Maternal Attitudes and Other Factors Associated with Infant Vaccination Status in the United States, 2011-2014.

OBJECTIVE: To assess the role of maternal attitudes and other factors associated with infant vaccination status. STUDY DESIGN: Data on reported vaccination status were analyzed from a nationally representative prospective survey of mothers of 2- to 6-month-old infants. Weighted univariate and multiple logistic regression analyses were conducted. Latent profile analysis of mothers reporting nonimmunized infants identified distinct groups, RESULTS: Of 3268 mothers, 2820 (weighted 86.2%), 311 (9.1%), and 137 (4.7%), respectively, reported their infant had received all, some, or no recommended vaccinations for age. Younger infants and infants with younger mothers were more likely to have received no vaccinations. Mothers with neutral and negative attitudes toward vaccination were >3 (aOR 3.66, 95% CI 1.80-7.46) and 43 times (aOR 43.23, 95% CI 20.28-92.16), respectively, more likely than mothers with positive attitudes to report their infants had received no vaccinations. Two subgroups of mothers reporting that their infants had received no vaccinations were identified: group A (52.5%) had less than positive attitudes and less than positive subjective norms about vaccination (ie, perceived social pressure from others); group B (47.5%) had positive attitudes and positive subjective norms. Group A mothers were more likely to be white (76.1% vs 48.3%, P?=?.002), more educated (43.5% vs 35.4% college or higher, P?=?.02), and to exclusively breastfeed (74.9% vs. 27.3%, P?

Differences in Infant Care Practices and Smoking among Hispanic Mothers Living in the United States.

OBJECTIVE: To assess the association between maternal birth country and adherence to the American Academy of Pediatrics safe sleep recommendations in a national sample of Hispanic mothers, given that data assessing the heterogeneity of infant care practices among Hispanics are lacking. STUDY DESIGN: We used a stratified, 2-stage, clustered design to obtain a nationally representative sample of mothers from 32 US intrapartum hospitals. A total of 907 completed follow-up surveys (administered 2-6 months postpartum) were received from mothers who self-identified as Hispanic/Latina, forming our sample, which we divided into 4 subpopulations by birth country (US, Mexico, Central/South America, and Caribbean). Prevalence estimates and aORs were determined for infant sleep position, location, breastfeeding, and maternal smoking. RESULTS: When compared with US-born mothers, we found that mothers born in the Caribbean (aOR 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. Caribbean-born mothers were significantly less likely to place infants to sleep supine (aOR 0.41). Mothers born in Mexico (aOR 1.67) and Central/South America (aOR 2.57) were significantly more likely to exclusively breastfeed; Caribbean-born mothers (aOR 0.13) were significantly less likely to do so. Foreign-born mothers were significantly less likely to smoke before and during pregnancy. CONCLUSIONS: Among US Hispanics, adherence to American Academy of Pediatrics safe sleep recommendations varies widely by maternal birth country. These data illustrate the importance of examining behavioral heterogeneity among ethnic groups and have potential relevance for developing targeted interventions for safe infant sleep.

The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices: A Randomized Clinical Trial.

