Welcome to the World Breastfeeding Week Blog Carnival! From August 1-7, we'll be featuring breastfeeding experts sharing their expertise about breastfeeding and breastfeeding issues. Each day will bring something new! Day 3 features Kathleen Kendall Tackett Ph.D., IBCLC, RLC, FAPA, who has given us her permission to reprint this editorial.
“Don’t
Sleep with Big Knives.”:
Interesting (and Promising) Developments
in the Mother-Infant Sleep Debate
 |
| The City of Milwaukee launches their most-recent infant sleep campaign. |
On November 9,
2011, amid much fanfare and media attention, the city of Milwaukee unveiled
their latest campaign to promote safe infant sleep. The images are disturbing
to say the least—they were designed that way. "Co-sleeping deaths are the most preventable form of infant death in
this community," Barrett said.
"Is it shocking? Is it provocative?" asked Baker, the health
commissioner. "Yes. But what is even more shocking and provocative is that
30 developed and underdeveloped countries have better (infant death) rates than
Milwaukee." A campaign such as this
has a noble goal: to prevent infants from dying. But does this type of campaign
keep infants safe? The tragic answer is
“no.” In less than two months after this campaign was launched, two more infants
had died in Milwaukee in what the press described as “cosleeping deaths.”
On
January 3, 2012, WITI-TV, the affiliate Fox News in Milwaukee reported this:
One-Month-Old
Infant Dies in Co-Sleeping Incident
Medical Examiner's Report Says Baby Was
Sleeping On Floor with Three Other Children
The second death was of a 10-day-old infant who had died while sleeping
with three other children on an adult bed. Neither of these infant sleep locations was
safe and should not be classified as “bedsharing deaths.” The sad take-away we
can learn from these cases is that “simple messages,” may be headline-grabbing.
But in the end, they do not communicate what parents need to know to keep their
infants safe while sleeping.
In the same month as the Milwaukee campaign was launched, the American
Academy of Pediatrics issued their new policy statement and follow-up technical
report (American Academy of Pediatrics &
Task Force on Sudden Infant Death Syndrome, 2011a, 2011b) on infant
sleep-related deaths. In their press release, they stated that they were
“expanding [the AAP guidelines] on safe sleep for babies, with additional
information for parents on creating a safe environment for their babies to
sleep.”
When I first read through this statement, it didn’t seem to differ all
that much from previous statements, particularly on the issue many of us are interested
in—namely, their recommendations regarding bedsharing. That recommendation did
not really change. But in reading the full statement, there were some interesting,
and dare I say hopeful, developments.
The AAP Policy Statement (2011a) lists their Levels A, B, and C
recommendations. A-Level recommendations are those with the strongest evidence.
Number 3 of their Level-A Recommendations is that parents and infants room
share, but not bedshare (p. 1031). They based their recommendation on the
results of a new meta-analysis of 11 studies comparing 2,404 cases where
infants died (28.8% of whom bedshared) with 6,495 healthy controls (13.3% of
whom bedshared). They calculated the odds ratio and found that it was 2.89 (95%
CI, 1,99-4.18).1 Based on their calculation, bedsharing
increased the risk of SIDS by almost three times. But wait…..The authors noted
that there was “some heterogeneity in the analysis” (p. 45). The heterogeneity in
question referred to the fact that several of the studies included infant
deaths that took place on a chair or couch (a situation that greatly increases
the risk of infant death), not just those that took place in an adult bed with
a non-smoking, non-impaired parent.
Footnote: An odds ratio of 1.0 indicates no increased risk. Above 1.0 means
increased risk. The higher the number, the worse the risk.
This issue has, of course, dogged the bedsharing debate for more than a
decade. The authors themselves acknowledged that this was a difficulty (Vennemann et al., 2012).
Only recent studies have disentangled infants
sleeping with adults in a parental bed from infants sleeping with an adult on a
sofa. This is certainly a limitation of the individual studies and hence of the
meta-analysis (p. 47).
But hopeful sign number 1: the AAP statement specifically differentiates
between bedsharing and the broader term, “cosleeping,” which often includes all
deaths that take place outside of a crib. I hope that this distinction will
trickle down into future research studies.
