Background: Prone sleeping by infants has been associated with increased risk of sudden infant death syndrome (SIDS). Many child caregivers continue to be unaware of the association of SIDS and infant  sleep position and/or are misinformed as to the risks and benefits of the various sleep positions.Objectives: To explore mothers’ knowledge and practice of infant sleep position and SIDS.Methods: The study was conducted in April – August 2012 amongst mothers of infants attending the Paediatric Outpatient Clinics of the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. A structured questionnaire was used to obtain information on biodata andknowledge and practice of infant sleep position and SIDS. Data were analyzed using SPSS version 16.0.Results: A total of 282 mothers participated in the study; 167 (59.2%) of them had tertiary education while 265 (94.0%) were married. The  commonest sleep position was prone position (44.3%).Baby’s comfort was the commonest reason for choice of position. There was no significantrelationship between mother’s age and education and choice of infant sleep position (p &gt; 0.05).A total of 229(81.2%) respondents were unawareof any medically recommended sleep position. Of those who were aware, the commonest source of knowledge was grandmothers. A total of 99 (35.1%) respondents had heard of SIDS but over 80% of them did not know the cause.Conclusion: Mothers in Port Harcourt have poor knowledge of infant sleep position. Doctors should take more active part in educating mothers on safe child care practices.Key words: Infant sleep position, mothers, sudden infant death syndrome,Nigeri

