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

Racial and Ethnic Disparities in Sudden Unexpected Infant Death Among US Infants Born Preterm

OBJECTIVE

To investigate among US infants born at <37 weeks gestation (a) racial and ethnic disparities in sudden unexpected infant death (SUID) and (b) state variation in SUID rates and non-Hispanic Black (NHB)-non-Hispanic White (NHW) SUID disparity ratio.

METHODS

In this retrospective cohort analysis of linked birth and death certificates from 50 states from 2005 to 2014, SUID was defined by the following International Classification of Diseases, 9th or 10th edition, codes listed on death certificates: (7980, R95 or Recode 135; ASSB: E913, W75 or Recode 146; Unknown: 7999 R99 or Recode 134). Multivariable models were used to assess the independent association between maternal race and ethnicity and SUID, adjusting for several maternal and infant characteristics. The NHB-NHW SUID disparity ratios were calculated for each state.

RESULTS

Among 4 086 504 preterm infants born during the study period, 8096 infants (0.2% or 2.0 per 1000 live births) experienced SUID. State variation in SUID ranged from the lowest rate of 0.82 per 1000 live births in Vermont to the highest rate of 3.87 per 1000 live births in Mississippi. Unadjusted SUID rates across racial and ethnic groups varied from 0.69 (Asian/Pacific Islander) to 3.51 (NHB) per 1000 live births. In the adjusted analysis, compared with NHW infants, NHB and Alaska Native/American Indian preterm infants had greater odds of SUID (aOR, 1.5;[95% CI, 1.42-1.59] and aOR, 1.44 [95% CI, 1.21-1.72]) with varying magnitude of SUID rates and NHB-NHW disparities across states.

CONCLUSIONS

Significant racial and ethnic disparities in SUID among preterm infants exist with variation across US states. Additional research to identify the drivers of these disparities within and across states is needed.

Fathers, Breastfeeding, and Infant Sleep Practices: Findings From a State-Representative Survey

OBJECTIVES

To assess infant breastfeeding initiation and any breastfeeding at 8 weeks and safe sleep practices (back sleep position, approved sleep surface, and no soft objects or loose bedding ["soft bedding"]) by select paternal characteristics among a state-representative sample of fathers with new infants.

METHODS

Pregnancy Risk Assessment Monitoring System (PRAMS) for Dads, a novel population-based cross-sectional study, surveyed fathers in Georgia 2-6 months after their infant's birth. Fathers were eligible if the infant's mother was sampled for maternal PRAMS from October 2018 to July 2019.

RESULTS

Of 250 respondents, 86.1% reported their infants ever breastfed and 63.4% reported breastfeeding at 8 weeks. Initiation and breastfeeding at 8 weeks were more likely to be reported by fathers who reported wanting their infant's mother to breastfeed than those who did not want her to breastfeed or had no opinion (adjusted prevalence ratio [aPR] = 1.39; 95% confidence interval [CI], 1.15-1.68; aPR = 2.33; 95% CI, 1.59-3.42, respectively) and fathers who were college graduates than those with ≤high school diploma (aPR = 1.25; 95% CI, 1.06-1.46; aPR = 1.44; 95% CI, 1.08-1.91, respectively). Although about four-fifths (81.1%) of fathers reported usually placing their infants to sleep on their back, fewer fathers report avoiding soft bedding (44.1%) or using an approved sleep surface (31.9%). Non-Hispanic Black fathers were less likely to report back sleep position (aPR = 0.70; 95% CI, 0.54-0.90) and no soft bedding (aPR = 0.52; 95% CI, 0.30-0.89) than non-Hispanic white fathers.

CONCLUSIONS

Fathers reported suboptimal infant breastfeeding rates and safe sleep practices overall and by paternal characteristics, suggesting opportunities to include fathers in promotion of breastfeeding and infant safe sleep.

Maternal Informal Learning Experiences that Shape Parenting Practices

Objective

Current understanding of the linkage between maternal education and parenting practices has largely been informed using a narrow definition of educational attainment-the highest level of education an individual has completed. However, the proximal processes that shape parenting, including informal learning experiences, are also important to understand. Less is known about the informal learning experiences that shape parenting decisions and practices. To this end, we conducted a qualitative inquiry about the informal learning experiences of mothers of children ages 3 to 4 years with the specific goal of understanding how maternal informal learning experiences shape parenting decisions and practices.

Design

We conducted interviews with 53 mothers from across the United States who had previously participated in a randomized controlled trial (RCT) of an intervention targeting infant care practices. We recruited a purposive sample of mothers chosen to maximize diversity across educational attainment and adherence to infant care practices targeted in the RCT. Using a grounded theory approach, data were analyzed using an iterative process for organizing codes and themes that mothers identified as informal learning experiences.

Results

We identified seven themes representing distinct types of maternal informal learning experiences that impact parenting practices, including: (1) experiential learning during childhood; (2) experiential learning during adulthood; (3) interpersonal interactions including via social media; (4) experiences with non-interactive media sources; (5) informal trainings; (6) beliefs; and (7) current circumstances.

Conclusions

Multiple informal learning experiences inform the parenting decisions and practices of mothers with varying levels of formal educational attainment.

Does Exposure to Pediatrician or Parent Blog Content Influence Infant Safe Sleep Practices?

OBJECTIVE

To examine whether exposure to safe sleep recommendations using a blog format changed infant sleep practices.

METHODS

We conducted a pilot randomized controlled trial via Qualtrics, a web-based platform, with a national sample of parents of children < 1 year old. Survey questions about infant sleep practices included: bed-sharing, location, position and objects present. Safe sleep was defined as not bed-sharing, in a crib, bassinet or playard, back positioning, and no other objects present except pacifiers. Participants were randomized to read one of the following: (1) pediatrician blog post, (2) parent blog post, or (3) no blog post. The blog posts contained the same content about infant sleep but varied by identified authorship. All participants received links to online content about safe sleep. Participants received a follow-up survey 2-4 weeks later with the same questions about infant sleep practices. We compared responses in pre- and post-surveys by type of blog post exposure using multivariable logistic regression models.

