Back To Sleep An Educational Intervention With Women, Infants, And Children Program Clients

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Back To Sleep An Educational Intervention With Women, Infants, And Children Program Clients

  1. 1. Back to Sleep: An Educational Intervention With Women, Infants, and Children Program Clients Rachel Y. Moon, Rosalind P. Oden and Katherine C. Grady Pediatrics 2004;113;542-547 DOI: 10.1542/peds.113.3.542 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/113/3/542 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2004 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org by on September 6, 2009
  2. 2. Back to Sleep: An Educational Intervention With Women, Infants, and Children Program Clients Rachel Y. Moon, MD*‡; Rosalind P. Oden*; and Katherine C. Grady, BA* ABSTRACT. Objective. The incidence of sudden in- months after the intervention, parents who attended the fant death syndrome (SIDS) is 2 to 3 times higher in the educational intervention were more likely to place their black population compared with the US population as a infants on the back (75% vs 45%), less likely to bedshare whole. Prone sleeping is also twice as prevalent in black (16% vs 44.2%), less likely to cite infant comfort as a infants. Standard modes of communication (media, bro- reason for sleep position (14.5% vs 29.2%), and more chures) regarding the Back to Sleep (BTS) campaign have likely to be aware of BTS recommendations (72.4% vs been less effective with blacks. The objective of this 38.9%). study was to determine whether a 15-minute educational Conclusions. A 15-minute educational session with intervention is effective in changing sleep position prac- small groups of black parents is effective in informing tice among black parents. parents about the importance of safe sleep position and Methods. A trained health educator led 15-minute in changing parent behavior. The effect of the interven- sessions about safe infant sleep practices for groups of 3 tion is sustained throughout the first 6 months of life, to 10 parents of young infants who attended a Women, when the infant is at the highest risk for SIDS. Pediatrics Infants, and Children clinic in Washington, DC. We per- 2004;113:542–547; sudden infant death syndrome, risk re- formed pre- and postsession surveys, asking about sleep duction, intervention, sleep position, WIC. position, reasons for choosing a sleep position, and knowledge of the relationship between sleep position and SIDS. We then interviewed parents 6 months after ABBREVIATIONS. AAP, American Academy of Pediatrics; SIDS, the intervention and compared this group with a group sudden infant death syndrome; BTS, Back to Sleep; WIC, Women, of parents at a different Women, Infants, and Children Infants, and Children. site who did not receive the intervention. Results. A total of 310 parents/caregivers participated S ince the American Academy of Pediatrics’ in sessions from October 2001 to July 2002. Mothers com- prised 84.5% of the participants, fathers 6.5%, and other (AAP’s) initial recommendation to place all relatives 9.0%. Parents had a mean age of 26.2 years healthy infants on their back or side to reduce (range: 15– 64; standard deviation: 8.3), and 76.5% had the risk of sudden infant death syndrome (SIDS)1 graduated from high school. For 51%, this was their first and the subsequent educational campaign Back to child. Before the intervention, more than half (57.7%) of Sleep (BTS), the incidence of SIDS in the United infants reportedly slept on their back, with the remainder States declined 40% to 0.67 deaths per 1000 live births sleeping back/side or side (15%) and prone (17.3%). Ap- in 1999 from 1.2 per 1000 live births in 1992.2 How- proximately 85% (266) of infants were sleeping in the ever, the rate of decline in SIDS for black infants has same room as the parents. Only 28.1% of parents initially believed that prone sleeping definitely increases the risk not kept pace with that in white infants; black infants of SIDS. Infants were more likely to be placed supine die of SIDS at more than double the rate of white when previous children were placed supine or when infants.2,3 It is unclear why this racial disparity exists; parents had more than a high school education. Parents however, it exists across all educational and income were also more likely to place infants supine when they categories and is worsening, despite the overall de- believed that prone increases the risk of