Survey of maternal sleep practices in late pregnancy in a multi-ethnic sample in South Auckland, New Zealand.

BACKGROUND: The Auckland Stillbirth study demonstrated a two-fold increased risk of late stillbirth for women who did not go to sleep on their left side. Two further studies have confirmed an increased risk of late stillbirth with supine sleep position. As sleep position is modifiable, we surveyed self-reported late pregnancy sleep position, knowledge about sleep position, and views about changing going-to-sleep position. METHODS: Participants in this 2014 survey were pregnant women (n = 377) in their third trimester from South Auckland, New Zealand, a multi-ethnic and predominantly low socio-economic population. An ethnically-representative sample was obtained using random sampling. Multivariable logistic regression was performed to identify factors independently associated with non-left sided going-to-sleep position in late pregnancy. RESULTS: Respondents were 28 to 42 weeks' gestation. Reported going-to-sleep position in the last week was left side (30%), right side (22%), supine (3%), either side (39%) and other (6%). Two thirds (68%) reported they had received advice about sleep position. Non-left sleepers were asked if they would be able to change to their left side if it was better for their baby; 87% reported they would have little or no difficulty changing. Women who reported a non-left going-to-sleep position were more likely to be of Maori (aOR 2.64 95% CI 1.23-5.66) or Pacific (aOR 2.91 95% CI 1.46-5.78) ethnicity; had a lower body mass index (BMI) (aOR 0.93 95% CI 0.89-0.96); and were less likely to sleep on the left-hand side of the bed (aOR 3.29 95% CI 2.03-5.32). CONCLUSIONS: Maternal going-to-sleep position in the last week was side-lying in 91% of participants. The majority had received advice to sleep on their side or avoid supine sleep position. Sleeping on the left-hand side of the bed was associated with going-to-sleep on the left side. Most non-left sleepers reported their sleeping position could be modified to the left side suggesting a public health intervention about sleep position is likely to be feasible in other multi-ethnic communities.

Infant care practices related to sudden unexpected death in infancy: a 2013 survey.

AIM: This survey aimed to evaluate mothers' knowledge of, and practices related to, risk factors for sudden unexpected death in infancy (SUDI) and to compare results with a similar survey conducted in 2005. METHOD: 400 randomly selected women with infants between the ages of 6 weeks and 4 months were sent a postal questionnaire asking about their knowledge and infant care practices related to SUDI risk factors. Included were questions on sleep position, bed sharing, room sharing, smoking, and breastfeeding. Results were compared with a similar survey conducted in 2005. RESULTS: There were 172 (43%) responses. Compared with 2005, more women in this survey cited avoiding bed sharing, keeping the face clear, avoiding soft bedding, and room sharing as SUDI prevention factors. Compared with 2005, more mothers usually used the supine sleep position and shared the parental bedroom, while fewer mothers reported smoking. Eight percent said the infant usually shared a bed, down from 15% in 2005. Of the five main protective factors promoted by New Zealand's Ministry of Health (supine sleep, own bed, room sharing, smoke free, breastfeeding), 43% were implementing all of these practices. CONCLUSION: There has been an increased knowledge of SUDI risk factors. Also evident are an increase in supine positioning and room sharing and a decrease in smoking and bed sharing. These results suggest possible reasons for the falling rate of SUDI in New Zealand.

Exploratory study of bed-sharing and maternal-infant bonding.

AIM: Bed-sharing with an infant is controversial due to the increased risk of sudden unexpected death in infancy versus postulated benefits of the practice such as enhanced breastfeeding and maternal-infant bonding. This study evaluated the association between bed-sharing and maternal-infant bonding. METHODS: Four hundred randomly selected mothers who had delivered in a large maternity unit in Auckland and whose infants were between the ages of 6 weeks and 4 months were sent a postal questionnaire asking about their bed-sharing practices last night, usually, and in the last 2 weeks. Included in the questionnaire were factors 1 and 2 questions from the Postpartum Bonding Questionnaire to assess maternal-infant bonding. RESULTS: Responders totalled 172 (43%), and infants were a mean age of 11 weeks. Fourteen per cent of infants slept in a bed-sharing situation last night, 8% usually, and 41% had slept with an adult in the last 2 weeks. Nine per cent of mothers scored above the cut-off for factor 1 for impaired maternal-infant bonding. Infants of these mothers were more likely to bed-share last night, usually, and in the last 2 weeks, and were less likely to use a pacifier and to breastfeed. Bed-sharing mothers scored more highly on individual questions relating to being annoyed or irritated by their baby. CONCLUSION: There is an inverse association between bed-sharing and maternal-infant bonding, which is contrary to the often expressed belief that bed-sharing enhances maternal-infant bonding.

