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Objective To identify facilitators and barriers to the implementation of safe sleep recommendations from the American Academy of Pediatrics from the perspective of hospital staff as part of a needs assessment that was used to design a successful quality improvement intervention to change clinical practice. Design Qualitative design. Setting Multiple sites of three hospitals in the northeastern and southern United States. Participants We used purposeful sampling to identify 46 participants who cared for infants on inpatient hospital units (nurses and other staff members). Methods A qualitative researcher used grounded theory to moderate the focus groups. We constructed the initial interview guide and then changed it as needed to capture more information about new ideas as they arose. Researchers from diverse backgrounds participated in the analysis and used the constant comparative method to select important concepts and to develop codes and subsequent themes. We continued to collect data until saturation was reached. Results We identified themes and subthemes, and the taxonomy fit into the Grol and Wensing framework for change in clinical practice. The six primary themes included The Innovation Itself, The Individual Health Care Professional, The Patient, The Social Context, The Organizational Context, and The Economic and Political Context. Conclusion Participants described facilitators and barriers to the implementation of the American Academy of Pediatrics recommendations for safe infant sleep. Identification of these themes informed our quality improvement intervention to promote safe infant sleep. Findings can be used by others when faced with the need for similar change.

BACKGROUND AND OBJECTIVES: Nursing education and role modeling can increase adherence to safe sleep practices. Eight US hospital maternity units with variable baseline approaches to education participated in a national multicenter nursing quality improvement (QI) intervention to promote safe sleep practices. The goals at participating maternity units were to (1) increase the rate of mothers who reported receiving safe sleep information from nurses to ≥90% and (2) increase the rates of infants observed sleeping supine in a safe environment to ≥90%. METHODS: A safe sleep QI toolkit, designed for and provided to all sites, included an educational curriculum and tools to use for staff and parent education. Local teams implemented safe sleep education using the tools as plan-do-study-act cycles. After each cycle, audits assessing maternal report of nursing education on safe sleep and inpatient infant sleep position and environment were performed. RESULTS: The QI interventions lasted a median of 160 days (range, 101–273). Mothers reported receiving information on 4 primary safe sleep topics 72% to 95% of the time (a 24%–57% increase over the baseline). Additionally, 93% of infants were observed in a supine sleep position, and 88% of infants were observed in a safe sleep environment (a 24% and 33% increase over baseline, respectively). These rates were sustained up to 12 months later. CONCLUSIONS: Implementation of a multisite QI intervention for safe sleep parenting education and role modeling led to increased knowledge of and compliance with safe sleep practices during postpartum hospitalization.

Importance Inadequate adherence to recommendations known to reduce the risk of sudden unexpected infant death has contributed to a slowing in the decline of these deaths. Objective To assess the effectiveness of 2 interventions separately and combined to promote infant safe sleep practices compared with control interventions. Design, Setting, and Participants Four-group cluster randomized clinical trial of mothers of healthy term newborns who were recruited between March 2015 and May 2016 at 16 US hospitals with more than 100 births annually. Data collection ended in October 2016. Interventions All participants were beneficiaries of a nursing quality improvement campaign in infant safe sleep practices (intervention) or breastfeeding (control), and then received a 60-day mobile health program, in which mothers received frequent emails or text messages containing short videos with educational content about infant safe sleep practices (intervention) or breastfeeding (control) and queries about infant care practices. Main Outcomes and Measures The primary outcome was maternal self-reported adherence to 4 infant safe sleep practices of sleep position (supine), sleep location (room sharing without bed sharing), soft bedding use (none), and pacifier use (any); data were collected by maternal survey when the infant was aged 60 to 240 days. Results Of the 1600 mothers who were randomized to 1 of 4 groups (400 per group), 1263 completed the survey (78.9%). The mean (SD) maternal age was 28.1 years (5.8 years) and 32.8% of respondents were non-Hispanic white, 32.3% Hispanic, 27.2% non-Hispanic black, and 7.7% other race/ethnicity. The mean (SD) infant age was 11.2 weeks (4.4 weeks) and 51.2% were female. In the adjusted analyses, mothers receiving the safe sleep mobile health intervention had higher prevalence of placing their infants supine compared with mothers receiving the control mobile health intervention (89.1% vs 80.2%, respectively; adjusted risk difference, 8.9% [95% CI, 5.3%-11.7%]), room sharing without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4% [95% CI, 9.3%-15.1%]), no soft bedding use (79.4% vs 67.6%; adjusted risk difference, 11.8% [95% CI, 8.1%-15.2%]), and any pacifier use (68.5% vs 59.8%; adjusted risk difference, 8.7% [95% CI, 3.9%-13.1%]). The independent effect of the nursing quality improvement intervention was not significant for all outcomes. Interactions between the 2 interventions were only significant for the supine sleep position. Conclusions and Relevance Among mothers of healthy term newborns, a mobile health intervention, but not a nursing quality improvement intervention, improved adherence to infant safe sleep practices compared with control interventions. Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied. Trial Registration clinicaltrials.gov Identifier:NCT01713868

