AIMS:Smoking during pregnancy when combined with bedsharing is a major risk factor for Sudden Unexpected Death in Infancy (SUDI). In-bed sleepers like Pēpi-Pod and wahakura provide a safe space for infants within adult beds. But the distribution and reach of these devices to high-risk infants remain unclear. Therefore, this study aimed to assess who receives in-bed sleepers and determine if they are reaching infants at the highest risk of SUDI. METHODS:We conducted a retrospective cross-sectional study combining sales data analysis of Pēpi-Pod in-bed sleepers with data from the National Maternity Collection, Ministry of Health and Change for our Children from 2019 to 2021. We compared characteristics of infants receiving in-bed sleepers with all New Zealand births. RESULTS:An estimated 15.9% of all infants born in New Zealand during 2019-2021 received in-bed sleepers, with significant regional variations. Only 37.5% of infants that were exposed to smoking during pregnancy received an in-bed sleeper. Of in-bed sleepers supplied, 72.9% were supplied to infants not exposed to smoking in pregnancy. In-bed sleeper reporting was poor, with only 36.4% of those supplied being reported. CONCLUSION:The distribution of in-bed sleepers is not optimally targeted, consistently failing to reach high-risk infants, particularly those exposed to smoking in pregnancy. Therefore, improved strategies for distribution and reporting are necessary to enhance the effectiveness of this SUDI prevention measure.

AIM:This study aimed to investigate the prevalence of family violence (FV) in sudden Unexpected Death in Infancy (SUDI) cases in New Zealand. METHODS:A case-control study was implemented from March 2012 to February 2015. Cases comprised all SUDI deaths referred to the coroner. Controls were selected randomly, based on characteristics of previous SUDI deaths. The primary risk factor assessed was exposure to "family violence ever". RESULTS:Of 258 controls, 248 (96.1%) had FV data and 73 (29.4%) had ever experienced FV. Among 132 SUDI cases, 58 (43.9%) had FV data and 35 (60.3%) had ever experienced FV. Adjusted risk factors associated with FV in controls included being in a de facto relationship, being single, mother's current partner not being the baby's biological father, maternal depression during pregnancy, and the number of previous pregnancies. In the multivariable model, FV was significantly associated with an increased risk of SUDI (OR 2.57 (95% CI 1.14, 5.81)). CONCLUSION:In this study, a history of FV was a significant risk factor for SUDI. Routine screening for FV exposure during perinatal and postnatal care is crucial, with appropriate support and referrals offered to affected families to potentially reduce SUDI risk.

In the United States the rate of stillbirth after 28 weeks’ gestation (late stillbirth) is 2.7/1000 births. Fetuses that are small for gestational age (SGA) or large for gestational age (LGA) are at increased risk of stillbirth. SGA and LGA are often categorized as growth or birthweight ≤ 10th and ≥ 90th centile, respectively; however, these cut-offs are arbitrary. We sought to characterize the relationship between birthweight and stillbirth risk in greater detail. Data on singleton births between 28- and 44-weeks’ gestation from 2014 to 2015 were extracted from the US Centers for Disease Control and Prevention live birth and fetal death files. Growth was assessed using customized birthweight centiles (Gestation Related Optimal Weight; GROW). The analyses included logistic regression using SGA/LGA categories and a generalized additive model (GAM) using birthweight centile as a continuous exposure. Although the SGA and LGA categories identified infants at risk of stillbirth, categorical models provided poor fits to the data within the high-risk bins, and in particular markedly underestimated the risk for the extreme centiles. For example, for fetuses in the lowest GROW centile, the observed rate was 39.8/1000 births compared with a predicted rate of 11.7/1000 from the category-based analysis. In contrast, the model-predicted risk from the GAM tracked closely with the observed risk, with the GAM providing an accurate characterization of stillbirth risk across the entire birthweight continuum. This study provides stillbirth risk estimates for each GROW centile, which clinicians can use in conjunction with other clinical details to guide obstetric management.

