Can Text Message Videos Help Families Keep Babies Safe While They Sleep?

What the SMARTER study (Moon et al., JAMA, 2026) found when it sent safe sleep videos to pregnant women and new mothers with low incomes in the United States

A large US study tested whether sending short safe sleep videos by text message to pregnant women and new mothers with low incomes would change how they put their babies to sleep. Most mothers in every group were already following the main safe sleep advice, and the videos did not clearly change those habits. Mothers who began getting the videos during pregnancy were more likely to say they put their baby on the back for every single sleep, a hopeful early sign that still needs confirming.

A study about safe sleep advice delivered by phone

Bringing a new baby home comes with a flood of advice, and some of the most important is about sleep: where the baby sleeps, in what position, and what should (and should not) be in the crib. A team of US researchers led by Dr Moon wanted to know whether a phone could help deliver that advice at the right moments. Their study, the Social Media and Risk-Reduction Training-Enhanced Reach (SMARTER) trial, was published in 2026 [1]. It took place across the United States, enrolling pregnant women through WIC offices and community health centres in 17 states and Washington, DC. WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children, a government programme that supports families with low incomes.

Why the way a baby sleeps matters so much

Each year in the United States, about 3500 babies die suddenly and unexpectedly during sleep, according to the American Academy of Pediatrics, the main professional organisation for US children's doctors. The rate of these deaths has barely changed since 2000 [2]. Doctors group them under the name sudden unexpected infant death, or SUID, which includes sudden infant death syndrome (SIDS, when no cause is found) and accidental suffocation in bed [2]. After the 1990s "back to sleep" advice told parents to put babies down on their backs, the number of babies dying during sleep fell dramatically [3]. Progress then stalled. A long-running national survey found that the share of babies placed on their backs stopped rising after 2001, and that parents' choices were shaped by worries about comfort and choking and by what their doctor said [4]. Over the same years, sharing a bed with a baby became more common, rising from about 7 in 100 families in 1993 to about 14 in 100 in 2010 [5]. Soft items such as blankets and pillows in the baby's sleep space became less common, but were still used for about 55 in 100 babies in 2008–2010 [6]. Even in recent years, roughly 80 in 100 mothers report putting their baby on the back, and only about 33 in 100 report a sleep space free of unsafe bedding [7]. These risks do not fall evenly. Black babies die of SUID at about twice the rate of White babies [8], and unsafe sleep habits are more common among mothers who have Medicaid or no health insurance [7].

Today's advice from the American Academy of Pediatrics is a simple set of habits: put the baby on the back for every sleep, on a firm flat surface, in the parents' room but not in the parents' bed, with nothing soft in the sleep space, and offer a pacifier [2][1]. Several years ago, the same research team tested sending short videos about these habits by email or text to new mothers who gave birth at 16 US hospitals. In that study of 1600 mothers of healthy full-term babies, the videos helped: for example, about 89 in 100 mothers who got safe sleep videos usually put their baby on the back, compared with about 80 in 100 who did not [9]. The new study asked whether this would also work for families with low incomes, and whether starting during pregnancy would help even more.

How the study worked

The researchers enrolled pregnant women with low incomes who were less than 32 weeks pregnant and could receive text messages in English or Spanish [1]. The study was "randomized", which means a computer decided by chance which videos each woman would receive, like flipping a coin. This is the fairest way to compare groups. It happened twice: once at 34 weeks of pregnancy, and again right after the baby was born. One group received safe sleep videos, and the comparison group received videos about breastfeeding. This created four groups of mothers: those who got safe sleep videos before and after birth, before birth only, after birth only, or not at all.

The videos, each less than 3 minutes long, mixed advice from health professionals with stories from other parents. They arrived once or twice a day in the first week, then two or three times a week, continuing until the baby was 60 days old. Mothers also answered short text questions about how their baby was sleeping. Those in the safe sleep group received encouragement or gentle correction based on their answers. All mothers continued to get the usual advice from their doctors, nurses and WIC staff. When the babies were about 2 months old, mothers filled in a final survey about their baby's sleep.

What the researchers found

In total, 1790 women took part, and 1383 of them answered the final survey [1]. The main question was about four habits mothers used most of the time: back sleeping, room sharing without bed sharing, keeping soft items out of the sleep space, and pacifier use. These habits were already very common in every group. For example, about 88 to 92 out of every 100 mothers said they usually put their baby on their back, whether or not they had received safe sleep videos. With so many families already doing the right thing, there was little room for the videos to make a difference. In the end, the researchers did not find a clear effect on any of the four main habits.

The more hopeful finding concerned a stricter measure: putting the baby on the back for every sleep, including naps. This matters because babies who are not used to sleeping on their tummies face a much higher risk of SIDS on the occasions they are put down that way [10]. Among mothers who received safe sleep videos during pregnancy, roughly 71 out of every 100 said they always put their baby on the back, compared with about 61 out of 100 in the comparison group [1]. Mothers who got the videos during pregnancy were also more likely to plan to always use back sleeping. These extra results were not the main question, and the researchers say they cannot draw firm conclusions from them.

