Nurses role in Sudden Infant Death Syndrome (SIDS) risk reduction:
A Selected Annotated Bibliography

Morgan KH, Groer MW, Smith LJ.
The controversy about what constitutes safe and nurturant infant sleep environments.
J Obstet Gynecol Neonatal Nurs. 2006 Nov-Dec; 35(6):684-91.

In 1999, the U.S. Consumer Product Safety Commission stated that cribs provide the safest sleep environment for infants. Scientific data fails to support that statement and controversy continues in the scientific, medical, and parenting communities. Recent data demonstrate that cribs may represent the most unsafe sleep. This article seeks to inform health care professionals of the issues involved in the controversy and to offer guidelines for educating parents about safe and unsafe sleep practices.

Full-text available at: http://www.sciencedirect.com

Aris C, Stevens TP, Lemura C, Lipke B, McMullen S, Cote-Arsenault D, Consenstein L.
NICU Nurses' knowledge and discharge teaching related to infant sleep position and risk of SIDS.
Adv Neonatal Care. 2006 Oct; 6(5):281-294.

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. Objective: 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. Study Design: 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. Results: 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%). Conclusions: 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.

Full-text available at: http://www.medscape.com

Krueger G.
Meaning-making in the aftermath of sudden infant death syndrome.
Nurs Inq. 2006 Sep; 13(3):163-71.

The reconstruction of meaning in the aftermath of sudden infant death syndrome (SIDS) is part of the grieving process but has to date been poorly understood. Earlier theorists including Freud, Bowlby and Kubler-Ross provided a foundation for what occurs during this time using stage theories. More recent researchers, often using qualitative techniques, have provided a more complex and expanded view that enhances our knowledge of meaning reconstruction following infant loss. This overview of representative contemporary authors compares and contrasts them with the longstanding models that are being supplanted within the emerging field of thanatology. Understanding parental reactions within this new framework can help healthcare professionals in dealing with those affected by SIDS and provide a more empathic and sensitive approach to individual differences. Parents' own accounts of their post-SIDS experience are consistent with these newer theories. Comprehending how parents cope and reconstruct their lives is an important element in providing appropriate psychological support services.

Full-text available at: http://www.sciencedirect.com

Bullock LF, Mickey K, Green J, Heine A.
Are nurses acting as role models for the prevention of SIDS.
MCN Am J Matern Child Nurs. 2004 May-Jun; 29(3):172-7.

Purpose: To examine nurses' knowledge, attitude, and practice in positioning healthy newborns for sleep in the hospital setting. Design and Methods: A cross-sectional descriptive design was used to survey a convenience sample of practicing maternal child nurses in 58 Missouri hospitals. A 24-item investigator designed questionnaire was developed with input from SIDS Resources in Missouri. Results: A total of 528 surveys were analyzed. These nurses reported no longer placing infants in the prone position for sleep, but almost 75% of those answering the survey used either the side-lying position or a mixture of side and back positioning, even though 96% of the nurses said they were aware of the AAP Guidelines recommending "back to sleep." Forty-five percent of the nurses thought the infant would be at risk for aspiration if only placed on his/her back. Only 53% of the nurses knew their hospital's policy about newborn positioning; 80% of those who knew about the policy said it included the lateral position as being acceptable practice. Clinical Implications: Nurses are the role models for new parents regarding newborn sleep position, and are in a unique position to influence parents' decisions about how to place their infants for sleep at home. Because nurses continue to worry about aspiration when newborns are placed on their backs, it is clear that more education is needed for hospital nurses about newborn sleep position and hospital policies, as well as AAP Guidelines.

Full-text available at: http://www.mcnjournal.com

Stastny PF, Ichinose TY, Thayer SD, Olson RJ, Keens TG.
Infant sleep positioning by nursery staff and mothers in newborn hospital nurseries.
Nurs Res. 2004 Mar-Apr; 53(2):122-9.

Background: Although advice from healthcare professionals may influence parental infant placement choice to reduce sudden infant death syndrome risk, literature on nursery staff infant placement behaviors and the degree to which they influence maternal infant sleep positioning is limited. Objective: To assess newborn placement practices of the mother and nursery staff and their interrelationship in the hospital setting. Methods: A cross-sectional survey-based study was conducted among hospital newborn nursery staff (n = 96) and mothers of newborns (n = 579) at eight perinatal hospitals in Orange County, California. Results: Although a majority of sampled nursery staff (72%) identified the supine position as the placement that most lowers sudden infant death syndrome risk, only 30% reported most often placing infants to sleep in that position, with most staff (91%) citing fear of aspiration as the motivation for supine position avoidance. Only 34% of staff reported advising exclusive supine infant positioning to mothers. Approximately 36% of mothers reported using supine infant placement exclusively. Maternal infant placement choice varied by both the advice (p <.01) and the placement modeling (p <.01) provided by staff, with the highest proportion of usual supine infant placement found among mothers who reported receiving both. A mother's race/ethnicity also affected the reception of exclusive supine placement recommendations (p <.01). Conclusions: Exclusive supine infant placement appears to be underused by both nursery staff and mothers of newborn infants. Culturally grounded educational intervention with nursery staff regarding infant positioning and placement in the hospital setting is indicated.

Full-text available at: http://www.nursingresearchonline.com

Jeffery HE.
SIDS guidelines and the importance of nurses as role models.
Jrl of neonatal, paediatric and child health nursing, 2004 Mar, 7(1): 4-8.

