Sleeping Position: Change in Practice, Advice, and Opinion in the Newborn Nursery

Sudden infant death syndrome (SIDS) is the leading cause of postneonatal infant mortality in the United States, accounting for approximately one third of all such deaths.¹ Between 1992 and 1996 the rate of SIDS deaths in the United States declined from 1.2 per 1000 live births to 0.74 per 1000 live births, and this decline accounted for 75% of the decline in the postneonatal infant death rate.²

By 1990 a strong association between the prone sleeping position and SIDS had been established,³ and in 1992 the American Academy of Pediatrics (AAP) Task Force on Infant Positioning and SIDS recommended that all full-term infants be placed in the lateral or supine position for sleep.^4,5 The Back to Sleep campaign was launched in 1994 by the US Department of Health and Human Services and other partners to help disseminate the message that back sleeping can reduce the risk of SIDS and save lives.^2,6 Studies in other countries indicated that SIDS rates declined concurrent with decreases in the prevalence of prone sleeping.³ Between 1992 and 1995 the SIDS rate in the United States declined 30%, while the prevalence of prone sleeping decreased from 78% to 43%.¹ Since the initial AAP recommendations, additional evidence has accumulated supporting supine or side positioning^7,8 and more recently that side positioning carries a higher risk for SIDS than supine.⁷

The recommendation of a health care professional and observation of sleep position in the hospital have both been shown to be important determinants in parents’ decision making about infant sleep position.^2,9,10 Although there are several studies of sleep positioning by caregivers and of sleep position recommendations by health care providers, there is only one study of nursery nursing staff regarding infant sleep position.^2,9,11,12 The National Institute of Child Health and Human Development has conducted a survey of health professionals regarding infant sleep position since 1993, but the results have not been published.⁹ Our study was initiated to assess the infant sleep position policies and practices of newborn nurseries in Missouri and evaluate nursery staff opinions of the AAP recommendation shortly after the recommendation was released in 1992 and again in 1999.

Methods

Study Design

A nurse interviewer conducted a telephone survey of all newborn nurseries in Missouri in 1992 and 1999. The Missouri Department of Health hospital profile database was used to identify hospitals with newborn nurseries before both surveys.¹³ An experienced obstetric nurse clinician contacted each hospital newborn nursery, spoke to the head nurse or charge nurse, and invited that nurse to participate in a short survey on infant sleep position.

After agreeing to participate, respondents were asked 10 questions about the policy and practice for infant sleep positioning in the nursery, what position they advise parents to use on discharge, and their opinion of the AAP recommendation. To maintain consistency between the 1992 and 1999 surveys, the 1999 survey was modified for date references and deletion of a question about any recent changes to their sleep position policy.

The opinion question was recorded as a narrative response during the interview. For data analysis, the responses were coded into 4 categories: agree, disagree, no opinion, or other Table 1. Three of the authors (J.E.D., R.L.P., P.G.S.) independently coded the opinion statements from the 1992 and 1999 surveys, and any discrepancies were resolved by consensus. The same coding criteria were used for both surveys. The data were analyzed using SAS software (SAS Institute, Cary, NC).

Our study was granted an exemption by the institutional review board at the University of Missouri–Columbia.

Results

In 1992 there were 79 hospitals with newborn nurseries in Missouri, and by 1999 this number had decreased to 75; however, the average number of nursery beds per hospital remained relatively constant with 16 in 1992 (median=12) and 15 in 1999 (median=12). For both surveys all hospitals with newborn nurseries in Missouri were contacted and agreed to participate.

In 1992, 92% of the head nurses were aware of the AAP recommendation for back or side sleeping position. By 1999, all were aware of the recommendation; however, the percentage of nurseries with an infant sleep position policy decreased from 98% to 95%.

Marked changes occurred in the infant sleep position used in these nurseries in the 7 years between surveys. In 1992, 32% of the survey respondents reported that their usual practice or policy was to use the prone position (exclusively) or stomach or side for sleep. In 1999, none of the respondents reported using the prone position as usual practice Table 2. Reported use of the supine position and of both supine and lateral position increased dramatically between 1992 and 1999 while exclusive use of side positioning decreased. Several of the nurses stated that they still place some babies on their stomach in the nursery and justified this by stating that they do not tell the parents or they watch the babies closely.

