National Patterns of SIDS Mortality: A CDC WONDER Population Analysis of Demographic and Geographic Disparities From 1999-2023

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Although the exact causes of SIDS have yet to be discovered, there are hypothesized contributors including maternal smoking, prematurity, and socioeconomic status. This study aims to identify the greatest changes in SIDS mortality rates using temporal trends. Understanding how demographic and geographic variables influence SIDS mortality is essential for identifying at-risk populations and developing targeted public health interventions aimed at education and prevention of infant deaths. Body: This is a retrospective analysis of the CDC WONDER Database from 1999–2023. Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify SIDS-related deaths occurring within the U.S.. Records for infants aged < 1 year old were identified using ICD-10 code R95 for sudden infant death syndrome. Data was analyzed using the Joinpoint Regression Program to estimate annual percentage change (APC) and average annual percent change (AAPC) with 95% confidence intervals (CI) for each demographic group. From 1999 to 2023, there were 48,244 deaths due to SIDS in the U.S. Overall, mortality decreased during this period from 70.79 in 1999 to 40.81 in 2023, with an AAPC of − 2.08%*. The Black community experienced the highest SIDS mortality rates throughout the study period, with a crude mortality rate of 147 in 1999, then decreasing to 101.76 in 2023. Geographic analysis demonstrates that all census regions demonstrated a decline in mortality over the study period. The Midwest region had the greatest decline in crude mortality rates. SIDS mortality rates were higher across rural areas. Conclusion: SIDS mortality in the U.S. has declined overall from 1999–2019 with a recent rise from 2019 to 2023. Despite these gains, substantial racial and geographic disparities persist, with Black infants and rural communities experiencing disproportionately higher mortality rates. The recent and sustained increases in mortality, however, temporally align with the ongoing residual effects of the COVID-19 pandemic. Sudden infant death syndrome health disparity neonatology rural urban regional Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Sudden infant death syndrome (SIDS) is a major contributor to infant mortality in the United States. Despite public health efforts to reduce SIDS, nearly 50,000 deaths have occurred since 1999. SIDS is defined as “infant deaths that cannot be explained after a thorough case investigation, including a death scene investigation, autopsy, and review of the clinical history” [ 1 ]. Government sponsored interventions such as “Back to Sleep,” initiated in 1994 and later renamed to “Safe to Sleep” in 2012, facilitated a significant reduction in SIDS deaths [ 2 ]. Despite this reduction, there has been an increase in infant mortality related to SIDS since 2019 within certain demographic groups, highlighting the persistent role of disparities in infant health. Although the exact etiology of SIDS remains unknown, there are hypothesized contributors such as maternal smoking, prematurity, and socioeconomic status [ 3 , 4 ]. While impacts of early government campaigns are well established, fewer studies have examined how SIDS mortality trends have evolved in the decades following widespread campaign implementation. Additionally, previous analyses are often focused on limited time frames or demographic variables, leaving gaps in understanding and opportunities to reduce risk. To date, literature for a comprehensive national analysis of SIDS mortality including demographic and geographic variables, is lacking. To address these gaps, this study provides longitudinal evaluation of SIDS mortality from 1999 to 2023 using the CDC WONDER database. Knowledge on which populations experience higher infant SIDS-related mortality rates enables proper assessment and implementation of prevention-focused initiatives for those most in need. These findings provide insight on the success of public health interventions, inform future targeted interventions, and reduce inequities in SIDS-related mortality within the U.S. Methods The Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify SIDS-related deaths occurring within the United States [ 5 ]. This public database contains standardized death-coding and enables reproducible population-level analysis across time and geography. Stratification by race, sex, region, urban/rural, and state-level patterns allows identification of populations and geographical regions that are most vulnerable to observed gaps in healthcare. The Multiple Cause-of-Death Public Use Record from the CDC WONDER database was queried to identify deaths among infants < 1 year of age in which sudden infant death syndrome was listed as a cause of death on nationwide death certificate records. This database has been previously used in several other studies to analyze nationwide trends in mortality of infants along with social determinants of health [ 6 , 7 ]. However, prior studies have often been limited by assessing select demographic factors separately, leaving a gap in understanding how SIDS-related mortality patterns compare across multiple populations in the contemporary period. Our study addresses this gap by analyzing several demographic groups within the same national analysis using recent post-pandemic data [ 7 ]. SIDS-related mortality was identified using the International Classification of Diseases, 10th Revision (ICD-10), Clinical Modification code R95 in patients under one year of age. The study was exempt from institutional review board approval because the CDC WONDER database contains de-identified, publicly available data. Demographic data were analyzed, including sex, race/ethnicity, age, urban-rural classification, and census region. State level data was excluded due to unreliable data as reported on the CDC WONDER database. Unreliable data, according to the CDC WONDER database, is defined as fewer than 20 deaths reported [ 8 ]. Race and ethnicity groups were categorized as non-Hispanic (NH) White, NH Black, NH American Indian/Alaskan Native, NH Asian/Pacific Islander, and Hispanic people as identified on death certificates. The age group for this study was less than one year of age. For urban-rural classifications, the National Center for Health Statistics Urban-Rural Classification Scheme was used to divide the population into urban (population > 50,000) and rural (population < 50,000) [ 9 ]. Regions were classified into Northeast, Midwest, South, and West according to the Census Bureau definitions [ 10 ]. Location of death included medical facilities (outpatient, emergency room, inpatient, death on arrival, or status unknown), home, hospice, and nursing home/long-term care. SIDS-related crude mortality rates (CMR) were calculated. AAMRs were not calculated because all cases occurred in infants less than one year of age [ 11 ]. Temporal trends in mortality were analyzed using the Joinpoint Regression Program (Version 5.4.0, National Cancer Institute, Bethesda, Maryland) [ 12 ]. Joinpoint regression identifies points where statistically significant changes in trend occur and estimates the annual percentage change (APC) for each segment of time. Annual percentage change (APC) and average annual percent change (AAPC) with 95% confidence intervals (CIs) were calculated for each Joinpoint-defined time segment using the Monte Carlo permutation test. The model selected the optimal number of Joinpoints based on permutation testing, allowing identification of statistically significant changes in mortality trends over time. APC and AAPC were considered increasing or decreasing if the slope describing the change in mortality over the time interval differed significantly from zero using a two-tailed t-test. Statistical significance was set at p ≤ 0.05. Statistically significant trends are denoted by an asterisks (*). Results Overall From 1999 to 2023, there were 48,244 deaths due to SIDS in the U.S. Overall mortality rates (per 100,000 live births) declined during this period, decreasing from 70.79 in 1999 to 40.81 in 2023, with an AAPC of -2.08%* (95% CI, − 2.55 to − 1.62) (Fig. 1 , Supplemental Table 1). Between 1999 and 2001, mortality rates declined, with an APC of -10.76%* (95% CI, -14.27 to -3.68). From 2001 to 2009, there was no significant change in mortality rates. However, during the years 2009 to 2013, the mortality rates declined with an APC of − 8.57%* (95% CI, − 11.93 to − 0.77). From 2013 to 2019, mortality rates demonstrated no significant decrease. However, from 2019 to 2023, SIDS mortality rates increased with an APC of 5.45%* (95% CI, 1.37 to 13.11) (Supplemental Fig. 1). Sex Stratified: From 1999 to 2023, SIDS