Running head: FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

Factors that Influence Sudden Infant Death Syndrome (SIDS): An Integrative Review
Tim Efremidis
Bon Secours Memorial College of Nursing

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

Abstract
During the 1990s, the Back to Sleep Campaign helped to drastically reduce the overall
incidence of SIDS. Data suggests that since 2001 there have been a steady and increasing
number of SIDS occurrences, primarily among disadvantaged populations (Smylie et al., 2014).
This paper explores various factors that influence Sudden Infant Death Syndrome (SIDS). A
more in depth look at five different studies is taken to examine specific factors that affect SIDS
rates, such as race and socioeconomic factors (SES). Each article is summarized in detail and
utilized to provide an overall summary of how factors that affect SIDS can be integrated to
improve the current educational material and teaching methods on SIDS. The integrative review
can be summarized into two major themes: (1) maternal factors that affect the incidence of SIDS
and (2) maternal teaching points that can be altered and improved as a result of research on
maternal decisions on infant sleep position.

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

Factors that Influence Sudden Infant Death Syndrome (SIDS): An Integrative Review
SIDS is one of the leading causes of infant mortality (Coleman, 2009). In the 1990s the
Back to Sleep Campaign was introduced, which helped reduce SIDS rates by more than 50%
(Oden, Joyner, Ajao, & Moon, 2010). Although SIDS rates have drastically improved, we
continue to see a high incidence of SIDS in certain populations. Throughout this integrative
review, we examined factors that influence SIDS by reviewing some of the literature available.
The first study reviewed was written by Coleman (2009) and is titled Culture care
Meanings of African American Parents to Infant Mortality and Health care. In this study,
Coleman used a qualitative approach (ethno nursing) to evaluate perceptions of African
American mothers related to infant care. More specifically, Coleman pinpoints that the
significance of the study was related to the increased incidence of SIDS in African American
mothers. Colemans writing style is very clear and organized. She has operationally defined key
terms and concepts within her study, in order to allow the readers to follow in her train of
thought. Coleman utilized interviewing to discover that African American mothers valued how
good they perceived their nurse was with the likelihood of those mothers following the teachings
on infant safety that the nurses provided. Furthermore, Coleman (2009) discusses that although
there is a high consensus of African American mothers placing their infants in the prone sleeping
position, the literature doesnt offer a clear explanation of why African American mothers
choose to do this.
The next study reviewed was written by Oden, Joyner, Ajao, & Moon (2010) and is titled
Factors Influencing African American Mothers Decisions About Sleep Position: A Qualitative
Study. This study was a qualitative study, with no philosophical underpinnings identified. Oden
et al. (2010) showed a very clear and organized writing style. Their study was systematic in

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

explaining the importance and SIDS and how it related to the African American population from
the abstract and throughout the rest of the article. Oden et al. (2010) introduced the background
of SIDS and how rates have decreased in the overall population, while remaining high in the
African American population, regardless of SES. Oden et al., have very clearly summarized the
importance of their study, as well as key concepts throughout the abstract.
The next study reviewed, was written by Hogan (2014) and is titled Socioeconomic
Factors Affecting Infant Sleep-Related Deaths in St. Louis. This study was a quantitative
(descriptive) study. Hogan (2014) reiterated that although the Back to Sleep Campaign caused
an overall decrease in SIDS rates, racial disparity related to SIDS has continued to increase.
Hogan wanted to look at the relationship between maternal SES factors and sleep-related infant
deaths. Hogans writing style was detailed in describing the background of her study and gave
the readers an in depth analysis of how SES affects SIDS and how individual components of
what made up SES in this study (race, poverty, maternal education, and parity) affected SIDS
either alone or in combination with each other. Hogans abstract was very concisely written and
gave the readers a thorough review of the study.
The following study looked at SIDS from a different angle. This study was written by
Smylie et al. (2014) and was titled Socioeconomic Position and Factors Associated with use of a
Nonsupine Infant sleep Position: Findings from the Canadian Maternity Experiences Survey.
This was a quantitative (descriptive) study. Smylie et al. (2014) studied a stratified random
sample of Canadian mothers, to evaluate how maternal education related to nonsupine sleep
position of their infant. In previous studies, we established that nonsupine sleeping positions
largely increase the risk of SIDS in infants (<1 year old). What Smylie et al. were able to do
different in this study, was to investigate how other variables, such as attending prenatal classes

