Changing parental high risk behaviour in the reduction of SIDS: the imperative of translational research
Editor,
The recent article by Blair et al on SIDS confirms the risk of
hazardous co-sleeping and factors resulting from parental risk behaviours
involving cigarette smoking, alcohol and drug use. Clearly, public
education campaigns such as “Back to Sleep” have contributed to the
decline in SIDS in the early 1990s , yet this recent study1 further
refines understanding of the individual behaviours of parents as the next
challenge in reducing the rate of infant mortality from SIDS. Indeed, it
is the challenge of how to change behaviour3 that needs to be addressed
through SIDS research and prevention practice.
The nature of SIDS involves a diverse and potent set of biomedical,
psychological, familial and socio-economic factors. Its very
categorisation, such as the replacement of “cot death” with “SIDS”,
illustrates its evolving etiology, and some consider it time to stop using
SIDS to mask the unpalatable dynamics surrounding the death of an infant
when its cause is attributable to modifiable parental behaviours4.
Additionally, national recommendations on SIDS prevention have been
expanded to include parental risk behaviours of smoking, alcohol and drug
use, and, in those circumstances, which contra-indicate co-sleeping, to
place infants in a cot beside a bed5 6 7. Yet, what is emerging from
scientific evidence is that of the multiple risk factors for SIDS,
parental behaviour change may lead to the next significant reduction in
incident infant mortality.
The challenge of changing behaviour
‘Blaming the victim’ versus ‘duty of care’
The challenge of changing behaviour in the field of SIDS shares many
of the complexities and difficulties of changing health related behaviours
of other conditions. However, it is when we examine the specifics of what
needs to change and who has to change that strategic research and practice
directions can be identified. Blair et al1 demonstrate that it is not bed-
sharing per se that places infants at risk but parents’ alcohol and drug
use prior to co-sleeping on beds, and especially co-sleeping on sofas.
Higher alcohol and drug use by the parents of SIDS infants compared with
other parents whose infants had died was also found in a study of
bereavement, although risk behaviours prior to infant loss were not
measured8. A more concerted campaign for the prevention of SIDS that
targets high risk parents about risk reduction strategies seems logical.
Although, it is at this point that the challenging nature of changing
parental behaviour becomes clearer.
Numerous health professionals, especially midwives, child health
nurses, general practitioners, psychologists and social workers, will
attest that their provision of information and education about SIDS
prevention is actually implemented by only a portion of the community. For
example, individual education conducted on a maternity ward does show an
increased rate of 42% of mothers placing their infants in the supine
position to sleep compared with 24% in a control group, but that education
is still insufficient for most mothers to adopt this behaviour9. In low
socio-economic regions where there are multiple types of deprivation and
often high rates of smoking, alcohol and drug use, health professionals
are faced with an on-going dilemma in prevention. On the one hand, health
interventions aimed at parental behaviour change do not want to result in
‘blaming the victim’ 10. Yet, on the other, there is a need to instil a
strong sense of the ‘duty of care’ in every individual parent of a
vulnerable newborn and sufficient timely information on strategies to
support parental regard rather than dereliction of that duty.
Empowering high risk parents to change behaviour
It is with the challenge of changing individual parental behaviours
of smoking, alcohol and drug use (what needs to change) and the dilemma of
targeting high risk parents (who has to change) in mind that broader
approaches to research translation need to be considered. In working with
high risk parents, especially mothers, much earlier studies, such as that
by Ovrebo et al11 have demonstrated that an empowerment model can result
in improved birth outcomes. Central to an empowerment model is the notion
of change as a process that is supported by social and community resources
that an individual can draw on to build internal capacity and a sense of
control. Therefore, changing parental risk behaviours that are directly
harmful to infants requires an approach that will target infants’ safety
in the context of empowering parents to become more actively involved in
the planning and prevention of SIDS, care of their infants and themselves.
Promoting behaviour change in any area is complex, but in the
prevention of SIDS it also involves intersections across diverse, and, at
times, competing practices and messages. The controversial use of Nicotine
Replacement Therapy in pregnant women12 is just one illustration of a
quick-fix approach to symptoms rather than addressing long-term patterns
of risk behaviours that affect health. In the community sector, movements
such as “Attachment Parenting”, which commends co-sleeping13 are also
sources of conflicting information. These examples are indicative of a
breadth of individual and environmental factors that complicate community
perceptions of public health education. Therefore, promoting healthy
parenting using general principles of individual health education and
information during pre-natal and post-natal care for all parents should be
continued as a strategy to prevent SIDS. In addition, the broader approach
of empowerment targeted at high risk communities and parents offers a way
to engage behavioural change that could contribute to the significant
reduction in SIDS infant mortality.
