Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 1

The Effectiveness of The Back to Sleep Campaign

Jackson College, School of Nursing

Mackenzie Green
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 2

The Effectiveness of the Back to Sleep Campaign

Sudden infant death syndrome (SIDS) is defined as “the unexplained death of an infant

younger than one year” and has been a pressing issue throughout the entire world for a long

time (Bartlow, Cartwright, & Shefferly, 2016). A campaign was initiated known as the Back to

Sleep Campaign to help reduce the rates of sudden infant death syndrome. The campaign

recommended placing infants on their back to sleep versus on their stomachs decreasing the

risk of suffocating during their sleep. The Back to Sleep Campaign continued to update their

intervention guidelines such as, infants should sleep on their backs as well as on a firm surface,

there should not be anything in the crib with the infant and there should not be bed sharing

with the infant. The guideline changes resulted in changing the name of the campaign to the

Safe to Sleep Campaign. Although the research shows the campaign has decreased rates of

sudden infant death syndrome there has been a slow decline in the campaigns effectiveness

over the years (Goodstein & Ostfeld, 2017).

PICOT Question

According to the Safe to Sleep Public Education Campaign, SIDS is the leading cause of

death among babies between one month and one year of age (“Fast Facts About SIDS”, 2018).

Infants are dying in their sleep of unknown causes. The Back to Sleep Campaign was initiated in

1990 to further address this growing problem. Since being initiated, has the campaign made an

impact on reducing the rates?

To better understand the effectiveness of The Back to Sleep Campaign on reducing the

rates of sudden infant death syndrome, the PICOT question for this project is stated as follows:
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 3

Has the Back to Sleep Campaign had a significant impact on the reduction of SIDS since being

implemented?

Diagnosis Question

The PICOT question being addressed in this paper is a prognosis type of question. This

type of question focuses more on the outcome/effectiveness of The Back to Sleep Campaign on

reducing the rate of sudden infant death syndrome.

Evidence

The prognosis type of question in research is best answered by evidence that focuses on

the outcome of The Back to Sleep Campaign. Research articles that pertain to the statistics

regarding the effect of the campaign as well as articles that focus on the purpose of the

campaign would be the most appropriate evidence to answer this PICOT question.

Databases

The databases used for this paper were CINAHL, NCBI and THE AMERICAN ACADEMY OF

PEDIATRICS. In the first search on CINAHL, using ‘back to sleep or safe sleep’ resulted in 604

hits. With the results being so vast I then typed in ‘Back to sleep campaign’ which narrowed the

results down to 31 hits. Four articles are being referenced in this paper from CINAHL. The NCBI

database that was used was found through searching ‘the effectiveness of the back to sleep

campaign’ on google and it led me to the database article.

In the first search on The American Academy of Pediatrics, ‘back to sleep campaign’ was

typed in yielding 214 results. The final search terms typed in were ‘back to sleep campaign
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 4

statistics in sudden infant death syndrome’ yielding 175 results. Although 175 is a lot of articles

there were quite a few that were pertinent to the PICOT question. Four articles are being

referenced in this paper from The American Academy of Pediatrics.

Research Methods

Of the nine articles used for this paper, four were systematic review from randomized

controlled trials, three were case control or cohort studies, one was a meta-analysis from

randomized controlled trials, and one was a systematic review of descriptive studies.

Level of Evidence

According to the evidence found regarding the PICOT question, the level of evidence is

high. There are many articles/journals published that research The Back to Sleep Campaign and

its effectiveness to decreasing sudden infant death rates. Most articles found stated that

although there was a decline in the sudden infant death rate after The Back to Sleep Campaign

was initiated, the rates have come to a plateau in the recent years. The Back to Sleep Campaign

made an impact but did not continue to.

Summary of Findings

The research found did support the PICOT question. Many articles stated that the Back

to Sleep Campaign reduced the rate of sudden infant death syndrome. The Back to Sleep

Campaign was initiated in 1994 (Zundo, Richards, Ahmel, &Codington, 2017). The campaign

instructed parents to place their infants on their backs to sleep instead of on their stomachs

(Trachtenberg, PhD, Haas, MPH, Kinney, MD, Stanley, MD & Krous, MD, 2012). According to one
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 5

article SIDS rates decreased by 35.8% from 1999 to 2015 (Erck Lambert, Parks, & Shapiro-

Mendoza, 2018). Another article reports that the overall rate of SIDS in the United States

decreased by more than 50% since 1990 (Zundo, Richards, Ahmel, & Codington, 2017).

