Infant Sleep Positioning by Nursery Staff and Mothers in Newborn Hospital Nurseries

Sudden Infant Death Syndrome: Risk Factors and Newer Risk Reduction Strategies

Sudden infant death syndrome (SIDS) continues to be one of the top causes of infant death in the U.S. Despite significant public health initiatives focused on high-risk populations to enhance sleep environments and techniques. The SIDS rate has remained stable in recent years. Risk factors and newer risk reduction strategies for SIDS are the focus of this review article. We conducted a comprehensive literature search on Medline, Cochrane, Embase, and Google Scholar until July 2022. The following search strings and Medical Subject Heading (MeSH) terms were used: "SIDS," "Sudden Infant Death" and "SUID". We explored the literature on SIDS for its epidemiology, pathophysiology, the role of various etiologies and their influence, associated complications leading to SIDS, and preventive and treatment modalities. Despite a more than 50% drop-in rates since the start of the "Back to Sleep" campaign in 1994, sudden infant death syndrome (SIDS) continues to be the top cause of post-neonatal mortality in the United States, despite continued educational initiatives that support safe sleep and other risk reduction strategies. The new American Academy of Pediatrics guidelines for lowering the risk of SIDS include a lot of emphasis on sleeping habits, bedding, and environment but also include elements that are frequently ignored (i.e., prenatal care, smoking, alcohol and drug use, and childhood vaccinations). This study highlights these less-frequently discussed aspects and identifies treatments that have produced beneficial behavioral shifts that benefit newborns as well as their mothers' health and wellbeing.

Modeling of infant safe sleep practice in a newborn nursery: a quality improvement initiative

Sudden infant death syndrome (SIDS) is a leading cause of infant mortality in the US. The American Academy of Pediatrics has provided recommendations for infant sleeping position and environment to decrease SIDS rates. These recommendations reinforce the importance of modeling safe sleep practices in the newborn nursery. Although many quality improvement initiatives have been undertaken to improve safe sleep in the nursery, such efforts are sparse in low-volume birth hospitals. This project aimed to improve infant sleep practices in a 10-bed level I nursery using visual cues (crib cards) and nursing education. We defined "safe sleep practice" if a newborn slept in a safe position in a flat bassinet and in a safe environment. We measured safe sleep practices before and after the intervention using an audit tool. As a result, safe sleep practices improved from 32% (30/95) preintervention to 75% (86/115) postintervention (P < 0.01). This study demonstrates that implementing a quality improvement initiative to improve infant sleep practices in a low-volume nursery is feasible and impactful.

Improving safe sleep practices in an urban inpatient newborn nursery and neonatal intensive care unit

OBJECTIVE

To improve safe sleep compliance in a newborn nursery (NN) and neonatal intensive care unit (NICU) to >80% in 1 year.

STUDY DESIGN

Prospective quality improvement study of infants admitted to a NN and NICU. Interventions were targeted at parent education, staff education, and system processes.

RESULTS

Compliance with safe sleep improved to >80% in both units. Tracking of process measures revealed NICU parents received safe sleep education 98-100% of the time. No change was observed in the balancing measures. Transfers from the NN to the NICU for temperature instability did not increase. Parent satisfaction with discharge preparedness did not change (98.2% prior to and 99.6% after).

CONCLUSION

We achieved improved compliance with safe sleep practices in our NN and NICU through education of staff and parents and improved system processes. We believe this will translate to improved safe sleep practices used by parents at home.

Factors Associated with Safe Infant Sleep Practices in Saudi Arabia

Purpose

To assess mothers’ approaches to infant sleep practices.

Patients and Methods

A cross-sectional survey study was conducted on mothers with babies aged below five months who were attending paediatric clinics between November 1st, 2020, and January 5th, 2021, in Riyadh, Saudi Arabia.

