Safe Sleep Behaviors

Narrative

Safe sleep behaviors are practices that reduce the risk of sleep-related sudden unexpected infant death (SUID), which accounts for the most deaths among infants aged 1 month to 1 year. SUID includes sudden infant death syndrome (SIDS), unknown causes, and accidental suffocation and strangulation in bed (see page on sleep-related SUID). Safe sleep practices recommended by the American Academy of Pediatrics (AAP) include placing an infant on his or her back in a separate crib or bassinet without soft bedding both at night and during naps.1 Additional practices with strong evidence for reducing the risk of SUID include breastfeeding, offering a pacifier before naptime or bedtime, and avoiding smoke and alcohol exposure during and after pregnancy.2

In 2011, 74.0 percent of recent mothers in 23 states and New York City reported that their infant was laid down to sleep on his or her back most of the time (Figure 1). The proportion of mothers reporting this safe sleep behavior was between 75.8 and 80.0 percent among non-Hispanic White, non-Hispanic American Indian/Alaska Native, non-Hispanic Asian, and non-Hispanic Native Hawaiian/other Pacific Islander mothers. Use of the back sleep position was lowest among non-Hispanic Black mothers (53.9 percent), followed by Hispanic mothers (66.0 percent).

sleep on back by maternal race

Figure 1 Source

The AAP recommends room sharing without bed sharing, in which infants may be brought into bed for breastfeeding or comfort but returned to a separate in-room crib or bassinet for sleep.3 Sharing a bed with an infant during sleep increases the risk of SUID, particularly with soft bedding and blankets, soft sleep surfaces like couches and armchairs, and parental smoking or substance use.4 In 2011, 43.3 percent of recent mothers in 13 states reported that their infants never slept in the same bed with an adult (Figure 2). The proportion of mothers who reported no infant and adult bed sharing was highest among non-Hispanic White mothers (50.6 percent), followed by Hispanic mothers (38.3 percent). About one-quarter or fewer mothers from most other racial and ethnic groups reported never bed sharing. Conversely, mothers who reported always or often bed sharing ranged from 13.8 percent of non-Hispanic White mothers to 43.2 percent of non-Hispanic Asian mothers.

bed sharing by maternal race

Figure 2 Source

Back sleep position and never bed sharing increase with maternal age and education. For example, usual practice of back sleep position ranged from 64.4 percent among mothers with less than 12 years of education to 82.4 percent among those with 16 or more years of education. Similarly, never bed sharing ranged from 27.5 percent among mothers less than 20 years old to nearly 50 percent among mothers aged 30 years and older.

To reduce the risk of sleep-related SUID, the AAP also recommends removing soft bedding from infant sleep areas, such as blankets, quilts, and pillows.5 A recent national study found that 54.7 percent of U.S. infants are placed to sleep underneath or on top of potentially hazardous bedding.6 Resources to educate parents, caregivers, and health care providers regarding ways to reduce the risk for SIDS and other sleep-related causes of infant death are provided by the “Safe to Sleep” campaign (previously known as the “Back to Sleep” campaign).7 This collaborative effort at the federal, state, and local levels was renamed and expanded in 2012 to reflect the AAP’s broader recommendations and to address all sleep-related infant deaths. Crib distribution programs may also be effective in providing safe sleep education and cribs to mothers and families who may not be able to afford them.8

Data Sources

Figure 1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Pregnancy Risk Assessment Monitoring System, 2011. Analysis conducted by the CDC Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion.

Figure 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Pregnancy Risk Assessment Monitoring System, 2011. Analysis conducted by the CDC Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion.

Endnotes

1 American Academy of Pediatrics. SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment. Pediatrics. November 2011;128(5):1030–1039.

2 American Academy of Pediatrics. SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment. Pediatrics. November 2011;128(5):1030–1039.

3 American Academy of Pediatrics. SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment. Pediatrics. November 2011;128(5):1030–1039.

4 American Academy of Pediatrics. SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment. Pediatrics. November 2011;128(5):1030–1039.

5 American Academy of Pediatrics. SIDS and other sleep-related deaths: expansion of recommendations for a safe infant sleep environment. Pediatrics. November 2011;128(5):1030–1039.

6 Shapiro-Mendoza CK, Colson ER, Willinger M, Rybin DV, Camperlengo L, Corwin MJ. Trends in Infant Bedding Use: National Infant Sleep Position Study, 1993–2010. Pediatrics. Dec 1, 2014.

7 U.S. Department of Health and Human Services, National Institutes of Health, National Institutes of Child Health and Human Development. Safe to Sleep® Public Education Campaign. Accessed September 26, 2014.

8 Carlins EM, Collins KS. Cribs for kids: risk and reduction of sudden infant death syndrome and accidental suffocation. Health & Social Work. August 2007;32(3):225–229.

Data

Statistical Significance Test

Calculate the difference between two estimates:

Calculated Z-Test Result 0.9567433 Not statistically significant

We follow statistical conventions in defining a significant difference by a p-value less than 0.05 where there is a less than 5% probability of observing a difference of that magnitude or greater by chance alone if there were really no difference between estimates. The 95% confidence interval includes a plausible range of values for the observed difference; 95% of random samples would include the true difference with fewer than 5% of random samples failing to capture the true difference.

This website allows comparisons between two estimates using the independent z-test for differences in rates or proportions. This test is appropriate for comparing independent populations across years (e.g., 2011 versus 2012) or subgroups (e.g., Male versus Female) on corresponding measures. To the extent possible, the functionality of this application has limited estimate comparisons based on appropriate use of the independent z-test. However, some tables present subgroup categories within broader categories that will allow comparisons between non-independent populations (e.g., low birth weight and very low birth weight). Users should exercise caution when interpreting these test results, which will frequently overstate statistical significance.

For some tables, the website does not allow for comparisons between two estimates, even though the data represent independent populations. Generally, this is because the standard errors were not publicly available at the time this website was created.

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