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ISSN: 2161-0711
Journal of Community Medicine & Health Education
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Parental Adherence to Infant Sleep Safety Recommendations

Martine Hackett1* Hannah Simons2

1Department of Health Professions, Hofstra University, Hempstead, New York, USA

2The Graduate Center, CUNY, Doctor in Public Health Program, New York, USA

Corresponding Author:
Dr. Martine Hackett
Department of Health Professions
Hofstra University, 130 Hofstra Dome 220
Hempstead, NY 11549, USA
Tel: +5164636513
Fax: +516-463-6275
E-mail: [email protected]

Received Date: May 30, 2013; Accepted Date: June 17, 2013; Published Date: June 19, 2013

Citation: Hackett M, Simons H (2013) Parental Adherence to Infant Sleep Safety Recommendations. J Community Med Health Educ 3:219. doi: 10.4172/2165-7904.1000219

Copyright: © 2013 Hackett M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Objective: Key infant sleep safety messages to prevent sudden infant death syndrome (SIDS) recommend putting infants to bed in the supine position and not sharing a bed with infants in order to prevent them from suffocating. Though these messages have been promoted by health care providers and health educators, adhering to them regularly remains a challenge for parents.
Methods: Using a web-based survey on a national sample, factors associated with increased probability of adherence were examined to assess how parents negotiate infant safety recommendations.
Results: Findings revealed that parents had knowledge of these recommendations but did not always follow them; adherence depended on how effective parents believed the recommendations are at preventing death and how the messages were presented.
Conclusion: Health care providers and educators of infant safety should continue to focus on changing the public’s beliefs about the risks of the prone position and bed sharing, with an understanding of how and why the information about infant sleep safety is negotiated in the day to day lives of parents.


SIDS; Bed sharing; Adherence; Communication; Infant safety


Infant sleep safety is a significant concern for parents, health care providers, and health educators during the perinatal period. Infant deaths due to sudden infant death syndrome (SIDS) account for over 2000 deaths per year-the third leading cause of infant mortality in the United States [1] and infant deaths due to sleep-related suffocation and undetermined causes have quadrupled over the past two decades in the United States [2]. Risk factors for SIDS include exposure to second hand smoke, overheating, the prone sleep position [3], excess bedding, and not using a safety-approved sleep surface. A primary risk factor of sleep-related suffocation or undetermined causes of infant death is sharing a sleep surface with an adult, which is thought to lead to death in 64% of 3136 sleep related sudden unexpected infant deaths in a national study [4]. Infant sleep safety messages for parents to reduce the risk of SIDS began with the national Back to Sleep campaign in 1994, which advised that infants be put to bed in the supine position. The campaign contributed significantly to a 50% decline of SIDS deaths over the course of a decade [5]. Sleep related suffocation is a more recent infant sleep safety concern, though the American Academy of Pediatrics (AAP) has been discouraging parent-infant bed-sharing since 2005. In 2011, the Taskforce on SIDS guidelines were expanded to state that bed-sharing in an adult bed puts infants at risk due to suffocation, asphyxia, and falls, and that “there is insufficient evidence to recommend any bed-sharing situation in the hospital or at home as safe” (p. e1351) [6]. Although these infant sleep safety messages have been promoted by pediatric health care providers and health educators and despite widespread media campaigns, bed-sharing remains a common practice that is increasing in prevalence [7] and rates of infants sleeping in the supine position have not decreased for over ten years in the United States [8]. Retrospective death-scene reviews of the sleeping conditions of infants found dead of SIDS or sleep-related suffocation revealed that most of them were in the prone position or were bed-sharing, reflecting a lack of adherence to sleep safety messages [9]. Indeed, a national study found that more than one third of mothers were non-compliant with safe sleep guidelines when their infants were 3 months old, an age when most infants are most vulnerable to sleep-related deaths [10].

Previous studies have examined some of the reasons why parents and caregivers were not following infant sleep safety messages. Through a variety of methodological approaches, including surveys, interviews, and focus groups, some of the reasons identified include fear that infants will choke if they vomit while sleeping on their backs [11]; uncertainty about the true cause of SIDS [12]; the belief that infants are more comfortable in the prone vs. supine position [13,14] and infant preference for the prone position [15]. Another possible reason why fewer parents put their infants to bed in the supine sleep position could be attributed to the success of the Back to Sleep campaign-since fewer infants are dying of SIDS over the past 20 years, fewer parents know or have heard about a family that has suffered a loss, lowering the perceived risk of death [16].

