 |
2002 PRAMS Surveillance Report: Multistate Exhibits
Infant Sleeping Position |
|
Data Highlights | References | Tables
Background
Infant sleeping position is a modifiable behavior that can decrease the risk of sudden infant death syndrome (SIDS).1 SIDS is defined as "the sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history."2 The risk of SIDS peaks at 2–4 months of age, and approximately 90% of SIDS cases occur in children aged 6 months or younger.3 Since 1992, the American Academy of Pediatrics (AAP) has recommended that caregivers place healthy infants to sleep in a nonprone position (back or side) to reduce the risk of SIDS. In 1996, the AAP revised this recommendation to emphasize back sleeping (supine position) as the least risky and preferred sleeping position for infants.4,5
SIDS is the leading cause of postneonatal mortality and the third leading cause of infant mortality in the United States.5 In 2002, SIDS accounted for 8% of all infant deaths. Between 2001 and 2002, the SIDS-specific infant mortality rate increased marginally from 55.5 infant deaths per 100,000 live births in 2001 to 57.1 in 2002.6,7 SIDS rates among American Indian (123.3) and non-Hispanic black (110.9) mothers were at least double the rates for non-Hispanic white mothers (55.2). Mothers who were Asian or Pacific Islander (24.3) or Hispanic (all races) (29.7) had the lowest SIDS rates.6 Other maternal risk factors for SIDS include young maternal age; having 3 or more births; having less than a high school education; using tobacco, alcohol, or illicit drugs during pregnancy; low income; and no or late entry into prenatal care.3,5,8–11 In addition, infants who are male, preterm, or who weigh less than 2,500 grams at birth have higher SIDS rates.3,9,10 The incidence of SIDS is also higher during the winter months (though seasonal variability is declining).12,13
The cause(s) and progression of SIDS are unknown. Nevertheless, an infant's sleeping environment, particularly use of soft bedding, use of a pillow, bed sharing, and most notably, placing an infant to sleep on his or her stomach or side, are important SIDS risk factors. According to several studies, the risk of SIDS increases (odds ratios [OR] = 2.4–9.3) when an infant is placed to sleep on his or her stomach, compared with other sleeping positions.14–18 Researchers think that a prone sleeping position may cause airway obstruction or a thermal imbalance or may interfere with arousal if the airway is obstructed.6,19
Although placing infants to sleep on their back alone will not eliminate SIDS, the study findings have prompted the medical community to encourage mothers to place their infants to sleep in a supine position unless not medically indicated. In 1994, the "Back to Sleep" campaign was launched by a coalition of federal agencies and organizations, including the U.S. Public Health Service (PHS), AAP, SIDS Alliance, and Association of SIDS and Infant Mortality Programs.5 The purpose of the campaign is to inform parents, family members, childcare providers, health professionals, and other infant caregivers about SIDS prevention and the importance of placing infants to sleep on their back.
Since 1996, the percentage of prone placement by nighttime caregivers has declined from 23.3% in 1996 to 13.0% in 2004, and supine placement has increased from 35.3% in 1996 to 70.4% in 2004.20 Despite the marked increase in supine placement, mothers who are black, young, poor, residents of a southern or mid-Atlantic state, or who have more than one child are significantly less likely to place their infants to sleep in a supine position and more likely to continue placing their infants to sleep in a prone position.4,21–23
PRAMS collects data on the position—side, back, or stomach—that mothers most often use to put down their infants to sleep. PRAMS data can be used to identify populations at risk of putting infants to sleep on their stomachs, to target prevention efforts, and to monitor progress toward achieving the Healthy People 2010 objective (Objective 16–13) of increasing the percentage of healthy full-term infants who are put down to sleep on their backs from 35% (1996) to 70%.24
Data Highlights
- In 2002, the prevalence of placing infants to sleep on their backs (supine position) ranged from 48.7% (Louisiana) to 79.1% (Vermont).
