Baby Sleep: In Defense of Back to Sleep
Submitted by SIDSEducator
Introduction
First, it is important to note that baby sleeping practices can be a hot-button emotional and/or cultural issue for some caregivers. After all, every parent wants what is best for her baby, and I do not have any doubts that all of the parents on this site are doing everything they can to ensure that their babies thrive in every possible way. However, there appears to be a lot of conflicting information out there and I would like to address some of the claims being made in order to ensure that everyone visiting this site has all of the information.
Sudden Infant Death Syndrome (SIDS) refers to the sudden and unexpected death of an apparently healthy infant, less than one year of age, which remains unexplained after a complete medical history, death scene investigation, and autopsy. SIDS has been around for centuries, and in the past, was referred to as "crib death." Although scientists have been learning more about SIDS in recent years, it is still somewhat of a mystery.
However, after several large studies demonstrated that placing babies on their backs to sleep could reduce the incidence of SIDS, the American Academy of Pediatrics began recommending that healthy infants be placed on their backs to sleep. This recommendation came in the mid-1990s and resulted in a 50 percent decrease in SIDS cases in the U.S. After this initial drop, the number of SIDS cases has leveled off and remained fairly static during the past decade. The AAP continues to recommend that babies be placed in a crib on their backs without soft bedding, pillows or other objects that may pose any type of barrier to the baby's breathing. While it not possible to predict or prevent the occurrence of SIDS, it is reasonable to wonder if rates would drop even lower if every caregiver adhered to the recommendations of Back to Sleep every time their baby slept.
There are proponents of sleep practices that directly oppose the recommendations of the "Back to Sleep" campaign, which deliver a simpler message: "Do what feels right." If you need to put your baby in bed with you in order for them to be calm, then do so. If your baby prefers tummy or side sleeping, it must be because the baby "knows" what its own safest sleep position is. It is a very seductive message, especially for new parents who are sleep deprived and emotional from the dramatic transformation that has occurred in their lives with the introduction of their new baby. It may not feel natural for a parent put her baby in a separate sleeping space, especially when the baby is fussing. After all, mothers share the same body with their babies for nine months and it only seems natural to be as close as possible to them when they are sleeping. Similarly, I would imagine that it might feel uncomfortable strapping an infant in a car seat the first few times, especially if the infant is distressed by being placed in the seat. However, it is universally acknowledged that this is necessary for safety. Why is this not the case with Back to Sleep? Or, it may not look cozy to place a baby on his back in an empty crib. As adults, we are used to soft pillows and blankets galore and many of our own parents put us on our tummies to sleep—we turned out OK, didn't we?
The epidemiological data and research on SIDS and accidental suffocation is a more complex issue to understand. However, the AAP's recommendations are backed by substantial research and have no other agenda than to reduce the risk of SIDS and accidental suffocation, while at the same time promoting the overall health and safety of children. While I am not suggesting that parents should never question the medical establishment, I would propose that it requires a lot of research and digging deeper to really see the problems with many of the arguments against Back to Sleep. AAP recommendations must go through a rigorous 2-3-year review process, before their recommendations are made public. These same standards are not applied to the recommendations of Dr. Sears and others whose recommendations against Back to Sleep often draw upon anecdotal arguments, or smaller research studies that are not as strong.
In the interest of making sure that everyone has all of the information, I would like to address some of the arguments against Back to Sleep.
Claim #1) The reduction in SIDS deaths is due to a diagnostic shift, rather than the success of the Back to Sleep campaign. This argument refers to the shift in medical examiners' practice to classify more deaths as accidental suffocation that would have been classified as SIDS in the past. This shift is actually due to the increased understanding among medical professionals that babies are less likely to succumb to either SIDS or accidental suffocation when they are placed on their backs, in a crib, with nothing else in the crib to pose a barrier to their breathing.
Accidental suffocation in this case refers to the process of re-breathing exhaled carbon dioxide. Scientists who study SIDS believe that a baby can actually suffocate when an object (such as a blanket, pillow, bumper pad, sleep positioner, or even the baby's mattress if he is on his tummy) blocks adequate oxygen from entering the baby's breathing space. This type of suffocation occurs silently and rapidly, usually while the baby is sleeping. The trend for MEs is to use SIDS only as a diagnosis of exclusion, when there are no possible barriers to the babyâs breathing (i.e., when the baby is found alone, on its back, in a crib with no soft bedding, etc.)
