Although the AAP has recommended against the use of soft sleep surfaces and soft bedding in infant sleep areas since 2000,21
the use of these products is still common.22
To the best of our knowledge, this is the first article to describe parents' attitudes about and reasons for using or not using soft bedding and sleep surfaces. It is essential for health care professionals and others who provide information to families to understand reasons for and concerns regarding use or nonuse of soft bedding and soft sleep surfaces so that appropriate advice is given and interventions developed.
In our interviews of black mothers, we found that, regardless of SES or educational level, the primary reasons for using soft bedding and soft sleep surfaces seem to center around infant safety and comfort. Mothers try to ensure both safety and comfort in the infant's sleeping environment. Unfortunately, many may have the misperception that soft bedding will protect the infant from injury and/or falls and thus may unknowingly place their infants at greater risk when they place these items in the sleeping environment. These items create an increased risk for SIDS13,15
and accidental suffocation.42
In a recent report from the Consumer Product Safety Commission, deaths reported in cribs/mattresses, playpens/play yards, and bassinets/cradles between 2005 and 2007 were mainly attributed to extra bedding, leading to asphyxiation or suffocation.43
Parents should be made aware that elimination of soft bedding and surfaces will make the sleep environment safer.
Likewise, many parents may use bumper pads because of the perception that these will keep their infant safe from injury. However, Thach et al,44
in a study using data from the Consumer Product Safety Commission, found 3 mechanisms of SIDS that can be caused by bumper pads: suffocation against the bumper pads, entrapment between the bumper pads and the crib or mattress, and strangulation by the ties. In addition, they found that the injuries that conceivably might be prevented by bumper pads in young infants are generally minor and nonlethal.44
Because of the potential risk of suffocation, strangulation, and entrapment with bumper pads and the lack of benefit, Thach concluded that bumper pads should not be used. However, it is important to acknowledge the concern of some parents that minor injuries that might be prevented by bumper pads may be misconstrued by vigilant child protection agencies as suggestive of child abuse or neglect. It is unlikely that the youngest infants (ie, those younger than 4 months [the ones at most risk for suffocation, entrapment, or strangulation from bumper pads]) will generate enough force when rolling into a crib side to result in injury. Nonetheless, child protection agencies may need updated training regarding injuries such as those sustained when a limb becomes stuck between crib slats or when an infant rolls into the crib side, such that these patterns of injury will be recognized as the result of no bumper pads. Finally, bumper pads obscure visibility of the infant, which may be an important consideration for some parents.
Although AAP recommendations state that infants should be placed on a firm sleep surface, the meaning of the adjective “firm” may not be understood by parents. Mothers in our interviews had many interpretations of firm. Some mothers believed a surface was firm if it “springs back,” indicating that the sleep surface does not have fixed malleability. Although malleability and softness are often related, they are not synonymous. Furthermore, sleep surfaces typically are not uniform in their firmness and are often softer in the middle than they are closer to the edge. Because softness may vary depending on where the infant's head is resting, a single measure of softness for a sleep surface will not be helpful.
Also of concern with regard to the sleep surface was that many mothers had the perception that firm means taut and that the surface would still be firm if a pillow or blanket was placed between the mattress and the sheet, as long as the sheet was tucked tautly around the pillow or blanket. However, pillows, quilts, and other items used to pad the sleep surface are hazardous.8–15
Health care professionals should be aware that sleep surface padding may be a common practice and should not assume that parents understand the meaning of “firm sleep surface.”
In addition, some parents may equate a thin, firm mattress (particularly those for bassinets and play yards) with being uncomfortable and may be more likely to pad such surfaces. To avoid this perception, manufacturers should be encouraged to produce mattresses, especially for bassinets and play yards, which are thicker yet still firm. In addition, because many parents may use bassinets and play yards as routine infant sleep areas because of financial and space concerns,35
it is particularly important for programs that work with these families, especially programs that provide portable cribs or play yards at no or reduced cost, to be aware that this may be a common practice.
Parents may also perceive that blankets are safe if they do not go past the shoulders, have holes (eg, afghans), or if the infant is supine. These misconceptions may exist because of the decreased risk of suffocation if the face is not covered and/or the decreased risk of SIDS when the infant is supine. However, infants can pull blankets over their heads during sleep.45
Loose bedding, particularly when the infants' heads become covered, has been associated with SIDS, even in supine sleeping infants.12,16,17,20
Infant sleep clothing may be an appropriate alternative to blankets.
Some parents may choose to use bedding, particularly bumper pads, for aesthetic reasons. Parents who are eager to decorate the infant's room should be encouraged to decorate the room instead of the crib. This will allow parents to enjoy the full infant experience, while still keeping the infant sleep area safe.
There are several limitations to this study. Our study population was limited to black mothers in the Washington, DC, area. In an effort to minimize cultural heterogeneity, the mothers in our study were born in the United States and had parents also born in the United States. In addition, one cannot determine prevalence of attitudes and opinions from qualitative studies. Although these mothers represent a wide range of infant care practices, the results may not be generalizable to other cultures, groups, or regions. However, our findings about opinions and beliefs influencing other infant sleep practices, such as sleep position37
and sleep location,35
have been consistent with other qualitative studies of both black populations46–49
and European populations.50,51
It will nonetheless be important to expand this study to other racial and ethnic groups to determine how prevalent these factors are in the society as a whole.