The positioning advice given to parents changed from 1992 to 1999, with more hospitals advising use of supine position exclusively or both the supine and the lateral position. In 1999, no nursery staff advised parents to place their babies prone. The position respondents stated that they used in the nursery and that they advised parents at discharge were highly correlated in 1999 but less so in 1992. The percentage agreement between the position used in the nursery and the advice given to parents in 1992 was 68% ({k}=0.52) and had increased to 75% ({k}=0.57) in 1999.

The proportion of respondents who agreed with the AAP recommendation increased between 1992 and 1999, while the proportion disagreeing decreased. Even so, in 1999 25% of the respondents stated opinions disagreeing with the recommendation.

The nurses who disagreed with the AAP recommendation in 1992 were more likely to state use of the prone position was their usual practice than respondents who agreed (68% vs 0%). In 1999 none of the respondents reported that prone position was their usual practice, and no respondent who disagreed with the recommendation used the supine position exclusively. Conversely, 36% of 1999 respondents who agreed with the recommendation placed babies exclusively on their backs (data not shown).

Discussion

This is the first published study that reports how newborn nurseries have implemented the AAP recommendations for infant sleep positioning. Our 2 surveys of head nurses in all newborn nurseries in Missouri show a significant change in nursery practice and nursing advice since the publication of the AAP statement on infant sleep positioning in 1992.

We were surprised to learn that 4 nurseries reported no infant sleep position policies or standard practice, but were encouraged by the overall decline in prone and exclusively side positioning. In 1992, 84% of Missouri nurseries were routinely placing babies prone or on their side. Both of these positions are of concern: Side positioning is the least stable, and both prone and side positioning are associated with an increased risk of SIDS.^2,7,8 In 1999, 78% of head nurses reported back or back or side positioning as their standard practice, and only 23% still used side positioning as their standard practice. Head nurses report that prone positioning is no longer a standard practice in any Missouri nursery, but some nurses indicate a willingness to make exceptions for “spitty” babies and immediately after feeding.

Nursery advice to parents about positioning has also changed. In 1992, 80% of head nurses advised parents to place their babies either on their sides or prone. In 1999, 8% still advised side; 20% recommended supine; and 72% recommended either back or side. No head nurses reported that placing babies prone for sleep was standard advice.

The overall change in head nurse opinions of the AAP recommendations is also encouraging. Between 1992 and 1999, head nurses who disagreed with the AAP recommendations declined from 63% to 25%. This opinion conversion is critical, because nurses who disagreed with the AAP recommendations did not use supine positioning as their standard practice. In 1999 there was 75% agreement between what nurses did and what they advised.

Changing behavior is difficult, but public policies can lead to change.¹⁴ There has been considerable research devoted to the effect that clinical guidelines have on practitioner behavior.¹⁵ Several barriers to behavioral change have been identified¹⁶ including familiarity, awareness, and agreement with the guideline. Our study demonstrates the effectiveness of a clinical policy and a public campaign to change clinical behavior and identifies targets for future educational programs. We believe the Back to Sleep Program was successful due to a multifaceted approach that included the general press, professional society outreach, nursing and physician involvement, and education of parents. The diversity of influences applied in this campaign offers a model for eliciting specific behavioral change by clinicians and patients. Even so, our findings suggest that some clinicians may still cling to behaviors, and changing these behaviors may require specific targeted actions.

Newborn nursery nurses have an important role in influencing infant sleep positioning at home. There is increasing evidence that what advice and observation regarding infant sleep positioning while in the hospital is important for what they do at home. A study of inner city mothers found that the most important determinant of intended and actual home sleep positioning was the mothers’ observation of the sleep position used in the hospital. These mothers observed their babies in prone positions 14% to 17% of the time in the newborn nursery, despite hospital policies regarding side or supine positioning in all 3 participating hospitals.⁹ This finding is of concern, because in our study nurses who disagreed with AAP recommendations made exceptions and positioned some babies prone. So, even though prone positioning is no longer standard practice, it is still used in some nurseries and may be witnessed by parents.

