A Longitudinal Cohort Analysis of Sudden Infant Death Syndrome Risk and Maltreatment History

Background and Purpose: Prior contact with Child Protective Services (CPS) has been documented as an independent risk factor for a child’s risk of both unintentional and intentional injury fatalities; yet, no such relationship between CPS contact and Sudden Infant Death Syndrome (SIDS) has emerged. The purpose of this study was to: (1) compare the sociodemographic characteristics of infants who died of SIDS with infants dying of other explained and unnatural causes, as well as with infants surviving to age one; and (2) examine prior child and family CPS referrals as a risk factor for SIDS.

Methods: Three linked sources of data from California were utilized for this analysis: vital birth records, vital death records, and administrative CPS records. Death served as the dependent variable and was classified using the International Classification of Diseases, 10th Revision (ICD-10). A prior allegation of maltreatment served as the independent variable. For first born infants, we determined prior CPS contact by examining the index child’s history of allegations; for infants falling second or higher in a maternally-established birth order on the birth record, we examined both the index child’s history of maltreatment allegations, as well as those of older siblings in the five years prior to the index child’s birth. Given well-documented variation in SIDS risk across sociodemographic characteristics, paralleled by often consistent sociodemographic differences in rates of CPS contacts, adjustments were made for nine covariates derived from the birth record. The linked dataset was restricted to fatality observations from the conclusion of the neonatal period (28 days) through the infant’s first birthday. Cox Regression Models were used to estimate the unadjusted and adjusted hazard of SIDS across several modeling specifications.

Results: Over 4 million live births, spanning the period 1999-2006, were captured in this analysis. There were a total of 1,271 postneonatal deaths attributed to SIDS. Consistent with the literature, there were a number of statistically significant differences in the distribution of sociodemographic characteristics for SIDS. Among first born children, there were no significant differences in CPS referral histories for SIDS versus deaths from natural causes. In contrast, relative to infants surviving to age 1, a CPS referral history was significantly more common among SIDS than for infants surviving to age one, even after adjusting for other risk factors. Among children falling second or higher in the birth order, a child’s risk of SIDS was even more strongly associated/elevated if there was prior family-level CPS history.

Conclusions and Implications: Although the American Academy of Pediatrics’ recommendations for a safe sleeping environment and the subsequent successful back-to-sleep public health campaign has decreased the incidence of SIDS for the general US infant population, this study indicates that infants in high risk families with prior referrals to CPS are at greater risk of SIDS than those from sociodemographically similar families without CPS contact. Mothers with prior CPS contact may need more intense educational/supportive interventions and monitoring. Further research is needed to explore whether CPS case management affects maternal adherence to established SIDS prevention standards.