Safer Sleep

By Christine Gorman

| The phone call came while Robert Shaw, features editor at the Des Moines Register, was researching a story at the newspaper's library. His son Benjamin, three months old, had stopped breathing during his afternoon nap. "They told me to meet my wife at the hospital, which is about five blocks from my office," Shaw recalls. "I ran all the way." Shaw was told that his son could not be revived. "I picked him up, held him and said goodbye." An autopsy yielded no clues to the tragedy. Like 7,000 other babies in the U.S. each year, Benjamin had fallen victim to sudden infant death syndrome (SIDS), or crib death, the leading cause of mortality for American newborns.

Two years later, Shaw and his wife Stephanie still wonder whether they could have done anything to save their child. Doctors assured them that they were blameless, since no one knows what causes otherwise healthy babies to stop breathing -- although everything from viral infections to secondhand smoke has been implicated. "Whether it's rational or not, you feel guilt," says Shaw. "It's like being haunted by a little ghost for the rest of your life."

While most American doctors continue to tell parents that there is little they can do to prevent SIDS, health authorities in Europe, New Zealand and Australia are taking another tack. Citing studies that show dramatic reductions in the incidence of crib death, clinicians are telling parents that they should place healthy, full-term babies to sleep on their back instead of their stomach.

In 1987, when half of all infants in the Netherlands were placed on their belly before going to sleep, there were 1.3 cases of SIDS per 1,000 babies. (The U.S. rate is 1.7 per 1,000.) After a national campaign to switch sleeping positions, the already low Dutch rate fell to 0.6 cases per 1,000. A similar campaign in Britain, which was launched three years ago and included warnings against parental smoking or keeping the baby too hot, produced equally dramatic results. Last month the government reported that the rate of unexplained infant deaths for England and Wales had been cut in half, from 912 cases in 1991 to 456 in 1992.

At first, European doctors were skeptical. "It seemed like such an ordinary thing to do," says Dr. Adele Engelberts of Amsterdam. "It was very hard to believe that it could be of such influence." But doubts have given way over the past eight years, as more than 25 studies in a dozen countries have demonstrated that fewer babies die while sleeping on their back.

No one knows why a change in position might make such a difference, but there are several possibilities. Breathing difficulties top the list. "Because of the shape of the face and the anatomy, lying on the tummy does not allow the jaw to fall forward as it does in an adult," says British pediatrician Peter Fleming, who has studied sleeping position for more than a decade. "It pushes the jaw slightly backward, and with a huge tongue and small airways, that may actually contribute to airway obstruction." Babies also sleep more deeply on their stomach than on their back and take longer to awaken -- perhaps fatally longer -- if something goes wrong physiologically. Other theories suggest that babies who sleep on their stomach become more easily overheated, which weakens their respiratory drive, or that they may rebreathe the oxygen-depleted air they've exhaled.

Advocates of back sleeping point out that the practice of putting babies on their stomach was introduced only in the past 30 years -- and only in certain Western countries -- based on limited evidence that it helps increase the survival of premature infants.

Whatever the explanation, it is hard to argue with the results achieved in so many studies. European researchers are therefore baffled as to why there has been no major public-service campaign to alter infant sleeping habits in the U.S., where three-fourths of all babies are still placed on their stomach. American doctors have two main areas of concern. While lying on their back, babies may vomit or choke more easily, says Dr. Susan Orenstein, a pediatrician at the University of Pittsburgh Medical Center. This is a particular risk with premature or underweight infants. In addition, she says, it is not fully clear from the European studies whether it is the sleeping position or some other factor that accounts for the drop in SIDS rates. For example, more parents might bundle up their babies, which could lead to overheating. Says Orenstein: "We need to be sure that the supine position has significant benefits that we cannot obtain any other way before we advocate a wide-scale switch in sleeping position in the U.S."

Last year a task force of the American Academy of Pediatrics decided to buck this conservative position and recommend that healthy, full-term babies be placed on their side or back. The decision was not widely publicized, however, and continues to be controversial. "We don't have U.S. data to support it," says SIDS Alliance spokeswoman Phipps Cohe. Maybe so, but crib-death specialists in other countries wonder if there isn't a more emotional reason for American foot dragging. Says New Zealand pediatrician Shirley Tonkin: "There is reluctance on the part of medical people to admit that what they had been recommending in the past could be harmful."

With reporting by Barry Hillenbrand/Bristol and Alice Park/New York