The purpose of this study is to gain insights into potential genetic factors contributing to the infant's vulnerability to Sudden Unexpected Infant Death (SUID). Whole Genome Sequencing (WGS) was performed on 144 infants that succumbed to SUID, and 573 healthy adults. Variants were filtered by gnomAD allele frequencies and predictions of functional consequences. Variants of interest were identified in 88 genes, in 64.6% of our cohort. Seventy-three of these have been previously associated with SIDS/SUID/SUDP. Forty-three can be characterized as cardiac genes and are related to cardiomyopathies, arrhythmias, and other conditions. Variants in 22 genes were associated with neurologic functions. Variants were also found in 13 genes reported to be pathogenic for various systemic disorders and in two genes associated with immunological function. Variants in eight genes are implicated in the response to hypoxia and the regulation of reactive oxygen species (ROS) and have not been previously described in SIDS/SUID/SUDP. Seventy-two infants met the triple risk hypothesis criteria. Our study confirms and further expands the list of genetic variants associated with SUID. The abundance of genes associated with heart disease and the discovery of variants associated with the redox metabolism have important mechanistic implications for the pathophysiology of SUID.

Bed-sharing refers to a baby and adult (usually mother) sleeping together on the same sleep surface (usually a bed) for some or all sleeps. Previous Scottish Government Reduce the Risk of Cot death advice, endorsed by the Scottish Cot Death Trust and Unicef, included: “The safest place for your baby to sleep at night, during the first six months, is on their back in a cot in your room.” Figure 1A illustrates the cot where the baby should sleep after a feed or cuddle. Figure 1 Feeding your baby in bed (A) with a cot next to bed (B) with no cot next to bed. The Scottish Government is now issuing the Lullaby Trust’s Safer Sleep-Saving Babies Lives leaflets for professionals (https://www.lullabytrust.org.uk/wp-content/uploads/Safer-sleep-saving-lives-a-guide-for-professionals-web.pdf) and parents (https://www.lullabytrust.org.uk/wp-content/uploads/Safer-sleep-for-babies-a-guide-for-parents-web.pdf) endorsed by Public Health England, which use clipart similar to figure 1B with no infant cot to indicate the safest place for your baby to sleep after a feed or cuddle. The Scottish Government now recommends avoidance of bed-sharing only if additional hazards are present such as parental smoking, alcohol or drug use or sleeping on a sofa. We believe this written literature—without spelling out inherent risk of bed-sharing for sleep and only recommending against bed-sharing if additional hazards are present—in conjunction with figure 1B with no infant cot to indicate the safest place for your baby to sleep, will encourage more parents to share their adult bed with their young baby and lead to many otherwise avoidable infant deaths. Bed-sharing is associated with sudden unexpected death in infancy (SUDI). SUDI includes SIDS (also known as cot death) (International Classification of Diseases ICD-10 …

BackgroundIn the United States (US) late stillbirth (at 28 weeks or more of gestation) occurs in 3/1000 births.AimWe examined risk factors for late stillbirth with the specific goal of identifying modifiable factors that contribute substantially to stillbirth burden.SettingAll singleton births in the US for 2014-2015.MethodsWe used a retrospective population-based design to assess the effects of multiple factors on the risk of late stillbirth in the US. Data were drawn from the US Centers for Disease Control and Prevention live birth and fetal death data files.ResultsThere were 6,732,157 live and 18,334 stillbirths available for analysis (late stillbirth rate = 2.72/1000 births). The importance of sociodemographic determinants was shown by higher risks for Black and Native Hawaiian and Other Pacific Islander mothers compared with White mothers, mothers with low educational attainment, and older mothers. Among modifiable risk factors, delayed/absent prenatal care, diabetes, hypertension, and maternal smoking were associated with increased risk, though they accounted for only 3-6% of stillbirths each. Two factors accounted for the largest proportion of late stillbirths: high maternal body mass index (BMI; 15%) and infants who were small for gestational age (38%). Participation in the supplemental nutrition for women, infants and children program was associated with a 28% reduction in overall stillbirth burden.ConclusionsThis study provides population-based evidence for stillbirth risk in the US. A high proportion of late stillbirths was associated with high maternal BMI and small for gestational age, whereas participation in supplemental nutrition programs was associated with a large reduction in stillbirth burden. Addressing obesity and fetal growth restriction, as well as broadening participation in nutritional supplementation programs could reduce late stillbirths.

