Caregiver Compliance With Safe Sleep Guidelines

Caregiver Compliance With Safe Sleep Guidelines

Newborn & Infant Nursing Reviews 16 (2016) 122–125 Contents lists available at ScienceDirect Newborn & Infant Nursing Reviews journal homepage: www...

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Newborn & Infant Nursing Reviews 16 (2016) 122–125

Contents lists available at ScienceDirect

Newborn & Infant Nursing Reviews journal homepage:

Family-Caregiver Column

Caregiver Compliance With Safe Sleep Guidelines Megan E. Cadematori, Melody A. Piranian, Patricia A. Skrzypek ⁎, Ann M. Pron University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104, USA

a r t i c l e

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Keywords: Safe sleep Compliance Sudden infant death syndrome (SIDS)

a b s t r a c t The objective of the study is to determine whether infant caregivers are complying with current safe sleep recommendations based on the American Academy of Pediatrics guidelines. This is a literature review utilizing four databases: PubMed, CINAHL, Scopus, and Embase. Numerous barriers prevent some infant caregivers from complying with current safe sleep recommendations. Formal intervention and education programs are effective in increasing safe sleep compliance. Not all caregivers are following back to sleep guidelines. Gaps in caregiver knowledge regarding safe sleep need to be addressed and further research should be conducted with emphasis on education. © 2016 Elsevier Inc. All rights reserved.

Sudden infant death syndrome, or SIDS, is defined as “infant deaths that cannot be explained after a thorough case investigation, including a scene investigation, autopsy, and review of the clinical history”. 1 While the cause of SIDS related deaths is not always clear, possible explanations include suffocation, asphyxia, and entrapment. 1 The American Academy of Pediatrics (AAP) first published its Back to Sleep campaign in 1992, addressing concerns about sudden infant death syndrome. Since then, multiple revisions and updates have been made, as new information regarding SIDS has been discovered. The most recent safe sleep recommendations, published by the AAP in 2011, suggest placing all infants, up to 1 year of age, on their backs to sleep.1 Once an infant is able to fully roll, the caregiver should continue to place them in a supine position, but if they roll to side lying or prone, they may be left in this position.1 If the infant falls asleep in an upright position, such as when they are in a car seat, stroller, swing, carrier, or sling, they should be moved onto their backs on a flat surface as soon as possible.1 The AAP also has specific recommendations regarding the infant sleep surface. 1 Infants should always be placed on a firm surface with a fitted sheet and soft bedding, pillows, stuffed animals, and bumper pads should not be placed in the crib. 1 Couches, chairs, water beds, and similar soft surfaces should be avoided. 1 Recommendations also strongly encourage room-sharing with the infant, however, they firmly advise against co-sleeping.1 The infant can be harmed while co-sleeping if they get caught inside the bedding or if the caregiver rolls on top of them.1 The AAP has identified breastfeeding and immunizations as protective factors against SIDS and both are associated with decreased SIDS rates. 1 Smoke exposure places infants at increased risk for SIDS, therefore, passive smoke exposure should be eliminated.1 In addition, ⁎ Corresponding author at: 85 Krispin Lane, Setauket, NY 11733. Tel.: +1 631 379 5154. E-mail address: [email protected] (P.A. Skrzypek). 1527-3369/© 2016 Elsevier Inc. All rights reserved.

overheating increases the risk of SIDS so caregivers should avoid overdressing their infant. 1 The AAP recommends pacifiers during naps and bedtime to decrease SIDS 1; however, breastfed babies should not be introduced to pacifiers until they have mastered breastfeeding. 1 Lastly, cardiorespiratory monitors and other items marketed to decrease the risk of SIDS have not been found to be effective and should not be used.1 While Mason et al.9 noted that there has been a fifty percent decline in SIDS since the initiative of the Back to Sleep campaign, McDonnell and Moon10 concluded that, in more recent years, there has been a plateau in the rate of infants' deaths due to SIDS. Objectives The plateau in infant deaths related to SIDS stimulated an interest for insight behind the issues surrounding safe sleep implementation. SIDS is the leading cause of death among infants age one month to one year and more than 2000 infants died of SIDS in 2010. 13 Infant death is devastating for parents and can lead to permanent emotional distress. The purpose of this State of the Science review is to determine whether infant caregivers are complying with current safe sleep guidelines. Through an extensive review of the literature, gaps in caregiver knowledge, recommendations for future practice, and areas for future research may be discovered. Methods Literature Search Methods A literature search was conducted utilizing PubMed, CINAHL, Scopus, and Embase. To maintain consistency, the keywords safe sleep and compliance were used and a filter for the past 5 years was applied for all searches. The only minor change was when utilizing the Embase