Results

A total of 522 mothers participated in this study. A total of 38.9% practised exclusive formula feeding. A total of 61.9% of the participants practised the supine position. The majority (93.3%) of the mothers shared a room with their babies, while 34.7% shared a bed. Only 6.9% did not use any soft bedding. Age was a significant predictor associated with participant practices regarding sleeping and feeding positions (p < 0.05). Having two or more children was associated with improper sleeping practices (p < 0.05). Being non-Saudi and having a university degree or higher were associated with having a higher risk of unsafe practices regarding bed-sharing (p < 0.05). On the other hand, being contacted by a doctor, nurse, or other healthcare worker about safe sleep practices were an important factor that influenced safe practices regarding feeding (p < 0.05). Receiving care at a private hospital was associated with safer practices regarding sleeping position and bed-sharing (p < 0.05).

Conclusion

We observed high-risk sleeping practices among Saudi mothers. This includes using soft bedding and unsafe sleeping positions. The importance of this study lies in the future implementation of this result through public health measures aimed at at-risk populations.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

The wake project: Improving safe sleep practices in a neonatal intensive care unit

BACKGROUND

Every year, about 50 babies in New York City die from a sleep-related injury. The Bronx County ranked second highest rate of sleep-related infant deaths (SRID) at 0.5 per 1000 among the other boroughs. The highest rate was among blacks and the rate of SRID cases were highest in our population at 0.97 (zip code 10466) among all other Bronx neighborhoods which comprises 77% of non-Hispanic black population. Further, Bronx has the highest preterm birth rate at 9.5%. This quality improvement (QI) project aimed to develop and implement an educational initiative on infant safe sleep (SS) to improve "Safe Sleep Practices (SSP) in a level III neonatal intensive care unit (NICU) for one of the highest risk populations in the country.

METHODS

Baseline data was collected prior to initiating the QI project. Multiple plan-do-study-act (PDSA) cycles were completed over a 12 month period. Run charts were utilized to identify improvement and guide interventions. These interventions included education for nurses, crib cards, posters, feedback forms, grand rounds and small group discussions.

RESULTS

Approximately 600 crib checks (CC) were performed over the duration of this project. At baseline, 7% of infants were placed in a SS position in the NICU. Following the QI project, SS position increased to 96% of infants.

CONCLUSION

Multifactorial interventions significantly improved SS compliance among NICU nurses. Cultivating personal motivation among nurses, consistent empowerment and dedication to culture change by the entire team was crucial for the sustainability of the project.

Implementing a Statewide Safe to Sleep Hospital Initiative: Lessons Learned

Sleep-related infant deaths continue to be a major, largely preventable cause of infant mortality, especially in Georgia. The Georgia Department of Public Health (DPH), as part of a multi-pronged safe infant sleep campaign, implemented a hospital initiative to (1) provide accurate safe infant sleep information to hospital personnel; (2) support hospitals in implementing and modeling safe sleep practices; and (3) provide guidance on addressing caregiver safe sleep concerns. A process evaluation was conducted to determine progress toward four goals set out by DPH: (1) all birthing hospitals have a safe infant sleep policy; (2) all safe infant sleep policies reference the AAP 2011 recommendations; (3) all safe infant sleep policies specify the type and/or content of patient safe sleep education; and (4) all hospitals require regular staff training on safe sleep recommendations. Data were collected via structured interviews and document review of crib audit data and safe sleep policies. All 79 birthing hospitals in the state participated in the statewide campaign. Prior to the initiative, 44.3% of hospitals had a safe sleep policy in place; currently, 87.3% have a policy in place. The majority (91.4%) of hospitals have provided safe sleep training to their staff at this time. Important lessons include: (1) Engagement is vital to success; (2) A comprehensive implementation guide is critical; (3) Piloting the program provides opportunities for refinement; (4) Ongoing support addresses barriers; and (5) Senior leadership facilitates success.

TodaysBaby Quality Improvement: Safe Sleep Teaching and Role Modeling in 8 US Maternity Units

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.

