Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Assessment, Sleep Environment Modification

Intervention Description: The objective of this study was to examine the association between the perceptions of inner city parents about teaching and modeling during the postpartum period of infant sleeping position, and their choice of sleeping position for their infants.

Intervention Results: Forty-two percent of parents reported that they usually placed their infants in the supine position for sleep; 26 percent placed their infants to sleep in the prone position at least some of the time. Parents who reported being told by a doctor or a nurse to have their infants sleep in the supine position were more likely to choose that position. Similarly, those who reported seeing their infants placed to sleep exclusively in the supine position in the hospital were also more likely usually to choose that position. Parents who reported that they both were told by a doctor or a nurse to put their infants to sleep in the supine position and reported seeing their infants exclusively placed that way in the nursery were the most likely usually to choose that position for their infants to sleep.

Conclusion: Perceptions by parents of instructions from a doctor or a nurse of the position in which the infants were placed in the nursery were associated with the position parents reported placing their infants to sleep at home. Efforts to promote the supine sleeping position in the inner-city setting should address both practices and education provided to parents in the nursery during the postpartum hospital stay and should be sufficiently powerful to align their perceptions of the postpartum experience with current American Academy of Pediatrics recommendations.

Study Design: Survey based on a convenience sample

Setting: Urban Primary Care Center

Data Source: A convenience sample of parents of 100 healthy infants who came for the 2-week well-child visit at an urban primary care center were invited to complete a questionnaire and to report on the position in which infants were placed for sleep.

Sample Size: 100 healthy infants

Age Range: Infants 2 weeks old

Intervention Components (click on component to see a list of all articles that use that intervention): Access, Sleep Environment Modification

Intervention Description: The risk for sudden infant death syndrome in black infants is twice that of white infants, and their parents are less likely to place them in the supine position for sleep. We previously identified barriers for parents to follow recommendations for sleep position. Our objective with this study was to quantify these barriers, particularly among low-income, primarily black mothers.

Intervention Results: Fifty-nine percent of mothers reported supine, 25% side, 15% prone, and 1% other as the usual position. Thirty-four percent reported that they ever placed infants in the prone position. Seventy-two percent said that a nurse, 53% a doctor, and 38% a female friend or relative provided source of advice. Only 42% reported that a nurse, only 36% a doctor, and only 15% a female friend or relative recommended the supine position for sleep. When a female friend or relative recommended the prone position, mothers were more likely ever to place their infants in the prone position and less likely usually to choose supine compared with those who received no advice from friends or relatives. When a doctor or a nurse recommended a nonsupine position, the mothers were less likely to choose supine compared with those who received no advice from a doctor or a nurse. Mothers who trusted the opinion of a doctor or a nurse about infant sleeping position were more likely to place their infants in the supine position. Half of the mothers believed that infants were more likely to choke when supine, and they were less likely to place their infants supine. Mothers who believed that infants are more comfortable in the prone position (36%) were more likely to place their infants prone. Twenty-nine percent believed that having their infants sleep with an adult helps prevent sudden infant death syndrome, and only 43% believed that sudden infant death syndrome is related to sleeping position.

Conclusion: We identified specific barriers to placing infants in the supine position for sleep (lack of or wrong advice, lack of trust in providers, knowledge and concerns about safety and comfort) in low-income, primarily black mothers that should be considered when designing interventions to get more infants onto their back for sleep.

Study Design: Survey

Setting: Women, Infants, and Children Program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut.

Data Source: Participant Testimony

Sample Size: 671 mothers

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Assessment, Sleep Environment Modification

Intervention Description: SIDS remains the leading cause of postneonatal death in the US. To decrease risk, infants should be placed supine for sleep. Objective: Determine trends and factors associated with choice of infant sleeping position. Design: National Infant Sleep Position Study (NISP): Annual nationally representative telephone surveys. Setting: 48 contiguous states of the United States. Participants: Nighttime caregivers of infants born within the last 7

Intervention Results: For the 15-year period, supine sleep increased (p<0.0001) and prone sleep decreased (p<0.0001) for all infants with no significant difference in trend by race. Since 2001 a plateau has been reached for all races. Factors associated with increase supine sleep between 1993-2007 included: time, maternal race other than Black, higher maternal education, not living in Southern States, first-born infant, and full-term infant. Impact of these variables was reduced when variables related to maternal concerns about infant comfort, infant choking and advice received from doctors were taken into account. Between 2003 and 2007, choice of infant sleep position could be explained almost entirely by caregiver concern about comfort, choking and advice. Race no longer was a significant predictor of supine sleep.

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

Study Design: National Infant Sleep Position Study (NISP): Annual nationally representative telephone surveys.

Setting: 48 contiguous states of the United States.

Data Source: Interviews

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Family-Based Interventions, Access, Sleep Environment Modification

Intervention Description: This study was intended to better understand how low-income, African-American mothers understand and act upon safe sleep recommendations for newborns and how providers counsel these mothers. We conducted focus groups with 60 African-American, low-income, first-time mothers and telephone interviews with 20 providers serving these populations to explore provider counseling and patient decision making.

Intervention Results: The large majority of mothers reported understanding, but not following, the safe-sleeping recommendations. Key reasons for non-compliance included perceived safety, convenience, quality of infant sleep and conflicting information from family members. Mothers often take measures intended to mitigate risk associated with noncompliance, instead increasing SIDS risk. Providers recognize that many mothers are non-compliant and attribute non-compliance largely to cultural and familial influence. However, few provider attempts are made to mitigate SIDS risks from non-compliant behaviors.

Conclusion: We suggest that counseling strategies should be adapted to: (1) provide greater detailed rationale for SIDS prevention recommendations; and (2) incorporate or acknowledge familial and cultural preferences. Ignoring the reasons for sleep decisions by African-American parents may perpetuate ongoing racial/ethnic disparities in SIDS.

Study Design: N/A

Setting: Georgia

Data Source: Mother interview

Sample Size: 80 mothers

Age Range: Parents of infants less than 6 months

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Crib Card, Sleep Environment Modification, Promotional Event, POPULATION-BASED SYSTEMS, COMMUNITY, Social Media, CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), Visual Display (Community)

Intervention Description: To improve sleep environment safety for inpatient infants.

Intervention Results: The proportion of infant cribs without loose objects in them increased (32-72%, p = .025), and safe sleep positioning remained stable (82% vs. 95%, p = .183).

Conclusion: Staff education, swaddle sleep sacks, and bedside storage containers were associated with improved sleep safety among pediatric inpatients at our institution and may help at other institutions.

Study Design: QE: pretest-posttest

Setting: University of Iowa Children’s Hospital

Population of Focus: Infants less than 1 year of age developmentally ready for a crib and asleep

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=22) Follow-up 1 (not reported) Follow-up 2 (n=37) Follow-up 3 (n=18)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Group Education, Access, Community-Based Group Education, Sleep Environment Modification

Intervention Description: To investigate, by using qualitative methods, beliefs among African-American and American Indian families about infant safe sleep practices, barriers to acceptance of prevention recommendations, and more effective messaging strategies.

Intervention Results: Themes included reasons for and influences on sleep decisions, and concerns about safe sleep recommendations. Parental sleep decisions seemed to be driven by perceptions of what would make their infant most comfortable and safe, and what would be most convenient. Parents were aware of safe sleep recommendations but unaware of the rationale. Because they generally did not believe that their infants were at risk for a sleep-related death, day-to-day decisions seemed to focus on what was most effective in getting their infant to sleep. There appeared to be no distinctions in opinions among African-American and American Indian families. African-American and American Indian families seemed to have similar concerns about infant comfort and safety, and their perceptions about what would be most effective in achieving these goals appeared to be important influences on their sleep practices.

Conclusion: Adherence with safe sleep recommendations may be enhanced if health care providers and educational materials discussed rationale underlying recommendations and addressed common parental concerns. It may be beneficial to target educational interventions towards fathers, as they may be untapped sources in implementing safe sleep practices.

