Back to Sleep: Good Advice for Parents but Not for Hospitals?

DISCUSSION

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.