Pediatric Annals

Special Issue Article 

Safe Infant Sleep Practices: Parental Engagement, Education, and Behavior Change

Sunah S. Hwang, MD, MPH; Michael J. Corwin, MD


Although the incidence of sudden unexpected infant death declined by nearly 50% in the 1990s, there has been little improvement in the past 15 years. Significant disparities in infant sleep practices and sleep-associated death exist, particularly by maternal race/ethnicity. This article provides a brief overview of recent observational and intervention studies related to infant sleep practices to describe the context and motivation for the population-based Study of Attitudes and Factors Effecting Infant Care (SAFE). [Pediatr Ann. 2017;46(8):e291–e296.]


Although the incidence of sudden unexpected infant death declined by nearly 50% in the 1990s, there has been little improvement in the past 15 years. Significant disparities in infant sleep practices and sleep-associated death exist, particularly by maternal race/ethnicity. This article provides a brief overview of recent observational and intervention studies related to infant sleep practices to describe the context and motivation for the population-based Study of Attitudes and Factors Effecting Infant Care (SAFE). [Pediatr Ann. 2017;46(8):e291–e296.]

In the United States, nearly 4,000 infants suffer sudden unexpected infant death (SUID) each year.1 Although the rate of SUIDs had declined with the initiation of the “Back to Sleep” campaign in the mid-1990s, there has been little improvement in the past 15 years and SUID remains the leading cause of postneonatal mortality.2 Most of these deaths are attributed to unsafe sleep practices and environments, and thus the American Academy of Pediatrics (AAP) continues to recommend that all infants be placed in the supine and flat position, in a separate sleep space, on a firm mattress without any objects in the crib.2 Despite these recommendations, only two-thirds of all infants and less than one-half of black infants in the US are placed on their backs to sleep.3 In addition, most infants who suffered SUID were found to be co-sleeping with another adult on a shared sleep surface.4 Moreover, according to the National Infant Sleep Position study,5 most infants were placed to sleep with bedding in their sleep space, with the strongest predictors being young maternal age, non-white ethnicity, and lower education level. Additional risk factors for sleep-associated infant death include prematurity, prenatal and postnatal smoke exposure, and parental substance use disorders. Protective factors include breast-feeding, pacifier use, vaccinations, and co-sleeping in the same room with the infant but not in the same bed.2

This review presents recent observational and intervention studies related to parental education and engagement regarding adherence to safe infant sleep recommendations, particularly focused on populations at highest risk for sleep-associated infant death.

For nearly all anticipatory guidance related to infant care, maternal and child health organizations recommend that caregiver education and engagement take place prior to delivery, with the goal being that consistent messages are being given before, during, and after pregnancy. This is in line with the life course approach to maternal and child health, which posits that the health of the infant is affected not only by maternal health during pregnancy, but even prior to conception, and that factors outside of traditional health care settings influence the health outcomes of mothers and babies.6,7

We also review recent studies related to parental education of infant sleep practices along the perinatal timeline and then highlight the work of the Study of Attitudes and Factors Effecting Infant Care (SAFE), which was designed to obtain nationally representative data about mothers' choices regarding recommended infant care practices.1,8–10

Parental Education Before Pregnancy

Prior to a family's first pregnancy, most of the knowledge and education that parents receive regarding safe infant sleep is likely from messaging and modeling received from public health organizations, medical communities, the media, family members, and friends. At this stage, parental engagement likely takes place outside of the hospital setting. Although public health messaging around safe infant sleep may be consistent with AAP recommendations, messages in the media may be in direct contrast. Joyner et al.11 evaluated pictures from the most popular magazines read by women of child-bearing age and found that more than one-third of pictures of sleeping infants demonstrated these babies to be in inappropriate positions, and two-thirds of pictures of the sleep environment were not consistent with AAP recommendations.

In response to unsafe media messaging and lack of improvement in SUID rates, various federal agencies, such as the Centers for Disease Control and Prevention and the National Institute of Child Health Development (NICHD), as well as local and state departments of public health, have undertaken major public messaging campaigns. The most well known is the “Safe to Sleep” public education campaign led by the NICHD, which was formerly the “Back to Sleep” campaign.12 In collaboration with the AAP, the Maternal and Child Health Bureau of the Health and Human Resources and Services Administration, and other nonprofit organizations, the Safe to Sleep campaign continues to educate caregivers, child care providers, health care providers, and others about reducing the risk for sleep-associated infant death. Although the effect of the Back to Sleep campaign in reducing the rates of sudden infant death syndrome (SIDS) in the mid-1990s is well documented,2 the effectiveness of this current Safe to Sleep campaign in increasing adherence to safe infant sleep practices is not as clear.

