Contradictions in Tizzie Hall's response to FSID

So the feedback I'm receiving from mothers, includes a little confusion over a couple of points Tizzie made in regard to the FSID reply.  I suspect we will not receive further clarification from Tizzie, but I figured we could note the questions anyway :)  We welcome discussion via the comments section - unfortunately Tizzie has felt it necessary to censor responses on her web page so only those who do not question/disagree can reply; I am happy for everyone to have their say here as long as it remains polite and civil.  Name calling or aggressive posts will be removed.

Firstly, this is from one of my earlier posts, a point raised by Fleur and includes Tizzie's reply in red:

“On my calculation of the tog rating – Tizzie’s fans have repeatedly told me that the tog rating of her bamboo blankets is 0.64 tog x 16= 10.24 tog (apparently she has had them tested.) and a cotton sheet folded in 2, at approx 0.2 tog (x2= 0.4 tog). I also included in my calculations the toggage (made up word, lol) of the ‘safe sleeping bags’ that she sells, which will be either 1 tog or 2 tog, depending which one you choose, and the tog of the ‘double wrap’ which again, equates to 4 layers in itself (2 inside wrap pieces and 2 outside fold over bits) which again, could be anywhere from 1 tog to 4 tog, depending on the material used). I didn't include the tog of a vest, a sleepsuit or a nappy. That was how i worked out the approx 13+ tog. What Fleur has stated in her clarification is fine but adults also dress themselves similarly for bed, use a sheet and many adults sleep next to another person which provides extra warmth under their 11-13 tog duvets, yet we expect our babies to sleep in much less…….. 

So this appears to confirm that Fleur's calculation of 13+ tog was accurate?

You can see the sleeping bag and wrap that goes under the blankets here as Fleur describes.  The bedding guide states ALL infants should be swaddled until they show signs of trying to roll swaddled.

I must admit a thought I had upon watching this was how can the baby show hunger cues if they cannot get out of the swaddle? (as Tizzie claims in the clip) If babies love having their arms restricted, why would they try to get them free?  Why not swaddle with arms out so baby is comfortable and can easily demonstrate when hungry?  In the womb an infant's arms are never restricted in this way.

Tizzie goes on to say:

"My recommended range of blankets have been tested at 0.6 tog – that means we could place up to 9.8 layers of these recommended blankets over the baby. I am aware this is less than the 16 that I said was the maximum but in reality the majority of my clients don’t use that many layers. But I do not believe that a baby would come to any harm if the baby was 100% healthy, sleeping supine and with the head and face uncovered under 16 layers of my recommended blankets. You may choose to disagree… but can you show me research that can prove or deny this?

Yet on the FSID reply Tizzie states:

"I do not, for the majority, recommend covering with 10 tog or MORE of bedding. So therefore my recommendations I believe are consistent with FSID guidelines"

For the majority?  How does this make recommendations consistent.

Confused? 

Fleur was:

"The thing is, she (Tizzie) is not including the tog of the sleeping bag, the double wrap swaddle or the baby's clothing in her calculations! Yes, her layers of blankets at the maximum usage equates 9.6 togs at 0.6 tog each (although she actually had them tested at 0.64 tog each, meaning it's actually 10.24 tog), but then forgets about everything else.... A sleeping bag can be anywhere from 0.5 tog to 2.5 tog depending, (Tizzie recommends 1 tog in summer & 2 tog in winter) and then the double wrap is a special swaddle which has 4 layers over the baby, which again adds anywhere between 1 and 4 tog.... Plus a sleepsuit, vest and nappy, which would be approx another 2-3 tog, equals WAY above the 10 tog max that FSID said was a major risk!"

Some mums also questioned the statement that the majority of clients don't use that many layers.  Here is the quote from Tizzie's forum that opened the initial blog piece.

"We have noticed with the increased membership to our new forum area that there are quite a few of you who are using more than the total recommended amount of blanket layers. I know we are normally suggesting that baby’s are cold and you need to add layers, and in many cases this is correct but we do need to let you know that there is a limit to amount of layers that you should be using with your babies.
Tizzie recommends that the maximum blanket layers that should be used on a newborn to 3 month old baby sleeping in a bassinet is 10 layers, a newborn to 3mth old baby sleeping in cot is 12 layers and a baby 4 months and over is 16 layers.
Tizzie’s safe bedding guide is written on the amount of layers NOT how many tog those layers add up to."

Togs or layers?  But research generally examines tog - the recognised measurement of insulation (regardless of whether that is made of bamboo, fleece or wool!)

Too many blankets at least appears to be an ongoing issue according to other mothers.  This was taken from Tizzie's Facebook group back in March 2011 - the reply is from a frequently posting fan but despite Tizzie/her admin team moderating other posts, no warning/editing/deletion happened to this reply:

"Q ~ 'I've recently started my 7 month old on s.o.s routine. Day 4 and our nights are getting so much better. Before starting bub was waking every 2 hours sometimes less. My partner and I were exhausted. The first night he slept for 4 hours before needing to be resettled, second night was 7 hours and last night was 9.5 hours. Praying tonight is 12. Two little issues, first my boobs are killing me in the mornings now- I'm so engorged. And the second issue is that i think he is getting cold at night. I sleep him in a long sleeve onesie, a sleeping bag and a cellular blanket but he manages to wriggle out from under the blanket and when i go in to check on him he is sleeping on top of the blanket, and he is cold to touch.'

A ~ Do you have the bedding guide from the SOS website? It shows you what to dress bubs in for temps in various states. Best $9 you'll ever spend! Need to make sure everything is 100% cotton (incl. mattress protector) otherwise bubs will sweat. Most of us use many more blankets than the guide, every bubs is different eg. I'm in Sydney and in a room of 24.2C my 6m has 12 blankets on + the clothing, bag and wrap mentioned in the guide."

Copied from here

Fleur goes on to add:

"I asked about why use both before (sleeping bag AND wrap) and was told it was because it prevented babies from rolling onto their tummies much longer than 1 or the other. The FSID leaflet I have states to use one or the other, and that if the room is 18-20 then you shouldn't need any other bedding. It also has a temp guide and it's own bedding guide which says 1 cotton sheet, then as the temp gets colder, it suggests to add 1-4 layers of lightweight cotton blankets. 4 was the absolute max they advised." 

Sure enough here it is:

Tizzie then says:

"I would like to point out that if the above study was undertaken on baby’s 3 months and under, which I suspect it was then I do not recommend more than 12 layers for baby in cot and 10 layers for a baby in moses basket"

Yet the study I quoted in my previous reply showed overheating risks were elevated in older infants, not younger:

"Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days."

 BMJ 301 : 85 doi: 10.1136/bmj.301.6743.85 (Published 14 July 1990) Research ArticleInteraction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study

Could someone also clarify - are ALL Tizzie's blankets 0.6 tog? I keep reading about her "recommended 0.6 tog blanket", but she has five listed in her shop and none have the tog value labelled.

Several mums also commented on the statement:

"My confusion comes because research I have read by Monique P L’Hoir states “ we hypothesized that turning prone is prostponed when a sleeping bag was used, and even more so if the baby was tucked in with a blanket as well.”

Firstly, a hypothesis is a proposed explanation for a phenomenon - one then has to test whether the hypothesis is true for it to become evidence.  Secondly the article that contains the above can be found here but it doesn't discuss using both a swaddle and a sleeping bag and sheets and blankets; does anyone have a link to research supporting this?

Another issue not addressed is that of swaddling.  Tizzie herself directed mothers towards the International Society for the Study and Prevention of Perinatal and Infant Death (ISPID).  Their website states all mothers should be advised of the potential risks of swaddling; yet Tizzie's bedding guide that recommends all infants are swaddled and doesn't mention any risks.  They state:

"Numerous studies have documented a "tranquil" behavioural state and longer sleep periods in swaddled infants [10-14]. Thus, despite the unknown effects on the risk for SIDS, swaddling is becoming increasingly popular as a settling technique in the Netherlands, the United Kingdom and the United States [15, 16].

