The Pēpi-Pod study: Overnight video, oximetry and thermal environment while using an in-bed sleep device for sudden unexpected death in infancy prevention

Sources of attitudes towards parent-child co-sleeping and their effects: A systematic scoping review

Parent-child co-sleeping is a common practice in many cultures, although in Western countries, families who engage in parent-child co-sleeping can encounter attitudes about co-sleeping that feel critical from the people around them, as it is not commonly accepted and often stigmatized. This systematic scoping review examined and synthesized the available literature on the attitudes about parent-child co-sleeping that people encounter, their origins, and their effect on parents' own attitudes and behaviors. A total of 9796 abstracts were screened, and 33 studies were included. While the scope of the literature on this topic was narrow, this review demonstrated that parents/caregivers mostly encounter encouraging attitudes about co-sleeping from their extended family members and within their culture and discouraging attitudes from healthcare professionals. Findings suggest that encouraging attitudes enhance the likelihood of parents engaging and continuing with co-sleeping behavior, while discouraging attitudes can lead to the avoidance of parents discussing sleep with their healthcare professionals and can cause conflicts with other family members, including partners. Based on these findings, we conclude that further research is needed in several areas related to co-sleeping in Western culture, most specifically in how external attitudes influence the decision to co-sleep, as well as other behaviors and cognitions such as engagement with healthcare professionals, family satisfaction, parental self-efficacy, and overall mental health.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

Pacific families navigating responsiveness and children's sleep in Aotearoa New Zealand

The stakes for understanding sleep practices are rising as health inequalities related to sleep become more apparent. Pacific peoples in Aotearoa New Zealand face disproportionate challenges around poverty and health and sleep is one growing area of importance in addressing health inequalities. Through a qualitative study of 17 Pacific families in Aotearoa New Zealand, we provide a rare and valuable glimpse into the familial, cultural, social and economic context of sleep for Pacific families and children in New Zealand. These Pacific families uphold a core value of responsiveness to family, community, culture and faith. These values feed wellbeing in a variety of ways, especially when health is considered through Pacific, holistic frameworks. These families apply the same responsiveness to economic pressures, often taking on shiftwork. We show how responsiveness to family and culture, as well as limited economic means, permeates sleep practices within these Pacific households. These broader shaping factors must be acknowledged, considered, respected and integrated into any healthy sleep initiatives and interventions, in order to ensure benefit - and not harm - is achieved.

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A rare, valuable and intimate glimpse into the familial, cultural, social and economic context of sleep for Pacific families in New Zealand.

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Many health initiatives and interventions do not account for cultural variation and do not reach the populations that need them most.

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A qualitative study, integrating the Fonofale Model of health, informing culturally relevant sleep interventions for Pacific families.

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Pacific families value family, community, faith and culture; they are also disproportionately affected by economic hardship. Both impact sleep.

A Box to Put the Baby in: UK Parent Perceptions of Two Baby Box Programmes Promoted for Infant Sleep

Between 2016 and 2019, two different infant sleeping-box interventions were implemented in England: (1) shallow polypropylene baby boxes were distributed via a feasibility study to families with Sudden Infant Death Syndrome (SIDS) risk factors; and (2) a commercial–health system partnership scheme distributed cardboard baby boxes to new mothers in particular locations. We conducted parent evaluations of both interventions at the time of implementation. The views of 79 parents receiving polypropylene boxes and 77 parents receiving cardboard boxes were captured using online questionnaires and telephone interviews. Participants provided feedback on education received about using the box, their perception of the box design and materials, their experiences of using the box they received, and whether they would recommend it to others. Parents appreciated that both boxes provided a portable space to place their baby near them anywhere in the home, discouraging other riskier practices. The polypropylene box was rated more favourably regarding transparency, hygiene, and portability outside the home. A minority of parents found the idea of putting their baby in any box unappealing; however, younger mothers and smokers particularly appreciated the ability to safely co-sleep with their babies using the shallower box. Overall, the versatility of the polypropylene box scheme was more positively evaluated than the cardboard baby box scheme, which, stripped of its social value as part of a larger welfare provision, had minimal value for parents that received it.