Lesko and colleagues¹⁷ found that advice from a health care professional had the most important influence on a mother’s decision to use nonprone sleep positions at 1 month. Gibson and coworkers¹⁸ found that nearly half of parents in suburban and inner city clinics reported that health professional advice influenced how they positioned their infants. The Centers for Disease Control and Prevention (CDC)¹⁹ recently cited this evidence in recommending that outreach programs to influence infant sleep position should consider the role of advice from health professionals. This should reinforce the important role that family physicians have in recommending supine positioning over all other sleep positions. We believe that the change in advice given to parents demonstrated in our study has an important effect on home infant sleep positioning. The strong correlation found between position used and advice given may indicate that nurses who make exceptions for prone or side positioning may also bias their advice.

Limitations and Strengths

Our study had several limitations. We relied solely on the head nurses’ reporting of the conditions within their institutions. We did not conduct any observations of nursery practices, contact parents of new infants to corroborate their experience with the responses from head nurses, or otherwise validate survey responses. It is possible that actual practice differs from what was reported. We were also unable to match hospitals from the 1992 and 1999 data because of the way the 1992 hospital data were collected. The individual surveys completed in 1992 did not include the name of the hospital on the data form, which made it impossible to compare them with the individual hospitals in 1999.

Despite these limitations, this study has several strengths. We contacted and interviewed head nurses at every hospital newborn nursery in Missouri shortly after the AAP infant sleep position recommendation was released and again 7 years later. Also, the same obstetrical nurse clinician conducted the interviews using identical questions, which provided consistency between surveys.

Conclusions

Important change has occurred in nursery practice, opinion, and advice to parents since the announcement of the AAP recommendation on infant sleep position in 1992; however, some head nurses still disagree with this recommendation, and this may affect the nursery positioning practice and the advice given to mothers. Infant sleep position and advice from newborn nursery nurses should be consistent with current AAP recommendations and hospital policy. Our study further supports the CDC recommendation that outreach programs to influence infant sleep position should consider the role of advice from health professionals¹⁹ and emphasizes the importance of family physicians in parental choice for infant sleep position. Our study should remind all health care professionals of the impact of their advice to parents regarding infant sleep position. With the overwhelming evidence supporting the supine position, increased educational efforts focused on influencing nursery staff practice and advice may be necessary to increase infant supine sleep positioning. These educational efforts should include the family physician’s role in influencing nursery staff practices.

Acknowledgments

Support for our study was provided by the Center for Family Medicine Science in the Department of Family and Community Medicine at the University of Missouri–Columbia. The Center is funded in part by the American Academy of Family Physicians. We would like to thank Sharon Cornelison, RNC, for her diligent data collection, Darla Horman, MA, for management of the 1992 survey data, and Mirra Smith for data abstraction.

Sudden infant death syndrome (SIDS) is the leading cause of postneonatal infant mortality in the United States, accounting for approximately one third of all such deaths.¹ Between 1992 and 1996 the rate of SIDS deaths in the United States declined from 1.2 per 1000 live births to 0.74 per 1000 live births, and this decline accounted for 75% of the decline in the postneonatal infant death rate.²

By 1990 a strong association between the prone sleeping position and SIDS had been established,³ and in 1992 the American Academy of Pediatrics (AAP) Task Force on Infant Positioning and SIDS recommended that all full-term infants be placed in the lateral or supine position for sleep.^4,5 The Back to Sleep campaign was launched in 1994 by the US Department of Health and Human Services and other partners to help disseminate the message that back sleeping can reduce the risk of SIDS and save lives.^2,6 Studies in other countries indicated that SIDS rates declined concurrent with decreases in the prevalence of prone sleeping.³ Between 1992 and 1995 the SIDS rate in the United States declined 30%, while the prevalence of prone sleeping decreased from 78% to 43%.¹ Since the initial AAP recommendations, additional evidence has accumulated supporting supine or side positioning^7,8 and more recently that side positioning carries a higher risk for SIDS than supine.⁷

The recommendation of a health care professional and observation of sleep position in the hospital have both been shown to be important determinants in parents’ decision making about infant sleep position.^2,9,10 Although there are several studies of sleep positioning by caregivers and of sleep position recommendations by health care providers, there is only one study of nursery nursing staff regarding infant sleep position.^2,9,11,12 The National Institute of Child Health and Human Development has conducted a survey of health professionals regarding infant sleep position since 1993, but the results have not been published.⁹ Our study was initiated to assess the infant sleep position policies and practices of newborn nurseries in Missouri and evaluate nursery staff opinions of the AAP recommendation shortly after the recommendation was released in 1992 and again in 1999.

