Infant Sleep Position Research Articles

NICU NURSES' KNOWLEDGE AND DISCHARGE TEACHING RELATED TO INFANT SLEEP POSITION AND RISK OF SIDS

Infants requiring neonatal intensive care are often placed prone during their acute illness. After hospital discharge the American Academy of Pediatrics (AAP) recommends supine sleep position to reduce the risk of Sudden Infant Death Syndrome (SIDS). Little is known about nursing knowledge and practice regarding best sleep positions for infants as they transition from neonatal intensive care to home. To explore and describe neonatal intensive care unit (NICU) nurses' knowledge and practice in the NICU, and to determine the content of parent instruction regarding infant sleep position at discharge. This survey was conducted in 2 phases. In Phase I, a questionnaire was designed and completed by 157 neonatal nurses currently practicing in Level III and IV NICUs in the state of New York. After content analysis of responses and item revisions, a panel of experts reviewed questionnaire items. Phase II involved completion of the final questionnaire by 95 NICU nurses in 4 additional hospitals. The combined results of Phase I and II are reported. Of 514 questionnaires distributed, 252 (49%) were completed and analyzed. During NICU hospitalization, nurse respondents identified prone position as the best general sleep position for preterm infants (65%) followed by either prone or side-lying (12%). The nurses' assessment of the infants' readiness for supine sleep position at the time of NICU discharge varied. Most nurses responded that preterm infants were ready to sleep supine anytime (29%), close to discharge (13%), when maintaining their body temperature in an open crib (25%), between 34 to 36 weeks postmenstrual age (PMA) (15%), after 37 weeks PMA (13%), and when the infant's respiratory status was stable (6%). Typical sleep positions chosen for full-term infants in the NICU were supine (40%), side or supine (30%), all positions (18%), side (8%), prone or side (3%), and prone (1%). Frequently cited reasons to place full-term infants to sleep prone were: reflux (45%), upper airway anomalies (40%), respiratory distress (29%), inconsolability (29%), and to promote development (17%). At NICU discharge, 52% of nurses instructed parents to place their infants in the supine position for sleep. The most common nonsupine sleep positions recommended by nurses at discharge were either supine or side (38%), and exclusive side positioning (9%). Nearly 95% of respondents identified a nonsupine sleep position as optimal for hospitalized preterm infants. Further, only 52% of neonatal nurses routinely provide discharge instructions that promote supine sleep positions at home. This study suggests that nursing self-reports of discharge teaching practices are inconsistent, and in some cases in direct conflict with the national "Back to Sleep" recommendations, which emphasize that the supine position is the safest position for healthy full-term and preterm infants after hospital discharge.

Statewide Quality Improvement Outreach Improves Preventive Services for Young Children

Although clinical trials demonstrate the efficacy of quality improvement outreach in improving service delivery, evidence for broad community effectiveness has been lacking. The objective of this study was to test the effectiveness of a statewide pediatric quality improvement outreach program in improving preventive services for children who are younger than 5 years. All pediatric practices in Vermont (n = 35) were invited to participate in a preventive services quality improvement initiative. Ninety-one percent agreed. Participating practices serve >80% of all Vermont children who are younger than 5 years. The main outcome measured was change in 9 preventive services areas: (1) immunizations up to date; (2) anemia screening; (3) tuberculosis risk assessment and indicated screening; (4) lead screening; (5) infant sleep position counseling; (6) environmental tobacco smoke-exposure risk assessment; (7) blood pressure screening; (8) vision screening; and (9) dental risk assessment. All practices demonstrated improvement in 1 or more preventive services areas. The mean number of areas chosen was 5 (range: 1-9). Practices that selected a specific preventive service area as a quality improvement goal were more likely to demonstrate improvement in that area than practices that did not choose to focus on that preventive services area. The work in this project has provided the evidence for an effective statewide pediatric quality improvement outreach program to improve preventive services for children who are younger than 5 years. Practices' decision to focus on a specific preventive service area as a quality improvement goal seems necessary for improvement in that area. This approach may be effective in other states or regions.