- During 1996–2002, the prevalence of placing infants to sleep on their backs increased in 9 states (Alabama, Alaska, Florida, Maine, New York, Oklahoma, South Carolina, Washington, and West Virginia).
- In 2002, the prevalence of placing infants to sleep on their stomachs (prone position) ranged from 6.7% (Montana and New Mexico) to 28.4% (Louisiana).
- During 1996–2002, the prevalence of placing infants to sleep on their stomachs decreased in 9 states (Alabama, Alaska, Florida, Maine, New York, Oklahoma, South Carolina, Washington, and West Virginia).
References
- Centers for Disease Control and Prevention. Guidelines for death scene investigation of sudden, unexplained infant deaths: recommendations of the Interagency Panel on Sudden Infant Death Syndrome. MMWR Recommendations and Reports 1996;45(RR-10):1–6.
- Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatric Pathology 1991;11(5):677–684.
- Hoffman HJ, Hillman LS. Epidemiology of the sudden infant death syndrome: maternal, neonatal, and postneonatal risk factors. Clinics in Perinatology 1992;19(4):717–737.
- Willinger M, Ko CW, Hoffman HJ, Kessler RC, Corwin MJ. Factors associated with caregivers' choice of infant sleep position, 1994–1998: The National Infant Sleep Position Study. JAMA (Journal of the American Medical Association) 2000;283(16):2135–2142.
- American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics 2000;105(3 Part 1):650–656.
- Mathews TJ, Menacker F, MacDorman MF. Infant mortality statistics from the 2002 period: linked birth/infant death data set. National Vital Statistics Reports 2004;53(10):1–29.
- Arias E, Anderson RN, Kung HC, Murphy SL, Kochanek KD. Deaths: final data for 2001. National Vital Statistics Reports 2003;52(3):1–115.
- Chung EK, Hung YY, Marchi K, Chavez GF, Braveman P. Infant sleep position: associated maternal and infant factors. Ambulatory Pediatrics 2003;3(5):234–239.
- Hoffman HJ, Damus K, Hillman L, Krongrad E. Risk factors for SIDS. Results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study. Annals of the New York Academy of Sciences 1988;533:13–30.
- Malloy MH. Sudden infant death syndrome among extremely preterm infants: United States 1997–1999. Journal of Perinatology 2004;24(3):181–187.
- Chong DS, Yip PS, Karlberg J. Maternal smoking: an increasing unique risk factor for sudden infant death syndrome in Sweden. Acta Paediatrica 2004;93(4):471–478.
- Centers for Disease Control and Prevention. Seasonality in sudden infant death syndrome—United States, 1980–1987. MMWR 1990;39(49):891–895.
- Malloy MH, Freeman DH. Age at death, season, and day of death as indicators of the effect of the back to sleep program on sudden infant death syndrome in the United States, 1992–1999. Archives of Pediatric and Adolescent Medicine 2004;158(4):359–365.
- Guntheroth WG, Spiers PS. Sleeping prone and the risk of sudden infant death syndrome. Archives of Pediatric and Adolescent Medicine 1992;267(17):2359–2362.
- Moon RY, Patel KM, Shaefer SJ. Sudden infant death syndrome in child care settings. Pediatrics 2000;106(2 Part 1):295–300.
- Hauck FR, Moore CM, Herman SM, Donovan M, Kalelkar M, Christoffel KK, et al. The contribution of prone sleeping position to the racial disparity in sudden infant death syndrome: the Chicago Infant Mortality Study. Pediatrics 2002;110(4):772–780.
- Hauck FR, Herman SM, Donovan M, Iyasu S, Merrick Moore C, Donoghue E, et al. Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago Infant Mortality Study. Pediatrics 2003;111(5 Part 2):1207–1214.
- Li DK, Petitti DB, Willinger M, McMahon R, Odouli R, Vu H, et al. Infant sleeping position and the risk of sudden infant death syndrome in California, 1997–2000. American Journal of Epidemiology 2003;157(5):446–455.
