| Back to Sleep
Infant Sleep Positioning and SIDS: Counseling Implications
In 1994, the Association of SIDS and Infant Mortality Programs (ASIP) joined with the U.S. Public Health Service, the American Academy of Pediatrics, the SIDS Alliance and others to launch a national public health campaign entitled Back to Sleep to reduce the risk of Sudden Infant Death Syndrome. This initiative was based on research reports from Australia, New
Zealand, England, Norway as well as data from the United States recommending placing healthy newborns to sleep on their back or side as a risk reduction strategy. In 1996, this recommendation was revised to endorse back sleeping as the best position for infants. Since the inception of this campaign, the SIDS rate has decreased 30-40% in the United States - the
greatest decrease in the SIDS rate since statistics have been compiled. While such a dramatic decline suggests that a change in sleep position to back sleeping may reduce the risk of SIDS, it has also demonstrated that sleep position in and of itself, is not a cause of SIDS.
What Can I Do to Lower My Baby’s Risk of SIDS?
- Always place your baby on his or her back to sleep, for naps and at night
- Place your baby on a firm sleep surface, such as on a safety-approved crib mattress, covered by a fitted sheet
- Keep soft objects, toys, and loose bedding out of your baby’s sleep area
- Do not allow smoking around your baby
- Keep your baby’s sleep area close to, but separate from where you and others sleep
- Think about using a clean, dry pacifier when placing your infant down to sleep
- Do not let your baby overheat during sleep
- Avoid products that claim to reduce the risk of SIDS
- Do not use home monitors to reduce the risk of SIDS
- Reduce the chance that flat spots will develop on your baby’s head
This change in sleep position from tummy to back poses no increased risk for illness or infant death in normally healthy infants. However, tummy sleeping may be recommended for some infants with symptoms of gastroesophageal reflux and infants with certain upper airway abnormalities. It is important for parents to discuss recommendations for their infant's sleep
position with their health care provider.
Professional caregivers who provide counseling and support to families are well aware of the impact any media coverage of SIDS research reports has on family members. Although there is no reason for self-blame, regardless of the sleeping position of the SIDS infant, parental responses may be more intense and complex due to the widespread coverage of this national
campaign and the observed decrease in the SIDS rate. Parents and caretakers may reexamine the circumstances and events of the child's death, causing them to revisit painful and emotional issues which they had previously resolved. Feelings of guilt and culpability may resurface, causing parents to again confront the "what if" and "if only" questions. It is anticipated that parents of newborns, child care providers, and families whose infant has died
in any sleep position will require guidance as a result of the Back to Sleep campaign.
Parents of Newborns and Infant Care Providers:
Start baby sleeping in the back position to help the baby become accustomed to that position.
Burp babies properly during and after a feeding before being put to sleep.
Do not restrain baby to maintain sleeping position.
Discuss the baby's sleep position preference with child care providers.
Consult with the pediatrician or health care provider about the need to maintain this recommended sleeping position as the baby becomes more active and begins to roll over.
Place baby on tummy when awake and observed to encourage motor development and to prevent flat spots from developing on baby's head.
Families and Child Care Providers Whose Infant Has Died in the Tummy, Back or Side Position:
No causal relationship has been determined by studies which have suggested in association between the tummy sleeping position and SIDS risk.
Back sleeping position will not eliminate SIDS.
Infants die in all positions including back or side.
SIDS is complex- one single factor has not been identified as the cause.
SIDS remains unpredictable and unpreventable.
Parents and caretakers should not be blamed.
Promotion of the supine sleeping position signifies a policy change in infant care practice. We must be mindful of the impact it will have on SIDS families and new parents. It is imperative that healthcare professionals continue to provide counseling and compassionate support services to families who experience a sudden infant death. ASIP strongly urges additional studies be conducted to identify the basic mechanisms of SIDS and to monitor compliance and the impact of the Risk Reduction Campaign.
Reprinted with permission from Frederick Mandell, MD, Editor, Pediatric Alert.
