Prenatally Substance-Exposed Infants and SUID

Source: Deutsch SA, Loiselle CE, Hossain J, et al. Sleep-related sudden unexpected infant death among infants prenatally substance exposed. Pediatrics. 2024;154(6):e2024067372; doi: 10.1542/peds.2024-067372.Investigators from Nemours Children’s Health, Wilmington, DE, conducted a retrospective study to compare sleep environment characteristics and markers of family vulnerability among infants with sudden unexpected infant death (SUID) who were prenatally substance exposed or unexposed. For the study, they reviewed the CDC SUID and Sudden Death in the Young Case Registry, which includes data collected by multidisciplinary child death review (CDR) teams on sudden and unexpected deaths in infants and children in participating jurisdictions in the US. Information collected is comprehensive and includes sleep environment, caregiver characteristics, clinical and toxicology results, and sociodemographic characteristics. Participants in the current study were infants included in the registry whose death was related to sleeping or the sleep environment and died between 2015 and 2020. Infants were classified as prenatally substance-exposed or not exposed based on the determination of the investigating CDR team, using available data on the infant and/or mother. Differences in sleep environment and markers of family vulnerability among those in the prenatally exposed and unexposed groups were assessed with chi-square tests.Data on 2,010 infants with SUID were analyzed, including 283 (14%) who were prenatally substance-exposed. The median age at death was 2 months, and 73% of study participants were born at term (≥37 weeks’ gestation). Among all study participants, deaths were classified as homicide in 2 infants, and 43 (2%) had abnormal toxicology results, indicating intoxication. For infants who were prenatally exposed, 61% were sleeping on the same surface as an adult at the time of death vs 53% of those unexposed (P = 0.10). Supervisors of the infants in the prenatally exposed group were significantly more likely to be impaired than supervisors of those unexposed (34% and 19%, respectively; P <0.001) and more likely to be asleep (71% and 50%; P <0.001) at the time of the SUID. Multiple markers of family vulnerability were significantly more common among infants in the exposed group than in those in the unexposed group, including health care access, barriers to prenatal care, family involvement in the child welfare system, family history of intimate partner violence, family criminal history, and family unemployment.The authors conclude that there were significant differences in sleep environment and social vulnerability between infants with SUID who were prenatally substance exposed and those who were unexposed.Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.To lose an infant to SUID is devastating. While a rare occurrence, affecting 93 cases per 100,000 live births, rates have remained unchanged from 2000 to 2020.1 Studies have shown that prenatal exposure to substances such as alcohol, marijuana, cocaine, and other substances increases the risk for SUID.2 Overall, 8% of births are affected by illicit substances.3 Infants who die from SUID are more likely to come from families who experience social and economic stressors such as poverty, housing instability, and lack of access to health care.4 Some social factors, such as race, are no longer observed when controlling for maternal substance use.5 The current researchers explored differences among children who died of SUID and had been prenatally exposed and those who had not.The investigators found that among the prenatally exposed, the infant who subsequently died of SUID was more likely to be using a pillow and a blanket; the supervisor was more likely to be asleep, impaired, and sleeping on the same surface as the infant. However, it is important to recognize that these data do not infer causation. All the children in this dataset had died from SUID. For example, bed-sharing is a commonly understood risk factor for SUID. (See AAP Grand Rounds. 2024;51[6]:69.)6 However, in this dataset, 53% of non-exposed infants were bed-sharing. The current researchers describe factors associated with prenatal substance exposure, not factors associated with SUID.The results of the current study suggest 2 future avenues of exploration. First, a non-SUID control group, such as a propensity model with matched cases, would be crucial to discern true associations among infants with prenatal exposure. Second, the current researchers lumped all substances together. Nicotine, alcohol, marijuana, cocaine, and combination of these substances likely confer different risk factors, which are not well-understood.2 To discern reversible factors associated with SUID is important to save lives. However, this study was not designed to answer this question.There are significant differences in sleep environment and social vulnerability between infants with SUID who were prenatally exposed and those who were not. However, these associations do not confer causation for SUID.