Factors Influencing African American Mothers’ Decisions About Sleep Position: A Qualitative Study

A Hospital-Based Infant Safe Sleep Intervention and Safe Sleep Practices Among Young Women: A Prospective Longitudinal Study

INTRODUCTION

The rates of sudden unexpected infant death (SUID) are still high in the U.S. The longitudinal effects of SUID preventive education on infant safe sleep practices are less known. The current study evaluated the effects of a comprehensive hospital-based, SUID preventive intervention on safe infant sleep practices in the first six months of life and to identify factors associated with infant sleep practices.

METHODS

Using a one-group pretest and multiple posttest design, the current quantitative study examined the impacts of the infant safe sleep intervention among 411 women recruited at a large, urban, university medical center. Participants were prospectively followed and completed four surveys from childbirth. Linear mixed models were used to evaluate the effects of the SUID prevention program on four sleep practice outcomes, including removing unsafe items from the sleeping environment, bed sharing, room sharing without bed sharing, and placing the infant in a supine sleep position.

RESULTS

Compared to the baseline, participants were less likely to use unsafe items (e.g., soft bedding) in infants' sleeping areas over time. However, we found that participants reported more frequent bed sharing at 3-month and 6-month follow-ups, compared to the baseline.

CONCLUSIONS

Overall, maternal education and family income were positively related to healthy infant safe sleep practices. A hospital-based preventive intervention pairing an educational initiative with home-visiting services might improve safe sleep practices to remove accidental suffocation risks from the infant sleep environment.

Half-Connecting Theory: Developing African Psychology Theory in a “Radical Beginnings” Direction

In existential philosophy, “radical beginnings” refers to the task of uncovering the earliest, constitutive moments of a phenomenon’s existence. In this article, the author develops African psychology in a radical beginnings direction by using the theory of half-connecting (HCT) to trace the origins of the African and European worldviews to the earliest stages of human development, particularly to the unconscious and physical bodies of people. It is found that the differences and tensions between the worldviews are traceable to their original and intimate relationship. It is also found that African and European worldviews do not operate only in obvious instances involving race and racism but in everything humans create, including in the technologies and infrastructures in the background of everyday life. Finally, the author discusses how HCT can help therapists expand their understanding of the sources of mental and behavioral distress, which may incite new, creative thinking around how disorders are treated.

Infant Safe Sleep Practices as Portrayed on Instagram: Observational Study

BACKGROUND

Parenting practices are highly influenced by perceived social norms. Social norms and American Academy of Pediatrics (AAP) guidelines for infant safe sleep practices are often inconsistent. Instagram has become one of the most popular social media websites among young adults (including many expectant and new parents). We hypothesized that the majority of Instagram images of infant sleep and sleep environments are inconsistent with AAP guidelines, and that the number of "likes" for each image would not correlate with adherence of the image to these guidelines.

OBJECTIVE

The objective of this study was to determine the extent of adherence of Instagram images of infant sleep and sleep environments to safe infant sleep guidelines.

METHODS

We searched Instagram using hashtags that were relevant to infant sleeping practices and environments. We then used an open-source web scraper to collect images and the number of "likes" for each image from 27 hashtags. Images were analyzed for adherence to AAP safe sleep guidelines.

RESULTS

A total of 1563 images (1134 of sleeping infant; 429 of infant sleep environment without sleeping infant) met inclusion criteria and were analyzed. Only 117 (7.49%) of the 1563 images were consistent with AAP guidelines. The most common reasons for inconsistency with AAP guidelines were presence of bedding (1173/1563, 75.05%) and nonrecommended sleep position (479/1134, 42.24%). The number of "likes" was not correlated with adherence of the image to AAP guidelines.

CONCLUSIONS

Although individuals who use Instagram and post pictures of sleeping infants or infant sleep environments may not actually use these practices regularly, the consistent portrayal of images inconsistent with AAP guidelines reinforces that these practices are normative and may influence the practice of young parents.

Impact of Personal Social Network Types on Breastfeeding Practices in United States-Born Black and White Women

Background: An individual's personal social network influences behavior; one is more likely to adopt behaviors consistent with norms within the network to avoid social stigma. Personal social network types, which are associated with individual behaviors, have been identified for new mothers: exclusive (kin centric) and expansive (not kin centric). Objective: To analyze the impact of personal social network type on breastfeeding practices in U.S.-born Black and White mothers. Methods: Mothers of infants <6 months old completed surveys about their personal social networks and feeding practices. Multinomial logit models examined how social network types moderated effects of sociodemographic factors on feeding practices. Results: Of 402 mothers, 67% self-identified as Black and 33% as White. Forty-six percent were exclusively breastfeeding; 26% were mixed breast and formula feeding. The likelihood of exclusively breastfeeding was positively associated with percentage of network members who had breastfed; this association was stronger for mothers with exclusive networks than those with expansive networks (β = 2.74, p < 0.001 versus β = 1.78, p = 0.03). Black race was positively correlated with exclusive breastfeeding or mixed feeding for mothers with exclusive networks (β = 1.50, p = 0.046; β = 1.86, p = 0.02, respectively). Lower educational level was negatively correlated with exclusive breastfeeding; this correlation was stronger for mothers with exclusive networks (β = -1.91, p = 0.002 versus β = -1.70, p = 0.04). Lower educational level was also negatively correlated with mixed feeding for mothers with exclusive networks (β = -1.61, p = 0.02). Conclusions: Mothers' personal social network type likely moderates the relationship between sociodemographic variables and feeding practices. While the influence of having network members with breastfeeding experience is important, the magnitude of influence is stronger in exclusive networks.

