Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change?

National SIDS Trends in the United States From 2000 to 2019: A Population-Based Study on 80 Million Live Births

Sudden infant death syndrome (SIDS) is the most common cause of death for infants between 1 month and 1 year of age in the United States. The objective was to examine recent trends in SIDS in the United States, over time and by sex and race. A population-based cross-sectional study was conducted on 80 710 348 live births using data from the Center for Disease Control and Prevention's (CDC) "Birth Data" and "Mortality Multiple Cause" files from 2000 to 2019. Logistic regression examined the effects of sex and race on the risk of SIDS and examined temporal changes in risk across sex and race over the study period. Incidence of SIDS decreased from 6.3 to 3.4/10 000 births from 2000 to 2019, with an overall incidence of 4.9/10 000 births (95% confidence interval [CI] = 4.4-5.3). Male infants were at the greatest risk of SIDS as were black and American Indian infants. Although SIDS incidence decreased by sex and race over time, the decline was smaller among Hispanic and American Indian infants.

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

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

A Risk Assessment and Planning Tool to Prevent Sudden Unexpected Death in Infancy: Development and Evaluation of The Baby Sleep Planner

BACKGROUND

Successful national safer sleep campaigns in the United Kingdom have lowered the death rates from sudden unexpected death in infancy (SUDI) over the past 3 decades, but deaths persist in socioeconomically deprived families. The circumstances of current deaths suggest that improvements in support for some families to follow safer sleep advice more consistently could save lives.

OBJECTIVE

This study aimed to develop and evaluate a risk assessment and planning tool designed to improve the uptake of safer sleep advice in families with infants at increased risk of SUDI.

METHODS

A co-design approach was used to develop the prototype interface of a web-based tool with 2 parts: an individual SUDI risk assessment at birth and a downloadable plan for safety during times of disruption. The advice contained within the tool is concordant with national guidance from the Lullaby Trust, the United Nations International Children's Emergency Fund (UNICEF), and the National Institute for Health and Care Excellence. User testing of the prototype tool was conducted by inviting health visitors, midwives, and family nurses to use it with families eligible for additional support. Qualitative interviews with health professionals and families allowed for iterative changes to the tool and for insights into its function and influence on parental behavior.

RESULTS

A total of 22 health professionals were enrolled in the study, of whom 20 (91%) were interviewed. They reported appreciating the functionality of the tool, which allowed them to identify at-risk families for further support. They felt that the tool improved how they communicated about risks with families. They suggested expanding its use to include relevance in the antenatal period and having versions available in languages other than English. They reported using the tool with 58 families; 20 parents gave consent to be interviewed by the research team about their experiences with the tool. Families were positive about the tool, appreciated the trustworthy information, and felt that it was useful and appropriate and that the plans for specific infant sleeps would be of benefit to them and other family members.

CONCLUSIONS

Our tool combines risk assessment and safety planning, both of which have the potential to improve the uptake of lifesaving advice. Refinements to the tool based on these findings have ensured that the tool is ready for further evaluation in a larger study before being rolled out to families with infants at increased risk.

A Hospital-Based Infant Safe Sleep Intervention and Safe Sleep Practices Among Young Women: A Prospective Longitudinal Study

INTRODUCTION

The rates of sudden unexpected infant death (SUID) are still high in the U.S. The longitudinal effects of SUID preventive education on infant safe sleep practices are less known. The current study evaluated the effects of a comprehensive hospital-based, SUID preventive intervention on safe infant sleep practices in the first six months of life and to identify factors associated with infant sleep practices.

METHODS

Using a one-group pretest and multiple posttest design, the current quantitative study examined the impacts of the infant safe sleep intervention among 411 women recruited at a large, urban, university medical center. Participants were prospectively followed and completed four surveys from childbirth. Linear mixed models were used to evaluate the effects of the SUID prevention program on four sleep practice outcomes, including removing unsafe items from the sleeping environment, bed sharing, room sharing without bed sharing, and placing the infant in a supine sleep position.

RESULTS

Compared to the baseline, participants were less likely to use unsafe items (e.g., soft bedding) in infants' sleeping areas over time. However, we found that participants reported more frequent bed sharing at 3-month and 6-month follow-ups, compared to the baseline.

CONCLUSIONS

Overall, maternal education and family income were positively related to healthy infant safe sleep practices. A hospital-based preventive intervention pairing an educational initiative with home-visiting services might improve safe sleep practices to remove accidental suffocation risks from the infant sleep environment.

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.

Impact of State Prioritization of Safe Infant Sleep Programs on Supine Sleep Positioning for Non-Hispanic White and Non-Hispanic Black Infants

OBJECTIVE

Investigate whether safe infant sleep prioritization by states through the Title V Maternal and Child Block Grant in 2010 differentially impacted maternal report of supine sleep positioning (SSP) for Non-Hispanic White (NHW) and Non-Hispanic Black (NHB) U.S.-born infants.

STUDY DESIGN

We analyzed retrospective cross-sectional data from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2005 to 2015 from 4 states: WV and OK (Intervention) and AR and UT (Control). PRAMS is a population-based surveillance system of maternal perinatal experiences which is linked to infant birth certificates. Piece-wise survey linear regression models were used to estimate the difference in the change in slopes of SSP percents in the pre- (2005-2009) and post- (2011-2015) periods, controlling for maternal and infant characteristics. Models were also stratified by race/ethnicity.

RESULTS

From 2005 to 2015, for NHW infants, SSP improved from 61.5% and 70.2% to 82.8% and 82.3% for intervention and control states, respectively. For NHB infants, SSP improved from 30.6% and 26.5% to 64.5% and 53.1% for intervention and control states, respectively. After adjustment for maternal characteristics, there was no difference in the rate of SSP change from the pre- to post- intervention periods for either NHW or NHB infants in intervention or control groups.

CONCLUSION

Compared with control states that did not prioritize safe infant sleep in their 2010 Title V Block Grant needs assessment, intervention states experienced no difference in SSP improvement rates for NHW and NHB infants. While SSP increased for all infants during the study period, there was no causal relationship between states' prioritization of safe infant sleep and SSP improvement. More targeted approaches may be needed to reduce the racial/ethnic disparity in SSP and reduce the risk for sleep-associated infant death.

KEY POINTS

· Supine sleep positioning improved for Black and White infants in the U.S.. · State prioritization of safe infant sleep did not directly impact SSP for NHB or NHW infants.. · More targeted approaches may be needed to reduce racial/ethnic disparities in safe sleep practices.

