Text-message video intervention does not improve infant safe sleep practices in low-income families

Prenatal and postnatal video education delivered by text message did not significantly improve the 4 primary infant safe sleep outcomes among low-income families, according to results of the SMARTER randomized clinical trial published in JAMA.¹ The 4-group trial enrolled 1790 pregnant individuals who were WIC clients or had Medicaid or no insurance, randomizing them separately at 34 weeks' gestation and again at delivery to receive safe sleep videos, breastfeeding-focused control videos, or both.¹

The study authors wrote that despite the null primary findings, several secondary outcomes—particularly exclusive supine positioning—improved among mothers who began safe sleep messaging before birth, suggesting prenatal timing may matter more than previously emphasized.¹

SMARTER trial design and primary safe sleep outcomes

The trial, conducted at WIC centers and federally qualified health centers across 17 states and Washington, DC, from May 2022 through December 2024, tested prenatal-only, postnatal-only, combined, and control video interventions delivered via text link, each under 3 minutes long.¹

Of 1383 participants who completed a survey 60 or more days after birth, primary outcomes—usual supine positioning, usual room sharing without bed-sharing, no soft bedding use, and any pacifier use—ranged from 87.6% to 92.2%, 83.8% to 89.5%, 75.6% to 84.5%, and 72.5% to 76.0%, respectively, across groups, with no statistically significant between-group differences after adjustment for multiple comparisons.¹

Secondary outcomes: exclusive supine positioning and soft bedding use

Among 7 secondary outcomes, the prenatal intervention alone was associated with higher exclusive supine positioning at 60 days compared with control (70.6% vs 60.9%; adjusted risk difference, 9.7 percentage points; 95% CI, 3.8-15.0), along with a longer time to first report of nonexclusive supine sleep and reduced soft bedding use.¹

Postnatal-only intervention did not show a similar benefit for exclusive supine positioning, though combined prenatal and postnatal exposure produced the highest observed rate (75.4%). Neither intervention arm affected exclusive room sharing without bed-sharing.¹

Clinical context: sudden unexpected infant death burden and disparities

Sudden unexpected infant death remains a leading cause of postneonatal mortality in the US, causing more than 3500 deaths annually, with disproportionate burden among low-income and racial and ethnic minority families.¹ The American Academy of Pediatrics' 2022 policy statement continues to recommend supine positioning, room sharing without bed-sharing, and a firm sleep surface free of soft bedding as core strategies to reduce risk, noting that death rates have plateaued since 2000 despite earlier gains from the Back to Sleep campaign.²

Comparing SMARTER with prior mobile health safe sleep data

The same research group previously reported that a nursing-delivered mobile health video intervention in an economically diverse population increased usual supine positioning to 92.5% and produced a 14.9–percentage point increase in exclusive supine positioning versus control.³

In the current trial, usual supine rates (87.6%-91.4%) were similar across all 4 groups, and postnatal messaging alone did not replicate the earlier exclusive-positioning benefit, a pattern the authors said may point to the added value of starting education before delivery rather than after.¹

Limitations and next steps for safe sleep text messaging research

The authors cited several constraints, including reliance on self-reported outcomes, which may have led intervention recipients to overreport adherence, and a study design with 4 primary outcomes, 7 secondary outcomes, and 2 intervention arms that limited statistical power.¹

Nonrespondents to the 60-day survey were more likely to be younger, Hispanic or non-Hispanic Black, non-US born, and lower income, raising questions about generalizability to families least likely to complete the trial. The authors also noted that ceiling effects—given that roughly 90% of all groups already reported usual supine and room-sharing practices—may have constrained the trial's ability to detect intervention effects on the primary outcomes.¹

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. Published online July 23, 2026. doi:10.1001/jama.2026.9119

2. Moon RY, Carlin RF, Hand I; Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. 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. 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