Other quantitative and qualitative studies in the United States have identified reasons why parents choose to bed-share with their infants. These reasons include the facilitation of breastfeeding infants during the night [17], to increase family bonding according to the attachment parenting philosophy that recommends consistent physical closeness between mothers and infants in several forms including bed sharing in a “family bed” [18], or cultural traditions. Additionally, inner-city mothers who are single, <18 years of age, and who move frequently were found to be more likely to bed-share [19].

Many studies on barriers to infant sleep postulate that increasing or targeting educational messages to parents and caregivers about the supine sleep position and addressing concerns of infant comfort and infant preferences [13,20] would address the issue of non-adherence and possibly induce parents to change their behavior. Increased education is also suggested as a way to persuade parents to comply with recommendations against bed-sharing [12].

However, additional education or more carefully worded messages alone is an insufficient approach to increase adherence to recommended behaviors for infant sleep safety in an environment where parents are presented with competing information. Contemporary parents have access to an overwhelming amount of information that they must understand and negotiate into their lives when caring for a new infant. In addition to the sheer amount of information available, infant sleep safety recommendations from media sources may also contradict recommendations from health care providers and health educators. Studies have found that the influence of magazine advertisements [21] and incorrect information found in Google searches [22] may contribute to the mixed messages parents receive and influence how they negotiate safe sleep recommendations. Parents would also negotiate safe sleep messages once they are knowledgeable about them. Chung-Park found those parents’ opinions of safe sleep positions and their practices were significantly associated with their behaviors, but not their knowledge of the recommendation [23]. For this reason, we sought to better understand how parents negotiate and make sense of the meaning of sleep-related health recommendations. This paper examines how parent’s knowledge, attitudes, and practices of safe sleep may influence their adherence to the recommended behaviors for infant sleep position and bed-sharing.


Overall study design

A cross sectional study was conducted with a self-administered internet accessed survey through the survey site in September 2009 among a sample of adults from across the United States. A web-based survey was selected as the method to gather data because it has been found to be as reliable as phone-based surveys [24] and because it is able to capture parents who were comfortable with using technology to give and receive information and who were more likely to obtain information about infant care from a variety of sources. The sample was drawn from a quality-assured panel of more than 2 million people maintained by Market Tools TrueSample who opted to be members of the panel. Those who met the attributes for participating in the survey (i.e., parents of children aged<12) were sent invitations by e-mail to participate in the survey, screened to meet the criteria for participation, and then sent a link to the survey. Participants who completed the survey received an incentive of points redeemable at the Zoomerang site. The survey took approximately 10 to 15 min to complete and the survey was voluntary, anonymous, and confidential. Responses of 312 individuals were analyzed.

Study subjects

Participants were mostly White (85%) and female (64%), with half of the respondents between 18 and 39 (49.5%) and half over 40 years old (50.5%). Most had college education (76%). More than half (53%) had a child younger than 5 years old at the time of the survey (Table 1).

Variables Number %
High School graduate/GED or less 76 24.1
Higher than High School 239 75.9
Employment status    
Employed 121 38.9
Unemployed 190 61.1
Income (US$)    
$50 K and under 169 53.7
Above $50 K 146 46.4
Age (years)    
18–39 155 49.5
40 and above 158 50.5
Age of youngest child (years)    
5 and below 169 53.7
Above 5 146 46.4
White 266 85.3
Black 14 4.5
Hispanic 15 4.8
Asian/Pacific-Islander 11 3.5
Native American/Alaska native 2 0.6
Mixed racial background 4 1.3
Male 112 36.5
Female 195 63.5

Table 1: Demographic characteristics of respondents.


The main dependent variables were adherence to the two infant sleep recommendations-putting an infant to sleep on his/her back and avoiding bed-sharing (dichotomized into adherent vs. nonadherent). For adherence to the sleep position recommendation, survey respondents were asked: “Is there any reason why you would not put your baby to sleep on his or her back? (check all that apply).” The following response categories were used: “family members recommended another position”; “the baby didn’t like sleeping on his/ her back”; “you got conflicting advice, the nurse/doctor recommended another position”; “I would only ever put the baby to sleep on his/her back”; and “other.” If the respondent’s only response was “I would only ever put the baby to sleep on his/her back,” then the respondent was categorized as adherent. Respondents who checked any other response category or combinations of categories were categorized as non-adherent. For adherence to the bed-sharing recommendation, survey respondents were asked: “Under what circumstances have you/ would you most likely sleep with your baby in his/her first 3 months?” Response categories included: “the baby was sick”; “the baby was being breastfed”; “the baby just came home from the hospital”; “I would never sleep with my baby before 3 months”; and “other.” Those who indicated only that they would never sleep with a baby younger than 3 months old were categorized as adherent. Those who indicated all other responses were categorized as non-adherent.

