Factors associated with knowledge of mothers on Sudden Infant Death Syndrome

Abstracts

The objective of this descriptive study was to identify factors associated with the mother’s knowledge of children assisted at a teaching hospital regarding the Sudden Infant Death Syndrome. Mothers of 202 were interviewed between May 2011 and October 2012, in the city of Recife. The association between maternal knowledge on SIDS and maternal variables was evaluated using chi-square and Fisher's exact tests. Only 15.8% of mothers knew about SIDS, and 29.4% of them mentioned the supine position as a preventive measure. Approximately 27% of mothers had information on sleeping position and 50.9% mentioned nurses as responsible for guidelines. Maternal education, family income and information on sleeping position were factors related to their knowledge on SIDS. Most mothers do not know about the proper infant sleeping position, which reinforces the need to include this family guidance in health education strategies.

Child care; Pediatric nursing; Sudden Infant Death; Newborn

Identificar os fatores associados ao conhecimento das mães de crianças atendidas em um Hospital Escola a respeito da Síndrome da Morte Súbita do Lactente. Estudo descritivo realizado por entrevistas a 202 mães no período de maio de 2011 a outubro de 2012 na cidade do Recife - PE. A associação do conhecimento materno sobre a SMSL e as variáveis independentes foi avaliada utilizando os Testes Qui-quadrado e Exato de Fisher. Apenas 15,8% das mães conheciam a SMSL. Destas, 29,4% citaram a posição dorsal para dormir como medida preventiva. Aproximadamente 27% das mães receberam informação sobre a posição de dormir e 50,9% indicaram os enfermeiros como responsáveis. A escolaridade materna, renda familiar e receber orientação apresentaram-se associadas ao conhecimento sobre a SMSL. A maioria das mães desconhece a posição adequada para o sono infantil, reforçando a necessidade de incluir essa orientação à família nas estratégias de educação em saúde.

Cuidado da criança; Enfermagem pediátrica; Morte súbita do lactente; Neonato

Identificar los factores asociados al conocimiento de las madres de niños tratados en un Hospital Escuela sobre la Síndrome de la Muerte Súbita del Lactante (SMSL). Estudio descriptivo realizado mediante entrevistas con 202 madres de Mayo/2011 a Octubre/2012, en Recife. La asociación de conocimientos maternos sobre la SMSL y las variables independientes se evaluaron mediante las pruebas de Chi-Cuadrado y Exacta de Fisher. Sólo el 5,8% de las madres conocían la SMSL. De estas, el 29,4% citó la posición de la espalda como medida preventiva para dormir. Aproximadamente el 27% recibió información sobre la posición para dormir y el 50,9% indicó enfermeros responsables. La escolaridad de la madre, la renta familiar y recibir orientación, se presentaron asociadas al conocimiento sobre el SMSL. La mayoría no sabe la posición adecuada para el sueño infantil, lo que refuerza la necesidad de incluir esta orientación en las estrategias de educación para salud.

Cuidado del niño; Enfermería pediátrica; Muerte súbita del lactante; Recién Nacido

INTRODUCTION

Sudden Infant Death Syndrome (SIDS) can be defined as the unexpected death of a child less than one year of age during sleep, and which remains unexplained after extensive investigation. In an attempt to clarify cases, a careful necropsy examination, an investigation of the death setting and a review of clinical history must be carried out¹.

Several pathophysiological mechanisms are suggested as a cause of SIDS and there is no clear elucidation of associated factors, which are probably multifactorial, including: conditions of the environment where the infant sleeps, sleeping position, shared bed, children aged between 2 and 4 months, male gender and maternal characteristics (teenage mothers, low level of education or smoking). In addition to these, late or no prenatal care and prematurity or low weight are also associated with SIDS², highlighting prone position during sleep as the main risk factor³.

The American Academy of Pediatrics (AAP) recommends different precautions in order to reduce the risk for SIDS and provide a safe environment to the child's sleep. Among them, we can mention that infants should sleep in the supine position, on firm surfaces, in the parents' bedroom and in their own bed/cradle; they should not share beds; overheating and exposure to smoke must be avoided; and breast-feeding should be encouraged⁴.