The NICHD has also focused on one of the highest-risk groups for sleep-associated death: the American Indian and Alaska Native (AI/AN) population. Consistent with prior literature, a recent analysis of National Vital Statistics mortality data for AI/AN infants and children demonstrated that SIDS and unintentional injuries were more prevalent in AI/AN than in white infants, with the most common cause of death in the postneonatal period being SIDS.13 The NICHD and Indian Health Service, along with local and state organizations, developed educational campaigns targeted to the AI/AN population.14 Audio, video, and written materials have been developed for use by caregivers as well as other groups who interact frequently with these families. However, research is lacking on the effectiveness of improving rates of safe sleep practices in the AI/AN communities through these multifaceted campaigns.

Parental Education During Pregnancy

Studies focused on parental education about safe sleep practices during pregnancy are limited and not as numerous as those undertaken after delivery. The few studies that have aimed to investigate the effect of various interventions during pregnancy to improve parental understanding of or adherence to safe infant sleep practices postnatally have focused on high-risk populations. In a prospective cohort study by Hauck et al.,15 mothers who are low income with at least one risk factor for SIDS and sleep-related death and who did not have a crib in the home were given a crib, a “safe sleep kit” (crib sheet, wearable blanket, and pacifier), and education materials related to safe infant sleep. Some mothers received the crib and related items during pregnancy and others after birth. Families answered survey questions at the time of enrollment and 1 to 3 months after receipt of the crib on safe sleep knowledge and intended or actual practices regarding infant care. More than 3,300 mothers completed the survey prenatally, and among these mothers, the percent who correctly stated they recommended supine sleep position for infants increased from 76% to 94% (P < .001). Moreover, the percent of mothers who intended to exclusively position their infants on their back increased from 84% to 87% (P < .001), albeit the change was not as large as change in knowledge of recommended sleep positioning. The lack of research related to maternal education and engagement about infant care practices during pregnancy parallels the deficit in the clinical training and practice in obstetrics related to newborn care. Tracy et al.16 make the case for the importance of obstetricians to counsel new parents about health-promoting infant care such as safe sleep practices. The authors emphasize the need to broaden obstetric training to include newborn safety, and for the American College of Gynecology and the AAP to partner in developing and disseminating guidelines related to safe infant care.

Parental Education After Pregnancy

Research on parental education and adherence to safe sleep practices has focused more on the postnatal period, either during the immediate postdelivery period in the hospital or in the weeks or months after hospital discharge. Most studies have focused on training and education of hospital staff about SIDS and AAP recommendations for infant sleep positioning and environment so that appropriate teaching and modeling could be passed onto parents.17–19 Given that black infants have the highest rate of sleep-associated death and lowest rates of compliance with safe sleep recommendations, several studies17–19 have focused on this high-risk population. Several studies17–19 sought to first better understand the barriers to safe sleep compliance in the black population through qualitative and quantitative approaches. Misconceptions about SIDS and what was considered to be safe infant sleep among this population were common results for several studies.17–19 For instance, Zoucha et al.17 explored safe sleep and SIDS risk perception in a black community using an ethnographic approach and found that study participants expressed both correct and incorrect information about SIDS. Several stated that co-sleeping with an infant on the same sleep surface was considered to be caring behavior that offered closeness and protection for their infants and that placing an infant to sleep in the crib could cause “crib death.” Colson et al.18 interviewed more than 670 mothers in four states, the majority of whom were black, who attended Women, Infants, and Children Program centers about barriers to following safe sleep recommendations. Investigators identified the following barriers to placing an infant in the supine position: lack of or incorrect advice, lack of trust in medical providers, and incomplete knowledge and concerns about infant safety and comfort. Mothers particularly felt that the risk for choking was greater when infants were placed on their backs. To overcome some of these barriers to safe infant sleep, a number of interventions have been used to improve maternal education about safe sleep in black communities. Recently, a randomized controlled trial designed to evaluate the impact of specific health messages on black parental decisions on infant sleep location was published.19 Mothers were enrolled during birth hospitalization and then surveyed at three time points during the 6 months after delivery.19 This study found no difference in sleep location between mothers who received the standard messaging about SIDS and safe infant sleep (control group) compared to those who received enhanced messaging emphasizing avoidance of bed-sharing for SIDS risk reduction and suffocation prevention (intervention group).19 As infants in the study became older, mothers in both groups were more likely to bed-share because they believed this protected their infants against SIDS or suffocation, highlighting the continued gap in maternal beliefs and scientific data about sleep practices that reduce SIDS risk.

