Introduction/background
Deaths, deaths, SUIDs, sleep-related deaths
SUFFOCATION
Sudden Unexpected Infant Deaths (SUIDs) that are sleep-environment related are diagnosed as suffocation, entrapment, or unknown etiology [In the late 1980s and early 1990s researchers in several European countries and New Zealand found many SUIDs were linked to the prone sleep position, which was followed by mass public health campaigns promoting “Back to Sleep”, whereby parents and care givers were instructed to place their infants in a supine or face up position to sleep [In 2002 investigators assessed sleep position recommendations medical professionals gave to new parents in 16 countries in Latin America and the Caribbean and found that only 25.7% recommended supine sleep position in the home [The current study took place in Ecuador where infant sleep practice was an understudied area. Although SUIDs were collected in each province annually by the Ministerio de Salud Publica (MSP), they were not commonly published or reported. One of our co-authors, Dr. Bahamonde, requested raw mortality data (unpublished) from the MSP for all provinces that reported data in 2018. In Santo Domingo de los Tsa’chilas province, where the study took place, the highest number of SUIDS deaths was reported (4 in a population of 442,788 people). In the absence of published data, anecdotal information was also collected from clinical staff where the study took place, a small clinic in a peri-urban and low-resource community. They indicated that in their patient population there were 4 infant deaths in the last 5 years, 3 of which were attributed to the sleep environment.The Ecuadorian MSP published practice recommendations to reduce sleep-related deaths between 1 month and 1 year of age and cite the American Academy of Pediatrics (AAP) 2016 recommendations [Published accounts of prenatal safe infant sleep education in the US demonstrated an increase in knowledge and intended adherence particularly when receiving advice from a healthcare provider, but often does not translate into sustained safe sleep practice after the infant is born [One intervention strategy used in numerous countries to mitigate risks in the sleep environment for low-income families was by promoting a portable, culturally acceptable, and affordable sleep device paired with comprehensive maternal and child health education and care. New Zealand’s indigenous Māori community had high rates of infant mortality and SUID prior to 2005, which was largely attributable to smoking and co-sleeping [In Finland another strategy to reduce social inequality and improve maternal and child health outcomes for people in poverty included the provision of a cardboard baby box as a portable sleep space as one part of a much larger investment in prenatal care, education and social programs in the 1930s [It is worth noting that other northern European countries also reduced infant mortality rates substantially at the same time as Finland and did not adopt the baby box but did invest in social programming and healthcare [Many states in the US have been providing a similar Finnish-style box and infant supplies, herein just referred to as baby box, to incentivize and engage low-income families to attend prenatal care [Research surrounding the efficacy of the baby box to promote safe sleep has been limited. In one study in the US researchers found that the provision of the baby box in combination with personalized face to face sleep education by a nurse reduced the rate of bed-sharing by 25% in the first week of life, as compared to standard discharge written post-partum instructions [An extensive review of the literature revealed no studies to our knowledge evaluating the provision of baby boxes to promote safe sleep in randomized controlled trial with systematic follow up in the home at several time points. Finnish researchers have interviewed numerous organizations that distribute baby boxes globally and found a governmental program in Chile has distributed 140,000 baby boxes over a 9-year period and another program reported operating in several Latin American countries [