Using an Exposure Call Center to Help Mitigate Outbreaks, Such as COVID-19, on a University Campus.

Rapid identification and management of close contacts is an important component of an effective university mitigation strategy for highly contagious infectious diseases such as measles and coronavirus disease-2019 (COVID-19). Institutions of higher education must plan for an associated large influx of calls that can overwhelm standard student health and local public health operations. In fall 2020, a large state public university's Department of Student Health and Wellness created a dedicated exposure call center (ECC), in close collaboration with the local public health department, to quickly assess students who learned of a COVID-19 exposure outside of the formal contact tracing process. The ECC operated 7 days a week and fielded 3361 calls: 3187 from students and 174 from staff, faculty, and parents. The ECC provided rapid assessment and guidance for students with COVID-19 exposure, allowing for prompt quarantine and medical assessment when warranted. Call centers can increase the bandwidth of university health centers and also reduce the burden on health care providers and other public health resources during periods of crisis or high demand.

Gender-diverse health on campus: Developing a comprehensive, multidisciplinary gender-diverse care team.

Objective: To optimize healthcare for gender-diverse students at a large, public university's Student Health and Wellness (SHW) Center. Methods: SHW professionals from medicine, gynecology, health promotion, counseling, psychiatry, and disability services developed a multidisciplinary gender-diverse care team (GDCT) in 2016. The GDCT's team-based design was created to support a diverse student body and provide extra resources to a vulnerable population, ensuring students engage fully in the University. Results: The GDCT has assisted approximately 93 unique students, in-person or by phone with clinical or supportive care. The number of students presenting with questions pertaining to transgender and gender-diverse health care has increased since 2016. Conclusions: Having a comprehensive, multidisciplinary GDCT available within a university SHW provides transgender and gender-diverse students with access to a safe, inclusive, and resource-rich environment to seek care and serves as a potential model for other college health centers.

Identifying vulnerable populations at a university during the COVID-19 pandemic.

Objective: Persons with high-risk for severe COVID-19 illness require special attention when considering university operations during the novel coronavirus pandemic. The objective of this study was to determine the number of students who fall within a high-risk category according to Centers for Disease Control and Prevention (CDC) guidelines using linked databases. Participants: Students enrolled at a large public University and who accessed the student health center between 2016 and 2020. Methods: Clinical data were linked with both university student enrollment and disability services databases to provide a comprehensive, de-identified dataset of students at higher medical risk of severe COVID-19 illness. Results: 1902 unique students (14% of the student health center population) were identified as having one or more high-risk condition. Conclusions: Utilizing a large and longitudinally linked student database provides universities with valuable information to make critical administrative decisions about how best to accommodate high-risk students to reduce their medical risk when returning to in-person instruction.

Predictors of cervical cancer screening for refugee women attending an international family medicine clinic in the United States.

PURPOSE: Cervical cancer screening (CCS) rates are lower for foreign-born women in the United States (U.S.) compared with the overall population. This study aimed to determine the CCS rate and predictors among refugees who were identified as female attending a family medicine clinic. METHODS: A retrospective chart review included refugee individuals aged 21+, seen in the previous 3 years (3/23/2015-3/20/2018), without hysterectomy (n = 525). Lab results determined CCS rate. Chi-square and logistic regression models explored predictors of CCS. RESULTS: Overall, 60.0% were up-to-date (UTD) on CCS. Individuals aged 30-49, married, and with [Formula: see text] 1 child had higher odds of being UTD. Ten or more years living in the U.S. was a significant bivariate predictor of CCS, and approached significance in the multivariate model. CONCLUSION: This study begins to fill gaps in knowledge about cervical cancer control among individuals who resettled in the U.S. as refugees and, given that CCS rates are suboptimal, informs clinical practice improvements and directions for future research.

Risk of Postneonatal Infant Mortality Associated With Prior Founded Allegations of Child Abuse.