Improving Safe Sleep Modeling in the Hospital through Policy Implementation

Introduction Sleep-related infant deaths are major contributors to Tennessee's high infant mortality rate. The purpose of this initiative was to evaluate the impact of policy-based efforts to improve modeling of safe sleep practices by health care providers in hospital settings across Tennessee. Methods Safe sleep policies were developed and implemented at 71 hospitals in Tennessee. Policies, at minimum, were required to address staff training on the American Academy of Pediatrics' safe sleep recommendations, correct modeling of infant safe sleep practices, and parent education. Hospital data on process measures related to training and results of crib audits were compiled for analysis. Results The overall observance of infants who were found with any risk factors for unsafe sleep decreased 45.6% (p ≤ 0.001) from the first crib audit to the last crib audit. Significant decreases were noted for specific risk factors, including infants found asleep not on their back, with a toy or object in the crib, and not sleeping in a crib. Significant improvements were observed at hospitals where printed materials or video were utilized for training staff compared to face-to-face training. Discussion Statewide implementation of the hospital policy intervention resulted in significant reductions in infants found in unsafe sleep situations. The most common risk factors for sleep-related infant deaths can be modeled in hospitals. This effort has the potential to reduce sleep-related infant deaths and ultimately infant mortality.

Effectiveness of the 'Back-to-Sleep' campaigns among healthcare professionals in the past 20 years: a systematic review

OBJECTIVES

From the late 1980s 'Back-to-Sleep' (BTS) campaigns were run in most developed countries to increase awareness of the supine position's protective effect against sleep-related infant deaths. Once the media awareness-raising action associated with these campaigns ended, healthcare professionals' role became crucial. The goal of this paper is to determine if healthcare professionals' knowledge and parent advice consistent with evidence-based infant sleep recommendations have changed over the past 20 years.

SETTING

All studies investigating healthcare professionals' knowledge and/or advice to parents were included in a systematic review. The search was performed in PubMed and in MEDLINE, and 21 studies were identified.

RESULTS

The correctness of healthcare professionals' knowledge and parent advice about the supine sleeping position increased over the past 20 years. However, the percentage of those aware that parents should avoid putting their babies to sleep in a prone position is decreasing over time: from about 97% in the 1990s to about 90% at the end of the 2000s.

CONCLUSIONS

The effectiveness of the BTS campaigns in publicising the benefits of the supine position is confirmed by this paper. More and more healthcare professionals know that it is the best position to reduce the risk of sleep-related deaths and they recommend it exclusively. However, the decrease in the knowledge about non-prone positions suggests that the campaigns may not have focused enough on the dangers of the prone position.

A prospective audit of adherence to safe sleeping guidelines in a general paediatric ward and special care nursery

AIM

Sudden Infant Death Syndrome (SIDS) remains one of the largest causes of infant mortality worldwide, and despite widespread educational campaigns compliance to safe sleeping guidelines remains low in many areas. Hospital staff play a significant role in educating parents on safe sleeping recommendations and providing appropriate sleeping environments for infants. The aim of the study was to evaluate adherence to safe sleeping guidelines in a special care nursery (SCN) and general paediatric ward (GPW).

METHODS

A prospective audit of sleeping environments in a SCN and GPW with data collected on 10 safe sleeping compliance rules, based on national and international guidelines.

RESULTS

Two hundred eleven sleeping environments were observed (161 in SCN, 50 in GPW). Supine sleeping compliance was high in both wards (83% SCN, 82% GPW). Overall the median compliance score was significantly lower in the GPW (7, IQR = 6-7) compared to the SCN (8, IQR = 7-9) (Mann Whitney U test, P < 0.001). Lowest compliance rates were seen in respect to removing soft items from the crib and infant positioning within the crib.

CONCLUSIONS

Compliance with supine sleeping was high; however, nurses and parents may not be aware, or do not implement, the full suite of safe sleeping guidelines. Further research is required to determine specific reasons for poor compliance and on the effectiveness of educational programmes in improving hospital infant sleeping environments.

Do nurses provide a safe sleep environment for infants in the hospital setting? An integrative review

BACKGROUND

Sudden infant death syndrome (SIDS) may be the most preventable cause of death for infants 0 to 6 months of age. The American Academy of Pediatrics (AAP) first published safe sleep recommendations for parents and healthcare professionals in 1992. In 1994, new guidelines were published and they became known as the "Back to Sleep" campaign. After this, a noticeable decline occurred in infant deaths from SIDS. However, this number seems to have plateaued with no continuing significant improvements in infant deaths.

