Infant Sleep Position: Pediatricians' Advice to Parents

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Infant

Sleep

Position:

Pediatricians’

Advice

to Parents

PEDIATRICS Vol. 95 No. 1 January 1995 55

Bonnie B. Hudak, MD; Jane O’Donnell, RN, PNP; and Nadine Mazyrka, RNC

ABSTRACT. Objective. The American Academy of

Pediatrics’ (AAP) recommendation for side or supine sleep position in healthy babies has generated much

controversy. We surveyed primary care physicians to

de-termine the effect of the AAP statement on physician

attitude toward infant sleep position and advice to

parents.

Methods. We sent a 23-question survey to 194

physi-cians in Western New York. The survey addressed their

attitude toward the AAP recommendations and its

impact on their advice to parents.

Results. Of the 149 physicians treating newborns, 121

(82%) completed the questionnaire; 98% were aware of the AAP statement. The most common sources of infor-mation were the AAP (86%) and professional literature

(77%). Of the respondents, 79% agreed with the AAP

statement. Reasons for reservation were lack of data

(64%), potential adverse consequences of supine position

(52%), and their own experience (47%). Gender, years in

practice, and type of reimbursement did not influence

attitude toward the AAP recommendation. The AAP

statement increased the frequency with which physicians routinely discussed sleep position from 34 to 70% (P <

.02). Physicians recommending the prone position

de-creased from 57 to 7% (P < .001), while those

recommend-ing supine sleep position increased from 10 to 42%

(P < .001).

Conclusions. Most physicians agreed with the AAP

statement and more frequently discussed sleep position

following the AAP recommendations. However, they did not routinely recommend supine sleep position. The ma-jority (69%) recommended the side position even though it is unstable. Although the AAP statement has increased discussion of infant sleep position by primary care

phy-sicians in WNY, only a minority recommend that infants sleep supine. Pediatrics 1995;95:55-58; sudden infant

death syndrome, infant, body position, sleep.

ABBREVIATION. SIDS, sudden infant death syndrome.

Little in medicine creates as much controversy as

suggesting that the conventional wisdom is unwise.

This has certainly been true of the recommendation

by the American Academy of Pediatrics that healthy

newborns be placed in the supine or side position. In

April 1992, the AAP recommended that “healthy

infants, when being put down for sleep, be

positioned on their side or back.”1 Although this

From the Department of Pediatrics, State University of New York at Buffalo and Children’s Hospital of Buffalo, NY.

Received for publication Feb 22, 1994; accepted May 5, 1994.

Reprint requests to (B.B.H.) Children’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222.

recommendation was based on unpublished data

from the United States and a wealth of international

literature, it has been met with both resistance and

opposition. One of the objections to the AAP

recom-mendation is that the supine sleep position has not

been proven to reduce the risk of sudden infant

death syndrome (SIDS) in the United States. While

the AAP Task Force on Infant Positioning and SIDS

recognized the scientific validity of this argument,

they concluded that “assessment of the risk/benefit

balance for prone vs non-prone positioning ...

favors the latter”.’

Shortly after the AAP recommendation was made

public, there was a flurry of attention given to infant

sleep position in the media. Newspapers, magazines,

television newscasts, and talk shows all featured

items on the potential benefits of the supine sleep

position in preventing SIDS. However, there has not

been a national education campaign directed at

changing infant sleep position or reducing other risk

factors for SIDS. The responsibility for the education

of infant caretakers currently falls with the primary

care practitioner. We surveyed primary care

practi-tioners in the Western New York region to determine

the effects of the AAP recommendations for infant

sleep position on their advice to parents.

Survey Methods

METhODS

We developed a 23-question survey and distributed it to pediatricians and family practitioners in the eight-county region of Western New York which serves as the referral base for the Children’s Hospital of Buffalo. The list of physicians surveyed was obtained from the hospital’s medical staff office. Surveys were remailed to nonrespondents I month after the initial mailing. Both mailings included a cover letter, survey, and postage-paid return envelope. Phone calls were made to those not responding to determine whether or not the physicians were still practicing in the community. Survey recipients were assigned a number for tracking purposes only. Those surveyed were offered anonymity and were assured confidentiality.

Survey Questionnaire

A prototype survey was developed by the authors and reviewed by selected pediatric faculty members at the Children’s Hospital of Buffalo. The final survey contained 23 questions; 20 multiple choice or fill-in-the-blank and 3 open-ended. The survey included demo-graphic questions about the physicians and nature of their practice, their attitude toward the AAP recommendations for sleep position in healthy infants and, the frequency and type of advice given to

par-ents before and after the AAP recommendations.