The independent variables were knowledge, attitudes, and practices (KAP) regarding safe sleep and demographic factors. Our main independent variables were measures of safe sleep KAP. These included knowledge of safe sleep position (yes vs. no), primary source(s) of advice about infant sleep (doctor, nurse, family, media, other), belief that sleeping on the back prevents infant death (yes. vs. no), frequency of bed-sharing (never, some of the time, all of the time), perception of infant suffocation risk (likely, possible, possible but usually only if adults had been drinking/taking drugs or are obese, very unlikely, other), and feelings about current bed-sharing recommendation (too strict for parents to follow all of the time, not really necessary because of small risk of suffocation, should not apply to babies who are breastfeeding, other). Demographic factors included parental education (high school degree or less vs. higher than high school degree), employment status (employed vs. unemployed), income ($50,000 and over vs. under $50,000), age (18–39 years vs. 40 years and over), age of youngest child (5 years and older vs. under 5 years), race (White, Black, Hispanic, Asian-Pacific Islander, Native American/Alaskan native, Mixed race), and gender (male vs. female).

We first conducted univariate analyses to describe the distributions of our study variables among the survey sample. Bivariate analysis using binary logistic regression was conducted to determine the associations between our main independent variables, safe sleep KAP, and adherence to the two infant sleep recommendations. Odds ratios were calculated with their respective 95% confidence intervals. Odds ratios that did not include 1.0 in the confidence interval were considered statistically significant at the alpha-level of .05. Statistical analysis was conducted with SAS v. 9.2 (SAS Institute, Cary, NC).


Frequencies of sleep knowledge, attitudes, and practices

Less than half (45.8%) of the respondents knew that the supine position was recommended for infants to be put to sleep in, and 54% did not know or were not sure. Knowledge of the bed-sharing recommendation was higher, with 75% of the respondents agreeing that it is likely or possible that infants who sleep in the same bed with their parents can suffocate. The attitudes of the respondents to the recommendations were assessed by asking the reasons why they would not follow the preferred behavior. The reasons cited for not following the Back to Sleep recommendations were that the baby did not like sleeping on its back (21%) and that they received conflicting advice (13%). One third (33.7%) of the respondents reported that they did not follow the Back to Sleep recommendation because a nurse or doctor recommended another position. Parents would share a bed with their infants if they were breastfeeding (25%) or if the baby was sick (22%). Additional reasons for not following the recommendation against bed sharing were that the baby just came home from the hospital (9.9%) and “other” reasons included the baby crying (6%) (Table 2).

Variable Number %
The supine sleep position prevents infant death    
Yes 143 45.8
No 40 12.8
Not sure 129 41.4
Risk of suffocation    
It is likely that babies will suffocate if they sleep with their parents 93 29.7
It is possible, but it’s a very small risk 144 46.0
It is possible, but usually only if the adults had been drinking, taking drugs, or are obese 35 11.2
It is very unlikely that this will happen 35 11.2
Other 6 1.9
Reasons for not following recommendation (adherence to sleep position recommendation)    
Family members recommend another position (yes) 16 5.1
The baby didn’t like sleeping on his/her back (yes) 67 21.3
You got conflicting advice (yes) 41 13.0
The nurse/doctor recommended another position (yes) 106 33.7
I would only ever put the baby to sleep on his/her back (yes) 101 32.1
Reasons for bed-sharing (adherence to bed-sharing recommendation)    
The baby was sick 70 22.2
The baby was being breastfed 80 25.5
The baby just came home from the hospital 31 9.9
I would never sleep with my baby in the first 3 months 113 36.0
Other 20 6.4
Sleep position recommendation    
Adherent 201 65.8
Non-adherent 114 36.2
Bed-sharing recommendation    
Adherent 113 36.0
Non-adherent 201 64.0

Table 2: Frequencies for sleep knowledge, attitudes, and practices.

Whether parents practiced the sleep-related recommendations were assessed into adherence/non-adherence. Most respondents adhered to the recommendation of putting infants to sleep on their backs (64% vs. 36%). On the other hand, respondents adhered less to the advice against bed-sharing, with 36% following the recommendation and 64% not.

