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

Objective: To assess the proportion of pictures of sleeping infants or infant sleep environments that are inconsistent with safe infant sleep recommendations (SISRs) in the visual exposome of infant caretakers. Design: A systematic review and meta-analysis. Data sources and study selection: In November 2023, we searched PubMed, Scopus, Web of Science and Google Scholar to identify studies evaluating the level of inconsistency between SISRs and pictures in public spaces. The risk of bias of included studies was assessed with a customised version of Hoy's tool for prevalence studies. Random-effects meta-analyses were used to obtain summary estimates of the proportion of pictures inconsistent with SISRs. Results: We screened 1380 records and included 7 peer-reviewed articles reporting studies conducted between 2008 and 2023 that analysed pictures found in parenting magazines, online and print newspapers, baby diaper packaging, commercial stock photography websites and Instagram. The overall risk of bias was low. Among the 5442 pictures depicting sleeping infants or infant sleep environments, summary estimates of the proportion of inconsistencies with SISRs were 37% for a non-supine sleeping position, 6% for a soft sleeping surface, 8% for sharing the sleeping surface, 15% for an unsafe crib, 73% for soft objects or loose bedding, 89% for no pacifier use, 17% for a covered head, and 89% for at least one SISR inconsistency. Conclusions: Infant caretakers' visual exposome is greatly inconsistent with SISRs. Given the evidence in support that pictures affecting human behaviour, these results should serve as a call to action for stakeholders and legislators.