Background. In October 1998, when we surveyed nurses working in Iowa obstetric units about infant sleeping position in the hospital and recommendations for infant sleeping position at home, we learned that the side position was used frequently in the hospital and also was considered to be an acceptable alternative for sleeping position at home.
Objective. The purpose of our present study was to determine why nurses continued to use and endorse the side sleeping position rather than the supine position.
Design. We surveyed all Iowa hospitals that had an obstetric service as of July 1999 to learn why the side position was used.
Results. All 94 hospitals with obstetric services responded to the survey and revealed that 2 major factors were considered when an infant was put to sleep on his/her side. The most frequent response was fear of aspiration (57 responses or 51.4%) and the second was adherence to a federal brochure that lists side sleeping as a reasonable alternative (38 responses or 34.2%).
Conclusion. We conclude that the reasons reported for use of the side position in Iowa maternity hospitals do not justify its continuing use. We believe that information about the importance of placing an infant on his/her back to sleep and its superiority over placing an infant on his/her side to sleep is sufficient to warrant its availability in every maternity hospital. We speculate that if the infant sleeping position used in the hospital is not different from that taught to parents, there will be less parental confusion and greater adherence to infant positioning shown to reduce sudden infant death syndrome.
Sudden infant death syndrome (SIDS) continues to be a leading cause of death for infants aged 1 month to 1 year. In the early 1990s, epidemiologic studies showed that the prone sleeping position was associated with an increased incidence of SIDS.1–3Based primarily on these findings, in 1992 the American Academy of Pediatrics (AAP) released a policy statement4 recommending that sleeping infants be placed in a back or side position. This recommendation was reaffirmed by the AAP in 19945 and a recommendation to avoid soft bedding and soft objects in the infant sleep environment was added.
In 1994, the AAP, the US Public Health Service, and the SIDS Alliance launched the Back to Sleep Campaign to urge parents, health professionals, and other care providers to place infants on their backs or sides, but not prone, for sleep. Despite new information6–8 demonstrating instability of the side position and its increased risk for SIDS, the AAP, the SIDS Alliance, and governmental agencies released another recommendation in 19969 promoting the supine position but still listing the side position as acceptable. A caveat was issued with this recommendation that if side position was chosen, caretakers should be sure that the infant's lower arm be placed forward to stop him/her from rolling over onto the stomach.
At the same time that back to sleep recommendations were being endorsed by the AAP and others, Kemp et al,10,11 using mechanical and animal models, provided information that associated soft bedding with rebreathing of exhaled carbon dioxide. This information afforded 1 plausible explanation of why prone positioning could put an infant at risk for SIDS.
Because of the findings described above, it seems important for parents and other caretakers of infants to have proper information about infant sleeping position and sleeping environment. We were interested to know what information was provided to parents while they were in the hospital after the birth of their infant. Also, we wanted to know how the infant was placed for sleep while in the hospital. Accordingly, we surveyed personnel in all of Iowa's maternity hospitals about these issues and received 100% response from the 95 hospitals that were delivering infants at that time (October 1998).
We were surprised to learn that 85 (89.5%) were using either the back or side position in the hospital and 86 (90.5%) informed parents that placing an infant on his/her side to sleep was acceptable at home. The purpose of this study was to learn why nurses in Iowa hospitals used the side position in preference to the supine position while the infant was in the hospital.
A survey instrument was developed for the purpose of learning why nurses used the side sleeping position for newborns in the hospital. The survey was very brief and constructed as follows. The nurses were asked the following question and the potential responses follow. “When you put an infant down for sleep on his/her side in the newborn nursery, the reason you do this is (please circle only one response) a) To prevent aspiration if he/she regurgitates; b) They sleep better; c) Force of habit; d) Don't know; e) Back to Sleep information indicates that side position is an acceptable alternative when positioning an infant for sleep; f) Other, specify; g) We do not use the side position in the newborn nursery.”
Thus, respondents had choices, but also there was the opportunity for an open-ended response. The survey was restricted to the care of term or near-term infants (≥ 37 weeks). It was sent to the head nurse of the obstetric service and asked that she respond or have a knowledgeable delegate do the same. We asked that the response reflect the consensus position of the obstetric service and not just the opinion of the nurse who filled out the questionnaire. We did not specify how the consensus opinion should be obtained because the majority of Iowa services are quite small and the number of nurses working in the area would be quite limited. All 94 Iowa hospitals that were providing obstetric services at the time of the survey responded and thus the response rate was 100%.
