Secular changes in sleep position during infancy: 1995-1998

Infant Care Practices, Caregiver Awareness of Safe Sleep Advice and Barriers to Implementation: A Scoping Review

Modifiable infant sleep and care practices are recognised as the most important factors parents and health practitioners can influence to reduce the risk of sleep-related infant mortality. Understanding caregiver awareness of, and perceptions relating to, public health messages and identifying trends in contemporary infant care practices are essential to appropriately inform and refine future infant safe sleep advice. This scoping review sought to examine the extent and nature of empirical literature concerning infant caregiver engagement with, and implementation of, safe sleep risk-reduction advice relating to Sudden Unexpected Deaths in Infancy (SUDI). Databases including PubMed, CINAHL, Scopus, Medline, EMBASE and Ovid were searched for relevant peer reviewed publications with publication dates set between January 2000-May 2021. A total of 137 articles met eligibility criteria. Review results map current infant sleeping and care practices that families adopt, primary infant caregivers' awareness of safe infant sleep advice and the challenges that families encounter implementing safe sleep recommendations when caring for their infant. Findings demonstrate a need for ongoing monitoring of infant sleep practices and family engagement with safe sleep advice so that potential disparities and population groups at greater risk can be identified, with focused support strategies applied.

The Impact of Health Messages on Maternal Decisions About Infant Sleep Position: A Randomized Controlled Trial

Sudden infant death syndrome (SIDS) rates in African-Americans are more than twice national rates, and historically, African-American parents are more likely than other groups to place infants prone, even when they are aware of supine sleep recommendations. Prior studies have shown African-Americans have low self-efficacy against SIDS but high self-efficacy against suffocation. This study aimed to determine the impact of a specific health message about suffocation prevention on African-American parental decisions regarding infant sleep position. We conducted a randomized controlled trial of 1194 African-American mothers, who were randomized to receive standard messages about safe sleep practices to reduce the risk of SIDS, or enhanced messages about safe sleep practices to prevent SIDS and suffocation. Mothers were interviewed about knowledge and attitude, self-efficacy and current infant care practices when infants were 2-3 weeks, 2-3 months and 5-6 months old. Analyses of covariance were conducted to estimate the change in knowledge, attitudes and practice in each group, and chi square tests were used to compare sleep position with each variable. Over the first 6 months, the proportion of African-American infants placed supine gradually decreased and was unchanged by enhanced education about SIDS, suffocation risk and sleep safety. While initially high self-efficacy against SIDS and suffocation correlated with supine positioning, by 5-6 months self-efficacy did not correspond to sleep position in either group.

Implications of Mothers' Social Networks for Risky Infant Sleep Practices

OBJECTIVE

To describe the structure of networks in a cohort of mothers and to analyze associations of social network characteristics and norms with infant sleep practices.

STUDY DESIGN

We recruited a prospective cohort of mothers with infants <6 months of age from January 2015 to December 2016. Mothers completed a survey about their personal social networks and infant care practices. Latent class analysis identified unobserved network types. Binary statistics and path analysis were performed.

RESULTS

Overall, 402 mothers were surveyed. Latent class analysis identified 2 a priori unknown social network types: "exclusive" (restricted) and "expansive." Mothers who were black, younger, unmarried, less educated, and of lower socioeconomic status were more likely to have exclusive networks than expansive networks. Mothers with exclusive networks were more likely to be exposed to the norm of soft bedding (P = .002). Exposure to norms of non-supine infant placement, bedsharing, and soft bedding use within one's network was associated with engaging in these practices (P < .0001 for each). First-time mothers were more likely to pay attention to a non-supine norm and place infants in a non-supine position. Black mothers and first-time mothers were more likely to pay attention to the norm and use soft bedding.

CONCLUSIONS

Both the type of networks mothers have and the norms regarding infant sleep practices that circulate within these networks differed by race. Network norms were strongly associated with infant sleep practices and may partially explain the racial disparity therein.

The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices: A Randomized Clinical Trial

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.

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.

Reasons for Pacifier Use and Non-Use in African-Americans: Does Knowledge of Reduced SIDS Risk Change Parents' Minds?

To investigate African-American parental reasons for pacifier use or non-use, and whether knowledge of the association with decreased SIDS risk changes decisions about pacifier use. We conducted focus groups and individual interviews with mothers. Grounded theory methodology was used. 83 mothers participated; 72.3 % of infants used pacifiers. Reasons for pacifier use included comfort/soothing, safety/SIDS, and preference over digit-sucking. Reasons for pacifier non-use included infant refusal, fear of attachment, nipple confusion, and germs. Many parents were unaware that pacifier use reduces SIDS risk; however, most parents of non-users did not think that this knowledge would have changed their decision. Reasons included skepticism about the pacifier-SIDS link. Many reasons underlie African-American parental decisions about pacifier use. Providers should provide information about the benefits of pacifiers. Establishing for parents any plausible link between the protective mechanism of pacifiers and SIDS pathophysiology may be important in promoting pacifier use.