Statistical Analysis

Responses from completed surveys were entered in a computer data base. They were analyzed with descriptive statistics using chi-square and Mantel-Haenszel tests. In all cases, P < .05 was considered significant.

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Never Rarely Somimes Usually Always

Frequency Sleep Position Discussed

56 INFANT SLEEP POSITION: ADVICE TO PARENTS

RESULTS

The survey was initially mailed to 194 physicians.

Of these, 45 physicians did not treat newborns and

were excluded from further analysis. Of the 149 who

saw newborn infants in their practice, 121 (81.8%)

returned the survey. Twenty-eight physicians either

declined to participate (n = 3) or did not return the

survey (n = 25).

The majority of physicians returning the survey

were pediatricians (93.4%). Most practiced in a

sub-urban (59.5%) or urban (33.0%) office. The ratio of

male to female respondents was 77:44. Half of those

responding (61, or 50%) had been in practice for 10

years or less (median 10, range 0 to 46). Twenty-nine

physicians (24.4%) had solo practices, while 93

(76.8%) practiced in a group of 5 or fewer (median 3,

range I to 80). The number of newborns seen in each

group ranged from 30 to 2000 (median 200), with 72

(59.5%) of physicians seeing between 50 and 400

newborns/year in their group. The majority of

phy-sicians (79, 65.3%), had over 50% of the patients in

their practice who were enrolled in managed health

care plans. For 26 (21.5%) physicians, the primary

means of reimbursement to their office was through

Medicaid. Eighty-one physicians (66.9%) had an

infant who died of SIDS in their practice.

Although almost all (119, 98.4%) of the

respon-dents were aware of the AAP recommendations for

sleep position in infants, the sources of information

varied. The AAP was the most common source,

reaching 85.7% of respondents. Other sources

in-cluded professional literature (77.3%), colleagues

(43.7%), meetings and speakers (37.0%), mass media

(30.3%), and parents of patients (11.8%). Several

phy-sicians expressed frustration in that they first learned

of the AAP recommendations from the latter two

sources.

Only 29 (24.4%) of physicians completing the

sur-vey strongly agreed with the AAP

recommenda-tions. Of the remainder, 67 (55.4%) somewhat agreed

and 19 (15.8%) somewhat disagreed. Among those

not strongly agreeing with the AAP statement, the

most common reason for reservation was “lack of

data” (see Table). The attitude of physicians toward

the AAP recommendations was not influenced by

gender or years in practice. However, those

TABLE. Reasons for Reservation in Physicians Not Strongly

Agreeing With the AAP Recommendations for Sleep Position in Infants

Reasons for Number o f Physicians C iting Reason

Reservation

----Primary Reason Additional Reasons Total Citing Reason

Lack of data 35 (40.6%) 20 (23.2%) 55 (64.0%)

Potential adverse 12 (13.8%) 33 (38.3%) 45 (52.3%) consequences of

supine position

Experience 20 (23.2%) 20 (23.2%) 40 (46.5%)

Previous training 9 (10.4%) 21 (24.4%) 30 (34.9%) Parental resistance I (1.2%) 13 (15.1%) 14 (16.3%)

Lack of 5 (5.8%) 6 (7.0%) II (12.8%)

knowledge of data

Other 4 (4.6%) 4 (4.6%) 8 (9.3%)

physicians who had not had a SIDS death in their

practice tended to be in practice for fewer years (chi

square = 3.81, P < .06) and were more likely to agree

with the AAP recommendation than were those

physicians who had a patient die of SIDS (91.9%

agree vs 74.1%, P < .05).

The AAP recommendations for sleep position had

a marked effect on the frequency with which

pedia-tricians routinely discussed sleep position (Fig 1).

Before 1992, only 41 physicians (33.9%) indicated

that they regularly discussed sleep position. Only 12

(9.9%) routinely provided literature addressing this

topic. However, by 1993, 70% of physicians

complet-ing the survey usually or always discussed sleep

position with parents and 25 (21 %) gave parents

literature which addressed sleep position.

In addition to more frequently discussing sleep

position, physicians are recommending different

sleep positions. Before the AAP statement, sleep

po-sitions recommended for healthy newborns were

prone (57.0%), side (47.1%), and, less frequently,

su-pine (9.9%) (Fig 2). Following the position

recom-mendations, there was a marked decrease in the

number of physicians recommending the prone

po-sition to 6.6%. At the time of the survey, the majority

of physicians recommended side sleep position for

healthy infants (69.0%). Supine position, though

more frequently recommended, was still advised by

only 42.1 % of physicians completing the survey.

While the frequency with which physicians

dis-cussed sleep position is independent of their attitude

toward the AAP recommendations, their attitude

in-fluenced the position they recommended to parents.

