Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited. 1 Advances in Neonatal Care • Vol. 00, No. 00 • pp. 1-10 Original Research Donna Dowling, PhD, RN ❍ Section Editor D espite recent updates to the American Academy of Pediatrics (AAP)’s sudden infant death syn- drome (SIDS) Policy Statement, 1,2 SIDS remains the second leading cause of death after 30 days of life. 3 Preterm infants have a risk for SIDS that is approxi- mately 3 times that of term infants, 4 a statistic that increases with decreasing gestational age. 5 Conse- quently, higher-order multiples (at least 3 infants from a single gestation), of whom more than 95% are born preterm and low birth weight, 6 are at high risk for SIDS. The stagnation in SIDS rates is attributed in part to parents’ lack of adherence to SIDS risk reduction recommendations. 7-9 Parents of twins have been found to have more difficulty with adherence to safe sleep practices compared with parents of singletons. 10 How- ever, little is known concerning the barriers parents of higher-order multiples face to adhere to the AAP’s rec- ommendations to reduce SIDS risk. The AAP Task Force’s only recommendation for families with twins or higher-order multiples advises against cobedding at any time. This is due to an increased potential for rebreathing and overheating while infants are cobedding. 11 Furthermore, discor- dant sizes raise the risk for accidental suffocation during cobedding. 11 The AAP SIDS recommenda- tions provide little advice for families with twins or higher-order multiples because of the paucity of evi- dence on the matter. Thus, the purpose of this research study was to determine the extent to which the infant care practices of mothers of higher-order multiples adhere to current AAP SIDS recommenda- tions over the infants’ first year of life, specifically concerning sleep practices and feeding. LITERATURE REVIEW Higher-order multiple infants are defined as the birth of triplets, quadruplets, and more from a single gestation. The birth rate of higher-order multiples peaked in 1998 and since then has declined to the Adherence to Safe Sleep Recommendations by Families With Higher-order Multiples Madeline C. Haas, BSN, RN; Donna Dowling, PhD, RN; Elizabeth G. Damato, PhD, RN ABSTRACT Background: More than 95% of higher-order multiples are born preterm and more than 90% are low birth weight, mak- ing this group of infants especially vulnerable to sudden infant death syndrome (SIDS). Emerging evidence suggests that families with twins face challenges adhering to the American Academy of Pediatrics (AAP) recommendations to reduce SIDS risks. Adherence to the AAP recommendations in families with higher-order multiples has not been described. Purpose: This study describes SIDS risk reduction infant care practices for higher-order multiples during the first year of life. Methods: Mothers caring for higher-order multiple-birth infants were recruited from an online support group. An online survey was used to assess infant care practices when the infants were first brought home from the hospital as well as at the time of the survey. Results: Ten mothers of triplets and 4 mothers of quadruplets responded. Less than 80% of the mothers practiced “back to sleep” immediately postdischarge. Supine sleep positioning decreased over time, particularly during daytime naps. Only 50% of the infants shared the parents’ bedroom and approximately 30% bed-shared with their siblings. Sleep-time pacifier use was low. Implications for Practice: Safe sleep education must include specific questions regarding home sleeping arrangements, encouragement of breast milk feedings, supine positioning, and pacifier use at every sleep for higher-order multiple infants well before discharge in order for parents to plan a safe sleep environment at home. Implications for Research: Prospective studies to identify barriers and facilitators can inform future strategies support- ing adherence to safe sleep practices for higher-order multiple infants. Key Words: child rearing, cobedding, education, infant, multiple-birth offspring, premature, quadruplets, safe sleep recommendation adherence, sleep, sudden infant death, triplets Author Affiliations: Hillcrest Hospital, Mayfield Heights, Ohio (Ms Haas); and Case Western Reserve University, Cleveland, Ohio (Drs Dowling and Damato). This study was conducted at Case Western Reserve University, Cleveland, Ohio. M. Haas, D. Dowling, and E. Damato have received travel support from Mead Johnson Nutrition. The authors declare no conflicts of interest. Dr. Dowling, who is a Section Editor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was han- dled by other members of the editorial team for the journal. Correspondence: Elizabeth G. Damato, PhD, RN, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106 (egd@case.edu). Copyright © 2017 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000416