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SUID/SIDS Prevention


Changing Knowledge and Behavior to Reduce Sudden Unexpected Infant Death

Safe Sleep Programs Research Articles

This information was compiled in response to a technical assistance request and is posted here for others who may be interested in these topics.

For more recent articles on these topics, see the automated PubMed search Evaluation of SUID/SIDS Interventions.

This list includes information on:
A. motivators for hospital programs to provide safe sleep education and methods for training them to do so;
B. evidence on identifying and overcoming barriers to parents' employing safe sleep practices at home;

A. Motivators for hospital programs to provide safe sleep education and methods for training them to do so

1. Integrating "Back to Sleep" Recommendations Into Neonatal ICU Practice.
Gelfer P, Cameron R, Masters K, Kennedy KA.
Pediatrics. 2013 Mar 4. [Epub ahead of print]

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics stresses that NICUs should endorse and model the sudden infant deaths syndrome risk-reduction recommendations significantly before anticipated discharge of the infant. Medical personnel are critical role models for parents, and the way they position infants in the hospital strongly influences parental practices at home. The aims of this project were to increase the percentage of infants following safe sleep practices in the NICU before discharge and to determine if improving compliance with these practices would influence parent behavior at home.

METHODS: An algorithm detailing when to start safe sleep practices, a "Back to Sleep" crib card, educational programs for nurses and parents, a crib audit tool, and postdischarge telephone reminders were developed as quality improvement intervention strategies.

RESULTS: NICU compliance with supine positioning increased from 39% to 83% (P < .001), provision of a firm sleeping surface increased from 5% to 96% (P < .001), and the removal of soft objects from the bed improved from 45% to 75% (P = .001). Through the use of a postdischarge telephone survey, parental compliance with safe sleep practices was noted to improve from 23% to 82% (P < .001).

CONCLUSIONS: Multifactorial interventions improved compliance with safe sleep practices in the NICU and at home.

2. Endorsing safe infant sleep: a call to action.
Hitchcock S.
Nurs Womens Health. 2012 Oct-Nov;16(5):386-96. doi: 10.1111/j.1751-486X.2012.01762.x.

The American Academy of Pediatrics (AAP) safe sleep recommendations are considered best practice and are effective in preventing sudden infant death syndrome (SIDS). Yet studies have found that nurses' practice in newborn nurseries and neonatal intensive care units is often inconsistent with safe sleep recommendations. Such inconsistencies cause confusion and hinder SIDS prevention efforts. In 2011, the AAP added significant content to its 2005 safe sleep recommendations and neonatal nurses are now being asked to endorse the recommendations from birth. This article reviews the recommendations, examines barriers and controversies and offers suggestions for how an organization might initiate change and move toward a unified endorsement of safe sleep strategies.

3. Creating a hospital and community based infant safe sleep education and awareness program: The York Hospital Experience. - Michael Goodstein

The objectives of this presentation were to review statistics supporting the need for increased family education on infant sleep safety; to understand how to organize a hospital-based infant sleep safety program; to be aware of the potential deterrents to development of an infant sleep safety program and how to overcome them; and to be familiar with ongoing research to demonstrate the effectiveness of increased family education efforts.
Additional evidence based studies from Dr. Goodstein:

4. Hospital initiative toolkit.
Cribs for Kids

This toolkit provides materials for starting a hospital-based infant safe sleep program designed to (1) provide accurate and consistent infant safe sleep information to hospital personnel including medical, nursing, breastfeeding, child birth education, and nutritional staff; (2) enabling the hospital to implement and model infant safe sleep practices throughout their facility; and (3) provide direction to health care professionals so that safe sleep education for parents is consistent and repetitive. It gives guidance on achieving program acceptance and on curriculum development. It provides resources to use in the program, including manuals, policies, and consumer materials.