Objective: Identify independent and novel risk factors for late-preterm (28- 36 weeks) and term (=37 weeks) stillbirth and explore development of a risk-prediction model.Design: Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors. Setting: An IPD database from five case- control studies in New Zealand, Australia, the UK and an international online study.Population: Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257).Methods: Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second- hand smoking, antenatal- care utilisation, and detailed fetal movement and sleep variables.Main outcome measures: Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth.Results: After model building, 575 late- stillbirth cases and 1541 controls from three contributing case- control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hic-coughs, increasing strength, frequency or vigorous fetal movements) aOR of still-birth. Poor antenatal- care utilisation increased risk while more- than-adequate care was protective. The area- under-the- curve was 0.84 (95% CI 0.82- 0.86).Conclusions: Similarities in risk factors for late-preterm and term stillbirth sug-gest the same approach for risk- assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal- care utilisation could be valuable in late-stillbirth risk assessment.

IntroductionMaternal perception of fetal movements during pregnancy are reassuring; however, the perception of a reduction in movements are concerning to women and known to be associated with increased odds of late stillbirth. Prior to full term, little evidence exists to provide guidelines on how to proceed unless there is an immediate risk to the fetus. Increased strength of movement is the most commonly reported perception of women through to full term, but perception of movement is also hypothesized to be influenced by fetal size. The study aimed to assess the pattern of maternal perception of strength and frequency of fetal movement by gestation and customized birthweight quartile in ongoing pregnancies. A further aim was to assess the association of stillbirth to perception of fetal movements stratified by customized birthweight quartile. Material and methodsThis analysis was an individual participant data meta-analyses of five case-control studies investigating factors associated with stillbirth. The dataset included 851 cases of women with late stillbirth (>28 weeks' gestation) and 2257 women with ongoing pregnancies who then had a liveborn infant. ResultsThe frequency of prioritized fetal movement from 28 weeks' gestation showed a similar pattern for each quartile of birthweight with increased strength being the predominant perception of fetal movement through to full term. The odds of stillbirth associated with reduced fetal movements was increased in all quartiles of customized birthweight centiles but was notably greater in babies in the lowest two quartiles (Q1: adjusted OR: 9.34, 95% CI: 5.43, 16.06 and Q2: adjusted OR: 6.11, 95% CI: 3.11, 11.99). The decreased odds associated with increased strength of movement was present for all customized birthweight quartiles (adjusted OR range: 0.25-0.56). ConclusionsIncreased strength of fetal movements in late pregnancy is a positive finding irrespective of fetal size. However, reduced fetal movements are associated with stillbirth, and more so when the fetus is small.

Background Infection is thought to play a part in some infant deaths. Maternal infection in pregnancy has focused on chlamydia with some reports suggesting an association with sudden unexpected infant death (SUID). Objectives We hypothesized that maternal infections in pregnancy are associated with subsequent SUID in their offspring. Setting All births in the United States, 2011–2015 Data source Centers for Disease Control and Prevention (CDC) Birth Cohort Linked Birth-Infant Death Data Files. Study design Cohort study, although the data were analysed as a case control study. Cases were infants that died from SUID. Controls were randomly sampled infants that survived their first year of life; approximately 10 controls per SUID case. Exposures Chlamydia, gonorrhea and hepatitis C. Results There were 19,849,690 live births in the U.S. for the period 2011–2015. There were 37,143 infant deaths of which 17,398 were classified as SUID cases (a rate of 0.86/1000 live births). The proportion of the control mothers with chlamydia was 1.7%, gonorrhea 0.2% and hepatitis C was 0.3%. Chlamydia was present in 3.8% of mothers whose infants subsequently died of SUID compared with 1.7% of controls (unadjusted OR = 2.35, 95% CI = 2.15, 2.56; adjusted OR = 1.08, 95% CI = 0.98, 1.19). Gonorrhea was present in 0.7% of mothers of SUID cases compared with 0.2% of mothers of controls (OR = 3.09, (2.50, 3.79); aOR = 1.20(0.95, 1.49)) and hepatitis C was present in 1.3% of mothers of SUID cases compared with 0.3% of mothers of controls (OR = 4.69 (3.97, 5.52): aOR = 1.80 (1.50, 2.15)). Conclusions The marked attenuation of SUID risk after adjustment for a wide variety of socioeconomic and demographic factors suggests the small increase in the risk of SUID of the offspring of mothers with infection with hepatitis C in pregnancy is due to residual confounding.

