Where should my baby sleep: a qualitative study of African American infant sleep location decisions

Infant Safe Sleep in the District of Columbia: Better for Both

Sudden unexpected infant death (SUID) rates within the District of Columbia (DC) vary, with rates 3 times higher in certain geographical areas than the cumulative rate in DC and 7 times higher than the national rate. The majority SUIDs are due to unsafe sleep practices. Although safe sleep education and resources are available in these areas, the high sleep-related infant mortality suggests unmet barriers to infant safe sleep. We sought to investigate potential contributions to local infant mortality through focus groups regarding infant sleep practices among DC caregivers. In this qualitative study, caregivers were probed regarding barriers and facilitators of infant sleep practices. Data were collected until thematic saturation was reached, then coded. Themes were developed and revised in an iterative manner. Fifteen caregivers participated in three focus groups. Themes included sources of infant sleep knowledge, challenges for infant sleep, and motivators for infant sleep choice. All caregivers reported knowledge of safe sleep practices. Infant sleep practices varied, and included unsafe practices such as bed sharing, co-sleeping, and use of swings or bouncers for infant sleep. Challenges of adhering to safe sleep practices included infant needs, competing family demands, the overwhelming nature of newborn sleep, threats, and conflicting information. Motivators for infant sleep practices included better sleep, convenience, safety, tradition, and needs of the infant and caregiver. Although caregivers report knowledge of safe sleep recommendations, actual infant sleep practices vary and include unsafe sleep practices. More focused interventions are needed to address this gap between safe sleep knowledge and practice.

Associations of preschool reactive bed-sharing with sociodemographic factors, sleep disturbance, and psychopathology

OBJECTIVE

To advance understanding of early childhood bed-sharing and its clinical significance, we examined reactive bed-sharing rates, sociodemographic correlates, persistence, and concurrent and longitudinal associations with sleep disturbances and psychopathology.

METHODS

Data from a representative cohort of 917 children (mean age 3.8 years) recruited from primary pediatric clinics in a Southeastern city for a preschool anxiety study were used. Sociodemographics and diagnostic classifications for sleep disturbances and psychopathology were obtained using the Preschool Age Psychiatric Assessment (PAPA), a structured diagnostic interview administered to caregivers. A subsample of 187 children was re-assessed approximately 24.7 months after the initial PAPA interview.

RESULTS

Reactive bed-sharing was reported by 38.4% of parents, 22.9% nightly and 15.5% weekly, and declined with age. At follow-up, 48.9% of nightly bed-sharers and 88.7% of weekly bed-sharers were no longer bed-sharing. Sociodemographics associated with nightly bed-sharing were Black and (combined) American Indian, Alaska Native and Asian race and ethnicity, low income and parent education less than high school. Concurrently, bed-sharing nightly was associated with separation anxiety and sleep terrors; bed-sharing weekly was associated with sleep terrors and difficulty staying asleep. No longitudinal associations were found between reactive bed-sharing and sleep disturbances or psychopathology after controlling for sociodemographics, baseline status of the outcome and time between interviews.

CONCLUSIONS

Reactive bed-sharing is relatively common among preschoolers, varies significantly by sociodemographic factors, declines during the preschool years and is more persistent among nightly than weekly bed-sharers. Reactive bed-sharing may be an indicator of sleep disturbances and/or anxiety but there is no evidence that bed-sharing is an antecedent or consequence of sleep disturbances or psychopathology.

Directionality of the associations between bedsharing, maternal depressive symptoms, and infant sleep during the first 15 months of life

OBJECTIVES

To identify predictors of infant sleep arrangement and examine the directionality of the relationships between maternal depressive symptoms, infant sleep problems, and bedsharing.

DESIGN

Secondary analysis of longitudinal data from the Mothers and Others: Family-Based Obesity Prevention for Infants and Toddlers randomized trial.

SETTING

Central North Carolina, USA.

PARTICIPANTS

Four-hundred and twenty-eight predominantly low-income, non-Hispanic Black mother-infant pairs.

MEASUREMENTS

Data were collected at 28 weeks pregnancy and 1, 3, 6, 9, 12, and 15 months postpartum. Maternal depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale and infant sleep variables were measured using the Brief Infant Sleep Questionnaire.

RESULTS

The prevalence of reported bedsharing increased from 16.7% at 1 month to 35.6% at 15 months postpartum. Bedsharing was associated with shortened breastfeeding duration and maternal perception of an infant sleep problem. Concurrently, maternal perception of an infant sleep problem, but not presence of maternal depressive symptoms, was associated with an increased likelihood of bedsharing. Longitudinally, neither maternal perception of an infant sleep problem nor presence of maternal depressive symptoms predicted bedsharing. Bedsharing predicted an increased likelihood of maternal perception of an infant sleep problem and presence of maternal depressive symptoms.

CONCLUSION

Prevalence of bedsharing increased over time and was predictive of maternal depressive symptoms. Providers should discuss the conflicting infant sleep recommendations with their patients and provide safe-sleep guidelines for mothers who intend to bedshare.

