SIDS, Back Sleeping, and Sleep Apnea?

I was doing some research on the internet about sleep position and SIDS (sudden infant death syndrome) and came across a blog post that says exactly what I was going to say, but in much more detail, and with a critical analysis of the statistics used when the American Academy of Pediatrics recommended that all infants be kept on their backs while sleeping. This campaign has lowered the rate of SIDS by about 50%, but about 3000 infants still die from SIDS every year.

Reading this story is heart-wrenching. It’s a long post, but I strongly recommend that you read through it. I frequently see parents in my practice that are literally in tears when they are berated by their pediatricians to keep their infants on their backs, despite the fact that their child can’t sleep in this position.

Sleep and pediatric researchers have shown that one possible mechanism as to why back sleeping helps to prevent SIDS is that it keeps babies in a lighter stage of sleep. This makes them much more easily aroused. If there is some kind of dangerous breathing stoppage, they’re more likely to wake up and start breathing again. What he also points out is that deep sleep is diminished by 8-9% in infants that sleep on their backs for the first 6 months. He calculated that back sleeping infants lose about 4 hours of sleep per day and 120 hours of sleep in the first month. We know that quality sleep is so important to an infant’s brain development and motor skills.

So it’s not surprising that there’s been an increase in rates of motor skill, cognitive and other developmental delays. Other studies have shown increased rates of sleep apnea, flat-head (my second son had this), and acid reflux. There’s even one blog that points to the back to sleep campaign as a major cause of the autism spike that began in the mid 1990s. I’ve also suspected that the decreasing rates of tonsillectomies in the 1980s and 1990s may adversely affect cognitive development (ADHD).

Numerous studies have shown that there are a number of other significant risk factors that increase the risk for SIDS, including bed-sharing, cold weather months, smoking, and soft bedding, whereas pacifier use and breast-feeding are protective. African Americans and Native Americans had significantly higher rates.

One major anatomic reason for SIDS is the fact the the infant’s voice box is very high in the throat, behind the tongue, with the epiglottis overlapping the soft palate. Gradually, over the course of 2-4 months, the voice box begins to descend. At a certain point, the collapsibility of the tongue into the newly created oropharynx may reach a critical point when various factors come into play (sleep stage, sleep position, cigarette smoke, etc). This timeframe is also when the rate of SIDS peaks.

In particular, the author points out that most SIDS studies use an odds ratio calculation that can easily overestimate the true risk, and is often confused with relative risk. Because these studies are retrospective studies with relatively small numbers of subjects along with a number of different variables, odds ratio is used over relative risk. The explanation of the difference between odds ratio and relative risk is a bit lengthy so I recommend you read the article, which is very clear. He hammers on the concept that correlation does not equate with causation. To date there’s no good explanation for SIDS, which still happens in about 1/1000 babies, of which 1/3 die while on their backs.

One interesting statistic that he pointed out is the fact the the risk of dying from SIDS if you have no other risk factors is only 10% (including no tummy sleeping) of the original risk. He poses this interesting question: Is it worth sleep depriving all infants of 25% of sleep in the first few months to protect less than 0.1% of babies?

I’m not recommending that everyone go against mainstream medicine’s recommendations. However, we need to re-evaluate the rationale for this recommendation and consider all the possible unintended consequences.

What are your thoughts on this subject?




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13 thoughts on “SIDS, Back Sleeping, and Sleep Apnea?

  1. I think that if a parent has tried everything to have their infant sleep on their back and nothing works, that infant is trying to tell us something; they cannot sleep on their back for a physiologic reason and we should not force the issue. more than likely that reason has to do with sleep disordered breathing. there should be some sort of policy change at the level of the AAP, because daycare centers mandate sleep position for the infants in their charge based on AAP recommendations and so these poor infants cannot even nap during the day. these infants should be able to get notes from their doctors allowing them to sleep prone or laterally, and pediatricians need to recognize that there is a spectrum that all babies are on such that they will not berate parents when they are unable to sleep their babies supine. we allow Pierre Robin babies to sleep prone, but treat this like a black and white issue such that all other babies must sleep supine and we imagine that they must be also ABLE to sleep supine. this is clearly in question.

  2. Dr. Deb,

    Pierre Robin sequence babies are at the extreme end of the continuum, but you can make the argument that all babies are along a continuum. As you said, it’s not a black or white issue.

    Infants with laryngomalacia (underdeveloped voice box) are also recommended to sleep on their tummies.