Importance: Inadequate adherence to recommendations known to reduce the risk of sudden unexpected infant death has contributed to a slowing in the decline of these deaths. Objective: To assess the effectiveness of 2 interventions separately and combined to promote infant safe sleep practices compared with control interventions. Design, Setting, and Participants: Four-group cluster randomized clinical trial of mothers of healthy term newborns who were recruited between March 2015 and May 2016 at 16 US hospitals with more than 100 births annually. Data collection ended in October 2016. Interventions: All participants were beneficiaries of a nursing quality improvement campaign in infant safe sleep practices (intervention) or breastfeeding (control), and then received a 60-day mobile health program, in which mothers received frequent emails or text messages containing short videos with educational content about infant safe sleep practices (intervention) or breastfeeding (control) and queries about infant care practices. Main Outcomes and Measures: The primary outcome was maternal self-reported adherence to 4 infant safe sleep practices of sleep position (supine), sleep location (room sharing without bed sharing), soft bedding use (none), and pacifier use (any); data were collected by maternal survey when the infant was aged 60 to 240 days. Results: Of the 1600 mothers who were randomized to 1 of 4 groups (400 per group), 1263 completed the survey (78.9%). The mean (SD) maternal age was 28.1 years (5.8 years) and 32.8% of respondents were non-Hispanic white, 32.3% Hispanic, 27.2% non-Hispanic black, and 7.7% other race/ethnicity. The mean (SD) infant age was 11.2 weeks (4.4 weeks) and 51.2% were female. In the adjusted analyses, mothers receiving the safe sleep mobile health intervention had higher prevalence of placing their infants supine compared with mothers receiving the control mobile health intervention (89.1% vs 80.2%, respectively; adjusted risk difference, 8.9% [95% CI, 5.3%-11.7%]), room sharing without bed sharing (82.8% vs 70.4%; adjusted risk difference, 12.4% [95% CI, 9.3%-15.1%]), no soft bedding use (79.4% vs 67.6%; adjusted risk difference, 11.8% [95% CI, 8.1%-15.2%]), and any pacifier use (68.5% vs 59.8%; adjusted risk difference, 8.7% [95% CI, 3.9%-13.1%]). The independent effect of the nursing quality improvement intervention was not significant for all outcomes. Interactions between the 2 interventions were only significant for the supine sleep position. Conclusions and Relevance: Among mothers of healthy term newborns, a mobile health intervention, but not a nursing quality improvement intervention, improved adherence to infant safe sleep practices compared with control interventions. Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied. Trial Registration: clinicaltrials.gov Identifier: NCT01713868.

An Innovative Needle-free Injection System: Comparison to 1 ml Standard Subcutaneous Injection.

A needle-free delivery system may lead to improved satisfaction and compliance, as well as reduced anxiety among patients requiring frequent or ongoing injections. This report describes a first-in-man assessment comparing Portal Instruments' innovative needle-free injection system with subcutaneous injections using a 27G needle. Forty healthy volunteer participants each received a total of four injections of 1.0 mL sterile saline solution, two with a standard subcutaneous injection using a 27G needle, and two using the Portal injection system. Perception of pain was measured using a 100-mm visual analog scale (VAS). Injection site reactions were assessed at 2 min and at 20-30 min after each injection. Follow-up contact was made 24-48 h after the injections. Subject preference regarding injection type was also assessed. VAS pain scores at Portal injection sites met the criteria to be considered non-inferior to the pain reported at 27G needle injection sites (i.e., upper 95% confidence bound less than +5 mm). Based on a mixed effects model, at time 0, accounting for potential confounding variables, the adjusted difference in VAS scores indicated that Portal injections were 6.5 mm lower than the 27G needle injections (95% CI -10.5, -2.5). No clinically important adverse events were noted. Portal injections were preferred by 24 (60%) of the subjects (P = 0.0015). As an early step in the development of this new needle-free delivery system, the current study has shown that a 1.0-mL saline injection can be given with less pain reported than a standard subcutaneous injection using a 27G needle.

Postdischarge Feeding Interactions and Neurodevelopmental Outcome at 1-Year Corrected Gestational Age.

OBJECTIVE: To determine the extent to which postdischarge feeding behaviors and interactions among caregiver-preterm infant dyads are associated with infant neurodevelopment at 1-year corrected gestational age (CGA). STUDY DESIGN: We studied 119 preterm infants born <34 weeks gestation and <1750 g at birth, and their caregivers, enrolled in the Collaborative Home Infant Monitoring Evaluation with in-person feeding assessments according to the Nursing Child Assessment Feeding Scale (NCAFS) at 39-59 weeks postmenstrual age that completed Bayley Scales of Infant Development, Second Edition testing at 1 year CGA. RESULTS: Mean ± SD gestational age was 29.6 ± 2.4 weeks, and birth weight was 1260 ± 320 g. After adjustment for maternal and infant demographics, gestational age at birth, discharge and birth weight, mode of infant feeding, and caregiver type during the postdischarge NCAFS assessment, overall NCAFS scores were positively associated with higher 1-year CGA Bayley mental developmental index (MDI) scores (for each 1 SD increase in overall NCAFS score, MDI increased by 2.8 [95% CI 0.7, 4.9] points). Among individual NCAFS domains, strongest effects were seen for caregiver responsiveness to infant distress, such that, compared with dyads having domain scores of 11 (highest possible score), the adjusted mean difference in MDI was 8.3 points (95% CI -15.2, -1.4) lower among dyads with scores <9. CONCLUSIONS: Caregiver-preterm infant feeding interaction and caregiver responsiveness to preterm infant feeding distress were associated with preterm infant Bayley MDI at 1-year CGA. Caregiver-infant feeding interaction may represent a modifiable factor to improve the neurodevelopment of at-risk preterm infants.