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search engine; the search included safe sleep in parenthesis to avoid the database separating this keyword into safe AND sleep. The Embase search produced 6 records. The search via PubMed resulted in 28 records with an additional 19 records that were obtained via the “Similar Articles” section of the database. The CINAHL search yielded 4 results and Scopus resulted in 68 records. Inclusion and Exclusion Criteria After performing this extensive literature search, the findings were compiled and summarized in Fig. 1. The keywords for the literature search included safe sleep and compliance with a filter of the past 5 years. The literature searches via PubMed, CINAHL, Scopus, and Embase revealed a combined total of 106 records. In addition to the 106 records, 19 additional records were found via the “Similar Articles” suggestion link in the PubMed database. After sorting through the 125 total articles, duplicates were removed and 91 records remained. The records were screened based on titles and abstracts to determine if they were relevant to the topic. There were 71 articles excluded because they did not apply to infant caregivers and they were not relevant to the topic. After applying these exclusion criteria, 20 relevant records remained. The final step was to read the full-text of these 20 articles and further assess their relevance. In the end, nine articles were kept and were included in the Table of Evidence (see Table 1). On the contrary, 11 articles were excluded for various reasons including: a systematic review, not English, and not a research study. Grade To determine the quality of the articles that were selected, each record was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. 3 GRADE results for all nine articles are summarized in Table 1. Article GRADE ranged


from very low to moderate. 3 Of note, the article by Moon et al. 11 was the only randomized control trial and the only article to receive a moderate GRADE.3 Results Description of Study Selection The nine articles that remained addressed an array of topics related to safe sleep practice. Common themes of the articles included caregiver beliefs and opinions regarding safe sleep recommendations, as well as, hospital based safe sleep interventions. Eight of the articles were observational studies; some of them utilized an intervention group, while others, were solely descriptive in nature. One of the articles was a randomized control trial. Synthesis of Current Research Chu et al.4 and Joyner et al.8 found that an overwhelming amount of caregivers admit to co-sleeping with their infants. Some barriers to implementation of safe sleep guidelines include, lack of available safe sleep surface due to size limitations of the living environment, convenience of night-time infant feedings, and parental concerns about infant comfort. 4,8 These authors concluded that there needs to be increased education targeting the risk-factors that contribute to SIDS with a large emphasis on co-sleeping.4,8 Chung-Park 5 and Von Kohorn et al.15 both concluded that the lack of compliance with safe sleep is related to caregiver opinions and concerns regarding choking hazards, infant comfort, and personal preferences. Increasing advice for placing infants in their back to sleep along with positive reinforcement seemed to increase the likelihood of caregivers' willingness to execute exclusive supine positioning for infants.5,15

Fig. 1. This diagram depicts the flow of the literature search throughout the phases of article inclusion and exclusion on safe sleep guidelines.


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Table 1 Caregiver compliance with safe sleep guidelines. Name of study Chu et al.





Study sample and setting


Grounded theory

n = 225 New York City, 2004–2010 n = 161 Military medical treatment facility in the southwestern United States n = 1092 and 490 WellSpan York Hospital and MedStar Health Research Institute n = 83 Washington, DC, and Maryland n = 201 Wesley Medical Center, Wichita, Kansas n = 36 September 2004–July 2012 deaths reported to the Consumer Product Safety Commission n = 1993 Licensed child care centers and family child care homes n = 121 Staten Island University Hospital n = 2299 Women, infants, and children centers in the United States from 2006 to 2008


Descriptive cross-sectional study

Goodstein et al.7

Descriptive cross-sectional study

Joyner et al.8

Grounded theory

Mason et al.