Interventions to Improve Safer Sleep Practices in Families With Children Considered to Be at Increased Risk for Sudden Unexpected Death in Infancy: A Systematic Review

Background: Advice to families to follow infant care practices known to reduce the risks of Sudden Unexpected Death in Infancy (SUDI) has led to a reduction in deaths across the world. This reduction has slowed in the last decade with most deaths now occurring in families experiencing social and economic deprivation. A systematic review of the literature was commissioned by the National Child Safeguarding Practice Review Panel in England. The review covered three areas: interventions to improve engagement with support services, parental decision-making for the infant sleep environment, and interventions to improve safer sleep practices in families with infants considered to be at risk of SUDI. Aim: To describe the safer sleep interventions tested with families with infants at risk of SUDI and investigate what this literature can tell us about what works to reduce risk and embed safer sleep practices in this group. Methods: Eight online databases were systematically searched in December 2019. Intervention studies that targeted families with infants (0-1 year) at increased risk of SUDI were included. Studies were limited to those from Western Europe, North America or Australasia, published in the last 15 years. The Quality Assessment Tool for Studies with Diverse Designs was applied to assess quality. Data from included studies were extracted for narrative synthesis, including mode of delivery using Michie et al.'s Mode of Delivery Taxonomy. Results: The wider review returned 3,367 papers, with 23 intervention papers. Five types of intervention were identified: (1) infant sleep space and safer sleep education programs, (2) intensive or targeted home visiting services, (3) peer educators/ambassadors, (4) health education/raising awareness interventions, (5) targeted health education messages using digital media. Conclusion: Influencing behavior in families with infants at risk of SUDI has traditionally focused on "getting messages across," with interventions predominantly using education and awareness raising mechanisms. This review found evidence of interventions moving from "information giving" to "information exchange" models using personalized, longer term relationship-building models. This shift may represent an improvement in how safer sleep advice is implemented in families with infants at risk, but more robust evidence of effectiveness is required. Systematic Review Registration: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf, identifier: CRD42020165302.

Reasons mothers bedshare: A review of its effects on infant behavior and development

Bedsharing is controversial for nighttime caregiving in the U.S. today, as in most of the West. However, from the standpoint of evolutionary pediatrics, anthropology, and cultural psychology, bedsharing is not controversial at all, representing the context for human infant evolution and conferring a host of physiological benefits to the infant as well as the mother. In an effort to understand the rise in Western bedsharing in recent decades (and following Ball, 2002; McKenna & Volpe, 2007), Salm Ward (2015) systematically reviewed the literature on mother-infant bedsharing and identified ten reasons why mothers choose to bedshare: (1) breastfeeding, (2) comforting for mother or infant, (3) better/more sleep for infant or parent, (4) monitoring, (5) bonding/ attachment, (6) environmental reasons, (7) crying, (8) cultural or familial traditions, (9) disagree with danger, and (10) maternal instinct. The current paper offers the "review behind the review," highlighting the scientific evidence behind the reasons mothers give for their decision to bedshare, focusing on how mothers' decisions about infant sleep location influence infant behavior and development.

Bed sharing versus no bed sharing for healthy term neonates

BACKGROUND

There is great global variation in the sleeping arrangements for healthy newborn infants. Bed sharing is a type of sleeping practice in which the sleeping surface (e.g. bed, couch or armchair, or some other sleeping surface) is shared between the infant and another person. The possible physiological benefits include better oxygen and cardiopulmonary stability, fewer crying episodes, less risk of hypothermia, and a longer duration of breastfeeding. On the other hand, the most important harmful effect of bed sharing is that it may increase the risk of sudden infant death syndrome (SIDS). Studies have found conflicting evidence regarding the safety and efficacy of bed sharing during infancy.

OBJECTIVES

To evaluate the efficacy and safety of bed sharing, started during the neonatal period, on breastfeeding status (exclusive and total duration of breastfeeding), incidence of SIDS, rates of hypothermia, neonatal and infant mortality, and long-term neurodevelopmental outcomes.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 7) in the Cochrane Library; MEDLINE via PubMed (1966 to 23 July 2020), CINAHL (1982 to 23 July 2020), and LILACS (1980 to 23 July 2020). We also searched clinical trials databases, and the reference lists of retrieved articles, for randomised controlled trials (RCTs) and quasi-RCTS.

SELECTION CRITERIA

We planned to include RCTs or quasi-RCTs (including cluster-randomised trials) that included term neonates initiated on bed sharing within 24 hours of birth (and continuing to bed share with the mother in the first four weeks of life, followed by a variable time period thereafter), and compared them to a 'no bed sharing' group.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We planned to use the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Our search strategy yielded 6231 records. After removal of duplicate records, we screened 2745 records by title and abstract. We excluded 2739 records that did not match our inclusion criteria. We obtained six full-text studies for assessment. These six studies did not meet the eligibility criteria and were excluded.

AUTHORS' CONCLUSIONS

We did not find any studies that met our inclusion criteria. There is a need for RCTs on bed sharing in healthy term neonates that directly assess efficacy (i.e. studies in a controlled setting, like hospital) or effectiveness (i.e. studies conducted in community or home settings) and safety. Future studies should assess outcomes such as breastfeeding status and risk of SIDS. They should also include neonates from high-income countries and low- and middle-income countries, especially those countries where bed sharing is more prevalent because of cultural practices (e.g. Asian countries).