caused 28,259 deaths (59%) in males and 19,985 deaths (41%) in females in the U.S. (Fig. 1 ). Among males, the mortality rate declined from 80.88 in 1999 to 46.02 in 2023, with an AAPC of − 2.14%* (95% CI, − 2.56 to − 1.65) (Supplemental Table 1). Male mortality rates declined from 1999 to 2001 with an APC of -10.00%* (95% CI, -14.10 to -3.12), followed by no significant change from 2001 to 2008. A further decline occurred from 2008 to 2015 with an APC of − 5.59%* (95% CI, − 7.31 to − 4.50). From 2018 to 2023, male SIDS mortality rates increased, with an APC of 5.64%* (95% CI, 2.57 to 10.54) (Supplemental Fig. 1). Among females, SIDS mortality rates declined from 60.2 in 1999 to 35.37 in 2023, with an overall AAPC of − 2.27%* (95% CI, − 2.66 to − 1.77) (Supplemental Table 1). Mortality rates declined from 1999 to 2001 with an APC of -11.92%* (95% CI, − 16.03 to -4.44), followed by a period of no significant change from 2001 to 2009. Mortality rates from 2009 to 2014 declined again by -4.30%* (95% CI, − 13.47 to -5.75), after which no significant change was observed from 2014 to 2023 (Supplemental Fig. 1). Race Stratified: Black or African American infants experienced the highest SIDS mortality rates throughout the study period (Fig. 2 ). In 1999, the rate was 147.0 and then decreased to 101.76 in 2023 (Supplemental Table 2). From 1999 to 2023, the AAPC in SIDS mortality was − 1.09%* (95% CI, -1.64 to -0.45). Joinpoint analysis demonstrated no significant change in mortality rates from 1999 to 2014. From 2014 to 2023, SIDS mortality rates increased, with an APC of 4.22%* (95% CI, 1.75 to 8.86) (Supplemental Fig. 2). Among the White population, SIDS mortality rates declined from 62.41 in 1999 to 32.53 in 2023 (Supplemental Table 2). The AAPC from 1999 to 2023 was − 2.42%* (95% CI, -2.91 to -2.02). Mortality rates declined from 1999 to 2003, with an APC of -4.88%* (95% CI, -9.24 to -2.57), followed by an increase from 2003 to 2007, with an APC of 4.56%* (95% CI, 1.48 to 8.36). Rates then declined from 2007 to 2019 with an APC of − 5.93%* (95% CI, − 6.96 to − 5.23), with no significant change observed from 2019 to 2023 (Supplemental Fig. 2). Among the American Indian or Alaska Native population, SIDS mortality rates declined from 124.14 in 1999 to 103.95 in 2023 (Supplemental Table 2). From 1999 to 2023, the AAPC was − 1.15%* (95% CI, -2.37 to -0.57). No Joinpoints were identified for this population, and the APC reflected the overall AAPC across the study period. (Supplemental Fig. 2). The Asian American/Pacific Islander population experienced a decline in SIDS mortality rates from 32.66 in 1999 to 14.42 in 2023 (Supplemental Table 2). From 1999 to 2023, the AAPC was − 3.69%* (95% CI, -4.70 to -1.88). Mortality rates declined from 1999 to 2001 with an APC of -20.81%* (95% CI, − 30.07 to -2.28), followed by a period of no significant change from 2001 to 2023 (Supplemental Fig. 2). Among the Hispanic population, SIDS mortality rates declined from 41.81 in 1999 to 25.8 in 2023 (Supplemental Table 2). The AAPC from 1999 to 2023 was − 1.81%* (95% CI, -2.42 to -0.92). Mortality rates declined from 1999 to 2001, with an APC of -14.86%* (95% CI, − 21.01 to -2.17), followed by no significant change from 2001 to 2009. From 2009 to 2016, SIDS mortality rates declined with an APC of -7.24%* (95% CI, -15.42 to -2.86). Then from 2016 to 2023, there was an increase to an APC of 5.97%* (95% CI, 2.57 to 12.44) (Supplemental Fig. 2). Regional Variation: All U.S. census regions experienced declines in SIDS mortality rates over time, with the Midwest demonstrating the greatest reduction from 82.34 in 1999 to 37.01 in 2023 (Fig. 3 ). The overall AAPC for the Midwest was − 3.05%* (95% CI, − 4.01 to − 2.45). The steepest decline occurred between 1999 and 2019, with an APC of − 4.33%* (95% CI, − 6.20 to − 3.79), followed by a period of no significant change from 2019 to 2023 (Supplemental Fig. 3). The South exhibited the smallest overall decline with an AAPC of − 1.30%* (95% CI, − 1.88 to − 0.71). Mortality rates demonstrated no significant change from 1999 to 2007, followed by a decline from 2007 to 2018 with an APC of -4.70%* (95% CI, -9.46 to -3.60). From 2018 to 2023, mortality rates in the South increased, with an APC of 4.66% ( 95% CI, 0.37 to 13.78). In the West, SIDS mortality rates declined overall from 1999 to 2023, with an AAPC of -2.84%* (95% CI, − 3.47 to -2.17) (Supplemental Fig. 3). Mortality rates declined from 1999 to 2001 with an APC of -19.10%* (95% CI, -24.77 to -9.93), followed by a period of no significant change from 2001 to 2009. From 2009 to 2017, mortality rates again declined with an APC of -7.39%* (95% CI, -12.41 to -5.50). Then from 2017 to 2023, there was an increase in APC of 4.04%* (95% CI, 0.61 to 10.19). In the Northeast, the mortality rates declined overall from 1999 to 2023 with an AAPC of -1.33%* (95% CI, -2.11 to -0.56). Mortality rates declined from 1999 to 2004 with an APC of -9.50%* (95% CI, -20.56 to -5.04), followed by an increase from 2004 to 2008 with an APC of 11.08% (95% CI, 3.83 to 22.14). From 2008 to 2014, mortality again declined with an APC of -10.93%* (95% CI, -21.56 to -6.85). Then from 2014 to 2023, there was an increase to an APC of 5.14%* (95% CI, 2.37 to 10.60). Full-range AAPCs were statistically significant in all regions from 1999–2023. Urban vs Rural: When comparing urban and rural regions, SIDS mortality rates were consistently higher in rural areas (Fig. 4 ). Rural zones experienced a gradual decrease from 94.01 in 1999 to 51.89 in 2020, with a consistent AAPC of -3.34%* (95% CI, -4.61 to -2.29) (Supplemental Fig. 4). Rural zones experienced no significant changes from 1999 to 2009. From 2009 to 2020, there was an APC decrease of -5.22%* (95% CI, -12.24 to -3.70). In urban zones, mortality rates decreased from 66.86 in 1999 to 35.82 in 2020, with an AAPC of − 3.33%* (95% CI, − 3.67 to − 2.94) (Supplemental Table 4). Rates in these areas decreased between 1999 and 2001 with an APC − 12.00%* (95% CI, − 14.94 to -6.80) with no significant change from 2001 to 2009. From 2009 to 2013, there was a decrease of −9.07%* (95% CI, − 12.16 to − 6.40) (Supplemental Fig. 4). From 2013 to 2020, no significant change was observed. Discussion Overall Trends The overall decline in SIDS mortality from 1999 to 2019 is temporally associated with the long-term impacts of national safe sleep initiatives, including the “Back to Sleep” and later “Safe to Sleep” campaigns, which emphasized supine sleep positioning and safer sleep environments [ 13 ]. These interventions have greatly reduced the SIDS burden across the country as a result of increased parental education and effective strategies that limit infant exposure to toxins associated with increased infant mortality risk. These include increased education about prenatal and postnatal exposure to tobacco products such as cigarette smoke and parental drug use [ 14 , 15 ]. Interestingly, prior studies have demonstrated that maternal recreational marijuana use is not associated with increased SIDS rates in children, but paternal use is associated with increased risks [ 16 ]. Increased ambient temperature has also been shown to increase SIDs mortality with more deaths occurring during summer months in hot and humid areas [ 17 ]. The decrease in SIDS mortality from 1999–2001 may reflect the non-standardized definitions of the time, leading to inconsistent classification of infant deaths. A standardized definition of SIDS was established in 2004 as “the sudden unexpected death of an infant < 1 year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including performance of a complete autopsy and review of the circumstances of death and the clinical history,” allowing a more accurate classification of unexplained infant death in the pediatric field [ 18 , 19 ]. The sharp nationwide decrease beginning in 2008 may be the culmination of decades of public interventions, more defined diagnostic criteria, and targeted outreach to bridge gaps in vulnerable or at-risk communities. Although nationwide numbers decreased overall, the marginalized communities continue to experience higher SIDS rates than White populations. Alarmingly, since 2019 SIDS rates have increased, this could be due to lasting effects of COVID-19 and recent reductions in public health spending [ 20 ]. This study helps fill existing gaps in understanding racial, regional, and urban-rural disparities over this time frame in the context of government interventions and public health outreach. Sex-Stratified Trends Males continue to make up the majority of SIDS deaths in America, aligning with prior studies demonstrating male sex as a risk factor for SIDS [ 21 , 22 ]. No definite cause for this disparity has been well established, but hypothesized to be multifactorial [ 23 ]. Male