Integrating "Back to Sleep" recommendations into neonatal ICU practice

Sleeping Safe and Sound: A Multidisciplinary Hospital-wide Infant Safe Sleep Quality Improvement Initiative

INTRODUCTION

Promoting safe sleep to decrease sudden unexpected infant death is challenging in the hospital setting.

LOCAL PROBLEM

Concern for adherence to safe sleep practice across inpatient units at a large pediatric hospital.

METHODS

Used quality improvement methodologies to promote safe sleep across all units.

INTERVENTIONS

Development of a multidisciplinary expert group, hospital-wide guidelines, targeted interventions, and bedside audits to track progress.

RESULTS

Adherence to safe sleep practices improved from 9% to 53%. Objects in the crib were a major barrier to maintaining a safe sleep environment. Safe sleep practices were less likely to be observed in infants with increased medical complexity (p = .027).

CONCLUSIONS

Quality improvement methodology improved adherence to infant safe sleep guidelines across multiple units. Medically complex infants continue to be a challenge to safe sleep. Therefore, ongoing education for staff and further research into best practices for the most complex infant populations are necessary.

Early and consistent safe sleep practices in the neonatal intensive care unit: a sustained regional quality improvement initiative

OBJECTIVE

To increase compliance with standardized safe sleep recommendations for patients in a cohort of regional level III/IV neonatal intensive care units (NICUs) in accordance with recently revised guidelines issued by the American Academy of Pediatrics (AAP).

STUDY DESIGN

A regional quality improvement (QI) initiative led by a multidisciplinary task force standardized safe sleep criteria across participating NICU sites. Universal and unit-specific interventions were implemented via Plan-Do-Study-Act (PDSA) cycles with evaluation of compliance through routine crib audits, run chart completion, and Pareto chart analysis.

RESULTS

Following QI implementation, compliance with safe sleep guidelines for eligible NICU infants improved from 34% to 90% from October 2019 through September 2022.

CONCLUSION

Compliance with early, consistent modeling of safe sleep practices nearly tripled in this cohort of regional NICUs. A standardized, timely approach to safe sleep transition demonstrated dramatic and sustained improvement in the practice and modeling of safe sleep behaviors in the NICU.

Characteristics of Sudden Unexpected Infant Deaths on Shared and Nonshared Sleep Surfaces

OBJECTIVES

Describe characteristics of sudden unexpected infant deaths (SUID) occurring on shared or nonshared sleep surfaces.

METHODS

We examined SUID among residents of 23 US jurisdictions who died during 2011 to 2020. We calculated frequencies and percentages of demographic, sleep environment, and other characteristics by sleep surface sharing status and reported differences of at least 5% between surface sharing and nonsharing infants.

RESULTS

Of 7595 SUID cases, 59.5% were sleep surface sharing when they died. Compared with nonsharing infants, sharing infants were more often aged 0 to 3 months, non-Hispanic Black, publicly insured, found supine, found in an adult bed or chair/couch, had a higher number of unsafe sleep factors present, were exposed to maternal cigarette smoking prenatally, were supervised by a parent at the time of death, or had a supervisor who was impaired by drugs or alcohol at the time of death. At least 76% of all SUID had multiple unsafe sleep factors present. Among surface-sharing SUID, most were sharing with adults only (68.2%), in an adult bed (75.9%), and with 1 other person (51.6%). Surface sharing was more common among multiples than singletons.

CONCLUSIONS

Among SUID, surface sharing and nonsharing infants varied by age at death, race and ethnicity, insurance type, presence of unsafe sleep factors, prenatal smoke exposure, and supervisor impairment. Most SUID, regardless of sleep location, had multiple unsafe sleep factors present, demonstrating the need for comprehensive safe sleep counseling for every family at every encounter.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

NICU Visitation Time and Adherence to Safe Sleep Practices Among Mothers of Very Preterm Infants

BACKGROUND

Sleep-associated infant death is the leading cause of postneonatal mortality in the United States. Preterm infants are at higher risk for sleep-associated death, but maternal adherence to safe sleep practices is lower than for mothers of full-term infants. Data are lacking on whether maternal neonatal intensive care unit (NICU) visitation time impacts safe sleep compliance after hospital discharge.

PURPOSE

For mothers of preterm infants, to investigate the association of time days per week spent in the NICU and adherence to safe sleep practices after discharge.

METHODS

A prospective observational study of 109 mothers with infants born at less than 32 weeks from 4 Colorado NICUs who completed a survey at 6 weeks after discharge about infant sleep practices. Maternal time spent in the NICU was defined as the average number of days spent in the NICU per week of infant hospitalization, as documented in the electronic medical record. Multivariable logistic regression models assessed the relationship between time in the NICU and safe sleep adherence. Covariates included maternal/infant characteristics significant at P < .2 level in bivariate analysis.

RESULTS

Predictors of compliance with all safe infant sleep practices included public/no insurance compared with private insurance (adjusted odds ratio [AOR] 0.29; 95% confidence interval [CI] 0.09-0.96), some college/associate-level education versus bachelor's degree (AOR 5.88; 95% CI 1.21-28.67), and depression/anxiety symptoms (AOR 0.37; 95% CI 0.14-0.97). NICU visitation days was not associated with adherence to safe sleep practices.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Maternal visitation days was not associated with adherence to safe infant sleep practices after discharge, highlighting the need to identify barriers and facilitators to engaging families about SUID risk-reducing behaviors.

Safe Newborn Sleep Practices on a Large Volume Maternity Service

PURPOSE

Reinforcing safe infant sleep conditions in the hospital setting supports continuation of safe sleep practices after hospital discharge and should be considered the first line of defense for reducing risk for sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS) at home. The purpose of this study is to determine knowledge of perinatal nurses, nursing assistants, physicians, and ancillary personnel about safe sleep recommendations and implementation of safe sleep practices on the mother-baby unit.

