- SIDS —
- sudden infant death syndrome
We all think we give good advice, and we think we do it well. We’ve mastered the anticipatory guidance section of the well-child or nursery visit. We have our formula: we cover the salient topics, throw in some personal experience, and assume our parental advice on child rearing has been received and understood. Unfortunately, as shown by Eisenberg et al1 in this issue of Pediatrics, we appear to be failing miserably. Mothers received correct advice from doctors about sleep position only 54% of the time and about sleep location only 19% of the time. Even if doctors gave correct advice more frequently than reported, information cannot protect infants if mothers do not hear, believe, and act on it.
Why does this matter? Is our advice really that important? In the case of sleep position and location, it can be a matter of life or death. Every day in the United States, healthy infants are dying in unsafe sleep environments. According to the Centers for Disease Control and Prevention, 3434 infants died suddenly and unexpectedly in 2013.2 Child death review has revealed that the vast majority of these infants die in an unsafe sleep environment: prone, in an adult bed, with soft bedding or mattresses, or co-bedding.3
Efforts to change the infant sleep environment culture began in the early 1990s with the “Back to Sleep” campaign. Initially promising reductions in the rate of sudden infant death syndrome (SIDS) plateaued as enhanced death scene investigations and child fatality review better elucidated the risk of an unsafe sleep environment.4 SIDS diagnoses decreased but “accidental strangulation and suffocation in bed” and “unknown” causes (a common determination when the cause of death could have been SIDS or accidental strangulation and suffocation in bed) have increased.4
Enhanced understanding of the circumstances surrounding infant sleep environment–related deaths showed that the common “back to sleep” message is about as effective as “buckle up,” which we know is not nearly specific enough to prevent motor vehicle crash injuries to infants.5 Advice needs to be clear and actionable. The correct message: “Place the infant alone, on their back, and in a crib or bassinette to sleep” is actionable and necessary, but is it sufficient? Previous research suggests that, although parents may be informed and satisfied by pediatricians’ advice, changing safety-related behaviors requires attention to socioecological factors.6
Even if parents understand and believe this message, they may be exposed to peers, family members, and other providers who do not. In addition, contradictory and unsafe messages abound in social media and infant product marketing. Until a unified public health message about safe sleep (such as the National Institute of Child Health and Human Development’s “Safe to Sleep” campaign)7 becomes engrained in societal norms via culture change (as has the use of car seats) individual-level messaging by pediatricians will not be sufficient to prevent healthy infants’ deaths. As Eisenberg et al note, a multimodal approach involving the medical community, public health, policy makers, and media will be more effective.1
A promising approach to help the medical community galvanize a consistent message is to create an interprofessional culture of sleep safety in the newborn nursery. Nurses in newborn nursery settings who integrate safe-sleep behaviors in their practice can be powerful change agents.8 If everyone who interacts with the family of a newborn consciously focuses on safe-sleep education, models safe-sleep practices, and encourages mental rehearsal of safe-sleep negotiation, the message is more likely to sink in. A recent study of comprehensive safe-sleep education presented via videos, brochures, and formal and informal teaching by nurses and doctors in 2 nurseries increased retention of safe-sleep knowledge at 4 months compared with the National Infant Sleep Prevention baseline.9 Ensuring that intensive efforts like this become the norm at hospitals, prenatal visits, and well-child visits would go a long way toward changing sleep-safety culture.
The study by Eisenberg et al1 is a wake-up call for all pediatricians. We can and must do a better job of engaging fully in evidence-informed, culturally appropriate public discourse that transforms social norms about the necessity of providing a safe sleep environment for infants.
- Accepted May 20, 2015.
- Address correspondence to Scott D. Krugman, MD, MS, Chairman, Department of Pediatrics, MedStar Franklin Square Medical Center, 9000 Franklin Square Dr, Baltimore, MD 21237. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page e315, online at www.pediatrics.org/cgi/doi/10.1542/peds.2015-0551.
- Eisenberg SR,
- Bair-Merritt MH,
- Colson ER,
- Heeren TC,
- Geller NL,
- Corwin MJ
- 2.↵Centers for Disease Control and Prevention. Sudden infant death fact sheet. Available at: www.cdc.gov/sids/pdf/sudden-unexpected-infant-death.pdf. Accessed May 18, 2015
- 3.↵Michigan Child Death State Advisory Team. Child deaths in Michigan: Tenth Annual Executive Report. 2011. Available at: www.michigan.gov/documents/dhs/CD2011_MPHI_CPfinal_Print_km_2_413237_7.pdf. Accessed May 18, 2015
- Moon RY
- 7.↵National Institute of Child Health and Human Development. Safe to Sleep campaign. Available at: www.NICHD.NIH.gov/sts. Accessed May 18, 2015
- Goodstein MH,
- Bell T,
- Krugman SD
- Copyright © 2015 by the American Academy of Pediatrics