Perinatal Disparities Between American Indians and Alaska Natives and Other US Populations: Comparative Changes in Fetal and First Day Mortality, 1995-2008

To compare fetal and first day outcomes of American Indian and Alaskan Natives (AIAN) with non-AIAN populations. Singleton deliveries to AIAN and non-AIAN populations were selected from live birth-infant death cohort and fetal deaths files from 1995-1998 and 2005-2008. We examined changes over time in maternal characteristics of deliveries and disparities and changes in risks of fetal, first day (<24 h), and cause-specific deaths. We calculated descriptive statistics, odds ratios and confidence intervals, and ratio of odds ratios (RORs) to indicate changes in disparities. Along with black mothers, AIANs exhibited the highest proportion of risk factors including the highest proportion of diabetes in both time periods (4.6 and 6.5 %). Over time, late fetal death for AIANs decreased 17 % (aOR = 0.83, 95 % CI 0.72-0.97), but we noted a 47 % increased risk over time for Hispanics (aOR = 1.47, 95 % CI 1.40-1.55). Our data indicated no change over time among AIANs for first day death. For AIANs compared to whites, increased risks and disparities persisted for mortality due to congenital anomalies (ROR = 1.28, 95 % CI 1.03-1.60). For blacks compared to AIANs, the increased risks of fetal death (2005-2008: aOR = 0.60, 95 % CI 0.53-0.68) persisted. For Hispanics, lower risks compared to AIANs persisted, but protective effect declined over time. Disparities between AIAN and other groups persist, but there is variability by race/ethnicity in improvement of perinatal outcomes over time. Variability in access to care and pregnancy management should be considered in relation to health equity for fetal and early infant deaths.

Evaluation of bedtime basics for babies: a national crib distribution program to reduce the risk of sleep-related sudden infant deaths

Rates of sleep-related infant deaths have remained stagnant in recent years. Although most parents are aware of safe sleep recommendations, barriers to adherence, including lack of access to a safe crib, remain. The objective of this study was to describe parental knowledge and practices regarding infant sleep position, bedsharing, pacifier use, and feeding practices before and after receipt of a free crib and safe sleep education. Bedtime Basics for Babies (BBB) enrolled high-risk families in Washington, Indiana, and Washington, DC and provided them with cribs and safe sleep education. Parents completed surveys before ("prenatal" and "postnatal") and 1-3 months after crib receipt ("follow-up"). Descriptive and bivariate analyses were completed. 3,303 prenatal, 1,483 postnatal, and 1,729 follow-up surveys were collected. Parental knowledge of recommended infant sleep position improved from 76% (prenatal) and 77% (postnatal) to 94% after crib receipt (p < 0.001). Intended use of supine positioning increased from 84% (prenatal) and 80% (postnatal) to 87% after the intervention (p < 0.001). Although only 8% of parents intended to bedshare when asked prenatally, 38% of parents receiving the crib after the infant's birth reported that they had bedshared the night before. This decreased to 16% after the intervention. Ninety percent reported that the baby slept in a crib after the intervention, compared with 51% postnatally (p < 0.01). BBB was successful in changing knowledge and practices in the majority of high-risk participants with regards to placing the infant supine in a crib for sleep. Crib distribution and safe sleep education positively influence knowledge and practices about safe sleep.

What new mothers need to know: perspectives from women and providers in Georgia

Identifying the educational and resource needs of new mothers is of paramount importance in developing programs to improve maternal and child health outcomes. The primary purpose of this study was to explore the educational needs of new mothers and identify opportunities to enhance healthcare providers' current educational efforts. A two-part methodology was utilized to qualitatively explore the topic of parenting information needs for new mothers in Georgia. Data collection included information from 11 focus groups with 92 first-time, new mothers and 20 interviews with healthcare providers who serve new mothers. Discussions with both new mothers and providers clearly indicated that new mothers face a significant informational deficit, especially regarding very basic, daily infant care information and health literacy challenges. Educational materials already exist; however, mothers report difficulty accessing and understanding this information. For this reason, both the mothers and the providers stressed a focus on developing programs or interventions that allow in-person education and/or alternative modalities to access information, as opposed to development of new written materials solely. Information from the focus group and interviews provided important insight regarding what improvements need to be made to help new mothers and their families during the early stages of parenthood. By improving the education of new mothers and their families, it is proposed that maternal and infant health status could be improved.

