Back to Sleep
Encyclopedia
National Institute of Child Health and Human Development
The Eunice Kennedy Shriver National Institute of Child Health and Human Development , created by Congress in 1962, supports and conducts research on topics related to the health of children, adults, families, and populations...
(NICHD) at the National Institutes of Health
National Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
to encourage parents to have their infants sleep on their backs (supine position
Supine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...
) to reduce the risk of Sudden Infant Death Syndrome
Sudden infant death syndrome
Sudden infant death syndrome is marked by the sudden death of an infant that is unexpected by medical history, and remains unexplained after a thorough forensic autopsy and a detailed death scene investigation. An infant is at the highest risk for SIDS during sleep, which is why it is sometimes...
, or SIDS. Since "Back to Sleep" was launched in 1994, the incidence of SIDS has declined by more than 50%.
History
In 1992, the American Academy of PediatricsAmerican Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...
(AAP) issued the recommendation that babies sleep on their backs or sides to reduce the risk of SIDS (a statement that was later revised in 1996 to say that only the back was safest). NICHD launched the "Back to Sleep" campaign in 1994 to spread the message.
The campaign was successful in that it significantly reduced the percentage of babies sleeping on their stomachs (prone position
Prone position
The term means to lie on bed or ground in a position with chest downwards and back upwards.-Etymology :The word "prone," meaning "naturally inclined to something, apt, liable," has been recorded in English since 1382; the meaning "lying face-down" was first recorded in 1578, but is also referred to...
). It was found, however, that a significant portion of African-American babies were still sleeping on their stomachs; in 1999, an African-American baby was 2.2 times more likely to die of SIDS than a white baby. Thus, then Secretary
United States Secretary of Health and Human Services
The United States Secretary of Health and Human Services is the head of the United States Department of Health and Human Services, concerned with health matters. The Secretary is a member of the President's Cabinet...
of Health and Human Services
United States Department of Health and Human Services
The United States Department of Health and Human Services is a Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services. Its motto is "Improving the health, safety, and well-being of America"...
Donna Shalala
Donna Shalala
Donna Edna Shalala served for eight years as Secretary of Health and Human Services under President Bill Clinton and has been president of the University of Miami, a private university in Coral Gables, Florida, since 2001. She was awarded the Presidential Medal of Freedom, the nation's highest...
and Tipper Gore
Tipper Gore
Mary Elizabeth "Tipper" Gore , née Aitcheson, is an author, photographer, former second lady of the United States, and the estranged wife of Al Gore...
refocused the "Back to Sleep" campaign on minority babies.
Campaign
In 1985 Davies reported that in Hong Kong, where the common Chinese habit was for supine infant sleep positionSupine position
The supine position is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the...
(face up), SIDS was a rare problem. In 1987 the Netherlands started a campaign advising parents to place their newborn infants to sleep on their backs (supine position) instead of their stomachs (prone position). This was followed by infant supine sleep position campaigns in the United Kingdom, New Zealand, and Australia in 1991, the U.S. and Sweden in 1992, and Canada in 1993.
This advice was based on the epidemiology of SIDS and physiological evidence which shows that infants who sleep on their back have lower arousal thresholds and less slow-wave sleep
Slow-wave sleep
Slow-wave sleep , often referred to as deep sleep, consists of stages 3 and 4 of non-rapid eye movement sleep, according to the Rechtschaffen & Kales standard of 1968. As of 2008, the American Academy of Sleep Medicine has discontinued the use of stage 4, such that the previous stages 3 and 4 now...
(SWS) compared to infants who sleep on their stomachs. In human infants sleep develops rapidly during early development. This development includes an increase in non-rapid eye movement sleep (NREM sleep) which is also called quiet sleep (QS) during the first 12 months of life in association with a decrease in rapid eye movement sleep (REM sleep) which is also known as active sleep (AS). In addition, slow wave sleep (SWS) which consists of stage 3 and stage 4 NREM sleep appears at 2 months of age and it is theorized that some infants have a brain-stem defect which increases their risk of being unable to arouse from SWS (also called deep sleep) and therefore have an increased risk of SIDS due to their decreased ability to arouse from SWS.
Studies have shown that preterm infants, full-term infants, and older infants have greater time periods of quiet sleep and also decreased time awake when they are positioned to sleep on their stomachs. In both human infants and rats, arousal thresholds have been shown to be at higher levels in the electroencephalography
Electroencephalography
Electroencephalography is the recording of electrical activity along the scalp. EEG measures voltage fluctuations resulting from ionic current flows within the neurons of the brain...
(EEG) during slow-wave sleep.