Effect of “This Side Up” T-shirts on Infant Sleep Position

To assess the impact of "This Side Up" T-shirts on parental practices in Nebraska. A random sample of 3,210 Nebraska women who gave birth in 2004, stratified by race/ethnicity, was mailed a brief questionnaire on their receipt of a T-shirt and SIDS risk reduction materials at their birthing hospital, and on infant sleep position. Response rates were low (25.9%), ranging from 10.6% for Native American mothers to 46.4% for White mothers. Half (52.0%) had received a T-shirt and 71.6% had received SIDS information. Two-thirds (64.0%) reported that their infants slept on their backs; African-American and Hispanic infants were significantly less likely to back sleep. In univariate logistic regression models, African-American race, Hispanic ethnicity and maternal age 30-39 were significant negative predictors of back sleeping; White race and having received a SIDS brochure were positive predictors. In the fully controlled model African American and Asian race and Hispanic ethnicity were negative predictors of back sleeping; neither receiving SIDS information nor the infant T-shirt was significant. Effects of maternal age and a SIDS informational brochure appeared in models stratified by race/ethnicity. In these data, receiving an infant T-shirt was not related to how mothers placed their infants to sleep. Additional research is needed on effective methods of delivering targeted counseling and promoting safe sleep practices among families, particularly among racial and ethnic subgroups.

State Child Care Regulations Regarding Infant Sleep Environment Since the Healthy Child Care America-Back to Sleep Campaign

Despite overall decreases in sudden infant death syndrome deaths and prone sleeping, the proportion of sudden infant death syndrome deaths that occurs in child care settings has remained constant at approximately 20%. In 2003, the American Academy of Pediatrics' Healthy Child Care America program launched its own Back to Sleep campaign to promote the Back to Sleep message for those who care for young children. The purpose of this study was to evaluate the effectiveness of the first 2 years of the Healthy Child Care America-Back to Sleep campaign in improving child care regulations by assessing the inclusion of the elements of a safe sleep environment in the individual state regulations for child care centers and family child care homes. We examined regulations available in October 2005 for licensed child care centers and family child care homes in the 50 states and the District of Columbia for specific regulations pertaining to (1) sudden infant death syndrome risk-reduction training for child care providers, (2) infant sleep position, (3) crib safety, (4) bedding safety, (5) smoking, and (6) provision of information about sleep positioning policies and arrangements to parents before the infant is enrolled in child care. Since 2003, when the Healthy Child Care America-Back to Sleep campaign began, 60 of the 101 state regulations for either child care centers or FCCHs have been revised. More than half of these regulations written since 2003 mandate a nonprone sleep position and restrictions on soft bedding in the crib, and the change in these regulations since 2003 is statistically significant. However, of the 101 existing state regulations, only 49 require that infants sleep nonprone, 18 mandate sudden infant death syndrome training for child care providers, 81 have > or = 1 crib safety standard, and 43 restrict soft bedding in the crib. Only 4 regulations require that parents be provided with sleep policy information. The initial 2 years of the Healthy Child Care America Back to Sleep campaign have been successful in promoting safe infant sleep regulations. Efforts must continue so that safe sleep regulations exist in all jurisdictions.

Bed Sharing With Unimpaired Parents Is Not an Important Risk for Sudden Infant Death Syndrome

To the Editor .— Recently, the American Academy of Pediatrics (AAP) released new sudden infant death syndrome (SIDS) prevention recommendations.1 Among much appropriate advice, the Task Force on Sudden Infant Death Syndrome “recommends that infants not bed share during sleep.” Several controlled studies have documented that infants who share a bed with a parent have an increased risk of SIDS. However, these studies have not taken into account the entire context in which SIDS events occur, including parental impairment at the time of the infant's death, the infant's sleep position, and whether the infant …