mortality declined sharply beginning in 2008, although no specific explanation for this change could be identified as female mortality also significantly declined during this period. Female mortality rates also decreased in 2008, mirroring the trend observed among males throughout the study period. This suggests that although females generally face a lower overall risk, they may derive less benefit from recent interventions designed to reduce mortality among the highest-risk cases [ 24 ]. Since neonatal intensive care unit (NICU) stays are associated with worse outcomes and the majority of NICU patients are male, this pattern may contribute to the higher mortality rate observed among male infants [ 23 , 25 ]. These findings highlight the importance of incorporating sex-based biological and behavioral factors into future SIDS prevention research and messaging. This area presents opportunities for further research on physiologic differences in male and female infants that may account for differences in infant resilience. Race and Ethnicity Tragically in the U.S., racial and ethnic minority status is frequently associated with worse health outcomes, and this holds true for the neonatal population as well, likely due to social injustices and systemic barriers preventing access to care in marginalized communities [ 26 ]. These barriers to care are associated with increased rates of preventable and chronic diseases in the adult community, but also contribute to higher neonatal mortality due to lack of prenatal care or follow-up [ 27 ]. Prior work demonstrated that barriers to care have actually increased across all age groups, with increased disparities in marginalized groups; an alarming finding given the amount of public health spending in the past and recent spending cuts [ 28 , 29 ]. The persistently elevated SIDS mortality rates among Black/African American infants compared to White infants, points to the persistence of structural and social inequities, including lack of access to prenatal care, safe sleep resources, and culturally tailored health education. In the African-American community, mortality peaks during summer months and may reflect lack of access to resources such as air conditioning or green space leading to increased temperature fluctuations [ 30 ]. Significant declines were observed in Black/African American communities after 2006, coinciding with multiple public health outreach projects in states such as Mississippi with a large African American population. In 2006, the Mississippi African American SIDS Outreach project worked with local churches and communities to educate on risk reduction which coincided with a decline in SIDS mortality [ 31 ]. The modest declines in Native American/Indigenous populations were complicated by small sample sizes leading to unreliable data, however, the “Healthy Native Babies Project;” a culturally tailored safe sleep education resources, were promoted starting in 2005 with varied success evidenced by fluctuating yearly SIDS rates in the Native American community [ 31 ]. Regional Variation The steep decline in SIDS mortality observed in the Midwest region may reflect differences in culturally specific interventions built to incorporate education into messaging for the African-American and Indigenous community due to different cultural practices [ 32 ]. These findings suggest that increased healthcare access and public health funding may be major drivers to decrease SIDS rates. The West region also experienced consistent decline from 1999–2001, likely consistent with public health interventions; however, the lack of change from 2001–2009 could not be explained. In 2016, the American Academy of Pediatrics updated their SIDS prevention recommendations which may have played a role in decreasing SIDS rates until the COVID-19 pandemic, potentially reflecting higher health literacy in western states, a result of higher standards of living and incomes [ 32 ]. The Southern region of the U.S. experienced the slowest decline. As the South already has well known disparities and worse outcomes, improvement may occur slower in these regions, yet progress since 2018 is encouraging [ 33 ]. This lag could also be explained by a higher Black/African American population in the South which are a historically oppressed group with decreased access to healthcare resources and medical distrust due to mistreatment and past experimentation without their consent [ 34 ]. These regional pattern differences suggest the need for geographically and culturally tailored messaging due to the different populations and resources available in each U.S. region. Despite having among the highest per capita health spending, the Northeast saw the second lowest overall decline [ 35 ]. In the Northeast, the mortality rates declined overall from 1999 to 2019 but a recent uptick in 2019 coincided with other regions due to COVID-19 [ 20 ]. Urban vs. Rural Differences Consistent with patterns seen across many major health outcomes, SIDS mortality rates remain higher in rural areas than in urban areas, reflecting the broader trend of urban populations experiencing generally better health outcomes [ 36 ]. Parental smoking, including secondhand exposure to cigarette smoke, is a well established risk factor. Increased smoking rates in more rural areas and the accompanying second-hand smoke exposure may contribute to higher SIDS mortality rates in rural zones compared with urban settings [ 37 , 38 ]. Substance abuse is also a well established risk factor, including the use of alcohol, drugs, and opiates [ 39 , 40 ]. The gradual, yet steady decline in rural areas may indicate limited reach of public health messaging, reduced access to healthcare resources, and worse educational outcomes [ 41 ]. Recently, telehealth initiatives have shown promise to improve health outcomes in rural communities that may have traditionally been limited by resources and provider availability in regard to smoking cessation resources [ 42 ]. Addressing rural-urban disparities will likely require further education and intervention, such as increasing telehealth availability, community-based outreach, and ensuring a safe home and sleeping environment. Conclusion This study revealed a sustained decrease in SIDS mortality from 1999–2019, coinciding with the widespread implementation of Safe Sleep Campaigns and other targeted public health interventions. However, based on current data and the timing of increasing SIDS mortality rates following the COVID-19 pandemic, we observe that this increase in SIDS mortality may be partly related to setbacks in prior gains due to health impacts of the pandemic. Despite substantial gains overall, SIDS rates of historically marginalized communities remain substantially higher than those among the White population and more research is needed on social determinants of health to close these gaps and achieve more equitable healthcare for all. The large difference in regional data suggest that different healthcare access, public health investment, and per-capita spending may influence reductions in SIDS mortality, with many states and regions with fewer resources lagging behind. Continued progress will require sustained public health funding, particularly as many programs face reductions in resources, and further exploration into physiologic mechanisms behind decreased physiological resilience of male infants. These findings emphasize the need for coordinated national and community-level strategies to ensure that future reductions in SIDS mortality are both sustained and equally distributed. Limitations: The CDC WONDER database has several limitations that should be considered. As with any database study, reporting errors are possible, including misclassification within categories such as cause of death (death certificates), race, and residential location. Moreover, cross-stratified analysis between demographic variables was not performed. In addition, the CDC WONDER database does not allow detailed analysis of individual-level demographic disparities, and this study could not account for income level, education, or health insurance coverage, all of which are known social determinants of health. Further, due to minimal state specific data, analysis between states was not completed. Additionally, observational analyses of national mortality databases cannot establish causal relationships between observed trends and potential contributing factors. These limitations highlight important opportunities for future research. Declarations The authors declare no competing interests. Ethics approval and consent to participate: The study was exempt from institutional review board (IRB) approval because the CDC WONDER database contains de-identified, publicly available data. Consent for publication: Not applicable. Availability of data and materials: Data can be found at http://wonder.cdc.gov. