The Messy Truth about SIDS and “Safety”

As the debate rages — and I’d bet it will continue to rage for a long time  — about whether or not bedsharing increases the risk of Sudden Infant Death Syndrome (SIDS), something else needs to be said about the way this whole conversation is framed in public discourse.

SIDS prevention is often couched in terms of safety. This sleeping arrangement, or these sleep practices, are safe and these other ones are risky. There’s an implication, perhaps unintended, that SIDS is the parents’ fault if they weren’t following SIDS prevention advice exactly to the letter.

That is a misleading premise.

SIDS is not an accident.  In many ways, we still only have a bunch of clues about the biological mechanisms that cause SIDS. I think researchers are right to try to look for environmental risk factors for SIDS. After all, that kind of research led to lives being saved by getting parents to put babies on their backs for sleep. The mistake some researchers and health promoters make is thinking that lots of other SIDS research findings translate into “evidence-based” (there’s a term I’m starting to hate because it is misapplied so often) advice for parents.

There is no proof that so-called environmental risk factors (being male is a big one, by the way) cause infants to die in their sleep, at least not of SIDS. The best guess anyone can really make is that the risk factors researchers have identified – sleeping on the stomach, parental smoking, overheating, etc.  – may somehow interact with the child’s biologically-based vulnerability. But even that’s still an educated guess right now. And educated guesses are not a sound basis for advice for parents.

Now, keep in mind a couple of things. First there is a legitimate discussion to be had about sleep safety. There are infants who suffocate accidentally during sleep. So yes, use common sense and keep babies’ sleep environments uncluttered, sleep surfaces not too soft, not too crowded and ensure there are no places where the baby could become wedged. But suffocating isn’t SIDS. SIDS is still a sad, tragic puzzle.

Second, with respect to SIDS the evidence about back sleeping is pretty overwhelming. There is no doubt that substantially fewer babies die of SIDS, particularly in cribs, since the advent of the “back to sleep campaign.”

But, anyone who tries to tell you that any sleeping arrangement or place – ANY sleeping arrangement or place – is perfectly “safe” — is going too far.  Babies can and do die of SIDS in the sleep arrangement many pundits promote as ideal: on their backs, in a certified safe crib with nothing in it but the baby and a light blanket, and the crib is located in the parents room (which is at just the right temperature).

Because, from my reading of the research evidence, front sleep, and parents and babies sleeping together on sofas, are the only risk factors where the evidence is clear enough to translate into general SIDS prevention advice for parents about how and where babies should sleep. Having the baby sleep in a crib your room makes sense (if your baby sleeps in a crib and your bedroom is big enough), but I remain underwhelmed by the evidence that room-sharing protects against SIDS. Some researchers speculate that room-sharing  parents may become aware that their babies are in trouble and intervene. Perhaps, but again, it’s a guess. And, um, geez, if that’s true, wouldn’t bedsharing parents be in an even better position to detect a baby in respiratory distress? Just sayin’.

By the way, while I am very sympathetic to bedsharing, no one can tell you it is perfectly SIDS-proof or perfectly “safe” either, although, if you are a sober, non-smoking breastfeeder who is not socially deprived (poverty is one of the biggest risk factors for SIDS, but health promoters don’t seem to like to talk about that), your baby’s risk of SIDS is very small indeed. Here’s a  link to a Today’s Parent article with some reasonable information  about safe bedsharing. Much of the info comes from anthropologist and co-sleeping researcher James McKenna, one of the people whose knowledge I would trust on this topic.

There is also strong evidence about two other potentially modifiable risk factors: fetal and infant exposure to cigarette smoke and intoxicated (or drugged) parents sleeping in the same bed with babies. Mind you, some of the deaths related to parental substance use are probably due to suffocation, not SIDS.  But smoking and substance abuse are complex problems that cannot be solved simply by posters, pamphlets and public service announcements. It’s a lot easier get parents to put babies to sleep on their backs via public health advice than it is to help them shed an addiction to tobacco, raise them out of poverty, or cure them of substance abuse problems.

Another problem I have with the SIDS safety paradigm is that it tries to put SIDS into this little box where the only thing that matters is trying to eliminate “risk factors.” Sorry. Sudden Infant Death is not this little world unto itself. The sad realities of SIDS reside within the diverse, messy world of family, the same world occupied by breastfeeding, tired parents looking for a decent night’s sleep, parent-child attachment, infant temperament, parent temperament, socioeconomic status, cultural norms and a whole bunch of other things. You can’t just put advice for SIDS “safety” in this little silo and pretend that it has nothing to do with the other parts of the infant/parent world.

Prime example of how this sort of tunnel vision works. Advice against bedsharing totally bumps head-on into the realities of breastfeeding. Tired mothers are likely to breastfeed their babies in bed (they’ve done it for eons) and given the hormones in breastmilk and the ones released by the mom during breastfeeding, both mom and baby are quite likely to fall asleep in the process. Anybody who constructs advice that ignores this biological reality (not to mention the fact that mothers and babies have slept together in various cultures for thousands of years)  should not be in the parent advice business. Actually, some experts are now starting to think that the blanket (no pun intended) advice to never bedshare has backfired, specifically in cases where parents fell as sleep with babies on couches or chairs because they were trying to avoid falling asleep with their babies in beds.