Most reports found in the literature regarding SIDS are done in developed countries, located in the American and European continents, where it was pointed as the main cause of child mortality in children under one year⁵. Still regarding epidemiological data, the incidence rate was 0.45 per one thousand live births in southeast England between 2003 and 2006⁵. In South Korea, between 2004 and 2007, the number of deaths was 26 for a total of 352,405 births of children with normal weight⁶.

In the USA, the incidence rate was 55.3 per 100,000 live births (8% of infant deaths) in 2008⁷. Even though the number of deaths by SIDS in the USA has decreased since the beginning of the "Back to Sleep" campaign in 1994, which aimed to raise awareness and educate people about sudden death syndrome, it remains the third main cause of death of children and the most common among children under one year².

In Brazil, SIDS is on the list of preventable causes by intervention of the Unified Health System (SUS, as per its acronym in Portuguese), and it is considered preventable as long as adequate measures of health promotion are taken⁸. According to the SUS IT Department (DATASUS), 207 cases of SIDS were reported in Brazil in 2012, of which 56 occurred in the northeast of the country⁹. This shows the importance of promotional and educational campaigns in Brazil and in other countries where the incidence of SIDS is high or unknown so as to guide health professionals and parents regarding preventive measures¹⁰.

Sudden Infant Death Syndrome has not been much studied in Brazil, with research being done mainly in the south and southeast. Therefore, the development of studies to identify the information families have on SIDS may support nursing practice regarding preventive actions by primary care professionals and in the hospital environment (neonatal ICUs, nursery and wards), as well as guidance to parents, relatives and caretakers regarding exposure to risk factors^4,11.

Education in health is a strategy that favors understanding of SIDS by people in charge of children, as well as of risk factors and efficient preventive measures, such as sleeping position. In that sense, the objective of this study was to identify factors associated with the knowledge of mothers of children treated at a teaching hospital regarding Sudden Infant Death Syndrome.

METHOD

A descriptive, cross-sectional and quantitative study¹² was developed, using the primary database from the research entitled “Exposição a fatores de risco para a síndrome da morte súbita no primeiro mês de vida das crianças atendidas no ambulatório de puericultura em um hospital escola em Recife - PE” [Exposure to risk factors of sudden death syndrome in the first month of life of children admitted to childcare wards of a teaching hospital in Recife, Pernambuco].

The study was carried out in the childcare wards of the Clinics Hospital of the Federal University of Pernambuco (HC/UFPE), where the first newborn consultations took place after hospital discharge. This is a large and complex general hospital, associated with the SUS, and which serves the population of the metropolitan area of Recife, the countryside of the state of Pernambuco, and the north and northeast regions.

The population studied was composed of mothers of children between 0 and 30 days of life, cared for in the first consultation after birth. For sample calculation, the Statcalc program, from Epinfo Software version 6.04, was used, based on the proportion of 78% of newborns exposed to the risk factor "side sleeping position"¹³, with maximum error of 5% and a total of 609 newborns cared for in discharge consultations from childcare wards of the HC/UFPE in 2010, ending up in 184 children. To this number, a 10% rate was added in order to compensate possible losses, totaling 202 mothers.

Sampling was intentional, so individuals were selected based on characteristics considered relevant by the researcher. Mothers of newborns or infants assisted in the first consultation after hospital or childcare discharge were included. Children with genetic syndromes and/or malformation were excluded.

Data were collected between May 2011 and October 2012 by a resident nurse and two undergraduate students previously trained. For interviews with mothers, a form containing sociodemographic information was used in order to characterize the sample (age, education, family income), birth conditions, information about health care (number of prenatal consultations, source, place and content of guidelines regarding SIDS) and parents’ opinion concerning sleeping position. Knowledge of mothers about SIDS was considered based on their statement whether they knew the syndrome or not.

Before data collection, people in charge of the children were informed of the objectives of the study and were asked to sign a Free and Informed Consent Form.

Data analysis was performed by means of the Epi-info software, version 6.04, and an estimate was made of absolute and relative frequencies of categorical variables, means and standard deviation of continuous variables, in order to describe the variables of the present study. In order to assess the association of age and education of mothers, family income and health care with the mothers’ knowledge of SIDS and also with their opinion on the adequate sleeping position for the child, a chi-square test was performed, or Fischer's exact test, when the expected values were below five. For all analyses, a significance level of 5% was considered.

