Luận văn Thạc sĩ Assessing Risk Factors For Sudden Infant Death Syndrome And Caregivers’ Perceptions Of The Cardboard Box For Infant Sleep

Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine January 2019 Assessing Risk Factors For Sudden Infant Death Syndrome And Caregivers’ Perceptions Of The Cardboard Box For Infant Sleep Nisha Dalvie Follow this and additional works at: https://elischolar.library.yale.edu/ymtdl Recommended Citation Dalvie, Nisha, "Assessing Risk Factors For Sudden Infant Death Syndrome And Caregivers’ Perceptions Of The Cardboard Box For Infant Sleep" (2019) Yale Medicine Thesis Digital Library 3893 https://elischolar.library.yale.edu/ymtdl/3893 This Open Access Thesis is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for Scholarly Publishing at Yale It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale For more information, please contact elischolar@yale.edu Assessing Risk Factors for Sudden Infant Death Syndrome and Caregivers’ Perceptions of the Cardboard Box for Infant Sleep A Thesis Submitted to the Yale University School of Medicine in Partial Fulfillment of the Requirements for the Degree of Doctor of Medicine by Nisha Dalvie 2020 ASSESSING RISK FACTORS FOR SUDDEN INFANT DEATH SYNDROME AND CAREGIVERS’ PERCEPTIONS OF THE CARDBOARD BOX FOR INFANT SLEEP Nisha S Dalvie, Victoria Nguyen, Eve Colson, and Jaspreet Loyal Department of Pediatrics, Yale University, School of Medicine, New Haven, CT Some US hospitals are giving out cardboard boxes as a way to address behaviors associated with Sudden Infant Death Syndrome (SIDS) Our goal was to evaluate the cardboard box for this purpose by quantifying current practices and qualitatively assessing caregivers’ perceptions of the cardboard box Study participants were English or Spanishspeaking caregivers of 2-16 week old infants presenting to primary care clinics in New Haven, CT Caregivers completed a survey asking about demographic data and SIDS risk factors, such as non-supine positioning and bed-sharing Some caregivers also participated in a semi-structured interview about the cardboard box, created used a grounded theory approach Of 120 survey respondents, 38% of all participants and 63% of Spanish-speaking participants reported bed-sharing at least some of the time Factors associated with bedsharing included Spanish as the primary language (OR: 4.3 [95% CI: 1.9-9.9]) Factors associated with non-supine positioning included Hispanic ethnicity (OR: 2.6 [95% CI 1.25.8]), caregiver born outside the US (OR: 4.2 [95% CI: 1.8-9.6]), Spanish as the primary language (OR: 6.3 [95% CI: 2.7-14.7]), and less than high school education (OR: 3.4 [95% CI: 1.3-8.9]) Of 50 interview participants, 52% said they would use the cardboard box for their infant to sleep in compared with 48% who said they would not The following themes emerged from the data: (1) safety of the cardboard box; (2) appearance and (3) variation in planned use In conclusion, bed-sharing rates were higher in our study population compared to the national average, highlighting the need for better resources; however, participants were divided about whether they would actually use the cardboard box, indicating it may not be a successful intervention in our community Acknowledgements Thank you to Dr Eve Colson for her introduction to this field and her crucial expertise Thank you to Dr Maryellen Flaherty-Hewitt and Camisha Taylor for their flexibility in the primary care clinic workflow so that this project could succeed Most importantly, thank you to Dr Jaspreet Loyal for her incredible mentorship, unwavering support, and life-long lessons in pediatric clinical care that all clinician-educators should aspire to This work was supported by the National Institutes of Health [Grant T35 HL 7649-31] Table of Contents Introduction Sudden Infant Death Syndrome: Background and Risk Factors Barriers to Safe Sleep and Studied Interventions The Cardboard Box for Infant Sleep Our Project 1-10 Statement of Purpose and Specific Aims 11 Methods Setting and Sample Data Collection Data Analysis 12-16 12 Results Overall Sleep Positioning Sleep Location Qualitative Themes Perceptions of the Cardboard Box, Demographics, and Sleep Practices 17-30 17 Discussion Our