The Impact of Health Messages on Maternal Decisions About Infant Sleep Position: A Randomized Controlled Trial.

Sudden infant death syndrome (SIDS) rates in African-Americans are more than twice national rates, and historically, African-American parents are more likely than other groups to place infants prone, even when they are aware of supine sleep recommendations. Prior studies have shown African-Americans have low self-efficacy against SIDS but high self-efficacy against suffocation. This study aimed to determine the impact of a specific health message about suffocation prevention on African-American parental decisions regarding infant sleep position. We conducted a randomized controlled trial of 1194 African-American mothers, who were randomized to receive standard messages about safe sleep practices to reduce the risk of SIDS, or enhanced messages about safe sleep practices to prevent SIDS and suffocation. Mothers were interviewed about knowledge and attitude, self-efficacy and current infant care practices when infants were 2-3 weeks, 2-3 months and 5-6 months old. Analyses of covariance were conducted to estimate the change in knowledge, attitudes and practice in each group, and chi square tests were used to compare sleep position with each variable. Over the first 6 months, the proportion of African-American infants placed supine gradually decreased and was unchanged by enhanced education about SIDS, suffocation risk and sleep safety. While initially high self-efficacy against SIDS and suffocation correlated with supine positioning, by 5-6 months self-efficacy did not correspond to sleep position in either group.

Stock Photographs Do Not Comply With Infant Safe Sleep Guidelines.

We evaluated images in popular stock photography websites for adherence with American Academy of Pediatrics (AAP) guidelines for safe infant sleep practices. Three top stock photo websites were used to collect photographs generated from key phrases. All images depicting an infant sleep environment were analyzed for consistency with AAP guidelines. Descriptive statistics, chi-square and z test of proportions, were conducted. A total of 1233 of 1947 stock photographs showed sleeping infants on a flat surface. In all, 627 (50.8%) photographs showed the infant in the supine position and 79 (5%) of all infant sleep environments were adherent with AAP recommendations. Bedding inconsistent with safe sleep recommendations was identified in 1133 images (71.3%), with blankets noted in 49.5%. Images depicting sleeping infants on stock photography sites do not routinely adhere to AAP recommendations. Media messages inconsistent with health care messages create confusion and misinformation about infant sleep safety and may lead inadvertently to unsafe practices.

Impact of a Randomized Controlled Trial to Reduce Bedsharing on Breastfeeding Rates and Duration for African-American Infants.

Bedsharing is associated with both increased breastfeeding and increased risk of sudden and unexpected infant deaths. The objective was to determine impact of sleep location and counseling about sleep location on breastfeeding exclusivity and duration in African-Americans. 1194 mothers of newborns were randomized to receive messaging emphasizing either safe sleep practices to reduce SIDS risk or safe sleep practices to prevent SIDS/suffocation. Mothers completed four interviews in the 6 months after delivery. The most common sleep arrangement was roomsharing without bedsharing ("roomsharing"). Duration of any breastfeeding was 6.1 and 5.3 weeks for infants who usually bedshared or roomshared, respectively (p = 0.01). Duration of exclusive breastfeeding was 3.0 and 1.6 weeks for infants who usually bedshared or roomshared, respectively (p < 0.001). Group assignment did not affect breastfeeding duration. The most common sleep arrangement for African-American infants <6 months was roomsharing. An intervention designed to discourage bedsharing did not impact breastfeeding duration.

Health Messaging and African-American Infant Sleep Location: A Randomized Controlled Trial.

Infant-parent bedsharing increases the risk of SIDS and other sleep-related deaths. Despite AAP recommendations to avoid bedsharing, public health efforts have been unsuccessful in changing behaviors. African-American infants are more than twice as likely to die from SIDS and other sleep-related deaths, and are also twice as likely to bedshare with their parents. Further, African-American parents have a high degree of self-efficacy with regards to preventing infant suffocation, but low self-efficacy with regards to SIDS risk reduction. It is unclear whether messages emphasizing suffocation prevention will decrease bedsharing. To evaluate the impact of specific health messages on African-American parental decisions regarding infant sleep location. We conducted a randomized, controlled trial of African-American mothers of infants. The control group received standard messaging emphasizing AAP-recommended safe sleep practices, including avoidance of bedsharing, for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices, including avoidance of bedsharing, for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth. 1194 mothers were enrolled in the study, and 637 completed all interviews. Bedsharing, both usually (aOR 1.005 [95 % CI 1.003, 1.006]) and last night (aOR 1.004 [95 % CI 1.002, 1.007]) increased slightly but statistically significantly with infant age (p < 0.001). Receipt of the enhanced message did not impact on sleep location. Maternal belief that bedsharing increased the risk of SIDS or suffocation declined over 6 months (p < 0.001) and did not differ by group assignment. African-American mothers who received an enhanced message about SIDS risk reduction and suffocation prevention were no less likely to bedshare with their infants. CLINICAL TRIALS REGISTRATION: Clinical Trials.gov identifier NCT01361880.

