Letters
Author Affiliations: Li Ka Shing Knowledge Institute of St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (Maguire, Thorpe); Pediatrics Outcomes Research Team, Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada (Birken, Parkin); Division of Pediatric Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada (Sochett). Corresponding Author: Jonathon L. Maguire, MD, MSc, FRCPC, Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Departments of Paediatrics and Health Policy Management and Evaluation, Faculty of Medicine, University of Toronto, and Department of Pediatrics, St Michael’s Hospital, 30 Bond St, 15-014 Cardinal Carter, Toronto, ON M5B 1W8, Canada ([email protected]). Published Online: February 17, 2014. doi:10.1001/jamapediatrics.2013.5379. Author Contributions: Dr Maguire and Mr Thorpe had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Maguire, Parkin. Acquisition of data: Maguire, Parkin. Analysis and interpretation of data: All authors. Drafting of the manuscript: Maguire. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Thorpe, Sochett. Obtained funding: Maguire, Birken, Parkin. Administrative, technical, and material support: Parkin. Study supervision: Maguire. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported in part by the Canadian Institutes of Health Research and the St Michael’s Foundation. The Paediatric Outcomes Research Team is supported by a grant from The Hospital for Sick Children Foundation. Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: The following clinical site investigators participated in the TARGetKids! Collaboration: Tony Barozzino, MD, Gary Bloch, MD, Ashna Bowry, MD, Douglas Campbell, MD, Sohail Cheema, MD, Brian Chisamore, MD, Karoon Danayan, MD, Anh Do, MD, Michael Evans, MD, Mark Feldman, MD, Sloane Freeman, MD, Moshe Ipp, MD, Sheila Jacobson, MD, Tara Kiran, MD, Holly Knowles, MD, Eddy Lau, MD, Fok-Han Leung, MD, Muhammad Mamdani, PharmD, MA, MPH, Julia Morinis, MD, MSc, Sharon Naymark, MD, Patricia Neelands, MD, Michael Peer, MD, Marty Perlmutar, MD, Michelle Porepa, MD, Noor Ramji, MD, Alana Rosenthal, MD, Janet Saunderson, MD, Michael Sgro, MD, Susan Shepherd, MD, Carolyn Taylor, MD, Sheila Wijayasinghe, MD, Ethel Ying, MD, and Elizabeth Young, MD. We also thank Azar Azad, PhD, Tonya D'Amour, Julie DeGroot, MSc, Sharmilaa Kandasamy, Kanthi Kavikondala, Tarandeep Malhi, Magda Melo, MSc, Subitha Rajakumaran, Juela Sejdo, and Laurie Thompson for administrative and technical support for the TARGetKids! program. 1. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: Institute of Medicine; 2011. 2. Canadian Paediatric Society. Vitamin D supplementation: recommendations for Canadian mothers and infants. Paediatr Child Health. 2007;12(7):583-598. 3. Lips P. Vitamin D physiology. Prog Biophys Mol Biol. 2006;92(1):4-8. 4. Harrell FE. Regression Modeling Strategies. New York, NY: Springer Science; 2001. 5. Hill KM, McCabe GP, McCabe LD, Gordon CM, Abrams SA, Weaver CM. An inflection point of serum 25-hydroxyvitamin D for maximal suppression of parathyroid hormone is not evident from multi-site pooled data in children and adolescents. J Nutr. 2010;140(11):1983-1988.