A comparison of safe sleep violations in child care and family child care learning homes in Georgia

BACKGROUND

High rates of infant death associated with sleeping practices continue to persist in the United States. Infants spend a large portion of their day with child care and family child care learning home providers. Safe sleeping practices continue to be an area of need for care providers of young children.

METHOD

The current study examines data drawn from a publicly available database of child care licensing reports in Georgia (n = 3,501), which contained data on child care centres and family child care learning homes. Information in the database included characteristics of the centres, year of data collection and the specific violations by child care provider type.

RESULTS

Results indicated clear differences in the prevalence of violations between child care centres and family child care learning homes. Within the overall sample, 13.3% of centres and family child care learning homes were cited for safe sleeping practice violations with higher prevalence in licensed child care centres and unaccredited centres. Violations were consistent with those commonly found in child care environments and inconsistent with the American Academy of Pediatrics safe sleep recommendations.

CONCLUSIONS

Data from the current study suggest a continued need for professional learning on safe sleep practices.

Decision-making for the infant sleep environment among families with children considered to be at risk of sudden unexpected death in infancy: a systematic review and qualitative metasynthesis

BACKGROUND

Advice to families to sleep infants on their backs, avoid smoke exposure, reduce excess bedcovering and avoid specific risks associated with cosleeping has greatly reduced sudden unexpected death in infancy (SUDI) rates worldwide. The fall in rates has not been equal across all groups, and this advice has been less effective for more socially deprived families. Understanding decision-making processes of families with infants at risk would support the development of more effective interventions.

AIM

To synthesise the qualitative evidence on parental decision-making for the infant sleep environment among families with children considered to be at increased risk of SUDI.

METHODS

This study was one of three related reviews of the literature for the Child Safeguarding Practice Review Panel's National Review in England into SUDI in families where the children are considered at risk of harm. A systematic search of eight online databases was carried out in December 2019. Metasynthesis was conducted, with themes extracted from each paper, starting with the earliest publication first.

RESULTS

The wider review returned 3367 papers, with 16 papers (across 13 studies) specifically referring to parental decision-making. Six overall themes were identified from the synthesis: (1) knowledge as different from action; (2) external advice must be credible; (3) comfort, convenience and disruption to the routine; (4) plausibility and mechanisms of protection; (5) meanings of safety and risk mitigation using alternative strategies; and (6) parents' own expertise, experience and instincts.

CONCLUSION

Interventions that are intended to improve the uptake of safer sleep advice in families with infants at risk of sleep-related SUDI need to be based on credible advice with mechanisms of protection that are understandable, consistent with other sources, widened to all carers of the infant and fit within the complex practice of caring for infants.

Applying a Social Exclusion Framework to Explore the Relationship Between Sudden Unexpected Deaths in Infancy (SUDI) and Social Vulnerability

Background: Sudden Unexpected Death in Infancy (SUDI) is a leading cause of preventable infant mortality and strongly associated with social adversity. While this has been noted over many decades, most previous studies have used single economic markers in social disadvantage analyses. To date there have been no previous attempts to analyze the cumulative effect of multiple adversities in combination on SUDI risk.

Methods: Based on sociological theories of social exclusion, a multidimensional framework capable of producing an overall measure of family-level social vulnerability was developed, accounting for both increasing disadvantage with increasing prevalence among family members and effect of family structures. This framework was applied retrospectively to all cases of SUDI that occurred in Queensland between 2010 and 2014. Additionally, an exploratory factor analysis was performed to investigate whether differing “types” of vulnerability could be identified.

Results: Increased family vulnerability was associated with four major known risk factors for sudden infant death: smoking, surface sharing, not-breastfeeding and use of excess bedding. However, families with lower levels of social vulnerability were more likely to display two major risk factors: prone infant sleep position and not room-sharing. There was a significant positive relationship between family vulnerability and the cumulative total of risk factors. Exploratory factor analysis identified three distinct vulnerability types (chaotic lifestyle, socioeconomic and psychosocial); the first two were associated with presence of major SUDI risk factors. Indigenous infants had significantly higher family vulnerability scores than non-Indigenous families.

Conclusion: A multidimensional measure that captures adversity across a range of indicators highlights the need for proportionate universalism to reduce the stalled rates of sudden infant death. In addition to information campaigns continuing to promote the importance of the back-sleeping position and close infant-caregiver proximity, socially vulnerable families should be a priority population for individually tailored or community based multi-model approaches.

Factors Associated With Choice of Infant Sleep Location

OBJECTIVE

To assess the prevalence of and factors associated with actual recent practice and near-future intention for infant sleep location in a national sample.

METHODS

There were 3260 mothers from 32 US hospitals who responded to a survey at infant age 2 to 6 months regarding care practices, including usual and all infant sleep locations in the previous 2 weeks and intended location for the next 2 weeks. Mothers were categorized as (1) having practiced and/or intending to practice exclusive room-sharing without bed-sharing, (2) having practiced anything other than exclusive room-sharing but intending to practice exclusive room-sharing, (3) intending to have the infant sleep in another room; and (4) intending to practice bed-sharing all night or part of the night. Multivariable multinomial logistic regression examined associations between sleep-location category, demographics, feeding method, doctor advice, and theory of planned behavior domains (attitudes, social norms, and perceived control).