The sudden, unexpected death of an infant affects all who come in contact with both the infant and the family. The professional who is providing bereavement support is often affected by this catastrophic family event. This article explores the significance of this effect in a population of sudden infant death syndrome (SIDS) nurse counselors in the Massachusetts SIDS program.

The rate of the sudden infant death syndrome (SIDS) among American Indian infants in the Northern Plains is almost 6 times higher than in U.S. white infants. In a study of infant mortality among Northern Plains Indians, we tested the hypothesis that receptor binding abnormalities to the neurotransmitter serotonin (5-HT) in SIDS cases, compared with autopsied controls, occur in regions of the medulla oblongata that contain 5-HT neurons and that are critical for the regulation of cardiorespiration and central chemosensitivity during sleep, i.e. the medullary 5-HT system. Tritiated-lysergic acid diethylamide binding to 5-HT(1A-D) and 5-HT2 receptors was measured in 19 brainstem nuclei in 23 SIDS and 6 control infants using tissue receptor autoradiography. Binding in the arcuate nucleus, a part of the medullary 5-HT system along the ventral surface, in the SIDS infants (mean age-adjusted binding 7.1 +/- 0.8 fmol/mg tissue, n = 23) was significantly lower than in controls (mean age-adjusted binding 13.1 +/- 1.6 fmol/mg tissue, n = 5) (p = 0.003). Binding also demonstrated significant diagnosis x age interactions (p < 0.04) in 4 other nuclei that are components of the 5-HT system. These data suggest that medullary 5-HT dysfunction can lead to sleep-related, sudden death in affected SIDS infants, and confirm the same binding abnormalities reported by us in a larger dataset of non-American Indian SIDS and control infants. This study also links 5-HT abnormalities in the arcuate nucleus with exposure to adverse prenatal exposures, i.e. cigarette smoking (p = 0.011) and alcohol (p = 0.075), during the periconceptional period or throughout pregnancy. Prenatal exposure to cigarette smoke and/or alcohol may contribute to abnormal fetal medullary 5-HT development in SIDS infants.

Objective. Prone sleeping among infants has been associated with an increased risk of sudden infant death syndrome. The objective of this study was to compare factors associated with sleep position in 1995–1996 and 1997–1998 and to assess secular trends in use of prone infant sleep position from 1995 through 1998 among families stratified by race and education.Methods. A prospective cohort study was conducted in eastern Massachusetts and northwest Ohio of 12 029 mothers of infants who weighed ≥2500 g at birth. Descriptive statistics and multivariate odds ratios were used to relate maternal and infant characteristics to prone and supine sleeping.Results. A total of 14 206 mothers (25% of those eligible) were enrolled. A total of 12 029 mothers (85% of enrolled) responded to the 1-month and 11 552 mothers (81% of enrolled) responded to the 3-month follow-up questionnaire. A decline in use of the prone sleep position and increase in use of the supine position was observed during the 4 years of the study. Factors associated with prone and supine sleep position were similar in 1995–1996 and 1997–1998. In 1997–1998, use of prone sleeping at 1 month of age reached the goal of ≤10% only among infants of white and Asian women, married women, women who were older than 25 years, women who were college graduates, and women with incomes >$55 000 per year. At 3 months of age, however, prone sleeping increased to 12% to 17% in these groups. These same groups were most likely to use the supine position; 38% to 45% were supine at 1 month, increasing to 56% to 64% by 3 months of age. However, as of the end of 1998, approximately 27% of infants of non-college-educated black and Hispanic mothers were placed to sleep in the prone position and only 20% to 30% were being placed to sleep in the supine position at 3 months of age.Conclusions. Recommendations to avoid prone sleep position and especially the recommendation that supine sleep position is preferred have not been effectively delivered to black and Hispanic families and to families of low-income and less than a college education.