These findings logically suggest that infant swaddling would increase infant sleep time by preventing awakening. However this may not be a desirable outcome, as the pathogenesis of SIDS is thought to involve an impaired ability to arouse from sleep in response to a life threatening respiratory or cardiovascular challenge [17]. Arousal from sleep in infants is a hierarchical response proceeding from sub-cortical activation involving changes in heart rate and breathing, to full cortical arousal involving changes in brain activity; and this progression has been reported to be incomplete in infants who later died of SIDS [18]. Infant swaddling has been shown to minimise arousals from sleep, crying time, spontaneous startles and the progression to full arousal [1, 12, 14, 19]."

Tizzie seems to feel that FSID are led by sleeping bag companies:

"I can’t help but wonder here if it is FSID who are suggesting a sleeping bag or bedding or if it is the sleeping bag companies suggesting this…. "

and 

"They (FSID) might not have had time to do there own research and their recommendations might be based on what a sleep bag company has recommended to them. My advice is based on years of my study and observation of how babies sleep".

So perhaps FSID may clarify this?  I shall email them and ask!


UPDATE: A mum called Julie from Facebook has contacted a company called "Little Bamboo" to enquire as to the tog of their blankets. They sell a 120 x 150 cm bamboo blanket (100% bamboo with 100% cotton trim) at £14.95 here and have confirmed this is 0.6 tog (interestingly it looks very much like the blanket Tizzie lists for £46.30 here and Tizzie sells other items from the Little Bamboo range) This may be helpful to mums shopping for a cheaper alternative.

I also want to add details I have received via email - relevant excerpts below:

I've been wading through a number of research articles over this weekend (I'm an academic in a School of Public Health) 

The Fleming et al (1990) article you refer to regarding the increased risk at >10 tog clearly states that it is the COMBINED tog of BOTH clothing and bedding that needs to be taken into consideration, and as you've noted yourself, Tizzie does not include clothing or the sleep sack as part of her tog calculations. The article also indicates the relative risk increases from 8 tog, and is significantly higher at 10 tog or above.
I note that you have referred to the fact that older infants are more at risk of overheating than younger, and that Tizzie advocates putting MORE layers on older infants than younger. I thus found the following quote from Fleming et al (1990) particularly significant: 

"Unexpected findings were that among the infants who had died the older infants tended to be more heavily wrapped than the young ones, though no such trends were noted among the control infants, and that the increased risk of sudden unexpected death with overwrapping was significant for only the older infants. The higher ratio of mass to surface area in the older infants, together with their higher metabolic rates, may make them more vulnerable to the effects of increased thermal insulation".

Tizzie still does not provide any research evidence that turning prone is in response to temperature, and again in this regard is contradictory. She argues that babies are less able to regulate their temperatures effectively until they are 18 months old (again, her one size fits all approach), yet at the same time argues that babies are all apparently spinning over in a desperate attempt to get warm. Infants do in fact have the ability to thermoregulate and some research suggests they are more efficient at thermoregulation during sleep than adults. One of the risks of sleeping prone means that babies lose less heat from their bodies, so keeping them supine is obviously preferable. What is astounding is that advising placing excessive layers of blankets on a baby in fact reduces or perhaps removes the very reason why supine sleeping is protective, namely, the ability to dissipate excess heat.

I also want to copy a comment from the blog into the post:

"Not to add to your confusion: but Tizzie's understanding of tog is also fundamentally flawed, so her calculations are largely meaningless.
Tog is the level of thermal insulation offered by any one "covering device", if you will (I can't think of a better term!), and takes into account only that one garment. e.g. a 5 tog duvet is, indeed, 5 tog. However, tog can ONLY be measured in this way, by assessing the individual piece. The way that the material lies, the gaps inbetween individual layers, etc. all come into play when combining layers.
Essentially, what this means is that 2 x 2 tog does NOT necessarily equal 4 tog... and when so many layers are taken into account it's actually highly UNlikely that it would be a simple calculation. 15 x 1 tog blankets is very likely to have its own distinct tog rating of 20+ tog.
It's fundamentally simplistic and flawed thinking that makes someone like Tizzie Hall especially dangerous. Her words seem - to anyone not clever enough or simply not inclined to question - to "make sense" or be logical when they are in fact nothing of the sort. They're pseudoscience at best, outright guesses as a middle ground, and blatant lies at worst."

Tizzie Hall responds to FSID (PART 4)

Some mums have noted that comment moderation is in place on Tizzie Hall's own website - therefore I have reproduced an excerpt of her post with a link to the rest, you are welcome to comment here :)

Thank you Prof Haycock

July 30th, 2011

I would like to thank Prof Haycock for taking the time to respond to the questions posed by Analytical Armadillo in concerns to my bedding advice. My official response is below. 
FSID believes that it is vital that all parents are offered safe sleep advice which is supported by independent, peer-reviewed scientific research. Babies are all very different so it is important for parents to be aware of their baby’s temperature by feeling their tummy or the back of their neck – not their hands or feet – and if they do feel hot they should remove a layer.
Here is our advice:
1. Babies do not need hot rooms and all night heating is rarely necessary.  Keep the room at a temperature between 16-20ºC.  18ºC (65ºF) is just right.  20 degrees is what I recommend in Australia and other areas on this side of the world and after a recent trip to the UK and Ireland I will now be recommending 18 degrees for that side of the world. My advice is consistent with FSID guidelines.
2. Adults find it difficult to judge the temperature in the room, so use a room thermometer in the rooms where your baby sleeps I always recommend my parents measure the room temperature with a room thermometer to establish the ambient temperature of the room. I recommend a room thermometer in my online store.
Taken from my bedding guide –
“ I suggest having a baby’s room cooled to 22 degrees centigrade in summer (if you are using air conditioning), or warmed to 20 degrees centigrade in winter. If you do not have hydronic heating, I suggest you use an oil-filled column heater. I do not advise using ducted heating in a baby’s room due to the dust it blows around. A good way of keeping an eye on the temperature is to use a room thermometer.” Please note:  to clarify one point above, I have found that if you set your air-conditioning to 22 degrees when trying to cool a room it gives a actual room temperature of 20 degrees.
My advice is consistent with FSID guidelines.
3. When you check your baby, if they are sweating or their tummy feels hot to the touch, take off some of the bedding or clothing. Don’t worry if their hands or feet feel cool, this is normal. I clearly state in my bedding this exact same thing. Here is the direct quote - 
Please note: Using the above guides, you will still need to watch your individual baby and adjust the bedding if your baby appears too hot or cold. Here are a couple of pointers to tell if your baby is too hot or cold. 
Signs of a baby who is too hot might include:
• the baby will be waking and moaning,
• having a sweaty back
• having sweaty or wet clothes.
• Shallow, rapid breathing
Signs that your baby is too cold might include:
• Moving all around the cot
• Never laying still
• Rolling on to their tummy
• Catnapping in the day, or
• Waking from 4am (but more often 5am)
You might also need to adjust the recommended bedding depending on the humidity level where you live as well.
The sheets and blankets in your child’s cot should be made from cotton or bamboo.
Tips:
• Never tuck a sleeping bag in under the mattress because this will restrict your little one’s movement and is dangerous.
• The most important rules to remember to protect your little one from SIDS are to have a totally smoke-free pregnancy and environment for your baby, and to always place a baby in the safe sleeping position on their back to sleep
• Toddlers over 18 months appear to be better at controlling their own body temperature while they sleep so might need less bedding.
• To see how I set a cot up with bedding please visit my BLOG February 2010
My recommendations are consistent with FSID guidelines.
 4. Use lightweight blankets or a baby sleeping bag. If your baby feels too warm, reduce the number of layers or use a lower tog baby sleeping bag. In warm summer weather, your baby may not need any bedclothes at all. Do not use a duvet, quilt or pillow for babies under 12 months. 
I am confused by the word “or” used here; “Use lightweight blankets or a baby sleeping sack” My confusion comes because research I have read by Monique P L’Hoir states “ we hypothesized that turning prone is prostponed when a sleeping bag was used, and even more so if the baby was tucked in with a blanket as well.” This statement is in line with what my observations have shown. Although I have also seen that if more lightweight bedding is used this may delay the baby rolling to their tummy for even longer. I can’t help but wonder here if it is FSID who are suggesting a sleeping bag or bedding or if it is the sleeping bag companies suggesting this….
For the research see information heading 134s COT DEATH AND SLEEPING SACKS the very last line states “we hypothesized that turning prone is prostponed when a sleeping back was used, and even more so if the baby was tucked in with a blanket as well.” http://www.ispid.org/fileadmin/user_upload/textfiles/SIDSI2006finalabstractbook.pdf
My recommendations is to use layers of lightweight 100% cotton or bamboo blankets and watch your baby for signs of being too hot or too cold as stated above. From my bedding guide–
 “So why not just add more clothing under the sleeping bag and then eliminate the need for blankets? The reason I recommend using bamboo or cotton blankets along with a safe sleeping bag, and not normally using more than two layers of clothing underneath the sleeping bag, is because I feel more than two layers under a sleeping bag causes a risk of its own. You might for example, as advised by some sleeping bag manufacturers, add extra layers under your baby’s sleeping bag. Then, when you go in to check your little one at night and discover he feels too hot, you may decide not risk lifting him to remove some clothing layers because you are scared of waking him. You and I would like to think we would put safety first, but it’s important to remember that some nights we might feel too tired to risk waking our sleeping baby. In my opinion this is a far more dangerous situation than using bamboo or cotton blankets that can be added and removed as needed. On the other hand, if you found your baby was too cold without enough layers under his sleeping bag you might just grab the nearest thing – for example a quilt or polyester blanket – and throw it over your baby. A safer approach is to have the correct safe bedding at hand and educate the people who are around your baby at sleep times about how to put your little one to bed safely. My advice is consistent with FSID recommendations.
5. Even in winter, babies who are unwell and feverish need fewer clothes and bedclothes. Currently I do not have this warning in my bedding guide but as a result of this blog I have now realised that some parents are confused how to dress their babies and what to cover them with when unwell so I will be adding a paragraph to explain that less bedding and clothing is needed when a baby is unwell. My advice will be updated to include this FSID recommendation.
6. Babies need to lose excess heat from their heads. Make sure their head cannot be covered by the bedclothes by sleeping them ‘feet to foot’ (with their feet to the foot of the cot) so they don’t wriggle down under the covers.
Taken from my safe bedding guide –