STUDY DESIGN AND METHODS

Nurses and other members of the perinatal health care team in a level III maternity service were invited to participate in a survey about safe sleep knowledge and practices. An audit for safe sleep adherence was conducted on the mother-baby unit for 120 mother-baby couplets over 1 year as a process improvement project.

RESULTS

N = 144 surveys were completed; most participants (86%) were nurses. They had high levels of knowledge about safe sleep recommendations and 74% reported making at least one safe sleep adjustment during one shift per week. The most common modifications at least once per week were removing baby from a sleeping caregiver (30%) and removing items from baby's bassinet (26%). Safe sleep audit findings revealed 32 out of 120 couplets were not fully following safe sleep recommendations, with most common unsafe sleep practice metrics being items in the baby's bassinet (18%) and bassinets propped up (8%).

CLINICAL IMPLICATIONS

During the hospitalization for childbirth, new parents can learn about safe sleep practices from the perinatal health care team. Sharing information and role modeling safe sleep practices can promote continuation of safe sleep practices for the newborn at home after hospital discharge.

Ensuring Safe Sleep in the Pediatric Intensive Care Unit: A Systematic Review of Informed Development of Clinical Guidelines for Implementation in Practice

INTRODUCTION

Although general safe sleep guidelines have been established, their utility and implementation have yet to be examined systematically for inpatient populations for application to infants in the pediatric intensive care unit (PICU) setting. This study aimed to complete a systematic review of inpatient safe sleep practices studies to develop then safe sleep clinical guidelines for implementation in the care of medically complex infants in the PICU.

METHOD

This review was registered with PROSPERO and adheres to Preferred Reporting Items for Systematic reviews and Meta-Analyses systematic review guidelines.

RESULTS

Nineteen articles met the inclusion criteria. A safe sleep guideline algorithm for medically complex infants in the PICU was created for implementation.

DISCUSSION

Consistent and comprehensive safe sleep education and modeling by health care professionals in the inpatient setting is an effective technique to reduce the risk of harm and promote safe sleep behaviors in the home setting.

Increasing Safe Sleep Practices in the Neonatal Intensive Care Unit

BACKGROUND

The American Academy of Pediatrics (AAP) encourages healthcare providers to practice and model safe sleep practices (SSPs) in the neonatal intensive care unit (NICU) when it is developmentally and medically appropriate for the infant. Preintervention data were collected as a baseline prior to the quality improvement (QI) initiative and revealed that 87% of eligible infants were in unsafe sleep environments (n = 331/379). This data revealed the need for an improvement project to help increase the percentage of infants placed in safe sleep in this NICU.

PURPOSE

The purpose of this QI initiative was to increase the percentage of eligible infants being placed in safe sleep environments by registered nurses in a NICU.

METHODS

The development of an evidence-based safe sleep bundle was implemented in a level IV NICU at an academic medical center in the Southeastern United States. Data were subsequently collected for 5 months via bi weekly crib audits.

RESULTS

Of the 744 infants audited in the QI period, 604 were observed in a safe sleep environment. From the pre- to postintervention period, SSPs increased by 68% (preintervention: 13%, postintervention: 81%, P value < .001). Adherence to the varying components of SSPs also reflected statistically significant improvements.

IMPLICATIONS FOR PRACTICE

SSPs should be endorsed and modeled in all NICUs. Introducing proper SSPs in the hospital setting may lead to better compliance at home by the infants' caregivers.

Training medical students to teach safe infant sleep environments using pyramidal behavioral skills training

Medical personnel play a critical role in caregiver safe infant sleep education. However, training outcomes in the safe infant sleep training literature have been mixed. Promising approaches that warrant further investigation are the use of behavioral skills training and pyramidal training. The current study consisted of two experiments. Experiment 1 extended Carrow et al. (2020) and Vladescu et al. (2020) by teaching medical students safe infant sleep practices using behavioral skills training. Discriminated responding was examined across trained and untrained environmental arrangements using a multiple-baseline design. All participants arranged safe sleep environments following behavioral skills training. In Experiment 2, we used pyramidal behavioral skills training to train medical students to teach others safe sleep practices. Results indicated high procedural integrity scores following training and generalization of skills.

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.

Practicing What We Preach: An Effort to Improve Safe Sleep of Hospitalized Infants

Introduction:

To prevent sudden unexpected infant death, pediatric providers recommend the ABCs of infant sleep: Alone, on the Back, and in an empty Crib. This study’s objective was to document sleep practices of infants admitted to a large children’s hospital, examine adherence to American Academy of Pediatrics safe sleep guidelines, and develop interventions to improve guideline adherence.

Methods:

We conducted a pre/post quality improvement study at a single quaternary care medical center from 2015 to 2019. Infants 0 to younger than 12 months were observed in their sleeping environment pre- and post-implementation of multiple hospital-wide interventions to improve the sleep safety of hospitalized infants.

Results:

Only 1.3% of 221 infants observed preintervention met all ABCs of safe sleep; 10.6% of 237 infants met the ABCs of safe sleep postintervention. Significant improvements in the post-intervention cohort included sleeping in a crib (94% versus 80% preintervention; P < 0.001), avoidance of co-sleeping (3% versus 15% preintervention; P < 0.001), absence of supplies in the crib (58% versus 15% preintervention; P < 0.001), and presence of an empty crib (13% versus 2% preintervention; P < 0.001).

Conclusions:

Most infants hospitalized at our institution do not sleep in a safe environment. However, the implementation of a care bundle led to improvements in the sleep environment in the hospital. Further research is necessary to continue improving in-hospital safe sleep and to assess whether these practices impact the home sleep environment.