Study Design: N/A

Setting: Focus Groups

Data Source: Mother and supporters participating in focus groups

Sample Size: 73 participants

Age Range: Mean age for the participants was 24.9 years for the mothers and 30.7 years for the supporters, and mean age for the children was 5.6 months for both groups.

Intervention Components (click on component to see a list of all articles that use that intervention): Sleep Environment Modification

Intervention Description: The article discusses several interventions and recommendations aimed at reducing the risk of Sudden Infant Death Syndrome (SIDS). These include placing infants on their backs to sleep, avoiding exposure to smoke before and after birth, having infants sleep in a separate cot in the parents' room (but not bed-sharing), using a firm sleep surface without loose bedding or toys, and encouraging breastfeeding. It advises against bed-sharing, especially for infants under 3 months old or if parents smoke, drink alcohol or use drugs.

Intervention Results: Several case-control studies are cited that found significant increased risk of SIDS associated with bed-sharing, especially when combined with parental smoking, alcohol use, or drug use. The largest analysis found a 5-fold increased risk for bed-sharing infants under 3 months even without those risk factors. Other major risk factors identified include prone sleeping position, maternal smoking, prematurity, and head covering during sleep. Protective factors include breastfeeding, room-sharing without bed-sharing, and pacifier use.

Conclusion: The article concludes by providing specific advice for parents to reduce SIDS risk, based primarily on recommendations from the American Academy of Pediatrics. This includes always placing infants on their backs for sleep, providing a smoke-free environment, room-sharing but not bed-sharing, avoiding any loose bedding or soft surfaces in the sleep area, encouraging breastfeeding and pacifier use, and being aware of the extreme risk of falling asleep with an infant on a sofa or couch.

Study Design: N/A

Setting: N/A

Data Source: searched PubMed for articles in English published between 1980 and January 2015 using the search terms “sudden infant death syndrome”, “SIDS”, and “cot death”.

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Assessment, Quality Improvement/Practice-Wide Intervention, Sleep Environment Modification

Intervention Description: (1) Determine the prevalence of maternal trust in advice sources on infant care practices; (2) Investigate the association of maternal and infant characteristics with trust in advice sources on infant care practices. Using probability sampling methods, we recruited mothers from 32 U.S. maternity hospitals with oversampling of Black and Hispanic women resulting in a nationally representative sample of mothers of infants aged 2-6 months. Survey questions assessed maternal trust in advice sources (physicians, nurses, family, friends, and media) regarding infant care practices including infant sleep practices (sleep position, bed sharing, and pacifier use), feeding, and vaccination.

Intervention Results: Mothers had the greatest trust in doctors for advice on all infant care practices (56-89 %), while trust was lowest for friends (13-22 %) and the media (10-14 %). In the adjusted analyses, there were significant associations of maternal race/ethnicity, education, and age with trust in advice sources.

Conclusion: for Practice Maternal trust in advice about infant care practices varied significantly by source. A better understanding of which advice sources are most trusted by mothers, as well as the factors associated with maternal trust, may guide the development of more effective strategies to improve adherence to health promoting infant care practices.

Study Design: Survey

Setting: Maternity Hospitals

Data Source: Recruited Mothers from Maternity Hospitals

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Sleep Environment Modification

Intervention Description: Healthy, term newborns were recruited for a parent study examining the role of parenting in the development of nighttime infant sleep patterns. For 1 night at ages 1, 3, and 6 months, video recordings were conducted within family homes. Videos were coded for sudden infant death syndrome risk factors in post hoc secondary analyses after the parent study was completed.

