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Babies Sleep Safest Where?

Well-intentioned public health campaign may harm as many infants as it helps—if not more

By Miriam Axel-Lute

The TV ad shows an infant sleeping peacefully. Then the camera pans out to show an adult sleeping next to it. Slowly, creepily, inexorably, to the sounds of a child’s music box, the adult moves closer and closer, until an arm comes down over the baby’s face, clearly about to suffocate it. The voiceover says, “Last year, 43 babies in New York died needlessly when they slept in an adult or sibling’s bed. They got tangled up in the bedcovers or trapped between the bed frame and mattress or smothered when an adult or older sibling fell asleep and rolled onto them. Remember, babies sleep safest alone.”

Babies sleep safest alone. It’s a simple, memorable, compelling message.

It’s also a lie. A well-intentioned lie, to be sure, told in an effort to reduce the incidence of some very real, tragic deaths. But by privileging some kinds of deaths over others and accepting scientific double standards when comparing crib deaths versus bedsharing deaths, New York’s Office of Children and Family Services is doing parents, and their infants, a potentially dangerous disservice.

Let’s start with some basics. When infants age 1 to 3 months old (the main target of the OCFS campaign) die, how does it usually happen? SIDS, or sudden infant death syndrome, is the leading cause of death in infants age 1 month to 1 year. While its incidence has dropped dramatically since the advent in the early 1990s of the campaign to place babies to sleep on their backs, SIDS still accounts for a third of infant deaths, or about 3,000 deaths per year in the United States.

Next, what does it mean for a baby to “sleep alone?” To most Americans, it means in a crib, in its own room. But statistically, this is perhaps the most dangerous place for a baby to sleep: It doubles the risk of SIDS, according to the Sudden Unexpected Deaths in Infancy study, the largest study done on SIDS deaths so far.

It raises other risks as well. Sleeping in another room puts a sleeping baby out of sight, sound, and touch of a caregiver. For infants, there are many life-threatening situations that are not picked up on a baby monitor. A recent study published in the Journal of Infant and Child Development contains dozens of stories of parents waking up and noticing by sight or feel that their infant had turned blue or gray and stopped breathing. Bedsharing parents also reported responding to life-threatening asthma attacks, vomit-induced choking, seizures, and allergic reactions, as well as escaping with their infant from a burning house. In every case, the parents believed that had the baby not been next to them they might not have noticed or been able to respond in time.

Andrea Lee, a Delmar mother who has bedshared with two children, says she started doing it just because it was “so much easier to sleep and nurse.” But it became much more than that for her after two scary experiences: One time her daughter spiked a sudden very high fever in the middle of the night, without stirring. “I could feel her body temperature rise,” recalls Lee. “I’m not sure I would have known if she hadn’t been sleeping right next to me.” The second time, her daughter threw up without waking up, and Lee worries that if she had been alone, she could have rolled into it and choked. With her second kid, Lee “didn’t even consider” putting him anywhere but right next to her.

If you delve into the print matter of the OCFS campaign, you’ll find that what they mean by alone is merely “in an approved crib/bassinet” rather than in an adult bed or on another surface with an adult. They are not actually opposed to roomsharing, and even mention the availability of cosleeping or “sidecar” cribs designed to fit snugly next to a parent’s bed.

However, all the campaign’s headlines, and the entirety of the TV and radio ads, say only “alone.”

Sandy Moses, Healthy Babies, Healthy Communities coordinator for Lane County in Oregon, who has been involved in working on a safe-sleep campaign for her county, says in her experience, people will take the headline of a campaign to heart. “As a parent, I’d read that and think ‘Yeah, I see this thing about [a crib next to the bed], but [they say alone] is the safest.’ . . . I think it’s confusing.”

That confusion gets Dr. James McKenna, professor of anthropology, director of the Mother-Infant Sleep Laboratory at University of Notre Dame, and international SIDS expert, steamed. “How could a campaign be known as ‘Babies Sleep Safest Alone,’ when that doubles the chance of a baby dying from SIDS?” he asks. “Parents are very susceptible to whatever people in positions of authority like this have said.”