Methods

Study Design

A nurse interviewer conducted a telephone survey of all newborn nurseries in Missouri in 1992 and 1999. The Missouri Department of Health hospital profile database was used to identify hospitals with newborn nurseries before both surveys.¹³ An experienced obstetric nurse clinician contacted each hospital newborn nursery, spoke to the head nurse or charge nurse, and invited that nurse to participate in a short survey on infant sleep position.

After agreeing to participate, respondents were asked 10 questions about the policy and practice for infant sleep positioning in the nursery, what position they advise parents to use on discharge, and their opinion of the AAP recommendation. To maintain consistency between the 1992 and 1999 surveys, the 1999 survey was modified for date references and deletion of a question about any recent changes to their sleep position policy.

The opinion question was recorded as a narrative response during the interview. For data analysis, the responses were coded into 4 categories: agree, disagree, no opinion, or other Table 1. Three of the authors (J.E.D., R.L.P., P.G.S.) independently coded the opinion statements from the 1992 and 1999 surveys, and any discrepancies were resolved by consensus. The same coding criteria were used for both surveys. The data were analyzed using SAS software (SAS Institute, Cary, NC).

Our study was granted an exemption by the institutional review board at the University of Missouri–Columbia.

Results

In 1992 there were 79 hospitals with newborn nurseries in Missouri, and by 1999 this number had decreased to 75; however, the average number of nursery beds per hospital remained relatively constant with 16 in 1992 (median=12) and 15 in 1999 (median=12). For both surveys all hospitals with newborn nurseries in Missouri were contacted and agreed to participate.

In 1992, 92% of the head nurses were aware of the AAP recommendation for back or side sleeping position. By 1999, all were aware of the recommendation; however, the percentage of nurseries with an infant sleep position policy decreased from 98% to 95%.

Marked changes occurred in the infant sleep position used in these nurseries in the 7 years between surveys. In 1992, 32% of the survey respondents reported that their usual practice or policy was to use the prone position (exclusively) or stomach or side for sleep. In 1999, none of the respondents reported using the prone position as usual practice Table 2. Reported use of the supine position and of both supine and lateral position increased dramatically between 1992 and 1999 while exclusive use of side positioning decreased. Several of the nurses stated that they still place some babies on their stomach in the nursery and justified this by stating that they do not tell the parents or they watch the babies closely.

The positioning advice given to parents changed from 1992 to 1999, with more hospitals advising use of supine position exclusively or both the supine and the lateral position. In 1999, no nursery staff advised parents to place their babies prone. The position respondents stated that they used in the nursery and that they advised parents at discharge were highly correlated in 1999 but less so in 1992. The percentage agreement between the position used in the nursery and the advice given to parents in 1992 was 68% ({k}=0.52) and had increased to 75% ({k}=0.57) in 1999.

The proportion of respondents who agreed with the AAP recommendation increased between 1992 and 1999, while the proportion disagreeing decreased. Even so, in 1999 25% of the respondents stated opinions disagreeing with the recommendation.

The nurses who disagreed with the AAP recommendation in 1992 were more likely to state use of the prone position was their usual practice than respondents who agreed (68% vs 0%). In 1999 none of the respondents reported that prone position was their usual practice, and no respondent who disagreed with the recommendation used the supine position exclusively. Conversely, 36% of 1999 respondents who agreed with the recommendation placed babies exclusively on their backs (data not shown).

Discussion

This is the first published study that reports how newborn nurseries have implemented the AAP recommendations for infant sleep positioning. Our 2 surveys of head nurses in all newborn nurseries in Missouri show a significant change in nursery practice and nursing advice since the publication of the AAP statement on infant sleep positioning in 1992.

