Face-straight-down and face-near-straight-down positions in healthy, prone-sleeping infants

Objective: To determine the frequency and physiologic consequences of the face-straight-down (FSD) position, a postulated mechanism for the sudden infant death syndrome in prone-sleeping infants. Study design: A survey of 151 infants, aged 1 to 7 months, in Montreal showed that 33% slept prone. Ten healthy prone-sleeping infants were studied in their homes at age 10 to 22 weeks. Infrared video and cardiorespiratory recordings were made on 3 consecutive nights in the prone (nights 1 and 3) and lateral (night 2) positions. Results: Infants maintained the prone position during 17 of 19 studies, but only 4 of 9 infants maintained the lateral position. The FSD position was observed 27 times in 17 prone nights: median frequency, 0.6 times per night (interquartile range, 0 to 4), and median total duration, 3.3 minutes (0.8% of total sleep time). A related position, the face-near-straight-down (FNSD) position, occurred more often, 5.3 (1 to 10) times per prone night, for 22.4 minutes (5.8% of total sleep time). Most periods in the FSD or FNSD position had no physiologic consequences; however, 14% of FSD and 3% of FNSD episodes were associated with airway obstruction as indicated by snoring, paradoxical respiratory movements, apnea, and/or increased partial pressure of transcutaneous carbon dioxide. Spontaneous arousal and head turning terminated the FSD and FNSD episodes. Conclusion: The FSD and FNSD positions occur commonly in healthy prone-sleeping infants, and these positions can cause airway obstruction. We speculate that those infants with sudden infant death syndrome found in the FSD or FNSD position either have a congenital or an acquired defect in the arousal-head turning response or have encountered insurmountable environmental factors that prevent effective head turning.