This study examined the association between prior reports of child abuse and subsequent postneonatal death and differences by cause of death, using data from the Chicago Infant Mortality Study (CIMS). CIMS included all sudden, unexplained infant deaths up to 1 year of age in Chicago (November 1993-April 1996), and age, race-ethnicity, and birthweight-matched living controls. Information on prior child abuse reports and outcomes was obtained through the Illinois Department of Children and Family Services (DCFS) State Central Registry for each case and control. Conditional logistic regression modeling determined the odds of postneonatal death when there was a founded prior allegation. Families with founded allegations were almost 4 times more likely to have a child die during the postneonatal period (aOR = 3.79, 95% CI, 1.56, 9.10). Child protective services involvement is an opportunity for education on safe sleep messaging to help reduce the incidence of potentially preventable infant deaths.

Building-Level Wastewater Surveillance for SARS-CoV-2 in Occupied University Dormitories as an Outbreak Forecasting Tool: One Year Case Study.

Congregate living poses one of the highest risk situations for the transmission of respiratory viruses including SARS-CoV-2. University dormitories exemplify such high-risk settings. We demonstrate the value of using building-level SARS-CoV-2 wastewater surveillance as an early warning system to inform when prevalence testing of all building occupants is warranted. Coordinated daily testing of composite wastewater samples and clinical testing in dormitories was used to prompt the screening of otherwise unrecognized infected occupants. We overlay the detection patterns in the context of regular scheduled occupant testing to validate a wastewater detection model. The trend of wastewater positivity largely aligned well with the clinical positivity and epidemiology of dormitory occupants. However, the predictive ability of wastewater-surveillance to detect new positive cases is hampered by convalescent shedding in recovered/noncontagious individuals as they return to the building. Building-level pooled wastewater-surveillance and forecasting is most productive for predicting new cases in low-prevalence instances at the community level. For higher-education facilities and other congregate living settings to remain in operation during a pandemic, a thorough surveillance-based decision-making system is vital. Building-level wastewater monitoring on a daily basis paired with regular testing of individual dormitory occupants is an effective and efficient approach for mitigating outbreaks on university campuses.

COVID-19 Isolation and Quarantine Experience for Residential Students at a Large Four-Year Public University.

Rapid identification and management of students with COVID-19 symptoms, exposure, or disease are critical to halting disease spread and protecting public health. We describe the interdisciplinary isolation and quarantine program of a large, public university, the University of Virginia, Charlottesville. The program provided students with wraparound services, including medical, mental health, academic, and other support services during their isolation or quarantine stay. The program successfully accommodated 844 cases during the fall 2020 semester, thereby decreasing exposure to the rest of the university and the local community. (Am J Public Health. 2021;111(10):1772-1775. https://doi.org/10.2105/AJPH.2021.306424).

Risk factors associated with concussions in a college student population.

PURPOSE: To determine risk factors associated with concussion among the general collegiate population using a unique data linkage methodology. METHODS: Student health medical, counseling, and disability access service data were linked with university enrollment data to provide a comprehensive, deidentified dataset of students who sought care at the student health center for concussion from 2016-2020. Using chi-squared tests and logistic regression, characteristics of students with and without concussion were evaluated. RESULTS: During the study period, 506 concussions from 474 students were identified (cumulative incidence rate of 51.7 per 10,000 students). Significant predictors of concussion included: younger age (<21 years): odds ratio (OR) = 3.52 (95% confidence intervals [CI], 2.78, 4.50), Greek affiliation: OR = 1.89 (95% CI, 1.56, 2.30), and utilization of counseling and psychological services: OR = 1.92 (95% CI 1.59, 2.32). Of the students with concussion, 47% had at least one other concussion within the preceding year. History of prior hospitalization or medical imaging for head injury increased subsequent concussion risk by 4.5 fold. CONCLUSIONS: Linking unique datasets provides a richer understanding of the characteristics and risk factors associated with student concussions than analysis of a single data source. This comprehensive dataset will enable future targeted interventions to prevent and treat college student concussions.

Complementary and Alternative Medicine Prescribing Practices Among Sports Medicine Providers.

