Empowerment and Knowledge: Guiding Parents in Creating Healthy Infant Sleep Routines

Wendy Middlemiss, Ph.D., CFLE, Associate Professor, and Kaylee Seddio, M.S., CFLE, doctoral candidate, Department of Educational Psychology, University of North Texas
NCFR Report
Content Area
Human Growth and Development Across the Lifespan
Internal Dynamics of Families
Parent Education and Guidance
Family Life Education Methodology

Wendy Middlemiss

In Brief

  • A variety of different safe sleep routines are recommended for infants, and many of them identified as the only safe routine.
  • The more that mothers feel that their nighttime care routines are criticized, the more they show high rates of stress hormones and low quality of care.
  • Family Life Educators should teach parents how to balance research results with their own preferences.


Kaylee Seddio

Recommending Infant Sleep Practices

Research has explored how best to help parents create healthy and safe sleep routines for their infants. Experts present varying results from that research and then often emphasize risks of noncompliance and possible negative outcomes when parenting behaviors contradict what they recommend (Moon, Hauck, & Colson, 2016). The contradictions in recommendations can be confusing and distressing for new parents, who may decide to avoid recommendations altogether and rely instead on instinctual or hearsay advice to guide their parenting practices.

Sources of infant sleep information can include health providers, such as nurses and pediatricians, as well as Family Life Educators who provide parenting classes or educational programs. Although much of the information from various professional sources has common themes, often the messages provided can be contradictory. This can create confusion, possibly placing the infant at risk. For example, most professional sources of information direct parents to avoid adult bedding or soft bedding or blankets in a crib or bassinette to protect infants from suffocation during sleep. However, parents may find themselves bombarded with commercial sources marketing attractive bedding and other hazardous products. Even parents who choose to limit their sources to professionals find that physicians, nurses, community educators, and associated persons of authority often disagree with one another and may speak out against the recommendations of other professionals (Lau & Hall, 2016).

Among these myriad conflicting recommendations, many sources of information, particularly medical ones, often try to help parents wend their way through the diversity of recommendations by providing one rigid statement of “what to do” to care for an infant during sleep. Often this advice endorses separate sleep spaces for infants and encourages infants’ self-settling without parents remaining present. Although there is not clear research that supports a single way as the best or only approach to healthy infant sleep routines, pediatricians often share this information as a direct instruction. This focus on a single approach to care is evident in nonmedical sources as well, such as those that parents find on the Internet. Many recommendations are provided without consideration of personal or cultural differences among parents. Of note, many of the definitive solitary-sleep recommendations conflict with studies that show that responsiveness to infants and presence during infants’ transitions to sleep is associated with healthy sleep outcomes (Miller & Commons, 2010).

We suggest that offering supportive guidance that informs parents of sleep options and empowers them to adapt that information to their parenting preferences is likely to be a stronger approach to sharing infant sleep information. Providing parents with the tools necessary to engage in healthy sleep patterns and to make decisions that work for them leads to a sense of efficacy and ultimately to positive parent–child relations. This approach to sharing information is consistent with best practice in Family Life Education, which asserts that responsibility for the transfer of knowledge should be shared rather than led by practitioner (Weis, Zoffmann, & Egerod, 2014). This person-centered approach is particularly helpful when parents are receiving information from many different sources, such as in post-natal hospital settings. When knowledge is conflicting or communicated with medical jargon and “what to do” language, a mother might lose confidence either in herself or in experts and may revert to seeking unreliable information from the Internet or peers. The following study investigated these assumptions.


Mothers’ Reactions to Sleep Recommendations

As already described, when mothers must reconcile their preferences for care with one set approach that is inconsistent with their personal preferences, they might feel criticized and less certain of their choices as a parent (Middlemiss, Yaure, & Huey, 2014). This was evidenced in research with 48 mother–infant dyads (infants aged 5–15 months, M = 8.7 months, SD = 2.93 months; 36 boys) who provided salivary samples (mothers and infants) and completed questionnaires (mothers). The results showed that mothers experienced higher physiological stress responses during their infants’ nighttime care routine if they felt criticized for their chosen practice. This was measured by correlational analyses computed to examine the levels of salivary alpha amylase (sAA; Middlemiss, 2014), which was assessed as a measure of stress response. The analysis identified a significant positive association between ratings of felt criticism of sleep routines and increase in mothers’ sAA from daytime activities to the initiation of the sleep routine (r(37) = .401, p = .019). Thus, mothers who reported greater felt criticism for their sleep routine choice exhibited greater physiological reactivity at the initiation of the sleep routine, despite their reports of being satisfied with their chosen sleep routines. Regression analyses computed in this research indicated both mothers’ felt criticism of the chosen nighttime sleep routine and mothers’ perception of how separation at night affected their infants explained significant variance in infants’ or mothers’ levels of sAA (Middlemiss, 2014). These findings regarding mothers’ felt criticism suggest that mothers who did not feel supported in their sleep routine choice experienced greater physiological response to the sleep routine. This in turn seems to increase the distress levels of both mothers and infants and reduces the quality of care.


