Positioning and SIDS - Pediatrics · Common Sleep Positions The predominant infant sleeping position appears to vary considerably from country to country. In the United States, most

1120 PEDIATRICS Vol. 89 No. 6 June 1992

Positioning and SIDS

AAP Task Force on Infant Positioning and SIDS

SUMMARY STATEMENT

Based on careful evaluation of existing data mdi-

cating an association between Sudden Infant DeathSyndrome (SIDS) and prone sleeping position forinfants, the Academy recommends that healthy in-

fants, when being put down for sleep, be positionedon their side or back. The most common position

currently used in the United States is prone.This recommendation is made with the full recog-

nition that the existing studies have methodologiclimitations and were conducted in countries with

infant care practices and other SIDS risk factors that

differ from those in the United States (eg, maternalsmoking, types of bedding, central heating, etc). How-ever, taken as a group the studies are convincing. Noreports show an advantage to the prone position withregard to SIDS incidence and there are no data prov-ing, or even strongly suggesting, that sleeping in thelateral or supine position is harmful to healthy infants.Thus, assessment of the risk/benefit balance for prone

vs nonprone positioning for such infants favors thelatter. It should be stressed that, the actual risk of

SIDS for an infant placed prone is still extremely low.There are still good reasons for placing certain

infants prone. For premature infants with respiratory

distress, for infants with symptoms of gastroesopha-geal reflux or with certain upper airway anomalies,and perhaps for some others, prone may well be theposition of choice. A nonprone sleeping position isrecommended for healthy infants only.

REPORT

Health care professionals frequently are asked how

it is best to place an infant down for sleep, prone or

supine. With lack of scientific studies clearly showingadvantages of one position over another, profession-als have tended to offer advice that seems most logicaland to be guided by general custom. However, thereis a growing body of literature reported from Europe,Australia, and New Zealand that suggests that theprone sleeping position may be associated with ahigher incidence of Sudden Infant Death Syndrome(SIDS). This report will review the evidence and offera recommendation for sleeping position of the healthybaby during early infancy.

The recommendations in this publication 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.

PEDIATRICS (ISSN 0031 4005). Copyright (� 1992 by the American Acad-

emy of Pediatrics.

Common Sleep Positions

The predominant infant sleeping position appears

to vary considerably from country to country. In theUnited States, most infants are placed in their bedsprone (Hoffman H. National Institute of Child Health

and Human Development: Cooperative Epidemiolog-ical Study of Sudden Infant Death Syndrome RiskFactors. Personal communication, 1992). Reasonsoften cited for this preference include a perceived

decrease in the likelihood of aspiration, less gastro-esophageal reflux,’3 and improved pulmonary

function46 and sleeping.7 Other reasons previouslycited for favoring the prone position include less headmolding,8 improved psychomotor development,7 lesscolic,9 possible prevention of infantile scoliosis,1#{176} anddecreasing upper airway resistance in infants withspecific abnormalities of the airwa�y such as are as-sociated with the Robin Anomaly.’

In parts of Europe’2”3 and Asia,’4’6 infants havehistorically been placed in either the lateral or supine

position, although until recently there has been littlepublished justification.

Several studies have shown that babies placed

either supine or prone, during the first few monthsfollowing birth, will generally remain in that positionthroughout sleep, while those placed in a lateralposition frequently turn to the supine position, butseldom to the prone.17”8

Association Between Sleeping Position and SIDS

A possible relationship of the prone position and

SIDS was suggested as early as the 196Os’� and early19705.20 Since then, a variety of publications havesupported this relationship. Most studies involved

retrospective interviews of parents after their infanthad recently died of SIDS or prospective interviewsof parents with children at high risk of SIDS. Wehave categorized the studies according to their adher-

ence to six criteria that we found to be essential forappropriate evaluation and comparison (Table 1), andfurther grouped them into three categories of studydesign: (1) those examining “usual” sleeping position(Table 2); (2) those examining how the infant was

TABLE 1. Criteria for Study Acceptance.

1 . SIDS appropriately defined

2. Autopsies performed in > 98% cases

3. Adequate description of SIDS ascertainment in the study popu-

lation

4. Use of controls

5. Adequate description of process of control selection

6. Inclusion of sufficient data to calculate odds ratio and 95%

confidence limits

SIDS = sudden infant death syndrome.

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“last put down” prior to death (Table 3); and (3) thoseasking how the infant was “found” following death(Table 4).