The project was approved by the Institutional Review Board of the Life Sciences Center of the Federal University of Pernambuco, in compliance with Brazilian Health Council Resolution number 466/2012, CAAE 22269113000005208, on November 6^th, 2013.

RESULTS

Regarding data from mothers, 80.2% of them were aged 20 or over, with a mean of 25.9 (SD = 6.7 year), and 75.9% had eight or more years of schooling. As for family income, 52.1% of mothers had an income above the minimum wage, with a mean of 3.4 times the minimum wage (SD = 1.1). Regarding obstetric history, the mean number of prenatal consultations was seven (SD = 2.3) and 59% of mothers attended more than six consultations.

As for biological characteristics and birth conditions, 84.8% of children were born at full-term and over 93% had an Apgar score above seven in the first and fifth minutes. Most infants (78.7%) were within the first 15 days of life, with a mean age of 12.1 (SD = 6.6 days); over 50% were male and 69.3% were white.

After investigation of knowledge of mothers about SIDS, only 15.8% of them had heard about the syndrome, of which 29.4% mentioned the supine position as a preventive measure. The main source of information was the media (64.3%), whereas health professionals contributed little to the health education process (25%). Regarding the opinion of mothers about the adequate sleeping position for the child, the present study showed that 87% of mothers mentioned prone or side position (Table 1).

Table 1
Knowledge of Sudden Infant Death Syndrome and opinion of mothers regarding the adequate sleeping position for the child, Recife, 2011-2012

Variables		n	%
Knowledge of SIDS	n = 202
Yes		32	15.8
No		170	84.2
Source of information	n = 28
Media (TV, magazines, newspapers, Internet)		18	64.3
Nurse		3	10.7
Doctor		3	10.7
Family		1	3.6
Community Health Agent		1	3.6
Others		2	7.1
Preventive Measures for SIDS	n = 17
Side sleeping position		12	70.6
Supine sleeping position		5	29.4
Opinion of mothers on sleeping position	n = 202
Prone/side		177	87.6
Supine		25	12.4

After assessing factors associated with knowledge of SIDS, education, family income and information on the correct sleeping position for the child, they were considered statistically significant, and the majority of mothers who declared they were aware of SIDS had eight years of study or more (21.2%), with a family income over the minimum wage (23%) and had information on the correct sleeping position for the child (29.6%). The age of the mother, the number of prenatal consultations and the source of information did not interfere in the knowledge of SIDS (Table 2).

Table 2
Knowledge of mothers about Sudden Infant Death Syndrome according to sociodemographic characteristics, number of prenatal consultations and information received, Recife, 2011-2012

Variables		Knowledge
		Yes		No		Total		Statistical Results
		n	%	n	%	n	%	χ2	p
Mother's age	n = 202
< 20 years		3	7.5	37	92.5	40	19.8	χ2 = 2.60	p* = 0.106
≥ 20 years		29	17.9	133	82.1	162	80.2
Mother's education	n = 199
< 8 years		00	00.0	48	100	48	24.1	χ2 = 12.12	p* = 0.001
≥ 8 years		32	21.2	119	78.8	151	75.9
Number of prenatal consultations	n = 200
≤ 6		12	14.6	70	85.4	82	41.0	χ2 = 0.19	p* = 0.66
> 6		20	16.9	98	83.1	118	59.0
Family income (minimum wage = 622.00)	n = 192
≤ 1		9	9.8	83	90.2	92	47.9	χ2 = 6.03	p* = 0.014
> 1		23	23	77	77	100	52.1
Information on child sleeping position	n = 202
Yes		16	29.6	38	70.4	54	26.7	χ2 = 10.51	p* = 0.001
No		16	10.8	132	89.2	148	73.3
Person in charge of providing information on child sleeping position	n = 54
Doctor/Nurse		13	29.5	31	70.5	44	81.5		p** = 1
Family/Media		2	33.3	4	66.7	6	11.1
Health Community Agent		1	25.0	3	75.0	4	7.40

• ^*
  Chi-square Test;
• ^**
  Fisher's Exact Test.

In table 3, we observed that the fact that mothers stated they knew the syndrome (15.8%) did not influence their opinion on the adequate sleeping position for the child. Socioeconomic variables, the number of prenatal consultations, information received and knowledge of ways to prevent the syndrome did not have a statistical association with the opinion on sleeping position.