The explanation of the diagnostic shift also answers Claim #2: More SIDS deaths occur in cribs than in adult beds. Logically, if MEs are not classifying deaths as SIDS when the baby is found in an unsafe sleeping environment, they are not classifying deaths in adult beds as SIDS. The deaths are still occurring; they are just being classified as accidental suffocation rather than SIDS.
Data on infant deaths in the CDC Wonder database, shows that from 1995-1998, 12,281 infant deaths were classified as SIDS (a rate of 0.79 per 1,000), while 645 (a rate of 0.04 per 1,000) were classified as accidental suffocation. From 1999-2002, 9,696 infant deaths were classified as SIDS (a rate of 0.60 per 1,000) and 1,340 were classified as accidental suffocation in bed. The data from 1999-2002 reflect the effects of the Back to Sleep campaign which took place in the mid 1990s. While there is some evidence of a diagnostic shift, the combined rate and number of deaths from SIDS and accidental suffocation was down significantly in 1999-2002 from where it was in 1995-1998. This data conclusively shows that the Back to Sleep campaign did reduce the overall number of deaths and therefore does provide compelling evidence for the safety of these recommendations in reducing the risk of both SIDS and accidental suffocation.
It is important to note that the Back to Sleep recommendations do not claim to prevent or eliminate the risk of SIDS; they reduce the risk. Currently, scientists who study SIDS propose a Triple Risk Model for SIDS. According to this model, there are three factors which may be contributing to SIDS deaths. The first factor is the infant's Critical Development Period. This period encompasses the first 6 months of life, when the infant is developing so rapidly that its bodily systems are unstable. 90% of SIDS deaths occur during the first 6 months of life and 70% occur between 2-4 months. The second factor is the Vulnerable Infant. Scientists believe that infants who are vulnerable to SIDS may have a brainstem abnormality which affects their ability to regulate respiration, heart rate, body temperature, and other bodily functions. This abnormality is not something that can be diagnosed at this time, so it is not possible to know whether or not an infant presents as vulnerable. The third factor is External Stressors, which a typical baby is normally able to overcome and survive, but that an infant that presents as vulnerable is not. External Stressors may include exposure to second-hand smoke, tummy sleeping, a soft object that poses a barrier to breathing, or a respiratory infection. While none of these stressors alone cause an infant to die, they may be a trigger for an infant who is already vulnerable. http://www.firstcandle.org/grieving-families/sids-suid/about-sids-suid/triple-risk-theory/
Claim #3) Back sleeping poses health risks to infants. Studies have actually shown that babies who are placed on their backs have fewer fevers, ear infections, and stuffy noses than babies who are placed on their tummies. http://www.sids-network.org/experts/infant-sleep-position-hunt.pdf
In addition, the concerns about impaired gross motor function, plagiocephaly (flat spots on the head), and other injuries due to babies spending too much time on their backs are avoidable when caregivers allow their babies to have plenty of supervised, awake tummy time. This way, babies can benefit from the same perceived âadvantagesâ of tummy sleeping, without the increased risk for SIDS and/or accidental suffocation associated with tummy sleeping. http://pediatrics.aappublications.org/cgi/content/full/117/3/994
Claim #4) Back sleeping results in a less restorative rest for babies which may be harmful. While studies have demonstrated that infants who sleep on their backs may experience decreased sleep duration, decreased non-REM sleep, and increased arousals; this effect peaks at 2 to 3 months of age and is not evident at 5 to 6 months of age. Since current scientific research indicates that a brainstem abnormality which results in a failure to arouse or respond to life-threatening circumstances may play a role in SIDS, a decreased arousal threshold is actually a good thing, especially since it occurs during the peak of SIDS risk between 2-4 months. In addition, back sleeping recommendations have been in place in many countries since the early 1990s and there has been no indication that back sleeping has had lasting negative effects on infant growth and development. http://pediatrics.aappublications.org/cgi/content/full/117/3/994
Claim #5) Many other countries routinely practice bed-sharing and do not have increased rates of SIDS. Just as there is some inconsistency in the United States regarding the classification of SIDS deaths, it is reasonable to assume that these deaths are occurring in other countries and simply not being documented in the same way. In addition, these cultures may be practicing bed-sharing in a way that is very different from the way it is practiced in the U.S. For example, with firm mats on the floor, separate mats for the infant, and/or the absence of soft pillows and bedding. http://pediatrics.aappublications.org/cgi/reprint/117/3/994