A survey of infant sleep positions associated with sudden infant death syndrome

Purpose : As the prone position is thought to be an important factor in sudden infant death syn- drome(SIDS), this study was conducted to contribute to reducing SIDS by analyzing sleeping positions of infants. Methods : A face-to-face questionnaire was carried out with a total of 170 parents with a baby aged less than 6 months. Results : A total of 170 infants included 95 males(55.9 percent) and 75 females(44.1 percent); their average age was 2.8 months. 45.3 percent slept in a supine position; 34.7 percent in a side or supine position; 7.1 percent in a side position; 4.7 percent in a prone position; 4.1 percent in a non-specific position. Among those in a side position, 59.7 percent were in a supine position in the morning; 19.5 percent were in the side position; 13.4 percent were in a non-specific position; and 4.1 percent were in a prone position. To the question why they slept in a specific position, 34.9 percent answered their baby slept comfortably, and particularly, 42.9 percent in the prone position group answered so. In the supine position group, 21.6 percent answered they had no reason. Both in the prone position and side position groups, 21 percent each answered they were worried about the shape of their baby's head. In the side position group, 22 percent answered that they had a fear of choking due to vomiting. In all sleeping position groups, 8.2 percent and 7.4 percent answered it was because they had a fear of suffocation and they wanted to avoid SIDS, respectively. Conclusion : Many of the parents preferred unstable positions, e.g. the side position and the prone position, which could cause SIDS. Their decision on their baby's sleeping position was not based on exact medical knowledge, but on convenience in taking care of their baby. As it was found that only 6 percent of the subjects were advised from their pediatrist about their baby's sleeping position, moreover, it is necessary to carry out more studies and activities for preventing SIDS caused by improper sleeping positions and educating patents about recommended sleeping positions for their baby. (Korean J Pediatr 2006;49:602-609)

IMPACTING INFANT HEAD SHAPES

Infant sleep position impacts the development of head shape. Changes in infant sleep position, specifically the movement toward supine sleep, have led to a redefinition of normal head shape for infants in the United States. Historically, a dolichocephalic (elongated) head shape was the norm. Currently the norm has changed to a more brachycephalic (shorter and broader) shape. Since the American Academy of Pediatrics' Back to Sleep Campaign, the incidence of positional plagiocephaly has increased dramatically with a concurrent rise in the incidence of torticollis. Infants who require newborn intensive care, particularly premature infants, are more prone to positional plagiocephaly and dolichocephaly. Both can be prevented or minimized by proper positioning. The infant with an abnormal head shape requires careful evaluation; treatment varies according to the etiology. Craniosynostosis, a less common but pathological etiology for plagiocephaly, should be considered in the diagnostic process. Successful treatment of positional plagiocephaly and dolichocephaly includes systematic positioning changes to overcome the mechanical forces of repetitive positioning, physical and/or occupational therapy to treat underlying muscle or developmental challenges, and in some cases, molding helmet therapy.

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.

Barriers to Following the Back-to-Sleep Recommendations: Insights From Focus Groups With Inner-City Caregivers

African American infants have a higher incidence of SIDS and increased risk of being placed in the prone position for sleep. To determine new barriers and more information about previously identified barriers that interfere with adherence to the Back-to-Sleep recommendations among inner-city, primarily African Americans. We conducted 9 focus groups with caregivers of infants and young children from women, infants, and children centers and clinics in New Haven and Boston. Themes were identified using standard qualitative techniques. Forty-nine caregivers participated, of whom 86% were African American, 6% were Hispanic, 4% were white, and 4% were other. Four themes were identified: 1) SAFETY: Participants chose the position for their infants based on which position they believed to be the safest. Some participants did not choose to put their infants in the supine position for sleep because they feared their infants would choke; 2) Advice: Participants relied on the advice of more experienced female family members. Health care providers were not uniformly a trusted source of advice; 3) Comfort: Participants made choices about their infants sleeping positions based on their perceptions of whether the infants appeared comfortable. Participants thought that their infants appeared more comfortable in the prone position; 4) Knowledge: Some participants had either limited or erroneous knowledge about the Back-to-Sleep recommendations. We identified multiple barriers to adherence to recommendations regarding infant sleep position. Data obtained from these focus groups could be used to design educational interventions aimed at improving communication about and adherence to the Back-to-Sleep recommendations.