Improving safe sleep practices in an urban inpatient newborn nursery and neonatal intensive care unit

OBJECTIVE

To improve safe sleep compliance in a newborn nursery (NN) and neonatal intensive care unit (NICU) to >80% in 1 year.

STUDY DESIGN

Prospective quality improvement study of infants admitted to a NN and NICU. Interventions were targeted at parent education, staff education, and system processes.

RESULTS

Compliance with safe sleep improved to >80% in both units. Tracking of process measures revealed NICU parents received safe sleep education 98-100% of the time. No change was observed in the balancing measures. Transfers from the NN to the NICU for temperature instability did not increase. Parent satisfaction with discharge preparedness did not change (98.2% prior to and 99.6% after).

CONCLUSION

We achieved improved compliance with safe sleep practices in our NN and NICU through education of staff and parents and improved system processes. We believe this will translate to improved safe sleep practices used by parents at home.

Safe Sleep Program for the NICU Nursing Staff: A Pilot Program

PURPOSE

Following an assessment of safe sleep practices (SSP) and nurses' safe sleep knowledge in a Neonatal Intensive Care Unit (NICU), an evidence-based 2-part safe sleep program including nurse education and the use of safe sleep cards was developed in an attempt to increase SSP.

DESIGN

A quality improvement project with time-series methodology, including observational and survey data collection.

SAMPLE

To assess SSP, sleep environment audits were completed pre- (N = 48) and post- safe sleep program (N = 44). To assess nurses' safe sleep knowledge, a safe sleep questionnaire was distributed pre-education (N = 48) and post-education (N = 23).

MAIN OUTCOME VARIABLE

The change in SSP (ΔSSP) following safe sleep program implementation and change in nurses' safe sleep knowledge (ΔKnowledge) following education.

RESULTS

SSP increased from 25 percent to 61 percent compliance, and nurses' knowledge scores increased from 83 percent to 97 percent.

Improving Adherence to Safe Sleep Guidelines for Hospitalized Infants at a Children’s Hospital

Supplemental Digital Content is available in the text.

Introduction:

Sudden unexpected infant deaths are a major problem nationally. We had poor adherence to safe sleep recommendations locally at our institution. Given the significance of this problem, hospital administration at a tertiary children’s hospital tasked a multidisciplinary group of faculty and staff with improving sleep environments for hospitalized infants.

Methods:

Our safe sleep task force implemented targeted interventions using the American Academy of Pediatrics policy statement as the gold standard and based on hospital data to address areas of greatest nonadherence to recommendations. We aimed to improve weekly average adherence to 95% over 12 months. A proportions process control chart (p-chart) tracked average weekly adherence over a 52-week time frame. In addition, we performed Student’s t-testing to evaluate differences in adherence over time.

Results:

There was a significant improvement in overall adherence to safe sleep recommendations from baseline (M = 70.8%, SD 21.6) to end of study period (M = 94.7%, SD 10.0) [t(427) = −15.1, P ≤ 0.001]. Crib audits with 100% adherence increased from a baseline (M = 0%, SD 0) to the end of the study period M = 70.4%, SD = 46) [t(381)= −21.4, P ≤ 0.001]. This resulted in two trend shifts on the p-chart using Institute for Healthcare Improvement control chart rules.

Conclusions:

Targeted interventions using QI methodology led to significant increases in adherence to safe sleep guidelines. Notable improvements in behavior indicated significant changes in safe sleep culture. We also noted continued adherence in follow-up audits reflecting sustainability.

Improving Hospital Infant Safe Sleep Compliance by Using Safety Prevention Bundle Methodology

BACKGROUND AND OBJECTIVES

Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children's hospital.

METHODS

A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts).

RESULTS

Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%.

CONCLUSIONS

Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital.

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.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Implementation of Safe Sleep Practices by Mothers with 0-1 Year-Old Infants

Aim: The sleep environment of an infant affects the likelihood of sudden infant death syndrome and other sleep-related infant deaths. This study was performed to determine the safe sleep practices of mothers with 0–1 year-old infants. Methods: This descriptive study included 204 mothers with 0–1 year-old infants who visited family health centers between October 30 and December 28, 2018. The data were collected using a questionnaire form and evaluated using the number, percentage, mean, standard deviation, and chi-squared test. Results: The mean age of the mothers was 28.48 ±5.83 years; 43.1% were primary school graduates and 84.8% were housewives; 53.9% of the infants were girls and 39.2% were 0–3 months old. It was found that 47.5% of the mothers put their infant to sleep in the supine position, 46.1% in the non-supine position, 70.1% on a soft bed, and 76.5% by using a pillow. In addition, 41.2% of the mothers stated that they used pacifiers while putting their infant to sleep, 9.8% stated that they slept in the same bed with their infant, and 92.9% stated that they slept in the same room. Conclusion: It was determined that the mothers performed certain risky practices related to the sleep environment, particularly regarding soft beds’ use, sleeping positions, pillow use, and bed-sharing. It may be recommended that healthcare professionals play an active role and take responsibility in increasing the level of knowledge and awareness of parents regarding safe sleep. Keywords: sleep, infant, mothers, family practice

Persistent Racial/Ethnic Disparities in Supine Sleep Positioning among US Preterm Infants, 2000-2015

OBJECTIVE

To assess trends in racial disparity in supine sleep positioning (SSP) across racial/ethnic groups of infants born early preterm (Early preterm; <34 weeks) and late preterm (Late preterm; 34-36 weeks) from 2000 to 2015.

