Putting Babies "Back to Sleep"
To the Editor: The authors of the 3 articles1-3 and the editorial4 that addressed infant sleep position seem to make 2 common assumptions. First is that parents "put" infants to sleep in a certain position. Few infants stay in 1 position once they are "put" to sleep, unless of course they are restrained, such as with tight swaddling. Most infants move during sleep, and when left unrestrained even newborns can change head position and move from side to back or from side to front.
The second assumption is that infants sleep alone and separate from parents and siblings. Cosleeping with parents is a common occurrence and has been studied with respect to sudden infant death syndrome (SIDS) risk reduction. Research demonstrates that sleep electroencephalograms of mother and baby show synchrony during cosleeping.5 This may protect infants from SIDS by providing a respiratory cue for the baby during the difficult periods of transition between sleep stages. Historically, infants sleeping separately from parents is a new and Western phenomenon. Most nonaffluent Americans born before World War II spent some time cosleeping, and many continued to cosleep with siblings before families could afford separate beds and separate rooms for all children. Separate sleeping must seem strange to an infant who has spent 9 months in continuous contact with mother and then is placed alone without human warmth, breathing motion, or proximity to heartbeat. Perhaps this explains the popularity of toys for cribs that mimic mothers' sounds.
The Back to Sleep campaign has more elements than just sleep position. Recommendations include avoidance of tight swaddling, avoidance of cigarette and other smoke exposure, and avoidance of overheating (as would occur when a restrained infant struggles to move). Breast-feeding is recommended more than feeding infants formula.
Before mothers are chastised for failing to swaddle their infants tightly and "put" them to sleep in a certain position, the risks and benefits of solo sleeping for infants and of restraining movement during sleep should be studied. Infants should be observed during sleep, alone, with parents, and with siblings. The other elements of the Back to Sleep campaign should be given equal emphasis, and cosleeping should be considered.
Julie Graves Moy, MD, MPH
1. Brenner RA, Simons-Morton BG, Bhaskar B, et al. Prevalence and predictors of the prone sleep position among inner-city infants. JAMA. 1998;280:341-346. MEDLINE
2. Lesko SM, Corwin MJ, Vezine RM, et al. Changes in sleep position during infancy: a prospective longitudinal assessment. JAMA. 1998;280:336-340. MEDLINE
3. Willinger M, Hoffman HJ, Wu K-T, et al. Factors associated with the transition to nonprone sleep positions of infants in the United States: the National Infant Sleep Position study. JAMA. 1998;280:329-335. MEDLINE
4. Malloy MH. Effectively delivering the message on infant sleep position [editorial]. JAMA. 1998;280:373-374. MEDLINE
5. McKenna JJ, Bernshaw NJ. Breastfeeding and infant-parent co-sleeping as adaptive strategies: Are they protective against SIDS? In: Stuart-Macadam P, Dettwyler KA, eds.Breastfeeding: Biocultural Perspectives. New York, NY: Aldine De Gruyter; 1995:265-304.
In Reply: In the National Infant Sleep Position (NISP) study we deliberately asked caregivers if their baby was placed for sleep in a specific position.1 Respondents reported a specific, usual sleep position for 97% of infants. Similarly, 87% of respondents in the District of Columbia reported usually placing their infant in a specific position, side, back, or stomach.2 The stability of various sleep positions was assessed in the NISP.1 The supine and prone sleep positions are very stable from birth through 15 weeks of age with about a 96% probability that infants will be found in the same position in which they are placed. The supine position, the current recommended infant sleep position, remains relatively stable at 16 to 23 weeks and at 24 to 28 weeks (84% and 68% probability of being found supine, respectively).
We also asked about bed sharing. More than 50% of mothers interviewed in the District of Columbia reported that their infants slept with another person on the night prior to the interview. Infants who shared a bed with another person were more likely to have been placed prone (44% vs 38%), but this association was not statistically significant. As stated by the American Academy of Pediatrics Task Force on Infant Positioning and SIDS, "there are no scientific studies demonstrating that bed-sharing reduces SIDS. Conversely, there are studies suggesting that bed-sharing, under certain conditions, may actually increase the risk of SIDS."2 For example, the risk of SIDS increases if a mother smokes and shares a bed with her infant.3, 4 The task force also stated that "There is no basis at this time for encouraging bed-sharing as a strategy to reduce SIDS risk."2
We have no recommendation either for or against swaddling, and we have never recommended "restraining [infant] movement during sleep" as implied by Dr Moy. We reiterate the messages of the Back to Sleep campaign:5 (1) the preferred sleep position for healthy term infants is supine, (2) infants should be placed for sleep on a firm surface, with no blankets or comforters under the infant, (3) infants should not get too warm in a room kept at a comfortable temperature, (4) mothers should refrain from smoking during pregnancy and keep their infants in a smoke free environment after birth, (5) infants should be immunized on schedule and the physician should be contacted when the infant is sick, and (6) mothers should receive regular prenatal care and should breast-feed if possible.
Ruth A. Brenner, MD, MPH
Marian Willinger, PhD
Bruce G. Simons-Morton, EdD
Howard J. Hoffman, MA
John D. Clemens, MD
National Institutes of Health
1. Willinger M, Hoffman HJ, Wu K-T, et al. Factors associated with the transition to nonprone sleep positions of infants in the United States: the National Infant Sleep Position Study. JAMA. 1998;280:329-335. MEDLINE
2. American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Does bed-sharing affect the risk of SIDS? Pediatrics. 1997;100:272. MEDLINE
3. Scragg R, Mitchell EA, Taylor BJ, et al. Bed sharing, smoking, and alcohol in the sudden infant death syndrome. BMJ. 1993;307:1312-1318. MEDLINE
4. Mitchell EA, Tuohy PG, Brunt JM, et al. Risk factors for sudden infant death syndrome following the prevention campaign in New Zealand: a prospective study. Pediatrics. 1997;100:835-840. MEDLINE
5. National Institute of Child Health and Human Development. Reduce the risk for sudden infant death syndrome: the Back to Sleep campaign. Available at: http://www.nih.gov/nichd. Accessed January 14, 1999.
In Reply: Since the introduction of public health campaigns to encourage back sleeping in a number of countries, the SIDS rates in those countries have declined substantially. Although these programs have often included messages regarding a number of other infant care practices, only modest changes have occurred in practices other than sleep position, which are unlikely to account for the decline in SIDS rates. Therefore, we disagree with Dr Moy's assertion that elements other than sleep position should be given equal emphasis at this time. In our study, we sought to identify risk factors associated with continued use of prone sleeping. We believe that an understanding of these factors may be useful in developing future public health efforts directed at reducing the prevalence of this behavior. We do not wish to chastise parents for continuing to use prone sleeping; rather, we should chastise ourselves for not delivering the Back-to-Sleep message more effectively.
Samuel M. Lesko, MD, MPH
Michael J. Corwin, MD
Richard M. Vezina, MPH
Allen A. Mitchell, MD
Boston University School of Medicine
Carl E. Hunt, MD
Medical College of Ohio
Guidelines for Letters
Edited by Margaret A. Winker, MD, Deputy Editor, and Phil B. Fontanarosa, MD, Interim Coeditor.
© 1999 American Medical Association. All rights reserved.