A postal survey of maternal sleep in late pregnancy.

BACKGROUND: Sleep disturbances in late pregnancy are common. This study aimed to survey sleep problems in third trimester pregnant women and to compare sleep in the pre-pregnancy period with the third trimester. METHODS: Third-trimester women (n=650) were sent a postal survey containing questions relating to sleep experience, including perceived sleep quality, sleep difficulties, night waking, sleep environment, snoring, daytime tiredness and daytime napping. Time periods reported on were before pregnancy and in the last week. RESULTS: Respondents numbered 244 (38%). Before pregnancy, the mean reported duration of night-time sleep was 8.1 (SD 1.1) hours; in the last week this had decreased to 7.5 (SD 1.8) hours (p<.0001). Only 29% rated their sleep quality in the last week as very good or fairly good, compared with 82% rating their sleep this way before the pregnancy. The main reasons for sleeping difficulties were discomfort (67%) and pain (36%). Snoring increased significantly over the course of the pregnancy, with 37% reporting snoring often or every night in the last week. Those with a pre-pregnancy body mass index of greater than 25 were significantly more likely to snore (p=.01). Only 4% of women had an abnormal Epworth Sleepiness Scale score (i.e. >10) prior to pregnancy, whereas in the last week 33% scored in the abnormal range. Likewise, 5% had regularly napped during the daytime before pregnancy, compared with 41% in the last week. CONCLUSIONS: Sleep problems are common in women in late pregnancy, and increase markedly compared with before pregnancy.

Serial developmental assessments in infants with deformational plagiocephaly.

AIM: An association between positional plagiocephaly and developmental problems has previously been noted, but whether delays persist over time has not been established. This study aimed to determine developmental outcomes for children with deformational plagiocephaly over 1 year of follow up. METHODS: This was a longitudinal cohort study of 126 infants with deformational plagiocephaly recruited at an outpatient clinic. Development was assessed with the parent-completed Ages and Stages Questionnaires at recruitment and repeated at follow-up assessments in the home 3, 6 and 12 months later. Questionnaires were scored according to cut-off scores from the Ages and Stages Questionnaires, Third Edition. RESULTS: Ninety-six percent of children were followed up for the full 12 months. The existence of one or more delays initially was 30%; this rose to 42% at the 3-month follow up then dropped back to 23% by the 12-month follow up. Delays were predominantly in the gross motor domain. Ten percent had > 4 delays in total over the four assessments. Mothers with tertiary education were more likely to have infants showing delays that persisted over time. CONCLUSIONS: Infants with deformational plagiocephaly exhibited marked delays especially in early infancy. These delays were largely gross motor in type but had reduced to approach the expected level by the time of the 12-month follow up, at a mean age of 17 months.

Sudden unexpected infant death in Auckland: a retrospective case review.

AIM: To review autopsy reports of all SUDI deaths in the Auckland region, New Zealand, from October 2000 to December 2009. METHODS: Information on all SUDI cases from 2000 to 2009 was extracted from autopsy and police reports from the National Forensic Pathology Service at Auckland Hospital. RESULTS: Of the 332 post-mortems in this period, 221 were classified as SUDI. Of these, 83% were Maori or Pacific infants. The median age at death was 11 weeks and 11% occurred in 7- to 28-day-olds. At the time of death, 64% overall were bedsharing; this was more common in 7-28 day olds (92%). Bedsharing infants were significantly younger at death than non-bedsharing infants (p=0.008). Where sleep position was known, 57% were placed in non-supine at the last sleep. There was no evidence of diagnostic shift and the prevalence of bedsharing did not change over the decade. CONCLUSIONS: Bedsharing was associated with a high proportion of SUDI cases, especially in the youngest infants, and non-supine sleep positions were common. There is a need to enhance SUDI prevention messages and consider innovative ways of promoting safe sleeping environment and supine sleep position in Maori and Pacific communities.