STUDY DESIGN

We analyzed Pregnancy Risk Assessment Monitoring System data (a population-based perinatal surveillance system) from 16 US states from 2000 to 2015 (Weighted N = 1 020 986). Marginal prevalence of SSP by year was estimated for infants who were early preterm and late preterm, adjusting for maternal and infant characteristics. After stratifying infants who were early preterm and late preterm, we compared the aOR of SSP trends across racial/ethnic groups by testing the time-race interaction.

RESULTS

From 2000 to 2015, Non-Hispanic Black infants had lower odds of SSP compared with Non-Hispanic White infants for early preterm (aOR 0.61; 95% CI 0.47-0.78) and late preterm (aOR 0.44; 95% CI 0.34-0.56) groups. For Hispanic infants, there was no statistically significant difference for either preterm group when compared with Non-Hispanic White infants. aOR of SSP increased (on average) annually by 10.0%, 7.3%, and 7.7%, respectively, in Non-Hispanic White, Non-Hispanic Black, and Hispanic early preterm infants and by 5.8%, 5.9%, and 4.8% among Non-Hispanic White, Non-Hispanic Black, and Hispanic late preterm infants. However, there were no significant between-group differences in annual changes (Early preterm: P = .11; Late preterm: P = .25).

CONCLUSIONS

SSP increased for all racial/ethnic preterm groups from 2000 to 2015. However, the racial/ethnic disparity in SSP among early preterm and late preterm groups persists.

Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants

BACKGROUND

An unsafe sleep environment remains the leading contributor to unexpected infant death.

PURPOSE

To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants.

METHODS

A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018.

RESULTS

Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%.

IMPLICATIONS FOR PRACTICE

WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices.

IMPLICATIONS FOR RESEARCH

Future studies on the impact of such an initiative at other hospitals are needed.

Coming Together to Save Babies: Our Institution's Quality Improvement Collaborative to Improve Infant Safe Sleep Practices

Supplemental Digital Content is available in the text.

Many hospitalized infants are not observed in an American Academy of Pediatrics-recommended safe sleep environment, which can translate to unsafe sleep practices at home. We implemented this collaborative to reduce our county’s sleep-related death rate by improving infant safe sleep practices in the freestanding children’s hospital setting and increasing safe sleep screening and education in our clinics and emergency departments (EDs).

Effects of Implementing a Simulation-Learning Based Training Using a Train-The-Trainer Model on the Acquisition and Retention of Knowledge about Infant Safe Sleep Practices Among Licensed Nurses

PURPOSE

The purpose of this study was to evaluate the effectiveness of the implementation of a simulation-learning based training using a train-the-trainer model on the acquisition and retention of knowledge about infant safe sleep practices among nursing staff employed at a women's and children's hospital.

DESIGN AND METHODS

This was a two-phase, quasi-experimental study with repeated measure in a women's and children's hospital in Southwest XXXX. A total of 120 nurses completed phase I of the study, while 74 completed phase II. Kolb's Experiential Learning Theory and Observational Experiential Theory were used to guide the development of the methods and research question.

RESULTS

Overall, there was statistically significant (p < .001) increases between pre-test and post-test scores immediately and at three months. The post-partum, well-baby nursery, and pediatric department had statistically significant (p < .001) increases between pre-test and post-test scores immediately and at three months. The pediatric intensive care unit did not have statistically significant increases between pre-test and post-test scores immediately and at three months (p = .086).

CONCLUSIONS

A train-the-trainer program in simulation and infant safe sleep can positively affect nurses' knowledge about safe sleep and SUID. Future research should include longer follow-up assessments to better determine long-term impact.

Safe to sleep: Community-based caregiver training

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

The wake project: Improving safe sleep practices in a neonatal intensive care unit

BACKGROUND

Every year, about 50 babies in New York City die from a sleep-related injury. The Bronx County ranked second highest rate of sleep-related infant deaths (SRID) at 0.5 per 1000 among the other boroughs. The highest rate was among blacks and the rate of SRID cases were highest in our population at 0.97 (zip code 10466) among all other Bronx neighborhoods which comprises 77% of non-Hispanic black population. Further, Bronx has the highest preterm birth rate at 9.5%. This quality improvement (QI) project aimed to develop and implement an educational initiative on infant safe sleep (SS) to improve "Safe Sleep Practices (SSP) in a level III neonatal intensive care unit (NICU) for one of the highest risk populations in the country.

METHODS

Baseline data was collected prior to initiating the QI project. Multiple plan-do-study-act (PDSA) cycles were completed over a 12 month period. Run charts were utilized to identify improvement and guide interventions. These interventions included education for nurses, crib cards, posters, feedback forms, grand rounds and small group discussions.

RESULTS

Approximately 600 crib checks (CC) were performed over the duration of this project. At baseline, 7% of infants were placed in a SS position in the NICU. Following the QI project, SS position increased to 96% of infants.

CONCLUSION

Multifactorial interventions significantly improved SS compliance among NICU nurses. Cultivating personal motivation among nurses, consistent empowerment and dedication to culture change by the entire team was crucial for the sustainability of the project.

As easy as ABC: evaluation of safe sleep initiative on safe sleep compliance in a freestanding pediatric hospital

Background

The American Academy of Pediatrics (AAP) recommends the ABCs of safe infant sleep (alone, back, clear crib) to combat the increasing rates of Sudden Unexplained Infant Death (SUID). It is unclear if these recommendations are followed for infants hospitalized in pediatric facilities after the newborn period. The objectives of this study were to assess baseline infant sleep behaviors at a tertiary care freestanding pediatric hospital and to evaluate the effectiveness of a hospital-based infant safe sleep program in improving adherence to safe sleep recommendations.