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare no competing interests. Funding: The authors have not received any outside funding. Authors' contributions: GG and LS helped with study design, data collection, data interpretation, and writing the manuscript. LP and VM aided in data collection, statistics, data interpretation, and manuscript writing. AT aided in project design, writing, and editing. All authors contributed to the final draft and approved it. Acknowledgements: We would like to thank the Creighton University School of Medicine Department of Internal Medicine for their support. Authors' information: see affiliations above References Rachel Y, Moon, Rebecca F, Carlin, Ivan Hand, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN; Sleep-Related Infant Deaths. 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Mitchell EA, Stewart AW. Gender and the sudden infant death syndrome. New Zealand Cot Death Study Group. Acta Paediatr. 1997;86(8):854-6. 10.1111/j.1651-2227.1997.tb08611.x . PMID: 9307167. Wong C, Schreiber V, Crawford K, Kumar S. Male infants are at higher risk of neonatal mortality and severe morbidity. Aust N Z J Obstet Gynaecol. 2023;63(4):550–5. 10.1111/ajo.13689 . Epub 2023 May 4. PMID: 37143308. Subedi D, DeBoer MD, Scharf RJ. Developmental trajectories in children with prolonged NICU stays. Arch Dis Child. 2017;102(1):29–34. 10.1136/archdischild-2016-310777 . Epub 2016 Sep 16. PMID: 27637907. Migliori C, Braga M, Siragusa V, Villa MC, Luzi L. The impact of gender medicine on neonatology: the disadvantage of being male: a narrative review. Ital J Pediatr. 2023;49(1):65. 10.1186/s13052-023-01447-2 . PMID: 37280693; PMCID: PMC10245647. Braun D, Braun E, Chiu V, Burgos AE, Gupta M, Volodarskiy M, Getahun D. Trends in Neonatal Intensive Care Unit Utilization in a Large Integrated Health Care System. JAMA Netw Open. 2020;3(6):e205239. 10.1001/jamanetworkopen.2020.5239 . PMID: 32556257; PMCID: PMC7303809. Ramsoondar N, Anawati A, Cameron E. Racism as a determinant of health and health care: Rapid evidence narrative from the SAFE for Health Institutions project. Can Fam Physician. 2023;69(9):594–8. 10.46747/cfp.6909594 . PMID: 37704247; PMCID: PMC10498908. Macias-Konstantopoulos WL, Collins KA, Diaz R, Duber HC, Edwards CD, Hsu AP, Ranney ML, Riviello RJ, Wettstein ZS, Sachs CJ. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. West J Emerg Med. 2023;24(5):906–18. 10.5811/westjem.58408 . PMID: 37788031; PMCID: PMC10527840. Caraballo C, Ndumele CD, Roy B, et al. Trends in Racial and Ethnic Disparities in Barriers to Timely Medical Care Among Adults in the US, 1999 to 2018. JAMA Health Forum. 2022;3(10):e223856. 10.1001/jamahealthforum.2022.3856 . Cutler DM, Glaeser E. Cutting the NIH-The $ 8 Trillion Health Care Catastrophe. JAMA Health Forum. 2025;6(5):e252791. 10.1001/jamahealthforum.2025.2791 . PMID: 40440048. Liu S, Smith-Greenaway E. Racial and ethnic minorities disproportionately exposed to extreme daily temperature variation in the United States. PNAS Nexus. 2024;3(5):pgae176. 10.1093/pnasnexus/pgae176 . PMID: 38774391; PMCID: PMC11107375. Mathews AA, Joyner BL, Oden RP, Alamo I, Moon RY. Comparison of Infant Sleep Practices in African-American and US Hispanic Families: Implications for Sleep-Related Infant Death. J Immigr Minor Health. 2015;17(3):834–42. 10.1007/s10903-014-0016-9 . PMID: 24705738; PMCID: PMC4185304. Fleary SA, Ettienne R. Social Disparities in Health Literacy in the United States. Health Lit Res Pract. 2019;3(1):e47–52. 10.3928/24748307-20190131-01 . PMID: 31294307; PMCID: PMC6608915. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet#:~ :text=Per%20capita%20spending%20in%20New,than%20the%20national%20average%2C%20respectively. Miller CE, Vasan RS. The southern rural health and mortality penalty: A review of regional health inequities in the United States. Soc Sci Med. 2021;268:113443. 10.1016/j.socscimed.2020.113443 . Epub 2020 Oct 23. PMID: 33137680; PMCID: PMC7755690. Cooper Z, Stiegman O, Ndumele CD, Staiger B, Skinner J. Geographical Variation in Health Spending Across the US Among Privately Insured Individuals and Enrollees in Medicaid and Medicare. JAMA Netw Open. 2022;5(7):e2222138. doi: 10.1001/jamanetworkopen.2022.22138. Erratum in: JAMA Netw Open. 2022;5(8):e2230459. 10.1001/jamanetworkopen.2022.30459 . PMID: 35857326; PMCID: PMC9301520. Connell CL, Wang SC, Crook L, Yadrick K. Barriers to Healthcare Seeking and Provision Among African American Adults in the Rural Mississippi Delta Region: Community and Provider Perspectives. J Community Health. 2019;44(4):636–45. 10.1007/s10900-019-00620-1 . PMID: 30661152; PMCID: PMC6612316. Weeks WB, Chang JE, Pagán JA, Lumpkin J, Michael D, Salcido S, Kim A, Speyer P, Aerts A, Weinstein JN, Lavista JM. Rural-urban disparities in health outcomes, clinical care, health behaviors, and social determinants of health and an action-oriented, dynamic tool for visualizing them. PLOS Glob Public Health. 2023;3(10):e0002420. 10.1371/journal.pgph.0002420 . PMID: 37788228; PMCID: PMC10547156. Anderson HR, Cook DG. Passive smoking and sudden infant death syndrome: review of the epidemiological evidence. Thorax. 1997;52(11):1003-9. 10.1136/thx.52.11.1003 . Erratum in: Thorax 1999;54(4):365-6. PMID: 9487351; PMCID: PMC1758452. Parker MA, Weinberger AH, Eggers EM, Parker ES, Villanti AC. Trends in Rural and Urban Cigarette Smoking Quit Ratios in the US From 2010 to 2020. JAMA Netw Open. 2022;5(8):e2225326. 10.1001/jamanetworkopen.2022.25326 . PMID: 35921112; PMCID: PMC9350718. Iyasu S, Randall LL, Welty TK, Hsia J, Kinney HC, Mandell F, McClain M, Randall B, Habbe D, Wilson H, Willinger M. Risk factors for sudden infant death syndrome among northern plains Indians. JAMA. 2002;288(21):2717-23. 10.1001/jama.288.21.2717 . Erratum in: JAMA. 2003;289(3):303. PMID: 12460095. Firebaugh G, Acciai F. For blacks in America, the gap in neighborhood poverty has declined faster than segregation. Proc Natl Acad Sci U S A. 2016;113(47):13372–7. 10.1073/pnas.1607220113 . Epub 2016 Nov 7. PMID: 27821759; PMCID: PMC5127296. Byun SY, Meece JL, Irvin MJ. Rural-Nonrural Disparities in Postsecondary Educational Attainment Revisited. Am Educ Res J. 2012;49(3). 10.3102/0002831211416344 . PMID: 24285873; PMCID: PMC3839859. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9350673","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635085702,"identity":"b99fbde5-a9e0-40df-9bad-b77afe96c502","order_by":0,"name":"Graham 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Abubakar","middleName":"","lastName":"Tauseef","suffix":""}],"badges":[],"createdAt":"2026-04-08 02:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9350673/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9350673/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108942747,"identity":"7c34adc1-6240-4b38-8d9c-c79228d97051","added_by":"auto","created_at":"2026-05-11 05:42:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44410,"visible":true,"origin":"","legend":"\u003cp\u003eSudden Infant Death Syndrome (SIDS) Related Mortality Trends, Overall and Stratified by Sex, 1999 to 2023\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9350673/v1/67eda2a1c87a1ef5a58da465.png"},{"id":108942760,"identity":"f19d0007-95eb-4b1e-abd3-b44307fea8d6","added_by":"auto","created_at":"2026-05-11 05:42:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61072,"visible":true,"origin":"","legend":"\u003cp\u003eSudden Infant Death Syndrome (SIDS) Related Mortality Trends, Stratified by Race and Ethnicity, 1999 to 2023\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9350673/v1/29d2192f5f8a8a20f0424215.png"},{"id":108942828,"identity":"34ecf106-fffa-4134-88db-fc30e961da56","added_by":"auto","created_at":"2026-05-11 05:42:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":53944,"visible":true,"origin":"","legend":"\u003cp\u003eSudden Infant Death Syndrome (SIDS) Related Mortality Trends, Stratified by Region, 1999 to 2023\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9350673/v1/1a6a8c67fa83bb73c4f07d78.png"},{"id":108942829,"identity":"d0641da5-dcec-480d-94ec-e167f4c35573","added_by":"auto","created_at":"2026-05-11 05:42:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":36655,"visible":true,"origin":"","legend":"\u003cp\u003eSudden Infant Death Syndrome (SIDS) Related Mortality Trends, Urban vs Rural, 1999 to 2023\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9350673/v1/5266afa0f1a8c00b8668ea57.png"},{"id":108982288,"identity":"06a4f117-5cf2-4e88-8eec-9a4bbfa81ea0","added_by":"auto","created_at":"2026-05-11 12:24:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":407357,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9350673/v1/66ee48a3-ad5d-48c2-a24f-533d163caf72.pdf"},{"id":108942746,"identity":"bea9dc30-2311-4b5d-9bbf-f43588c65eb7","added_by":"auto","created_at":"2026-05-11 05:42:28","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":682161,"visible":true,"origin":"","legend":"","description":"","filename":"SIDSSupplementalTablesBMC.docx","url":"https://assets-eu.researchsquare.com/files/rs-9350673/v1/4eefe63694ad294399903947.