In the interval between the first survey and our present survey, 1 hospital discontinued obstetric services and thus only 94 hospitals responded to the current survey. The response rate was still 100%. The contents of this survey are shown in Table 1. Review of these data reveal that 2 major factors were considered when an infant was put to sleep on his/her side. The most frequent response was fear of aspiration (57 responses or 51.4%). The second most frequent response was adherence to the most recent federal brochure12 that lists placing an infant on his/her side to sleep as a reasonable alternative (38 responses or 34.2%).
The results of our survey reveal that Iowa nurses still have concerns over aspiration when a newborn is placed in the supine position. Given this concern, because the prone position has been clearly shown to be an increased risk for SIDS, nurses are left with the side position as their only “safe” choice.
But how safe is the side position if parents mimic the nurse's use of the side position when they take their infant home? Also, is there an authentic basis for the nurse's concern about neonatal aspiration after vomiting?
The literature on infant sleeping position provides evidence that the side position is unstable and thus increases the risk of rolling to the prone position, which may put the infant at increased risk for SIDS. In 1997, the position statement of the SIDS Global Strategy Task Force13 indicated that health care professionals having contact with newborn infants in hospital settings should establish, before discharge, the same safe sleeping practices they desire the family to use after discharge. They also state that studies document that SIDS rates are twice as high in infants routinely placed on the side for sleeping compared with supine.
In 1994, Mitchell and Scragg6 identified the side position as being a risk factor for SIDS. When compared with back sleeping, the side position had an odds ratio of 2.57 (1.15–6.78). Later, in 1996, Skadberg and Markestad14 noted that during the first weeks of life there is still a reluctance to accept a supine rather than a side position in many countries. They observe that the side position, as they showed in a previous study, is the least stable body position and that young infants are at risk to change their position to prone.
In 1998, an increased risk for side-sleeping infants compared with those in supine position, odds ratio 4.03 (1.36–11.96), was reported by L'Hoir et al.15 Also in 1998, Scragg and Mitchell8 reviewed studies from the years 1987 to 1995 that compared placing infants to sleep in their backs and sides. They concluded that after correcting for sleeping in the prone position, sleeping on the side as a cause for SIDS second only in importance to maternal smoking.
As we noted above and as noted by others,16 one of the main arguments against sleeping in the supine position seems to center on the nurse's fear of vomiting and aspiration. The fear of aspiration does not have support in the literature and, in fact, the converse is true. Henderson-Smart et al17 in a review article on reducing the risk of SIDS, note that recent data indicate that the supine position is not associated with an increase in significant morbidity outcomes and that it provides greater protection from SIDS than the side position.
This observation is corroborated by Adams et al16 who also did not notice an increase in morbidities of infants who were placed in the supine position. Carroll and Siska18 note that no scientific evidence shows that the supine position poses a risk for vomiting and aspiration in healthy infants. Dwyer et al,19in studying potential adverse characteristics of sleeping in the supine position, concluded that sleeping in the supine position was associated with only 1 adverse characteristic—an increase in noisy breathing. Thus, the fear of increased morbidity, especially aspiration associated with the supine position, does not seem to be supported in the literature.
We are not promoting sleeping in the supine position in the hospital because of fear of an increased risk of SIDS. Indeed, the risk for SIDS in the first few days of life is extremely low. However, we agree with Rose et al20 that parents may imitate what they see in the hospital vis a vis sleeping position. That may be particularly true for those who will not or cannot read. In our hospital, we have a number of maternity patients who are recent immigrants and cannot read even in their native language. Accordingly, we believe that the use of the supine position in the hospital is important to illustrate how the infant should sleep at home.
Our surveys of Iowa hospital personnel about the use of infant sleeping positions and the reasons why those positions were used suggest that we have a significant educational challenge to change existing care practices. However, we believe that because we now have more information about what is done and why, more appropriate educational intervention may be possible.
We believe that all information about infant sleeping position should recommend only the supine position. The brochure provided by the US Public Health Service and others12 is recognized as an authoritative source and thus, as shown by our data, influences behavior in Iowa hospitals. Accordingly, we urge that the next edition of the brochure no longer list the side position as an acceptable alternative.
Second, we must make all personnel working in infant care areas such as newborn nurseries and other child care settings aware of the safety and utility of the supine position and the risk of the side position.
We thank the Iowa Department of Public Health for assistance in conducting the survey.
- Received April 4, 2000.
- Accepted June 30, 2000.
Reprint requests to (H.A.H.) Department of Pediatrics, 200 Hawkins Dr, Iowa City, IA 52242. E-mail:
- SIDS =
- sudden infant death syndrome •
- AAP =
- American Academy of Pediatrics
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- Copyright © 2001 American Academy of Pediatrics