An evaluation of factors associated with safe infant sleep practices among perinatal home visiting participants in Florida, United States

Sleep-related deaths are a leading cause of infant mortality in Florida. The American Academy of Pediatrics recommends placing infants to sleep on their back, alone, and without soft bedding. Compliance with these guidelines varies among parents. This evaluation examined the rates of safe infant sleep practices and associated factors among 1985 participants enrolled in Florida Maternal, Infant, and Early Childhood Home Visiting (FL MIECHV) programs during 2017-2019. Participant- and program-level variables were examined in relation to three sleep practices: infant position, bedding, and bed-sharing at 2-3 months to determine which factors were associated with high rates of safe sleep outcomes. Analyses included univariate descriptive statistics, bivariate statistics, and multivariable logistic regression. Most caregivers (70%) reported always placing their babies to sleep on their back, alone, and without soft bedding. Factors such as primary language, race, education, housing situation, and year the Safe Baby™ curriculum implemented were significantly associated with safe infant sleep practices. Bearing this in mind, FL MIECHV can tailor safe sleep education, messaging, and strategies to support participants at highest risk. Recent adoption of the Safe Baby™ curriculum, and associated staff training, was an important factor influencing parents' infant sleep practices.

Outcomes of Childbirth Education in PRAMS, Phase 8

OBJECTIVE

To determine if childbirth education is associated with improved outcomes for national maternal child health goals in the United States.

METHODS

This was a secondary analysis of PRAMS data. The sample was limited to survey respondents who answered a question "During your most recent pregnancy, did you take a class or classes to prepare for childbirth and learn what to expect during labor and delivery?" The outcomes included nine national objectives from Title V and Healthy People. Logistic regression models were built with control for characteristics associated with attending childbirth education. Odds ratios were converted to adjusted risk ratios for interpretation. Stratification by maternal race/ethnicity and use of Medicaid identified opportunities for improvement in childbirth education.

RESULTS

Of the 2,256 eligible respondents, 936 (41.5%) attended childbirth education. Attending childbirth education was associated with reduced likelihood of primary cesarean (ARR 0.79), increased attendance at postpartum visit (ARR 1.06), use of birth control (ARR 1.07), safe infant sleep (Back to Sleep ARR 1.04; Sleep on Own 1.12), and breastfeeding (Ever breastfeed ARR 1.08; still breastfeeding ARR 1.15). No association was found for LARC use or postpartum depression. Not all benefits of childbirth education were apparent for all racial/ethnic groups, nor for those with Medicaid insurance.

CONCLUSIONS FOR PRACTICE

Childbirth education is a community intervention that may help achieve population maternal and child health goals.

The Baby Box scheme in Scotland: A study of public attitudes and social value

BACKGROUND

The Scottish Government introduced a free Baby Box scheme for all new parents in 2017, modelled on the Finnish scheme, to give every baby 'an equal start in life'. There is little evidence that it results in better health outcomes, but there has been limited research into different perspectives and discourses on such schemes.

METHODS

Four focus groups were conducted with 21 parents in North-East Scotland. Recordings were transcribed verbatim, anonymized and analysed thematically with NVivo 12 software. Our thematic analysis was both inductive and deductive-remaining open to themes identified by participants themselves but also informed by the social policy literature on universalism and social cohesion.

RESULTS

Across all the focus groups, we found a high degree of positivity about the principle of the Baby Box scheme, and for the most part the practical value of the contents. This was remarkably consistent across different communities and backgrounds. There was little evidence of the strongly polarized views present in media reporting. Parents seemed considerably less focused than the media on safety and health outcomes, and more focused on practical, material and social impacts. They reported little in the way of feeling patronized or monitored by the government.

CONCLUSION

Our findings have important implications for future economic evaluations of the baby box. Such evaluations should broaden the valuation space beyond health outcomes to allow for the value of feelings of inclusion, solidarity and being part of a community.

PATIENT OR PUBLIC CONTRIBUTION

This small project was designed in response to parent views already collected in the early roll-out of the Baby Box scheme in Scotland, about their priorities and responses to the scheme. Additional views were sought on the topic guide for the focus groups, and local community groups advised us on recruitment and the best timing and location for the focus groups to be held. The focus groups themselves were conducted as research, but with the intent of ensuring parent views featured more prominently in a debate that has been largely dominated by clinical and public health perspectives.

Characteristics and Geographic Variation in Sudden Unexpected Infant Deaths in the District of Columbia

ABSTRACT

Sleep-related infant death is a major cause of infant mortality in the United States. In the District of Columbia, infant mortality varies widely among regions (2 to 14 per 1000 live births). The study objectives were to analyze the patient characteristics and related variables to sudden unexpected infant deaths at 2 pediatric emergency department (ED) sites and the geographic patterns of infant deaths and their relationship to social vulnerability. This retrospective cohort study examined infants under 1 year of age presenting with cardiac arrest at 2 ED sites from 2010 to 2020. Analysis showed 81 deaths with a median population age of 75 days (SD, 46 days). The most frequent demographics of deceased patients were African American Black (89%) with Medicaid insurance (63%), born at term gestation (66%), and without comorbidity (60%). The cause of death was most frequently undetermined (32%) and asphyxia (31%). Most cases involved bed-sharing (63%), despite more than half of those cases having a known safe sleep surface available. Infant death location showed that most deaths occurred in areas with the highest social vulnerability index, including near a community ED location. Understanding the etiologies of this geographic variability may enhance sleep-related infant death prevention strategies.

Survey of Korean daycare personnel on safe sleep practices related to sudden unexplained infant death: a cross-sectional exploratory study

PURPOSE

Safe sleep practices (SSP) are among the main strategies to reduce sleep-related sudden unexplained infant death (SUID). Daycare personnel must be knowledgeable and trained in SSP related to SUID. This study explored the experience, knowledge, and confidence regarding SSP associated with SUID of daycare personnel.

METHODS

A cross-sectional survey was conducted with 395 staff members at 61 daycare centers to measure their experience related to SSP (10 items), related to sleep position and location, bedding materials, and other topics; knowledge of SSP (18 items); and confidence in SSP (1 item) related to SUID.

RESULTS

A substantial proportion (23.6%) of respondents used the lateral or prone positions for infant sleep. On average, 4.5 bedding materials were used for infant sleep. Participants showed a lack of knowledge about SSP as indicated by a 56.6% knowledge of SSP related to SUID correct answer rate. Personnel who received SUID education were more knowledgeable and had more confidence regarding SSP than those who did not. More knowledge and confidence related to SSP were associated with better adherence to SSP.

CONCLUSION

Standard SSP guidelines should be developed based on South Korea's culture of childcare for educating both childcare professionals and parents at home.

Emergency Department Visits Before Sudden Unexpected Infant Death: A Touchpoint for Unsafe Sleep Reduction

OBJECTIVES

Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death.

