What the AAP Doesn’t Tell You
By Linda Folden Palmer, DC
Does cosleeping really lead to Sudden Infant Death Syndrome (SIDS)? Are pacifiers really a smart way of preventing SIDS? The American Academy of Pediatrics (AAP) would like you to think so, releasing this fall what other medical experts have called “an ill-advised and ill-informed statement” that simply flies in the face of reason. Recommendations that advise against parent-infant bed-sharing and support the generic use of pacifiers imply a “truly astounding triumph of ethnocentric assumptions over common sense and medical research,” according to Nancy Wight, M.D., president of the Academy of Breastfeeding Medicine.
Yet if we review the very same research the AAP used to come to its conclusions, the message is clear: The relative risk of death to infants who sleep in a safe adult bed with a safe parent is not greater than those who sleep next to their parents’ beds – and their risk of death is far smaller than that of infants who sleep in a crib in another room. In fact, for infants over 2 to 3 months of age, the studies show that letting infants sleep in the same bed as their parents in fact protects them from SIDS more effectively than placing them near their bed.
Infants are at risk of suffocation in adult beds, just as they are in cribs. The clear message should be that adult beds need to be made safe, without overly fluffy or heavy bedding, wedging dangers, overheating, siblings (with a very young infant), parents who have consumed drugs or alcohol or parents who smoke. Sofa sleeping is not safe with babies.
Yet the message we get from the AAP is that cosleeping is unsafe – period. While breastfeeding is shown to reduce SIDS, the AAP does not even mention breastfeeding. Instead, the AAP promotes the use of pacifiers – an intervention that can impede breastfeeding and that the AAP recommends without appropriate substantiation.
Safe co-sleeping = healthy co-sleeping
Unfortunately, none of the studies cited by the AAP report bother to derive from their statistics a risk ratio for deaths of babies co-sleeping in a family bed with safe, non-smoking, sober parents who take reasonable efforts to reduce wedging and other suffocation dangers. From the available statistics, full numbers can only be guessed at – but cosleeping in safe conditions is clearly as safe or safer than sleeping in cribs in the same room as parents and far safer than sleeping in cribs in another room. Contradictory to the AAP’s statements, it is clear that limiting safe cosleeping will not reduce SIDS.
How could the facts from these research reports become so confused? It’s important to understand what’s actually meant by the terms used in the research.
The term “adult bed” usually includes dangerous sofas, sofa chairs, make-shift beds and waterbeds, which account for a large portion of the adult-surface deaths. Also, the term doesn’t necessarily mean cosleeping is occurring, only that an infant is sleeping on that particular surface. An infant sleeping alone on an adult bed is at greater risk than when sleeping there with a parent. Failing to understand these points makes appropriate adult bed-sharing mistakenly sound dangerous.
” Bed-sharing/cosleeping” statistics and comments usually lump together cases of infants sleeping with any adult in any state, including over-exhausted, intoxicated adults, smoking adults, other children and even combinations of these. These comments and statistics also generally include dangerous practices such as sofa-sharing. Another limiting factor of these definitions is that they usually include statistics on infants who coslept at any point during the night of their SIDS-related death – not necessarily at the time of death. Conscientious parents are scared away from safe cosleeping by such slanted reporting.
SIDS or suffocation?
Notice that most studies define all unexpected infant deaths as SIDS, while a few pose suspected suffocations as distinct from SIDS. The resulting statistics are quite different. While cosleeping may reduce actual SIDS, suffocation risks are greater for bed-sharing (as great as they used to be for crib-sleeping, before safety standards were taught), when appropriate precautions are not taken.
A few studies look for a new risk association with infant death in bed-sharing: the finding that possibly half of those dying while bed-sharing were not accustomed to bed-sharing – meaning, among other possibilities, that the parents or adults were not experienced in protecting the baby from hazards, that the bed-sharing was impromptu due to overtired or intoxicated parents, or that the baby may have been experiencing extra fussiness for some health reason and was brought to the parental bed for that reason.
What’s behind the figures?
Why do no studies fully compare safe, conscientious cosleeping with other sleep situations? The results would reveal the safety and benefits of the family bed. The numbers in the largest study on cosleeping around the world suggest that safe cosleeping reduces SIDS greatly. Most nations with SIDS rates much lower than the United States regularly practice cosleeping on firm surfaces with low rates of adult smoking. Countries with increased cosleeping frequency also show decreased rates of SIDS.
It’s become obvious in recent years that pharmaceutical companies wield powerful influence over doctors’ prescribing habits. Parents who like to read and investigate are well aware of the strong ties between formula companies and pediatricians’ advisements.
A few years ago, it became apparent who was behind the curious disinformation campaigns about cosleeping. In May 2002, the Consumer Product Safety Commission (CPSC) released a weakly supported announcement purporting the dangers of cosleeping.
Interestingly, the announcement was sponsored by the Juvenile Products Manufacturers Association (JPMA) – in other words, the crib industry. The crib industry went further by providing “Safe Sleep” brochures to Toys ‘R Us and other venues, creating a video clip for wide media distribution, and granting continued “education” on the topic to doctors.
Frightening families away from safe, natural cosleeping sells more than more cribs. Research shows that cosleeping supports breastfeeding. Crib sleeping makes breastfeeding less convenient and more difficult; therefore, enforcing crib sleeping sells more formula. Keep following the progression: increased formula feeding means increased illnesses for babies, which means increased pharmaceutical sales.
Despite the 2002 CPSC statement about cosleeping “dangers,” the American Academy of Pediatrics (AAP) continued to support safe cosleeping. But now, with encouragement from SIDS organizations that are backed by pacifier and formula company funding, the AAP seems to have joined the anti-cosleeping bandwagon – and has begun plugging pacifier use, as well.
The facts speak for themselves
Yet the AAP’s latest announcement is not backed by sound scientific data. Review for yourself the summaries of key points from the largest and most recent studies. A large portion of these come from the AAP’s own journal, Pediatrics. They include all the relevant studies referenced in the AAP’s October 2005 journal announcement or more current reports from the same studies or authors
Pediatrics October 2005
M. Lahr et al., “Bedsharing and Maternal Smoking in a Population-Based Survey of New Mothers,” Pediatrics (U.S.) 116, no. 4 (Oct 2005): e530-42.
This study on smoking and cosleeping with 1,867 women in Oregon appeared in the October 2005 issue of Pediatrics, just before the issue containing the big AAP announcement warning against all cosleeping. Its authors, M.D.s and Ph.D.s, extensively analyze nine large, case-controlled studies of bed-sharing and SIDS as well as several other studies. These authors state that “recommendations must be based on solid scientific evidence, which, to date, does not support the rejection of all bed-sharing between nonsmoking mothers and their infants.”
The American Journal of Forensic Medicine and Pathology, March 2005
L. Knight et al., “Cosleeping and Sudden Unexpected Infant Deaths in Kentucky,” The American Journal of Forensic Medicine and Pathology (U.S.) 26, no. 1 (Mar 2005): 28-32.
Knight and co-authors examined 697 sudden unexpected infant deaths in Kentucky from 1991 to 2000. In this report, 43% of co-sleeping deaths occurred on sofas (36%) or waterbeds (7%). A large portion of dying co-sleepers had been sleeping with siblings, “disinterested caregivers” or other inappropriate partners or in over-crowded beds.
The authors opine upon their analysis that cosleeping itself is perhaps not dangerous but that death risks are related to unsafe cosleeping environments, including unsafe sleep partners, partners who smoke and unsafe surfaces and bedding.
Pediatrics November 1997
E. Mitchell et al., “Risk Factors for Sudden Infant Death Syndrome Following the Prevention Campaign in New Zealand: A Prospective Study,” Pediatrics (New Zealand) 100, no. 5 (Nov 1997): 835-40.
This study examined 232 New Zealand SIDS cases and 1,200 control cases between 1991 and 1993 for risk factors. No increased risk of SIDS was found when bed-sharing with non-smoking mothers. There was a 31% increased risk of SIDS for not breastfeeding (after considering modifiable risk factors; the raw figure was 67% for increased risk.).
British Medical Journal November 1995
H. Klonoff-Cohen and S. Edelstein, “Bed Sharing and the Sudden Infant Death Syndrome,” British Medical Journal (England) 311, no. 7015 (Nov 11, 1995): 1269-72.
Two hundred infants dying of SIDS in Southern California and 200 control infants were studied to measure whether infants bed-sharing with their parents were more likely to die from SIDS than other infants. Forty-five of the 200 infants died while cosleeping: 35 sharing their parents’ bed, 6 sharing a babysitter’s bed, and 4 while sleeping in their mothers’ arms (this was included as cosleeping). This represents 22.5% of the total SIDS deaths as occurring during cosleeping – a number similar to or likely lower than the number of infants usually cosleeping. Smoking, drug use and medical conditions were accounted for statistically.
The authors reported that there was “no significant relation between routine bed sharing and the sudden infant death syndrome.”
British Medical Journal December 1999
P. Blair et al., “Babies Sleeping with Parents: Case-Control Study of Factors Influencing the Risk of Sudden Infant Death Syndrome. CESDI SUDI Research Group,” British Medical Journal (England) 319, no. 7223 (Dec 4, 1999): 1457-61.
This study looked at 325 babies who died of SIDS, including suffocation deaths, around England from 1993 to 1995, along with 1,300 matched controls. The highest risk of SIDS in this study, like in most others, was associated with shared sofa-sleeping, at 49 times the risk of sleeping alone in the parents’ room (the same number found by Unger et al.; see Pediatrics February 2003 below). The second-highest risk for SIDS in this study was associated with sleeping outside of the parental room, at 10.5 times the risk of sleeping
in the parents’ room.
Thirty-seven percent of the control bedsharers (four matched live controls for every SIDS infant) slept between their parents, suggesting this is the normal rate for this, while only 22% of infants dying in bed with a parent or parents were found between the parents at time of death – contradicting Unger’s implied factor of added danger in having the father in bed.
Sharing the parental bed at the last sleep was found to be safer than sleeping in another room but still nearly 10 times the risk of sleeping alone in the parental room. This is the highest reported factor among studies. However, after the authors removed risk factors such as prone sleeping, being placed on a pillow, being found with head covered, smoking, alcohol, parental tiredness, overcrowded situations and pacifier use (which was considered a risk factor in this study), the risk of bed-sharing at last sleep was 1.35 times (or 35% higher than) that of sleeping next to the bed – a number that the authors referred to as statistically not significant for the strength of their figures. Still, wedging deaths from unprepared beds (usually a considerable factor), waterbed usage and parental drug usage were apparently not removed from this value. These are all modifiable factors. Also not reported is how many of these children were actually in the adult bed at time of death, rather than for some other period during their last night.
Excluding infants under 14 weeks of age, the risk of death from sharing sleep with a parent or parents was 1.08 times that of lone sleeping in the parental bedroom, before wedging, drugs and other factors are taken into consideration.
Archives of Disease in Childhood May 2005
P. Blair et al., “Sudden Infant Death Syndrome and Sleeping Position in Pre-Term and Low Birthweight Infants: An Opportunity for Targeted Intervention,” Archives of Disease in Childhood (England) epub ahead of time: 10.1136/adc.2004.070391 (May 24 2005).
This paper is a continued and extended evaluation of the CESDI SUDI study noted above, with 325 case infants and 1,300 controls, this time looking at the aspect of infant size at birth. This study, like most, includes suffocation deaths in the term SIDS.
The calculated odds of SIDS for being small at birth (pre-term or low birthweight) and bed-sharing with a smoking parent is 37 times the risk of full-sized term infants sleeping alone in the parental room. For those born small, co-sleeping with a non-smoking parent posed a quadrupled risk of SIDS versus sleeping alone near the parental bed. Other risk factors are not removed from this statistic, but clearly the tiniest babies are vulnerable to suffocation and overheating complications when not well prevented.
Those who were not small at birth and were cosleeping with parents who don’t smoke had only four-fifths the risk of dying of SIDS of not-small infants who slept next to the parental bed. As in other studies, when measured, a protective effect of cosleeping is shown statistically beyond the first 2 or 3 months, or a certain weight, before other risk factors are even accounted for. Full-sized infants cosleeping with a smoking parent showed nearly eight times the risk of SIDS as those who slept alongside non-smoking parents.
Forensic Science International March 2005
L. Li et al., “Investigation of Sudden Infant Deaths in the State of Maryland (1990-2000),” Forensic Science International (U.S.) 148, no. 2-3 (Mar 10, 2005): 85-92.
While causes of deaths for 1,619 Maryland infants during 1990-2000 are examined, 930 infants comprised of 802 SIDS infants plus 128 accidental infant deaths (including suffocations) are evaluated for sleeping locations.
Thirty-three percent of SIDS cases were found among infants who were bed-sharing with any type of partner(s). (So what percentage of all infants are bed-sharing?) An additional 1.6% of the total SIDS plus accidental death cases were diagnosed as overlayings. The literature commonly recognizes a likely overdiagnosis of overlying resulting from opinions on cosleeping. While only one-third of these showed physical evidence of suffocation, such evidence is commonly not found in many kinds of suspected suffocations.
45% of infants in SIDS deaths were found alone in cribs. An additional 3% died from defective cribs – twice that of the suspected overlayings.
Lancet January 2004
R. Carpenter, P. Blair, P. Fleming et al., “Sudden Unexplained Infant Death in 20 Regions in Europe: Case Control Study,” Lancet (England) 363, no. 9404 (Jan 17, 2004):185-91.
Twenty European regions were covered during the years of 1992 to 1996, totaling 745 SIDS cases, including suffocation cases, and 2,411 controls.
