Back vs. Tummy

The Babble Staff

The data are clear on back-sleeping — it lessens the risk of SIDS. In 1992 the AAP issued a recommendation that babies sleep on their backs; rates of back-sleeping soared in the following decade and SIDS rates dropped. Clearly, the only responsible thing to do is to make sure your child sleeps on her back. However, many parents (even parents who happen to be pediatricians) still succumb to the temptation of placing baby on her stomach. Many babies appear to prefer sleeping on their stomachs, and many parents guiltily admit to indulging this preference when, worn down by sleepless nights, they are faced with the choice of a backsleeper who won't sleep or the one-in-two-thousand chance of SIDS. In only a few situations — such as birth defects of the upper airway — doctors recommend stomach-sleeping over back-sleeping. In all other cases, back-sleeping is the less risky position. Yet one doctor cited in a 1995 New York Times article says he wouldn't be a responsible pediatrician if he didn't recommend parents put their babies to sleep on their backs, but admits to letting his own grandchildren sleep on their stomachs.

In homes across the country, parents like Mrs. Stanciu are mounting a minor mutiny against the medical establishment. For more than a decade, doctors have advocated putting babies to bed on their backs as a precaution against sudden infant death syndrome, or SIDS.

Increasingly, however, some new parents are finding that the benefits of having babies sleep soundly — more likely when they sleep on their stomachs — outweigh the comparatively tiny risk of SIDS.

[After the AAP recommended backsleeping] deaths from SIDS fell by half, to 0.57 deaths per 1,000 live births in 2002, the most recent year for which figures are available, from 1.2 deaths per 1,000 live births in 1992, according to the National Center for Health Statistics. Still, most pediatricians concede that when babies are placed on their stomachs, they tend to sleep better, they are less apt to startle and they often sleep through the night sooner.

And despite the warnings, a growing number of parents — exactly how many is impossible to quantify — are turning their backs on the Back to Sleep campaign. Postings on child-rearing Websites also indicate a trend.

Backsleeping is safer. It has decreased the SIDS rate by at least 50 percent. Given these data, the medical profession should be ashamed of having recommended for years that babies sleep on their bellies. [Many Parents ask,] "What if my baby is more comfortable on her belly?" This is a common misconception. Lucy is comfortable in the position she experiences the most. Lucy will learn to roll over by about five to six months. Once this happens, worrying about turning her back [...] is pointless.

Many parents fear that babies put to sleep on their backs could choke on spit-up or vomit. According to the AAP, however, there is no increased risk of choking for healthy infants who sleep on their backs. (For infants with chronic gastroesophageal reflux disease [GERD] or certain upper airway malformations, sleeping on the stomach may be the better option. The AAP urges parents to consult with their child's doctor in these cases to determine the best sleeping position for the baby.) Placing infants on their sides to sleep is not a good idea, the AAP said. There is too much risk that the infants will roll over onto their bellies while they sleep. Some parents may also be concerned about positional plagiocephaly, a condition in which babies develop a flat spot on the back of their heads from spending too much time lying on their backs. Since the Back to Sleep campaign, this condition has become quite common — but it is usually easily treatable by changing your baby's position frequently and allowing for more "tummy time" while he or she is awake.

Of course, once babies can roll over consistently — usually around 4 to 7 months — they may choose not to stay on their backs all night long. At this point, it's fine to let babies pick a sleep position on their own.

The American Academy of Pediatrics (AAP) recommends that all healthy infants sleep on their backs the first 6 months of life. Studies have shown sleeping on the back reduces the risk of Sudden Infant Death Syndrome (SIDS). The AAP started recommending that babies sleep on their backs in 1992. Eighty percent of parents now follow this advice and there has been a 40% drop in the rate of SIDS.

Laying a baby on his stomach puts pressure on his jaw bone. This causes the airway in the back of the mouth to become narrower. Also, if the baby sleeps on a soft surface, the nose and mouth may sink in so the child breathes from a small pocket of stale air.

If your baby sleeps on his stomach, the risk of SIDS is 3 to 9 times greater. Sleeping on the side is safer than the stomach but still has twice the risk of SIDS as the back position. If you use a child-care center or babysitter, be sure they know how important it is to put your baby on his back to sleep.