METHODS

We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID.

RESULTS

Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3.

CONCLUSIONS

Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts.

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.

Infant Care Practices, Caregiver Awareness of Safe Sleep Advice and Barriers to Implementation: A Scoping Review

Modifiable infant sleep and care practices are recognised as the most important factors parents and health practitioners can influence to reduce the risk of sleep-related infant mortality. Understanding caregiver awareness of, and perceptions relating to, public health messages and identifying trends in contemporary infant care practices are essential to appropriately inform and refine future infant safe sleep advice. This scoping review sought to examine the extent and nature of empirical literature concerning infant caregiver engagement with, and implementation of, safe sleep risk-reduction advice relating to Sudden Unexpected Deaths in Infancy (SUDI). Databases including PubMed, CINAHL, Scopus, Medline, EMBASE and Ovid were searched for relevant peer reviewed publications with publication dates set between January 2000–May 2021. A total of 137 articles met eligibility criteria. Review results map current infant sleeping and care practices that families adopt, primary infant caregivers’ awareness of safe infant sleep advice and the challenges that families encounter implementing safe sleep recommendations when caring for their infant. Findings demonstrate a need for ongoing monitoring of infant sleep practices and family engagement with safe sleep advice so that potential disparities and population groups at greater risk can be identified, with focused support strategies applied.

The Impact of Local Education and Resource Distribution on Maternal Health Behaviors

INTRODUCTION

Community forum participants voted for an education and resource distribution program (using a baby box) to help reduce local infant mortality. Although multiple sites have implemented similar programs, there is limited peer-reviewed literature about outcomes.

METHODS

A retrospective pre- and immediate post-survey design with an intervention (video and written education and resource distribution) in between was utilized with a follow-up survey. The primary research objectives were whether viewing educational videos led to change in self-reported likelihood of select maternal behaviors. Other objectives were whether demographic characteristics were associated with self-reported likelihood of behaviors, and to assess the actual self-reported postpartum behavior.

RESULTS

Participants reported a change in likelihood in: asking a WIC counselor for help (p < 0.001); talking with a provider about substance use (p = 0.014), postpartum depression (p < 0.001) and birth control (p = 0.025); and using the baby box as a sleeping space (p < 0.01). After watching the educational videos, college-educated participants were significantly more likely than participants with high school education or less to report likelihood to breastfeed (p = 0.039). Over half of the participants (59.2%) in the follow-up survey reported breastfeeding most to all of the time, compared to 91.5% who reported they were more likely to breastfeed in the post-education survey. The proportion of participants at the follow-up survey who reported bed-sharing most or all of the time (5.7%) was lower than those participants who had said they were likely or very likely to bed-share in the post-education survey (11.3%). Although nearly all participants (98.6%) in the post-education survey reported that they were likely to use the baby box, at the postpartum follow-up, 39.1% reported actual use of the baby box.

CONCLUSIONS FOR PRACTICE

The program positively impacted self-reported likelihood of several health behaviors. A community-driven approach to maternal education and resource distribution may be beneficial in other cities.

Variations in Safe Sleep Practices and Beliefs: Knowledge is not Enough

OBJECTIVES

Sleep-related infant deaths in the District of Columbia (DC) varies, with rates in certain geographical areas three times higher than DC and seven times higher than the national average. We sought to understand differences in infant sleep knowledge, beliefs, and practices between families in high-risk infant mortality and low-risk infant mortality areas in DC.

METHODS

Caregivers of infants presenting to the emergency department were surveyed. The associations between location and safe sleep knowledge, beliefs, and practices were analyzed.

RESULTS

Two hundred and eighty-four caregivers were surveyed; 105 (37%) were from the high-risk infant mortality area. The majority (68%) of caregivers reported placing their infant to sleep on their backs, sleeping in a crib, bassinet, or pack and play (72%), and were familiar with the phrase "safe sleep" (72%). Caregivers from the high-risk infant mortality area were more likely to report that their infants sleep in homes other than their own (aOR 1.53; 95% CI 1.23, 2.81) and other people took care of their infants while sleeping (aOR 1.76; 95% CI 1.17, 3.19), adjusting for race/ethnicity, education, marital status, and help with childcare. No differences in safe sleep knowledge, beliefs, and practices were present.

CONCLUSIONS FOR PRACTICE

Infants from the high-risk infant mortality area were more likely to sleep in homes other than their own and have other caretakers while sleeping. Lack of differences in caregiver awareness of safe sleep recommendation or practices suggests effective safe sleep messaging. Outreach to other caregivers and study of unmet barriers is needed.

Promoting Safe Sleep, Tobacco Cessation, and Breastfeeding to Rural Women During the COVID-19 Pandemic: Quasi-Experimental Study

BACKGROUND

Safe Sleep Community Baby Showers address strategies to prevent sleep-related infant deaths. Due to the COVID-19 pandemic, these events transitioned from in-person to virtual.

OBJECTIVE

This study describes outcomes of transitioning Safe Sleep Community Baby Showers to a virtual format and compares outcomes to previous in-person events.

METHODS

Participants from four rural Kansas counties were emailed the presurvey, provided educational materials (videos, livestream, or digital documents), and completed a postsurvey. Those who completed both surveys received a portable crib and wearable blanket. Within-group comparisons were assessed between pre- and postsurveys; between-group comparisons (virtual vs in-person) were assessed by postsurveys.

RESULTS

Based on data from 145 in-person and 74 virtual participants, virtual participants were more likely to be married (P<.001) and have private insurance (P<.001), and were less likely to report tobacco use (P<.001). Both event formats significantly increased knowledge and intentions regarding safe sleep and avoidance of secondhand smoke (all P≤.001). Breastfeeding intentions did not change. Differences were observed between in-person and virtual meetings regarding confidence in the ability to avoid secondhand smoke (in-person: 121/144, 84% vs virtual: 53/74, 72%; P=.03), intention to breastfeed ≥6 months (in-person: 79/128, 62% vs virtual: 52/66, 79%; P=.008), and confidence in the ability to breastfeed ≥6 months (in-person: 58/123, 47% vs virtual: 44/69, 64%; P=.02).

CONCLUSIONS

Although both event formats demonstrated increased knowledge/intentions to follow safe sleep recommendations, virtual events may further marginalize groups who are at high risk for poor birth outcomes. Strategies to increase technology access, recruit priority populations, and ensure disparities are not exacerbated will be critical for the implementation of future virtual events.

Challenges parents encounter when implementing infant safe sleep advice

AIM

To understand which safe sleep recommendations parents find most challenging to implement, identifying common barriers encountered; and investigate whether challenges are associated with practices employed.