Claim #6) Infants may spit up and choke while sleeping on their backs. In fact, the opposite is true—babies are less likely to choke when sleeping on their backs. When babies sleep on their back, the esophagus (food pipe) is below the trachea (wind pipe.) As a result, the spit-up or vomit cannot be breathed into the wind pipe. When a baby sleeps on his stomach, the food pipe is above the wind pipe. Gravity would then allow for the spit-up/vomit to be breathed in, causing the baby to choke. Since babies have been sleeping on their backs, studies worldwide have not found any increase in the incidence of aspiration, choking, pneumonia or other problems. http://www.firstcandle.org/new-expectant-parents/about-sids-suid/sudden-infant-death-syndrom-sids-faq/#11
Claim #7) Healthy babies are not at risk for SIDS. While it is true that current research points to a brain stem defect as a possible contributing factor to SIDS, it is not possible to know at birth if a baby has this defect or not. In most cases of SIDS, the babies seem to be perfectly healthy and functioning normally before the episode occurs. While certain factors such as low birth weight, premature birth, and exposure to smoke can increase a baby's risk for SIDS these factors are by no means present in all SIDS cases.
Conclusion
It is not my intention (nor, I believe, the intention of the Back to Sleep campaign) to scare parents or to make their lives more difficult. It is simply the case that when SIDS cases occur, parents cannot go back and do things differently. While it is true that we do not know everything about SIDS, and it cannot be fully prevented, we do know that cases are much more rare when Back to Sleep recommendations are followed. My intention is for this information to be empowering to parents, not scary.
First, it is important to note that baby sleeping practices can be a hot-button emotional and/or cultural issue for some caregivers. After all, every parent wants what is best for her baby, and I do not have any doubts that all of the parents on this site are doing everything they can to ensure that their babies thrive in every possible way. However, there appears to be a lot of conflicting information out there and I would like to address some of the claims being made in order to ensure that everyone visiting this site has all of the information.
Sudden Infant Death Syndrome (SIDS) refers to the sudden and unexpected death of an apparently healthy infant, less than one year of age, which remains unexplained after a complete medical history, death scene investigation, and autopsy. SIDS has been around for centuries, and in the past, was referred to as "crib death." Although scientists have been learning more about SIDS in recent years, it is still somewhat of a mystery.
However, after several large studies demonstrated that placing babies on their backs to sleep could reduce the incidence of SIDS, the American Academy of Pediatrics began recommending that healthy infants be placed on their backs to sleep. This recommendation came in the mid-1990s and resulted in a 50 percent decrease in SIDS cases in the U.S. After this initial drop, the number of SIDS cases has leveled off and remained fairly static during the past decade. The AAP continues to recommend that babies be placed in a crib on their backs without soft bedding, pillows or other objects that may pose any type of barrier to the baby's breathing. While it not possible to predict or prevent the occurrence of SIDS, it is reasonable to wonder if rates would drop even lower if every caregiver adhered to the recommendations of Back to Sleep every time their baby slept.
There are proponents of sleep practices that directly oppose the recommendations of the "Back to Sleep" campaign, which deliver a simpler message: "Do what feels right." If you need to put your baby in bed with you in order for them to be calm, then do so. If your baby prefers tummy or side sleeping, it must be because the baby "knows" what its own safest sleep position is. It is a very seductive message, especially for new parents who are sleep deprived and emotional from the dramatic transformation that has occurred in their lives with the introduction of their new baby. It may not feel natural for a parent put her baby in a separate sleeping space, especially when the baby is fussing. After all, mothers share the same body with their babies for nine months and it only seems natural to be as close as possible to them when they are sleeping. Similarly, I would imagine that it might feel uncomfortable strapping an infant in a car seat the first few times, especially if the infant is distressed by being placed in the seat. However, it is universally acknowledged that this is necessary for safety. Why is this not the case with Back to Sleep? Or, it may not look cozy to place a baby on his back in an empty crib. As adults, we are used to soft pillows and blankets galore and many of our own parents put us on our tummies to sleep—we turned out OK, didn't we?