Using surveillance data to inform a SUID reduction strategy in Massachusetts

BACKGROUND

Non-supine infant sleep positions put infants at risk for sudden unexpected infant death (SUID). Disparities in safe sleep practices are associated with maternal income and race/ethnicity. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a nutrition supplement program for low-income (≤185% Federal Poverty Level) pregnant and postpartum women. Currently in Massachusetts, approximately 40% of pregnant/postpartum women are WIC clients. To inform the development of a SUID intervention strategy, the Massachusetts Department of Public Health (MDPH) investigated the association between WIC status and infant safe sleep practices among postpartum Massachusetts mothers using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey.

METHODS

PRAMS is an ongoing statewide health surveillance system of new mothers conducted by the MDPH in collaboration with the Centers for Disease Control and Prevention (CDC). PRAMS includes questions about infant sleep position and mothers' prenatal WIC status. Risk Ratio (RR) and 95 percent confidence intervals (CI) were calculated for infant supine sleep positioning by WIC enrollment, yearly and in aggregate (2007-2010).

RESULTS/OUTCOMES

The aggregate (2007-2010) weighted sample included 276,252 women (weighted n ≈ 69,063 women/year; mean survey response rate 69%). Compared to non-WIC mothers, WIC mothers were less likely to usually or always place their infants in supine sleeping positions [RR = 0.81 (95% CI: 0.80, 0.81)]. Overall, significant differences were found for each year (2007, 2008, 2009, 2010), and in aggregate (2007-2010) by WIC status.

CONCLUSION

Massachusetts WIC mothers more frequently placed their babies in non-supine positions than non-WIC mothers. While this relationship likely reflects the demographic factors associated with safe sleep practices (e.g., maternal income and race/ethnicity), the finding informed the deployment of an intervention strategy for SUID prevention. Given WIC's statewide infrastructure and the large proportion of pregnant/postpartum women in Massachusetts that are enrolled in WIC, a WIC-based safe sleep intervention may be an effective SUID reduction strategy with potential national application.

Trends in racial and ethnic disparities in infant mortality rates in the United States, 1989-2006

OBJECTIVES

We sought to measure overall disparities in pregnancy outcome, incorporating data from the many race and ethnic groups that compose the US population, to improve understanding of how disparities may have changed over time.

METHODS

We used Birth Cohort Linked Birth-Infant Death Data Files from US Vital Statistics from 1989-1990 and 2005-2006 to examine multigroup indices of racial and ethnic disparities in the overall infant mortality rate (IMR), preterm birth rate, and gestational age-specific IMRs. We calculated selected absolute and relative multigroup disparity metrics weighting subgroups equally and by population size.

RESULTS

Overall IMR decreased on the absolute scale, but increased on the population-weighted relative scale. Disparities in the preterm birth rate decreased on both the absolute and relative scales, and across equally weighted and population-weighted indices. Disparities in preterm IMR increased on both the absolute and relative scales.

CONCLUSIONS

Infant mortality is a common bellwether of general and maternal and child health. Despite significant decreases in disparities in the preterm birth rate, relative disparities in overall and preterm IMRs increased significantly over the past 20 years.

Growth patterns among HIV-exposed infants receiving nevirapine prophylaxis in Pune, India

Background

India has among the highest rates of infant malnutrition. Few studies investigating the growth patterns of HIV-exposed infants in India or the impact of timing of HIV infection on growth in settings such as India exist.

Methods

We used data from the Six Week Extended Nevirapine (SWEN) trial to compare the growth patterns of HIV-infected and HIV-exposed but uninfected infants accounting for timing of HIV infection, and to identify risk factors for stunting, underweight and wasting. Growth and timing of HIV infection were assessed at weeks 1, 2, 4, 6, 10, 14 weeks and 6, 9, 12 months of life. Random effects multivariable logistic regression method was used to assess factors associated with stunting, underweight and wasting.

Results

Among 737 HIV-exposed infants, 93 (13%) were HIV-infected by 12 months of age. Among HIV-infected and uninfected infants, baseline prevalence of stunting (48% vs. 46%), underweight (27% vs. 26%) and wasting (7% vs. 11%) was similar (p>0.29), but by 12 months stunting and underweight, but not wasting, were significantly higher in HIV-infected infants (80% vs. 56%, 52% vs. 29%, p< 0.0001; 5% vs. 6%, p=0.65, respectively). These differences rapidly manifested within 4–6 weeks of birth. Infants infected in utero had the worst growth outcomes during the follow-up period. SWEN was associated with non-significant reductions in stunting and underweight among HIV-infected infants and significantly less wasting in HIV-uninfected infants. In multivariate analysis, maternal CD4 < 250, infant HIV status, less breastfeeding, low birth weight, non-vaginal delivery, and infant gestational age were significant risk factors for underweight and stunting.