METHODS

A cross-sectional survey of 3341 Australian families with young infants who birthed a live baby during April-May 2017. Caregivers were asked about infant care practices and family characteristics. Qualitative free-text items explored challenges faced with current safe sleep recommendations.

RESULTS

Nearly one-third (n = 1033, 31%) of caregivers reported difficulty with at least one safe sleep recommendation. Infant sleep position and avoiding bed-sharing were identified as the most challenging recommendations. Caregivers described barriers which influenced consistency in uptake of advice. Families who described difficulty with a recommendation were significantly less likely to consistently employ that advice compared to those who did not report difficulty (sleep position: 198/473,42% vs 2548/2837,90% [p < 0.0001]; own sleep space: (269/344,78% vs 1331/2884,46% [p < 0.0001]). When families encountered challenges, they often proposed alternate strategies with an inference their substitute action compensated potential increased risk.

CONCLUSION

Many families encounter difficulties implementing safe sleep advice; these challenges negatively impact care practices. Effective interventions meeting individual family needs, to provide safe sleep environments consistently, are necessary to improve sleep-related infant care and further reduce infant mortality.

Safe sleep community baby showers to reduce infant mortality risk factors for women who speak Spanish

OBJECTIVES

In the United States, sleep-related deaths are one of the primary causes of death for infants age 28 days to one year. The American Academy of Pediatrics (AAP) developed Safe Sleep Recommendations which provide risk reduction strategies for sleep-related infant deaths. Interventions such as Safe Sleep Community Baby Showers have increased knowledge and intentions to engage in these safe sleep behaviors for women who speak English. This study assessed the feasibility, acceptability and initial outcomes of Safe Sleep Community Baby Showers for women who speak Spanish.

METHODS

Six Spanish Safe Sleep Community Baby Showers were held in Sedgwick County, Kansas. One hundred forty-six pregnant or recently delivered women who spoke Spanish completed pre- and post-assessments. Univariate comparisons were made using McNemar's test for paired dichotomous variables.

RESULTS

Participants had a high school diploma/General Educational Diploma (GED) or less (75.3%), and were uninsured (52.1%) or had Medicaid (n = 49; 33.6%). The majority reported being very satisfied (n = 130; 89.0%) or satisfied (n = 8; 5.5%). Compared to baseline, significant increases in intentions and confidence to follow the AAP Safe Sleep Recommendations were observed following the events. The majority of participants reported intending to place their infant on the back to sleep (98.6%), use only a safe surface (crib, portable crib, bassinet; 99.3%), and only include safe items (firm mattress, fitted sheet; 93.5%) (all p < .001).

CONCLUSIONS

Study findings support both feasibility and acceptability of modifying Safe Sleep Community Baby Showers to provide culturally and linguistically appropriate education for women who speak Spanish. Initial outcomes suggest increased intentions to follow safe sleep recommendations.

Evaluation of a Multisite Safe Infant Sleep Education and Crib Distribution Program

Rates of sleep-related infant deaths have plateaued in the past few decades despite ongoing infant sleep practice recommendations to reduce risk of sleep-related infant deaths by the American Academy of Pediatrics. The state department of public health trained facilitators at 28 sites across the state to facilitate a group safe sleep educational program. A prospective, matched pre- and post-test cohort design with follow-up was used to evaluate changes in self-reported knowledge, intentions, and practices. The final sample included 615 matched pre- and post-test surveys, and 66 matched follow-up surveys. The proportion of correct responses on all knowledge and intended practice items increased significantly from pre- to post-test. When asked where their babies would have slept if they had not received the portable crib, 66.1% of participants planned to use a recommended sleep location (e.g., crib or bassinet). At post-test, 62.3% planned to change something about their infant’s sleep based on what they learned. At follow-up, knowledge was maintained for all but two items and practices and for half of practice items. The results suggest that participating in the education program was associated with increased knowledge and intended adherence, but that these changes were not maintained at follow-up. These results are in line with the research literature that finds a difference in intentions and actual practices after the baby is born.

Infant Safe Sleep Promotion: Increasing Capacity of Child Protective Services Employees

Sleep-related infant deaths, including Sudden Infant Death Syndrome (SIDS), are the number one cause of death in infants between 28 days and one year of life. Nearly half of families experiencing a sleep-related infant death in Kansas were involved with the Department of Children and Families Child Protective Services (CPS), making CPS staff a priority for safe sleep training. This study assessed the impact of the two-day Kansas Infant Death and SIDS (KIDS) Network Safe Sleep Instructor (SSI) train-the-trainer program on CPS staffs’ knowledge of the American Academy of Pediatrics safe sleep recommendations. Training was attended by 43 participants, 27 (63%) of whom were employed by CPS. CPS staff had significantly lower baseline knowledge on the 10-item pretest (t = 3.33, p = 0.002), but both CPS and other attendees showed significant improvement by posttest (t = 8.53, p < 0.001 and t = 4.44, p < 0.001, respectively). Following SSI certification, CPS SSIs provided more safe sleep training to professionals than other SSIs (1051 vs. 165, respectively), and both groups of SSIs were able to significantly increase the knowledge of their trainees. Overall, the KIDS Network SSI training was successful. The innovative partnership with CPS allowed for provision of training to a group not historically targeted for safe sleep education.

Feasibility and Acceptability of a Tailored Infant Safe Sleep Coaching Intervention for African American Families

Background: Approximately 3600 infants die suddenly and unexpectedly annually in the United States. Research suggests limitations of current behavioral interventions to reduce the risk for sleep-related deaths among African American families living in under-resourced neighborhoods. Guided by the theory of planned behavior and the socio-ecological model, the My Baby’s Sleep (MBS) intervention intends to reduce the risk for sleep-related infant deaths while addressing complex needs of African American families living in under-resourced neighborhoods. Objective: To assess feasibility and acceptability of MBS, a 7-month intervention that includes four home visits and multiple check-ins via phone and text message. Methods: This was a single-arm feasibility and acceptability study with quantitative and qualitive measures. African American families were recruited from community agencies that served an under-resourced metropolitan area. Results: Eight families (eight mothers, nine co-caregivers) completed the intervention. Families reported high acceptability of MBS content, process, and format, as evidenced by qualitative data and mean evaluation scores. Conclusion: MBS is feasible and acceptable among African American families living in under-resourced neighborhoods. These results suggest further investigation of MBS intervention efficacy in a large-scale randomized controlled trial.

Priority setting: Consensus for Australia's infant safe sleeping public health promotion programme

AIM

To develop focused priorities to inform the revision of Australia's Sudden Unexpected Death in Infancy (SUDI) risk reduction public health programme.