1 Blair P, Sidebotham PD, Evason-Coombe C, Edmonds M, Heckstall-Smith
EMA, Fleming P. Risky co-sleeping environments and risk factors amenable
to change: case-control study of SIDS in south west England. BMJ 2009;
339:b3666.
2 Office for National Statistics. Infant mortality 1921-2021.Social
trends 32. London: ONS, 2002.
3 Mitchell EA. Risk factors for SIDS. BMJ 2009;339:b3466.
4 Gornall J. Sudden infant death. Does cot death still exist? BMJ
2008; 336: 302-304.
5 American Academy of Pediatrics. The changing concept of sudden
infant death syndrome: diagnostic coding shifts, controversies regarding
the sleep environment, and new variables to consider reducing the risk.
Paediatrics 2005;116:1245-55.
8 Vance JC, Najman JM, Boyle FM, Embleton G, Foster WJ, Thearle MJ.
Alcohol and drug usage in parents soon after stillbirth, neonatal death or
SIDS. J Paediatr. Child Health 1994;30:269-272.
9 Issler RMS, Marostica PJC, Giugliani ERJ. Infant sleep positions: a
randomized control trial of an educational intervention in the maternity
ward in Port Alegre, Brazil.
10 Petersen A, Bunton R (eds) Foucault, health and medicine. London:
Routledge.
11 Ovrebo B, Ryan M, Jackson K, Hutchinson K. The homeless prenatal
program: a model for empowering homeless pregnant women. Health Educ Behav
1994; 21-187.
12 Ginzel KH, Maritz GS, Marks D, Neuberger M, Pauly JR, Polito JR,
Schulte-Hermann R, Slotkin TA. Nicotine for the fetus, the infant and the
adolescent? J Health Psycho 2007;12,2:215-224.
Rapid Response:
Changing parental high risk behaviour in the reduction of SIDS: the imperative of translational research
Editor,
The recent article by Blair et al on SIDS confirms the risk of
hazardous co-sleeping and factors resulting from parental risk behaviours
involving cigarette smoking, alcohol and drug use. Clearly, public
education campaigns such as “Back to Sleep” have contributed to the
decline in SIDS in the early 1990s , yet this recent study1 further
refines understanding of the individual behaviours of parents as the next
challenge in reducing the rate of infant mortality from SIDS. Indeed, it
is the challenge of how to change behaviour3 that needs to be addressed
through SIDS research and prevention practice.
The nature of SIDS involves a diverse and potent set of biomedical,
psychological, familial and socio-economic factors. Its very
categorisation, such as the replacement of “cot death” with “SIDS”,
illustrates its evolving etiology, and some consider it time to stop using
SIDS to mask the unpalatable dynamics surrounding the death of an infant
when its cause is attributable to modifiable parental behaviours4.
Additionally, national recommendations on SIDS prevention have been
expanded to include parental risk behaviours of smoking, alcohol and drug
use, and, in those circumstances, which contra-indicate co-sleeping, to
place infants in a cot beside a bed5 6 7. Yet, what is emerging from
scientific evidence is that of the multiple risk factors for SIDS,
parental behaviour change may lead to the next significant reduction in
incident infant mortality.
The challenge of changing behaviour
‘Blaming the victim’ versus ‘duty of care’
The challenge of changing behaviour in the field of SIDS shares many
of the complexities and difficulties of changing health related behaviours
of other conditions. However, it is when we examine the specifics of what
needs to change and who has to change that strategic research and practice
directions can be identified. Blair et al1 demonstrate that it is not bed-
sharing per se that places infants at risk but parents’ alcohol and drug
use prior to co-sleeping on beds, and especially co-sleeping on sofas.
Higher alcohol and drug use by the parents of SIDS infants compared with
other parents whose infants had died was also found in a study of
bereavement, although risk behaviours prior to infant loss were not
measured8. A more concerted campaign for the prevention of SIDS that
targets high risk parents about risk reduction strategies seems logical.
Although, it is at this point that the challenging nature of changing
parental behaviour becomes clearer.
