Background: The baby’s sleeping position is the most important modifiable risk factor in Sudden Infant Death Syndrome (SIDS). The “back to sleep” position is safer than side or prone position. Objectives: To determine what advice midwives and nurses at St Luke’s Hospital give to new mothers about the baby’s sleeping position; and whether the practice has changed following a series of lectures on SIDS and a focused circular issued by the Department of Health in February 2007. Methods: A questionnaire-based, descriptive, and crosssectional before-after trial. Results: In 2007, 81% of midwives/nurses advised exclusive back sleeping position, compared to 38% in 2006 (p<0.0001). Conclusion: The audit demonstrates a notable increase in the number of midwives/nurses giving correct advice to the new mothers.peer-reviewe

Attard Montalto, Simon

Mizzi, Joseph

Pace Parascandalo, Rita

English

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Malta Medical Journal    Volume 20   Issue 04   December 2008 2Joseph Mizzi, Rita Pace Parascandalo, Simon Attard MontaltoOriginal ArticleSIDS and infant sleeping position: audit on the advisory campaign in MaltaAbstractBackground: The baby’s sleeping position is the most important modifiable risk factor in Sudden Infant Death Syndrome (SIDS). The “back to sleep” position is safer than side or prone position.Objectives: To determine what advice midwives and nurses at St Luke’s Hospital give to new mothers about the baby’s sleeping position; and whether the practice has changed following a series of lectures on SIDS and a focused circular issued by the Department of Health in February 2007.Methods: A questionnaire-based, descriptive, and cross-sectional before-after trial. Results: In 2007, 81% of midwives/nurses advised exclusive back sleeping position, compared to 38% in 2006 (p<0.0001). Conclusion: The audit demonstrates a notable increase in the number of midwives/nurses giving correct advice to the new mothers. Key wordsSleeping position, SIDS, MaltaJoseph Mizzi * MD, MRCPDepartment of Paediatrics, Mater Dei Hospital, Malta.Email: josephmizzi@onvol.netRita Pace Parascandalo MSc, RMAssistant Lecturer, Midwifery, University of Malta.Email: rita.pace-parascandalo@um.edu.mtSimon Attard Montalto MD, FRCPCHDepartment of Paediatrics, Mater Dei Hospital, Malta.Email: samjam@maltanet.netIntroductionMedical research in the early 1990s had shown that infants sleeping in the prone position were more likely to suffer a cot death.1 As a result, educational campaigns were launched to encourage parents to place their babies to sleep either on the side or on the back. The result was dramatic: the number of cot deaths was reduced by half. 2  Recent studies have demonstrated that the side sleep position confers an increased risk when compared to the back.3-4 This is partly due to the fact that babies sleeping on the side tend to roll to the prone position. Therefore the side sleeping position is no longer recognised as a reasonable alternative and the ‘back to sleep’ position should be adopted at all times.ObjectivesThe purpose of this audit was to determine what advice relating to the baby’s sleeping position midwives and nurses in the maternity unit at St Luke’s Hospital gave to new mothers; and whether the practice has changed following a series of lectures on SIDS and the issue of a Department of Health circular.5MethodsIn mid November 2006, a simple questionnaire (Appendix 1) was distributed to the midwives and nurses who were present on the Labour Ward, Postnatal Ward and Special Care Baby Unit (SCBU) during four consecutive shifts. They were asked whether they considered the baby’s sleeping position as an important risk factor for SIDS and what advice they give to new mothers on the sleeping position of the baby.During late 2006 a series of lectures were given to the midwifery and nursing staff of the maternity department. In February 2007, a DH Circular, “Update: Correct Infant Sleeping Position”, was issued by the Department of Health, with a clear conclusion stating: “Infants should be placed to sleep in the supine position (entirely on their back). Side sleeping is not as safe as supine sleeping and is not advised.”In August 2007, the same questionnaire was distributed to a corresponding sample of midwives and nurses in the same wards.ResultsSixty-five out of 68 questionnaires (96%) were returned from the 2006 study; 74 of 77 (96%) from the 2007 study. These * corresponding author22 Malta Medical Journal    Volume 20   Issue 04   December 2008two cohorts amounted to almost 50% of the total number of 150 midwives/nurses employed in the maternity unit during the study period.94% of respondents in 2006 and 89% in 2007 believed that sleeping position is an important risk factor for SIDS whilst 6 % in 2006 and 11% in 2007 were unaware that sleeping position was a risk factor (p=0.5).The advice given by the maternity staff to new mothers is tabulated (Table 1). In both studies, none of the respondents advised parents to place their baby to sleep in the prone position. In 2006, 38% of midwives/nurses exclusively advised the back sleeping position, compared to 81% in 2007 (χ2 (Yates corrected) =22.9, p<0.001) (Figure 1).DiscussionThis audit has clearly demonstrated a notable change in attitude among the nursing and midwifery staff at the maternity department of St Luke’s Hospital. The number of midwifes/nurses giving the correct advice to mothers has more than doubled in less than a year from 38% to 81% following a simple focused educational campaign. Whether the improvement in correct advice will result in a decrease in cot deaths is difficult to prove because the rate of SIDS is very small in Malta (there were 3 reported deaths due to SIDS over the period from 1995-20076). The study has also shown that a small number of midwives and nurses are still unaware or unconvinced on the importance of the supine sleeping position in infants. About 20% are still advising mothers to place their baby to sleep on the side, or at least, recommending