Caregiver Population Comparing National Prevalence of Sleep Practices with Our Data Evaluation of the Cardboard Box for Infant Sleep Study Limitations and Opportunities for Future Work 30-45 29 31 37 12 15 20 22 26 29 41 References 46-51 Appendices Appendix A: PDF of Yale Qualtrics Survey 52-62 52 Introduction Sudden Infant Death Syndrome (SIDS): Background and Risk Factors Sudden infant death syndrome (SIDS), a type of sudden unexpected infant death (SUID) often associated with sleep, is defined as the sudden unexpected death of a child less than year of age and outside of the perinatal period that remains unexplained after thorough work-up, including a complete autopsy.1 It is the leading cause of post-neonatal mortality in the United States and the third leading cause of infant death overall, responsible for 3,600 deaths in 2017.2 Although SIDS remains a diagnosis of exclusion, risk factors related to intrinsic biological factors as well as the external sleep environment have been identified.3 The most well-established risk factors are non-supine sleep positioning, soft and loose bedding, presence of items such as pillows and blankets, sleeping on surfaces other than cribs (i.e adult beds, sofas), and bed-sharing, where bedsharing is defined as an infant sleeping on the same surface as another person.4 Other factors correlated with higher SIDS incidence include male sex, black race, families who identify as lower socio-economic status, mothers younger than 20, low birth weight / preterm infants, and cigarette smoking during pregnancy.5 It is important to note that none of these risk factors are sufficiently strong enough to identify a pathophysiologic cause, but have assisted in creating a descriptive profile that associates maternal, neonatal, and environmental factors with SIDS risk, as illustrated in Figure Based on this emerging profile, the American Academy of Pediatrics has published recommendations for pediatricians to counsel families on modifiable factors to prevent SIDS The first guideline, published in 1992, recommended that infants be placed in a nonprone position for sleep; in 1994, this guideline became the basis for the “Back-to-Sleep” Figure 1: Maternal, Neonatal, and Environmental Risk Factors for SIDS (Triple Risk Model adapted from Filiano and Kinney6) campaign (later becoming the “Safe-to-Sleep” campaign), a collaboration between the AAP and the National Institute of Child Health and Development (NICHD).7 Over the next years, the percent of infants placed on their backs to sleep increased from 17% to 70%, and the incidence of SIDS decreased by over 40%.8-9 Some papers note that part of the reason for the drop in SIDS incidence may simply be because of diagnostic shift, with more cases of SUID being ruled as accidental suffocation rather than SIDS as more thorough death scene investigations were performed later in the decade, but it is unlikely for changing classifications to account for all the decrease throughout the decade.10-12 The safe sleep recommendations have been updated several times since the 1990s, with the most recent 2016 recommendations expanding to specify placing infants in the supine position for sleep, avoiding cigarette smoke during and after pregnancy, using a firm sleep surface with tight fitting bedding and no other loose articles such as pillows, and to avoid bed-sharing.5 Despite the improved strength of these recommendations and their uptake by pediatricians and parents alike, SIDS incidence has not significantly decreased in the past two decades in the United States as a whole, although there are wide variations between states.13 Several large-scale studies have identified non-adherence to the AAP recommendations and associated factors as a potential explanation for this plateau An analysis of results from the Web-based National Child Death Review Case Reporting System (NCDR-CDS) showed that, out of over 3000 cases of SIDS across states, 70% of cases identified the infant on a surface not intended for infant sleep and 64% of infants were sharing a sleep surface with an adult or older child.14 The nationally representative Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed over 3000 caregivers about infant sleep practices between 