Salivary caffeine concentrations are comparable to plasma concentrations in preterm infants receiving extended caffeine therapy.

AIMS: Caffeine concentrations in preterm infants are usually measured in the blood. However, salivary assays may provide a valid and practical alternative. The present study explored the validity and clinical utility of salivary caffeine concentrations as an alternative to blood concentrations and developed a novel plasma/salivary caffeine distribution model. METHODS: Paired salivary and plasma samples were obtained in 29 infants. Salivary samples were obtained using a commercially available salivary collection system. Caffeine concentrations in the saliva and plasma were determined using high-performance liquid chromatography. A population pharmacokinetic (PK) model was developed using NONMEM 7.3. RESULTS: The mean (± standard deviation) gestational age (GA) at birth and birth weight were 27.9 ± 2.1 weeks and 1171.6 ± 384.9 g, respectively. Paired samples were obtained at a mean postmenstrual age (PMA) of 35.5 ± 1.1 weeks. The range of plasma caffeine concentrations was 9.5-54.1 µg ml(-1) , with a mean difference (95% confidence interval) between plasma and salivary concentrations of -0.18 µg ml(-1) (-1.90, 1.54). Salivary and plasma caffeine concentrations were strongly correlated (Pearson's correlation coefficient = 0.87, P < 0.001). Caffeine PK in plasma and saliva was simultaneously described by a three-compartment recirculation model. Current body weight, birth weight, GA, PMA and postnatal age were not significantly correlated with any PK parameter. CONCLUSIONS: Salivary sampling provides an easy, non-invasive method for measuring caffeine concentrations. Salivary concentrations correlate highly with plasma concentrations. Caffeine PK in saliva and plasma are well described by a three-compartment recirculation model.

Trust in Sources of Advice about Infant Care Practices: The SAFE Study.

Objectives (1) Determine the prevalence of maternal trust in advice sources on infant care practices; (2) Investigate the association of maternal and infant characteristics with trust in advice sources on infant care practices. Methods Using probability sampling methods, we recruited mothers from 32 U.S. maternity hospitals with oversampling of Black and Hispanic women resulting in a nationally representative sample of mothers of infants aged 2-6 months. Survey questions assessed maternal trust in advice sources (physicians, nurses, family, friends, and media) regarding infant care practices including infant sleep practices (sleep position, bed sharing, and pacifier use), feeding, and vaccination. Weighted frequencies of maternal trust in advice sources were calculated to obtain prevalence estimates. Multivariable logistic regression was used to assess the association of maternal and infant characteristics with maternal trust in advice sources. Results Mothers had the greatest trust in doctors for advice on all infant care practices (56-89 %), while trust was lowest for friends (13-22 %) and the media (10-14 %). In the adjusted analyses, there were significant associations of maternal race/ethnicity, education, and age with trust in advice sources. Conclusions for Practice Maternal trust in advice about infant care practices varied significantly by source. A better understanding of which advice sources are most trusted by mothers, as well as the factors associated with maternal trust, may guide the development of more effective strategies to improve adherence to health promoting infant care practices.

Maternal Education and Child Self-Regulation: Do Maternal Self-Regulation and Responsiveness Mediate the Association?

