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

Associations between bed-sharing in infancy and childhood internalizing and externalizing symptoms

Bed-sharing is a controversial but common parenting practice with claimed benefits for emotional and behavioral development. Using data from the UK Millennium Cohort Study (N = 16,599), this prospective study investigated whether bed-sharing at 9 months is associated with childhood internalizing and externalizing symptom trajectories. Children were grouped by their patterns of co-developing internalizing and externalizing symptoms from 3 to 11 years of age using a parallel process latent class growth analysis. There were no associations between bed-sharing at 9 months of age and internalizing and externalizing symptom trajectories across childhood. This finding suggests that bed-sharing at 9 months has no positive or negative influence on the development of internalizing and externalizing symptoms across childhood. Clinicians should inform parents that bed-sharing during the second half of the first year is unlikely to have an impact on the later emotional and behavioral development of the children.

Prenatal and postnatal factors associated with sudden infant death syndrome: an umbrella review of meta-analyses

BACKGROUND

Comprehensive quantitative evidence on the risk and protective factors for sudden infant death syndrome (SIDS) effects is lacking. We investigated the risk and protective factors related to SIDS.

METHODS

We conducted an umbrella review of meta-analyses of observational and interventional studies assessing SIDS-related factors. PubMed/MEDLINE, Embase, EBSCO, and Google Scholar were searched from inception until January 18, 2023. Data extraction, quality assessment, and certainty of evidence were assessed by using A Measurement Tool Assessment Systematic Reviews 2 following PRISMA guidelines. According to observational evidence, credibility was graded and classified by class and quality of evidence (CE; convincing, highly suggestive, suggestive, weak, or not significant). Our study protocol was registered with PROSPERO (CRD42023458696). The risk and protective factors related to SIDS are presented as equivalent odds ratios (eORs).

RESULTS

We identified eight original meta-analyses, including 152 original articles, covering 12 unique risk and protective factors for SIDS across 21 countries/regions and five continents. Several risk factors, including prenatal drug exposure [eOR = 7.84 (95% CI = 4.81-12.79), CE = highly suggestive], prenatal opioid exposure [9.55 (95% CI = 4.87-18.72), CE = suggestive], prenatal methadone exposure [9.52 (95% CI = 3.34-27.10), CE = weak], prenatal cocaine exposure [4.38 (95% CI = 1.95-9.86), CE = weak], prenatal maternal smoking [2.25 (95% CI = 1.95-2.60), CE = highly suggestive], postnatal maternal smoking [1.97 (95% CI = 1.75-2.22), CE = weak], bed sharing [2.89 (95% CI = 1.81-4.60), CE = weak], and infants found with heads covered by bedclothes after last sleep [11.01 (95% CI = 5.40-22.45), CE = suggestive], were identified. On the other hand, three protective factors, namely, breastfeeding [0.57 (95% CI = 0.39-0.83), CE = non-significant], supine sleeping position [0.48 (95% CI = 0.37-0.63), CE = suggestive], and pacifier use [0.44 (95% CI = 0.30-0.65), CE = weak], were also identified.

CONCLUSIONS

Based on the evidence, we propose several risk and protective factors for SIDS. This study suggests the need for further studies on SIDS-related factors supported by weak credibility, no association, or a lack of adequate research.

Comorbidities of deformational plagiocephaly in infancy: A scoping review

AIM

While deformational plagiocephaly (DP) is suspected to be associated with comorbidities, their nature and prevalence are unclear. This scoping review aims to report DP comorbidities occurring until the age of 2 years, their prevalence and whether they depend on the child's age and sex.

METHODS

Relevant studies were identified by searching the Cochrane, MEDLINE, EMBASE, PubMed and EBSCO databases from 1992 to 30 April 2021. Data on study characteristics, comorbidities and assessment instruments were extracted and qualitatively synthesised. Risk of bias was assessed and studies with high risk of bias were excluded.

RESULTS

Studies meeting selection criteria (n = 27) often evaluated groups from tertiary clinics, implying selection bias. Studies reported on developmental delay (n = 16), limited speech production (n = 1), auditory (n = 3), visual (n = 3), mandibular (n = 3) and neurological impairments (n = 1). The data did not allow prevalence calculation or modifying effect of sex. Due to biased data, the review provided no evidence on DP comorbidities. Weak evidence suggested that in the selective samples, DP was associated with motor and language delays in the first year.

