Discussion post - co-sleeping and SIDS

POLICY STATEMENT

SIDS andOther Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment

abstract Despite amajordecrease in the incidenceof sudden infant death syn- drome(SIDS)sincetheAmericanAcademyofPediatrics(AAP)released its recommendation in 1992 that infants be placed for sleep in a non- prone position, this decline has plateaued in recent years. Concur- rently, other causes of sudden unexpected infant death that occur during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death.Many of the modifiableandnonmodifiablerisk factors forSIDSandsuffocationare strikingly similar. The AAP, therefore, is expanding its recommenda- tions from focusing only on SIDS to focusing on a safe sleep environ- ment thatcanreduce theriskofall sleep-related infantdeaths, includ- ing SIDS. The recommendations described in this policy statement include supinepositioning, useof afirmsleep surface, breastfeeding, room-sharing without bed-sharing, routine immunizations, consider- ation of using a pacifier, and avoidance of soft bedding, overheating, andexposureto tobaccosmoke,alcohol,and illicitdrugs. Therationale for these recommendations is discussed in detail in the accompanying “TechnicalReport—SIDSandOtherSleep-RelatedInfantDeaths:Expansion of Recommendations for a Safe Infant Sleeping Environment,” which is included in this issue ofPediatrics (www.pediatrics.org/cgi/content/full/ 128/5/e1341).Pediatrics2011;128:1030–1039

INTRODUCTION Sudden infant death syndrome (SIDS) is a cause assigned to infant deaths that cannot be explained after a thorough case investigation, including a scene investigation, autopsy, and review of the clinical history.1Suddenunexpectedinfantdeath(SUID),alsoknownassudden unexpecteddeathin infancy, isatermusedtodescribeanysuddenand unexpecteddeath,whetherexplainedorunexplained (includingSIDS), that occurs during infancy. After case investigation, SUIDs can be at- tributed to suffocation, asphyxia, entrapment, infection, ingestions, metabolic diseases, arrhythmia-associated cardiac channelopathies, and trauma (accidental or nonaccidental). The distinction between SIDSandotherSUIDs,particularly thosethatoccurduringanobserved or unobserved sleep period (sleep-related infant deaths), such as ac-

TASK FORCEONSUDDEN INFANTDEATHSYNDROME

KEYWORDS SIDS, sudden infant death, infantmortality, sleepposition, bed- sharing, tobacco, pacifier, immunization, bedding, sleep surface

ABBREVIATIONS SIDS—sudden infant death syndrome SUID—suddenunexpected infant death AAP—AmericanAcademyof Pediatrics

This document is copyrighted and is property of the American Academyof Pediatrics and its Board of Directors. All authors have filed conflict of interest statementswith the American Academyof Pediatrics. Any conflicts have been resolved through aprocess approvedby theBoard of Directors. The American Academyof Pediatrics hasneither solicited nor accepted any commercial involvement in the development of the content of this publication.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-2284

doi:10.1542/peds.2011-2284

All policy statements from the American Academyof Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

PEDIATRICS (ISSNNumbers: Print, 0031-4005; Online, 1098-4275).

Copyright©2011by the American Academyof Pediatrics

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

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cidental suffocation, is challenging and cannot be determined by autopsy alone. Scene investigation and review of the clinical history are also re- quired. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. This document focuses on the subset of SUIDs that occurs during sleep.

The recommendations outlinedherein were developed to reduce the risk of SIDSandsleep-relatedsuffocation, as- phyxia,andentrapmentamong infants in the general population. As defined by epidemiologists, risk refers to the probability that anoutcomewill occur given thepresence of a particular fac- tororsetof factors.Althoughall of the 18 recommendations cited below are intended for parents, health care pro- viders, and others who care for in- fants, the last 4 recommendationsare also directed toward health policy

makers, researchers, and profession- als who care for or work on behalf of infants. In addition, because certain behaviors, such as smoking, can in- creaseriskfortheinfant,somerecom- mendations are directed toward women who are pregnant or may be- comepregnant in the near future.

Table 1 summarizes themajor recom- mendations,alongwith thestrengthof each recommendation. It should be notedthat therehavebeennorandom- ized controlled trials with regards to SIDS and other sleep-related deaths; instead, case-control studies are the standard.