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

and being contacted by a health care provider after birth, affected the incidence of mothers using
a nonsupine sleeping position for their infants. Smylie, et al. (2014) aimed to use the results of
their study to change how we educate mothers about sleep position, by individualizing the
teaching process to each mothers needs. The writing style of this study was appropriate in
identifying the different variables examined and evaluated the Maternal Experiences Survey
(MES) for the readers to look at the individual components. The abstract provided an excellent
summary of the key components of the study.
Finally, we reviewed a study written by Colvin, Collie-Akers, Schunn, & Moon (2014)
and was titled Sleep Environment Risks for Younger and Older Infants. This study was a
quantitative (cross sectional) study. This study was a great tool in better understanding risk
factors in the range of infant age (birth to 1 year old). What Colvin et al. (2014) were able to
accomplish is a further in depth look of factors that lead to SIDS in relation to the infant;
furthermore, the authors look at how the knowledge they obtained from their study could be
utilized to improve maternal education. The writing style and study as a whole were clear and
organized so that the reader was able to understand how each aspect of the study was utilized to
explain to purpose of the study. Operational definitions were clearly laid out and provided the
readers a better understanding of key components of the study. The abstract provided was very
easily read and gave a thorough summary of the research article.
Background
SIDS is one of the leading causes of infant death (Coleman, 2009). The Back to Sleep
Campaign, which was developed in the 1990s, helped to drastically decrease the incidence of
SIDS in the USA and Canada (Smylie et al., 2014). Two things were noted in all five articles
reviewed: (1) the incidence of SIDS increased in the African American population, (2) sleep

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

related deaths are on the rise, which in part could be attributed to categorization of infant, sleeprelated deaths (Colvin et al., 2014).
The problem statements of the five studies reviewed in this paper can be divided into two
groups, which guided this integrative review. The first group is made up of Hogan (2014), Oden
et al. (2010), & Colvin et al. (2014). The problem statement of the first group was that previous
research had looked at how individual factors contribute to higher rates of SIDS in at risk
populations, such as African American mothers. These three studies wanted to examine how a
multitude of factors that are encompassed in SES, can affect the incidence of SIDS. In the
second group, which was made up of Smylie et al. (2014) and Coleman (2009), the problem
statements were geared on factors that lead to non-adherence of health care recommendations.
Both studies show evidence of an inconsistency between mothers knowledge of SIDS and
factors that may lead to SIDS, versus how the mothers actually place their infants to sleep
(nonsupine positions) (Coleman, 2009).
The purpose or aim of each study is clearly identified. As an entity, all five studies fit
into the aim of the integrative review: To examine which factors increase the risk of SIDS and
use said knowledge to improve on how we educate mothers about SIDS and factors that lead to
SIDS. Smylie et al. (2014) add to the overall purpose, by noting that what we learn from the
research on SIDS should be used to individualize the teaching process, amongst entirely
improving the current body of knowledge on SIDS.
Throughout the integrative review, its important to always refer to the main question,
also known as the PICO question for conducting this review. Our population of interest is
infants who have suffered mortality by SIDS, defined as sleep related death of unknown etiology,
in the first year of life. The population also included mothers of SIDS affected infants, in order

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

to evaluate what factors, related to the mothers, increase the risk of SIDS. The primary interest
of this integrative review was to determine how the current education provided by healthcare
providers to mothers could be altered and improved to help reduce SIDS. The teachings on
SIDS should be based on the knowledge we gain from the studies reviewed, on factors that affect
SIDS. The alternative to reevaluating and individualizing teaching on SIDS will be to possibly
see a steady rise or continued incidence of SIDS. Utilizing the current and past literature on
SIDS would help improving and individualizing teaching on SIDS. Our overall question was: In
infants at higher risk of SIDS, how can our knowledge of SIDS factors help shape teaching on
SIDS, compared to the current way of teaching mothers about SIDS, affect the prevalence of
SIDS deaths?
Search Methods
Research articles obtained through this search were reviewed to ensure relevance to the
overall theme and PICO question. A literature search was conducted using EBSCO and PubMed
databases. The search criteria used were SIDS, Factors that affect SIDS, and SIDS and
SES. Searches were limited to studies that pertained to SIDS and factors that affect SIDS.
Studies that met that met the following inclusion criteria were selected: (1) discussed SIDS and
associated risk factors, (2) studies were published in the last five year (2009-2014), (3)
mentioned the Back to Sleep Campaign as a reference, and (4) included teaching on SIDS by a
health care professional. Once inclusion criteria were considered, there were no exclusion
criteria set forth for this integrative review.
Results
After a review of the studies yielded by the search and having accounted for the inclusion
criteria, five articles were chosen. The five articles chosen were reviewed in two categories: (1)