Messaging Affects the Behavior of African American Parents with Regards to Soft Bedding in the Infant Sleep Environment: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the impact of specific health messages on the decisions of African American parents regarding soft bedding use, specifically related to the high degree of self-efficacy that African American parents have with regards to preventing infant suffocation vs low self-efficacy with regards to sudden infant death syndrome (SIDS) risk reduction. STUDY DESIGN: We conducted a randomized, controlled clinical trial of African American mothers of infants. The control group received standard messaging emphasizing safe sleep practices recommended by the American Academy of Pediatrics for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth. RESULTS: Of 1194 mothers enrolled, 637 completed all interviews. The use of soft bedding both in the past week and last night declined with age (P < .001). Infants in the enhanced group had a lower rate of use of soft bedding in the past week (P = .006) and last night (P = .013). Mothers who received the enhanced message were more likely to state that they avoided soft bedding to protect their infant from suffocation. CONCLUSIONS: African American mothers who receive an enhanced message about SIDS risk reduction and suffocation prevention are less likely to use soft bedding in their infant's sleep environment. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01361880.

Differences in African-American Maternal Self-Efficacy Regarding Practices Impacting Risk for Sudden Infant Death.

Sudden Infant Death Syndrome (SIDS) and other sleep-related deaths, including accidental suffocation, account for ~4000 US deaths annually. Parents may have higher self-efficacy with regards to preventing accidental suffocation than SIDS. The objective of this study was to assess self-efficacy in African-American mothers with regards to safe sleep practices and risk for SIDS and accidental suffocation. As part of randomized clinical trial in African-American mothers of newborn infants, mothers completed a baseline survey about knowledge of and attitudes towards safe sleep recommendations, current intent, self-efficacy, and demographics. Tabular and adjusted, regression-based analyses of these cross-sectional data evaluated the impact of the message target (SIDS risk reduction vs. suffocation prevention) on perceived self-efficacy. 1194 mothers were interviewed. Mean infant age was 1.5 days. 90.8 % of mothers planned to place their infant supine, 96.7 % stated that their infant would sleep in the same room, 3.6 % planned to bedshare with the infant, and 72.9 % intended to have soft bedding in the crib. Mothers were more likely to believe that prone placement (70.9 vs. 50.5 %, p < 0.001), bedsharing (73.5 vs. 50.1 %, p < 0.001), and having soft bedding in the sleep area (78.3 vs. 59.5 %, p < 0.001) increased their infant's risk for suffocation than it did for SIDS. Mothers had higher self-efficacy, viz. increased confidence that their actions could keep their infant safe, with regards to suffocation than SIDS (88.0 vs. 79.4 %, p < 0.001). These differences remained significant when controlled for sociodemographics, grandmother in home, number of people in home, and breastfeeding intention. Maternal self-efficacy is higher with regards to prevention of accidental suffocation in African-Americans, regardless of sociodemographics. Healthcare professionals should discuss both SIDS risk reduction and prevention of accidental suffocation when advising African-American parents about safe sleep practices.

Reasons for Pacifier Use and Non-Use in African-Americans: Does Knowledge of Reduced SIDS Risk Change Parents' Minds?

To investigate African-American parental reasons for pacifier use or non-use, and whether knowledge of the association with decreased SIDS risk changes decisions about pacifier use. We conducted focus groups and individual interviews with mothers. Grounded theory methodology was used. 83 mothers participated; 72.3 % of infants used pacifiers. Reasons for pacifier use included comfort/soothing, safety/SIDS, and preference over digit-sucking. Reasons for pacifier non-use included infant refusal, fear of attachment, nipple confusion, and germs. Many parents were unaware that pacifier use reduces SIDS risk; however, most parents of non-users did not think that this knowledge would have changed their decision. Reasons included skepticism about the pacifier-SIDS link. Many reasons underlie African-American parental decisions about pacifier use. Providers should provide information about the benefits of pacifiers. Establishing for parents any plausible link between the protective mechanism of pacifiers and SIDS pathophysiology may be important in promoting pacifier use.

Breastfeeding in African Americans may not depend on sleep arrangement: a mixed-methods study.

BACKGROUND: Despite high bedsharing rates, breastfeeding rates are low among African Americans. OBJECTIVE: Describe the association between breastfeeding and bedsharing; elucidate barriers to breastfeeding in African Americans. METHODS: African American mothers with infants <6 months were recruited for this cross-sectional, mixed-methods study and completed an infant care practices survey. A subgroup participated in focus groups or individual interviews. RESULTS: A total of 412 completed the survey; 83 participated in a focus group or interview. Lower socioeconomic status mothers were more likely to breastfeed exclusively or at all if they bedshared (P = .02 and P = .01, respectively). Bedsharing was not associated with breastfeeding among higher socioeconomic status mothers. Breast pain, lack of support, and maternal skepticism about breastfeeding benefits were barriers; the latter was a recurrent theme among nonbreastfeeding mothers. CONCLUSIONS: While bedsharing is associated with breastfeeding in lower socioeconomic groups, it is not in higher socioeconomic African American groups. Skepticism about breastfeeding benefits may contribute to low breastfeeding rates in African Americans.