Numerous health professionals, especially midwives, child health
nurses, general practitioners, psychologists and social workers, will
attest that their provision of information and education about SIDS
prevention is actually implemented by only a portion of the community. For
example, individual education conducted on a maternity ward does show an
increased rate of 42% of mothers placing their infants in the supine
position to sleep compared with 24% in a control group, but that education
is still insufficient for most mothers to adopt this behaviour9. In low
socio-economic regions where there are multiple types of deprivation and
often high rates of smoking, alcohol and drug use, health professionals
are faced with an on-going dilemma in prevention. On the one hand, health
interventions aimed at parental behaviour change do not want to result in
‘blaming the victim’ 10. Yet, on the other, there is a need to instil a
strong sense of the ‘duty of care’ in every individual parent of a
vulnerable newborn and sufficient timely information on strategies to
support parental regard rather than dereliction of that duty.
Empowering high risk parents to change behaviour
It is with the challenge of changing individual parental behaviours
of smoking, alcohol and drug use (what needs to change) and the dilemma of
targeting high risk parents (who has to change) in mind that broader
approaches to research translation need to be considered. In working with
high risk parents, especially mothers, much earlier studies, such as that
by Ovrebo et al11 have demonstrated that an empowerment model can result
in improved birth outcomes. Central to an empowerment model is the notion
of change as a process that is supported by social and community resources
that an individual can draw on to build internal capacity and a sense of
control. Therefore, changing parental risk behaviours that are directly
harmful to infants requires an approach that will target infants’ safety
in the context of empowering parents to become more actively involved in
the planning and prevention of SIDS, care of their infants and themselves.
Promoting behaviour change in any area is complex, but in the
prevention of SIDS it also involves intersections across diverse, and, at
times, competing practices and messages. The controversial use of Nicotine
Replacement Therapy in pregnant women12 is just one illustration of a
quick-fix approach to symptoms rather than addressing long-term patterns
of risk behaviours that affect health. In the community sector, movements
such as “Attachment Parenting”, which commends co-sleeping13 are also
sources of conflicting information. These examples are indicative of a
breadth of individual and environmental factors that complicate community
perceptions of public health education. Therefore, promoting healthy
parenting using general principles of individual health education and
information during pre-natal and post-natal care for all parents should be
continued as a strategy to prevent SIDS. In addition, the broader approach
of empowerment targeted at high risk communities and parents offers a way
to engage behavioural change that could contribute to the significant
reduction in SIDS infant mortality.
1 Blair P, Sidebotham PD, Evason-Coombe C, Edmonds M, Heckstall-Smith
EMA, Fleming P. Risky co-sleeping environments and risk factors amenable
to change: case-control study of SIDS in south west England. BMJ 2009;
339:b3666.
2 Office for National Statistics. Infant mortality 1921-2021.Social
trends 32. London: ONS, 2002.
3 Mitchell EA. Risk factors for SIDS. BMJ 2009;339:b3466.
4 Gornall J. Sudden infant death. Does cot death still exist? BMJ
2008; 336: 302-304.
5 American Academy of Pediatrics. The changing concept of sudden
infant death syndrome: diagnostic coding shifts, controversies regarding
the sleep environment, and new variables to consider reducing the risk.
Paediatrics 2005;116:1245-55.
6 Ministry of Health. Preventing sudden unexpected death in infancy:
information for health
professionals2008.www.moh.govt.nz/moh.nsf/0/5118C5C5561CEC79CC2573A6000B3BBE
7 Sids and Kids (2007) Information statement: Sleeping with a baby.
September http://www.sidsandkids.org/current_topics.html
8 Vance JC, Najman JM, Boyle FM, Embleton G, Foster WJ, Thearle MJ.
Alcohol and drug usage in parents soon after stillbirth, neonatal death or
SIDS. J Paediatr. Child Health 1994;30:269-272.
9 Issler RMS, Marostica PJC, Giugliani ERJ. Infant sleep positions: a
randomized control trial of an educational intervention in the maternity
ward in Port Alegre, Brazil.
10 Petersen A, Bunton R (eds) Foucault, health and medicine. London:
Routledge.
11 Ovrebo B, Ryan M, Jackson K, Hutchinson K. The homeless prenatal
program: a model for empowering homeless pregnant women. Health Educ Behav
1994; 21-187.
12 Ginzel KH, Maritz GS, Marks D, Neuberger M, Pauly JR, Polito JR,
Schulte-Hermann R, Slotkin TA. Nicotine for the fetus, the infant and the
adolescent? J Health Psycho 2007;12,2:215-224.
13 Attachment Parenting www.attachmentparenting.org
Competing interests:
None declared
Competing interests: No competing interests