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.

Feasibility and Acceptability of a Tailored Infant Safe Sleep Coaching Intervention for African American Families

Background: Approximately 3600 infants die suddenly and unexpectedly annually in the United States. Research suggests limitations of current behavioral interventions to reduce the risk for sleep-related deaths among African American families living in under-resourced neighborhoods. Guided by the theory of planned behavior and the socio-ecological model, the My Baby’s Sleep (MBS) intervention intends to reduce the risk for sleep-related infant deaths while addressing complex needs of African American families living in under-resourced neighborhoods. Objective: To assess feasibility and acceptability of MBS, a 7-month intervention that includes four home visits and multiple check-ins via phone and text message. Methods: This was a single-arm feasibility and acceptability study with quantitative and qualitive measures. African American families were recruited from community agencies that served an under-resourced metropolitan area. Results: Eight families (eight mothers, nine co-caregivers) completed the intervention. Families reported high acceptability of MBS content, process, and format, as evidenced by qualitative data and mean evaluation scores. Conclusion: MBS is feasible and acceptable among African American families living in under-resourced neighborhoods. These results suggest further investigation of MBS intervention efficacy in a large-scale randomized controlled trial.

Social network influences on new mothers' infant sleep adjustments

Despite public awareness campaigns, some parents continue to engage in infant sleep practices that are considered risky by health experts, such as bedsharing or placing their infants on their stomachs. This study examines the role their social networks play in shaping parents' responsiveness to new information and/or suggestions about how they should place their infants for sleep, paying attention to the respective effects of health professionals and their close interpersonal ties. We collected data from a sample of 323 new mothers in Washington, D.C., who described their infant sleep practices and perceived personal social networks. We find evidence that mothers' social networks play a significant role in the likelihood that they adjust their infant sleep practices within the first few months of their infants' lives. Mothers are more likely to change sleep practices when health professionals and/or (lay) family members advise them to do so. The influence of network members is not always positive. For mothers who initially follow safe practices, their probability of change increases if their network members substantially espouse unsafe practices. Among mothers with initially unsafe practices, network members' level of support for safe sleep practices is not predictive of the likelihood of sleep practice change. Implications for potential interventions are discussed.

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.

Implementation of a Statewide Program to Promote Safe Sleep, Breastfeeding and Tobacco Cessation to High Risk Pregnant Women

Infant mortality remains a problem in the United States with sleep-related deaths accounting for a significant portion. Known risk reduction strategies include breastfeeding, avoiding tobacco use and following the American Academy of Pediatrics' safe sleep guidelines. The purpose of this project was to evaluate outcomes of Safe Sleep Instructor-led community baby showers, which included safe sleep promotion, breastfeeding promotion and tobacco cessation education. Certified Safe Sleep Instructors (n = 35) were trained on how to plan and host a Community Baby Shower to provide education to pregnant women of low socioeconomic status or with high risk of infant mortality. Eighteen Community Baby Showers were held across two urban and eight rural counties in Kansas. Surveys were administered pre- and post-event to assess participant knowledge, confidence and intentions to follow through with planned action related to safe sleep, breastfeeding and reducing tobacco risk. Matched data were summarized and evaluated for differences using McNemar's and Wilcoxon Signed Rank tests. Significant increases were observed in Baby Shower participants' (n = 845) reported plans to follow the AAP Safe Sleep guidelines (all p < 0.001), likelihood to breastfeed (p < 0.001), confidence in ability to breastfeed for more than 6 months (p < 0.001), knowledge of local breastfeeding support resources (p < 0.001), knowledge of ways to avoid second-hand smoke exposure (p < 0.001) and knowledge of local tobacco cessation services (p = 0.004). Based on the result of the pre- and post-event surveys, certified Safe Sleep Instructors were able to plan and host successful events to increase knowledge and confidence related to risk reduction strategies to reduce sleep-related infant deaths.