OBJECTIVES

The objective of this review was to determine whether nurses provide a safe sleep environment for infants in the hospital setting. Research studies that dealt with nursing behaviors and nursing knowledge in the hospital setting were included in the review.

DATA SOURCES

A search was conducted of Google Scholar, CINAHL, PubMed, and Cochrane, using the key words "NICU," "newborn," "SIDS," "safe sleep environment," "nurse," "education," "supine sleep," "prone sleep," "safe sleep," "special care nursery," "hospital policy for safe sleep," "research," "premature," "knowledge," "practice," "health care professionals," and "parents."

STUDY ELIGIBILITY CRITERIA

The review included research reports on nursing knowledge and behaviors as well as parental knowledge obtained through education and role modeling of nursing staff. Only research studies were included to ensure that our analysis was based on rigorous research-based findings. Several international studies were included because they mirrored findings noted in the United States. All studies were published between 1999 and 2012.

PARTICIPANTS

Healthcare professionals and parents were included in the studies. They were primarily self-report surveys, designed to determine what nurses, other healthcare professionals, and parents knew or had been taught about SIDS.

SYNTHESIS METHOD

Integrative review.

RESULTS

Thirteen of the 16 studies included in the review found that some nurses and some mothers continued to use nonsupine positioning. Four of the 16 studies discussed nursing knowledge and noncompliance with AAP safe sleep recommendations. Eleven of the 16 studies found that some nurses were recommending incorrect sleep positions to mothers. Five of the 16 studies noted that some nurses and mothers gave fear of aspiration as the reason they chose to use a nonsupine sleep position.

LIMITATIONS

In the majority of the studies, the information was self-reported, which could impact the validity of the findings. Also, the studies used convenience sampling, which makes study findings difficult to generalize.

CONCLUSIONS AND IMPLICATIONS

The research indicates that there has been a plateau in safe sleeping practices in the hospital setting. Some infants continue to be placed in positions that increase the risk for SIDS. The research also shows that some nurses are not following the 2011 AAP recommendations for a safe sleep environment. Clearly, nurses need additional education on SIDS prevention and the safe sleep environment, and additional measures need to be adopted to ensure that all nurses and all families understand the research supporting the AAP recommendation that supine sleep is best. Further work is needed to promote evidence-based practice among healthcare professionals and families.

Improving safe sleep environments for well newborns in the hospital setting

OBJECTIVE

Following the "Back to Sleep" campaign, deaths from sudden infant death syndrome (SIDS) were reduced. However, SIDS and sleep-related deaths continue to occur. Studies demonstrate that modeling by health care workers influences parents to place infants supine for sleep. Recently, additional emphasis has been placed on environment. The purpose of this study was to improve sleep position and environment in the hospital.

METHODS

A Plan-Do-Study-Act cycle was initiated. Sleeping infants were observed at baseline. A bundled intervention was implemented; infants were again observed. Parents were surveyed.

RESULTS

At baseline, 25% (36/144) of sleeping infants were safe; the majority of unsafe sleep was a result of environment. Postintervention, significantly more (58%; 145/249) had safe sleep (P < .0001). Most parents planned to use the supine position (95%; 96/101); none planned to cosleep. Many intended to adjust their infants' home sleep environment.

CONCLUSION

Using a multifaceted approach significantly improved infant safe sleep practice in the hospital setting.

Implementation of the American Academy of Pediatrics recommendations to reduce sudden infant death syndrome risk in neonatal intensive care units: An evaluation of nursing knowledge and practice

There is a direct relationship between nonsupine sleeping and sudden infant death syndrome (SIDS). Premature infants are at greater risk for SIDS and are often cared for in nonsupine positions during the course of hospitalization. Healthy premature infants should be placed supine for sleep before discharge from the neonatal intensive care unit (NICU), and parents receive specific instruction about infant sleep position and other risk factors for SIDS. Most published literature addressing nursing practices for SIDS reduction reflects practices with the healthy newborn population.