CONTEXT: The drive for a quick return to sport after injury can be great. Athletes look to their sports medicine provider for guidance on a speedy and effective recovery. The sports medicine physician has a number of different treatment options to consider when they turn to their medical armamentarium. One of those treatment choices is complementary and alternative medicine (CAM). Unfortunately, there is limited evidence for many of the CAM modalities. Furthermore, CAM prescribing practices among sports medicine physicians is unknown. The aim of this study is to determine the prescribing practices of CAM among physicians for common sports medicine pathologies. METHODS: An online survey of the prescribing practices of CAM by physician members of the American Medical Society for Sports Medicine. RESULTS: A total of 257 physicians answered the question on prescribing CAM for a response rate of 11%. Of those who responded, 88% prescribed at least one type of CAM in the last one year. The responders identified 23 different CAM modalities they prescribed. Of those modalities prescribed, chiropractic/osteopathic manipulation was the most common followed by acupuncture/electroacupuncture and yoga. Less commonly prescribed CAM included omega-3 fatty acids, riboflavin, and meditation. Providers utilized CAM for common sports medicine pathologies including ligamentous, tendinous and muscle injury, concussion, and low back pain among others. The survey participants believed many of these CAM modalities to be effective. CONCLUSIONS: Among responders, the prescribing prevalence of at least one CAM therapy was high. Sports medicine physicians utilized a number of different CAM modalities to treat common sports medicine pathologies.

Video Analysis of Concussion Exposures in a National Collegiate Athletic Association Division I Football Team.

BACKGROUND: Research into improving player safety of sport-related concussion (SRC) in American football has been an ongoing endeavor. In an attempt to better understand the incidence of SRCs in American football, research has focused on the characteristics of SRC during gameplay. Determining SRC specifics and assessing them quantitatively can help identify high-risk scenarios and predict exposure risk. PURPOSE: To identify and assess the incidence of SRCs in a National Collegiate Athletic Association football team by comparing field location, player positions, collision partners, and player cues. STUDY DESIGN: Descriptive epidemiology study. METHODS: We used physician sideline reports of diagnosed concussions from a Division I football team from September 2010 to December 2018. Game videos were analyzed to identify the field location where the SRC occurred, collision partner, and player behavior postconcussion. The incidence of in-game SRCs by position was also assessed. We used the "words of estimative probability" model to categorize each concussion as certain, almost certain, probable, or even on the basis of our confidence in identifying them using game film. RESULTS: This study examined 44 SRCs that occurred over 9 seasons. The SRC incidence was significantly higher in the middle defense (5-20 yards from the line of scrimmage) compared with all other field locations (relative risk, 2.46; 95% CI, 1.14-5.29; P < .05). In-game collision partners were most commonly defensive backs. The most common player cue was a hand to helmet/face mask. The positions with the highest SRC incidence by athlete-exposure, game position, and position play belonged to the defensive backs, wide receivers, and running backs. CONCLUSION: The middle defense had a significantly higher incidence of SRCs than all other field locations. We pose a new method to categorize concussions during video analysis by using words of estimative probability. Knowledge of SRC gameplay characteristics can potentially guide the medical staff and medical observer to better identify them.

The Prevalence of Elevated Blood Lead Levels in Foreign-Born Refugee Children Upon Arrival to the U.S. and the Adequacy of Follow-up Treatment.

This study sought to evaluate the prevalence of blood lead levels (BLL) in refugee children upon arrival to the U.S. and determine whether they received BLL screening and follow-up according to CDC guidelines. 301 refugee children ages 6 months to 16 years were seen at the International Family Medicine Clinic from 2003 to 2016. Data were collected on BLL, treatment, age, gender, English proficiency, native language, anemia, malnutrition, and microcytosis. Bivariate analyses were conducted to determine the association between these variables and BLL. The prevalence of elevated blood lead levels (EBLL), defined as ≥ 10 µg/dL before June 2012 and ≥ 5 µg/dL from June 2012, was observed in 13% (n = 39). Male sex (p = 0.033), young age (p = 0.003), and microcytosis (p = 0.009) were significantly associated with EBLL. Follow-up and treatment for EBLL were lower than the recommended CDC guidelines for BLL and greater education of healthcare providers is needed.

Role of the Ambulatory Care Clinical Pharmacist in Management of a Refugee Patient Population at a University-Based Refugee Healthcare Clinic.