We were surprised to learn that 4 nurseries reported no infant sleep position policies or standard practice, but were encouraged by the overall decline in prone and exclusively side positioning. In 1992, 84% of Missouri nurseries were routinely placing babies prone or on their side. Both of these positions are of concern: Side positioning is the least stable, and both prone and side positioning are associated with an increased risk of SIDS.^2,7,8 In 1999, 78% of head nurses reported back or back or side positioning as their standard practice, and only 23% still used side positioning as their standard practice. Head nurses report that prone positioning is no longer a standard practice in any Missouri nursery, but some nurses indicate a willingness to make exceptions for “spitty” babies and immediately after feeding.

Nursery advice to parents about positioning has also changed. In 1992, 80% of head nurses advised parents to place their babies either on their sides or prone. In 1999, 8% still advised side; 20% recommended supine; and 72% recommended either back or side. No head nurses reported that placing babies prone for sleep was standard advice.

The overall change in head nurse opinions of the AAP recommendations is also encouraging. Between 1992 and 1999, head nurses who disagreed with the AAP recommendations declined from 63% to 25%. This opinion conversion is critical, because nurses who disagreed with the AAP recommendations did not use supine positioning as their standard practice. In 1999 there was 75% agreement between what nurses did and what they advised.

Changing behavior is difficult, but public policies can lead to change.¹⁴ There has been considerable research devoted to the effect that clinical guidelines have on practitioner behavior.¹⁵ Several barriers to behavioral change have been identified¹⁶ including familiarity, awareness, and agreement with the guideline. Our study demonstrates the effectiveness of a clinical policy and a public campaign to change clinical behavior and identifies targets for future educational programs. We believe the Back to Sleep Program was successful due to a multifaceted approach that included the general press, professional society outreach, nursing and physician involvement, and education of parents. The diversity of influences applied in this campaign offers a model for eliciting specific behavioral change by clinicians and patients. Even so, our findings suggest that some clinicians may still cling to behaviors, and changing these behaviors may require specific targeted actions.

Newborn nursery nurses have an important role in influencing infant sleep positioning at home. There is increasing evidence that what advice and observation regarding infant sleep positioning while in the hospital is important for what they do at home. A study of inner city mothers found that the most important determinant of intended and actual home sleep positioning was the mothers’ observation of the sleep position used in the hospital. These mothers observed their babies in prone positions 14% to 17% of the time in the newborn nursery, despite hospital policies regarding side or supine positioning in all 3 participating hospitals.⁹ This finding is of concern, because in our study nurses who disagreed with AAP recommendations made exceptions and positioned some babies prone. So, even though prone positioning is no longer standard practice, it is still used in some nurseries and may be witnessed by parents.

Lesko and colleagues¹⁷ found that advice from a health care professional had the most important influence on a mother’s decision to use nonprone sleep positions at 1 month. Gibson and coworkers¹⁸ found that nearly half of parents in suburban and inner city clinics reported that health professional advice influenced how they positioned their infants. The Centers for Disease Control and Prevention (CDC)¹⁹ recently cited this evidence in recommending that outreach programs to influence infant sleep position should consider the role of advice from health professionals. This should reinforce the important role that family physicians have in recommending supine positioning over all other sleep positions. We believe that the change in advice given to parents demonstrated in our study has an important effect on home infant sleep positioning. The strong correlation found between position used and advice given may indicate that nurses who make exceptions for prone or side positioning may also bias their advice.

Limitations and Strengths

Our study had several limitations. We relied solely on the head nurses’ reporting of the conditions within their institutions. We did not conduct any observations of nursery practices, contact parents of new infants to corroborate their experience with the responses from head nurses, or otherwise validate survey responses. It is possible that actual practice differs from what was reported. We were also unable to match hospitals from the 1992 and 1999 data because of the way the 1992 hospital data were collected. The individual surveys completed in 1992 did not include the name of the hospital on the data form, which made it impossible to compare them with the individual hospitals in 1999.

