sidsoctober2005

Breastfeeding Is Associated with a Lower Risk of SIDS
According to The Academy of Breastfeeding Medicine
Friday October 14, 2:26 pm ET

LARCHMONT, New York--(BUSINESS WIRE)--Oct. 14, 2005--Contrary to even the
recommendations of its own Section on Breastfeeding, the American Academy of
Pediatrics (AAP) released an ill-advised and ill-informed statement from its Task
Force on SIDS (1) (sudden infant death syndrome). Recommendations that advise
against parent-infant bed-sharing and support the generic use of pacifiers imply a
"truly astounding triumph of ethnocentric assumptions over common sense and
medical research," according to Nancy Wight, M.D., president of The Academy of
Breastfeeding Medicine. These controversies, and many more, will be addressed in
the upcoming, new peer-reviewed journal Breastfeeding Medicine
(www.liebertpub.com/bfm), the Official Journal of the Academy of Breastfeeding
Medicine (www.brmed.org).

Current research from the CDC (2), as well as AAP's existing policy statement
on Breastfeeding and the Use of Human Milk (3), note that breastfeeding is
associated with a lower risk of SIDS. Since 1992, SIDS has decreased as both
co-sleeping and breastfeeding have increased. Sleeping near one's baby or
in the same room has been shown to reduce the risks of SIDS and more
broadly promote maternal and child health by facilitating breastfeeding. 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.

Pacifiers have been associated with increased risk of ear infections, later dental
problems, and reduced breastfeeding. As reduced breastfeeding increases infant
mortality from infectious disease and several other causes, we agree with the AAP
that a pacifier should not be introduced until breastfeeding is well established and
never forced on an infant. Pacifiers would only be of possible benefit to infants
lacking in the natural opportunity of night-time suckling (breastfeeding).

Extensive research on infant sleep has revealed that infants are frequently
aroused to lighter stages of sleep by parental movement when co-sleeping.
Dr. James J. McKenna of the University of Notre Dame was a consultant to the AAP
on the new policy, but disagrees strongly with their conclusions.(4) Dr. McKenna
points out that there are many forms of co-sleeping and that recommendations for
SAFE co-sleeping need to be publicized. Co-sleeping is defined as sleeping in close
proximity to one's infant, which can include but does not necessarily imply being in the
same bed. Infants should never co-sleep with other siblings, with smoking or
substance-abusing parents, on sofas or waterbeds, with soft bedding materials, or
adjacent to spaces that could trap the infant. As with sleeping in a crib, infants should
be placed on their backs, with only a thin blanket on a firm bedding surface.

The Academy of Breastfeeding Medicine (ABM) is a worldwide organization of
physicians dedicated to the promotion, protection and support of breastfeeding and
human lactation through education, research and advocacy. For evidence-based
recommendations regarding co-sleeping and breastfeeding, see Protocol #6 on our
website www.bfmed.org.

Mary Ann Liebert, Inc. is a privately held, fully integrated media company known for
establishing authoritative peer-reviewed journals in many promising areas of science
and biomedical research, including Journal of Breastfeeding Medicine, Journal of
Women's Health, Obesity Management, and Disease Management. Its biotechnology
trade magazine, Genetic Engineering News (GEN), was the first in its field and is
today the industry's most widely read publication worldwide. A complete list of the
firm's 60 journals, books, and newsletters is available at www.liebertpub.com.

1. AAP Task Force on Sudden Infant Death Syndrome. The Changing Concept of
Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding
Sleeping Environment, and New Variables to Consider in Reducing Risk. Pediatrics
November 2005; 116(5):1245-1255

2. American Academy of Pediatrics, Section on Breastfeeding, Policy Statement:
Breastfeeding and the Use of Human Milk. Pediatrics 2005; 115(2):496-506

3. Chen A, Rogan WJ. Breastfeeding and the Risk of Postneonatal Death in the
United States. Pediatrics 2004; 113:e435-439 URL:
http://www.pediatrics.org/cgi/content/full/113/5/e435

4. McKenna JJ, McDade T. Why babies should never sleep alone: A Review of the
co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Pediatric
Respiratory Reviews 2005; 6:134-152 (available on line at www.sciencedirect.com)
Contact:

Mary Ann Liebert, Inc., Larchmont
Karla Shepard Rubinger, 914-740-2100 ext. 2153
krubinger@liebertpub.com
or
Academy of Breastfeeding Medicine
Nancy E. Wight, MD (Neonatology), 619-222-0442
Fax: 619-222-0443
Pager: 858-493-0198
wightsd@aol.com
www.bfmed.org
or
University of Notre Dame
Professor of Anthropology
James J. McKenna, Ph.D.
James.J.McKenna.25@nd.edu

AAP releases controversial guidelines on SIDS prevention
Oct 15, 2005

On October 10, the American Academy of Pediatrics released new
recommendations aimed at further reducing the incidence of Sudden
Infant Death Syndrome (SIDS). Press coverage emphasized new recommendations
on the avoidance of bedsharing and the recommendation to use pacifiers,
and downplayed widespread concerns among researchers, infant sleep and
breastfeeding experts. The media also largely overlooked other aspects
of the AAP statement which, while less controversial than bed-sharing
and pacifiers, are areas that also need to be addressed in SIDS
prevention.

SIDS, also known as crib death, is diagnosed when an otherwise healthy
infant is found dead, and no other obvious cause can be found after
thorough investigation. Death by suffocation, for example, is ruled
out.

It is estimated that 2300 babies die of SIDS each year. The incidence
has been reduced by the "back to sleep" campaign. Other known risk
factors for SIDS are maternal smoking during pregnancy, overheating the
infant, use of soft sleeping surfaces such as couches or waterbeds, and
use of pillows, sheets, and blankets in the infant's sleep environment.
The Academy of Breastfeeding Medicine, an international organization of
physicians, has also released a statement noting that breastfeeding
itself is protective against SIDS, and strongly disagrees with the AAP
recommendations.

In the new recommendations, the five-member task force strengthened the
Academy's advice that infants be put "back to sleep" - that is, that
newborns not be put down to sleep prone (on their tummies or sides).
This advice is well supported by empirical evidence, not least by the
decline in SIDS rates in the US since the "back to sleep"
recommendation was initiated in the 1990s. The task force also notes that 20% (or
1 in 5) SIDS deaths occurs when the infant is not being cared for by a
parent- and reports that as many as one quarter of childcare providers,
including licensed daycare centers, are not aware of the
"back-to-sleep" recommendation.

The group goes on to recommend that parents "consider offering a
pacifier at night and at naptime," although use of pacifiers should be
delayed until one month of age in breastfeeding infants, until
breastfeeding can be well-established. They also recommend that babies
should sleep near parents, but in a separate sleep environment such as
crib, bassinet, or cradle. They note that safety standards for
attachable "co-sleepers" have yet to be established by the Consumer
Product Safety Commission. Other recommendations include a firm sleep
surface; avoiding smoke exposure to baby both pre- and postnatally;
avoiding overheating; avoiding commercial devices marketed to reduce
the risk of SIDS, including home monitors; encouraging tummy time while
awake; and ensuring that all involved in a baby's care are aware of
these recommendations.

The new recommendations on pacifiers and bedsharing, upon which so much
attention has been focused, are controversial. Many health care
providers, breastfeeding authorities, and infant sleep experts question
the strength of some of the underlying evidence. Pacifiers are linked
with dental problems, fungal infections, ear infections,
gastrointestinal infections, and breastfeeding difficulties. Bedsharing
facilitates breastfeeding. If the public follows these recommendations,
some women may avoid breastfeeding or wean prematurely due to fatigue,
difficulties with milk supply, and other problems.

Evaluating the strength of the evidence: Pacifiers

Both the pacifier and bed-sharing recommendations are based on
case-control studies. In this type of study, researchers compare babies
who died from SIDS to other "control" babies who did not die from SIDS.
It's difficult to choose "control" babies in a way that is truly
representative of the general population. In addition, this type of
study cannot prove cause and effect.

