When It Comes to Safe Sleep, It Takes a Village

By: Dr. Daniel P. Hall Riggins and Verleaner Lane

According to the Center for Disease Control and Prevention, each year, there are nearly 3,500 sudden unexpected infant deaths (SUID) in the United States. In 2020, 27% of those deaths occurred in infants under the age of one due to an unsafe sleep environment.

The American Academy of Pediatrics understood the dangers of unsafe sleep nearly three decades ago, resulting in the launch of their Safe to Sleep, (formerly Back to Sleep) campaign in partnership with the National Institute of Child Health and Human Development. The campaign advocated for parents to place children on their backs to sleep and to remove loose bedding. As a result, child death rates from SUIDs dropped precipitously, but in the early 2000s those advances stalled, with infant mortality rates remaining stagnant at around 85-100 deaths per 100,000 births each year.

Since then, researchers have recognized that rates of infant death remain high in American Indian/Alaska Native and Black communities, leading child health experts to examine the role that race may play in these health disparities.

AAP updated its safe sleep guidance last year, with a focus on addressing disparities by contextualizing safe sleep behavior within broader societal and cultural factors, including the impact of poverty, lack of access to prenatal and well-childcare, and lack of culturally appropriate messaging around safe sleep. As a result, communities nationwide are taking a fresh look at sleep-related infant deaths through the lens of a population health approach.

That was one of the goals of Cook County Health Project CHILD’s participation in the Child Safety Forward initiative — one of five sites that was selected for a Department of Justice-funded grant to reduce child abuse and neglect fatalities and injuries through a collaborative, community-based approach.

An initial data review showed that Cook County’s SUID rate is twice the national rate and the Cook County incidence of SUID in Black infants was over 10 times higher compared to Non-Hispanic White infants, based on data from 2019.

Project CHILD began its efforts by using geospatial risk analysis mapping to demonstrate neighborhood “hot spots” of SUIDs. We discovered noted clusters of deaths on the Westside of Chicago in neighborhoods like Garfield Park, Humboldt Park, and North Lawndale; on the Southside in neighborhoods like Englewood, Pullman, and Woodlawn; and in Southern suburbs like Chicago Heights, Harvey, Hazel Crest, Olympia Fields, and Park Forest.

Project CHILD also approached the issue with an understanding that child welfare cannot do this work alone. In fact, data indicates that 50 percent of infants and children who die from fatal injuries caused by maltreatment, including unsafe sleep practices, are unknown to the child welfare system. This led to Project CHILD convening a multi-disciplinary group of stakeholders comprised of healthcare providers, community health workers, maternal infant health providers, educators, social service providers, and law enforcement – all those who come into contact with children and families.

We then partnered with the Child Protection Training Academy, (CPTA) located on the University of Illinois campus, which had created a simulation training model for DCFS Child Protection Investigators. The simulation was structured around training to recognize elements of unsafe sleep practices based on a fictional family with numerous underlying conditions including domestic violence, mental health concerns, substance use disorder and suspicions of sexual & physical abuse.

The simulation developed a home that was designed to draw attention to unsafe sleep practices, with the environment staged with a pack and play that was cluttered with clothing, bedding, and other objects. The simulation’s life-like doll was placed on a soft couch, to draw attention to other risk factors for unsafe sleep. Though the training was conducted on Zoom the teams were able to “investigate” the environment through the use of the “proxy” who walked through the home with a camera enabling the participants to see the home and its contents. Team members could ask for close up examination of particular items in order to determine what questions they might need to ask to gather additional evidence. Additional risk factors were added within the house, such as a premature infant and evidence of smoking.

What the simulation training revealed was that safe sleep issues were often not the primary concerns of members of the MDT as they observed the family’s home. Law enforcement, for example, is often called to homes for other reasons but are rarely trained to look for unsafe sleep practices.

It’s also important for members of the MDT to hear from families and parents with lived experience about the other factors that can influence sleep practices. Project CHILD met with families and heard from them about conflicting messaging coming from older generations who are respected for their wisdom, beliefs about the importance of skin-to-skin bonding, and, in communities where violence is prevalent, thoughts on family beds as perhaps one of the safer places for infants. We also heard loud and clear that families often do not trust public agencies and that the child safety messaging they do receive appears punitive and reactive.

Based on the insights from our geospatial mapping, simulation training and parent insights, we hope to create more advanced safe sleep trainings and guides for all stakeholders, not just those across the child welfare system. This information can also be used to assist in planning targeted messaging to hot spot communities, and the implementation of services and greater awareness, education and outreach to those communities.

Ultimately, we hope that, through the collaboration with key partners, such as Be Strong Families, EverThrive Illinois and the MDT teams, we can apply these learnings in new ways to enhance community understanding and action around safe sleep practices to reduce child fatalities.

Daniel P. Riggins, MD is a pediatrician with Cook County Health. Verleaner Lane is the project director for Project CHILD of Cook County Health, one of five Child Safety Forward sites.

Disclaimer: This product was supported by cooperative agreement number 2019-V3-GX-K005 Reducing Child Fatalities and Recurring Injuries Caused by Crime Victimization, awarded by the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this product are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice.