|
 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.)
|
Site
Search 