Innovation to prevent sudden infant death: the wahakura as an Indigenous vision for a safe sleep environment

The bassinet-like wahakura is an Indigenous initiative for the prevention of Sudden Unexpected Death in Infancy (SUDI). It was developed by New Zealand Māori in 2005 when Māori were rejecting the 'stop bedsharing' SUDI prevention message and the SUDI disparity between Māori and non-Māori had become entrenched. Made of native flax, the wahakura was promoted as a culturally resonant, in-bed safe sleep device that would disrupt the SUDI risk associated with 'bedsharing where there was smoking in pregnancy' without relying on smoking cessation. A significant movement of weavers and health professionals grew around the wahakura program. A body of research, including infant care surveys, retrospective case review, qualitative enquiry and a randomised controlled trial comparing wahakura and bassinet safety demonstrated the device's public health plausibility, acceptability to Māori women and its essential safety. This facilitated the distribution, by District Health Boards, of safe sleep devices, including a related device called the Pēpi-Pod, and safe sleep education to high-risk, mainly Māori, mothers. Infant mortality in New Zealand fell by 29%, primarily among Māori infants, over the period 2009-15, suggesting that Māori cultural concepts, traditional activities and community engagement can have a significant effect on ethnic inequities in infant mortality.

Crafting effective messages to enhance safe infant sleep

BACKGROUND

Health care professionals are continually challenged by the need to provide health information in a way that successfully changes health practices. Research has documented this as a concern in relation to safe infant sleep health campaigns. Often, caregivers' knowledge of recommended practices is not associated with a change in infant sleep choices.

PURPOSE

Health campaigns, including most safe infant sleep efforts, often share specific risk factors and steps for avoiding risk, that is, in a verbatim format. Research has shown that caregivers' behavior may be more likely to change when presented with messages based on their general understanding of risk, that is, gist-based format. This research examines caregivers' responses as related to verbatim- and gist-based safe sleep information.

METHODS

Five hundred forty-one caregivers of infants were shown 12 images depicting infants in safe or unsafe sleep spaces. Images varied across three commercially available spaces, infant race, and presence/absence of one policy-based risk factor.

RESULTS

Differences in caregivers' discernment of safe and unsafe sleep images paralleled reported differences in knowledge of safe sleep recommendations. Discernment of safe/unsafe images was greater for White than Black caregivers, as well as for females in comparison with male caregivers. Gist-based considerations, such as familiarity with the sleeper depicted or infant race, were also associated with caregivers' discernment of safe/unsafe images.

IMPLICATIONS FOR PRACTICE

Attending to both gist- and verbatim-based knowledge regarding safe infant sleep campaign information may help to effectively facilitate caregivers' ability to always create safe sleep spaces for their infants.

Considerations in Safe to Sleep® messaging: Learning from African-American mothers

PURPOSE

The purpose of this study was to identify why African-American mothers do not tend to follow the Safe to Sleep® recommendations and to begin to identify a way to frame the Safe to Sleep® message so that African-American mothers might be more likely to follow these recommendations.

DESIGN

We recruited African-American mothers with infants over the age of 6 months to participate in two focus groups facilitated by a community engagement manager experienced in focus group facilitation. We used ethnography to find shared patterns of behavior and beliefs in African-American women related to safe sleep.

RESULTS

We identified 14 concepts and formulated them into three categories: it's just easier; can't fight culture and grandma; and Effectively teaching mother. From these we were able to identify the shared value of multifaceted learning.

PRACTICE IMPLICATIONS

African-American mothers say that they are generally aware of the Safe to Sleep® recommendations, even though the majority of mothers do not follow them. The reasons they give for not following them are that they are not comfortable doing so, they feel they are unable to do so, or find it unnecessary. Many of the mothers attempted to follow the Safe to Sleep® recommendations but abandoned the effort due to the stress of their crying infant. Trying to follow the Safe to Sleep® recommendations were stressful for the mothers, even though there was concern expressed by some that their infant could indeed suffocate or die from sudden infant death syndrome. The mothers gave suggestions on how they would change the message or the delivery of the message.