Methods

A quality improvement program with pre- and post- analyses was performed on a convenience sample of infants < 12-months old utilizing a crib audit tool on two general pediatric inpatient units. The crib audit tool was used before and after the safe sleep program intervention. It recorded the infant's sleep position, location during sleep, and sleep environment. Interventions included: 1) nursing education, 2) crib cards with a checklist of the ABC's of safe sleep provided for the cribs of hospitalized infants, and 3) tracking boards to report weekly measured compliance with the ABCs. Chi square analysis was used to compare adherence to recommendations before and after program implementation.

Results

There were 62 cribs included pre-intervention and 90 cribs post-intervention. Overall, there was no significant change in safe sleep positioning (81% to 82%, p = 0.97). There was a significant increase in adherence to the safe sleep environment recommendation (3% to 38%, p < 0.01). Overall safe sleep, including both position and environment, referred to as ABC compliance, improved from 3% pre-intervention to 34% post-intervention (p < 0.01). Only 18% of cribs audited displayed a crib card, demonstrating poor compliance on placement of the cards. There was no significant difference in compliance with safe sleep recommendations between infants with a crib card compared to those without (25% vs. 37%, p = 0.51).

Conclusions

Significant improvements were made in sleep environments and overall safe sleep compliance after introduction of crib cards and tracking boards. Most likely the crib auditing process itself and the tracking boards had a larger impact than the crib cards.

"Choose Physical Therapy" for Neonatal Abstinence Syndrome: Clinical Management for Infants Affected by the Opioid Crisis

In response to the opioid crisis, the American Physical Therapy Association has strongly advocated for physical therapy as a safe alternative to pharmacological pain management through the "#ChoosePT" campaign and the dedication of a PTJ special issue to the nonpharmacological management of pain. Physical therapists not only play an important role in the rehabilitation of the nearly 2 million adolescents and adults addicted to prescription opioids but also provide care to infants born to mothers with various drug addictions. This Perspective article explores the incidence, pathophysiology, and risk factors for neonatal abstinence syndrome and describes the clinical presentations of withdrawal and neurotoxicity in infants. Discipline-specific recommendations for the physical therapist examination and plan of care, including pharmacological management considerations, are outlined. Nonpharmacological management, including supportive care, feeding, parent education, social aspects of care, and follow-up services, are discussed from a physical therapy perspective. Finally, this article reviews developmental outcomes in infants with neonatal abstinence syndrome and reflects on challenges and future directions of research in this area.

An exploratory study of the perception of contraceptive safety and impact on lactation among postpartum nurses at Women and Infants Hospital in 2017

OBJECTIVE

To describe contraceptive knowledge and counseling practices of postpartum nurses.

METHODS

We surveyed postpartum nurses at the largest women's hospital in Rhode Island.

RESULTS

We distributed 117 anonymous questionnaires and received 58 responses (response rate=50%). Twenty-three of 51 nurses (45%) reported routinely offering contraceptive advice to new mothers. Only 5/55 (9%) responded correctly that combined hormonal contraceptives were an "unacceptable health risk" in the immediate postpartum period. A minority of respondents correctly classified the progestin-only pill, depot medroxyprogesterone acetate, the etonogestrel implant, the levonorgestrel intrauterine system and the copper intrauterine device as safe to use during lactation [14/56 (25%), 24/56 (43%), 27/56 (48%), 19/55 (35%) and 9/55 (16%), respectively]. Thirty-three of 51 nurses (65%) incorrectly responded that depot medroxyprogesterone acetate decreases milk supply if started immediately postpartum.

CONCLUSION

There are opportunities to improve knowledge regarding contraceptive safety and impact on lactation among postpartum nurses at our institution.

Nurses Leading Safe Infant Sleep Initiatives in the Hospital Setting

Every day, 10 otherwise healthy infants die from sleep-related deaths in the United States. These deaths, termed sudden unexpected infant death, remain the leading cause of post-neonatal death in the United States despite known modifiable risk factors and prevention recommendations. In birthing hospitals, many parents report being given incorrect and sometimes no information about infant sleep safety, which creates immediate and long-term safety concerns. In this article, we provide an overview of sudden unexpected infant death, including sudden unexpected postnatal collapse, and the latest safe sleep recommendations from the American Academy of Pediatrics. We also offer practical guidelines for nurses-those working at the bedside and those in leadership positions-who may be seeking to improve the quality of infant sleep practices in their organizations.

Creating a Safe Sleep Environment for the Infant: What the Pediatric Nurse Needs to Know

Despite the release of guidelines by the American Academy of Pediatrics (AAP) on safe infant sleep and public service campaigns aimed at reducing risk factors over the past 25 years, deaths due to Sudden Infant Death Syndrome (SIDS) and Sudden Unexplained Infant Death (SUID) are still the 4th leading causes of infant death in the United States. Findings from several studies demonstrate that nurses do not consistently model safe sleep practices with infants due to a lack of education on evidence-based practice and misconceptions regarding safe infant sleep. The aim of this paper is to demonstrate the need for expanded education to both nurses and parents on the principles of safe infant sleep and the impact it can have on decreasing risk factors for SIDS and SUID. Strategies are outlined for additional education for nurses and parents to enhance adherence to safe sleep guidelines and quality improvement projects aimed at the implementation of culture change are discussed. Going forward it is critical that nurses take an active role in seeking additional education on modifiable risk factors linked to SIDS and SUID and use that education to model and teach safe infant sleep practices with every infant at every encounter.

Response to a National Issue: Moving Beyond "Back to Sleep" at Three Hospitals

PURPOSE

To measure changes in registered nurse (RN) knowledge/beliefs and practices, parents' recall of infant safe sleep (ISS) teaching, and inpatient infant sleep environments and safety after implementing an ISS initiative.