OBJECTIVE: To examine the mediating role of observed maternal responsiveness and maternal self-regulation on the association between maternal education and children's self-regulation. METHODS: English-speaking mother-child dyads (n = 189) were recruited from a previous study and were eligible if the child was kindergarten eligible at the start of the 2020 to 2021 or 2021 to 2022 school year. Key measures included: Difficulties in Emotion Regulation Scale-Short Form for maternal emotional self-regulation, Culturally Affirming and Responsive Experiences for maternal responsiveness, and the Head-Toes-Knees-Shoulders for child self-regulation. The association between years of maternal education and child self-regulation was examined with linear regression, and the mediation analyses utilized 4 subsequent steps examining their relations. These steps were checked through a series of linear regressions, and beta weights were used to describe associations. Each potential mediator was examined separately. RESULTS: Children of mothers with higher education had significantly higher self-regulation, slope of 1.3 (95% confidence interval 0.3, 2.4, P = 0.015, beta = 0.18). Further, mothers with higher education had significantly higher observed responsiveness. The beta-weight of 0.34 (P < 0.001) supported maternal responsiveness as a mediator. Finally, in the test for direct and indirect effects, observed maternal responsiveness explained 29% (95% confidence interval 3.3%, 115%) of the association between maternal education and child self-regulation. CONCLUSIONS: This study highlights a key mechanism related to children's self-regulation skills and the significant role of observed maternal responsiveness in explaining the association between maternal education and child self-regulation.

Adverse effects of COVID-19 pandemic on a multicenter randomized controlled trial.

OBJECTIVE: Describe the effects of the COVID-19 pandemic on subject enrollment in a multicenter randomized controlled trial. STUDY DESIGN: We assessed the number of eligible infants approached and consented for enrollment over five separate epochs including baseline, peak pandemic, and gradual but incomplete recovery. RESULT: The pandemic had a major effect on ability to approach parents for consent. Parents approached dropped from 95.4% baseline to 13.1% in the peak pandemic epoch and has not recovered to baseline even in the just-completed post-pandemic epoch (84.9%). Despite the decrease in subjects approached, there was no significant change in the overall consent rate for the study CONCLUSION: The pandemic has significantly limited ability to approach parents of eligible infants for consent, with only partial recovery. Opportunities for interactions of investigators and study coordinators with parents continue to present challenges limiting full recovery.

Relationship between sleep position and risk of extreme cardiorespiratory events.

OBJECTIVE: To determine whether infants at sleep in the prone side positions are at higher risk for an extreme cardiorespiratory event compared with infants at sleep in the supine position. STUDY DESIGN: We used a case-control study to compare sleep position, determined with an accelerometer, in 116 infants during an extreme cardiorespiratory event with that in 231 matched control subjects (2 per case) who did not experience any extreme events during monitoring. RESULTS: From calculation of adjusted ORs and 95% CIs, infants placed in the prone or side position were no more likely to experience an extreme cardiorespiratory event compared with infants at sleep in the supine position. We used conditional logistic regression to account for the matched design of the study and to adjust for potential confounders or effect-modifiers. CONCLUSION: These findings, coupled with our earlier observation that the peak incidence of severe cardiorespiratory events occurred before the peak incidence of sudden infant death syndrome, strongly suggest that the supine sleeping position decreases the risk of sudden infant death syndrome by mechanisms other than by decreasing extreme cardiorespiratory events detected by monitoring.

The Impact of Breastfeeding and Safe Sleep Mobile Health Messaging on Breastfeeding and Bedsharing.

OBJECTIVE: Mobile health (mHealth) safe sleep messaging increases rates of safe sleep. Bedsharing is more common among breastfeeders. Advice to not bedshare may negatively impact breastfeeding. We compared the impact of safe sleep or breastfeeding mHealth messaging on bedsharing and breastfeeding at 2 to 5 months. METHODS: This is a secondary analysis of mothers who initiated breastfeeding from a cluster randomized clinical trial of mHealth messaging for safe sleep or breastfeeding. A multi-ethnic sample of 1600 mothers was recruited from 16 US birth hospitals and surveyed at 2 to 5 months regarding the previous 2 weeks' breastfeeding and bedsharing practices. Data on 997 mothers who initiated breastfeeding were analyzed with multivariable generalized estimating logistic regression models to examine the association of mHealth messaging with infant care practices. RESULTS: Overall, exposure to breastfeeding versus safe sleep messaging was not associated with a difference in any breastfeeding at 2 to 5 months (69.3% vs 65.5%, respectively; adjusted odds ratio [aOR] = 1.33 [95% confidence interval, 0.91, 1.94]). Women with shorter planned duration of breastfeeding who received breastfeeding messaging had increased odds of breastfeeding at 2 to 5 months (50% vs 31%; aOR 3.13 [95% CI, 1.47, 6.65]). Mothers who received safe sleep messaging had lower rates of bedsharing overall when compared to breastfeeding messaging (24.8% vs 35.2%; aOR = 0.58 [95% CI, 0.44, 0.78]). CONCLUSIONS: In this large multi-ethnic US sample, receipt of safe sleep mHealth messaging was associated with lower rates of bedsharing without negatively impacting breastfeeding rates. Future research should focus on continued development of interventions to improve adherence to both safe sleep and breastfeeding recommendations.