• The most important rules to remember to protect your little one from SIDS are to have a totally smoke-free pregnancy and environment for your baby, and to always place a baby in the safe sleeping position on their back to sleep

And taken from my SIDS article – http://www.saveoursleep.com.au/reading/free/sids.asp Which can be found under ‘Free Reading’ on my website –
Make sure your baby’s face and head stay uncovered while your baby is sleeping. A good way to ensure this is to put your baby’s feet at the bottom of the cot so that she can’t slip down underneath the bedclothes. Tuck in bedclothes securely so they can’t become loose. Never put quilts, doonas, duvets, pillows, lambskins or cot bumpers in a cot or under the sheet covering the mattress.
My grandmother says I should put a hat on my five-week-old baby to make him sleep better. What do you think? This is a question posed to me which is on my website and my answer to the question is below – this FAQ is also in my book.
I have heard this a few times and believe it to be a very dangerous old wives’ tale. You should most definitely not put a hat on your baby to help him sleep as this could cause your baby to overheat and will increase the risk of SIDS. If your baby is too hot and needs to cool down, he will need to be able to lose that heat through his head. You may put a hat on your baby if you are outdoors in cold weather, but take it off once inside.
My advice is consistent with FSID guidelines.
 7. Babies should never sleep with a hot water bottle or electric blanket, or next to a radiator, heater or fire, or in direct sunshine. I do not recommend any of these things but do not state this in my bedding guide. My advice will be updated to include this FSID recommendation.
8. When it’s warm, you can cool the room where your baby sleeps by closing the curtains and opening the windows during the day.  Offer your baby plenty to drink, and in very hot weather, sponge them down regularly with tepid water.  Use a fan but do not place it directly onto your baby. I concur as stated in my bedding guide.
My advice is consistent with FSID guidelines.
9. Remove hats and extra clothing as soon as you come indoors or enter a warm bus, train or shop, even if it means waking your baby. I have shown an example above where I also recommend this. My advice is consistent with FSID guidelines.
10. A car can become very hot in the summer. Avoid direct sunlight on your baby.  In winter, keep the heating low, and remove your baby’s outdoor clothing.  A thermometer may be helpful. I believe we have addressed this above. I will add the point about babies getting hot in cars to my SIDS article.  My advice is consistent with FSID guidelines
Research Evidence:
The most important publication implicating over-wrapping of babies as a risk factor for SIDS is the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report ¹ which had a very large dataset. Some of the data in the report had been published before. ^2-4 In the chapter Thermal Environment and Arrangement of Bedding the authors state
 “For both the usual sleep and last/reference sleep, the SIDS infants were wrapped significantly more warmly than the control infants. The difference in the distribution of tog values remained significant when adjusted for socio-economic status. Notably twice as many SIDS infants put down for the last/reference sleep were covered by 10 tog or more bedding, and three times as many were found this way compared to the control infants.” – I do not, for the majority, recommend covering with 10 tog or MORE of bedding. So therefore my recommendations I believe are consistent with FSID guidelines. I recommend in my guide 6 layers of 0.6 tog blankets which is 3.6 tog plus a doubled over sheet of 0.4 tog totalling 4.0 tog and a maximum of 16 layers at 0.6 tog with is 9.6 tog include the doubled over sheet at 0.4 tog which is 10 tog. I note the above statement is 10 or more so I will adjust my maximum layers for a baby over 4 months sleeping in a cot to 15 layers as 16 layers equals 10 tog. I would like to point out that if the above study was undertaken on baby’s 3 months and under, which I suspect it was then I do not recommend more than 12 layers for baby in cot and 10 layers for a baby in moses basket – total 6.4 tog and 7.6 tog respectively (including doubled over sheet calculated to .4 tog) I also strongly advise my parents to begin with my recommended bedding, not my maximum bedding and watch their baby’s for signs of being too hot or too cold and add or remove the bedding as needed. My advice is 99% consistent with that of the current research outlined here  and I will adjust the maximum layers for a baby over 4 months sleeping in a cot to 15 layers of my recommended blankets.
To Note: You may argue that the ‘standard blanket layer’ is 1.5 to 2.0 tog however it is my belief that this average would have been achieved by evaluating the broad range of blankets on the market – cotton, bamboo, wool, polyester, polar fleece etc. I have not been able to find an answer to ‘what is the average tog of a cotton or bamboo blanket?’ so therefore I can only go with what the range of blankets I recommend have been tog tested too. I have made it clear in my bedding advice as taken from my bedding guide – “The sheets and blankets in your child’s cot should be made from cotton or bamboo”
 CESDI indicated that worrying about overheating might actually be protective:
“Significantly more control than index mothers worried about their baby getting too hot, suggesting a protective effect…”
It was the mothers of the SIDS infants who worried most about their baby being too cold:
27.8% of the mothers of SIDS infants compared to 15.8% of controls. I would argue that parents following my routines and advice could be more aware of the dangers of both overheating and underheating than parents not following my advice because of the emphasis and importance I stress in bedding and setting up a safe sleeping environment. I would argue that you would find my parents would be monitoring their babies on a very regular basis.


