Source:Willinger M, Ko CW, Hoffman HJ, et al. Factors associated with caregivers’ choice of infant sleep position, 1994–1998.
JAMA
.
2000
;
283
:
2135
–2142.

These investigators studied the factors that determine caregiver behavior in response to the 1994 “Back to Sleep” campaign to reduce sudden infant death syndrome. Annual telephone surveys were conducted between 1994 and 1998 among a nationally representative sample in the United States. Approximately 1000 interviews per year were conducted with nighttime caregivers of infants born in the prior 7 months. The participating caregivers were asked about the infant’s usual sleep position, where they had received sleep position recommendations, and the reasons for their choices. From 1994 to 1998, prone placement declined from 44% to 17% among white infants and 53% to 32% among black infants. Supine placement increased among white infants from 27% to 58%, and among black infants from 17% to 31%. There was little change in the prevalence of lateral placement among either white or black infants during this period. At least one recommendation for supine infant sleeping was received by 38% of caregivers in 1995, increasing to 79% in 1998. Among caregivers preferring the prone position, 86% had received only non-prone recommendations, and the main reason for their choice was infant comfort. In logistic regression analysis, physical recommendation was associated with the greatest reduction in prone placement (odds ratio [OR] 0.25; 95% CI, 0.16–0.39) and increase in supine position (OR 3.37; 95% CI, 2.38–4.76). Recommendations from 4 distinct sources (physician, neonatal nurse, readings and radio/television) further increased likelihood of supine placement (OR 6.01; 95% CI, 4.57–7.90). Other factors independently related to increased prone and decreased supine placement included maternal black race, parity > 1, and residing in southern or mid-Atlantic states (all comparisons, P<.001). The influence of these factors could not be accounted for by differences in exposure to a recommendation. The authors conclude that only half of infants were placed supine to sleep in 1998, and that caregivers are influenced by multiple sources. They suggest that caregiver beliefs about the perceived advantages of prone sleeping should be addressed to achieve further increases in supine placement.

In 1992, the AAP recommended a non-prone sleeping position for healthy young infants.1 This advice was expanded in 1994 with the initiation of the “Back to Sleep” campaign,2 and in 1996, with the emphasis on supine sleeping.3 Several studies have confirmed the safety of supine sleeping.4 Most of the decline in SIDS from 1992–1996 has been attributed to reduction in prone sleeping position.5 Willinger et al previously showed the importance of physician counseling in changing caregiver behavior to promote supine sleeping: those receiving such advice were more than three times as likely to place infants on their backs. More sobering, as described in this article, was the persistence of an important subgroup of parents who continue the prone infant sleeping position despite advice to the contrary. This behavior was stronger among caregivers of infants identified as black. The authors...

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