Sleeping Position and SIDS

Questions and Answers for Professionals
on Infant Sleeping Position and SIDS

From;116/5/1245 and (Back to Sleep Public Education Campaign)

In 1992, the American Academy of Pediatrics (AAP)released a statement recommending that all healthy infants be placed down for sleep on their backs (Pediatrics, 1992;89:1120-1126). This recommendation was based on numerous reports that babies who sleep prone (face down) have a significantly increased likelihood of dying of sudden infant death syndrome (SIDS). The recommendation was reaffirmed in 1994 (Pediatrics, 1994;93:820). Health care professionals are encouraged to read both publications for a review of the evidence that led to the recommendation.

A national campaign (the “Back to Sleep” campaign) was launched in 1994 to promote supine (lying on back) positioning during sleep. Periodic surveys have confirmed that the prevalence of prone sleeping among infants in the United States has decreased from approximately 75 percent in 1992 to 11 percent  in 2002. Between 1992 and 2001, there was a more than 50 percent reduction in SIDS deaths, but a slight increase in prone sleeping since 2002 may be contributing to the lack of further reduction.

Although the recommendation appears simple (most babies should be put to sleep on their backs), a variety of questions have arisen about the practicalities of implementation. The AAP Task Force on Infant Sleep Position and SIDS has considered these questions and prepared the following responses. It should be emphasized, however, that for most of these questions there are not sufficient data to provide definitive answers.

Is the side position as effective as the back?

Recent reports indicate that the risk of SIDS is greater for babies placed on their sides versus those placed truly supine. The reason for this difference is that babies placed on their sides have a higher likelihood of spontaneously turning to prone. The AAP now recommends only supine (back) position for sleep.

Baby on tummy

Should healthy babies ever be placed prone?

Since the initiation of the national campaign, some parents have misinterpreted the recommendation to say that babies should never be placed prone. This is incorrect. Developmental experts advise that prone positioning during the awake state is important for shoulder girdle motor development to promote head control. Therefore, parents should be advised that a certain amount of “tummy time” when the baby is awake and observed is good.

Which sleeping position is best for a baby born preterm who is ready for discharge?

There have been studies showing that preterm babies who have active respiratory disease have improved oxygenation if they are prone. However, these babies have not been specifically examined as a group once they are recovered from respiratory problems and are ready for hospital discharge. There is no reason to believe that they should be treated any differently than a baby who was born at term.

At what age can you stop using the back position for sleep?

We are unsure of the level of risk associated with prone positioning at specific ages during the first year of life, although there are some data that suggest that the greatest decrease in SIDS incidence in those countries that have changed to mostly non-prone sleeping has been seen in the younger infants (2 to 6 months).

Therefore, the first 6 months, when babies are forming sleeping habits, are probably the most important time to focus on. Nevertheless, until more data suggest otherwise, it seems reasonable to continue to place babies down for sleep supine throughout infancy.

Do I need to keep checking on my baby after laying him or her down for sleep in a non-prone position?

We recommend that parents do not keep checking on their baby after he or she is laid down to sleep. Although the infant’s risk of SIDS could be increased slightly if he or she spontaneously assumes the prone position, the risk is not sufficient to outweigh the great disruption to the parents, and possibly to the infant, by frequent checking. Also, studies have shown that it is unusual for a baby who is placed in a supine position to roll into a prone position during early infancy.

Will babies aspirate on their backs?

While this has been a significant concern to health professionals and parents, there is no evidence that healthy babies are more likely to experience serious or fatal aspiration episodes when they are supine. In fact, in the majority of the very small number of reported cases of death due to aspiration, the infant’s position at death, when known, was prone.

In addition, indirect reassurance of the safety of the supine position for infants comes from the knowledge that this position has been standard in China, India and other Asian countries for many years. Finally, in countries such as England, Australia and New Zealand, where there has been a major change in infant sleeping position from predominantly prone to predominantly supine or side sleeping, there is no evidence of any increased number of serious or fatal episodes of aspiration of gastric contents.

Will supine sleeping cause flat heads?

There is some suggestion that the incidence of babies developing a flat spot on their occiputs (back part of head or skull) may have increased since the incidence of prone sleeping has decreased. This is almost always a benign condition that will disappear within several months after the baby has begun to sit up.

Flat spots can be avoided by altering the supine head position. Techniques for accomplishing this include turning the head to one side for a week or so and then changing to the other, reversing the head-to-toe axis in the crib and changing the orientation of the baby to outside activity (e.g., the door of the room). “Positional plagiocephaly” seldom, if ever, requires surgery and is quite distinguishable from craniosynostosis.

The risk of positional plagiocephaly can be reduced through a few simple measures:

  • Baby on shoulderProvide an infant with plenty of supervised play time on his or her tummy. This helps build and strengthen neck, shoulder and arm muscles.
  • Change the direction that the baby is lying in the crib on a regular basis to ensure he or she is not always resting on the same part of the head. For example, have the baby’s feet point toward one end of the crib for a few days, and then change the position so his or her feet point toward the other end of the crib.
  • Avoid too much time in car seats, carriers and bouncers while the baby is awake.
  • Frequently get “cuddle time” during the day by holding the baby upright over one shoulder.
  • When holding, feeding or carrying an infant, make sure that there is no undue pressure placed on the flat side of the head. Change infant’s head position from side to side during feeding time.
  • Change the location of the baby’s crib in the room so that he or she has to look in different directions to see the door or the window

Should products be used to keep babies on their backs or sides during sleep?

Baby in a crib

Although various devices have been marketed to maintain babies in a non-prone position during sleep, the Task Force does not recommend their use. None of the studies that showed a reduction In risk when the prevalence of prone sleeping was reduced used devices. No studies examining the relative safety of the devices have been published.

Should soft surfaces be avoided?

Several studies indicate that soft sleeping surfaces increase the risk of SIDS in infants who sleep prone. How soft a surface must be to pose a threat is unknown.

Until more information becomes available, a standard firm infant mattress with no more than a thin covering, such as a sheet or rubberized pad, between the infant and mattress is advised. The U.S. Consumer Product Safety Commission has also warned against placing any soft, plush or bulky items, such as pillows, rolls of bedding or cushions, in the baby’s immediate sleeping environment. These items can potentially come into close contact with the infant’s face, impeding ventilation or entrapping the infant’s head and causing suffocation.

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