Despite these limitations, this study has several strengths. We contacted and interviewed head nurses at every hospital newborn nursery in Missouri shortly after the AAP infant sleep position recommendation was released and again 7 years later. Also, the same obstetrical nurse clinician conducted the interviews using identical questions, which provided consistency between surveys.

Conclusions

Important change has occurred in nursery practice, opinion, and advice to parents since the announcement of the AAP recommendation on infant sleep position in 1992; however, some head nurses still disagree with this recommendation, and this may affect the nursery positioning practice and the advice given to mothers. Infant sleep position and advice from newborn nursery nurses should be consistent with current AAP recommendations and hospital policy. Our study further supports the CDC recommendation that outreach programs to influence infant sleep position should consider the role of advice from health professionals¹⁹ and emphasizes the importance of family physicians in parental choice for infant sleep position. Our study should remind all health care professionals of the impact of their advice to parents regarding infant sleep position. With the overwhelming evidence supporting the supine position, increased educational efforts focused on influencing nursery staff practice and advice may be necessary to increase infant supine sleep positioning. These educational efforts should include the family physician’s role in influencing nursery staff practices.

Acknowledgments

Support for our study was provided by the Center for Family Medicine Science in the Department of Family and Community Medicine at the University of Missouri–Columbia. The Center is funded in part by the American Academy of Family Physicians. We would like to thank Sharon Cornelison, RNC, for her diligent data collection, Darla Horman, MA, for management of the 1992 survey data, and Mirra Smith for data abstraction.

Sudden infant death syndrome (SIDS) is the leading cause of postneonatal infant mortality in the United States, accounting for approximately one third of all such deaths.¹ Between 1992 and 1996 the rate of SIDS deaths in the United States declined from 1.2 per 1000 live births to 0.74 per 1000 live births, and this decline accounted for 75% of the decline in the postneonatal infant death rate.²

By 1990 a strong association between the prone sleeping position and SIDS had been established,³ and in 1992 the American Academy of Pediatrics (AAP) Task Force on Infant Positioning and SIDS recommended that all full-term infants be placed in the lateral or supine position for sleep.^4,5 The Back to Sleep campaign was launched in 1994 by the US Department of Health and Human Services and other partners to help disseminate the message that back sleeping can reduce the risk of SIDS and save lives.^2,6 Studies in other countries indicated that SIDS rates declined concurrent with decreases in the prevalence of prone sleeping.³ Between 1992 and 1995 the SIDS rate in the United States declined 30%, while the prevalence of prone sleeping decreased from 78% to 43%.¹ Since the initial AAP recommendations, additional evidence has accumulated supporting supine or side positioning^7,8 and more recently that side positioning carries a higher risk for SIDS than supine.⁷

The recommendation of a health care professional and observation of sleep position in the hospital have both been shown to be important determinants in parents’ decision making about infant sleep position.^2,9,10 Although there are several studies of sleep positioning by caregivers and of sleep position recommendations by health care providers, there is only one study of nursery nursing staff regarding infant sleep position.^2,9,11,12 The National Institute of Child Health and Human Development has conducted a survey of health professionals regarding infant sleep position since 1993, but the results have not been published.⁹ Our study was initiated to assess the infant sleep position policies and practices of newborn nurseries in Missouri and evaluate nursery staff opinions of the AAP recommendation shortly after the recommendation was released in 1992 and again in 1999.

Methods

Study Design

A nurse interviewer conducted a telephone survey of all newborn nurseries in Missouri in 1992 and 1999. The Missouri Department of Health hospital profile database was used to identify hospitals with newborn nurseries before both surveys.¹³ An experienced obstetric nurse clinician contacted each hospital newborn nursery, spoke to the head nurse or charge nurse, and invited that nurse to participate in a short survey on infant sleep position.

After agreeing to participate, respondents were asked 10 questions about the policy and practice for infant sleep positioning in the nursery, what position they advise parents to use on discharge, and their opinion of the AAP recommendation. To maintain consistency between the 1992 and 1999 surveys, the 1999 survey was modified for date references and deletion of a question about any recent changes to their sleep position policy.

