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Changing Nursery Practice Gets Inner-city Infants in the Supine Position for Sleep
Eve R. Colson, MD;
Sharon Cohen Joslin, MSN, APRN, IBCLC, NNP
Arch Pediatr Adolesc Med. 2002;156:717-720.
ABSTRACT
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Objective To determine whether an educational intervention to change nursery practice
would result in more inner-city parents placing their infants in the supine
position for sleep.
Design We conducted semistructured interviews at the 2-week health supervision
visit with 1 convenience sample of parents before and a different convenience
sample of parents after an educational intervention was conducted to change
nursery practice in positioning infants for sleep.
Setting University hospital clinic located in an urban setting.
Participants Parents of 2-week-old infants at their first health supervision visit
in an urban, university-affiliated clinic. All parents who were approached
agreed to participate.
Intervention Nurses were instructed to place infants exclusively in the supine position
in the nursery and to instruct parents to exclusively place infants in the
supine sleeping position at home.
Main Outcome Measure The usual sleeping position in which parents reported placing their
2-week old infants.
Results Before the intervention, 41% of parents reported that a clinician had
told them to place their infants to sleep in the supine position compared
with 81% after the intervention (odds ratio [OR], 6.1; 95% confidence interval
[CI], 3.1-12.3). Before the intervention, 37% of parents reported that the
nursery staff placed their infants to sleep in the supine position, compared
with 88% after the intervention (OR, 12.5; 95% CI, 5.7-27.7). Before the intervention,
42% of parents reported that they usually placed their infants to sleep in
the supine position at home compared with 75% after the intervention (OR,
4.2; 95% CI, 2.1-7.9).
Conclusion After an educational intervention to change practice in a well-newborn
nursery, many more parents reported placing their infants in the supine position
for sleep, which suggests that such an intervention may have an impact on
the position in which parents place their children to sleep.
INTRODUCTION
IN THE UNITED STATES, sudden infant death syndrome (SIDS) is the leading
cause of death among infants between the ages of 1 and 12 months.1 Although the etiology of SIDS is unclear, infants
who sleep in the prone or side position are at increased risk.2-5
The incidence of SIDS has dropped substantially in countries in which the
usual sleeping position has changed from prone to supine.6-7
The supine position has been shown to be the most stable and the safest position
in which to have infants sleep.5 The American
Academy of Pediatrics (AAP) now recommends the supine position for sleep for
all healthy infants because it has the lowest risk.8
Since the AAP began advocating that parents place their infants to sleep
in the supine position, the incidence of SIDS has decreased by nearly 40%
in the United States.1 However, this effect
has not been observed in all segments of the population. African American
infants continue to have a higher incidence of SIDS than do white infants.9 Several studies have shown that infants born to African
American families and families in an inner-city setting are more likely to
be placed in the prone position to sleep.9-11
In response, organizations such as the AAP have designed public health
campaigns to educate families about the importance of the supine sleeping
position for infants. Nursery practice was targeted in the initial campaigns
as one way to disseminate information to most families about the safest sleeping
position for infants. However, a recent study showed that nursery practice
has not changed in many areas and that many infants are not placed in the
supine sleeping position in well-newborn nurseries. In addition, nursery staff
do not uniformly recommend the supine sleeping position to families.12-14
Preliminary data from parents of 2-week old infants who had received
their perinatal care from our nursery, which serves an inner-city population,
indicated that fewer than half of the parents placed their infants exclusively
in the supine position for sleep at home. Our preliminary interviews also
indicated that parents were more likely to place their infants to sleep in
the supine position if, during the postpartum period, they received specific
advice to place their infants to sleep in this position and they saw nursery
staff consistently model this behavior. However, many parents reported that
they had not received advice from a clinician on sleep position and many parents
did not report that their infants had been placed in the supine position for
sleep by nursery staff during their postpartum stay.15
The purpose of this study was to examine whether an educational intervention
to change practice in a well-newborn nursery would increase the proportion
of inner-city parents who place their infants in the supine position for sleep.
PARTICIPANTS AND METHODS
INTERVIEWS
We conducted semistructured interviews at the infants' 2-week health
supervision visit with 2 convenience samples of parents. The first sample
of parents was interviewed prior to the implementation of the educational
intervention. The second sample was interviewed after the educational intervention.