The Impact of Health Messages on Maternal Decisions About Infant Sleep Position: A Randomized Controlled Trial

Sudden infant death syndrome (SIDS) rates in African-Americans are more than twice national rates, and historically, African-American parents are more likely than other groups to place infants prone, even when they are aware of supine sleep recommendations. Prior studies have shown African-Americans have low self-efficacy against SIDS but high self-efficacy against suffocation. This study aimed to determine the impact of a specific health message about suffocation prevention on African-American parental decisions regarding infant sleep position. We conducted a randomized controlled trial of 1194 African-American mothers, who were randomized to receive standard messages about safe sleep practices to reduce the risk of SIDS, or enhanced messages about safe sleep practices to prevent SIDS and suffocation. Mothers were interviewed about knowledge and attitude, self-efficacy and current infant care practices when infants were 2-3 weeks, 2-3 months and 5-6 months old. Analyses of covariance were conducted to estimate the change in knowledge, attitudes and practice in each group, and chi square tests were used to compare sleep position with each variable. Over the first 6 months, the proportion of African-American infants placed supine gradually decreased and was unchanged by enhanced education about SIDS, suffocation risk and sleep safety. While initially high self-efficacy against SIDS and suffocation correlated with supine positioning, by 5-6 months self-efficacy did not correspond to sleep position in either group.

Evaluation of a Crib Distribution and Safe Sleep Educational Program to Reduce Risk of Sleep-Related Infant Death

To increase access to safe infant sleep surfaces and reduce risk of sleep-related infant deaths, the Georgia Department of Public Health implemented a portable crib distribution and safe sleep educational program. The aim of this evaluation was to compare parental knowledge and practices related to infant sleep before and after receipt of the safe sleep educational program and crib. A prospective, matched pre- and post-test cohort design with a follow-up survey was utilized to evaluate changes in knowledge and practices. Female participants were recruited through the county health department and met the following criteria: (1) between 32 and 40 weeks pregnant or within 3 months postpartum, and (2) demonstrated financial need. Participants completed a survey prior to the start of a group educational program and upon program completion. For those who agreed, a follow-up phone survey was conducted approximately 10 weeks after program completion or after the infant's birth. McNemar's Chi square tests were conducted to detect significant differences between specific items on pre-test, post-test, and follow-up surveys, and paired sample t tests were conducted to compare differences in knowledge and practice scores. A total of 132 participants completed matched pre- and post-test surveys and 76 completed follow-up surveys. Knowledge of recommendations regarding position, surface, environment, smoking, breastfeeding, and pacifier use increased significantly between pre- and post-test, with most participants maintaining knowledge at follow-up. The proportion of recommended practices also increased significantly. A group-based safe sleep educational program can be effective in reducing risky infant sleep practices.

Implications of Mothers' Social Networks for Risky Infant Sleep Practices

OBJECTIVE

To describe the structure of networks in a cohort of mothers and to analyze associations of social network characteristics and norms with infant sleep practices.

STUDY DESIGN

We recruited a prospective cohort of mothers with infants <6 months of age from January 2015 to December 2016. Mothers completed a survey about their personal social networks and infant care practices. Latent class analysis identified unobserved network types. Binary statistics and path analysis were performed.

RESULTS

Overall, 402 mothers were surveyed. Latent class analysis identified 2 a priori unknown social network types: "exclusive" (restricted) and "expansive." Mothers who were black, younger, unmarried, less educated, and of lower socioeconomic status were more likely to have exclusive networks than expansive networks. Mothers with exclusive networks were more likely to be exposed to the norm of soft bedding (P = .002). Exposure to norms of non-supine infant placement, bedsharing, and soft bedding use within one's network was associated with engaging in these practices (P < .0001 for each). First-time mothers were more likely to pay attention to a non-supine norm and place infants in a non-supine position. Black mothers and first-time mothers were more likely to pay attention to the norm and use soft bedding.

CONCLUSIONS

Both the type of networks mothers have and the norms regarding infant sleep practices that circulate within these networks differed by race. Network norms were strongly associated with infant sleep practices and may partially explain the racial disparity therein.

A Qualitative Analysis of How Mothers' Social Networks Are Established and Used to Make Infant Care Decisions

Background. Mothers often look to family members and friends (ie, their social network) for advice and support regarding infant care decisions. However, little is known about the process by which mothers' social networks are established and how mothers use these networks to make decisions regarding infant care. We thus conducted a qualitative analysis to explore how mothers choose individuals for their social networks, and how they use these for decision-making. Methods. Focus groups or individual interviews were conducted with 28 mothers. We asked probing questions about whom mothers turned to for advice and support, and how they made infant care decisions. Data were coded and analyzed iteratively for emerging themes. Results. Themes that emerged were changes in social networks once children are born, reasons for being in the mother's social network, importance of the pediatrician as a trusted source, and process of making infant care decisions. After an infant is born, mothers gravitate toward friends with children; trustworthiness of those whom mothers turn to is based on their perceived experience and knowledge. Pediatricians are valued for their professional and personal experience with children. Mothers use consensus and/or instinct to make infant care decisions, but continually seek reassurance that these decisions are correct. Conclusion. Mothers' social networks are important sources of infant care information. Because mothers rely on consensus and continued reassurance when making decisions, health care professionals have many opportunities to influence decision-making. Consistent health care messaging can enhance mothers' perceptions that there is consensus of opinion from trusted sources.

