Inconsistency of infant caretakers' visual exposome with safe infant sleep recommendations: a systematic review and meta-analysis

ImportanceRates of sudden unexpected death in infancy (SUDI) remain high in several high-income countries. Several studies reported rates of pictures of sleeping infants or infant sleeping environments that were highly inconsistent with safe infant sleep recommendations (SISRs) to prevent SUDI. ObjectiveTo provide robust and synthetized evidence to decision-makers involved in corrective actions, we systematically assessed the proportion of pictures that were inconsistent with SISRs in the visual exposome of infant caretakers. Data SourcesIn November 2023, we searched PubMed, Web of Science, and Google Scholar. Study SelectionEligible studies included were those reporting the quantitative evaluation of the inconsistency between one or several SISRs and pictures depicting sleeping infants or a sleeping environment intended for an infant in physical and digital public spaces. Data Extraction and SynthesisData were extracted independently by 2 authors. The risk of bias of included studies was assessed with a customized version of Hoys tool for prevalence studies. A random-effects logistic regression model was used to obtain summary estimates of proportions of pictures. Between-study heterogeneity was estimated with the I2 statistic. Main Outcomes(s) and Measure(s)The proportion of pictures inconsistent with one or several SISRs from the American Academy of Pediatrics. ResultsWe screened 1,086 articles and included 7 studies conducted between 2008 and 2023 that analyzed pictures found in parenting magazines, online and print newspapers, baby diaper packaging, commercial stock photography websites, and Instagram. The overall risk of bias was deemed low. Among the 5,442 pictures depicting sleeping infants or infant sleep environments, the summary estimates of the proportion of inconsistencies with SISRs were 39% for a non-supine sleeping position, 5% for a soft sleeping surface, 8% for sharing the sleeping surface, 14% for an unsafe crib, 58% for soft objects or loose bedding, 17% for a covered head, and 85% for at least one SISR inconsistency. All summary estimates had significant between-study heterogeneity. Conclusions and RelevanceInfant caretakers visual exposome is greatly inconsistent with SISRs and could lead to dangerous practices, which should prompt actions from manufacturers, advertisers, newspaper and website editors, social media moderators, and legislators.