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

articles that primarily examined maternal factors that affect SIDS, and (2) articles that primarily
examined factors that affect how we teach mothers about SIDS. The first category was
composed of studies by Coleman (2009), Oden et al. (2010), & Hogan (2014). Coleman (2009)
focused on African American mothers, since the previous literature supports they are at much
higher risk for SIDS than non-African American mothers. The data obtained via interviewing
African American mothers about their perceptions related to infant health care was grouped into
three categorical themes: (1) presence of the nurse as essential to heath and well-being, (2)
family as support, and (3) knowledge is protecting to keep infants safe (Coleman, 2009, p. 114).
Colemans results were helpful in integrating knowledge on what mothers reported as being
important to them in regards to their infants care. Oden et al. (2010) stated that results were
grouped into two central themes, via thematic saturation of the interview data that the authors
analyzed. The two central themes that were noted, in regards to parental decisions about sleep
position, included infant safety and infant comfort. Mothers cited infant comfort as the main
reason for placing their infants in the prone sleeping position. Hogan (2014) stated that the
results of her study were that poor mothers experienced infant death more often than nonpoor
mothers (chi-squared (1) = 5.111, p = .024), African American mothers had a higher likelihood
of experiencing sleep-related infant death than Caucasian mothers (chi-squared (2) = 13.090, p
= .001). These results help to show a statistical significance between race of the mother and
infant-sleep related deaths. Hogan (2014) also discovered that maternal SES factors (race,
poverty, maternal education, and parity) were significant in their relationship to sleep-related
infant death (chi-squared (5) = 14.303, p = .014).
In the second category of integrative review articles, the focus was on articles that
primarily examined factors that affect how we teach mothers about SIDS. Smylie et al. (2014)

FACTORS THAT INFLUENCE SUDDEN INFANT DEATH SYNDROME

stated that analysis of the full sample showed a strong, inverse association between maternal
education and choice of nonsupine sleeping position. More specifically, mothers with less than a
high school education were more than twice as likely to place their infants in a nonsupine sleep
position than mothers who completed a post-secondary education (un-adjusted odds ratio [OR]
= 2.09, 95% CI = 1.71, 2.55). Smylie et al. (2006) results were helpful in understanding
teaching on SIDS could be individualized in each mother so that teaching would be more
effective in reducing SIDS rates in vulnerable populations. Colvin et al. (2014) concluded two
key points in regards to SIDS in infants. First, Colvin et al. defined younger infants as those
between the ages of 0-3 months and older infants as those between the ages of 4 months to 364
days. Colvin et al. (2014) found that younger SIDS victims were more likely due to bed sharing
than older infants (73.8% vs 58.9%, P < .001) and sleeping in an adult bed or on a person (51.6%
vs 43.8%, P < .001). Conversely, older infant victims were more likely due to having an object
in the sleep environment (39.4% vs 33.5%, P< .001) and changing position from side/supine to
prone (18.4% vs 13.8%, P < .001). These results help us infer that the causes of infant death can
vary within the first year of life. Using this data, we may shape and individualize the maternal
teaching on SIDS to better encompass factors that affect SIDS in each sub-population of infants.
Discussion
The integrative review on factors that influence SIDS can be summarized into two key
topics: (1) maternal factors that affect the incidence of SIDS and (2) maternal teaching points
that can be altered and improved as a result of research on maternal decisions on infant sleep
position. SIDS campaigning has been the same since the 1990s, while SIDS rates are still
elevated in the lower SES and African American subpopulations (Smylie et al., 2014).
Throughout this integrative review, we have seen how factors, such as race and SES have had a

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strong relationship with SIDS rates. Using this knowledge, subpopulations should be targeted in
terms of improving and individualizing teaching on SIDS. Furthermore, Smylie et al. (2014) and
Colvin et al. (2014) have shed light on specific factors that should be used to improve the Back
to Sleep Campaign and SIDS prevention education. In Colvin et al. (2014), further elaboration
on factors that differ within infants help to create even more specific teaching in the primary care
setting. Nurses can focus on teaching mothers and families about early infant SIDS risk factors
and primary care pediatricians can tailor their teaching toward late infant risk factors associated
with SIDS.
The implications of the studies reviewed in this integrative review are geared toward
practice. Coleman stated that one of the central themes of her research was that, the presence of
the nurse was essential to health and well-being (Coleman, 2009, p. 114). Nurses have to
become a vital aspect of maternal teaching in regards to SIDS and infant safety. Oden et al.
(2010) noted that pediatricians might be able to better influence parental decisions on sleep by
providing education on how sleep position and SIDS are related. Creating a trusting relationship
with mothers may not be enough to convince mothers to take recommendations on infant sleep
position (Oden et al., 2010). Providers should be tailoring their education to the mother and her
learning needs. Although this sound tedious, providers already have a vast amount of
information regarding the mothers educational level, amongst other variables, as part of their
psychosocial assessment. Data on SIDS rates, throughout all five studies, may indicate that the
Back to Sleep Campaign and the current education provided on SIDS is in need of revision.
Despite the consistency of teaching on sleep position, rates on the use of nonsupine sleep
positioned infants have not changed in the past decade (Smylie et al., 2014). Smylie et al. (2014)