RESULTS

The average infant age (n = 1500) was 6.6 months (Standard Deviation 3.3). Most participants (74%) were female; 77% were married; 65% identified as white Non-Hispanic, 12% were black and 17% were Hispanic. 47% (n = 711) completed both surveys. We identified no differences in the odds of any of the four safe sleep practices after exposure to safe sleep recommendations in blog post format.

CONCLUSION

Although in-person advice has been associated with improved safe sleep practices, we did not identify changes in infant sleep practices after exposure to safe sleep advice using blog posts.

Evaluation of Breastfeeding Applications Through the Eyes of Saudi Mothers

INTRODUCTION

Breastfeeding is crucial for an infant's health and plays a significant role in mothers' well-being. The recommendation from WHO is to breastfeed your baby for the first six months exclusively, then complementary food is introduced with the continuity of breastfeeding until 24 months or more. Breastfeeding can be challenging, especially for a first-time mom; some mothers also lack knowledge about breastfeeding benefits. Thus, mobile health (mHealth) intervention can raise awareness, provide educational information and emotional support, and offer consultation. Saudi mothers seek an application designed based on their needs.

OBJECTIVES

The objective of this study was to analyze the most common breastfeeding application, then extract standard and valuable features. The most useful features were added to the survey and distributed among Saudi mothers. Next, participants' responses to these features were evaluated for recommendation when building a breastfeeding application for Saudi mothers.

METHOD

This is a quantitative cross-sectional study designed to analyze and explore what Saudi women need in a breastfeeding application to help them make better decisions and provide support. The data was collected through a questionnaire instrument designed after collecting the most valuable features in mobile breastfeeding applications.

RESULTS

The number of Saudi mothers enrolled in this study was 492. Most mothers (90%) were currently breastfeeding or had previous experience with breastfeeding. The participant responses divided results into three categories: essential, recommended, and nice-to-be-added features. One of the highest percentages of important features was adding a section for baby food recipes and how to introduce food.

CONCLUSION

Saudi mothers need a trustable source of information, consultation, support, and tools to guide them through breastfeeding. With the help of the mHealth application, the breastfeeding experience can be improved.

Analysis of research on interventions for the prevention of safety accidents involving infants: a scoping review

PURPOSE

This study aimed to conduct a scoping review of studies on interventions for the prevention of safety accidents involving infants.

METHODS

The scoping review method by Arksey and O'Malley was used to conduct an overview based on information spanning a wide range of fields. Multiple electronic databases, PubMed, CINAHL, RISS, and KISS, were searched for articles written in English or Korean published from 2012 to the present on safety accident prevention interventions. A total of 2,137 papers were found, and 20 papers were ultimately analyzed.

RESULTS

Most studies were conducted in the United States (55.0%) and in the medical field (45.0%), and most were experimental studies (35.0%). The results were organized across five categories: 1) preventive precautions, 2) characteristics of children's developmental stages, 3) encouraging voluntary participation, 4) continuity of interventions, and 5) teaching methods.

CONCLUSION

Safety accident prevention interventions should cover the establishment of a safe home environment, include voluntary participation, and provide routine follow-up interventions. Additionally, practical training and teaching methods that incorporate feedback rather than a lectureoriented approach should be adopted.

Mobile Health Interventions and RCTs: Structured Taxonomy and Research Framework

Mobile Health Interventions (MHIs) have addressed a range of healthcare challenges and have been evaluated using Randomized Controlled Trials (RCTs) to establish clinical effectiveness. Using PRISMA we conducted a systematic literature review of RCTs for MHIs and identified 70 studies which were analyzed and classified using Nickerson-Varshney-Muntermann (NVM) taxonomy. From the resultant iterations of the taxonomy, we extracted insights from the categorized studies. RCTs cover a wide range of health conditions including chronic diseases, general wellness, unhealthy practices, family planning, end-of-life, and post-transplant care. The MHIs that were utilized by the RCTs were varied as well, although most studies did not find significant differences between MHIs and usual care. The challenges for MHI-based RCTs include the use of technologies, delayed outcomes, patient recruitment, patient retention, and complex regulatory requirements. These variances can lead to a higher rate of Type I/Type II errors. Further considerations are the impact of infrastructure, contextual and cultural factors, and reductions in the technological relevancy of the intervention itself. Finally, due to the delayed effect of most outcomes, RCTs of insufficient duration are unable to measure significant, lasting improvements. Using the insights from seventy identified studies, we developed a classification of existing RCTs along with guidelines for MHI-based RCTs and a research framework for future RCTs. The framework offers opportunities for (a) personalization of MHIs, (b) use of richer technologies, and (c) emerging areas for RCTs.

Emergency Department Visits Before Sudden Unexpected Infant Death: A Touchpoint for Unsafe Sleep Reduction

OBJECTIVES

Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death.

METHODS

We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID.

RESULTS

Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3.

CONCLUSIONS

Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts.

The Impact of Breastfeeding and Safe Sleep Mobile Health Messaging on Breastfeeding and Bedsharing

OBJECTIVE

Mobile health (mHealth) safe sleep messaging increases rates of safe sleep. Bedsharing is more common among breastfeeders. Advice to not bedshare may negatively impact breastfeeding. We compared the impact of safe sleep or breastfeeding mHealth messaging on bedsharing and breastfeeding at 2 to 5 months.

METHODS

This is a secondary analysis of mothers who initiated breastfeeding from a cluster randomized clinical trial of mHealth messaging for safe sleep or breastfeeding. A multi-ethnic sample of 1600 mothers was recruited from 16 US birth hospitals and surveyed at 2 to 5 months regarding the previous 2 weeks' breastfeeding and bedsharing practices. Data on 997 mothers who initiated breastfeeding were analyzed with multivariable generalized estimating logistic regression models to examine the association of mHealth messaging with infant care practices.