Conclusion

Baseline stunting and underweight was high in both HIV-infected and uninfected infants; growth indices diverged early and were impacted by timing of infection and SWEN prophylaxis. Early growth monitoring of all HIV-exposed infants is an important low-cost strategy for improving health and survival outcomes of these infants.

Trial Registration

NCT00061321

Measuring health disparities: trends in racial-ethnic and socioeconomic disparities in obesity among 2- to 18-year old youth in the United States, 2001-2010

PURPOSE

Although eliminating health disparities by race, ethnicity, and socioeconomic status (SES) is a top public health priority internationally and in the United States, weight-related racial/ethnic and SES disparities persist among adults and children in the United States. Few studies have examined how these disparities have changed over time; these studies are limited by the reliance on rate differences or ratios to measure disparities. We sought to advance existing research by using a set of disparity metrics on both the absolute and relative scales to examine trends in childhood obesity disparities over time.

METHODS

Data from 7066 children, ages 2 to 18 years, in the National Health and Nutrition Examination Surveys were used to explore trends in racial/ethnic and SES disparities in pediatric obesity from 2001 to 2010 using a set of different disparity metrics.

RESULTS

Racial/ethnic and SES-related disparities in pediatric obesity did not change significantly from 2001 to 2010 and remain significant.

CONCLUSIONS

Disparities in obesity have not improved during the past decade. The use of different disparity metrics may lead to different conclusions with respect to how disparities have changed over time, highlighting the need to evaluate disparities using a variety of metrics.

Hyperlactatemia and in utero exposure to antiretrovirals: is the control group the clue?

Perinatal antiretroviral (ARV) exposure has been related to hyperlactatemia and lactic acidosis in infants born to HIV-infected mothers. Our objective was to determine the incidence of these conditions during the first year of life in uninfected infants born to HIV-infected mothers and compare the data with infants born to mothers with hepatitis C virus (HCV) infection. We investigated the relationships between hyperlactatemia and neurological and neurodevelopmental disorders by conducting a prospective, comparative cohort study (October 2004 to October 2007) consecutively including children of HIV- and HCV-infected mothers. Liver enzymes, pH, lactic acid, and plasma amino acids were determined at 1.5, 3, 6, and 12 months of life. Pathological hyperlactatemia was defined as lactate >2.1 mmol/liter together with alanine >475 μmol/liter. Seventy-nine patients (39 HIV-exposed patients and 40 unexposed patients) were included. Baseline maternal characteristics in the two groups were similar. Almost 90% of HIV-infected mothers received HAART during gestation, while 10.3% were given AZT monotherapy. Eight newborns received combined therapy and 31 received AZT-based monotherapy. Twelve patients (five exposed and seven nonexposed) had some neurological disorder, and four other patients (one vs. three) showed signs of neurodevelopmental delay, with no significant differences between the groups (p=0.34). Pathological hyperlactatemia was detected in 56.4% (95% CI 39.6-72.2) and 57.5% (95% CI 40.9-73.0) of patients, respectively (p=0.92), and this condition was more frequent in preterm children (p<0.05). ARV use during pregnancy and the neonatal period was not associated with pathological hyperlactatemia. The presence of hyperlactatemia was not associated with neurological or neurodevelopmental disorders. No association was established between the use of ARV agents and the development of hyperlactatemia or neurological disorders in HIV-exposed children during their first year of life.

Maternal assessment of physician qualification to give advice on AAP-recommended infant sleep practices related to SIDS

OBJECTIVE

The American Academy of Pediatrics (AAP) strongly recommends the supine-only sleep position for infants and issued 2 more sudden infant death syndrome (SIDS) reduction recommendations: avoid bed sharing and use pacifiers during sleep. In this study, we investigated the following: 1) if mothers from at risk populations rate physicians as qualified to give advice about sleep practices and 2) if these ratings were associated with reports of recommended practice.

METHODS

A cross-sectional survey of mothers (N=2355) of infants aged <8 months was conducted at Women, Infants, and Children (WIC) Program centers in 6 cities from 2006 to 2008. The predictor measures were maternal rating of physician qualification to give advice about 3 recommended sleep practices and reported nature of physician advice. The dependent measures were maternal report of usage of recommended behavior: 1) "infant usually placed supine for sleep," 2) "infant usually does not share a bed with an adult during sleep," and 3) "infant usually uses a pacifier during sleep."

RESULTS

Physician qualification ratings varied by topic: sleep position (80%), bed sharing (69%), and pacifier use (60%). High ratings of physician qualification were associated with maternal reports of recommended behavior: supine sleep (adjusted odds ratio [AOR] 2.1, 95% confidence interval [CI], 1.6-2.6); usually no bed sharing (AOR 1.5, 95% CI, 1.2-1.9), and usually use a pacifier during sleep (AOR 1.2, 95% CI, 1.0-1.5).

