICEF Baby-Friendly initiative, demonstrate that there are safe sleeping alternatives for families unable to adopt AAP recommendations.

Conclusion: While safe sleep is a focus in pediatrics, there is a lack of acknowledgment that the provision of safe, clean, and affordable housing is the ultimate necessity for safe infant sleep. Housing instability disproportionately affects families of color, contributing to a higher risk for SUID in this population. As pediatricians, we must use open ended questions to understand reasons behind families’ sleep practices, with a goal of harm reduction rather than focusing on all-or-nothing recommendations regarding co-sleeping and infant sleep positioning.