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pointed out that teaching strategies on the prevention of SIDS should be tailored to fit the needs
of disadvantaged populations, such as lower SES and African American mothers.
Conclusion
An integrative review is helpful in defining a problem and reviewing what, if any,
solutions are available for the problem. In order to better comprehend the data of articles
reviewed in this integrative review, readers must be aware of limitations presented within each
study. One of the central themes of this integrative review was that African American mothers
had a higher risk for SIDS. Limitations were present in regards to this statement, because in one
study the population studied was limited to data available from the Missouri Department of
Health and Senior Services (Hogan, 2014). Another similar limitation was that mothers of
another study were all African American mothers from the Washington, DC area (Oden et al.,
2010). Although these limitations are important to note, the results of those two studies
mentioned, were consistent with national averages presented in previous literature (Oden et al.,
2010). Another limitation on the overall theme of this integrative review was assuming the
knowledge of health care providers. As Coleman (2009) stated, further research is needed to
understand the level of education and personal beliefs on sleep position help by health care
providers. This limitation has the potential to be a big factor in reducing SIDS rates across all
populations if it creates a knowledge gap in the maternal teaching of infant sleep position.
All across the research on SIDS, there has been a common agreement that any incidence
of SIDS is too high. Although SIDS has been defined as an unknown etiology death, there is
data to support that a change in recommendation on sleep positioning in the 1990s, helped to
dramatically reduce the incidence of SIDS. Having reviewed the studies in this integrative
review, readers have a better understanding of what specific factors (race, SES, etc.) influence

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SIDS rates. Utilizing this knowledge has been a key component of better planning on how to
help further reduce SIDS rates. Through interviewing some of the at risk populations, such as
African American mothers, we have gained better insight as to their perceptions on sleep
positioning and how it related to SIDS. An alarming finding was that mothers report
understanding the recommendations of health care professionals in regards to sleep position, yet
ignoring them because of personal beliefs on the matter (Coleman, 2009). Although alarming,
this finding provided us with a better idea of how to begin to solve the problem related to SIDS
education. Each study in this review pointed out that there is a need for revitalizing teaching on
infant sleep position and SIDS. The key seems to be that teaching needs to be improved and
individualized to reflect the needs of each mother. Individualization of teaching can be achieved
by interviewing mothers on their personal teaching needs and beliefs, as well as reviewing data
already collected on mothers through prenatal visits. Finally, there is a need for finding a way to
provide early prenatal education to the population of mothers who receives limited or no prenatal
care (Smylie et al., 2010). Rebuilding the Back to Sleep Campaign may cost a lot of money and
require a lot of work, but ultimately it has the potential to be a key factor in further reducing
overall SIDS rates and helping reduce the disparities of SIDS in disadvantaged populations.

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References
Coleman, J. (2009). Culture care meanings of African American parents related to infant
mortality and health care. Journal of Cultural Diversity, 16(3), 109-119. PMID:
19824290
Colvin, J., Collie-Akers, V., Schunn, C., & Moon, R. (2014). Sleep environment risks for
younger and older infants. Journal of the American Academy of Pediatrics, 134(2), 406412. doi: 10.1542/peds.2-14-0401
Hogan, C. (2014). Socioeconomic factors affecting infant sleep-related death in St. Louis. Public
Health Nursing, 31(1), 10-18. doi: 10.1111/phn.12052
Oden, R., Joyner, B., Ajao, T., & Moon, R. (2010). Factors influencing African American
mothers decisions about sleep position: A qualitative study. Journal of the National
Medical Association, 102(10), 870-880. Retrieved from
http://nmanet.org/publications/October2010/OC870.pdf
Smylie, J., Fell, D., Chalmers, B., Sauve, R., Royle, C., Allan, B., & O'Campo, P. (2014).
Socioeconomic position and factors associated with use of a nonsupine infant sleep
position: Findings from the Canadian maternity experiences survey. American Journal of
Public Health, 104(3), 539-547. doi: 10.2105/AJPH.2012.301061