CONCLUSIONS

High maternal ratings of physician qualification to give advice on 2 of the 3 recommended sleep practices targeted to reduce the risk of SIDS were significantly associated with maternal report of using these behaviors. Lower ratings of physician qualification to give advice about these sleep practices may undermine physician effectiveness in promoting the recommended behavior.

Lack of effect on prematurity, birth weight, and infant growth from exposure to protease inhibitors in utero and after birth

STUDY OBJECTIVE

To determine whether an association exists between exposure in utero and after birth to highly active antiretroviral therapy (HAART) containing protease inhibitors and prematurity, birth weight, and infant growth parameters.

DESIGN

Retrospective cohort study.

SETTING

Tertiary, university-affiliated hospital in Montreal, Canada.

PATIENTS

Cohort of 206 pairs of mothers who had human immunodeficiency virus (HIV) and had been treated with HAART between 1997 and 2005, of whom 176 had regimens containing protease inhibitors, and their infants, as well as a control group of 206 infants born to non-HIV-infected mothers and thus not exposed to HAART.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical characteristics were retrieved from patients' medical records and the hospital's HIV database. Duration of HAART use, rates of prematurity and low birth weight, and infant growth parameters during the first 2 years of the child's life were evaluated. Median duration of HAART use for the women before delivery was 18 weeks (range 4-36 wks) and for infants, started within the first 8-12 hours of life, was 6 weeks (range 2-6 wks). In infants exposed to HAART, the 10.6% rate of prematurity (11.1% with and 7.1% without protease inhibitors) was not significantly higher than that in the control group (7.8%). Moreover, the 9.9% rate for small for gestational age (9.8% with and 10.3% without protease inhibitors) was also not significantly higher than that in the control group (5.3%). The 176 mothers and infants exposed to protease inhibitors had a median follow-up of 5 years. Stillbirth or death was not observed. At delivery, the weight, length, and head circumference of the 176 infants exposed to protease inhibitors were similar to those of the control group. During the first 2 years of life, premature infants were in the lower percentiles of growth; however, they followed normal Centers for Disease Control and Prevention growth curves matched for age and sex.

CONCLUSION

Significantly higher rates of prematurity and low birth weight were not demonstrated in infants exposed in utero to HAART with protease inhibitors. Moreover, these children reached normal growth percentiles during the first 2 years of life.

Reversal of growth failure in HIV-infected Thai children treated with non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy

Growth failure is a common problem in HIV-infected children. The extent to which this growth failure could be reversed after the children receive antiretroviral therapy (ART) is not known. This study assessed the incidence of growth failure in HIV-infected Thai children, impact of ART on growth, and the predictors of growth reversal after initiating ART. Growth parameters and other characteristics were extracted from the database of a prospective cohort of HIV-infected children (age <or=15 years) who were enrolled to initiate non-nucleoside reverse transcriptase inhibitor-based ART between August 2002 and May 2007. Body weight and height measurements, CD4 cell counts, plasma HIV RNA levels were collected at baseline and 24-week intervals. A total of 225 HIV-infected children were included, 116 (51%) were males. The median age at baseline was 7.4 years (interquartile range [IQR] 5.2-9.8). Fifty-three percent were in Centers for Disease Control and Prevention (CDC) category C and 54% had CD4 percentage 5 or less. The mean (standard deviation [SD]) of baseline weight-for-age (WAZ) and height-for-age (HAZ) z-scores were -2.02 (1.17) and -2.22 (1.51). The median follow-up time was 216 weeks (IQR 120-240). The cumulative probability of growth reversal among the 179 subjects with growth failure at entry was 58% (95% confidence interval [CI] 49-67) at week 240. In a multivariate Cox regression model, higher entry WAZ (p < 0.001) and HAZ (p < 0.001), use of a nevirapine-based regimen (compared to efavirenz, p = 0.027) and larger CD4% gains to week 48 (p < 0.001) were significant predictors of growth reversal after initiating ART. NNRTI-based ART leads to a substantial improvement in growth of HIV-infected children. Initiation of ART before the children developed growth failure should be encouraged.

The use of exercises in the treatment of scoliosis: an evidence-based critical review of the literature

The loss of flexibility in a spinal curvature defines it as a structural spinal deformity; a curvature sufficiently mobile to resolve with a change in posture is a non-structural or 'functional' scoliosis which is within the normal limits of movement for a human spine. It, therefore, seems logical that exercise-based therapies designed to improve and/or maintain flexibility and range of motion of the spine and thorax would be useful in the treatment of scoliosis. Recognition of the importance of maintaining flexibility of the thoracic spinal column to avoid scoliosis-associated pulmonary dysfunction made the use of exercise-based therapies a topic of clinical interest in ancient Greece. In recent years, successful prevention of polio epidemics has resulted in a stable change in patient populations such that most individuals diagnosed with scoliosis do not suffer from irreversible central nervous system compromise. As a result, realistic opportunities to examine the role of exercise in treatment of scoliosis are available for the first time in history. A growing body of evidence from independent sources is consistent with the hypothesis that exercise-based approaches can be used effectively to reverse the signs and symptoms of spinal deformity and to prevent progression in children and adults.