Bed-sharing with a non-smoking mother was shown to have 1.5 times the risk as not bed-sharing but sleeping in the same room, before removing from the statistics any other risk factors such as unsafe bedding, drug use, alcohol use (which more than doubled risk), infants not accustomed to bed-sharing, etc. Any of this small statistical risk of bed-sharing, with non-smoking mothers but under any other risk factor, was only significant for infants under 8 weeks of age. As pretty much seen across the board, once suffocation risk from inappropriate practices is out of the picture, cosleeping becomes safer than not.
Bed-sharing with a smoking mother was 18 times the risk of not bed-sharing with a non-smoking mother.
No increase in infant deaths was found when mother had one to two alcoholic drinks, versus none, but when mother had three or more drinks, the risk of infant death (alcohol risk only found when cosleeping) was 2.3 times the risk of sleeping with a non-drinking mother. Although drinking statistics were obtained, the risk for bed-sharing with a non-smoking and non-drinking mother was not reported.
Pediatrics February 2003
B. Unger, J. Kemp et al., “Racial Disparity and Modifiable Risk Factors Among Infants Dying Suddenly and Unexpectedly” Pediatrics (U.S.) 111, no. 2 (Feb 2003): 127-131.
This study looked at all deaths of infants under age 2 years in St. Louis County from 1994 through 1997, totaling 119 deaths of SIDS, accidental suffocation or undetermined causes. The question as to why the rates of such unexplained infant deaths are several times higher in African-Americans than in other Americans was addressed.
Twenty-one percent of sudden and unexpected African-American infant deaths and 54% of non-African-American deaths occurred in cribs. Twenty-three percent of “bed-sharing” deaths of African-American children occurred while sharing sleep with another individual on a sofa, compared to 9% among non-African-American infants.
The risk of SIDS for “bed-sharing” on a sofa was 49 times the risk of not bed-sharing.
Thirty-three percent of African-American cosleeping deaths and 18% of non-African-American cosleeping deaths occurred when sharing sleep with siblings – another well-known risk factor for tiny infants.
The great majority (percentage undeterminable) of deaths outside of cribs included modifiable risk factors such as inappropriate or overly soft bedding, sofa sleeping, intoxicated mothers or otherwise inappropriate sleeping partner(s). Smoking was not taken into account in this study.
Only 15% of the unexpected deaths of all African-American infants and 3.5% of non-African-American infants occurred on an adult bed with their mothers alone (additional number in attendance by the fathers is not provided in study, but their presence is usually not statistically contraindicated) – and the majority of these still included other known risk factors.
Forty-one percent of African-American babies in St. Louis bed-share. (No non-African-American rates were provided.)
Pediatrics October 2001
B. Gessner et al., “Association Between Sudden Infant Death Syndrome and Prone Sleep Position, Bed Sharing, and Sleeping Outside an Infant Crib in Alaska” Pediatrics (U.S.) 108, no. 4 (Oct 2001): 923-7.
This study examined all 130 SIDS cases in Alaska between 1992 and 1997. Forty-five percent of Alaskan SIDS deaths involved some form of bed-sharing, while 35% of Alaskan infants cosleep always and 75% do so sometimes or always. (K. Perham-Hester, “Co-sleeping in Alaska: Data from PRAMS. Executive Session of the Maternal-Infant Mortality Review Committee,” Anchorage, AK; December 1999.) Of all the SIDS deaths in Alaska from 1992 to 1997, only one infant death involved an infant sleeping on a safe mattress with a non-drug-using parent (< 1% of total deaths).
Pediatrics May 2003
F. Hauck et al., “Sleep Environment and the Risk of Sudden Infant Death Syndrome in an Urban Population: The Chicago Infant Mortality Study” Pediatrics (U.S.) 111, no. 5, part 2 (May 2003): 1207-14.
Data from 260 SIDS cases and 260 controls in Chicago, consisting of 75% African-American infants, 31% Latino infants and 12% Causasian infants, are analyzed.
Bed-sharing with one or both parents in any condition posed 1.4 times the risk of sleeping alone. This factor was stated to be statistically non-significant. There was no compensation made for those sleeping with an adult under the influence of drugs or alcohol, while other studies show these to be significant risk factors in infant bed-sharing. When other children were in the bed, the cosleeping SIDS risk was 3.6 times the risk of sleeping alone.
Breastfeeding appeared to reduce SIDS to one-fifth the risk; however, after accounting for factors including the mother’s age, education, marital status and prenatal care, the strength of the number became statistically insignificant. The factors that are more typically associated with breastfeeding are the same factors that are associated with lower SIDS rates, but studies have not determined how much of this result extends from breastfeeding itself.
Archives of Disease in Childhood October 2005
C. McGarvey et al., “An Eight-Year Study of Risk Factors for SIDS: Bed-Sharing vs. Non Bed-Sharing” Archives of Disease in Childhood (Ireland) epub ahead of time: doi:10.1136/adc.(Oct 2005) .074674
This study examined 287 SIDS cases and 831 controls between 1994 and 2001 in Ireland for factors associated with bed-sharing deaths. Bed-sharing death risks were reported to be three times greater among low-birthweight babies. Other studies point out dangers for young, premature infants as well. These tiny and young infants are less able to move themselves out of a low-oxygen situation and may not put up as much of a fuss to alert parents.
The bed-sharing death risk was 14 times greater for those with smoking mothers. There was a doubled risk of death for bed-sharing with non-smokers versus lone sleeping, before any other high-risk behaviors were removed from the statistic – and a new risk factor was discovered in this study: 50% of infants dying while bed-sharing were not in their accustomed sleep arrangement – they and their parents were not accustomed to bed-sharing. Removing this 50% of impromptu bed-sharers would leave no increased risk for customary, non-smoking bed-sharers.
Heavy blankets and comforters were found to be a major risk factor. Bed-sharing deaths decrease with age, and babies bed-sharing over the age of 12 months had less than half the risk of sleep deaths than those sleeping alone. Breastfeeding bed-sharing infants had half the risk of SIDS of non breastfeeding bed-sharers.
Journal of Pediatrics July 2005
D. Tappin et al., “Bedsharing, Roomsharing, and Sudden Infant Death Syndrome in Scotland: A Case-Control Study” Journal of Pediatrics (Scotland) 147, no. 1 (Jul 2005): 32-7.
This study examined 123 SIDS and 262 control cases in Scotland between 1996 and 2000 for association between bed-sharing and SIDS. Suffocation deaths are included in the term SIDS here.
Sleeping alone in a separate room was associated with more than three times the risk of SIDS as sleeping in the same room with parents. Fifty-two percent of SIDS infants were reported as sharing a sleep surface at some time during the night of death, but only 32% were found sharing the parents’ bed at time of death. (The use of statistics for having co-slept for some time during the night of death is often used to make co-sleeping dangers sound higher.)
The study does not give quantitative figures but suggests that heavy bedding (the weight of bedding or duvet, referred to as “tog”) is a strong factor in SIDS deaths. In an earlier study of theirs, the study authors found 81% of bed-sharing deaths relating to heavy comforters/bedding.
Very few of the parents of infants found dead in their parents’ bed at time of death reported that this was their usual sleeping arrangement.
This study reports an increased risk of SIDS for breastfeeding in bed-sharing infants, but many of those infants were found dead in cribs and were not cosleeping at the time of death; only the number found cosleeping at time of death would have been relevant to report. Many of the infants found dead in cribs may have been unaccustomed to crib sleeping or too fussy to bed-share (for some health reason), although this is conjecture.
Twenty percent of control infants shared a sleep surface during a reference sleep. Twenty-two percent of infants found sharing at time of death were sharing a couch. Seventy-two percent of those bed-sharing at time of death were under 11 weeks of age.
As usual, no figure is given for the percentage of SIDS cases that represented bed sharing with a safe parent in a safe adult bed.
Archives of Pathology and Laboratory Medicine March 2002
T. Person et al., “Cosleeping and Sudden Unexpected Death in Infancy” Archives of Pathology and Laboratory Medicine (U.S.) 126, no. 3 (Mar 2002): 343-5.
This smaller study looked at 56 cases of sudden unexpected infant deaths or SIDS diagnoses from the files of one author doctor in upstate New York. I find this study valuable to mention in that the circumstances of deaths were well described and delineated and provide a good idea of what can be assumed from untold stories in larger studies.
Fifty-two percent of SIDS cases were among infants sleeping alone: 34% among infants alone in cribs, 9% among infants alone in adult beds and 5% among infants alone on couches. (The other 4% were in other solo sleeping situations.)
Twenty-five percent of all SIDS deaths occurred among infants in an adult bed with an adult(s), in any condition. Seven percent occurred among infants who were cosleeping with an intoxicated adult on a bed or couch; 16% were cosleeping on a couch; and 7% were cosleeping with a twin in a crib. (There is no evidence of twin cosleeping to be of greater risk than separate sleeping. It may be safer, as certain physiological advantages have been documented, but the numbers have not been checked. Twins overall have double the SIDS rate of singletons. A study of simultaneous twin SIDS deaths reported eight out of 41 cases where the twins were cosleeping. Anecdotally, cosleeping is very high among twins.)
British Medical Journal November 1993
R. Scragg, E. Mitchell et al., “Bed Sharing, Smoking, and Alcohol in the Sudden Infant Death Syndrome. New Zealand Cot Death Study Group” British Medical Journal (New Zealand) 307, no. 6915 (Nov 20, 1993): 1312-8.