Table 3
Opinion of mothers regarding the adequate sleeping position according to their knowledge of the Sudden Infant Death Syndrome, to socioeconomic characteristics, to the number of prenatal consultations and to information received, Recife, 2011-2012

Variables	Opinion of mothers on sleeping position
	Prone/side		Supine		Total		Statistical Results
	n	%	n	%	n	%	χ2	p
Knowledge of SIDS
Yes	29	90.6	3	9.4	32	15.8		p** = 1.00
No	154	90.6	16	9.4	170	84.2
Information on sleeping position
Yes	50	92.6	4	7.4	54	26.7	χ2 = 0.35	p* = 0.56
No	133	89.9	15	10.1	148	73.3
Preventive Measures for SIDS
Side position	12	100	0	0	12	70.6		p** = 0.29
Supine Position	4	80.0	1	20	5	29.4
Mother's age
< 20 years	36	90	4	10	40	19.8		p** = 1.00
≥ 20 years	147	90.7	15	9.3	162	80.2
Education (years of study)
< 8	46	95.8	2	4.2	48	24.1		p** = 0.17
≥ 8	134	88.7	17	11.3	151	75.9
Family income (minimum wage)
≤ 1	85	92.4	7	7.6	92	47.9	χ2 = 0.34	p* = 0.56
> 1	90	90	10	10	100	52.1
Number of prenatal consultations
≤ 6	72	87.8	10	12.2	82	41	χ2 = 1.17	p* = 0.28
> 6	109	92.4	9	7.6	118	59

• ^*
  Chi-square Test;
• ^**
  Fisher's Exact Test.

DISCUSSION

Factors such as maternal education, family income and information on the correct sleeping position for the child were statistically significant when associated with knowledge of mothers about SIDS. On the other hand, there was no significant difference between age, education, family income and the opinion of mothers regarding the adequate sleeping position, which confirms the results of a study conducted in Istanbul with mothers of children under one year that investigated practices of child care associated with SIDS¹⁴.

Among risk factors for SIDS, teenage pregnancy and mothers with low education levels contribute to the prevalence of the choice for prone position as the most comfortable for the child, which is very alarming as the occurrence of SIDS is associated with that position³. Unfavorable socioeconomic conditions also increase the possibility of its occurrence².

The AAP states that sleeping in the prone position results in changes in the child's autonomous cardiovascular system, which is more evident at the age of 2-3 months, and it may also cause a decrease in brain oxygenation. These facts could encourage parents and relatives to put their children in the supine position. However, caregivers report they fear choking and increased restlessness, in cases of children diagnosed with gastroesophageal reflux⁴.

In a study carried out in Istanbul¹⁴, it was observed that mothers who received prenatal care and those who did not were informed about sleeping position. Nevertheless, over a half of mothers (59%) attended more than six consultations, as recommended by the Ministry of Health¹⁵, and even so, they were not aware of SIDS. These results show that prenatal consultation may be desirable for providing information on SIDS prevention, as in this moment mothers are willing to receive information regarding mother and child care¹⁶.

Still concerning the source of information, over a half of mothers (64.3%) received information about the syndrome through the media, as found in a study conducted in Lisbon¹⁰, which obtained a frequency of 84% of mothers who mentioned media as the main source of information. The media plays an important role in the change of habits and in the process of knowledge construction as regards its information role, and it can be used to disseminate aspects related to health, including SIDS¹⁰.

As for the activity of health professionals, it was observed that it contributed little to the process of health education regarding SIDS (25%), regarding guidance of child caregivers, people in charge and relatives about preventive measures, and to favor supine position during sleep as the correct one¹⁰. A study conducted in Turkey with 174 health professionals reported that they mentioned side sleeping position as the correct one¹⁴, which shows that they ignored that the supine position is the safest. When professionals do not know preventive measures for sudden death and advise parents to adopt an unsafe sleeping position for their children, they expose them to risk factors that should be avoided instead⁴.

Health professionals, doctors and nurses, were not frequently mentioned as responsible for providing information about SIDS (21.4%), but they did inform about the supine position being the correct one for child sleep (81.5%). In spite of these guidelines, prone and side positions were mentioned as the most adequate in the opinion of mothers (87.6%).