RESULTS

Overall, exposure to breastfeeding versus safe sleep messaging was not associated with a difference in any breastfeeding at 2 to 5 months (69.3% vs 65.5%, respectively; adjusted odds ratio [aOR] = 1.33 [95% confidence interval, 0.91, 1.94]). Women with shorter planned duration of breastfeeding who received breastfeeding messaging had increased odds of breastfeeding at 2 to 5 months (50% vs 31%; aOR 3.13 [95% CI, 1.47, 6.65]). Mothers who received safe sleep messaging had lower rates of bedsharing overall when compared to breastfeeding messaging (24.8% vs 35.2%; aOR = 0.58 [95% CI, 0.44, 0.78]).

CONCLUSIONS

In this large multi-ethnic US sample, receipt of safe sleep mHealth messaging was associated with lower rates of bedsharing without negatively impacting breastfeeding rates. Future research should focus on continued development of interventions to improve adherence to both safe sleep and breastfeeding recommendations.

Exploring the Use of a Facebook-Based Support Group for Caregivers of Children and Youth With Complex Care Needs: Qualitative Descriptive Study

BACKGROUND

Caregivers of children and youth with complex care needs (CCN) require substantial support to ensure the well-being of their families. Web-based peer-to-peer (P2P) support groups present an opportunity for caregivers to seek and provide timely informational and emotional support. Despite the widespread use of social media for health-related support across diverse patient and caregiver populations, it is unclear how caregivers of children and youth with CCN use and potentially benefit from these groups.

OBJECTIVE

The aim of this study is to explore the use of a web-based P2P support group for caregivers of children and youth with CCN in New Brunswick, Canada, and investigate factors related to its use by members.

METHODS

The study sample consisted of individuals who joined a closed Facebook group and an analysis of content published to the group. In phase 1, a Facebook group was developed in consultation with a patient and family advisory council, and members were recruited to the group. Phase 2 of this study consisted of an observation period during which posts and related interactions (ie, likes, loves, and comments) by members were collected. In phase 3, a web-based survey was distributed, and semistructured interviews were conducted with a subsample of group members. Survey and interview data were analyzed using thematic analysis.

RESULTS

A total of 108 caregivers joined the Facebook group between October 2020 and March 2021. There were 93 posts with 405 comments and 542 associated interactions (448/542, 82.7% likes and 94/542, 17.3% loves). Of these 93 posts, 37 (40%) were made by group members, and 56 (60%) were made by moderators. Of the 108 members, a subsample of 39 (36.1%) completed a web-based survey, and 14 (13%) participated in the interviews. Content analyses of posts by members revealed that inquiry (17/37, 46%), informational (15/37, 41%), and emotional posts (4/37, 11%) were the most common. Emotional posts received the highest number of interactions (median 24.5). In total, 5 themes emerged from the interviews related to the use of the group and mediating factors of interactions between group members: resource for information, altruistic contribution, varying level of engagement, perceived barriers to and facilitators of group activity, and moderators as contributing members.

CONCLUSIONS

These findings demonstrate that caregivers of children and youth with CCN seek geography-specific P2P support groups to meet informational and social support needs. This study contributes to the knowledge on how caregivers use Facebook groups to meet their support needs through moderate and passive engagement.

Safe Sleep Behaviors and Factors Associated With Infant Second Sleep Practices

OBJECTIVES

To examine the prevalence and safety of infant second-sleep practices.

METHODS

A cross-sectional online survey of parents with infants ≤12 months assessed parent-reported sleep practices: position, use of a separate sleep surface, and sleep location at 2 time points (sleep onset and after nighttime waking). A composite score examined if all 3 safe sleep practices were used at each time point. Safe sleep was defined as: supine position, sleeping in a separate space, and in a crib, bassinet, cradle, or playard. Wilcoxon sign rank test was used to examine changes between the time points. Poisson regression models compared parents who reported a second-sleep location with those who did not.

RESULTS

Of participants (n = 1500), 74% were female, 65% were White, 12% were Black, and 17% were of Hispanic ethnicity. Thirty-nine percent (n = 581) reported a second-sleep practice. Of parents who reported a second-sleep practice, 28% (n = 137) met all 3 safe sleep criteria at sleep onset; 9% (n = 42) met all 3 safe sleep criteria at both time points. A higher proportion of changes in sleep practices were to less-safe practices (P <.001). Factors associated with a second-sleep practice were parental age <25 years, parental race and ethnicity, first-time parents, homes with smoke exposure, and infants born at <37 weeks.

CONCLUSIONS

Less than 10% of infants met all 3 safe sleep criteria at sleep onset and after nighttime waking. Interventions focused on safe sleep should highlight the importance of safe sleep practices after nighttime waking.

Renewed Attention Needed for Prevention of Sudden Unexpected Death in Infancy in the Netherlands

Background: The incidence of sudden unexpected death in infancy (SUDI), which includes sudden infant death syndrome (SIDS), has declined in developed countries since the 1980s, including the Netherlands. To identify improvement opportunities in SUDI prevention, we monitored the adherence of parents to the prevention advice on infant care habits over the past 20 years, especially in relation to the SUDI incidence over time. Potential changes in parental adherence between the latest surveys are of specific interest, as these indicate where current focus is needed. Methods: Description of the prevalence of infant care factors related to the risk of SUDI, assessed from five Dutch national surveys from 1999 to 2017 among parents of infants under 12 months, and analysis of the potential differences in these prevalences between the two latest surveys in 2010/11 and 2017 with a z-test. Results: Supine sleeping position decreased from the highest prevalence of 92% in 2010/11, to 83% in 2017. Sleep sack use has increased to 55%, the highest prevalence up to now. Avoiding a duvet has remained reasonably stable since 2002/03 and now 95% of parents do not use a duvet. The prevalence of room-sharing, without sharing the bed, increased from 14% in 1999 to the highest prevalence in 2017 (31%). However, also bed-sharing almost doubled from 5.6% in 2010/11 to 10% in 2017. Breastfeeding decreased between 1999 and 2010/11, but increased from 34% in 2010/11 to 42% in 2017. An increased prevalence of mothers who abstained from smoking during pregnancy, as well as both parents not smoking, was observed, although mostly higher educated parents showed this beneficial behavior. Discussion and Conclusion: Much has already been achieved first by decreasing prone sleeping since the 80's, and subsequently promoting supine as the safest sleep position. The decrease in duvet use and smoking, and an increase in breastfeeding have also had impact. Indications of a recent decreased prevalence of the supine sleeping position and higher prevalence of bed-sharing might relate to the slightly increasing SUDI incidence in the Netherlands. Renewed attention for prevention of SUDI and specific advice targeting high-risk groups is needed. Modern, picture driven information via internet is recommended.