METHODS

A content expert consensus research activity was designed using two consensus techniques. The two-phase study employed a Delphi process (phase 1) and a Nominal Group workshop technique (phase 2). The Delphi invited 56 national and international content experts. The Nominal Group comprised 17 Australasian experts and stakeholders to ensure priority setting was relevant to the Australian context.

RESULTS

Phase 1 established a ranked thematic list of 10 key SUDI risk reduction themes. Phase 2 addressed three nominal questions producing prioritised lists for: key-message wording; contextual information and strategies to support caregiver implementation of key messages; and considerations in redesigning and dissemination of a safe sleep campaign. The top four priority themes were: sleep position, sleep space, smoking and surface-sharing.

CONCLUSION

This two-phase priority setting was successful in establishing clearly defined infant safe sleep priorities. International content expert participation in phase 1 strengthened priority setting outcomes while phase 2 ensured final outcomes provided a strong national focus reflective of identified needs of Australian families. Findings provide a foundation from which important components can be considered when revising and developing future SUDI risk reduction programmes.

Maternal intentions towards infant sleeping practices in Ireland

AIM

Mortality from Sudden Infant Death Syndrome (SIDS) has reduced by 50%-85% globally. Despite improvements from 1990 to 2009, the Irish SIDS rate has plateaued. Reasons for this are unclear, but may be related to a reduced parental SIDS awareness. Our study aimed to assess intentions regarding infant sleeping practices in mothers in Ireland.

METHODS

A cross-sectional survey of post-partum mothers was performed in the Rotunda Hospital over a four month period. Mothers with a history of SIDS, miscarriage or neonatal admissions were excluded.

RESULTS

Of 451 participants, unsafe sleeping positions were intended by 15.4%, reduced by Irish ethnicity [AOR = 0.52, 95% CI = 0.277-0.959, P = .036]. Safe sleep locations were intended by 66%, increased by Irish ethnicity [AOR = 2.6, 95% CI = 1.617-4.191, P < .001], and reduced by young maternal age [AOR = 0.15, 95% CI = 0.03-0.713, P = .02]. Maternal smoking was more likely in mothers with lower educational level [AOR = 3.51, 95% CI = 1.169-10.56, P = .03]. Soft bedding use was intended by 34.8%, increased in younger mothers [AOR = 2.28, 95% CI = 1.04-4.98, P = .04]. Breastfeeding was intended by 72.2%, decreased by Irish ethnicity [AOR = 0.14, 95% CI = 0.067-0.271, P < .001], and low maternal education [AOR = 0.22, 95% CI = 0.117-0.406, P < .001].

CONCLUSION

Educational campaigns on safe sleep for infants in Ireland need to address modifiable SIDS risks factors, focusing on younger, non-Irish mothers, with lower educational attainment.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Awareness of infant safe sleep messages and associated care practices: findings from an Australian cohort of families with young infants

OBJECTIVE

To investigate primary infant caregiver awareness of the current national public health safe sleep messages and the associations of awareness with care practices.

DESIGN AND SETTING

A cross-sectional survey in Queensland, Australia. All families with live babies birthed during April-May 2017 were eligible. Questionnaires were distributed when infants were approximately 3 months old.

PARTICIPANTS

Of the 10 200 eligible families, 3341 (33%) primary caregivers participated.

MAIN OUTCOME MEASURES

Participants were asked: to recall key safe sleeping messages they were aware of (unprompted); questions about their infant care practices; and to select the current, national six safe sleeping messages (prompted multi-choice).

RESULTS

Overall, the majority of families are aware of sleep-related infant mortality and sudden infant death (3178/3317, 96%); however, approximately one in four caregivers (867/3292, 26%) could not identify the current six messages to promote safer infant sleep in a multi-choice question. Despite being aware of the six key messages, some caregiver practices did not always align with advice (336/2423, 14% were not smoke-free; 349/2423, 14% were not usually supine for sleep; 649/2339, 28% employed practices which may increase risk of head or face covering; 426/2423, 18% were not receiving breastmilk).

CONCLUSIONS

There is considerable scope for improvement in parent awareness and ability to recall key safe sleep messages. Awareness of advice does not always translate into safe infant care. Health promotion messaging to encourage safer infant sleep, ultimately aimed at reducing sudden unexpected infant deaths, needs more effective supportive strategies and dissemination if future campaigns are to be successful.

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.

Screening and Support for Infant Safe Sleep: A Quality Improvement Project

Infant sleep is an anticipatory guidance topic that is discussed frequently at well child checks, starting with the newborn visit. It is challenging to cover a large amount of information in a short visit. This article describes a quality improvement project implemented at a pediatric primary care practice to improve screening for infant safe sleep. The screening form was updated to include questions from the Pregnancy Risk Assessment Monitoring System (PRAMS). This updated screening better captured actual sleeping practices, allowing for more targeted education.

Implementation of Safe Sleep Practice Recommendations for Infants in Inpatient Wards

Background

Sudden infant death syndrome (SIDS) is defined as the sudden unexpected death of an infant, even after conducting thorough investigations and autopsy. SIDS is related to several factors, such as baby’s position and presence of pillows, blankets and objects in the crib. The implementation of safe sleep recommendations in the inpatient setting is unknown and there is a scarcity of available data.

Methods

This was an observational, cross-sectional study that was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. All infants less than one year of age were considered after fulfilling the inclusion criteria. A checklist was developed in alignment with the latest American Association of Pediatrics (AAP) recommendations and an an independent observer was trained on how to evaluate and record the various components of the checklist.

Results

One hundred and two patients were enrolled in this study. The mean age of participants was 18.85 weeks. Asleep infants were found to be mostly placed in their cribs (71.4%), on their back (81%). Among the sleeping infants, 46% of them were swaddled at the time of data collection. Blankets were present in 79.4% of the cases, and loose sheets in more than half of the cases. Pillows were seen in 42.2% of the beds. No bumper pads were present in any of the beds.

Conclusion

This observational study highlights the importance of increasing awareness about safe sleep practices. Not only is it important for ensuring patient safety during admissions but also to send an important message to caregivers through role-modeling. Further studies are required to examine the barriers to implementing recommended safe sleep practices both within institutions that care for infants as well as among parents and caregivers.

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.

Predictors of infant-survival practices among mothers attending paediatric clinics in Ijebu-Ode, Ogun State, Nigeria

Background

Despite concerted global efforts towards achieving infant-survival, infant mortality lingers as a problem in developing countries. Environmental and personal-level factors are assumed to account for this situation. This study was undertaken to provide better understanding of the dynamics of predictors of infant-survival practices among mothers with infants attending paediatric clinics.