SIDS, they had cline in SIDS rates. This racial disparity is greatly previous knowledge of BTS, and they were aware that reflected in the District of Columbia, where three the American Academy of Pediatrics recommends supine quarters of the children are black.4 In Washington, position for infants. Sleep position was not affected by DC, the rate of SIDS was 1.2 per 1000 live births in where the infant slept, number of parents in the home, presence of a grandmother in the home, or presence of 1998 (State Center for Health Statistics, District of smokers in the home. Immediately after the intervention, Columbia Department of Health), almost double the 85.3% planned to place infants on the back, and 55.7% national rate, and this rate continues to be high. In now believed that prone definitely increases the risk of 2001, there were 9 reported SIDS deaths in Washing- SIDS. When compared with a control group of parents 6 ton, DC, a city with 7700 live births per year (State Center for Health Statistics, District of Columbia De- partment of Health). From the *Department of General Pediatrics, Children’s National Medical Center, Washington, DC; and ‡Department of Pediatrics, George Washing- Epidemiologic risk factors for SIDS include black ton University School of Medicine and Health Sciences, Washington, DC. race, young parental age, low socioeconomic status, Received for publication Mar 26, 2003; accepted Jul 22, 2003. low parental educational level, and lack of prenatal Reprint requests to (R.Y.M.) Department of General Pediatrics, Children’s care. In the District of Columbia, 75.1% of the chil- National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: rmoon@cnmc.org dren are black, 14.8% are born to teenage mothers, PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- 30.2% live below the federal poverty threshold, and emy of Pediatrics. only 59% of pregnant women receive adequate pre- 542 PEDIATRICS Vol. 113 No. 3 March 2004 Downloaded from www.pediatrics.org by on September 6, 2009
  3. 3. natal care.4 These families are those for whom the tober 2001 to July 2002. Mothers comprised 84.5% of Back to Sleep (BTS) campaign, for unclear reasons, the participants, fathers comprised 6.5%, and other has been least effective in changing behavior. Black relatives comprised the rest. Participants had a mean families are more likely to place infants prone for age of 26.2 years (range: 15– 64; standard deviation: sleep.5–7 In one study, it was found that one third of 8.3), and 76.5% had graduated from high school. SIDS deaths could be attributed to prone sleeping.5 Approximately half (52.9%) of the infants had 1 par- Despite this, black parents are more likely to report ent in the home; 42.6% lived with both parents. A being advised to place infants prone in the hospital grandmother or great-aunt lived in 37.4% (116) of the after delivery5 and may be less likely to receive ap- households. For 51% of families, this was their first propriate sleep position counseling by their infant’s child. Among families with previous children, 119 physician.8 It is important that parents receive ap- (43%) of 277 children had slept supine, 67 (24.2%) propriate verbal and written counseling regarding side, and 91 (32.9%) prone. Sleep position of previous sleep position, because written material alone is of- children was directly correlated with birth year, with ten ineffective in changing behavior.9 infants born before the AAP recommendation of The purpose of this project was to provide current nonprone sleeping (1992) and the BTS campaign information regarding SIDS risk reduction to current (1994) more likely to sleep prone (P .0002; Table 1). and prospective parents and senior caregivers (eg, Of the participants, 246 (79.4%) agreed to partici- grandparents, great aunts) in Washington, DC. To pate in a follow-up telephone survey. Of these, 98 that end, we developed a collaboration with the (39.8%) had disconnected or incorrect telephone Women, Infants, and Children (WIC) program to numbers, and 72 (29.3%) did not answer despite reach parents and senior caregivers. WIC is the Spe- multiple attempts. A total of 76 (30.8%) families were cial Supplemental Nutrition Program for Women, contacted; all agreed to participate in the follow-up Infants, and Children, which provides food assis- survey. The subgroup of 76 families was similar to tance and nutrition education to pregnant and lac- the large intervention group with regards to racial/ tating women and their