"Physicians can greatly help to increase back sleeping by advising parents and caregivers to
place infants to sleep on their backs," said Dr. Duane Alexander, M.D., Director of the National
Institute of Child Health and Human Development (NICHD), which funded the study.
The analysis also found that the number of infants being put to sleep on their stomachs continues
to drop. But a significant portion of the population is still placing infants to sleep on their
stomachs-despite having been told that back sleeping reduces the risk of SIDS.
Marian Willinger, Ph.D., of NICHD's Pregnancy and Perinatology Branch, led the research
team that reported the findings, which appear in the April 26 Journal of the American Medical
Association. Other members of the research team are from the National Institute on Deafness
and Other Communication Disorders (NIDCD), the Harvard School of Medicine, and the
Boston University School of Medicine.
SIDS strikes nearly 3,000 babies each year. SIDS is the sudden, unexplained death of an infant
in the first year of life. The causes of SIDS are still unclear, and it is not currently possible to
predict which infants might fall victim to SIDS. Back sleeping has been found to significantly
reduce the risk of SIDS. Since the dissemination of the recommendation to place infants to sleep
on their backs or sides, the SIDS rate has fallen almost 40 percent.
The NISP study is an annual telephone survey of nighttime caregivers of infants under 8 months
of age conducted in the 48 contiguous states to assess infant care practices and to help evaluate
the dissemination of the Back to Sleep Campaign messages. This campaign, which encourages
that infants be placed to sleep on their backs to reduce the risk of SIDS, was launched in 1994
by the NICHD, in partnership with other agencies of the U.S. Public Health Service, the AAP,
the SIDS Alliance, and the Association of SIDS and Infant Mortality Programs.
This report examines the factors that determine sleep position choice between 1994 and 1998.
The study found that physicians had the greatest influence on whether or not caregivers placed
infants to sleep on their backs. In fact, caregivers that were advised by physicians to put infants
on their backs to sleep were about three times more likely to do so than were caregivers not
given a recommendation.
"Unfortunately, 41 percent of respondents said that their physicians had not made a
recommendation on sleep position in 1997-1998," the researchers wrote.
A variety of other sources also helped to increase the rate of back sleeping. The study found that
in 1997-1998, about 79 percent of caregivers said they had received the recommendation to put
infants to sleep on their backs or sides from at least one of four sources: physician, nurse,
reading materials, or radio and television, compared with 38 percent in 1994. Also, by
1997-1998 only 5.8 percent of caregivers said they had been told by at least one source to
place infants to sleep on their stomachs, compared with 24.4 percent in 1994. Caregivers who
reported that they received a recommendation of back sleep position from all four sources were
six times more likely to place the infant on the back.
Significant racial disparities remain in sleep position choice. Between 1994 and 1998, stomach
placement had decreased from 44 percent to 17 percent among white infants, and from 53 to 32
percent among black infants. African American infants are 2.2 times more likely to die from
SIDS than are white infants.
Stomach sleeping was not confined to infants whose caregivers had not heard the Back to Sleep
message. Indeed, from 1995 to 1998, 86 percent of those caregivers who placed their infants on
the stomach reported receiving only recommendations to place them on their backs or sides.
"In contrast, within a subgroup of caregivers, there appears to be a strong motivation to place
the infant prone that overrides the health education message," the authors wrote.
Specifically, caregivers who put infants to sleep on their stomachs said that the baby liked it or
slept better that way. They also feared the infants might choke on their own vomit. The
researchers added that studies in England and Australia had shown that there were no increases
in breathing problems that might be due to choking for infants placed on their backs. In contrast,
both studies had found that parents reported that there were more breathing problems in infants
placed to sleep on their stomachs.
"Motivation strongly influences the choice of prone position in the current environment; thus
clinicians should discuss the reasons for choice of sleep position with the caregiver," the authors
To help eliminate the racial disparity in the SIDS rate between African American and white
infants, the NICHD is developing a community-based outreach program in collaboration with
African American organizations to extend the Back to Sleep message into diverse communities.
NICHD and the NIDCD are both institutes of the National Institutes of Health, the Federal
government's premier biomedical research agency. NICHD supports and conducts research on
the reproductive, neurobiological, developmental, and behavioral processes that determine and
maintain the health of children, adults, families, and populations. The NICHD website,
http://www.nichd.nih.gov/, contains additional information about the Back to Sleep Campaign,
the institute, and its mission.