Intervention Results: Among 160 one-month-olds, initially 21% were placed to sleep on nonrecommended sleep surfaces and 14% were placed nonsupine; 91% had loose/nonapproved items on their sleep surface, including bedding, bumper pads, pillows, stuffed animals, and sleep positioners. Among 151 three-month-olds, 10% were initially placed on a nonrecommended sleep surface, 18% were placed nonsupine, and 87% had potentially hazardous items on their sleep surface. By 6 months, 12% of the 147 infants initially slept on a nonrecommended surface, 33% were placed to bed nonsupine, and 93% had loose/nonrecommended items on their surface. At 1, 3, and 6 months, 28%, 18%, and 12% changed sleep locations overnight, respectively, with an increased likelihood of bed-sharing and nonsupine position at the second location at each time point.

Conclusion: Most parents, even when aware of being recorded, placed their infants in sleep environments with established risk factors. If infants were moved overnight, the second sleep environment generally had more hazards.

Study Design: Parent Study

Setting: N/A

Data Source: Video of infants, recorded by families

Sample Size: 160 infants

Age Range: 1-6 months

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Provision of Safe Sleep Item, HOSPITAL, Policy/Guideline (Hospital), Sleep Environment Modification, CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: The purpose of this study was to improve safe sleep practices for infants in nonneonatal pediatric units with implementation of specific interventions.

Intervention Results: Safe sleep was observed for 4.9% of 264 infants at baseline and 31.2% of 234 infants postintervention (P<.001). Extra blankets, the most common of unsafe items, were present in 77% of cribs at baseline and 44% postintervention. However, the mean number of unsafe items observed in each sleeping environment was reduced by >50% (P=.001).

Conclusion: Implementation of site-specific interventions seems to improve overall safe sleep in inpatient pediatric units, although continued improvement is needed. Specifically, extra items are persistently left in the sleeping environment.

Study Design: QE: pretest-posttest

Setting: Eight children’s hospitals

Population of Focus: Infants aged 0 to 6 months admitted to the general pediatric unit (excluding infants in the NICUs, PICUs, and maternal fetal units)

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=234) Follow-up (n=210)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROFESSIONAL_CAREGIVER, Provision of Safe Sleep Item, Educational Material (caregiver), HOSPITAL, Sleep Environment Modification

Intervention Description: This was a multicenter prospective study in which exposed/unexposed mothers answered questionnaires (by telephone and online) one month after giving birth. The exposed group consisted of mothers who had given birth in a maternity hospital of the ELENA perinatal network in which an embroidered sleeping bag with a safe-sleep message was used as a preventive action; the unexposed group of mothers gave birth in a maternity hospital of the RP2S network, without this specific preventive action. Devised by the perinatal network to promote and encourage back sleeping, the embroidered “I sleep on my back” (baby) sleeping bags are systematically used in postpartum recovery rooms.

Intervention Results: A total of 540 mothers participated in the study: 245 in the exposed group and 295 in the unexposed group. In the exposed group, 87.3% of infants slept exclusively on their back versus 75.9% in the unexposed group (P<0.001); 91% of the mothers reported having actually used the sleeping bag. Except for room-sharing, compliance with the other sleeping recommendations was higher in the exposed group.

Conclusion: Sleeping practices when infants were 1 month old were not optimal in our study population. A simple preventive initiative in maternity hospitals, using the embroidered "I sleep on my back" sleeping bags, is relevant and effective in improving compliance with the sleeping recommendations for infants at home.

Setting: Three maternity hospitals in the ELENA perinatal network in France

Population of Focus: Mothers of newborns

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Sleep Environment Modification, CAREGIVER, Education/Training (caregiver)

Intervention Description: This project assessed the change in infant safe sleep practices within 6 children's hospitals after the implementation of a statewide quality improvement program.

Intervention Results: At baseline, only 279 (32.6%) of 856 of the sleeping infants were observed to follow AAP recommendations, compared with 110 (58.2%) of 189 (P < .001) at the project's conclusion. The presence of empty cribs was the greatest improvement (38.1% to 67.2%) (P < .001). Removing loose blankets (77.8% to 50.0%) (P < .001) was the most common change made. Audits also showed an increase in education of families about safe sleep practices from 48.2% to 75.4% (P < .001).

