Safe Sleep Guideline Adherence in Nationwide Marketing of Infant Cribs and Products

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Safe Sleep Guideline Adherence
                                   in Nationwide Marketing of
                                   Infant Cribs and Products
                                   Matthew Kreth, MD, FAAP,a Tammy Shikany, MAE, RRT,a,b Claire Lenker, LCSW, CCM,a R. Bradley Troxler, MD, FAAPa

BACKGROUND: Sudden infant death syndrome and sleep-related sudden unexpected infant                                                               abstract
death remain leading causes of infant mortality in the United States despite 4 safe sleep
guideline restatements over the previous 24 years. Advertising and retail crib displays
often promote infant sleep environments that are counter to the most recent American
Academy of Pediatrics (AAP) guidelines.
METHODS: Magazine advertisements featuring sleep in parenting magazines from 1992,
2010, and 2015 were reviewed for adherence. Crib displays from nationwide retailers were
surveyed for adherence to the latest AAP safe sleep guidelines. The primary outcome was
adherence to the guidelines.
RESULTS: Of 1758 retail crib displays reviewed, only half adhered to the latest AAP guidelines.
The most common reasons for nonadherence were the use of bumper pads and loose
bedding. The depiction of infant cribs and sleep products in magazine advertising has
become significantly more adherent over time; however, 35% of current advertisements
depict nonadherent, unsafe sleep environments. Magazine advertising portraying safe sleep
environments revealed racial and ethnic disparities.
CONCLUSIONS: Although improvements have been made over time with increased adherence to
AAP safe sleep guidelines, significant deficiencies remain. Advertising continues to depict
unsafe sleep environments. Crib manufacturers and retail establishments continue to
market and sell bedding and sleep products considered unsafe by the AAP in approximately
half of retail crib displays. Pediatric and public health care providers should continue
educational and advocacy efforts aimed at the public, but should also include retailers,
manufacturers, and advertising professionals to foster improved sleep environments for all
children.

aDepartment of Pediatrics, Division of Pediatric Pulmonary and Sleep Medicine, University of Alabama at    WHAT’S KNOWN ON THIS SUBJECT: There have been
Birmingham, Birmingham, Alabama; and bDepartment of Respiratory Care, Children’s of Alabama, Birmingham,   few published studies examining the marketing of
Alabama                                                                                                    infant cribs and products for adherence to the most
Dr Kreth codesigned the study, carried out the majority of data gathering, assisted in the data            recent American Academy of Pediatrics safe sleep
analysis, and authored the initial manuscript; Ms Shikany helped with study design, carried                guidelines. Retail marketing often includes items that
out a significant portion of the data gathering, and reviewed and revised the manuscript;                   are not adherent to the guidelines.
Ms Lenker conceptualized the study and reviewed and revised the manuscript; Dr Troxler
                                                                                                           WHAT THIS STUDY ADDS: This is the first survey of
codesigned the study, carried out a significant portion of the data gathering, provided the main
                                                                                                           infant cribs and product marketing with respect
statistical analysis, and coauthored, reviewed, and revised the manuscript; and all authors
approved the final manuscript as submitted.                                                                 to safe sleep guideline adherence since the 2011
                                                                                                           American Academy of Pediatrics guidelines. These
DOI: 10.1542/peds.2016-1729
                                                                                                           data may inform health care providers and help tailor
Accepted for publication Oct 24, 2016                                                                      future policy and advocacy efforts.

                                                                                                            To cite: Kreth M, Shikany T, Lenker C, et al. Safe Sleep Guideline Adherence
                                                                                                            in Nationwide Marketing of Infant Cribs and Products. Pediatrics. 2017;
                                                                                                            139(1):e20161729