Mothers' Perceptions of the Internet and Social Media as Sources of Parenting and Health Information: Qualitative Study

BACKGROUND

Traditionally, guidance and support to new parents have come from family, friends, and health care providers. However, the internet and social media are growing sources of guidance and support for parents. Little is known about how the internet and social media are used by parents of young infants and specifically about parental perceptions of the internet and social media as sources of parenting and infant health information.

OBJECTIVE

The aim of this study was to explore, using qualitative methods, parental perceptions of the advantages and disadvantages of the internet and social media as sources of parenting and health information regarding their infant.

METHODS

A total of 28 mothers participated in focus groups or individual interviews. Probing questions concerning parenting and health information sources were asked. Themes were developed in an iterative manner from coded data.

RESULTS

The central themes were (1) reasons that mothers turn to the internet for parenting and health information, (2) cautionary advice about the internet, and (3) reasons that mothers turn to social media for parenting and health information. Mothers appreciated the ability to gather unlimited information and multiple opinions quickly and anonymously, but recognized the need to use reputable sources of information. Mothers also appreciated the immediacy of affirmation, support, and tailored information available through social media.

CONCLUSIONS

The internet and social media are rapidly becoming important and trusted sources of parenting and health information that mothers turn to when making infant care decisions.

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.

Characteristics of Infant Deaths during Sleep While Under Nonparental Supervision

OBJECTIVE

To compare risk factors for infant sleep-related deaths under the supervision of parents and nonparents.

STUDY DESIGN

We conducted a secondary analysis of sleep-related infant deaths from 2004 to 2014 in the National Center for Fatality Review and Prevention Child Death Review Case Reporting System. The main exposure was supervisor at time of death. Primary outcomes included sleep position, location, and objects in the environment. Risk factors for parental vs nonparental supervisor were compared using χ² and multivariable logistic regression models. Risk factors associated with different nonparental supervisors were analyzed using χ².

RESULTS

Of the 10 490 deaths, 1375 (13.1%) occurred under nonparental supervision. Infants who died under nonparental supervision had higher adjusted odds of dying outside the home (OR 12.87, 95% CI 11.31-14.65), being placed prone (OR 1.61, 95% CI 1.39-1.86) or on their side (OR 1.35, 95% CI 1.12-1.62), or being found prone (OR 1.74, 95% CI 1.50-2.02). Among infants who died under nonparental supervision, those supervised by relatives or friends were more often placed on an adult bed or couch for sleep and bed sharing (P < .0001), and to have objects in the sleep environment (P = .01).

CONCLUSIONS

Infants who died of sleep-related causes under nonparental supervision were more likely to have been placed nonsupine. Among nonparental supervisors, relatives and friends were more likely to use unsafe sleep environments, such as locations other than a crib or bassinet and bed sharing. Pediatricians should educate parents that all caregivers must always follow safe sleep practices.

Stock Photographs Do Not Comply With Infant Safe Sleep Guidelines

We evaluated images in popular stock photography websites for adherence with American Academy of Pediatrics (AAP) guidelines for safe infant sleep practices. Three top stock photo websites were used to collect photographs generated from key phrases. All images depicting an infant sleep environment were analyzed for consistency with AAP guidelines. Descriptive statistics, chi-square and z test of proportions, were conducted. A total of 1233 of 1947 stock photographs showed sleeping infants on a flat surface. In all, 627 (50.8%) photographs showed the infant in the supine position and 79 (5%) of all infant sleep environments were adherent with AAP recommendations. Bedding inconsistent with safe sleep recommendations was identified in 1133 images (71.3%), with blankets noted in 49.5%. Images depicting sleeping infants on stock photography sites do not routinely adhere to AAP recommendations. Media messages inconsistent with health care messages create confusion and misinformation about infant sleep safety and may lead inadvertently to unsafe practices.

TodaysBaby Quality Improvement: Safe Sleep Teaching and Role Modeling in 8 US Maternity Units

BACKGROUND AND OBJECTIVES

Nursing education and role modeling can increase adherence to safe sleep practices. Eight US hospital maternity units with variable baseline approaches to education participated in a national multicenter nursing quality improvement (QI) intervention to promote safe sleep practices. The goals at participating maternity units were to (1) increase the rate of mothers who reported receiving safe sleep information from nurses to ≥90% and (2) increase the rates of infants observed sleeping supine in a safe environment to ≥90%.