Understanding the barriers and facilitators to safe infant sleep for mothers of preterm infants

OBJECTIVE

To identify barriers and facilitators to adherence to safe sleep practices (SSP) among mothers of preterm infants using qualitative methodology.

DESIGN

We conducted 23 in-depth interviews in English or Spanish with mothers of preterm infants who were recently discharged from four hospitals, utilizing a grounded-theory approach and framework of the Theory of Planned Behavior (attitudes, perceived control, social norms).

RESULTS

For attitudes, mothers' fear about their infants' vulnerable preterm state related to suffocation, apnea of prematurity, and reflux influenced infant sleep practices. For social norms, education received in the NICU and advice from other health care providers, family, friends, and media impacted their choices. For perceived control, mothers adapted infant sleep practices to meet their own needs and address the perceived safety and comfort of infants.

CONCLUSION

Factors identified that influence maternal decision-making about infant sleep practices can inform interventions to address sudden unexpected infant death reduction in preterm infants.

Sudden Unexpected Infant Death: Keeping the Newborn Safe in Hospital and at Home

Sudden unexpected infant death is a leading cause of death in infancy. Both safe sleep practices and breastfeeding can help decrease the risk, although the current practice of educating parents about the recommendations has not resulted in universal adherence. Prenatal counseling provides opportunities to discuss recommendations as well as troubleshoot common barriers to breastfeeding and safe infant sleep with goals to gradually change attitudes, address social norms, and prepare new parents. A conversational, motivational approach to discussions about the importance of safe sleep and continued breastfeeding, with explanations as to the reasoning behind these recommendations, can help parents incorporate optimal practices into their lifestyles in a way that is sustainable for adherence.

Influence of psychological nursing on negative emotion and sleep quality of glaucoma trabeculectomy patients

OBJECTIVE

To investigate the influence of psychological nursing on negative emotion and sleep quality of glaucoma trabeculectomy patients.

METHODS

Ninety glaucoma patients treated in our hospital were obtained as research participants and were randomly divided into the control group (45 cases, adopted eyeball massage) and the observation group (45 cases adopted eyeball massage with psychological nursing). The negative emotions (Hamilton Anxiety and Depression Scale (HAMA, HAMD)), sleep quality (PSQI scale), quality of life (GQOLI-74 scale), vision (national standard visual acuity chart) and complications were compared between the two groups.

RESULTS

The scores of HAMA, HAMD and PSQI of patients in both groups decreased when they were discharged from hospital, especially in the observation group (all P<0.05). One month and 3 months after operation, BCVA of affected eyes in both groups was significantly higher than that before operation, and that of the control group was higher than that in the observation group (all P<0.05). The scores of GQOLI-74 in both groups were increased, and the scores of the control group were higher than those in the observation group (all P<0.05). The incidence of complications in the observation group was lower than that in the control group (P<0.05).

CONCLUSION

Psychological nursing on the basis of eyeball massage can effectively relieve the bad psychology of glaucoma patients after trabeculectomy, improve their sleep quality and life quality, and have less postoperative complications and good vision recovery.

Using an App to monitor postoperative pain at home in pediatric patients

A prospective comparative study was conducted in 487 pediatric patients (69% male, mean age = 6.4 ± 4.0) to evaluate (a) the incidence, intensity, and characteristics of pain in pediatric patients at home during the first 24 hours and 5 days after surgery and (b) the factors associated with higher pain intensity, including the impact of an application (App) compared to the paper-and-pencil approach. Postoperative pain was assessed by patients or their parents at home using the 'Bambino Gesù' Children's Hospital (Ospedale Pediatrico Bambino Gesù, OPBG) tool for participants aged 4-17 years or the Faces, Legs, Arms, Cry, and Consolability scale for participants less than four years old. Participants were assigned to two groups: those who used the paper-and-pencil version of the pain scale and those who used the App. Overall, 209 of the 472 (44%) participants reported pain during the first 24 hours, and 92 of the 420 (22%) reported pain between one and five days after surgery. Higher pain intensity scores were associated with being in the App group, directly assessing own pain, and using the OPBG tool. The App was effective in facilitating pain assessment. Health professionals could empower pediatric patients and their parents in assessing pain at home through a dedicated App.

Type I error control for cluster randomized trials under varying small sample structures

Background

Linear mixed models (LMM) are a common approach to analyzing data from cluster randomized trials (CRTs). Inference on parameters can be performed via Wald tests or likelihood ratio tests (LRT), but both approaches may give incorrect Type I error rates in common finite sample settings. The impact of different combinations of cluster size, number of clusters, intraclass correlation coefficient (ICC), and analysis approach on Type I error rates has not been well studied. Reviews of published CRTs find that small sample sizes are not uncommon, so the performance of different inferential approaches in these settings can guide data analysts to the best choices.

Methods

Using a random-intercept LMM stucture, we use simulations to study Type I error rates with the LRT and Wald test with different degrees of freedom (DF) choices across different combinations of cluster size, number of clusters, and ICC.

Results

Our simulations show that the LRT can be anti-conservative when the ICC is large and the number of clusters is small, with the effect most pronouced when the cluster size is relatively large. Wald tests with the between-within DF method or the Satterthwaite DF approximation maintain Type I error control at the stated level, though they are conservative when the number of clusters, the cluster size, and the ICC are small.

Conclusions

Depending on the structure of the CRT, analysts should choose a hypothesis testing approach that will maintain the appropriate Type I error rate for their data. Wald tests with the Satterthwaite DF approximation work well in many circumstances, but in other cases the LRT may have Type I error rates closer to the nominal level.

