Socioeconomic Position and Factors Associated With Use of a Nonsupine Infant Sleep Position: Findings From the Canadian Maternity Experiences Survey

Objectives. With a focus on socioeconomic position, we examined the association between maternal education and nonsupine infant sleep position, and examined patterns of effect modification with additional sociodemographic, maternal, infant, and health services predictors.Methods. Data were from the Maternity Experiences Survey, a national population-based sample of 76 178 new Canadian mothers (unweighted n = 6421) aged 15 years or older interviewed in 2006–2007. Using logistic regression, we developed multivariate models for 3 maternal education strata.Results. Level of maternal education was significantly and inversely related to nonsupine infant sleep position. Stratified analyses revealed different predictive factors for nonsupine infant sleep position across strata of maternal education. Postpartum home visits were not associated with use of this sleep position among new mothers with less than high school completion. Adequacy of postpartum information regarding sudden infant death syndrome was not associated with nonsupine infant sleep position in any of the educational strata.Conclusions. These findings suggest a need to revisit Back to Sleep health promotion strategies and to ensure that these interventions are tailored to match the information needs of all families, including mothers with lower levels of formal education.Optimizing infant sleep position in an effort to reduce the incidence of sudden infant death syndrome (SIDS) has been an important maternal child health promotion strategy since nonsupine sleep position was identified as an important modifiable risk factor for SIDS in the early 1990s.1 Dramatic decreases in SIDS rates in many countries over the subsequent decade2–5 were largely credited to the success of public health campaigns that initially advised that infants be placed in nonprone positions for sleep and later restricted the recommendation to the supine sleep position only.5–10 In Canada and the United States, SIDS rates dropped by 70% and 60%, respectively, between 1985 and 2004.2,5,6,11 These reductions in SIDS rates were accompanied by reductions in postneonatal mortality rates, suggesting that they were real reductions rather than artifacts of changes in diagnostic criteria or coding practices.5More recently, SIDS rates have stabilized in most countries. In some countries, such as the United States and New Zealand,5 and among socioeconomically disadvantaged, indigenous, and African American subpopulations,12,13 SIDS rates remain unacceptably high. These rates have been linked to the need for ongoing promotion of risk-reduction activities, such as supine sleep position, particularly in communities still experiencing a high SIDS burden.5 For example, despite efforts to promote parents’ and caregivers’ use of a supine position for infant sleep, longitudinal data from the National Infant Sleep Position Study in the United States have demonstrated that a sizable proportion of infants continue to be placed in nonsupine positions for usual sleep (27.9% in 2008).14 Moreover, following consistent increases in the proportion of infants being placed to sleep in supine positions throughout the 1990s, the rates have shown little change since approximately 2001.14Analysis of data from the US Pregnancy Risk Assessment Monitoring System survey has shown that socioeconomic position (SEP), measured by both education level and income, has been consistently, significantly, and positively associated with supine sleep position across states.15 Accordingly, nonsupine sleep position has been associated with socioeconomic deprivation in several other studies.16,17 For example, in a prospective cohort study of sleep position among inner-city mothers of infants aged 3 to 7 months in the United States, Brenner et al.16 found that mothers living below the poverty level were 1.81 times more likely to put their infant to sleep in a prone position than mothers living above the poverty level (95% confidence interval [CI] = 1.10, 2.99). Low SEP was not found to be significantly associated with nonsupine sleep position in an analysis of the National Infant Sleep Position Study; however, this data set underrepresented women with fewer than 12 years of education by more than 50% compared with other national surveys.18,19The size and scope of the population surveyed by the Canadian Maternity Experiences Survey (MES) provided a unique opportunity to pursue our study objectives, which were to (1) clarify the significance of the association between SEP and nonsupine sleep position, and (2) examine patterns of effect modification by SEP on the associations between nonsupine infant sleep position and additional sociodemographic, maternal, infant, and health services predictors.     

Validating administratively derived frailty scores for use in Veterans Health Administration emergency departments

Objectives

Frailty is a clinical syndrome characterized by decreased physiologic reserve that diminishes the ability to respond to stressors such as acute illness. Veterans Health Administration (VA) emergency departments (ED) are the primary venue of care for Veterans with acute illness and represent key sites for frailty recognition. As questionnaire-based frailty instruments can be cumbersome to implement in the ED, we examined two administratively derived frailty scores for use among VA ED patients.

Methods

This national retrospective cohort study included all VA ED visits (2017–2020). We evaluated two administratively derived scores: the Care Assessment Needs (CAN) score and the VA Frailty Index (VA-FI). We categorized all ED visits across four frailty groups and examined associations with outcomes of 30-day and 90-day hospitalization and 30-day, 90-day, and 1-year mortality. We used logistic regression to assess the model performance of the CAN score and the VA-FI.

Results

The cohort included 9,213,571 ED visits. With the CAN score, 28.7% of the cohort were classified as severely frail; by VA-FI, 13.2% were severely frail. All outcome rates increased with progressive frailty (p-values for all comparisons < 0.001). For example, for 1-year mortality based on the CAN score frailty was determined as: robust, 1.4%; prefrail, 3.4%; moderately frail, 7.0%; and severely frail, 20.2%. Similarly, for 90-day hospitalization based on VA-FI, frailty was determined as prefrail, 8.3%; mildly frail, 15.3%; moderately frail, 29.5%; and severely frail, 55.4%. The c-statistics for CAN score models were higher than for VA-FI models across all outcomes (e.g., 1-year mortality, 0.721 vs. 0.659).

Conclusions

Frailty was common among VA ED patients. Increased frailty, whether measured by CAN score or VA-FI, was strongly associated with hospitalization and mortality and both can be used in the ED to identify Veterans at high risk for adverse outcomes. Having an effective automatic score in VA EDs to identify frail Veterans may allow for better targeting of scarce resources.     

Modulation of alpha and gamma oscillations related to retrospectively orienting attention within working memory

Selective attention mechanisms allow us to focus on information that is relevant to the current behavior and, equally important, ignore irrelevant information. An influential model proposes that oscillatory neural activity in the alpha band serves as an active functional inhibitory mechanism. Recent studies have shown that, in the same way that attention can be selectively oriented to bias sensory processing in favor of relevant stimuli in perceptual tasks, it is also possible to retrospectively orient attention to internal representations held in working memory. However, these studies have not explored the associated oscillatory phenomena. In the current study, we analysed the patterns of neural oscillatory activity recorded with magnetoencephalography while participants performed a change detection task, in which a spatial retro‐cue was presented during the maintenance period, indicating which item or items were relevant for subsequent retrieval. Participants benefited from retro‐cues in terms of accuracy and reaction time. Retro‐cues also modulated oscillatory activity in the alpha and gamma frequency bands. We observed greater alpha activity in a ventral visual region ipsilateral to the attended hemifield, thus supporting its suppressive role, i.e. a functional disengagement of task‐irrelevant regions. Accompanying this modulation, we found an increase in gamma activity contralateral to the attended hemifield, which could reflect attentional orienting and selective processing. These findings suggest that the oscillatory mechanisms underlying attentional orienting to representations held in working memory are similar to those engaged when attention is oriented in the perceptual space.