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"National Patterns of SIDS Mortality: A CDC WONDER Population Analysis of Demographic and Geographic Disparities From 1999-2023","fulltext":[{"header":"Introduction","content":" \u003cp\u003eSudden infant death syndrome (SIDS) is a major contributor to infant mortality in the United States. Despite public health efforts to reduce SIDS, nearly 50,000 deaths have occurred since 1999. SIDS is defined as \u0026ldquo;infant deaths that cannot be explained after a thorough case investigation, including a death scene investigation, autopsy, and review of the clinical history\u0026rdquo; [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Government sponsored interventions such as \u0026ldquo;Back to Sleep,\u0026rdquo; initiated in 1994 and later renamed to \u0026ldquo;Safe to Sleep\u0026rdquo; in 2012, facilitated a significant reduction in SIDS deaths [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite this reduction, there has been an increase in infant mortality related to SIDS since 2019 within certain demographic groups, highlighting the persistent role of disparities in infant health.\u003c/p\u003e \u003cp\u003eAlthough the exact etiology of SIDS remains unknown, there are hypothesized contributors such as maternal smoking, prematurity, and socioeconomic status [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While impacts of early government campaigns are well established, fewer studies have examined how SIDS mortality trends have evolved in the decades following widespread campaign implementation. Additionally, previous analyses are often focused on limited time frames or demographic variables, leaving gaps in understanding and opportunities to reduce risk. To date, literature for a comprehensive national analysis of SIDS mortality including demographic and geographic variables, is lacking.\u003c/p\u003e \u003cp\u003eTo address these gaps, this study provides longitudinal evaluation of SIDS mortality from 1999 to 2023 using the CDC WONDER database. Knowledge on which populations experience higher infant SIDS-related mortality rates enables proper assessment and implementation of prevention-focused initiatives for those most in need. These findings provide insight on the success of public health interventions, inform future targeted interventions, and reduce inequities in SIDS-related mortality within the U.S.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify SIDS-related deaths occurring within the United States [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This public database contains standardized death-coding and enables reproducible population-level analysis across time and geography. Stratification by race, sex, region, urban/rural, and state-level patterns allows identification of populations and geographical regions that are most vulnerable to observed gaps in healthcare. The Multiple Cause-of-Death Public Use Record from the CDC WONDER database was queried to identify deaths among infants\u0026thinsp;\u0026lt;\u0026thinsp;1 year of age in which sudden infant death syndrome was listed as a cause of death on nationwide death certificate records. This database has been previously used in several other studies to analyze nationwide trends in mortality of infants along with social determinants of health [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, prior studies have often been limited by assessing select demographic factors separately, leaving a gap in understanding how SIDS-related mortality patterns compare across multiple populations in the contemporary period. Our study addresses this gap by analyzing several demographic groups within the same national analysis using recent post-pandemic data [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. SIDS-related mortality was identified using the International Classification of Diseases, 10th Revision (ICD-10), Clinical Modification code R95 in patients under one year of age. The study was exempt from institutional review board approval because the CDC WONDER database contains de-identified, publicly available data.\u003c/p\u003e \u003cp\u003eDemographic data were analyzed, including sex, race/ethnicity, age, urban-rural classification, and census region. State level data was excluded due to unreliable data as reported on the CDC WONDER database. Unreliable data, according to the CDC WONDER database, is defined as fewer than 20 deaths reported [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Race and ethnicity groups were categorized as non-Hispanic (NH) White, NH Black, NH American Indian/Alaskan Native, NH Asian/Pacific Islander, and Hispanic people as identified on death certificates. The age group for this study was less than one year of age. For urban-rural classifications, the National Center for Health Statistics Urban-Rural Classification Scheme was used to divide the population into urban (population\u0026thinsp;\u0026gt;\u0026thinsp;50,000) and rural (population\u0026thinsp;\u0026lt;\u0026thinsp;50,000) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Regions were classified into Northeast, Midwest, South, and West according to the Census Bureau definitions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Location of death included medical facilities (outpatient, emergency room, inpatient, death on arrival, or status unknown), home, hospice, and nursing home/long-term care.\u003c/p\u003e \u003cp\u003eSIDS-related crude mortality rates (CMR) were calculated. AAMRs were not calculated because all cases occurred in infants less than one year of age [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Temporal trends in mortality were analyzed using the Joinpoint Regression Program (Version 5.4.0, National Cancer Institute, Bethesda, Maryland) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Joinpoint regression identifies points where statistically significant changes in trend occur and estimates the annual percentage change (APC) for each segment of time. Annual percentage change (APC) and average annual percent change (AAPC) with 95% confidence intervals (CIs) were calculated for each Joinpoint-defined time segment using the Monte Carlo permutation test. The model selected the optimal number of Joinpoints based on permutation testing, allowing identification of statistically significant changes in mortality trends over time. APC and AAPC were considered increasing or decreasing if the slope describing the change in mortality over the time interval differed significantly from zero using a two-tailed t-test. Statistical significance was set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05. Statistically significant trends are denoted by an asterisks (*).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eOverall\u003c/h2\u003e \u003cp\u003eFrom 1999 to 2023, there were 48,244 deaths due to SIDS in the U.S. Overall mortality rates (per 100,000 live births) declined during this period, decreasing from 70.79 in 1999 to 40.81 in 2023, with an AAPC of -2.08%* (95% CI, \u0026minus;\u0026thinsp;2.55 to \u0026minus;\u0026thinsp;1.62) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Supplemental Table\u0026nbsp;1). Between 1999 and 2001, mortality rates declined, with an APC of -10.76%* (95% CI, -14.27 to -3.68). From 2001 to 2009, there was no significant change in mortality rates. However, during the years 2009 to 2013, the mortality rates declined with an APC of \u0026minus;\u0026thinsp;8.57%* (95% CI, \u0026minus;\u0026thinsp;11.93 to \u0026minus;\u0026thinsp;0.77). From 2013 to 2019, mortality rates demonstrated no significant decrease. However, from 2019 to 2023, SIDS mortality rates increased with an APC of 5.45%* (95% CI, 1.37 to 13.11) (Supplemental Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSex Stratified:\u003c/h3\u003e\n\u003cp\u003eFrom 1999 to 2023, SIDS caused 28,259 deaths (59%) in males and 19,985 deaths (41%) in females in the U.S. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among males, the mortality rate declined from 80.88 in 1999 to 46.02 in 2023, with an AAPC of \u0026minus;\u0026thinsp;2.14%* (95% CI, \u0026minus;\u0026thinsp;2.56 to \u0026minus;\u0026thinsp;1.65) (Supplemental Table\u0026nbsp;1). Male mortality rates declined from 1999 to 2001 with an APC of -10.00%* (95% CI, -14.10 to -3.12), followed by no significant change from 2001 to 2008. A further decline occurred from 2008 to 2015 with an APC of \u0026minus;\u0026thinsp;5.59%* (95% CI, \u0026minus;\u0026thinsp;7.31 to \u0026minus;\u0026thinsp;4.50). From 2018 to 2023, male SIDS mortality rates increased, with an APC of 5.64%* (95% CI, 2.57 to 10.54) (Supplemental Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eAmong females, SIDS mortality rates declined from 60.2 in 1999 to 35.37 in 2023, with an overall AAPC of \u0026minus;\u0026thinsp;2.27%* (95% CI, \u0026minus;\u0026thinsp;2.66 to \u0026minus;\u0026thinsp;1.77) (Supplemental Table\u0026nbsp;1). Mortality rates declined from 1999 to 2001 with an APC of -11.92%* (95% CI, \u0026minus;\u0026thinsp;16.03 to -4.44), followed by a period of no significant change from 2001 to 2009. Mortality rates from 2009 to 2014 declined again by -4.30%* (95% CI, \u0026minus;\u0026thinsp;13.47 to -5.75), after which no significant change was observed from 2014 to 2023 (Supplemental Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003ch3\u003eRace Stratified:\u003c/h3\u003e\n\u003cp\u003eBlack or African American infants experienced the highest SIDS mortality rates throughout the study period (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In 1999, the rate was 147.0 and then decreased to 101.76 in 2023 (Supplemental Table\u0026nbsp;2). From 1999 to 2023, the AAPC in SIDS mortality was \u0026minus;\u0026thinsp;1.09%* (95% CI, -1.64 to -0.45). Joinpoint analysis demonstrated no significant change in mortality rates from 1999 to 2014. From 2014 to 2023, SIDS mortality rates increased, with an APC of 4.22%* (95% CI, 1.75 to 8.86) (Supplemental Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eAmong the White population, SIDS mortality rates declined from 62.41 in 1999 to 32.53 in 2023 (Supplemental Table\u0026nbsp;2). The AAPC from 1999 to 2023 was \u0026minus;\u0026thinsp;2.42%* (95% CI, -2.91 to -2.02). Mortality rates declined from 1999 to 2003, with an APC of -4.88%* (95% CI, -9.24 to -2.57), followed by an increase from 2003 to 2007, with an APC of 4.56%* (95% CI, 1.48 to 8.36). Rates then declined from 2007 to 2019 with an APC of \u0026minus;\u0026thinsp;5.93%* (95% CI, \u0026minus;\u0026thinsp;6.96 to \u0026minus;\u0026thinsp;5.23), with no significant change observed from 2019 to 2023 (Supplemental Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eAmong the American Indian or Alaska Native population, SIDS mortality rates declined from 124.14 in 1999 to 103.95 in 2023 (Supplemental Table\u0026nbsp;2). From 1999 to 2023, the AAPC was \u0026minus;\u0026thinsp;1.15%* (95% CI, -2.37 to -0.57). No Joinpoints were identified for this population, and the APC reflected the overall AAPC across the study period. (Supplemental Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eThe Asian American/Pacific Islander population experienced a decline in SIDS mortality rates from 32.66 in 1999 to 14.42 in 2023 (Supplemental Table\u0026nbsp;2). From 1999 to 2023, the AAPC was \u0026minus;\u0026thinsp;3.69%* (95% CI, -4.70 to -1.88). Mortality rates declined from 1999 to 2001 with an APC of -20.81%* (95% CI, \u0026minus;\u0026thinsp;30.07 to -2.28), followed by a period of no significant change from 2001 to 2023 (Supplemental Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eAmong the Hispanic population, SIDS mortality rates declined from 41.81 in 1999 to 25.8 in 2023 (Supplemental Table\u0026nbsp;2). The AAPC from 1999 to 2023 was \u0026minus;\u0026thinsp;1.81%* (95% CI, -2.42 to -0.92). Mortality rates declined from 1999 to 2001, with an APC of -14.86%* (95% CI, \u0026minus;\u0026thinsp;21.01 to -2.17), followed by no significant change from 2001 to 2009. From 2009 to 2016, SIDS mortality rates declined with an APC of -7.24%* (95% CI, -15.42 to -2.86). Then from 2016 to 2023, there was an increase to an APC of 5.97%* (95% CI, 2.57 to 12.44) (Supplemental Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eRegional Variation:\u003c/h3\u003e\n\u003cp\u003eAll U.S. census regions experienced declines in SIDS mortality rates over time, with the Midwest demonstrating the greatest reduction from 82.34 in 1999 to 37.01 in 2023 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The overall AAPC for the Midwest was \u0026minus;\u0026thinsp;3.05%* (95% CI, \u0026minus;\u0026thinsp;4.01 to \u0026minus;\u0026thinsp;2.45). The steepest decline occurred between 1999 and 2019, with an APC of \u0026minus;\u0026thinsp;4.33%* (95% CI, \u0026minus;\u0026thinsp;6.20 to \u0026minus;\u0026thinsp;3.79), followed by a period of no significant change from 2019 to 2023 (Supplemental Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eThe South exhibited the smallest overall decline with an AAPC of \u0026minus;\u0026thinsp;1.30%* (95% CI, \u0026minus;\u0026thinsp;1.88 to \u0026minus;\u0026thinsp;0.71). Mortality rates demonstrated no significant change from 1999 to 2007, followed by a decline from 2007 to 2018 with an APC of -4.70%* (95% CI, -9.46 to -3.60). From 2018 to 2023, mortality rates in the South increased, with an APC of 4.66% ( 95% CI, 0.37 to 13.78).\u003c/p\u003e \u003cp\u003eIn the West, SIDS mortality rates declined overall from 1999 to 2023, with an AAPC of -2.84%* (95% CI, \u0026minus;\u0026thinsp;3.47 to -2.17) (Supplemental Fig.\u0026nbsp;3). Mortality rates declined from 1999 to 2001 with an APC of -19.10%* (95% CI, -24.77 to -9.93), followed by a period of no significant change from 2001 to 2009. From 2009 to 2017, mortality rates again declined with an APC of -7.39%* (95% CI, -12.41 to -5.50). Then from 2017 to 2023, there was an increase in APC of 4.04%* (95% CI, 0.61 to 10.19).\u003c/p\u003e \u003cp\u003eIn the Northeast, the mortality rates declined overall from 1999 to 2023 with an AAPC of -1.33%* (95% CI, -2.11 to -0.56). Mortality rates declined from 1999 to 2004 with an APC of -9.50%* (95% CI, -20.56 to -5.04), followed by an increase from 2004 to 2008 with an APC of 11.08% (95% CI, 3.83 to 22.14). From 2008 to 2014, mortality again declined with an APC of -10.93%* (95% CI, -21.56 to -6.85). Then from 2014 to 2023, there was an increase to an APC of 5.14%* (95% CI, 2.37 to 10.60). Full-range AAPCs were statistically significant in all regions from 1999\u0026ndash;2023.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eUrban vs Rural:\u003c/h2\u003e \u003cp\u003eWhen comparing urban and rural regions, SIDS mortality rates were consistently higher in rural areas (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Rural zones experienced a gradual decrease from 94.01 in 1999 to 51.89 in 2020, with a consistent AAPC of -3.34%* (95% CI, -4.61 to -2.29) (Supplemental Fig.\u0026nbsp;4). Rural zones experienced no significant changes from 1999 to 2009. From 2009 to 2020, there was an APC decrease of -5.22%* (95% CI, -12.24 to -3.70).\u003c/p\u003e \u003cp\u003eIn urban zones, mortality rates decreased from 66.86 in 1999 to 35.82 in 2020, with an AAPC of \u0026minus;\u0026thinsp;3.33%* (95% CI, \u0026minus;\u0026thinsp;3.67 to \u0026minus;\u0026thinsp;2.94) (Supplemental Table\u0026nbsp;4). Rates in these areas decreased between 1999 and 2001 with an APC\u0026thinsp;\u0026minus;\u0026thinsp;12.00%* (95% CI, \u0026minus;\u0026thinsp;14.94 to -6.80) with no significant change from 2001 to 2009. From 2009 to 2013, there was a decrease of \u0026minus;9.07%* (95% CI, \u0026minus;\u0026thinsp;12.16 to \u0026minus;\u0026thinsp;6.40) (Supplemental Fig.\u0026nbsp;4). From 2013 to 2020, no significant change was observed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eOverall Trends\u003c/h2\u003e \u003cp\u003eThe overall decline in SIDS mortality from 1999 to 2019 is temporally associated with the long-term impacts of national safe sleep initiatives, including the \u0026ldquo;Back to Sleep\u0026rdquo; and later \u0026ldquo;Safe to Sleep\u0026rdquo; campaigns, which emphasized supine sleep positioning and safer sleep environments [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These interventions have greatly reduced the SIDS burden across the country as a result of increased parental education and effective strategies that limit infant exposure to toxins associated with increased infant mortality risk. These include increased education about prenatal and postnatal exposure to tobacco products such as cigarette smoke and parental drug use [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Interestingly, prior studies have demonstrated that maternal recreational marijuana use is not associated with increased SIDS rates in children, but paternal use is associated with increased risks [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Increased ambient temperature has also been shown to increase SIDs mortality with more deaths occurring during summer months in hot and humid areas [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The decrease in SIDS mortality from 1999\u0026ndash;2001 may