METHODS

A safe sleep QI toolkit, designed for and provided to all sites, included an educational curriculum and tools to use for staff and parent education. Local teams implemented safe sleep education using the tools as plan-do-study-act cycles. After each cycle, audits assessing maternal report of nursing education on safe sleep and inpatient infant sleep position and environment were performed.

RESULTS

The QI interventions lasted a median of 160 days (range, 101-273). Mothers reported receiving information on 4 primary safe sleep topics 72% to 95% of the time (a 24%-57% increase over the baseline). Additionally, 93% of infants were observed in a supine sleep position, and 88% of infants were observed in a safe sleep environment (a 24% and 33% increase over baseline, respectively). These rates were sustained up to 12 months later.

CONCLUSIONS

Implementation of a multisite QI intervention for safe sleep parenting education and role modeling led to increased knowledge of and compliance with safe sleep practices during postpartum hospitalization.

Variation in Safe Sleep and Breastfeeding Practices Among Non-Hispanic Black Mothers in the United States According to Birth Country

OBJECTIVE

To examine variation in safe sleep and breastfeeding practices among US non-Hispanic black (NHB) mothers according to birth country.

METHODS

We analyzed NHB mothers who were surveyed regarding safe sleep and breastfeeding practices when their infants were 2 to 6 months of age in 2011 to 2014, as part of a larger national study. We examined prevalences of safe sleep and breastfeeding practices according to birth country and examined odds of adherence to American Academy of Pediatrics recommended safe sleep and breastfeeding practices in foreign-born NHB mothers, compared with US-born NHB mothers. Our multivariate models included adjustment for maternal age, education, income, and US geographic region, and infant age at the time of the survey.

RESULTS

Among 828 NHB mothers, 690 (83%) were US-born, 42 (5%) were African-born, 47 (6%) were Haitian-born, 24 (3%) were Jamaican-born, and 25 (3%) were born elsewhere. In the analysis of 803 US, African-, Haitian-, and Jamaican-born mothers, we found that Jamaican-born mothers had a lower rate of supine sleep compared with US-born mothers (40% vs 66%; adjusted odds ratio, 0.34; 95% confidence interval, 0.18-0.63). African-born mothers had lower rates of bedsharing compared with US-born mothers (11% vs 25% adjusted odds ratio, 0.22; 95% confidence interval, 0.11-0.46). Foreign-born mothers had higher rates of any and exclusive breastfeeding, compared with US-born mothers (85% and 40% vs 23% and 13%, respectively).

CONCLUSIONS

Safe sleep and breastfeeding practices vary among US NHB mothers according to birth country. These data illustrate the importance of recognizing heterogeneity of safe sleep and breastfeeding practices within racial/ethnic groups.

Collaborating with obstetrical providers to promote infant safe sleep guidelines

OBJECTIVES

To partner with obstetrical providers to increase promotion of the American Academy of Pediatrics guidelines for infant safe sleep. Specifically, this study evaluates the effectiveness of the Safe Sleep Toolkit during obstetrical visits. Secondary objectives include improving provider and maternal knowledge of safe sleep.

METHODS

Obstetrical providers (n=11) and staff at an outpatient clinic were trained using the Safe Sleep Toolkit and encouraged to discuss infant safe sleep with pregnant women at their 28- or 36-week gestation appointment (n=111, 56 pre- and 55 post-intervention). Provider-reported time spent counseling women on safe sleep recommendations and safe sleep knowledge was measured before and after the intervention. Surveys were conducted with women assessing safe sleep knowledge, intention to follow guidelines, and whether safe sleep was discussed at the appointment.

RESULTS

Significantly more post-intervention women reported their provider had discussed safe sleep (78% vs 32%) (P<.001). Similarly, provider-reported discussion with women increased significantly for all safe sleep guidelines (82%-90% vs 8%-12%) (all P<.001). Maternal knowledge, especially surrounding unsafe sleep practices, improved significantly post-intervention.

CONCLUSION

Training obstetricians to use a toolkit to promote infant safe sleep guidelines increases the prenatal delivery of this information, and improves pregnant women's knowledge and intentions regarding safe infant sleep.

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.

Comparison of Text Messages Versus E-mail When Communicating and Querying With Mothers About Safe Infant Sleep

OBJECTIVE

To assess how mothers' choice of e-mail or text messages (SMS) to receive safe sleep communications is associated with educational video viewing and responses to care practice queries.

METHODS

Seven hundred ninety-two new mothers received safe sleep-related communications for 60 days after newborn hospital discharge as part of a trial of health education interventions on infant care practices. Mothers chose e-mail or SMS for study communications and were sent 22 short safe sleep videos and 41 queries regarding infant care practices.

RESULTS

Study communications via e-mail were elected by 55.7% of participants. The SMS group had a modestly higher overall view rate of videos (59.1% vs 54.4%; adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.07-1.81) and a substantially higher response rate to queries (70.0% vs 45.2%; aOR, 3.48; 95% CI, 2.74-4.43).