Another group of infants at greater risk for sleep-associated death are preterm infants (ie, those born at less than 37 weeks gestational age). Population-based studies have demonstrated that prematurity confers a nearly 2- to 3-fold increased risk for SUIDS/SIDS compared to term infants,20 likely due to the immature respiratory system that is not as sensitive to hypoxia or hypercarbia.21 Despite this higher risk, preterm infants are less likely to be placed in the supine sleep position after hospital discharge.3 To address this disparity, several neonatal intensive care units (NICUs) have developed quality improvement initiatives focused on implementing safe sleep practices in the NICU weeks or months prior to discharge, with the hope that modeling safe sleep practices long before discharge will improve adherence to these behaviors by families when home. In a large tertiary care unit in Houston, TX, Gelfer et al.22 implemented a multifaceted initiative that included an algorithm specifying when safe sleep practices should be started, a crib card noting the appropriate position of the infant, education programs for nurses and parents, a crib audit tool, and postdischarge telephone reminders to families. This comprehensive approach resulted in improved compliance with safe sleep practices by both NICU staff and by parents after discharge home.22 A similar approach was taken at two level III NICUs in the area of Boston, MA, resulting in improved adherence to recommended sleep practices for eligible infants during hospitalization.23 Parental compliance with safe sleep practices after hospital discharge was not assessed for this study. Building upon this work, the Massachusetts Perinatal Quality Improvement Collaborative has developed a state-wide initiative to implement safe sleep practices in every level III NICU in the state.24 Currently, all level III and IV NICUs are participating and work has expanded to level II units as well. Given that sleep-associated infant mortality is a relatively rare event and preterm infants comprise only 10% of all births,1,25 it will be several years before a potential decrease in sleep-associated death in this high-risk population could be considered statistically significant.

The SAFE Study

Although substantial research related to parental intention and adherence to infant sleep recommendations has been done, data on a number of key factors associated with parental compliance are lacking. Thus, the Study of Attitudes and Factors Effecting Infant Care Practices (SAFE) study8–10 was developed to better understand the contextual factors influencing caregivers' intention and ultimate adherence to recommended infant care practices on a population level. We used a stratified, two-stage, cluster design to obtain a nationally representative sample of mothers of infants age 2 to 6 months, with oversampling of Hispanic and non-Hispanic black (NHB) mothers. Using the 2010 American Hospital Association (AHA) annual survey of hospitals,26 32 maternity hospitals with at least 100 births reported in the past year were sampled. Between January 2011 and March 2014, hospitals were assigned targets for sampling and enrollment of Hispanic, NHB, and mothers of other non-Hispanic ethnicities. Approximately 3,000 completed surveys were obtained from mothers, including at least 750 surveys from Hispanic and NHB mothers. Mothers were eligible for the study if they spoke English or Spanish, lived in the US, and would be providing care for their infant 2 to 4 months after delivery. At the time of enrollment, mothers completed a short initial interview to collect demographic information, including mother's age, education, and income level; pregnancy and delivery history, including mother's parity and infant gender and birth weight; and contact information for follow-up by study staff. Mothers completed the survey when their infant was older than age 60 days, and in preparation they received reminders prior to the infant's 60th day of life. Subsequent weekly reminders were then sent until completion of the survey or until the infants were age 180 days, after which time no additional reminders were sent but mothers were still permitted to complete the survey. Ninety mothers completed the survey after their infants was age 180 days, with the oldest infant being age 227 days at the time the survey was completed.1,8–10

Although SAFE addressed several infant care practices such as breast-feeding and vaccination, our review here is limited to infant sleep practices. A wide range of factors was included in SAFE but we address only four key topics related to infant sleep: (1) sources of advice, (2) maternal trust in advice sources, (3) heterogeneity of beliefs and decision-making about infant sleep practices by non-white mothers, and (4) the relationship between breast-feeding and safe sleep practices.

Prior qualitative and quantitative studies demonstrated that mothers receive advice about infant care from a number of sources outside of the health care arena.8,9 SAFE found that although doctors were the most prevalent source of advice, 20% of mothers reported receiving no advice from a physician for sleep position and more than 50% reported no advice on sleep location.8 Estimates were similar for maternal receipt of advice on sleep position and location from nurses. Approximately 20% of mothers reported receiving sleep position and location advice from family members, nearly 30% received sleep position advice from the media, and about 10% of mothers received sleep location information from the media.8 Notably, nearly one-third of mothers reported receiving sleep position advice from family that was not consistent with guidelines, and more than one-half of mothers reported receiving advice in support of prone sleeping.8