The opinion question was recorded as a narrative response during the interview. For data analysis, the responses were coded into 4 categories: agree, disagree, no opinion, or other Table 1. Three of the authors (J.E.D., R.L.P., P.G.S.) independently coded the opinion statements from the 1992 and 1999 surveys, and any discrepancies were resolved by consensus. The same coding criteria were used for both surveys. The data were analyzed using SAS software (SAS Institute, Cary, NC).

Our study was granted an exemption by the institutional review board at the University of Missouri–Columbia.

Results

In 1992 there were 79 hospitals with newborn nurseries in Missouri, and by 1999 this number had decreased to 75; however, the average number of nursery beds per hospital remained relatively constant with 16 in 1992 (median=12) and 15 in 1999 (median=12). For both surveys all hospitals with newborn nurseries in Missouri were contacted and agreed to participate.

In 1992, 92% of the head nurses were aware of the AAP recommendation for back or side sleeping position. By 1999, all were aware of the recommendation; however, the percentage of nurseries with an infant sleep position policy decreased from 98% to 95%.

Marked changes occurred in the infant sleep position used in these nurseries in the 7 years between surveys. In 1992, 32% of the survey respondents reported that their usual practice or policy was to use the prone position (exclusively) or stomach or side for sleep. In 1999, none of the respondents reported using the prone position as usual practice Table 2. Reported use of the supine position and of both supine and lateral position increased dramatically between 1992 and 1999 while exclusive use of side positioning decreased. Several of the nurses stated that they still place some babies on their stomach in the nursery and justified this by stating that they do not tell the parents or they watch the babies closely.

The positioning advice given to parents changed from 1992 to 1999, with more hospitals advising use of supine position exclusively or both the supine and the lateral position. In 1999, no nursery staff advised parents to place their babies prone. The position respondents stated that they used in the nursery and that they advised parents at discharge were highly correlated in 1999 but less so in 1992. The percentage agreement between the position used in the nursery and the advice given to parents in 1992 was 68% ({k}=0.52) and had increased to 75% ({k}=0.57) in 1999.

The proportion of respondents who agreed with the AAP recommendation increased between 1992 and 1999, while the proportion disagreeing decreased. Even so, in 1999 25% of the respondents stated opinions disagreeing with the recommendation.

The nurses who disagreed with the AAP recommendation in 1992 were more likely to state use of the prone position was their usual practice than respondents who agreed (68% vs 0%). In 1999 none of the respondents reported that prone position was their usual practice, and no respondent who disagreed with the recommendation used the supine position exclusively. Conversely, 36% of 1999 respondents who agreed with the recommendation placed babies exclusively on their backs (data not shown).

Discussion

This is the first published study that reports how newborn nurseries have implemented the AAP recommendations for infant sleep positioning. Our 2 surveys of head nurses in all newborn nurseries in Missouri show a significant change in nursery practice and nursing advice since the publication of the AAP statement on infant sleep positioning in 1992.

We were surprised to learn that 4 nurseries reported no infant sleep position policies or standard practice, but were encouraged by the overall decline in prone and exclusively side positioning. In 1992, 84% of Missouri nurseries were routinely placing babies prone or on their side. Both of these positions are of concern: Side positioning is the least stable, and both prone and side positioning are associated with an increased risk of SIDS.^2,7,8 In 1999, 78% of head nurses reported back or back or side positioning as their standard practice, and only 23% still used side positioning as their standard practice. Head nurses report that prone positioning is no longer a standard practice in any Missouri nursery, but some nurses indicate a willingness to make exceptions for “spitty” babies and immediately after feeding.

Nursery advice to parents about positioning has also changed. In 1992, 80% of head nurses advised parents to place their babies either on their sides or prone. In 1999, 8% still advised side; 20% recommended supine; and 72% recommended either back or side. No head nurses reported that placing babies prone for sleep was standard advice.

The overall change in head nurse opinions of the AAP recommendations is also encouraging. Between 1992 and 1999, head nurses who disagreed with the AAP recommendations declined from 63% to 25%. This opinion conversion is critical, because nurses who disagreed with the AAP recommendations did not use supine positioning as their standard practice. In 1999 there was 75% agreement between what nurses did and what they advised.

