Babies Sleep Safest Where?

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 aged one to three 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 aged one month to one 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 stories of parents waking up and noticing by sight or feel that their infant had turned blue or gray and stopped breathing (these would likely have been classified as SIDS deaths if not caught). 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 had not been next to them they might not have noticed or been able to respond in time.

Andrea Lee, a Capital Region parent 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 doing a disservice.”

It’s a disservice that gets James McKenna, director of the Mother-Infant Sleep Laboratory at Notre Dame University and international SIDS expert, steamed. “How could a campaign be known as ‘Babies Sleep Safest,’ when it 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 it’s imperfect, there is still, some data out there. The Consumer Product Safety Commission’s 2002 data 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 CDC’s own Pregnancy Risk Assessment Monitoring System and calculated that by the government’s own numbers, crib sleeping may actually be twice as dangerous as bedsharing. Better studies need to be done (the time frames and geographies of the two data sets are not the same for starters), but clearly there is cause to question an assumption that crib sleeping is automatically safest.

Second, and perhaps even more important, precious 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. 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.

If a baby dies sleeping on the same surface with an adult, however—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.

“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 list them in their 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 three months of age, if you have been taken 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 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 judgment 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 were probably 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 the safest option—sleeping alone—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? If we don’t have crystal clear safety rates, why not put all infants in a crib next to the bed? 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, although Steele argues to the contrary, 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, a mother from [X], was one of those. “Before we started to co-sleep, getting up in the night to get both of us 'prepared' for breastfeeding would wake me completely up,” she says. “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 six months. When Dr. Linda Folden Palmer compiled the various medical studies showing breastfeeding’s protective effects against various causes of infant death and apply those rates to infant mortality numbers, she found that universal exclusive breastfeeding to six months in the United States would save 9,000 infant lives every year. (This is actually a low number, as she didn’t account for the high rate of weaning between 1 and 6 months.) Regarding SIDS alone, exclusively breastfed infants have 1/2 to 1/5 the risk of formula-fed infants. In other words, since bedsharing promotes 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. Andrea Lee, a mother of two from Delmar, echoes the sentiments of many parents I spoke with when she says “We’re all better off if I’ve had better sleep. My husband was happy to do whatever got me enough 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 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, Chap. 14.)

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--possibly genetically linked—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. Not only do breastfeeding mothers who bedshare put babies to sleep on their sides or backs automatically, in order to facilitate nursing, but 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 (but they have 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 three months.

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 non-existent. (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 only be done 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 post-partum 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.