BACKGROUND: The International Family Medicine Clinic (IFMC) at University of Virginia Health System serves refugees and special immigrants in Virginia. The IFMC comprises an interprofessional team including a clinical pharmacist. METHODS: A retrospective chart review of electronic medical records was performed. Adult refugee patients who attended a scheduled clinical pharmacist visit between October 6, 2015 and December 31, 2016 were included. The primary outcome was to characterize interventions made by a clinical pharmacist. Secondary outcomes included describing chronic disease states experienced by certain refugee populations and the clinical impact of pharmacist interventions in diabetes management. RESULTS: 80 refugee patients attended 275 clinical pharmacist visits. On average, visits lasted 30 min. Numerous patient interventions were made, including initiation of 68 new medications, discontinuation of 49 medications, and 66 medication dose changes. An average A1c reduction of 1.8% (p < 0.001) was noted. DISCUSSION: The clinical pharmacist can play an important role in refugee healthcare.

Facilitators and Barriers to Implementation of Safe Infant Sleep Recommendations in the Hospital Setting.

OBJECTIVE: To identify facilitators and barriers to the implementation of safe sleep recommendations from the American Academy of Pediatrics from the perspective of hospital staff as part of a needs assessment that was used to design a successful quality improvement intervention to change clinical practice. DESIGN: Qualitative design. SETTING: Multiple sites of three hospitals in the northeastern and southern United States. PARTICIPANTS: We used purposeful sampling to identify 46 participants who cared for infants on inpatient hospital units (nurses and other staff members). METHODS: A qualitative researcher used grounded theory to moderate the focus groups. We constructed the initial interview guide and then changed it as needed to capture more information about new ideas as they arose. Researchers from diverse backgrounds participated in the analysis and used the constant comparative method to select important concepts and to develop codes and subsequent themes. We continued to collect data until saturation was reached. RESULTS: We identified themes and subthemes, and the taxonomy fit into the Grol and Wensing framework for change in clinical practice. The six primary themes included The Innovation Itself, The Individual Health Care Professional, The Patient, The Social Context, The Organizational Context, and The Economic and Political Context. CONCLUSION: Participants described facilitators and barriers to the implementation of the American Academy of Pediatrics recommendations for safe infant sleep. Identification of these themes informed our quality improvement intervention to promote safe infant sleep. Findings can be used by others when faced with the need for similar change.

Mediators of Improved Adherence to Infant Safe Sleep Using a Mobile Health Intervention.

OBJECTIVES: To determine mediators of improvements in infant safe-sleep (SS) practices in a mobile health intervention. METHODS: In a cluster-randomized controlled trial, mothers received SS intervention or breastfeeding control videos for 60 days. Maternal responses about infant sleep position and location (outcomes) and mediators (attitudes, perceived social norms, and perceived control) from the theory of planned behavior were assessed. Intervention effects on mediators and association between mediators and outcomes were examined. RESULTS: Of 1600 recruited, 1263 mothers participated. Mothers receiving SS videos were more likely to have positive attitudes and norms for supine sleep (attitudes: adjusted odds ratio [aOR] = 2.35 [95% confidence interval (CI) 1.72 to 3.20]; norms: aOR = 1.75 [95% CI 1.27 to 2.42]) and recommended sleep location (attitudes: aOR = 1.91 [95% CI 1.54 to 2.36]; norms: aOR = 1.37 [95% CI 1.13 to 1.66]). Positive attitudes and norms toward supine sleep and room-sharing without bed-sharing were associated with higher odds of both practices (supine: aOR = 8.25 [95% CI 4.72 to 14.43] for positive attitudes and aOR = 6.67 [95% CI 4.25 to 10.46] for norms; room-sharing: aOR = 7.14 [95% CI 5.35 to 9.53] for positive attitudes and aOR = 4.44 [95% CI 3.03 to 6.51] for norms). Both positive attitudes and positive norms mediated the effect of the intervention. CONCLUSIONS: The intervention achieved success in improving adherence to SS recommendations by changing maternal attitudes and norms about supine sleeping and room-sharing without bed-sharing. Recognition that these attitudes and norms appear to be the main drivers of mothers' choices regarding infant-sleep practices should inform health messaging strategies to promote SS.

Emergency Department and Primary Care Use by Refugees Compared to Non-refugee Controls.