It seems that OCFS considers this misunderstanding acceptable collateral damage in the greater war against bedsharing. (Cosleeping is the more common term, but since some people, including researchers like McKenna, consider cribs right next to the bed to be a form of cosleeping, I am using the more specific term “bedsharing” for clarity.)

There is a fundamental problem with arguing that crib sleeping is safer than bedsharing: No one actually knows that.

There are two major gaps in our statistical knowledge about safe sleep for infants. First, we don’t have a reliable percentage of families who bedshare with their infants for some or all of the night, which would be needed to turn mortality statistics into a death rate. Official estimates are likely to be low, however, since in the current climate many families don’t admit to bedsharing, or don’t consider it cosleeping if their baby falls asleep in the crib but joins them in the bed later in the night. Applying an artificially low bedsharing rate to cause-of-death statistics makes the bedsharing death rate look higher and the crib sleeping death rate look lower.

Though imperfect, there are still some data out there. A set of data from the Consumer Product Safety Commission on unintentional infant suffocations from 1980 to 1997 shows that where the sleeping location was known, four times as many deaths happened in cribs as in adult beds. Mothering magazine took bedsharing rates from the Center for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System and calculated that by the government’s own numbers, crib sleeping may actually be more than twice as dangerous as bedsharing. Better studies need to be done, but clearly there is cause to question the assumption that crib sleeping is safest.

Second, and perhaps more important, anti- bedsharing studies, public health campaigns, and even coroner reports rarely distinguish between unsafe bedsharing with multiple risk factors (see sidebar), and bedsharing that follows accepted safety rules. If a baby dies sleeping on the same surface with an adult—even if there were multiple known risk factors, from an intoxicated caregiver to being on a sofa or waterbed—it is almost always blamed on bedsharing as a practice. The Consumer Product Safety Commission, for example, after detailing how entrapment in bed frames or inappropriate bedding accounts for the majority of deaths in adult beds, concludes that adult beds are always bad places for infants to sleep.

If there are no risk factors or identifiable cause of death, an infant death in an adult bed is usually recorded as asphyxiation, not SIDS. In fact, infants who died sleeping alone on an adult bed were included in one high-profile study, Nakamara et al (Pediatrics and Adolescent Medicine, 1999), that is routinely cited as evidence of cosleeping dangers.

A double standard, however, is applied to crib sleeping: If a baby dies in a recalled crib or in a crib with an ill-fitting mattress or large fluffy pillows or a dangling blind cord, or while sleeping on its stomach, the death is blamed on the practices and not crib sleeping itself. If a baby dies in an unexplained way in a crib, it’s called SIDS.

“There’s a selective bias as to which information should be considered important and what should be dismissed,” says McKenna. “There’s this notion that if some people can’t sleep safely with their babies, no one should even try.”

OCFS is aware of the factors that make bedsharing risky; they are listed in the brochure, and when asked for the core goals of the campaign, communications director Susan Steele rattles a number of them off: “The message is that we want to be sure anyone who is caring for a young child under 3 months of age, if you have been taking medication, if you’ve been drinking, if you are overweight, if you’re really tired, if there’s the possibility that you may fall into a very deep sleep . . . or if you have comforters or a lot of bedding, those are times you want to say, ‘You know, this is not a good idea.’”

But given the campaign’s upfront bias that bedsharing is a risk in and of itself, it presents these risk factors not as a contrast to safe bedsharing, but as a list of times really not to do it, for those parents stubborn enough to insist on doing it at all. As Steele says, “The materials do outline those other aspects of safe sleeping. But the primary reality is the safest way for a baby to sleep is alone.”

The only basis the state has for this “reality” is a tally of calls to the State Central Register, a hotline for calls about child abuse and maltreatment, in which callers such as law-enforcement officials and social workers identify that a child died when it was sleeping next to an adult. From 2006 through this summer, the hotline has recorded 89 deaths as “cosleeping accidents.” OCFS has no medical records about the cause of death in these cases and no other context for the incidents, although given the nature of the hotline, multiple other risk factors probably were present.