CONTINUES HERE: http://blog.saveoursleep.com/2011/07/30/thank-you-prof-haycock/#respond


You can read Contradictions in Tizzie Hall's response to FSID HERE

FSID's formal reply to request for guidance re Tizzie Hall's advice (PART 3)

As those who have been following this blog know - I recently asked both Tizzie Hall and FSID for guidance regarding bedding and SIDS.  If you missed that post you can read it here.


Tizzie Hall replied here & I responded again to Tizzie here.


FSID have now also sent me a formal reply from Prof Haycock which you can read below :)  It includes both FSID's official advice and also the relevant research supporting.  Huge thank you to FSID for taking the time to respond with such detailed information and evidence.

FSID believes that it is vital that all parents are offered safe sleep advice which is supported by independent, peer-reviewed scientific research. 

Babies are all very different so it is important for parents to be aware of their baby’s temperature by feeling their tummy or the back of their neck - not their hands or feet - and if they do feel hot they should remove a layer. 

Here is our advice:

1. Babies do not need hot rooms and all night heating is rarely necessary.  Keep the room at a temperature between 16-20ºC.  18ºC (65ºF) is just right. 

2. Adults find it difficult to judge the temperature in the room, so use a room thermometer in the rooms where your baby sleeps 

3. When you check your baby, if they are sweating or their tummy feels hot to the touch, take off some of the bedding or clothing. Don't worry if their hands or feet feel cool, this is normal. 

4. Use lightweight blankets or a baby sleeping bag. If your baby feels too warm, reduce the number of layers or use a lower tog baby sleeping bag. In warm summer weather, your baby may not need any bedclothes at all. Do not use a duvet, quilt or pillow for babies under 12 months. 

5. Even in winter, babies who are unwell and feverish need fewer clothes and bedclothes. 

6. Babies need to lose excess heat from their heads. Make sure their head cannot be covered by the bedclothes by sleeping them 'feet to foot' (with their feet to the foot of the cot) so they don't wriggle down under the covers. 

7. Babies should never sleep with a hot water bottle or electric blanket, or next to a radiator, heater or fire, or in direct sunshine. 

8. When it's warm, you can cool the room where your baby sleeps by closing the curtains and opening the windows during the day.  Offer your baby plenty to drink, and in very hot weather, sponge them down regularly with tepid water.  Use a fan but do not place it directly onto your baby. 

9. Remove hats and extra clothing as soon as you come indoors or enter a warm bus, train or shop, even if it means waking your baby. 

10. A car can become very hot in the summer. Avoid direct sunlight on your baby.  In winter, keep the heating low, and remove your baby's outdoor clothing.  A thermometer may be helpful. 

Research Evidence:

The most important publication implicating over-wrapping of babies as a risk factor for SIDS is the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report ¹ which had a very large dataset. Some of the data in the report had been published before. ^2-4 In the chapter Thermal Environment and Arrangement of Bedding the authors state 

 “For both the usual sleep and last/reference sleep, the SIDS infants were wrapped significantly more warmly than the control infants. The difference in the distribution of tog values remained significant when adjusted for socio-economic status. Notably twice as many SIDS infants put down for the last/reference sleep were covered by 10 tog or more bedding, and three times as many were found this way compared to the control infants.”

CESDI indicated that worrying about overheating might actually be protective:

“Significantly more control than index mothers worried about their baby getting too hot, suggesting a protective effect…”

It was the mothers of the SIDS infants who worried most about their baby being too cold:
27.8% of the mothers of SIDS infants compared to 15.8% of controls. 

There is no scientific evidence to suggest babies roll over because they are cold, indeed, the peak age of death for SIDS infants is 2-3 months, an age when most babies are unable to roll.

Two other studies examined the relationship between wrapping and SIDS risk, one from Tasmania ⁵ and one from New Zealand ⁶. Both of these found that the risk was only significant for infants slept prone, but the numbers were relatively small. The New Zealand study also found an interaction between over-wrapping and maternal smoking. 

There is also evidence to show that overheating interacts adversely with infection so it would be unsafe to overwrap a baby who was unwell and there are two studies that show that SIDS may occur against a background of minor illness^7-8: 

The current evidence-based advice is that over-wrapping increases the risk of SIDS especially for infants slept prone, who are unwell and for those of smoking mothers. All parents should check that their baby is not too hot by feeling their tummy or the back of their neck.  FSID encourages parents to follow the Reduce the Risk guidelines because they are supported by externally reviewed, scientific studies conducted by leading SIDS researchers. 

1. Fleming PJ, Bacon C, Blair PS, Berry PJ, editors. Sudden unexpected deaths in infancy. The CESDI SUDI studies 1993-1996. London: The Stationery Office, 2000.
2. Fleming P, Berry J, Gilbert R, Rudd P. Bedding and sleeping position in the sudden infant death syndrome. Bmj 1990;301(6756):871-2.
3. Gilbert R, Rudd P, Berry PJ, Fleming PJ, Hall E, White DG, et al. Combined effect of infection and heavy wrapping on the risk of sudden unexpected infant death. Arch Dis Child 1992;67(2):171-7.
4. Fleming PJ, Blair PS, Bacon C, Bensley D, Smith I, Taylor E, et al. Environment of infants during sleep and risk of the sudden infant death syndrome: results of 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. Bmj 1996;313(7051):191-5
5. Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med 1993;329(6):377-82.
6. Williams SM, Taylor BJ, Mitchell EA. Sudden infant death syndrome: insulation from bedding and clothing and its effect modifiers. The National Cot Death Study Group. Int J Epidemiol 1996;25(2):366-75.
7. Stanton AN, Downham MA, Oakley JR, Emery JL, Knowelden J. Terminal Symptoms in children dying suddenly and unexpectedly at home. Preliminary report of the DHSS multicentre study of postneonatal mortality. Bmj. 1978 Nov 4;2(6147):1249- 51.
8. Gilbert RE, Fleming PJ, Azaz Y, Rudd PT. Signs of illness preceding sudden unexpected death in infants. Bmj. 1990 May 12;300(6734):1237-9. 

Tizzie replies to FSID here. 

Armadillo Reply to Tizzie Hall's Official Response (PART 2)

Firstly I would really like to thank Tizzie Hall, for taking time from her schedule to reply to my blog post - and provide further information for parents who had raised concerns.  I would like to reply to some of the points Tizzie made (I have changed the lilac font Tizzie used for a darker shade to make for easier reading; blue = Tizzie Hall's official response):

Firstly, I by no means feel anything I say here is going to change anyone’s minds in regards to my advice or books.

Why would you think this Tizzie?  People have asked for further explanation for the basis of some elements of your advice - I absolutely think many are open to re-evaluating ideas should that be forthcoming.  My opinions have changed numerous times over the years as I have learnt and read more, studied more research from respected sources -  to be closed to new evidence and change is I think a potentially dangerous position, and one which underestimates readers.

Parents hear they should try to ‘exclusively breastfeed’ their baby until six months. But on the other hand allergy experts recommend introducing solids between four to six months as research is increasingly suggesting this reduces the risk of food allergies.

Exclusive breast-feeding for six months is a WHO recommendation, and is aimed at reducing serious illnesses, such as severe diarrhoea, in developing countries where contaminated water. In most of Australia, the UK and Ireland water is clean and so it’s safe to introduce solids at 16 weeks but unfortunately all the advice just makes new parents lives hard and confusing. 

I'm not entirely sure research is increasingly suggesting starting solids before gut closure reduces allergies - at least non I have seen.  Nor is the WHO guideline purely about contaminated water (although this is a common myth/misconception).  I think I have pretty much covered everything I could say on that subject here and here  which address the points made.  I do agree that is another area confusing for parents as discussed in my post; however UK guidance from the DOH, UNICEF and WHO is consistent.

So back to blanket recommendations!