Wherever possible, we have calculated from thepublished data the odds ratio2’ of SIDS occurring ifthe infants were prone versus the number of infantsprone in the control group. An odds ratio of greater

than 1 .0 describes a positive relationship of proneand SIDS for the particular population studied, while

an odds ratio of less than 1 .0 would describe aninverse relationship (ie, a protective effect of prone).The range listed in parentheses denotes the 95%

confidence interval for the odds ratio. If the lowerlimit of the confidence interval is greater than 1.0,

Seven studies comparing “usual sleeping position”of infants who died of SIDS and controls were judgedto satisfy all six of our criteria. Six of the seven studiesreported a significant correlation of prone position

with SIDS, with odds ratios ranging from 1 .3 to 11.7.Three studies that examined the infant’s position

when “last put down” fulfilled the criteria; all reportedan association between sleeping prone and SIDS, with

odds ratios from 3.53 to 9.46. The one study thatfulfilled criteria and examined the infant’s positionwhen “found dead” reported that infants were nearly1 2 times more likely to be found prone, when com-

pared to the usual sleeping position of controls. Evenamong those studies that met criteria, many wereassociated with some flaw in study design. (For ex-ample, the study just mentioned determined “found”position through parental interviews, but estimated“usual” position via a mail survey.) When considered

together, however, the studies present substantialevidence of an association of prone position andSIDS, independent of other variables. In three ofthese studies, the odds ratio increased further afteraccounting for confounding effects of other vari-ables.2224 No published report has suggested theconverse-ie, a reduced incidence of SIDS with theprone position.

Several investigators have called attention to the

apparent relationship of predominant sleeping posi-tion and SIDS incidence when one country is com-pared to another. Such comparisons must be viewedvery cautiously because of numerous other coexist-

ing cultural differences and variances in data collec-tion. For example, the SIDS rates among Asians, for

whom supine position is the norm, appear to be very1OW’4’2528� however, numerous variables such asswaddling, lack of central heating, and increased fre-quency of the infant sleeping in the same bed withthe parents29 are also quite different when comparedto most Western countries.

Change in SIDS Associated with Change in SleepingPosition

During the 1970s, infant sleeping position in theNetherlands reportedly changed from predominantly

supine to predominantly prone. An abrupt increasein SIDS was noted soon afterward.’8 In the mid 1980s,after several retrospective analyses had noted a rela-tionship between SIDS and prone position, the laypress and a few investigators began to advocate su-pine or lateral positioning rather than prone in other

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1122 POSITIONING AND SIDS


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countries.3#{176} Subsequently, very preliminary reportsfrom New Zealand3”32 and the United Kingdom33

noted decreases in the incidence of SIDS by morethan 50%, coincident with a change in sleeping po-sition from mostly prone to predominantly supine or

lateral. It is quite possible that other variables werealso changing during this time.

Hypotheses Regarding Possible Mechanisms

Several hypotheses relating prone position andSIDS have been proposed, although they certainlyhave not been proven. Oropharyngeal obstruction hasbeen demonstrated to precipitate apnea in preterm

infants3436 and perhaps in some infants through thefirst several months after birth.37 Posterior displace-

ment of the mandible with resultant obstruction ofthe narrow, relatively vulnerable, pharyngeal airwayof the infant38 may be precipitated by facial pres-sure,39 which is more likely to occur in the proneposition. Obstruction may also be precipitated bydistortion of the compliant nasal cartilage of theyoung infant when prone.4#{176}

An animal model has been developed to explainhow rebreathing, from a pocket formed in the infant’sbedding which would be more likely to occur in theprone position, may be responsible for a few cases

of 51D5.4’ Soft or porous sleeping surfaces may in-crease the likelihood of rebreathing. A proposal im-plicating a compromise of cerebral blood flow during

cervical hyperextension (more likely to occur in proneinfants) has been supported by studies with autopsysubjects.4’ Both the airway obstruction and the bloodflow compromise theories have been challenged byphysiologic monitoring studies, involving small num-bers of subjects during relatively brief time pe-riods.43’44 Overheating, which may be more likely inprone infants for whom heat dissipation may be lesseffective, has been proposed by several investigators

as a possible mechanism.45’46 Overheating has alsobeen suggested as a possible explanation for someintercountry variations, perhaps reflecting differences

in climate, heating conditions, and infant dressingcustoms.47�’

Possible Deleterious Effects of Lateral or SupinePosition

If one is to advocate changing the norm, which is

the prone position in the United States, there must berelative assurance that the alternative lateral or supineposition is not more hazardous for some other reason,

perhaps unrelated to SIDS. Scoring systems havebeen developed for separating healthy infants intogroups that are at high risk or low risk for S1D55254;studies that have examined the effect of position haveeither not considered risk status or have consideredonly the high-risk population. Healthy infants at highrisk for SIDS stand to benefit most from avoiding theprone position. There is a theoretical possibility thatinfants at low risk for SIDS may have a more adverse

risk/benefit ratio. Future observations of infants withspecific risk status may allow an identification ofinfants most likely to benefit from one position vs

another.