Disparities in Breastfeeding Among U.S. Black Mothers: Identification of Mechanisms

Objective: Disparities in U.S. breastfeeding rates persist among Black mothers according to birth country and between Black and White mothers, necessitating further investigation of modifiable mediating factors to inform interventions. This study seeks to examine the extent that social, maternal, infant factors and Theory of Planned Behavior (TPB) domains (attitudes, perceived control, and subjective norms) mediate the association of maternal race/birth country and breastfeeding continuation. Methods: A national cohort of 2,050 mothers self-identifying as U.S.-born non-Hispanic Black (n = 689), foreign-born non-Hispanic Black (n = 139), and U.S.-born non-Hispanic White (n = 1,222) was analyzed. Using logistic regression, associations of race/birth country and any/exclusive breastfeeding at 2-6 months were examined. Structural equation modeling was used to determine whether social, maternal, and infant factors and TPB domains mediate these relationships. Results: 40.0% of U.S.-born Black, 82.2% of foreign-born Black, and 57.3% of U.S.-born White mothers reported any breastfeeding at 2-6 months. Compared with U.S.-born Black mothers, odds of any breastfeeding were sevenfold higher among foreign-born Black mothers (odds ratio [OR] = 7.04 95% confidence interval [CI] = 4.80-10.31), which was explained partly by social/maternal/infant factors and TPB domains. Compared with U.S.-born White mothers, any breastfeeding was lower (OR = 0.54, 95% CI = 0.40-0.73) among U.S.-born Black mothers and higher (OR = 3.81, 95% CI = 2.48-5.87) among foreign-born Black mothers; these differences were also mediated by the aforementioned factors. Conclusions: Among Black mothers in the United States, breastfeeding continuation varied substantially by birth country. Promotion of interventions targeting positive attitudes, perceived control, and subjective norms may reduce disparities among Black and between Black and White mothers.

Information and communication technologies in neonatal health

Objectives. To identify scientific evidence on the use and results of information and communication technologies for the improvement of neonatal health in general or specific health problems or interventions, and to describe the type of intervention and its results.

Methods. A systematic review of the available evidence was performed. The search was carried out in peerreviewed journals between January 1, 2008 and April 30, 2018, in English and Spanish. The searched key terms were (health informatics OR telemedicine OR mHealth) AND (newborn OR newborn care OR neonatal care).

Results. From a total of 305 articles initially identified, 10 articles fulfilled the inclusion criteria. The main domains of eHealth identified as applied to neonatal health were telemedicine (3 studies), eLearning (1 study) and mHealth (7 studies). Target population were health care providers or parents. The studies aimed at diagnosis, provision of health care and training, promoting adherence to interventions in parents or improving quality of care.

Conclusions. The use of eHealth in general and specifically focused on neonatal health shows important possibilities for development and expansion, given the advances and present needs, and should be considered a key tool for the reduction of inequalities.

Improving infant sleep safety via electronic health record communication: a randomized controlled trial

BACKGROUND

With increased use of telehealth, interventions to improve infant sleep environments have not been explored. This study sought to assess the feasibility and efficacy of using electronic health record patient portals to transmit photographs of infant sleep between mothers and healthcare professionals as part of an intervention to promote sleep environments consistent with AAP guidelines.

METHODS

One hundred eighty-four mother-newborn dyads consented to participate in a randomized trial requiring patient portal registration within 1 month of delivery. We first assessed feasibility as measured by a) the proportion of consented mothers enrolling in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Intervention group mothers were prompted at 1 and 2 months; controls were prompted only at 2 months. Efficacy was determined via research assistant review of submitted photographs. These assistants were trained to detect sudden unexplained infant death risk factors utilizing AAP guidelines. Standardized feedback was returned to mothers through the patient portal. We used Fisher's Exact test to assess group differences in guideline adherence at 2 months.

RESULTS

One hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25-52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28-46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI - 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface.

CONCLUSIONS

Utilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices.

TRIAL REGISTRATION

Name: Improving Infant Sleep Safety With the Electronic Health Record; Clinicaltrials.gov: NCT03662048 ; Date of Registration: September 7, 2018; Data Sharing Statement: None.

Perspectives and experiences of Chinese nurses on quality improvement initiatives: A mixed-methods study

AIM

To investigate Chinese nurses' views and experiences in relation to quality improvement implementation, as well as to determine the impact of contextual factors on nursing quality improvement initiatives.

BACKGROUND

Nurses play a major role in carrying out quality improvement initiatives. Contextual factors influence the implementation and success of quality improvement initiatives. Studies that investigated the impact of contextual factors on Chinese nurses' practice in quality improvement remain limited.

METHODS

A sequential explanatory mixed-methods design was used for this study. A quantitative cross-sectional survey was used to assess the context of quality improvement initiatives. Simple random sampling was used to recruit quality improvement teams. The sample included 356 nurses from tertiary teaching hospitals; 291 (81.7%) of them completed questionnaires. Nursing managers and nurses (n = 18) were purposively selected to participate in semi-structured interviews; their experiences and perceptions regarding the contextual factors of quality improvement initiatives were obtained.

RESULTS

In the quantitative phase, the "microsystem" (mean=5.24) and "QI team" (mean = 4.97) contexts were reported as supportive contexts. The organizational context was weak, with a mean score of 3.92. In the qualitative phase, three themes related to the contextual challenges emerged: (1) nurses' attitudes and satisfaction, (2) team efficacy, and (3) organizational infrastructure and culture.

CONCLUSIONS

Efforts to elevate organizational culture and reward systems are needed in Chinese hospitals. Further education aimed at increasing skills and knowledge should be provided, to ensure effective quality improvement implementation.

IMPLICATIONS FOR NURSING MANAGEMENT

During quality improvement initiatives, management tasks should focus on increasing nurses' satisfaction, solving skill and knowledge deficits, and clarifying nurses' roles in relation to quality improvement.