Observational study

McDonnell and Moon10

Descriptive study

Moon et al.11

Randomized control trial

Varghese et al.


Von Kohorn et al.

Descriptive study 15

Descriptive cross-sectional study

Low Low Very low Low Very low Moderate Very low Low

Note. GRADE = Grading of Recommendations, Assessment, Development and Evaluation; n = sample size. a GRADE is a rating of the level of quality of evidence.

Both, McDonnell and Moon 10 and Varghese et al., 14 highlight that many caregivers swaddle their infants when putting them to sleep; however, recommendations regarding swaddling are inconclusive in AAP Back to Sleep guidelines. 1 The AAP guidelines do not specifically address swaddling, therefore, it is unclear whether swaddling technique should be utilized. 1 Only on their parent directed Web site does the AAP provide guidance that swaddling may be utilized up until the age of two months when the baby starts to roll.2 However, swaddling may only be utilized if performed correctly, maintaining a minimum of two fingers gaps between the blanket and the infant's chest. 2 According to Varghese et al.,14 sixty percent of caregivers reported swaddling with blankets or swaddling products. Misinformation and misconceptions surrounding swaddling need to be addressed by hospital staff and primary care providers in order to improve compliance with current recommendations. 10,14 Hopefully there will be some clarification of swaddling safety information from the AAP in the near future since swaddling is so prevalent among caregivers. While there are many barriers to implementing safe sleep practices, Mason et al.9 and Goodstein et al., 7 shed light on hospital based intervention programs that demonstrated improved back to sleep compliance. Interventions included consistent staff modeling of safe sleep and having parents view a safe sleep video prior to discharge.7,9 In the Mason et al. 9 article, the SIDS network of Kansas provided the video, and in the Goodstein et al. 7 article, the video utilized was titled Safe Sleep for Your Baby: Right From the Start. 6 Mason et al.,9 found that prior to the intervention, twenty-five percent of infants were in the supine sleep position with a safe sleep environment and thus, were deemed safe. While, post-intervention, fifty-eight percent of infants were placed on their back in a safe environment and were considered safe. This study was statistically significant, with p b 0.0001.9 Moon et al.11 looked at similar interventions in child care centers and also concluded that SIDS risk reduction education is effective at improving the compliance of infant caregivers to implement current safe sleep practices. In this study, healthcare providers educated and trained daycare staff members on proper sleep positions.11 After the child care providers in the intervention group received safe sleep focused training, the providers demonstrated an increase in the percentage of infants sleeping supine by 11.2% (p = .01); the control group showed no difference and was not significant.11 The barriers to safe sleep implementation described by Chu et al. 4 and Joyner et al., 8 such as, bed sharing theories, cultural beliefs, and ease of breastfeeding access could be contributing to the recent plateau in SIDS related deaths. All of the articles recommended increasing communication between healthcare providers and infant caregivers with consistent reinforcement of safe sleep practices including

positioning and surfaces recommended by the AAP. In addition, it is pertinent to uncover caregiver biases and opinions regarding safe sleep in order to effectively educate and implement change. Relevance to Clinical Practice Not all caregivers are complying with safe sleep recommendations.4,5 One major factor in not following AAP guidelines on safe sleep is a lack of communication between healthcare providers and infant caregivers concerning infant sleep position. According to, Chung-Park,5 only fourteen percent of parents reported being counseled about safe sleep position by their provider. In order to break out of the plateau for infant deaths related to SIDS it is imperative for healthcare providers to educate infant caregivers and to discuss safe sleep. Education should begin during the prenatal period, continue in the newborn nursery, and be emphasized at each primary care visit. As widely respected professional role models, it is the responsibility of all healthcare providers to initiate caregiver education.5 Education should include formal hands on training sessions with return demonstration, incorporating positive reinforcement and constructive feedback. As demonstrated by Moon et al., 11 formal education using demonstrations was an effective method to promote caregiver compliance with safe sleep guidelines. Future Research Recommendations After this review of the current literature, gaps were identified in caregiver education and it was determined that high GRADE quality evidence is lacking. One explanation for this is that it is difficult to carry out higher quality GRADE research, such as randomized control trials, because withholding lifesaving interventions is unethical. However, randomized control trials, utilizing intervention and control groups, can still be conducted related to the manner of delivering education to caregivers or methods to change opinions, in a safe and effective way. For example, a study that compares the efficacy of utilizing videos versus utilizing pamphlets to educate caregivers may be beneficial to determine the most effective technique. Also, the use of motivational interviewing, as addressed in Naar-King and Suarez,12 may be an advantageous method for changing opinions and behaviors while empowering caregivers to practice safe sleep. In addition, the AAP should continue to publish updated Back to Sleep guidelines as more information becomes available. In the next edition, it would be advantageous for the AAP to address and clarify swaddling so that health care providers can consistently educate caregivers. Perhaps another explanation for the plateau in number of SIDS related deaths is that this plateau reflects the other