The brainstem and serotonin in the sudden infant death syndrome

The sudden infant death syndrome (SIDS) is the sudden death of an infant under one year of age that is typically associated with sleep and that remains unexplained after a complete autopsy and death scene investigation. A leading hypothesis about its pathogenesis is that many cases result from defects in brainstem-mediated protective responses to homeostatic stressors occurring during sleep in a critical developmental period. Here we review the evidence for the brainstem hypothesis in SIDS with a focus upon abnormalities related to the neurotransmitter serotonin in the medulla oblongata, as these are the most robust pathologic findings to date. In this context, we synthesize the human autopsy data with genetic, whole-animal, and cellular data concerning the function and development of the medullary serotonergic system. These emerging data suggest an important underlying mechanism in SIDS that may help lead to identification of infants at risk and specific interventions to prevent death.

Maternal and infant characteristics associated with prone and lateral infant sleep positioning in Washington state, 1996-2002

OBJECTIVE

To identify factors predictive of either lateral or prone infant sleep positioning.

STUDY DESIGN

We used data for 11340 mother-infant pairs from the Pregnancy Risk Assessment Monitoring System for infants born in Washington State, 1996 to 2002. We used predictive modeling to identify statistically significant (P < .05) predictors of lateral and prone sleep positioning.

RESULTS

Factors associated with both high-risk sleep positions included infant's year of birth, maternal race and ethnicity, maternal county of residence, and maternal parity. Mother's being US-born (versus foreign-born) and male infant sex were predictive only of prone sleep positioning. Having Medicaid as primary insurance, receipt of government benefits, low infant gestational age, and low birth weight were predictive only of lateral sleep positioning.

CONCLUSIONS

Factors predictive of either high-risk sleep position should be considered when devising public health intervention strategies for the prevention of SIDS.

Growth parameters in HIV-vertically-infected adolescents on antiretroviral therapy in Rio de Janeiro, Brazil

BACKGROUND

Growth failure in HIV-infected children is an important factor in either initiating or changing antiretroviral therapy (ART). This study assesses the impact of HIV infection on growth parameters of adolescents who acquired HIV vertically.

METHODS

This retrospective, longitudinal study involved adolescents aged 10-20 years with vertically-acquired HIV infection who were followed up in one of the three main referral centres for paediatric HIV/AIDS in Rio de Janeiro, Brazil. Length, weight and variables related to demographic, clinical and laboratory issues were analysed.

RESULTS

108 subjects were enrolled. Median age was 12.7 years, median duration of follow-up was 97.2 months and 61 (56.5%) were female. The difference between the baseline and final weight Z-scores was -0.31 (p=0.02). Patients with final weight Z-scores < or = -2 used more ART regimens (average 4.13) than those with Z-scores > -2 (average 2.90, p<0.01) and also had a lower final CD4+ cell percentage--average 19% vs 24% (p<0.01), respectively. The difference between baseline and final-height Z-scores was -0.27 (p<0.01). Several factors were associated with a final-height Z-score < or = -2: clinical stage C during follow-up (RR 1.60, 95% CI 1.11-2.31), chronic diarrhoea during follow-up (RR 2.02, 95% CI 1.04-3.90), HAART use (RR 1.41, 95% CI 1.16-1.71), number of ART regimens (p<0.01) and final CD4+ cell percentage (p<0.01). In multivariate analysis, presentation in clinical stage C during follow-up was the only significant variable (OR 4.04, 95% CI 1.23-13.28).

CONCLUSION

Even on HAART, HIV-infected adolescents have lower growth parameters than the normal population and this is associated with a worse prognosis.

Factors associated with bed sharing and sleep position in Thai neonates

BACKGROUND

Sleep in a supine position and in a bed separate from but proximate to adults is recommended, in several Western countries, to prevent Sudden Infant Death Syndrome (SIDS). Cultural differences and a lower rate of SIDS in Asian populations may affect concern with this problem and thus infant sleeping arrangements. Objective To study bed sharing and sleep position in Thai neonates and the relationship to infant and maternal characteristics.

METHODS

A cross-sectional survey based on interviews with parents of infants aged 21 days old, was conducted under the Prospective Cohort Study of Thai Children.

RESULTS

Of the total sample, 2236/3692 (60.6%) infants shared a bed with their parents. Sixty per cent of the parents placed their infants to sleep in a supine position, 32.2% on their side and 4.9% in a prone position. Bed sharing was associated with older maternal age, higher education, Muslim mother, and with work status of professional career or unemployed. Placing the infants to sleep in a prone position was associated with infant birth weight of greater than 2500 g, older maternal age, higher education, Buddhist mother, mother with professional career and middle-class household economic status.