Fortunately I have seen examples of health promoting organizations – the Canadian Paediatric Society (CPS) comes to mind – which have made admirable efforts to avoid rigidity in safe sleep messages.  An organization like the CPS has to be careful to stay within the bounds of what the medical establishment calls evidence, but they have made great efforts to understand and acknowledge the realities of parents and constructed reasonably balanced advice as a result. I may not totally agree with everything they say, but I applaud their efforts to understand and communicate realistically with parents.

Mainstream organizations like the CPS really do need to have parents listening to them. As for the organizations and individuals who  seem bound and determined to eliminate bedsharing, I’ve got two things to say to you. 1. Not gonna happen. 2. Lots and lots of parents are tuning you out because they see you as biased and irrelevant. You need to ask yourselves. Is that what we really want?

One more thing. The number of SIDS cases has declined drastically in the past 20 years. So, the risk, which was very, very small even when I was a child, is much smaller now. Keep reminding yourself of that as this debate continues.

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Update (added, July 4, 2013) For a very wise and sensible perspective on all this read this reassuring interview with anthropologist Helen Ball, an academic with deep knowledge on SIDS and breastfeeding.

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About uncommonjohn

I am one of Canada's top parenting writers. My areas of expertise and interest include debunking bad parenting advice (especially about sleep), self-regulation, fatherhood, child development, children's mental health, childbirth and breastfeeding.
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5 Responses to The Messy Truth about SIDS and “Safety”

  1. Rebecca says:

    Excellent!! Very thought-provoking critique of current advice.

  2. John, great article! I’ll be posting that on my parenting educator page.

  3. As a Safe Sleep educator, I’d like to dispute a few of your. Male infants do die at a higher rate than female infants; however, that is not considered a risk factor, but an occurrence. As a member of a Child Death Review Team and the former Executive Director for a large statewide SIDS organization, I can tell you that in my state, by far the babies that die are not on their backs in safe cribs but rather on adult surfaces like beds, couches, futons and the like. It is, in fact, quite rare for a baby in my state to die on his or her back in a safe crib with no soft bedding.

    As a SIDS mother myself, I would never blame the parents. Most parents are doing what they feel is right for their family at the time. The problem, in my view, is that too many parents and caregivers believe that because SIDS (and accidental suffocation) are rare, it will not happen to them.

    Bed sharing as it is typically practiced in the US today cannot be made safe. It can be made less dangerous. Thoughtful planning is necessary if breast-feeding mom intends to bed share. Check all the guidelines in advance. We know that Chaotic bed sharing is the riskiest. That’s where an exhausted mom simply falls asleep with her baby without any plan to bed share.

    Yes, women have shared a sleep surface with their babies for eons. That sleep surface did not look anything like the typical western bed of today with our piles of pillows, soft mattresses, pillow toppers and quilts. Also our babies used to wear cloth diapers which caused them to wake frequently to be changed.

    We simply cannot take one behavior and move it into the future without considering how other factors have evolved over time. SIDS occurs when a vulnerable infant collides with a certain situation. Unfortunately, we haven’t yet identified exactly what that vulnerability is. Rather than blame parents, as you suggest, I try to empower parents to recognize all the behaviors that we have today to reduce the possibility that a tragedy may occur. Isn’t it wonderful that except for the crib, all these recommendations are free so that families of all economic backgrounds can afford them.

    • uncommonjohn says:

      Hi Pam: Thank you for your comments. I welcome thoughtful debate on these tricky issues. I’d just like to point out that some of what you say actually supports the points I am trying to make. I never said that babies dying of SIDS in cribs while sleeping on their backs was common. (In fact, all forms of sudden infant death are exceedingly rare.) I only said it could happen, which your statements confirm. I agree that evidence suggests that certain contexts of bedsharing or co-sleeping are associated with the most risk – especially sleeping on sofas and the like, as you say. Therefore what would be logical would be to educate parents about how to avoid the situations where bedsharing is risky rather than characterize any and all bedsharing as equally dangerous. I dispute the idea that cribs can be considered safe. Many infants have died in cribs and, as you noted, some still do, unfortunately. What education (especially around back sleeping) has done has made solitary sleeping in cribs less risky than it was in the past. Now the same effort needs to be put toward reducing the number of sudden infant deaths in risky types of co-sleeping. That is a far better, and far more attainable, goal than trying to extinguish all bedsharing and making parents feel guilty for engaging in a practice that is biologically inevitable in families where children are breastfed.

  4. Chrystal says:

    God, I so needed this tonight. I swaddled my now 3 year old until he was 7 months old because he would not sleep otherwise. I have an almost 5 year old who is exactly the same but I have not been swaddling him because I read new information on how swaddling MAY contribute to SIDS. I am tired and worn out and have been considering swaddling him but obviously terrified of the POTENTIAL outcome. I do what I can to keep him safe but I need to be rational and understand that even if I do everything every article tells me to do, my son can still die from SIDS. Tonight, I will swaddle him; he will likely sleep well and I won’t. LOL But hopefully I’ll pull myself together soon enough and we’ll both get a good night’s sleep.

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