RESULTS

Fewer than half (45.4%) of the mothers practiced and also intended to practice room-sharing without bed-sharing, and 24.2% intended to practice some bed-sharing. Factors associated with intended bed-sharing included African American race and exclusive breastfeeding; however, the highest likelihood of bed-sharing intent was associated with perceived social norms favoring bed-sharing (adjusted odds ratio [aOR] 5.84; 95% confidence interval [CI] 4.14-8.22) and positive attitudes toward bed-sharing (aOR 190.1; 95% CI 62.4-579.0). Women with a doctor's advice to room-share without bed-sharing intended to practice bed-sharing less (aOR 0.56; 95% CI 0.36-0.85).

CONCLUSIONS

Sleep-location practices do not always align with the recommendation to room-share without bed-sharing, and intention does not always correspond with previous practice. Attitudes, perceived social norms, and doctor advice are factors that are amenable to change and should be considered in educational interventions.

Exploring Malaysian mothers' plans on sleeping arrangement with their newborn

AIM

Bed sharing is defined as a newborn sleeping in the same bed with an adult. Bed sharing may put the newborn at risk of suffocation due to accidental smothering.

METHODS

This was a quasi-experimental study conducted in a tertiary referral hospital. Healthy post-delivery Malaysian mothers were randomly selected and enrolled into the control or the intervention group. On the day of discharge, mothers in the intervention group were interviewed face-to-face in the post-natal ward on their plans for sleeping arrangement with their newborn. After the interview, mothers were advised not to bed share with their newborn and were given an educational leaflet on safe sleeping practices. One week after discharge, mothers in both groups were interviewed over the telephone regarding their actual sleeping arrangements with their newborn using the same questionnaire. Logistic regression was performed to determine factors associated with reduced bed sharing.

RESULTS

A total of 94 mothers and 95 mothers were recruited to the control and intervention group, respectively. The baseline bed-sharing prevalence was similar between groups: 60.6% in the control group and 61.1% in the interventional group. The proportion of mothers who bed shared with their newborn reduced from 61.1 to 37.9% after the intervention (P < 0.001). Most mothers in the control group opted for bed sharing to ease breastfeeding (68.4%). Mothers in the control group had a 5.9 times higher odds of bed sharing.

CONCLUSIONS

In this study, the majority of mothers practiced bed sharing at baseline. A significant proportion of mothers changed their sleeping practices after receiving the intervention in the form of an information leaflet.

Bedsharing and Breastfeeding: The Academy of Breastfeeding Medicine Protocol #6, Revision 2019

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

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.

An Integrated Analysis of Maternal-Infant Sleep, Breastfeeding, and Sudden Infant Death Syndrome Research Supporting a Balanced Discourse

Breastfeeding and the place of sleep for the mother and the infant have been controversial internationally due to reported concerns regarding infant deaths despite the known benefits of exclusive and prolonged breastfeeding, which are increased by breastfeeding at night. The aims of this integrated analysis were to (a) review breastfeeding and maternal and infant sleep research literature via historical, epidemiological, anthropological, and methodological lenses; (b) use this information to determine where we are currently in safeguarding both infant lives and breastfeeding; and (c) postulate the direction that research might take from this point forward to improve our knowledge and inform our policy and practice. Despite well-meaning but unsuccessful campaigns in some countries to dissuade parents from sleeping with their babies, many breastfeeding mothers and caregivers do sleep with their infants whether intentionally or unintentionally. Taking cultural contexts and socio-ecological circumstances into consideration, data supports policies to counsel parents and caregivers on safe sleep practices, including bed-sharing in non-hazardous circumstances, particularly in the absence of parental smoking, recent parental alcohol consumption, or sleeping next to an adult on a sofa. Further research with appropriate methodology is needed to drill down on actual rates of infant deaths, paying close attention to the definitions of deaths, the circumstances of the deaths, and confounding factors, in order to ensure we have the best information with which to derive public health policy. Introduction and use of the concept of "breastsleeping" is a plausible way to remove the negative connotations of "co-sleeping" and redirect ongoing data-driven discussions and education of best practices of breastfeeding and sleep.

Modifiable sleep-related risk factors in infant deaths in Cook County, Illinois

Background

Each year, approximately 3500 infants in the United States die from sleep-related deaths. The number of sleep-related infant deaths has decreased overall since the 1990s, but disparities in sleep-related deaths persist among different populations. The purpose of this study was to determine the most common risk factors and locations in Cook County, Illinois for sleep-related deaths in infants under 6 months of age.

Methods

We conducted a retrospective study among infants less than 6 months of age who died in Cook County, Illinois in 2015 and 2016, in which the manner of death was of undetermined intent with at least one modifiable sleeping risk factor present, as reported by the medical examiner. Data were obtained from the Illinois Violent Death Reporting System (IVDRS), a state-based, anonymous, surveillance system. County trends and circumstances of the deaths were also evaluated. Frequencies, percentages, and Chi-square analysis were used to describe and characterize these deaths.