All of the infants were cared for in the well-newborn nursery at Yale–New
Haven Hospital (New Haven, Conn) and were brought for regular pediatric care
to the Pediatric Primary Care Center of the Yale–New Haven Hospital.
The Pediatric Primary Care Center is located in the inner city and serves
predominantly Medicaid-eligible families. Approximately 50% of the patients
are African American, 25% are Hispanic, 10% are white, and the rest are from
a variety of ethnic groups. Parents were approached for the interview based
exclusively on the availability of the research assistant. No parents refused
to participate.
Both groups were interviewed using the same format. The interview consisted
of questions about sociodemographics, risk factors for SIDS, as well as knowledge,
attitudes, and behavior related to the sleep position of infants. Specific
questions were asked about the advice parents received about infant sleeping
position during the postpartum stay and about the sleeping position in which
their infants were placed by nursery staff.
INTERVENTION
The educational intervention consisted of mandatory training of all
nursing staff responsible for the care of newborns in the well-newborn nursery.
Seventy-eight percent of all nursery staff participated. The intervention
was led by a physician and a clinical nurse specialist and took approximately
30 minutes. For each class, an update about SIDS was provided, the current
recommendations of the AAP for positioning of infants for sleep were reviewed,
and unfounded concerns about choking in the supine position were discussed.
The importance of giving the appropriate advice about the sleeping position
of infants and of modeling the advice for families by always placing the infants
in the supine position in the nursery was emphasized.
To assess the efficacy of the educational intervention, covert observations
were made of the positions of infants sleeping in the nursery during all 3
shifts. The nursery staff was told that observations were being made of new
ankle bracelets that were being tested at the time.
STATISTICAL METHODS
The magnitude of the differences between the groups of parents interviewed
before and after the intervention was estimated by odds ratios and associated
95% confidence intervals. Odds ratios for which the 95% confidence intervals
did not include 1.0 were considered statistically significant.16
Logistic regression was used to adjust for differences in ethnicity and parity
between the 2 groups. This study was approved by the institutional review
board of Yale University School of Medicine (New Haven).
RESULTS
EFFICACY OF THE INTERVENTION
One month prior to the intervention, the sleeping positions of 100 infants
in the well-newborn nursery during the postpartum stay were observed. Three
months after the intervention, the sleeping positions of another 100 infants
in the nursery were again assessed. Before the intervention, 20% of the infants
were placed in the supine position, 79% were placed on their sides, and 1%
were placed in the prone position. Three months after the intervention, 99%
of the infants were placed in the supine position.
PARENT INTERVIEWS
Before the intervention, a group of 100 parents was interviewed at their
infants' 2-week health supervision visit, between December 1999 and March
2000. A different group of 100 parents was interviewed after the intervention
was completed, between July 2000 and January 2001. Sociodemographic characteristics
of the 2 groups are presented in Table 1. The group of parents before the intervention differed slightly
from the group after the intervention in that the first group had fewer Hispanic
parents and fewer parents with more than 1 child.
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Table 1. Sociodemographic Characteristics of the 2 Samples*
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Table 2 presents the reports
of the 2 groups before and after the intervention. The magnitude and the statistical
significance of the association between sleep position and study group (before
vs after the intervention) were virtually unchanged after adjusting for ethnicity
and parity using logistic regression.
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Table 2. Parents' Reports at the 2-Week Health Supervision Visits:
Before and After the Intervention
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COMMENT
This study was designed to assess whether an educational intervention
in a well-newborn nursery would increase the proportion of inner-city parents
who reported that they placed their infants in the supine position for sleep.
The intervention was successful; almost twice the number of parents reported
placing their infants to sleep in the supine position after the intervention
and one third fewer parents reported sometimes placing their infants to sleep
in the prone position.
Prior to the intervention, fewer than half of parents reported that
they usually placed their infants in the supine position for sleep. In addition,
we found that many parents put their infants to sleep in the prone position
at least some of the time. These findings are similar to prior studies from
1996 and 1997.17-18 This is likely
related to parents' reports that most had not received appropriate education
from nursery staff about sleeping position during the postpartum stay. The
initial public health campaigns aimed at getting infants "back-to-sleep" specifically
targeted well-newborn nurseries; yet, prior to our intervention, only 41%
of the parents in our study reported having received advice from a clinician
to have their infants sleep exclusively in the supine position. In addition,
parents reported that members of the nursery staff did not always model the
appropriate sleeping position for infants by consistently placing them in
the supine position in the nursery.