Despite improved knowledge about the risk factors associated with sudden infant death syndrome (SIDS) and successful public health campaigns to inform parents and health professionals about them, the SIDS rate in Australia remains higher than in some other developed countries. Nurses share a special and close parental and infant advocacy role both in hospital and the community which can have a powerful influence on the parent's choice of infant sleeping position. Practice that incorporates safe infant sleeping position and environment, accompanied by a verbal recommendation, can potentially save lives and as such is a duty of care for all nurses. This requires nurses to be aware of current evidence and to implement and promote recommendations for reducing the risk of SIDS.

Full-text available at: http://www.acnn.org.au/journal.php

Colson ER, Joslin, SC.
Changing nursery practice gets inner-city infants in the supine position for sleep.
Arch Pediatr Adolesc Med. 2002 Jul; 156(7):717-20.

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 Measures: 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.

Full-text available at: http://archpedi.ama-assn.org

Horstman K, van Rens-Leenaarts E.
Beyond the boundary between science and values: Re-evaluating the moral dimension of the nurse's role in cot death prevention.
Nurs Ethics. 2002 Mar; 9(2):137-54.

This article combines a philosophical critique of the idea that public health nurses are primary technicians who neutrally hand over scientifically established facts on risks to the public and an empirical analysis of the actual work of public health nurses. It is argued that the relationship between facts and values in public health is complex and that, despite the introduction of several scientifically-based standards and guidelines, public health nurses are not technicians. They do moral work and experience ethical dilemmas. To get a grip on the specific character of this moral work, we distance ourselves from the idea that there are ethical dilemmas in public health nursing for which we can provide general ethical rules and principles. Instead we suggest a contextual ethical approach, in which several different kinds of consideration may be important. To illustrate this, we analysed 15 in-depth interviews with nurses involved in the prevention of cot deaths in the Netherlands. It is shown that these nurses do not neutrally pass on the epidemiological facts on the risks of prone sleeping, warm bed-clothes and passive smoking, but they are the moral architects of this preventive practice. It is also shown that this moral work and the ethical dilemmas they experience cannot be characterized in terms of general ethical rules and principles. It becomes clear that the moral work of nurses differs according to the three main risks at stake: the balance between virtue, risk taking and responsibility depends on the specific context.

Full-text available at: http://www.ingentaconnect.com

Huffman AD, Smok-Pearsall SM, Silvestri JM, Weese-Mayer DE.
SIDS risk factor awareness: Assessment among nursing students.
J Obstet Gynecol Neonatal Nurs.1999 Jan-Feb; 28(1):68-73.

Objective: To test the hypotheses that nursing students (a) have limited knowledge of risk factors for sudden infant death syndrome (SIDS) and the American Academy of Pediatrics (AAP) recommendation of placing infants on their backs or sides for sleep, and (b) after careful education about SIDS, would retain this information and teach it to parents. Design: A pretest questionnaire was used to identify knowledge of 13 risk factors and personal recommendation for sleep position. Participants attended a lecture on SIDS and received written educational material. A posttest was completed after 6 weeks. Setting: Nursing students were assessed during their family practice course. Participants: Fifty-one 4th-year nursing students (mean age 28.4 years, SD=7.6) enrolled in the BSN program completed the pretest; 29 completed the identical posttest. Intervention: A lecture on SIDS and SIDS risk factors with written educational material after the pretest. Main Outcome Measures: Pretest and posttest responses. Results: The Mann-Whitney test and McNemar chi-square analyses were used to determine factors on the pretest which influenced the awareness of prone position and to compare pretest and posttest data. On the pretest, 69% of students were aware of the AAP recommendation but significantly more (92%) were aware on the posttest. Posttest responses increased significantly for 12 of the 13 risk factors; 41% of the students identified all 13 risk factors on the posttest, in contrast to 0% on the pretest. On both the pretest and posttest, 93% of students stated that it was important to discuss their infant's sleep position with parents. Posttest results showed that students unanimously recommend the side or back sleep position. Conclusion: Nursing students were aware of the AAP recommendation, yet their knowledge of other risk factors was limited. A careful educational process resulted in retention of information about the AAP recommendation and other risk factors. In addition, students were willing to teach parents to place their infants on the back or side to sleep.

Full-text available at: http://www.medscape.com

Henderson-Smart DJ, Ponsonby AL, Murphy E.
Reducing the risk of sudden infant death syndrome: A review of the scientific literature.
J Paediatr Child Health. 1998 Jun; 34(3):213-9.

In March 1997 a multidisciplinary forum was convened by the National SIDS Council of Australia to review recent evidence concerning risk factors of sudden infant death syndrome (SIDS) and to revise and refine the current guidelines for reducing the risk of SIDS. The forum provided an assessment of the evidence for recommendations to reduce the risk of SIDS using an evidence-based process. Strong evidence has now accumulated that the intervention campaigns to reduce prone sleeping during infancy have been followed by SIDS rate declines. Recent data indicate that the supine position is not associated with an increase in significant morbidity outcomes and provides greater protection for SIDS than the side position, which may be unstable. Covering of the baby's head by bedding is strongly related to SIDS. The infant's sleeping environment should be carefully set up to ensure that the baby's head, including the face, cannot be obstructed during sleep. Parental smoking is strongly associated with SIDS. Structural supportive interventions for parental smoking cessation are required. Bed sharing increases the risk of SIDS amongst smokers and the data are currently not sufficient to provide complete reassurance to nonsmoking parents that bed sharing is safe. Infants should be maintained in a comfortable temperature zone. The evidence for a protective effect of breast-feeding is conflicting, so breast-feeding cannot be promoted strongly as reducing the risk of SIDS. Immunization has not been associated with SIDS. Parents and careers should be aware of the current guidelines. Health professionals should also be aware of the evidence on which the current recommendations are based. Effective health education programmes should lead to a further decline in SIDS mortality in Australia.

Full-text available at: http://www.blackwell-synergy.com

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