DESIGN AND METHODS

This longitudinal quasi-experimental study took place in three hospitals in the United States. An existing infant safe sleep tool was revised and updated to align with current recommendations on sleep environments. A bundled intervention included educating nurses, changing unit processes and implementing crib cards and room signs. Paired questionnaires surveyed 62 nurses before and 2 months after the intervention. Audits of 462 cribs/sleep environments with parent conversations assessed infant sleep conditions and parents' recall of RN teaching before and after the intervention.

RESULTS

After Bonferroni correction, eight of 19 items for RN knowledge/beliefs and self-reported practice showed statistically significant improvements with moderate effect sizes. All 11 items for parents' recall of RN teaching showed statistically significant improvements, with odds ratios ranging from 7 to 76. Five of six real-time sleep safety conditions (from crib/sleep environment audits) had statistically significant improvements. Odds ratios ranged from eight to 83.

CONCLUSION

An updated educational tool improved nurses' and parents' knowledge and practices related to current and updated safety factors for infant sleep conditions. Inpatient adherence to infant sleep safety recommendations improved.

PRACTICE IMPLICATIONS

A two-hour investment of nurses' time yielded statistically significant improvements. Factors critical to the success of the ISS project roll-out are reported. Improvements in parents' recall of teaching and actual sleep environments suggest potential for long-term changes in infant safety at home.

Infant Safe Sleep: A Survey of the Knowledge, Attitudes, and Behaviors of Obstetric Physicians

Obstetricians may be a pregnant woman's primary professional source of information about her infant prior to the birth, but infant safe sleep knowledge, attitudes and behaviors of this population are unknown. This study explores obstetric physicians' knowledge, attitudes, and behaviors related to Sudden Infant Death Syndrome and infant safe sleep and identifies barriers as well as enabling and/or reinforcing factors associated with providing infant safe sleep education in the prenatal environment. A cross-sectional survey was conducted with obstetric physicians who provide prenatal healthcare to women in Ohio. Surveys were sent to all licensed physicians included in the registry of the State Medical Board of Ohio with "obstetrics," "obstetrics and gynecology," or "maternal and fetal medicine" as their primary specialty (n = 1771). The response rate was 30%, with 418 physicians included in the analysis. Many participants were knowledgeable about infant safe sleep recommendations; however, only 55% indicated that it was important for obstetric physicians to discuss Sudden Infant Death Syndrome and/or infant safe sleep with prenatal patients. Many participants (70%) perceived barriers to providing infant safe sleep education, however most (82%) indicated interest in doing so. Participants' knowledge and attitudes were significant predictors of whether they discuss this topic with patients. Obstetric physicians can influence the infant safe sleep decisions that women make. Improving obstetricians' knowledge and attitudes about infant safe sleep and supporting physicians who wish to provide education on this topic may help to ensure that women are receiving frequent and consistent infant safe sleep messaging throughout the prenatal period.

Implementation of safe sleep practices in Massachusetts NICUs: a state-wide QI collaborative

OBJECTIVE

To increase the use of safe sleep practices (SSP) among high-risk infants discharged from Massachusetts (MA) NICUs to 90% in 2 years.

DESIGN/METHODS

The Neonatal Quality Improvement Collaborative of MA (NeoQIC) is a consortium of neonatal providers that provides infrastructure to lead and manage state-wide quality improvement initiatives. The safe sleep initiative was started in July 2015 with participation of all 10 MA level III NICUs. Based upon the project algorithm, infants are eligible for two sleep practices: SSP or NICU therapeutic positioning (NTP) depending on their gestational age, weight, and clinical illness. Compliance with SSP is defined as: (1) supine positioning, (2) in a flat crib with no incline, (3) without positioning devices, and (4) without soft objects. NTP comprised usual NICU care. Local improvement teams devise intervention strategies, perform weekly crib audits for all NICU infants, and submit data on overall compliance and compliance with each SSP component on a monthly basis to NeoQIC.

RESULTS

From July 2015 to June 2017, 7261 cribs were audited. Statistical process control charts showed significant improvement in the primary outcome of interest, overall compliance with SSP, for all participating NICUs. Compliance increased from 47.7% at the start of the project to 75.5% by the end of year 1 and to 81.0% by June 2017.

CONCLUSIONS

This state-wide collaborative has improved SSP compliance in all level III MA NICUs and demonstrated that on a state-wide level, SSPs can be routinely integrated into the care of high-risk infants.

Certified Nurse-Midwives' Knowledge, Attitudes, and Behaviors About Infant Safe Sleep

INTRODUCTION

Little is known about the knowledge, attitudes, and behaviors of certified nurse-midwives related to sudden infant death syndrome and infant safe sleep. However, this population is an important and trusted source of information for pregnant women and may provide guidance on infant care. We explored these topics with certified nurse-midwives to identify potential barriers as well as enabling and reinforcing factors associated with providing infant safe sleep education in the prenatal health care environment.

METHODS

Participants in this cross-sectional survey study were certified nurse-midwives who provide prenatal health care to women in Ohio. Surveys were mailed to all certified nurse-midwives listed with the licensing registry of the Ohio Board of Nursing (N = 333).

RESULTS

A total of 153 eligible respondents completed the survey for a response rate of 55%. Most participants had at least some knowledge of the infant safe sleep recommendations from the American Academy of Pediatrics, and two-thirds had positive attitudes about providing infant safe sleep education in the prenatal environment. Many participants (61%) perceived that there were barriers to providing prenatal infant safe sleep education, but nearly all (94%) indicated that they were interested in providing this education to their patients. Positive attitudes about providing infant safe sleep education were predictive of whether they discussed this topic with their patients.