CONCLUSIONS

Participants more commonly opted to receive infant care practice videos and queries via e-mail. SMS was associated with higher viewing and response rates, especially for query responses. These results highlight the importance of understanding how specific modalities of communication might vary in reach.

Comparison of Infant Sleep Practices in African-American and US Hispanic Families: Implications for Sleep-Related Infant Death

African-American and Hispanic families share similar socioeconomic profiles. Hispanic rates of sleep-related infant death are four times lower than African-American rates. We conducted a cross-sectional, multi-modal (surveys, qualitative interviews) study to compare infant care practices that impact risk for sleep-related infant death in African-American and Hispanic families. We surveyed 422 African-American and 90 Hispanic mothers. Eighty-three African-American and six Hispanic mothers participated in qualitative interviews. African-American infants were more likely to be placed prone (p < 0.001), share the bed with the parent (p < 0.001), and to be exposed to smoke (p < 0.001). Hispanic women were more likely to breastfeed (p < .001), while African-American women were more knowledgeable about SIDS. Qualitative interviews indicate that, although African-American and Hispanic parents had similar concerns, behaviors differed. Although the rationale for infant care decisions was similar for African-American and Hispanic families, practices differed. This may help to explain the racial/ethnic disparity seen in sleep-related infant deaths.

SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment

Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. After an initial decrease in the 1990s, the overall sleep-related infant death rate has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," which is included in this issue.

Nocturnal Video Assessment of Infant Sleep Environments

BACKGROUND AND OBJECTIVE

Reports describing factors associated with sleep-related infant death rely on caregiver report or postmortem findings. We sought to determine the frequency of environmental risk factors by using nocturnal sleep videos of infants.

METHODS

Healthy, term newborns were recruited for a parent study examining the role of parenting in the development of nighttime infant sleep patterns. For 1 night at ages 1, 3, and 6 months, video recordings were conducted within family homes. Videos were coded for sudden infant death syndrome risk factors in post hoc secondary analyses after the parent study was completed.

RESULTS

Among 160 one-month-olds, initially 21% were placed to sleep on nonrecommended sleep surfaces and 14% were placed nonsupine; 91% had loose/nonapproved items on their sleep surface, including bedding, bumper pads, pillows, stuffed animals, and sleep positioners. Among 151 three-month-olds, 10% were initially placed on a nonrecommended sleep surface, 18% were placed nonsupine, and 87% had potentially hazardous items on their sleep surface. By 6 months, 12% of the 147 infants initially slept on a nonrecommended surface, 33% were placed to bed nonsupine, and 93% had loose/nonrecommended items on their surface. At 1, 3, and 6 months, 28%, 18%, and 12% changed sleep locations overnight, respectively, with an increased likelihood of bed-sharing and nonsupine position at the second location at each time point.

CONCLUSIONS

Most parents, even when aware of being recorded, placed their infants in sleep environments with established risk factors. If infants were moved overnight, the second sleep environment generally had more hazards.

Reasons for Pacifier Use and Non-Use in African-Americans: Does Knowledge of Reduced SIDS Risk Change Parents' Minds?

To investigate African-American parental reasons for pacifier use or non-use, and whether knowledge of the association with decreased SIDS risk changes decisions about pacifier use. We conducted focus groups and individual interviews with mothers. Grounded theory methodology was used. 83 mothers participated; 72.3 % of infants used pacifiers. Reasons for pacifier use included comfort/soothing, safety/SIDS, and preference over digit-sucking. Reasons for pacifier non-use included infant refusal, fear of attachment, nipple confusion, and germs. Many parents were unaware that pacifier use reduces SIDS risk; however, most parents of non-users did not think that this knowledge would have changed their decision. Reasons included skepticism about the pacifier-SIDS link. Many reasons underlie African-American parental decisions about pacifier use. Providers should provide information about the benefits of pacifiers. Establishing for parents any plausible link between the protective mechanism of pacifiers and SIDS pathophysiology may be important in promoting pacifier use.

Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change?

Sudden infant death syndrome (SIDS) and other sleep-related infant deaths, such as accidental suffocation and strangulation in bed and ill-defined deaths, account for >4000 deaths annually in the USA. Evidence-based recommendations for reducing the risk of sleep-related deaths have been published, but some caregivers resist adoption of these recommendations. Multiple interventions to change infant sleep-related practices of parents and professionals have been implemented. In this review, we will discuss illustrative examples of safe infant sleep interventions and evidence of their effectiveness. Facilitators of and barriers to change, as well as the limitations of the data currently available for these interventions, will be considered.