5. Translating infant safe sleep evidence into nursing practice.
Shaefer SJ, Herman SE, Frank SJ, Adkins M, Terhaar M.
J Obstet Gynecol Neonatal Nurs. 2010 Nov-Dec;39(6):618-26. doi: 10.1111/j.1552-6909.2010.01194.x.

The authors describe a 4-year demonstration project (2004-2007) to reduce infant deaths related to sleep environments by changing attitudes and practices among nurses who work with African American parents and caregivers in urban Michigan hospitals. An approach was developed for creating sustainable change in nursing practice by implementing nursing practice policies that could be monitored through quality improvement processes already established within the hospital organization. Following the policy change effort, nurses changed their behavior and placed infants on the back to sleep.

6. Changing hospital newborn nursery practice: results from a statewide "Back to Sleep" nurses training program.
Price SK, Hillman L, Gardner P, Schenk K, Warren C.
Matern Child Health J. 2008 May;12(3):363-71. Epub 2007 Jun 15.

OBJECTIVE: In response to findings from a statewide survey of hospital nurses, the authors designed, conducted, and evaluated a "Back to Sleep" nursing curriculum and training program in Missouri hospitals using two distinct training formats. This article evaluates the initial and follow-up outcomes for training participants and assesses the impact of training format on participant outcomes.

METHODS: Participants selected training format by hospital site. In each training format, participants responded to a pre and post test questionnaire measuring knowledge, beliefs, and current infant care behaviors as well as satisfaction with the training. Three months after completion of all statewide trainings, the authors also conducted a follow-up survey.

RESULTS: Nurses who participated in the training reported statistically significant improvements in knowledge and "Back to Sleep" adherent beliefs. Over 98% of participants (N=515) intended to place infants in back-only sleep positions following the training. Knowledge, attitudes, and practice intentions were significantly improved across both training formats. Additionally, follow-up survey respondents statewide (N=295) reported lasting improvements, including 63% of nurses reportedly using supine-only sleep position for infants after the first 24 h of life, compared to 28% in the original statewide survey.

CONCLUSIONS: Further research is needed to determine the long-term impact of this intervention and assess its applicability beyond this initial implementation. Ultimately, the findings from the evaluation of this pilot intervention and nursing-specific "Back to Sleep" curriculum demonstrate that it has a promising effect on risk-reduction adherence in hospital settings where parent observations of safe sleep behavior first occur.
This program is also described here:
Back to Sleep Training for Nursery Room Nurses AMCHP Innovation Station

7. Educating parents about the risk factors of sudden infant death syndrome: the role of neonatal intensive care unit and well baby nursery nurses.
Esposito L, Hegyi T, and Ostfeld BM.
Journal of Perinatal and Neonatal Nursing, 2007 Apr-Jun; 21(2): 158-64.
Abstract: Nurses in newborn nurseries and neonatal intensive care units are instrumental in educating parents about reducing the risk for SIDS. Nurse participation is acknowledged and encouraged in the current policy statement on SIDS Risk Reduction put forth by the American Academy of Pediatrics. Despite the decline in SIDS, it remains the leading cause of postneonatal infant mortality, and despite greater public compliance with the risk reduction guidelines there is room for improvement in how effectively and consistently they are disseminated. To facilitate nursing participation as educators, role models, and collaborators in the development of relevant hospital policies and procedures, we review the current recommendations, addressing issues that may serve as barriers to participation, describing the biological plausibility underlying risk-reducing practices, and presenting resources from which nurses may obtain teaching materials and model policies.

B. Evidence on identifying and overcoming barriers to parents' employing safe sleep practices at home

1. Factors influencing infant sleep position: decisions do not differ by SES in African-American families.
Robida D, Moon RY.
Arch Dis Child. 2012 Oct;97(10):900-5. doi: 10.1136/archdischild-2011-301360. Epub 2012 Aug 17.

OBJECTIVE: To investigate factors influencing African-American parents' knowledge, attitudes and practice regarding infant sleep position and determine if these differ by socioeconomic status (SES).

METHODS: A cross-sectional sample of 412 parents with infants <=6 months of age participated in a validated survey of knowledge, attitudes and practice.

