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March 8, 1995, Vol 273, No. 10 >
ARTICLE | March 8, 1995

The Contribution of Changes in the Prevalence of Prone Sleeping Position to the Decline in Sudden Infant Death Syndrome in Tasmania FREE

Terence Dwyer, MPH, MD; Anne-Louise Ponsonby, MBBS, PhD; Leigh Blizzard, MEc; Neville M. Newman, MBBS, FRACP; Jennifer A. Cochrane
[+] Author Affiliations

Reprint requests to the Menzies Centre for Population Health Research, GPO Box 252C, Hobart 7000, Tasmania, Australia (Dr Dwyer),


JAMA. 1995;273(10):783-789. doi:10.1001/jama.1995.03520340039033
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References

Objective.  —To determine the independent contribution of changes in infant sleep position to the recent decline in sudden infant death syndrome (SIDS) rate in Tasmania.

Design.  —(1) A comparison of the whole population incidence of SIDS before and after an intervention to reduce the prevalence of prone sleeping position. (2) A within-cohort analysis of the contribution of sleep position and other exposures to the decline in SIDS after the intervention.

Setting.  —Tasmania, Australia.

Participants.  —(1) All SIDS cases from 1975 through 1992. (2) A sample of one in five infants born in Tasmania who at perinatal assessment were scored to be at higher risk for SIDS since January 1988. Of 5534 infants included in the study, 39 later died of SIDS.

Interventions.  —Multiple public health activities to reduce the prevalence of the prone infant sleeping position in Tasmania and verbal information on the association between prone position and SIDS to cohort participants from May 1, 1991.

Main Outcome Measure.  —Sudden infant death syndrome incidence.

Results.  —The Tasmanian SIDS rate decreased (P<.01) from 3.8 (95% confidence interval [CI], 3.5 to 4.2) deaths per 1000 live births from 1975 through 1990 to a rate of 1.5(95% CI, 0.9 to 2.2) deaths per 1000 live births in 1991 through 1992. The SIDS mortality rate in the cohort by period of birth was 7.6 (95% CI, 4.9 to 10.3) deaths per 1000 live births for those born from May 1, 1988, through April 30, 1991, and 4.1 (95% CI, 1.3 7.0) deaths per 1000 infants for those born from May 1,1991, through October 31, 1992. The prevalence of usual prone sleeping position at 1 month of age was 29.9% and 4.3% in these two cohorts, respectively (adjusted odds ratio, 0.11; 95% CI, 0.08 to 0.13). Logistic regression demonstrated that 70% of the SIDS rate reduction in the cohort could be accounted for by the decreased prevalence of the prone sleeping position. Other factors examined individually contributed to less than 10% of the SIDS rate reduction.

Conclusions.  —The major contributing factor to the recent SIDS rate decline in Tasmania has been the reduction in the proportion of infants usually sleeping prone.EVIDENCE has