DISCUSSION

Certified nurse-midwives routinely provide guidance on infant care, and it is important that they are familiar with current evidence-based recommendations on infant safe sleep. They should be supported in their desire to provide infant safe sleep education to their prenatal patients. In addition, efforts should be made to improve attitudes and social norms related to providing infant safe sleep education in the prenatal environment.

Implementing a Statewide Safe to Sleep Hospital Initiative: Lessons Learned

Sleep-related infant deaths continue to be a major, largely preventable cause of infant mortality, especially in Georgia. The Georgia Department of Public Health (DPH), as part of a multi-pronged safe infant sleep campaign, implemented a hospital initiative to (1) provide accurate safe infant sleep information to hospital personnel; (2) support hospitals in implementing and modeling safe sleep practices; and (3) provide guidance on addressing caregiver safe sleep concerns. A process evaluation was conducted to determine progress toward four goals set out by DPH: (1) all birthing hospitals have a safe infant sleep policy; (2) all safe infant sleep policies reference the AAP 2011 recommendations; (3) all safe infant sleep policies specify the type and/or content of patient safe sleep education; and (4) all hospitals require regular staff training on safe sleep recommendations. Data were collected via structured interviews and document review of crib audit data and safe sleep policies. All 79 birthing hospitals in the state participated in the statewide campaign. Prior to the initiative, 44.3% of hospitals had a safe sleep policy in place; currently, 87.3% have a policy in place. The majority (91.4%) of hospitals have provided safe sleep training to their staff at this time. Important lessons include: (1) Engagement is vital to success; (2) A comprehensive implementation guide is critical; (3) Piloting the program provides opportunities for refinement; (4) Ongoing support addresses barriers; and (5) Senior leadership facilitates success.

Barriers to and Interventions that Increase Nurses' and Parents' Compliance With Safe Sleep Recommendations for Preterm Infants

The purpose of this integrative review was to identify interventions that increase compliance of nurses and of parents with safe sleep recommendations for premature infants. Ten studies were included in the final sample, including three studies with a prospective descriptive design, five quality improvement initiatives with an interventional research design, one secondary analysis, and one retrospective medical chart review. Study samples included neonatal nurses and parents of premature infants in NICUs and transitional care nurseries in Massachusetts, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas. Sample sizes ranged from 5 to 259 NICU parents and 86 to 658 neonatal nurses. The categories of interventions we identified include identifying barriers to compliance, changing hospital policy, and providing safe sleep education for nurses and parents. We conclude that hospitals should have current, evidence-based safe sleep policies with clear transition guidelines for premature infants and that consistent and comprehensive nursing and parental education related to safe sleep should include current American Academy of Pediatrics recommendations and should address potential barriers to compliance.

Caring about Preemies' Safe Sleep (CaPSS): An Educational Program to Improve Adherence to Safe Sleep Recommendations by Mothers of Preterm Infants

Preterm infants born before 37 weeks' gestation die of sudden infant death syndrome (SIDS) at a rate more than double that of term infants. There is a need for SIDS prevention programs tailored to the specific needs of parents of high-risk infants. The purpose of this study was to pilot test an online educational module addressing SIDS risk-reduction recommendations (RRRs) for parents of preterm infants. This study was conducted in a 44-bed transitional care unit at a level IV NICU in the Midwest. A repeated-measures design was used. Two weeks before discharge, mothers completed a survey, addressing knowledge and plans for caring for their baby at home. Mothers then viewed the 5-section Caring about Preemies' Safe Sleep (CaPSS) education module and completed the postmodule evaluation. A discharge survey was completed 4 weeks postdischarge. Fifteen mothers, mean age 26.4 years, participated; 8 (53%) returned the postdischarge survey. Module evaluation rated clarity and completeness of information high. Mothers' ratings of SIDS knowledge were significantly higher after viewing the module (P = .000) and 4 weeks after discharge home (P = .012). Mothers found the use of a pacifier at sleep times to be new information and changed their plans for caring for their infant, with 28.6% of mothers always offering a pacifier before sleep after discharge compared with the 6.7% who had planned to do this before discharge. However, only 71% of infants slept in parents' room after discharge and only 41% were receiving at least some breast milk, which are not consistent with SIDS RRRs.

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.

Identifying a quality improvement project

An important step on the roadmap to a successful quality improvement (QI) project is careful selection of topics and aims to be addressed by QI projects. Using information from a variety of data monitoring systems as well as individual events and experiences, leaders of neonatal units and QI teams should first identify quality and safety gaps in their unit. They should then use an explicit, formal process for selecting the best projects to which their limited time and resources should be allocated. Priority should be given to projects that address a quality gap of high magnitude and impact, have a high likelihood of success, have a champion, fit with the unit's state of readiness for change, have organizational support and align with organizational priorities. The scope of the project should also match the experience and expertise of the QI team.

Safe Infant Sleep Practices: Parental Engagement, Education, and Behavior Change

Although the incidence of sudden unexpected infant death declined by nearly 50% in the 1990s, there has been little improvement in the past 15 years. Significant disparities in infant sleep practices and sleep-associated death exist, particularly by maternal race/ethnicity. This article provides a brief overview of recent observational and intervention studies related to infant sleep practices to describe the context and motivation for the population-based Study of Attitudes and Factors Effecting Infant Care (SAFE). [Pediatr Ann. 2017;46(8):e291-e296.].

Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit

Despite the recent improvements in perinatal medical care leading to an increase in survival rates, adverse neurodevelopmental outcomes occur more frequently in preterm and/or high-risk infants. Medical risk factors for neurodevelopmental delays like male gender or intrauterine growth restriction and family sociocultural characteristics have been identified. Significant data have provided evidence of the detrimental impact of overhelming environmental sensory inputs, such as pain and stress, on the developing human brain and strategies aimed at preventing this impact. These strategies, such as free parental access or sleep protection, could be considered 'principles of care'. Implementation of these principles do not require additional research due to the body of evidence. We review the scientific evidence for these principles here.