Safe to sleep: Community-based caregiver training

Annually, thousands of infant deaths are classified as sudden unexpected infant deaths (SUIDs). In an effort to reduce the risk of SUIDs, the American Academy of Pediatrics has made a number of recommendations to educate caregivers, childcare providers, and healthcare professionals on safe infant sleep practices. The purpose of the current study was to extend the literature on safe infant sleep practices by teaching caregivers to arrange safe infant sleep environments using a mannequin and common infant items. We partnered with community-based agencies to evaluate the effectiveness of behavioral skills training delivered in a single training session as part of the ongoing pre- or postnatal care these agencies provided. Following training, all participants demonstrated a substantial change in responding and returned favorable social validity ratings. We discuss these outcomes in light of previous studies, limitations, and future directions.

Telemedicine in Pediatric Sleep

Prior to the COVID-19 pandemic, few pediatric sleep medicine clinicians routinely engaged in telemedicine visits because thorough examinations were difficult to perform; there was lack of consistent reimbursement; and many clinicians were busy with their in-office practices. This article reviews how telemedicine has been explored in pediatric sleep medicine prior to the pandemic, current applications of telemedicine, challenges, and reimagining pediatric sleep within the realm of telemedicine.

Investigating Mechanisms for Maternal Education Disparities in Enacting Health-Promoting Infant Care Practices

BACKGROUND

Although higher education and healthier practices are positively associated, the explanatory mechanisms for this association remain unclear. The purpose of this study was to better understand mechanisms underlying this association by examining maternal adherence to 2 health-promoting infant care practices: supine placement and breastfeeding.

METHODS

We analyzed nationally representative data from the Study of Attitudes and Factors Effecting Infant Care, which surveyed US mothers after infant birth and 2 months thereafter. Using the Theory of Planned Behavior as a framework, we used structural equation models to elucidate mediational pathways from maternal education to supine infant placement or any breastfeeding.

RESULTS

Data from 3297 mothers demonstrated 77.0% of infants usually were placed supine, and 57.8% received any breastfeeding. The overall direct effect of maternal educational level on supine placement and any breastfeeding was odds ratio (OR) 1.31 (95% confidence interval [CI] 1.11-1.54) and OR 2.82 (95% CI 2.35-3.37), respectively. In pathway analyses, the strongest associations with both supine position and breastfeeding were seen with positive attitudes (supine: aOR 18.96, 95% CI 9.00-39.92; breastfeeding: aOR 3.86, 95% CI 2.19-6.82) and positive social norms (supine: aOR 6.69, 95% CI 4.52-9.89; breastfeeding: aOR 5.17, 95% CI 4.28-6.23). Mothers with more education had higher odds of both positive attitudes and positive norms for the 2 practices.

CONCLUSIONS

The associations linking educational attainment with health practices are intricate, with multiple mediating pathways. Attitudes and social norms are powerful forces that mediate the association between maternal educational attainment and both infant supine positioning and breastfeeding, and may be important mediators for other health behaviors.

Impact of statewide safe sleep legislation on hospital practices and rates of sudden unexpected infant deaths

Background

Sudden Unexpected Infant Death (SUID) is the leading cause of death in the post-neonatal period in the United States. In 2015, Connecticut (CT) passed legislation to reduce the number of SUIDs from hazardous sleep environments requiring birthing hospitals/centers provide anticipatory guidance on safe sleep to newborn caregivers before discharge. The objective of our study was to understand the barriers and facilitators for compliance with the safe sleep legislation by birthing hospitals and to determine the effect of this legislation on SUIDs associated with unsafe sleep environments.

Methods

We surveyed the directors and/or educators of the 27 birthing hospitals & one birthing center in CT, about the following: 1) methods of anticipatory guidance given to parents at newborn hospital discharge; 2) knowledge about the legislation; and 3) barriers and facilitators to complying with the law. We used a voluntary online, anonymous survey. In addition, we evaluated the proportion of SUID cases presented at the CT Child Fatality Review Panel as a result of unsafe sleep environments before (2011–2015) and after implementation of the legislation (2016–2018). Chi-Square and Fisher’s exact tests were used to evaluate the proportion of deaths due to Positional Asphyxia/Accident occurring before and after legislation implementation.

Results

All 27 birthing hospitals and the one birthing center in CT responded to the request for the method of anticipatory guidance provided to caregivers. All hospitals reported providing anticipatory guidance; the birthing center did not provide any anticipatory guidance. The materials provided by 26/27 (96%) of hospitals was consistent with the American Academy of Pediatrics (AAP) Guidelines. There was no significant change in rates of SUID in CT before (58.86/100,000) and after (55.92/100,000) the passage of the legislation (p = 0.78). However, more infants died from positional asphyxia after (20, 27.0%) than before the enactment of the law (p < 0.01).

Conclusions

Despite most CT hospitals providing caregivers with anticipatory guidance on safe sleep at newborn hospital discharge, SUIDs rates associated with positional asphyxia increased in CT after the passage of the legislation. The role of legislation for reducing the number of SUIDs from hazardous sleep environments should be reconsidered.

Assessing Feasibility of an Early Childhood Intervention Using Mobile Phones Among Low-Income Mothers of Newborns: Qualitative Interview Study

Background

Many children aged younger than 5 years living in low- and middle-income countries are at risk for poor development. Early child development (ECD) programs are cost-effective strategies to reduce poverty, crime, school dropouts, and socioeconomic inequality. With the spread of low-cost mobile phones and internet access in low- and middle-income countries, new service delivery models such as mobile phone–aided interventions have a great potential to improve early childhood development.

Objective

This study aimed to identify the beliefs on importance of ECD, feasibility of a proposed intervention using mobile phones and factors that may affect the usability of the intervention among mothers of newborns in a poverty-stricken area in southwestern China.

Methods

We conducted an in-depth, semistructured interview study of 25 low-income mothers of newborns recruited from two county hospitals in Yunnan Province. We applied the health belief model and cultural competence theories to identify the facilitators, barriers, and preferences among the target population for parenting knowledge.