Transportation Barriers to Child Health Care Access Remain After Health Reform The Affordable Care Act will improve access to pediatric care by expanding health insurance coverage.1 The law has provisions to increase primary care provider supply to meet increased demand but not to improve access for families without resources to travel to health care providers. Lack of
transportation is a known barrier to children attending well care visits and receiving preventive health services.2 Nationally, regardless of insurance status, 4% of children (approximately 3 million) missed a health care appointment each year because transportation was unavailable; this includes 9% of children in families with incomes less than $50 000. Thirty-one percent later used a hospital emergency department for the health condition associated with that missed appointment. Rural areas are especially affected, having significantly fewer available public transit resources compared with metropolitan areas. Low-income households may not own a working vehicle, further limiting their options.3 Many rural areas experience severe and protracted health professional workforce shortages. In a study of federal health professional shortage area (HPSA) designations over time, 85% of rural counties were HPSA-designated at some point during a 7-year period. One-third were designated a full-county HPSA for at least 6 of the 7 years.4 An estimated 10.5 million US children live in an HPSA.5 Methods | Using a newly developed and validated tool, the Health Transportation Shortage Index (HTSI),3 we quantified and stratified the degree of risk for transportation-related access barriers for each of the 82 counties in Mississippi, which was selected as a rural state with high child poverty rates. Numeric HTSI scores (from 0-14) reflect factors associated with health care access barriers. A score of 8 or higher indicates highest risk of transportation barriers. Each county was geomapped with Geographic Information Systems software to precisely locate population centers by Census Bureau blocks, and federally qualified health centers and rural health clinics (“clinics”) by longitude and latitude. Straight-line distances were calculated from population centers to the nearest clinic, including those in contiguous counties. Census Bureau data were used to ascertain county demographics. Results | Based on its HTSI score, 55 Mississippi counties (67%) were identified as being at the highest risk for transportation barriers to health care access (mean score, 9.1; range, 8-13). All but 2 had full-county HPSA designation; 18% had populations less than 10 000 and 71% had populations between 10 000 and 30 000. All had no (13%) or limited (87%) public transit resources. The mean child population was 4709 (range, 2819103); mean child poverty rate was 31.8% and uninsured rate was 11.8%. In 78% of these counties, the most populous areas were within 6 miles of a clinic. Mean distances from outlying population centers to clinics ranged from 6 to 14 miles. Discussion | These results suggest that for most families in this very rural state with high child poverty rates and health workforce shortages, nonemergency medical transportation to facilitate child health care access would involve transports within a relatively narrow radius from a clinic. Additional planning would be needed to assist residents of outlying areas. While there are costs associated with the development of new transportation services, these could be offset over time by savings associated with reduced emergency department use. In a 2005 study done for the Transportation Research Board of the Na-
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Letters
tional Academies, nonemergency medical transportation services were found to be cost-effective especially for patients with chronic conditions.6 While health reform can be predicted to improve access to child health care for millions of currently uninsured children, geospatial barriers will persist. Only by resolving these barriers with new transportation resources will children reliably benefit from health reform. Roy Grant, MA Delaney Gracy, MD, MPH Grifin Goldsmith, MPH Morissa Sobelson Dennis Johnson, MPS Author Affiliations: Children’s Health Fund, New York, New York (Grant, Gracy, Goldsmith, Sobelson, Johnson). Corresponding Author: Roy Grant, MA, Medical Affairs, Children’s Health Fund, 215 W 125th St, Ste 301, New York, NY 10027 ([email protected]). Published Online: February 10, 2014. doi:10.1001/jamapediatrics.2013.4653. Author Contributions: Mr Grant had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Grant, Gracy, Johnson. Acquisition of data: Grant, Gracy, Goldsmith. Analysis and interpretation of data: Grant, Gracy, Goldsmith, Sobelson. Drafting of the manuscript: Grant, Gracy. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Grant, Goldsmith. Obtained funding: Johnson. Administrative, technical, and material support: Grant, Goldsmith, Sobelson, Johnson. Study supervision: Gracy. Conflict of Interest Disclosures: None reported. Funding/Support: The Children’s Health Fund Transportation Initiative is supported by The W. K. Kellogg Foundation and The Kresge Foundation. Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Correction: This article was corrected on February 11, 2014, to update the corresponding author’s e-mail address. 1. Health reform for children: the Affordable Care Act gives parents greater control over their children’s health care. The White House website. http://www.whitehouse.gov/files/documents/health_reform_for_children.pdf. Accessed September 12, 2013. 2. Riportella-Muller R, Selby-Harrington ML, Richardson LA, Donat PLN, Luchok KJ, Quade D. Barriers to the use of preventive health care services for children. Public Health Rep. 1996;111(1):71-77. 3. Grant R, Johnson D, Borders S, Gracy D, Rostholder T, Redlener I. The Health Transportation Shortage Index: the development and validation of a new tool to identify underserved communities. Children’s Health Fund website. http://issuu .com/childrenshealthfund/docs/chf_htsi-monograph__2_?e =6796486%2F1866261. Published 2012. Accessed August 15, 2013. 4. Doescher MP, Fordyce MA, Skillman SM, Jackson JE, Rosenblatt RA. Persistent primary care health professional shortage areas (HPSAs) and health care access in rural America. Rural Health Research and Policy Centers, University of Washington website. http://depts.washington.edu/uwrhrc/uploads/Persistent _HPSAs_PB.pdf. Published September 2009. Accessed August 15, 2013. 5. Hoffman C, Damico A, Garfield R. Insurance coverage and access to care in primary care shortage areas. The Henry J. Kaiser Family Foundation website. www.kaiserfamilyfoundation.files.wordpress.com/2013/01/8161.pdf. Published February 2011. Accessed August 15, 2013. 6. Hughes-Cromwick P, Wallace R, Mull H, Bologna J. Cost benefit analysis of providing non-emergency medical transportation. Transportation Research Board of the National Academies website. http://onlinepubs.trb.org/onlinepubs /tcrp/tcrp_webdoc_29.pdf. Published October 2005. Accessed August 15, 2013. 386
COMMENT & RESPONSE
Parent-Infant Bedsharing Is Not Recommended To the Editor The recently published study by Colson et al1 on the increasing trends of bedsharing highlights the challenges faced by the pediatric community in preventing sudden and unexpected infant deaths (SUIDs). Unfortunately, the accompanying editorial2 by Bergman undermines the message and importance of the article. Bergman cites his work from the early 1990s3 to question epidemiological risk factors, noting that there was no difference between the control group and the “classic sudden infant death syndrome (SIDS)” group. Unfortunately, the Haas et al study3 failed to address the single most important risk factor—the child’s sleep environment. Since the early 2000s when Child Fatality Review (CFR) Teams helped improve death scene investigations and review cases of SUIDs looking for modifiable risk factors, the sleep environment has become the number one most significant risk. Even though there are differences in classification of these deaths as noted by Bergman2 (SIDS, sudden unexpected death in infancy, undetermined, asphyxia, accidental suffocation and strangulation in bed), the single most prevalent underlying risk factor for all of these types is an unsafe sleep environment. Sleep-related deaths account for up to 90% of postnatal SUID deaths (see annual CFR reports from New Jersey, Arizona, and Michigan, for example), and the majority of these infants are dying in adult beds and many from bedsharing. In the 10-year period from 2003 to 2012 in Baltimore County, Maryland, approximately 100 000 infants were born. Before their first birthday, 119 died suddenly and unexpectedly after discharge from the hospital. Of these 119, 65% (77) died in an unsafe sleep environment and more than half were in an adult bed. In that same period, only 3 infants died alone, on their back, and in a crib (following the ABCs of safe sleep)—what I would call “classic SIDS.” A 25-fold increase in risk speaks to the importance of using the ABC safe sleep message and discouraging bedsharing as much as possible. More impressive than local statistics, Carpenter et al4 recently published a very large casecontrol study that demonstrated a 2.7 adjusted odds ratio for bedsharing. Any time an infant dies suddenly and unexpectedly it is a tragedy for the family as well as the care team in the emergency department that so often is unable to resuscitate the infant. Providing parents with a consistent message about reducing the risk of sudden death that includes avoidance of bedsharing is one that all pediatricians should promote and in no way places blame on the parent. Fortunately, the improved death scene investigations and CFR Teams have led to a positive step toward preventing these tragedies. Scott D. Krugman, MD, MS Author Affiliation: Department of Pediatrics, MedStar Franklin Square Medical Center, Baltimore, Maryland. Corresponding Author: Scott D. Krugman, MD, MS, Department of Pediatrics, MedStar Franklin Square Medical Center, Baltimore County Child Fatality Review Team, 9000 Franklin Square Dr, Baltimore, MD 21237 (scott.krugman @medstar.net). Conflict of Interest Disclosures: None reported.
