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Sleep Position and SIDS: Update from the American Academy of Pediatrics

Update from the American Academy of Pediatrics:

Positioning and SIDS: Update
Task Force on Infant Positioning and SIDS

Abstract: This statement provides an update to the June 1992 AAP policy, "Infant Positioning and SIDS," which recommended that healthy term infants be placed on their sides or backs to sleep. Recent data show that the original policy appears to have had a positive effect in decreasing the prevalence of prone sleeping significantly. Simultaneously, the SIDS rate in the United States has also dropped. New data also suggest that the supine position confers the lowest risk; however, the side position is still significantly safer than the prone position. Additional information regarding sleeping surface and exceptions to these recommendations are addressed.

In April 1992, the American Academy of Pediatrics (AAP) released a statement recommending that healthy infants be placed for sleep on their sides or backs, rather than being placed prone. The recommendation was based on numerous reports from other countries that showed that the prone sleeping position is associated with a higher incidence of sudden infant death syndrome (SIDS). The statement was followed by a detailed report from the Task Force on Infant Positioning and SIDS, which was published in the June 1992 issue of Pediatrics.[1] In 1994, another statement in Pediatrics reaffirmed the original statement and added a recommendation that soft surfaces or objects that might trap exhaled air should not be in an infant's sleeping environment, particularly under a sleeping infant.[2] The 1994 statement was issued jointly by the AAP and several governmental agencies and SIDS organizations and marked the initiation of a national campaign to encourage parents and caregivers to place healthy infants on their sides or backs when putting them down to sleep.

Since 1992, the National Institute of Child Health and Human Development has been funding annual surveys that have shown that the incidence of prone sleeping has decreased substantially. Currently, provisional data from the United States* suggest that the rate of SIDS has fallen progressively and coincidentally with the decrease in the number of infants sleeping prone. Although final mortality statistics require approximately 2 years for publication, the recently released final data for 1994 show the rate of SIDS in the United States to have fallen to 1.03 per 1000 live births - a 15%-20% decrease since before the 1992 recommendation and the largest significant decrease in the past decade.

The original recommendation was based on a series of studies that examined whether infants were placed in prone or nonprone sleeping positions, which resulted in the recommendation that infants be placed "on their backs or sides." However, recent reports from England[3] and New Zealand[4] indicate that the risk of SIDS is slightly greater for infants placed on their sides compared to those placed truly supine. There is some evidence that the reason for this difference is that infants placed on their sides have a higher likelihood of spontaneously turning to a prone position. However, both nonprone positions (side or back) are associated with a much lower risk of SIDS than the prone position.

The original recommendation also listed three exceptions for nonprone sleeping: "premature infants while they are experiencing respiratory disease, infants with symptomatic gastroesophageal reflux, and babies with certain upper airway malformations such as Robin Syndrome." The first exception, premature infants with respiratory disease, has caused some confusion when discharge from the hospital is being contemplated for a premature infant who has recovered from respiratory disease. Some data from both preterm[5] and term[6] infants show that respiratory function is slightly more stable when infants are lying prone. The Task Force has reviewed these studies and concluded that in asymptomatic infants, the slightly greater stability in respiratory physiology variables confers no proven clinical benefit to the healthy infant and does not outweigh the decrease in risk for SIDS conferred by the supine position. Therefore, to minimize confusion, the Task Force has deleted the reference to preterm infants in the list of exceptions to the recommendation. The action was taken primarily because the recommendation is for healthy infants only and also because there are no studies suggesting that recovered preterm infants are exempt from the increased risk of SIDS when placed prone.

When the recommendation was originally released, concerns were expressed that supine sleeping might be associated with an increase in adverse events, such as aspiration, acute life-threatening events, vomiting, poor sleeping, and flattened heads (positional plagiocephaly). Since 1992, Golding and coworkers (Jean Golding, PhD, DSc, written communication, September 1996) have carefully monitored such health factors of infants in the Avon area of the United Kingdom, where a marked change in sleeping positions from prone to supine occurred following a similar "Back-to-Sleep" campaign in England. Although a slight increase in the frequency of diaper rashes occurred with the increase in the numbers of infants sleeping supine, none of the other perceived complications were reported, and some of these adverse effects were actually found to be worse when infants were sleeping prone. Reports exist of an increase in the number of flat spots on the occiput, which apparently are occasionally misdiagnosed as lambdoidal craniosynostosis.[7] However, flat spots are generally of cosmetic significance only, can usually be avoided, and surgery is almost never indicated.[8,9] Positional plagiocephaly can also be avoided by altering the supine head position during sleep time by changing the orientation of the baby to outside activity (eg, the door of the room). The AAP does not approve of restrictive devices to hold the infant's head in place. When infants are able to easily turn over from the supine to the prone position, they should still be put to sleep in the supine position, but allowed to adopt whatever position they prefer.