"This confused one mum Fleur who posted on Facebook saying:
If you use her special bamboo blankets that she recommends, at the max 16 layers, at approx 0.6 tog each, that would put your child under a massive, surely dangerous 13.6 tog…. to put that in perspective, the average adult duvet here in the UK is 11-13 tog, which is considered ‘winter weight.’The math here is totally incorrect. IF and I say IF a parent is using the maximum of 16 layers which when using my recommended blanket is highly unlikely the total tog rating would be 9.6 – quite a difference to 13.6!"

But I clarified below how Fleur had reached 13.6:

“On my calculation of the tog rating – Tizzie’s fans have repeatedly told me that the tog rating of her bamboo blankets is 0.64 tog x 16= 10.24 tog (apparently she has had them tested.) and a cotton sheet folded in 2, at approx 0.2 tog (x2= 0.4 tog). I also included in my calculations the toggage (made up word, lol) of the ‘safe sleeping bags’ that she sells, which will be either 1 tog or 2 tog, depending which one you choose, and the tog of the ‘double wrap’ which again, equates to 4 layers in itself (2 inside wrap pieces and 2 outside fold over bits) which again, could be anywhere from 1 tog to 4 tog, depending on the material used). I didnt include the tog of a vest, a sleepsuit or a nappy. That was how i worked out the approx 13+ tog. What Fleur has stated in her clarification is fine but adults also dress themselves similarly for bed, use a sheet and many adults sleep next to another person which provides extra warmth under their 11-13 tog duvets, yet we expect our babies to sleep in much less…….. 

Just to be clear then - Fleur's maths is correct? As when she clarifies how she came to this you state it is fine.  So (I think) we have 13.6 confirmed approximate tog (based on your recommended 0.6 tog blanket), NOT including a vest, sleepsuit or nappy - so can we potentially add another 3 tog there?

" My recommended range of blankets have been tested at 0.6 tog – that means we could place up to 9.8 layers of these recommended blankets over the baby. I am aware this is less than the 16 that I said was the maximum but in reality the majority of my clients don’t use that many layers. But I do not believe that a baby would come to any harm if the baby was 100% healthy, sleeping supine and with the head and face uncovered under 16 layers of my recommended blankets. You may choose to disagree… but can you show me research that can prove or deny this?

Yes this would be 6 layers less than your recommended maximum (not including clothes).  Whether the "majority of your clients use that many layers" is I think an aside, as using your guidance they could.  It appears as though you are asking me to show research that can prove or deny your statement you don't believe a baby would come to harm under heavier tog - but with all due respect I think the onus should really be on the person giving advice to present the evidence supporting it?

However, I  have found something that I think is appropriate:

BMJ 301 : 85 doi: 10.1136/bmj.301.6743.85 (Published 14 July 1990) Research Article
Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study.

From the study:

RESULTS: Compared with the control infants the infants who had died from the sudden infant death syndrome were more likely to have been more heavily wrapped (relative risk 1.14 per tog above 8 tog; 1.03 to 1.28; p less than 0.05), and to have had the heating on all night (relative risk 2.7; 1.4 to 5.2; p less than 0.01)
These differences were less pronounced in the younger infants (less than 70 days) than the older ones. 

CONCLUSION: Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days. Educating parents about appropriate thermal care and sleeping position of infants may help to reduce the incidence of the sudden infant death syndrome.

From your webpage: "In the UK parents put a lot more clothing on their babies at night, and I believe the temperature of their homes is actually warmer than the night time temperature in most of the homes I visit in Australia. In the UK they have a different type of central heating which keeps the house at a more even temperature throughout the night.

I am not sure if it is even the warmth the babies like or if it is that with more layers on they feel cosier and more secure. But I do know that the extra layers can stop babies from waking at night."

But surely you need to be pretty sure it's the warmth to make the recommendations you do?  

Your comments re blankets I found a little confusing, as in your original statement it said:

"We have observed that many of you have been trying to achieve the total tog of the Save Our Sleep® recommended blankets with other brand blankets but we do not advise that you do this. This is because you need to use too many layers of other blankets to achieve the same warmth as the Save Our Sleep® blankets for your baby to sleep safely."

"If you do a search on the average tog of a blanket it is 1.5-2 tog, as stated above. My recommended blankets have been tog tested to 0.6 tog I have had other blankets tog tested and some blankets have come back with results of 0.2 tog and one blanket came back at 4.5 tog "

But if your blanket is 0.6 tog, compared to the average figure you quoted of 1.5-2 tog of a standard blanket, why would the mothers need more standard blankets to achieve the same warmth?  Surely they would need less?  You stated above 16 x 0.6 = 9.6 tog, whereas 16 x 1.5-2 (the figure you quoted as the tog of a standard blanket) comes to 32 tog based on 2 tog blankets.

Are we now disputing average tog rating is 1.5-2 per blanket?

"Analytical Armadillo are you trying to imply that the one and only reason I recommend layering blankets if for financial gain…..really? If this would be putting babies at risk would this not be professional suicide on my behalf…? What could I possibly have to gain from that? I am trying to keep this professional but implying financial gain is my main goal while risking baby safety is insulting."

I don't think I implied any such thing, other than this is the price of the blankets and buying a lot would work out expensive.  I think this is something you acknowledge yourself Tizzie as I've seen you state on FB if people can't afford the blankets they are better buying second hand from other mums than to use an alternative brand? 

"Secondly In order to state using different brands or more blankets is unsafe – one must have identified and proven (i.e. tested) what is safe?"

"The weight of the blankets I recommend are the same as a blanket I have had tested which came back at 0.2 tog. To get the same warmth you might have to use 20 blankets but the weight would be far too much to have on a baby and in my opinion would be unsafe so this is why I suggest using the blankets I have tested because you can use less blanket which in return is less weight on the baby but the same warmth."

Well yes, if you used 0.2 tog blankets it of course follows you would need more than if using 0.6 tog; however until now the average tog rating of a blanket has been discussed at 1.5-2 tog. I'm not sure how the fact yours weighs the same as one blanket you tested at 0.2 is really relevant, because according to an "average", it also has to mean a significant amount on the market are a lot warmer than 0.2 tog to obtain a 1.5-2 average? Therefore it also potentially means people could use less blankets (and therefore less weight) to obtain the same warmth as with (your recommended) 0.6 tog blanket?  Say this one at 3.7 tog or the ones they refer to at the bottom of the page ranging from 1.7-2.6 - then parents could just add a thinner layer or two if required?

"To get the same warmth you might have to use 20 blankets but the weight would be far too much to have on a baby and in my opinion would be unsafe" -  The logic of mothers need far more of another brand is only applicable though when comparing to the specific (unidentified) blanket you tested at 0.2.

To go back to my orignial question how have you decided upon 16 layers - not 15 or 17?  ie how via observation does one calculate X amount is unsafe via Y not being?  I genuinely struggle to see how this could be established via observational means unless you have observed infants have suffered at 17 layers?  Have you weighed 15 blankets v 17 and established 16 was a safe weight and if so how?  Did you record these observations, create data you can share? (I think this is what parents are asking)

"I do have evidence it is just not in a formal official paper, perhaps observations is a better term. I would be more than happy to help FSID or SIDS and Kids in Australia conduct further study into the effect of thermal layering and SIDS as long as they also investigated my belief that a cold baby will roll to the prone position as soon as he/she possibly can."

Yes I think perhaps observations is the only term if you don't have "paper evidence" - because evidence is by definition something that furnishes proof which anecdotal evidence does not.  I think it really is key we appreciate the difference - ie I could observe locally that the rate of gastroenteritis wasn't higher in non breastfed infants, luck of the draw could mean the group of infants I happened to deal with don't contract the illness.  In contrast masses of "paper evidence" that explore large numbers to an appropriate scientific model, find that rates are increased even when numerous other factors are accounted for, and other research exploring the constituents of breastmilk fills the gaps as to why.   The point is unless we know how these observations were noted, what factors were accounted and controlled for, who the study group was and so on and so forth - observations are pretty meaningless; they needed to be clearly identified as opinion, not evidence based guidelines.

