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Perspective on the paper by Kassim et al (see page 347)
Supine sleeping is recommended to prevent the sudden infant death syndrome (SIDS). In preterm and/or low birthweight infants in particular, prone or side sleeping is associated with an increased risk of SIDS with an odds ratio of between 37 (side position) and 140 (prone position) compared with term infants sleeping on their back. This risk is multiplicative to the individual risks associated with either prematurity or the prone/side position.1,2
These epidemiological data contrast with the fact that infants who are born prematurely exhibit less apnoea and intermittent hypoxia, have better thoracoabdominal synchrony, higher lung volumes and better oxygenation when nursed in the prone position, which is particularly true for those with chronic lung disease.3,4,5,6,7,8,9,10,11 Once the infants are nearing discharge, however, these physiological advantages of the prone position become less clear.12 Nonetheless, these advantages, plus an unsubstantiated fear of a higher risk of aspiration in the supine position, may be responsible for many maternity hospitals in both the USA and Europe continuing to advocate a non‐supine sleeping position for infants at the time of discharge.13,14
The study by Kassim et al in this issue of the Archives adds to the wealth of pathophysiological studies on this issue. They measured lung volume and pulse oximeter saturation repeatedly until discharge in a group of infants born at 24–31 weeks' gestation and found higher functional residual capacity (FRC) as well as significantly higher baseline oxygenation in those still requiring additional inspired oxygen, while placed prone.15
What conclusions can be drawn from these data? Using sophisticated equipment for pulmonary function testing and a pulse oximeter, Kassim et al15 confirm previous work suggesting that the prone position is associated with a higher lung volume and a better ventilation/perfusion matching.3,5 This is why these infants are nursed predominantly in the prone position in neonatal intensive care units (NICUs) throughout the world, and there is no reason to change this practice, particularly as SIDS is not an issue in these infants during their first few weeks of life in the NICU. However, soon after discharge SIDS becomes the leading cause of death, and then the benefits associated with a 1% increase in baseline oxygenation or a 10–15% increase in FRC have to be weighed against the dramatically increased risk of dying suddenly and unexpectedly. Because of this situation, and because the seeing‐is‐believing paradigm is also valid for parental behaviour following discharge,16 it has become our practice to nurse all infants <32 weeks' gestation initially in the prone position, but to turn them over to the supine position approximately one week prior to discharge. At the same time, we explain to the parents that their baby has now largely outgrown the problems initially associated with their premature birth, and that we are now preparing everything for going home, where supine is the recommended sleeping position for their baby. This approach is similar to that adopted by many British NICUs according to a recent survey,17 and includes infants still receiving additional inspired oxygen at the time of hospital discharge.
Although admittedly unproved, we feel that this approach offers a solution to the cognitive dissonance otherwise resulting from parents seeing their baby being nursed in the prone position for several weeks while still in the hospital, but then being told that they must place their baby supine once at home. At the same time it allows us to take advantage of the physiological benefits of the prone sleeping position during the first weeks of life—which is now confirmed by Kassim et al.15
Competing interests: None.