In view of the previously described findings, the AAP Task Force on Infant Positioning and SIDS has elected to modify its original recommendations slightly:

1.Infants should be placed for sleep in a nonprone position. a supine position (wholly on the back) confers the lowest risk and is preferred. However, a side position also carries a significantly lower risk than a prone position. If the side position is used, caregivers should be advised to bring the dependent arm forward, to lessen the likelihood of the baby rolling into a prone position.

2.Soft surfaces and gas-trapping objects should be avoided in an infant's sleeping environment. Of particular importance, soft surfaces such as pillows or quilts should not be placed under a sleeping infant.

3.The current recommendation is for healthy infants only. The pediatrician should consider the relative risks and benefits. Gastroesophageal reflux and certain upper airway anomalies that predispose to airway obstruction and perhaps some other illnesses may be indications for a prone sleeping position.

4.The current recommendation is for infants during sleep. A certain amount of "tummy time," while the infant is awake and observed, is recommended for developmental reasons and to help prevent flat spots on the occiput.

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Task Force on Infant Positioning and SIDS, 1996-1997

John Kattwinkel, MD, Chair
John Brooks, MD
Maurice E. Keenan, MD
Michael Malloy, MD

Marian Willinger, PhD


1.American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89:1120-1126

2.Willinger M, Hoffman H, Hartford RB. Infant sleep position and risk for sudden infant death syndrome: report of meeting held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD. Pediatrics. 1994;93:814-819

3.Blair PS, Fleming PJ, Bensley D, et al. Smoking and the sudden infant death syndrome: results from 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. BMJ. 1996;313:195-198

4.Mitchell EA, Scragg R. Observations on ethnic differences in SIDS mortality in New Zealand. Early Hum Dev. 1994;38:151-157

5.Martin RJ, DiFiore JM, Korenke CB, Randal H, Miller MJ, Brooks LJ. Vulnerability of respiratory control in healthy preterm infants placed supine. J Pediatr. 1995;127:609-614

6.Adams JA, Zabaleta IA, Sackner MA. Comparison of supine and prone noninvasive measurements of breathing patterns in fullterm newborns. Pediatr Pulmonol. 1994;18:8-12

7.Kane AA, Mitchell LE, Craven KP, Marsh JL. Observations on a recent increase in plagiocephaly without synostosis. Pediatrics. 1996;97:877-885

8.Hunt CE, Puczynski MS. Does supine sleeping cause asymmetric heads? Pediatrics. 1996;98:127-29.

9.Persing J. Avoid needless skull surgeries by pinpointing cause. AAP News. 1996;12:13

The data from many countries around the world indicate the sleeping in the prone position (on the stomach) is associated with a higher risk of SIDS than not sleeping that way. Thus, from a scientific point of view, it seems that either back sleeping or side sleeping would reduce the risk conferred by prone sleeping.

My opinion is that back sleeping is preferable. The reason is that the side position is the most unstable. Infants will often roll one way or the other. Usually, parents have to prop their baby to keep them on the side. Most commonly, the prop is placed in the back, which insures that the baby will roll onto the stomach --- the position we do not want. In other countries, back sleeping has NOT been associated with aspiration or choking on vomitus. It appears that otherwise healthy babies can handle their secretions in any position.

I am concerned that gadgets designed to hold the baby on the side, but which also constrain the baby's movement, may also pose risks. Therefore, I recommend sleeping on the back.

I hope this helps. Thank you.

Tom Keens
Children's Hospital Los Angeles

The side position has in general been considered less effective than supine because it is less stable, and some infants rolling from the side will end up sleeping prone. The only specific and objective data in this regard was reported at the June International Conference by Peter Fleming (Avon, UK). He reported that the relative risk of SIDS when sleeping on the side is double the risk of SIDS when sleeping supine. We do not currently have any data on this question in the U.S.; nevertheless, I am in full agreement that we should recommend only the supine position for sleeping. That is, although side appears to be much better than prone, it is not as effective as supine sleeping. I hope this is helpful.

Carl E. Hunt, M.D.
Toledo/Washington D.C.

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