Although our findings are from a single urban center in the northeastern
United States, we do not believe that they are unique to this medical center
because they are consistent with findings from other studies. Investigators
from Iowa reported similar findings; newborn nursery staff in 94 hospitals
most often placed infants on their sides because of unfounded concerns about
aspiration if infants were placed in the supine position.12
Investigators in Washington, DC, and in Hartford, Conn, have also found that
nursery staff do not uniformly recommend the supine sleeping position for
infants.13-14
The educational intervention in our study seems to have been effective
in changing nursery staff behavior and subsequent parent behavior. The reason
for the apparent efficacy of the intervention in changing parent behavior
may be related to the impact that education can have during the postpartum
period. Our data are supported by other studies that have shown that parents
make decisions about the sleeping position they will choose for their infants
based on what they see the nursery staff do in the hospital and what their
clinicians tell them to do.13-15
This study has some potential limitations. Although there may be some
reporting bias, parents reports about their infant's sleeping position in
the nursery were consistent with our covert observations, which were made
in the nursery before and after the intervention.
This study did not include a control group that was not exposed to the
intervention. It is possible that other factors besides the intervention could
have caused the change in infant sleeping position. However, a large change
occurred during a relatively short time and we know of no other events that
are likely to have caused this change. We did not include a control group
for practical and ethical reasons. For practical reasons, we were logistically
unable to have separate groups because all of our postpartum staff rotate
to each of the maternity floors. For ethical reasons, we felt that we should
provide education for all parents to place their infants in the supine sleeping
position, knowing the association between SIDS and sleeping in the side or
prone positions.
Bias may have been introduced because the interviewers were not blinded
to the group status. To minimize bias, the interview tool was straightforward
and standardized. We instructed interviewers not to deviate from the interview
tool. Each interviewer was observed using the interview tool prior to beginning
the study.
Finally, the parents were not selected randomly but rather based on
the availability of the interviewer. There was no fixed pattern for the interviews,
which occurred at various times of the day throughout the week. We have no
specific reason to believe that the selection of the parents for interview
in this manner had an effect on the results of the study. Our results regarding
the proportion of parents in our study who placed their infants in positions
other than the supine position for sleep prior to our intervention are similar
to previous studies of inner-city populations.9-10,14
Consequently, we believe that the results of this study likely would be generalizable
to other similar populations.
Despite these limitations, this study is the first, to our knowledge,
to show that an educational intervention that recommends the uniform placement
of infants in the supine position for sleep in the newborn nursery and emphasizes
the importance of the supine position to parents is effective in getting inner-city
parents to place their infants in the supine sleeping position. Future studies
in this area might be aimed at confirming these findings using other methodologies.
Future research should also assess whether such interventions in the nursery
are potent enough to convince families to keep their infants sleeping in the
supine position as their infants get older, when parents are more likely to
switch them to the prone position for sleep.19
| What This Study Adds
It is known that sleeping in the prone or side position increases the
risk of SIDS. It is also known that some parents (particularly African American
and inner-city parents), clinicians, and nursery staff do not use or recommend
the supine sleeping position for infants. We found that providing parent education
to place infants in the supine position and modeling this behavior by always
placing infants in that position during the postpartum stay changes inner-city
parents' behaviors in a significant way. This study demonstrates the importance
of a consistent message given to parents about the supine sleeping position
for their infants.
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AUTHOR INFORMATION
Accepted for publication March 14, 2002.
This work was supported, in part, by grant M01-RR06022 from the Yale
Children's Clinical Research Center, General Clinical Research Centers Program,
National Center for Research Resources, National Institutes of Health, Bethesda,
Md.
This study was presented in part at the annual meeting of the Pediatric
Academic Society, Baltimore, Md, May 2, 2001.
We would like to thank Eugene Shapiro, MD, John Leventhal, MD, and Theodore
Walls, PhD, for their assistance with this project.
Corresponding author: Eve R. Colson, MD, Well Newborn Nursery, Yale-New
Haven Hospital, West Pavilion 1180A, 20 York St, New Haven, CT 06504 (e-mail: eve.colson{at}yale.edu).
From the Department of Pediatrics, Yale University School of Medicine
(Dr Colson); Yale New Haven Hospital (Ms Joslin); and Yale University School
of Nursing (Ms Joslin), New Haven, Conn.
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