The recommendation on pacifiers is based on case-control studies
showing lower rates of SIDS in babies who went to sleep with pacifiers. In the
same issue of Pediatrics in which the recommendations were issued, a
large meta-analysis on pacifier use and SIDS was published by Fern
Hauck et al. Dr. Hauck was also one of the five members of AAP panel, and her
meta-analysis put together the most definitive data on pacifiers and
SIDS. Of 384 studies, the group analyzed only 7 studies which met
quality inclusion criteria. All 7 studies were case-control; that is,
known cases of SIDS were compared to matched babies without SIDS.
Parents were asked questions about pacifier use after the baby's death.
The meta-analysis found that babies whose parents reported that they
usually used pacifiers, but did not use one on the night in question,
were more likely to have had SIDS. The AAP task force extrapolated this
finding to recommend that ALL babies be put to sleep with pacifiers.

One problem with this approach is that the association with SIDS was
not found in babies who did not usually use pacifiers. We do not know if
pacifiers themselves decrease the risk. We also do not know why these
babies were using pacifiers to begin with - did they already have
breathing problems and thus needed pacifiers or did the pacifiers
create a dependency on them for breathing and arousal regulation? Were they
breastfed or not? Breastfed babies may be less likely to use pacifiers
and some data link breastfeeding, itself, to a lower risk of SIDS. The
articles from the meta-analysis do not distinguish whether it is the
absence of a pacifier (eg, babies who never use them) or whether it is
being accustomed to or dependent on a pacifier but then being denied it
that puts the baby at risk.

One theory about SIDS is that it arises from a deficit in arousal
responses to a life-threatening situation. Infants dying of SIDS
typically have less mature autonomic function and delayed neuronal
maturation that affects the arousal pathway in the brain. Using a
pacifier increases arousability, something which is already present in
a breastfed infant. Arousal thresholds from sleep are different between
breastfed and bottle-fed babies. Breastfed babies are more easily
aroused from active sleep at 2-3 months of age than formula fed babies.
This age coincides with the peak incidence of SIDS. Breastfeeding a
baby during the critical risk period for SIDS (2-4 months) "covers" the
period of time when reduced arousal capability impairs the infant's
ability to respond to life threatening situations.

The retrospective nature of the studies means that parents of SIDS
babies may be likely to remember things differently than parents of
control babies. There were many things the studies did not ask, such as
whether parents were using any of the sleep training programs (Ezzo,
Ferber, Baby Whisperer, etc) that deliberately train babies to sleep
soundly through the night, especially during the peak time of night
when SIDS occurs.

While the AAP task force acknowledged data linking pacifiers to ear
infections and dental problems, it was unconvinced by data associating
pacifiers with breastfeeding difficulties. However, because pacifiers
can mask signs of hunger, it is possible for a mother to put a baby to
bed with a pacifier before he is done nursing. On an ongoing basis this
may lead to a diminishing milk supply, an increased likelihood of
formula supplementation, and increased risks of illnesses associated
with lack of breastfeeding.

Even though the statement advises that breastfed babies not be given a
pacifier until one month of age, and that babies not be "forced" to
take a pacifier, the weight of the advice to "prevent SIDS by using
pacifiers" may be uppermost in many parents' minds.

Evaluating the Evidence: Bedsharing

Bedsharing is very common. An Oregon study published in October 2005
(Lahr et al, Pediatrics) found that 35.2% of new mothers bedshared
always or almost always, and an additional 41.4% bedshared sometimes.
While mothers who smoke are advised not to bedshare, this study found
that they bedshared just as often as nonsmokers.

Many case-control studies have shown an association (not causality)
with SIDS only in certain situations, such as families where mothers smoke.
A July 2005 study from Scotland (Tappin et al, J. Pediatrics) found that
SIDS risk was increased in babies who slept with 2 adults, especially
if the baby was between two parents, and found the risks were highest in
babies under 11 weeks of age. This study, like many others, assessed
bed-sharing alone as a risk factor (rather than the environment within
which the bed-sharing occurred), did not assess the presence of
parental alcohol use at the time of bed-sharing, and did not include
breastfeeding in the analysis. (It did note that only "16 [of 46] SIDS
infants who bedshared for some time during their last sleep were still
being breastfed.") Other studies have linked breastfeeding with a lower
incidence of SIDS.