The Impact of Maternal Worry on Infant Care Practices.

OBJECTIVES: Examine the 1) prevalence of worries among US mothers of infants; 2) association between worries and American Academy of Pediatrics recommended infant care practices (breastfeeding, supine sleep, roomsharing without bedsharing); 3) association of maternal and household characteristics with worries. METHODS: We analyzed a nationally representative sample of 3165 mothers who were surveyed regarding safe sleep and breastfeeding when infants were 2 to 6 months of age in 2011-2014. We examined the prevalence of 8 maternal worries (housing, job, income, neighborhood, family relationships, health, baby's health, family member health). We used multivariable logistic regression to examine associations of A) both overall number of worries and individual worries with each infant care practice; and B) maternal and household characteristics with worries. RESULTS: Twenty-six percent of mothers reported 0 worries, 26% reported 1-2 worries, 23% reported 3-4 worries, and 25% reported 5-8 worries. Compared to those with 0 worries, mothers with 5-8 worries had increased odds of bedsharing (adjusted odds ratio = 1.60 [1.19-2.14]) and non-supine sleep (aOR = 1.37 [1.07-1.74]). Specific worries associated with increased odds of bedsharing included: housing (aOR = 1.39 [1.09-1.78]), income (aOR = 1.35 [1.09-1.67]), neighborhood (aOR = 1.37 [1.05-1.78]), family relationships (aOR = 1.43 [1.10-1.86]), and health of a family member (aOR = 1.24 [1.06-1.46]). Maternal worries were not associated with infant feeding practices. CONCLUSIONS: We found a high prevalence of worries regarding basic needs, family relationships, and health among US mothers. Greater total worries and several individual worries were associated with higher odds of bedsharing. The "cognitive load" of maternal worries may impact adherence to safe sleep practices and requires further investigation.

Longitudinal assessment of hemoglobin oxygen saturation in preterm and term infants in the first six months of life.

OBJECTIVE: To report longitudinal home recordings of hemoglobin O(2) saturation by pulse oximetry (Spo(2)) during unperturbed sleep in preterm and term infants. STUDY DESIGN: We recorded continuous pulse oximetry during the first 3 minutes of each hour of monitor use (nonevent epochs) for 103 preterm infants born at <1750 g and ≤ 34 weeks postmenstrual age (PMA), and 99 healthy term infants. RESULTS: Median baseline Spo(2) was approximately 98% for both the preterm and term groups. Episodes of intermittent hypoxemia occurred in 74% of preterm and 62% of term infants. Among infants with intermittent hypoxemia, the number of seconds/hour of monitoring <90% Spo(2) was initially significantly greater in the preterm than the term group and declined with age at a similar rate in both groups. The 75(th) to 95(th) percentiles for seconds/hour of Spo(2) <90% in preterm infants were highest at 36 weeks PMA and progressively decreased until 44 weeks PMA, after which time they did not differ from term infants. CONCLUSIONS: Clinically inapparent intermittent hypoxemia occurs in epochs unperturbed by and temporally unrelated to apnea or bradycardia events, especially in preterm infants at 36 to 44 weeks PMA.

Disparities in Breastfeeding Among U.S. Black Mothers: Identification of Mechanisms.

