Charles A. Bertrand, M.D., FACP, DIM-CD (Ret.)
Associate Clinical Professor of Medicine at New York Medical College
and at the Medical University of South Carolina


There are just three positions in which an infant can be placed - supine (lying on back), prone (lying on stomach or face down), and lateral (lying on the side). For centuries the best position has been debated among mothers, grandmothers, family members, etc. The key question is what is the best position in which to place an infant - and this encompasses the time period of from 2-4 weeks up to about 9-10 months of age. Why is this important? There are a number of reasons for this, but the key one is SIDS.

It has long been known that infants may suddenly be found dead in bed - this used to be called "crib death" and more recently "sudden infant death syndrome," known as "SIDS." This is a condition in which an apparently healthy infant is suddenly and unexpectedly found dead in bed for no apparent cause. Despite investigations of the circumstances and even autopsies in most cases, there has been no cause of death determined. It has been a mystery for decades. It occurs most often in the period from 2-4 months and is rare after the seventh month. The overall incidence is over one per 1,000. Statistically, this may not seem like a lot but it certainly is a tragedy to all concerned.

In the early 1990's in other parts of the world there was suggestive evidence that an infant lying in the prone position is more likely to develop SIDS. As a result, the American Academy of Pediatrics in 1992 reviewed the literature and made an initial recommendation that infants be placed in bed in the supine position (lying on their backs), or on their sides in the lateral position. Later this was amended to include only the supine position. The purpose was to see if this would have any effect in reducing or even eliminating the SIDS syndrome.

In June 1994 a coalition was formed of various groups interested in this problem. A catchy title, "Back to Sleep," campaign was instituted to have as many mothers or other caregivers to place infants in the supine position.

In a recent edition of the Journal of the American Medical Association (JAMA), July 28, 1998, Vol. 280, No. 4, there were three articles and one editorial dealing with this important subject of positioning of the infant during sleep for the first 7-8 months of life. When the survey was begun in 1992 the incidence of infants being placed in the prone position was about 70%. This was reduced to 24% by 1996, according to the paper by Willinger, et. al. This certainly does show marked improvement. Associated with this was a very significant decrease in SIDS. The incidence of SIDS declined by approximately 38% during this span of time - and it is anticipated that a further decline will be noted in the years ahead. This is important because this syndrome is the leading cause of infant mortality in the span of time between one month and one year of age. For example, in the year 1992 there were 4,891 infants who died with this syndrome and at that time the old recommendation favoring the prone position was in place.

There are a number of reasons for mothers having placed their infants in the prone position. For example, it was more common in blacks and Hispanics than in the white population, and more common in those who had less education and were in a poorer socioeconomic status. But there is one other factor that also may be important.

This was well illustrated in another article by Brenner, et al which reported in a study done in three District of Columbia hospitals between late 1995 and the first nine months of 1996. In this particular study there were 394 mothers studied and it was found that 157 infants, or 40%, were placed in the prone position and one of the major reasons given was that the new mother had noticed that the infants were in the prone sleep position while in the nursery. This relates to a very significant point in that nurseries should virtually always have the infants in a supine position (as this is now being done in most hospitals) and education should be given to the new mother explaining that the infant should be placed in the supine position for sleep.

The editorial by Michael H. Malloy further amplifies these conclusions. Setting a good example (for the mothers) in the nursery is imperative as well as education of the new mother in placing the child in a supine position. Further, education should be stressed during follow up visits to the doctor or to a clinic, particularly in the first months of life. Further, these efforts should be targeted primarily to the black and Hispanic community and especially those who are young and have little education, and have poor socioeconomic status. It is this group that the major problems reside unfortunately.

But, continued efforts should be helpful and one looks forward to the day when SIDS may be largely conquered.

December 1998

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