23 years have passed since the American Academy of Pediatrics began urging parents to place their babies supine (on their back) to sleep. This “Back to Sleep” effort to decrease the incidence of sudden infant death syndrome (SIDS) was highlighted recently in Pediatrics:

On the basis of the New Zealand Cot Study and European data, in 1992 the American Academy of Pediatrics (AAP) recommended that infants no longer sleep in the prone position. By 1994, the National Institutes of Health, with other stakeholders, introduced the Back to Sleep campaign. Over the next 10 years, the sudden infant death syndrome (SIDS) rate in the United States fell 53%, correlating with an increase in exclusive supine sleep from <10% to 78%. The AAP considers this 1 of the 7 great achievements in pediatric research in the last 40 years.


A study published in Pediatrics last month discovered that many American parents don’t always follow through with the AAP’s recommendations on safe infant sleep environments:

Not all mothers place their infants exclusively supine for sleep. Many mothers intend to place their infants supine yet often do not do so in actual practice.


Maybe it is parental fear that the baby will choke if placed on his back to sleep. Maybe sleeping on the back looks less comfortable to parents than placing the baby on her stomach. Maybe it has been suggested by a friend or family member that the baby will sleep better (longer) on his stomach than on his back, contrary to the advice given by the baby’s pediatrician. Daniella Emanuele says “educating parents’ friends and families, facilitating open conversations about infant sleep and encouraging the media and advertisers to display images of safe sleep practices” are key to seeing improvements to these numbers:

The study […] surveyed 3,297 mothers, of whom 77.3% reported that they usually — but not always — put their babies to sleep on their backs.

“What was new and hadn’t been explored before was this idea of what people intended to do versus what they actually do,” said Dr. Eve Colson, professor of pediatrics at Yale School of Medicine and co-author of the study. “What we found was that people intended to put their baby on their back but didn’t always do that.”

Another finding was that those who felt the baby’s sleeping position was not up to them, but rather the baby or another family member, were more than three times as likely to place the baby on its stomach.


The study also showed a racial disparity in parental practices:

There were about 3,700 sudden unexpected infant deaths in the US in 2015, according to the CDC. SIDS account for 1,600 of those while 1,200 are due to unknown causes and 900 were due to accidental suffocation and strangulation while in bed. The sudden unexpected infant death rate of non-Hispanic black infants was 170.2 per 100,000 live births between 2011 and 2014, more than twice that of non-Hispanic white infants (83.8 per 100,000).

The elevated rate has a lot to do with societal norms, said Dr. Rachel Moon, a pediatrician who has studied SIDS in African-American communities.

“There’s very much a culture of putting babies on their stomach in an African-American community,” said Moon, who was not involved in the new study. “There’s a lot more dependence on grandmothers and other senior family members as trusted sources, and lots of times, the information that you get from your family members is more persuasive than what you get from physicians and other sources.”


An accompanying editorial underlines another worrisome finding:

A worrisome finding by Colson et al is that African American mothers and mothers with less than high school education continue to be more likely to use prone positioning, which is associated with a twofold increased risk of SIDS. Other researchers have demonstrated these same groups also are more likely to use soft bedding and bed-sharing and are less likely to breastfeed, all of which increase the risk of SIDS and partially explains the persistent discrepancy in the rates of SIDS in these populations.


The National Institutes of Health lists SIDS as the leading cause of death in infants between the ages of 1 month and 1 year, with most SIDS deaths occurring in the first 4 months of life. About 4,ooo infants die unexpectedly during sleep time each year in the United States from SIDS, accidental suffocation, or undetermined causes. After the first birthday, SIDS is no longer a risk.

Read (and share!) the AAP’s most recent safe sleep guidelines for infants here on The PediaBlog.


(Google Images)