Data from 27 hashtags were collected in June 2020. Of the 5400 Instagram images scraped (first 200 images from 27 hashtags), a total of 1563 met inclusion criteria. Of those, nearly three-quarters (1134, 72.55%) had a sleeping infant, and 429 (27.45%) portrayed a sleep environment without a sleeping infant (Table 2). Of the 1563 images, 117 (7.49%) were consistent with AAP safe sleep guidelines. For another 93 (5.95%) images, the sleep location (eg, crib, bed) of the sleeping infant could not be determined, but these images otherwise were consistent with AAP safe sleep guidelines.

Table 3 provides details about the images. The percentages in Table 3 are row percentages, which indicate the number of images in the particular cell, divided by the total number of images in the same row.

Of the 1134 images that portrayed a sleeping infant, 488 (43.03%) showed the infant sleeping supine, and 169 (14.90%) showed a sleeping infant held by an awake adult. There were 479 (42.24%) images that were inconsistent with AAP recommendation to place infants supine on a firm and flat surface, including 222 (19.58%) images with an infant sleeping on the side, 156 (13.76%) with an infant sleeping prone, and 101 (8.91%) with a sleeping infant that was in the sitting position.

In the 1563 images of infant sleep environments, the presence of bedding was the most common reason that the image was inconsistent with safe sleep guidelines; of all images, 1173 (75.05%) contained some form of soft or loose bedding. The most commonly observed bedding type was an unswaddled blanket, which was present in 836 images (71.27% of 1173 images with bedding, 53.49% of all 1563 images). The next most common was a pillow, found in 536 images (45.69% of 1173 images with bedding, 34.29% of all 1563 images). Bumpers were found in 146 images (12.45% of 1173 images with bedding, 9.34% of all 1563 images), and a stuffed animal or other soft bedding was found in 331 images (28.22% of 1173 images with bedding, 21.18% of all 1563 images).

A crib, bassinet, play yard, or bedside co-sleeper was the most commonly observed sleep location (422/1563, 27.00%). Other sleep locations included a Moses basket (150/1563, 9.60%); adult or child bed (128/1563, 8.19%); sitting device such as a car seat or stroller (90/1563, 5.76%); a couch or sofa (55/1563, 3.52%); the ground or floor (31/1563, 1.98%); and an in-bed co-sleeper, positioner, or infant “dock” (eg, DockATot; 17/1563, 1.09%). The largest proportion (670/1563, 42.87%) of images portrayed an infant in a location that could not be definitively identified. Of the images with an unidentified location, 577/670 (86.1%) demonstrated other aspects of the sleep environment that were inconsistent with AAP safe sleep guidelines.

Bed-sharing was seen in 65 (5.73%) of all 1134 images with an infant present. An adult bed-sharer was the most common (n=37; 22.4% [37/165] of bed-sharing images, 3.26% [37/1134] of images with an infant present) followed by a child (n=21; 12.7% [21/165] of bed-sharing images, 1.85% [21/1134] of images with an infant present) and an animal (n=7; 4.24% [7/165] of bed-sharing images, 0.62% [7/1134] of images with an infant present).

We separately analyzed images in which the infant was obviously posed and did not represent a true infant sleep environment (eg, flowerpot). This category does not include other images for which the infant may have been posed but were potential infant sleep environments (eg, infant posed on a sofa). There were 174 such images (15.34% of 1134 images with an infant present). Of these, 167 (96.0%) images had elements that were inconsistent with AAP guidelines. The other 7 images (4.0%) were consistent with AAP guidelines with the possible exception of the sleep location, which could not be determined. In the 174 posed images, the infant was prone in 52 (29.9%), supine in 45 (25.9%), on the side in 36 (20.7%), sitting upright in 34 (19.5%), and held by an adult in 7 (4.0%). Infants in posed images, when compared with those in unposed images, were 19.7 percentage points more likely to be portrayed in a nonsupine or upright position (P<.001), and were overall more likely to be portrayed in a sleep environment that was inconsistent with AAP guidelines (P<.01).

Images adhering to AAP safe sleep guidelines had a mean 127.8 likes (SD 370.5); if the images with undetermined location were excluded, the mean like count was 181.7 (SD 461.0). Images with elements inconsistent with AAP guidelines had a mean of 128.4 likes (SD 509.9). There was no significant difference in the mean like count between nonadherent images and total adherent images (P=.99). When images with undetermined location were excluded, images adhering to AAP guidelines had a higher mean like count than nonadherent images (P=.001).

Of the 1563 Instagram images analyzed, only 117 (7.49%) were clearly consistent with AAP safe sleep guidelines. Another 93 (5.95%) were possibly consistent, but were taken in such a way that the sleep environment could not be fully visualized. This means that, even when these images with incomplete information are included, an overwhelming majority (1353/1563, 87%) of Instagram images portrayed unsafe infant sleep environments, as defined by the AAP.

Nearly half of businesses are active on Instagram [56]. As with any marketing strategy, businesses use Instagram to increase sales of their product(s). Businesses are guided to post aesthetically pleasing photos of their products, liberally use hashtags, and facilitate purchases from the website [59]. Company statistics indicate that these strategies are successful in promoting sales of products, as nearly half of surveyed Instagram users stated that they have purchased a product after seeing it on Instagram [56]. While Instagram’s Community Guidelines prohibit content with “the potential to contribute to real-world harm” [60] and the Commerce Policies prohibit sale of “medical and healthcare products and services, including medical devices” [61], there are no rules that specifically address posting of photos that demonstrate unsafe sleep practices.

