Positional plagiocephaly and sleep positioning: An update to the joint statement on sudden infant death syndrome

Co-signatories: The Canadian Foundation for the Study of Infant Deaths, Canadian Institute of Child Health, Canadian Paediatric Society, Health Canada

In an effort to reduce the number of babies who die from sudden infant death syndrome (SIDS) in Canada, a coalition was formed among Health Canada, The SIDS Foundation, the Canadian Institute of Child Health and the Canadian Paediatric Society. An initial statement was released in 1993 and updated in 1999 (1) with the launch of the national Back to Sleep campaign. The key recommendation is that babies should be placed to sleep on their back to decrease the incidence of SIDS.

Statistics reveal that the recommendations against prone (tummy) sleeping have coincided with a reduction in the number of SIDS deaths in Canada. The number of SIDS deaths has fallen steadily since the late 1980s – from 385 in 1989 (2) to 138 in 1999 (3).

There is concern that infants may choke if they are put to sleep on their back. Research has shown that the back sleeping position does not increase the risk of choking. Data from countries where back sleeping has always been the norm support this observation. Choking has not emerged as a problem in countries where there has been a change from tummy to back sleeping. There are a few rare conditions present at birth for which sleeping on the back is inappropriate. Examples include the Pierre Robin syndrome and other airway abnormalities. The infant’s doctor should advise parents whether sleeping on the child’s back is inappropriate.

Along with the decreased incidence, public awareness about SIDS is growing. A recent survey conducted for Health Canada by Environics Research Group Limited, Toronto, Ontario compared awareness, knowledge and behaviours before the latest campaign (1999) and post-campaign (May 2001) (unpublished data). The survey reported that this campaign resulted in more parents and caregivers being aware that the back sleeping position reduces the risk of SIDS. As well, many more parents are placing their infants on their backs to sleep. Overall, 71% of parents and caregivers reported putting their babies to sleep on their backs. This number is up significantly from 40% before the campaign.

POSITIONAL PLAGIOCEPHALY

Along with the success of the campaign, there has been public concern over positional plagiocephaly, commonly referred to as ‘flat head’. While there are no scientific data to show conclusively an increase in positional plagiocephaly, anecdotal reports do suggest an increase in this condition. Special clinics to treat this problem have been established in some children’s hospitals in Canada.

In response to public concern over positional plagiocephaly, the partners in the Back to Sleep campaign are publishing this update regarding sleep position and plagiocephaly. Although it is intended for health care professionals, there is an accompanying fact sheet for parents and caregivers.

The development of plagiocephaly can occur if an infant sleeps with its head in the same position. This is because its skull is very soft and the bones can be affected by pressure. Because the neck muscles of young infants are weak, they tend to turn their heads to one side when placed on their backs. If they constantly turn their head to the same side, the skull becomes flat on that side and on the back. A minor degree of flattening resolves on its own. However, more severe flattening may be permanent. While this outcome is cosmetically undesirable, brain function and development are not affected.

PREVENTION STRATEGIES

Plagiocephaly can be prevented by the following:

• ensuring that young infants have supervised tummy time several times a day while awake; and

• placing infants’ heads in different positions for sleep.

One way to ensure changes in head position is to use ‘counter positioning’, which involves changing the baby’s orientation in the crib. While in their cribs, babies prefer to look out into a room rather than at a wall. Alternating the baby’s orientation in the crib allows the baby to have the same ‘view’ without always lying on the same side of the head. For instance, on even calendar days the infant can be placed with its head at the head of the crib and on odd calendar days the infant can be placed with its head at the foot of the crib. Placing a mobile on the side of the crib facing out into the room gives the baby something interesting to look at.

If, despite these strategies, the baby still develops a flat area on the skull, a medical assessment should be obtained to rule out more serious conditions.

RECOMMENDATIONS

• The partners in the Back to Sleep campaign recommend that normal healthy infants be placed on their backs for sleep. Their heads should be placed in different positions on alternate days.

• While awake, infants should have supervised tummy time.