- Kahn A, Groswasser J, Franco P, Scaillet S, Sawaguchi T, Kelmanson I, et al. Sudden infant deaths: stress, arousal and SIDS. Early Human Development 2003;75(Supplement):S147–S166.
- National Institute of Child Health and Human Development (NICHD). National Infant Sleep Position (NISP) Study. Summary data: sleep position 1992–2004 (all races and ethnic groups). Bethesda, MD: NICHD; 2005.
- Lesko SM, Corwin MJ, Vezina RM, Hunt CE, Mandell F, McClain M, et al. Changes in sleep position during infancy: a prospective longitudinal assessment. JAMA (Journal of the American Medical Association) 1998;280(4):336–340.
- Brenner RA, Simons-Morton BG, Bhaskar B, Mehta N, Melnick VL, Revenis M, et al. Prevalence and predictors of the prone sleep position among inner-city infants. JAMA (Journal of the American Medical Association) 1998;280(4):341–346.
- Gibson E, Dembofsky CA, Rubin S, Greenspan JS. Infant sleep position practices 2 years into the "back to sleep" campaign. Clinical Pediatrics 2000;39(5):285–289.
- U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd Edition. Washington, DC: U.S. Government Printing Office; 2000.
Prevalence of Placing Infant to Sleep on Back, 2002
| State |
Respondents |
Percent† |
Standard Error |
95% CI‡ |
| Alabama |
1,360 |
52.0 |
1.7 |
48.8–55.3 |
| Alaska |
1,400 |
69.3 |
1.4 |
66.5–72.0 |
| Arkansas |
1,831 |
51.6 |
1.6 |
48.4–54.7 |
| Colorado |
2,087 |
71.4 |
1.3 |
68.9–73.9 |
| Florida |
1,682 |
55.5†† |
1.8 |
52.0–59.0 |
| Hawaii |
1,615 |
70.4 |
1.3 |
67.7–72.9 |
| Illinois |
1,719 |
68.5 |
1.2 |
66.1–70.8 |
| Louisiana |
1,412 |
48.7 |
1.4 |
45.8–51.5 |
| Maine |
1,056 |
77.6 |
1.4 |
74.7–80.3 |
| Maryland |
1,310 |
66.8 |
2.0 |
62.8–70.5 |
| Michigan |
1,420 |
71.0 |
1.4 |
68.2–73.6 |
| Minnesotaa |
1,057 |
74.3 |
1.7 |
70.9–77.5 |
| Montana |
994 |
77.8 |
1.4 |
75.0–80.4 |
| Nebraska |
1,711 |
74.0 |
1.3 |
71.4–76.4 |
| New Jerseyb |
837 |
64.2 |
1.9 |
60.4–67.8 |
| New Mexico |
1,423 |
67.3 |
1.3 |
64.7–69.7 |
| New Yorkc |
1,112 |
68.6 |
1.8 |
65.3–72.2 |
| North Carolina |
1,361 |
64.1 |
1.6 |
61.0–67.2 |
| North Dakota |
879 |
78.1 |
1.4 |
75.3–80.7 |
| Ohio |
1,202 |
65.1 |
1.7 |
61.6–68.4 |
| Oklahoma |
1,629 |
54.9 |
1.9 |
51.2–58.6 |
| Rhode Island |
1,303 |
67.9 |
1.5 |
64.9–70.8 |
| South Carolina |
1,150 |
57.3 |
2.2 |
52.9–61.6 |
| Utah |
1,422 |
76.4 |
1.4 |
73.5–79.1 |
| Vermont |
1,041 |
79.1 |
1.2 |
76.6–81.4 |
| Washington |
1,388 |
76.5 |
1.6 |
73.2–79.6 |
| West Virginia |
1,542 |
62.1 |
1.7 |
58.7–65.4 |
| All PRAMS states§ |
36,943 |
65.1 |
0.4 |
64.3–65.9 |
† 2002 state range is 48.7–79.1%.
‡ Confidence interval.