Bedsharing and Maternal Smoking in a Population-Based Survey of New Mothers

Objective. Sudden infant death syndrome (SIDS) remains the number 1 cause of postneonatal infant death. Prone infant sleep position and maternal smoking have been established as risk factors for SIDS mortality. Some studies have found that bedsharing is associated with SIDS, but, to date, there is only strong evidence for a risk among infants of smoking mothers and some evidence of a risk among young infants of nonsmoking mothers. Despite the lack of convincing scientific evidence, bedsharing with nonsmoking mothers remains controversial. In some states, nonsmoking mothers are currently being told that they should not bedshare with their infants, and mothers of infants who died of SIDS are told that they caused the death of their infant because they bedshared. The objective of this study was to explore the relationship between maternal smoking and bedsharing among Oregon mothers to explore whether smoking mothers, in contrast to nonsmoking mothers, are getting the message that they should not bedshare. Methods. Oregon Pregnancy Risk Assessment Monitoring System surveys a stratified random sample, drawn from birth certificates, of women after a live birth. Hispanic and non-Hispanic black, non-Hispanic Asian/Pacific Islander and non-Hispanic American Indian/Alaskan Native women, and non-Hispanic white women with low birth weight infants are oversampled to ensure sufficient numbers for stratified analysis. The sample then was weighted to reflect Oregon’s population. In 1998–1999, 1867 women completed the survey (73.5% weighted response). The median time from birth to completion of the survey was 4 months. Women were asked whether they shared a bed with their infant “always,” “almost always,” “sometimes,” or “never.” Frequent bedsharing was defined as “always” or “almost always”; infrequent was defined as “sometimes” or “never.” Results. Of all new mothers, 35.2% reported bedsharing frequently (always: 20.5%; almost always: 14.7%) and 64.8% infrequently (sometimes: 41.4%; never: 23.4%). Bedsharing among postpartum smoking mothers was 18.8% always, 12.6% almost always, 45.1% sometimes, and 23.6% never; this was not statistically different from among nonsmoking mothers. Results for prenatal smokers were similar. When stratified by race/ethnicity, there was no association between smoking and bedsharing in any racial or ethnic group. In univariable and multivariable logistic regression, there were no statistical differences in frequent or any bedsharing among either prenatal or postpartum smoking mothers compared with nonsmokers; the adjusted odds ratio for postpartum smokers who frequently bedshared was 0.73 (95% confidence interval [CI]: 0.42–1.25) and for any bedsharing was 1.05 (95% CI: 0.57–1.94). Results for prenatal smoking were similar. This is the first US population-based study to look at the prevalence of bedsharing among smoking and nonsmoking mothers. Bedsharing is common in Oregon, with 35.2% of mothers in Oregon reporting frequently bedsharing and an additional 41.4% sometimes bedsharing. There was no significant association between smoking and bedsharing for either prenatal or postpartum smokers among any racial or ethnic group. Smoking mothers were as likely to bedshare as nonsmoking mothers. The frequency of bedsharing in Oregon was similar to estimates from other sources. Our study has the advantage of being a population-based sample drawn from birth certificates, weighted for nonresponse. Conclusions. Although a number of case series have raised concerns about the safety of mother–infant bedsharing, even among nonsmoking mothers, this has not yet been confirmed by careful, controlled studies. There have been 9 large-scale case-control studies of the relationship between bedsharing and SIDS. Three case-control studies did not stratify by maternal smoking status, but found no increased risk for SIDS. Six case control studies reported results stratified by maternal smoking status: 1 study, while asserting an association, provided an unexplained range of univariable odds ratios without CIs; 3 found no increased risk for older infants of nonsmoking mothers; and 2 found a risk only for infants

Health Departments Do It Better: Prenatal Care Site and Prone Infant Sleep Position

Reduction of prone infant sleep position has been the main public health effort to reduce the incidence of Sudden Infant Death Syndrome (SIDS). Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) surveys a stratified random sample of women after a live birth. In 1998-1999, 1867 women completed the survey (64.0% unweighted response; 73.5% weighted response). Overall, 9.2% of all women "usually" chose prone infant sleep position, while 24.2% chose side and 66.5% chose supine position. Women receiving care from private physicians or HMOs more often chose prone position (10.6%) than women receiving prenatal care from health department clinics (2.5%), hospital clinics (6.1%) or other sites (8.3%). Compared to health department prenatal clinic patients, private prenatal patients were more likely to choose prone infant sleep position, adjusted odds ratio = 4.78 (95% confidence interval [CI] 1.64-13.92). Health Department clinics have done a better job than private physicians in educating mothers about putting infants to sleep on their backs. Providers-especially private providers-should continue to stress the importance of supine sleep position for infants.

