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Despite knowledge of and intention to follow safe sleep guidelines for infants, mothers often engaged in non-recommended sleep practices, a series of small focus groups and surveys showed.

Among 25 mothers, 80% reported holding or rocking their infant to sleep, and 76% reported feeding their infant to sleep, Lara McKenzie, PhD, MA, of Nationwide Children's Hospital in Columbus, Ohio, and colleagues found.

However, all of the mothers displayed knowledge of the ABCs (Alone, Back, Crib) of safe sleep, they .

"Sleep strategies that do not follow AAP [American Academy of Pediatrics] guidelines may increase the infant's risk of SUID [sudden unexplained infant death]," McKenzie and colleagues wrote. "Parents should be educated about normal sleep hygiene and the risk of SUID (i.e., death) of their infant in an unsafe sleep environment."

Just last month, detailed that most cases of SUID, regardless of sleep location, had multiple unsafe sleep factors present. In that study, out of 7,595 cases of SUID, 59.5% were sleep surface sharing when the infants died, and at least 76% had multiple unsafe sleep factors present.

"Because the risk of SUID may not be tangible to parents, using understandable terms such as 'suffocation' may be more effective in communicating this risk," McKenzie and colleagues said. "Interventions that teach parents about developmentally appropriate sleep patterns and strategies to promote infant sleep and self-soothing may increase adherence to safe sleep guidelines."

Other themes that emerged from the focus groups and surveys included challenges regarding infant sleep, deviations from the ABCs to help infants sleep, and justifications for not following the ABCs.

Overall, 36% of mothers reported that their infant had a sleep problem, and 40% indicated that their infant's sleep "somewhat" or "very much" negatively affected their own. And though 96% of mothers were confident they could hold as well as easily soothe their infant to sleep, 72% were not confident in their ability to get their infants back to sleep without feeding.

"If I had to follow the safe sleep, back is best, and nothing in the crib and no contact sleeping, I don't think that she would get much sleep, nor would I, so I don't feel too confident in that," one mother said.

Nearly all of the mothers (92%) reported using at least one product not approved as infant sleep space by the Consumer Product Safety Commission, including a car seat (56%), swing (48%), and/or an infant carrier worn on an adult's body (40%).

Confusion also existed regarding the fact that there are infant products for sale that seem suitable for sleep but are not recommended. Mothers indicated that such products -- like infant loungers and nursing pillows -- were tempting to use, especially when sleep-deprived.

Some mothers reported being more willing to deviate from the ABCs of Safe Sleep during naps because they felt they could closely monitor their infant. Others were skeptical that the ABCs were the only safe sleep option.

"[T]here's like 100 different ways to feed your baby, but there's only one way that you're supposed to have your baby sleep..." one mother said. "Every baby's different, but when it comes to sleep, every baby's supposed to do something the same."

"I think that can be frustrating sometimes, because then we blame ourselves ... [w]hereas, when it comes to feeding or maybe something else, it's OK if my baby does it differently because they're still growing and adapting," the mother added. "When it comes to sleep, if we're not doing it the correct way that we are taught, then we're doing something wrong."

Some mothers reported being reassured when they were not following the ABCs if they received such advice from trusted sources in their social network. Meanwhile, none of the mothers expressed concern that alternative sleep strategies placed their infant at higher risk for SUID.

Focus groups and surveys were conducted from November 2022 to March 2023. Mothers who had infants less than 6 months of age, who were U.S.-based and English-speaking, and who had reported a non-recommended sleep position and/or location two or more times in the past week were recruited via social media and via flyers emailed to hospital employees.

The average age of mothers who participated was 28.1 years, and the average age of infants was 3.7 months. The majority of mothers self-identified as white (80%), while 12% self-identified as Black, and 8% as Hispanic.

Limitations included that mothers who participated were self-selected and may not be representative of all families who engage in non-recommended sleep practices and that the study precluded examination of decision-making about sleep over time. Other factors that may be contributory, such as cultural beliefs and environmental considerations, should also be explored, McKenzie and colleagues added, as should perspectives from all family members, not just mothers, regarding unsafe sleep.

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