The prevalence of cobedding and SIDS-related child care practices in twins.

UNLABELLED: Sudden unexplained and unexpected death in twins has not been well studied, particularly in relation to the common practice of sleeping twin infants together in the same cot (cobedding). Postal surveys of 109 mothers of twins were undertaken when the infants were 6 weeks, 4 months, and 8 months of age to determine the prevalence of cobedding, infant care practices related to sudden infant death syndrome (SIDS), and the mother's knowledge of SIDS risk factors. SIDS risk factor knowledge was similar to an earlier survey of singletons in 2005. At 6 weeks, 76% of infants usually slept on the back; this changed to 86% at 4 months and 73% at 8 months. At 6 weeks, 52% usually cobedded with their twin all or part of the time. At 4 and 8 months, this had reduced to 31% and 10%, respectively. Side-by-side cobedding configurations were predominant at 6 weeks, with feet-to-feet configurations increasing as the infants grew older. Breastfeeding was reported in 83%, 61% and 31% of infants at 6 weeks, 4 months and 8 months, respectively. Pacifier use was reported in 38%, 50% and 33% at the respective surveys. As the age of the twins increased, mothers were significantly more likely to be concerned about deformational plagiocephaly in Twin 1 than in Twin 2. CONCLUSION: Despite a lack of evidence of the risks or benefits of cobedding, this practice was very popular, especially in the younger infants. More research is needed to establish the safety of cobedding in relation to the risk of SIDS.

A randomized controlled trial of positioning treatments in infants with positional head shape deformities.

BACKGROUND: Randomized controlled trials of treatment for deformational plagiocephaly and brachycephaly have been lacking in the literature. METHODS: Infants (n = 126) presenting to a plagiocephaly clinic were randomized to either positioning strategies or to positioning plus the use of a Safe T Sleep™ positioning wrap. Head shape was measured using a digital photographic technique, and neck function was assessed. They were followed up at home 3, 6 and 12 months later. RESULTS: There was no difference in head shape outcomes for the two treatment groups after 12 months of follow-up, with 42% of infants having head shapes in the normal range by that time. Eighty per cent of children showed good improvement. Those that had poor improvement were more likely to have both plagiocephaly and brachycephaly and to have presented later to clinic. CONCLUSIONS: Most infants improved over the 12-month study period, although the use of a sleep positioning wrap did not increase the rate of improvement.

Quantification of plagiocephaly and brachycephaly in infants using a digital photographic technique.

OBJECTIVES: The aims of the study were: (1) to develop a technique to quantify plagiocephaly that is safe, accurate, objective, easy to use, well tolerated, and inexpensive; and (2) to compare this method with tracings from a flexicurve ruler. DESIGN: A case-control study of 31 case infants recruited from outpatient plagiocephaly clinics and 29 control infants recruited from other pediatric outpatient clinics. PARTICIPANTS: Infants in the study had been diagnosed with nonsynostotic plagiocephaly or brachycephaly and were between 2 and 12 months old. INTERVENTIONS: Infants' head shapes were measured using (a) digital photographs of a head circumference band and (b) a flexicurve ruler. Flexicurve tracings were scanned, and both the digital photos and the scanned flexicurve tracings were analyzed using a custom-written computer program. MAIN OUTCOME MEASURES: The oblique cranial length ratio was used to quantify cranial asymmetry, and the cephalic index was used to quantify the degree of brachycephaly. RESULTS: The infants tolerated the photo technique better than the flexicurve. Also, mothers preferred the photo technique. There was less within-subject variance for the photos than for the flexicurve measurements. The results suggested that an oblique cranial length ratio of >or= 106% can define plagiocephaly and that a cephalic index of >or= 93% can define brachycephaly. CONCLUSIONS: The photographic technique was better accepted and more repeatable than the flexicurve measuring system. We propose that "normal" head shape is indicated in infants with both an oblique cranial length ratio of less than 106% and a cephalic index of less than 93%.

Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study.

OBJECTIVES: Although referrals for nonsynostotic plagiocephaly (NSP) have increased in recent years, the prevalence, natural history, and determinants of the condition have been unclear. The objective of this study was to assess the prevalence and natural history of NSP in normal infants in the first 2 years of life and to identify factors that may contribute to the development of NSP. METHODS: Two hundred infants were recruited at birth. At 6 weeks, 4 months, 8 months, 12 months, and 2 years, the head circumference shape was digitally photographed, and head shape was quantified using custom-written software. At each age, infants were classified as cases when the cephalic index was > or =93% and/or the oblique cranial length ratio was > or =106%. Neck rotation and a range of infant, infant care, socioeconomic, and obstetric factors were assessed. RESULTS: Ninety-six percent of infants were followed to 12 months, and 90.5% were followed to 2 years. Prevalence of plagiocephaly and/or brachycephaly at 6 weeks and 4, 8, 12, and 24 months was 16.0%, 19.7%, 9.2%, 6.8%, and 3.3% respectively. The mean cephalic index by 2 years was 81.6% (range: 72.0%-102.6%); the mean oblique cranial length ratio was 102.6% (range: 100.1%-109.4%). Significant univariate risk factors of NSP at 6 weeks include limited passive neck rotation at birth, preferential head orientation, supine sleep position, and head position not varied when put to sleep. At 4 months, risk factors were male gender, firstborn, limited passive neck rotation at birth, limited active head rotation at 4 months, supine sleeping at birth and 6 weeks, lower activity level, and trying unsuccessfully to vary the head position when putting the infant down to sleep. CONCLUSIONS: There is a wide range of head shapes in infants, and prevalence of NSP increases to 4 months but diminishes as infants grow older. The majority of cases will have resolved by 2 years of age. Limited head rotation, lower activity levels, and supine sleep position seem to be important determinants.

Determinants of nonsynostotic plagiocephaly: a case-control study.

OBJECTIVE: There has been a large increase in reported cases of nonsynostotic plagiocephaly in infants since the adoption of supine sleeping recommendations to prevent sudden infant death syndrome. The objective of this study was to identify and quantify the determinants of nonsynostotic plagiocephaly in infants. METHODS: One hundred infants who received a diagnosis of having nonsynostotic plagiocephaly were recruited as case patients and compared with 94 control subjects who were selected from a citywide database of infants. The infants all were aged between 2 and 12 months. Information concerning sociodemographic variables, obstetric factors, infant factors, and infant care practices was obtained by parental interview. RESULTS: Case patients were significantly more likely to be male (adjusted odds ratio [aOR]: 2.51; 95% confidence interval [CI]: 1.23-5.16), to be a firstborn (aOR: 2.94; 95% CI: 1.46-5.96), and to have been premature (aOR: 3.26; 95% CI: 1.02-10.47). In the first 6 weeks, they were more likely to have been sleeping in the supine position (aOR: 7.02; 95% CI: 2.98-16.53), not to have had the head position varied when put down to sleep (aOR: 7.11; 95% CI: 2.75-18.37), and to have had <5 minutes a day of tummy time (OR: 2.26; 95% CI: 1.03-5.00). Mothers of case patients were more likely to perceive their infants as less active (aOR: 3.23; 95% CI: 1.38-7.56), to have a developmental delay (aOR: 3.32; 95% CI: 1.01-10.85), and to have had a definite preferred head orientation at 6 weeks (aOR: 37.46; 95% CI: 8.44-166.32). Case mothers were more likely to have no or low educational qualifications (aOR: 5.61; 95% CI: 2.02-15.56), although they were more likely to have attended antenatal classes (aOR: 6.61; 95% CI: 1.59-27.47). CONCLUSIONS: Early identification of a preferred head orientation, which may indicate the presence of neck muscle dysfunction, may help prevent the development or further development of nonsynostotic plagiocephaly in infants. Plagiocephaly might also be prevented by varying the head position when putting the very young infant down to sleep and by giving supervised tummy time when awake.