News: Bed-sharing raises cot death risk fivefold

Screams the BBC headline today, followed by "The risk applies even if parents avoid tobacco, alcohol and drugs - other factors firmly linked to cot deaths."

Several organisations have responded with statements highlighting why 15-26 year old data, collected in different countries at different time points, using different methods and definitions for data collection might not be the most reliable of evidence.  The first is a report from the fantabulous folk at ISIS, big thanks to them as they've saved me a lot of blogging time!

There's also one from UNICEF, and another from the NCT.

I think Isis cover the science side well in terms of picking apart why we shouldn't discount all the existing, contradictory studies because of this one piece, so here's a few thoughts of mine that sprang to mind:

Nestled within the study, researchers note:

• "Bottle feeding increases the risk of SIDS. When analysed as a single factor, the OR for bottle feeding is 2.9 (2.5 to 3.3), the multivariate AOR is 1.5 (1.2 to 1.8)."

But this didn't seem to make the headlines...Funny that...

Perhaps this is why the comments some have shared from parenting forums today, include those from  parents who cannot understand why anyone would consider bedsharing given the risks, whilst themselves exclusively bottle feeding?

On the subject of bedsharing and breastfeeding the researchers state:

"When the baby is breastfed and under 3 months, there is a fivefold increase in the risk of SIDS"

Cripes right!  I'm sure to make such a sweeping claim the authors must have carefully considered data surrounding breastfed infants?  

Let's check out their criteria!

"Breastfed: infant was being partially or completely breastfed at the time of death or interview." 

Meaning if the baby goes to the breast once per day for 5 mins he is, for the purpose of this study considered "breastfed", despite the fact other studies have suggested a dose related risk.  Should exclusive v mix fed be considered separately, it's entirely feasible that we would note even more statistically dramatic differences in outcome as have been highlighted in other studies.

• Suffocation or SIDS?  It seems researchers included cases where suffocation occurred, because the characteristics are similar.  Yet despite this there is no consideration for other pretty significant known risk factors:

• No mention of bedding or other variables...

Did the babies usually co-sleep and so the sleep space had been altered accordingly (removing pillows/preventing baby becoming wedged etc) or had the parent(s) brought the baby into bed occasionally or even for the first time that night?  Could any of the babies have been unwell during the day which in turn could have led to bedsharing when they typically didn't?

Were the babies swaddled?

What about room temps (which can vary massively depending upon location and are another known risk factor)   

What types of bedding were involved?

Without considering all of the above, the guideline is simply to cot sleep?  Despite the fact babies die in cots too.

As I was pondering how to conclude this post, this must read response paper plopped into my inbox - which neatly sums up all there really is to say on the subject.

So I'm going to close with some personal thoughts about sleep, based on my own two (ie entirely anecdotal).  

With number one we didn't co-sleep, we had a moses basket and then a cot.  I was exhausted from getting up frequently to feed (as newborns typically do so often!) and I nearly fell asleep numerous times during night feeds; something we know is a significant risk factor for SIDS.

Even with a moses basket you have to sit up, lean to reach them and then get up again when the feed has finished.  My daughter was windy and so often after getting settled we would have to "rinse and repeat" numerous times - all with that super responsive startle reflex young babies have when they are being lowered, arms flailing out to grasp as they panic they are being dropped.

If mum has to return to work you can see how easily the appeal of a bottle someone else can give, sleep training and a sleep "routine" become so normalised.  Indeed mothers who bed-share tend to breastfeed longer and maintain exclusive breastfeeding longer than those who do not.1–3  Therefore surely studies need to offset the increased rates of formula feeding, and thus increased risk of SIDS that may follow any recommendation that all should use cots?

The second time around we were more aware of the works of people like Mckenna, has considered different "cultural norms" and so we used a combination of a bedside cot and bed sharing between myself and the cot.  We ensured there were no gaps he could get wedged in, or soft bedding within his reach.

Night feeds were easy, no crying as I would rouse as he did.  No sitting up and getting in and out of bed meant neither of us woke fully, and thus needed much less settling (plus parents know young babies settle so much easier next to mum!).  Regardless of how many nightfeeds he had I was never shattered  - making continued breastfeeding with unrestricted night feeds easy despite returning to work part time, something UNICEF also acknowledge.

The unrestricted part may indeed be important as we also know from studies considering pacifier use that sucking to sleep can reduce SIDS risk if the pacifier is used at every sleep, indeed the Academy of Breastfeeding Medicine say:

"As exclusively breastfed infants feed frequently through the night, breastfeeding is thought to reduce SIDS by the same proposed mechanism as supine sleep and pacifiers, namely less deep sleep and frequent brief awakenings. Breastfed babies do not need artificial pacifiers to get stimulation since they already have the protective effect of suckling during the night."

A study promoted by FSID to support pacifier use also suggested increased risk of SIDS if an infant normally has a pacifier, but does not have one at the last sleep. The same may therefore potentially be true of "sleep training" a breastfed infant, if the techniques include "self soothing" or "teaching" the baby to sleep without sucking for fear of "bad habits".

Lastly we never needed to try and hinder his natural reflexes with techniques such as swaddling (something linked to increased respiratory rate 4–5).

None of this is considered in a study that didn't even separate out those exclusive breastfeeding from those having "some breastmilk", before making sweeping recommendations all babies should sleep alone.  Seriously?

