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“ We do not put new-born babies to sleep on their tummies,” said the lady in the day care centre we had visited in the US. “We rule out the possibility of obstruction of the upper airways and suffocation due to a roll up of the sheet in the crib. Plus today it’s a mandatory rule enforced by the government.”

We were putting the baby down to sleep on his tummy at home, and therefore decided to  read up and do some research on the phenomenon. It is terrifying and as the research says, it is the preferred choice over life and death. Avoid putting an infant down to sleep on it’s tummy, period.

If you’re a parent in the 21st century, then you’ve no doubt heard the recommendations about safe sleeping for babies, given by paediatricians. Every new parent understands that the safest way for a baby to sleep is on her back, and not on her stomach. Why? Because back sleeping reduces the risk of SIDS (presumably because it reduces the risk of the infant re-inhaling its expelled carbon dioxide and therefore not getting enough oxygen). However, the mechanisms by which putting an infant down to sleep on it’s tummy  might lead to SIDS are not entirely known.

This recommendation was the cornerstone of the 1992 Back to Sleep campaign, and at that time, it was fairly earth-shattering. Up until 1992, parents were urged to place their babies on their tummies to sleep, since it reduced the risk that baby would spit up and then choke during the night. The Back to Sleep campaign, was an initiative backed by the US National Institute of Child Health and Human Development (NICHD) at the US National Institutes of Health to encourage parents to have their infants sleep on their backs (supine position) to reduce the risk of SID.

And, research on Back Sleeping and SIDS off the net says that the single most effective action that parents and caregivers can take to lower a baby’s risk of SIDS is to place the baby to sleep on his or her back for naps and at night.

Compared with back sleeping, stomach sleeping carries between 1.7 and 12.9 times the risk of SIDS says the American Academy of Paediatrics. The mechanisms by which stomach sleeping might lead to SIDS are not entirely known. Studies suggest that stomach sleeping may increase SIDS risk through a variety of mechanisms, including:

  • Increasing the probability that the baby re-breathes his or her own exhaled breath, leading to carbon dioxide buildup and low oxygen levels
  • Causing upper airway obstruction
  • Interfering with body heat dissipation, leading to overheating says a researcher named Carroll.

Hard numbers and evidence from numerous countries—including New Zealand, Sweden, and the United States have come up with numbers that suggests that when placing babies on their backs to sleep there was a substantial decline in the SIDS rate compared to placing babies on their stomachs to sleep. Researchers have established the link between stomach sleeping and SIDS by showing that babies who died from SIDS were more likely to be put to sleep on their stomachs compared to babies who slept on their backs.

Public health campaigns were launched by those governments, to promote back sleep position and reduce the use of the stomach sleep position. There were dramatic decreases in SIDS rates occurred in all countries with these public health campaigns as the information was  successful in reducing the preference of the stomach sleep position among infants, by parents. Countries like Hong Kong, where stomach sleeping is rare, SIDS rates historically have been very low, which further strengthens the research deductions.

Compared with infants who sleep on their backs, infants who sleep on their stomachs:

  • Are less reactive to noise.
  • Experience sudden decreases in blood pressure and heart rate control.
  • Experience less movement, higher arousal thresholds, and longer periods of deep sleep said researchers Sahni and Khan.

These characteristics might put an infant at higher risk of SIDS. The simple act of placing infants on their backs to sleep, significantly lowers the risk of SIDS, a fact backed with research.

As stomach sleeping has declined in response to back-sleeping campaigns worldwide, statistics show that the contribution of side sleeping to SIDS risk has increased. Research shows that side sleeping is just as risky as stomach sleep position and, therefore, should not be used as well.

Placing babies on their backs to sleep is not associated with risks for other problems. For example, there is no increase in aspiration or complaints of vomiting when babies are placed on their backs to sleep. That was the main reason that young mothers cited for placing their babies on their stomachs to sleep. Just incase the infant had not burped before being put down, the risk of choking was their reason for preferring the face down method.

Moreover, babies may benefit in other ways from sleeping on their backs. A 2003 study found that infants who slept on their backs were less likely than infants who slept on their stomachs to develop ear infections, stuffy noses, or fevers.