    I think that pediatricians can come up with certain guidelines for parents who have no significant risk factors for SIDS to be able to let their babies sleep on their tummies. Perhaps the pediatrician can have the parents sign a form stating that they understand the risks.

  3. My first child was born in 1991, and she slept on her tummy. My second child was born in 1994, and recommendations were starting to emerge. We were instructed to position in sidelying or on the back for sleeping. As my first child was a “spitter”, I was worried about aspiration, so #2 slept on his side. He was really big and hard to prop, so frequently, I would find him on his tummy. He definitely slept better in prone. My third child was born in 1997, and we were told to position her on her back. Again, as I was fearful of spitting/aspiration, I propped her in sidelying. She was just on okay sleeper.

    As a pediatric physical therapist, who started in 1994, I have seen the flattened heads and the delayed motor development due to lack of prone positioning during waking hours. As a person with Upper Airway Resistance Syndrome, who has suffered from sleep deprivation for countless years, the thought that we may be significantly depriving babies of their much needed sleep is horrifying. I have one college student and two teenagers at home, who are very busy and laden with homework, and I know that they are getting shorted. What is this going to do our population by the time they are adults?

    So much for the phrase “sleeping like baby”.

  4. well, IF the back to sleep program has contributed to the autism epidemic, and you run the numbers, what I calculate is that for every 1 child saved from having SIDS by placing all infants to sleep on their backs, we may be generating 13.6 children with autism. is it really worth it?

  5. Dr. Deb,

    That number sounds about right. Not to mention other developmental delays, flat head, acid reflux and more sleep apnea. With no risk factors, it’s probably safe to let your baby sleep prone, but that would take too much effort to determine who’s at high risk and who’s at low risk, and the medical community won’t risk taking any chances, no matter how low the risk.

    I was thinking that there will be some doctors that are adamantly against anyone questioning the back to sleep campaign. My question to them is, is there any proof that supine sleep does not cause any significant sleep deprivation, leading to developmental or cognitive delays? If there is some degree of neuro-cognitive damage from supine sleep, what’s the acceptable rate to be able to save one child from SIDS?

  6. Hi,

    My mother uses a simple wide size tower like rice back to put over my baby after finding a best position for my infant to sleep. This will help to prevent the baby to move around so that the infant can sleep well. A traditional method that been use for many decades that hands down from my ancesters. So far this prevent SIDS or this is just a coincidents?


  7. (simple wide size tower like rice back )

    CORRECTION: Simple wide size TOWEL like RICE Bag.

  8. Thank you for this article, and for the links to the other blogs! I have, from before I even became pregnant, believed that tummy sleeping is the way to go. My biggest hangup with the whole ‘back to sleep’ campaign is that the reason it is called SIDS is because it is the sudden, UNEXPLAINABLE death of a child under the age of 2. So to say that tummy sleeping is causing SIDS is an overstatement bordering on falsehood. I’ve slept my daughter on her tummy from the day she was born (yes, in the bassinet at the hospital!). She regained her birth weight in 4 days, was sleeping 5-6 hours in less than 3 weeks, and before she turned 3 months, she was sleeping 12+ hours at night. When people ask me how she sleeps, and I tell them, they almost always respond with “Oh, you’re so lucky! You have a content child.” Well, I don’t think LUCK has anything to do with it. I think it has everything to do with what you were talking about here, about the fact that she gets solid cycles of uninterrupted deep sleep in both the day and the night. And frankly, I think she’s content because she sleeps, not the other way around!

  9. We are expecting our first grandchild in February, and I am very concerned about this ‘back to sleep’ campaign I’ve been hearing about. I was told (back in the 80’s) NEVER to put my children to sleep on their backs. Due to aspirations, and apnea and SIDS. I was told to swaddle them and support side sleeping with a rolled towel until they could hold their heads up, which they did quite young. Then they rolled to their tummies and slept ‘like babies’. I could vacuum under their cribs and they still sleep like that today. Their family history is one with ‘sleep apnea’, ‘acid reflux’ and their father has always slept badly. I don’t want anything to happen to our grandchild but I don’t believe that parents should be forced to make their babies sleep supine. I think this may be like forcing a left-handed child to be right-handed. BTW, I have always been a tummy sleeper and I’ve always slept very well. I will be forwarding this article to my son certainly.