Conclusion: Multifactorial interventions by hospitalist teams in a multi-institutional program within 1 state's children's hospitals improved observed infant safe sleep behaviors and family report of safe sleep education. These behavior changes may lead to more appropriate safe sleep practices at home.

Study Design: QE: pretest-posttest

Setting: Six children’s hospitals without internal maternity centers or wellbaby nurseries (academic tertiary or quaternary care institutions) in OH

Population of Focus: Infants ≤1 year of age admitted to the general medical/surgical units who were not awake during the audit (excluding those in the ICUs, with tracheostomies, ventilator or noninvasive ventilator dependence, recent spinal surgeries, or upper airway anatomic abnormalities)

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=856) Follow-up (n=189)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Crib Card, Visual Display (Hospital), Sleep Environment Modification, Promotional Event, CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), Attestation (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: The purpose of this quality improvement project was to promote the AAP safe sleep recommendations and provide appropriate role modeling of these recommendations for hemodynamically stable infants throughout their hospital stay.

Intervention Results: Observations noted an improvement from 70% to 90% (p< 0.01) of infants in a safe sleep position when comparing pre- and postintervention results. There were some improvements in knowledge of and agreement with the AAP guidelines after the educational intervention, but not as much as expected.

Conclusion: There was inconsistency between nursing knowledge and practice about safe infant sleep. Nurses were aware of the AAP recommendations, but it took time to achieve close to full compliance in changing clinical practice. Observation was an important part of this initiative to reinforce knowledge and role model best practice for parents.

Study Design: QE: pretest-posttest

Setting: Golisano Children’s Hospital at the University of Rochester in NY

Population of Focus: Hemodynamically stable infants less than 1 year of age in the mother-baby unit and nine pediatric units

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=65) Follow-up (n=60)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Sleep Environment Modification, Policy/Guideline (Hospital), Audit/Attestation

Intervention Description: The hospital’s safe sleep task force (SSTF) implemented targeted interventions using the American Academy of Pediatrics (AAP) policy statement as the gold standard and based on hospital data/crib audits to address areas of greatest nonadherence to recommendations. The SSTF created a standalone Infant Safe Sleep Policy for all infants admitted to the hospital; provided education on safe sleep to health care providers; created a patient education video for parents of all hospitalized infants; increased its Halo sleep sack allotment; and revised the room set-up to encourage adherence to AAP’s safe sleep guidelines. A safe sleep audit tool was used by clinical assistant or nurse (per hospitalized sleeping session) to assess adherence to safe sleep guidelines. The overall aim of the initiative was to increase the average weekly adherence to the AAP-recommended safe sleep practices for hospitalized infants to ≥95% over 12 months.

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

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

Setting: Tertiary children's hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): Sleep Environment Modification

Intervention Description: New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, “SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment,” which is included in this issue.

Intervention Results: The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included.

Conclusion: The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," which is included in this issue.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Sleep Environment Modification

Intervention Description: The AAP, therefore, is expanding its recommendations from focusing only on SIDS to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths, including SIDS.

Intervention Results: Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death that occur during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar.

Conclusion: The recommendations described in this policy statement include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunizations, consideration of using a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Group Education, Sleep Environment Modification, Training (Parent/Family)

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

Intervention 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.

Conclusion: 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.

Study Design: N/A

Setting: Washington, DC, and Maryland

Data Source: Mother interview

Sample Size: 83 mothers

Age Range: parents with infants 0 to 6 months of age

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Sleep Environment Modification, CAREGIVER, Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: A quality improvement project for implementing safe sleep practices (SSP) was conducted at a large, U.S children's hospital.

Intervention Results: Audit data showed that 72% and 77% of infants were asleep supine at baseline and follow-up respectively (p=0.07).

Conclusion: Infant safe sleep practices have the potential to reduce infant mortality.

