The “Back Is Best” campaign, launched in the United States in 1994, was a major public health initiative designed to reduce the incidence of Sudden Infant Death Syndrome (SIDS). SIDS is defined as the sudden, unexplained death of an infant under one year of age, often occurring during sleep. Led by the National Institute of Child Health and Human Development (NICHD), the campaign focused on a single, actionable recommendation for parents. This instruction represented a dramatic shift in infant care practices aimed at addressing the primary risk factor for SIDS.
Sleep Positions Before the Campaign
Prior to the 1990s, medical and cultural wisdom often recommended placing infants to sleep on their stomachs, known as the prone position. This advice stemmed from the belief that prone sleeping aided digestion and reduced the likelihood of choking on spit-up.
Before the campaign, a significant percentage of infants, estimated to be over 80% in the United States, were routinely placed on their stomachs. The medical community had not yet fully recognized the strong statistical link between the prone position and an elevated SIDS risk. The campaign required a substantial behavioral change, reversing established parenting norms.
The Central Recommendation
The core message of the campaign was the instruction to place healthy infants on their backs—the supine position—for every sleep, including naps and nighttime. This recommendation applied to all infants up to one year of age, the period when SIDS risk is highest.
The campaign directly addressed parental anxiety regarding choking on regurgitated milk or spit-up. It explained that an infant’s airway anatomy and protective reflexes prevent this from happening. Studies confirmed no increase in aspiration or choking deaths after the widespread adoption of the back-to-sleep position.
Measuring the Public Health Impact
The measurable success of the “Back Is Best” campaign was immediate and dramatic. Following the 1994 launch, the rate of SIDS in the United States declined by more than 50 percent within a decade. This sharp reduction correlated directly with the increase in infants being placed in the supine position for sleep.
Mechanisms of Risk Reduction
Scientific hypotheses suggest several mechanisms explain why back sleeping reduces SIDS risk. Sleeping on the stomach can cause an infant to re-breathe exhaled air, leading to a build-up of carbon dioxide and a lack of oxygen, especially if the face is pressed against soft bedding. Prone sleeping is also associated with reduced arousal from deep sleep, a factor in the SIDS “triple-risk model.” Back sleeping may also help with better thermal regulation, preventing overheating that can increase SIDS risk.
Modern Safe Sleep Guidelines
The initial “Back Is Best” campaign evolved into the more comprehensive “Safe to Sleep” initiative, broadening the focus from just sleep position to the entire sleep environment. This expansion was necessary because, while SIDS rates dropped significantly, other sleep-related infant deaths, such as accidental suffocation, began to rise. Current recommendations, promoted by organizations like the American Academy of Pediatrics (AAP), establish a multi-faceted approach to infant safety.
The guidelines emphasize several key elements for a safe sleep environment:
- A firm sleep surface, such as a mattress in a safety-approved crib, covered only by a fitted sheet, is strongly recommended.
- All soft bedding, including blankets, pillows, bumper pads, and soft toys, must be kept out of the crib entirely to prevent suffocation and entrapment.
- Room-sharing—placing the baby’s crib or bassinet in the parents’ bedroom—is recommended for at least the first six months.
- Bed-sharing is cautioned against due to the significantly increased risk of accidental suffocation.