Okpere, AN

Opara, PI

English

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                 ORIGINAL Niger J Paed 2014; 41 (4):312– 315 Okpere AN Opara PI Mothers’ knowledge and practice of infant sleep position  Accepted: 12th April 2014  Okpere AN Opara PI Department of Paediatrics University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria E-mail: anokpere@yahoo.com (      )DOI:http://dx.doi.org/10.4314/njp.v41i4,4 Abstract Background: Prone sleeping by infants has been asso-ciated with increased risk of sud-den infant death syndrome (SIDS). Many child caregivers continue to be unaware of the association of SIDS and infant sleep position and/or are misin-formed as to the risks and benefits of the various sleep positions.  Objectives: To explore mothers’ knowledge and practice of infant sleep position and SIDS. Methods: The study was con-ducted in April – August 2012 amongst mothers of infants at-tending the Paediatric Outpatient Clinics of the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. A structured questionnaire was used to obtain information on biodata and knowledge and practice of infant sleep position and SIDS. Data were analyzed using SPSS version 16.0. Results: A total of 282 mothers participated in the study; 167 (59.2%) of them had tertiary  education while 265 (94.0%) were married. The commonest sleep position was prone position (44.3%).Baby’s comfort was the commonest reason for choice of position. There was no significant relationship between mother’s age and education and choice of infant sleep position (p > 0.05).A total of 229(81.2%) respondents were un-aware of any medically recom-mended sleep position. Of those who were aware, the commonest source of knowledge was grand-mothers. A total of 99 (35.1%) respondents had heard of SIDS but over 80% of them did not know the cause. Conclusion: Mothers in Port Har-court have poor knowledge of in-fant sleep position. Doctors should take more active part in educating mothers on safe child care prac-tices.  Key words: Infant sleep position, mothers, sudden infant death syn-drome, Nigeria Introduction  Sleeping in the prone position by infants has been asso-ciated with increased risk of sudden infant death syn-drome (SIDS)1. SIDS is defined as the sudden death of an infant less than one year of age that cannot be ex-plained after a thorough investigation is conducted, in-cluding a complete autopsy, examination of the death scene, and review of the clinical history2. It is the leading cause of postneonatal death in the UnitedStates, accounting for approximately2200 infant deaths each year3,4. Although the aetiology ofSIDS is unknown, placing the infant to sleep in the supine position has been found to besignificantly associated with a decrease in the rate of SIDS5.  Reducing the risk of SIDS is an important public health priority in the United States of America (USA)3. This has led to the recommendation by the American Acad-emy of Pediatrics (AAP) that infants be placed to sleep in the supine position in other to reduce the incidence of SIDS.6In many developed countries including the United States of America that implemented the ‘Back  to Sleep’ public education campaign, there has been remarkable reduction in the incidence of SIDS7,8,9,10. However, many child caregivers continue to be unaware of the association of SIDS and infant sleep position and/or are misinformed as to the risks and benefits of the various sleep positions11.  The choice of infants sleep position by caregivers is influenced by many factors. These include maternal age,  race, parity, education, income, parental needs and  beliefs, prematurity, infant’s age and recommendations received from specific sources12,13.  Young maternal age, high parity, black race, preterm birth, maternal smoking and substance abuse during pregnancy and postnatal exposure to environmental cigarette smoke are some of the identified risk factors for SIDS12,13,14. Recent data from the National Infant Sleep Position Survey in the USA suggests that African American infants born to mothers in all educational and income categories are 313 consistently and increasingly placed in the prone sle p position and remain twice as likely to die from SID as Caucasian infants15,16,17. In Africa, there is paucity of data on the relationship between infant sleep position and SIDS. The present study was conducted to explore mothers’ knowledge and practices concerning infant sleep position and SIDS in Port Harcourt, Nigeria.    Materials and Methods  A cross-sectional survey carried out over a period of four months from April to August, 2012 among mothers of infants attending the Paediatric Outpatient and Well–baby clinics of the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria. The study group comprised of mothers who presented with their children to the hospital on each clinic day. The partici-pants were selected by random sampling of these moth-ers using the numbers assigned to them by the nurses and only those mothers with infants were recruited for the study. A total of 282 mothers were recruited into the study.  A structured, anonymous questionnaire was used to ob-tain information on biodata, knowledge and practice of infant sleep position and locations as well as knowledge on SIDS. Data was analyzed using the Statistical Pack-age for Social Sciences (SPSS) version 16.0(SPSS Inc., Chicago, Illinois, USA). The differences among groups were assessed using Pearson’s Chi- square (χ2) test. Probability (p) values of less than 0.05 were considered statistically significant.    Results  Two hundred and eighty two mother–infant pairs par-ticipated in the study. Majority of the mothers were in the age range 25 - 34 years. Two hundred and sixty five (94.0%) of them were married while the others were single mothers. One hundred and sixty seven (59.2%) had tertiary education while 250 (88.7%) had between one and three children (Table 1). The mean age of the babies was 5.9 ± 3.8 months.  