The epidemiological data and research on SIDS and accidental suffocation is a more complex issue to understand. However, the AAP's recommendations are backed by substantial research and have no other agenda than to reduce the risk of SIDS and accidental suffocation, while at the same time promoting the overall health and safety of children. While I am not suggesting that parents should never question the medical establishment, I would propose that it requires a lot of research and digging deeper to really see the problems with many of the arguments against Back to Sleep. AAP recommendations must go through a rigorous 2-3-year review process, before their recommendations are made public. These same standards are not applied to the recommendations of Dr. Sears and others whose recommendations against Back to Sleep often draw upon anecdotal arguments, or smaller research studies that are not as strong.
In the interest of making sure that everyone has all of the information, I would like to address some of the arguments against Back to Sleep.
Claim #1) The reduction in SIDS deaths is due to a diagnostic shift, rather than the success of the Back to Sleep campaign. This argument refers to the shift in medical examiners' practice to classify more deaths as accidental suffocation that would have been classified as SIDS in the past. This shift is actually due to the increased understanding among medical professionals that babies are less likely to succumb to either SIDS or accidental suffocation when they are placed on their backs, in a crib, with nothing else in the crib to pose a barrier to their breathing.
Accidental suffocation in this case refers to the process of re-breathing exhaled carbon dioxide. Scientists who study SIDS believe that a baby can actually suffocate when an object (such as a blanket, pillow, bumper pad, sleep positioner, or even the baby's mattress if he is on his tummy) blocks adequate oxygen from entering the baby's breathing space. This type of suffocation occurs silently and rapidly, usually while the baby is sleeping. The trend for MEs is to use SIDS only as a diagnosis of exclusion, when there are no possible barriers to the babyâs breathing (i.e., when the baby is found alone, on its back, in a crib with no soft bedding, etc.)
The explanation of the diagnostic shift also answers Claim #2: More SIDS deaths occur in cribs than in adult beds. Logically, if MEs are not classifying deaths as SIDS when the baby is found in an unsafe sleeping environment, they are not classifying deaths in adult beds as SIDS. The deaths are still occurring; they are just being classified as accidental suffocation rather than SIDS.
Data on infant deaths in the CDC Wonder database, shows that from 1995-1998, 12,281 infant deaths were classified as SIDS (a rate of 0.79 per 1,000), while 645 (a rate of 0.04 per 1,000) were classified as accidental suffocation. From 1999-2002, 9,696 infant deaths were classified as SIDS (a rate of 0.60 per 1,000) and 1,340 were classified as accidental suffocation in bed. The data from 1999-2002 reflect the effects of the Back to Sleep campaign which took place in the mid 1990s. While there is some evidence of a diagnostic shift, the combined rate and number of deaths from SIDS and accidental suffocation was down significantly in 1999-2002 from where it was in 1995-1998. This data conclusively shows that the Back to Sleep campaign did reduce the overall number of deaths and therefore does provide compelling evidence for the safety of these recommendations in reducing the risk of both SIDS and accidental suffocation.