  10. I don’t believe the back to sleep has saved one single SIDS baby!! NOT ONE!! I believe the reduction in SIDS is #1 better forensic and technology that enables us to determine why a infant died, thus not classifying it as SIDS, such as suffocation and shaken baby syndrome and “other causes” of death can now be determined.. #2 right about the same time back to sleep started, all the information about 2nd hand smoke being so harmful came out and parents not only stopped smoking around their infants, but stopped smoking in the house and kept infants away from 2nd hand smoke. #3 Several other “unsafe” sleeping conditions were stopped or at least frowned upon, like not sleeping on soft beds or with a lot of soft stuffed toys or blankets and co sleeping. Now stop to think about it the 50% reduction sounds impressive, but what does that number actually mean? Let’s go by the above article that says 3000 still died of SIDS in a year and 1 in every 1000 (I’ve read that it is actually 1 in 1500), so 50% means it was 2 in every 1000 (or 1500 which ever) or 6000 would have died in a year.. Most likely that ONE child in a 1000 was NOT saved by back to sleep, but actually just the cause was “determined”.. Here is a report of 2010 SIDS or SUID report:

    “SIDS rates declined from 1998 to 2001 while death rates due to other known causes and accidental suffocation and strangulation in bed were rising.” Gee ya don’t think one leads to the other? Because with modern technology, research and forensics they now “determined a cause”. SIDS declined because causes were determined and they used to lump “suffication and strangulation” in with SIDS, even though it was NOT “unexplained” (SUID = Sudden Unexplained Infant Death).. A lot of reports still include “unsafe sleeping conditions” as SIDS, to get the REAL unexplained sometimes you need to look for SUID..

    Here’s another study: “In an analysis of the 954 babies who died suddenly and unexpectedly in San Diego County between 1991 and 2008 — 568 of these deaths were attributed to SIDS.” .. Well there ya go, before the back to sleep campaign probably ALL those would have been classified as SIDS, so there’s a 40% drop right there..

    Now how about the “other” factors that also could easily account for that ONE child out of 1000 being saved, like the MAJOR one being parents not smoking or being around smoke while pregnant and keeping 2nd hand smoke not only away from the infant, but out of the house, especially in the room the infant sleeps!! Sleeping on firm mattresses, keeping blankets, pillows and soft stuffed toys out of the crib as well as improved cribs so that infants don’t get stuck between mattresses and crib bars. How many SIDS babies has this saved? So if you take that all into consideration maybe back to sleep is actually an increased RISK of SIDS and those 1/3 that died because they were on their backs would not have “IF” they were sleeping on their stomachs!

    Now here’s the real problem.. You will never get them to admit back to sleeping was wrong!! Why? because they then would have to admit, they caused all these other problems; autism, flat head syndrome, slow motor skills, possibly ADHD, kept parents and infants from vital sleep for NOTHING!!! If they can tell themselves and convince you it saved ONE child they can justify their “over reaction” and totally unresearched, unjustified, unsubstantiated recommendation and condemnation of those that didn’t follow that recommendation.. At any rate it should NOT be a law or “requirement” and parents should be allowed to make up their own minds.. They should be allowed to tell pre-schools and babysitters, “their” preference and not be looked down on and vilified for letting their infants sleep… the 999 infants that would not suffer are now being subjected to other side effects against their will!! Why don’t we ask the mothers of the autistic or flat head syndrome children if they slept their children on their backs? And if they reply “yes”, then we condemn them or blame them for their childs condition..

  11. “”came across a blog post that says exactly what I was going to say, but in much more detail, and with a critical analysis of the statistics . . “”

    I also came across the Heraclitean River blog whilst researching this topic. Do you know who the author is – or how he can be contacted? It was written in 2011 and he seems to have moved on and abandoned this blog which is a shame. I have tried sending a message through his Contact page and writing Comments after the Sorting out SIDS and Sleeping Position blog – but no response.

    What I find fascinating is that if you talk to parents or look on any closed parenting group or forum this is discussed freely with many happy to recommend side or prone sleeping to other desperate parents. The latter have often gone through weeks of sleeplessness with a miserable baby, having consulted with health professionals and been strongly discouraged from anything other than ‘back to sleep’ before discovering this secret society of parental advice givers!!


  12. I suspect that tongue tie has a bigger impact on sids. Only on the last couple of decades we have come to understand how grave this midline defect is. I would have an experienced provider check the muddle child that had a flat hrad in fact. I had tethered oral tissue released as an adult and I found d it intetesting how hard I had to,work to hold my tongue in the up position when laying on my back, however when I roll unto my stomach my tongue rises and I am not straining muscles to achieve the lift. Btw, tongue tie and other tethered tissues are associated with inflamed tonsils too. The tongue tethered down removes the protection the tonsils would get. The open mouth breathing also causes dry mouth. has 3 blogs about tethered oral tissue you may find intetesting.