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Author Affiliations: Li Ka Shing Knowledge Institute of St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (Maguire, Thorpe); Pediatrics Outcomes Research Team, Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada (Birken, Parkin); Division of Pediatric Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada (Sochett). Corresponding Author: Jonathon L. Maguire, MD, MSc, FRCPC, Applied Health Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Departments of Paediatrics and Health Policy Management and Evaluation, Faculty of Medicine, University of Toronto, and Department of Pediatrics, St Michael’s Hospital, 30 Bond St, 15-014 Cardinal Carter, Toronto, ON M5B 1W8, Canada ([email protected]). Published Online: February 17, 2014. doi:10.1001/jamapediatrics.2013.5379. Author Contributions: Dr Maguire and Mr Thorpe had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Maguire, Parkin. Acquisition of data: Maguire, Parkin. Analysis and interpretation of data: All authors. Drafting of the manuscript: Maguire. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Thorpe, Sochett. Obtained funding: Maguire, Birken, Parkin. Administrative, technical, and material support: Parkin. Study supervision: Maguire. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported in part by the Canadian Institutes of Health Research and the St Michael’s Foundation. The Paediatric Outcomes Research Team is supported by a grant from The Hospital for Sick Children Foundation. Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: The following clinical site investigators participated in the TARGetKids! Collaboration: Tony Barozzino, MD, Gary Bloch, MD, Ashna Bowry, MD, Douglas Campbell, MD, Sohail Cheema, MD, Brian Chisamore, MD, Karoon Danayan, MD, Anh Do, MD, Michael Evans, MD, Mark Feldman, MD, Sloane Freeman, MD, Moshe Ipp, MD, Sheila Jacobson, MD, Tara Kiran, MD, Holly Knowles, MD, Eddy Lau, MD, Fok-Han Leung, MD, Muhammad Mamdani, PharmD, MA, MPH, Julia Morinis, MD, MSc, Sharon Naymark, MD, Patricia Neelands, MD, Michael Peer, MD, Marty Perlmutar, MD, Michelle Porepa, MD, Noor Ramji, MD, Alana Rosenthal, MD, Janet Saunderson, MD, Michael Sgro, MD, Susan Shepherd, MD, Carolyn Taylor, MD, Sheila Wijayasinghe, MD, Ethel Ying, MD, and Elizabeth Young, MD. We also thank Azar Azad, PhD, Tonya D'Amour, Julie DeGroot, MSc, Sharmilaa Kandasamy, Kanthi Kavikondala, Tarandeep Malhi, Magda Melo, MSc, Subitha Rajakumaran, Juela Sejdo, and Laurie Thompson for administrative and technical support for the TARGetKids! program. 1. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: Institute of Medicine; 2011. 2. Canadian Paediatric Society. Vitamin D supplementation: recommendations for Canadian mothers and infants. Paediatr Child Health. 2007;12(7):583-598. 3. Lips P. Vitamin D physiology. Prog Biophys Mol Biol. 2006;92(1):4-8. 4. Harrell FE. Regression Modeling Strategies. New York, NY: Springer Science; 2001. 5. Hill KM, McCabe GP, McCabe LD, Gordon CM, Abrams SA, Weaver CM. An inflection point of serum 25-hydroxyvitamin D for maximal suppression of parathyroid hormone is not evident from multi-site pooled data in children and adolescents. J Nutr. 2010;140(11):1983-1988.