CONCLUSIONS

Infant bed sharing is a common practice in the Thai culture, as in other Asian countries. The prone sleep position is less common than in Western populations. The main factor associated with both bed sharing and putting infants to sleep in the prone position was a higher maternal socioeconomic status (SES), in contrast to previous studies in some Western countries in which both practices were associated with low maternal SES. Cultural differences may play an important role in these different findings.

Characteristics of 2733 cases diagnosed with deformational plagiocephaly and changes in risk factors over time

OBJECTIVES

To describe infant and maternal characteristics among infants with plagiocephaly and to quantify time trends in potential risk factors for plagiocephaly.

DESIGN

Case-only study. We described the characteristics of individuals born between 1987 and 2002. We also compared characteristics of individuals born from 1987 through 1990, before the American Academy of Pediatrics 1992 sleep-position recommendations, with those of individuals born from 1991 to 2002.

SETTING

Children's Craniofacial Center at Children's Hospital and Regional Medical Center in Seattle, Washington.

PARTICIPANTS

Subjects included 2733 infants diagnosed with deformational plagiocephaly or brachycephaly before 18 months of age who were born from 1987 to 2002.

MAIN OUTCOME MEASURE

Descriptive statistics, odds ratios, and 95% confidence intervals.

RESULTS

Among individuals born from 1991 to 2002, 91.6% had occipital-only flattening, 17.2% were brachycephalic, 67.7% were boys, and 9.9% were multiple birth infants. As compared with individuals born from 1987 through 1990, those born from 1991 to 2002 were more apt to be a multiple birth (odds ratio [OR] 3.4, 95% confidence interval [CI]: 0.8, 14.1) and to have a mother > or =35 years of age (OR, 3.2; 95% CI, 1.4 to 7.3); they were hospitalized less commonly at birth for 4 or more days (OR, 0.02; 95% CI, 0.01 to 0.06).

CONCLUSIONS

Several risk factors for plagiocephaly were more common among individuals born after the 1992 American Academy of Pediatrics sleep-position recommendations. These results are consistent with the explanation that supine sleeping modifies the association between such risk factors and plagiocephaly. Further studies with a control group are needed to validate this conclusion.

Growth in HIV-infected children receiving antiretroviral therapy at a pediatric infectious diseases clinic in Uganda

Antiretroviral therapy (ART) improves growth and survival of HIV-infected individuals. We designed a retrospective cohort study to assess clinical factors associated with growth in HIV-infected children on ART in Uganda between July 2003 and March 2006. Height and weight measurements taken pre- and post-ART initiation for at least 6 months were age- and gender-standardized to CDC 2000 reference. We analyzed medical records of 749 children receiving ART. Descriptive and logistic regression analyses were conducted to identify covariates associated with risk of either stunting or being underweight. Longitudinal regression analysis with a mixed model using autoregressive covariance structure was used to compare change in height and weight before and after initiation of ART. The mean age of the study population at first visit was 7.5 years. Mean height-for-age, weight-for-age, and weight-for-height percentiles at first visit were 8.6, 7.7, and 7.9, respectively. At last visit mean height-for-age, weight-for-age, and weight-for-height percentiles were 8.6, 13.3, and 13.8, respectively. Baseline weight-for-age z score of 1 or more was protective against stunting (odds ratio [OR] 0.25, confidence interval [CI] 0.18-0.35) while baseline height-for-age z score of 1 or more was protective against becoming underweight (OR 0.75, CI 0.63-0.88). Children in World Health Organization (WHO) stages II, III, and IV at baseline were 1.5 times more likely to become underweight (OR 1.51, CI 1.07-2.14). Initiation of ART resulted in improvement in mean standardized weight-for-age z score and weight-for-age percentiles (p < 0.001). Weight-for-age percentile and z score improved significantly after initiation of ART. This pediatric population gained weight more rapidly than height after initiation of ART.

Education and nutritional status of orphans and children of HIV-infected parents in Kenya

We examined whether orphaned and fostered children and children of HIV-infected parents are disadvantaged in schooling, nutrition, and health care. We analyzed data on 2,756 children aged 0-4 years and 4,172 children aged 6-14 years included in the 2003 Kenya Demographic and Health Survey, with linked anonymous HIV testing, using multivariate logistic regression. Results indicate that orphans, fostered children, and children of HIV-infected parents are significantly less likely to attend school than non-orphaned/non-fostered children of HIV-negative parents. Children of HIV-infected parents are more likely to be underweight and wasted, and less likely to receive medical care for ARI and diarrhea. Children of HIV-negative single mothers are also disadvantaged on most indicators. The findings highlight the need to expand child welfare programs to include not only orphans but also fostered children, children of single mothers, and children of HIV-infected parents, who tend to be equally, if not more, disadvantaged.