Steele does say she hopes that the campaign will lead to better data collection in the future. But in the meantime, OCFS has a simple solution to the problem: It has decided to identify sleeping alone as the safest option without considering the safety of that option at all. When asked about comparative risks, Steele will only say, “We can only deal with the data we have, the calls we’re getting.”

“It’s ostensibly to save lives,” notes Britin, a mother of one from Delmar, “but if they’ve got incomplete numbers and insufficient information, then it’s just propaganda.”

Why should we care? Why do people care so much about bedsharing anyway?

Opponents of bedsharing like to put it down to a touchy-feely sentimentality about “bonding.” But proponents say the benefits of safe bedsharing go far beyond extra cuddle time.

First, bedsharing demonstrably promotes breastfeeding. Researcher Helen Ball has found that mother-infant bedsharing leads to more milk production, more frequent and longer feedings, and breastfeeding to a later age. Ease of breastfeeding is the most common reason parents give for choosing to bedshare, and according to McKenna, one of the most common profiles of bedsharing families in Western countries is a family that was committed to breastfeeding, but had not planned ahead of time to cosleep.

Jacqueline Kirkpatrick was one of those mothers. “Before we started to co-sleep,” the Albany mother writes in an e-mail, “getting up in the night to get both of us ‘prepared’ for breastfeeding would wake me completely up. After the feeding she would pass back out, but I’d be wide awake. Breastfeeding and co-sleeping became a perfect answer. I could feed her and not even need to get out of bed, turn a light on, or open my eyes.”

A woeful 12 percent of American babies receive the minimal World Health Organization recommendation of exclusive breastfeeding until 6 months. When Dr. Linda Folden Palmer compiled medical studies showing breastfeeding’s protective effects against various causes of infant death and applied those rates to infant mortality numbers, she found that universal exclusive breastfeeding to 6 months in the United States would save at least 9,000 infant lives every year. Regarding SIDS alone, exclusively breastfed infants have one-half to one-fifth the risk of formula-fed infants. In other words, since bedsharing improves the rate of extended breastfeeding, it could be argued that safe bedsharing has the potential to reduce infant mortality.

Of course, not all parenting decisions are made only on the basis of life and death. Quality of life matters too, and we judge small risks against large returns every day, when we put our kids in cars, on roller coasters, or in someone else’s care. Given that, another very common reason for bedsharing—improved sleep for mother and baby—can’t be swept under the rug, especially since lack of sleep is one of the biggest challenges facing new parents and affects their judgment and ability to parent well throughout the rest of the day. Lee echoes the sentiments of many parents I spoke with when she says, “We’re all better off if I’ve had better sleep.”

There are also indications that mother-infant bedsharing has numerous benefits for a baby’s development. After all, it’s what we as a species evolved to do. Research has found that extended close physical contact improves brain development, hormonal regulation, temperature regulation, digestive response, and respiratory development. Several studies have also found a correlation between cosleeping and lower levels of psychiatric disorders, as well as higher levels of self-esteem and independence. (See The Textbook of Lactation, 2007, Chapter 14, for a list of studies.)

But here’s the kicker. When combined with breastfeeding in a nonsmoking household (and that caveat is essential), bedsharing may actually provide its own additional protection against SIDS. McKenna, who has studied mother-infant sleep behaviors in the lab for years, tracking everything from sleep position to arousal patterns, has found several reasons to believe that—other risk factors removed—this could be one of the safest ways for infants to sleep.

One of the leading theories on SIDS is that it is an arousal disorder in which babies who are too deeply asleep don’t rouse themselves from an apnea (temporary stopped breathing period). This is why placing babies on their backs to sleep, which discourages deep sleeping, is thought to help. McKenna’s studies have shown that the mothers’ arousal patterns are very finely tuned to that of their babies. Both mother and baby arouse more often, frequently in tandem (though they obtain more total sleep time). Far from being likely to roll over their babies without noticing, the mothers in McKenna’s studies were instead quick to arouse to even the smallest signs of distress. McKenna is also studying the role of CO2 from the mother’s breathing, surmising that it creates a stimulating effect on the as yet immature respiratory response of infants under 3 months old.