In New Zealand, 393 SIDS cases and 1,592 controls were examined for the interval between 1987 and 1990.
The SIDS risk for last sleep (where the infant was laid down or spent most of the night) spent in bed with a mother who smoked was 4.5 times the risk of having a non-smoking mother and not sleep-sharing. For infants with non-smoking mothers who usually bed-shared in the two weeks before their death, the risk of SIDS was 1.7, but for those who were bed-sharing during their last sleep, there was no risk at all found. Alcohol usage did not appear to be a risk factor in this study.
The infants’ actual location at time of death was not reported in this study. While sleeping with a mother with smoke in her lungs can reasonably increase the risk of death after being removed from bed-sharing, there is no apparent reason why in the absence of a smoking parent usual cosleeping should increase death risk outside of the parental bed. We have seen that some studies look at whether bed-sharing SIDS cases occur among infants accustomed to cosleeping or not. These studies report that deaths are most common in impromptu or unaccustomed bed-sharing situations.
Notice in this New Zealand study that a higher rate of SIDS is reported for regular co-sleepers but not for those cosleeping at the night of death. It appears, as in a few other studies, that there may be a danger factor for infants to be alone in a crib when they are accustomed to the regulation of their parental bed-sharers. This factor may confound many risk reports for bed-sharing deaths, as it is usual to report based upon where the infant was first placed to sleep, spent most of their last night or simply what their usual sleep arrangement was, rather than where the infants were actually found at time of death.
Pediatrics October 2003
N. Scheers, J. Kemp et al., “Where Should Infants Sleep? A Comparison of Risk for Suffocation of Infants Sleeping in Cribs, Adult Beds, and Other Sleeping Locations” Pediatrics (U.S.) 112, no. 4 (Oct 2003): 883-9.
This study attempts to compare infant suffocation trends (suffocation diagnoses only, as opposed to all SIDS cases) between the 1980s and the 1990s. While reports from James McKenna and others reveal reasons why true SIDS should be lower when sharing sleep with mother, suffocation accidents in adult beds are higher, as they were in cribs before safety education about crib sleeping became widespread. Although the great number of variables and complicating factors (most admitted to) prevents solid comparisons, the statistical information in this study can provide much insight into the causes of adult-surface deaths. It studies 883 cases of infant suffocation reported to the Consumer Products Safety Commission from the 1990s.
The numbers in this study support a risk of 20 times or more for suffocation-only deaths while sleeping in actual adult beds versus sleeping in cribs. This ratio is based upon an assumption that 18% of all infants are sleeping in adult beds. Yet studies suggest that the numbers of infants cosleeping are higher than this number, and adding those in adult beds without co-sleeping would make the true adult-surface sleeping number even higher. Therefore, their risk ratio estimate is likely to be high. There is also likely to be some portion of the deaths that were reported as overlying that were actually SIDS prior to overlying, making this study’s risk figure slightly more overestimated. There is no mention as to how many of these cases involved co-sleeping. It is known from other studies that suffocation deaths are greater in adult beds when no protective parent is present. While SIDS deaths should be lower while cosleeping with a mother or other protective adult, suffocation accidents are known to be higher in adult beds, as they were in cribs before safety education about crib sleeping became widespread.
Great praise is made in this report as to the large reductions in crib deaths once various mandatory and voluntary safety standards were imposed and parents were educated in making cribs safer. Oddly, the report never makes a similar suggestion to do the same for family beds; rather, it is suggested that any attempts to make adult beds safer should be discouraged because they have “unproven efficacy.”
Twenty-two percent of adult-surface suffocations occurred on sofas. More than 57% of specified-cause suffocations in actual adult beds were due to wedging or entrapment, mostly with walls, headboards or bedrails. Bedding, plastic and overlying are other sources of suffocation.
Eighteen percent of the adult bed suffocations (remember – not of all SIDS, just among those diagnosed as suffocations) are suggested to be from overlying. It is well understood that overlying is very likely to be over-diagnosed, since it often selected as the diagnosis based solely upon opinions about cosleeping. Even when an infant is found dead underneath an adult’s body, there is often no means of determining whether the adult overlaid the infant after it died because it was no longer a warm, reactive body but rather cold and non-responsive, more like a pillow.
AAP Views on Pacifiers
A pacifier is, of course, an artificial replacement for the mother’s nipple. Scientists have confirmed in many ways that sucking is an important part of babyhood, in terms of emotional comfort and security, neurological development, pain management and optimal physiological status.
The opportunity for natural sucking is likely to be one component of reduced SIDS rates among breastfeeding, cosleeping infants. It has been shown in studies of preemies that providing artificial means of sucking maintains their physiology far better than having no such opportunity, although it does not provide as much benefit as actual nursing at the breast, when available.