§ Aggregate of the 27 PRAMS states.
†† Missing ≥ 10% data.
a Data represent Minnesota births from May–December 2002.
b Data represent New Jersey births from July–December 2002.
c Data exclude New York City. |
Prevalence of Placing Infant to Sleep on Back, 2002
Healthy People 2010 Objective 16–13
Increase the percentage of healthy full-term infants who are put down to sleep on their backs to at least 70%. |
Prevalence of Placing Infant to Sleep on Back, 1996–2002
| State |
1996
(%) |
1997
(%) |
1998
(%) |
1999
(%) |
2000
(%) |
2001
(%) |
2002
(%) |
P value
for trend# |
| Alabama |
27.0 |
33.7 |
38.7 |
44.5 |
51.4 |
47.9 |
52.0 |
0.000** |
| Alaska |
40.8 |
48.2 |
59.6 |
60.5 |
66.8 |
69.6 |
69.3 |
0.000** |
| Arkansas |
— |
33.9 |
39.2 |
42.6 |
48.0 |
52.1 |
51.6 |
0.000** |
| Colorado |
— |
— |
55.7 |
63.4 |
67.6 |
74.3 |
71.4 |
0.000** |
| Florida |
25.4 |
32.4 |
40.4 |
46.4 |
52.5 |
56.5†† |
55.5†† |
0.000** |
| Hawaii |
— |
— |
— |
— |
66.2 |
68.4†† |
70.4 |
0.018* |
| Illinois |
— |
50.4g |
53.8 |
56.5 |
64.2 |
68.7 |
68.5 |
0.000** |
| Louisiana |
— |
— |
33.4 |
35.1 |
41.5 |
43.0 |
48.7 |
0.000** |
| Maine |
37.5 |
48.7 |
58.9 |
64.7 |
72.7 |
76.9 |
77.6 |
0.000** |
| Maryland |
— |
— |
— |
— |
— |
63.7d |
66.8 |
# # |
| Michigan |
— |
— |
— |
— |
— |
71.4e |
71.0 |
# # |
| Minnesota |
— |
— |
— |
— |
— |
— |
74.3a |
# # |
| Montana |
— |
— |
— |
— |
— |
— |
77.8 |
# # |
| Nebraska |
— |
— |
— |
— |
66.0 |
69.8 |
74.0 |
0.000** |
| New Jersey |
— |
— |
— |
— |
— |
— |
64.2b |
# # |
| New Mexico |
— |
—h |
47.2h |
53.5 |
63.7 |
68.0 |
67.3 |
0.000** |
| New Yorkc |
34.5 |
45.2 |
53.0 |
56.7 |
65.7 |
68.2 |
68.8 |
0.000** |
| North Carolina |
— |
41.9i |
46.3 |
51.8 |
56.5 |
60.9 |
64.1 |
0.000** |
| North Dakota |
— |
— |
— |
— |
— |
— |
78.1 |
# # |
| Ohio |
— |
— |
— |
54.3 |
66.5 |
66.3 |
65.1 |
0.000** |
| Oklahoma |
33.8 |
41.7 |
43.9 |
45.7 |
55.7 |
54.2 |
54.9 |
0.000** |
| Rhode Island |
— |
— |
— |
— |
— |
— |
67.9 |
# # |
| South Carolina |
25.8 |
34.7 |
44.5 |
45.0 |
57.5†† |
53.5 |
57.3 |
0.000** |
| Utah |
— |
— |
— |
74.6 |
74.9 |
76.4 |
76.4 |
0.282 |
| Vermont |
— |
— |
— |
— |
—f |
78.3f |
79.1 |
# # |
| Washington |
42.9 |
53.2 |
63.4 |
65.4 |
75.6 |
75.6 |
76.5 |
0.000** |
| West Virginia |
35.1 |
39.4 |
47.0 |
54.9 |
55.7 |
63.1 |
62.1 |
0.000** |
# Based on a test for linear trend using logistic regression.
* p value is less than 0.05.