RESULTS: There was no significant difference in attitudes or practice, and knowledge was similar regarding infant sleep position between African-American parents of higher and lower SES. The healthcare provider recommendation of exclusive supine sleep position use was associated with increased knowledge, overall decreased use of the side position (5.0% vs 16.8%, p<0.01) and increased occasional use of the supine position in the lower SES group (81.6% vs 68.6%, p=0.03). It was not associated with increased positive parental attitudes about the supine sleep position in either group. Neither a senior caregiver living in the home nor observation of hospital personnel placing infants in a non-supine position was associated with differences in sleep position practices in either group.

CONCLUSIONS:Sleep position practices in African-American families do not differ by SES. Improved attitudes toward positioning and increased use of supine positioning may result if healthcare providers address common concerns and misconceptions about sleep position.

2. Decisions of black parents about infant bedding and sleep surfaces: a qualitative study.
Ajao TI, Oden RP, Joyner BL, Moon RY.
Pediatrics. 2011 Sep;128(3):494-502. doi: 10.1542/peds.2011-0072. Epub 2011 Aug 22.

OBJECTIVE: The goal of this qualitative study was to examine factors influencing decisions by black parents regarding use of soft bedding and sleep surfaces for their infants.

METHODS: We conducted focus groups and individual interviews with black mothers of lower and higher socioeconomic status (SES). Mothers were asked about many infant care practices, including sleep surface and bedding.

RESULTS: Eighty-three mothers were interviewed, 73 (47 lower and 26 higher SES) in focus groups and 10 (7 lower and 3 higher SES) in individual interviews. The primary reason for using soft surfaces was infant comfort. Parents perceived that infants were uncomfortable if the surface was not soft. Many parents also interpreted "firm sleep surface" to mean taut; they were comfortable with and believed that they were following recommendations for a firm sleep surface when they placed pillows/blankets on the mattress as long as a sheet was pulled tautly over the pillows/blankets. The primary reasons for using soft bedding (including bumper pads) were comfort, safety, and aesthetics. In addition to using bedding to soften sleep surfaces, bedding was used to prevent infant rollover and falls, particularly for infants sleeping on a bed or sofa. Some parents used soft bedding to create an attractive space for the infant.

CONCLUSIONS: Many black parents believe that soft bedding will keep their infant safe and comfortable. There is much misunderstanding about the meaning of a "firm" sleep surface. Additional educational messages apparently are needed to change parental perceptions and practices.

3. Where should my baby sleep: a qualitative study of African American infant sleep location decisions.
Joyner BL, Oden RP, Ajao TI, Moon RY.
J Natl Med Assoc. 2010 Oct;102(10):881-9.

BACKGROUND: African American infants are of higher risk for sudden infant death syndrome (SIDS) and accidental suffocation than other infants and are up to 4 times more likely to bedshare with their parents.

OBJECTIVE: To investigate, using qualitative methods, factors influencing African American parents' decisions regarding infant sleep location (room location and sleep surface).

METHODS: Eighty-three mothers participated in focus groups or individual interviews. Questions probed reasons for infant sleep location decisions and influences on decision making.

RESULTS: Most of the mothers in this study slept in the same room as their infant. Reasons for roomsharing included space, convenience, and safety. Mothers largely decided on infant sleep surface because of space for/availability of crib, comfort, convenience, and safety. Both roomsharing and bedsharing were often chosen to make feeding and checking on the infant more convenient. Mothers who chose not to bedshare cited privacy, concern that the infant would become attached to the parents' bed, and fears about suffocation. Mothers who chose to bedshare often cited the ability to maintain vigilance while asleep. Low-income mothers also used bedsharing as a defense against environmental dangers.

CONCLUSION: African American mothers in this study viewed both roomsharing and bedsharing as strategies to keep their infants safe. Efforts to encourage roomsharing without bed-sharing must address parental concerns about space for/ availability of a crib, convenience, infant and parent comfort, and infant safety.