Understanding the Risks Sitting and Carrying Devices Pose to Safe Infant Sleep

There have been various campaigns and recommendations to decrease the incidence of sudden unexpected infant death. Despite this, caregivers continue to place infants in unsafe sleeping environments. These environments, such as sitting devices, slings, carriers, and car seats, pose a significant risk to an infant's safety because of the risk from suffocation and cardiorespiratory instability. It is important for health care providers to understand the appropriate use of car seats, slings, and other sitting devices, to model appropriate behaviors, and to educate parents and caregivers. All parents, hospital staff, and other caregivers should understand the potential dangers associated with the inappropriate use of sitting devices for routine sleep.

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.

Infant Safe Sleep Interventions, 1990-2015: A Review

Sleep-related infant deaths remain a major public health issue. Multiple interventions have been implemented in efforts to increase adherence to safe sleep recommendations. We conducted a systematic review of the international research literature to synthesize research on interventions to reduce the risk of sleep-related deaths and their effectiveness in changing infant sleep practices. We searched PubMed, CINAHL, PsycINFO, and Google Scholar for peer-reviewed articles published between 1990 and 2015 which described an intervention and reported results. Twenty-nine articles were included for review. Studies focused on infant caregivers, health care professionals, peers, and child care professionals. Targeted behaviors included sleep position, location, removing items from the crib, breastfeeding, smoke exposure, clothing, pacifier use, and knowledge of Sudden Infant Death Syndrome. Most articles described multi-faceted interventions, including: one-on-one or group education, printed materials, visual displays, videos, and providing resources such as cribs, pacifiers, wearable blankets, and infant t-shirts. Two described public education campaigns, one used an educative questionnaire, and one encouraged maternal note taking. Health professional interventions included implementing safe sleep policies, in-service training, printed provider materials, eliciting agreement on a Declaration of Safe Sleep Practice, and sharing adherence data. Data collection methods included self-report via surveys and observational crib audits. Over half of the studies utilized comparison groups which helped determine effectiveness. Most articles reported some degree of success in changing some of the targeted behaviors; no studies reported complete adherence to recommendations. Future studies should incorporate rigorous evaluation plans, utilize comparison groups, and collect demographic and collect follow-up data.

Supine sleep positioning in preterm and term infants after hospital discharge from 2000 to 2011

OBJECTIVE

Supine sleep positioning (SSP) has been shown to reduce the risk of sudden infant death syndrome (SIDS) and preterm infants are at higher risk for SIDS. Population-based estimates of SSP are lacking for the preterm population. The objectives of this study are: (1) compare the prevalence of SSP after hospital discharge for preterm and term infants in the United States; and (2) assess racial/ethnic disparities in SSP for preterm and term infants.

STUDY DESIGN

We analyzed the 2000 to 2011 data from the Pregnancy Risk Assessment Monitoring System of Centers for Disease Control and Prevention from 35 states. We measured prevalence of SSP by preterm and term gestational age (GA) categories. We calculated adjusted prevalence ratios (APR) to evaluate the likelihood of SSP for each GA category compared with term infants and the likelihood of SSP for non-Hispanic black (NHB) and Hispanic infants compared with non-Hispanic white (NHW) infants.

RESULTS

Prevalence of SSP varied by GA: ⩽27, 59.7%; 28 0/7 to 33 6/7, 63.7%; 34 0/7 to 36 6/7 (late preterm), 63.6%; and 37 0/7 to 42 6/7 (term) weeks, 66.8% (P<0.001). In the adjusted analyses, late preterm infants were slightly less likely to be placed in SSP compared with term infants (APR: 0.96, confidence interval: 0.95 to 0.98). There were racial/ethnic disparities in SSP for all GA categories when NHB and Hispanic infants were compared with NHW infants.

CONCLUSIONS

All infants had suboptimal adherence to SSP indicating a continued need to better engage families about SSP. Parents of late preterm infants and families of NHB and Hispanic infants will also require greater attention given their decreased likelihood of SSP.

Improving Safe Sleep Practices for Hospitalized Infants

BACKGROUND AND OBJECTIVES

Adherence to the American Academy of Pediatrics safe sleep practice (SSP) recommendations among hospitalized infants is unknown, but is assumed to be low. This quality improvement study aimed to increase adherence to SSPs for infants admitted to a children's hospital general care unit between October 2013 and December 2014.

METHODS

After development of a hospital policy and redesign of room setup processes, a multidisciplinary team developed intervention strategies based on root cause analysis and implemented changes using iterative Plan-Do-Study-Act cycles. Nurse knowledge was assessed before and after education. SSPs were measured continuously with room audits during sleeping episodes. Statistical process control and run charts identified improvements and sustainability in hospital SSPs. Caregiver home practices after discharge were assessed via structured questionnaires before and after intervention.

RESULTS

Nursing knowledge of SSPs increased significantly for each item (P ≤ .001) except avoidance of bed sharing. Audits were completed for 316 sleep episodes. Simultaneous adherence to all SSP recommendations improved significantly from 0% to 26.9% after intervention. Significant improvements were noted in individual practices, including maintaining a flat, empty crib, with an appropriately bundled infant. The largest gains were noted in the proportion of empty cribs (from 3.4% to 60.3% after intervention, P < .001). Improvements in caregiver home practices after discharge were not statistically significant.

CONCLUSIONS

Sustained improvements in hospital SSPs were achieved through this quality improvement initiative, with opportunity for continued improvement. Nurse knowledge increased during the intervention. It is uncertain whether these findings translate to changes in caregiver home practices after discharge.