International Journal of Legal Medicine

, Volume 132, Issue 1, pp 181–185 | Cite as

The prone sleeping position and SIDS. Historical aspects and possible pathomechanisms

  • Jan Sperhake
  • Gerhard Jorch
  • Thomas BajanowskiEmail author


The incidence of SIDS decreased during the previous 25 years significantly. This is mainly due to epidemiological research identifying important risk factors such as prone sleeping position and subsequent campaigns to reduce this risk factor.

Originally, the prone sleeping position for babies had been strongly recommended in the sixties and seventies despite previous publications pointed to the associated risk. Worldwide, many infants died of SIDS whose deaths could have been avoided. Today, the recommendation that infants should sleep in supine position has been scientifically verified. In supine sleeping position, pathophysiological mechanisms can be avoided which may lead to hypoxia and death in prone position. Such mechanisms could be occlusion of airways (in particularly associated with face-down position), elevated diaphragm, positional cerebral hypoxia caused by constriction of arteries, rebreathing CO2, and overheating.

Irrespective of the specific pathomechanism leading to death in individual cases, it has been established that the prone position is the most important risk factor for SIDS and therefore should be incorporated in the definition of the term SIDS.


SIDS Prone sleeping position Pathomechanism Definition 


Compliance with ethical standards

Humans were not investigated. Animal experiments have not been performed.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Abramson H (1944) Accidental mechanical suffocation in infants. J Pediatr 25(5):404–413. CrossRefGoogle Scholar
  2. 2.
    EmeryJL (1959) Epidemiology of “sudden unexpected, or rapid” deaths in children. BMJ 2(5157):925–928. CrossRefGoogle Scholar
  3. 3.
    Carpenter RG, Shaddick CW (1965) Role of infection, suffocation, and bottle-feeding in cot death. An analysis of some factors in the histories of 110 cases and their controls. Br J Prev Soc Med 19:1–7PubMedPubMedCentralGoogle Scholar
  4. 4.
    Froggat P (1970) Epidemiological aspects of the Northern Ireland study. In: Bergmann AB, Beckwith JB, Ray CG (eds) Suden infant death syndrome. University of Washington Press, Seattle, pp 32–46Google Scholar
  5. 5.
    Erlacher P (1959) Muß das menschenkind auf dem Rücken liegen? Wien Klein Wochenschr 71:937–938Google Scholar
  6. 6.
    Reisetbauer E, Czermak H (1972) Die Körperlage des Säuglings. Padiatr Prax 11:5–14Google Scholar
  7. 7.
    Schwab HJ (2004) Das Verbot der Bauchlage für schlafende Säuglinge in der DDR. In: Paditz E (ed) Prävention Plötzlicher Säuglingstod in Deutschland. Hille, Dresden, pp 148–161Google Scholar
  8. 8.
    Leetz I (1977) Medizinisch-statistische Daten der DDR zum plötzlichen Tod im Säuglingsalter. Kinderärztl Prax 45(4):145–150PubMedGoogle Scholar
  9. 9.
    Zumpe R (1973) Die Bauchlage – Ursache von Todesfällen von Säuglingen. Kriminalistik 27:315–316Google Scholar
  10. 10.
    Althoff H (1973) Der plötzliche und unerwartete Tod von Säuglingen und Kleinkindern. Fischer, StuttgartGoogle Scholar
  11. 11.
    Saternus KS (1985) Plötzlicher Kindstod – eine Folge der Bauchlage? Zur Theorie der lageabhängigen cerebralen Hypoxämie. Kriminalistik – Wissenschaft und Praxis. 19: 67-88. In: Walther G, Haffner HAT (eds) Festschrift für H. Leithoff. Kriminalsistik, HeidelbergGoogle Scholar
  12. 12.
    de Jonge GA, Engelberts AC, Koomen-Liefting AJM, Kostense PJ (1989) Cot death and prone sleeping position in the Netherlands. BMJ 298(6675):722. CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Engelberts AC, de Jonge GA (1990) Choice of sleeping position for infants. Possible association with cot death. Arch Dis Child 65(4):462–467. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Beal SM (1988) Sleeping position and sudden infant death syndrome (letter). Med J Aust 149(10):562PubMedGoogle Scholar