Because most of the epidemiologic studies that established the risk fac- torsandonwhich theserecommenda- tionsarebased include infantsup to1 year of age, these recommendations for sleep position and the sleep envi-

ronment should be used consistently for infants up to 1 year of age. Individ- ual medical conditionsmight warrant that a physician recommend other- wise after weighing the relative risks andbenefits.

For the background literature review anddataanalysesonwhich thispolicy statement and recommendations are based, please refer to theaccompany- ing“TechnicalReport—SIDSandOther Sleep-Related InfantDeaths:Expansion of Recommendations for a Safe Infant SleepingEnvironment,”available inthe online version of this issue of Pediatrics.2

RECOMMENDATIONS

1. Back to sleep for every sleep—To reduce the risk of SIDS, infants should be placed for sleep in a supine position (wholly on the back) for every

TABLE1 Summary andStrength of Recommendations

Level A recommendations Back to sleep for every sleep Use afirmsleep surface Room-sharingwithout bed-sharing is recommended Keep soft objects and loosebedding out of the crib Pregnantwomenshould receive regular prenatal care Avoid smoke exposure during pregnancy andafter birth Avoid alcohol and illicit druguseduring pregnancy andafter birth Breastfeeding is recommended Consider offering apacifier at nap timeandbedtime Avoid overheating Donot usehomecardiorespiratorymonitors as a strategy for reducing the risk of SIDS Expand thenational campaign to reduce the risks of SIDS to include amajor focus on the safe sleep environment andways to reduce the risks of all sleep- related infant deaths, includingSIDS, suffocation, andother accidental deaths; pediatricians, family physicians, andother primary care providers should actively participate in this campaign

Level B recommendations Infants should be immunized in accordancewith recommendations of the AAPandCenters for DiseaseControl andPrevention Avoid commercial devicesmarketed to reduce the risk of SIDS Supervised, awake tummy time is recommended to facilitate development and tominimize development of positional plagiocephaly Level C recommendations Health care professionals, staff in newbornnurseries andNICUs, and child care providers should endorse the SIDS risk-reduction recommendations from birth Media andmanufacturers should followsafe-sleep guidelines in theirmessaging andadvertising Continue research and surveillance on the risk factors, causes, andpathophysiologicalmechanismsof SIDS andother sleep-related infant deaths,with the ultimate goal of eliminating thesedeaths entirely

These recommendations are basedon theUSPreventive Services Task Force levels of recommendation (www.uspreventiveservicestaskforce.org/uspstf/grades.htm). Level A: Recommendations are based on good and consistent scientific evidence (ie, there are consistent findings from at least 2 well-designed, well-conducted case-control studies, a systematic review, or ameta-analysis). There is high certainty that the net benefit is substantial, and the conclusion is unlikely to be strongly affectedby the results of future studies. LevelB:Recommendationsarebasedonlimitedor inconsistentscientificevidence.Theavailableevidence issufficient todeterminetheeffectsof therecommendationsonhealthoutcomes, but confidence in the estimate is constrained by such factors as the number, size, or quality of individual studies or inconsistent findings across individual studies. Asmore information becomesavailable, themagnitude or direction of the observed effect could change, and this changemaybe large enough to alter the conclusion. Level C: Recommendations are basedprimarily on consensus andexpert opinion.

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sleep by every caregiver until 1 yearof life.3–7Sidesleepingisnot safe and is not advised.4,6

a. The supine sleep position does not increase the risk of choking and aspiration in in- fants, even thosewithgastro- esophageal reflux, because they have protective airway mechanisms.8,9 Infants with gastroesophageal reflux should be placed for sleep in the supine position for every sleep,with therareexception of infants for whom the risk of death from complica- tionsofgastroesophageal re- flux isgreater thantheriskof SIDS(ie, thosewithupperair- way disorders, for whom air- way protective mechanisms are impaired),10 including in- fantswithanatomicabnormal- ities such as type 3 or 4 laryn- geal clefts who have not undergone antireflux surgery. Elevating the head of the in- fant’s crib while the infant is supine is not recommended.11

It is ineffective inreducinggas- troesophageal reflux; in addi- tion,itmightresultintheinfant sliding to the foot of the crib intoaposition thatmightcom- promiserespiration.