Study Design: QE: pretest-posttest

Setting: A tertiary care children’s hospital in AR

Population of Focus: Infants 0-12 months in intensive care and medical-surgical units caring asleep at the time of the audit

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=398) Follow-up (n=498)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provision of Safe Sleep Item, Provider Training/Education, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Visual Display (Hospital), Sleep Environment Modification, CAREGIVER

Intervention Description: This quality improvement study aimed to increase adherence to SSPs for infants admitted to a children's hospital general care unit between October 2013 and December 2014.

Intervention Results: Audit data showed that there was a non-significant increase in supine position from 81.0% to 84.3% from baseline to follow-up (p=0.54). Caregiver report showed that there was a non-significant increase in supine position from 89.3% to 93.8% (p=0.42).

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

Study Design: QE: pretest-posttest

Setting: American Family Children’s Hospital in WI

Population of Focus: Infants <12 months admitted to medical and surgical units; Caregivers of infants <6 months after hospital discharge

Data Source: Crib audit/infant observation; Caregiver report

Sample Size: Baseline (n=59) Follow-up (n=257); Baseline (n=56) Follow-up (n=48)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Sleep Environment Modification

Intervention Description: The American Academy of Pediatrics provides updated recommendations aimed at reducing the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths. Key interventions recommended include: placing infants on their back to sleep, using a firm sleep surface, room-sharing without bed-sharing, avoiding soft bedding and overheating, considering pacifier use, avoiding smoke/alcohol/drug exposure, breastfeeding, and ensuring infants are immunized. Additional recommendations involve safe sleep practices by childcare staff, media campaigns, and further research.

Intervention Results: Several major risk factors for SIDS are identified based on previous studies, including stomach or side sleeping position, smoke exposure, soft bedding, loose covers, bed-sharing (especially with smoking/impaired caregivers or premature/low birth weight infants), and factors like maternal smoking or substance use during pregnancy. Protective factors discussed include breastfeeding, pacifier use, room-sharing without bed-sharing, and avoidance of overheating.

Conclusion: The policy statement emphasizes a safe sleep environment to reduce SIDS risk, providing 19 specific recommendations along with the strengths of each recommendation based on available evidence. It advocates for healthcare provider endorsement, education campaigns, regulation of childcare settings, and further research. The ultimate goal is eliminating these preventable sleep-related infant deaths through safe sleep practices.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practitioner, HOSPITAL, Quality Improvement, Sleep Environment Modification, Crib Card, Visual Display, Audit/Attestation

Intervention Description: A quality improvement (QI) model was developed to introduce the AAP guidelines on safe sleep (SS) practices into the NICU nursing practice in a consistent and sustainable method. The project team included the NICU hospitalist, a neonatologist, the Director of Newborn Services at the Wakefield Division, the nurse manager, two nurses, and a nurse practitioner. The team members met at monthly QI meetings to discuss progress for the duration of the project. Key drivers were identified, and the team used PDSA cycles to target interventions, which included a crib check tool and presentations by SS experts. One of the team’s main concerns during the initial deliberation sessions was the suboptimal temperature control in the NICU, and after meeting with the engineering staff, more sensors were placed in the NICU to eliminate the wide variations of temperatures throughout the day. The primary aim of the project was a 20% improvement in the SS compliance rates (from 7% to 27%) by December, 2017.

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

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

Setting: Wakefield neonatal service, Montefiore Medical Center

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Assessment (Provider), HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), Sleep Environment Modification

Intervention Description: The dual aims of this project were to develop a safe sleep educational model for our neonatal intensive care unit (NICU), and to increase the percentage of eligible infants in a safe sleep environment.

Intervention Results: At baseline, 21% of eligible infants were in a safe sleep environment. After education and reported observation, safe sleep compliance increased to 88%.

Conclusion: With formal staff and family education, optional wearable blanket, and data sharing, safe sleep compliance increased and patient safety improved.

Study Design: QE: pretest-posttest

Setting: The Children’s Mercy Hospital NICU in MO

Population of Focus: Safe sleep eligible infants (medically stable and transitioned to open cribs)

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=28) Follow-up (n=26)

Age Range: Not specified