[Position and sudden death of the infant]

In western countries, the sudden infant death syndrome (SIDS) is the leading cause of mortality in infants under one year of age. In an official statement on prevention from the French Ministry of Health, sleeping in the supine position or on the side is recommended for all infants unaffected by a particular medical condition. This clear restrictive recommendation is based on valid epidemiological data but raises questions in the minds of paediatricians and general practitioners since the most recent recommendations for treatment of gastro-oesophageal reflux indicate that the prone position at a 30 degrees angle is the first preventive measure to be taken. We present here an objective view point on this complex problem which others may find helpful in developing a sound approach to each individual case. First it must be emphasized that multiple factors are involved in SIDS. While the confirmed correlation between the supine sleeping position and reduced incidence of SIDS is a valid rationale for population-based preventive measures, it does not indicate any causal relationship. Secondly, epidemiological data is valid for a given geographical area but cannot be extrapolated to other areas without taking into account intercurrent factors such as soft bedding, use of feather-bed quilts, excessive bedroom temperature and passive smoking. The public campaign for the prevention of SIDS should be encouraged as an effective low-cost measure, but both physicians and parents should be aware of its multifactorial nature in order to avoid psychologically catastrophic consequences of the guilt syndrome. For infants with uncomplicated simple gastro-oesophageal reflux, a formerly well-known condition but currently less well tolerated by modern parents, it is essential to explain the physiological nature of the reflux to parents then to propose formula thickeners, antacids or prokinetic agents in particularly symtomatic cases. Sleeping in the 30 degrees prone position should not, in this particular case, be introduced as a preventive measure since the risk induced would probably be greater than the beneficial effect. For complicated reflux, after careful exploration and elimination of other causes of vomiting, treatment should be optimized first, followed by discussion on placing the infant in the 30 degrees prone position which should be considered as a therapeutic tool with the same risk of secondary effects as expected with drugs.