Mothers' Perceptions of the Cardboard Box as a Potential Sleep Space

OBJECTIVE

Due to increasing popularity, our hospital began considering distributing cardboard boxes combined with safe sleep education to new mothers. As a first step in studying the impact of this intervention on bedsharing in our community, we sought to understand mothers' perceptions of the cardboard box.

METHODS

We recruited primarily low-income, English- or Spanish-speaking mothers of infants aged 2 to 16 weeks during routine primary care visits. Participants responding to a cross-sectional survey about infant sleep practices were invited to participate in in-depth interviews about the cardboard box. We used a grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

Of 120 participants in the survey, 50 (42%) participated in the qualitative study. Participants were mothers of infants aged ≤4 weeks (46%), 4 to 8 weeks (32%), and 16 weeks (22%). Of 50 participants, 52% said they would use the cardboard box for their infant to sleep in, if provided, compared with 42% who said they would not and 6% were unsure. Three themes emerged from the data: (1) safety of the cardboard box; (2) appearance, and (3) variation in planned use. Some participants planned to place the cardboard box in their bed.

CONCLUSIONS

Participants in our study were divided about whether they would use the cardboard box for their infant to sleep in. If distributed, hospital staff should advise families to not place the cardboard box in their bed. Next steps include determining bedsharing frequency among parents who choose to use the cardboard box for their infant.

The influence of bed-sharing on infant physiology, breastfeeding and behaviour: A systematic review

This review aimed to better understand the underlying physiology of the risks and benefits of bed-sharing. Eight databases were searched using terms relating to adult-infant/baby, bed-sharing/co-sleeping combined with outcome terms for physiology, sleep, cardiovascular, respiratory, temperature and behaviour. Of 836 papers identified, 59 papers representing 48 cohorts met inclusion criteria. Objective data using various methodologies were available in 27 papers and subjective data in 32 papers. Diverse measures were reported using variable definitions of bed-sharing. Identified physiological and behavioural differences between bed-sharing and cot-sleeping included increased behavioural arousals, warmer in-bed temperatures and increased breastfeeding duration in bedshare infants as well as differences in infant overnight sleep architecture, cardiorespiratory control and cortisol responses to stress. We concluded that many differences are context-specific, and dependent on the subjective view of the parents and their cultural values. Objective risk arises if the infant is unable to mount an appropriate physiological or behavioural response to their micro-environment. More studies in the bed-sharing setting are needed to identify infant risk, the potential benefits of a safer environment, and how bed-sharing interacts with infant care practices other than sleep.

Pediatric Videosomnography: Can Signal/Video Processing Distinguish Sleep and Wake States?

The term videosomnography captures a range of video-based methods used to record and subsequently score sleep behaviors (most commonly sleep vs. wake states). Until recently, the time consuming nature of behavioral videosomnography coding has limited its clinical and research applications. However, with recent technological advancements, the use of auto-videosomnography techniques may be a practical and valuable extension of behavioral videosomnography coding. To test an auto-videosomnography system within a pediatric sample, we processed 30 videos of infant/toddler sleep using a series of signal/video-processing techniques. The resulting auto-videosomnography system provided minute-by-minute sleep vs. wake estimates, which were then compared to behaviorally coded videosomnography and actigraphy. Minute-by-minute estimates demonstrated moderate agreement across compared methods (auto-videosomnography with behavioral videosomnography, Cohen's kappa = 0.46; with actigraphy = 0.41). Additionally, auto-videosomnography agreements exhibited high sensitivity for sleep but only about half of the wake minutes were correctly identified. For sleep timing (sleep onset and morning rise time), behavioral videosomnography and auto-videosomnography demonstrated strong agreement. However, nighttime waking agreements were poor across both behavioral videosomnography and actigraphy comparisons. Overall, this study provides preliminary support for the use of an auto-videosomnography system to index sleep onset and morning rise time only, which may have potential telemedicine implications. With replication, auto-videosomnography may be useful for researchers and clinicians as a minimally invasive sleep timing assessment method.