Sudden Infant Death Syndrome and prenatal maternal smoking: rising attributed risk in the Back to Sleepera

BackgroundParental smoking and prone sleep positioning are recognized causal features of Sudden Infant Death. This study quantifies the relationship between prenatal smoking and infant death over the time period of the Back to Sleep campaign in the United States, which encouraged parents to use a supine sleeping position for infants.MethodsThis retrospective cohort study utilized the Colorado Birth Registry. All singleton, normal birth weight infants born from 1989 to 1998 were identified and linked to the Colorado Infant Death registry. Multivariable logistic regression was used to analyze the relationship between outcomes of interest and prenatal maternal cigarette use. Potential confounders analyzed included infant gender, gestational age, and birth year as well as maternal marital status, ethnicity, pregnancy interval, age, education, and alcohol use.ResultsWe analyzed 488,918 birth records after excluding 5835 records with missing smoking status. Smokers were more likely to be single, non-Hispanic, less educated, and to report alcohol use while pregnant (p < 0.001). The study included 598 SIDS cases of which 172 occurred in smoke-exposed infants. Smoke exposed infants were 1.9 times (95% CI 1.6 to 2.3) more likely to die of SIDS. The attributed risk associating smoking and SIDS increased during the study period from approximately 50% to 80%. During the entire study period 59% (101/172) of SIDS deaths in smoke-exposed infants were attributed to maternal smoking.ConclusionsDue to a decreased overall rate of SIDS likely due to changing infant sleep position, the attributed risk associating maternal smoking and SIDS has increased following the Back to Sleep campaign. Mothers should be informed of the 2-fold increased rate of SIDS associated with maternal cigarette consumption.

2. Stastny, P. F., Ichinose, T. Y., Thayer, S. D., Olson, R. J., &amp; Keens, T .G. (2004). Infant sleep positioning by nursery staff and mothers in newborn hospital nurseries, Nursing Research, 53, 122-9*1

Sudden infant death syndrome (SIDS), the second most common cause of death in children 1 to 12 months of age, is the sudden death of an infant less than a year-old from an unknown cause. Research has shown that putting infants to sleep in the supine position (on their backs) dramatically decreases death from SIDS. Deaths from SIDS have decreased up to 50% in countries that have instituted programs encouraging putting infants to sleep on their backs. Even infants put to sleep on their sides are more than 6.5 times more likely to die from SIDS. In spite of the evidence and the recommendations by groups such as the American Academy of Pediatrics (“Back to Sleep”) that encourage placing infants on their backs to sleep, many parents still place their infants on their stomachs or sides, possibly due to fears that infants will aspirate if they sleep on their backs. Unfortunately, many health care providers, including nursery staff, do not recommend to parents that they place their infants to sleep on their backs.

Supine and prone infant positioning: a winning combination.

Since 1992, the optimal sleeping position for infants in the United States has been supine. This position has been shown to greatly reduce the rate of Sudden Infant Death Syndrome (Skadberg, Morild, & Markestad, 1998). However, the supine position may lead to other unintended consequences or complications. Through a review of literature, this article explores some of the complications associated with the "Back to Sleep" campaign in the U.S. and discusses educational strategies for perinatal educators.

Infant Sleep Position: Associated Maternal and Infant Factors

To determine the maternal and infant characteristics associated with the back sleep position for infants to guide efforts to increase its use and reduce the risk of Sudden Infant Death Syndrome. Cross-sectional survey of 3349 mothers delivering in California, February-May 1999. Fifty-two percent of infants were placed in the back sleep position. Factors associated with a lower likelihood of using the back position included all levels of maternal education less than college (eg, for education eighth grade or less--adjusted odds ratio [OR] 0.59; 95% confidence interval [CI], 0.40-0.86); income at or below federal poverty level (OR, 0.65; 95% CI, 0.47-0.90); multiparity (OR, 0.80; 95% CI, 0.67-0.95); race/ethnicity African American (OR, 0.49; 95% CI, 0.37-0.65) and Asian/Pacific Islander (OR, 0.65; 95% CI, 0.48-0.89); speaking a non-English language (OR, 0.69; 95% CI, 0.55, 0.86); and infant age over 7 months (OR, 0.70, 95% CI, 0.52-0.96). Women in Los Angeles (OR, 0.57; 95% CI, 0.42-0.77) and urban areas other than San Diego (OR, 0.70; 95% CI, 0.53-0.92) were less likely to use the back position than those in San Francisco. Greater efforts are needed to promote the back sleep position among families with mothers who lack education beyond some college; live in poverty; and who are African American, Asian/Pacific Islander, multiparous, or non-English speaking.