2011-2014, found that although 77.3% of mothers usually place their child supine, only 43.7% intentionally place their child exclusively supine.15 In addition, this study found that black mothers and mothers with less than a high school education were more likely to place their child in a non-supine position compared to white mothers and mothers with at least a high school education, aligning with results from a prior national survey from 1993-2007 and older studies on SIDS risk factors.5,16 Barriers to Safe Sleep and Successful Interventions These findings lead to the all-important question: why are caregivers still practicing sleep positions that are non-adherent to current safety recommendations? It seems unlikely to be primarily caused by lack of adequate education, as caregivers who practice non- supine positioning indicate they are aware of their doctors’ recommendations, although studies have found caregivers that use prone positioning are less likely to be aware of the associated SIDS risk.16 Studies on the “ABC” messaging of safe sleep (Alone, on the Back, and in a Crib) have found no statistically significant changes in sleep positioning before and after caregivers receive this information via crib card, as more than 80% of them were already aware supine positioning is the safest This study found significant changes in sleep environment before and after patients communicated with nursing about safe sleep practice, including a 40% reduction in loose articles within the crib, but could not attribute this to “ABC” messaging due to low compliance of using the crib card.17 These findings indicate that such communication methods may not be the most effective target to reducing SIDS risk factors, possibly because lack of knowledge is no longer the biggest barrier to safe sleep practices as it was in the 1990s and early 2000s: in 2015, 99% of caregivers at one hospital were aware of supine positioning and crib recommendations both at time of discharge and at month follow-up, a significant increase compared to the National Infant Sleep Position (NISP) study results from 1993-2010.16,18 Interventions based in health messaging have been more successful if they gave caregivers specific rationales rather than re-iterating the best practices This has been demonstrated by randomized controlled trials in Washington, DC and Porto Alegre, Brazil that showed reduced bed-sharing rates and increased supine positioning after educational sessions designed to elicit reasons for choosing sleep positions.19-20 Other examples of successful education-based interventions include a nursing quality improvement (NQI) pilot to provide postpartum teaching about safe sleep practices prior to discharge, and a mobile health texting service to deliver tailored messages to caregivers about safe sleep for months post-discharge These were both evaluated through the Social Media and RiskReduction Training (SMART) clinical trial, which demonstrated that caregivers who received both the NQI and the mobile health interventions for safe sleep reported the highest percentages of adherence to safe sleep practices.21 The success of all these initiatives emphasizes the importance of understanding families’ attitudes about safe sleep practices in order to actually counteract barriers adherence: the one-on-one discussions, mobile health messages, and nursing education time were to address each caregiver’s unique concerns about safety recommendations, specifically about the comfort of supine positioning and reminders that their children are not immune to SIDS This was not the first study to identify caregivers’ attitudes around the AAP recommendations as a potential barrier to safe sleep practices In 2005, qualitative findings from focus groups of mainly black mothers in urban areas, a population which has been identified as high-risk for non-adherent practices since the 1990s, demonstrated concerns about choking in supine position, lack of trust in health providers compared to mothers in their families, and the perception that infants would be more comfortable on their stomachs.22 The previously mentioned Study of Attitudes and Factors Effecting Infant Care (SAFE) from 2011-2014 also examined caregivers’ attitudes about