As noted, one theory on the cause of SIDS is that babies are not
arousable enough, and stop breathing as a result. James McKenna, a
leading investigator in mother/infant sleep patterns, has found that
babies who bedshare and breastfeed have more regular arousals which are
coordinated with those of their mothers. He holds that from an
anthropological perspective, co-sleeping is the evolved context of
human infant sleep development in which mother and baby respond to each
other's breathing and movements. In their acknowledgments, the AAP task
force authors note that they received reports from consultants
including Dr. McKenna, but that "the consultants do not necessarily agree with
the evidence, analysis and recommendations set forth in this document."

It's unclear whether the advice not to bedshare will adversely affect
breastfeeding. However, when a baby is nursing every two hours during
the night, the mother can be expected to suffer significantly more
fatigue if she has to get up after each feed and put the baby back in a
crib. Conceivably, some women may stop breastfeeding, and others may
keep the baby in bed with them against recommendations, as they can get
considerably more rest this way.

Potential Public Health Implications

It is not possible to predict from available evidence that SIDS would
be reduced if parents followed all of the new AAP recommendations.

However, since media coverage of the new guidelines highlighted only
the recommendations to avoid bed-sharing and introduce pacifiers, it is
possible that some families will follow only these two guidelines.
Unfortunately, both of these interventions have potential adverse
effects on breastfeeding.

Public health interventions might better target other areas, including
the alarmingly high rate of prone sleeping in daycare centers.
Similarly, infant bedding manufacturers continue to market crib
bumpers, pillows, quilts and blankets that have been associated with SIDS
risk.

It is also important to note that SIDS is a rare occurrence, albeit a
devastating one, and one whose cause is not well understood.

However, breastfeeding affects many aspects of maternal and child
health, and absence of exclusive breastfeeding or early weaning is
linked with higher rates of other serious diseases such as obesity and
its complications, diabetes, childhood cancers, and serious infections.
In mothers, absence of breastfeeding or early weaning is linked with
increased rates of breast cancer, ovarian cancer, and diabetes.

Thus, if this new AAP policy discourages sustained exclusive
breastfeeding, it may not be entirely beneficial for public health.

Public Accountability and Conflicts of Interest:

The new AAP statement raises many questions: Why do so many licensed
childcare providers engage in the known, dangerous practice of putting
babies to sleep on their bellies? When the parents hire licensed care
providers, aren't the licensing organizations accountable for ensuring
that providers do not engage in unsafe practices?

Next, we know that sheets, pillows and blankets in a child's sleep
environment increase risk of death, and yet such products for babies
are routinely sold, and packaged with crib bumpers. Why is this allowable?

Next, why hasn't the Consumer Product Safety Commission yet evaluated
the safety of co-sleeper devices?

Finally, SIDS organizations such as CJ SIDS and FirstCandle, for which
Dr. Hauck is a board member, have received funding from pacifier
manufacturers and formula companies such as Ross and Mead-Johnson.
The AAP itself has also received millions of dollars from formula
companies. It's unclear if these donations have resulted in any conflict of
interest with the researchers or with AAP, but it is clear that the new
recommendations could increase sales of infant formula and pacifiers.

References:

Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer
and breastfeeding: collaborative reanalysis of individual data from 47
epidemiological studies in 30 countries, including 50302 women with
breast cancer and 96973 women without the disease. Lancet. 2002 Jul 20;
360(9328):187-95.

The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding
Shifts, Controversies Regarding the Sleeping Environment, and New
Variables to Consider in Reducing Risk. Pediatrics. 2005 Oct 10

Fleming PJ, Blair PS, Pollard K, et al. Pacifier use and sudden infant
death syndrome: results from the CESDI/SUDI case control study. Arch
Dis
Child 1999; 81:112-116

Hauck, FR et al. Do pacifiers reduce the risk of sudden infant death
syndrome? A met-analysis. Pediatrics, 2005, Oct 10.

Horne RSC, Parslow PM, Ferens D, et al. Comparison of evoked
arousability in breast and formula fed infants. Arch Dis Child 2004;
89:22-25

Labbok MH. Effects of breastfeeding on the mother. Pediatr Clin North
Am. 2001 Feb;48(1):143-58.