One hundred and three(36.5%) were reported to sleep on a cot/crib while 179 (63. 5%) did not. Of these, 114 (63.7%) slept with their mothers on the bed, 60 (33.5%) slept with both parents on the same bed whilst 5 (2.8%) shared a bed with one or more siblings.   Table 2 shows reasons for not putting babies to sleep on a cot or crib. The commonest reason given was that it was easier to reach the babies when they needed help.       Table 1: General characteristics of the mothers                   Table 2: Reasons for non use of cots/cribs by the  mothers (n=179) Table 3 shows sleep position and reasons for choice of position. Two hundred and thirty four (83.0%) of the babies had a particular sleep position. Of these, 125(44.3%) usually slept in the tummy down/ prone posi-tion. The commonest reason for choice of sleep position, irrespective of whether it was side, supine or prone was that it was more comfortable for the baby (Fig 1). Per-ceived comfort of the baby was significantly associated with the choice of sleep position (p< 0.001). There was no significant relationship between mothers’ age and choice of infant sleep position (p=0.291), or between mothers educational status and choice of infant sleep position (p= 0.608). Fifty three (18.8%) respondents were aware of a recom-mended sleep position for infants. Sources of knowledge on infant sleep position are shown in Table 3. Grand-mothers were the highest source (33%) of knowledge, followed by nurses. Ninety nine (35.1%) respondents had heard of SIDS. Reported causes of SIDS amongst the mothers included suffocation (5.3%), aspiration (7.4%) and spiritual attack (1.1%). The rest of the moth-ers either did not know or had never heard of SIDS.  Table 3: Infant sleep position and reasons for choice of posi-tion Age range (years) Frequency Percent (%) 20 – 24 27 9.6 25 – 29 99 35.1 30 – 34 115 40.8 ≥ 35 41 14.5 Marital status Married 265 94.0 Single   17   6.0 Educational status Primary 18 6.4 Secondary 97 34.4 Tertiary 167 59.2 Number of children 1 – 3 250 88.7 4-6   30 10.6 ≥ 6     2 0.7 Reason No  (%) Baby refuses to sleep on cot/crib 10 5.6 Easy to reach baby when he/she needs help 87 48.6 Father wants to get used to baby 10 5.6 No cot/crib 23 12.8 None stated 39 21.8 Sleep position Frequency % On the side 58 20.6 On the back (supine) 51 18.1 Tummy down (prone) 125 44.3 No particular position  48 17.0 Reasons for choice of sleep position     Baby sleeps longer 10 3.5 Helps baby breathe well 20 7.1 More comfortable for baby 175 62.1 Prevents aspirations/choking 20 7.1 Prevents vomiting 4 1.4 Aids breast feeding 5 1.8 None 48 17.0 314 Bed sharing either with parents or siblings was a com-mon phenomenon noted in the present study. Although only a small proportion of mothers reported not having cots/cribs, most still preferred to share a bed with their infants. Sharing a bed with an infant is common practice in our environment and many other countries and there have been controversies over its contribution to SIDS23,24. However, in recent times there seems to be growing evidence linking the practice and SIDS. To prevent sleep-related infant deaths, the recommendatio  is that infants share a room with their parents, but not a bed for sleeping25.  Very few respondents in the present study were aware of a recommended sleep position for infants. This may be because unlike in many developed countries, SIDS does not feature as one of the major causes of infant mor ality in Nigeria and so rarely features as a topic for healt  education even among healthcare providers. Many of the respondents had also not heard of SIDS. This may imply as earlier stated that healthcare providers in this environ-ment do not educate parents about the condition. This is further supported by the finding that doctors were a very small source of knowledge on infant sleep position. Grandmothers and nurses were high contributors as sources of knowledge on infant sleep position. The study did not go on to explore what knowledge was passed on by these individuals to mothers but it has been reported that advice from doctors and nurses tended to affect mothers’ choice of infant sleep position.20Oden et al19 in a study conducted in Washington DC in the United States of America (USA), found that infants with a grandmother living in the home were more likely to be placed in the prone position for sleep.Grandmothers play an important role in maternal and child care in Nigeria and Africa at large; they are therefore an important r-get group for education on improved child care practices including safe sleep position for infants.     Conclusion  In conclusion, mothers in Port Harcourt have very poor knowledge of safe sleep position for infants irrespective of their age or educational status. The prone position was the preferred infant sleep position and infants’ com-fort was the greatest reason for choice of any sleep posi-tion. Health care providers are not providing needed information to mothers on safe sleep practices for in-fants. It is thus recommended that heath workers, espe-cially doctors should play a key role in disseminati g information on safe sleep practices for infants in theclinics, through the media and in any contact with moth-ers of young infants.  Authors' contributions Both authors conceived the study, designed the study instrument, prepared and approved the final version of the manuscript. Conflict of Interest: None Funding: None Fig 1: Reasons for choice of infant sleep position  Table 4: Sources of knowledge on infant sleep position               Discussion  The present study showed that close to half of the babies sleep in the prone position. This is very worrisome as this position has been recognised as a risk factor for SIDS in several reported studies1,7,8,9.  