Barriers to following the supine sleep recommendation among mothers at four centers for the Women, Infants, and Children Program

OBJECTIVES

The risk for sudden infant death syndrome in black infants is twice that of white infants, and their parents are less likely to place them in the supine position for sleep. We previously identified barriers for parents to follow recommendations for sleep position. Our objective with this study was to quantify these barriers, particularly among low-income, primarily black mothers.

DESIGN/METHODS

We conducted face-to-face interviews with 671 mothers, 64% of whom were black, who attended Women, Infants, and Children Program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut. We used univariate analyses to quantify factors that were associated with choice of sleeping position and multivariate logistic regression to calculate adjusted odds ratios for the 2 outcome variables: "ever" (meaning usually, sometimes, or last night) put infant in the prone position for sleep and "usually" put infant in the supine position to sleep.

RESULTS

Fifty-nine percent of mothers reported supine, 25% side, 15% prone, and 1% other as the usual position. Thirty-four percent reported that they ever placed infants in the prone position. Seventy-two percent said that a nurse, 53% a doctor, and 38% a female friend or relative provided source of advice. Only 42% reported that a nurse, only 36% a doctor, and only 15% a female friend or relative recommended the supine position for sleep. When a female friend or relative recommended the prone position, mothers were more likely ever to place their infants in the prone position and less likely usually to choose supine compared with those who received no advice from friends or relatives. When a doctor or a nurse recommended a nonsupine position, the mothers were less likely to choose supine compared with those who received no advice from a doctor or a nurse. Mothers who trusted the opinion of a doctor or a nurse about infant sleeping position were more likely to place their infants in the supine position. Half of the mothers believed that infants were more likely to choke when supine, and they were less likely to place their infants supine. Mothers who believed that infants are more comfortable in the prone position (36%) were more likely to place their infants prone. Twenty-nine percent believed that having their infants sleep with an adult helps prevent sudden infant death syndrome, and only 43% believed that sudden infant death syndrome is related to sleeping position.

CONCLUSIONS

We identified specific barriers to placing infants in the supine position for sleep (lack of or wrong advice, lack of trust in providers, knowledge and concerns about safety and comfort) in low-income, primarily black mothers that should be considered when designing interventions to get more infants onto their back for sleep.

Knowledge of sudden infant death syndrome prevention strategies in a multicultural, disadvantaged community

AIM

This study assessed levels of maternal knowledge of sudden infant death syndrome prevention strategies in a socio-economically disadvantaged, culturally diverse population.

METHODS

Pregnant women (n=233) were asked to name three things they could do to reduce the risk of cot death. Answers were marked in accordance with the US National Institute of Child Health and Development guide-lines.

RESULTS

Of women 51.5% could correctly name two or more strategies that could reduce the risk of sudden infant death syndrome. There was significant difference by the woman's country of birth: 68.2% of Australian-born women were able to correctly identify two or more strategies, compared with only 37.3% of those born overseas (P<0.001). Most of the small number of Indigenous women included in the study were able to correctly identify two or more strategies. Year of arrival in Australia, number of previous children, age and level of education were not significantly related to women's knowledge.

CONCLUSION

Knowledge of sudden infant death syndrome prevention strategies was poorer in overseas-born women. Practitioners working with disadvantaged, overseas-born women should give consideration to women's knowledge of sudden infant death syndrome prevention if current low rates of sudden infant death syndrome deaths are to be maintained.

Infection, inflammation, height, and longevity

Using historical data from cohorts born before the 20th century in four northern European countries, we show that increasing longevity and declining mortality in the elderly occurred among the same birth cohorts that experienced a reduction in mortality at younger ages. Concurrently, these cohorts also experienced increasing adult height. We hypothesize that both the decline in old-age mortality and the increase in height were promoted by the reduced burden of infections and inflammation. Thus, early growth and cardiovascular diseases of old age may share infectious and inflammatory causes rooted in the external environment.

Deformational plagiocephaly: diagnosis, prevention, and treatment

The "Back to Sleep" campaign has dramatically decreased the incidence of sudden infant death syndrome; however, its sequelae of deformational plagiocephaly have today reached epidemic proportions. In the last decade, we have learned to distinguish deformational plagiocephaly clinically from craniosynostosis, thereby preventing its unnecessary surgical correction. Primary care providers must increasingly be aware of this condition and, in turn, educate new parents about its prevention. Should preventative measures fail and infants develop persistent sleep patterns that result in craniofacial deformities, deformational plagiocephaly can be treated successfully with behavior modification or cranial molding-helmet therapy.