P2A004: How to Keep Infants Safe While Sleeping - A Qualitative Analysis of Differences Between Siblings

Background: The US has one of the highest infant mortality rates in the developed world, ranking 33rd among the 37 OECD countries. Sleep-related infant deaths (SRIDs) are the 3rd leading cause of infant mortality. Despite national efforts, such as the “Back to Sleep Campaign,” there has been an increase in the number of SRIDs in recent years. The aim of this study is to better understand how experienced parents decide on their infant’s sleep environment. Specifically, the goal is to qualitatively explore parents’ knowledge of infant sleep safety and assess whether their practices, motivations, and influencers differ over time between children.

Methods: Purposive criterion-based heterogenous sampling was used to recruit parents from an urban children’s ED. Participants were eligible for the study if they were: a parent or primary caregiver of at least two children (the youngest being 2-6mo at the time of the interview); 18yrs or older; regularly responsible for placing each child to sleep during infancy; and English or Spanish-speaking. Individuals were excluded if the current infant had a chronic illness, was born at < 37wks gestation, was critically ill during the ED visit, or the caregiver lacked access to a smartphone, tablet, or computer and Wi-Fi to enable a Zoom interview. Semi-structured qualitative interviews were then conducted by trained interviewers, and themes were identified using NVivo coding. The study was IRB approved.

Results: Fourteen parents were interviewed in English or Spanish (64.3% vs. 35.7%, respectively). Parental ages ranged from 22 to 41yrs (median age 30.5yrs). 50% had public insurance, and the majority of families (57.1%) received WIC at the time of the interview.

All 14 families were aware of the AAP safe-sleep recommendations, but 57.1% did not follow all of them. Co-sleeping was the most common unsafe sleep practice (42.9%), followed by the presence of stuffed animals or blankets (28.6%) and non-supine sleep positions (21.4%). Common barriers to guideline adherence included parental mental health, exhaustion, and financial constraints. Common facilitators included having a strong support system and a trusting, nonjudgmental relationship with their pediatrician. Furthermore, if parents were successful with specific practices with their first child, they were likely to continue them with their next children, even if advised that the practice was unsafe.

Conclusion: This qualitative assessment of infant sleep practices suggests that lack of knowledge or education is not the primary cause of unsafe sleep environments. Psychosocial barriers significantly contribute to parents’ choices. Importantly, nonjudgmental, trusting relationships with pediatricians may influence parents’ decisions. The results of this qualitative study can be used to inform larger, prospective studies and trials, with the ultimate goal of designing a successful, informed public health campaign to reduce sleep-related infant mortality.