Volume 28, Number 7, April 10, 2003, 39-41
SIDS: Risk in Relation to Sleep Position…
The last couple of months have seen a number of reports focused on the relation of sleep position to sudden infant death syndrome (SIDS). In the first case-control study of SIDS in the U.S. since the "back to sleep" campaign was initiated, researchers in California identified 185 SIDS cases and 312 matched controls and interviewed the parents about sleep position. They found that, compared to the back position, infants put down to sleep prone were 2.6 times more likely to die of SIDS, and those put down on their side were twice as likely to die of SIDS. Of note was the finding that SIDS risk was particularly high (7-9 fold) for an unstable side position (in which infants were placed on their side and found prone) or for an unaccustomed position (infants who were usually placed on their backs but had last been put down in the prone or side position). Indeed, infants placed in an unaccustomed prone or side-sleeping position had a higher risk of SIDS than infants who were always placed prone or on the side. (De-Kun L et al: Am J Epidemiol, Mar 1 2003; 157:446-455)
…Sleep Position in LBW Infants…
Low birth weight (LBW) and preterm infants are 3-6 times more likely to die of SIDS than term infants. Still, many clinicians have advocated placing premies on their stomachs in the nursery, and it's unclear whether parents continue this practice when they bring their infants home. Researchers in Boston, Massachusetts, and Toledo, Ohio, surveyed sleep position practices among parents of premature infants recruited in both cities between 1995 and 1998. At 1, 3, and 6 months after hospital discharge, prone sleeping was reported among 16, 27, and 28% of the 907 LBW infants. Very low birthweight infants were most likely to be placed prone. Over the study years, prone sleeping at one month decreased from 20 to 11%, but in the lowest weight babies, virtually all of the prone sleeping was replaced by side sleeping.
When asked what influenced their decision to place their infants prone, mothers most frequently cited the infant's preference (whereas mothers of non-prone infants most frequently cited professional medical advice for their choices). On the other hand, mothers of prone-sleeping VLBW infants also frequently cited the influence of medical professionals and nursery practices as most important in choosing sleep position. (Vernacchio L et al: Pediatrics, Mar 2003; 111:633-640)
…Sleep Position in Nighttime Child Care…
Parents are not the only targets of efforts to reduce the risk of SIDS. To identify what practices are followed in facilities that provide nighttime child care, researchers surveyed 110 centers in 27 states that provide such care to infants under 6 months of age. Although only one center reported exclusively placing infants to bed prone, 20 % reported that practice for at least some of the infants. Among these, most were unaware of or misinformed about safe sleep practices; even those that knew about the back to sleep campaign did not uniformly follow the guidelines, often because of requests from parents. Smoking was prohibited in 86% of the surveyed centers. (Moon RY et al: Pediatrics, Apr 2003; 111:795-799)
… And Reducing Risk In Urban Communities
Because SIDS risk is particularly high in black urban communities, and because lack of compliance with SIDS reduction recommendations is though to account for some of the racial disparities in SIDS occurrence, researchers conducted telephone surveys in urban Chicago, Illinois neighborhoods that were at least 86% black. The surveys occurred before and after an aggressive and comprehensive ethnically-sensitive SIDS risk reduction campaign. The authors found that nighttime prone sleeping decreased somewhat in the two years between surveys, though the decline wasn't statistically significant. On the other hand, use of pillows, stuffed toys, and soft bedding among blacks, relative to whites, increased between surveys.