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PEDIATRICS Volume 139, number 1, January 2017:e20161729                                                                                                                   ARTICLE
In 1992, the American Academy                guidelines, anticipatory guidance                Review Board reviewed the
of Pediatrics (AAP) first released           on safe sleep is just one of >20                 research protocol and approved
recommendations that all infants             suggested topics to cover during the             the project as not human research.
should be placed in a supine position        prenatal visit, the newborn visit, and           The investigators reviewed print
for sleep to lower the incidence             the 1-week visit.16 The advertising              advertisements from a nationally
of sudden infant death syndrome              onslaught parents experience while               distributed parenting magazine,
(SIDS).1 After revisions in 1996 and         shopping for infant cribs or reading             with a monthly circulation of >10
2005, the guidelines were expanded in        parent-oriented magazines easily                 million readers, for depictions of
2011 to address sudden unexpected            eclipses the brief safe sleep advice             safe sleep in the advertisements. Six
infant deaths (SUID) during sleep.2–4        received from primary care providers             consecutive issues from 3 temporal
Despite these official statements,           during these visits.                             cohorts were chosen a priori for
SIDS/SUID remains the leading cause                                                           assessment: preceding the initial
                                             The socioecological model endorsed
of infant mortality in the United                                                             1992 sleep guidelines, before the
                                             by the National Action Partnership to
States for children 1 month to 1 year                                                         most recent guideline restatement
                                             Promote Safe Sleep recognizes that
of age according to the US Centers                                                            in 2011, and the current year. All
                                             the normative beliefs of others and
for Disease Control and Prevention.5                                                          advertisements in these cohorts
                                             societal pressures influence parents
After the initial publication of the AAP                                                      were reviewed, totaling 1893 ads
                                             and caregivers.17 Advertisements
safe sleep recommendations in 1992,                                                           across the 3 cohorts. Information
                                             by crib manufacturers, national
the rate of SIDS/SUID in the United                                                           collected from each advertisement
                                             retailers, and magazines directed
States decreased from 1.2 per 1000                                                            included company, product, whether
                                             at parents are sources of societal
live births to 0.56 per 1000 live births,                                                     sleep was featured, and whether the
                                             pressure. Despite at least 1 national
where it has remained.4,6–8 More than                                                         sleep environment portrayed was
                                             effort by a major advertising trade
95% of infant deaths attributed to                                                            adherent to the 2011 guidelines. Data
                                             association to portray safe sleep
SIDS/SUID are associated with ≥1                                                              on the race of portrayed adults and
                                             environments adherent to the
modifiable risk factors.9 Over the                                                            children were gathered. The race
                                             most recent AAP guidelines in the
ensuing 2 decades, there has been                                                             of subjects portrayed was analyzed
                                             marketing of infant sleep-related
increasing awareness of, and national                                                         by a 2-reviewer visual assessment
                                             products,18 such advertising
attention directed at, strategies to                                                          of the advertisement. If agreement
                                             continues to show nonadherent sleep
decrease these preventable deaths.                                                            was not reached, the race was
                                             environments.
Such efforts have included changing                                                           considered indeterminate. Analysis
hospital practices, instituting parent/      The purpose of this study is to                  focused on advertisements depicting
caregiver education programs,                examine the online, print, and                   sleep and featuring children
determined each crib’s adherence to                    RESULTS                                           could not be determined. When
the guidelines. Specific questions are                                                                   race was able to be determined,
detailed in Table 1. Information was                   Investigators analyzed a total of                 safe sleep was far more likely to
gathered on the crib manufacturer,                     1893 print advertisements: 767                    be shown using white children
model, price, the retail store                         from the 1991–1992 cohort, 698                    versus nonwhite children (P =
classification as listed above, and                    from the 2010–2011 cohort, and                    .028). Excluding the advertisements
whether the display was online or in                   428 from the 2015–2016 cohort.                    depicting children of indeterminable
a physical store. One local store from                 The total number of advertisements                race, guideline-adherent sleep was
each national brand was chosen and                     declined in the most recent                       only depicted with white children.
every physical in-store crib display                   magazine cohort with 44.2% fewer                  Out of the 1893 advertisements
as well as every crib displayed on                     advertisements compared with the                  reviewed, no children identified from
that store’s national Web site were                    1991–1992 cohort (P < .001). Only 95              underrepresented minorities were
reviewed by 1 of 2 reviewers. These                    advertisements featured sleep, cribs,             featured in any guideline-adherent
reviewers independently assessed                       or bedding in any form, and only                  sleep advertisements (Fig 2).
the same store (108 cribs total) to                    66 depicted sleep or sleep-related
assess for validity and reproducibility                products for children estimated                   Advertisements were reviewed
of their results.                                      to be
than online displays. Online images
                                                                                                                             were more likely to display bumper
                                                                                                                             pads in use compared with physical
                                                                                                                             stores (P < .001). When analyzed
                                                                                                                             by price quartile, the least and most
                                                                                                                             expensive cribs were more likely to
                                                                                                                             have bumper pads (P = .008) and
                                                                                                                             loose bedding (P = .002) than the
                                                                                                                             mid-range priced cribs. The most
                                                                                                                             expensive cribs were more likely to
                                                                                                                             have soft objects present in them
                                                                                                                             compared with the other quartiles
FIGURE 2                                                                                                                     (P < .001).
Adherence to the AAP safe sleep recommendations by race/ethnicity of children depicted in
advertisements featuring sleep in 3 temporal cohorts. The numbers on the graph denote the
