In a newborn (including preterm or low‑birth‑weight), should sleep be positioned supine or prone?

Infant Sleep Position Recommendation

Infants should always be placed on their back (supine position) for every sleep by every caregiver until 1 year of age to reduce the risk of sudden infant death syndrome (SIDS). 1, 2

Why Back Sleeping is Critical

The supine sleep position dramatically reduces SIDS mortality, which remains the leading cause of death in infants beyond the neonatal period. 1 Since the American Academy of Pediatrics began recommending back sleeping in 1992, prone sleeping has decreased from over 70% to approximately 20% of US infants, and the SIDS rate has decreased by more than 40%. 3

Side sleeping is not safe and should not be used, as it is inherently unstable and increases the risk of the infant rolling to the prone (stomach) position. 1, 2

Addressing Common Parental Concerns

Fear of Choking or Aspiration

The supine sleep position does not increase the risk of choking or aspiration, even in infants with gastroesophageal reflux. 1, 2 Infants have protective airway anatomy and mechanisms that prevent aspiration when placed on their backs. 1, 2

• The AAP concurs with the North American Society for Pediatric Gastroenterology and Nutrition that the risk of SIDS outweighs any benefit of prone or side sleeping for reflux management. 1
• Elevating the head of the infant's crib is ineffective for reducing gastroesophageal reflux and is not recommended, as it may cause the infant to slide into a position that compromises respiration. 1, 4
• Infants receiving nasogastric or orogastric feeds are not at increased risk of aspiration when placed supine. 1

Perception of Poor Sleep Quality

Parents often believe their infant sleeps better on the stomach, but this is actually a warning sign, not a benefit. 1 Physiologic studies show that infants are less likely to arouse from sleep when prone, and the ability to arouse is an important protective response to stressors during sleep. 1, 2 Frequent waking is normal infant behavior and should not be perceived as poor sleep. 1

Special Populations

Preterm and Low Birth Weight Infants

Preterm infants should be placed supine as soon as their clinical status has stabilized. 1 The association between prone sleep position and SIDS among low birth weight and preterm infants is equal to, or perhaps even stronger than, the association among term infants. 1

• Hospitalized preterm infants should be kept predominantly in the supine position from at least 32 weeks postmenstrual age onward to acclimate them to this position before discharge. 1, 2
• NICU personnel should endorse safe sleeping guidelines with parents from the time of admission. 1

Rare Exceptions

Prone positioning during sleep should only be considered in extremely rare cases of infants with certain upper airway disorders where airway protective mechanisms are impaired and the risk of death from gastroesophageal reflux disease may outweigh the risk of SIDS. 1, 2 This includes infants with anatomic abnormalities such as type 3 or 4 laryngeal clefts who have not undergone antireflux surgery. 1

Prone positioning is acceptable if the infant is observed and awake, particularly after feeding. 1, 2

When Infants Can Roll Over

Once an infant can roll from supine to prone and from prone to supine independently (typically 4-6 months), the infant can be allowed to remain in the sleep position they assume. 1 However, the infant should still be placed on their back at the start of every sleep period. 1

Critical Implementation Points

Healthcare Provider Role

Healthcare providers must model appropriate behavior from birth. 1 When nursery staff place infants on their sides or stomachs, parents infer that supine positioning is not important and are more likely to copy this practice at home. 1 Infants should be placed on their backs as soon as they are ready to be placed in a bassinet. 1

Consistency Across All Caregivers

Every caregiver must use the supine sleep position for every sleep period. 1 Infants usually placed supine but occasionally placed prone have a dramatically greater risk of SIDS (adjusted odds ratio: 8.7-45.4) compared to those consistently placed supine. 1

Physiologic Mechanisms of Risk

The prone or side sleep position increases SIDS risk through multiple mechanisms:

• Rebreathing of expired gases, resulting in hypercapnia and hypoxia 1
• Increased risk of overheating by decreasing heat loss and increasing body temperature 1
• Decreased arousal from sleep, which impairs protective responses to stressors 1, 2