Every year, approximately 3,500 infants in the U.S. die from sleep-related causes, a category which includes sudden infant death syndrome (SIDS), accidental suffocation and deaths from unknown causes. Despite past public health campaigns that have made strides in this area, significant disparities remain, and the problem is still poorly understood.
Anna Briker, a second-year medical student, is hoping that her recent research will help to better illustrate the issue in Cook County, as well as inform future investigations and targeted prevention strategies.
Briker, who conducted the research under mentor Karen Sheehan, ’89 MD, MPH, ’92 GME, professor of Pediatrics in the Division of Emergency Medicine and of Preventive Medicine, presented her findings at the Institute for Public Health and Medicine’s inaugural Population Health Forum in December.
In this Q&A, Briker discusses the key findings of her study, the barriers to researching sleep-related infant deaths, and why wellness drew her to Feinberg.
Why did you choose Feinberg?
I chose Feinberg for a lot of reasons. I was at first very interested because of Feinberg’s strong research program, especially as I had done a lot of research as an undergrad and knew it was something I wanted to continue as a medical student. I was also drawn to the early clinical experiences, such as in Education-Centered Medical Home (ECMH), and the opportunities to get involved in Chicago, through free clinics and tutoring. Then when I visited, it became clear to me that students seemed really friendly and happy, and there was this strong emphasis on wellness. I think that’s what sealed the decision for me.
Feinberg is such a supportive environment; it’s something you feel coming from the administration but also among classmates — we all care about each other. The deans offer students many opportunities to give feedback and to voice our concerns, and I appreciate that they truly listen and act on that feedback.
How did you become interested in sleep-related infant deaths?
When I came to medical school, one of the things I was very interested in was health disparities — understanding why some people in one zip code live much longer than people in another. I did a pre-orientation program called Destination Chicago and learned about different programs throughout Chicago that work to address this. Early on in my first year of medical school, Dr. Sheehan spoke to us about her own research and advocacy in health disparities.
When I was deciding on an Area of Scholarly Concentration (AOSC) project, I contacted Dr. Sheehan and she mentioned this project on sleep-related infant deaths. After looking into it a bit more, I became intrigued by the topic. It felt so strange that there’s this public health problem that has been persisting for years and yet no one really understands why it’s happening.
In the 1990s, the NIH launched a “Safe to Sleep” campaign that emphasized safe sleep behaviors, such as placing infants on their backs to sleep and not having anything else in a crib. The rate of deaths in the U.S. declined in part due to the campaign, but unfortunately that progress has stagnated since about 2000.
Sleep-related infant death is not very well understood, partially because of the difficulty of studying this problem, as it is feasibly and ethically very difficult to do randomized controlled trials. There are also differences in how the data is reported and how the deaths are even classified. There’s no national standardized approach within the United States to survey unexpected infant deaths. The data is very limited. Unfortunately, it’s hard to get a handle on how to prevent something if you don’t fully understand the problem in the first place.
What did your study specifically look at?
We studied sleep-related factors in infant deaths in Cook County, Illinois. We used the Illinois Violent Death Reporting System, which in Illinois includes deaths of infants who died while sleeping. Using that database, we performed a descriptive epidemiological study of all the infants who died in Cook County in 2015 and 2016.
We looked at what percentage of such deaths had clear sleep-related risk factors. We also assessed other trends, such as geographical hotspots. Knowing what populations within Cook County are at increased risk is important for prevention purposes.
What were your key findings?
We found that over 70 percent of infants who died of undetermined manner in Cook County died in the presence of a sleep-related risk factor. The most common risk factor was co-sleeping, or sleeping with someone else on the same sleep surface — that was a factor in two-thirds of all cases of infants who died with a sleeping risk factor. Other risk factors, for example, included sleeping with other items in the area, such as stuffed animals or pillows, or sleeping in an area besides a crib.
Of course, there are a lot of other risk factors for sleep-related infant death, and not all of them are captured in the Illinois Violent Death Reporting System. The triple-risk model is an established theory about sleep-related infant death that states that a combination of genetic vulnerability, the developmental stage of the infant and environmental factors combine to make an infant susceptible. But we focused on the risk factors that are modifiable and potentially preventable.
Our heat map also showed spots within Chicago where there was the highest incidence of such deaths, and the majority of deaths were in only six zip codes within all of Cook County, concentrated on the south and west sides of Chicago. This wasn’t surprising, given what we know about socioeconomic divisions in Chicago and social determinants of health.
A striking finding in our study was that almost two-thirds of the deaths were African-American infants. African-Americans comprised about one-third of children under five years of age in Cook County in the same time period. This discrepancy suggests that African-American infants are disproportionately affected by sleep-related deaths.
In the future, we’d like to implement an intervention to target the populations that have increased deaths and the risk factors that were associated with them, specifically co-sleeping. With our current study, we now we have the baseline data to do that.
What are other next steps in the research?
Last month, I presented my research at the Injury Free Coalition for Kids Conference in Florida, and we’re now working on finalizing our paper for submission.
In terms of the future, there are a lot of directions. First, we’re missing a lot of information that could be really helpful. The CDC recently launched a database that combines the kind of information that we had in our study with information that we wanted to have — such as more details about the families and medical histories of the infants. When we were conducting our analysis, the database only covered about 30 percent of all the deaths in the U.S., and Illinois wasn’t included. But starting in 2019, Cook County will be included. That’s a positive step.
As for my own research, I’m definitely interested in continuing to investigate health disparities and health outcomes in different populations. It’s a major problem in our healthcare system as a whole, and it’s one of the reasons why I wanted to pursue medicine in the first place.