reflect the non-standardized definitions of the time, leading to inconsistent classification of infant deaths. A standardized definition of SIDS was established in 2004 as \u0026ldquo;the sudden unexpected death of an infant\u0026thinsp;\u0026lt;\u0026thinsp;1 year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including performance of a complete autopsy and review of the circumstances of death and the clinical history,\u0026rdquo; allowing a more accurate classification of unexplained infant death in the pediatric field [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The sharp nationwide decrease beginning in 2008 may be the culmination of decades of public interventions, more defined diagnostic criteria, and targeted outreach to bridge gaps in vulnerable or at-risk communities. Although nationwide numbers decreased overall, the marginalized communities continue to experience higher SIDS rates than White populations. Alarmingly, since 2019 SIDS rates have increased, this could be due to lasting effects of COVID-19 and recent reductions in public health spending [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This study helps fill existing gaps in understanding racial, regional, and urban-rural disparities over this time frame in the context of government interventions and public health outreach.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSex-Stratified Trends\u003c/h2\u003e \u003cp\u003eMales continue to make up the majority of SIDS deaths in America, aligning with prior studies demonstrating male sex as a risk factor for SIDS [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. No definite cause for this disparity has been well established, but hypothesized to be multifactorial [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Male mortality declined sharply beginning in 2008, although no specific explanation for this change could be identified as female mortality also significantly declined during this period. Female mortality rates also decreased in 2008, mirroring the trend observed among males throughout the study period. This suggests that although females generally face a lower overall risk, they may derive less benefit from recent interventions designed to reduce mortality among the highest-risk cases [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Since neonatal intensive care unit (NICU) stays are associated with worse outcomes and the majority of NICU patients are male, this pattern may contribute to the higher mortality rate observed among male infants [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These findings highlight the importance of incorporating sex-based biological and behavioral factors into future SIDS prevention research and messaging. This area presents opportunities for further research on physiologic differences in male and female infants that may account for differences in infant resilience.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRace and Ethnicity\u003c/h2\u003e \u003cp\u003eTragically in the U.S., racial and ethnic minority status is frequently associated with worse health outcomes, and this holds true for the neonatal population as well, likely due to social injustices and systemic barriers preventing access to care in marginalized communities [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These barriers to care are associated with increased rates of preventable and chronic diseases in the adult community, but also contribute to higher neonatal mortality due to lack of prenatal care or follow-up [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Prior work demonstrated that barriers to care have actually increased across all age groups, with increased disparities in marginalized groups; an alarming finding given the amount of public health spending in the past and recent spending cuts [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The persistently elevated SIDS mortality rates among Black/African American infants compared to White infants, points to the persistence of structural and social inequities, including lack of access to prenatal care, safe sleep resources, and culturally tailored health education. In the African-American community, mortality peaks during summer months and may reflect lack of access to resources such as air conditioning or green space leading to increased temperature fluctuations [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Significant declines were observed in Black/African American communities after 2006, coinciding with multiple public health outreach projects in states such as Mississippi with a large African American population. In 2006, the Mississippi African American SIDS Outreach project worked with local churches and communities to educate on risk reduction which coincided with a decline in SIDS mortality [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The modest declines in Native American/Indigenous populations were complicated by small sample sizes leading to unreliable data, however, the \u0026ldquo;Healthy Native Babies Project;\u0026rdquo; a culturally tailored safe sleep education resources, were promoted starting in 2005 with varied success evidenced by fluctuating yearly SIDS rates in the Native American community [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRegional Variation\u003c/h2\u003e \u003cp\u003eThe steep decline in SIDS mortality observed in the Midwest region may reflect differences in culturally specific interventions built to incorporate education into messaging for the African-American and Indigenous community due to different cultural practices [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These findings suggest that increased healthcare access and public health funding may be major drivers to decrease SIDS rates. The West region also experienced consistent decline from 1999\u0026ndash;2001, likely consistent with public health interventions; however, the lack of change from 2001\u0026ndash;2009 could not be explained. In 2016, the American Academy of Pediatrics updated their SIDS prevention recommendations which may have played a role in decreasing SIDS rates until the COVID-19 pandemic, potentially reflecting higher health literacy in western states, a result of higher standards of living and incomes [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Southern region of the U.S. experienced the slowest decline. As the South already has well known disparities and worse outcomes, improvement may occur slower in these regions, yet progress since 2018 is encouraging [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This lag could also be explained by a higher Black/African American population in the South which are a historically oppressed group with decreased access to healthcare resources and medical distrust due to mistreatment and past experimentation without their consent [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These regional pattern differences suggest the need for geographically and culturally tailored messaging due to the different populations and resources available in each U.S. region. Despite having among the highest per capita health spending, the Northeast saw the second lowest overall decline [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In the Northeast, the mortality rates declined overall from 1999 to 2019 but a recent uptick in 2019 coincided with other regions due to COVID-19 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eUrban vs. Rural Differences\u003c/h2\u003e \u003cp\u003eConsistent with patterns seen across many major health outcomes, SIDS mortality rates remain higher in rural areas than in urban areas, reflecting the broader trend of urban populations experiencing generally better health outcomes [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Parental smoking, including secondhand exposure to cigarette smoke, is a well established risk factor. Increased smoking rates in more rural areas and the accompanying second-hand smoke exposure may contribute to higher SIDS mortality rates in rural zones compared with urban settings [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Substance abuse is also a well established risk factor, including the use of alcohol, drugs, and opiates [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The gradual, yet steady decline in rural areas may indicate limited reach of public health messaging, reduced access to healthcare resources, and worse educational outcomes [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Recently, telehealth initiatives have shown promise to improve health outcomes in rural communities that may have traditionally been limited by resources and provider availability in regard to smoking cessation resources [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Addressing