Background Mortality from sudden unexpected death in infancy (SUDI) has declined dramatically since the ‘Back to Sleep’ campaign. Deaths now are more prevalent in those with socioeconomic disadvantage. The investigation of SUDI frequently identifies parents that have mental health or drug, alcohol and addiction problems. Aims To estimate the prevalence of maternal mental health and substance use disorders and assess the magnitude of their risk for SUDI. Methods We conducted a population-based cohort study using data from the Integrated Data Infrastructure (IDI), a large research database containing linked data from a range of government agencies. The study population was all live births and their mothers in New Zealand from 2000 to 2016. The exposures of interest were maternal mental health problems and maternal substance use disorders in the year prior to the birth. The outcome was deaths from SUDI. Results The total population was 1086 504 live births and of these 1078 811 (99.3%) were able to be linked to other data sets within the IDI. The prevalence of maternal mental health problems in the total population was 5.2% and substance use disorder was 0.7%. There were 42 deaths from SUDI (0.75/1000) that were exposed to maternal mental illness and 864 deaths (0.84/1000) that were not exposed (adjusted relative risk (aRR)=1.23, 95% CI 0.90 to 1.68). There were 21 deaths from SUDI (2.67/1000) that were exposed to maternal substance use disorders and 885 (0.83/1000) that were not exposed (aRR=1.82, 95% CI 1.17 to 2.83). Conclusions Maternal substance use disorders, but not maternal mental health problems, in the year prior to the child’s birth was associated with an increased risk of SUDI. However, the numbers that are affected are small and the effect size moderate. This group of women should receive additional SUDI prevention services and Safe Sleep advice.

BACKGROUND:Studies suggest that bioactive compounds such as probiotics may positively influence psychological health. This study aimed to determine whether supplementation with the probiotic Lacticaseibacillus rhamnosus HN001 reduced stress and improve psychological wellbeing in university students sitting examinations.METHODS:In this randomized, double-blind, placebo-controlled study, 483 undergraduate students received either the probiotic L. rhamnosus HN001, or placebo, daily during a university semester. Students completed measures of stress, anxiety, and psychological wellbeing at baseline and post-intervention before examinations. Mann Whitney U tests compared the change in psychological outcomes between groups.RESULTS:Of the 483 students, 391 (81.0%) completed the post-intervention questions. There was no significant difference between the probiotic and placebo supplemented groups in psychological health outcomes. The COVID19 pandemic restrictions may have influenced the typical trajectory of stress leading up to examinations.CONCLUSION:We found no evidence of significant benefit of probiotics on the psychological health of university students. These findings highlight the challenges of conducting probiotic trials in human populations where the potential for contextual factors such as COVID19 response, and participant adherence to the intervention may influence results.

AimTo estimate the relative risk of sudden unexpected death in infancy (SUDI) by district health board (DHB) in New Zealand after adjustment for socio‐economic deprivation, ethnicity and other demographic factors.MethodsWe conducted a population‐based cohort study using data from the Integrated Data Infrastructure, a large research database containing linked data from a range of government agencies. The study population was all live births and their mothers in New Zealand from 2012 to 2018. The exposure of interest was DHB. The outcome was SUDI.ResultsThere were 418 068 live births in New Zealand from 2012 to 2018, and of these 415 401 (99.4%) had valid DHB data. There was considerable variation in the proportion of infants in each DHB living in the most deprived decile varying from 4.5% in Nelson, West Coast and Canterbury to 29.7% in Counties Manukau. There were 267 SUDI cases, giving an overall rate of 0.64/1000 live births during the study period (2012–2018). The SUDI rate varied from 1.11/1000 in Northland to 0.30/1000 in Waitemata and Auckland. Counties Manukau had the largest number of deaths (n = 54; rate = 1.08/1000). Five DHB regions had increased risk of SUDI compared to the reference group but, after adjustment, no DHB was significantly increased.ConclusionsThis study found that there is marked variation in SUDI risk by DHB, but this is explained by socio‐economic and demographic variation within DHBs. This study emphasises the importance of the contribution of social determinants of health to SUDI.