Transportation Barriers to Child Health Care Access Remain After Health Reform The Affordable Care Act will improve access to pediatric care by expanding health insurance coverage.1 The law has provisions to increase primary care provider supply to meet increased demand but not to improve access for families without resources to travel to health care providers. Lack of
transportation is a known barrier to children attending well care visits and receiving preventive health services.2 Nationally, regardless of insurance status, 4% of children (approximately 3 million) missed a health care appointment each year because transportation was unavailable; this includes 9% of children in families with incomes less than $50 000. Thirty-one percent later used a hospital emergency department for the health condition associated with that missed appointment. Rural areas are especially affected, having significantly fewer available public transit resources compared with metropolitan areas. Low-income households may not own a working vehicle, further limiting their options.3 Many rural areas experience severe and protracted health professional workforce shortages. In a study of federal health professional shortage area (HPSA) designations over time, 85% of rural counties were HPSA-designated at some point during a 7-year period. One-third were designated a full-county HPSA for at least 6 of the 7 years.4 An estimated 10.5 million US children live in an HPSA.5 Methods | Using a newly developed and validated tool, the Health Transportation Shortage Index (HTSI),3 we quantified and stratified the degree of risk for transportation-related access barriers for each of the 82 counties in Mississippi, which was selected as a rural state with high child poverty rates. Numeric HTSI scores (from 0-14) reflect factors associated with health care access barriers. A score of 8 or higher indicates highest risk of transportation barriers. Each county was geomapped with Geographic Information Systems software to precisely locate population centers by Census Bureau blocks, and federally qualified health centers and rural health clinics (“clinics”) by longitude and latitude. Straight-line distances were calculated from population centers to the nearest clinic, including those in contiguous counties. Census Bureau data were used to ascertain county demographics. Results | Based on its HTSI score, 55 Mississippi counties (67%) were identified as being at the highest risk for transportation barriers to health care access (mean score, 9.1; range, 8-13). All but 2 had full-county HPSA designation; 18% had populations less than 10 000 and 71% had populations between 10 000 and 30 000. All had no (13%) or limited (87%) public transit resources. The mean child population was 4709 (range, 2819103); mean child poverty rate was 31.8% and uninsured rate was 11.8%. In 78% of these counties, the most populous areas were within 6 miles of a clinic. Mean distances from outlying population centers to clinics ranged from 6 to 14 miles. Discussion | These results suggest that for most families in this very rural state with high child poverty rates and health workforce shortages, nonemergency medical transportation to facilitate child health care access would involve transports within a relatively narrow radius from a clinic. Additional planning would be needed to assist residents of outlying areas. While there are costs associated with the development of new transportation services, these could be offset over time by savings associated with reduced emergency department use. In a 2005 study done for the Transportation Research Board of the Na-
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JAMA Pediatrics April 2014 Volume 168, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of North Dakota User on 05/21/2015
385
Letters
tional Academies, nonemergency medical transportation services were found to be cost-effective especially for patients with chronic conditions.6 While health reform can be predicted to improve access to child health care for millions of currently uninsured children, geospatial barriers will persist. Only by resolving these barriers with new transportation resources will children reliably benefit from health reform. Roy Grant, MA Delaney Gracy, MD, MPH Grifin Goldsmith, MPH Morissa Sobelson Dennis Johnson, MPS Author Affiliations: Children’s Health Fund, New York, New York (Grant, Gracy, Goldsmith, Sobelson, Johnson). Corresponding Author: Roy Grant, MA, Medical Affairs, Children’s Health Fund, 215 W 125th St, Ste 301, New York, NY 10027 ([email protected]). Published Online: February 10, 2014. doi:10.1001/jamapediatrics.2013.4653. Author Contributions: Mr Grant had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Grant, Gracy, Johnson. Acquisition of data: Grant, Gracy, Goldsmith. Analysis and interpretation of data: Grant, Gracy, Goldsmith, Sobelson. Drafting of the manuscript: Grant, Gracy. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Grant, Goldsmith. Obtained funding: Johnson. Administrative, technical, and material support: Grant, Goldsmith, Sobelson, Johnson. Study supervision: Gracy. Conflict of Interest Disclosures: None reported. Funding/Support: The Children’s Health Fund Transportation Initiative is supported by The W. K. Kellogg Foundation and The Kresge Foundation. Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Correction: This article was corrected on February 11, 2014, to update the corresponding author’s e-mail address. 1. Health reform for children: the Affordable Care Act gives parents greater control over their children’s health care. The White House website. http://www.whitehouse.gov/files/documents/health_reform_for_children.pdf. Accessed September 12, 2013. 2. Riportella-Muller R, Selby-Harrington ML, Richardson LA, Donat PLN, Luchok KJ, Quade D. Barriers to the use of preventive health care services for children. Public Health Rep. 1996;111(1):71-77. 3. Grant R, Johnson D, Borders S, Gracy D, Rostholder T, Redlener I. The Health Transportation Shortage Index: the development and validation of a new tool to identify underserved communities. Children’s Health Fund website. http://issuu .com/childrenshealthfund/docs/chf_htsi-monograph__2_?e =6796486%2F1866261. Published 2012. Accessed August 15, 2013. 4. Doescher MP, Fordyce MA, Skillman SM, Jackson JE, Rosenblatt RA. Persistent primary care health professional shortage areas (HPSAs) and health care access in rural America. Rural Health Research and Policy Centers, University of Washington website. http://depts.washington.edu/uwrhrc/uploads/Persistent _HPSAs_PB.pdf. Published September 2009. Accessed August 15, 2013. 5. Hoffman C, Damico A, Garfield R. Insurance coverage and access to care in primary care shortage areas. The Henry J. Kaiser Family Foundation website. www.kaiserfamilyfoundation.files.wordpress.com/2013/01/8161.pdf. Published February 2011. Accessed August 15, 2013. 6. Hughes-Cromwick P, Wallace R, Mull H, Bologna J. Cost benefit analysis of providing non-emergency medical transportation. Transportation Research Board of the National Academies website. http://onlinepubs.trb.org/onlinepubs /tcrp/tcrp_webdoc_29.pdf. Published October 2005. Accessed August 15, 2013. 386
COMMENT & RESPONSE
Parent-Infant Bedsharing Is Not Recommended To the Editor The recently published study by Colson et al1 on the increasing trends of bedsharing highlights the challenges faced by the pediatric community in preventing sudden and unexpected infant deaths (SUIDs). Unfortunately, the accompanying editorial2 by Bergman undermines the message and importance of the article. Bergman cites his work from the early 1990s3 to question epidemiological risk factors, noting that there was no difference between the control group and the “classic sudden infant death syndrome (SIDS)” group. Unfortunately, the Haas et al study3 failed to address the single most important risk factor—the child’s sleep environment. Since the early 2000s when Child Fatality Review (CFR) Teams helped improve death scene investigations and review cases of SUIDs looking for modifiable risk factors, the sleep environment has become the number one most significant risk. Even though there are differences in classification of these deaths as noted by Bergman2 (SIDS, sudden unexpected death in infancy, undetermined, asphyxia, accidental suffocation and strangulation in bed), the single most prevalent underlying risk factor for all of these types is an unsafe sleep environment. Sleep-related deaths account for up to 90% of postnatal SUID deaths (see annual CFR reports from New Jersey, Arizona, and Michigan, for example), and the majority of these infants are dying in adult beds and many from bedsharing. In the 10-year period from 2003 to 2012 in Baltimore County, Maryland, approximately 100 000 infants were born. Before their first birthday, 119 died suddenly and unexpectedly after discharge from the hospital. Of these 119, 65% (77) died in an unsafe sleep environment and more than half were in an adult bed. In that same period, only 3 infants died alone, on their back, and in a crib (following the ABCs of safe sleep)—what I would call “classic SIDS.” A 25-fold increase in risk speaks to the importance of using the ABC safe sleep message and discouraging bedsharing as much as possible. More impressive than local statistics, Carpenter et al4 recently published a very large casecontrol study that demonstrated a 2.7 adjusted odds ratio for bedsharing. Any time an infant dies suddenly and unexpectedly it is a tragedy for the family as well as the care team in the emergency department that so often is unable to resuscitate the infant. Providing parents with a consistent message about reducing the risk of sudden death that includes avoidance of bedsharing is one that all pediatricians should promote and in no way places blame on the parent. Fortunately, the improved death scene investigations and CFR Teams have led to a positive step toward preventing these tragedies. Scott D. Krugman, MD, MS Author Affiliation: Department of Pediatrics, MedStar Franklin Square Medical Center, Baltimore, Maryland. Corresponding Author: Scott D. Krugman, MD, MS, Department of Pediatrics, MedStar Franklin Square Medical Center, Baltimore County Child Fatality Review Team, 9000 Franklin Square Dr, Baltimore, MD 21237 (scott.krugman @medstar.net). Conflict of Interest Disclosures: None reported.
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