Although many prospective and new parents purchase products from traditional stores that sell products in person (and in some stores, employees may provide guidance regarding safe sleep guidance), there has been a steady increase over the past decade in the proportion of products sold online [62]. Thus, images posted online, particularly on websites that are viewed by a large proportion of the population, can be extremely influential [63]. Many companies, especially those that advertise on Instagram, utilize a “brand ambassador” program in which parents themselves are sponsored to post pictures promoting a certain product. A direct potential consequence of peers consistently modeling and posting images of specific, unsafe sleep environments is the misconception among new parents that these practices are safe, when physician advice is to the contrary. With regard to infant sleep practices, mothers are more likely to change from safe to unsafe sleep practice if their network members substantially espouse unsafe practices [64], and this may be true for virtual network members as well. The ability for social media to influence the behavior of a large proportion of the population is a well-known phenomenon [47]; indeed, there are now “influencers,” who are especially prominent on Instagram. These individuals are paid for their posts because their use of products results in increased sales [65]. Not only do they influence certain practices, but they may create completely new ones as well [66,67].

The Theory of Planned Behavior states that one’s behavior is shaped by social norms, and that these norms directly impact one’s attitudes about the specific behavior [68]. One’s practices and rationalizations for these practices are learned from and reinforced by others [69,70], so that one’s behavior becomes increasingly similar to that of network members [2,3,15-22]. Infant sleep practices, especially sleep environments, are not immune from these forces. Images of cribs and bassinets littered with toys, blankets and pillows, infants sleeping nonsupine, or infants wearing warm head coverings or hats with long strings (that pose a strangulation hazard) are displayed, often unopposed, on social media sites. The images, which are usually well produced and chosen because they appear “authentic,” come to represent “desirable” environments one wants to emulate [71]. With no regulations relevant to safe infant sleep practices inherent to Instagram, the proxy for acceptability may become how popular or common a sleep environment is. Even though not all of the nonadherent images were posted by individuals, and many (174/1134, 15.3%) were very obviously posed for a photographer, our findings demonstrate that the culture of infant sleep on Instagram is one that does not promote infant safety as a priority.

Nearly half (479/1134; 42.24%) of sleeping infants were portrayed in the nonsupine position; while some may think it encouraging that the majority were in recommended positions (supine or held by an awake adult), the sizeable proportion of infants sleeping nonsupine suggests that supine positioning is not the social norm for many. More concerning is the majority (1173/1563; 75.05%) of images demonstrating the presence of soft bedding. This proportion is similar to national data on bedding use reported by Shapiro-Mendoza and colleagues [37]. Important reasons for such widespread use of soft bedding by parents or guardians include concerns about comfort and warmth [72]. On a social media platform such as Instagram, the use of bedding could also be for purely aesthetic purposes [72], or to signify the status or creativity of the person posting the image.

Cribs were found in 77.62% (333/429) of the images with no baby present, but in only 27.00% (422/1563) of images overall. Many of these images were posted by marketers or decorators (eg, #nurseryinspirations) who aim to establish images of expected or normative practice for parents decorating a new nursery. While cribs are consistent with AAP safe sleep recommendations, many of the other products shown in these marketing images are not. Three-quarters (1173/1563; 75.05%) of these images had soft bedding, including loose blankets, pillows, and bumpers, present.

There is a common assumption that if an object is being sold, then it is safe to use [44]. On social media platforms, the safety assumption can be taken one step further because there is a scoring mechanism to see how popular a practice is: likes. Pictures with more likes may be viewed as more acceptable and thus safe. With regard to the number of likes for images that were consistent or inconsistent with AAP safe sleep guidelines, the mean was similar for these 2 categories. However, it should be noted that there were approximately 12 times fewer images that were consistent with safe sleep guidelines, potentially creating a bias.

This study, as is any study involving social media as its data source, is limited by the fact that the sample is inherently biased. Individuals who use Instagram and post pictures of sleeping infants or infant sleep environments may not actually use these practices regularly. For example, a large proportion of images included bedding. Blankets, stuffed animals, and pillows can all be used to make the image more aesthetically pleasing, but may not be in the infant’s actual sleep environment. However, the purpose of this study was not to analyze actual practices, but to look at the culture of what is considered desirable to display and be propagated on the platform. We also did not analyze image captions, which may alter the viewer’s perception of the image. However, Tiggemann et al [73] found that the effect of a “positive” caption did not significantly change someone’s perception of an image that would otherwise make them feel dissatisfied with their body. Further study into the types of captions associated with certain hashtags, as well as the content of captions in safe versus unsafe pictures is necessary to more fully understand the landscape of safe infant sleep on Instagram.

In conclusion, the vast majority of images pertaining to infant sleep are inconsistent with AAP safe sleep guidelines. It is imperative that health care providers at least know and understand the landscape of normative practices on social media so they can best tailor either specific patient advice or public health approaches [74]. Additionally, campaigns to promote safe sleep may require health care professionals and officials to work with influencers and social media companies to promote up-to-date, evidence-based information about current recommendations that is trustworthy and engaging.