Marcia Frellick

September 22, 2017

CHICAGO — New insights from focus groups show that the reasons many parents do not put their babies to sleep safely include thinking sudden infant death syndrome (SIDS) "is fate" or "the will of God" and believing their baby is the exception to the rule.

"We need to understand what parents are thinking because it's only then that we will be able to develop messages that resonate," said Rachel Moon, MD, from the University of Virginia in Charlottesville.

The American Academy of Pediatrics (AAP) calls for always putting babies to sleep on their backs, but a recent study showed that less than 44% of parents in the United States adhere strictly to those guidelines, as reported by Medscape Medical News (Pediatrics. 2017;140:e20170596).

Every year in the United States, 3500 infants die from sleep-related deaths, including SIDS, ill-defined deaths, and accidental suffocation and strangulation, according to the AAP.

In recent years, there has been an increase in prone sleeping, bedsharing, and the use of soft bedding, said Dr Moon.

We need to understand what parents are thinking because it's only then that we will be able to develop messages that resonate.

To determine why there is reluctance to follow the guidelines, the AAP hired SalterMitchell to conduct focus groups with high-risk populations. Dr Moon presented the findings here at the AAP 2017 National Conference and Exhibition.

The first finding was that some parents think that SIDS is "fate" or "God's will," and that because "it happens for a reason," there is nothing they can do to prevent it, she reported.

In contrast, parents think they can take measures to prevent suffocation, which suggests that a change in terminology could encourage parents to modify their behavior, she explained.

Another finding was that many parents do not believe the science. "Every 10 years, it's like the opposite," said a participant in one focus group. "Five years from now, they could say, 'Oh, we were wrong. Put them on their stomachs'."

And some parents said they don't follow the guidelines because babies sleep better on their stomachs.

"They do," Dr Moon conceded, "but we also know that it's because they have higher arousal thresholds so they don't arouse as well. And we know that SIDS is a failure of arousal."

We need to change the definition of what a good sleeper is.

"We need to change the definition of what a good sleeper is," she suggested. "A good sleeper is not a baby who sleeps 10 hours a night without waking up. A good sleeper is a baby who wakes up periodically and can go back to sleep on his or her own."

Vigilance was identified by parents as the most important factor for the prevention of SIDS. They expressed the misconception that if parents are vigilant, they can put the baby prone, Dr Moon reported. That sometimes led parents to think that if they brought the baby into their bed (which goes against AAP guidelines), they could watch the baby more carefully and prevent SIDS.

The clash between comfort and safety was also an issue. Babies look uncomfortable on their backs, some participants explained. And soft bedding in cribs, which guidelines strongly warn against, looks comfortable.

Although participants could conceptualize the risk of putting a baby in a crib, they were unable to recognize the risks associated with sharing a bed with the baby. For instance, parents who understood that a crib should have a firm mattress with no pillows or soft bedding did not apply those rules when the baby slept in their bed, Dr Moon pointed out.

Some parents also think that their baby is the exception to the rule. Participants in the focus group said, for example, "My baby has reflux, so she can't sleep on her back" and "SIDS only happens to bad parents who aren't paying attention to their babies."

This research indicates that pediatricians should identify barriers and address, individually, concerns that parents have about comfort and safety.

If parents say they are bedsharing because they want to be able to see the baby at all times, one solution might be to put the crib next to the parents' bed, Dr Moon suggested. And if parents say they are using bumper pads on the edges of the crib to keep the baby's legs from getting stuck in the slats, they could instead use a sleeping sack that encases the baby's legs.

Messages need to be consistent and need to make sense to the parents, she emphasized. And messages must drive home the fact that there are ways to prevent death.

Many of the responses reported by Dr Moon have been heard by Amy Seery, MD, from Via Christi Health in Wichita, Kansas.

She is currently involved in a focus group study with her local health department, she told Medscape Medical News. Although she anticipates that she'll hear similar comments, she wants to hear from her own community — Sedgwick County — which has among the highest national rates of all-cause infant mortality in the black population.

Changing Terminology

Dr Seery said she agrees that using the term "suffocation" instead of "SIDS" will likely help because it calls to mind something that can be prevented, not something out of a parent's control.

With a change in terminology, parents can more clearly see the goal ahead. They can then take action and resolve that "I will not let my baby suffocate," she explained.

"I've been using that terminology for the last 2 years and I have seen a change in the responsiveness of parents during newborn counseling," she added.

Dr Moon and Dr Seery have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2017 National Conference and Exhibition. Presented September 19, 2017.

Follow Medscape Pediatrics on Twitter @MedscapePeds and Marcia Frellick @mfrellick

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