Cases of sudden infant death syndrome (SIDS) in the United States have fallen more than 40% since the American Academy of Pediatrics (AAP) recommended in 1992 that infants be placed on their backs to sleep. In the hopes of eradicating SIDS, experts are now focusing on who isn't getting the message and why, as well as on other relevant sleep issues, such as bedding.
Nearly 2,500 infants die from SIDS each year. Once known as "crib death," because it often happens during sleep, SIDS remains the leading cause of infant death in the United States.
SIDS is the sudden and unexplained death of an infant under one year of age. SIDS deaths occur quickly, usually during sleep. The problem is most common among infants between two and four months of age, with the risk declining steadily as babies get older and stronger. Ninety percent of cases occur before 6 months of age. Boys are slightly more likely to fall victim to SIDS than girls. Low birth-weight and prematurely born babies are also at increased risk.
Two years after its 1992 recommendation, the AAP created the slogan "Back to Sleep," which has been adopted and disseminated by doctors, clinics, hospitals, the media, and even diaper manufacturers. The exact causes of SIDS still elude researchers, but studies have shown that back sleeping rather than stomach sleeping is the best way to prevent SIDS.
Two recent studies, however, have revealed problems in implementing the AAP's message.
A survey released by the Consumer Product Safety Commission in July 2000 found that many grandparents in African-American families suggest to parents that they put the babies to sleep on their stomachs. Babies in African-American families are twice as likely to sleep on their stomachs as other babies.
In addition, a study released in the August 2000 issue of the medical journal Pediatrics found that more than 20% of SIDS cases occurred in daycare settings. The study of about 2,000 SIDS cases from across the country involved infants from mostly white, higher-income, educated households who were in daycare. Most of the daytime caregivers had children of school-age or older themselves, and often weren't aware of the "back to sleep" recommendations.
"Parents can't assume that just because a daycare provider has years and years of experience, he or she knows to put their child on her back," says Rachel Moon, MD, pediatric medical director at Children's National Medical Center in Washington, who led the study. "Just as you would talk to your child care provider about what you want your baby to eat and how you want your baby diapered, you should also talk about sleep position."
"Some of the confusion…is that the public perceives that we pediatricians can't make up our minds. And these caregivers and grandparents raised their children successfully when belly-sleeping was the norm," Moon says. "But the statistics are very, very strong. Whenever the baby is sleeping, she should be on her back."
Some parents and daycare providers believe that naps—as opposed to overnight sleeping—can be safely taken prone. But Moon strongly reiterated that only in rare cases should babies ever sleep on their stomachs. In fact, Moon said, a baby who is used to sleeping on her back at night may be at even greater risk for SIDS if she naps on her stomach. That's because children who sleep on their backs develop upper body strength less quickly than do babies who sleep on their stomachs. Because stomach sleeping causes a "trapping" of carbon dioxide and SIDS experts believe that rebreathing carbon dioxide is a factor in SIDS, it may be that these less developed babies can't move away from the trapped air they create when they sleep on their tummies.
"Parents should defer to pediatricians, and caregivers should require a note from a doctor when parents say their babies can sleep on their stomachs," Moon says. "Babies die from SIDS during the day as often as they do at night."
Some parents worry about the fact that back-sleepers don't develop upper-body strength in the same way as stomach-sleepers. Back sleeping can cause some temporary, but unimportant, developmental delays. For example, studies have shown that babies who sleep on their stomachs start rolling over, sitting, creeping, crawling, and pulling to stand earlier than back-sleepers do. But the studies show that back-sleepers reach these milestones within normal age ranges. Experts like T. Berry Brazelton, MD, have always stressed that babies reach these milestones at different rates anyway, and Brazelton has long noted that it's normal for some babies to never crawl at all.
To help babies develop upper-body strength, the AAP recommends having daytime "tummy time," always supervised and always when the baby is awake.
Parents may worry that a baby's head will become flat is she sleeps on her back, because her skull bones haven't fused. Doctors have observed that such flattening sometimes occurs. It can usually be prevented by giving babies plenty of “tummy time” when they are awake and supervised. Even when flattening ("posterior plagiocephaly") occurs, it rarely poses a serious problem and can be managed where necessary by wearing a special helmet, or by alternating side sleeping (see below) with back sleeping. Pediatricians are confident that the small risk of head flattening is far outweighed by the importance of preventing SIDS.
Although side sleeping was originally suggested by the AAP to be an acceptable alternative position for preventing SIDS, it is no longer recommended. Babies who sleep on their sides can roll onto their stomachs, and studies continue to show an increase risk for SIDS in side sleepers compared to back sleepers.
Parents can also help prevent head flattening by playing with the baby while she's on her stomach.
Another fear regarding back sleeping is that babies will choke when they spit up. Because babies automatically swallow or cough up such fluid, doctors have found no increase in choking or other problems in babies sleeping on their backs. Statistics show that babies are more likely to choke on spit-up or vomit when they're on their stomachs.
The AAP offers these recommendations:
And remember that once babies start rolling over onto their stomachs on their own, their risk for SIDS decreases dramatically; as long as you start the baby out on her back, there's no need to continually stand guard at the crib.
RESOURCES:
American SIDS Institute
http://www.sids.org/
"Back to Sleep" Program
National Institute of Child Health and Human Development
http://www.nichd.nih.gov/sids/
National SIDS Resource Center
http://www.sidscenter.org/
SIDS Alliance
http://www.sidsalliance.org/
CANADIAN RESOURCES:
Canadian Association of Family Physicians
http://www.cfpc.ca/
Canadian Public Health
Health Unit
http://www.phac-aspc.gc.ca/pau-uap/fitness/
References:
Hoffman HJ, Damus K Hillman L, et al. Risk factors for SIDS. Results of the National Institute of Health and Human Development SIDS Cooperative Epidemiologic Study. Ann NY Acad Scien. 1988;533:13.
Moon RY, Patel KM, McDermott Shaefer SJ. Sudden infant death syndrome in childcare settings. Pediatrics. 2000;106:295-300.
Nelson Horchler J, Rice Morris. The SIDS Survival Guide: Information and Comfort for Grieving Families and Friends and Professionals Who Seek to Help Them. SIDS Educational Services; 1997.
Persing J, James H, Swanson J, Kattwinkel J; American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery and Section on Neurological Surgery. Prevention and management of positional skull deformities in infants. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery and Section on Neurological Surgery. Pediatrics . 2003;112(1 Pt 1):199-202. Pediatrics website. Available at: http://pediatrics.aappublications.org/cgi/reprint/112/1/199 .
Sears W. SIDS: A Parents Guide to Understanding and Preventing Sudden Infant Death Syndrome. Little Brown & Co; 1996.
Task Force on Sudden Infant Death Syndrome. American Academy of Pediatrics Statement: The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reduction risk. Pediatrics. 2005;116:1245-1255.
Unger B, Kemp JS, Wilkins D, et al. Racial disparity and modifiable risk factors among infants dying suddenly and unexpectedly. Pediatrics . 2003;111:E127-131.
¹10/23/2009 DynaMed Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Blair P, Sidebotham P, Evason-Coombe C, Edmonds, M, Heckstall-Smith, Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. BMJ . 2009;339:b3666.
Last reviewed January 2009 by Kari Kassir, MD
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