The commonest reason given for  choice of sleep position irrespectiv  of whether supine, prone or otherwise was comfort. Differ-ent authors had reported that the position perceived by mothers as most comfortable for their babies was veryinfluential in choosing the sleep position for their in-fants19,20,21. Mothers who thought that their infants were more comfortable sleeping in the prone position were more likely to choose this position for their infants and those who thought that their babies were more comfort-able in the supine position were more likely to place their infants in the supine position19,20. This is in conso-nance with the findings in this study. Another important factor affecting mother’s choice of infant sleep positi n is the risk of choking and ability of the baby to breathe well and this has also been reported in a previous study22. Mothers who believe that their infants will choke in the supine position are also less likely to lie their infants on their back to sleep22.  There was no significant relationship between mothers’ age or educational status and choice of infant sleep posi-tion. This emphasizes the fact that mothers need to be given specific information about safe infant sleep posi-tion. This may be inculcated into the school curriculum as part of health education or information given rou-tinely to mothers during the antenatal period. Source Frequency Percentage Books 5 1.8 Doctors 13 4.6 Friends 18 6.4 Grandmother 93 33.0 Neighbours 10 3.5 Nurses 40 14.2 Other relatives 23 8.2 Self 25 8.9 None /unaware 55 19.5 Total 282 100.0 References   1.     Willinger M, Hoffman HJ, Wu KT, et al. Factorsassociated with the transition to nonprone sleep positionsof infants in the United States: the National InfantSleep Position Study. JAMA 1998;280:329-335 2.     Carl Hunt. Sudden Infant Death Syndrome. In: Berhrman RE, Kliegman RM, Jenson HB editors. Nelson Textbook of Paediatrics, 16th ed. WB Saunders Company, Philadelphia; 2000: pp 2139-2143 3.     Centers for Disease Control and Prevention Atlanta. Avaliable at cdcinfo@cdc.gov. Accessed Febru-ary 9, 2013 4.     Matthews TJ, MacDorman MF. Infant mortality from 2004 period linked birth/death data set. Natl Vital Stat Rep 2007;55:1–32. 5.     Kattwinkel J, Hauck FR, Keenan ME, Malloy MH, Moon RY. Task Force on Sudden Infant DeathSyndrome, American Academy of Pediatrics. The changing concept of sudden infant death syndrome:diagnostic coding shifts, controversies regarding the sleeping environment, and new variables toconsider in reducing risk. Pediatrics 2005;116:1245–1255 6.     American Academy of Pediatrics Task Force on InfantPositioning and SIDS. Positioning and sudden infantdeath syndrome (SIDS): update. Pediatrics 1996;98:1216-1218. 7. Mitchell EA, Grunt JM, Evard C. Reduction in mortality from sudden infant death syndrome in New Zealand. Arch Dis Child. 1994;70:291-294   8.     Hiley CM, Morley CJ. Risk factors for sudden infantdeath syndrome: further change in 1992-3. BMJ1996;312:1397-1398. 9.     Platt MJ, Pharoah PO. Child health statistical review,1996. Arch Dis Child. 1996;75:527-533. 10.   Wennergren G, Alm B, Oyen N, et al, on behalf ofthe Nordic Epidemiological SIDS Study. The declinein the incidence of SIDS in Scandinavia and its relationto risk-intervention campaigns. Acta Paediatr1997;86:963-968. 11. Moon RY, Oden RP. Back to sleep: Can we influence child care providers? Pediatrics 2003; 112 (4): 878-82 12.   Colson ER, Rybin D, Smith LA, Colton T, Lister G, Corwin MJ. Trends and Factors Associated with Infant Sleeping Position: TheNational Infant Sleep Position Study 1993-2007. Arch Pediatr Adolesc Med 2009; 163:1122–1128 13.   Hoffman HJ, Hillman LS. Epide-miology of the sudden infant death syndrome: maternal, neonatal and postneonatal risk factors. Clin Perinatol 1992; 19:717-737  14.   Schoendorf KC, Kiely JL. Rela-tionship of sudden infant death to maternal smoking during and after pregnancy. Pediatrics 1992; 90:905-908 15.   National Infant Sleep Position Survey database. Available at http://dccwww.bumc.bu.edu/ChimeNisp/NISP_Data. Assessed February 9, 2013 16. Mattews TJ, MacDorman MF, Menacker F. Infant mortality sta-tistics from the 1999 period linked birth/infant death data set. Natl Vital Stat Rep 2002; 50:1-28   17.   Muhuri PK, Mac Dorman MF, Ezzati-Rice TM. Racial differences in leading causes of infant death in the United States. Pediatr Perinat Epidemiol 2008;18:51-60  18.   Oden RP, Joyner BL, Ajao TI, Moon RY. Factors influencing African American mothers’ deci-sion about sleep position: a quanti-tative study. J Natl Med Assoc 2010; 102:870-880 19.   Von Kohorn I, Corwin MJ, Rybin DV, Heerenn TC, Lister G, Colson ER. Influence of prior advice and beliefs of mothers on infant sleep position. Arch Pediatr Adolescent Med 2010; 164: 363-369 20.   Willinger M, Ko CW, Hoffman HJ, Kessler RC, Corwin MJ. Fac-tors associated with caregivers choice of infant sleep position. The National infant sleep position study. JAMA 2000; 28: 2135-2142 21.   Hunt CE, Shannon DC. Sudden infant death syndrome and sleep position. Pediatrics 1992; 90: 115-118 22.   Venneman MM, Hense  HW, Baja-nowski T, et al. Bed sharing and the risk of SIDS: Can we resolve the debate? J Pediatr 2012; 160: 44-48 23.   Clonoff-Cohen H, Edelstein SL. Bed sharing and the sudden infant death syndrome. BMJ 1995; 311: 1269 24.   Colson ER, Levenson S, Rybin D, et al. Barriers to following the supine recommendation among mothers at 4 centers for the women, infants and children’s program. Pediatrics 2005; 118: e243-e250     315 

Mothers’ knowledge and practice of infant sleep position

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Mothers’ knowledge and practice of infant sleep position

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