Objective: Disparities in U.S. breastfeeding rates persist among Black mothers according to birth country and between Black and White mothers, necessitating further investigation of modifiable mediating factors to inform interventions. This study seeks to examine the extent that social, maternal, infant factors and Theory of Planned Behavior (TPB) domains (attitudes, perceived control, and subjective norms) mediate the association of maternal race/birth country and breastfeeding continuation. Methods: A national cohort of 2,050 mothers self-identifying as U.S.-born non-Hispanic Black (n = 689), foreign-born non-Hispanic Black (n = 139), and U.S.-born non-Hispanic White (n = 1,222) was analyzed. Using logistic regression, associations of race/birth country and any/exclusive breastfeeding at 2-6 months were examined. Structural equation modeling was used to determine whether social, maternal, and infant factors and TPB domains mediate these relationships. Results: 40.0% of U.S.-born Black, 82.2% of foreign-born Black, and 57.3% of U.S.-born White mothers reported any breastfeeding at 2-6 months. Compared with U.S.-born Black mothers, odds of any breastfeeding were sevenfold higher among foreign-born Black mothers (odds ratio [OR] = 7.04 95% confidence interval [CI] = 4.80-10.31), which was explained partly by social/maternal/infant factors and TPB domains. Compared with U.S.-born White mothers, any breastfeeding was lower (OR = 0.54, 95% CI = 0.40-0.73) among U.S.-born Black mothers and higher (OR = 3.81, 95% CI = 2.48-5.87) among foreign-born Black mothers; these differences were also mediated by the aforementioned factors. Conclusions: Among Black mothers in the United States, breastfeeding continuation varied substantially by birth country. Promotion of interventions targeting positive attitudes, perceived control, and subjective norms may reduce disparities among Black and between Black and White mothers.

Efficacy and safety of epoetin alfa in critically ill patients.

BACKGROUND: Anemia, which is common in the critically ill, is often treated with red-cell transfusions, which are associated with poor clinical outcomes. We hypothesized that therapy with recombinant human erythropoietin (epoetin alfa) might reduce the need for red-cell transfusions. METHODS: In this prospective, randomized, placebo-controlled trial, we enrolled 1460 medical, surgical, or trauma patients between 48 and 96 hours after admission to the intensive care unit. Epoetin alfa (40,000 U) or placebo was administered weekly, for a maximum of 3 weeks; patients were followed for 140 days. The primary end point was the percentage of patients who received a red-cell transfusion. Secondary end points were the number of red-cell units transfused, mortality, and the change in hemoglobin concentration from baseline. RESULTS: As compared with the use of placebo, epoetin alfa therapy did not result in a decrease in either the number of patients who received a red-cell transfusion (relative risk for the epoetin alfa group vs. the placebo group, 0.95; 95% confidence interval [CI], 0.85 to 1.06) or the mean (+/-SD) number of red-cell units transfused (4.5+/-4.6 units in the epoetin alfa group and 4.3+/-4.8 units in the placebo group, P=0.42). However, the hemoglobin concentration at day 29 increased more in the epoetin alfa group than in the placebo group (1.6+/-2.0 g per deciliter vs. 1.2+/-1.8 g per deciliter, P<0.001). Mortality tended to be lower at day 29 among patients receiving epoetin alfa (adjusted hazard ratio, 0.79; 95% CI, 0.56 to 1.10); this effect was also seen in prespecified analyses in those with a diagnosis of trauma (adjusted hazard ratio, 0.37; 95% CI, 0.19 to 0.72). A similar pattern was seen at day 140 (adjusted hazard ratio, 0.86; 95% CI, 0.65 to 1.13), particularly in those with trauma (adjusted hazard ratio, 0.40; 95% CI, 0.23 to 0.69). As compared with placebo, epoetin alfa was associated with a significant increase in the incidence of thrombotic events (hazard ratio, 1.41; 95% CI, 1.06 to 1.86). CONCLUSIONS: The use of epoetin alfa does not reduce the incidence of red-cell transfusion among critically ill patients, but it may reduce mortality in patients with trauma. Treatment with epoetin alfa is associated with an increase in the incidence of thrombotic events. (ClinicalTrials.gov number, NCT00091910 [ClinicalTrials.gov].).

National Prevalence of Donor Milk Use Among Level 1 Nurseries.