REFERENCES

1 +
Guntheroth WG, Spiers PS.  Sleeping prone and the risk of sudden infant death syndrome. JAMA . 1992;;267:2359-2362.
2 +
Beal SM, Finch CF.  An overview of retrospective case-control studies investigating the relationship between prone sleeping position and SIDS. J Paediatr Child Health . 1991;;27:334-339.
3 +
Dwyer T, Ponsonby A-L, Newman NM, Gibbons LE.  Prospective cohort study of prone sleeping position and sudden infant death syndrome. Lancet . 1991;;337:1244-1247.
4 +
Beal SM.  Sudden infant death syndrome: epidemiological comparisons between South Australia and communities with a different incidence. Aust Paediatr J . 1986;;22( (suppl) ):13-16.
5 +
Lee NNY, Chan YF, Davies DP, Lau E, Yip DCP.  Sudden infant death syndrome in Hong Kong: confirmation of low incidence. BMJ . 1989;;298:721.
6 +
Engelberts AC, de Jonge GA.  Choice of sleeping position for infants: possible association with cot death. Arch Dis Child . 1990;;65:462-467.
7 +
Beal S.  Sudden infant death syndrome related to sleeping position and bedding. Med J Aust . 1991;; 155:507-508.
8 +
Lewis J, Samuels M, Southall D.  Is the decline in cot deaths due to child-health reorganisation? Lancet . 1993;;341:51.
9 +
 Recommendation: a scientific review of the association between prone sleeping position and sudden infant death syndrome. J Paediatr Child Health . 1991;;27:323-324.
10 +
Risk Factors Associated With Sudden Infant Death Syndrome. In: Program and abstracts of the 112th Session of NHMRC Council; October 1991. Canberra.
11 +
Mitchell EA.  Cot death: should the prone sleeping position be discouraged? J Paediatr Child Health . 1991;;27:319-321.
12 +
Australian Bureau of Statistics. Births 1988-1992, Australia . Canberra: Australian Government Printing Office: 1993;. Australian Bureau of Statistics catalogue 3301.0.
13 +
Australian Bureau of Statistics. Deaths 1988-1992, Australia . Canberra: Australian Government Printing Office; 1993;. Australian Bureau of Statistics catalogue 3302.0.
14 +
Fetal and Infant Deaths 1988-1990 . Wellington: New Zealand Health Information Service, Ministry of Health; 1993;.
15 +
Fetal and Infant Deaths 1992 . Wellington: New Zealand Health Information Service, Ministry of Health; 1994;.
16 +
Holborow P.  Preventing cot death: sleep position and/or diet? N Z Med J . 1991;;104:296-297.
17 +
Ponsonby A-L, Dwyer T, Kasl S, Cochrane JA, Newman NM.  An assessment of the impact of public health activities to reduce the prevalence of the prone sleeping position during infancy: the Tasmanian cohort study. Prev Med . 1994;;23:402-408.
18 +
World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Based on the Recommendations of the Ninth Revision Conference, 1975 . Geneva, Switzerland: World Health Organization; 1977;.
19 +
