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.