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Prone position and prematurity; aspiration

As a new first time mother, SIDS has become a constant thought/fear. I ask new mothers, "Do you place your child on their stomach to sleep?". Some do admit cautiously that they do. One new mother who had a very premature baby commented that the NICU nurses kept her baby girl on her stomach and now the baby prefers to sleep that way. Why would NICU staff put babies on their stomach at all???? I also worry about placing the baby on her back, in fear that she will spit up and choke to death?? What to do??

Perhaps one of our physicians on the list will address your question more specifically, but I can provide the following, quoted from the "Back to Sleep - Questions and Answers for Professionals on Infant Sleeping Position and SIDS" brochure. I hope this helps.

Ellen Siska
In Loving Memory of Edward David Siska - 6/25/91 - 9/15/91 - SIDS

"Are there any babies who should be placed prone for sleep?

In published studies, the vast majority of babies examined were born at term and had no known medical problems. Babies with certain disorders have been shown to have fewer problems when lying prone. These babies include:

--premature infants while they are experiencing respiratory disease (arterial oxygenation is somewhat higher in the prone position).

--infants with symptomatic gastro-esophageal reflux (reflux is usually less in the prone position).

--babies with certain upper airway malformations such as Robin syndrome (there are fewer episodes of airway obstruction in the prone position).

There may also be other specific infants in whom the risk/benefit balance favors prone sleeping. The risk of SIDS increases from approximately 0.86 SIDS deaths per 1,000 live births to 1.62 when babies sleep prone (that is, 998 of every 1,000 prone-sleeping babies will not die of SIDS). This relatively small increasd risk may be reasonable to accept, when balanced against the benefit of prone sleeping for certain babies. Health professionals need to consider the potential benefit when taking into account each baby's circumstances.

If it is decided to allow a baby to sleep prone, special care should be taken to avoid overheating or use of soft bedding since these factors are particularly hazardous for prone-sleeping infants.

Which sleeping position is best for the baby born perterm who is ready for discharge?

There have been studies showing that preterm babies who have active respiratory disease have improved oxygenation if they are prone. However, these babies have not been specifically examined as a group once they are recovered from respiratory problems and are ready for hospital discharge. There is no reason to believe that they should be treated any differently than a baby who was born at term. Unless there are specific indications to do otherwise (see exceptions above), the Task Force believes that such babies should be placed for sleep on their backs or sides.

Will babies aspirate on their backs?

While this has been a significant concern to health professionals and parents, there is no evidence that healthy babies are more likely to experience serious or fatal aspiration episodes when they are supine. In fact, in the majority of the very small number of reported cases of death due to aspiration, the infant's position at death, when known, was prone. In addition, indirect reassurance of the safety of the supine position for infants comes from the knowledge that this position has been standard in China, India, and other Asian countries for many years. Finally, in countries such as England, Australia, and New Zealand, where there has been a major change in infant sleeping position from predominantly prone to predominantly supine or side sleeping, there is no evidence of any increased number of serious or fatal episodes of aspiration of gastric contents.

The information quoted by Ellen Siska is quite complete, and I am in full agreement. Although I am in full support of the recommendation that even preterm infants should sleep supine by the time of NICU discharge, it is quite standard in the NICU that sleep position is rotated between prone, side and supine if the medical status permits. At these levels of prematurity, studies have shown that preterm infants do breath better prone.

As in term infants, there is no apparent increased risk for aspiration when supine if overall neurological function is intact.

Just as is needed for infants at home, we need to develop more aggressive education/intervention strategies in the NICU to ensure that preterm infants are routinely placed supine for sleeping as they progress through the convalescent stages.

Hope this is helpful.

Carl E. Hunt, M.D.
Toledo/Washington D.C.

What are the numbers  'statistics' of babies that experience fatal aspiration episodes when they are supine?  We had such an occurrence and it appears to me that in the struggle to breath a infant  around 3 months, could flip himself in the struggle even if he was put down supine. Please clarify this. Thank you (September 2003)

Fortunately, fatal aspiration is very rare except when associated with underlying or associated medical conditions. However, there are no data to suggest that aspiration of any severity is more common supine than prone. The infant care practice study that included several thousand infants (PDF attached) did not find any increased problems with aspiration during the first 6 months of age in infants sleeping supine compared to side and prone. I hope this information is helpful.

Carl E. Hunt, MD
Director, National Center on Sleep Disorders Research
Bethesda, MD

It appears incontrovertible that the incidence of SIDS is reduced by the employment of the supine sleeping position. Fewer infants expire sleeping in this position than do infants in the prone position. If the problem arises in the central nervous system (CNS) ,say in the arcuate nucleus in the brainstem, then why would the sleeping position on the tummy be contributory to exacerbating the neurological 'defect'? Put another way, how could such a peripheral input effect changes in the brainstem and increase the risk of SIDS? There has to be a connection in SIDS between belly and brainstem. A ridiculous notion?.... Maybe...

An excellent question. The 2 prevailing hypotheses to explain the risk of prone sleeping are related to impaired respiratory control and overheating. Both of these are regulated in the brain stem, so that any impairment in brain stem function (however subtle or mild) would be expected to increase the "risk" of prone sleeping in that infant.

I hope this is helpful.

Dr. Carl Hunt
Washington, DC/Toledo

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