Those who disagreed were less likely to recommend

the supine sleep position than were those who

agreed (19.0% vs 46.3%, P < .025). The side sleep

position was recommended with equal frequency

among all groups, regardless of their attitude toward

the statement. The number of years in practice did

not influence the frequency with which the supine

position was recommended.

C 0 0 0. 0 2 E z

0 PrIor to AAP Rcommendatlons

.

Following AAP Recommendations

Fig 1. The AAP recommendation increased the frequency with

which physicians usually or always discuss sleep position

(P < .02).

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ARTICLES 57 C 0 0 0 0. C C 0 E E 2 E z

. : #{149}_C e

B Cl) a ,,

. 0 C C a a e C C .. 2 Ca

0 Pre.AAP Rscommsndations Post-AAP Recommendations

0

C

0 0

a:

Fig 2. Following the AAP statement, fewer pediatricians recom-mended the prone position (P < .001), while more recommended the supine and side positions (P < .001 and P < .025, respectively)

DISCUSSION

It has been 2 years since the American Academy of

Pediatrics Task Force on Infant Positioning and SIDS

recommended that healthy infants be placed on their

side or back when being put down to sleep.’ Yet, this

apparently simple suggestion continues to generate

debate in the medical literature, in the mass media,

and in physicians’ offices. While the AAP statement

was prepared after careful and thoughtful review of

the international literature, the lack of confirmatory

data from prospective, controlled trials in the United

States has led many to protest this recommendation.

The academic debate and the public interest and

controversy surrounding the AAP recommendation

to abandon the prone sleep position has produced a

potentially uncomfortable situation for the practicing

pediatrician.

The results of this survey indicate that, while many

pediatricians continue to have reservations about the

AAP recommendations for infant sleep position,

they no longer recommend placing infants in the

prone position for sleep. However, only 42%

recom-mended the supine sleep position, either alone or in

combination with side positioning. Of those who

routinely discuss sleep position with parents, most

(68%) recommend placing infants on their side to

sleep. These results raise two questions: why are

pediatricians reluctant to recommend the supine

p0-sition and why do they prefer the side position?

While this survey did not specifically ask why

pediatricians did not recommend the supine

posi-lion, it did ask those not strongly agreeing with the

AAP statement to indicate the reasons for their

res-ervations. The most frequently given response was

that there was a lack of data to support the

recom-mendation. Many pediatricians commented that they

had concerns regarding the applicability of data

orig-mating in other countries. They cited international

differences in sleeping practices, bedding materials,

and incidence of SIDS as possible confounding

variables.

The side position appears to represent a

compro-mise between the AAP statement, which endorses

both the supine and side sleep positions, and the

reservations expressed both in the medical literature

and by the surveyed pediatricians. The reasons for

the previously widespread acceptance of prone sleep

position in the United States are certainly

multifac-tonal and are probably different than those cited as

reasons not to abandon it. A decreased risk of

gas-troesophageal reflux and, by implication, aspiration

has been cited as a reason to position sleeping infants

on their abdomens.2’3 In fact, the possible

relation-ship between gastroesophageal reflux, sleep

posi-tion, and aspiration was one of the most frequent

reasons that physicians did not strongly agree with

the AAP recommendations. Other historic

argu-ments in favor of the prone position have included

increased comfort of the infant, decreased agitation

and crying, decreased colic, earlier attainment of

cer-tam motor milestones, and less flattening of the head.

While some of these arguments are more founded in

fact than others, they have combined to result in

generations of American infants sleeping prone.

These factors probably also contribute to the

reluc-tance of pediatricians to fully support the

recommen-dation for supine or side sleep position, because 66%

of pediatricians returning this survey cited either

previous training or experience as reasons for

reservation. Although they are of questionable

sig-nificance in healthy full-term infants, other

argu-ments favoring the prone position have also

evolved including improved lung mechanics and

oxygenation.4’5

While many pediatricians are most comfortable

recommending that infants be put to sleep lying on

their side, the advantages to this over the supine

position are not clear. The side sleep position is

Un-stable; some infants placed on the side will roll to

other positions, including the prone position. Hassall

and Vandenberg,6 studied sleep position in New

Zealand infants between the ages of 1 and 4.5

months. They found that only 53% of 1-month

in-fants and 31 % of 4-month infants placed on their side

usually remained on their sides. The majority had

turned to a supine position, while some rolled to

prone. Engelberts and de Jonge7 surveyed parents

and found only 30% of infants between 2 weeks and

4 months placed to sleep in the side position were

found there the next morning. Sixty-five percent of

infants placed to sleep on their side had turned to

supine, while 4% turned to prone. The side sleep

position was more unstable in infants over 4 months.