Knowledge and beliefs of African-American and American Indian parents and supporters about infant safe sleep

To investigate, by using qualitative methods, beliefs among African-American and American Indian families about infant safe sleep practices, barriers to acceptance of prevention recommendations, and more effective messaging strategies. Seventy-three mothers and supporters participated in focus groups. Participants discussed infant sleep practices and effectiveness of safe sleep messages. Data were coded, and themes were developed and revised in an iterative manner as patterns became more apparent. Themes included reasons for and influences on sleep decisions, and concerns about safe sleep recommendations. Parental sleep decisions seemed to be driven by perceptions of what would make their infant most comfortable and safe, and what would be most convenient. Parents were aware of safe sleep recommendations but unaware of the rationale. Because they generally did not believe that their infants were at risk for a sleep-related death, day-to-day decisions seemed to focus on what was most effective in getting their infant to sleep. There appeared to be no distinctions in opinions among African-American and American Indian families. African-American and American Indian families seemed to have similar concerns about infant comfort and safety, and their perceptions about what would be most effective in achieving these goals appeared to be important influences on their sleep practices. Adherence with safe sleep recommendations may be enhanced if health care providers and educational materials discussed rationale underlying recommendations and addressed common parental concerns. It may be beneficial to target educational interventions towards fathers, as they may be untapped sources in implementing safe sleep practices.

Proposal for mechanisms of protection of supine sleep against sudden infant death syndrome: an integrated mechanism review

Supine sleep decreases sudden infant death syndrome (SIDS) incidence, however the mechanisms for this are unclear. The triple risk model for SIDS requires that one or more underlying abnormalities of breathing or autonomic control are present; these are rare, but brainstem defects are found in most SIDS cases. Supine sleep increases sympathetic nervous system tone, and level of state organization, and may therefore act as a stressor. This is evidenced by physiological arousal, and by delayed neurodevelopment in supine compared to prone sleepers. It is argued here that prone sleep position is the biological normative standard in healthy infants, supporting autonomic regulation. During rapid eye movement (REM) sleep (and other circumstances), a parasympathetic-mediated adverse autonomic event (AAE) may be spontaneously triggered. In healthy infants, gasping initiates autoresuscitation and recovery.

HYPOTHESIS

The underlying vulnerability to SIDS is specific to autoresuscitation from an AAE, the initial serotonin-dependent gasp is commonly compromised. Serotonin metabolism defects also influence sleep architecture, increasing the likelihood of AAE. The mechanism whereby supine sleep decreases SIDS may therefore be a stressor effect, disturbing sleep architecture to decrease REM and AAEs, and increasing sympathetic tone, which may prevent and counteract the purely parasympathetic-mediated AAE, thereby decreasing the risk of SIDS.

Breastfeeding in African Americans may not depend on sleep arrangement: a mixed-methods study

BACKGROUND

Despite high bedsharing rates, breastfeeding rates are low among African Americans.

OBJECTIVE

Describe the association between breastfeeding and bedsharing; elucidate barriers to breastfeeding in African Americans.

METHODS

African American mothers with infants <6 months were recruited for this cross-sectional, mixed-methods study and completed an infant care practices survey. A subgroup participated in focus groups or individual interviews.

RESULTS

A total of 412 completed the survey; 83 participated in a focus group or interview. Lower socioeconomic status mothers were more likely to breastfeed exclusively or at all if they bedshared (P = .02 and P = .01, respectively). Bedsharing was not associated with breastfeeding among higher socioeconomic status mothers. Breast pain, lack of support, and maternal skepticism about breastfeeding benefits were barriers; the latter was a recurrent theme among nonbreastfeeding mothers.

CONCLUSIONS

While bedsharing is associated with breastfeeding in lower socioeconomic groups, it is not in higher socioeconomic African American groups. Skepticism about breastfeeding benefits may contribute to low breastfeeding rates in African Americans.

Safe infant sleep recommendations on the Internet: let's Google it

OBJECTIVES

To determine the accuracy of information on infant sleep safety on the Internet using Google. We hypothesized that the majority of Web sites would accurately reflect the American Academy of Pediatrics (AAP) recommendations for infant sleep safety.

STUDY DESIGN

We searched for advice using 13 key phrases and analyzed the first 100 Web sites for each phrase. Web sites were categorized by type and assessed for accuracy of information provided, based on AAP recommendations. The accuracy of information was classified as "accurate," "inaccurate," or "not relevant."

RESULTS

Overall, 43.5% of the 1300 Web sites provided accurate information, 28.1% provided inaccurate information, and 28.4% were not relevant. The search terms "infant cigarette smoking," "infant sleep position," and "infant sleep surface" yielded the highest percentage of Web sites with accurate information. "Pacifier infant," "infant home monitors," and "infant co-sleeping" produced the lowest percentage of Web sites with accurate information. Government Web sites had the highest rate of accuracy; blogs, the lowest.

CONCLUSION

The Internet contains much information about infant sleep safety that is inconsistent with AAP recommendations. Health care providers should realize the extent to which parents may turn to the Internet for information about infant sleep safety.