4. Factors influencing African American mothers' decisions about sleep position: a qualitative study.
Oden RP, Joyner BL, Ajao TI, Moon RY.
J Natl Med Assoc. 2010 Oct;102(10):870-2, 875-80.

BACKGROUND: African American infants continue to be at more than twice the risk for sudden infant death syndrome (SIDS) than Caucasian Americans. In addition, African Americans are twice as likely to place their infants prone for sleep.

OBJECTIVE: To investigate, using qualitative methods, factors influencing African American parents' decisions regarding infant sleep position.

METHODS: Eighty-three mothers participated in focus groups or individual interviews. Questions probed reasons for infant sleep position decisions and influences on decision making.

RESULTS: All of the mothers in this study were aware of the recommendation to place infants supine for sleep. Mothers largely chose infant sleep position for either safety or comfort reasons. Many mothers who chose the prone position did so because they perceived it to be safer than supine. Sleep position decisions were influenced by parental needs (largely the need for sleep), perception of SIDS risk and biological plausibility, and trusted sources of information. Mothers sought information from multiple trusted sources before making any decision. Even if mothers had trust in their pediatrician, they were comfortable making decisions counter to their pediatrician's recommendations if they felt it to be in the best interests of their infant.

CONCLUSIONS: African American mothers are generally aware of the Back to Sleep recommendation. However, many may not believe that the supine position is the safest position. Other mothers may use the prone position because of infant comfort or parent's need for longer sleep. Trust in the pediatrician may not be sufficient reason for parents to use the supine position.

5. Qualitative analysis of beliefs and perceptions about sudden infant death syndrome in African-American mothers: implications for safe sleep recommendations.
Moon RY, Oden RP, Joyner BL, Ajao TI.
J Pediatr. 2010 Jul;157(1):92-97.e2. doi: 10.1016/j.jpeds.2010.01.027. Epub 2010 Mar 19.

OBJECTIVE: To investigate, by using qualitative methods, perceptions about sudden infant death syndrome (SIDS) in African-American parents and how these influence decisions.

STUDY DESIGN: Eighty-three mothers participated in focus groups or individual interviews. Interviews probed reasons for decisions about infant sleep environment and influences affecting these decisions. Data were coded, and themes were developed and revised in an iterative manner as patterns became more apparent.

RESULTS: Themes included lack of plausibility, randomness, and vigilance. Many mothers believed that the link between SIDS and sleep position was implausible. Because the cause of SIDS was unknown, they did not understand how certain behaviors could be defined as risk factors. This confusion was reinforced by perceived inconsistency in the recommendations. Most mothers believed that SIDS occurred randomly ("God's will") and that the only way to prevent it was vigilance.

CONCLUSIONS: Many African-American mothers may not understand the connection between SIDS and sleep behaviors or believe that behavior (other than vigilance) cannot affect risk. These beliefs, if acted on, may affect rates of safe sleep practices. Efforts to explain a plausible link between SIDS and safe sleep recommendations and to improve consistency of the message may result in increased adherence to these recommendations.

6. Trends and factors associated with infant sleeping position: the national infant sleep position study, 1993-2007.
Colson ER, Rybin D, Smith LA, Colton T, Lister G, Corwin MJ.
Arch Pediatr Adolesc Med. 2009 Dec;163(12):1122-8. doi: 10.1001/archpediatrics.2009.234.

OBJECTIVE: To determine trends and factors associated with choice of infant sleeping position.

DESIGN: Annual nationally representative telephone surveys from 1993 through 2007.

SETTING: Forty-eight contiguous states of the United States.

PARTICIPANTS: Nighttime caregivers of infants born within the last 7 months; approximately 1000 interviews were given each year. Main Outcome Measure Whether infant is usually placed supine to sleep.