And there’s more. Vennemann et al. (2012) noted that bedsharing was much
more hazardous with a smoking mother (OR=6.27; 95% CI, 3.94-9.99) than a
non-smoking mother
(OR=1.66; 95% CI, 0.91-3.01). So there
was still some increased risk if an infant slept with a non-smoking mother. But
remember that this analysis included studies where babies died on couches and
chairs. The next analysis was by age of infant. For infants less than 12 weeks, the odds ratio was 10.37 (95% CI. 4.44-24.21). But for older infants, 1.02 (95% CI, 0.49 - 2.12), i.e., no increased risk. Another analysis looked at whether bedsharing was routine. They found that if bedsharing was routine, the odds ratio was 1.42 (95% CI, 0.85-2.38). If bedsharing was not routine, but happened on the last night, the odds ratio was 2.18 (95% CI, 1.45 - 2.38). The authors noted that the risk was NOT significantly elevated in
the routine-bedsharing group (although I note that there does seem to be some elevation
in risk, probably due to the studies that included couch sharing).
The next interesting issue is regarding their recommendations on chair or
couch sharing with an infant. This has been a long-standing concern of mine due to the massively increased
risk of infant death if parents fall asleep with infants on these surfaces. In
fact, I have spoken with quite a few parents who routinely do this because they
want to avoid bedsharing. Here’s what AAP says.
Because of the extremely high risk of SIDS and
suffocation on couches and armchairs, infants should not be fed on a couch or armchair when there is a high risk
that the parent might fall asleep (AAP, 2011a, p. 1033).
Further, they acknowledge—and seem to affirm—feeding babies in bed, but putting them in their own cribs for
sleep.
Therefore, if the infant is brought into the bed for
feeding, comforting, and bonding, the infant should be returned to the crib
when the parent is ready for sleep (AAP, 2011a, p. 1033).
Unfortunately, this statement does not acknowledge that it’s quite easy
to fall asleep in bed: 70% of mothers in our study who fed their babies in bed
said that they fall asleep there (Kendall-Tackett, Cong, & Hale, 2010). And many a
new parent would argue that that is precisely the point. There needs to be some
recognition of, and planning for, that contingency. But other than that, I am happy to see this
recommendation included.
The final point that I would like discuss is the role of breastfeeding in
SIDS prevention, and how bedsharing has
a role in sustaining breastfeeding. For example, Helen Ball (2007) found, in her longitudinal study
of 97 initially breastfed infants, that breastfeeding for at least a month was
significantly associated with regular bedsharing.
We, in the
breastfeeding world, have been saying
this for a very long time (Academy of Breastfeeding Medicine,
2008; McKenna & McDade, 2005; McKenna & Volpe, 2007). But now the
SIDS researchers are saying it too.
For example, Vennemann et al. (2009) found that breastfeeding reduced
the risk of SIDS by 50%. (Yes, this is the same Vennemann whose meta-analysis
was cited above.) Regarding breastfeeding, Vennemann et al. (2009) said the
following.
We recommend including the advice to breastfeed
through 6 months of age in sudden infant death syndrome risk-reduction messages
(p. e406).
Peter Blair and colleagues (Blair, Heron, & Fleming, 2010) went further
and highlighted the role of bedsharing in maintaining breastfeeding. (Peter
Blair is also a co-author on Vennemann et al., 2012.)
Advice on whether bed sharing should be discouraged
needs to take into account the important relationship with breastfeeding (p.
1119).
So I am hopeful that we may be reaching a possible accord on this issue.
While the AAP will probably never come straight out and recommend bedsharing, it would be helpful if they acknowledged that
it will likely continue, and that our role is to help all parents sleep as
safely as possible--either with or near their infants. Such a statement is possible. I’d like to close with the
words from the Canadian Paediatric Society (Canadian Paediatric Society &
Committee, 2004/2011).
Based on the available scientific evidence, the
Canadian Paediatric Society recommends that for the first year of life, the
safest place for babies to sleep is in their own crib, and in the parent’s room
for the first six month. However, the Canadian Paediatric Society also
acknowledges that some parents will, nonetheless, choose to share a bed with
their child…..
The recommended practice of independent sleeping
will likely continue to be the preferred sleeping arrangement for infants in
Canada, but a significant proportion of families will still elect to sleep
together…….
The risk of suffocation and entrapment in adult beds
or unsafe cribs will need to be addressed for
both practices to achieve any reduction in this devastating adverse event
(emphasis added).
References
Canadian Paediatric
Society, & Committee, C. P. (2004/2011). Recommendations for safe sleeping
environments for infants and children. Retrieved from http://www.cps.ca/english/statements/cp/cp04-02.htm#Recommendations
Kathleen
Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA is a health psychologist, IBCLC,
and Fellow of the American Psychological Association. Dr. Kendall-Tackett is Editor-in-Chief
of Clinical Lactation, clinical
associate professor of pediatrics at Texas Tech University Health Sciences
Center, and owner of Praeclarus Press. More information on the mother-infant
sleep debate can be found at http://praeclaruspress.com/sense-sensibility.html
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