The Role of Family Professionals

For Certified Family Life Educators (CFLEs) and other practitioners, this highlights the importance of balancing education about empirical evidence for safe and healthy sleep practices with providing parents the skills and latitude to incorporate their preferences for care. This is reflected also in the latest report from the American Academy of Pediatrics’ Task Force on Sudden Infant Death Syndrome (AAP Task Force, 2016). In this revision of its policy statement, the AAP acknowledges that parents may engage in sleep routines other than those proposed as evidence-based best practice. In the revised statement, recommendations are made encouraging parents to apply the guidelines to other potential sleep spaces. Providing information about alternative spaces increases protection of infants even outside formerly restricted proposed sleep locations. This is an important revision to the policy statement, given that some of the information had been underutilized by parents and placed some infants at high risk, partly because of the mismatch between parents’ preferences and the proposed steps to provide safety.

Benefits of educating and empowering parents to make decisions that fit them and their lives were illustrated in a random-control trial conducted in two urban settings in the Midwest (Parrish et al., 2016). In this project, mothers received information about safe sleep that focused on their infants’ breathing. Some mothers also received an in-bed sleeper that would provide an option for mothers to bedshare with infants while still protecting their breathing. As was hypothesized on the basis of research in New Zealand (Cowan, 2014), mothers who were given in-bed sleepers and could then create safe spaces for sleep across settings, maintained safe sleep spaces more often than mothers provided with only the sleep message (Parrish, et al., 2016). At 3 months after infants’ births, mothers with sleepers engaged in safe sleep practices at a significantly higher rate than mothers without sleepers, and the practices were applied across situations, such as placing their infants on their backs to sleep and arranging for safe sleep arrangements during the day and night.

The findings of these studies suggest that, when given proper and effective tools to make decisions about and engage in safe sleep behaviors, mothers can and will participate to protect their infants. In Parrish and colleague’s (2016) study, providers spoke to mothers and grandmothers at length regarding their participation with the sleepers. They utilized a family-centered model in which caregivers and providers worked together to familiarize mothers with the information important to continue risk-free sleep patterns. Providers visited mothers in their homes and established mutual respect for one another. At the same time that participants were provided with an evidence-based method to engage in safe sleep, mothers reported more confidence in their roles as caregivers, endorsing the benefits of community providers using a shared-knowledge approach.



Guiding families toward balancing infant health, safety, and family goals is an important task for CFLEs and other family professionals working with new parents. An essential piece of this guidance is the sharing of information in a manner that provides parents with tools to adapt the evidence-informed information with how life exists at home. As noted in the revised AAP policy statement, engaging parents in discussions that provide space for the parents’ voice and sleep practice decisions is key (AAP, 2016). These discussions empower parents to play a role in deciding and implementing effective sleep practices and thus providing safe, healthy spaces for their infants.


Complete References

American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138, e20162938.

Cowan, S. (2014). The Pepi-Pod Programme, 2013 report. Christchurch, New Zealand: Change for Our Children.

Lau, A., & Hall, W. (2016). Safe sleep, day and night: Mothers’ experiences regarding infant sleep safety. Journal of Clinical Nursing, 25, 2816–2826.

Middlemiss, W. (2014, August). Infants’ self-regulation is built on early responsiveness to infants’ signals: Cautionary notes on implications for early autonomy. Paper presented at the American Psychological Association annual convention, Washington, DC.

Middlemiss, W., Yaure, R., & Huey, E. (2014, August 1). Translating research-based knowledge about infant sleep into practice. Journal of the American Academy of Nurse Practitioners. doi:10.1002/2327-6924.12159

Moon, R. Y., Hauck, F. R., & Colson, E. R. (2016). Safe infant sleep interventions: What is the evidence for successful behavior change? Current Pediatric Reviews, 12, 67–75.

Parrish, C., Welch, G., Viewins, Y., Edmond, P., Busby, K., Middlemiss, W., & Grzywacz, J. J. (2016, November). Reducing SUID in at-risk infants: What information will help? Paper presented at the National Council on Family Relations conference, Minneapolis.

Weis, J., Zoffmann, V., & Egerod, I. (2014). Improved nurse–parent communication in neonatal intensive care unit: Evaluation and adjustment of an implementation strategy. Journal of Clinical Nursing, 23(23–24), 3478–3489.

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