Methods

A cross-sectional survey design was adopted. Data was collected from 386 nursing mothers selected by convenience sampling. Interviewer-administered questionnaires were used for data collection. The questionnaire consisted of 38-items including demographic information of respondents, health-literacy counsels received during antenatal care, social-support from significant others, and self-efficacy to carry-out infant-survival instructions. Responses were transformed into rating scales for each variable and data analysis was conducted by linear regression analysis with test of hypotheses at 5% level of significance.

Results

The mean age of respondents was 29.8 ± 5.8 years. Majority (81.6%) were married. Yorubas (83.90%) were predominant. Participants had mean scores of 10.50 ± 3.83, 10.56 ± 3.70 and 16.61 ± 4.56 respectively computed for levels of health-literacy, social-support, and self-efficacy. The dependent variable measured level of infant-survival practices and respondents scored 16.53 ± 4.71. The study found a significant association among variables. Self-efficacy was the major predictor variable of self-reported infant-survival practices (R = 0.466; R² = 0.217; P<0.05).

Conclusion

We conclude that participants had average levels of health-literacy, social-support, self-efficacy, and infant-survival practices. Healthcare providers should make efforts to empower pregnant women on activities essential for infant-survival. Family members of nursing mothers should as well be knowledgeable about the advantages of supporting them.

Impact of statewide safe sleep legislation on hospital practices and rates of sudden unexpected infant deaths

Background

Sudden Unexpected Infant Death (SUID) is the leading cause of death in the post-neonatal period in the United States. In 2015, Connecticut (CT) passed legislation to reduce the number of SUIDs from hazardous sleep environments requiring birthing hospitals/centers provide anticipatory guidance on safe sleep to newborn caregivers before discharge. The objective of our study was to understand the barriers and facilitators for compliance with the safe sleep legislation by birthing hospitals and to determine the effect of this legislation on SUIDs associated with unsafe sleep environments.

Methods

We surveyed the directors and/or educators of the 27 birthing hospitals & one birthing center in CT, about the following: 1) methods of anticipatory guidance given to parents at newborn hospital discharge; 2) knowledge about the legislation; and 3) barriers and facilitators to complying with the law. We used a voluntary online, anonymous survey. In addition, we evaluated the proportion of SUID cases presented at the CT Child Fatality Review Panel as a result of unsafe sleep environments before (2011–2015) and after implementation of the legislation (2016–2018). Chi-Square and Fisher’s exact tests were used to evaluate the proportion of deaths due to Positional Asphyxia/Accident occurring before and after legislation implementation.

Results

All 27 birthing hospitals and the one birthing center in CT responded to the request for the method of anticipatory guidance provided to caregivers. All hospitals reported providing anticipatory guidance; the birthing center did not provide any anticipatory guidance. The materials provided by 26/27 (96%) of hospitals was consistent with the American Academy of Pediatrics (AAP) Guidelines. There was no significant change in rates of SUID in CT before (58.86/100,000) and after (55.92/100,000) the passage of the legislation (p = 0.78). However, more infants died from positional asphyxia after (20, 27.0%) than before the enactment of the law (p < 0.01).

Conclusions

Despite most CT hospitals providing caregivers with anticipatory guidance on safe sleep at newborn hospital discharge, SUIDs rates associated with positional asphyxia increased in CT after the passage of the legislation. The role of legislation for reducing the number of SUIDs from hazardous sleep environments should be reconsidered.

Obstetricians' and Gynecologists' Communication Practices around Smoking Cessation in Pregnancy, Secondhand Smoke and Sudden Infant Death Syndrome (SIDS): A Survey

Secondhand smoke (SHS) is a potential direct cause of Sudden Infant Death Syndrome (SIDS) among infants. Disparities in SHS exposure and SIDS deaths may be due to inconsistent communication among practitioners about SHS/SIDS risks. In order to assess current SHS/SIDS risks and communication practices and to identify areas of improvement, we conducted a survey of 316 obstetricians and gynecologists (ob/gyns) about the length of time spent having discussions, supplemental materials used, risks covered, cessation, and frequency of discussions. Most (55.3%) reported spending 1-4 min discussing risks/cessation. Nearly a third reported not using any supplemental materials; few used apps (4.4%) or videos (1.9%). Assisting patients with steps toward cessation was infrequent. Few ob/gyns had discussions with patients immediately postpartum. Only 51.9% strongly agreed that they felt sufficiently informed about SHS/SIDS risks to educate their patients. The communication by ob/gyns of SHS/SIDS risk varies greatly and presents opportunities for improvement. Each additional minute spent having discussions and the use of supplemental materials, such as apps, may improve communication effectiveness. The discussion of smoking behaviors immediately postpartum may help to prevent smoker relapse. An increased awareness of statewide cessation resources by ob/gyns is needed to assist patients with cessation. The development of standardized risk messaging may reduce the variation in communication practices among ob/gyns.

Outpatient- or community-based interventions to prevent SIDS and sleep-related deaths

PURPOSE

To determine the state of science of outpatient- or community-based interventions for sudden infant death syndrome prevention in the United States, an integrative review was completed and studies identified through the application of inclusion and exclusion criteria.

CONCLUSIONS

Of the nine studies identified, three were randomized controlled trials. There was a wide range of measurement tools and variables measured. The timing of interventions also varied. There was a focus on mothers and African Americans. Lastly, study design and approach have not changed significantly over time.

PRACTICE IMPLICATIONS

Findings highlight recommendations for future research: expanding the target population, addressing culture in the development of the intervention or program, including additional providers, such as nurses, in the intervention or program, advancing innovation, and increasing rigor of study design.

Implementation of a Statewide Program to Promote Safe Sleep, Breastfeeding and Tobacco Cessation to High Risk Pregnant Women

Infant mortality remains a problem in the United States with sleep-related deaths accounting for a significant portion. Known risk reduction strategies include breastfeeding, avoiding tobacco use and following the American Academy of Pediatrics' safe sleep guidelines. The purpose of this project was to evaluate outcomes of Safe Sleep Instructor-led community baby showers, which included safe sleep promotion, breastfeeding promotion and tobacco cessation education. Certified Safe Sleep Instructors (n = 35) were trained on how to plan and host a Community Baby Shower to provide education to pregnant women of low socioeconomic status or with high risk of infant mortality. Eighteen Community Baby Showers were held across two urban and eight rural counties in Kansas. Surveys were administered pre- and post-event to assess participant knowledge, confidence and intentions to follow through with planned action related to safe sleep, breastfeeding and reducing tobacco risk. Matched data were summarized and evaluated for differences using McNemar's and Wilcoxon Signed Rank tests. Significant increases were observed in Baby Shower participants' (n = 845) reported plans to follow the AAP Safe Sleep guidelines (all p < 0.001), likelihood to breastfeed (p < 0.001), confidence in ability to breastfeed for more than 6 months (p < 0.001), knowledge of local breastfeeding support resources (p < 0.001), knowledge of ways to avoid second-hand smoke exposure (p < 0.001) and knowledge of local tobacco cessation services (p = 0.004). Based on the result of the pre- and post-event surveys, certified Safe Sleep Instructors were able to plan and host successful events to increase knowledge and confidence related to risk reduction strategies to reduce sleep-related infant deaths.

