Introduction

The impact on sudden infant death rates of the “Back to Sleep” or “Reduce the Risk” campaigns introduced across many countries in the late 1980s and early 1990s has been hailed as one of the great public health success stories of the 20th century (1, 2). Many countries around the world saw substantial reductions in their sudden infant death syndrome (SIDS) rates around the time of introduction of the campaigns (Figure 12.1), with falls of between 42% and 92% (Figure 12.2). The rate of SIDS was halved in the United Kingdom (UK) in just one year, and in New Zealand in two years (1, 3). Instituting a “Back to Sleep” campaign has been estimated to have saved 3,000 lives in New Zealand, 17,000 lives in the UK, and 40,000 lives in the United States (3).

Since the initial drop-off immediately after the “Back to Sleep” campaigns, the rate of SIDS has continued to decline in line with overall post-neonatal mortality (4). For example, in England and Wales, SIDS rates fell from an average of 2.27 per 1,000 live births in 1986-88 to 0.66 per 1,000 live births in 1993-95 and 0.32 per 1,000 live births in 2012-14 (5). These reductions have been accompanied by a shift in the demographics of SIDS cases, such that most cases now occur in high-risk families with multiple recognized risk factors (6). As a result, SIDS rates are much higher in families from deprived socioeconomic backgrounds and particular population groups, such as the Māori population in New Zealand (7) or the Indigenous and black populations in the United States (8). While these campaigns appear to have effectively reached some segments of our population and resulted in behavioral change, this is not universal.

In order to better understand how we can reach those higher-risk groups and achieve further reductions in SIDS rates, we need a better understanding of the nature and impact of preventive strategies. In this chapter we will outline the principles of public health approaches to prevention and the evidence base for different strategies; in light of this, we will consider the evidence for current approaches to further reduce the risk of SIDS.