Thus, the question arises as to whether mothers actually trust the advice they receive from such various sources. Although the SAFE survey does not measure dimensions of trust such as fidelity, competence, honesty, and confidentiality,27 maternal trust is assessed by asking mothers the following: “Who do you trust when deciding about sleeping in the same bed with your baby?”9 Similar questions are asked for a number of sleep-related practices, including supine positioning and pacifier use. This study demonstrated that whereas mothers had the greatest trust in doctors for advice about infant sleep practices, the prevalence ranged from 55% for pacifier use, to 60% for bed sharing, and to 80% for sleep position.9 In general, maternal trust in nurses was low (<35%) for sleep-related care, and low for friends and media (<15%). Maternal trust in family ranged from about 30% to 35%.9 In the adjusted analyses, there were significant associations between maternal race/ethnicity, education, and age to trust in sources of advice. NHB mothers were less likely to trust several sources of advice, including nurses, family, and the media, for nearly all sleep practices when compared to white mothers. In addition, NHB mothers were less likely to trust doctors regarding advice on bed sharing and pacifier use compared to non-Hispanic white mothers. Hispanic mothers were more likely to trust the media compared to white mothers. Mothers age 30 years or older were less likely to trust their family and more likely to trust the media compared to mothers age 20 to 29 years. Mothers with a college (or higher) education were more likely to trust doctors and friends about sleep-related practices compared to mothers with less than a high school education.9 The differences in level of trust in sources of advice by maternal characteristics highlight the challenge of developing effective interventions that are targeted to specific groups of caregivers.9

In the cohort of SAFE mothers, more than 900 women identified themselves as Hispanic, so the study of heterogeneity in infant sleep practices by birth country was feasible for this group. Hispanic mothers were divided into four subpopulations: US, Mexico, Central/South America, and the Caribbean. Compared to US-born mothers, women from the Caribbean (adjusted odds ratio [aOR] 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. In addition, Caribbean-born mothers were significantly less likely to place infants in supine sleep position (aOR 0.41).28 These results, again, illustrate the heterogeneity of maternal attitudes and behaviors even within one ethnic group and the importance of understanding these differences when developing and implementing targeted interventions.

SAFE also sought to better understand the relationship between maternal adherence to safe infant sleep practices and breast-feeding, especially with regard to the impact of advice received regarding these practices, which is a controversial topic in both perinatal research and clinical arenas. Smith et al.10 found that adherence to recommended practice is reported by 65% of mothers for sleep location, and by only 30.5% of mothers for exclusive breast-feeding. After controlling for demographic factors, advice to have the infant sleep in the parents' room but in his or her own bed (room sharing) and advice to breast-feed both increased the likelihood of those practices with a strong dose-response relationship, which is an indication that advice matters, and that advice from multiple sources appears cumulative. Smith et al.10 also found that compared to mothers who usually room shared, mothers who usually bed shared for all or part of the night were more likely to breast-feed (exclusive breast-feeding, aOR 2.46, 95% CI 1.76–3.45; and partial breast-feeding, aOR 1.75, 95% CI 1.33–2.31). The aOR of breast-feeding were lowest among mothers whose infants usually slept in a separate room. Despite the higher odds of breast-feeding among bed sharing mothers, the majority of mothers reported usually room sharing (without bed sharing), including 58.2% of exclusively breast-feeding mothers and 70% of mothers reporting no breast-feeding, allowing us to conclude that many mothers are able to both breast-feed and room share successfully without bed sharing.10


The Back to Sleep campaign of the 1990s continues to serve as a prime example of how a broad public health campaign, developed outside of typical health care settings, can dramatically affect infant health outcomes. Although the infant mortality rate attributed to SUID decreased by nearly 50% in the 1990s, there has been little improvement in more than 15 years, frustrating the medical and public health communities. Based upon the studies included in this review, including the results of SAFE, we hypothesize that prior interventions have not adequately addressed the heterogeneity of maternal beliefs about safe infant sleep practices as well as consideration of broader social, cultural, and economic factors that influence maternal decision-making related to safe infant sleep. In addition, the majority of intervention studies occurred postnatally, and perhaps it is already too late to effectively influence maternal behavior after the birth of the infant. Thus, future studies and public health interventions may need to target women of reproductive age prior to pregnancy, with continuation during and after pregnancy, as well as targeting the different maternal beliefs that vary with race and ethnicity. Finally, the Infant Care Practices Study, a multicenter prospective longitudinal study, found that maternal adherence to nonprone sleeping position declined significantly over time, from 1 month, 3 months, and 6 months after delivery.29 For instance, between age 1 and 3 months, prone sleeping increased from 18% to 29% of mothers in this cohort.29 The results of this study highlight the need to develop interventions that go beyond the immediate postnatal period. Novel strategies to educate and support families throughout the entire first year of their infants' lives, and particularly during the first 6 months, when the risk of sleep-associated death is greatest, will be required.


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Sunah S. Hwang, MD, MPH, is an Assistant Professor of Pediatrics, University of Colorado School of Medicine; and a Neonatologist, Children's Hospital Colorado. Michael J. Corwin, MD, is an Associate Professor of Pediatrics and Epidemiology, Boston University; and a Senior Epidemiologist, Slone Epidemiology Center.

Address correspondence to Sunah S. Hwang, MD, MPH, Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado, 13121 E. 17th Street, Mailstop 8402, Aurora, CO 80045; email:

Disclosure: The authors have no relevant financial relationships to disclose.


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