both back or side. This may pose a problem as parents are unlikely to be convinced of the best approach to adopt if they receive conflicting advice from the hospital.Although respondents were recruited sequentially (from midwifery staff working consecutive shifts on labour ward), and not sampled randomly, any bias was offset since the size of  both study cohorts amounts to half the size of the total staff population studied (the total number of midwives and nurses working in the maternity unit is 150), it was likely to be representative of the whole population.As in previous studies, some of the respondents expressed concern about the possible increased risk of regurgitation and choking if the baby is put to sleep in the supine position.7 This fear is unfounded - indeed, there is no evidence that the supine position is associated with increased risk of choking. Moreover, since mothers tend to copy the practices that they observe in hospital, at home, it is imperative that newborns in the nursery are placed to sleep on their back.Similarly, it behooves health care professionals involved in the care of the newborn to dispel other concerns relating to the supine sleeping position such as the flattening of the head (positional plagiocephaly). This is a benign and temporary phenomenon; it can also be prevented by (i) encouraging “tummy time” when the baby is awake and observed; (ii), altering the head position during sleep (e.g. one week on the right side, followed by a week on the left); and (iii) avoiding excessive time in car seats, carriers and bouncers.ConclusionHospital staff should instruct parents who, in turn, must emphasise to secondary care-givers (grandparents, babysitters) that the baby must always be placed to sleep on the back and never on the tummy, since prone sleep increases the risk of SIDS by as much as 18-fold.8Table 1: Advice given by midwives/nurses to new mothers at St Luke’s Hospital Back Side Side/Back Prone  Total 2006 23 (38%) 17 (28.5%) 20 (33.5%) 0  0 (00%) 2007 58 (81%) 4 (5%) 10 (14%) 0  2 (00%)Table 2: Reducing the risk of SIDS; advice to parents 9,10 1. Always place your baby on the back to sleep2. Do not smoke during pregnancy3. Do not allow smoking around your baby4. Place your baby on a firm sleep surface5. Keep the baby’s head uncovered6. Keep soft objects, toys, and loose bedding out of your baby’s sleep area7. Place the baby to sleep in the cot; not in the parents’ bed8. Do not let your baby overheat during sleepFigure 1: Advice given by nurses/midwives to new mothers at Karin Grech Hospital in 2006 and 2007Malta Medical Journal    Volume 20   Issue 04   December 2008 2The midwives and nurses in the maternity department are in a key position to educate parents on safe sleeping practices (Table 2) and should continue to stress the key message: ‘Back to Sleep.’AcknowledgementsThanks to Dr Kathleen England, Malta National Mortality Registry, for providing the data on the local rates of SIDS.References1. American Academy of Pediatrics AAP Task Force on Infant Positioning and SIDS: Positioning and SIDS. Pediatrics.1992:89:1120-6.2. Centers for Disease Control and Prevention. CDC Wonder. Compressed mortality file: underlying cause-of-death. Mortality for 1979–1998 with ICD 9 codes; Mortality for 1999-2001 with ICD 10  codes. Available at: http://wonder.cdc.gov/mortSQL.html. Accessed August, 2007.3. Li DK, Petitti DB, Willinger M, McMahon R, Odouli R, Vu H, et al. Infant sleeping position and the risk of sudden infant death syndrome in California, 1997–2000. Am J Epidemiol. 2003;157:446–55.4. Oyen N, Markestad T, Skjaerven R, Irgens LM, Helweg-Larsen K, Alm B, et al. Combined effects of sleeping position and prenatal risk factors in sudden infant death syndrome: the Nordic Epidemiological SIDS Study. Pediatrics. 1997;100:613–21.5. DH Circular 25/07. Update: Correct Infant Sleeping Position. February 2007.6. Malta National Mortality Registry, Department of Health Information.7. Srivatsa B, Eden AN, Mir MA. Infant sleep position and SIDS: a hospital-based interventional study. J Urban Health. 1999;76:314-21.8. Mitchell EA, Thach BT, Thompson JM, Williams S. Changing infants’ sleep position increases risk of sudden infant death syndrome. New Zealand Cot Death Study. Arch Pediatr Adolesc Med. 1999;153:1136–41.9. American Academy of Pediatrics. Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Available from:  http://www.healthychildcare.org/Revised%20SIDS.pdf. Accessed August 2007.10. NHS Direct. How can I reduce the risk of cot death?12.  Available from: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=814. Accessed March 2008.Appendix 1SUDDEN INFANT DEATH SYNDROMEQUESTIONNAIRE1. What is your professional status? nurse midwife other (specify)2. Where do you work? nursery labour ward scbu other (specify)3. Do you think that baby’s sleeping position is an important risk factor for SIDS (cot death)? yes no don’t know4. What is the safest position to put the baby to sleep? supine (on back) prone (on tummy) on side on side or back5. Have you ever advised mothers on the baby’s sleeping position? yes no don’t know6. If your answer to question (5) is yes, what advice did you give about the baby’s sleeping position? supine (on back) prone (on tummy) on side on side or back6. Do you think that bed-sharing (baby sleeps with his parents in the same bed) is a risk factor for SIDS? yes no don’t know7. Do you think that smoking (during pregnancy) is a risk factor for SIDS? yes no don’t know8. Do you think that home apnoea monitors are effective in preventing SIDS? yes no don’t know9. Any comments?Thanks!

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How can I reduce the risk of cot death?12. Available from: http://www.nhsdirect.nhs.uk/articles/article. aspx?articleId=814. Accessed

SIDS and infant sleeping position : audit on the advisory campaign in Malta

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SIDS and infant sleeping position : audit on the advisory campaign in Malta

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