absolute number of advertisements in each category.                                                                          DISCUSSION
                                                                                                                             By examining magazine
and online displays as outlined in                            complete nursery furniture set that
                                                                                                                             advertisements, we were able to
Table 2. Cronbach’s α for interrater                          included a crib. The median price for
                                                                                                                             assess changes in marketing over
reliability was 0.927. Although                               a crib purchased online was $250
                                                                                                                             time. Although the total number
online crib displays far outnumbered                          compared with $399 for physical
                                                                                                                             of advertisements decreased
the physical store displays, overall                          stores (P < .001). When cribs were
                                                                                                                             over this time frame by ∼44%,
guideline adherence was not                                   analyzed by price quartile, there was
                                                                                                                             the percentage of advertisements
significantly different between the                           a statistically significant difference
                                                                                                                             featuring sleep in children
is needed to reach this at-risk
                                                                                                         population; the cultural norm of safe
                                                                                                         infant bedding needs to change.
                                                                                                         Overall, a slight majority of marketed
                                                                                                         cribs were adherent to the AAP safe
                                                                                                         sleep recommendations. Big-box
                                                                                                         retail establishments and department
                                                                                                         store physical crib displays were
                                                                                                         100% guideline-adherent (Table 2).
                                                                                                         This finding was in contrast to the
                                                                                                         in-store displays for furniture stores
                                                                                                         and baby-specific retailers, who had
                                                                                                         far less adherence. We hypothesized
                                                                                                         that baby-specific stores would be
                                                                                                         less likely to be guideline-adherent
                                                                                                         compared with other store types due
                                                                                                         to these stores attempting to increase
                                                                                                         sales of bedding, bumper pads,
FIGURE 3
Adherence to the 2011 AAP safe sleep guidelines by crib price quartile. The median price of a crib was   and soft toys. Both baby-specific
found to be $250.00. The 25th percentile was $194.50 and the 75th percentile was $350.00.                and furniture stores marketed
                                                                                                         a significant number of bedding
significant shift (P = .021) and likely              advertising depicting minority                      accessories under their store’s own
reflects the continued advocacy by                   children is alarming considering                    brand that increased the inclusion
the AAP, pediatricians, and other                    that infants of non-Hispanic, African-              of nonadherent items in their
health care professionals. Our study                 American mothers had more than                      displays. Department and big box
expands on the work described by                     double the rate of death by SIDS/                   stores may not focus on marketing
Joyner et al19 in their 2008 review of               SUID when compared with all race                    these nonadherent items or may be
images of sleep environments in 28                   mortality.20 The reason for this                    adopting and promoting the AAP’s
magazines with large readership of                   disparity is unclear, but the overall               safe sleep message. Regardless of
women of child-bearing age. Their                    number of children shown in unsafe                  the reason, they deserve a special
study demonstrated that 36.4% of                     sleep environments in present day                   mention for 100% in-store guideline
sleep environments shown were                        advertising demonstrates the need                   adherence.
adherent to the latest AAP guidelines                for ongoing education and advocacy                  The majority of online crib displays
available at the time. Their findings                on behalf of all children, especially               used stock images provided by
included images from articles, not                   for children from underrepresented                  the manufacturers and, therefore,
just advertisements, possibly leading                minorities.                                         reflected the manufacturer’s display
to greater adherence in their study                                                                      preferences. Stores that sold their
                                                     A 2014 study by Gaydos et al21 of 92
compared with the 2010–2011                                                                              own brand of cribs did not follow
                                                     African-American mothers and 20
cohort described in this study. Joyner                                                                   this pattern. There was 1 store that
                                                     health care providers outlines the
did not assess the changes over                                                                          allowed parents and other reviewers
                                                     understanding of and reasons for
time, which we have shown to be                                                                          to submit user-generated photos.
                                                     nonadherence to the AAP safe sleep
significant.                                                                                             These reviews and photos were then
                                                     guidelines among this community.
The racial/ethnic disparities                        They note “almost universally,                      approved by the individual store
observed in the advertisement of                     both mothers and providers stated                   before they were posted online and
safe sleep are of particular concern.                that mothers understand the                         so were included in our analysis.
Among advertisements in which the                    content of the AAP safe sleeping                    The inclusion of bumper pads, loose
race of the child could be determined,               recommendations.”21 All mothers                     bedding, and soft objects in the crib
the adherent sleep environments                      in this study had either a crib or                  were the most common reasons
only featured white children. In                     a bassinet available to them to                     for displays to be nonadherent.
contrast, nonwhite children were                     use; however, 96.7% of mothers                      In physical stores, 95.8% of
depicted in 18.5% of advertisements,                 in the study reported unsafe sleep                  nonadherent cribs had loose
all showing unsafe sleep                             environments for their infants.                     bedding included in the display. The
environments. The lack of guideline-                 Gaydos et al21 demonstrate that                     removal of these items from retail
adherent sleep environments in                       more than counseling by providers                   crib displays would convert the