** p value is less than 0.001.
# # < 3 years of data available; test for linear trend not applicable.
†† Missing ≥ 10% data.
a Data represent Minnesota births from May–December 2002.
b Data represent New Jersey births from July–December 2002.
c Data exclude New York City.
d Data represent Maryland births from February–December 2001.
e Data represent Michigan births from July–December 2001.
f Data represent Vermont births from October 2000–December 2001.
g Data represent Illinois births from June–December 1997.
h Data represent New Mexico births from July 1997–December 1998.
i Data represent North Carolina births from July–December 1997. |
Prevalence of Placing Infant to Sleep on Stomach, 2002
| State |
Respondents |
Percent† |
Standard Error |
95% CI‡ |
| Alabama |
1,360 |
24.0 |
1.4 |
21.4–26.9 |
| Alaska |
1,400 |
12.3 |
1.0 |
10.4–14.4 |
| Arkansas |
1,831 |
22.2 |
1.3 |
19.7–24.9 |
| Colorado |
2,087 |
7.8 |
0.7 |
6.4–9.3 |
| Florida |
1,682 |
22.1†† |
1.5 |
19.3–25.1 |
| Hawaii |
1,615 |
13.0 |
1.0 |
11.2–15.0 |
| Illinois |
1,719 |
13.0 |
0.9 |
11.4–14.8 |
| Louisiana |
1,412 |
28.4 |
1.3 |
25.9–31.1 |
| Maine |
1,056 |
9.9 |
1.0 |
8.0–12.1 |
| Maryland |
1,310 |
16.1 |
1.5 |
13.3–19.4 |
| Michigan |
1,420 |
15.0 |
1.1 |
13.0–17.2 |
| Minnesotaa |
1,057 |
12.4 |
1.3 |
10.1–15.1 |
| Montana |
994 |
6.7 |
0.8 |
5.2–8.4 |
| Nebraska |
1,711 |
9.0 |
0.8 |
7.5–10.8 |
| New Jerseyb |
837 |
17.2 |
1.5 |
14.5–20.3 |
| New Mexico |
1,423 |
6.7 |
0.7 |
5.4–8.1 |
| New Yorkc |
1,112 |
15.5 |
1.4 |
13.0–18.4 |
| North Carolina |
1,361 |
17.5 |
1.3 |
15.1–20.1 |
| North Dakota |
879 |
9.5 |
1.0 |
7.7–11.7 |
| Ohio |
1,202 |
16.1 |
1.3 |
13.7–18.8 |
| Oklahoma |
1,629 |
18.6 |
1.5 |
15.9–21.7 |
| Rhode Island |
1,303 |
13.0 |
1.1 |
11.1–15.3 |
| South Carolina |
1,150 |
20.4 |
1.8 |
17.1–24.1 |
| Utah |
1,422 |
9.1 |
1.0 |
7.4–11.2 |
| Vermont |
1,041 |
9.1 |
0.9 |
7.5–11.0 |
| Washington |
1,388 |
9.8 |
1.2 |
7.7–12.3 |
| West Virginia |
1,542 |
13.9 |
1.2 |
11.7–16.4 |
| All PRAMS states§ |
36,943 |
16.1 |
0.3 |
15.4–16.7 |
† 2002 state range is 6.7–28.4%.
‡ Confidence interval.
§ Aggregate of the 27 PRAMS states.