In 1992 a SIDS risk reduction strategy based upon lowering arousal thresholds during SWS was implemented by the American Academy of Pediatrics (AAP) which began recommending that healthy infants be positioned to sleep on their back (supine position) or side (lateral position), instead of their stomach (prone position), when being placed down for sleep. In 1994, a number of organizations in the United States combined to further communicate these non-prone sleep position recommendations and this became formally known as the "Back To Sleep" campaign. In 1996 the AAP further refined its sleep position recommendation by stating that infants should only be placed to sleep in the supine position and not in the prone or lateral positions.
In 1992, the first National Infant Sleep Position (NISP) Household Survey was conducted to determine the usual position in which U.S. mothers placed their babies to sleep: lateral (side), prone (stomach), supine (back), other, or no usual position. According to the 1992 NISP survey, 13.0% of U.S. infants were positioned in the supine position for sleep. According to the 2006 NISP survey 75.7% of infants were positioned in the supine position to sleep.
Since 1998 there have been several studies published which report that infants placed to sleep in the supine position lag in motor skills, social skills, and cognitive ability development when compared to infants who sleep in the prone position. In a 1998 article entitled "Effects of Sleep Position on Infant Motor Development" by Davis, Moon, Sachs, and Ottolini, the authors state "We found that sleep position significantly impacts early motor development." The prone (stomach) sleeping infants in this study slept an average of 225.2 hours (8.3%) more in their first 6 months of life than the supine (back) sleeping infants.
In the 1998 article entitled "Does the Supine Sleeping Position Have Any Adverse Effects on the Child? II. Development in the First 18 Months" by Dewey, Fleming, Golding, and the ALSPAC Study Team the objective of the study was "To assess whether the recommendations that infants sleep supine could have adverse consequences on their motor and mental development." They used the Denver Developmental Screening Test (DDST) and studied infants at 6 and 18 months. According to the study, at 6 months of age, the infants who were placed to sleep in the prone position had statistically significant higher social skills scores, gross motor scores, and total development scores than those infants who were put to sleep in the supine position. In the 2005 article entitled "Influence of supine sleep positioning on early motor milestone acquisition" by Majnemer and Barr they used the Alberta Infant Motor Scale Scores (AIMS Scores) to analyze the impact of infant sleep position. They reported that "Typically developing infants who were sleep-positioned in supine had delayed motor development by age 6 months, and this was significantly associated with limited exposure to awake prone positioning." But, the authors also note that awake prone (stomach) positioning is associated with prone (stomach) sleeping. No studies have been conducted which compare supine sleeping infants who have regular awake prone positioning (tummy time) to prone sleeping infants who have regular awake prone positioning (tummy time).
Placing infants on their stomachs while they are awake (tummy time) has been recommended to offset the motor skills delays associated with the back sleep position but positioning the infant on their stomach while awake will not impact the amount of slow wave sleep since tummy time only occurs when an infant is awake.
Flat Back of Head Babies and Reflux
Since parents started to put babies on their backs there has been a new phenomena of babies having flat backs of heads and reflux where they bring up food.
The flat back of heads are because the back of the skull is far thiner than the front, this is why babies have historically not been put on their fronts. There is now a new industry of baby helmets to help resolve this issue. Sadly newer research has shown that the flat back of head does not resolve itself naturally without an orthotic helmet, although as the head grows it becomes a proportionally less noticeable feature on the skull. A metaphor commonly used is how a 1 centimeter dent on a golf ball is more noticeable on a golf ball, than the same sized dent on a basket ball, because the basket ball is larger.
The reflux is because when a baby is not on its front there is no pressure on the esophegus so the newly developed body is not able to keep food down so easily.
As a result many parents are putting babies on their fronts when these issues appear or putting babies on their fronts at all times. There are many differing views and as putting babies on their backs is a new field there have not been many controlled experiments with many of the viewpoints.
There are other viewpoints that putting babies on their backs has not actually decreased cot death in itself, research has not been in actual controlled environments because of other changing factors in modern baby care. Examples include that cot death before babies were put on their backs was high because artificial fibre sleeping materials had just come out. These early artificial materials were less easy to breath through than the natural ones used before and so cot death actually decreased because the artificial fibre materials have improved as they have been developed over time.
See also
- Sudden Infant Death SyndromeSudden infant death syndromeSudden infant death syndrome is marked by the sudden death of an infant that is unexpected by medical history, and remains unexplained after a thorough forensic autopsy and a detailed death scene investigation. An infant is at the highest risk for SIDS during sleep, which is why it is sometimes...
- National Institute of Child Health and Human DevelopmentNational Institute of Child Health and Human DevelopmentThe Eunice Kennedy Shriver National Institute of Child Health and Human Development , created by Congress in 1962, supports and conducts research on topics related to the health of children, adults, families, and populations...
- National Institutes of HealthNational Institutes of HealthThe National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
- United States Department of Health and Human ServicesUnited States Department of Health and Human ServicesThe United States Department of Health and Human Services is a Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services. Its motto is "Improving the health, safety, and well-being of America"...