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PEDIATRICS Volume 139, number 1, January 2017                                                                                                    5
majority of nonadherent displays to                    these were national chain stores, the                  and in-store crib displays featured
safe sleep environments. Shapiro-                      displays in each store should adhere                   items specifically mentioned by the
Mendoza et al13 demonstrated that                      to the standards of the national store                 AAP as not recommended in a safe
more than half of mothers reported                     brand; however, this may vary from                     sleep environment. Although the
using some form of loose bedding                       store to store and by geographic                       recommendations have clearly made
with their sleeping infants. Although                  region. The review of online crib                      an impact over time, the message has
Shapiro-Mendoza et al13 showed an                      displays was limited by the stock                      not been adopted by all. Parents are
improving trend away from bedding                      images manufacturers provided                          likely to hear about safe sleep from
use with time, the declines seen with                  to each retailer. Stores that sold                     their providers during office visits,
other racial groups stagnated among                    cribs that were not manufactured                       but as one of >20 recommended
black infants. The presence of loose                   under their own store brand used                       topics to be discussed in early visits,16
bedding in retail displays only serves                 images of the cribs supplied by                        this discussion can be easily
to normalize their use. Due to their                   the manufacturers, which may not                       overshadowed by what parents see
continued high prevalence, pediatric                   represent the sleeping environment                     when shopping for cribs or reading
and public health care providers                       that the stores wish to promote.                       parent-oriented magazines. The
should target loose bedding and                        However, each store is advertising                     lack of safe sleep in advertising
bumper pads for discussion with                        using these images and is reflective                   depicting underrepresented
parents, manufacturers, and retailers.                 of the sleep environment that is                       minority children along with the
                                                       being portrayed to consumers                           high incidence of SIDS/SUID in this
Limitations of this study include the                  and parents.                                           population makes messaging for this
review of only 1 parent-oriented                                                                              population a priority. The AAP and
magazine. We were able to find                         Finally, the study did not assess the
                                                       type of soft object in the crib and so                 public health care providers need
only 1 parent-oriented magazine                                                                               to broaden current educational and
that was continuously published                        was unable to address the percentage
                                                       of cribs that contained pillows or                     advocacy efforts beyond parents and
throughout the time span assessed.                                                                            caregivers to include advertisers,
We postulate that this magazine has                    blankets. These objects have been
                                                       associated with an increased risk of                   stores, and crib manufacturers.
a majority white readership that may                                                                          By doing this, we may change the
skew the advertisements included.                      SIDS/SUID and should be evaluated
                                                       in subsequent studies.                                 advertisements that shape societal
Bias of magazine advertisers may                                                                              norms of what an infant sleep
help to explain the limited number                                                                            environment should look like to
of minority children featured in                       CONCLUSIONS                                            ensure a safe place to sleep for all
advertising, because companies                                                                                children.
likely focus advertisements to match                   Although much has improved
the subscriber demographics. Due                       in terms of safe sleep guideline
to the limitations of some print                       adherence in advertising over the
advertisements, we were unable to                      years, much more is still left to
determine the race of every child
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PEDIATRICS Volume 139, number 1, January 2017                                                                                                     7
Safe Sleep Guideline Adherence in Nationwide Marketing of Infant Cribs and
                                   Products
     Matthew Kreth, Tammy Shikany, Claire Lenker and R. Bradley Troxler
           Pediatrics originally published online December 19, 2016;

Updated Information &          including high resolution figures, can be found at:
Services                       http://pediatrics.aappublications.org/content/early/2016/12/15/peds.2
                               016-1729
References                     This article cites 12 articles, 8 of which you can access for free at:
                               http://pediatrics.aappublications.org/content/early/2016/12/15/peds.2
                               016-1729#BIBL
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                               Injury, Violence & Poison Prevention
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Safe Sleep Guideline Adherence in Nationwide Marketing of Infant Cribs and
                                   Products
     Matthew Kreth, Tammy Shikany, Claire Lenker and R. Bradley Troxler
           Pediatrics originally published online December 19, 2016;

The online version of this article, along with updated information and services, is
                       located on the World Wide Web at:
 http://pediatrics.aappublications.org/content/early/2016/12/15/peds.2016-1729

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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