PURPOSE

To examine and describe NICU nurses' knowledge of SIDS risk-reduction measures, modeling of safe infant sleep interventions prior to discharge, and inclusion of SIDS risk reduction in parent education.

SUBJECTS

Convenience sample of nurses practicing in level II and III NICUs located in 2 Middle Atlantic States.

DESIGN AND METHODS

A prospective survey design was used for the study. The 14-item questionnaire was developed by a team of neonatal clinical experts and distributed via site coordinators to nurses in 19 NICUs.

PRINCIPAL RESULTS

A total of 1080 surveys were distributed and 430 (40%) NICU nurses completed the survey. The majority of nurses (85%) identified the American Academy of Pediatrics SIDS risk-reduction strategies for safe sleep. The investigators found that age, years of nursing and neonatal nursing experience, and educational preparation did not significantly contribute to the practice of "supine-only" position for sleep for infants in NICUs. The study revealed that nurses frequently position healthy preterm infants supine for sleep when weaned to an open crib (50%). Others wait one to a few days before discharge (15%) and some never position supine for sleep (6%). Stuffed toys are removed from cribs 90.5% of the time. For term infants without major medical complications, 45.5% of surveyed nurses continued to use positioning aids/rolls in infants' cribs. The most common reasons nurses cited to position preterm infants side-lying or prone in a crib were fear of aspiration (29%), infant comfort (28%), and infant safety (20%). NICU nurses educated parents about SIDS and reduction strategies, using various media. At discharge, 73% of the nurses verbally communicated with parents, 53% provided printed literature, and 14% used audiovisual aids with parents.

CONCLUSIONS

NICU nurses are in influential positions to educate parents and model SIDS risk-reduction strategies. This study supports other published research that points to inconsistencies in nursing practice regarding implementation of methods to reduce the risk of SIDS.

Qualitative analysis of beliefs and perceptions about sudden infant death syndrome in African-American mothers: implications for safe sleep recommendations

OBJECTIVE

To investigate, by using qualitative methods, perceptions about sudden infant death syndrome (SIDS) in African-American parents and how these influence decisions.

STUDY DESIGN

Eighty-three mothers participated in focus groups or individual interviews. Interviews probed reasons for decisions about infant sleep environment and influences affecting these decisions. Data were coded, and themes were developed and revised in an iterative manner as patterns became more apparent.

RESULTS

Themes included lack of plausibility, randomness, and vigilance. Many mothers believed that the link between SIDS and sleep position was implausible. Because the cause of SIDS was unknown, they did not understand how certain behaviors could be defined as risk factors. This confusion was reinforced by perceived inconsistency in the recommendations. Most mothers believed that SIDS occurred randomly ("God's will") and that the only way to prevent it was vigilance.

CONCLUSIONS

Many African-American mothers may not understand the connection between SIDS and sleep behaviors or believe that behavior (other than vigilance) cannot affect risk. These beliefs, if acted on, may affect rates of safe sleep practices. Efforts to explain a plausible link between SIDS and safe sleep recommendations and to improve consistency of the message may result in increased adherence to these recommendations.

The relationship between characteristics of context and research utilization in a pediatric setting

Background

Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.

Methods

A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context (culture, leadership and evaluation) were used to categorize respondent data into one of four context groups (high, moderately high, moderately low and low). We then examined the relationships between nurses' self-reported research use and their perceived context.

Results

A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.

Conclusions

Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior.

Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project

OBJECTIVE

The goal was to evaluate, through an American Academy of Pediatrics demonstration project, the effectiveness of a curriculum and train-the-trainer model in changing child care providers' behaviors regarding safe infant sleep practices.

METHODS

Participating licensed child care centers and family child care homes were assigned randomly to intervention and control groups. Observers performed an initial unannounced visit to each site, to watch infants being placed for sleep, to inventory sleep policies, and to administer questionnaires to center staff members. Trainers then used the American Academy of Pediatrics curriculum in educational sessions at intervention sites. Three months later, observers conducted a follow-up observation at each site, and staff members completed a questionnaire about logistic barriers encountered in implementation of safe sleep recommendations.

