Preterm Infants and Sleeping Position

William T. Basco, Jr, MD, FAAP


October 03, 2006

Effect of Prone and Supine Position on Sleep, Apneas, and Arousal in Preterm Infants

Bhat RY, Hannam S, Pressler R, Rafferty GF, Peacock JL, Greenough A
Pediatrics. 2006;118(1):101-107


According to Bhat and colleagues, previous research has demonstrated that, in preterm infants, prone sleeping position is associated with a marked increase in rates of sudden infant death syndrome (SIDS).[1] This study sought to examine a larger number of preterm infants than that included in other studies in order to determine how sleep position might be associated with apneas or sleep quality.

The subjects for this study were infants born at < 33 weeks gestation. Each infant was monitored for two 3-hour periods on 2 consecutive days. Infants were in the prone position for 1 period each day and in the supine position for another period during each day. The data were then aggregated by patient and by position (the "prone" data from Day 1 were combined with the prone data from Day 2 for each infant, etc). Monitoring included video-polysomnography.

The authors defined apnea as a lack of nasal airflow of ≥ 5 seconds. An arousal was defined as ≥ 10 seconds of movement, with ≥ 60 seconds of movement or crying constituting an "awakening." The authors studied 24 infants, 14 of whom developed bronchopulmonary dysplasia (BPD). These 14 infants were on supplemental oxygen during their respective studies. The policy of the unit was to have infants sleep supine for at least 2 weeks prior to discharge so that the infants studied would be used to the supine position.

Overall, prone sleeping position was associated with more sleep and more efficient sleep. For example, the mean number of minuses of sleep time recorded was 116 in the supine position and 146 minutes in the prone position. Infants in prone sleep also spent more time in quiet sleep (25.8 minutes on average vs 15.5 minutes for infants in the supine position). Prone sleep times were associated with fewer awakenings (3.5 vs 9.7) and arousals. However, central apneas were much more common among infants sleeping in the prone position (5.6 on average) than among infants sleeping in the supine position (2.2). Obstructive apneas were more common in among infants in the supine position at 0.9 vs 0.5 among infants in the prone position. The results were similar when the infants were analyzed as subgroups - with and without BPD.

The authors concluded that prone sleeping position is associated with fewer spontaneous arousals and more episodes of central apnea.


This study supports the clinical observation that infants may sleep better in the prone position (as evidenced by longer sleep times and fewer arousals in this study). However, the increased risk of central apneas is notable. Back-to-sleep campaigns have led to decreases in the rates of SIDS; these data lend evidence to the recommendation that infants avoid sleeping in the prone position.[2]



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