CONCLUSION

Due to biased data, no evidence on comorbidity in infants with DP was available. Our study underlined the need of risk of bias assessment in scoping reviews.

Photos Shared on Facebook in the Context of Safe Sleep Recommendations: Content Analysis of Images

Background

Sudden unexpected infant death (SUID) remains a leading cause of infant mortality; therefore, understanding parental practices of infant sleep at home is essential. Since social media analyses yield invaluable patient perspectives, understanding sleep practices in the context of safe sleep recommendations via a Facebook mothers' group is instrumental for policy makers, health care providers, and researchers.

Objective

This study aimed to identify photos shared by mothers discussing SUID and safe sleep online and assess their consistency with infant sleep guidelines per the American Academy of Pediatrics (AAP). We hypothesized the photos would not be consistent with guidelines based on prior research and increasing rates of accidental suffocation and strangulation in bed.

Methods

Data were extracted from a Facebook mothers' group in May 2019. After trialing various search terms, searching for the term "SIDS" on the selected Facebook group resulted in the most relevant discussions on SUID and safe sleep. The resulting data, including 20 posts and 912 comments among 512 mothers, were extracted and underwent qualitative descriptive content analysis. In completing the extraction and subsequent analysis, 24 shared personal photos were identified among the discussions. Of the photos, 14 pertained to the infant sleep environment. Photos of the infant sleep environment were then assessed for consistency with safe sleep guidelines per the AAP standards by 2 separate reviewers.

Results

Of the shared photos relating to the infant sleep environment, 86% (12/14) were not consistent with AAP safe sleep guidelines. Specific inconsistencies included prone sleeping, foreign objects in the sleeping environment, and use of infant sleeping devices. Use of infant monitoring devices was also identified.

Conclusions

This study is unique because the photos originated from the home setting, were in the context of SUID and safe sleep, and were obtained without researcher interference. Despite study limitations, the commonality of prone sleeping, foreign objects, and the use of both infant sleep and monitoring devices (ie, overall inconsistency regarding AAP safe sleep guidelines) sets the stage for future investigation regarding parental barriers to practicing safe infant sleep and has implications for policy makers, clinicians, and researchers.

Sudden Unexpected Postnatal Collapse: Review and Management

Sudden unexpected postnatal collapse (SUPC) of healthy newborns is a catastrophic event caused by cardiorespiratory collapse in a healthy newborn. The most common cause of SUPC is poor positioning of the newborn during skin-to-skin contact or breastfeeding when the newborn is not being observed by a health professional, attentive parent, or caretaker. Maternal/newborn health care professionals need to know about the essential information, definitions, incidence, risk factors, clinical presentation, outcomes, and prevention and management strategies to minimize the occurrence and impact of SUPC. A sample SUPC hospital policy is included in the manuscript.

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.

Characteristics Associated with Sudden Unexpected Infant Death in a Rural Hispanic Population: A Case-Control Study

INTRODUCTION

Sudden unexpected infant death (SUID) is the leading cause of death among U.S. infants aged 28 days to 1 year. In Kansas, Hispanic infant mortality is nearly 50% higher than non-Hispanic White. Further, the SUID rate did not change between 2005-2018, while rates for non-Hispanic Black and White infants decreased significantly. This study sought to identify characteristics and behaviors of Hispanic birthing persons related to SUID.

METHODS

Linked Kansas birth/death vital statistics data (2005-2018) identified Hispanic birthing persons with a singleton birth who experienced SUID. To reduce confounding effects, greedy nearest neighbor matching paired each SUID case sequentially with the four nearest controls based on age, race, payor source and parity. Matching procedures, likelihood-ratio χ2, Fisher exact test and multiple logistic regression model with Firth's penalized maximum likelihood estimation were computed.

RESULTS

Of 86,052 Hispanic singleton births, 66 involved SUID and were matched with 264 controls. No differences were related to marital status, population density of residence, education level, language spoken, prenatal BMI, weight gained during pregnancy, adequacy of prenatal care, enrollment in WIC, or state immunization registry participation (all p>0.05). However, tobacco use during pregnancy contributed to a three times greater risk of SUID (OR=3.208; 95% CI=1.438 to 7.154). Multivariable models for behavioral variables revealed low predictive accuracy with area under the ROC curve=0.6303.