b. Preterm infants are at in- creased risk of SIDS,12,13 and the association between pronesleeppositionandSIDS among low birth weight in- fants is equal to, or perhaps even stronger than, the asso- ciation among those born at term.14 Preterm infants and other infants in the NICU should be placed in the su- pine position for sleep as soon as the infant is medi- cally stable and significantly before the infant’s antici-

pateddischarge,by32weeks’ postmenstrual age.15 NICU personnel should endorse safe-sleeping guidelines with parents of infants from the timeofadmissiontotheNICU.

c. There is no evidence that placing infants on the side during the first few hours of life promotes clearance of amniotic fluid and decreases the risk of aspiration. Infants in the newborn nursery and infants who are rooming in with their parents should be placed in the supine position as soon as they are ready to beplaced in the bassinet.

d. Although data to make spe- cific recommendations as to when it is safe for infants to sleep in theproneor sidepo- sition are lacking, studies that have established prone and side sleeping as risk fac- tors for SIDS include infants upto1yearofage.Therefore, infants should continue to be placed supine until 1 year of age. Once an infant can roll from supine to prone and from prone to supine, the in- fantcanbeallowedtoremain in the sleep position that he or she assumes.

2. Useafirmsleepsurface—Afirm crib mattress, covered by a fit- ted sheet, is the recommended sleeping surface to reduce the risk of SIDS and suffocation.

a. A crib, bassinet, or portable crib/play yard that conforms to thesafety standardsof the Consumer Product Safety Commission and ASTM Inter- national (formerly the Ameri- can Society for Testing and Materials) is recom- mended.16 In addition, par- ents and providers should

check to make sure that the product has not been re- called. Cribs with missing hardwareshouldnotbeused, and the parent or provider should not attempt to fix bro- kencomponentsofacrib, be- causemany deaths are asso- ciated with cribs that are brokenorhavemissingparts (including those that have presumablybeenfixed).Local organizations throughout the UnitedStatescanhelp topro- vide low-cost or free cribs or playyards for familieswithfi- nancial constraints.

b. Onlymattressesdesigned for the specific product should be used. Mattresses should be firm and maintain their shape even when the fitted sheet designated for that model is used, such that there are no gaps between the mattress and the side of the crib, bassinet, portable crib, or play yard. Pillows or cushions should not be used assubstitutes formattresses or in addition to a mattress. Soft materials or objects such as pillows, quilts, com- forters,orsheepskins,even if covered by a sheet, should not be placed under a sleep- ing infant. If amattresscover to protect againstwetness is used, it should be tightly fit- ting and thin.

c. Infants should not be placed for sleep on beds because of the risk of entrapment and suffocation.17,18 In addition, portable bed rails should not be usedwith infants because of the riskof entrapment and strangulation.

d. The infant should sleep in an area free of hazards, such

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as dangling cords, electric wires, and window-covering cords, because they might present a strangulation risk.

e. Sitting devices, such as car safety seats, strollers, swings, infant carriers, and infant slings, are not recom- mended for routine sleep in the hospital or at home.19–23

Infantswhoare younger than 4 months are particularly at risk, because they might as- sume positions that can cre- ate risk of suffocation or air- way obstruction. When infant slings and cloth carriers are used for carrying, it is impor- tant to ensure that the in- fant’s head is up and above the fabric, the face is visible, and that the nose andmouth areclearofobstructions.24Af- ter nursing, the infant should berepositionedintheslingso that thehead isup, is clearof fabric, and is not against the adult’s bodyor thesling. If an infant falls asleep in a sitting device, he or she should be removed from the product andmoved to a crib or other appropriate flat surface as soon as is practical. Car safetyseatsandsimilarprod- ucts are not stable on a crib mattress or other elevated surfaces.25–29

3. Room-sharing without bed- sharing is recommended— There is evidence that this ar- rangementdecreasestheriskof SIDSby asmuchas 50%.5,7,30,31 In addition, this arrangement is most likely to prevent suffoca- tion, strangulation, and entrap- ment thatmight occurwhen the infant issleepinginanadultbed.

