Forensic Science, Medicine and Pathology

, Volume 14, Issue 1, pp 114–116 | Cite as

Why is a prone sleeping position dangerous for certain infants?

  • Roger W. ByardEmail author
  • Fiona Bright
  • Robert Vink


The prone (face down) sleeping position is known to be associated with a significantly increased risk of sudden and unexpected death in infancy (sudden infant death syndrome or SIDS), however, the reasons for this are unclear. Suggested mechanisms have involved suffocation from occlusion of the external airways by soft bedding/pillows or from flattening of the nose with backward displacement of the tongue, rebreathing of carbon dioxide, blunting of arousal responses with decreased cardiac responses to auditory stimulation, diaphragmatic splinting or fatigue, lowering of vasomotor tone with tachycardia, nasopharyngeal bacterial overgrowth, overheating, alteration of sleep patterns, compromise of cerebral blood flow and upper airway obstruction from distortion of nasal cartilages. Recent studies have, however, shown a significant reduction in substance P in the inferior portion of the olivo-cerebellar complex in SIDS infants which is crucial for the integration of motor and sensory information for the control of head and neck movement. This deficit may explain why some infants are not able to move their faces away from potentially dangerous sleeping environments.


SIDS Prone position Substance P Head and neck movement 


  1. 1.
    Beal SM. Sudden infant death syndrome: epidemiological comparisons between South Australia and communities with a different incidence. Aust Paediatr J. 1986;22(Suppl):13–6.PubMedGoogle Scholar
  2. 2.
    De Jonge GA, Engelberts AC. Cot deaths and sleeping position. Lancet. 1989;ii:1149–50.CrossRefGoogle Scholar
  3. 3.
    De Jonge GA, Engelberts AC, Koomen-Liefting AJM, Kostense PJ. Cot death and prone sleeping position in the Netherlands. Brit Med J. 1989;298:722.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Dwyer T, Ponsonby AL, Newman NM, Gibbons LE. Prospective cohort study of prone sleeping position and sudden infant death syndrome. Lancet. 1991;337:1244–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Fleming PJ, Gilbert R, Azaz Y, et al. Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case–control study. Brit Med J. 1990;301:85–9.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Ponsonby AL, Dwyer T, Kasl SV, Cochrane JA. The Tasmanian SIDS case–control study: univariable and multivariable risk factor analysis. Paediatr Perinat Epidemiol. 1995;9:256–72.CrossRefPubMedGoogle Scholar
  7. 7.
    Byard RW. Sudden infant death syndrome. In: Byard RW, editor. Sudden death in the young. 3rd ed. Cambridge: Cambridge University Press; 2010. p. 555–630.CrossRefGoogle Scholar
  8. 8.
    Abramson H. Accidental mechanical suffocation in infants. J Pediatr. 1944;25:404–13.CrossRefGoogle Scholar
  9. 9.
    Woolley PV. Mechanical suffocation during infancy. J Pediatr. 1945;26:572–5.CrossRefGoogle Scholar
  10. 10.
    Byard RW, Beal SM. Gastric aspiration and sleeping position in infancy and early childhood. J Paediatr Child Health. 2000;36:403–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Bovbjerg ML. Rethinking Dr Spock. Am J Public Health. 2011;101:1812.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Gilbert R, Salanti G, Harden M, See S. Infant sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002. Int J Epidemiol. 2005;34:874–87.CrossRefPubMedGoogle Scholar
  13. 13.
    Byard RW. Is breast feeding in bed always a safe practice? J Paediatr Child Health. 1998;34:418–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Byard RW. Overlaying, co-sleeping, suffocation, and sudden infant death syndrome – the elephant in the room. Forensic Sci Med Pathol. 2015;11:273–4.CrossRefPubMedGoogle Scholar
  15. 15.
    Byard RW. The triple risk model for shared sleeping. J Paediatr Child Health. 2012;48:947–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Vennemann MM, Hense HW, Bajanowski T, et al. Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate? J Pediatr. 2012;160:44–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Carpenter R, McGarvey C, Mitchell EA, et al. Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case-control studies. BMJ Open. 2013;3:e002299.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Byard RW, Elliott J, Vink R. Infant gender, cosleeping and sudden death. J Paediatr Child Health. 2012;48:517–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Jensen LL, Banner J, Byard RW. Does β-APP staining of the brain in infant bed sharing deaths differentiate these cases from sudden infant death syndrome? J Forensic Legal Med. 2014;27:46–9.CrossRefGoogle Scholar
  20. 20.
    Spinelli J, Byard RW, Van den Heuvel C, Collins-Praino L. The intensity of GFAP staining of the brainstem in sudden infant death varies with sleeping environment. J Child Neurol. In press.Google Scholar
  21. 21.
    Stanley FJ, Byard RW. The association between the prone sleeping position and sudden infant death syndrome (SIDS): an editorial overview. J Paediatr Child Health. 1991;27:325–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Simson LR, Brantley RE. Postural asphyxia as a cause of death in sudden infant death syndrome. J Forensic Sci. 1977;22:178–87.CrossRefPubMedGoogle Scholar
  23. 23.
    Hassall IB, Vandenberg M. Infant sleep position: a New Zealand survey. NZ Med J. 1985;98:97–9.Google Scholar
  24. 24.
    Kemp JS. Rebreathing of exhaled gases: importance as a mechanism for the causal association between prone sleep and sudden infant death syndrome. Sleep. 1996;19:S263–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Kemp JS, Thach BT. Rebreathing of exhaled air. In: Byard RW, Krous HF, editors. Sudden infant death syndrome. Problems, progress and possibilities. London: Arnold; 2001. p. 138–55.Google Scholar
  26. 26.
    Mitchell EA. Recommendations for sudden infant death syndrome prevention: a discussion document. Arch Dis Child. 2007;92:155–9.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Blair PS, Mitchell EA, Heckstall-Smith EM, Fleming PJ. Head covering – a major modifiable risk factor for sudden infant death syndrome: a systematic review. Arch Dis Child. 2008;93:778–83.CrossRefPubMedGoogle Scholar
  28. 28.
    Naeye RL, Olsson JM, Combs JW. New brain stem and bone marrow abnormalities in victims of sudden infant death syndrome. J Perinatol. 1989;9:180–3.PubMedGoogle Scholar
  29. 29.
    Sperhake J, Jorch G, Bajanowski T. The prone sleeping position and SIDS. Historical aspects and possible pathomechanisms. Int J Legal Med. 2017.
  30. 30.
    Bright FM, Vink R, Byard RW, Duncan JR, Krous H, Paterson DS. Abnormalities in substance P neurokinin-1 receptor binding in key brainstem nuclei in sudden infant death syndrome related to prematurity and sex. PLoS One. 2017;12:e0184958.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Coffman KA, Dum RP, Strick PL. Cerebellar vermis is a target of projections from the motor areas in the cerebral cortex. Proc Natl Acad Sci U S A. 2011;108:16068–73.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    De Zeeuw CI, Simpson JI, Hoogenraad CC, et al. Microcircuitry and function of the inferior olive. Trends Neurosci. 1998;21:391–400.CrossRefPubMedGoogle Scholar
  33. 33.
    Spinelli J, Collins-Praino L, Van Den Heuvel C, Byard RW. The evolution and significance of the triple-risk model in sudden infant death syndrome (SIDS). J Paediatr Child Health. 2017;53:112–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2017

Authors and Affiliations

  1. 1.School of MedicineThe University of AdelaideAdelaideAustralia
  2. 2.Sansom Institute for Health ResearchUniversity of South AustraliaAdelaideAustralia

Personalised recommendations