Your baby should only sleep on the stomach if recommended and supervised by your child's health care provider. The American Academy of Pediatrics recommends putting your baby to sleep on his stomach in the following cases:

- Infants with complications of spitting up. These complications include recurrent pneumonia from aspiration, interruption of breathing (apnea), or acid damage to the lower esophagus (esophagitis), and choking. While spitting up is common, these complications are rare. Years ago, doctors recommended that babies sleep on their stomachs to decrease the chance of choking. But choking is extremely rare and it was never proven that the stomach position prevented choking better than any other position.

- A birth defect of the upper airway that interferes with breathing. Examples are a large tongue, a very small mouth, or a large and floppy larynx.

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

There are two minor disadvantages [to back-sleeping]. When lying on the back, young infants are more likely to have a startle reflex that awakens them. Swaddling your baby in a snug blanket can prevent this. The other disadvantage is that some babies get a flattening of the back of the head. You can prevent this by changing the baby's head position slightly during sleep.

National efforts to reduce the incidence of Sudden Infant Death Syndrome (SIDS) by placing healthy infants on their backs or sides to sleep appear to have been extremely successful.

In 1992, the American Academy of Pediatrics (AAP) recommended placing healthy infants to sleep on their sides or backs, based on studies showing that infants who were placed to sleep on their stomachs were at greater risk for SIDS. In 1994, the NICHD, in partnership with other agencies of the U.S. Public Health Service, the AAP, the SIDS Alliance, and the Association of SIDS and Infant Mortality Programs, launched the Back to Sleep Campaign, a national campaign that encourages that infants be placed to sleep on their backs.

The first of the three studies, the National Infant Sleep Position (NISP) Study, found that between 1992 and 1996, the prevalence of U.S. infants being placed to sleep on their stomachs has dropped by 66 percent. Although a cause-and-effect relationship cannot be conclusively proven, the rate of SIDS dropped by 38 percent during that period.

The proportion of babies placed prone was higher for older babies. The Boston study found that while only 18 percent of the infants in the study were sleeping prone at 1 month of age, 29 percent were sleeping prone by 3 months of age. The peak incidence of SIDS is between 2 to 4 months of age. In the District of Columbia study, approximately a third of the mothers who first said they intended to place their infants in a non-prone sleep position, ended up placing their infants prone at 3 months of age.

In the NISP study, 1,000 telephone interviews were conducted each spring, from 1992 through 1996, with nighttime caregivers in households having an infant younger than 8 months. During this time, the proportion of babies being placed prone to sleep declined from 70 percent to 24 percent. Simultaneously, the proportion of infants placed to sleep on their backs increased from 13 percent to 35 percent; and the proportion of infants placed to sleep on their sides also increased from 15 percent to 39 percent

"The success in reducing prone sleeping and SIDS deaths has been accomplished through collaborations between the Federal government, health professionals, concerned families, and industry." Dr. Willinger, said. "Nonetheless, our work is not done. We need a better understanding of why some caregivers still do not place infants to sleep on their backs."

"It seems reasonable that efforts intended to further reduce the prevalence of prone sleeping should be designed to target the population groups who are at particular risk for using this practice," the authors wrote. They recommended that medical practitioners who see infants at well-child visits during the first few weeks of life stress the importance of placing infants to sleep on their backs and keeping them there.

Forty percent of the 394 mothers indicated at the follow-up interview that they had placed their infant to sleep in the prone position on the night before the interview.

Mothers who saw nurses placing their infants to sleep in the prone position in the hospital during the postpartum stay, were also more likely to place their infants prone.

"Ideally, hospitals should adopt and implement policies on infant sleep position that are consistent with current recommendations and should monitor compliance with policies once adopted," the authors wrote.

Approximately a third of the mothers who, shortly after birth, said that they intended to place their infants to sleep on either their backs or sides later indicated that they had placed their infants to sleep in the prone position. The most common reason the mothers cited for placing infants in the prone position was infant comfort.

"Therefore, counseling and reinforcement on the importance of the supine (back) sleep position should continue beyond the initial hospital stay, and, when possible, be directed to both the primary care giver and other extended family members, such as grandmothers," the authors wrote.