McKenna suspects that it is some combination of these factors that explains the fact that in places like Japan and Southeast Asia, where maternal smoking is low and both breastfeeding and bedsharing are the norm, SIDS is virtually nonexistent. (It’s not just genetics: When those populations come to the United States and adopt American practices, their SIDS rates rise.)

Since there are so many interconnected factors, and the resource-intensive research can be done only on small samples, none of this is conclusive yet. But it is the only research out there studying the safety of bedsharing itself, rather than undifferentiated, out-of-context accounts of infant deaths, and it doesn’t seem to be pointing to an all-cribs-all-the-time answer to safe sleep. As with nearly everything else, it seems that the answer is, “It depends how you do it.”

Parents who know this and have chosen bedsharing with their eyes open are incensed that the state, on such shaky grounds, is telling them they are being irresponsible. “We’re talking about Big Brother dictating how we parent in this country,” says Nancy Howland, a postpartum doula and mother of six from Queensbury. “They should expect a well-organized backlash from those of us who are educated.”

“This campaign is trying to make your choice for you,” says Britin. “An uninformed choice, in an inflammatory manner.”

OCFS’s Steele is, of course, inarguably right when she says, “No parents want to live with the thought that they could have prevented their child’s death.” She is also right that the rate of deaths from unsafe bedsharing is too high and should be addressed.

But it should be the role of a public health campaign to promote what will actually lead to the fewest deaths and the healthiest babies, not to attack the issues in the ways that push our emotional buttons the hardest.

Many parents and safe-sleeping advocates fear that taking a simplistic “bedsharing is bad” approach will backfire. Not only will it increase the risks that come with solitary sleep and premature weaning among those who take the campaign to heart, but it may isolate those families who are, in fact, bedsharing unsafely. As bedsharing becomes more and more widely associated with child neglect, cautious or embarrassed bedsharing families may refrain from asking their pediatricians or others about how to do it safely, or even from admitting to anyone that they are practicing it. Immigrant populations with a cultural norm of bedsharing and parents living in crowded conditions and unable to afford a crib may be among the least likely to reach out for safety information.

“People will do it, but be afraid to discuss the issue with physicians or others who know how to do it safely, and as a consequence some babies will die,” says McKenna. “Little things parents could know, they will be deprived of them.”

Some have argued that the simpler “Just don’t” message is better for “high-risk populations.” In fact, when Albany mother Lauralee Holtz called OCFS to complain about the campaign, the woman she spoke with told her, “I understand a lot of parents do this because they think it’s best and they’ve done their research. That’s not who I’m worried about.”

So the research that’s good enough for the educated parents isn’t good enough for the public at large? McKenna begs to differ. “Just because you’re in poverty doesn’t mean you’re not motivated or you’re incapable of providing a safe environment for your baby,” he says. “That’s condescending.”

Although Steele did reassure me that the state was not recommending child-protective interventions based solely on the practice of bedsharing, campaigns like Babies Sleep Safest Alone, not to mention the fact that the abuse hotline tends to be called for a death in an adult bed, but not for a SIDS death in a crib, have put that fear out there. Some of the women I spoke with for this article, none of whom had had any previous interaction with the child- protective system, were hesitant to give me their names. This is not just paranoia. Deanne Tilton Durfee, director of the Los Angeles County Inter-Agency Council on Child Abuse and Neglect, told the Los Angeles Times in April, “We know the value of holding your child, cuddling your child, loving your child. But if you take the baby to bed with you and fall asleep, you are committing a potentially lethal act.” Given that phrasing, it’s not hard to imagine that said council might want to intervene on the basis of “potentially lethal acts.”

And indeed, some New York counties and individual CPS workers are already ready and willing to call bedsharing automatically neglectful.

