Safe Sleep Practices Improve With Digital Reminders to Moms

Diana Phillips

July 26, 2017

Using email and text messages to remind new mothers of the importance of safe sleep practices for infants improves adherence to those practices, a study has shown.

Mothers who received the mobile health (mHealth) educational intervention on safe sleep practices after they went home with their babies reported statistically significantly higher rates of adherence to those practices compared with mothers who received a nursing quality improvement intervention (NQI) on safe sleep during their hospitalization.

"Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied," the researchers write.

Rachel Y. Moon, MD, from the University of Virginia, Charlottesville, and colleagues, report their findings in an article published online July 25 in JAMA.

The Social Media and Risk-Reduction Training (SMART) study recruited new mothers of healthy term infants from 16 US hospitals to evaluate two safe sleep educational strategies. The NQI delivers education and modeling during the mother's postpartum hospital stay, and the mHealth intervention delivers targeted messages and videos to mothers via email or text message for up to 2 months postpartum.

The researchers randomly assigned each of the participating hospitals to deliver one of four intervention combinations: a breast-feeding NQI and a breast-feeding mHealth intervention, a safe sleep NQI and a breast-feeding mHealth intervention, a breast-feeding NQI and a safe sleep mHealth intervention, or a safe sleep NQI and a safe sleep mHealth intervention.

The primary outcome measure was adherence to four safe sleep recommendations, as reported by the mothers on a survey asking about usual practice during the prior 2 weeks.

Mothers who received the safe sleep mHealth intervention were significantly more likely than those who received the breast-feeding mHealth intervention to place their infants on their back to sleep (89.1% vs 80.2%; adjusted risk difference, 8.9%; 95% confidence interval [CI], 5.3% - 11.7%). They were also significantly more likely to share a room without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4%; 95% CI, 9.3% - 15.1%), to not use soft bedding (79.4% vs 67.6%; adjusted risk difference, 11.8%; 95% CI, 8.1% - 15.2%), and to report any pacifier use at age 2 months (68.5% vs 59.8%; adjusted risk difference, 8.7%; 95% CI, 3.9% - 13.1%).

The mHealth safe sleep intervention was particularly effective for improving room sharing without bed sharing and increasing elimination of soft bedding use, both of which met the minimal clinically important difference of 10% (based on study sample size), the authors report.

The researchers found no significant effect for the NQI safe sleep intervention alone. "It is possible that hospital staff teaching and modelling (although important in establishing the practice standard) may not be sufficient, or that already existing hospital educational policies may have limited the incremental effect of this NQI intervention," they write.

For supine sleep position only, a significant interaction was seen between the NQI and mHealth safe sleep interventions, suggesting mothers receiving both had better adherence to supine sleep recommendations than mothers receiving only the mHealth safe sleep intervention, the authors add.

"Mothers in all groups received basic information about breastfeeding and safe sleep per hospital protocols, including advice to bring the infant into the parental bed for feeding, but to move the infant back into a separate sleep space when the parent was ready for sleep, and to postpone pacifier use for directly breastfed infants until breastfeeding was well established," the authors explain.

The safe sleep and breast-feeding NQI interventions were developed on the basis of previous quantitative and qualitative research. Nurse champions from each hospital received training in strategies for addressing barriers to safe sleep and breast-feeding, and they in turn trained the bedside nurses to deliver these interventions through direct communication and role modeling while new mothers were still in the hospital.

Messages Timed to Anticipate Questions, Barriers

The timing of the message dissemination through the mHealth intervention aligned with times when questions and barriers to safe sleep and breast-feeding were likely to arise. "The mHealth interventions provided ongoing messaging timed to anticipate likely adherence challenges," the authors explain. "For instance, because concern about aspiration while an infant is placed in the supine sleep position is a major reason for early prone placement, a video addressing this concern was among the first videos mothers were given."

"[P]roviding this additional information to parents at critical times may have been important in assuaging concerns about adherence to recommended practices," the researchers hypothesize. "Furthermore, receiving frequent videos and email or text messages may have served as a virtual support system for mothers, reinforcing safe parental practices."

The investigators developed the mHealth messages and videos, and experts in safe sleep, breast-feeding, health education, and social marketing, as well as family caregivers of newborns, reviewed them. "Mothers received daily messages and videos for the first 11 days and then every 3 to 4 days for 60 days," the authors write, noting that the messages were delivered centrally by the study data center.

The American Academy of Pediatrics recommends the four practices, which are associated with reduced risk for sudden infant death syndrome (SIDS): placing infants to sleep on their back, room sharing without bed sharing, no use of soft bedding such as blankets and pillows in the infant's sleep environment, and pacifier use.

Questions Remain

The findings may not be readily generalizable, given the underrepresentation of populations at high risk for SIDS, Carrie K. Shapiro-Mendoza, PhD, from the Division of Reproductive Health at the Centers for Disease Control and Prevention in Atlanta, Georgia, writes in an accompanying editorial. For example, "compared with enrolled mothers who responded at follow-up, nonrespondents were more likely to be younger, black, single, and less educated, which are all risk factors for SIDS and are associated with higher rates of nonadherence with safe sleep recommendations." Further, she adds, "because the study was restricted to healthy term infants, it is unknown if the intervention would be effective for mothers with infants born preterm, which is another high-risk SIDS group."

Although the study was neither powered nor long enough to determine long-term outcomes with respect to SIDS rate reductions at a population level, any intervention must be adapted for implementation among the highest-risk groups to have the greatest effect on reducing infant mortality, she stresses. "At the same time, interventions tailored to individual caregivers and to the cultural beliefs of a particular demographic or racial/ethnic group should be investigated."

The mean maternal age of the mothers who completed the survey was 28.1 years, and the mean infant age at the time of mothers' survey completion was 11.2 weeks. Nearly one third of the survey respondents were non-Hispanic white (32.8%) or Hispanic (32.3%). Non-Hispanic blacks made up 27.2% of the study population, and 7.7% identified as another race/ethnicity.

In terms of feasibility of implementing mHealth on a large scale, the intervention "likely requires fewer resources and less effort to scale up than follow-up home visits or telephone coaching from health care professionals because it relies on delivering emails and text messages," Dr Shapiro-Mendoza writes.

"Scaling up interventions that improve safe sleep practices, especially among those at highest risk, would be an important step forward."

The authors and editorialist have disclosed no relevant financial relationships.

JAMA. 2017;318(4):336-338,351-359. Article abstract, Editorial extract

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