Other studies found that back sleepers have delayed early motor skill milestones, although one recent Israeli study found no difference in gross motor developmental skills at 6 months among supine and prone sleepers say researchers Majnemer and Cameli. Some studies have noted that even though supine sleepers experience these early delays, there is no significant age difference in terms of when the infants learn to walk, again from research done by Davis.

Multiple studies have found a positive correlation between the amount of time supine sleepers spend prone during their awake hours and motor skills development, research conducted by Salis and Majnemer.  This finding reinforces the need to educate parents about the importance of Tummy Time, or placing a mat on the floor and putting the infant face – down to strengthen their neck and back muscles.

But a paradox which happens as babies are not programmed machines — some babies seem to prefer sleeping on their stomachs. And typically, once a baby can roll onto his stomach, he’ll roll mid-nap, or in the middle of the night, and end up sleeping on his stomach.

So one wonders, what should you do when your baby is able to roll from her back to her stomach during sleep? Should you leave her on her stomach, or should you roll her back the other way? Doctors  advise that parents should try to get the baby used to lying on his back. While many babies seem to prefer to sleep on their stomachs, a baby can get used to lying on his back, and will eventually grow more comfortable sleeping that way. So try this as a first step: have your baby spend time on his back, during his awake time, and try to start off each nap and bedtime with your baby on his back.

If your baby is still being irritable and not sleeping, then doctors advise swaddling your baby in a blanket. Many babies dislike sleeping on their backs,  because they can’t curl up tightly into snug fetal positions, the way they can when they’re on their stomachs. But if you swaddle your baby snugly, you can create that warm, womb-like feel while still placing your child on her back.

And by about 3-4 months of age, many babies are learning to roll, and while rolling is an important milestone that paves the way for even greater mobility in the coming months, it concerns many parents when they check in on their babies and find them sleeping on their stomachs.

So what’s a parent to do? Do you leave your baby on her stomach, or do you roll your baby over again onto her back, and risk waking her up? It is recommended that you start each sleep time by putting your baby down on her back, but then, if she rolls onto her stomach, you can leave her to sleep that way. There are a few safe sleeping recommendations that need to be followed strictly:
Your baby should sleep on a firm surface that’s covered by a tight-fitting sheet. There should be no loose bedding, soft pillows, or stuffed toys in the baby’s sleeping area. It’s safest if your baby is sleeping near your bed (so that you can keep an eye on her), but not sleeping in your bed, which carries risks of suffocation. And a lot of research has shown that overheating is linked to SIDS, so a baby  needs to be in light layers for sleep, and the bedroom temperature should be on the cool side.

Dr Marianne de Nazareth, Freelance Journalist, Adjunct faculty St Joseph’s College of Mass Communication, Bangalore.

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6 Comments

  1. Sally Dugman says:

    At this link is the link to our MA, USA model for SIDS. Please feel free to use it and pass it onward to others.

    Training on safe sleep practices for infants | Mass.gov
    https://www.mass.gov/service-details/training-on-safe-sleep-practices-for-infants
    If you are a Family Child Care Provider or Assistant, you must take EEC’s training on Sudden Unexpected Infant Death (SUID), (formerly called Sudden Infant Death Syndrome, or SIDS), every 3 years. If you work in a Group Child Care center, you must take EEC’s training on Sudden Unexpected Infant Death (SUID), …

  2. Thanks for this article.

    Here are links to more information as needed:

    1.The National Safe to sleep program
    https://www1.nichd.nih.gov/sts/about/SIDS/Pages/common.aspx
    2. Recent article in Pediatrics on why the SUID rates have plateaued.
    http://pediatrics.aappublications.org/content/early/2018/02/09/peds.2017-4083

    In LIC/LMIC setting it would be good to get at the data.

  3. Kiran Pereira says:

    I did not know there was such a thing Marianne. Thank you for the well-researched and thoughtful post.

  4. Marianne Nazareth says:

    It’s pretty scary Kiran after all the mother has been through.

  5. THELMA M CARDOZA says:

    After going through all the pros and cons, Marianne, it seems safest to let baby sleep on it’s back till baby can hold it’s head up independently. I have seen mothers and grandmothers put baby to sleep by patting their backs while laying them on their laps. Thereafter, placing them in their cradles ON THEIR BACKS. Why take a chance? Baby needs to be strong enough not to tire while holding up it’s neck and also be able to roll over onto it’s back INDEPENDENTLY.

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