The U.S. grants asylum to 60,000-70,000 refugees yearly. However, little is known about their healthcare utilization practices. We examined data from emergency department (ED) and primary care (PC) visits of 694 refugees and 738 non-refugee controls over a 3 years period at a large academic medical center, comparing visit frequencies, Emergency Severity Index (ESI) scores, diagnoses, and dispositions. Refugees used emergency care services less frequently than the non-refugee controls (1.19 vs. 2.31, p < 0.0001) while there was no difference in their use of primary care services (8.45 vs. 9.07, p = 0.18). Non-English-speaking refugees were more likely to use the ED than English-speaking refugees (mean ED use in study period 1.50 visits vs. 0.73, p < 0.0001). Refugee patients utilized emergency services less often compared to controls. These results differ from previously studied refugee populations. Refugee-specific primary care services in this study population may reduce unnecessary ED use.

Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis.

CONTEXT: Sudden infant death syndrome (SIDS) is a leading cause of postneonatal infant mortality. Our previous meta-analyses showed that any breastfeeding is protective against SIDS with exclusive breastfeeding conferring a stronger effect.The duration of breastfeeding required to confer a protective effect is unknown. OBJECTIVE: To assess the associations between breastfeeding duration and SIDS. DATA SOURCES: Individual-level data from 8 case-control studies. STUDY SELECTION: Case-control SIDS studies with breastfeeding data. DATA EXTRACTION: Breastfeeding variables, demographic factors, and other potential confounders were identified. Individual-study and pooled analyses were performed. RESULTS: A total of 2267 SIDS cases and 6837 control infants were included. In multivariable pooled analysis, breastfeeding for <2 months was not protective (adjusted odds ratio [aOR]: 0.91, 95% confidence interval [CI]: 0.68-1.22). Any breastfeeding ≥2 months was protective, with greater protection seen with increased duration (2-4 months: aOR: 0.60, 95% CI: 0.44-0.82; 4-6 months: aOR: 0.40, 95% CI: 0.26-0.63; and >6 months: aOR: 0.36, 95% CI: 0.22-0.61). Although exclusive breastfeeding for <2 months was not protective (aOR: 0.82, 95% CI: 0.59-1.14), longer periods were protective (2-4 months: aOR: 0.61, 95% CI: 0.42-0.87; 4-6 months: aOR: 0.46, 95% CI: 0.29-0.74). LIMITATIONS: The variables collected in each study varied slightly, limiting our ability to include all studies in the analysis and control for all confounders. CONCLUSIONS: Breastfeeding duration of at least 2 months was associated with half the risk of SIDS. Breastfeeding does not need to be exclusive to confer this protection.

Beyond "Back to Sleep": Ways to Further Reduce the Risk of Sudden Infant Death Syndrome.

Sudden infant death syndrome (SIDS) remains the leading cause of postneonatal mortality in the United States, despite reduction in rates of more than 50% since the initiation of the "Back to Sleep" (now called "Safe to Sleep") campaign in 1994. In recent years, the rate of decline in SIDS deaths has plateaued, even with the ongoing educational efforts that promote safe sleep and other risk reduction measures. The 2016 American Academy of Pediatrics guidelines for reducing the risk of SIDS focus heavily on sleep practices, bedding, and location, but also include factors that often receive less attention (ie, prenatal care, maternal smoking, alcohol and drug use, and childhood vaccinations). This review describes these factors that are less often addressed and identifies interventions that have resulted in positive behavioral changes that not only benefit infants, but also promote the health and well-being of their mothers. [Pediatr Ann. 2017;46(8):e284-e290.].

The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices: A Randomized Clinical Trial.