Infant sleep position and associated health outcomes.

The incidence of sudden infant death syndrome has decreased in the United States as the percentage of infants sleeping prone has decreased, but persisting concerns about the safety of supine sleeping likely contribute to prone sleeping prevalence rates that remain higher than 10%. To document health outcomes in infants aged 1 to 6 months in relation to sleep position. Prospective cohort study. Massachusetts and Ohio, from February 21, 1995, to December 31, 1998. A total of 3733 infants with consistent sleep positions at ages 1, 3, and 6 months. Descriptive statistics and multiple logistic regression analysis relating sleep position at each follow-up age to symptoms in the prior week (fever, cough, wheezing, stuffy nose, trouble breathing or sleeping, diarrhea, vomiting, or spitting up) and outpatient visits in the prior month (ear infection, breathing problem, vomiting, spitting up, colic, seizure, accident, or injury). No symptoms or outpatient visits were significantly more common among infants sleeping on the side or supine than in infants sleeping prone, and 3 symptoms were less common: (1) fever at 1 month in infants sleeping in the supine (adjusted odds ratio [OR], 0.56; 95% confidence interval [CI], 0.34-0.93) and side positions (OR, 0.48; 95% CI, 0.28-0.82); (2) stuffy nose at 6 months in the supine (OR, 0.74; 95% CI, 0.61-0.89) and side positions (OR, 0.82; 95% CI, 0.68-0.99); and (3) trouble sleeping at 6 months in the supine (OR, 0.57; 95% CI, 0.44-0.73) and side positions (OR, 0.69; 95% CI, 0.53-0.89). Also, outpatient visits for ear infections were less common at 3 and 6 months in infants sleeping in the supine position (OR, 0.64; 95% CI, 0.46-0.88; and OR, 0.73; 95% CI, 0.58-0.92, respectively) and at 3 months in the side position (OR, 0.68; 95% CI, 0.49-0.96). No identified symptom or illness was significantly increased among nonprone sleepers during the first 6 months of life. These reassuring results may contribute to increased use of the supine position for infant sleeping.

The Relationship Between Awake Positioning and Motor Performance Among Infants Who Slept Supine

The purpose of this study was to describe the gross motor development of infants who slept supine and spent different amounts of time in the prone position when awake. Thirty infants who were six months old and slept supine were evaluated using the Alberta Infant Motor Scale (AIMS) and then divided into two groups: prone (n = 16) and no prone (n = 14) based on the number of times per day they were placed in prone position while awake. The prone group scored higher than the no prone group on the AIMS total scores (U = 36, p = 0.004), total percentile scores (U = 42, p = 0.003), and prone subscale scores (U = 25, p < 0.001). Gross motor performance as measured by the AIMS was more advanced in infants who slept supine and had been placed in the prone position when awake than in infants who slept supine but had limited or no experience in the prone position while awake. The influence of awake positioning needs to be considered when interpreting the developmental motor performance of infants who are six months old.

Secular changes in sleep position during infancy: 1995-1998.