Results

In Cook County in 2015 and 2016, 116 infants less than 6 months of age died where the manner of death was classified as undetermined intent. The median age of death was 2 months. Of these deaths, 63 (54.3%) of the infants were boys. African-American and Hispanic infants comprised 71 (65.7%) and 23 (21.3%) of the deaths, respectively. In 84 (72.4%) of the cases, at least one known sleeping risk factor was present and 56 (66.7%) of the infants who died with a known sleeping risk factor were co-sleeping. Notably, 33 (29.7%) of the deaths in Cook County were clustered within six zip codes.

Conclusions

The majority of infants who died unexpectedly in Cook County in 2015 and 2016 did so in the presence of sleeping risk factors, with co-sleeping being the most common. African-American infants, infants under 2 months of age, and several geographical areas within Chicago appear to be at increased risk. Interventions to target these preventable causes in the populations at increased risk should be instituted to prevent future deaths.

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.

Sudden infant death and sleep practices in the Black community

PURPOSE

A Black infant dies every 13 hours in the state of Indiana. The overall infant mortality rate in 2013 was 7.2 deaths per 1000 live births, but for Black infants, the rate was 15.3 deaths per 1000 live births. For over 20 years, placing an infant to sleep on his back has decreased the death rate from sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS), but many Black families continue to advocate bed sharing, prone sleeping, and inappropriate bedding/sleep surfaces, predisposing an infant to a significantly higher risk for SUID/SIDS. Therefore, the purpose of this study is to understand why Black women are less likely than White women to follow safe sleep recommendations for their infants.

DESIGN

A rigorous search of the literature was performed by searching the Web of Science, OVID, CINAHL, PsychINFO, and PubMed using the search terms: infant or child, death, loss, SIDS, SUID, qualitative, African American, Black, culture, safe sleep, experiences, and United States. A total of 217 articles were obtained. After review of inclusion and exclusion criteria and critical appraisal, only seven articles remained for the research study.

METHODS

The meta-synthesis of these seven original qualitative studies was performed using the Qualitative Assessment and Review Instrument from the Joanna Briggs Institute to assist with data management. Data were extracted and representative quotations were categorized. Categories were arranged into like themes. Themes were then synthesized with meta-aggregation.

RESULTS

A total of 17 subthemes were identified and were formulated into three primary themes: convenience, safety, and culture. The final synthesized theme was that Black mothers are motivated by their beliefs.

PRACTICE IMPLICATIONS

Black mothers tend to believe that SUIDS/SIDS is a random occurrence and is not preventable, so they see a little reason to make their infant sleep in a cold, hard crib, when they could sleep in a warm, comfortable bed with them. Nurses should work with Black mothers to understand their cultural beliefs while educating them about safe sleep practices.

Health Messaging and African-American Infant Sleep Location: A Randomized Controlled Trial

Infant-parent bedsharing increases the risk of SIDS and other sleep-related deaths. Despite AAP recommendations to avoid bedsharing, public health efforts have been unsuccessful in changing behaviors. African-American infants are more than twice as likely to die from SIDS and other sleep-related deaths, and are also twice as likely to bedshare with their parents. Further, African-American parents have a high degree of self-efficacy with regards to preventing infant suffocation, but low self-efficacy with regards to SIDS risk reduction. It is unclear whether messages emphasizing suffocation prevention will decrease bedsharing. To evaluate the impact of specific health messages on African-American parental decisions regarding infant sleep location. We conducted a randomized, controlled trial of African-American mothers of infants. The control group received standard messaging emphasizing AAP-recommended safe sleep practices, including avoidance of bedsharing, for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices, including avoidance of bedsharing, for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth. 1194 mothers were enrolled in the study, and 637 completed all interviews. Bedsharing, both usually (aOR 1.005 [95 % CI 1.003, 1.006]) and last night (aOR 1.004 [95 % CI 1.002, 1.007]) increased slightly but statistically significantly with infant age (p < 0.001). Receipt of the enhanced message did not impact on sleep location. Maternal belief that bedsharing increased the risk of SIDS or suffocation declined over 6 months (p < 0.001) and did not differ by group assignment. African-American mothers who received an enhanced message about SIDS risk reduction and suffocation prevention were no less likely to bedshare with their infants.

CLINICAL TRIALS REGISTRATION

Clinical Trials.gov identifier NCT01361880.

Care Through the Newborn's Eyes

Separation of mothers and infants after birth is standard practice for many hospitals, yet not evidence-based. Nonseparation clearly has numerous benefits. However, newborns lack a voice to make choices to direct their course of care. The evidence supports nonseparation strategies for mothers and infants that promote attachment, physiologic regulation, nutrition, sleep, communication, and management of stress/pain. Moreover, the evidence is compelling that nonseparation is essential. The time has come to act on the evidence and begin seeing the care we provide through the newborn's eyes.