The Back to Sleep Campaign promotes infants to be place supine instead of prone when

sleeping. The campaign also promotes there being no bed sharing with infants, they should lay

on a hard surface, and there should not be anything in the crib with the infants for risk of

suffocation during the night (Moon, 2016). A study was done in San Diego County, California

from 1991 to 2008 regarding the changes in risk factors after the initiation of The Back to Sleep

Campaign. Results show the percentage of infants placed on their stomach decreased from

85.4% to 30.1% as the percentage of infants placed on their back increased from 1.9% to 41.7%

during the Back to Sleep initiation period (Trachtenberg, PhD, Haas, MPH, Kinney, MD, Stanley,

MD & Krous, MD, 2012) In conclusion, the study found that there are many risk factors

associated with sudden infant death syndrome, and the risk factors, the prevalence of them,

changed after the Back to Sleep Campaign was initiated. The article states, “risk reduction

campaigns that emphasize the importance of avoiding multiple and simultaneous SIDS risks are

essential” (Trachtenberg, PhD, Haas, MPH, Kinney, MD, Stanley, MD & Krous, MD, 2012).

Another study was done by collecting a number of articles that met their criteria for

their research. The study was looking for articles that described an intervention to increase the

safety of the sleep environment for infants and the effectiveness of that intervention. There

were six interventions this study focused on; SIDS knowledge, items in the crib, infant sleep

position, infant sleep location, sharing safe sleep information with others and other behaviors.

The article concluded that most articles that were studied did show some success to changing
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 6

behaviors, there was not complete adherence to the interventions proposed in The Back to

Sleep Campaign (Salm Ward & Balfour, 2015).

A study was done to evaluate the effectiveness of the Back to Sleep Campaign in New

Zealand by mailing a survey to mothers simply asking in what position did they put their infant

to sleep last night? Of the 278 responses 72.3% were placing their infants on their back, 14.0%

on their side, 1.4% on their stomach and 12.2% on their back and side to sleep(Mitchell,

Hutchison, & Stewart, 2007). The article reports that sudden infant death mortality rates

decreased by 63% from 1993 to 2004, around the time the Back to Sleep Campaign was

initiated (Mitchell, Hutchison, & Stewart, 2007).

Although The Back to Sleep Campaign has been effective in reducing the rates of sudden

infant death syndrome there are still barriers keeping the campaign from being a complete

success. There are barriers with the patients and the healthcare professionals.

A study was done to see how much the nurses knew about and how well they adhered

to the SIDS prevention guidelines. Nurses in two hospitals were observed in the postpartum

nursery setting as well as there was a questionnaire that was sent out for the nurses to

complete. During observations the observers were looking for infant placement for sleeping

and items present in the cribs. The questionnaire was in regards to the nurses knowledge of the

guidelines and their opinions. Out of the total observations made regarding infant sleep

position, 34.8% did not meet the guidelines and 59.1% did not meet the recommendations for a

safe sleep environment (Bartlow, Cartwright, & Shefferly, 2016). Regarding the questionnaire,

19 nurses responded and out of the 19, 95% correctly identified the supine position as the safe
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 7

sleep position but only 53% of them reported actually placing the infants in that position 100%

of the time (Bartlow, Cartwright, & Shefferly, 2016). Of the responding nurses, 89% of them

stated they do educate parents before discharge about implementing the supine position.

Regarding the nurses attitudes about SIDS 74% of the nurses said they believed infant

positioning to be associated with the incidence of SIDS and 26% said they were unsure

(Bartlow, Cartwright, & Shefferly, 2016).

Parents of infants are also noncompliant with the recommended guidelines for SIDS

because of many reasons. Advice from healthcare professionals and others are always

changing. This constant change is a reason why some parents are not adhering to the

guidelines, claiming it confuses them (Zundo, Richards, Ahmel, &Codington, 2017). Another

noncompliance reason was infant comfort, parents believed that laying their infant supine was

and is uncomfortable for the infant to sleep (Zundo, Richards, Ahmel, &Codington, 2017).

Another concern was choking. Parents were using either the side lying position or prone

position believing there is a higher risk of the infant choking laying supine instead of prone

(Zundo, Richards, Ahmel, &Codington, 2017).

Research was done to evaluate healthcare professionals knowledge about safe sleep

and the advice they give to patients regarding infant safe sleep. The number of healthcare

professionals aware of the supine position for infants has been increasing due to The Back to

Sleep Campaign suggesting the campaign is in fact making an impact (Luca & Hinde, 2016). The

amount of accurate advice healthcare professionals have been giving to parents of infants has

increased as well, due to The Back to Sleep Campaign (Luca & Hinde, 2016). Healthcare

professionals are knowledgeable about the recommended guidelines regarding reducing the
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 8

rates of sudden infant death syndrome and have been efficient with giving the correct advice to

parents of infants the past 20 years (Luca & Hinde, 2016).