The COVID-19 pandemic resulted in the complete closure of many university campuses and a rapid shift to complete online delivery of university teaching. Understanding the student experience of online learning under these conditions is important to inform improvements and adaptations to continued online delivery of university services. The aim of this study was to examine students' experience of online learning, studying, and assessment during the pandemic and investigate the association between these perceptions and measures of psychological health. A cohort of 391 undergraduate students completed measures of stress, anxiety and psychological wellbeing at the beginning and end of a semester during which a shift to complete remote delivery of university teaching occurred due to COVID-19 restrictions. Students also rated how stressful or difficult they found five aspects of online learning, study and assessment which was used to calculate a composite score. T-tests were used to compare stress, anxiety and psychological wellbeing scores from the beginning and end of the semester. Regression models were used to examine the relationship between online learning composite score and psychological health measures. Unexpectedly, stress and psychological wellbeing improved over the semester during which the university campus closed, and all teaching and assessments w ere online. Students with higher stress scores and lower psychological wellbeing scores at the beginning of the semester were more likely to experience difficulty and stress with online teaching.

When a supposedly healthy infant passes away, it can be hard to understand why. Juan Lavista Ferres (Microsoft), Dr Jan-Marino Ramirez and Dr Tatiana Anderson (both from Seattle Children’s Research Institute), and Professor Edwin Mitchell (University of Auckland), form the core of a novel collaboration to conduct vital and extensive research into the risk factors and mechanisms behind sudden unexpected infant death. This unique collaboration spanning across disciplines, industries and continents, is providing the deeper understanding that is needed to prevent unnecessary infant deaths.

Objective To examine the effects of infant sofa-sleeping, recent use by caregivers of alcohol, cannabis, and/or other drugs, and bed type and pillows, on the risk of sudden unexpected death in infancy (SUDI) in New Zealand. Study design A nationwide prospective case-control study was implemented between March 2012 and February 2015. Data were collected during interviews with parents/caregivers. "Hazards" were defined as infant exposure to 1 or more of sofa-sleeping and recent use by caregivers of alcohol, cannabis, and other drugs. The interaction of hazards with tobacco smoking in pregnancy and bed sharing, including for very young infants, and the difference in risk for Maori and non-Maori infants, also were assessed. Results The study enrolled 132 cases and 258 controls. SUDI risk increased with infant sofa-sleeping (imputed aOR [IaOR] 24.22, 95% CI 1.65-356.40) and with hazards (IaOR 3.35, 95% CI 1.40-8.01). The SUDI risk from the combination of tobacco smoking in pregnancy and bed sharing (IaOR 29.0, 95% CI 10.10-83.33) increased with the addition of 1 or more hazards (IaOR 148.24, 95% CI 15.72-1398), and infants younger than 3 months appeared to be at greater risk (IaOR 450.61, 95% CI 26.84-7593.14). Conclusions Tobacco smoking in pregnancy and bed sharing remain the greatest SUDI risks for infants and risk increases further in the presence of sofa-sleeping or recent caregiver use of alcohol and/or cannabis and other drugs. Continued implementation of effective, appropriate programs for smoking cessation, safe sleep, and supplying safe sleep beds is required to reduce New Zealand SUDI rates and SUDI disparity among Maori.

The fall of a newborn baby to the hospital floor is a devastating experience for the family and staff caring for the mother and baby. The aim of this study was to report our experience in an ethnically diverse and socioeconomically disadvantaged community.