CONCLUSION

This study suggests SUID deaths to rural Hispanic families are likely multifaceted. Study results inform educational programs on the importance of addressing tobacco cessation in SUID risk reduction interventions for Hispanic families.

Pre- and postnatal safe sleep knowledge and planned as compared to actual infant sleep practices

BACKGROUND

Our objectives were to compare safe sleep knowledge, attitudes and planned vs. actual infant sleep practices among expectant mothers before and after their infant's birth and to determine whether differences (if present) were associated with any demographic variables.

METHODS

Study participants were surveyed at their 28-week prenatal and 6-week postpartum obstetric clinic visits from November 2019-February 2021. Due to COVID-19 pandemic cancellation of in-person postpartum visits, many participants received text messaging encouraging them to take the follow-up survey online. Frequency and comparative analyses were performed.

RESULTS

355 women (44%) completed both pre- and postnatal surveys. Many participants increased their safe sleep knowledge during the study. For example, of those who were unsure or thought it safe for a baby to sleep in a baby swing/bouncy seat, two-thirds (67/102, 66%) stated it was unsafe on the postnatal survey. In addition, many who were unsure or planned sleep practices considered unsafe prenatally reported utilizing safe sleep practices on their postnatal survey. For example, of those unsure or planning to use a crib bumper (17% of the total), almost all (88%) were not using one postnatally. Conversely, some participants who reported they would be following safe sleep practices prenatally were not doing so postpartum. For example, 13% of those stating they would place their child on their back reported using another sleep position on the postnatal survey. Certain demographics had higher proportions reporting this reversal for specific safe sleep practices. For example, non-Hispanic Whites (19%) as compared to other races/ethnicities (5%) and those with incomes ≥ $75,000 (21%) as compared with those with less income (9%) had higher proportions stating their infant would sleep in the same room but then reported postnatally they were sleeping in a different room, p = 0.0094 and p = 0.0138, respectively.

CONCLUSIONS

We observed increases in safe sleep knowledge and that some participants followed safer sleep practices than they had planned. However, there were also participants who planned to use safe sleep practices prenatally who were not doing so after their baby's birth. Our study identified demographics for which targeted safe sleep education and more effective interventions may be needed.

The fundamental need for unifying phenotypes in sudden unexpected pediatric deaths

A definitive, authoritative approach to evaluate the causes of unexpected, and ultimately unexplained, pediatric deaths remains elusive, relegating final conclusions to diagnoses of exclusion in the vast majority of cases. Research into unexplained pediatric deaths has focused primarily on sudden infant deaths (under 1 year of age) and led to the identification of several potential, albeit incompletely understood, contributory factors: nonspecific pathology findings, associations with sleep position and environment that may not be uniformly relevant, and the elucidation of a role for serotonin that is practically difficult to estimate in any individual case. Any assessment of progress in this field must also acknowledge the failure of current approaches to substantially decrease mortality rates in decades. Furthermore, potential commonalities with pediatric deaths across a broader age spectrum have not been widely considered. Recent epilepsy-related observations and genetic findings, identified post-mortem in both infants and children who died suddenly and unexpectedly, suggest a role for more intense and specific phenotyping efforts as well as an expanded role for genetic and genomic evaluation. We therefore present a new approach to reframe the phenotype in sudden unexplained deaths in the pediatric age range, collapsing many distinctions based on arbitrary factors (such as age) that have previously guided research in this area, and discuss its implications for the future of postmortem investigation.