Results

The results showed that the participants had low health literacy and high perceived needs for learning ECD knowledge. At the same time, they experienced several barriers to learning parenting information and following evidence-based instructions including having limited time, limited financial resources, and different opinions on childcare among family members. Many participants preferred to receive personalized messages tailored to their specific needs and preferred videos or graphics to text only in the messages. Many favored a separate module to support postpartum mental health.

Conclusions

The study assessed the acceptability of an early childhood intervention using mobile phones to meet the needs of the target population based on their beliefs, traits, and preferences and provided suggestions to refine the intervention to improve its usability.

The potential of digital phenotyping to advance the contributions of mobile health to self-management science

Digital phenotyping consists of moment-by-moment quantification of behavioral data from individual people, typically collected passively from smartphones and other sensors. Within the evolving context of precision health, digital phenotyping can advance the use of mobile health -based self-management tools and interventions by enabling more accurate prediction for prevention and treatment, facilitating supportive strategies, and informing the development of features to motivate self-management behaviors within real-world conditions. This represents an advancement in self-management science: with digital phenotyping, nurse scientists have opportunities to tailor interventions with increased precision. In this paper, we discuss the emergence of digital phenotyping, the historical background of ecological momentary assessment, and the current state of the science of digital phenotyping, with implications for research design, computational requirements, and ethical considerations in self-management science, as well as limitations.

Supporting African American Mothers during Nurse Home Visits in Adopting Safe Sleep Practices

BACKGROUND

Nurses providing home visits were concerned that some mothers were not routinely using safe sleep practices for their newborns and infants.

PURPOSE

The purpose of this study was to listen to how home visit nurses offer education to their African American clients about the safe to sleep guidelines during the prenatal and postpartum periods and discuss ways nurses could support mothers to be more successful in using safe sleep practices.

STUDY DESIGN AND METHODS

A focus group was conducted with home visit nurses who partner with pregnant mothers and follow them through the first 2 years of their child's life. We asked the nurses to discuss how they offer information and education to their African American clients about safe sleep practices and what could be done to support adoption of the guidelines. A qualitative narrative approach was used for data analysis.

RESULTS

Seventeen home visit nurses participated in the focus group. We identified two overall themes with eight subthemes. The first theme focused on nurses' perceptions about challenges some mothers have in following the recommendations. The second theme included nurses' perspectives on how to better promote the safe sleep message and educating mothers within their cultural context.

CLINICAL IMPLICATIONS

Expectant and new mothers need advice and knowledge about the Safe to Sleep guidelines that provide ways to decrease risk of infant death. Nurses must be aware of their clients' culture and beliefs so they can offer support and information on infant safety within that context.

Outpatient- or community-based interventions to prevent SIDS and sleep-related deaths

PURPOSE

To determine the state of science of outpatient- or community-based interventions for sudden infant death syndrome prevention in the United States, an integrative review was completed and studies identified through the application of inclusion and exclusion criteria.

CONCLUSIONS

Of the nine studies identified, three were randomized controlled trials. There was a wide range of measurement tools and variables measured. The timing of interventions also varied. There was a focus on mothers and African Americans. Lastly, study design and approach have not changed significantly over time.

PRACTICE IMPLICATIONS

Findings highlight recommendations for future research: expanding the target population, addressing culture in the development of the intervention or program, including additional providers, such as nurses, in the intervention or program, advancing innovation, and increasing rigor of study design.

Prevalence and Factors Associated With Safe Infant Sleep Practices

OBJECTIVES

To examine prevalence of safe infant sleep practices and variation by sociodemographic, behavioral, and health care characteristics, including provider advice.

METHODS

Using 2016 Pregnancy Risk Assessment Monitoring System data from 29 states, we examined maternal report of 4 safe sleep practices indicating how their infant usually slept: (1) back sleep position, (2) separate approved sleep surface, (3) room-sharing without bed-sharing, and (4) no soft objects or loose bedding as well as receipt of health care provider advice corresponding to each sleep practice.

RESULTS

Most mothers reported usually placing their infants to sleep on their backs (78.0%), followed by room-sharing without bed-sharing (57.1%). Fewer reported avoiding soft bedding (42.4%) and using a separate approved sleep surface (31.8%). Reported receipt of provider advice ranged from 48.8% (room-sharing without bed-sharing) to 92.6% (back sleep position). Differences by sociodemographic, behavioral, and health care characteristics were larger for safe sleep practices (∼10-20 percentage points) than receipt of advice (∼5-10 percentage points). Receipt of provider advice was associated with increased use of safe sleep practices, ranging from 12% for room-sharing without bed-sharing (adjusted prevalence ratio: 1.12; 95% confidence interval: 1.09-1.16) to 28% for back sleep position (adjusted prevalence ratio: 1.28; 95% confidence interval: 1.21-1.35). State-level differences in safe sleep practices spanned 20 to 25 percentage points and did not change substantially after adjustment for available characteristics.

CONCLUSIONS

Safe infant sleep practices, especially those other than back sleep position, are suboptimal, with demographic and state-level differences indicating improvement opportunities. Receipt of provider advice is an important modifiable factor to improve infant sleep practices.

Content of Infant Safe Sleep Counseling and Maternal Reported Practices in an Urban Clinic

OBJECTIVE

Sudden Infant Death Syndrome is a leading cause of mortality in infants, and pediatric providers can influence caregiver infant safe sleep practices. We described the content of safe sleep counseling by pediatric providers and examined pediatric provider and caregiver factors that may be related to the delivery of safe sleep counseling.

METHODS

A sample of mothers and providers enrolled in the Safe Start Study, a randomized controlled trial assessing a safe sleep intervention, were audio-recorded during the 2-week well child visits (WCV) at a large urban pediatric practice in Baltimore, Maryland from October 2015 to April 2017. Provider counseling content related to infant sleep was transcribed and coded based on American Academy of Pediatrics (AAP) policy statement Grade A recommendations. Maternal reported infant sleep practices were defined by items on an interviewer administered survey. Multivariate logistic regression analyses were used to examine the relation between maternal reported infant sleep practices and provider counseling.