infants who are considered ethnic background, parental educational level, at risk for nutritional deficiency because of low in- household income, and infant birth order. come and/or medical or dietary risk. As part of the nutritional and safety counseling for the families, we Behavior, Knowledge, and Attitudes Before developed and evaluated an educational interven- Intervention tion regarding SIDS risk reduction. Before the intervention, 90% (276) of parents co- slept or planned to co-sleep (defined as sleeping in METHODS the same room as their infant), and 21% (65) planned Current and prospective parents and other adult caregivers (eg, to bedshare (defined as sharing the same sleep sur- grandparents, aunts, uncles, cousins) of young infants were tar- geted during a 15-minute educational intervention in the WIC face, most commonly an adult bed) with the infant. clinic at Children’s National Medical Center. The clientele served Almost half (41.9% [130]) of participants reported by this WIC site is largely black. This specific intervention was that there was at least 1 smoker in the home. In part of an educational program aimed toward improved fetal and approximately one fourth (25.5% [79]) of the families, infant nutrition, appropriate nutrition for pregnant and lactating women, and infant safety. The educational sessions were a pre- at least 1 parent smoked; 61 families had 1 parent requisite to obtaining food vouchers. A trained health educator led who smoked; and an additional 18 had 2 parents a small group (3–10 people) discussion regarding safe infant sleep practices. Topics discussed included sleep position, bedsharing/ co-sleeping, and smoke avoidance. Emphasis was placed on de- TABLE 1. Household Characteristics of Participants (n 310) veloping a curriculum that was culturally sensitive. Because it is common in this community for multiple adults to care for an Characteristic n (%) infant, all potential caregivers were welcomed to the sessions. Participants completed written questionnaires regarding be- Parent educational attainment havioral intent before and immediately after the discussion. Al- Did not finish high school 69 (22.3) though the educational sessions were a prerequisite to obtaining High school graduate 132 (42.6) food vouchers, completion of questionnaires was voluntary. Par- Some college or technical school 77 (24.8) ticipants were also asked whether they would be willing to par- Technical school graduate 9 (2.9) ticipate in a follow-up telephone survey; no incentive was pro- 4-y college graduate 12 (3.9) vided for follow-up, and 20.6% declined additional participation. Postgraduate training 7 (2.3) Families who had indicated that they would be willing to Unknown 4 (1.3) participate in a follow-up telephone survey were telephoned 6 No. of parents in home months after the infant’s birth to determine infant sleep practices. 2 132 (42.6) In addition, a comparison group of 113 families from other WIC 1 164 (52.9) sites in Washington, DC, with similar client demographic charac- 0 13 (4.2) teristics were interviewed when the infant was 0 to 12 months of No. of people in home, excluding baby age. Outcome measures included intended and reported infant 1 17 (5.7) sleep practices and knowledge of BTS recommendations. The 2 122 (26.3) institutional review board of Children’s National Medical Center 3 78 (26.3) approved this study. 4 55 (18.3) 5 27 (9.0) RESULTS No. of smokers in home 0 168 (56.4) Participant Demographics and Household 1 92 (30.9) Characteristics 2 28 (9.4) A total of 310 parents/caregivers from 282 house- 3 10 (3.3) Grandmother/senior caregiver in home 116 (37.4) holds participated in educational sessions from Oc- ARTICLES 543 Downloaded from www.pediatrics.org by on September 6, 2009
  4. 4. TABLE 2. Behavior and Knowledge of Participants Regarding Sleep Position Before Intervention Immediately After P Value Intervention Sleep position Back 173 (57.7%) Back 262 (85.3%) .0001 Back/side or side 75 (25%) Back/side or side 35 (11.4%) Prone 52 (17.3%) Side/prone 10 (3.3%) Does sleeping on the belly increase No 11 (3.5%) No 16 (5.2%) .0001 the risk of SIDS? Doubtful 16 (5.2%) Doubtful 5 (1.6%) Unsure 93 (30%) Unsure 21 (6.8%) Possibly 113 (36.5%) Possibly 96 (31.1%) Definitely 87 (28.1%) Definitely 172 (55.7%) What is the AAP recommendation Back 137 (44.2%) Back 267 (86.1%) .0001 for infant sleep position? Back/side 98 (31.6%) Back/side 30 (9.7%) Side 10 (3.2%) Side 1 (0.3%) Side/prone 5 (1.6%) Side/prone 4 (1.3%) Prone 4 (1.3%) Prone 3 (1%) Don’t know (18.1%) Don’t know 5 (1.6%) who smoked. Neither co-sleeping nor bedsharing great-aunt in the household than those in the inter- was associated with the number of parents who vention group (42.1%; P .01). The average age of smoked. infants was 20.1 weeks in the intervention group and More than half (183 [57.7%]) of participants re- 25.1 weeks in the comparison group. ported placing or intending to place their infant su- Infants in the intervention group were less likely to pine, with another fourth (75 [25%]) placing infants sleep in the same room with the parents (P .0006) on the back/side or side and the remainder placing and less likely to have shared a bed with the parent them prone (52 [17.3%]). Only 28.1% of parents be- the night before the interview (P .0001) than the lieved that prone sleeping definitely increases the comparison group (Table 4). They were also more risk of SIDS. Infants were more likely to be placed likely to be placed supine than those in the compar- supine when previous children were placed supine ison group (P .0005). When asked why infants (P .0001) or when parents had more than a high were placed in a particular sleep position, parents in school education (P .03). Parents were also more the intervention group were more likely to cite SIDS likely to place infants supine when they believed that as a reason (P .0001) and less likely to cite infant prone increases the risk of SIDS (P .0013), they had comfort (P .02) or suggestion of a family member previous knowledge of BTS (P .007), and they were or friend (P .001). aware that the AAP recommends supine position for When infants in the intervention group first came infants (P .0001). Sleep position was not affected home after delivery, they were more likely to be by where the infant slept, number of parents in the placed exclusively supine by parents (82.9%) than home, presence of a grandmother in the home, or comparison infants (59.3%; P .008). In addition, presence of smokers in the home. although not statistically significant, there is a sug- gestion that parents who received the intervention Behavior, Knowledge, and Attitudes Immediately After were less likely to change the infant’s position from Intervention supine. One infant in the intervention group changed Immediately after the intervention, 85.3% of par- from supine to prone, compared with 7 in the com- ents planned to place infants on the back, compared parison group. with 57.7% preintervention (P .0001). Only 11.4% (35) of parents planned to place infants on the side, DISCUSSION and 3.3% (10) planned to place infants side/prone. Although BTS has been tremendously successful No parents planned to place infants exclusively in changing parent and child care provider behavior prone after the intervention. When asked about the with regard to safe infant sleep environment, behav- relationship between the prone position and SIDS, ior change has been more difficult to effect in black 55.7% of parents believed that prone definitely in- families. The standard forms of communication used creases the risk of SIDS, a 2-fold increase from before by BTS (brochures, media) have been less effective in the intervention (P .0001). The percentage of par- this group. In addition, nurses and physicians who ents who recognized supine as the AAP-recom- serve black communities may be less inclined to mended position also increased from 44.2% to 86.1% discuss sleep position or more likely to recommend (P .0001; Table 2). prone.5,8 Alternative methods of communication are necessary to eliminate the racial disparity that pres- Behavior, Knowledge, and Attitudes 6 Months After ently exists in SIDS. Intervention This format of using small groups of WIC clients to The 76 intervention families and the 113 compari- convey medical information was effective in increas- son families were similar with regard to racial/eth- ing knowledge and changing behavior in black par- nic background, parental educational level, parental ents. Parents who had participated in the interven- marital status, household income, and infant’s birth tion were more likely to be aware of the relationship order (Table 3). Families in the comparison group between sleep position and SIDS and were more were less likely (32.7%) to have a grandparent or likely to place their infants supine from the time of 544 BACK TO SLEEP Downloaded from www.pediatrics.org by on September 6, 2009