Despite common beliefs, we discovered no evi-

dence that aspiration is a more frequent complication

in healthy infants lying supine when compared toother positions. Although we could find no controlledstudies, aspiration is a very rare cause of infant

death.48 One review of infant deaths that were notrelated to SIDS reports that the three infants who hadaspirated prior to death had all been found prone.47

There are several studies that suggest that symp-tomatic infants who have documented gastroesoph-ageal reflux may reflux less in the prone position.’3Gastroesophageal reflux is common in healthy in-fants, but only a very small number are symptomaticand develop complications such as esophagitis, recur-rent pneumonia, failure to thrive, or apparent life-

threatening events. The proposed change in positionis intended for healthy asymptomatic infants only.

Several investigations have demonstrated thathealthy infants4 and preterm infants with respiratory

distress5 have improved oxygenation and pulmonaryfunction in the prone position, particularly if a depres-sion has been cut in the mattress to facilitate abdom-

inal excursions.6All of these observations may provide good ration-

ale for placing some infants prone, as indicated under

“Summary and Recommendations. “ However, noconvincing long-term beneficial effects or positiveinfluences on decreasing mortality have ever beenshown for the prone position in the populations stud-ied.

Recent Recommendations Regarding Sleep Position inOther Countries

At least two countries have undertaken formal

action to encourage parents to avoid placing theirinfants prone. The New Zealand Cot Death Preven-tion Programme began in March 1991; it advocates

the lateral or supine sleeping position, discourageshousehold and maternal smoking, and encourages

breast-feeding.23 On October 31, 1991, the ChiefMedical Officer for the Department of Health for theUnited Kingdom issued a press release advocatingthat “babies not (be) placed on their tummies whenthey are going to sleep.”56 Campaigns against the

prone position have also been mounted by individuals

or foundations in the Netherlands57 and in Aus-tralia 58

SUMMARY AND RECOMMENDATIONS

Although prospective randomized clinical trialshave not been performed, the weight of evidence

implicates the prone position as a significant riskfactor for SIDS. There is some concern that many ofthe studies have come from countries and regionswith SIDS rates which are significantly higher thanthat of the United States. Nevertheless, the consist-ency of the results from a variety of countries makesit more likely that the data should be applicable tothis country as well. In addition for the healthy infant,there appears to be little hazard associated with thelateral or supine positions. The preponderance of datahave come from studies that asked about “usual” sleepposition, as opposed to position “when found dead”or “last position seen.” Nevertheless, during the first



few months after birth, it appears as if the position inwhich the infant is first placed will substantiallydetermine the position that the infant will maintain

throughout sleep. Therefore, it appears reasonable torecommend that most healthy infants be placed inthe lateral or supine position.

Many will advocate development of a carefully

controlled clinical trial to test definitively the relation-ship of sleep position and SIDS. In view of the largepopulation required for a study, the requirement forlay participation in any trial, and the bias that hasalready been introduced by previous publications andthe lay press, it appears unlikely that such an impar-tial controlled trial could be conducted. However,

there are techniques other than the controlled trialthat can be used to evaluate this issue further. Weencourage ongoing rigorous analysis of the relation-

ship between sleeping position and SIDS in theUnited States. Subsequent increases or decreases ofthe incidence of SIDS in the United States may reflecta change in sleeping position or a change in someother variable. Watching for and reporting possible

changes in selected regions during the next decademust be a high research priority for investigators andfunding agencies.

Although not the subject of this review, it is im-portant that society recognize that other potentiallyalterable factors have also been shown to be associ-

ated with SIDS. Maternal smoking and prematurityhave both been identified as risk factors59; breast-

feeding has been associated with a decreased risk.6#{176}Programs aimed at changing these variables may well

lead to improved rates. Also, we want to emphasizethat there are still good reasons for placing certaininfants prone. For premature infants with respiratorydistress, infants with symptoms of gastroesophagealreflux, infants with certain craniofacial anomalies orother evidence of upper airway obstruction, and per-haps some others, prone may well be the position ofchoice. It should be stressed that, although the relativerisk of the prone position may be several times thatof the lateral or supine position, the actual risk ofSIDS when placing an infant in a prone position isstill extremely low.

In conclusion, after evaluation of all available evi-

dence to date, for the well infant who was born atterm and has no medical complications, the Academyrecommends that these infants be placed down forsleep on either their side or back.

AAP TtsK FORCE ON INFANT Posmorsxmic �rsm SIDSJohn Kattwinkel, MD, ChairUniversity of VirginiaCharlottesville, VA

John Brooks, MDUniversity of RochesterRochester, NY

David Myerberg, MDWest Virginia UniversityMorgantown, WV

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Positioning and SIDS - Pediatrics · Common Sleep Positions The predominant infant sleeping position appears to vary considerably from country to country. In the United States, most