Assessing Risk Factors For Sudden Infant Death Syndrome And Caregivers’ Perceptions Of The Cardboard Box For Infant Sleep

Yale University

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Yale Medicine Thesis Digital Library School of Medicine

January 2019

Assessing Risk Factors For Sudden Infant Death Syndrome And

Caregivers’ Perceptions Of The Car ceptions Of The Cardboard Box For Infant Sleep or Infant Sleep

Nisha Dalvie

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Dalvie, Nisha, "Assessing Risk Factors For Sudden Infant Death Syndrome And Caregivers’ Perceptions Of

The Cardboard Box For Infant Sleep" (2019). Yale Medicine Thesis Digital Library. 3893.

https://elischolar.library.yale.edu/ymtdl/3893

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Assessing Risk Factors for Sudden Infant Death Syndrome and Caregivers’ Perceptions of

the Cardboard Box for Infant Sleep

A Thesis Submitted to the

Yale University School of Medicine

in Partial Fulfillment of the Requirements for the

Degree of Doctor of Medicine

by

Nisha Dalvie

2020

ASSESSING RISK FACTORS FOR SUDDEN INFANT DEATH SYNDROME AND

CAREGIVERS’ PERCEPTIONS OF THE CARDBOARD BOX FOR INFANT SLEEP.

Nisha S. Dalvie, Victoria Nguyen, Eve Colson, and Jaspreet Loyal. Department of Pediatrics,

Yale University, School of Medicine, New Haven, CT.

Some US hospitals are giving out cardboard boxes as a way to address behaviors

associated with Sudden Infant Death Syndrome (SIDS). Our goal was to evaluate the

cardboard box for this purpose by quantifying current practices and qualitatively assessing

caregivers’ perceptions of the cardboard box. Study participants were English or Spanish￾speaking caregivers of 2-16 week old infants presenting to primary care clinics in New

Haven, CT. Caregivers completed a survey asking about demographic data and SIDS risk

factors, such as non-supine positioning and bed-sharing. Some caregivers also participated in

a semi-structured interview about the cardboard box, created used a grounded theory

approach. Of 120 survey respondents, 38% of all participants and 63% of Spanish-speaking

participants reported bed-sharing at least some of the time. Factors associated with bed￾sharing included Spanish as the primary language (OR: 4.3 [95% CI: 1.9-9.9]). Factors

associated with non-supine positioning included Hispanic ethnicity (OR: 2.6 [95% CI 1.2-

5.8]), caregiver born outside the US (OR: 4.2 [95% CI: 1.8-9.6]), Spanish as the primary

language (OR: 6.3 [95% CI: 2.7-14.7]), and less than high school education (OR: 3.4 [95%

CI: 1.3-8.9]). Of 50 interview participants, 52% said they would use the cardboard box for

their infant to sleep in compared with 48% who said they would not. The following 3 themes

emerged from the data: (1) safety of the cardboard box; (2) appearance and (3) variation in

planned use. In conclusion, bed-sharing rates were higher in our study population compared

to the national average, highlighting the need for better resources; however, participants were

divided about whether they would actually use the cardboard box, indicating it may not be a

successful intervention in our community.

Acknowledgements

Thank you to Dr. Eve Colson for her introduction to this field and her crucial

expertise. Thank you to Dr. Maryellen Flaherty-Hewitt and Camisha Taylor for their

flexibility in the primary care clinic workflow so that this project could succeed. Most

importantly, thank you to Dr. Jaspreet Loyal for her incredible mentorship, unwavering

support, and life-long lessons in pediatric clinical care that all clinician-educators should

aspire to.

This work was supported by the National Institutes of Health

[Grant 2 T35 HL 7649-31].

Table of Contents

Introduction...............................................................................................................

Sudden Infant Death Syndrome: Background and Risk Factors...................

Barriers to Safe Sleep and Studied Interventions..........................................

The Cardboard Box for Infant Sleep..............................................................

Our Project....................................................................................................

Statement of Purpose and Specific Aims..................................................................

Methods.....................................................................................................................

Setting and Sample........................................................................................

Data Collection..............................................................................................

Data Analysis.................................................................................................

Results........................................................................................................................

Overall...........................................................................................................

Sleep Positioning...........................................................................................

Sleep Location................................................................................................

Qualitative Themes........................................................................................

Perceptions of the Cardboard Box, Demographics, and Sleep Practices.....

Discussion..................................................................................................................

Our Caregiver Population.............................................................................

Comparing National Prevalence of Sleep Practices with Our Data.............

Evaluation of the Cardboard Box for Infant Sleep........................................

Study Limitations and Opportunities for Future Work..................................

References..................................................................................................................

Appendices.................................................................................................................

Appendix A: PDF of Yale Qualtrics Survey...................................................

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1

Introduction

Sudden Infant Death Syndrome (SIDS): Background and Risk Factors

Sudden infant death syndrome (SIDS), a type of sudden unexpected infant death

(SUID) often associated with sleep, is defined as the sudden unexpected death of a child

less than 1 year of age and outside of the perinatal period that remains unexplained after

thorough work-up, including a complete autopsy.

1 It is the leading cause of post-neonatal

mortality in the United States and the third leading cause of infant death overall,

responsible for 3,600 deaths in 2017.

2 Although SIDS remains a diagnosis of exclusion,

risk factors related to intrinsic biological factors as well as the external sleep environment

have been identified.

3 The most well-established risk factors are non-supine sleep

positioning, soft and loose bedding, presence of items such as pillows and blankets,

sleeping on surfaces other than cribs (i.e. adult beds, sofas), and bed-sharing, where bed￾sharing is defined as an infant sleeping on the same surface as another person.

4 Other

factors correlated with higher SIDS incidence include male sex, black race, families who

identify as lower socio-economic status, mothers younger than 20, low birth weight / pre￾term infants, and cigarette smoking during pregnancy.

5 It is important to note that none of

these risk factors are sufficiently strong enough to identify a pathophysiologic cause, but

have assisted in creating a descriptive profile that associates maternal, neonatal, and

environmental factors with SIDS risk, as illustrated in Figure 1.

Based on this emerging profile, the American Academy of Pediatrics has published

recommendations for pediatricians to counsel families on modifiable factors to prevent

SIDS. The first guideline, published in 1992, recommended that infants be placed in a non￾prone position for sleep; in 1994, this guideline became the basis for the “Back-to-Sleep”