RESULTS

Most, 92%, of WCVs included at least 1 safe sleep topic, but there was inconsistency in content delivered based on AAP recommendations. Yet, only 12% of WCVs included all 4 components of ABC counseling. Maternal report of infant sleeping with a person or an object in sleep space was associated with decreased odds of receiving counseling on alone no person, no objects (adjusted odds ratio: 0.34, 95% confidence interval: 0.13, 0.90).

CONCLUSIONS

Pediatric provider counseling on safe sleep is inconsistent across AAP recommendations demonstrating a need for enhanced provider education and a more standardized approach to assess infant sleep practices.

A Statewide Hospital-Based Safe Infant Sleep Initiative: Measurement of Parental Knowledge and Behavior

Sleep-related infant deaths are a leading cause of infant mortality in Georgia, and these deaths are largely associated with unsafe sleep practices among caregivers. In early 2016, the Georgia Department of Public Health launched the Georgia Safe to Sleep Hospital Initiative, providing hospitals with safe infant sleep information and educational materials to be distributed to families and newborns. This study examined the knowledge and behaviors of a sample of Georgia parents after the implementation of the Hospital Initiative and identified the family characteristics and intervention components most closely associated with the knowledge and practice of safe infant sleep. The primary caretakers of all infants born in Georgia from August to October 2016 were invited to complete a web-based survey 1 month after hospital discharge. The final sample size included 420 parents of newborns, and the primary outcomes assessed included two measures of knowledge and four measures of infant sleep behaviors regarding infant sleep position and location. Most respondents demonstrated knowledge of the correct recommended sleep position (90%) and location (85%). Logistic regression revealed that receipt of information in the hospital was significantly correlated with safe sleep behaviors, and infant sleep habits tended to influence safe sleep practices. Additionally, Medicaid parents receiving bassinets from the hospital were 74% less likely to bed share (OR 0.26; 95% CI 0.007). Implementation of a statewide hospital initiative was associated with high levels of parental knowledge and behavior and may have been successful in reducing the practice of bed sharing among Medicaid parents.

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.

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.

Preventing sudden infant death syndrome and other sleep-related infant deaths

Sudden infant death syndrome, a type of sleep-related sudden unexpected infant death (SUID) is the leading cause of postneonatal mortality in the United States and the third leading cause of infant death overall. Despite the evidence-based risk-reduction strategies and the highly publicized campaigns for a safe sleep environment, some infants continue to sleep in unsafe sleep conditions. Clinicians need to know the current best practices to reduce the incidence of sleep-related SUID and be knowledgeable to counsel caregivers who may resist adhering to these recommendations. This article describes the different types of SUID, associated risk factors, and highlights recommendations to help parents and caregivers ensure safe sleep environments for infants.

DEVELOPMENT AND EVALUATION OF MOBILE APPLICATION FOR THE PREVENTION OF MUSCULOSKELETAL RISKS IN NURSING WORK

ABSTRACT Objective: to develop a multi-platform mobile application for the prevention of musculoskeletal risk factors related to nursing work in a hospital unit and to evaluate the usability criteria with nurses and computer professionals. Method: technological production study for the development of a mobile application, following the phases of software engineering: analysis of requirements, design and specification, construction, internal tests, maintenance and external evaluation. The product was evaluated for usability by nurses from public hospital units in the city of Rio de Janeiro (Brazil). The System Usability Scale instrument was used for the evaluation of the nurses and the instrument of heuristics of compliance of digital interfaces was used with the informational technology professionals. The application development period lasted from November 2017 to March 2018 and the usability assessment from March to May 2018. Results: the evaluation data showed that the application shows agreement and compliance with the principles of usability in the criteria of effectiveness, efficiency and user satisfaction, however, the evaluators suggest that the application's functionalities should be simplified. Conclusion: the application was designed as a care strategy for the nursing professional, considering the musculoskeletal risks which they are exposed to in their professional activities. The development and evaluation methods were satisfactory and the proposed objectives were achieved.

Trends in the Incidence of Sudden Unexpected Infant Death in the Newborn: 1995-2014

OBJECTIVE

To evaluate the epidemiology of sudden unexpected infant death (SUID) over a 20-year period in the US, to assess the potential frequency of sudden unexpected postnatal collapse in the early days of life, and to determine if SUID rates in the neonatal period (0-27 days) have changed in parallel with rates in the postneonatal periods, including the percentages attributed to codes that include accidental suffocation.

STUDY DESIGN

Data from the US Centers for Disease Control and Prevention Linked Birth/Infant Death Records for 1995-2014 were analyzed for the first hour, day, week, and month of life. A comparison of neonatal and postneonatal data related to SUID, including accidental suffocation, was carried out.

RESULTS

Death records for 1995-2014 indicate that, although SUID rates in the postneonatal period have declined subsequent to the 1992 American Academy of Pediatrics sleep position policy change, newborn SUIDs have failed to decrease, and the percentage of SUIDs attributed to unsafe sleep conditions has increased significantly in both periods; 29.2% of the neonatal cases occurred within the first 6 days of life.

CONCLUSIONS

The frequency of SUIDs during the neonatal period warrants ongoing attention to all circumstances contributing to this category of deaths. The development of a standardized definition of sudden unexpected postnatal collapse and a national registry of these events is recommended. Ongoing research on the effects of early neonatal practices on postneonatal SUID should also be encouraged.

Sudden Infant Death Syndrome: A Global Public Health Issue and Nursing's Response

Sudden unexplained death in infancy, including sudden infant death syndrome (SIDS), is a global public health challenge. Despite public health campaigns and efforts, SIDS remains the leading cause of postneonatal mortality in many developed countries. In this article, we review SIDS, describe nursing's unique professional position in addressing this problem, and explore how the principles of social justice can inform nursing's response. Motivated by nursing's ethical and moral obligations, the profession is called to take an active role in educating others regarding this phenomenon, to participate in research, and to develop or advocate for policy that aims to reduce the incidence of SIDS on an international scale.