Importance: Inadequate adherence to recommendations known to reduce the risk of sudden unexpected infant death has contributed to a slowing in the decline of these deaths. Objective: To assess the effectiveness of 2 interventions separately and combined to promote infant safe sleep practices compared with control interventions. Design, Setting, and Participants: Four-group cluster randomized clinical trial of mothers of healthy term newborns who were recruited between March 2015 and May 2016 at 16 US hospitals with more than 100 births annually. Data collection ended in October 2016. Interventions: All participants were beneficiaries of a nursing quality improvement campaign in infant safe sleep practices (intervention) or breastfeeding (control), and then received a 60-day mobile health program, in which mothers received frequent emails or text messages containing short videos with educational content about infant safe sleep practices (intervention) or breastfeeding (control) and queries about infant care practices. Main Outcomes and Measures: The primary outcome was maternal self-reported adherence to 4 infant safe sleep practices of sleep position (supine), sleep location (room sharing without bed sharing), soft bedding use (none), and pacifier use (any); data were collected by maternal survey when the infant was aged 60 to 240 days. Results: Of the 1600 mothers who were randomized to 1 of 4 groups (400 per group), 1263 completed the survey (78.9%). The mean (SD) maternal age was 28.1 years (5.8 years) and 32.8% of respondents were non-Hispanic white, 32.3% Hispanic, 27.2% non-Hispanic black, and 7.7% other race/ethnicity. The mean (SD) infant age was 11.2 weeks (4.4 weeks) and 51.2% were female. In the adjusted analyses, mothers receiving the safe sleep mobile health intervention had higher prevalence of placing their infants supine compared with mothers receiving the control mobile health intervention (89.1% vs 80.2%, respectively; adjusted risk difference, 8.9% [95% CI, 5.3%-11.7%]), room sharing without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4% [95% CI, 9.3%-15.1%]), no soft bedding use (79.4% vs 67.6%; adjusted risk difference, 11.8% [95% CI, 8.1%-15.2%]), and any pacifier use (68.5% vs 59.8%; adjusted risk difference, 8.7% [95% CI, 3.9%-13.1%]). The independent effect of the nursing quality improvement intervention was not significant for all outcomes. Interactions between the 2 interventions were only significant for the supine sleep position. Conclusions and Relevance: Among mothers of healthy term newborns, a mobile health intervention, but not a nursing quality improvement intervention, improved adherence to infant safe sleep practices compared with control interventions. Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied. Trial Registration: clinicaltrials.gov Identifier: NCT01713868.

Evaluation of bedtime basics for babies: a national crib distribution program to reduce the risk of sleep-related sudden infant deaths.

Rates of sleep-related infant deaths have remained stagnant in recent years. Although most parents are aware of safe sleep recommendations, barriers to adherence, including lack of access to a safe crib, remain. The objective of this study was to describe parental knowledge and practices regarding infant sleep position, bedsharing, pacifier use, and feeding practices before and after receipt of a free crib and safe sleep education. Bedtime Basics for Babies (BBB) enrolled high-risk families in Washington, Indiana, and Washington, DC and provided them with cribs and safe sleep education. Parents completed surveys before ("prenatal" and "postnatal") and 1-3 months after crib receipt ("follow-up"). Descriptive and bivariate analyses were completed. 3,303 prenatal, 1,483 postnatal, and 1,729 follow-up surveys were collected. Parental knowledge of recommended infant sleep position improved from 76% (prenatal) and 77% (postnatal) to 94% after crib receipt (p < 0.001). Intended use of supine positioning increased from 84% (prenatal) and 80% (postnatal) to 87% after the intervention (p < 0.001). Although only 8% of parents intended to bedshare when asked prenatally, 38% of parents receiving the crib after the infant's birth reported that they had bedshared the night before. This decreased to 16% after the intervention. Ninety percent reported that the baby slept in a crib after the intervention, compared with 51% postnatally (p < 0.01). BBB was successful in changing knowledge and practices in the majority of high-risk participants with regards to placing the infant supine in a crib for sleep. Crib distribution and safe sleep education positively influence knowledge and practices about safe sleep.

Pacifier use and SIDS: evidence for a consistently reduced risk.

Pacifier use at sleep time decreases sudden infant death syndrome (SIDS) risk. It is yet unclear whether pacifier use can modify the impact of other sleep-related factors upon SIDS risk. The objective of this study was to examine the association between pacifier use during sleep and SIDS in relation to other risk factors and to determine if pacifier use modifies the impact of these risk factors. Data source was a population based case-control study of 260 SIDS deaths and 260 matched living controls. Pacifier use during last sleep decreased SIDS risk (aOR 0.30, 95% CI 0.17-0.52). Furthermore, pacifier use decreased SIDS risk more when mothers were ≥20 years of age, married, nonsmokers, had adequate prenatal care, and if the infant was ever breastfed. Pacifier use also decreased the risk of SIDS more when the infant was sleeping in the prone/side position, bedsharing, and when soft bedding was present. The association between adverse environmental factors and SIDS risk was modified favorably by pacifier use, but the interactions between pacifier use and these factors were not significant. Pacifier use may provide an additional strategy to reduce the risk of SIDS for infants at high risk or in adverse sleep environments.