Infant care practices and parent uptake of safe sleep messages: a cross-sectional survey in Queensland, Australia

Background

Globally, the incidence of sleep-related infant mortality declined dramatically following the first public health campaigns seen internationally in the 1990s to reduce the risks of sudden infant death. However, Australian Sudden Unexpected Death in Infancy (SUDI) rates have plateaued with little change in incidence since 2004 despite two further public health safe sleep campaigns. This study aims to describe contemporary infant care practices employed by families related to the current public health SUDI prevention program.

Methods

A cross-sectional survey of 3341 Queensland primary caregivers with infants approximately 3-months of age was conducted using the Queensland Registry of Births, Deaths and Marriages as a sampling frame. Surveys were returned either via reply-paid mail or online. Questionnaires explored prevalence of infant care practices and awareness of safe sleep recommendations. Univariable analysis was used to generate descriptive statistics for key variables.

Results

Overall, only 13% of families routinely practised all six ‘Safe Sleeping’ program messages. More than one third (1118, 34%) of infants had slept in a non-supine sleep position at some time. Potentially hazardous sleep environments were common, with 38% of infants sleeping with soft items or bulky bedding, or on soft surfaces. Nearly half, for either day- or night-time sleeps, were routinely placed in a sleep environment that was not designed or recommended for safe infant sleep (i.e. a bouncer, pram, beanbag). Most babies (84%) were reportedly smoke free before and after birth. Sleeping in the same room as their caregiver for night-time sleeps was usual practice for 75% of babies. Half (1600, 50%) of all babies shared a sleep surface in the last two-weeks. At 8-weeks, 17% of infants were no longer receiving any breastmilk.

Conclusions

The prevalence rates of infant care practices among this Australian population demonstrate many families continue to employ suboptimal practices despite Australia’s current safe sleep campaign. Strategic approaches together with informed decisions about pertinent messages to feature within future public health campaigns and government policies are required so targeted support can be provided to families with young infants to aid the translation of safe sleep evidence into safe sleeping practices.

Modeling Safe Infant Sleep in the Hospital

PURPOSE

Despite reductions in the rate of sudden infant death syndrome (SIDS) over the last 25 years, over 3000 infant deaths annually in the US are attributable to sleep-related causes. We aimed to improve safe sleep practice (SSP) adherence by healthcare providers working with infants admitted to an inpatient pediatric unit in an urban academic center specifically increasing compliance on five core SSP (supine, alone in the crib, no objects in crib, appropriate bundling, and flat crib).

DESIGN AND METHODS

This Quality Improvement project evaluated a staff education intervention using a pre- and post-design. Surveys of providers determined baseline SSP knowledge. Adherence to SSP in the hospital was audited before and after education. One hundred pre-intervention infant sleep placement observations were recorded and 123 were collected post-intervention.

RESULTS

Surveyed providers had appropriate knowledge of SSP; however, baseline audits indicated that no patients met all SSP practices in the hospital. Post-intervention adherence to SSP showed significant (p < .05) improvements in keeping the crib flat, removing objects from the crib, and avoiding over-bundling. Overall, SSP adherence increased by 12.5% post-intervention.

CONCLUSIONS

This quality improvement project suggests that the inpatient setting provides opportunities for providers to demonstrate SSP but that healthcare providers often do not follow SSP in practice. Continued education can lead to improvements in SSP adherence ensuring that hospitals are modeling SSP for the families of infants.

PRACTICE IMPLICATIONS

Limited improvements to SSP adherence illustrate the complexities of modifying provider behaviors in the absence of formal policy.

A Hospital-Based Initiative to Reduce Postdischarge Sudden Unexpected Infant Deaths

BACKGROUND AND OBJECTIVES

Sudden unexpected infant deaths (SUID) most often occur because infants are placed in unsafe sleep environments. Although authors of previous literature have demonstrated that parents who receive comprehensive safe sleep education increase knowledge and intention to place children in safe sleep environments, no studies have demonstrated improved outcomes. We describe the development of a hospital-based newborn SUID risk reduction quality improvement project and its effectiveness in reducing subsequent SUIDs in a community using linked outcome data from local Child Fatality Review Teams.

METHODS

Qualitative and quantitative evaluation of a long-term iterative performance improvement intervention for a nursery-based comprehensive safe sleep program in a community teaching hospital. Key themes and exemplary comments were noted. The rate of infant deaths per 1000 births was the primary quantitative outcome. The rate is calculated quarterly and monitored with control charts by using Child Fatality Review data about infant sleep deaths.

RESULTS

The average death rate fell from 1.08 infants per 1000 births preintervention to 0.48 infants per 1000 births after complete intervention, and the average number of deaths between deliveries increased from 1 in every 584 deliveries (upper control limit: 3371) to 1 in every 1420 deliveries (upper control limit: 8198). Qualitative observation of nursery providers revealed 3 themes, including routine inclusion of sleep safety information, dissemination of safety information by all staff, and personal commitment to success.

CONCLUSIONS

A comprehensive sleep safety culture change can be effectively integrated into a nursery setting over time by using feedback from Child Fatality Review and performance improvement methodology. Repeated messaging and education by the entire nursery staff has the potential to play a role in reducing sleep-related deaths in infants born at their hospital.

Evaluation of a Crib Distribution and Safe Sleep Educational Program to Reduce Risk of Sleep-Related Infant Death

To increase access to safe infant sleep surfaces and reduce risk of sleep-related infant deaths, the Georgia Department of Public Health implemented a portable crib distribution and safe sleep educational program. The aim of this evaluation was to compare parental knowledge and practices related to infant sleep before and after receipt of the safe sleep educational program and crib. A prospective, matched pre- and post-test cohort design with a follow-up survey was utilized to evaluate changes in knowledge and practices. Female participants were recruited through the county health department and met the following criteria: (1) between 32 and 40 weeks pregnant or within 3 months postpartum, and (2) demonstrated financial need. Participants completed a survey prior to the start of a group educational program and upon program completion. For those who agreed, a follow-up phone survey was conducted approximately 10 weeks after program completion or after the infant's birth. McNemar's Chi square tests were conducted to detect significant differences between specific items on pre-test, post-test, and follow-up surveys, and paired sample t tests were conducted to compare differences in knowledge and practice scores. A total of 132 participants completed matched pre- and post-test surveys and 76 completed follow-up surveys. Knowledge of recommendations regarding position, surface, environment, smoking, breastfeeding, and pacifier use increased significantly between pre- and post-test, with most participants maintaining knowledge at follow-up. The proportion of recommended practices also increased significantly. A group-based safe sleep educational program can be effective in reducing risky infant sleep practices.