RESULTS: For the 15-year period, supine sleep increased (P < .001) and prone sleep decreased (P < .001) for all infants, with no significant difference in trend by race. Since 2001, a plateau has been reached for all races. Factors associated with increased supine sleep between 1993 and 2007 included time, maternal race other than African American, higher maternal educational level, not living in Southern states, first-born infant, and full-term infant. The effect of these variables was reduced when variables related to maternal concerns about infant comfort, choking, and advice from physicians were taken into account. Between 2003 and 2007, there was no significant yearly increase in supine sleep. Choice of sleep position could be explained almost entirely by caregiver concern about comfort, choking, and advice. Race no longer was a significant predictor.

CONCLUSIONS: Since 2001, supine sleep has reached a plateau, and there continue to be racial disparities. There have been changes in factors associated with sleep position, and maternal attitudes about issues such as comfort and choking may account for much of the racial disparity in practice. To decrease sudden infant death syndrome rates, we must ensure that public health measures reach the populations at risk and include messages that address concerns about infant comfort and choking.

7. Back to Sleep: an educational intervention with women, infants, and children program clients.
Moon RY, Oden RP, Grady KC.
Pediatrics. 2004 Mar;113(3 Pt 1):542-7.

OBJECTIVE: The incidence of sudden infant death syndrome (SIDS) is 2 to 3 times higher in the black population compared with the US population as a whole. Prone sleeping is also twice as prevalent in black infants. Standard modes of communication (media, brochures) regarding the Back to Sleep (BTS) campaign have been less effective with blacks. The objective of this study was to determine whether a 15-minute educational intervention is effective in changing sleep position practice among black parents.

METHODS: A trained health educator led 15-minute sessions about safe infant sleep practices for groups of 3 to 10 parents of young infants who attended a Women, Infants, and Children clinic in Washington, DC. We performed pre- and postsession surveys, asking about sleep position, reasons for choosing a sleep position, and knowledge of the relationship between sleep position and SIDS. We then interviewed parents 6 months after the intervention and compared this group with a group of parents at a different Women, Infants, and Children site who did not receive the intervention.

RESULTS: A total of 310 parents/caregivers participated in sessions from October 2001 to July 2002. Mothers comprised 84.5% of the participants, fathers 6.5%, and other relatives 9.0%. Parents had a mean age of 26.2 years (range: 15-64; standard deviation: 8.3), and 76.5% had graduated from high school. For 51%, this was their first child. Before the intervention, more than half (57.7%) of infants reportedly slept on their back, with the remainder sleeping back/side or side (15%) and prone (17.3%). Approximately 85% (266) of infants were sleeping in the same room as the parents. Only 28.1% of parents initially believed that prone sleeping definitely increases the risk of SIDS. Infants were more likely to be placed supine when previous children were placed supine or when parents had more than a high school education. Parents were also more likely to place infants supine when they believed that prone increases the risk of SIDS, they had previous knowledge of BTS, and they were aware that the American Academy of Pediatrics recommends supine position for infants. Sleep position was not affected by where the infant slept, number of parents in the home, presence of a grandmother in the home, or presence of smokers in the home. Immediately after the intervention, 85.3% planned to place infants on the back, and 55.7% now believed that prone definitely increases the risk of SIDS. When compared with a control group of parents 6 months after the intervention, parents who attended the educational intervention were more likely to place their infants on the back (75% vs 45%), less likely to bedshare (16% vs 44.2%), less likely to cite infant comfort as a reason for sleep position (14.5% vs 29.2%), and more likely to be aware of BTS recommendations (72.4% vs 38.9%).

CONCLUSIONS: A 15-minute educational session with small groups of black parents is effective in informing parents about the importance of safe sleep position and in changing parent behavior. The effect of the intervention is sustained throughout the first 6 months of life, when the infant is at the highest risk for SIDS.

8. Sudden Infant Death Syndrome (SIDS) risk reduction and infant sleep location - moving the discussion forward (2013).

Compiled by Olivia Pickett, M.A., M.L.S. and Beth DeFrancis, M.L.S.
March 7, 2013