Correlates of adherence to infant sleep position recommendation

Several infant sleep KAP factors were significantly associated with adherence to the recommendation regarding infant sleep position. Respondents who agreed that the supine position prevented sudden infant deaths were more likely to adhere than those who were not persuaded by the information (OR = 2.92, 95% CI: 1.80–4.79). Similarly, those who were knowledgeable about the recommended sleep position were nearly 2.5 times more likely to adhere than those who were unaware of the recommended position (OR = 2.44, 95% CI: 1.50–3.97). Compared to those whose primary source of advice was a doctor, those who indicated family as the primary source were significantly less likely to adhere (OR = 0.22, 95% CI: 0.12–0.41) (Table 3).

Variable Adherent (n = 201) Non-adherent (n = 113) OR (95% CI)
Knowledge of sleep position (yes) 149 (74.1) 61 (54.0) 2.44 (1.50–3.97)**
Source of advice      
Doctor 108 (54.0) 36 (32.1) REF
Nurse 22 (11.0) 16 (14.3) 0.46 (0.22–0.967)*
Family 25 (12.5) 38 (33.9) 0.22 (0.12–0.41)***
Media 40 (20.0) 14 (12.5) 0.95 (0.47–1.50)
Other 5 (2.50) 8 (7.1) 0.21 (0.06–0.68)**
The supine sleep position prevents infant death (yes) 110 (55.0) 33 (29.5) 2.92 (1.80–4.79)***

Table 3: Cross-tabulations for adherence to infant sleep position recommendation.

Correlates of adherence to bed-sharing recommendation

Several infant sleep KAP factors were significantly associated with adherence to the bed-sharing recommendation. Those who perceived a low risk of suffocation were less likely to adhere than those who felt otherwise (OR = 0.29, 95% CI: 0.17–0.50; = 0.09, 95% CI: 0.03–0.26; OR = 0.11, 95% CI: 0.04–0.31). Participants who reported bed-sharing some or all of the time were significantly less likely to adhere to the bedsharing recommendation than those who never bed-shared (OR = 0.07, 95% CI: 0.04–0.13; OR = 0.03, 95% CI: 0.01–0.15). Those who indicated that the bed-sharing recommendation was too strict were significantly less likely to adhere than those who felt that it was helpful for new parents (OR = 0.07, 95% CI: 0.02–0.24). Similarly, those who indicated that the recommendation was not necessary because the suffocation risk was small were also significantly less likely to be adherent (OR = 0.12, 95% CI: 0.04–0.36) (Table 4).

Variable Adherent (n = 113) Non-adherent (n = 201) OR (95% CI)
Frequency of bed-sharing      
Never 70 (62.0) 19 (9.55) REF
Some of the time 41 (36.3) 163 (81.91) 0.07 (0.04–0.13)***
All of the time 2 (1.8) 17 (8.54) 0.03 (0.01–0.15)***
Risk of suffocation      
Likely 56 (50.0) 37 (18.41) REF
Possible, but small 44 (39.3) 100 (49.75) 0.29 (0.17–0.50)***
Possible, but usually only if  the adults had been drinking/taking drugs or are obese 4 (3.6) 31 (15.42) 0.09 (0.03–0.26)***
Very unlikely 5 (4.5) 30 (14.93) 0.11 (0.04–0.31)***
Other 3 (2.7) 3 (1.49) 0.66 (0.13-3.45)
Feelings about current recommendation      
Too strict for parents to follow all of the time 3 (2.7) 44 (22.00) 0.07 (0.02–0.24)***
Not really necessary because of the small risk of suffocation 4 (3.54) 34 (17.00) 0.12 (0.04–0.36)***
Helpful information for new parents 99 (87.61) 105 (53.50) REF
Should not apply to babies who are breastfeeding 3 (2.65) 4 (2.00) 0.79 (0.17–3.64)
Other 4 (3.54) 13 (6.50) 0.32 (0.10–1.03)

Table 4: Cross-tabulations for adherence to bed-sharing recommendation.

Discussion and Implications for Practice

Most sleep-related infant deaths can be prevented by following the recommended practices consistently. Adherence to providing a safety approved, separate, clutter-free sleep environment and placing infants to sleep in the supine position should be observed every time infants below the age of 1 are sleeping, since suffocation or SIDS have no warning signs and are by their nature sudden and unexpected [6]. The findings of this study support previous research that suggested that educating parents about the supine position is an important starting point to ensure that parents adhere to the recommendation [25]. However, health educators are aware of the overwhelming amount of information that parents are presented with regarding care and protection of their infants during the perinatal period from web sites, social media, family, and friends. Parents must therefore constantly make sense of and incorporate this information into the daily practice of infant care. Health educators can facilitate this process by understanding how infant sleep safety messages are interpreted, understood, and negotiated by parents in order to increase adherence.