Ponsonby A-L, Dwyer T, Gibbons LE, Cochrane JA, Jones ME, McCalf MJ.  Thermal environment and sudden infant death syndrome: case-control study. BMJ . 1992;;304:277-282.
20 +
Ponsonby A-L, Dwyer T, Gibbons LE, Cochrane JA, Wang Y-G.  Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med . 1993;;329:377-382.
21 +
D'Espaignet E, Dwyer T, Newman NM, Ponsonby A-L, Candy SG.  The development of a model for predicting infants at high risk of SIDS in Tasmania. Paediatr Perinatal Epidemiol . 1990;;4:422-435.
22 +
Williams AL.  Sudden infant death syndrome. Aust N Z J Obstet Gynaecol . 1990;;30:98-107.
23 +
Emery JL.  Cot deaths in Australia, 1984. Med J Aust . 1986;;144:469-473.
24 +
 Fitting models to group data.  In: Breslow NE, Day NE, eds. Statistical Methods in Cancer Research: The Design and Analysis of Cohort Studies . Lyon, France: International Agency for Research on Cancer; 1993;;2:131-135.
25 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co Inc; 1986;:146.
26 +
 Comparisons of exposure groups.  In: Breslow NE, Day NE, eds. Statistical Methods in Cancer Research: The Design and Analysis of Cohort Studies . Lyon, France: International Agency for Research on Cancer; 1993;;2:109.
27 +
Salonen JT, Tuimilehto J, Nissinen A, et al.  Contribution of risk factor changes to the decline in coronary incidence during the North Karelia project: a within-community analysis. Int J Epidemiol . 1989;; 18:595-601.
28 +
Greenland S.  Modeling and variable selection in epidemiologic analysis. Am J Public Health . 1989;; 79:340-349.
29 +
SAS/STAT User's Guide, Version 6.07 . 4th ed. Cary, NC: SAS Institute Inc; 1990;:vols 1, 2.
30 +
Spiers PS, Guntheroth WG.  Recommendation to avoid the prone sleeping position and recent statistics for sudden infant death syndrome in the United States. Arch Pediatr Adolesc Med . 1994;; 148:141-146.
31 +
Mitchell EA, Ford R, Taylor BJ, et al.  Further evidence supporting a causal relationship between prone sleeping position and SIDS. J Paediatr Child Health . 1992;;28( (suppl) ):S9-S12.
32 +
Gibbons LE, Ponsonby A-L, Dwyer T.  A comparison of prospective and retrospective responses on sudden infant death syndrome by case and control mothers. Am J Epidemiol . 1993;;137:654-659.
33 +
Survey of Infant Sleeping Positions: Australia, July 1992 . Canberra: Australian Government Printing Office Canberra, 1992;. Australian Bureau of Statistics catalogue 43860.
34 +
Jones M, Ponsonby A-L, Dwyer T, Gilbert N.  The relation between climatic temperature and SIDS differs among communities: results from an ecologic analysis. Epidemiology . 1994;;5:332-336.
35 +
Ponsonby A-L, Dwyer T, Gibbons LE.  The risk of sudden infant death. N Engl J Med . 1994;;330:64.
36 +
Hoffman HJ, Hillman LS.  Epidemiology of the sudden infant death syndrome: maternal, neonatal and postneonatal risk factors. Clin Perinatol . 1992;; 19:717-737.