It is odd that the AAP suggests an artificial replacement for something natural without even comparing the benefits of the natural version, as most pacifier studies do.
Archives of Disease in Childhood August 1999
P. Fleming et al., “Pacifier Use and Sudden Infant Death Syndrome: Results from the CESDI/SUDI Case Control Study” Archives of Disease in Childhood (England) 81, no. 2 (Aug 1999): 112-116.
This report was performed using the statistics from the CESDI/SUDI study of 325 SIDS infants in England with 1,300 matched controls.
While there was no difference between the incidence of SIDS between those who regularly used a pacifier and those who did not, there was a slight difference in the number of infants found dead with pacifiers vs. controls (children without): 40% versus 51%.
Archives of Disease in Childhood May 2005
P. Blair, P. Fleming et al., “Sudden Infant Death Syndrome and Sleeping Position in Pre-Term and Low Birthweight Infants: An Opportunity for Targeted Intervention” Archives of Disease in Childhood (England) epub ahead of time: 10.1136/adc.2004.070391 (May 24 2005).
This report was a closer analysis of the above study, using the statistics from the CESDI/SUDI study of 325 SIDS infants in England with 1,300 matched controls.
This study demonstrates that the statistical odds of dying without a pacifier when accustomed to using one is 17.5 times the risk of not having a pacifier at all.
The SIDS/Suffocation Risk Factors for Co-Sleeping
• Bed sharing not being the accustomed sleep arrangement
• Sofa sleeping
• Smoking parent
• Unsafe space between mattress and headboard or wall
• Prone sleeping
• Parent compromised by drugs or alcohol
• Overly heavy or fluffy bedding
• Sleeping with sibling (for tiny infants) or a non-interested adult
Also, for parental bed sleeping:
• Sleeping without protective parent in room
What About All Those Crib Products?
An intriguing figure emerges from any close examination of cosleeping and SIDS – and it has nothing to do with who is sleeping where. This figure has to do with crib bedding: bumpers, quilts, pillows, comforters, soft toys and other items often found in cribs.
In May 2002, the media trumpeted a report from the Consumer and Products Safety Commission (CPSC) showing that 60 accidental infant deaths (known suffocations; not SIDS, which includes suspected suffocations) have occurred per year in adult beds for age birth to 2 years. Much of the coverage implied that cosleeping was to blame, although the report did not reveal how many of the deaths actually involved cosleeping. In fact, many experts noted that some of the reported suffocation “accidents” were described as “suffocations of unknown cause” and would have likely been diagnosed as SIDS – not accidental suffocation – if they had occurred in cribs, thus decreasing the total number of reported deaths.
Yet strangely, a strikingly similar figure also released by the CPSC just two months later failed to create headlines. Shortly following its report on infant deaths in adult beds, the CPSC issued another report noting that 65 deaths per year are reported due to crib accidents, in which cribs and other nursery devices collapse, strangle or cause other fatal injuries. Sixty adult bed deaths per year, versus 65 crib accidents per year …
Yet the discrepancies in reporting don’t end there. Suspected suffocation from inappropriate bedding materials on adult beds, which is included in the diagnosis of SIDS, is a real danger that a true consumer protection agency would educate the public about. However, if the CPSC were to do so, another uncomfortable truth would have to emerge. The CPSC reported in 1999 that an average of 900 children per year were dying due to suffocation from fancy crib bedding and soft nursery product items (a number now over 1,000 and continuing to climb) – yet the attention remains on children sleeping in adult beds, not those sleeping in cribs.
One-quarter to just over one-third of SIDS deaths, including suspected suffocation, in the United States are demonstrated to occur during cosleeping. With the other two-thirds or more of SIDS deaths occurring in cribs and other solo sleeping situations, we come to the amazing realization that half of these – a full one-third of all SIDS deaths – are reported by the CPSC to be caused by overly fluffy, soft and otherwise inappropriate nursery bedding, bumpers, pillows and comforters. Both the CPSC and the AAP have been aware of these figures for a long time, but the crib industry is still allowed to flagrantly market these items to families with crib-sleeping infants. These dangers need to be eliminated now – in cribs, in family beds, in strollers and in other infant sleep situations.
These crib products-related deaths are particularly troublesome given the fact that over the last decade, each of the top five juvenile product manufacturers has had at least nine product recalls. Consumers Union is supporting legislation that would require pre-market testing of all durable children’s products by an independent entity. This legislation was initiated by a leading child safety advocacy organization, Kids in Danger, whose founders’ son was killed in a recalled portable crib provided at his day care center.