Refusal of Vitamin K by Parents of Newborns: A Qualitative Study

OBJECTIVE

Despite American Academy of Pediatrics recommendations, some parents refuse intramuscular (IM) vitamin K as prophylaxis against vitamin K deficiency bleeding for their newborns. The purpose of our study was to describe attitudes and perceptions of parents who choose to defer IM vitamin K for their newborns.

METHODS

Using qualitative methodology, we conducted in-depth semi-structured interviews with parents of newborns in 3 hospitals in Connecticut and California. We used the grounded theory approach and the constant comparative method until saturation was reached.

RESULTS

Nineteen participants (17 mothers and 2 fathers) of 17 newborns were interviewed; 14 newborns did not receive IM vitamin K due to refusal by the parents, and for 3 newborns IM vitamin K administration was delayed due to initial hesitation by the parents. Four major themes emerged: 1) risk-to-benefit ratio, where parents refused IM vitamin K due to a perceived risk to their newborn from preservatives, for example; 2) "natural" approaches, which led to seeking oral vitamin K or increasing the mother's own prenatal dietary vitamin K intake; 3) placement of trust and mistrust, which involved mistrust of the medical and pharmaceutical community with overlapping concerns about vaccines and trust of self, like-minded allopathic and non-allopathic health care providers, the social circle, the internet, and social media; and 4) informed by experiences, reflecting hospital experiences with prior pregnancies and communication with health care providers.

CONCLUSIONS

Parents' perception of risk, preference for alternative options, trust, and communication with health care providers were pivotal factors when making decisions about IM vitamin K.

Content of Infant Safe Sleep Counseling and Maternal Reported Practices in an Urban Clinic

OBJECTIVE

Sudden Infant Death Syndrome is a leading cause of mortality in infants, and pediatric providers can influence caregiver infant safe sleep practices. We described the content of safe sleep counseling by pediatric providers and examined pediatric provider and caregiver factors that may be related to the delivery of safe sleep counseling.

METHODS

A sample of mothers and providers enrolled in the Safe Start Study, a randomized controlled trial assessing a safe sleep intervention, were audio-recorded during the 2-week well child visits (WCV) at a large urban pediatric practice in Baltimore, Maryland from October 2015 to April 2017. Provider counseling content related to infant sleep was transcribed and coded based on American Academy of Pediatrics (AAP) policy statement Grade A recommendations. Maternal reported infant sleep practices were defined by items on an interviewer administered survey. Multivariate logistic regression analyses were used to examine the relation between maternal reported infant sleep practices and provider counseling.

RESULTS

Most, 92%, of WCVs included at least 1 safe sleep topic, but there was inconsistency in content delivered based on AAP recommendations. Yet, only 12% of WCVs included all 4 components of ABC counseling. Maternal report of infant sleeping with a person or an object in sleep space was associated with decreased odds of receiving counseling on alone no person, no objects (adjusted odds ratio: 0.34, 95% confidence interval: 0.13, 0.90).

CONCLUSIONS

Pediatric provider counseling on safe sleep is inconsistent across AAP recommendations demonstrating a need for enhanced provider education and a more standardized approach to assess infant sleep practices.

Accidental Infant Suffocation and Strangulation in Bed: Disparities and Opportunities

Objectives (a) Update previous descriptions of trends in ASSB; (b) determine if factors previously associated with ASSB are replicated by updated data; and (c) generate new hypotheses about the occurrence of ASSB and racial inequalities in ASSB mortality. Methods National Center for Health Statistics files (International Classification of Diseases, Tenth Edition) Code W75 to describe race-ethnicity-specific ASSB occurrence. Results (a) ASSB mortality continues to increase significantly; for 1999-2016, 4.4-fold for NHB girls (45.8 per 100,000 in 2016), 3.5-fold for NHB boys (53.8), 2.7-fold for NHW girls (15.8) and 4.0-fold for NHW boys (25.9); (b) F actors previously associated with ASSB (unmarried mothers and mothers with low educational attainment, low infant birth weight, low gestational age, lack of prenatal care, male infant, multiple birth, high birth order) continue to be associated with both overall ASSB and inequalities adversely affecting NHB; (c) (1) geographic differences and similarities in ASSB occurrence support hypotheses related to positive deviance; (2) lower ASSB mortality for births attended by midwives as contrasted to physicians generate hypotheses related to both medical infrastructure and maternal engagement; (3) high rates of ASSB among infants born to teenage mothers generate hypotheses related to the possibility that poor maternal health may be a barrier to ASSB prevention based on education, culture and tradition. Conclusions for Practice These descriptive data may generate new hypotheses and targets for interventions for reducing both ASSB mortality and racial inequalities. Analytic epidemiologic studies designed a priori to do so are required to address these hypotheses.

A Statewide Hospital-Based Safe Infant Sleep Initiative: Measurement of Parental Knowledge and Behavior

Sleep-related infant deaths are a leading cause of infant mortality in Georgia, and these deaths are largely associated with unsafe sleep practices among caregivers. In early 2016, the Georgia Department of Public Health launched the Georgia Safe to Sleep Hospital Initiative, providing hospitals with safe infant sleep information and educational materials to be distributed to families and newborns. This study examined the knowledge and behaviors of a sample of Georgia parents after the implementation of the Hospital Initiative and identified the family characteristics and intervention components most closely associated with the knowledge and practice of safe infant sleep. The primary caretakers of all infants born in Georgia from August to October 2016 were invited to complete a web-based survey 1 month after hospital discharge. The final sample size included 420 parents of newborns, and the primary outcomes assessed included two measures of knowledge and four measures of infant sleep behaviors regarding infant sleep position and location. Most respondents demonstrated knowledge of the correct recommended sleep position (90%) and location (85%). Logistic regression revealed that receipt of information in the hospital was significantly correlated with safe sleep behaviors, and infant sleep habits tended to influence safe sleep practices. Additionally, Medicaid parents receiving bassinets from the hospital were 74% less likely to bed share (OR 0.26; 95% CI 0.007). Implementation of a statewide hospital initiative was associated with high levels of parental knowledge and behavior and may have been successful in reducing the practice of bed sharing among Medicaid parents.

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.