a. The infant’s crib, portable crib, play yard, or bassinet

should be placed in the par- ents’ bedroom close to the parents’ bed. This arrange- ment reduces SIDS risk and removesthepossibilityofsuf- focation, strangulation, and entrapment thatmight occur when the infant is sleeping in the adults’ bed. It also allows close parental proximity to theinfantandfacilitatesfeed- ing, comforting, andmonitor- ing of the infant.

b. Devices promoted to make bed-sharing “safe” (eg, in- bed co-sleepers) are not recommended.

c. Infants may be brought into the bed for feeding or com- forting but should be re- turned to their own crib or bassinet when the parent is ready to return to sleep.6,32

Becauseoftheextremelyhigh risk of SIDS and suffocation on couches and arm- chairs,3,5,6,31,32 infants should notbe fedonacouchorarm- chair when there is a high risk that theparentmight fall asleep.

d. Epidemiologic studies have not demonstrated any bed- sharing situations that are protective against SIDS or suffocation.Furthermore,not all risks associatedwith bed- sharing, such as parental fa- tigue, can be controlled. Therefore, the American Academy of Pediatrics (AAP) does not recommend any specific bed-sharing situa- tionsassafe.Moreover, there are specific circumstances that, in epidemiologic stud- ies, substantially increase theriskofSIDSorsuffocation while bed-sharing. In particu- lar, it should be stressed to

parents that they avoid the following situations at all times:

i. Bed-sharingwhen the in- fant is younger than 3 months, regardless of whether the parents are smokers or not.5,7,31–34

ii. Bed-sharingwith a current smoker (even if he or she doesnotsmokeinbed)orif themother smokedduring pregnancy.5,6,34–36

iii. Bed-sharingwithsomeone whoisexcessivelytired.

iv. Bed-sharing with some- one who has or is using medications (eg, certain antidepressants, pain medications) or sub- stances (eg, alcohol, il- licitdrugs) thatcould im- pair his or her alertness or ability to arouse.7,37

v. Bed-sharing with anyone who is not a parent, in- cluding other children.3

vi. Bed-sharing with multi- ple persons.3

vii. Bed-sharing on a soft surface such as awater- bed, old mattress, sofa, couch,orarmchair.3,5,6,31,32

viii. Bed-sharing on a surface withsoftbedding, including pillows, heavy blankets, quilts,andcomforters.3,38

e. It is prudent to provide sepa- ratesleepareasandavoidco- bedding for twinsandhigher- order multiples in the hospital andat home.39

4. Keep soft objects and loosebed- dingoutof thecrib toreducethe risk of SIDS, suffocation, entrap- ment, and strangulation.

a. Softobjects,suchaspillowsand pillow-like toys, quilts, comfort-

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ers, and sheepskins, should be kept out of an infant’s sleeping environment.40–45

b. Loose bedding, such as blan- kets and sheets, might be hazardous and should not be used in the infant’s sleeping environment.3,6,46–51

c. Because there is no evidence that bumper pads or similar products that attach to crib slats or sides prevent injury in young infants andbecause there is the potential for suf- focation, entrapment, and strangulation, theseproducts are not recommended.52,53

d. Infant sleep clothing that is designed to keep the infant warm without the possible hazard of head covering or entrapment canbeused.

5. Pregnantwomenshould receive regularprenatal care—There is substantial epidemiologic evi- dence linking a lower risk of SIDS for infants whosemothers obtainregularprenatalcare.54–57

6. Avoid smoke exposure during pregnancy and after birth— Both maternal smoking during pregnancy and smoke in the in- fant’s environment after birth aremajor risk factors for SIDS.

a. Mothers should not smoke duringpregnancyorafter the infant’s birth.1,58–61

b. There should be no smoking near pregnant women or in- fants. Encourage families to set strict rules for smoke- free homes and cars and to eliminate secondhand to- bacco smoke from all places in which children and other nonsmokers spend time.62,63

c. TheriskofSIDSisparticularly high when the infant bed-

shares with an adult smoker.5,6,34–36

7. Avoidalcoholand illicit druguse during pregnancy and after birth—There is an increased risk of SIDS with prenatal and postnatal exposure toalcoholor illicit druguse.

a. Mothers should avoid alco- hol and illicit drugspericon- ceptionally and during pregnancy.64–70

b. Parental alcohol and/or illicit druguse in combinationwith bed-sharingplaces the infant at particularly high risk of SIDS.7,37