sleep practices, and identified that mothers who believed they did not have control over their infants’ choice of sleeping position were much more likely to include prone sleep in their intended practices.15 These findings make it clear that simply stating AAP recommendations to caregivers is not enough to ensure their uptake- successful interventions must address the root causes of parents’ concerns, whether that means anticipatory explanations about choking risk in the supine position or being culturally respectful of mothers’ traditions 48 28 2017 Scottish Baby Box Pilot Scheme Launched BBC News Magazine https://www.bbc.com/news/uk-scotland-tayside-central-38470905 29 de Klee, K 2019 “Make Change: Thinking inside the Box.” Design Indaba https://www.designindaba.com/articles/creative-work/makechange-thinking-inside-box 30 2018 A Baby Box Aims to Save Infant and Maternal Lives Harvard T H Chan School of Public Health News https://www.hsph.harvard.edu/news/features/a-baby-boxaims-to-save-infant-and-maternal-lives/ 31 Barford, V 2016 Why babies all over the world are now sleeping in boxes BBC News Magazine https://www.bbc.com/news/magazine-35834370 32 2017 Baby Box University The Baby Box Company https://www.babyboxco.com/pages/baby-box-university 33 Heere, M., Moughan, B., Alfonsi, J., Rodriguez, J., and Aronoff, S 2019 Effect of Education and Cardboard Bassinet Distribution on Newborn Bed-Sharing Global Pediatric Health 6:1-9 34 2019 Giving: Baby Boxes Lewis Katz School of Medicine News https://medicine.temple.edu/about/giving/where-give/special-campaigns/baby-boxes 35 2019 Temple University Baby Boxes Offer Infants Safe Sleeping Space Healthy Me PA https://www.healthymepa.com/2019/09/11/temple-university-hospital-baby-boxesoffer-infants-safe-sleeping-space 36 Zoppa, A 2017 Hospitals Give Away Baby Boxes to Curb Infant Mortality NBC News https://www.nbcnews.com/news/us-news/hospitals-u-s-give-away-free-baby-boxescurb-infant-n732421 37 May, B 2020 New Jersey Baby Box Initiative Southern New Jersey Perinatal Cooperative https://www.snjpc.org/what-we-do/nj-launches-baby-box-initiative.html 38 2017 Baby Box program launches statewide Fox News San Antonio https://foxsanantonio.com/news/local/baby-box-program-launches-statewide-05-02-2017 39 Cantrell, A 2017 Alabama initiates statewide Baby Box program WHNT 19 News https://whnt.com/2017/03/27/alabama-initiates-statewide-baby-box-program/ 40 2017 Ohio Launches Universal Baby Box Program to Improve State’s Ranking as 43 out of 50 States for Highest Infant Deaths in the Nation Baby Box Company News https://www.babyboxco.com/blogs/press/ohio-launches-universal-baby-box-program-toimprove-state-s-ranking-as-43-out-of-50-states-for-highest-infant-deaths-in-the-nation 49 41 2018 Toronto Baby Box Community Event The New Mom Project http://www.newmomproject.ca/mc-events/toronto-baby-box-community-event/ 42 Wiebe, S 2017 Alberta parents of newborns get boxes filled with products, resour2es in Finnish-inspired program CBC News https://www.cbc.ca/news/canada/calgary/babybox-new-parents-alberta-1.3951663 43 Korioth, T 2017 Health Alerts: Baby boxes, fireworks, gates, and more AAP News https://www.aappublications.org/news/2017/07/18/HealthAlerts071817 44 2017 CPSC statement on cardboard baby boxes US Consumer Product Safety Commission https://www.cpsc.gov/cpsc-statement-on-cardboard-baby-boxes 45 2017 FAQs The Baby Box Company https://www.babyboxco.com/pages/faq#How_do_most_parents_use_the_Baby_Box 46 Peachman, R 2017 Put Your Baby in a Box? Experts Advise Caution The New York Times https://www.nytimes.com/2017/05/24/well/family/put-your-baby-in-a-box-expertsadvise-caution.html 47 Wise J 2018 Cardboard baby boxes should not be promoted as safe to sleep in, warn experts BMJ www.sciencedaily.com/releases/2018/10/181017184959.html 48 Ahlers-Schmidt, C., Schunn, C., Redmond, M.L., Smith, S., Brown, M., et al 2017 Qualitative Assessment of Pregnant Women’s Perceptions of Infant Sleep Boxes Global Pediatric Health 4:1-7 49 Colson, E.R and Joslin, S.C 2002 Changing nursery practice gets inner-city infants in the supine position for sleep Arch Pediatr Adolesc Med 156(7):717-20 50 Creswell, J.W and Plano-Clark, V.L 2011 Choosing a Mixed Methods Design In