A number of mums on Facebook have also commented that their infants rolled prone as soon as possible completely unrelated to temperature - they did the same in the hot temperatures of Spain as they did the UK.  Some also noted their children had shoulder/neck discomfort which is surely another viable reason why an infant may not want to back sleep?

I'm also not sure that because an infant loses less thermal heat when prone - we can therefore assume this means they roll when cold (although it indeed may!) or demonstrates safety of increased layering supine.  If thermal heat is less well retained when baby is on back - this is absolutely an interesting factor that should be taken into account when conducting research.  But we also have to filter in to the big picture other associated risk factors I think, such as feeding method, central heating and also fully explore co versus cot sleeping (particularly given the experiment Sears conducted on his daughter's oxygen sats).  I'm not sure we can cherry pick bits we feel are more relevant and discount the rest.

"My recommendation of a room temp of 20 degrees falls within these parameters, and after my recent trip home to Ireland I will also be editing my recommendations for this area and saying that ideal room temperature in Ireland and the UK is 18 degrees. I fully support the statement that too much bedding, clothing or possibly (but not proven) more importantly the incorrect material of bedding and clothing can cause thermal stress. However my recommendations will NOT cause a baby to overheat. I clearly state in my bedding guide what signs a parents should look for in a hot baby and a cold baby and to adjust the layers accordingly. I have not found using only my recommended bedding ( a 100% cotton mattress protector, 100% cotton or bamboo sheets, all 100% cotton or bamboo clothing and only 100% cotton or bamboo blankets) within my guidelines to cause a baby to get too hot. Of course each baby is different which is why I have written my bedding guide and encourage parents to only try more bedding one layer at a time if their baby continues to shows signs of being cold."

I think it's excellent you are updating your recommendation to sit with current government guidance.  I think the problem is though Tizzie, that whilst you clearly state your recommendations will NOT cause a baby to overheat, mothers need hard evidence, from appropriately qualified people demonstrating this.  Also the feedback from some mothers on your FB group (and on another discussing your advice) seems to be that their infants did get very hot and a not insignificant number repeatedly wriggled out of blankets.  If an infant does indeed roll when cold, surely they can also attempt to remove themselves from some layers if they're hot?  But tips were given to tuck the blankets in more firmly..  Also on your group when mothers have reported continued waking - an often noted response from other fans is "try another layer or two of blankets" - not "did your baby feel cold"; which would seem a much more appropriate response?

Lastly I also note the bedding guide states you recommend swaddling infants until they show signs of wanting to roll over - yet this also now seems recognised as a potential SIDS risk factor too?  From the link you shared (ISPID):

Parents should be aware of the potential risks of swaddling their infant, particularly of the use of heavy materials for swaddling.

• Current research suggests that it is safest to swaddle infants from birth and not to change infant care practices by beginning to swaddle their infant at 3 months of age when SIDS risk is greatest.

Do you make parents aware of potential risks and also clarify they should not commence this practice if they find your advice after the newborn period?

Another relevant point from the same source:

Numerous studies have documented a "tranquil" behavioural state and longer sleep periods in swaddled infants [10-14]. Thus, despite the unknown effects on the risk for SIDS, swaddling is becoming increasingly popular as a settling technique in the Netherlands, the United Kingdom and the United States [15, 16].

These findings logically suggest that infant swaddling would increase infant sleep time by preventing awakening. However this may not be a desirable outcome, as the pathogenesis of SIDS is thought to involve an impaired ability to arouse from sleep in response to a life threatening respiratory or cardiovascular challenge [17]. Arousal from sleep in infants is a hierarchical response proceeding from sub-cortical activation involving changes in heart rate and breathing, to full cortical arousal involving changes in brain activity; and this progression has been reported to be incomplete in infants who later died of SIDS [18]. Infant swaddling has been shown to minimise arousals from sleep, crying time, spontaneous startles and the progression to full arousal [1, 12, 14, 19].

How do we know this isn't also why infants with extra blankets stop waking?

Ultimately, I wonder how much is down to different fundamental beliefs about infant sleep..  Are young infants meant to sleep for huge stretches? (despite this currently being the social trend and most acceptable to the expectations of the majority of mothers, ie what sells).  It's rarely what happens as the norm for breastfed infants without some sort of training, which it surely would be if that's how infants were supposed to sleep.  We also know some mothers can struggle to maintain a milk supply and an infant their weight gain if night feeds cease early (prolactin levels are highest at night).  In younger infants longer/deeper sleep spells have also been linked to SIDS and it seems normal, if not desirable for an infant to rouse and signal frequently.  I'm not for a second suggesting anyone leaves an infant cold, but I'm not sure an infant not waking because they are hotter therefore shows this baby is more content or even was cold!  Infants can sleep longer sleep spells for other reasons - a drop in calories is a perfect example.  We could (as many parents do) assume the infant would wake if hungry, the fact they're sleeping long spells shows they must be happy!  In reality the infant starts to conserve energy and the consequence is a long sleep spell - perhaps long sleep is a consequence of too much bedding?

In contrast Tizzie feels:

"I am not sure if it is even the warmth the babies like or if it is that with more layers on they feel cosier and more secure. But I do know that the extra layers can stop babies from waking at night."

The expectation is sleep patterns comparable to that of an adult and if this doesn't happen there must be a reason, something that needs "fixing".

I would encourage readers to check out the full reply here: http://blog.saveoursleep.com/2011/07/28/in-responce-to-%E2%80%98the-analytical-armadillos%E2%80%99-blog/


REPLY RECEIVED FROM TIZZIE HALL:
Tizzie has notified me via email that she will not be responding further to any questions or discussions on this or other topics raised in her books.  I have been silenced from sharing any further details as she insists the email remains confidential; the only bit I am allowed to share is that she would not be answering further questions from myself or other bloggers.

COMMENT FROM DR FLANDERS MD, FRCPC

"Tizzie may or may not realize that she is attempting to manage quite a conflict of interest. When one stands to profit financially from the advice one offers, it becomes very difficult to maintain credibility. Medical advice NEEDS to be derived from solid scientific research that is free (to whatever extent possible) from bias. Tizzie may feel like she's contributing meaningfully to society by 'keeping babies safe' with her blankets. But the subconscious (perhaps conscious) drive to profit financially can undermine this ideal. There is a long and unfortunate history of industry tainting medical science, which repeats itself over and over again. Most recent case in point: http://nyti.ms/qZwZuh
Do be careful, Tizzie."

-------------------------

What do you think?  Do you feel reassured by Tizzie's reply?  Has it brought anything to the table you weren't aware of and which makes sense to you? Let me know below :)

Related Posts:

Tizzie Hall & FSID, a formal request for information please

FSID's formal reply to request for guidance re Tizzie Hall's advice

We don't DEMAND feed, we CUE feed...

de·mand

verb Insist on having A very firm statement that you want something

an outraged public demanded retribution.

Recently we have heard a lot about "feeding on demand", but I really don't think it accurately describes the breastfeeding relationship. Demand suggests insistence, provoking an almost hostile image of a mother with no choice but to yield to her baby's demands! Why not request feeding, or need feeding?

A far more accurate term is "cue feeding". We now know that crying is in fact a late sign of hunger, and by this stage young infants can easily have become uncoordinated and disorganised - making feeding more difficult when it does ensue.   Instead what research has shown is that infants run through a sequence of cues when they need to feed:  Regardless of how your baby is fed (breast or bottle) you can feed responsively.

1) Mouthing (Early cue): opening and closing the mouth rather like a goldfish. The infant then starts sucking their hand/fingers (sometimes a shirt collar if there's one handy)  Get ready to breastfeed...