Comparison of Infant Sleep Practices in African-American and US Hispanic Families: Implications for Sleep-Related Infant Death.

African-American and Hispanic families share similar socioeconomic profiles. Hispanic rates of sleep-related infant death are four times lower than African-American rates. We conducted a cross-sectional, multi-modal (surveys, qualitative interviews) study to compare infant care practices that impact risk for sleep-related infant death in African-American and Hispanic families. We surveyed 422 African-American and 90 Hispanic mothers. Eighty-three African-American and six Hispanic mothers participated in qualitative interviews. African-American infants were more likely to be placed prone (p < 0.001), share the bed with the parent (p < 0.001), and to be exposed to smoke (p < 0.001). Hispanic women were more likely to breastfeed (p < .001), while African-American women were more knowledgeable about SIDS. Qualitative interviews indicate that, although African-American and Hispanic parents had similar concerns, behaviors differed. Although the rationale for infant care decisions was similar for African-American and Hispanic families, practices differed. This may help to explain the racial/ethnic disparity seen in sleep-related infant deaths.

Safe infant sleep recommendations on the Internet: let's Google it.

OBJECTIVES: To determine the accuracy of information on infant sleep safety on the Internet using Google. We hypothesized that the majority of Web sites would accurately reflect the American Academy of Pediatrics (AAP) recommendations for infant sleep safety. STUDY DESIGN: We searched for advice using 13 key phrases and analyzed the first 100 Web sites for each phrase. Web sites were categorized by type and assessed for accuracy of information provided, based on AAP recommendations. The accuracy of information was classified as "accurate," "inaccurate," or "not relevant." RESULTS: Overall, 43.5% of the 1300 Web sites provided accurate information, 28.1% provided inaccurate information, and 28.4% were not relevant. The search terms "infant cigarette smoking," "infant sleep position," and "infant sleep surface" yielded the highest percentage of Web sites with accurate information. "Pacifier infant," "infant home monitors," and "infant co-sleeping" produced the lowest percentage of Web sites with accurate information. Government Web sites had the highest rate of accuracy; blogs, the lowest. CONCLUSION: The Internet contains much information about infant sleep safety that is inconsistent with AAP recommendations. Health care providers should realize the extent to which parents may turn to the Internet for information about infant sleep safety.

Swaddling: will it get babies onto their backs for sleep?

INTRODUCTION: The supine sleep position is recommended to reduce sudden infant death syndrome risk. Swaddling may improve adherence with supine placement. AIM: To assess knowledge, attitudes, and practice regarding swaddling among adult caregivers of 0- to 3-month-old infants. METHODS: Cross-sectional descriptive survey. RESULTS: All 103 adults interviewed had swaddled their infant. Common reasons for swaddling included infant comfort and warmth. Almost 80% of those who swaddled their infant found it effective, 80% believed it to be comfortable, and ~90% believed swaddling to be safe. Parents who routinely used swaddling were more likely to find it effective and to place their infant supine when swaddled (P < .01). CONCLUSIONS: Parents often use swaddling to comfort the infant, and most find it effective. Parents who routinely use swaddling are more likely to place their infant supine if swaddled. Swaddling may be a strategy for parents of infants who have difficulty sleeping in the supine position.

Decisions of black parents about infant bedding and sleep surfaces: a qualitative study.

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.

Factors influencing African American mothers' decisions about sleep position: a qualitative study.

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.

Where should my baby sleep: a qualitative study of African American infant sleep location decisions.

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.

Qualitative analysis of beliefs and perceptions about sudden infant death syndrome in African-American mothers: implications for safe sleep recommendations.

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.

Infant sleep environments depicted in magazines targeted to women of childbearing age.

OBJECTIVE: The goal was to evaluate pictures in magazines widely read by women of childbearing age, for adherence to American Academy of Pediatrics (AAP) guidelines for safe infant sleep practices. METHODS: Magazines were included in this study if they had an average female readership of >5 million, circulation of >900000, and median age of female readers of 20 to 40 years. Twenty magazines met these criteria. An additional 8 magazines targeted toward expectant parents and parents of young children were included, for a total of 28 magazines. Pictures of infant sleep environments and sleeping infants in articles and advertisements in issues of these 28 magazines were analyzed for adherence to AAP guidelines for decreasing the risk of sudden infant death syndrome. RESULTS: A total of 391 unique pictures from 34 magazine issues were included in the analysis. Only 57 pictures (64%) portraying sleeping infants not being held by an adult portrayed the infants in the supine position, and 14.8% of sleeping infants were portrayed as sleeping with another person. Only 36 pictures (36.4%) of infant sleep environments portrayed a safe sleep environment, as recommended by the AAP. CONCLUSIONS: More than one third of pictures of sleeping infants in magazines geared toward childbearing women demonstrated infants in an inappropriate sleep position, and two thirds of pictures of infant sleep environments were not consistent with AAP recommendations. Messages in the media that are inconsistent with health care messages create confusion and misinformation about infant sleep safety and may lead inadvertently to unsafe practices.