Designing and Conducting Mixed Methods Research Thousand Oaks, CA: SAGE Publications Inc 53-60 51 Corwin, M.J 2010 The Infant Care Practices Survey The Study of Attitudes and Factors Affecting Infant Care Practices: Survey Boston University Slone Epidemiology Center http://www.bu.edu/infantcp/survey/ 52 Charmaz, K 2006 Coding in Grounded Theory Practice In Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis Thousand Oaks, CA: SAGE Publications Inc 42-52 50 53 Glaser, B.G., and Strauss, A.L 2008 Developing Coding Theory In The Discovery of Grounded Theory: Strategies for Qualitative Research New Brunswick, PA: Aldine Transaction 54 Strauss, A., and Corbin, K 1998 Basics of qualitative research Thousand Oaks, CA: SAGE Publications Inc 55 Dalvie, N., Nguyen, V., Colson, E.R., and Loyal, J 2019 Mothers’ Perceptions of the Cardboard Box as a Potential Sleeping Space Acad Pediatr 19(7): 787-792 56 Boston Public Health Commission, Research and Evaluation Office 2015 Boston’s Child Population Health of Boston’s Children: Child Health Assessment Mapping Project 57 Pollack, H.A., and Frohna, J.G 2002 Infant sleep placement after the back to sleep campaign Pediatrics 109: 608-614 58 Center for Disease Control 2019 Breastfeeding Among U.S Children Born 2009– 2016 CDC National Immunization Survey www.cdc.gov/breastfeeding/data/nis_data 59 McKenna, J.J., Mosko S.S., and Richard C.A 1997 Bedsharing promotes breastfeeding Pediatrics 100: 214–219 60 Thompson, J.M.D., Tanabe K., Moon R.Y., Mitchell E.A., McGarvey C., et al 2017 Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis Pediatrics 140(5): e20171324 61 Shah, T., Sullivan, K., and Carter, J 2006 Sudden infant death syndrome and reported maternal smoking during pregnancy Am J Public Health 96(10): 1757–1759 62 Center for Disease Control 2018 Cigarette Smoking During Pregnancy, United States 2016 National Vital Statistics System www.cdc.gov/nchs/products/databriefs/ 63 Heere, M., Moughan, B., Alfonsi J., Rodriguez, J., and Aronoff S 2017 Factors Associated With Infant Bed-Sharing Global Pediatric Health 4: 1-4 64 Hsueh, L., Hirsh, A.T., Maupome, G., and Stewart, J.C 2019 Patient–Provider Language Concordance and Health Outcomes: A Systematic Review, Evidence Map, and Research Agenda Medical Care Research and Review In Press 65 Matthews, A.A., Joyner, B.L., Oden, R.P., Alamo, I., and Moon, R.Y 2015 Comparison of Infant Sleep practices in African-American and U.S Hispanic Families: Implications for Sleep-Related Infant Death J Immigr Minor Health 17(3): 834–842 66 Fu, L.Y., Colson, E.R., Corwin, M.J., and Moon, R.Y 2008 Infant Sleep Location: Associated Maternal and Infant Characteristics with Sudden Infant Death Syndrome Prevention Recommendations J Pediatr 153(4): 503-508 51 67 Joyner, B.L., Oden, R.P., Ajao, T.I., and Moon, R.Y 2010 Where should my baby sleep: a qualitative study of African-American infant sleep position decisions J Natl Med Assoc 102(10): 881-889 68 Friedkin, N.E and Johnsen, E.C 2011 Models of Group Decision Making In Social influence network theory: a sociological examination of small group dynamics Cambridge, UK: Cambridge University Press 235-250 69 Moon, R.Y., Carlin, R.F., Cornwell, B., Matthews, A., Oden, R.P., et al 2019 Implications of mothers’ social networks for risky infant sleep practices J Pediatr 212(2): 151-158 70 Sung, J.H., Lee, J.E., and Lee, J.Y 2018 Role of Social Support in the Relationship between Acculturative Stress and Discrimination among Latino Immigrants in the USA Int J Adv Res Sci Eng Technol 5(9): 6778-6784 71 Moon, R.Y., Hauck, F.R., and Colson, E.R 2016 Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change? Current Pediatric Reviews 12: 6775 72 Olaoluwa, H.A 2019 Evaluation of Safe Sleep Practices of Cribs for Kids Class Attendees Wright State University, Dayton, OH 73 Main, M 2018 Safer Sleep: An Overview of Bed-Sharing Alternatives Northwest Bulletin University of Washington School of Public Health https://depts.washington.edu/nwbfch/safer-sleep-bed-sharing 74 75 Baddock, S.A., Tipene-Leach, D., Williams, S.M., Tangiora, A., Jones, R., et al 2017 Wahakura versus Bassinet for Safe Infant Sleep: A Randomized Trial Pediatrics 139(2): e20160162 76 Tipene-Leach, D and Abel, S 