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1 +
Guntheroth WG, Spiers PS.  Sleeping prone and the risk of sudden infant death syndrome. JAMA . 1992;;267:2359-2362.
2 +
Beal SM, Finch CF.  An overview of retrospective case-control studies investigating the relationship between prone sleeping position and SIDS. J Paediatr Child Health . 1991;;27:334-339.
3 +
Dwyer T, Ponsonby A-L, Newman NM, Gibbons LE.  Prospective cohort study of prone sleeping position and sudden infant death syndrome. Lancet . 1991;;337:1244-1247.
4 +
Beal SM.  Sudden infant death syndrome: epidemiological comparisons between South Australia and communities with a different incidence. Aust Paediatr J . 1986;;22( (suppl) ):13-16.
5 +
Lee NNY, Chan YF, Davies DP, Lau E, Yip DCP.  Sudden infant death syndrome in Hong Kong: confirmation of low incidence. BMJ . 1989;;298:721.
6 +
Engelberts AC, de Jonge GA.  Choice of sleeping position for infants: possible association with cot death. Arch Dis Child . 1990;;65:462-467.
7 +
Beal S.  Sudden infant death syndrome related to sleeping position and bedding. Med J Aust . 1991;; 155:507-508.
8 +
Lewis J, Samuels M, Southall D.  Is the decline in cot deaths due to child-health reorganisation? Lancet . 1993;;341:51.
9 +
 Recommendation: a scientific review of the association between prone sleeping position and sudden infant death syndrome. J Paediatr Child Health . 1991;;27:323-324.
10 +
Risk Factors Associated With Sudden Infant Death Syndrome. In: Program and abstracts of the 112th Session of NHMRC Council; October 1991. Canberra.
11 +
Mitchell EA.  Cot death: should the prone sleeping position be discouraged? J Paediatr Child Health . 1991;;27:319-321.
12 +
Australian Bureau of Statistics. Births 1988-1992, Australia . Canberra: Australian Government Printing Office: 1993;. Australian Bureau of Statistics catalogue 3301.0.
13 +
Australian Bureau of Statistics. Deaths 1988-1992, Australia . Canberra: Australian Government Printing Office; 1993;. Australian Bureau of Statistics catalogue 3302.0.
14 +
Fetal and Infant Deaths 1988-1990 . Wellington: New Zealand Health Information Service, Ministry of Health; 1993;.
15 +
Fetal and Infant Deaths 1992 . Wellington: New Zealand Health Information Service, Ministry of Health; 1994;.
16 +
Holborow P.  Preventing cot death: sleep position and/or diet? N Z Med J . 1991;;104:296-297.
17 +
Ponsonby A-L, Dwyer T, Kasl S, Cochrane JA, Newman NM.  An assessment of the impact of public health activities to reduce the prevalence of the prone sleeping position during infancy: the Tasmanian cohort study. Prev Med . 1994;;23:402-408.
18 +
World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Based on the Recommendations of the Ninth Revision Conference, 1975 . Geneva, Switzerland: World Health Organization; 1977;.
19 +
Ponsonby A-L, Dwyer T, Gibbons LE, Cochrane JA, Jones ME, McCalf MJ.  Thermal environment and sudden infant death syndrome: case-control study. BMJ . 1992;;304:277-282.
20 +
Ponsonby A-L, Dwyer T, Gibbons LE, Cochrane JA, Wang Y-G.  Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med . 1993;;329:377-382.
21 +
D'Espaignet E, Dwyer T, Newman NM, Ponsonby A-L, Candy SG.  The development of a model for predicting infants at high risk of SIDS in Tasmania. Paediatr Perinatal Epidemiol . 1990;;4:422-435.
22 +
Williams AL.  Sudden infant death syndrome. Aust N Z J Obstet Gynaecol . 1990;;30:98-107.
23 +
Emery JL.  Cot deaths in Australia, 1984. Med J Aust . 1986;;144:469-473.
24 +
 Fitting models to group data.  In: Breslow NE, Day NE, eds. Statistical Methods in Cancer Research: The Design and Analysis of Cohort Studies . Lyon, France: International Agency for Research on Cancer; 1993;;2:131-135.
25 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co Inc; 1986;:146.
26 +
 Comparisons of exposure groups.  In: Breslow NE, Day NE, eds. Statistical Methods in Cancer Research: The Design and Analysis of Cohort Studies . Lyon, France: International Agency for Research on Cancer; 1993;;2:109.
27 +
Salonen JT, Tuimilehto J, Nissinen A, et al.  Contribution of risk factor changes to the decline in coronary incidence during the North Karelia project: a within-community analysis. Int J Epidemiol . 1989;; 18:595-601.
28 +
Greenland S.  Modeling and variable selection in epidemiologic analysis. Am J Public Health . 1989;; 79:340-349.
29 +
SAS/STAT User's Guide, Version 6.07 . 4th ed. Cary, NC: SAS Institute Inc; 1990;:vols 1, 2.
30 +
Spiers PS, Guntheroth WG.  Recommendation to avoid the prone sleeping position and recent statistics for sudden infant death syndrome in the United States. Arch Pediatr Adolesc Med . 1994;; 148:141-146.
31 +
Mitchell EA, Ford R, Taylor BJ, et al.  Further evidence supporting a causal relationship between prone sleeping position and SIDS. J Paediatr Child Health . 1992;;28( (suppl) ):S9-S12.
32 +
Gibbons LE, Ponsonby A-L, Dwyer T.  A comparison of prospective and retrospective responses on sudden infant death syndrome by case and control mothers. Am J Epidemiol . 1993;;137:654-659.
33 +
Survey of Infant Sleeping Positions: Australia, July 1992 . Canberra: Australian Government Printing Office Canberra, 1992;. Australian Bureau of Statistics catalogue 43860.
34 +
Jones M, Ponsonby A-L, Dwyer T, Gilbert N.  The relation between climatic temperature and SIDS differs among communities: results from an ecologic analysis. Epidemiology . 1994;;5:332-336.
35 +
Ponsonby A-L, Dwyer T, Gibbons LE.  The risk of sudden infant death. N Engl J Med . 1994;;330:64.
36 +
Hoffman HJ, Hillman LS.  Epidemiology of the sudden infant death syndrome: maternal, neonatal and postneonatal risk factors. Clin Perinatol . 1992;; 19:717-737.

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