RESULTS

A total of 264 programs and 1212 providers completed the study; the care of 1993 infants was observed. Provider awareness of the American Academy of Pediatrics infant supine sleep position recommendation increased from 59.7% (both groups) to 64.8% (control) and 80.5% (intervention). Exclusive use of the supine position in programs increased from 65.0% to 70.4% (control) and 87.8% (intervention). Observed supine placement increased from 51.0% to 57.1% (control) and 62.1% (intervention).

CONCLUSIONS

A sudden infant death syndrome risk reduction curriculum using a train-the-trainer model is effective in improving the knowledge and practices of child care providers. Perceived parental objections, provider skepticism about the benefits of supine positioning, and lack of program policies and training opportunities are important barriers to implementation of safe sleep policies. Continued education of parents, expanded training efforts, and statewide regulations, mandates, and monitoring are critical to ongoing efforts to decrease further the risk of sudden infant death syndrome in child care.

Placing preterm infants for sleep: first prone, then supine

Perspective on the paper by Kassim et al (see page 347)

Fewer spontaneous arousals during prone sleep in preterm infants at 1 and 3 months corrected age

OBJECTIVE

This study was performed to determine if there were fewer spontaneous arousals in prone sleep than in supine sleep.

STUDY DESIGN

Home polysomnography/video recordings were done during daytime naps in 14 preterm infants: four at corrected age of 1 month, nine at both 1 and 3 months, and one only at 3 month. A body movement lasting 3 to 60 s during sleep was used as an indicator of spontaneous arousals.

RESULTS

Most arousals had a heart rate increase and change in respiration pattern. The mean duration of the intervals between successive arousals in active and quiet sleep was significantly longer in prone at 1 and 3 months of age. The duration of arousals was significantly shorter at 3 months corrected age compared with one month corrected age during active sleep. The duration of arousals was shorter during quiet sleep at one month compared with active sleep.

CONCLUSION

There were fewer spontaneous arousals that is, longer interval between successive arousals in prone, which may, in part, explain the increase in risk of Sudden Infant Death Syndrome.

Evidence for best practices in the neonatal period

The purpose of this article is to provide a review of current nursing research that supports best practices during the newborn period. The literature review of peer-reviewed research articles published between January 2000 and October 2004 was conducted via keyword searches using the databases of the Cochrane Library, CINAHL, and MEDLINE. Key words included neonatal nursing, newborn, neonate, premature infant, preterm infant, and low birthweight. Content analysis revealed the following primary categories of studies that provide solid evidence for nursing practice: developmentally focused nursing care, neonatal skin care, feeding, skin-to-skin care, and pain management. Neonatal nurse researchers have made many important contributions to the research literature. Future research should expand the findings to date on the effective use of pain scales, the outcomes of skin-to-skin care and infant massage as standard practice for all neonates, and the effectiveness of nursing interventions to support the developmental sequelae of prematurity. Neonatal nurses should become familiar with and implement those findings from nursing research that strongly support evidence-based nursing practice.

Putting babies "back to sleep": can we do better?

The American Academy of Pediatrics first recommended in 1992 that infants be placed on their backs for sleep to reduce the risk for sudden infant death syndrome (SIDS). Since that time, there has been a national drop in the incidence of SIDS of more than 40 percent. Unfortunately, many parents and other caregivers are still receiving inconsistent information and observing varying practices regarding infant sleep position. This article emphasizes the role of the health care professional in both teaching and modeling these potentially life-saving practices consistently and unambiguously. Available literature is reviewed regarding attitudes and beliefs about infant sleep positioning, and specific concerns are addressed in order to allow for better tailoring of educational programs.

Gaps and disparities in neonatal nursing care

AS I WAS PREPARING THE “UPDATE ON RESEARCH Evidence for Neonatal Care” column for this issue, I was surprised to read that nursery nurses were not placing healthy newborns in the supine position for sleep as prevention for sudden infant death syndrome (SIDS).1 But what equally got my attention was that Latina and Pacific Islander mothers were less likely than white mothers to be instructed by their nurses about the use of the supine position for infant sleep.