2019 Innovation to prevent sudden infant death: the wahakura as an Indigenous vision for a safe sleep environment Aust J Prim Health In Press 52 Thank you for participating in this study The beginning of the survey is in sections according to positioning your baby for sleep and where the baby sleeps Each section begins with what you originally planned to when the baby came home from the hospital Then we will ask if your plans changed; what you now and why Remember, this survey is about your baby Many of the questions use a scale from to Choose the scale number according to how strongly you agree or disagree with the statement Also, there is a number you may call or an email address you may use if you wish to ask a question of the study staff At the end of the survey we have a few questions about a new product that we are planning to use in our hospital and would like your opinion For this part of the survey we will be audiotaping your responses Sleep Response ID:  When I first brought my baby home from the hospital, I planned to place him/her   On the side to sleep Neither agree Strongly Somewhat nor Somewhat Disagree Disagree disagree disagree agree    Agree Strongly agree Agree Strongly agree    On the stomach to    sleep On the back to sleep    Now, I plan to place my baby   Neither agree Strongly Somewhat nor Somewhat Disagree Disagree disagree disagree agree    Neither agree On the side to    Strongly Somewhat nor Somewhat sleep Disagree Disagree disagree disagree agree      On the stomach to    sleep On the back to sleep 53 Agree Strongly agree    Since you brought your baby home, what position have you USUALLY placed your baby to sleep? On the side to sleep On the stomach to sleep On the back to sleep Other (please specify): Do you SOMETIMES place your baby to sleep in a different position? No, it's always the same Yes, on the side Yes, on the stomach Yes, on the back LAST NIGHT, what position did you place your baby to sleep? On the side to sleep On the stomach to sleep On the back to sleep Other (please specify): Where you USUALLY placed your baby to sleep? Crib Bassinet Cradle 54 Carry cot Pack and play Adult bed or mattress Sofa Car or infant seat Other (please specify): Have you SOMETIMES placed your baby to sleep somewhere else? (Check all that apply.) No, it's always the same Yes, crib Yes, bassinet Yes, cradle Yes, carry cot Yes, pack and play Yes, adult bed or mattress Yes, sofa Yes, car or infant seat Other (please specify): LAST NIGHT, where did you place your baby to sleep? Crib Bassinet Cradle Carry cot Pack and play Adult bed or mattress Sofa Car or infant seat 55 Other (please specify): My baby's sleeping area has a firm mattress Neither agree Strongly Somewhat nor Somewhat Disagree Disagree disagree disagree agree      My baby's sleeping area has a firm    mattress Agree Strongly agree 10 What items you USUALLY place in your baby's sleeping area? (Check all that apply.) None Swaddle Blanket only Other Blankets Pillow(s) Other (please specify): 11 Have you SOMETIMES placed other items in your baby's sleeping area? (Check all that apply.) No, none Swaddle Blanket only Yes, blankets Yes, pillow(s) Yes, other (please specify): 12 LAST NIGHT, what items did your baby have in his/her sleeping area? Nothing Swaddle Blanket only 56 Other Blankets Pillow(s) Other (please specify): 13 When I first brought my baby home from the hospital, I planned to sleep in the same bed with him/her   For part of the night Neither agree nor Strongly Somewhat disagree Somewhat Disagree Disagree disagree (or N/A) agree    Agree Strongly agree Agree Strongly agree    For all of the night    14 Now, I plan to sleep in the same bed with him/her   For part of the night Neither agree Strongly Somewhat nor Somewhat Disagree Disagree disagree disagree agree       For all of the night    15 If your plan changed, please tell us why I planned to sleep in the same room (but not the same bad) as my baby Strongly Somewhat Neither agree nor Somewhat Strongly gy    Disagree Disagree disagree disagree agree Neither   agree When I first brought    Strongly Somewhat nor Somewhat them home Disagree Disagree disagree disagree agree      Now    Agree Agree gy agree 57 Strongly agree 18 Where does your baby