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indistinguishable causes for SIDS, which cannot be prevented, although data about this has not been hypothesized in recent years. Conclusion A standardized safe sleep education plan implemented prenatally, in the delivery center, and further reviewed in the primary care setting at multiple visits, may lessen misconceptions regarding safe sleep and increase adherence. Media involvement portraying proper sleep practices may further encourage caregivers to follow AAP guidelines. Motivational interviewing may be an effective technique to begin the safe sleep conversation with caregivers and to further understand and re-direct caregiver opinions.12 Development of a nationwide requirement for all infant caregivers to watch a video regarding the AAP Back to Sleep campaign prior to hospital discharge may improve caregiver awareness and positively reinforce beliefs and opinions. Consistent and persistent education by healthcare providers is vital to further reduce SIDS related deaths. Further research, education, and interventions will aid in increasing compliance with current safe sleep recommendations. References 1. American Academy of Pediatrics. SIDS and other sleep-related infant deaths: expansion for a safe infant sleeping environment. Pediatrics. 2011;128:1341-66, 2. American Academy of Pediatrics. Swaddling: is it safe?. 2015. Retrieved from. https:// Swaddling-Is-it-Safe.aspx.


3. Balshem H, Helfand M, Schunemann HL, et al. GRADE guidelines: 3. rating the quality of evidence. J Clin Epidemiol. 2011;64:401-6, 4. Chu T, Hackett M, Kaur N. Exploring caregiver behavior and knowledge about unsafe sleep surfaces in infant injury death cases. Health Educ Behav. 2015;42: 293-301, 5. Chung-Park MS. Knowledge, opinions, and practices of infant sleep position among parents. Mil Med. 2012;177:235-9. 6. Cribs for Kids. Safe sleep for your baby right from the start DVD. (n.d.). Retrieved from [Accessed July 13, 2016]. 7. Goodstein MH, Bell T, Krugman SD. Improving infant sleep safety through a comprehensive hospital-based program. Clin Pediatr. 2015;54: 212-21, 8. Joyner BL, Oden RP, Ajao TI, Moon RY. Where should my baby sleep: a qualitative study of African American infant sleep location decisions. J Natl Med Assoc. 2010;102:881-9, 9. Mason B, Ahlers-Schmidt CR, Schunn C. Improving safe sleep environments for well newborns in the hospital setting. Clin Pediatr. 2013;52:969-75, 10. McDonnell E, Moon RY. Infant deaths and injuries associated with wearable blankets, swaddle wraps, and swaddling. J Pediatr. 2014;164:1152-6, 11. Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project. Pediatrics. 2008;122:788-9, 12. Naar-King S, Suarez M. Motivational interviewing with adolescents and young adults. New York, NY: The Guilford Press. 2011. 13. NIH. Fast facts about SIDS. 2015. Retrieved from about/SIDS/Pages/fastfacts.aspx. 14. Varghese S, Gasalberti D, Ahern K, Chang JC. An analysis of attitude toward infant sleep safety and SIDS risk reduction behavior among caregivers of newborns and infants. J Perinatol. 2015;35:970-3, 15. Von Kohorn IV, Corwin MJ, Rybin DV, Heeren TC, Lister G, Colson ER. Influence of prior advice and beliefs of mothers on infant sleep position. Arch Pediatr Adolesc Med. 2010;164:363-9,