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
Downloaded from www.aappublications.org/news by guest on April 24, 2021
PEDIATRICS Volume 139, number 1, January 2017:e20161729 ARTICLEIn 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 childrendetermined 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 childrenis 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 5majority 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
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PEDIATRICS Volume 139, number 1, January 2017 7Safe Sleep Guideline Adherence in Nationwide Marketing of Infant Cribs and
Products
Matthew Kreth, Tammy Shikany, Claire Lenker and R. Bradley Troxler
Pediatrics 2017;139;
DOI: 10.1542/peds.2016-1729 originally published online December 19, 2016;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/139/1/e20161729
References This article cites 12 articles, 8 of which you can access for free at:
http://pediatrics.aappublications.org/content/139/1/e20161729#BIBL
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Injury, Violence & Poison Prevention
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son_prevention_sub
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Downloaded from www.aappublications.org/news by guest on April 24, 2021Safe Sleep Guideline Adherence in Nationwide Marketing of Infant Cribs and
Products
Matthew Kreth, Tammy Shikany, Claire Lenker and R. Bradley Troxler
Pediatrics 2017;139;
DOI: 10.1542/peds.2016-1729 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/139/1/e20161729
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