Altered 5-HT2A/C receptor binding in the medulla oblongata in the sudden infant death syndrome (SIDS): Part I. Tissue-based evidence for serotonin receptor signaling abnormalities in cardiorespiratory- and arousal-related circuits

The sudden infant death syndrome (SIDS), the leading cause of postneonatal infant mortality in the United States, is typically associated with a sleep period. Previously, we showed evidence of serotonergic abnormalities in the medulla (e.g. altered serotonin (5-HT)1A receptor binding), in SIDS cases. In rodents, 5-HT2A/C receptor signaling contributes to arousal and autoresuscitation, protecting brain oxygen status during sleep. Nonetheless, the role of 5-HT2A/C receptors in the pathophysiology of SIDS is unclear. We hypothesize that in SIDS, 5-HT2A/C receptor binding is altered in medullary nuclei that are key for arousal and autoresuscitation. Here, we report altered 5-HT2A/C binding in several key medullary nuclei in SIDS cases (n = 58) compared to controls (n = 12). In some nuclei the reduced 5-HT2A/C and 5-HT1A binding overlapped, suggesting abnormal 5-HT receptor interactions. The data presented here (Part 1) suggest that a subset of SIDS is due in part to abnormal 5-HT2A/C and 5-HT1A signaling across multiple medullary nuclei vital for arousal and autoresuscitation. In Part II to follow, we highlight 8 medullary subnetworks with altered 5-HT receptor binding in SIDS. We propose the existence of an integrative brainstem network that fails to facilitate arousal and/or autoresuscitation in SIDS cases.

The influence of video-based training on caregiver arrangement of infant sleeping environments

Recent behavior analytic studies have examined behavioral skills training to teach adults to arrange safe infant sleeping environments. These studies were conducted in an analogue environment and with all training components delivered by an expert staff trainer. The purpose of the current study was to replicate and extend this literature by substituting video-based training for behavioral skills training. We assessed whether expectant caregivers could arrange safe infant sleeping environments following video-based training. The results suggested that video-based training alone resulted in positive outcomes for a portion of participants, whereas a subset of participants required feedback to reach mastery criteria. The social validity data suggest that the participants found the training procedures favorable.

Prävention des plötzlichen Säuglingstods (SIDS, „sudden infant death syndrome“, ICD 10: R95)

Dieser Beitrag fasst die Datenlage zu den wichtigsten Handlungsanweisungen für Eltern bezüglich der Gewährleistung einer sicheren Schlafumgebung für Säuglinge zusammen. Hierzu gehören folgende: 1. Legen Sie Ihr Kind zum Schlafen auf den Rücken; benutzen Sie dabei eine feste und waagerechte Unterlage. 2. Legen Sie Ihr Kind tagsüber, solange es wach ist und Sie es gut beobachten können, regelmäßig für kurze Zeit auch auf den Bauch. 3. Vermeiden Sie Überwärmung: Während der Nacht ist eine Raumtemperatur von 18 °C optimal, anstelle einer Bettdecke empfiehlt sich die Verwendung eines Baby-Schlafsacks in altersentsprechender Größe. 4. Falls Sie keinen Schlafsack verwenden möchten, achten Sie darauf, dass Ihr Kind nicht mit dem Kopf unter die Bettdecke rutschen kann, indem Sie es so ins Bett legen, dass es mit den Füßen am Fußende anstößt. 6. Verzichten Sie auf Kopfkissen, Fellunterlagen, „Nestchen“, gepolsterte Bettumrandungen und größere Kuscheltiere, mit denen sich Ihr Kind überdecken könnte. 7. Wickeln Sie Ihr Kind zum Schlafen nicht fest ein. 8. lassen Sie Ihr Kind bei sich im Zimmer, aber im eigenen Kinderbett schlafen. 9. Achten Sie auf eine rauchfreie Umgebung für Ihr Kind auch schon während der gesamten Schwangerschaft. 10. Stillen Sie im 1. Lebensjahr, möglichst mindestens 4 bis 6 Monate. 11. Bieten Sie Ihrem Kind zum Schlafengehen einen Schnuller an. 12. Diese Empfehlungen gelten auch für die Zeit unmittelbar nach Geburt: Sollte Ihr Kind auf Ihrem Körper liegen, achten Sie darauf, dass es stets freie Atemwege hat.

Outcomes for the apparent life-threatening event infant

Aim

To examine the outcome for apparent life-threatening event infants and the determining factors for that outcome.

Methods

A retrospective review of 903 infants (0-12 months of age) presenting to the pediatric wards at Christchurch Hospital between 1985 and 1996 with events characterized by some combination of apnoea, change in color, and muscle tone. Events, resulting in 1088 admissions, were classified from medical record review according to the severity and underlying conditions, with risk factors and long-term outcomes examined.

