Does Supine Sleeping Cause Asymmetric Heads?

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COMMENTARIES 127

7. Groneck P, Gotze-Speer B, Oppermann M, Eiffert H, Speer CF. Associ-ation of pulmonary inflammation and increased microvascular

permi-ability during the development of bronchopulmonary dysplasia: a Se-quential analysis of inflammatory mediators in respiratory fluid of

high-risk preterm neonates. Pediatrics. 1994;93:712-718

8. Watts CL, Fanaroff AA, Bruce MC. Elevation of fibronectin levels in lung secretions of infants with respiratory distress syndrome and

development of bronchopulmonary dysplasia. I Pediatr. 1992;120: 614-620

9. Singhai KK, Parton LA. Plasminogen activator activity in preterm infants with respiratory distress syndrome: relationship to the

de-velopment of bronchopulmonary dysplasia. Pediatr Res. 1996;39:

229 -235

10. Cassady G, Crouse DT, Kirklin JW, et al. A randomized, controlled trial of very early prophylactic ligation of the ductus arteriosus in babies who weighed 1000 g or less at birth. N Engl I Med. 1989;320:

1511-1516

11. Darlow BA, Inder TE, Graham PJ, et al. The relationship of selenium

status to respiratory outcome in the very low birth weight infant. Pediatrcs. 1995;96:314-319

12. Pearson E, Bose C, Snidow T, et al. Trial of vitamin A supplementation in very low birth weight infants at risk for bronchopulmonary dyspla-sia. IPediatr. 1992;121:420-427

13. Phelps D. The role of vitamin E therapy in high-risk neonates. Cli,, Perinatol. 1988;15:955-963

14. Giffin F, Greenough A, Yuksel B. Does a family history of stopy influ-ence lung function at follow-up of infants born prematurely? Acta Paediatr. 1995;84:1 7-21

15. Avery ME, Tooley WH, Keller JB, et al. Is chronic lung disease in low

birth weight infants preventable? A survey of eight centers. Pediatrics.

1987;79:26-30

16. Kraybill EN, Runyan DK, Bose CL, Khan JF1. Risk factors for chronic

lung disease in infants with birthweights of 751 to 1000 grams. /Pediatr.

1989;115:115-120

17. Corcoran JD, Patterson CC, Thomas PS, Halliday HL. Reduction in

the risk of bronchopulmonary dysplasia from 1980-1990: results of a

multivariate logistic regression analysis. Eur I Pediatr. 1993;152:

677-681

18. Kraybill EN, Bose CL, D’Ercole AJ. Chronic lung disease in infants with

very low birth weight: a population-based study. Air: IDis Child. 1987;

141:784-788

19. Horbar JD, McAuliffe IL, Adler SM, et al. Variability in 28-day out-comes for very low birth weight infants: an analysis of outcomes of II

neonatal intensive care units. Pediatrics. 1988;82:554-559

20. van Marter U, Pagano M, Allred EN, Leviton A, Kuban KC. Rate of bronchopulmonary dysplasia as a function of neonatal intensive care practices. IPediatr. 1992;1 20:938-946

21. Fanaroff AA, Wright LL, Stevenson DK, et al. Very-low-birth-weight outcomes of the National Institute of Child Health and Human

Devel-opment Neonatal Research Network, May 1991 through December, 1992. Ai;z IObstet Gyzecol. 1995;173:1423-1431

22. Garland JS, Buck RK, Allred EN, Leviton A. Hypocarbia before surfac-tant therapy appears to increase bronchopulmonary dysplasia risk in

infants with respiratory distress syndrome. Arc/i Pediatr Adolesc Med.

1995;149:61 7-622

23. Fujimoto S, Togari H, Yamaguchi N, Mizutani F, Suzuki 5, Sobajima H.

Hypocarbia and cystic periventricular leukomalacia in premature

in-fants. Arc/i Dis Child. 1994;71 :F107-F1 10

24. Lee 5K, Low G. The infant ventilator: time to kill the technology overkill? Pediatr Re’s. 1 996;39:225A. Abstract

25. Oh W, Fanaroff AA, Verter J, et al. Neonatal mortality and morbidities in very low birth weight (VLBW) infants: a seven-year trend analysis of the Neonatal Research Network data. Pediatr Res. 199639:235A. Abstract

Does

Supine

Sleeping

Cause

Asymmetric

Heads?

Kane et a11 are reporting an increased frequency of

referrals of unilateral occipital flattening (plagio-cephaly) without synostosis (PWS). They have attrib-uted this more than sixfold increase in referrals

be-ginning in 1992 to an increased frequency of supine

sleeping in response to the 1992 American Academy

of Pediatrics (AAP) recommendation.2 Similar

obser-vations have been reported from other craniofacial

centers, and a recent front-page newspaper article

(The Wall Street Journal, Midwest edition. February 23, 1996, pages Al, A4) also attributed this increased incidence of PWS to the Back to Sleep campaign.

