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Edwin A. Mitchell, BSc, MBBS, DCh, FRACP, FRCPCH, DSc; Bradley T. Thach, MD; John M. D. Thompson, PhD; Sheila Williams, BSc; for the New Zealand Cot Death Study

Arch Pediatr Adolesc Med. 1999;153:1136-1141.

Objective  To examine whether the prone sleeping position may increase the risk for sudden infant death syndrome (SIDS), particularly in infants unused to prone sleep.

Design  A 3-year (1987-1990) case-control study.

Setting  Nationwide study in New Zealand.

Subjects  Four hundred eighty-five infants who died of SIDS and 1800 controls.

Main Outcome Measures  Infants were classified as unaccustomed to prone if their usual sleep position was nonprone and they were placed prone for the last sleep. Secondary prone was used to describe infants placed nonprone but found prone.

Results  Infants usually and last placed nonprone were at the lowest risk for SIDS (odds ratio [OR], 1.0); those usually and last placed prone were at increased risk (adjusted OR, 4.6; 95% confidence interval, 3.4-6.3). Risk was greatly increased among infants unaccustomed to the prone position (adjusted OR, 19.3; 95% confidence interval, 8.2-44.8). These infants accounted for 8% (31/386) of all SIDS deaths. Ninety percent (28/ 31) of infants in this group were found prone, and 71% (20/28) of those found prone were found with their faces turned down into bedding—a position in which asphyxia has been implicated as a mechanism of death. In addition, 138 infants who died of SIDS were last placed nonprone. Forty-seven infants (34%) in this group were found prone (secondary prone), and 60% (28/47) of those found prone were found with their faces turned down into the bedding. This group accounted for 12% of all SIDS deaths. Most of these infants (91% [43/47]) were usually placed nonprone.

Conclusions  Infants placed supine to sleep were at the lowest risk of SIDS, which supports the recommendation that this is the preferred sleeping position for healthy infants. In New Zealand, 20% of SIDS deaths involved lack of experience with the prone sleeping position. Our findings suggest the possibility that an infant's competence in escaping from potentially lethal situations during prone sleep (eg, the face-down position) may be impaired by inexperience in prone sleeping. Great caution should be exercised in placing infants unaccustomed to the prone sleeping position in the prone position.

From the Department of Paediatrics, University of Auckland, Auckland, New Zealand (Drs Mitchell and Thompson); Department of Pediatrics, Washington University School of Medicine, St Louis, Mo (Dr Thach); and Department of Social and Preventive Medicine, University of Otago, Dunedin, New Zealand (Ms Williams).

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