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."