The first question to be resolved is whether the

incidence of PWS has increased. The frequency of

referral can be affected by a number of factors in

addition to the frequency of occurrence in the

pop-ulation, however, and no data regarding the latter

are available. No objective and uniform criteria for

diagnosing and referring PWS are presented, and the

incidence of diagnosed but unreferred cases is

un-known. We are not aware of any increased frequency

of PWS in northwest Ohio, and our craniofacial

cen-ter has not had any increased referrals for

asymme-try of the head. Preliminary data from the 14 000

infants studied in Avon County, England, before and

after sleep intervention have not identified any

re-ferrals for PWS or any increased incidence of

posi-tional asymmetry (P.J. Fleming, personal

communi-cation, April 26, 1996).

The prevalence of the prone sleep position (prone

prevalence) is the relevant rate to quantify in regard

to the risk of sudden infant death syndrome (SIDS).

SIDS rates have decreased by more than 50% in

association with significant decreases in prone

prey-alence.2 In regard to PWS, however, supine

preva-lence is the relevant number; the side position would

not cause the unilateral occipital flattening (PWS)

being reported1 but would be almost as effective as

the supine position in reducing the relative risk of

SIDS. To whatever extent subsequent studies do

identify an increased incidence of PWS, can we

at-tribute this increased frequency of PWS to increased supine prevalence?

No data are presented regarding the magnitude

and timing of increasing supine prevalence in Illinois and Missouri, the sources of 97% of their referrals.

The increase in PWS referrals,’ however, seems to

precede any significant sleep position intervention in

the United States. Although we were aware before

1992 of the international data identifying the prone sleep position as a risk factor for SIDS, the first public report of this risk was an AAP news release on April

15, 1992. There were no publications in US medical

journals until June 1992,2 and the documented

in-Received for publication May 1, 1996; accepted May 2, 1996.

Reprint requests to (C.E.H.) Department of Pediatrics, Medical College of Ohio, P0 Box 10008, Toledo, OH 43699-0088.

Acad-emy of Pediatrics.

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

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128 COMMENTARIES

creases in supine prevalence were relatively modest

until the national Back to Sleep campaign was begun

in May and June l994.- Supine prevalence in

north-west Ohio5 was 8% before the AAP statement in 1992

and increased to 15% by mid-1993. Nationally,6

su-pine prevalence in May and June 1992 was 12%. The

preliminary results of a longitudinal study in Boston

and Toledo7 indicate a supine prevalence in 1995 of

16% at I month of age, increasing to 33% by 3 months of age.

RECOMMENDATIONS

Pending definitive data regarding the incidence of

PWS associated with supine sleeping, what should

we be recommending? Because PWS is a minor and

temporary problem compared with the anticipated

decrease in US SIDS rates as supine prevalence

in-creases, we should continue to support the Back to

Sleep campaign aggressively. However, are there

any preventive measures that we should be

recom-mending to minimize the risk of PWS and to correct

PWS if and when it occurs?

Flattening of the head will occur beginning at

about 2 months of age whenever one part of the

head repetitively rests on the mattress.8 The simple

recommendation to correct any such asymmetry

was to change sleep position so that the pressure

fell on the opposite side of the head. In both

pre-term and full-term infants,9 head flattening from

side to side, indicated by an increasing

anteropos-tenor to bipanietal index, progresses from birth to

44 weeks’ postconceptional age; thereafter, heads

progressively become more spherical. In that

study,9 occipital flattening related to supine

sleep-ing was not identified, but it was noted that

full-term infants in the prone position had their heads

turned laterally to a greater extent than infants

kept supine, and significantly more

dolichoceph-aly developed in those infants.

Primary care physicians have not routinely

dis-cussed with parents any strategies for promoting

symmetrical head growth. Similarly, the Back to

Sleep brochure includes no recommendations

re-garding head position, although the picture of the

supine infant does show the head turned to the

side. Although some primary care physicians

might consider recommending the side position as

a means of avoiding PWS but still reducing the risk

of SIDS, the relative risk for SIDS is 2.2 times

greater in infants sleeping in the side position

compared with the supine position.1#{176} Furthermore,

the side position is unstable compared with the

supine position; when placed on the side at

bed-time, 10% of infants were prone at awakening.11

Thus, we continue to recommend that infants sleep

in the supine position.4

What should primary care physicians be

recom-mending for infants sleeping supine to eliminate

any potential risk of PWS? There are no data to

suggest a preference for the head to be at 0#{176}

(occi-put on the mattress) versus turned to either side;

whereas 0#{176}positioning may require greater

endur-ance of upper-airway dilator muscles,12 other data

suggest that the respiratory pattern is optimal at

00.13 Thus, we recommend that parents should

al-ternate equally between 0#{176},partial turning to the

right, and partial turning to the left. This rotation

in head position needs to be implemented when

the infant is a newborn to avoid establishing a

preference for a single head position if and when

occipital flattening begins to develop. Further data

will be necessary before we can recommend to

parents any specific methods for enforcing such a

rotation schedule for head position that are

effec-tive, safe, simple, and practical.

