title: Racial disparity and modifiable risk factors among infants dying suddenly and unexpectedly.
abstract: BACKGROUND
  Racial disparity in rates of death attributable to sudden infant death syndrome (SIDS) has been observed for many years. Despite decreased SIDS death rates following the "Back to Sleep" intervention in 1994, this disparity in death rates has increased. The prone sleep position, unsafe sleep surfaces, and sharing a sleep surface with others (bedsharing) increase the risk of sudden infant death. The race-specific prevalence of these modifiable risk factors in sudden unexpected infant deaths-including SIDS, accidental suffocation (AS), and cause of death undetermined (UD)-has not been investigated in a population-based study. Death rates attributable to AS and UD are also higher in African Americans (AAs) than in other races (non-AA). The potential contribution of unsafe sleep practices to this overall disparity in death rates is uncertain.
  
  
  OBJECTIVE
  The objective of this study was to compare death rates attributable to SIDS and related causes of death (AS and UD) in AA and non-AA infants and the prevalence of unsafe sleep practices at time of death. Our hypothesis was that there is a large racial disparity in these modifiable risk factors at the time of death, and that public awareness of this could lead to improved intervention strategies to reduce the disparity in death rates.
  
  
  METHODS
  In this population-based study, we retrospectively reviewed death-scene information and medical examiners' investigations of deaths in St Louis City and County between January 1, 1994, and December 31, 1997. The deaths of all infants <2 years old with the diagnoses of SIDS, AS, or UD were included. Sleep surfaces other than those specifically designed and approved for infant use were termed nonstandard (adult beds, sofas, etc). Denominators for our rate estimates were the number of births (AA and non-AA) in St Louis City and County during the study period.
  
  
  RESULTS
  The deaths of 119 infants were studied (81 AA and 38 non-AA). SIDS rates were much higher in AA than non-AA infants (2.08 vs 0.65 per 1000 live births), as was the rate of AS (0.47 vs 0.06). There was a trend for increased deaths diagnosed as UD in AA infants (0.36 vs 0.06). Bedsharing deaths were nearly twice as common in AAs (67.1% vs 35.1% of deaths), as were deaths on nonstandard sleep surfaces (79.0% vs 46.0%). Forty-nine percent (49.1%) of all infants who died while bedsharing were found on their backs or sides compared with 20.4% of infants who were not bedsharing. Overall, the fraction of infants found in these nonprone positions was not different for AA infants and non-AA infants (43.3% vs 38.5%). In AA and non-AA infants, factors that greatly increase the risk of bedsharing, such as sofa sharing or all-night bedsharing, were present in all or many bedsharing deaths.
  
  
  CONCLUSIONS
  Among AA infants dying suddenly and unexpectedly, the high prevalence of nonstandard bed use and bedsharing may underlie, in part, their increased death rates. Public health messages tailored for the AA community have stressed first and foremost using nonprone sleep positions. The observation that there was no difference between AA and non-AA infants in position found at death suggests that racial disparity in sleep position is not the most important contributor to racial disparity in death rates. The finding that more infants died on their back or side while bedsharing than otherwise suggests that these sleep positions are less protective when associated with bedsharing. We conclude that public health information tailored for the AA community should give equal emphasis to risks and alternatives to bedsharing as to avoidance of the prone position.
authors.affiliation: Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri 63110, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Unger
authors.forename: James S
authors.initials: JS
authors.lastname: Kemp
authors.forename: Davida
authors.initials: D
authors.lastname: Wilkins
authors.forename: Rose
authors.initials: R
authors.lastname: Psara
authors.forename: Terrance
authors.initials: T
authors.lastname: Ledbetter
authors.forename: Michael
authors.initials: M
authors.lastname: Graham
authors.forename: Mary
authors.initials: M
authors.lastname: Case
authors.forename: Bradley T
authors.initials: BT
authors.lastname: Thach
mesh_terms: D001741:Black or African American; D001237:Asphyxia / Q000453:epidemiology; D002423:Cause of Death; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008923:Missouri / Q000453:epidemiology; D011159:Population Surveillance; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D013398:Sudden Infant Death / Q000453:epidemiology* / Q000208:ethnology*