References:

1. Ball HL 2003, Breastfeeding, bed sharing and infant sleep. Birth. 30(3): 181-188.
2. Blair PS, Heron J, Fleming PH 2010, Relationship between bed sharing and breastfeeding: Longitudinal, population-based analysis Pediatrics 126(5): e1119-e1126.
3. McCoy RC, Hunt CE, Lesko SM, Vezina R, Corwin MJ, Willinger M, Hoffman HJ, Mitchell AA 2004, Frequency of bed sharing and its relationship to breastfeeding Dev Behav Pediatr. 2004, 25(3): 141-14.
4. 11. Gerard CM, Harris KA, Thach BTT. Physiologic Studies in Swaddling: An ancient childcare practice, which may promote the supine for infant sleep. J Pediatr. 2002;141:398–404. [PubMed]
5. Narangerel G, Pollock J, Manaseki-Holland S, Henderson J. The effects of swaddling on oxygen saturation and respiratory rate of healthy infants in Mongolia. Acta Paediatrica. 2007;96:261–5.

The NHS lacks compassion when it comes to breastfeeding...

Is the headline in the Daily Telegraph today.

Sally Peck talks us through her experience trying to breastfeed her tongue tied baby.  It seems that despite early diagnosis of the problem, Sally ended up waiting four weeks for treatment.  Furthermore even though her baby was struggling to breastfeed, she was told not to supplement formula as this would lead to further problems.

Sally explains:

"NHS guidelines require a new baby to be under observation for at least a week before the tongue tie is dealt with - though no one told me this until my son was nearly a week old, despite the fact that many midwives in hospital and three excellent community midwives saw him and confirmed the initial tongue tie diagnosis."

This is all despite the fact there were very clear signs both mum and baby were struggling:

"We therefore spent two weeks with a very hungry baby, who lost 13 percent of his already modest (for his size) birth weight, and a mother with very sore nipples."

Sally comments her husband asked whether the baby should be supplemented formula but:

"The universal response from the NHS workers was NO! Substituting formula would confuse him, it wasn't necessary, it would deter him from latching on once the tongue was separated, and it would confuse my breasts in terms of how much milk they ought to produce."

Her beef (quite rightly) is what should we do, let babies starve?  The NHS shouldn't be so down on formula if the baby is hungry and can't feed well; and look here's some evidence showing early formula helps extend breastfeeding duration!

Well quite, in a system as FUBAR as Sally describes, I'm totally with the theory that some supplementation may actually improve breastfeeding rates overall!  If the alternative is having a distressed, clearly hungry baby  who is losing or unable to gain adequate weight (for a month!) of course many mothers will opt to stop breastfeeding if supplementation is shunned.

That's without taking into consideration that a baby intaking significantly less calories than they need, becomes even less effective at feeding which may further deplete mum's morale, raise her anxiety levels and pose significant health risks.

Throw some pain into the mix and it can quickly turn what is already an emotionally intense time into a severe cause of stress (which coincidentally further hinders breastfeeding by reducing the amount of milk released with mum's milk ejection or "letdown").

But surely, ultimately the problem is the FUBAR system, not the sticking plaster that is formula?

If nobody will treat the cause of baby's feeding issues, nor help the mum in what could be any number of ways to increase the amount of breastmilk her baby is receiving, how on earth can we then tell them they shouldn't use formula either?

Since when do we have to wait a week to treat a tongue tie?  Which NHS trust decided this?  It's not on the NHS page here, nor is in the NICE guidelines which state:

"If the condition is causing problems with feeding, conservative treatment includes breastfeeding advice and counselling, massaging the frenulum, and exercising the tongue*. Some practitioners, however, believe that if a baby with tongue-tie has difficulty breastfeeding, surgical division of the lingual frenulum should be carried out as early as possible. This may enable the mother to continue breastfeeding rather than having to switch to artificial feeding."

* I have never been able to find any evidence that massaging or exercising the tongue carries any benefit.  I contacted NICE who said it had been information a consultant provided at the time of drafting guidelines, but they couldn't provide me with any evidence base.

Frenulotomy, the term for treatment of tongue tie is a minor procedure (so much so our local ENT doesn't even take the baby out of their baby carrier!).    The risks are small, infection rate is minimal (estimated around 1 in 10,000) yet the risks of formula include potentially sensitising baby to a cow's milk allergy and changing the gut flora, the effects of which may be far wider reaching.

If for some reason this isn't possible, helping mum optimise attachment, showing her how to massage her breasts to help her baby receive as much colostrum/milk as possible should come next.

If baby is still shows signs of insufficient intake, showing mum how to hand express is the next option.  We run into a problem here however as some midwives don't know how to effectively hand express, so they give a mum expressing drops of a colostrum a huge hospital grade pump; epic fail (as my youngest would say!).

If baby still needs more, where is the NHS supply of donor milk?  If they're not prepared to rectify the cause of the feeding problems, surely an alternative from the same species should be on offer?

If not, it appears to me the only option is formula?  It was once said to me years ago that the first rule always has to be "feed the baby".  Yep there are risks to formula, but then again losing 13% of your body weight is hardly risk free.

Mums reaching breaking point and throwing in the towel totally because it's painful and their baby is constantly unsettled and wanting to be at the breast 24/7 - dreading each feed, putting off holding her baby incase he wants to feed, struggling to bond, isn't risk free.

How do we quantify all these risks?

I'm not sure how formula would "confuse the baby", very hungry babies don't organise and latch on too well either!  As for the claims it would impact on mum's supply, perhaps if someone was helping her drain them sufficiently and use that for the supplement, we wouldn't be having the debate!  Before mum's milk comes in, the process is hormone driven.  Once it has, showing her how to drain her breasts well will protect her supply.

Here is a bit of a news flash, but a baby who is effectively starving, isn't transferring milk well - whether mum gives the baby another milk or not is a moot point, her breasts are not getting the milk removed and thus supply may suffer! (I say may as constant removal of small amounts of milk seems to trigger an over supply in some mothers.)

The NHS do need to up their game, but on a much bigger scale than simply advocating formula use.

For UK independent in person breastfeeding support please visit my site: www.milkmatters.org.uk