  5. 5. TABLE 3. Demographics of 6-Month Follow-up Intervention Group Versus Comparison Group Intervention Comparison P Value Group (n 76) Group (n 113) Infant’s age 20.1 wk (1–52) 25.1 wk (0–52) .0379 Parent’s age 25.3 y (15–44) 25.9 y (16–44) NS Parent marital status Married 30 (39.5%) 26 (23.6%) NS Never married 44 (57.9%) 76 (69.1%) Divorced/separated 2 (2.6%) 8 (7.3%) No. of parents in the home 2 26 (34.2%) 32 (28.3%) NS 1 50 (65.8%) 81 (71.7%) Grandmother/senior caregiver in home 32 (42.1%) 37 (32.7%) .01 Parent educational level Did not finish high school 19 (25.0%) 20 (17.7%) NS High school graduate 39 (57.3%) 56 (49.6%) Some college or technical school 13 (17.1%) 27 (23.9%) Technical school graduate 1 (1.3%) 0 4-y college graduate 3 (3.9%) 0 Postgraduate training 1 (1.3%) 10 (8.9%) Racial/ethnic background White 1 (1.3%) 1 (0.9%) NS Asian 2 (2.6%) 3 (2.7%) Hispanic 5 (6.6%) 1 (0.9%) Black 63 (82.9%) 94 (83.2%) Other 5 (6.6%) 4 (3.5%) Infant was first child in family 36 (47.4%) 43 (38.1%) NS NS indicates not significant. TABLE 4. Six-Month Follow-up of Infant Sleep Practices Intervention Comparison P Value Group Group (n 76) (n 113) Usually co-sleep (ie, sleep in same room) .0006 Yes 12 (15.8%) 44 (38.9%) No 64 (84.2%) 69 (61.1%) Co-slept last night .01 Yes 25 (32.9%) 58 (51.3%) No 51 (67.1%) 55 (48.7%) Usually bedshare (ie, share same sleep surface) NS Yes 17 (22.4%) 38 (33.6%) No 59 (77.6%) 75 (66.4%) Bedshared last night .0001 Yes 12 (15.8%) 50 (44.2%) No 64 (84.2%) 63 (55.8%) Usual sleep position .0005 Back 57 (75%) 51 (45.1%) Back/side 11 (14.5%) 22 (19.5%) Side 3 (3.9%) 23 (20.4%) Prone 5 (6.5%) 17 (15%) Reason for sleep position Family/friend suggested it 4 (5.3%) 26 (23%) .001 Infant comfort 11 (14.5%) 33 (29.2%) .02 Previous experience 1 (1.3%) 7 (6.2%) NS Vomiting/choking 7 (9.2%) 13 (11.5%) NS SIDS 55 (72.4%) 44 (38.9%) .0001 Other 0 2 (1.8%) NS No reason 1 (1.3%) 5 (4.4%) NS First sleep position .008 Back 63 (82.9%) 67 (59.3%) Back/side 3 (3.9%) 18 (15.9%) Side 5 (6.6%) 28 (24.8%) Prone 5 (6.6%) 9 (8%) NS indicates not significant. delivery. Although the proportion of initially prone tant, because it is often difficult for parents to change sleepers was similar in the intervention and compar- the infant’s sleep position to supine when another ison groups, there were many more side and back/ position was used previously.10 In addition, inter- side sleepers in the latter group. The primary effect vention infants were more likely to continue to sleep on sleep position was for potential side sleepers to be supine throughout the first 6 months of life (when placed supine from the time of birth. This is impor- 90% of SIDS occurs). This is especially noteworthy, ARTICLES 545 Downloaded from www.pediatrics.org by on September 6, 2009
  6. 6. because 22% of infants who begin sleeping in the This study has the apparent limitations inherent in nonprone position after hospital discharge will parental reporting. Parents may have been reluctant change to the prone position between 2 and 4 months to admit to prone positioning, thus leading us to of age.10 underestimate the incidence of prone sleeping for Friends and family members often influence both the intervention and control groups. However, health decisions in black families.7,11 However, the it is unlikely that underreporting of prone sleeping is small-group format with WIC clients was successful sufficient to explain the results reported. In addition, in empowering parents to use health professional even if the impact of this program is exaggerated by advice rather than advice from family or friends in parental reporting, this intervention is nonetheless making a sleep position decision. It also effectively cost-effective. It will be important to correlate re- decreased parental concerns about decreased arousal ported parental practice with actual practice, and we thresholds in infants who sleep supine, because par- hope to do so with home health nurse visits in the ents who received the intervention were less likely to near future. cite infant comfort as a reason for sleep position. Targeted educational opportunities for low-in- Unfortunately, other misconceptions, such as the fear come black parents are effective in increasing knowl- of choking or aspiration with supine, were not af- edge and awareness of SIDS risk factors and chang- fected by our intervention. ing parental behavior with regard to infant sleep This small-group format also resulted in a de- position and bedsharing. The effects of the