  15. 15.
    Jorch G, Findeisen M, Brinkamnn B, Trowisch E, Weihrauch B (1991) Bauchlage und plötzlicher Säuglingstod. DÄ 88: 2767–2771Google Scholar
  16. 16.
    MMT V, Finseisen M, Butterfaß-Bahloul T, Jorch G, Brinkmann B, Köpcke W, Bajanowski T, Mitchell E, the GeSID Group (2005) Modifiable risk factors for SIDS in Germany: results of GeSID. Acta Paediatr 94:655–660CrossRefGoogle Scholar
  17. 17.
    Kleemann JW, Schlaud M, Fieguth A, Hiller AS, Rothämel T, Tröger HD (1998) Body and head position, covering of the head by bedding and risk of sudden infant death (SID). Int J Legal Med 112(1):22–26. CrossRefPubMedGoogle Scholar
  18. 18.
    Guntheroth WG, Spiers PS (1992) Sleeping prone and the risk of sudden infant death syndrome. JAMA 267(17):2359–2362. CrossRefPubMedGoogle Scholar
  19. 19.
    Emery JL (1990) Towards safer cot mattresses. Health Visitor 63(5):157–159PubMedGoogle Scholar
  20. 20.
    Schäfer AT, Lemke R, Althoff H (1991) Airway resistance of the posterior nasal pathways in sudden infant death victims. Eur J Pediatr 150(8):595–598. CrossRefPubMedGoogle Scholar
  21. 21.
    Bayes BJ (1974) Prone infants and SIDS. New Engl J Med 290(12):693–694PubMedGoogle Scholar
  22. 22.
    Kadlub KI, Kadlub IB (1974) Crib death: disease or accident? Mich Med 73(32):663–664PubMedGoogle Scholar
  23. 23.
    Roll P, Dirnhofer R, Ranner G (1985) Plötzlicher Säuglingstod (S.I.D.S.) und Magenfüllung. In: Walther G, Haffner HAT (eds) Festschrift für H. Leithoff. Kriminalsistik, Heidelberg, pp 89–94Google Scholar
  24. 24.
    Saternus KS (1982) Lageabhängige zirkulationsbedingte cerebrale Hypoxämie – eine Erklärungsmöglichkeit des plötzlichen Kindstodes. Zbl. Rechtsmedizin 24:635Google Scholar
  25. 25.
    Saternus KS, Adam G (1985) Der Plötzliche Kindstod. Postmortale Flußmessungen an den großen Halsgefäßen zum Nachweis einer lageabhängigen zerebralen Hypoxämie DMW 11:297–303Google Scholar
  26. 26.
    Orr WC, Stahl ML, Duke J, McCaffree MA, Toubas P, Mattice C, Krous HF (1985) Effect of sleep state and position on the incidence of obstructive and central apnea in infants. Pediatrics 75(5):832–835PubMedGoogle Scholar
  27. 27.
    Lawson B, Anday E, Guillet R, Wagerle LC, Chance B, Delivoria-Papadopoulos M (1987) Brain oxidative phosphorylation following alternation in head position in preterm and term neonates. Pediatr Res 22(3):302–305. CrossRefPubMedGoogle Scholar
  28. 28.
    Levene S, McKenzie SA (1990) Transcutaneous oxygen saturation in sleeping infants: prone and supine. Arch Dis Child 65(5):524–526. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Oehmichen M, Wullen B, Zilles K, Saternus KS (1989) Cytological investigations on the cerebellar cortex of sudden infant death victims. Acta Neuropathol 78(4):404–409. CrossRefPubMedGoogle Scholar
  30. 30.
    Poets CF, Rudolph A, Neber K, Buch U, von der Hardt H (1995) Oxygen saturation in infants at risk of sudden death: influence of sleep position. Acta Pediatr Scand 84(4):379–382. CrossRefGoogle Scholar
  31. 31.
    Deeg KH, Erhardt P, Fortsch K, Hense A, Windschall D, Alderath W (2001) Dependency of blood flow in the basilar artery on head and body position—a possible cause of SIDS? Results of a Doppler sonographic screening program of 3840 newborns. Klin Paediat 213(3):124–133. CrossRefGoogle Scholar
  32. 32.
    Fleming PJ, Gilbert R, Azaz Y, Berry PJ, Rudd PT, Stewart A, Hall E (1990) Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study. BMJ 301(6743):85–89. CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Ryan EL Distribution of expired air in carry cots – a possible explanation for some sudden infant deaths. Australas Phys Eng Sci Med 14:112–118Google Scholar
