Transitioning the premature infant from nonsupine to supine position prior to hospital discharge

Risk factors for unexpected infant death among very premature infants in France

BACKGROUND

Prematurity is one of the risk factors for sudden unexpected infant death (SUID), a phenomenon that remains poorly explained.

MATERIALS AND METHODS

The analysis of specific factors associated with SUID among very premature infants (VPI) was performed through a retrospective review of data collected in the French SUID registry from May 2015 to December 2018. The factors associated with SUID among VPI were compared with those observed among full-term infants (FTI). Results are expressed as means (standard deviation [SD]) or medians (interquartile range [IQR)].

RESULTS

During the study period, 719 cases of SUID were included in the registry, 36 (incidence: 0.60 ‰) of which involved VPI (gestational age: 29.2 [2] weeks, 1157 [364]) g] and 313 (0.18 ‰) involved FTI (gestational age: 40 [0.8] weeks, 3298 [452] g). The infants' postnatal age at the time of death was similar in the two groups: 15.5 (12.2-21.8) vs. 14.5 (7.1-23.4) weeks. We observed low breastfeeding rates and a high proportion of fathers with no occupation or unemployment status among the VPI compared to the FTI group (31% vs. 55 %, p = 0.01 and 32% vs. 13 %, p = 0.05, respectively). Among the VPI, only 52 % were in supine position, and 29 % were lying prone at the time of the SUID (compared to 63 % and 17 %, respectively, in the FTI group).

CONCLUSION

This study confirms prematurity as a risk factor for SUID with no difference in the SUID-specific risk factors studied except for breastfeeding and socioeconomic status of the fathers. VPI and FTI died at similar chronological ages with a high proportion of infants dying in prone position. These results argue for reinforcement of prevention strategies in cases of prematurity.

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.

An Interprofessional, Multimodal, Family-Centered Quality Improvement Project for Sleep Safety of Hospitalized Infants

The American Academy of Pediatrics published expanded guidelines for infant safe sleep in 2011, expanding the definition from "back to sleep" to "safe to sleep," more fully describing risk factors and guidelines. In 2016, the guidelines were revised to promote "providers modeling safe sleep behavior" to the highest level of recommendation. Previous studies have addressed the difficulty in creating clear, consistent communication between health care providers and families during an infant's inpatient stay. This institutional update describes an interprofessional and family-centered quality improvement project to improve sleep safety for hospitalized infants through a multimodal approach. Five family-centered interventions were designed: a designated safe sleep web page, a clear bedside guide to safe sleep, additional training for nursing staff in motivational interviewing, a Kamishibai card audit system, and electronic health record smart phrases. These coordinated interventions reflect advantages of an interprofessional and family-centered approach: building rapport and achieving improvements to infant sleep safety.

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.

Predicting transition to the supine sleep position in preterm infants

The purpose of this secondary analysis was to determine what factors predict the transition of preterm infants to the supine sleep position prior to hospital discharge (N = 286). The supine position reduces the risk of sudden infant death syndrome. Factors found to predict a greater than 1-week transition to the supine sleep position were hospital policy (P < .001), gestational age (P < .001), and birth weight (P < .01). Transition to the supine position during hospitalization potentially reduces the risk of preterm infants being placed in nonsupine positions after hospitalization and, ultimately, the risk of untimely death by sudden infant death syndrome.