Swaddling: will it get babies onto their backs for sleep?

INTRODUCTION

The supine sleep position is recommended to reduce sudden infant death syndrome risk. Swaddling may improve adherence with supine placement.

AIM

To assess knowledge, attitudes, and practice regarding swaddling among adult caregivers of 0- to 3-month-old infants.

METHODS

Cross-sectional descriptive survey.

RESULTS

All 103 adults interviewed had swaddled their infant. Common reasons for swaddling included infant comfort and warmth. Almost 80% of those who swaddled their infant found it effective, 80% believed it to be comfortable, and ~90% believed swaddling to be safe. Parents who routinely used swaddling were more likely to find it effective and to place their infant supine when swaddled (P < .01).

CONCLUSIONS

Parents often use swaddling to comfort the infant, and most find it effective. Parents who routinely use swaddling are more likely to place their infant supine if swaddled. Swaddling may be a strategy for parents of infants who have difficulty sleeping in the supine position.

SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment

Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death occurring during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in this technical report. The recommendations are published in the accompanying "Policy Statement--Sudden Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).

Decisions of black parents about infant bedding and sleep surfaces: a qualitative study

OBJECTIVE

The goal of this qualitative study was to examine factors influencing decisions by black parents regarding use of soft bedding and sleep surfaces for their infants.

METHODS

We conducted focus groups and individual interviews with black mothers of lower and higher socioeconomic status (SES). Mothers were asked about many infant care practices, including sleep surface and bedding.

RESULTS

Eighty-three mothers were interviewed, 73 (47 lower and 26 higher SES) in focus groups and 10 (7 lower and 3 higher SES) in individual interviews. The primary reason for using soft surfaces was infant comfort. Parents perceived that infants were uncomfortable if the surface was not soft. Many parents also interpreted "firm sleep surface" to mean taut; they were comfortable with and believed that they were following recommendations for a firm sleep surface when they placed pillows/blankets on the mattress as long as a sheet was pulled tautly over the pillows/blankets. The primary reasons for using soft bedding (including bumper pads) were comfort, safety, and aesthetics. In addition to using bedding to soften sleep surfaces, bedding was used to prevent infant rollover and falls, particularly for infants sleeping on a bed or sofa. Some parents used soft bedding to create an attractive space for the infant.

CONCLUSIONS

Many black parents believe that soft bedding will keep their infant safe and comfortable. There is much misunderstanding about the meaning of a "firm" sleep surface. Additional educational messages apparently are needed to change parental perceptions and practices.

Racial and ethnic disparities in infant mortality

Racial and ethnic disparities in infant mortality in the United States seem to defy all attempts at elimination. Despite national priorities to eliminate these disparities, black infants are 2.5 times more likely to die in infancy compared with non-Hispanic white infants. This disparity is largely related to the greater incidence among black infants of prematurity and low birth weight, congenital malformations, sudden infant death syndrome, and unintentional injuries. This greater incidence, in turn, is related to a complex interaction of behavioral, social, political, genetic, medical, and health care access factors. Thus, to influence the persistent racial disparity in infant mortality, a highly integrated approach is needed, with interventions adapted along a continuum from childhood through the periods of young adulthood, pregnancy, postpartum and beyond. The content and methodologies of these interventions need to be adapted to the underlying behaviors, social influences, and technology and access issues they are meant to address.

Bed sharing among black infants and sudden infant death syndrome: interactions with other known risk factors

OBJECTIVE

Bed sharing has been associated with sudden infant death syndrome (SIDS) and may contribute to the racial disparity seen in infant mortality. It is unclear how bed sharing interacts with other factors to impact SIDS risk. We aimed to measure the effects of bed sharing on risk of SIDS in blacks and to determine whether the risk is modified by other characteristics of the sleep environment.

METHODS

Characteristics of 195 black infants who died of SIDS were compared with matched controls. The moderating influence of known SIDS risk factors on the effect of bed sharing on risk of SIDS was examined using logistic regression.

RESULTS

Almost half (47.4%) of the study population bed shared during the last/reference sleep (58% cases and 37% controls). Bed sharing was associated with 2 times greater risk of SIDS compared with not bed sharing. The deleterious effect of bed sharing was more pronounced with a soft sleep surface, pillow use, maternal smoking, and younger infant age. However, bed sharing was still associated with an increased risk of SIDS, even when the infant was not using a pillow or sleeping on a firm surface. The strongest predictors of SIDS among bed-sharing infants were soft sleep surface, nonuse of a pacifier, and maternal smoking during pregnancy.

CONCLUSIONS

Bed sharing is a common practice among black infants. It is associated with a clear and strong increased risk of SIDS, which is even greater when combined with other known risk factors for SIDS. This practice likely contributes to the excess incidence of SIDS among blacks, and culturally competent education methods must be developed to target this high-risk group.