rural-urban disparities will likely require further education and intervention, such as increasing telehealth availability, community-based outreach, and ensuring a safe home and sleeping environment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed a sustained decrease in SIDS mortality from 1999\u0026ndash;2019, coinciding with the widespread implementation of Safe Sleep Campaigns and other targeted public health interventions. However, based on current data and the timing of increasing SIDS mortality rates following the COVID-19 pandemic, we observe that this increase in SIDS mortality may be partly related to setbacks in prior gains due to health impacts of the pandemic. Despite substantial gains overall, SIDS rates of historically marginalized communities remain substantially higher than those among the White population and more research is needed on social determinants of health to close these gaps and achieve more equitable healthcare for all. The large difference in regional data suggest that different healthcare access, public health investment, and per-capita spending may influence reductions in SIDS mortality, with many states and regions with fewer resources lagging behind. Continued progress will require sustained public health funding, particularly as many programs face reductions in resources, and further exploration into physiologic mechanisms behind decreased physiological resilience of male infants. These findings emphasize the need for coordinated national and community-level strategies to ensure that future reductions in SIDS mortality are both sustained and equally distributed.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eThe CDC WONDER database has several limitations that should be considered. As with any database study, reporting errors are possible, including misclassification within categories such as cause of death (death certificates), race, and residential location. Moreover, cross-stratified analysis between demographic variables was not performed. In addition, the CDC WONDER database does not allow detailed analysis of individual-level demographic disparities, and this study could not account for income level, education, or health insurance coverage, all of which are known social determinants of health. Further, due to minimal state specific data, analysis between states was not completed. Additionally, observational analyses of national mortality databases cannot establish causal relationships between observed trends and potential contributing factors. These limitations highlight important opportunities for future research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: The study was exempt from institutional review board (IRB) approval because the CDC WONDER database contains de-identified, publicly available data. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: Data can be found at http://wonder.cdc.gov. \u0026nbsp;The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: The authors have not received any outside funding.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: GG and LS helped with study design, data collection, data interpretation, and writing the manuscript. LP and VM aided in data collection, statistics, data interpretation, and manuscript writing. AT aided in project design, writing, and editing. All authors contributed to the final draft and approved it.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: We would like to thank the Creighton University School of Medicine Department of Internal Medicine for their support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information: see affiliations above\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRachel Y, Moon, Rebecca F, Carlin, Ivan Hand, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN; Sleep-Related Infant Deaths. Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. 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PMID: 24285873; PMCID: PMC3839859.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sudden infant death syndrome, health disparity, neonatology, rural, urban, regional","lastPublishedDoi":"10.21203/rs.3.rs-9350673/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9350673/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eSudden infant death syndrome (SIDS) is one of the major contributors to infant mortality in the United States (U.S.). Although the exact causes of SIDS have yet to be discovered, there are hypothesized contributors including maternal smoking, prematurity, and socioeconomic status. This study aims to identify the greatest changes in SIDS mortality rates using temporal trends. Understanding how demographic and geographic variables influence SIDS mortality is essential for identifying at-risk populations and developing targeted public health interventions aimed at education and prevention of infant deaths.\u003c/p\u003e\u003ch2\u003eBody:\u003c/h2\u003e \u003cp\u003eThis is a retrospective analysis of the CDC WONDER Database from 1999\u0026ndash;2023. Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) was used to identify SIDS-related deaths occurring within the U.S.. Records for infants aged\u0026thinsp;\u0026lt;\u0026thinsp;1 year old were identified using ICD-10 code R95 for sudden infant death syndrome. Data was analyzed using the Joinpoint Regression Program to estimate annual percentage change (APC) and average annual percent change (AAPC) with 95% confidence intervals (CI) for each demographic group. From 1999 to 2023, there were 48,244 deaths due to SIDS in the U.S. Overall, mortality decreased during this period from 70.79 in 1999 to 40.81 in 2023, with an AAPC of \u0026minus;\u0026thinsp;2.08%*. The Black community experienced the highest SIDS mortality rates throughout the study period, with a crude mortality rate of 147 in 1999, then decreasing to 101.76 in 2023. Geographic analysis demonstrates that all census regions demonstrated a decline in mortality over the study period. The Midwest region had the greatest decline in crude mortality rates. SIDS mortality rates were higher across rural areas.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eSIDS mortality in the U.S. has declined overall from 1999\u0026ndash;2019 with a recent rise from 2019 to 2023. Despite these gains, substantial racial and geographic disparities persist, with Black infants and rural communities experiencing disproportionately higher mortality rates. The recent and sustained increases in mortality, however, temporally align with the ongoing residual effects of the COVID-19 pandemic.\u003c/p\u003e","manuscriptTitle":"National Patterns of SIDS Mortality: A CDC WONDER Population Analysis of Demographic and Geographic Disparities From 1999-2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 05:40:52","doi":"10.21203/rs.3.rs-9350673/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d80a8c7f-dc8b-492a-9625-ae158f49570f","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-07T07:39:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T16:03:42+00:00","index":178,"fulltext":""},{"type":"reviewerAgreed","content":"199324340918343022672457862244935045678","date":"2026-05-05T17:47:09+00:00","index":176,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T13:07:06+00:00","index":174,"fulltext":""},{"type":"reviewerAgreed","content":"138847887763446782189063342092383440872","date":"2026-05-04T08:01:53+00:00","index":170,"fulltext":""},{"type":"reviewerAgreed","content":"100889147459621897282698018075757957356","date":"2026-05-04T00:04:29+00:00","index":169,"fulltext":""},{"type":"reviewerAgreed","content":"171107014631124333887351430237757218669","date":"2026-05-03T09:19:48+00:00","index":167,"fulltext":""},{"type":"reviewerAgreed","content":"52709931125261537741789986271781003784","date":"2026-05-02T04:12:53+00:00","index":150,"fulltext":""},{"type":"reviewerAgreed","content":"180262596862799040926760735987901695647","date":"2026-04-29T18:06:14+00:00","index":135,"fulltext":""},{"type":"reviewerAgreed","content":"104029036886164423419184060617765179521","date":"2026-04-29T18:02:57+00:00","index":134,"fulltext":""},{"type":"reviewerAgreed","content":"20311878544658821150267897808116145551","date":"2026-04-29T17:05:30+00:00","index":133,"fulltext":""},{"type":"reviewerAgreed","content":"100261421296698084167390703016820273965","date":"2026-04-29T12:59:12+00:00","index":132,"fulltext":""},{"type":"reviewerAgreed","content":"47217000343518152295592684560732201998","date":"2026-04-29T00:15:34+00:00","index":74,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T11:32:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 05:40:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9350673","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9350673","identity":"rs-9350673","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}