Is there a downside to having supervised skin-to-skin (STS) contact naps in a prone position during the day for newborns, followed by supine positioning for independent sleep at night?

Supervised Skin-to-Skin Prone Naps for Newborns: Safety Considerations

Supervised skin-to-skin contact naps in the prone position are acceptable when the infant is observed and awake, but all sleep periods should be in the supine position to reduce the risk of SIDS. 1

Understanding Safe Sleep Positioning

The American Academy of Pediatrics (AAP) provides clear guidelines regarding infant sleep positioning to reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related deaths:

• Back to sleep for EVERY sleep: Infants should be placed wholly on their back for every sleep period by every caregiver until 1 year of age 1
• Supervision requirement: Prone positioning is only acceptable if the infant is observed and awake 1
• Critical distinction: There is an important difference between supervised awake time and sleep time

When Prone Positioning Is Acceptable

The AAP specifically states that "prone positioning is acceptable if the infant is observed and awake, particularly in the postprandial period" 1. This means:

• Skin-to-skin contact while the infant is awake and being actively supervised is beneficial
• The key factor is ensuring the infant is not allowed to fall asleep in this position
• If the infant begins to fall asleep during skin-to-skin contact, they should be repositioned to their back

Risks of Prone Sleep Position

The prone sleep position significantly increases SIDS risk through several mechanisms:

• Increases risk of rebreathing expired gases, resulting in hypercapnia and hypoxia 1
• Increases risk of overheating by decreasing heat loss 1
• Alters autonomic control of the infant cardiovascular system during sleep 1
• May decrease cerebral oxygenation 1

Research shows the prone position places infants at high risk of SIDS with odds ratios ranging from 2.3 to 13.1 1.

Benefits of Supervised Tummy Time

While prone sleeping is dangerous, supervised "tummy time" when the infant is awake offers important benefits:

• Promotes motor development 1
• Facilitates development of upper body muscles 1
• Minimizes the risk of positional plagiocephaly (flat head syndrome) 1, 2

The AAP recommends supervised tummy time while the infant is awake on a daily basis, beginning as early as possible 1.

Practical Recommendations for Parents

To balance the benefits of skin-to-skin contact with safe sleep practices:

1. For skin-to-skin contact:

   • Ensure active supervision at all times
   • Monitor the infant for signs of falling asleep
   • Reposition to supine if the infant begins to fall asleep

2. For all sleep periods:

   • Always place infant on their back on a firm sleep surface
   • This includes both nighttime sleep and daytime naps
   • Maintain consistent practice with all caregivers

Common Pitfalls to Avoid

• Misinterpreting "supervised": Even with supervision, an infant should not be allowed to sleep in the prone position 1
• Inconsistent practices: Using different sleep positions for different sleep periods can increase risk 1
• False reassurance: Parents may believe that supervision eliminates all risk during sleep, but this is not the case for prone positioning

Remember that the supine sleep position does not increase the risk of choking or aspiration in infants, even those with gastroesophageal reflux, as infants have protective airway mechanisms 1, 2.

By following these guidelines, parents can safely enjoy skin-to-skin contact with their newborn while minimizing the risk of sleep-related infant deaths.