'Back to Sleep' Advice Followed by Less Than Half of Parents

Bridget M. Kuehn

August 21, 2017

Less than 44% of US parents exclusively put their babies to sleep on their backs in accordance with American Academy of Pediatrics recommendations, a study has found. Adherence to the recommendation intended to prevent sudden infant death syndrome (SIDS) remains persistently low among black mothers and those with less than a high school education, the researchers write.

Eve R. Colson, MD, professor of pediatrics at Yale School of Medicine, New Haven, Connecticut, and colleagues report their findings online August 21 in Pediatrics.

The Study of Attitudes and Factors Effecting Infant Care (SAFE) is a nationally representative survey of 3297 mothers with infants age 2 to 6 months about their intentions regarding sleep positioning and their babies' actual sleep position. Most (77.3%) mothers reported they usually placed their infants on their backs to sleep, but less than half said they only did so.

"Position changes are of particular concern given studies revealing that infants who are unaccustomed to prone sleeping are especially at risk when placed in that position and that those placed to sleep on their sides can easily roll to the prone position," the authors explain.

Advice from a physician remains influential, with women who received "Back to Sleep" advice (the national "Back to Sleep" campaign was launched in 1992) much less likely to place babies on their stomach (adjusted odds ratio [aOR], 0.6; 95% confidence interval [CI], 0.39 - 0.93) or side (aOR, 0.5; 95% CI, 0.36 - 0.67).

Several other factors were associated with a mother's likelihood of following "Back to Sleep" advice. Black mothers (aOR, 2.5; 95% CI, 1.57 - 3.85) and mothers with less than a high school education (aOR, 2.1; 95% CI, 1.16 - 3.73) were more likely to report they intended to place their babies on their stomachs to sleep.

Community norms were highly influential in sleep positioning as well. Mothers who reported that their social norms supported putting babies to sleep on their bellies were much more likely to do so (aOR, 11.6; 95% CI, 7.24 - 18.7). Women who reported that they did not control their infant's sleep position were also more likely to have babies who slept in a prone position (aOR, 3.5; 95% CI, 1.70 - 7.25). This suggests that caregivers may not be following the "Back to Sleep" campaign advice or heeding the mothers' wishes.

More education geared toward childcare providers, grandparents, or others who may influence parents is needed, Michael Goodstein, MD, a neonatologist at WellSpan York Hospital in Pennsylvania, and Barbara Ostfeld, PhD, professor at the Robert Wood Johnson Medical School at Rutgers University and program director of the SIDS Center of New Jersey, New Brunswick, write in an accompanying editorial.

"Mothers who want to practice safe sleep need to be empowered to insist that other caregivers in their lives support their parenting decisions," they say.

Mothers may also continue to harbor favorable beliefs about prone sleeping, the study found. Those who thought that babies sleeping on their stomach would be healthier, safer, and more comfortable were much more likely to use this sleep position (aOR, 130; 95% CI, 71.8 - 236).

The findings suggest that the "Back to Sleep" campaign may have stalled, the editorialists write. The campaign was created in response to evidence that babies who sleep on their stomachs may be at greater risk for SIDS. During its first 10 years, the campaign helped reduce the rate of SIDS in the United States by 53%, with the rate of exclusive supine sleep increasing from less than 10% to 78%, they explain.

"The [American Academy of Pediatrics] AAP considers this 1 of the 7 great achievements in pediatric research in the last 40 years," Dr Goodstein and Dr Ostfeld write.

However, more recent data from the National Infant Sleep Position study suggest the campaign may have stalled, with just 72% of caregivers reporting that they usually put infants to sleep on their backs in 2007. That study relied on a telephone survey and underrepresented minority groups. SAFE replaced it.

Overall, the work suggests the need for more education and consistent advice about infants sleeping on their backs, as well as support for mothers.

"These beliefs persist and are potentially modifiable, so they should be considered an important part of any intervention to change practice," the researchers write.

The study authors and editorial writers have disclosed no relevant financial relationships.

Pediatrics. Published online August 21, 2017.  Abstract, Editorial  

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