June 2017, VOLUME139 /ISSUE 6

Race, Ethnicity, and SIDS

  1. Richard D. Goldstein, MDa,b,c and
  2. Hannah C. Kinney, MDc
  1. aDepartment of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; and
  2. bDepartments of Medicine and
  3. cPathology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
  • Abbreviations:
    sudden infant death syndrome
    sudden unexpected infant death
  • In the United States, race and ethnicity predict different outcomes in known diseases. Race and ethnicity also predict different outcomes in sudden infant death syndrome (SIDS) and sudden unexpected infant death (SUID), categories of mortality that are arguably as yet undiscovered diseases. It is important to monitor disparities affecting the health of children and to understand the impact of interventions aimed at them. In this issue of Pediatrics, Parks et al1 make a significant contribution to our understanding of the racial and ethnic factors in SUID trends after the introduction of the Back to Sleep campaign. In “Racial and Ethnic Trends in Sudden Unexpected Infant Deaths: United States, 1995–2013,” the authors examine whether all children have shared equally in the decreases in SIDS/SUID that are attributed to the Back to Sleep campaign.

    The relative ranking of SUID rates by race and ethnicity remained constant throughout the 1995–2013 study period. But the authors also report that racial and ethnic trends in SUID rates since the Back to Sleep campaign were distinct for each racial/ethnic group, with varying significance in the declines. Their major public health message emphasizes that strategies to reduce risk must consider these trends, and that culturally-appropriate approaches for these unique racial/ethnic populations must be developed. This is a significant message.

    It is essential to look closely at racial disparities in this area and investigate their basis. The closer we look, however, the more clouded the picture becomes. Although the authors acknowledge that genetic factors influence the risk of SIDS/SUID overall, they present their results with an implication that they represent the impact of Back to Sleep. This framing is supported by important previous research in which prone sleeping was found to be a significant risk factor for SIDS in a primarily African American sample, and approximately one-third of the SIDS deaths were attributed to “un-safe” sleep.2 The AAP Taskforce on SIDS has consequently and correctly recommended a focus on “differences in the prevalence of supine positioning and other sleep environment conditions among racial and ethnic populations.”3 It is important to think about how this current research relates to our profession’s strong messaging in SIDS/SUID prevention.

    The authors found that the most significant declines in SUID occurred in the group whose implementation of Back to Sleep recommendations has been most problematic, specifically non-Hispanic African American infants, and not in groups with greater adherence to sleep environment recommendations. Reconciling the fact that the group historically identified to have the greatest difficulty embracing Back to Sleep recommendations was the same group whose SIDS rates had the most significant improvements during the study period is worthy of attention. Recommendations to improve prevention messaging may only go so far.

    One aspect to consider is that the biological contribution to SIDS/SUID, the underpinnings of disease, was also influenced during the study period. We have shown elsewhere that trends in declining SUID mortality are not simply due to Back to Sleep, but reflect changes in medical care influencing biological risk for SIDS.4 We agree with the authors when they point out that there is limited evidence that race or ethnicity in themselves directly predict outcomes. But there is no reason to be overly narrow in our understanding of this area of disease and not fully consider the complex models we have for disparities in other diseases. Such models incorporate both genetic and racial factors, as well as biological effects from increased exposure to the adverse risks and stresses that can accompany minority status, including poverty or differential access to care.

    In this important research, the authors provide further evidence that we may be complacent when we treat SIDS/SUID as a tragic mishap due only to risk in the sleep environment and tend to ignore the possibility that it is the consequence of biological vulnerabilities in at least some of these infants. The elimination of any disparities and ultimately the elimination of SIDS is the goal. This may require increased efforts at biomedical discovery in addition to more effective messaging about reducing risk factors. “Racial and Ethnic Trends in Sudden Unexpected Infant Deaths: United States, 1995–2013” provides important reasons to examine our premises.


      • Accepted March 20, 2017.
    • Address correspondence to Richard D. Goldstein, MD, Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, D2008, 450 Brookline Ave, Boston, MA 02115. E-mail: richard_goldstein{at}
    • Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at