8. Breastfeeding is recommended.

a. Breastfeeding is associated with a reduced risk of SIDS.71–73 If possible, mothers shouldexclusivelybreastfeed or feed with expressed hu- man milk (ie, not offer any formulaorothernon–human milk–based supplements) for 6 months, in alignment with recommendationsof the AAP.74

b. The protective effect of breastfeeding increaseswith exclusivity.73 However, any breastfeeding has been shown to bemore protective against SIDS than no breastfeeding.73

9. Consider offering a pacifier at nap time and bedtime— Although the mechanism is yet unclear, studieshavereporteda protective effect of pacifiers on the incidence of SIDS.3,7,32

The protective effect persists throughout the sleep period, even if the pacifier falls out of the infant’smouth.

a. The pacifier should be used when placing the infant for sleep. It does not need to be

reinserted once the infant falls asleep. If the infant re- fuses the pacifier, he or she should not be forced to take it. In thosecases,parentscan try to offer the pacifier again when the infant is a little older.

b. Because of the risk of stran- gulation, pacifiers should not be hung around the infant’s neck. Pacifiers that attach to infant clothing should not be usedwith sleeping infants.

c. Objects such as stuffed toys, whichmight present a suffo- cationorchokingrisk, should not be attached to pacifiers.

d. For breastfed infants, delay pacifier introduction until breastfeeding has been firmly established,74 usually by 3 to 4weeks of age.

e. There is insufficient evidence that finger-sucking is protec- tive against SIDS.

10. Avoid overheating—Although studies have revealed an in- creased risk of SIDS with over- heating,75–78 the definition of overheating in these studies varied. Therefore, it is difficult to provide specific room- temperature guidelines for avoiding overheating.

a. In general, infants should be dressedappropriately for the environment, with no more than 1 layer more than an adult would wear to be com- fortable in that environment.

b. Parents and caregivers shouldevaluate the infant for signs of overheating, such as sweatingor the infant’schest feeling hot to the touch.

c. Overbundling and covering of the face and head should be avoided.79

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d. There iscurrently insufficient evidence to recommend the use of a fan as a SIDS risk- reduction strategy.

11. Infantsshouldbeimmunizedinac- cordance with recommendations of theAAPandtheCenters forDis- ease Control and Prevention— Thereisnoevidencethat there is a causal relationship between immunizations and SIDS.80 In- deed, recent evidence suggests that immunization might have a protective effect against SIDS.81–83 Infants should also be seen for regular well-child checks in accordance with AAP recommendations.

12. Avoid commercial devices mar- keted to reduce the risk of SIDS—These devices include wedges, positioners, special mattresses, and special sleep surfaces. There is no evidence that these devices reduce the risk of SIDS or suffocation or that they are safe.

a. The AAP concurs with the US Food and Drug Administra- tion and Consumer Product Safety Commission thatman- ufacturers should not claim thataproductordevicepro- tects against SIDS unless there is scientific evidence to that effect.

13. Donotusehomecardiorespira- tory monitors as a strategy to reduce the risk of SIDS— Although cardiorespiratory monitors can be used at home to detect apnea, bradycardia, and, when pulse oximetry is used, decreases in oxyhemo- globin saturation, there is no evidence that use of such de- vices decreases the incidence of SIDS.84–87 They might be of value for selected infants but should not be used routinely.

There is also no evidence that routine in-hospital cardiorespi- ratory monitoring before dis- charge from the hospital can identifynewborn infantsatrisk of SIDS.

14. Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly.

a. Although therearenodata to make specific recommenda- tionsastohowoftenandhow long it shouldbeundertaken, supervised, awake tummy time is recommended on a daily basis, beginning as early as possible, to promote motordevelopment, facilitate development of the upper body muscles, and minimize the risk of positional plagiocephaly.88

b. Diagnosis, management, and other prevention strategies for positional plagiocephaly, such as avoidance of exces- sive time in car safety seats andchanging the infant’s ori- entation in the crib, are dis- cussed in detail in the recent AAP clinical report on posi- tional skull deformities.88

15. Health care professionals, staff in newborn nurseries and neo- natal intensive care nurseries, andchildcareprovidersshoulden- dorse the SIDS risk-reduction rec- ommendationsfrombirth.89–91

a. Staff in NICUs should model and implement all SIDS risk- reduction recommendations as soon as the infant is clini- cally stable and significantly beforeanticipateddischarge.

b. Staff in newborn nurseries shouldmodel and implement these recommendations be-

ginning at birth and well be- fore anticipateddischarge.

c. All physicians, nurses, and other health care profession- als should receive education on safe infant sleep.

d. All child care providers should receive education on safe infant sleep and imple- ment safe sleep practices. It is preferable that they have written policies.