BACKGROUND AND OBJECTIVES: Donor milk use has increased among very preterm infants because of mounting evidence of health benefits; however, the extent that donor milk is used among healthy term infants in level 1 nurseries is unclear. We aimed to determine (1) national prevalence of and (2) hospital factors associated with donor milk use in level 1 nurseries. METHODS: Among 3040 US birthing hospitals, we randomly selected hospitals from each of 4 US regions (119 in northeast, 120 in Midwest, 116 in west, and 103 in south) for a total of 458 hospitals. We surveyed the nursing leaders of these hospitals from October to December 2017 regarding routine use of donor milk in the level 1 nursery (yes or no). To estimate national prevalence, we weighted responses according to the number of birthing hospitals within each region. We examined relationships between routine donor milk use in the level 1 nursery and hospital characteristics using multivariable logistic regression. RESULTS: In total, 214 of 458 (47%) nursing leaders responded. The national prevalence of routine donor milk use in level 1 nurseries was 17.6%. Eighty-five percent of donor milk programs were ≤5 years old. Donor milk use occurred more often in hospitals with ≥1500 annual births (41.7%), compared to ≤500 annual births (6.3%) (adjusted odds ratio 7.8; 95% confidence interval 1.8-34.4), and in the west (30.9%), compared to the northeast (10.5%) (adjusted odds ratio 4.1; 95% confidence interval [1.1-14.9]). CONCLUSIONS: Although there is limited evidence to support donor milk for healthy infants in the nursery, nearly one-fifth of level 1 US nurseries routinely used donor milk in 2017.

Factors Associated With Choice of Infant Sleep Location.

OBJECTIVE: To assess the prevalence of and factors associated with actual recent practice and near-future intention for infant sleep location in a national sample. METHODS: There were 3260 mothers from 32 US hospitals who responded to a survey at infant age 2 to 6 months regarding care practices, including usual and all infant sleep locations in the previous 2 weeks and intended location for the next 2 weeks. Mothers were categorized as (1) having practiced and/or intending to practice exclusive room-sharing without bed-sharing, (2) having practiced anything other than exclusive room-sharing but intending to practice exclusive room-sharing, (3) intending to have the infant sleep in another room; and (4) intending to practice bed-sharing all night or part of the night. Multivariable multinomial logistic regression examined associations between sleep-location category, demographics, feeding method, doctor advice, and theory of planned behavior domains (attitudes, social norms, and perceived control). RESULTS: Fewer than half (45.4%) of the mothers practiced and also intended to practice room-sharing without bed-sharing, and 24.2% intended to practice some bed-sharing. Factors associated with intended bed-sharing included African American race and exclusive breastfeeding; however, the highest likelihood of bed-sharing intent was associated with perceived social norms favoring bed-sharing (adjusted odds ratio [aOR] 5.84; 95% confidence interval [CI] 4.14-8.22) and positive attitudes toward bed-sharing (aOR 190.1; 95% CI 62.4-579.0). Women with a doctor's advice to room-share without bed-sharing intended to practice bed-sharing less (aOR 0.56; 95% CI 0.36-0.85). CONCLUSIONS: Sleep-location practices do not always align with the recommendation to room-share without bed-sharing, and intention does not always correspond with previous practice. Attitudes, perceived social norms, and doctor advice are factors that are amenable to change and should be considered in educational interventions.

Investigating Mechanisms for Maternal Education Disparities in Enacting Health-Promoting Infant Care Practices.