Colleen Olney, director of Services for Oneida County Child and Adult Welfare, says that her agency investigates “reports of cosleeping.” If parents say that the baby sleeps in bed with them, or cannot show a separate sleeping location for the baby, then she says the agency educates them about the dangers of bedsharing and helps them get a crib and appropriate bedding for it.

If a family was found to have continued cosleeping after that, Olney says, her agency would file formal child-welfare charges against them.

Olney says they consider all bedsharing to be unacceptable, regardless of context.

They do not, however, tell parents that babies should not be in cribs in a room by themselves because that raises SIDS risk.

“That wouldn’t be a CPS issue per se,” explains Olney. “That issue is more public educational. CPS is related to imminent risk.” When asked if that meant she had evidence that bedsharing risks were higher than a doubled SIDS risk, Olney said she couldn’t comment.

Ami Redmond, who worked for Oneida County Child Protective Services from 2006 to 2007, says she was never trained in risk factors for SIDS or told anything else about safe sleeping practices, but she was told to always discourage bedsharing. On at least one occasion she says she was ordered to indicate a family for “inadequate guardianship” solely for bedsharing. On another she was told to encourage a family to create a makeshift crib out of a dresser drawer or a laundry basket rather than have a baby remain in bed with its parents. (Olney says she doesn’t know of Oneida County workers being told to do that. “We’d tried to provide the means [for safe sleeping] without putting the babies in a dresser drawer.”)

Sandy Moses can understand these approaches, which are not unique to Oneida. “In this field there is a lot of passion,” she says. “We’ve jumped to conclusions without looking at all the facts. We know there are times when no bedsharing should take place, [but] there tends to be an overreaction, on both sides, out of concern.”

Moses heads up a team that’s working on a number of ways to reduce infant mortality in Lane County. After looking at the data they had about local infant deaths, they made safe sleep one of their top priorities, but they are formulating their message in a way that accommodates safe bedsharing. “We looked at the research and the science and the best practices,” explains Moses. “It’s like everybody has a bit of the truth. We’re saying, ‘Let’s look at the whole truth. What will be the best for families?’ It’s not the same for every family.”

When asked what message he thinks should be given about safe sleep, McKenna says, “Start with a positive statement: ‘Mothers and babies are designed to sleep in close proximity.’ [Then note that] recent cultural practices can change what was a protective arrangement into something dangerous.” Then, he says, you can present the options for safe sleep, including how to arrange separate-surface cosleeping and what the rules are for crib and bedsharing safety.

“We know that many parents, at one time or another, end up sharing their bed with their baby. So we said, ‘Let’s look at what makes a baby safe when they sleep, whether it applies to a crib or a parents’ bed, and make a consistent message,’ ” says Moses. “We’re saying, ‘These are the ways to make your baby safe whenever they sleep.’ ”

 

Safe Bedsharing: When to Bring Your Infant to Bed With You-And When Not To

Safe bedsharing involves:

a firm mattress

no gaps between the mattress and the wall

no bedframe with gaps or bars that a baby can get wedged in

infant not placed on or near fluffy comforters or pillows

no older children or pets in the bed

infant sleeping on its back

a room that is not overheated

a caregiver attuned to the infant

 

Do not bedshare with an infant:

on a waterbed, sofa, featherbed, or recliner

if you or any other person in the bed is a smoker (whether or not you smoke in bed) or if the infant's mother smoked during pregnancy

if you or any other person in the bed has been drinking, has taken illegal drugs, or has taken legal prescription drugs that increase drowsiness.

if you do not have a safe sleep surface (see above)

if you or any other person in the bed is seriously obese

 

It may also be safer to practice "separate surface cosleeping" (using a "sidecar crib" or bassinet):

if you are formula feeding

 

Cosleeping can be particularly beneficial:

for deaf babies or parents

for premature babies who need help to gain weight and catch up developmentally

for mothers having trouble with milk supply

for babies of working parents who need time to catch up on physical contact

 

(Adapted from Sleeping With Your Baby: A Parent's Guide to Cosleeping, by James McKenna.)


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