Prevention Messages in Parent-Infant Bed-Sharing: Message Source, Credibility, and Effectiveness

Objective. Despite educational outreach, bed-sharing prevalence is rising. Mothers’ and fathers’ bed-sharing practices, prevention message source, perceived source credibility, and the effectiveness of the prevention message were evaluated. Methods. Data were collected from 678 community parents via an online survey. Results were analyzed using descriptive statistics and phi tests. Results. Bed-sharing reasons focused on comfort and ease. Mothers were more likely to receive prevention messages from individual professionals or organizations, whereas fathers were more likely to hear prevention messages from spouses/coparents and grandfathers. Physicians were the most common source, and physicians and grandmothers were rated as the most credible and effective. Conclusions. Prevention message source varies between mothers and fathers, highlighting the need for continued research with fathers. Grandmothers and physicians are effective and credible sources of prevention messages. Although less frequent, prevention messages from grandmothers were most effective. There was no evidence of effective messages from educational campaigns.

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.

Impact of a Randomized Controlled Trial to Reduce Bedsharing on Breastfeeding Rates and Duration for African-American Infants

Bedsharing is associated with both increased breastfeeding and increased risk of sudden and unexpected infant deaths. The objective was to determine impact of sleep location and counseling about sleep location on breastfeeding exclusivity and duration in African-Americans. 1194 mothers of newborns were randomized to receive messaging emphasizing either safe sleep practices to reduce SIDS risk or safe sleep practices to prevent SIDS/suffocation. Mothers completed four interviews in the 6 months after delivery. The most common sleep arrangement was roomsharing without bedsharing ("roomsharing"). Duration of any breastfeeding was 6.1 and 5.3 weeks for infants who usually bedshared or roomshared, respectively (p = 0.01). Duration of exclusive breastfeeding was 3.0 and 1.6 weeks for infants who usually bedshared or roomshared, respectively (p < 0.001). Group assignment did not affect breastfeeding duration. The most common sleep arrangement for African-American infants <6 months was roomsharing. An intervention designed to discourage bedsharing did not impact breastfeeding duration.

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.

Do gender and racial/ethnic disparities in sleep duration emerge in early adulthood? Evidence from a longitudinal study of U.S. adults

OBJECTIVE

Gender and racial/ethnic disparities in sleep duration are well documented among the U.S. adult population, but we know little about how these disparities are shaped during the early course of adult life, a period marked by substantial changes in social roles that can influence time for sleep.

METHODS

Prospective data was used from the National Longitudinal Survey of Youth 1997 (NLSY97), a U.S.-based representative sample of persons born between 1980 and 1984, who were first interviewed in 1997. Sleep duration was assessed in 2002, 2007/2008, 2009, 2010, and 2011. Random-coefficient models were estimated to examine gender and racial/ethnic disparities in trajectories of sleep duration across early adulthood as a function of educational experiences, employment, and family relationships.

RESULTS

Sleep duration declined during early adulthood. Women reported shorter sleep than men from age 18 to 22, but slept longer than men by age 28. Black Young adults reported sleep durations similar to those of White young adults until age 24, after which blacks slept less than whites. Educational experiences and employment characteristics reduced gender and racial/ethnic disparities, but family relationships exacerbated them.

CONCLUSION

This study is the first to establish the emergence of gender and racial/ethnic disparities in sleep duration during early adulthood.

Parent decision factors, safety strategies, and fears about infant sleep locations

Infant sleep safety is a primary concern of parents. Infant sleep locations vary around the world.

PURPOSE

This pilot study investigated the decision factors, fears, and safety strategies reported by parents internationally.

METHODS

participants (n=49) recruited online from 10 countries completed an anonymous Internet survey in English and submitted a picture of the infant's primary nighttime sleep location. Pictures were coded into 'shared' (29%) or 'separate' (71%) sleep surfaces.

RESULTS

primary decision factors about infant sleep location were safety, comfort, family sleep quality, and overall ease. Parents maximized safety by providing a clear sleep surface, no blankets, no toys, sleep sack use, and a firm mattress. Different worries and fears emerged depending on the sleep surface.

CONCLUSION

differences in the specific worries and strategies used by parents when deciding whether to share or not share a sleep surface with an infant may be used to tailor future interventions.

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.

"Same Room, Safe Place"

There are many different professional stances on safe sleep and then there is the reality of caring for a newborn. There is a debate among professionals regarding safe sleep recommendations. The continum of recommendations vary from the American Academy of Pediatrics (AAP) Safe Sleep Guidelines to the bed-sharing recommendations from the Mother-Baby Behavioral Sleep Laboratory. The lack of consistent and uniform safe sleep recommendations from health professionals has been confusing for families but has more recently raised a real professional ethical dilemma. Despite years of focused safe sleep community education and interventions, sleep-related infant deaths are on the rise in many communities. This commentary calls for a united safe sleep message from all health professionals to improve health for mothers and infants most at-risk, “Same Room, Safe Place.”

Hazard Patterns Associated With Co-sleepers

We conducted a retrospective review of incidents associated with co-sleepers. A total of 26 incidents (6 deaths and 20 injuries) were reported to the Consumer Product Safety Commission. Of these, 5 deaths were caused by asphyxia, and 1 was attributed to sudden infant death syndrome (SIDS). The mean age at death was 3.1 months. Two-thirds of deaths had known risk factors for SIDS. Of the 20 injuries, entrapment (60%) and suffocation (35%) hazards were most common. Almost half of the injuries occurred after the co-sleeper was improperly assembled. Infant deaths and injuries associated with co-sleepers are infrequent. Most deaths were associated with other SIDS risk factors. Many deaths and injuries were associated with improper use or assembly of the co-sleeper. It is important for pediatricians to advise parents not to use previously owned co-sleepers or to use co-sleepers in any way other than what is specifically stated in the product instructions to avoid infant injury or death.

