Questions and Answers for Professionals on Infant Sleeping Position and SIDS
In 1992, the American Academy of Pediatrics 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 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 positioning during sleep. Periodic surveys have confirmed that the prevalence of prone sleeping among infants in the United States has decreased from approximately 75% in 1992 to less than 25% in 1995. Provisional mortality statistics suggest that the death rate from SIDS has simultaneously decreased by over 25% -- by far the largest decrease in SIDS rates since such statistics have been compiled.
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?
The vast majority of studies which showed a relationship between sleep position and SIDS examined whether babies were placed "prone" versus "non-prone" (i.e., side or back). However, a few recent reports indicate that the risk of SIDS is greater for babies placed on their sides versus those placed truly supine. There is some evidence that the reason for this difference is that babies placed on their sides have a higher likelihood of spontaneously turning to prone. However, both non-prone positions (side or back) are associated with a much lower risk of SIDS than is prone. If the side position is used, caretakers should be advised to bring the dependent arm forward, to lessen the likelihood of the baby rolling prone.
Are there any babies who should be placed prone for sleep?
In published studies, the vast majority of babies examined were born at term and had no known medical problems. Babies with certain disorders have been shown to have fewer problems when lying prone. These babies include:
infants with symptomatic gastro-esophageal reflux (reflux is usually less in the prone position).
babies with certain upper airway malformations such as Robin syndrome (there are fewer episodes of airway obstruction in the prone position).
There may also be other specific infants in whom the risk/benefit balance favors prone sleeping. The risk of SIDS increases from approximately 0.86 SIDS deaths per 1,000 live births to 1.62 when babies sleep prone* (that is, 998 of every 1,000 prone-sleeping babies will not die of SIDS). This relatively small increased risk may be reasonable to accept, when balanced against the benefit of prone sleeping for certain babies. Health professionals need to consider the potential benefit when taking into account each baby's circumstances.
If it is decided to allow a baby to sleep prone, special care should be taken to avoid overheating or use of soft bedding since these factors are particularly hazardous for prone-sleeping infants.
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. 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. Unless there are specific indications to do otherwise (see exceptions above), the Task Force believes that such babies should be placed for sleep on their backs.
In what position should babies be placed for sleep in hospital full-term nurseries?
Nearly all of the studies have been performed on babies who were beyond the neonatal period, mostly babies who were 2 to 6 months of age. However, experience in other countries has shown that mothers generally position their babies at home similar to the way they were placed in the hospital. Therefore, the Task Force recommends that personnel in hospital nurseries place babies in a supine position or on their sides. If there are concerns about possible aspiration in the immediate neonatal period, the baby may be placed on the side and propped against the side of the bassinet for stability.
If a baby doesn't sleep well in the supine position, is it okay to turn him or her to a prone position?
Positional preference appears to be a learned behavior among infants from birth to 4 to 6 months of age. The infant, being placed in a back or side position in the newborn nursery, will become accustomed to this position.
If the parent finds that the infant has great difficulty going to sleep in the supine position, consider placing the infant prone and moving the infant to a back position when he or she is sleeping. Again, be sure to avoid overheating or use of soft bedding with such an infant.
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 aged 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.
How should hospitals place babies down for sleep after they are readmitted?
We recommend, as a general guideline, that hospitalized infants sleep in the same position that they have used at home, to minimize additional disruption to the infant. There may, however, be extenuating circumstances that would indicate preference for the prone position (e.g., an infant with significant upper airway obstruction).
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.
There is some suggestion that the incidence of babies developing a flat spot on their occiputs may have increased since the incidence of prone sleeping has decreased. This is almost always a benign condition, which 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.
Should products be used to keep babies on their backs or sides during sleep?
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.
Experience from sleep position campaigns overseas suggests that most infants can be stabilized in the side position by bringing the infant's dependent arm forward, at right angles to the body, with the infant's back propped against the side of the crib. There should be no need for additional support. Infants who sleep on their backs need no extra support.
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 US 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.
For information on sleep position and SIDS risk reduction, call the "Back to Sleep" campaign line:
American Academy of Pediatrics
U.S. Public Health Service
Association of SIDS and Infant Mortality Programs