interven- crease in the number of families who bedshare. The tion are sustained throughout the infant’s first 6 practice of co-sleeping (sleeping in the same room as months of life. Similar private–public collaborations an infant) is very common, especially in the first few should be encouraged as a means of providing im- months of an infant’s life. The proportion of bedshar- portant medical information to parents. ing (sleeping on the same sleep surface, most com- monly an adult bed) infants in the United States has ACKNOWLEDGMENTS increased in the past few years12 and is high in black This work was supported by a grant from the Gerber Founda- families.5,9,13 Infant death during bedsharing is par- tion. ticularly high among blacks and may be an impor- We thank Jayasri Janakiram, Sonia Pessoa, and Inge Mauger, tant contributor to the racial disparity seen in SIDS.14 WIC nutritionists, for their collaboration in developing the edu- Bedsharing may pose an especially increased risk of cational inservice; and the WIC staff at Children’s National Med- ical Center, Children’s Health Center–Shaw, Children’s Health SIDS when parents are smokers,15–17 and supine Center at Dorchester, and Children’s Health Center at Good Hope sleep position may be less protective when associ- Road for cooperation and assistance with patient recruitment. In ated with bedsharing.14 Because bedsharing may addition, we are grateful to Joana Iglesias for assistance in data also increase the risk of unexpected infant death collection and database management. from entrapment, overlying, or accidental suffoca- tion,18,19 any discussion about safe infant sleep envi- REFERENCES ronment should include discussion about the poten- 1. AAP Task Force on Infant Positioning and SIDS. Positioning and SIDS. tial dangers of bedsharing. Pediatrics. 1992;89:1120 –1126 Although an analysis to determine cost-effective- 2. Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. Deaths: final data for 1999. Natl Vital Stat Rep. 2001;49:1–113 ness of this intervention is beyond the scope of this 3. Mathews T, MacDorman M, Menacker F. Infant mortality statistics from article, 1 study has estimated that approximately one the 1999 period linked birth/infant death data set. Natl Vital Stat Rep. third of SIDS deaths could be prevented if infants are 2002;50:1–28 placed supine.5 Given this and that this intervention 4. Every Kid Counts in the District of Columbia, 8th Annual Fact Book. Wash- is not costly, even an increase in supine sleeping by ington, DC: DC KIDS COUNT Collaborative for Children and Families; 2001 10% would be extremely cost-effective. 5. Hauck FR, Moore CM, Herman SM, et al. The contribution of prone The success of this intervention can be largely sleeping position to the racial disparity in sudden infant death attributed to 2 factors. The health educator who led syndrome: the Chicago Infant Mortality Study. Pediatrics. 2002;110: the discussions is black and has always lived in 772–780 6. Pollack HA, Frohna JG. Infant sleep placement after the Back to Sleep Washington, DC. She was quickly accepted by the campaign. Pediatrics. 2002;109:608 – 614 participants as someone who was both knowledge- 7. Willinger M, Ko C-W, Hoffman HJ, Kessler RC, Corwin MJ. Factors able about medical questions and familiar with the associated with caregivers’ choice of infant sleep position, 1994 –1998: culture of the community. In addition, this collabo- the National Infant Sleep Position Study. JAMA. 2000;283:2135–2142 ration with a publicly funded program (WIC) was 8. Ray BJ, Metcalf SC, Franco SM, Mitchell CK. Infant sleep position instruction and parental practice: comparison of a private pediatric enormously successful in identifying and targeting a office and an inner-city clinic. Pediatrics. 1997;99(5). Available at: high-risk population. Receipt of WIC food vouchers www.pediatrics.org/cgi/content/full/99/5/e12 was contingent on attending the safe sleep session. 9. Moon RY, Omron R. Determinants of infant sleep position in an urban We therefore were able to disseminate the informa- population. Clin Pediatr (Phila). 