Infant Co-Bedding: Practices and Teaching Strategies

PURPOSE

Studies show that co-bedding is a common cause of death in babies. The purpose of this study is to identify teaching strategies that can be used to increase safe sleep practices.

DESIGN AND METHODS

A rigorous systematic literature search identified articles that expressed ways in which to provide co-bedding teaching or provided recommended approaches to educating mothers and families about co-bedding risks. NOTARI software, from OVID Tools, was used to appraise articles, extract data, and thematically organize the findings, resulting in meta-aggregation.

RESULTS

Two major findings were synthesized from four categories. First, co-bedding occurred despite knowing risks and having received teaching. Second, families should receive co-bedding messages tailored to their specific circumstances and risks.

PRACTICE IMPLICATIONS

Findings showed that the lack of dialogue in co-bedding teaching often deters caregivers and families from seeking further education or consultation. Nurses need to ensure that safe sleep practices are taught and that the material provided pertains to the caregiver's specific cultural and familial situation.

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.

Reasons for mother-infant bed-sharing: a systematic narrative synthesis of the literature and implications for future research

Mother-infant bed-sharing has been a common practice for centuries. Understanding the reasons parents choose to bed-share can help tailor safe sleep education. The purpose of this article was to systematically review the international literature on: (1) reasons parents bed-share, (2) the cultural context of bed-sharing, and (3) implications for interventions and future research. The search occurred August-September 2013 via PubMed, CINAHL, and Psyc INFO using the terms: "infant," "sleep," "bed shar*," "co sleep*," "sleep location," "sleep practices," and "sleep arrangements," alone or in combination. Google Scholar was searched using: "bed share," "bed sharing," "co sleep," and "co sleeping." Inclusion criteria were: (1) referenced bed-sharing with infants 12 months or younger; (2) provided reasons for bed-sharing; and (3) published between 1990 and 2013. Studies were excluded if they focused on disorders such as epilepsy, breathing disorders, or among multi-gestational infants. Narrative synthesis was used to summarize findings. Thirty-four studies met inclusion criteria. The main themes around bed-sharing based on this synthesis included: (1) breastfeeding, (2) comforting, (3) better/more sleep, (4) monitoring, (5) bonding/attachment, (6) environmental, (7) crying, (8) tradition, (9) disagree with danger, and (10) maternal instinct. Findings suggest that future research should examine parents' decision-making process on infant sleep location, including how they weigh personal reasons and sources of advice. Public health interventions should incorporate the particular reasons of the population they are targeting. Clinicians should discuss infant sleep environment with each family, along with their motivations for choosing this environment, and work within that framework to address the safety of the sleep environment.

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

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

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.

Socioeconomic position, health behaviors, and racial disparities in cause-specific infant mortality in Michigan, USA

OBJECTIVES

Studies about racial disparities in infant mortality suggest that racial differences in socioeconomic position (SEP) and maternal risk behaviors explain some, but not all, excess infant mortality among Blacks relative to non-Hispanic Whites. We examined the contribution of these to disparities in specific causes of infant mortality.

METHODS

We analyzed data about 2,087,191 mother-child dyads in Michigan between 1989 and 2005. First, we calculated crude Black-White infant mortality ratios independently and by specific cause of death. Second, we fit multivariable Poisson regression models of infant mortality, overall and by cause, adjusting for SEP and maternal risk behaviors. Third, Crude Black-White mortality ratios were compared to adjusted predicted probability ratios, overall and by specific cause.

RESULTS

SEP and maternal risk behaviors explained nearly a third of the disparity in infant mortality overall, and over 25% of disparities in several specific causes including homicide, accident, sudden infant death syndrome, and respiratory distress syndrome. However, SEP and maternal risk behaviors had little influence on disparities in other specific causes, such as septicemia and congenital anomalies.

CONCLUSIONS

These findings help focus policy attention toward disparities in those specific causes of infant mortality most amenable to social and behavioral intervention, as well as research attention to disparities in specific causes unexplained by SEP and behavioral differences.

Housing influences among sleep-related infant injury deaths in the USA

This article examines the role of housing conditions in sleep-related infant injury death, a leading cause of infant mortality in the USA. The use of an unsafe sleep surface is a major risk factor for sleep-related infant injury. This exploratory study examined contextual circumstances, specifically those related to the physical environment, which may contribute to caregivers' decisions to place an infant on an unsafe sleep surface. It employed a retrospective review of 255 sleep-related infant injury death cases in a large urban area from 2004 to 2010 where an infant was found sleeping on an unsafe sleep surface, including 122 cases where a crib or bassinet was identified in the home. Quantitative findings indicated no differences in demographic or risk characteristics between infants with cribs or bassinets and those without them. Qualitative findings suggested the lack of crib or bassinet use may be related to environmental factors influenced by poverty, specifically crowded living space, room temperature and vermin infestation. This study suggests that infants may be at risk of sleep-related injury deaths even when a crib or bassinet is present in the home and supports the consideration of housing conditions in health promotion efforts to reduce infant mortality. Understanding environmental factors that may contribute to infants sleeping on an unsafe surface can help maternal child health and public health professionals develop more appropriate interventions that address deleterious living conditions.