Results

The severity of events was reduced with implementing sudden infant death syndrome recommendations regarding the risk of prone sleeping. There were no sudden infant death syndrome deaths on home apnoea monitoring. Five apparent life-threatening event infants, not referred for home apnoea monitoring, subsequently died of sudden infant death syndrome. Two infants died and one suffered significant hypoxic insult when apnoea monitoring was interrupted under the age of 4 months. Asthma and neurodevelopmental conditions appeared to be over-represented subsequently in the apparent life-threatening event group.

Conclusion

Identifying apparent life-threatening event infants at risk of sudden infant death syndrome lacked specificity. The use of apnoea home monitoring appeared protective in this cohort, but safe sleeping practices remained central for reducing sudden infant death syndrome risk.

Reclassification of the Etiology of Infant Mortality With Whole-Genome Sequencing

Importance

Understanding the causes of infant mortality shapes public health, surveillance, and research investments. However, the association of single-locus (mendelian) genetic diseases with infant mortality is poorly understood.

Objective

To determine the association of genetic diseases with infant mortality.

Design, Setting, and Participants

This cohort study was conducted at a large pediatric hospital system in San Diego County (California) and included 546 infants (112 infant deaths [20.5%] and 434 infants [79.5%] with acute illness who survived; age, 0 to 1 year) who underwent diagnostic whole-genome sequencing (WGS) between January 2015 and December 2020. Data analysis was conducted between 2015 and 2022.

Exposure

Infants underwent WGS either premortem or postmortem with semiautomated phenotyping and diagnostic interpretation.

Main Outcomes and Measures

Proportion of infant deaths associated with single-locus genetic diseases.

Results

Among 112 infant deaths (54 girls [48.2%]; 8 [7.1%] African American or Black, 1 [0.9%] American Indian or Alaska Native, 8 [7.1%] Asian, 48 [42.9%] Hispanic, 1 [0.9%] Native Hawaiian or Pacific Islander, and 34 [30.4%] White infants) in San Diego County between 2015 and 2020, single-locus genetic diseases were the most common identifiable cause of infant mortality, with 47 genetic diseases identified in 46 infants (41%). Thirty-nine (83%) of these diseases had been previously reported to be associated with childhood mortality. Twenty-eight death certificates (62%) for 45 of the 46 infants did not mention a genetic etiology. Treatments that can improve outcomes were available for 14 (30%) of the genetic diseases. In 5 of 7 infants in whom genetic diseases were identified postmortem, death might have been avoided had rapid, diagnostic WGS been performed at time of symptom onset or regional intensive care unit admission.

Conclusions and Relevance

In this cohort study of 112 infant deaths, the association of genetic diseases with infant mortality was higher than previously recognized. Strategies to increase neonatal diagnosis of genetic diseases and immediately implement treatment may decrease infant mortality. Additional study is required to explore the generalizability of these findings and measure reduction in infant mortality.

Perceptions and Use of Safe Sleep Baby Boxes at Hospital Discharge by New Mothers

BACKGROUND

A large community hospital in South Texas began distributing safe sleep baby boxes to reduce sudden unexplained infant death (SUID) in 2017.

PURPOSE

To describe safe sleep practices among new mothers who received a safe sleep baby box at hospital discharge.

METHODS

An information sheet containing a link to an online survey was mailed to all women who received a safe sleep baby box prior to discharge from the hospital from January 2018 to January 2019.

RESULTS

N = 84 women participated. Most reported using the safe sleep baby box only during nap time (n = 62, 88.6%). Only 70.2% of participants reported that baby always slept their back (n = 59). Most reported their baby did not use a pacifier (n = 62, 73.8%), and many reported they were not breastfeeding their baby (n = 38, 45.2%).

CLINICAL IMPLICATIONS

Many women were not using the safe sleep baby box as intended and were not following many of the other safe sleep guidelines. Nurses should ask their patients about plans for infant safe sleep after discharge to provide individualized education or recommend specific resources to address the family's needs.

Risk Factors for Suffocation and Unexplained Causes of Infant Deaths

BACKGROUND

Observational studies have improved our understanding of the risk factors for sudden infant death syndrome, but separate examination of risk for sleep-related suffocation and unexplained infant deaths has been limited. We examined the association between unsafe infant sleep practices and sudden infant deaths (sleep-related suffocation and unexplained causes including sudden infant death syndrome).