Reading the results fairly

Like all studies, this one has limits. The information came from mothers' own reports, and mothers who had been sent safe sleep videos might have felt uncomfortable admitting that they did not always follow the advice [1]. Nearly 1 in 4 women did not complete the final survey. Those who did not answer were more likely to be younger, to have lower incomes, or to speak Spanish, so the results may not fully reflect the families who face the greatest risks. Only about half of mothers opened six or more of the 53 videos they were sent. The study also did not report on any possible downsides.

What this means for families, including NICU families

If you are expecting a baby or have just brought one home, this study is a reminder that the small details matter. "Usually on the back" is good, but "always on the back, for every nap and every night" is the goal. Talking about safe sleep before the baby arrives may help families plan ahead. Many parents in this study were already doing a great job, which is genuinely encouraging.

Families whose babies spent time in a neonatal intensive care unit (NICU), the hospital unit that cares for sick or premature newborns, should know that babies born before 34 weeks of pregnancy were not included in this study. The researchers left them out so the videos would not conflict with the advice parents receive from the NICU team. Babies born a few weeks early are less often placed on their backs than full-term babies [11], and premature babies remain at higher risk of SIDS [12]. If your baby was in the NICU, the safe sleep habits your nurses model before you go home are especially important. Another In[Neo]Sight article, From Rounds to Release, looks at how NICUs teach safe sleep before discharge.

What researchers are working on next

The research team suggests that starting safe sleep education during pregnancy "may hold promise" and deserves a new study focused on back sleeping for every sleep [1]. They also call for a programme designed specifically for babies born prematurely. Future studies will need to reach and keep the families at highest risk, because unsafe sleep habits are linked to both accidental suffocation and unexplained deaths [13].

The take-home message

Sending safe sleep videos by text did not clearly change the main sleep habits of families with low incomes, possibly because so many were already following the advice. Starting the conversation during pregnancy, and aiming for back sleeping at every single sleep, may be where the next gains lie.

References

  1. Moon RY, Colson ER, Hauck FR, et al. Safe Sleep Video Intervention via Text Messaging to Low-Income Families: The SMARTER Randomized Clinical Trial. JAMA. 2026;336(9):774-782. doi:10.1001/jama.2026.9119 ↩
  2. Moon RY, Carlin RF, Hand I. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990 ↩
  3. Bombard JM, Kortsmit K, Warner L, et al. Vital Signs: Trends and Disparities in Infant Safe Sleep Practices - United States, 2009-2015. MMWR Morb Mortal Wkly Rep. 2018;67(1):39-46. doi:10.15585/mmwr.mm6701e1 ↩
  4. Colson ER, Rybin D, Smith LA, Colton T, Lister G, Corwin MJ. Trends and factors associated with infant sleeping position: the national infant sleep position study, 1993-2007. Arch Pediatr Adolesc Med. 2009;163(12):1122-1128. doi:10.1001/archpediatrics.2009.234 ↩
  5. Colson ER, Willinger M, Rybin D, et al. Trends and factors associated with infant bed sharing, 1993-2010: the National Infant Sleep Position Study. JAMA Pediatr. 2013;167(11):1032-1037. doi:10.1001/jamapediatrics.2013.2560 ↩
  6. Shapiro-Mendoza CK, Colson ER, Willinger M, Rybin DV, Camperlengo L, Corwin MJ. Trends in infant bedding use: National Infant Sleep Position study, 1993-2010. Pediatrics. 2015;135(1):10-17. doi:10.1542/peds.2014-1793 ↩
  7. Edmondson C, Shenoy RD, Herrera JH, Williams K, Acuna JM. Maternal adherence to safe infant sleep recommendations in the USA: trends and disparities from PRAMS 2016-2022. BMJ Paediatr Open. 2026;10(1):e004382. doi:10.1136/bmjpo-2025-004382 ↩
  8. Boyer BT, Lowell GS, Roehler DR, Quinlan KP. Racial and ethnic disparities of sudden unexpected infant death in large US cities: a descriptive epidemiological study. Inj Epidemiol. 2022;9(1):12. doi:10.1186/s40621-022-00377-7 ↩
  9. Moon RY, Hauck FR, Colson ER, et al. The Effect of Nursing Quality Improvement and Mobile Health Interventions on Infant Sleep Practices: A Randomized Clinical Trial. JAMA. 2017;318(4):351-359. doi:10.1001/jama.2017.8982 ↩
  10. Mitchell EA, Thach BT, Thompson JM, Williams S. Changing infants' sleep position increases risk of sudden infant death syndrome. New Zealand Cot Death Study. Arch Pediatr Adolesc Med. 1999;153(11):1136-1141. doi:10.1001/archpedi.153.11.1136 ↩
  11. Hwang SS, Barfield WD, Smith RA, et al. Discharge timing, outpatient follow-up, and home care of late-preterm and early-term infants. Pediatrics. 2013;132(1):101-108. doi:10.1542/peds.2012-3892 ↩
  12. Malloy MH. Prematurity and sudden infant death syndrome: United States 2005-2007. J Perinatol. 2013;33(6):470-475. doi:10.1038/jp.2012.158 ↩
  13. Parks SE, DeSisto CL, Kortsmit K, Bombard JM, Shapiro-Mendoza CK. Risk Factors for Suffocation and Unexplained Causes of Infant Deaths. Pediatrics. 2023;151(1):e2022057771. doi:10.1542/peds.2022-057771 ↩