Prone sleeping among infants has been associated with an increased risk of sudden infant death syndrome. The objective of this study was to compare factors associated with sleep position in 1995-1996 and 1997-1998 and to assess secular trends in use of prone infant sleep position from 1995 through 1998 among families stratified by race and education. A prospective cohort study was conducted in eastern Massachusetts and northwest Ohio of 12 029 mothers of infants who weighed > or =2500 g at birth. Descriptive statistics and multivariate odds ratios were used to relate maternal and infant characteristics to prone and supine sleeping. A total of 14 206 mothers (25% of those eligible) were enrolled. A total of 12 029 mothers (85% of enrolled) responded to the 1-month and 11 552 mothers (81% of enrolled) responded to the 3-month follow-up questionnaire. A decline in use of the prone sleep position and increase in use of the supine position was observed during the 4 years of the study. Factors associated with prone and supine sleep position were similar in 1995-1996 and 1997-1998. In 1997-1998, use of prone sleeping at 1 month of age reached the goal of < or =10% only among infants of white and Asian women, married women, women who were older than 25 years, women who were college graduates, and women with incomes >$55 000 per year. At 3 months of age, however, prone sleeping increased to 12% to 17% in these groups. These same groups were most likely to use the supine position; 38% to 45% were supine at 1 month, increasing to 56% to 64% by 3 months of age. However, as of the end of 1998, approximately 27% of infants of non-college-educated black and Hispanic mothers were placed to sleep in the prone position and only 20% to 30% were being placed to sleep in the supine position at 3 months of age. Recommendations to avoid prone sleep position and especially the recommendation that supine sleep position is preferred have not been effectively delivered to black and Hispanic families and to families of low-income and less than a college education.

Determinants of infant sleep position in an urban population.

The incidence of SIDS has decreased by 40% since the Back to Sleep campaign was initiated. However, the rate of SIDS in the District of Columbia continues to be approximately double the national rate. The purpose of this study was to determine the prevalence and determinants of prone sleeping among infants in the District of Columbia and to ascertain what information is being provided to parents by health care professionals by a cross-sectional survey of parents of infants 0-6 months of age presenting for well child care at Children's Health Center, Children's National Medical Center, in Washington, DC. We recruited a consecutive sample of 126 parent-infant pairs, of which 92.9% were African-American. The average infant was 73 days old, was 3,003 grams at birth, and was full term. When asked how the infants were placed for sleep the night before the interview, 34.1 % of parents had placed the infant supine, 50.8% side, and 15.1% prone. Nearly half (48%) of infants slept in an adult bed with the mother. More than one third of the infants had been placed prone for sleep at least once since hospital discharge. Most common reasons for sleeping supine included SIDS risk reduction or health care professional advice. Side sleepers did so primarily because of concern about vomiting, health care provider advice, or SIDS. Infants were placed prone primarily because the infant slept better. When asked about information received from a health care provider, 70.6% of parents stated that they had received information about sleep position and 64.3% about the hazards of passive smoking. Eight parents observed nursery personnel placing their infants prone. Only 16.7% of the total study population had received a Back to Sleep brochure, read it, and recalled that it recommended back sleeping. Infants were more likely to sleep prone if there was a grandparent in the home (OR 2.9, p<0.05) or if they were the firstborn (OR 2.17, p<0.05). Infants were more likely to sleep supine if parents had heard a back recommendation from a health care professional (OR 5.7, p<0.001). Infants were least likely to sleep supine if the parents had heard a side or a side/back recommendation (OR 0.26, p=0.001). Infant sleep position was not ter, reading the Back to Sleep brochure. In conclusion, more than one third (35.7%) of infants in this predominantly African-American population have been placed prone for sleep at least once; 15% slept prone the night before the interview. Almost one third of parents received no information about sleep position, but parents receiving a verbal supine recommendation were most likely to place their infant supine. Receiving written information did not affect sleep position. Improved educational efforts for parents of African-American newborns should continue to focus on encouraging supine positioning, smoke cessation, and other safe sleep practices.

Transformative unlearning: safety, discernment and communities of learning.

This paper aims to stimulate awareness about the intellectual and emotional work of 'unlearning' in knowledge workers in the emerging learning age. The importance of providing a safe space for dialogue to promote transformative learning, through building 'communities of learning', is highlighted. Unlearning is conceptualized within a transformative education paradigm, one whose primary orientation is discernment, a personal growth process involving the activities of receptivity, recognition and grieving. The author utilizes the metaphor of an unfolding spiral path to explore her experience of needing to 'unlearn' a trusted nursing practice prior to 'learning' new best caring practices related to infant sleep positions. Macro and micro approaches to facilitating unlearning in organizations, in learners and in nurses are suggested.