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Call to Change How Safer Sleep Information is Communicated

Change is needed to the way safer sleep information is communicated, if risks to babies from unsafe sleeping practices are to be reduced, said experts.

While rates of sudden unexpected death in infancy (SUDI) declined steeply in the 1990s as a result of the 'Reduce the Risks' campaign, and continued to decline until 2014, families living in the most deprived neighbourhoods continued to experience a "disproportionately" higher rate, said the authors of a new report.

Between April 2019 and March 2021, there were 711 sudden and unexpected infant deaths in the UK. Authors of the report,  Promoting safer sleeping for babies in high-risk groups in England, highlighted that the National Child Mortality Database recently found that over five times as many (42% versus 8%) of SUDIs occurred in deprived neighbourhoods, compared with the least deprived.

At the time, the Lullaby Trust pointed out that SUDI was "strongly associated with low birthweight, prematurity, multiple births, larger families, admission to a neonatal unit, maternal smoking during pregnancy, young maternal age, parental smoking, and parental drug misuse". The unexplained deaths of infants were also associated with "particular sleeping arrangements", the charity said.

The vast majority of unexplained deaths (98%) occurred when the infant was thought to be asleep. Over a third of infants (38%) were found on their front and nearly half the infants (47%) were found sharing a sleeping surface in hazardous circumstances, such as on a sofa or with an adult who had consumed alcohol, drugs, or smoked, emphasised the charity.

These stark findings prompted researchers from Oxford, University College London, Bristol, and Newcastle Universities to set about identifying what type of support was needed to reduce the incidence of SUDI in "all families".  

Range of Motivational Factors Influence Sleep Environment

For the new report, which particularly focused on families who faced significant adversity and who may had been receiving support from Children's Social Care Services, researchers interviewed parents, talked to local professional services, and studied data on decision-making and safer sleep interventions.

The researchers sought to establish from parents and social workers what were the relevant decision-making factors in terms of the capability, opportunities, and motivations that might provide a focus for the modification of existing practice, with regard to safer sleep. Also, what were the most promising behaviour change approaches in terms of capability, opportunities, and motivations for promoting safer sleep practices? Lastly, they explored what changes to existing best practice were needed to further reduce the risk of SUDI to infants.

The researchers found that a range of motivational factors played a key role in influencing decision-making about the infant sleep environment, including parents' own needs for adequate sleep and the need to bond with their babies. They also identified that "social pressures" with regards 'good parenting' might act as barriers to parents acknowledging and discussing/planning for "out of routine" circumstances. 

Amongst professionals responsible for conversations about infant sleep safety, there were concerns about providing "personalised and tailored" support and managing risk in families with a social worker.

"These findings suggest that change to current practice is needed if the risk of SUDI in this particular group of families is to be further reduced, highlighted the authors.

Professor Jane Barlow, from the department of social policy and intervention at the University of Oxford, and co-author, suggested that it may be "beneficial" for practitioners working to promote safe sleep practices with parents who are faced with a range of adverse life circumstances – some of whom may also have a social worker – to focus on exploring in an "open and honest way" the reasons that parents "might co-sleep with an infant, and how to do so safely".

"While this is consistent with national guidance on safe infant sleep practice, it represents a less didactic approach to working with these families," she said, and added that it relied on the development of a "trusting" relationship between the parent and practitioner.

Credible, Trusted Sources and Sound Evidence

The authors recommended that "open conversations" between parents and professionals could be used to support safer sleep for babies who have a social worker, and that the open conversations would need to acknowledge and discuss the "reality of people's lives" in order to understand and address the motivation behind parental decisions and actions.

Conversations should include "credible, trusted sources, and sound evidence" they said, to explain how and why safer sleep practices aim to protect infants. These were "key to the delivery of effective communications" about safer sleep with families of infants at increased risk of poor outcomes.

Dr Anna Pease, research fellow, Bristol Medical School, Bristol University, and co-author, emphasised that families had "a right" to evidence-based information about how to reduce their baby’s risk of sudden infant death. "We know that overall, safer sleep advice has worked to save the lives of thousands of babies, but this approach has not been as effective for families with more vulnerable infants," she pointed out.

She expressed the vitality of focussing on supporting those families who need extra support, and "tailoring" the messages to their circumstances, working with caregiver's own motivations and instincts, and making sure that these messages come from "credible and trusted sources of support".

In-depth conversations about safer sleep might best be delivered to families in receipt of social care by a practitioner, such as a health visitor, the authors postulated, who can provide "continuity of care" and who has "established a trusting relationship" with them. Peer and family support networks were also important to reinforce messages and provide practical advice, they said.

The authors also suggested that professionals could engage parents to identify motivations and provide personalised support that was still consistent with national guidance, but based on the "needs of individual families".

Asked to comment for Medscape News UK, Jenny Ward, CEO of The Lullaby Trust explained how deprivation can have a "significant impact" on infant mortality. "We’ve seen through the decline in the rate of sudden infant deaths over the last 30 years that safer sleep advice saves babies' lives. However, circumstances relating to deprivation can make accessing and following this advice difficult for some families," she cautioned.

Co-sleeping Discussion Needed

Also published Monday was a survey of over 3400 new parents by The Lullaby Trust that showed 9 in 10 co-sleep with their baby, whilst only 4 in 10 parents had been advised by a health professional on how to reduce the risk of sudden infant death syndrome (SIDS) if co-sleeping with their baby. 

The survey revealed that "many parents will co-sleep with their baby at some point, either by choice or by accident".

Jenny Ward, chief executive of The Lullaby Trust said: "Co-sleeping needs to be discussed with all families. It is really important that parents feel able to have open conversations about co-sleeping with health professionals so they get the right advice. Most parents will co-sleep at some point, whether this is planned or unintentional. Simply telling parents not to co-sleep, or not discussing co-sleeping at all means that a lot of families could miss out on vital safer sleep advice that would help to reduce the risk of SIDS for their baby. 

"Every parent, regardless of where their baby sleeps, needs to know about both the risks of bringing a baby into an adult bed, and how to prepare the bed in case co-sleeping happens, intentionally or not," she urged.

Funding for the study was provided by the National Institute for Health and Care Research (NIHR) Children and Families Policy Research Unit. HC was supported by a NIHR Local Authority Short Placement Award and NIHR Pre-doctoral Fellowship Award. RM was funded by multiple grants awarded by NIHR and MRC; she also holds a substantive role with North-East North Cumbria Clinical Research Network as the Associate Lead for Social Care Research. AP, a research fellow, was funded via an Advanced Fellowship from the NIHR.