Clinical Implications and Conclusion

Practice changes need to include a different way to go about education and

implementation of the recommended guidelines included in the Back to Sleep Campaign. There

needs to be a set education program that is followed and required by all institutions. That way

all patients, parents of infants, are receiving the same and the most up to date information. The

information needs to be taught before the family leaves the hospitals multiple times. There also

needs to be some kind of program that does a follow up in the home, kind of like an

unannounced visit to see if the parents are adhering to the guidelines. If they are not adhering

to the guidelines then a survey should be done to seek why the parents are not following the

guidelines in hopes to take the information received to help improve future education.

Patient/family preferences of how they were lied down to sleep and “nothing happened

to them” would influence implementation. Patients will listen to the information given but then

get mixed information from other resources because it has not always been “back to sleep” for

infants. That is why education needs to be the same throughout the country and there needs to

be more of it. I recommend those who are going to be taking care of the infant have to go

through a specific course of training to gain knowledge about the risk factors and interventions

needed to be done in order to help further reduce the rates of sudden infant death syndrome.

If I were a staff nurse who had completed this search I would definitely provide more

education. I would research what the policy states for what kind of education my facility is
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 9

giving regarding sudden infant death syndrome. I would start the education the first day after

delivery and continue to give the education everyday until the patient is discharged.

Information would be explained thoroughly and statistics would be given to help the patient

better understand why the supine position is recommended for their infant. I would also

recommend there being a paper above the crib reminding whoever is putting the infant to bed

to place them in the supine position and to double check that there is nothing in the crib with

them.

Even though there was enough evidence to answer my PICOT questions there are still

improvements that could be made to help further reduce the rates of sudden infant death

syndrome.
Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 10

References

Bartlow, K. L., Cartwright, S. B., & Shefferly, E. K. (2016). Nurses' Knowledge and Adherence To Sudden

Infant Death Syndrome Prevention Guidelines. Pediatric Nursing,42, 1st ser., 7-13. Retrieved

March 15, 2018, from

http://web.b.ebscohost.com.ezproxy.jccmi.edu/ehost/pdfviewer/pdfviewer?vid=5&sid=b407c0

c1-15f3-4452-8c0e-14a7cc573d9e@sessionmgr103

Erck Lambert, A. B., Parks, S. E., & Shapiro-Mendoza, C. K. (2018). National and State Trends in Sudden

Unexpected Infant Death: 1990-2015. PEDIATRICS,141, 3rd ser., 1-7. Retrieved March 15, 2018,

from http://pediatrics.aappublications.org/content/pediatrics/141/3/e20173519.full.pdf

Fast Facts About SIDS. (n.d.). Retrieved April 11, 2018, from

https://www1.nichd.nih.gov/sts/about/SIDS/Pages/fastfacts.aspx

Goodstein, M. H., & Ostfeld, B. M. (2017). Improvements in Infant Sleep Position: We Can Do

Better! PEDIATRICS,140, 3rd ser., 1-3. Retrieved April 10, 2018, from

http://pediatrics.aappublications.org/content/pediatrics/140/3/e20172068.full.pdf

Luca, F. D., & Hinde, A. (2016). Effectiveness of the 'Back-to-Sleep' Campaign Among Healthcare

Professionals in the Past 20 Years. BMJ,1-8. Retrieved April 10, 2018, from

file:///C:/Users/Mackenzie/Downloads/EBN project/Effectiveness of the 'Back-to-Sleep'

campaigns among healthcare professionals in the past 20 years.pdf.

Mitchell, E. A., Hutchison, L., & Stewart, A. W. (2007). The Continuing Decline in SIDS Mortality. BMJ.

Retrieved April 9, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2083749/.

Running head: THE EFFECTIVENESS OF THE BACK TO SLEEP CAMPAIGN 11

References Continued

Moon, R. Y. (2016). SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated

Recommendations for a Safe Infant Sleeping Environment. PEDIATRICS,138(5), 1-34. Retrieved

April 9, 2018, from

http://pediatrics.aappublications.org/content/pediatrics/138/5/e20162940.full.pdf

Salm Ward, T. C., & Balfour, G. M. (2015). Infant Safe Sleep Interventions, 1990-2015: A

Review. Springer,180-196. Retrieved April 9, 2018, from

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0c1-15f3-4452-8c0e-14a7cc573d9e@sessionmgr103

Trachtenberg, PhD, F. L., Haas, MPH, E. A., Kinney, MD, H. C., Stanley, MD, C., & Krous, MD, H. F. (2012).

Risk Factor Changes for Sudden Infant Death Syndrome After Initiation of Back-to-Sleep

Campaign. PEDIATRICS,129, 4th ser., 630-638. Retrieved March 18, 2018, from

http://pediatrics.aappublications.org/content/129/4/630

Zundo, K., Richards, E. A., Ahmel, A. H., & Codington, J. A. (2017). Factors Associated with Parental

Compliance with Supine Infant Sleep: An Integrative Review. PEDIATRIC NURSING,43, 2nd ser.,

83-91. Retrieved March 15, 2018, from

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