These data suggest that, while placing infants on

their sides represents an intellectual compromise, it

is a subtle endorsement of the supine position. The

international literature overwhelmingly

demon-strates an increased risk of SIDS in babies who sleep

prone. The risk of SIDS in the side versus supine

positions has not been clearly differentiated.

At this time, national educational campaigns

aimed at reducing the risk of SIDS through changes

in sleep position and other child care practices are

just beginning. Other countries, including Great

Brit-am,8’9 The Netherlands,1#{176} and New Zealand,’1 have

already adopted comprehensive educational

pro-grams that advocate the supine or side sleep position

for healthy infants. In addition, these programs have

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58 INFANT SLEEP POSITION: ADVICE TO PARENTS

included education regarding proper bedding

mate-rials and thermal environment, breast-feeding, and

cessation of tobacco smoking as other means of

reducing the risk of SIDS.

Although some authors have linked a recent 12%

decline in the United States SIDS rate to publication

of the AAP recommendations,’2 others have argued

that the effect of sleep position should be determined

by a prospective, controlled trial.’3 They note that the

high relative risks associated with prone sleeping in

other countries may be related to child care practices

not common in the US)4”5

While the debate over the need for a clinical trial

and the ethical implications of such a trial continues,

pediatricians must make recommendations to

par-ents. We have shown that the AAP

recommenda-tions succeed in changing the practices and the

ad-vice of primary care physicians, although most

pediatricians remain reluctant to advise the supine

sleep position.

ACKNOWLEDGMENTS

We thank the physicians of Western New York for their interest and participation in this study. B.B.H. also acknowledges her daughter, who thwarted all efforts to comply with the AAP

rec-ommendations.

REFERENCES

1. AAP Task Force on Infant Positioning and 5105. Positioning and 5105.

Pediatric. 1992;89:1 120-1126

2. Orenstein SR. Whitington PF. Positioning for prevention of infant gastro-esophageal reflux. / Pediatr. 1983;103:534-537

3. Meyers WF, Herbst JJ. Effectiveness of positioning therapy for gastroesophageal reflu.x. Pediatrics. 1982;69:768-772

4. Wagaman MJ, ShutackJG, Moomijian AS, SchwartzJG, Shaffer TH, Fox wW. Improved oxygenation and lung compliance with prone position-ing of neonates. /Pediatr. 1979;94:787-791

5. Martin RJ, Herrell N, Rubin 0, Fanaroff A. Effect of supine and prone positions on arterial oxygen tension in the preterm infant. Pediatrics.

1979;63:528-531

6. Hassall lB. Vandenberg M. Infant sleep position: a New Zealand survey. NZ Med /. 1985;98:97-99

7. Engelberts AC, de Jonge GA. Choice of sleeping position for infants: possible association with cot death. Arc/i Dis Child. 1990;65:462-467 8. Bignall J.Decline in sudden infant deaths. Lancet. 1993;41:887

9. Wigfield RE, Fleming PJ, Berry PJ, Rudd PT, Golding J. Can the fall in Avon’s sudden infant death rate be explained by changes in sleeping position? Br Med /. 1992304:282-283

10. Engelberts AC, de Jonge GA, Kostense PJ. An analysis of trends in the incidence of sudden death in the Netherlands. /Paediatr Child Health. 1991;27:329-333

I I. Taylor BJ.A review of epidemiological studies of sudden infant death syndrome in southern New Zealand. / Paediatr Child Health. 1991;27: 344-348

12. Spiers PS, Guntheroth WG. Recommendations to avoid the prone sleep-ing position and recent statistics for sudden infant death syndrome in the United States. Arch Pediatr Adolesc Med. 1994;148:141-146

13. Hunt CE. Infant sleeping position. Back to the bench. Arch Pediatr

Adolesc Med. 1994;148:131-133

14. Orenstein SR. Mitchell AA, Ward SD. Concerning the American Acad-emy of Pediatrics recommendation on sleep position for infants.

Pedi-atrics. 1993;91 :497-499 (Commentary)

15. Hunt, CE, Shannon DC. Sudden infant death syndrome and sleeping position. Pediatrics. 199290:1 15-1 18 (Commentary)

8TH PEDIATRIC TUMOURS CONGRESS AND

NEW TRENDS IN MEDICINE

May 1-5, 1995

Cukurova University

Medical Faculty

Adana, Turkey

Secretary of Congress: Associate Professor Dr Atila Tanyeli, Department of

Pediatric Oncology, Cukurova University Medical Faculty, Adana, Turkey. Tel: 0322-3386060; Fax: 0322-3386906.

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1995;95;55

Pediatrics

Bonnie B. Hudak, Jane O'Donnell and Nadine Mazyrka