16. Media and manufacturers should follow safe-sleep guide- lines in their messaging and advertising.

Media exposures (including movie, television, magazines, newspapers, and Web sites), manufacturer advertisements, andstoredisplaysaffect individ- ual behavior by influencing be- liefsandattitudes.89,91Mediaand advertising messages contrary to safe-sleep recommendations might create misinformation about safe sleeppractices.92

17. Expand thenationalcampaign to reduce the risks of SIDS to in- clude amajor focus on the safe sleep environment and ways to reduce the risks of all sleep- related infant deaths, including SIDS,suffocation,andotheracci- dental deaths. Pediatricians, family physicians, and other primary care providers should actively participate in this campaign.

a. Public education should con- tinue for all who care for in- fants, including parents, child care providers, grandparents, foster parents, and baby- sitters, and should include strategies forovercomingbar- riers tobehaviorchange.

b. The campaign should con- tinue to have a special focus

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ontheblackandAmerican In- dian/Alaskan Native popula- tions because of the higher incidence of SIDS and other sleep-related infantdeaths in these groups.

c. The campaign should specifi- cally includestrategies for in- creasing breastfeedingwhile decreasing bed-sharing and eliminating tobacco smoke exposure.

d. Theserecommendationsshould be introduced before preg- nancy and ideally in second- ary school curricula for both boys and girls. The im- portance of maternal pre- conceptional health and avoidance of substance use (including alcohol and smoking) should be in- cluded in this training.

e. Safe-sleep messages should be reviewed, revised, and re- issued at least every 5 years to address the next genera- tionofnewparentsandprod- ucts on themarket.

18. Continue research and surveil- lanceontheriskfactors,causes, and pathophysiological mecha- nisms of SIDS and other sleep- relatedinfantdeaths,withtheul-

timate goal of eliminating these deaths entirely.

a. Educationcampaignsneed to be evaluated, and innovative interventionmethodsneed to be encouragedand funded.

b. Continued research and im- proved surveillance on the etiology andpathophysiologi- cal basis of SIDS should be funded.

c. Standardized protocols for death-scene investigations should continue to be imple- mented. Comprehensive au- topsies that include fullexter- nal and internal examination of all major organs and tis- sues (including the brain), complete radiographs, meta- bolic testing, and toxicology screening should be per- formed. Training about how to conduct comprehensive death-scene investigation of- fered to medical examiners, coroners, death-scene inves- tigators, first responders, and law enforcement should continue, and resources for maintaining trainingandcon- duct of these investigations need to be allocated. In addi- tion,childdeathreviews,with involvement of pediatricians

and other primary care pro- viders, should be supported and funded.

d. Improved and widespread surveillanceof SIDSandSUID cases should be imple- mented and funded.

e. Federal and private funding agenciesshould remaincom- mitted to all aspects of the aforementioned research.

LEADAUTHOR RachelY.Moon,MD

TASK FORCEONSUDDEN INFANT DEATHSYNDROME, 2010–2011 Rachel Y.Moon,MD, Chairperson Robert A. Darnall,MD Michael H. Goodstein,MD FernR. Hauck,MD,MS

CONSULTANTS MarianWillinger, PhD–Eunice Kennedy Shriver National Institute for Child Health andHumanDevelopment Carrie K. Shapiro-Mendoza, PhD,MPH– Centers for DiseaseControl andPrevention

STAFF JamesCouto,MA

ACKNOWLEDGMENTS The task force acknowledges the con- tributions provided by others to the collection and interpretation of data examinedinpreparationofthisreport. The task force is particularly grateful for the report submitted by Dr Suad Wanna-Nakamura (Consumer Product Safety Commission).

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