This study suggests there is a need to support the efforts already present to include SIDS in medical and nursing school curricula. Both programs have indicated a need for audiovisual and printed teaching materials. Consideration should be given to teaching materials that are easily updated such as computer-generated materials because of the many rapid changes that take place in SIDS research. Currently, textbooks are the most common source of educational material used by students. Textbooks could be supplemented with information from recent journals and current Web sites. Facilitation of clinical contact with families affected by SIDS is important. The availability of local SIDS resources should be stressed to both medical and nursing programs as well as opportunities for nursing student involvement in the activities of SIDS organizations. While lectures are often the only feasible way to deliver SIDS content to large groups of students, interactive teaching strategies and involvement with bereaved families probably would increase learning beyond the basic level. Nursing schools as well as medical schools, confronted with the realities of decreased faculty time and budgets, face major challenges in developing case-based curricula that prepare students for the next century (Zimmerman et al., 1997). To address these needs, curriculum notes were developed by the Education Working Party of the SIDS Global Strategy Task Force under the direction of Professor John C. Vance and printed in February 1998. The curriculum is divided into seven modules that include content and questions as well as references on a variety of issues. A problem-based learning package is included and is becoming increasingly popular as a teaching strategy (Amos & White, 1998; David & Patel, 1995). There is one case each for medical and nursing students in the curriculum package. This curriculum can be accessed at www. sidsaustralia.org.au. Other useful Web sites include: www.sidsalliance.org. The SIDS Alliance Web site provides support to families and information about SIDS. www.sidscenter.org. The National SIDS Resource Center Web site provides information and technical assistance for parents and professionals on SIDS and related topics. www.aap.org. The American Academy of Pediatrics Web site provides guidelines on sleep position and infant sleeping environment. www.asipl.org. The Association of SIDS and Infant Mortality Programs Web site includes publications and position papers. Finally, many states have SIDS services provided by professional programs and parent organizations. Students have the opportunity to work with these organizations to provide bereavement services and risk-reduction education. The organizations listed above can be contacted for further information.

Infant mortality-specially postneonatal deaths occurring 1 to 12 months after birth-is increased in American Indians. Sudden infant death syndrome (SIDS), the major cause of postneonatal death, was up to recently the leading cause of infant deaths in American Indian populations. Risk factors for SIDS were sought by reviewing findings from a population-based case-control study of 33 infants who died of SIDS and 66 matched living control infants (the Aberdeen Area Infant Mortality Study). All participants were American Indians living in the Dakotas, Nebraska, and Iowa in the years 1992-1996. The study group included infants dying before 12 months of age but excluded those who died while still hospitalized after delivery. The mean age at death in the SIDS group was 109 days. Univariate analyses showed that parents of SIDS infants had fewer years of education and more often reported fewer than seven prenatal visits. More case mothers had smoked and taken alcohol just before and during pregnancy, and more of them engaged in binge drinking in the first trimester. There was no difference in the use of illicit drugs during pregnancy. Comparable numbers of infants in the case and control groups were put to sleep on their stomachs in the 2 weeks before death. Infants given two or more layers of clothing were at increased risk of SIDS. Those having fewer than three well-baby visits had a nearly 14-fold greater risk of SIDS. Breast-feeding was not a significant factor. On logistic regression analysis, periconceptional drinking remained associated with SIDS (adjusted odds ratio, 6.2). Infants who usually had two or more layers of clothing were also at increased risk, with an identical odds ratio. These findings suggest that controlling alcohol consumption before and during pregnancy could lessen the risk of SIDS in this American Indian population. Attention also should be given to infant clothing, and efforts should be made to promote regular public health nurse visits.

