Physicians Fail to Heed Academy Advice On How to Place Infants In Their Beds

BUFFALO, N.Y. -- Physicians are reluctant to follow the recommendation of the American Academy of Pediatrics and suggest that parents put infants to bed on their backs as a way of reducing the risk of sudden infant death syndrome (SIDS), new research from the University at Buffalo has shown.

SIDS is the term for the sudden, unexplained death of a healthy baby under the age of 1 year. Some incidences of the syndrome, which accounts for between 1.4 and 1.7 deaths per 1,000 infants in the U.S. each year, have been linked to the prone position and may be caused by accidental suffocation in soft mattresses and fluffy bedclothes.

The academy in 1992 recommended abandoning the practice of placing babies on their stomachs, the conventional wisdom since the 1930s, in favor of the "tummy-up" or side position.

Results of the UB study, involving 121 primary-care physicians who care for newborns, were reported in the January issue of Pediatrics. They showed that only 24.4 percent of the respondents said they strongly agreed with the AAP recommendation and only 42 percent recommended the supine or tummy-up position. Most recommended the side position, a less well-studied alternative.

The new guidelines did change significantly one aspect of physician behavior -- the frequency with which they discussed sleeping position with parents. Before the recommendation, only 34 percent of the respondents addressed the issue regularly; afterwards, 70 percent said they usually or always talked about sleeping position with parents.

Principal author Bonnie B. Hudak, M.D., UB assistant professor of pediatrics affiliated with Children's Hospital of Buffalo, undertook the project as a result of her own experience with her new daughter.

"When I had my baby in 1993, nobody talked to me about sleep position," she said. "I began talking to other parents and learned that pediatricians weren't recommending the back position, despite the AAP recommendation. Parents were getting conflicting advice from nurses and doctors."

She designed the study to determine how physicians felt about the issue and how their attitudes influenced what they were telling parents.

Reasons given most often for having reservations about the recommendation were the lack of published data on the connection between sleep position and SIDS in the U.S., and past experience. Also mentioned frequently was the possibility that an infant on its back might regurgitate stomach contents, an occurrence called gastroesophageal reflux, and breath the material into its lungs.

Hudak acknowledged that there are no published U.S. data on sleep position and SIDS, but noted that extensive studies have been published using data from Europe, Australia and New Zealand, where SIDS rates are high. Great Britain reported in December that SIDS cases had decreased by more than half since 1991, when it began an educational campaign urging parents to put infants to bed on their backs.

Some physicians have questioned whether such data apply to the U.S., pointing out that bedding materials common to these areas -- down mattresses in northern Europe and sheepskins in Australia and New Zealand -- may be the culprit rather than sleep position, Hudak said.

The AAP has acknowledged the importance of proper bedding, and recommends putting babies to bed on a firm mattress without pillows.

Hudak said another often-mentioned reason for not recommending back-sleeping -- gastroesophageal reflux and possible aspiration -- probably doesn't happen often. "There is no evidence than any healthy child placed on its back died of aspiration," she stated.

Sixty-nine percent of the physicians in the study recommended the side position, even though it is unstable, resulting in babies rolling onto their backs or stomachs during the night. Hudak cited a New Zealand study showing that only 30 percent of infants younger than 4 months who were placed on their sides at night were found in that position in the morning. Sixty-five percent had turned on their backs, while 4 percent were found on their stomachs. Another study showed similar results.

"These data suggest that while placing infants on their sides represents an intellectual compromise for physicians, it is a subtle endorsement of the supine position," she said.

"While the debate over the need for a clinical trial in the U.S. and the ethical implications of such a trial continues, physicians must make recommendations to parents," she stated. "All physicians should discuss sleep positions and recommend either the back or side position, firm mattresses, no pillows and a cool room."

Despite the best intentions of parents and physicians, however, babies ultimately will do what they want, a fact Hudak knows well: Her own daughter steadfastly refused to sleep on her back.

Assisting in the study were Jane O'Donnell, a pediatric nurse practitioner, and Nadine Mazyrka, a registered nurse, both from Children's Hospital.