BACKGROUND: Although higher education and healthier practices are positively associated, the explanatory mechanisms for this association remain unclear. The purpose of this study was to better understand mechanisms underlying this association by examining maternal adherence to 2 health-promoting infant care practices: supine placement and breastfeeding. METHODS: We analyzed nationally representative data from the Study of Attitudes and Factors Effecting Infant Care, which surveyed US mothers after infant birth and 2 months thereafter. Using the Theory of Planned Behavior as a framework, we used structural equation models to elucidate mediational pathways from maternal education to supine infant placement or any breastfeeding. RESULTS: Data from 3297 mothers demonstrated 77.0% of infants usually were placed supine, and 57.8% received any breastfeeding. The overall direct effect of maternal educational level on supine placement and any breastfeeding was odds ratio (OR) 1.31 (95% confidence interval [CI] 1.11-1.54) and OR 2.82 (95% CI 2.35-3.37), respectively. In pathway analyses, the strongest associations with both supine position and breastfeeding were seen with positive attitudes (supine: aOR 18.96, 95% CI 9.00-39.92; breastfeeding: aOR 3.86, 95% CI 2.19-6.82) and positive social norms (supine: aOR 6.69, 95% CI 4.52-9.89; breastfeeding: aOR 5.17, 95% CI 4.28-6.23). Mothers with more education had higher odds of both positive attitudes and positive norms for the 2 practices. CONCLUSIONS: The associations linking educational attainment with health practices are intricate, with multiple mediating pathways. Attitudes and social norms are powerful forces that mediate the association between maternal educational attainment and both infant supine positioning and breastfeeding, and may be important mediators for other health behaviors.

Facilitators and Barriers to Implementation of Safe Infant Sleep Recommendations in the Hospital Setting.

OBJECTIVE: To identify facilitators and barriers to the implementation of safe sleep recommendations from the American Academy of Pediatrics from the perspective of hospital staff as part of a needs assessment that was used to design a successful quality improvement intervention to change clinical practice. DESIGN: Qualitative design. SETTING: Multiple sites of three hospitals in the northeastern and southern United States. PARTICIPANTS: We used purposeful sampling to identify 46 participants who cared for infants on inpatient hospital units (nurses and other staff members). METHODS: A qualitative researcher used grounded theory to moderate the focus groups. We constructed the initial interview guide and then changed it as needed to capture more information about new ideas as they arose. Researchers from diverse backgrounds participated in the analysis and used the constant comparative method to select important concepts and to develop codes and subsequent themes. We continued to collect data until saturation was reached. RESULTS: We identified themes and subthemes, and the taxonomy fit into the Grol and Wensing framework for change in clinical practice. The six primary themes included The Innovation Itself, The Individual Health Care Professional, The Patient, The Social Context, The Organizational Context, and The Economic and Political Context. CONCLUSION: Participants described facilitators and barriers to the implementation of the American Academy of Pediatrics recommendations for safe infant sleep. Identification of these themes informed our quality improvement intervention to promote safe infant sleep. Findings can be used by others when faced with the need for similar change.

Mediators of Improved Adherence to Infant Safe Sleep Using a Mobile Health Intervention.

OBJECTIVES: To determine mediators of improvements in infant safe-sleep (SS) practices in a mobile health intervention. METHODS: In a cluster-randomized controlled trial, mothers received SS intervention or breastfeeding control videos for 60 days. Maternal responses about infant sleep position and location (outcomes) and mediators (attitudes, perceived social norms, and perceived control) from the theory of planned behavior were assessed. Intervention effects on mediators and association between mediators and outcomes were examined. RESULTS: Of 1600 recruited, 1263 mothers participated. Mothers receiving SS videos were more likely to have positive attitudes and norms for supine sleep (attitudes: adjusted odds ratio [aOR] = 2.35 [95% confidence interval (CI) 1.72 to 3.20]; norms: aOR = 1.75 [95% CI 1.27 to 2.42]) and recommended sleep location (attitudes: aOR = 1.91 [95% CI 1.54 to 2.36]; norms: aOR = 1.37 [95% CI 1.13 to 1.66]). Positive attitudes and norms toward supine sleep and room-sharing without bed-sharing were associated with higher odds of both practices (supine: aOR = 8.25 [95% CI 4.72 to 14.43] for positive attitudes and aOR = 6.67 [95% CI 4.25 to 10.46] for norms; room-sharing: aOR = 7.14 [95% CI 5.35 to 9.53] for positive attitudes and aOR = 4.44 [95% CI 3.03 to 6.51] for norms). Both positive attitudes and positive norms mediated the effect of the intervention. CONCLUSIONS: The intervention achieved success in improving adherence to SS recommendations by changing maternal attitudes and norms about supine sleeping and room-sharing without bed-sharing. Recognition that these attitudes and norms appear to be the main drivers of mothers' choices regarding infant-sleep practices should inform health messaging strategies to promote SS.