We describe the development and validation of a Sudden Unexpected Death in Infancy (SUDI) risk assessment clinical tool. An initial SUDI risk assessment algorithm was developed from an individual participant data meta-analysis of five international SIDS/SUDI case-control studies. The algorithm was translated into a clinical web tool called the Safe Sleep Calculator, which was tested at the routine infant 6-week check-up in primary care clinics in New Zealand. Evidence was gathered through mixed-methods research to inform the revision of the algorithm and the clinical tool. The revised algorithm performance was validated on a new contemporary New Zealand SUDI case-control study dataset and the pilot population data set. The area under the Receiver Operator Characteristic (ROC) curve is 0.89, with a sensitivity of 83.0% and a specificity of 80.9% in the NZ infant population when 0.3 per 1000 live births or more risk is used to define 'at higher risk'. The Safe Sleep Calculator SUDI risk assessment tool provides individualized evidence-based specific SUDI prevention advice for every infant and enables the concentration of additional SUDI prevention efforts and resource for infants at higher risk.

Background:The sudden collapse of an apparently healthy newborn, or sudden unexpected postnatal collapse (SUPC) is fatal in about half of cases. Epidemiological characteristics of sudden unexpected infant death (SUID) in the first week of life differ from those in the postperinatal age group (7-365 days).Aim:To describe the characteristics of SUPC resulting in neonatal death.Methods:We analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2003-2013: 41,125,233 births and 37,624 SUIDs). SUPC was defined as infants born >= 35 weeks gestational age, with a 5-minute Apgar score of >= 7, who died suddenly and unexpectedly in the first week of life.Results:Of the 37,624 deaths categorized as SUID during the study period, 616 met the SUPC criteria (1.5/100,000 live births). Eleven percent occurred on the first day of life and nearly three quarters occurred during postnatal days 3-6. SUPC deaths differed statistically from SUID deaths occurring 7-364 days of age, in particular for sex, marital status, and live birth order.Implications:These data support the need for adequate nurse staffing during the immediate recovery period and for the entire postpartum stay as well as nurse rounding for new mothers in the hospital setting.

The long-term impact of a father’s involvement in offspring development is understudied. The current study investigated the relations between early paternal engagement (i.e., the amount of time fathers engaged in one-to-one activity with their child), paternal accessibility (i.e., fathers’ physical proximity to their children) and later child behavioral difficulties. Data were obtained from five phases of the Auckland Birthweight Collaborative (ABC) longitudinal cohort study: at the study children’s birth; at 12 months; 3.5 years; 7 years; and 11 years of age. Moderated linear regression analyses revealed that there was a negative, long-term effect of paternal departure from the family household (i.e., reduced paternal accessibility) by 3.5 years of age on children’s total behavioral difficulties and conduct problems scores, but only if departed fathers had been highly engaged during the child’s first year of life. These findings suggest that the relationship between paternal accessibility and paternal engagement is potentially more nuanced than previously thought.

Objective: To explore pepe [infant] sleep practices and the key motivators among selected Maori and non-Maori mama [mothers] in Auckland, New Zealand, in relation to the risk of sudden unexpected death in infancy (SUDI). Methods: Qualitative research underpinned by a kaupapa Maori cultural framework was undertaken. In-depth face-to-face interviews occurred in the homes of mama with young pepe born in Counties Manukau, Auckland. Interview transcripts were analyzed using general purpose thematic analysis. Results: Thirty mama participated, including 17 Maori. Two-thirds of mama reported previous or current bed sharing. The fundamental human need for adequate sleep motivated half the mama in the present study, and especially Maori mama, to bed share. The second most common reason given was closeness and convenience. This was followed by breastfeeding, which was cited as a reason by Maori mama" only. These findings were interpreted in terms of intrinsic fear, culture, and mama deployment of knowledge. Conclusion: Service providers are encouraged to respond to the lived experiences and cultural realities, values, and beliefs of mama when designing and delivering effective SUDI prevention interventions. Innovative approaches for providing structured and opportunistic, culturally appropriate education and support around safe sleep are likely to be well-received by mama and their whanau [family/ies].