  34. 34.
    Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Jones ME, McCall MJ (1992) Thermal environment and sudden infant death syndrome: case-control study. Br Med J 304(6822):277–282. CrossRefGoogle Scholar
  35. 35.
    Chiodini BA, Thach BT (1993) Impaired ventilation in infants sleeping facedown: potential significance for sudden infant death syndrome. J Pediatr 123(5):686–692. CrossRefPubMedGoogle Scholar
  36. 36.
    Lijowska AS, Reed NW, Mertins Chiodini BA, Thach BT (1997) Sequential arousal and airway-defensive behavior of infants in asphyxial sleep environments. J Appl Physiol 83(1):219–228CrossRefPubMedGoogle Scholar
  37. 37.
    Berthon-Jones M, Sullivan CE (1982) Ventilatory and arousal responses to hypoxia in sleeping humans. Am Rev Respir Dis 125(6):632–639. PubMedGoogle Scholar
  38. 38.
    Franco P, Pardou A, Hassid S, Lurquin P, Groswasser J, Kahn A (1998) Auditory arousal thresholds are higher when infants sleep in the prone position. J Pediatr 132(2):240–243. CrossRefPubMedGoogle Scholar
  39. 39.
    Read PA, Horne R, Cranage SM, Walker AM, Walker DW, Adamson TM (1998) Dynamic changes in arousal threshold during sleep in the human infant. Pediatr Res 43(5):697–703. CrossRefPubMedGoogle Scholar
  40. 40.
    Horne RSC, Ferens D, Watts AM, Vitkovic J, Lacey B, Andrew S, Cranage SM, Chau B, Adamson TM (2001) The prone sleeping position impairs arousability in term infants. J Pediatr 138(6):811–816. CrossRefPubMedGoogle Scholar
  41. 41.
    Kinney HC, Brody BA, Finkelstein DM, Vawter GF, Mandell F, Gilles FH (1991) Delayed central nervous system myelination in the sudden infant death syndrome. J Neuropathol Exp Neurol 50(1):29–48. CrossRefPubMedGoogle Scholar
  42. 42.
    Carlin RF, Moon RY (2016) Risk factors, protective factors, and current recommendations to reduce the sudden infant death syndrome. JAMA Pediatr 171:175–180CrossRefGoogle Scholar
  43. 43.
    Goodyear JE (19799 Haet hyperperesia in infant (a case report). Med Sci Law 19: 208–209Google Scholar
  44. 44.
    Wilske J (1984) Der plötzliche Säuglingstod (SIDS). Springer, Berlin Heidelberg. CrossRefGoogle Scholar
  45. 45.
    Bentele KHP (1992) Körperlage im Schlaf, autonome Atemregulation und plötzlicher Säuglingstod – Gibt es pathophysiologische Zusammenhänge? In: NRW MAGS (ed) Plötzlicher Säuglingstod – Dokumentation eines Fachgespräches. IDIS, Bielefeld, pp 42–49Google Scholar
  46. 46.
    Butterworth J, Tennant MC (1989) Postmortem human brain pH and lactate in sudden infant death syndrome. J Neurochem 53(5):1494–1499. CrossRefPubMedGoogle Scholar
  47. 47.
    Le Cam-Duchez V, Coquerel A, Chevallier F, Vaz E, Menard JF, Basset C, Lahary A, Vannier JP (1999) Erythropoietin blood level is increased in sudden infant death. Biol Neonate 76(1):1–9. CrossRefPubMedGoogle Scholar
  48. 48.
    Jones KL, Krous HF, Nadeau J, Blackbourne B, Zielke HR, Gozal D (2003) Vascular endothelial growth factor in the cerebrospinal fluid of infants who died of sudden infant death syndrome: evidence for antecedent hypoxia. Pediatrics 111(2):358–363. CrossRefPubMedGoogle Scholar
  49. 49.
    Sperhake JP (2011) Bauchlage oder Rückenlage? Rechtsmed 21(6):518–521. CrossRefGoogle Scholar
  50. 50.
    Krous HF, Beckwith JB, Byard RW, Rognum TO, Bajanowski T, Corey T, Cutz E, Hanzlick R, Keens TG, Mitchell EA (2004) Sudden infant death syndrome (SIDS) and unclassified sudden infant deaths (USID): a definitional and diagnostic approach. Pediatrics 114(1):234–238. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Department of Legal MedicineUniversity Medical Center Hamburg-EppendorfHamburgGermany
  2. 2.Department of PediatricsUniversity Hospital MagdeburgMagdeburgGermany
  3. 3.Department of Legal MedicineUniversity Hospital EssenEssenGermany

Personalised recommendations