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.

Sofas and infant mortality

OBJECTIVE

Sleeping on sofas increases the risk of sudden infant death syndrome and other sleep-related deaths. We sought to describe factors associated with infant deaths on sofas.

METHODS

We analyzed data for infant deaths on sofas from 24 states in 2004 to 2012 in the National Center for the Review and Prevention of Child Deaths Case Reporting System database. Demographic and environmental data for deaths on sofas were compared with data for sleep-related infant deaths in other locations, using bivariate and multivariable, multinomial logistic regression analyses.

RESULTS

A total of 1024 deaths on sofas made up 12.9% of sleep-related infant deaths. They were more likely than deaths in other locations to be classified as accidental suffocation or strangulation (adjusted odds ratio [aOR] 1.9; 95% confidence interval [CI], 1.6-2.3) or ill-defined cause of death (aOR 1.2; 95% CI, 1.0-1.5). Infants who died on sofas were less likely to be Hispanic (aOR 0.7; 95% CI, 0.6-0.9) compared with non-Hispanic white infants or to have objects in the environment (aOR 0.6; 95% CI, 0.5-0.7) and more likely to be sharing the surface with another person (aOR 2.4; 95% CI, 1.9-3.0), to be found on the side (aOR 1.9; 95% CI, 1.4-2.4), to be found in a new sleep location (aOR 6.5; 95% CI, 5.2-8.2), and to have had prenatal smoke exposure (aOR 1.4; 95% CI, 1.2-1.6). Data on recent parental alcohol and drug consumption were not available.

CONCLUSIONS

The sofa is an extremely hazardous sleep surface for infants. Deaths on sofas are associated with surface sharing, being found on the side, changing sleep location, and experiencing prenatal tobacco exposure, which are all risk factors for sudden infant death syndrome and sleep-related deaths.

Exploring caregiver behavior and knowledge about unsafe sleep surfaces in infant injury death cases

OBJECTIVES

In the United States, infant deaths due to sleep-related injuries have quadrupled over the past two decades. One of the major risk factors is the placement of an infant to sleep on a surface other than a crib or bassinet. This study examines contextual circumstances and knowledge and behaviors that may contribute to the placement of infants on an unsafe sleep surface in infant injury death cases.

METHOD

This study employed a retrospective review of 255 sleep-related injury death cases in New York City from 2004 to 2010 where an infant was found sleeping on an unsafe sleep surface. Mixed-methods analyses, employing both quantitative analysis of vital statistics data and risk variables extracted from the medical examiner files and qualitative analysis of the narrative content of the files, were conducted.

RESULTS

In 48% of cases, a crib or bassinet was identified in the home. Quantitative analysis revealed no significant differences in demographic or risk factor characteristics between infants who had a crib or bassinet and those who did not. Qualitative analysis highlighted factors in caregivers' decision making related to situational convenience, preference, and misconceptions concerning safe infant sleep. The health belief model (HBM), specifically the constructs of perceived susceptibility, severity, benefits, and barriers, was used as a lens to understand factors associated with caregiver behavior.

CONCLUSIONS

This study provides evidence that infants are at risk of sleep-related injury death even when a crib or bassinet is present. Understanding the factors that may influence safe sleep behaviors can help produce more appropriate interventions.

Application of a Socio-Ecological Model to Mother–Infant Bed-Sharing

Mother–infant bed-sharing has been associated with an increased risk of sleep-related infant deaths, and thus, health messaging has aimed to discourage this behavior. Despite this messaging, bed-sharing remains a common practice in the United States, especially among minority families. Moreover, rates of accidental suffocation and strangulation in bed (often related to bed-sharing) are on the rise, with Black infants at two to three times greater risk than Whites. Multiple studies have identified risk factors for bed-sharing, but a gap remains between findings and translation into interventions. The socio-ecological model (SEM) has been suggested as a way to study and design interventions addressing complex public health issues. This article reconceptualizes the literature on mother–infant bed-sharing using the SEM. PubMed, POPLINE, ERIC, and Psych Info were searched for articles that (a) included bed-sharing as the outcome variable, (b) were published between 2000 and 2013, (c) were conducted in the United States, and (d) included quantitative comparison of more than one factor. The following data were extracted: sample characteristics, bed-sharing definition, methods, factors examined, key findings, and conclusions. Data were summarized into five SEM levels—infant, maternal, family and household, and community and society, nested within the historical context of race. Sixteen studies met inclusion criteria. Significant factors associated with bed-sharing were present within each SEM level of influence. Educational interventions may increase efficacy by attending to multiple levels of the SEM, especially when implementing such interventions within minority subpopulations. Using a harm reduction approach to reducing the risk around bed-sharing may be one way to account for the multiple influences on bed-sharing. The science and practice of minimizing mother–infant bed-sharing may be advanced through use of the SEM.