Medical Advice >> Pediatric Advisor

The Preferred Position: On the Back (Supine)

In 1992 the American Academy of Pediatrics (AAP) recommended that all healthy infants be positioned for sleep on their backs (supine) or on their sides for the first 6 months of life. In 1996, the AAP recommended the back as being preferred over the side position. The side position is an unstable one and has twice the risk of SIDS as the back position. In 1992, only 30% of U.S. infants slept on their back or side. Now about 80% of U.S. infants sleep on their backs.

Research Linking the Stomach (Prone) Position and SIDS

Most infants in the world are put to sleep lying on their backs. In the 1980s, research studies from Europe, Australia, and New Zealand showed that the back sleep position reduces SIDS (sudden infant death syndrome) 20% to 70%. Laying a baby on his stomach (prone position) has a 3 to 9 times greater risk of SIDS than the back position. The side position has a 2 times greater risk of SIDS than the back position. Although none of these studies were perfect, in 1992 the AAP recommended the back position because of the 6000 to 7000 SIDS deaths each year in the U.S. Although this change in sleeping position won't eliminate all SIDS risk factors, it should reduce the number of SIDS deaths.

Reasons the Stomach Position Might Increase SIDS

Laying a child on his stomach puts pressure on a his jaw bone. As a result, the airway in the back of the mouth becomes narrower. Also, if the child sleeps on a soft surface, the nose and mouth may sink in so the child breathes from a small pocket of stale air. In fact, the increased SIDS rate in countries such as New Zealand may be due not just to the stomach position, but also because they often place children on sheepskin pads. Everyone now agrees that young infants should never be placed on waterbeds, sheepskin, soft pillows, bean-filled pillows, or other soft, spongy surfaces. These surfaces are also potentially dangerous when a child is placed in the crib on his back because he may roll over during the night.

Risks of the Back Position

The main reason for the earlier recommendation of the stomach position was the concern that if a child spits up or vomits while lying on his back, he could inhale and choke on the vomited material. This concern led to a change of recommendations from the back to the stomach position in the U.S. and Canada in the 1950s. However, the AAP has found no evidence to support the belief that choking occurs more commonly in the back position than in other positions. Choking is an extremely rare cause of infant death in healthy, full-term infants. During the last 4 years, the rate of choking in infants has not increased.

The Exceptions: When the Stomach Position Is Recommended

The American Academy of Pediatrics recommends putting your baby to sleep on his stomach if he falls into one of the following 3 categories:

• Infants with complications of gastroesophageal reflux (spitting up). These complications include recurrent pneumonia from aspiration, choking, interruption of breathing (apnea), or acid damage to the lower esophagus (esophagitis). While spitting up is common, these complications are rare.
• Infants with birth defects of the upper airway that interfere with breathing. Examples are a large tongue, a very small mouth, or a large and floppy larynx.
• Premature babies who are having difficulty breathing or require oxygen. (Research shows that premature babies breathe better in the prone position.) By the time they come home, most premature babies should sleep on their backs.

Any baby who needs to sleep on his stomach must also be placed on a firm sleeping surface.

Stomach Position for Playtime

The back position is recommended for bedtime and naps. It is not necessary if your infant is awake. Yet many parents keep the infant lying on his back throughout the day. This can cause some flattening of the back of the head and also some decreased strength in the shoulder muscles. Avoid these side effects by keeping your infant on his stomach for some of his playtime and waking hours. When in the crib, babies tend to turn slightly toward the side where they can see people. Therefore, every week reverse the direction you lay your baby in his crib.

Summary

Many years have passed since 1992, when the AAP recommended that infants sleep on their backs. Now over 80% of parents follow this advice. Current national data shows a 40% drop in the SIDS rate. One study in Seattle showed a 50% drop in SIDS following an intensive sleeping-on-the-back campaign. Provide your baby an added margin of safety by placing him or her on the back for sleep. If you use a child care center or babysitter, be sure they know how important this is.

Other ways to reduce the risk of SIDS are to use a firm mattress (avoid soft bedding), breast-feed if possible, and protect your infant from exposure to cigarette, cigar, or pipe smoke. Don't let your baby sleep in your bed during the first 6 months. The mattresses in most adult beds are too soft for babies. Blankets and pillows also increase the risk.

For more information:

Sudden Infant Death Syndrome Alliance
1314 Bedford Ave. Ste. 210
Baltimore, MD 21208
800-221-SIDS(7437)
E-mail: sidshq@charm.net
http://www.sidsalliance.org

This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.