In practice, it is seen that these positions prevail in neonatal ICUs and wards, as they are considered more reliable, so as to avoid the risk of bronchoaspiration, a fact that also seems to lead parents and relatives to adopt this sleeping habit at home. Side sleeping position contradicts the recommendation of the AAP (2011), which advise health professionals to guide parents and caregivers to put the child in the supine position⁴.

It is worth highlighting the influence of recommendations provided by relatives, which are relevant to caregivers when compared to recommendations provided by health units. Change of habits is something that might take time; that is why it is essential that the community have access to information in order to adopt new concepts, and consequently make conscious choices¹¹.

Incentive campaigns for supine position for children contribute to the adoption of this practice. The "Back to Sleep" campaign in the United States resulted in a decrease in the use of the prone position for sleep and rest of infants when compared to the supine position, although the side position is one of the first choices of parents. Among some characteristics associated with a greater probability of choice for the supine position, we can mention the advanced age of mothers, higher level of education, higher family income, and birth after 37 weeks of pregnancy⁵, which is in line with the results of this study.

As for gestational age and the Apgar score, most children were born at full-term and with an Apgar score above seven; therefore they were not exposed to these risk factors for SIDS, as shown in a study⁵ which identified a higher incidence of SIDS in infants who were born at the 37^th week of pregnancy or before, suggesting prematurity as a risk factor for SIDS.

An Apgar score below eight in the first minute has little to do with reported cases of the syndrome, as well as the Apgar score below seven in the fifth minute. Children born in these conditions present other risk factors for the increase of morbimortality and they should be given attention for their vulnerability³.

The occurrence of SIDS in the first month is rare, with an increased risk between the second and the fourth month¹⁷. As for the gender, there was a prevalence of males, even though the difference was small; this fact increases the risk of SIDS as boys are more likely to be affected, in a 3:2 ratio². Regarding the color of the skin, over a half of newborns were white, which does not imply a risk factor, as Black individuals are more susceptible to the syndrome than Caucasians, and Asians have the lowest incidence of SIDS².

In this study, it was observed that mother's knowledge of SIDS remains insufficient. There is little information about SIDS, and consequently, caregivers do not know how to apply preventive measures¹⁰. The present study found that 15.8% of mothers know the syndrome; however, this did not have an influence on their choice for the adequate sleeping position. This fact can be associated with care practices that are based on popular culture, as they are transmitted through generations and shaped by scientific and popular knowledge¹¹.

Health professionals, such as nurses, must educate patients on the topic, at all levels of health care. The education exercise done by the nurse is of critical importance due to its comprehensiveness in different sectors: hospitals, wards, schools and companies^18,11. Information provided in the prenatal period and during childcare consultations must include preventive measures of SIDS, associated risk factors (age between 2 and 4 months, male children, teenage mothers with low level of education, late or no prenatal care and prematurity), with emphasis on prone position of the child, which is the main risk factor³.

CONCLUSIONS

By means of this study, it was possible to find few mothers who stated they knew about SIDS; most of them reported prone or side position as the ideal factor for protecting the child's sleep and rest. In addition, mothers who reported they knew SIDS and who received information about the sleeping position considered prone or side position as adequate.

In order to clarify SIDS and reinforce preventive measures, it is important to make sure that educating actions in health are being taken. Education in health becomes essential so people in charge of children understand SIDS, the risk factors involved and also efficient forms of prevention, especially the correct sleeping position.

The study will contribute to improve services provided to newborns, infants and families, since these results can support professional practice in SIDS prevention. Moreover, it will contribute with new data on the topic in Recife, and may also contribute to the development of new studies. From results obtained in this study, we suggest the development of new studies in Brazil, aiming to establish public health measures oriented toward the dissemination of SIDS awareness, risk factors associated with the syndrome and preventive measures, both for health professionals and the population.

The media, reported as an important and efficient source of information, should be more active in order to disseminate topics related to health and guidance to families so as to reinforce information provided by health professionals. Nursing and childcare consultation during the prenatal period is also an appropriate time for providing information to caregivers.

The limitations of this study are due to its impossibility of generalizing results, as the sample came from a healthcare service; therefore it may not reflect the reality of other groups of people with different levels of access to information.

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Publication Dates

• Publication in this collection
  Apr-Jun 2015

History

• Received
  25 Apr 2014
• Accepted
  17 Dec 2014