Despite the fact that the CPSC recommends that infants under a year old should be sleeping in a crib that’s nearly bare – with just a mattress and fitted sheet – retailers are still displaying cribs made up with all the trimmings. Despite the fact that more than 1,000 children a year are dying from these unnecessary trappings, the CPSC has not moved to restrict their prolific marketing.
Soft bedding can suffocate infants, whether they are in cribs or in beds with their mothers. Soft bedding is proven to kill infants; the presence of a conscientious and safe co-sleeping mother is not.
© Linda Folden Palmer, DC
Dr. Linda Folden Palmer consults and lectures on natural infant health, optimal child nutrition and attachment parenting. After running a successful chiropractic practice focused on nutrition and women’s health for more than a decade, Linda’s life became transformed by the birth of her son. Her research into his particular health challenges led her to write Baby Matters: What Your Doctor May Not Tell You About Caring for Your Baby. Extensively documented, this healthy parenting book presents the scientific evidence behind attachment parenting practices, supporting baby’s immune system, preventing colic and sparing drug usage. Visit Linda’s web site at www.babyreference.com.
So How Many Actually Are Cosleeping?
According to the gathered statistics from available studies:
• 77% of mothers in Oregon bed-share at least sometimes. 35% bedshare usually or always. (M. Lahr et al., “Bedsharing and maternal smoking in a population-based survey of new mothers,” Pediatrics (U.S.) 116, no. 4 (Oct 2005): e530-42.)
• 41% of African-American babies in St. Louis bed-share. (B. Unger et al., “Racial and modifiable risk factors among infants dying suddenly and unexpectedly,” Pediatrics (U.S.) 111, no. 2 (Feb 2003): 127-131.)
• 13% of U.S. infants bed-share usually or always; 20% share half the time or more; and almost 50% were sharing sometime during the two weeks before the survey. This study admits to under-representing poor families, leading to an underestimation of bedsharing percentages. (M. Willinger et al., “Trends in Infant Bed Sharing in the United States, 1993-2000. The National Infant Sleep Position Study,” Archives of Pediatric and Adolescent Medicine (U.S.) 157, no. 1 (Jan 2003): 43-49.)
• 75% of Alaskan infants cosleep sometimes or always. 35% do so always.(K. Perham-Hester, “Co-sleeping in Alaska: Data from PRAMS. Executive Session of the Maternal-Infant Mortality Review Committee,” Anchorage, AK; December 1999.)
• 50% of Chicago infants were bedsharing on a reference night. (F. Hauck et al., “Sleep Environment and the Risk of Sudden Infant Death Syndrome in an Urban Population: The Chicago Infant Mortality Study” Pediatrics (U.S.) 111, no. 5, part 2 (May 2003): 1207-14.)
• 46% of infants in England are bed-sharing for at least some time during the night. 30% were found bed-sharing on any given night. (P. Blair and H. Ball, “The Prevalence and Characteristics Associated with Parent-Infant Bed-Sharing in England,” Archives of Disease in Childhood (England) 89, no. 12 (Dec2004): 1106-10.)
• 20% of infants in Scotland were sleep-sharing during a reference sleep. The number co-sleeping at least part-time would be greater. (D. Tappin et al., “Bedsharing, Roomsharing, and Sudden Infant Death Syndrome in Scotland: A Case-Control Study,” Journal of Pediatrics (Scotland) 147, no. 1 (Jul 2005): 32-7.)
• 12% are regularly bedsharing in Canterbury, New Zealand. (R. Ford et al., “Changes to infant sleep practices in Canterbury,” New Zealand Medical Journal (New Zealand) 113, no. 1102 (Jan 28, 2000): 8-10.)
• 23% in Sweden. (C. Lindgren et al., “Sleeping position, breastfeeding, bedsharing and passive smoking in 3-month-old Swedish infants,” Acta Paediatrica (Sweden) 87, no. 10 (Oct 1998):1028-32.)
• 25% of infants studied in Australasia, Europe, and North America. (R. Scragg and E. Mitchell, “Side sleeping position and bed sharing in the sudden infant death syndrome,” Annals of Medicine (New Zealand) 30, no. 4 (Aug 1998): 345-9.)
SIDS Organizations Backed by Pacifier and Formula Company Funding
Who’s funding the SIDS organizations? Take a look at these disturbing facts.
• First Candle/SIDS Alliance received at least $100,000 in funding from formula and baby food companies in 2004.
$100,000 and Above
The 2004 Albertsons Campaign: A partnership between Albertsons Inc., Gerber Products Company, Johnson & Johnson, Procter & Gamble and Ross Products Division
HALO Innovations, Inc.
• CJSIDS is another top SIDS organization that is strongly supported by formula companies, including Mead Johnson, Enfamil and Similac.
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