2002;41:569 –573 10. Ottolini MC, Davis BE, Patel K, Sachs HC, Gershon NB, Moon RY. tion to all expectant and new parents, many of whom Prone infant sleeping despite the “Back to Sleep” campaign. Arch Pediatr likely would not receive this information elsewhere. Adolesc Med. 1999;153:512–517 Up to now, medical professionals have been only 11. Ellen JM, Ott MA, Schwarz DF. The relationship between grandmoth- variably successful in changing safe infant sleep ers’ involvement in child care and emergency department utilization. practices in the black community. Community health Pediatr Emerg Med. 1995;11:223–225 12. Willinger M, Ko CW, Hoffman HJ, Kessler RC, Corwin MJ. Trends in educators and governmental agencies such as WIC infant bed sharing in the United States, 1993–2000: the National Infant may provide successful alternative routes of health Sleep Position study. Arch Pediatr Adolesc Med. 2003;157:43– 49 promotion. 13. 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  7. 7. JD. Infant-parent bed sharing in an inner-city population. Arch Pediatr control study for confidential inquiry into stillbirths and deaths in Adolesc Med. 2003;157:33–39 infancy. BMJ. 1996;313:191–195 14. Unger B, Kemp JS, Wilkins D, et al. Racial disparity and modifiable risk 17. Mitchell EA, Tuohy PG, Brunt JM, et al. Risk factors for sudden infant factors among infants dying suddenly and unexpectedly. Pediatrics. death syndrome following the prevention campaign in New Zealand: a 2003;111(2). Available at: www.pediatrics.org/cgi/content/full/111/ prospective study. Pediatrics. 1997;100:835– 840 2/e127 18. Task Force on Infant Positioning and SIDS. Does bed sharing affect the 15. Scragg R, Mitchell EA, Taylor BJ, et al. Bed sharing, smoking, and risk of SIDS? Pediatrics. 1997;100:272 alcohol in the sudden infant death syndrome. New Zealand Cot Death 19. Task Force on Infant Sleep Position and Sudden Infant Death Syn- Study Group. BMJ. 1993;307:1312–1318 drome. Changing concepts of sudden infant death syndrome: implica- 16. Fleming PJ, Blair PS, Bacon C, et al. Environment of infants during sleep tions for infant sleeping environment and sleep position. Pediatrics. and risk of the sudden infant death syndrome: results of 1993–5 case- 2000;105:650 – 656 BOOK REVIEW Appleton R, Peters B. Common Neurological Problems in General Pediatrics. London, United Kingdom: Martin Dunitz; 2003 The world of child neurology has become increasingly complex with rare, bizarre syndromes, complex investigations and brain imaging, new genetics, and exotic medications. The generalist pediatrician may feel in danger of obsolescence, yet neurologic problems of varying severity are common in children. This little book comes to the rescue. The authors are well-known child neurologists (one Dutch, one British), but the book is aimed at general pediatricians. There are only four chapters but they cover by far the most frequent problems in child neurolo- gy—“Fits, Faints, and Funny Turns,” “The Floppy Infant,” “Headache in Chil- dren,” and “The Child With Learning Difficulties.” The differential diagnosis for seizures is elegantly and simply discussed. The authors endorse an approach of waiting for additional attacks if the diagnosis is unclear. The headache discussion emphasizes when to be concerned about serious intracranial pathology and how to treat migraine (the most common pediatric headache). Floppy infants may have all kinds of disorders ranging from serious muscle disease to chromosomal abnor- malities with brain malformations. An algorithm is proposed that leads the clini- cian fairly easily through this complex symptom. “Learning disability” in Europe means “mental handicap/retardation” in North America; here is a chapter about how to investigate serious cognitive problems. These four key subjects are admi- rably discussed by two master clinicians. Buy it; you will like it. Peter Camfield, MD, FRCP(C) Carol Camfield, MD, FRCP(C) Department of Pediatrics Dalhousie University and the IWK Health Centre Halifax, Nova Scotia ARTICLES 547 Downloaded from www.pediatrics.org by on September 6, 2009
  8. 8. Back to Sleep: An Educational Intervention With Women, Infants, and Children Program Clients Rachel Y. Moon, Rosalind P. Oden and Katherine C. Grady Pediatrics 2004;113;542-547 DOI: 10.1542/peds.113.3.542 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/113/3/542 References This article cites 14 articles, 12 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/113/3/542#BIBL Citations This article has been cited by 5 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/113/3/542#otherarticle s Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Office Practice http://www.pediatrics.org/cgi/collection/office_practice Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org by on September 6, 2009

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