Photo Credit: Jordi Magrans

Many mothers regularly engage in unsafe sleep practices with their infants, despite being aware of the American Academy of Pediatrics safe sleep guidelines.

“Over the past two decades in the United States, there has been no improvement in adherence to safe infant sleep guidelines,” Lara B. McKenzie, PhD, MA, FAAHB, notes. “Awareness of the American Academy of Pediatrics safe sleep guidelines—which are often called the ABCs of Safe Sleep, for Alone, Back, Crib—is high nationally, but mothers often struggle with following the guidelines and helping their infant fall and stay asleep.”

For a study published in Pediatrics, Dr. McKenzie and colleagues aimed to understand the “tension” mothers experience when trying to follow AAP guidelines on safe sleep and improving infant and parental sleep. The researchers conducted focus groups and surveys with US-based, English-speaking mothers of infants aged less than 6 months. Mothers were identified through social media, and all reported using an unrecommended sleep position and/or location two or more times in the previous week.

Physician’s Weekly (PW) spoke with Dr. McKenzie to learn more.

PW: What were the primary findings of your study?

Dr. McKenzie: Despite awareness of the ABCs, mothers regularly engage in practices that aren’t recommended in order to improve sleep for themselves and their infants.

Many prioritized more minor safety concerns, such as fall prevention, over the prevention of sudden infant death syndrome or sudden unexpected infant death (SUID). Some of the riskiest behaviors identified included placing infants on couches, pillows, in the parents’ bed, and in or on products not approved for infant sleep, including car seats, swings, and infant carriers worn on an adult’s body.

Five central themes emerged in the virtual focus group discussions:

• Universal knowledge of the AAP infant safe sleep guidelines (ie, the ABCs);
• Challenges regarding getting their infant to sleep and nap;
• Deviations mothers made from the ABCs to help their infants sleep;
• Mothers’ justifications and rationale for not following the ABCs; and
• Mothers’ low self-efficacy regarding getting their infant to sleep and back to sleep during the night while following the ABCs.

In general, mothers originally intended to follow the ABCs but deviated in an attempt to help their infant, and often themselves, “sleep better and longer.” They described placing their infants for sleep in the parents’ bed, on couches or other soft surfaces, in bouncers, swings, car seats, nursing pillows, or loungers. Those who believed that their infant disliked firm surfaces sought more comfortable surfaces. Mothers were confused that there were infant products for sale that seemed to be appropriate for sleep but not recommended (eg, infant loungers and nursing pillows), and they found these products tempting, particularly when they were sleep deprived.

Further, when infants fell asleep spontaneously in an unrecommended place, mothers let them remain there. Some mothers were more willing to deviate from the ABCs of Safe Sleep during naps because they were awake and believed they could closely monitor their infant.

How can these results inform counseling about safe sleep?

Pediatricians can use this information to help parents understand normative infant sleep and make it clear that sleep strategies that do not follow AAP guidelines may increase an infant’s risk for SUID. Parents should be educated about normal sleep hygiene and the risk for SUID—ie, the death of their infant—in an unsafe sleep environment.

Because the risk for SUID may not be tangible to parents, understandable terms such as “suffocation” may be more effective in communicating this risk. Interventions that teach parents about developmentally appropriate sleep patterns and strategies that promote infant sleep and self-soothing may increase adherence to safe sleep guidelines.

What other suggestions do you have for pediatricians?

As we identified in this study, the perception of poor infant and family sleep is one area that may significantly contribute to unsafe sleep practices. An intervention to set expectations and teach parents how to get their infant to sleep safely and for longer periods would likely help improve rates of adherence to safe sleep. Our findings suggest that effective safe sleep interventions that go beyond solely increasing knowledge about sleep safety may more effectively address identified barriers.