The data suggested that observation of the infant's sleep position in the hospital had no impact on practice, but specific instruction from a nurse or doctor in the hospital did have an impact on the parent's choice of the back sleep position. The biggest effect of the campaign seemed to be in changing where infants were placed for daytime naps, with appreciable reductions in the use of adult beds, sofas, or cots. The authors conclude that "cultural explanations for specific infant care practices must be more clearly understood to close the gap between SIDS risk factor compliance and apparent knowledge about SIDS risk factors." (Rasinski KA et al: Pediatrics, Apr 2003; 111:e347 [electronic edition])
COMMENT: Whatever reduction in the incidence of SIDS has resulted from the "back to sleep" campaign can be credited to findings from epidemiologic studies that identified sleep position and smoking as two major - and modifiable - risk factors for this condition. The mechanisms by which these factors operate remain elusive, but readers interested in that aspect of the story are referred to two current reports: One suggests that prone position doesn't improve sleep in premies, and may actually increase vulnerability by increasing QT and JT intervals (Ariagno RL et al: Pediatrics, Mar 2003; 111: 622-625), and the other suggests that in a low O2 environment that occurs during rebreathing when the infant's face is covered with soft bedding, respiratory patterns may produce rapid and potentially dangerous desaturations (Patel AL et al: Pediatrics, Apr 2003; 111:e328 [electronic edition]).
Whatever the mechanism, it appears that we have identified interventions that can make a real difference in a child's risk of SIDS. As is often the case in medicine, identifying a solution can be easier than incorporating it into practice. While it will fall to others to figure out broad and culturally-sensitive educational interventions, the accumulated data identify a clear role for pediatric practitioners. In both the Vernacchio and Rasinski studies, parents reported that what was practiced or recommended by a physician, nurse or other provider had considerable influence on their decision regarding sleep position. Practitioners should not underestimate the positive impact their direct counseling can have on parents, and they shouldn't hesitate to use this influence to further reduce the risk of SIDS in their practices.
Reprinted with permission from Frederick Mandell, MD, Editor, Pediatric Alert
Volume 28, Number 10, May 22, 2003, 56 -57
Back To Sleep - Unexpected Benefits?
The decreased risk of sudden infant death syndrome (SIDS) associated with non-prone sleep positions led the American Academy of Pediatrics in 1992 to recommend that infants be placed to sleep on their side or back; two years later the "Back to Sleep" campaign was launched, and now the supine sleep position is recommended. As the prevalence of infants sleeping prone decreased from 70% in 1992 to 17% in 1998, SIDS rates in the U.S. decreased by about 40%. Still, some parents and physicians have been concerned that nonprone sleep positions may be associated with trouble sleeping and gastroesophageal reflux, and perhaps aspiration as well. To determine whether non-prone positions might be associated with various health problems (other than SIDS), researchers in Massachusetts and Ohio studied 9773 infants who had been enrolled at birth and followed for the first six months of life. Among these, 3733 had been reported to have the same sleep position at 1, 3, and 6 months of age, and these infants were the subject of further analysis. Included in outcomes studied were fever, cough, respiratory problems (wheezing and trouble breathing), trouble sleeping, spitting up or vomiting, and outpatient visits for ear infections, colic, seizures or accidents/injuries.
Over the six-month period of observation for each of the infants, the authors found no symptoms or outpatient visits to be more frequent among infants sleeping on the side or supine than among infants sleeping prone. Indeed, some outcomes were actually less common among infants sleeping on their side or supine - fever at one month of age was about half as common compared to prone sleepers, stuffy nose was about 25% less frequent at 6 months of age, and trouble sleeping was about 30-40% less common at 6 months of age. Outpatient visits for ear infections at 3 and 6 months were also reported about 25-33% less frequently among infants sleeping supine and a similar effect was seen at 3 months for infants sleeping on their sides.
The authors argue that these finding serve as reassurance that placing infants to sleep on the side or back does not increase any of a wide range of health risks. "Of particular importance is the fact that the study sample was sufficiently large for most health outcomes to rule out even modest increases in risk. A secondary observation of a decrease in reported ear infections associated with infants sleeping in the side and supine positions warrants further study." Finally, they note that "conclusions about possible health risks associated with supine sleep have limited the degree to which some health care providers advocate and some parents comply with Back to Sleep recommendations. Our findings should lead to more wide spread adoption of this important public health intervention." (Hunt CE et al: Arch Pediatr Adolesc Med, May 2003, 157:469-474)
Contact the SIDS Center
Mary McClain, RN, MS
Boston Medical Center
1 Boston Medical Center Pl
Boston, MA 02118-2393
(617) 414-SIDS
(800) 641-7437 (MA & RI) |