†† Missing ≥ 10% data.
a Data represent Minnesota births from May–December 2002.
b Data represent New Jersey births from July–December 2002.
c Data exclude New York City. |
Prevalence of Placing Infant to Sleep on Stomach, 2002
Prevalence of Placing Infant to Sleep on Stomach, 1996–2002
| State |
1996
(%) |
1997
(%) |
1998
(%) |
1999
(%) |
2000
(%) |
2001
(%) |
2002
(%) |
P value
for trend# |
| Alabama |
30.8 |
28.5 |
25.9 |
22.6 |
20.5 |
25.0 |
24.0 |
0.000** |
| Alaska |
19.9 |
18.2 |
13.8 |
12.8 |
12.3 |
12.7 |
12.3 |
0.000** |
| Arkansas |
— |
28.8 |
26.3 |
24.9 |
23.6 |
23.5 |
22.2 |
0.001** |
| Colorado |
— |
— |
9.8 |
7.7 |
8.1 |
7.7 |
7.8 |
0.112 |
| Florida |
30.3 |
26.8 |
24.6 |
23.5 |
19.7 |
21.2†† |
22.1†† |
0.000** |
| Hawaii |
— |
— |
— |
— |
14.4 |
13.0†† |
13.0 |
0.241 |
| Illinois |
— |
18.9g |
15.3 |
13.1 |
12.4 |
12.7 |
13.0 |
0.000** |
| Louisiana |
— |
— |
32.9 |
31.2 |
30.6 |
32.4 |
28.4 |
0.054 |
| Maine |
16.1 |
14.4 |
14.4 |
10.0 |
10.8 |
9.6 |
9.9 |
0.000** |
| Maryland |
— |
— |
— |
— |
— |
17.2d |
16.1 |
# # |
| Michigan |
— |
— |
— |
— |
— |
12.8e |
15.0 |
# # |
| Minnesota |
— |
— |
— |
— |
— |
— |
12.4a |
# # |
| Montana |
— |
— |
— |
— |
— |
— |
6.7 |
# # |
| Nebraska |
— |
— |
— |
— |
11.3 |
13.1 |
9.0 |
0.061 |
| New Jersey |
— |
— |
— |
— |
— |
— |
17.2b |
# # |
| New Mexico |
— |
—h |
7.9h |
6.8 |
7.5 |
7.1 |
6.7 |
0.342 |
| New Yorkc |
24.0 |
19.9 |
17.4 |
18.3 |
13.4 |
15.8 |
15.5 |
0.000** |
| North Carolina |
— |
21.4i |
20.7 |
18.0 |
15.4 |
17.0 |
17.5 |
0.011* |
| North Dakota |
— |
— |
— |
— |
— |
— |
9.5 |
# # |
| Ohio |
— |
— |
— |
14.9 |
14.5 |
15.3 |
16.1 |
0.412 |
| Oklahoma |
30.1 |
25.2 |
22.1 |
21.5 |
18.7 |
19.3 |
18.6 |
0.000** |
| Rhode Island |
— |
— |
— |
— |
— |
— |
13.0 |
# # |
| South Carolina |
30.4 |
24.4 |
23.0 |
22.2 |
19.8†† |
20.2 |
20.4 |
0.000** |
| Utah |
— |
— |
— |
7.5 |
7.9 |
7.1 |
9.1 |
0.313 |
| Vermont |
— |
— |
— |
— |
—f |
9.0f |
9.1 |
# # |
| Washington |
16.1 |
10.5 |
11.1 |
11.6 |
7.0 |
9.2 |
9.8 |
0.000** |
| West Virginia |
20.8 |
18.0 |
15.5 |
13.0 |
13.6 |
12.0 |
13.9 |
0.000** |
# Based on a test for linear trend using logistic regression.
* p value is less than 0.05.
** p value is less than 0.001.
# # < 3 years of data available; test for linear trend not applicable.
†† Missing ≥ 10% data.
a Data represent Minnesota births from May–December 2002.
b Data represent New Jersey births from July–December 2002.
c Data exclude New York City.
d Data represent Maryland births from February–December 2001.
e Data represent Michigan births from July–December 2001.
f Data represent Vermont births from October 2000–December 2001.
g Data represent Illinois births from June–December 1997.
h Data represent New Mexico births from July 1997–December 1998.
i Data represent North Carolina births from July–December 1997. |
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Page last reviewed: 8/23/06
Page last modified: 8/23/06
Content source: Division
of Reproductive Health,
National Center for Chronic Disease
Prevention and Health Promotion |
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