METHODS

We conducted a population-based case-control study using 2016 to 2017 Centers for Disease Control and Prevention data. Controls were liveborn infants from the Pregnancy Risk Assessment Monitoring System; cases were from the Sudden Unexpected Infant Death Case Registry. We calculated risk factor prevalence among cases and controls and crude and adjusted odds ratios.

RESULTS

We included 112 sleep-related suffocation cases with 448 age-matched controls and 300 unexplained infant death cases with 1200 age-matched controls. Adjusted odds for sleep-related suffocation ranged from 18.7 (95% confidence interval [CI]: 6.8-51.3) among infants not sharing a room with their mother or caregiver to 1.9 (95% CI: 0.9-4.1) among infants with nonsupine sleep positioning. Adjusted odds for unexplained death ranged from 7.6 (95% CI: 4.7-12.2) among infants not sharing a room with their mother or caregiver to 1.6 (95% CI: 1.1-2.4) among nonsupine positioned infants.

COCLUSIONS

We confirmed previously identified risk factors for unexplained infant death and independently estimated risk factors for sleep-related suffocation. Significance of associations for suffocation followed similar patterns but was of larger magnitude. This information can be used to improve messaging about safe infant sleep.

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.

Subject Matter Expert Nurses in Safe Sleep Program Implementation

BACKGROUND

Pennsylvania sudden unexpected infant death rates rank among the highest nationally. A nursing team developed, implemented, evaluated, and disseminated an evidence-based quality improvement (QI) program at birthing hospitals in Pennsylvania to address this issue. To facilitate implementation, clinical nurses were educated as Subject Matter Experts (SMEs) to empower them to transform and sustain outcomes-driven QI for infant safe sleep nursing practice.

METHODS

This descriptive study examined outcomes from 268 nurses who received comprehensive education on infant safe sleep and the SME role. Likert-type scale surveys measured knowledge gained and progress made in practice following education. A programmatic dashboard tracked program implementation. Descriptive statistics were used to report findings.

INTERVENTION

SME nurses ( N = 268) completed two interactive learning modules addressing safe sleep guidelines and teaching strategies and attended a workshop to acquire skills for program implementation. Key competencies included data collection and dissemination, policy development, and communication techniques.

RESULTS

Immediate posteducation surveys completed by SMEs indicated that over 98% of respondents strongly agreed or agreed they were able to effectively demonstrate communication strategies, identify SME role components, provide environment surveillance, and demonstrate best practices in infant safe sleep. To allow time for assimilation of the of SME role, a survey was initiated at 6 months to capture progress made. Seventy-eight SMEs responded to the survey and reported exceptional or substantial progress in 10 areas for SME responsibilities.

CONCLUSION

Use of the SME role for program implementation led to highly favorable SME-reported outcomes in leading a hospital-based QI program.

Development of a Risk Score to Predict Sudden Infant Death Syndrome

Sudden Infant Death Syndrome (SIDS) is the third leading cause of death among infants younger than one year of age. Effective SIDS prediction models have yet to be developed. Hence, we developed a risk score for SIDS, testing contemporary factors including infant exposure to passive smoke, circumcision, and sleep position along with known risk factors based on 291 SIDS and 242 healthy control infants. The data were retrieved from death certificates, parent interviews, and medical records collected between 1989−1992, prior to the Back to Sleep Campaign. Multivariable logistic regression models were performed to develop a risk score model. Our finalized risk score model included: (i) breastfeeding duration (OR = 13.85, p < 0.001); (ii) family history of SIDS (OR = 4.31, p < 0.001); (iii) low birth weight (OR = 2.74, p = 0.003); (iv) exposure to passive smoking (OR = 2.64, p < 0.001); (v) maternal anemia during pregnancy (OR = 2.07, p = 0.03); and (vi) maternal age <25 years (OR = 1.77, p = 0.01). The area under the curve for the overall model was 0.79, and the sensitivity and specificity were 79% and 63%, respectively. Once this risk score is further validated it could ultimately help physicians identify the high risk infants and counsel parents about modifiable risk factors that are most predictive of SIDS.

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.

Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

Each year in the United States, ∼3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Classification of Diseases, 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 has 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. Additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is also included. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report.