2. Rooting (Active cue): Eyes open, baby begins "rooting", some try and lay themselves down into the feeding position,  others try and attach to the nearest thing (noses and chins seem particularly popular!). Baby's breathing may also become more rapid and he is likely to begin squirming and fussing if he cannot locate his food source.  This is when baby is primed to feed.

3.  Crying (Late Cue): If his earlier cues are ignored, baby moves on to his last cue, from squirming and fussing to crying.   This burns calories baby needs and can make latching on more difficult.  If he's very distressed sucking a clean upturned (ie nail down) little finger for a few seconds can help re-organise his suck.

Remember you can't overfeed or "spoil" a breastfed baby.  It will not create bad habits, nor create a "snacking" baby always at the breast - as they grow things naturally change and he will find a regular feeding pattern for himself.  If you are concerned about any aspect of feeding contact a lactation consultant, breastfeeding counsellor, or milkmatters.org.uk

ENJOY YOUR CUE FED BABIES!

Tizzie Hall & FSID, a formal request for information please (PART 1)

I am being contacted by an increasing number of mothers, concerned and confused by blanket guidelines provided by "Tizzie Hall, International Baby Whisperer and author of Save Our Sleep (SOS)".  These guidelines are so different to the information provided by other sources of SIDS guidance, and some mothers are concerned babies could be at risk of overheating - a factor we often hear linked with SIDS.  Tizzie Hall appears to claim the opposite however, that being cold is a bigger risk factor for SIDS.

Some mums claim they have asked Tizzie for evidence to support the blanket recommendations via her Facebook page, but have not received a satisfactory response.

Therefore I thought I would create a blog post to openly and clearly ask both Tizzie Hall, and the Foundation for the Study of Infant Deaths (FSID) for further information, evidence & guidance.

It is unfair that mothers receive such conflicting information and clarification is needed as to what evidence shows is safest for the prevention of SIDS.

A Facebook group named "The Dangers of Baby Training" sums up the problem neatly:

As an example, in a room heated to 20* C in the winter or cooled to 22*C in the summer, Tizzie hall suggests for those of us in the UK & ireland to use a vest, a sleepsuit/babygro, a 'double wrap' swaddle, a cotton sheet folded into 2, and 4 layers of blankets, preferably bamboo. Our UK/Ireland SIDS & government guidelines suggest a room temp of between 18-20*C, with your child wearing a vest, sleepsuit/babygro, a light swaddle or light sleeping bag (never both, as shown in TH's video guide on youtube), 1 cotton sheet and 1 lightweight blanket....and never advocates the use of more than 4 layers, even in the coldest of conditions. Why is there such a big difference?

Earlier this week, Tizzie's forum was available to non subscribed members, where apart from clarifying  the maximum blanket layers that should be used 

"on a newborn to 3 month old baby sleeping in a bassinet is 10 layers, a newborn to 3mth old baby sleeping in cot is 12 layers and a baby 4 months and over is 16 layers". (no reference to room temperature was made) 

also stated:

"Tizzie’s safe bedding guide is written on the amount of layers NOT how many tog those layers add up to. When we talk about references to the tog of a quilt in relation to the amount of bedding needed to keep your baby sleeping warm and safely this is an example to demonstrate that babies do require bedding to sleep safely. Cotton or Bamboo cellular blankets will trap warm air in to keep your baby warm enough to sleep safely with more efficiency than a adult quilt does. We do not need to achieve the same tog rating as a 14 tog quilt but we need to achieve the same warmth which is quite different when using cotton/bamboo blankets.

It was available here - but the page has since changed to read:

Access Denied

Error

Only members with sufficient permission can access this page.

with an option to login, so it appears one needs to register and pay now to obtain this post.

This confused one mum Fleur who posted on Facebook saying:

If you use her special bamboo blankets that she recommends, at the max 16 layers, at approx 0.6 tog each, that would put your child under a massive, surely dangerous 13.6 tog.... to put that in perspective, the average adult duvet here in the UK is 11-13 tog, which is considered 'winter weight.'

It does seem very confusing, if a mum creates 13.6 tog from layering, and if the above comments are correct that "cotton or bamboo cellular blankets will trap warm air in with more efficiency than a quilt would of the same tog", doesn't that mean the 13.6 tog of blankets will make baby even hotter than an equivalent quilt would?  It then gets more confusing as it states the aim is not to achieve the same tog rating as a duvet, because achieving the same warmth is different with blankets - but the layers can easily add up to the same tog rating as a duvet, no?

EDIT - I THOUGHT THESE CALCULATIONS WERE INCORRECT AS 0.6 TOG X 16 DOES NOT ADD UP TO 13.6 TOG.  I CHECKED FLEUR'S CALCULATIONS AND THE TOTAL TOG OF 16 BLANKETS BASED ON THE TOG FLEUR QUOTED OF 0.6 IS 9.6.


So I checked with Fleur:

"On my calculation of the tog rating - Tizzie's fans have repeatedly told me that the tog rating of her bamboo blankets is 0.64 tog x 16= 10.24 tog (apparently she has had them tested.) and a cotton sheet folded in 2, at approx 0.2 tog (x2= 0.4 tog). I also included in my calculations the toggage (made up word, lol) of the 'safe sleeping bags' that she sells, which will be either 1 tog or 2 tog, depending which one you choose, and the tog of the 'double wrap' which again, equates to 4 layers in itself (2 inside wrap pieces and 2 outside fold over bits) which again, could be anywhere from 1 tog to 4 tog, depending on the material used). I didnt include the tog of a vest, a sleepsuit or a nappy. That was how i worked out the approx 13+ tog.

Vest	0.2
Babygro	1
Jumper	2
Trouser	2
Nappy (disposable)	2 (less when wet)
Sleep suit	4
Sheet	0.2

I'm optimistic however that Tizzie Hall will have evidence to share with us, because of the next half of her comment:

We have observed that many of you have been trying to achieve the total tog of the Save Our Sleep® recommended blankets with other brand blankets but we do not advise that you do this. This is because you need to use too many layers of other blankets to achieve the same warmth as the Save Our Sleep® blankets for your baby to sleep safely. Using anymore than the recommended amounts listed above is not safe.

This confused the founder of Dispelling Breastfeeding Myths:

"What I'd REALLY like to know is whether her products conform to BS8510 (describes tog testing for baby products, the concern here being to ensure that babies do not overheat)? Otherwise how is a parent to have any clue about the level of thermal insulation their child is going to experience when layering up her products? That's the whole reason for the tog system in the first place... She says her blankets work in a different way - but BS 8510: 2009 'specifies requirements for the safety of sleep bags for the use of children with a minimum weight of 4 kg designed to provide sufficient warmth SO AS TO REMOVE THE NEED FOR ADDITIONAL BEDDING when sleeping in a cot or similar product in which a child is contained.'

Tizzie doesn't advise anyone uses blankets other than her own brand?  Why - if a mum needs to use more than the 10-16 layers recommended to achieve the same warmth as the branded blankets - there surely must be a unique factor?  Ultimately the tog rating of blankets is comparable, regardless of brand.  (In case anyone wonders, blankets range from £18.50 - £46.30 each depending upon which you choose. This makes the cost of 16 blankets £296-£740.80, not including spares for washing ie if they vomit to manipulate as Tizzie confirms they may, or sheets.)

Secondly In order to state using different brands or more blankets is unsafe - one must have identified and proven ie tested what is safe? Otherwise how could you know that more or different brands would be unsafe?  Plus I'm sure nobody would give parents so directly contradicting official SIDS advice without having hard evidence, because that would be madness right?

And it does directly contradict FSID as they state:

Babies who get too hot are at an increased risk of cot death. They can get too hot because the room is too hot or because they have too much bedding or clothing. The ideal room temperature is 16-20ºC.