Primary care physicians also need to encourage

parents actively to continue using the prone position

for supervised infant play. We have ignored this

point to date, and 26% of parents thus never use the

prone position for playing.14 However, prone

posi-tioning for play is not a risk factor for SIDS, and the

prone position during wakefulness may be

impor-tant in developing some of the motor skills necessary

for maintaining the normal rate of motor

develop-ment. Unless infants spend supervised awake time in

the prone position, therefore, they may be at some

increased risk for positional asymmetry of the head

and perhaps also some increased risk for a transient delay in motor milestones.

CONCLUSIONS

A relationship between PWS and supine sleeping

is theoretically plausible. Additional studies are

nec-essary, however, to confirm that the incidence of

appropriately defined PWS has increased, and that

the magnitude and timing of this increase are

con-sistent with the magnitude and timing of increasing

supine prevalence. The recommended strategy to

prevent any risk for PWS is to rotate the head

posi-tion during supine sleeping and to use the prone

position for supervised awake time. With the

com-bined efforts of primary care physicians and parents,

therefore, orthotic devices such as soft helmets or

rigid head bands (The Wall Street Journal, Midwest

edition. February 23, 1996) should rarely, if ever, be

necessary, and surgery for PWS should never be

necessary.

CARL E. HUNT, MD MARK S. PUCZYNSKI, MD Department of Pediatrics Medical College of Ohio

Toledo, OH 43699

REFERENCES

1. Kane AA, Mitchell LE, Craven KP, Marsh JL. Observations on a recent

increase in plagiocephaly without synostosis. Pediatrics. 1996;97:

877-885

2. Kattwinkel J, Brooks 1’ Myerberg D. Positioning and SIDS: AAP Task Force on Infant Positioning and SIDS. Pediatrics. 1992;89:1 120-1126 3. Willinger M, Hoffman HJ, Hartford RB. Infant sleep position and risk

for sudden infant death syndrome: report of meeting held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD. Pediatrics.

1994;95:814-820

4. Hunt CE. Infant sleep position and sudden infant death syndrome risk: a time for change. Pediatrics. 1994;94:105-107. Commentary

5. Chessare JB, Hunt CE, Bourguignon C, Pediatric Research in Office

Practices Network. A community-based survey of infant sleep position.

Pediatrics. 1995;96:893-896

6. Wihinger M, Hoffman HJ, Scheidt PC, et a!. Infant sleep position and SIDS in the United States. Am JDis Child. 1993;147:460

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COMMENTARIES 129

7. Corwin MJ, Lesko SM, Vezina RM, et al. Longitudinal survey of infant

sleep practices. Presented at the Fourth SIDS International Conference;

June 23-26, 1996; Bethesda, MD

8. Greene D. Asymmetry of the head and face in infants and in children.

Am JDis Child. 1931;41:1317-1326

9. Largo RH, Duc G. Head growth and changes in head configuration in

healthy preterm and term infants during the first six months of life. Helv Paediatr Acta. 1977;32:432-442

10. Mitchell EA, Engleberts AC. Sleeping position and cot deaths. Lancet.

1991;338:192

11. Gibson E, Cullen JA, Spinner 5, Rankin K, Spitzer AR. Infant sieep

position following new AAP guidelines. Pediatrics. 1995;96:69-72 12. Scardella AT, Krawciw N, PetrozzinoJJ, Co MA, Santiago TV, Edelman

NH. Strength and endurance characteristics of the normal human go-nioglossus. Am Rev Respir Dis. 1993;148:179-184

13. Downs JA, Stocks J. Effect of neck rotation on the timing and pattern of

infant tidal breathing. Pediatr Pulmonol. 1995;20:380-386

14. Mildred J, Beard K, Dallwitz A, Unwin J. Play position is influenced by knowledge of SIDS sleep position recommendations. I Paediatr Child Health. 1995;31 :499-502

MOTHERHOOD, MEDICINE, AND MURDER

Waneta Hoyt’s first baby died. Then her second. Then her third. Nobody,

including her husband, suspected Waneta Hoyt-or stopped her from having

more babies. Then her fourth baby died. Then her fifth. And a famed medical

expert declared they had died of sudden infant death syndrome (SIDS) and used

them to support his theory that SIDS ran in families.

One man, however, did not accept this diagnosis. District Attorney Bill

Fitz-patrick set out to expose the truth about a crime hard to imagine. To do so meant

convicting a woman who had won the hearts of all, and disproving a doctor who

had climbed to the top of his field with the help of little corpses.

Brace yourself for a true story of motherhood, medicine, and murder you will

remember every time you hear a baby crying...

Hickey C, Lighty T, O’Brien J. Goodbye, My Little Out’s. Onyx; March 1996, $5.99.

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1996;98;127

Pediatrics

Carl E. Hunt and Mark S. Puczynski