USUALLY sleep? Alone in his/her own room In a parent's room (or another adult's room) in his/her own crib In a parent's bed (or another adult's bed) for part of the night In a parent's bed for the whole night In a child's room in his/her own crib In a child's bed for part of the night In a child's bed for the whole night Other (please specify): 19 Has your baby ever SOMETIMES slept somewhere else? (Check all that apply.) No, nowhere else Alone in his/her own room In a parent's room (or another adult's room) in his/her own crib In a parent's bed (or another adult's bed) for part of the night In a parent's bed for the whole night In a child's room in his/her own crib In a child's bed for the part of the night In a child's bed for the whole night Other (please specify): 20 LAST NIGHT, where did your baby sleep? Alone in his/her own room 58 In a parent's room (or another adult's room) in his/her own crib In a parent's bed (or another adult's bed) for part of the night In a parent's bed for the whole night In a child's room in his/her own crib In a child's bed for part of the night In a child's bed for the whole night Other (please specify): 21 If last night was different from where your baby usually sleeps, is there a reason why? Feeding 22 When I first brought my baby home from the hospital, I planned to breastfeed Neither Agree Strongly Somewhat Nor Somewhat Agree    Disagree Disagree Disagree Disagree   When I first brought my baby home from the hospital, I    planned to breastfeed 23 Since you brought your baby home, what has he/she been drinking? Only breastmilk Mostly breastmilk Only formula Mostly formula Equally formula and breastmilk Agree Strongly Agree Other Smoking 24 Did you smoke within a month of becoming pregnant? Yes No 25 Did you quit smoking just before getting pregnant or during pregnancy? Yes No 26 Are you a smoker now? Yes No 27 Is anyone else around the baby a smoker? Yes No Don't know The Baby Box 36 Have you ever heard of the Baby Box? Yes No 59 37 If yes, where did you hear about it? 60 38 The Baby Box is a cardboard box with a fitted mattress that some hospitals are going to give to mothers at their time of discharge from the post-partum unit Yale New Haven Hospital will begin distributing them soon What you think about this? Demographics We would now like to ask some questions about your background These questions are purely to provide cultural context for our study to help us understand how demographics affect the way newborns are cared for As a reminder, all of your responses are completely anonymous and confidential 28 Over the next few months, who will be the person taking care of the baby the most while in the home? You (baby's mother) Baby's father Mother and Father equally 61 Your partner (not baby's father) Baby's grandparent(s) Baby's great-grandparent(s) Baby's sibling Baby's aunt/uncle Baby's great-aunt/uncle Non-relative (babysitter, friend, nanny) Other (please specify): What brand of diapers you use at home? 29 How many babies have you given birth to (including the baby that was just born)? 5+ 30 What is the sex of your baby? Male Female 31 How old are you? 32 In what country were you born? 62 33 Do you consider yourself Hispanic or Latino? Yes No 34 In addition, you consider yourself to be American-Indian or Alaskan Native Asian Black or African-American Native Hawaiian or Other Pacific Islander White Other Do not wish to answer 35 What is the highest level of education you have completed? Less than high school completion High school / GED Some college or associate's degree College Graduate Graduate School Do not wish to answer Powered by Qualtrics ... Fulfillment of the Requirements for the Degree of Doctor of Medicine by Nisha Dalvie 2020 ASSESSING RISK FACTORS FOR SUDDEN INFANT DEATH SYNDROME AND CAREGIVERS’ PERCEPTIONS OF THE CARDBOARD BOX FOR INFANT. . .Assessing Risk Factors for Sudden Infant Death Syndrome and Caregivers’ Perceptions of the Cardboard Box for Infant Sleep A Thesis Submitted to the Yale University School of Medicine... Another concern was the possibility of the infant rolling out of the cardboard box in their sleep In contrast, others felt that the cardboard box would be safe for the baby For example, one participant