Context.—Prone sleeping by infants has been associated with an increased risk of sudden infant death syndrome.Objective.—To document the prevalence of and identify risk factors for prone sleeping during the first 6 months of life.Design.—Prospective cohort study.Setting.—Eastern Massachusetts and northwest Ohio.Study Participants.—A total of 7796 mothers of infants weighing 2500 g or more at birth.Main Outcome Measures.—Maternal and infant characteristics related to prone sleeping at 1 month and 3 months of age.Results.—Between 1 month and 3 months of age, prone sleeping increased from 18% to 29%. At 1 month, prone sleeping was associated with the following maternal characteristics: non-Hispanic black or Hispanic race/ethnicity, younger age, less education, and higher parity. At 3 months, switching from nonprone to prone position was associated with mother's race/ethnicity of non-Hispanic black (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.3) or Hispanic (OR, 1.5; 95% CI, 1.1-2.2); younger maternal age (compared with mothers >34 years: 18-24 years, OR, 1.6; 95% CI, 1.2-2.2

The Back to Sleep campaign was begun in mid-1994 to reduce the prevalence of prone infant sleeping from 40-50% to < 10%. Using data from an ongoing longitudinal study of early infant care practices, we assessed trends in prone sleeping from 6/95 - 9/97. Mother-infant pairs are recruited at birth hospitals in Massacusetts and Ohio and followed for six months. Descriptive data are collected at enrollment; information on sleep position and other infant care practices is collected by follow-up mail/phone questionnaire. From 6/95 - 12/95 mothers of 1607 three month (9-16 weeks) old infants (birthweight≥ 2500g) responded to a question asking the position their infant was placed to sleep on the previous night. From 1/97 - 9/97 mothers of 2028 three month old infants responded to this question. In each year, 80% of mothers were White, 10% Black, and 10% Hispanic. Stratified analyses were performed for prevalence of prone sleeping in 1995 and 1997. Relative risks and 95% confidence intervals (CI) presented in the Table describe the reduction in prevalence of prone sleeping from 1995 to 1997. Trends were similar for Black and Hispanic infants, so data were pooled. There was a significant reduction in the prevalence of prone sleeping across all strata. The greatest decline was observed among infants of highly educated(high = college degree), minority mothers. These associations between race, education, and prone sleeping remain after controlling for other factors through multiple logistic regression. The prevalence of prone sleeping is approaching the target of 10% among infants of highly educated mothers regardless of race/ethnicity, however, prone sleeping remains higher among infants of less educated mothers, especially minorities. These data may be useful in directing future efforts for the Back to Sleep campaign.

• When an infant dies suddenly and unexpectedly, the sense of loss and terrible grief may overwhelm not only the parents but also the physician. When that sudden death is due to a known cause, the concrete character of the event can be incorporated into the normal rationalization of mourning. However, when death is due to an unknown mechanism, as in the sudden infant death syndrome, feelings of inadequacy in caring for the child are reinforced. The essential need for support of these families is clear. For physicians, this kind of loss is disquieting and anxiety-provoking. Forty-seven physicians responded to a survey exploring the relationship between the physician and the family after the death of an infant, the feelings of the physician about the death and his or her own sense of loss, and the physician's need for personal support and educational preparation for such an event. While 41 of the physicians indicated they had discussed the death with the family, six had made no contact with the survivors. Thirty-six of the respondents indicated that their relationship with the family continued, and ten physicians stated that their relationship terminated after the death. Physicians characterized their initial responses to the death as frustration, sadness, shock, anger, guilt, regret, hurt, and inadequacy. Most of the physicians believed that they had "missed" something and feared they might be blamed for the death. The competence, sincerity, and sensitivity shown to families during this tragic experience can positively influence the family's mourning and recovery. The pediatrician can provide a rational voice and a medical understanding of tragedy without blame. ( AJDC 1987;141:748-750)

To determine whether the risk of sudden infant death syndrome (SIDS) among infants exposed to cocaine in utero may be elevated, we assessed the risk for SIDS in a large, well-described, prospective cohort of infants whose mothers had or had not used cocaine during pregnancy. Of 996 women consecutively enrolled while registering for prenatal care, 175 used cocaine during pregnancy. Only one infant of the mothers who used cocaine died of SIDS, a risk of 5.6 in 1000, compared with four infants among the 821 nonexposed infants, a risk of 4.9 in 1000. The relative risk for SIDS among infants whose mothers used cocaine during pregnancy compared with those whose mothers did not use cocaine was 1.17 (95% confidence interval 0.13, 10.43), suggesting that there is no increased risk of SIDS among infants exposed in utero to cocaine.