It is important to note that the Back to Sleep recommendations do not claim to prevent or eliminate the risk of SIDS; they reduce the risk. Currently, scientists who study SIDS propose a Triple Risk Model for SIDS. According to this model, there are three factors which may be contributing to SIDS deaths. The first factor is the infant's Critical Development Period. This period encompasses the first 6 months of life, when the infant is developing so rapidly that its bodily systems are unstable. 90% of SIDS deaths occur during the first 6 months of life and 70% occur between 2-4 months. The second factor is the Vulnerable Infant. Scientists believe that infants who are vulnerable to SIDS may have a brainstem abnormality which affects their ability to regulate respiration, heart rate, body temperature, and other bodily functions. This abnormality is not something that can be diagnosed at this time, so it is not possible to know whether or not an infant presents as vulnerable. The third factor is External Stressors, which a typical baby is normally able to overcome and survive, but that an infant that presents as vulnerable is not. External Stressors may include exposure to second-hand smoke, tummy sleeping, a soft object that poses a barrier to breathing, or a respiratory infection. While none of these stressors alone cause an infant to die, they may be a trigger for an infant who is already vulnerable. http://www.firstcandle.org/grieving-families/sids-suid/about-sids-suid/triple-risk-theory/
Claim #3) Back sleeping poses health risks to infants. Studies have actually shown that babies who are placed on their backs have fewer fevers, ear infections, and stuffy noses than babies who are placed on their tummies. http://www.sids-network.org/experts/infant-sleep-position-hunt.pdf
In addition, the concerns about impaired gross motor function, plagiocephaly (flat spots on the head), and other injuries due to babies spending too much time on their backs are avoidable when caregivers allow their babies to have plenty of supervised, awake tummy time. This way, babies can benefit from the same perceived âadvantagesâ of tummy sleeping, without the increased risk for SIDS and/or accidental suffocation associated with tummy sleeping. http://pediatrics.aappublications.org/cgi/content/full/117/3/994
Claim #4) Back sleeping results in a less restorative rest for babies which may be harmful. While studies have demonstrated that infants who sleep on their backs may experience decreased sleep duration, decreased non-REM sleep, and increased arousals; this effect peaks at 2 to 3 months of age and is not evident at 5 to 6 months of age. Since current scientific research indicates that a brainstem abnormality which results in a failure to arouse or respond to life-threatening circumstances may play a role in SIDS, a decreased arousal threshold is actually a good thing, especially since it occurs during the peak of SIDS risk between 2-4 months. In addition, back sleeping recommendations have been in place in many countries since the early 1990s and there has been no indication that back sleeping has had lasting negative effects on infant growth and development. http://pediatrics.aappublications.org/cgi/content/full/117/3/994
Claim #5) Many other countries routinely practice bed-sharing and do not have increased rates of SIDS. Just as there is some inconsistency in the United States regarding the classification of SIDS deaths, it is reasonable to assume that these deaths are occurring in other countries and simply not being documented in the same way. In addition, these cultures may be practicing bed-sharing in a way that is very different from the way it is practiced in the U.S. For example, with firm mats on the floor, separate mats for the infant, and/or the absence of soft pillows and bedding. http://pediatrics.aappublications.org/cgi/reprint/117/3/994
Claim #6) Infants may spit up and choke while sleeping on their backs. In fact, the opposite is true—babies are less likely to choke when sleeping on their backs. When babies sleep on their back, the esophagus (food pipe) is below the trachea (wind pipe.) As a result, the spit-up or vomit cannot be breathed into the wind pipe. When a baby sleeps on his stomach, the food pipe is above the wind pipe. Gravity would then allow for the spit-up/vomit to be breathed in, causing the baby to choke. Since babies have been sleeping on their backs, studies worldwide have not found any increase in the incidence of aspiration, choking, pneumonia or other problems. http://www.firstcandle.org/new-expectant-parents/about-sids-suid/sudden-infant-death-syndrom-sids-faq/#11
Claim #7) Healthy babies are not at risk for SIDS. While it is true that current research points to a brain stem defect as a possible contributing factor to SIDS, it is not possible to know at birth if a baby has this defect or not. In most cases of SIDS, the babies seem to be perfectly healthy and functioning normally before the episode occurs. While certain factors such as low birth weight, premature birth, and exposure to smoke can increase a baby's risk for SIDS these factors are by no means present in all SIDS cases.
Conclusion
It is not my intention (nor, I believe, the intention of the Back to Sleep campaign) to scare parents or to make their lives more difficult. It is simply the case that when SIDS cases occur, parents cannot go back and do things differently. While it is true that we do not know everything about SIDS, and it cannot be fully prevented, we do know that cases are much more rare when Back to Sleep recommendations are followed. My intention is for this information to be empowering to parents, not scary.
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