Changing behavior is difficult, but public policies can lead to change.¹⁴ There has been considerable research devoted to the effect that clinical guidelines have on practitioner behavior.¹⁵ Several barriers to behavioral change have been identified¹⁶ including familiarity, awareness, and agreement with the guideline. Our study demonstrates the effectiveness of a clinical policy and a public campaign to change clinical behavior and identifies targets for future educational programs. We believe the Back to Sleep Program was successful due to a multifaceted approach that included the general press, professional society outreach, nursing and physician involvement, and education of parents. The diversity of influences applied in this campaign offers a model for eliciting specific behavioral change by clinicians and patients. Even so, our findings suggest that some clinicians may still cling to behaviors, and changing these behaviors may require specific targeted actions.

Newborn nursery nurses have an important role in influencing infant sleep positioning at home. There is increasing evidence that what advice and observation regarding infant sleep positioning while in the hospital is important for what they do at home. A study of inner city mothers found that the most important determinant of intended and actual home sleep positioning was the mothers’ observation of the sleep position used in the hospital. These mothers observed their babies in prone positions 14% to 17% of the time in the newborn nursery, despite hospital policies regarding side or supine positioning in all 3 participating hospitals.⁹ This finding is of concern, because in our study nurses who disagreed with AAP recommendations made exceptions and positioned some babies prone. So, even though prone positioning is no longer standard practice, it is still used in some nurseries and may be witnessed by parents.

Lesko and colleagues¹⁷ found that advice from a health care professional had the most important influence on a mother’s decision to use nonprone sleep positions at 1 month. Gibson and coworkers¹⁸ found that nearly half of parents in suburban and inner city clinics reported that health professional advice influenced how they positioned their infants. The Centers for Disease Control and Prevention (CDC)¹⁹ recently cited this evidence in recommending that outreach programs to influence infant sleep position should consider the role of advice from health professionals. This should reinforce the important role that family physicians have in recommending supine positioning over all other sleep positions. We believe that the change in advice given to parents demonstrated in our study has an important effect on home infant sleep positioning. The strong correlation found between position used and advice given may indicate that nurses who make exceptions for prone or side positioning may also bias their advice.

Limitations and Strengths

Our study had several limitations. We relied solely on the head nurses’ reporting of the conditions within their institutions. We did not conduct any observations of nursery practices, contact parents of new infants to corroborate their experience with the responses from head nurses, or otherwise validate survey responses. It is possible that actual practice differs from what was reported. We were also unable to match hospitals from the 1992 and 1999 data because of the way the 1992 hospital data were collected. The individual surveys completed in 1992 did not include the name of the hospital on the data form, which made it impossible to compare them with the individual hospitals in 1999.

Despite these limitations, this study has several strengths. We contacted and interviewed head nurses at every hospital newborn nursery in Missouri shortly after the AAP infant sleep position recommendation was released and again 7 years later. Also, the same obstetrical nurse clinician conducted the interviews using identical questions, which provided consistency between surveys.

Conclusions

Important change has occurred in nursery practice, opinion, and advice to parents since the announcement of the AAP recommendation on infant sleep position in 1992; however, some head nurses still disagree with this recommendation, and this may affect the nursery positioning practice and the advice given to mothers. Infant sleep position and advice from newborn nursery nurses should be consistent with current AAP recommendations and hospital policy. Our study further supports the CDC recommendation that outreach programs to influence infant sleep position should consider the role of advice from health professionals¹⁹ and emphasizes the importance of family physicians in parental choice for infant sleep position. Our study should remind all health care professionals of the impact of their advice to parents regarding infant sleep position. With the overwhelming evidence supporting the supine position, increased educational efforts focused on influencing nursery staff practice and advice may be necessary to increase infant supine sleep positioning. These educational efforts should include the family physician’s role in influencing nursery staff practices.

Acknowledgments

Support for our study was provided by the Center for Family Medicine Science in the Department of Family and Community Medicine at the University of Missouri–Columbia. The Center is funded in part by the American Academy of Family Physicians. We would like to thank Sharon Cornelison, RNC, for her diligent data collection, Darla Horman, MA, for management of the 1992 survey data, and Mirra Smith for data abstraction.