In 2008 researcher at the University of Calgary showed that thermal stress, can lead to an increased risk of Sudden Infant Death Syndrome (SIDS). Increased ambient temperature such as over-wrapping a baby at night time or increasing the room temperature can affect the baby's pattern of breathing.
Australia's Practical Parenting magazine published the following, and is based on baby wearing nappy/vest/babygro plus a cotton sheet:

Room temp	No of blankets
12 ⁰	4 layers
14 ⁰	3-4 layers
16 ⁰	3 layers
18 ⁰	2 layers
20 ⁰	1-2 layers
22 ⁰	1 layer
24 ⁰	Sheet only

Here is the information from Gro-bag (a company that makes baby sleeping bags)

and details of what should go with the recommended tog sleeping bag:

I decided to try and ask Tizzie Hall direct on her Facebook page:

and a close up of my message:

The response wasn't under my post, but as a new message:

So I went to visit the page I was told to and you too can read it here 

"As all of you know before giving any advice I do countless hours of research so I stand by all of my advice. These ladies don’t seem to be aware of the current SIDS guidelines stating as long as your babies head and face are uncovered and you are using cotton or bamboo bedding then it is perfectly safe to layer up the amount of these blankets to keep your baby warm. My opinion and research shows this in return keeps our babies in the safe back sleeping position. Also it is now clear overheating is only cited a risk factor and not as big a factor as was first thought but we do live in a generation with parents so scared of over heating their babies they are doing the opposite and under heating them which in my opinion a greater factor because a cold baby will roll to his or her tummy and sleep face down in the mattress.

These concerned parents may not be aware of my research that shows that if a baby is cold and not warm enough in bed they will, as soon as they are able, roll to their tummy, tuck their knees and arms in under their body, stick their bottom in the air with their face pressed down in the mattress to try and warm up, which of course we know is a very dangerous sleeping position for a baby and toddler. New research shows this causes less oxygen to get to the brain and could be connected to SIDS.

Link to research http://pediatrics.aappublications.org/cgi/content/abstract/127/3/e558
Having had a personal experience of loosing a sibling to SIDS I am passionate about baby safety and ensuring everything I recommend down to the bodysuit your baby wears and the toys your baby plays with are the safest on the market."

So of course I checked out the quoted research.

Cerebral Oxygenation Is Depressed During Sleep in Healthy Term Infants When They Sleep Prone

SUBJECTS AND METHODS: Seventeen healthy term infants (8 girls and 9 boys) were recruited as study participants. Infants were studied at ages 2 to 4 weeks, 2 to 3 months, and 5 to 6 months by use of daytime polysomnography, with additional measurements of blood pressure

RESULTS: In infants who slept in the prone position, tissue oxygenation index was lower in both quiet sleep and active sleep at age 2 to 4 weeks and in quiet sleep at age 2 to 3 months. Tissue oxygenation index was lower in active sleep compared with quiet sleep in infants aged 2 to 4 weeks (P < .05). When the infants reached 5 to 6 months of age, tissue oxygenation index was greater in active sleep, as there was a profound decrease in tissue oxygenation index during quiet sleep over this period. 

All this tells us is that oxygenation index for a young infant is reduced in the prone position.  Isn't that the whole point of the "Back To Sleep" campaign?  Again Tizzie stated: my research that shows that if a baby is cold and not warm enough in bed they will, as soon as they are able, roll to their tummy, tuck their knees and arms in under their body, stick their bottom in the air with their face pressed down in the mattress to try and warm up.


THIS is the research we would like to see Tizzie please?

Otherwise it's just confusing for parents:

"Once a baby is strong enough to roll onto his stomach by himself, you don't need to worry about him staying on his back all night. This is especially true if he's been enjoying playtime on his tummy during the day, can hold his head up well, and can roll from his tummy onto his back again by himself." 

Fern R. Hauck, M.D., M.S professor of family medicine and public health sciences at the University of Virginia

"Losing sleep because your former back snoozer is now flipping onto his tummy? You probably don't need to risk waking him by trying to roll him back. If your baby can get himself onto his tummy, he can usually get himself off it, because rolling from back to tummy is the tougher milestone (try it yourself and you'll see what we mean).
By the time your baby has mastered rolling around, the SIDS risk has dropped dramatically"

Learning to Roll Over, By Anita Sethi, Ph.d

Has Tizzie measured the vital statistics of infants under 16 blankets? Unless the blankets are weighless, what is the impact of the weight of this on top of baby to their oyxgen sats?

I hope we can obtain some evidence and further clarification for mothers and will update should either party respond!

PS Sears also conducted a small experiment with fascinating results:

"In 1992 we set up equipment in our bedroom to study eight-week-old Lauren's breathing while she slept in two different arrangements. One night Lauren and Martha slept together in the same bed, as they were used to doing. The next night, Lauren slept alone in our bed and Martha slept in an adjacent room. Lauren was wired to a computer that recorded her electrocardiogram, her breathing movements, the airflow from her nose, and her blood oxygen level. The instrumentation was painless and didn't appear to disturb her sleep.

A technician and I observed and recorded the information. The data was analyzed by computer and interpreted by a pediatric pulmonologist who was "blind" to the situation—that is, he didn't know whether the data he was analyzing came from the shared-sleeping or the solo-sleeping arrangement.

Our study revealed that Lauren breathed better when sleeping next to Martha than when sleeping alone. Her breathing and her heart rate were more regular during shared sleep, and there were fewer "dips," low points in respiration and blood oxygen from stop-breathing episodes. On the night Lauren slept with Martha, there were no dips in her blood oxygen. On the night Lauren slept alone, there were 132 dips. The results were similar in a second infant, whose parents generously allowed us into their bedroom."

UPDATE ONE
I posted a link to my blog in the hope of a response, but I then checked back and it has been deleted.

I am unsure why Tizzie Hall would simply delete a polite post asking for clarification on her methods?  I have emailed her a link to this blog, just in case her admin team is deleting these message, unaware how this appears.

UPDATE TWO:
I have received a reply to my email giving a reason why Tizzie hasn't yet answered - however they have marked the email CONFIDENTIAL, so I guess I can't share any more than that!  Should I receive an answer from Tizzie answering any points raised in the blog, I will advise that unless the confidential disclaimer is removed from her email, thus allowing me to share the contents with readers - I will not be able to post in on the blog as an official response.


UPDATE THREE:

I have received a (very speedy) response from FSID, excerpt below:

"We have read your article and are more than willing to respond, my colleague who would normally do this is out of the office today, so we will let you have something shortly."

UPDATE FOUR:
FSID Excerpt: Dear Analytical Armadillo.

Thank you very much for your email. So sorry for the delay, but our Scientific Adviser, Prof Haycock, is preparing a detailed response with all the research references for you.  I’m hoping he will send me the document by Friday.

UPDATE FIVE:  Tizzie Hall submits a formal reply:
http://blog.saveoursleep.com/2011/07/28/in-responce-to-‘the-analytical-armadillos’-blog/

UPDATE SIX:  Armadillo reply to Tizzie Hall's formal response:
http://www.analyticalarmadillo.co.uk/2011/07/armadillo-reply-to-tizzie-halls.html

UPDATE SEVEN: FSID submits a formal reply::
http://www.analyticalarmadillo.co.uk/2011/07/fsids-formal-reply-to-request-for.html

UPDATE EIGHT:  Tizzie replies to the FSID response:http://www.analyticalarmadillo.co.uk/2011/07/tizzie-hall-responds-to-fsid.html


UPDATE NINE: Contradictions in Tizzie Hall's response to FSID: http://www.analyticalarmadillo.co.uk/2011/07/contradictions-in-tizzie-halls-response.html

WHAT OTHERS ONLINE ARE SAYING:

• Discussion of this blog entry @ rollercoaster
• Blog entry about Tizzie's methods that links to this page
• Discussion general regarding Tizzie Hall from concerned parents @ rollercoaster