Belief in the advice

One way that parents interpret recommendations is whether they believe that what is recommended will be effective or if the risks apply to them. Previous research has found that parents’ belief in the efficacy and appropriateness of recommended advice about infant sleep position are crucial predictors of behavior [12-14,20,26]. This study supports the findings of those studies; we found that those who agreed that the recommendations in the Back to Sleep campaign could prevent infant deaths were 2.5 times more likely to put infants to bed in the supine position. This study also found a similar result for bed sharing; parents who perceived a low risk of their infants suffocating if they shared a bed were less likely to adhere to the no-bed-sharing recommendation. Health care providers can use these findings to explore parents’ beliefs about the connection between infant sleep position and SIDS risk reduction and their beliefs about the risks of suffocation posed by bed-sharing with their infants in order to explain why a recommendation is made and how these recommendations can protect the safety of their infants. A previous study by Moon et al. has also found that parents, particularly Black parents, question the connection between SIDS and the recommendations [12]. The authors recommended that health educators “explain a plausible link between SIDS and safe sleep recommendation and improve the consistency of the message” (p. 96) in order to increase adherence. For example, health care providers could explain how the supine position reduces the risk of SIDS and emphasize how successful this change in practice has been in reducing the rates of SIDS. Studies have recommended that education from providers should be comprehensive and address the multiple risk factors of SIDS [27]. Additionally, health care providers could discuss the mechanism of how an infant’s nose and mouth can be obstructed by loose bedding or the body of a parent when bed-sharing, which can cause the infant to asphyxiate, and that there is a risk to infant safety every time an infant is put to bed.

Credibility and how advice is presented

As parents negotiate infant sleep safety messages, there is a crucial factor that predicts their adherence: the quality of how the message is presented and by whom. Effective parent-provider communication is associated with adherence to treatment recommendations [28]. Previous research has found that the credibility of health advice influenced parents’ adherence to infant care practices designed to reduce SIDS [26] and that specific instruction by a nurse or doctor in the hospital about how to properly place the infant for sleep influenced behavior after the mother left the hospital [29]. The findings of this study indicate that parents who felt that the bed sharing recommendation was “too strict” were less likely to adhere than those who thought that the recommendation was “helpful.” Health care providers can help parents to negotiate safe sleep messages by being aware of how they are presenting the information and how it is being interpreted. Health care providers can also make safe sleep messages seem less strict by exploring how parents can integrate these recommendations into their lives and provide practical tips about how to negotiate around bed sharing if they are breastfeeding or how to negotiate Back to Sleep recommendations if the infant seems to prefer sleeping in the prone position.

Study Limitations and Conclusion

The study’s findings are limited by the sample size and the ability to generalize the findings of this study. The respondents were not representative of the population but were from a convenience sample; therefore, these findings could not be applied more broadly. In particular, Black parents and parents with low income were underrepresented in this sample. This study was also conducted before the new AAP guidelines were released and does not capture any changes that might have taken place as a result of the promotion of those safe sleep recommendations.

On the other hand, the strengths of this study are that it examines how knowledge, attitudes, and practices influence adherence to health promotion messages for infant safety. The creation and communication of health education recommendations should build on a more open acknowledgement of the public’s beliefs about risks and how they apply at an individual level. As they question and negotiate the information they are given, parents should be seen as partners in a dialogue with health care providers about reducing the risk of sleep-related infant deaths. In our current media landscape, understanding the fluidity with which parents interpret health messages while making decisions is increasingly necessary.

This study examined how parents interpret and understand infant sleep safety practices to place infants to sleep in the supine position and in a separate sleep surface. We found that parents’ understanding and interpretation of these messages can have an influence on how likely they are to follow the recommendations. Though knowledge about the recommendations is important for adherence, so are the parent’s beliefs about their risks and how well the recommendations will work to prevent infant death. Parents are constantly trying to make sense of how to implement the many messages they receive from pediatricians to keep their children safe. Health care providers and educators of infant safety should continue to focus on changing the public’s beliefs about the risks of the prone position and bed sharing, and consider how and why the information about infant sleep safety is negotiated in the day to day lives of parents.


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