Lahr MB, Rosenberg KD, Lapidus JA. Bedsharing and maternal smoking in a
population-based survey of new mothers. Pediatrics. 2005
Oct;116(4):e530-42.

L'Hoir MP, Engelberts AC, van Well GTJ, et al. Dummy use, thumb
sucking,
mouth breathing and cot death. Eur J Pediatr 1999; 158:896-901

McKenna JJ, McDade T. Why babies should never sleep alone: a review of
the co-sleeping controversy in relation to SIDS, bedsharing and breast
feeding. Paediatr Respir Rev. 2005 Jun;6(2):134-52

Moreland J, Coombs J. Promoting and supporting breast-feeding. Am Fam
Physician. 2000 Apr 1;61(7):2093-100, 2103-4.

Tappin D, Ecob R, Brooke H. Bedsharing, roomsharing, and sudden infant
death syndrome in Scotland: a case-control study. J Pediatr. 2005
Jul;147(1):32-7.

Vennemann MMT, Findeisen M, Butterfab-Bahloul T, et al. Modifiable risk
factors for SIDS in Germany: results of GeSID. Acta Paediatr 2005;

Mixed Credibility of the Revised AAP SIDS Prevention
Recommendations

WASHINGTON, D.C. (October 17, 2005) - The American Academy of
Pediatrics (AAP) released revised recommendations for Sudden Infant Death
Syndrome (SIDS) prevention last week, one of which provides valuable new
information to help parents protect their infant, while others not only
lack a solid scientific basis but also entail some risks.

The AAP now recommends that infants sleep in the same room as their
parents because this is associated with a reduced risk of SIDS. While
studies have consistently found that isolating infants for sleep (in a
separate bedroom) is associated with a higher risk of SIDS, this
information has not previously been widely disseminated. Sleeping near
one's infant has also been shown to increase maternal responsiveness to
the infant's nighttime physiologic signals and to make it easier for
mother to succeed with breastfeeding. Breastfeeding, in turn, is
linked to a reduced risk of many acute and chronic illnesses, including a 21%
lower all-cause infant mortality rate in an analysis by the National
Institutes of Health, and to a reduced risk of SIDS in a number of
studies.

Two recommendations in the new AAP statement have stirred particular
concern: to give babies pacifiers and to remove the infant from the
parental bed prior to sleep. Both recommendations are problematic in a
number of ways, including that they lack a clear scientific basis,
constrain parental choice, complicate the potentially challenging
process of putting infants to sleep, and impair breastfeeding.

Because early pacifier use reduces breastfeeding duration, the AAP SIDS
statement recommends waiting until one month of age (to allow
breastfeeding to get off to a good start) before starting pacifiers in
breastfed infants. Even beyond this period pacifiers entail health
risks, however, and may undermine breastfeeding success.

A number of studies (but not all) have found an association between
pacifier use and lower rates of SIDS. But these studies cannot
determine if the relationship is causal, and therefore whether pacifier
use can reduce the risk of SIDS. Nevertheless, even if the oral
stimulation of sucking were protective, only those infants lacking the
natural source of nighttime suckling, breastfeeding, would be likely to
benefit from an artificial pacifier source of such stimulation. Only
in such "at risk" groups might it make sense to assume the health risks of
pacifier use which include yeast infections, oral malocclusion, and ear
infections.

Data are also lacking to justify telling parents whether or not they
should sleep with their infants-beyond informing them of the protective
effect of sleeping in the same room as their baby. In the best
controlled studies, infant safety is not associated with whether the
baby sleeps in the parents' bed per se, but on specific environmental
factors that warrant attention whether the baby is in a bed, a crib, or
other sleeping surface. For example, SIDS has been associated with
prone sleep position, maternal smoking, soft mattresses, and bedding
near the baby that could cover the head. Avoidable exceptions in which
bedsharing itself has been associated with an increased risk of SIDS
include the use of particularly unsafe furniture (e.g., couches, which
are associated with a 25-fold increased risk of SIDS) and parent
smoking or incapacitation due to alcohol or drug use, or exhaustion.

The United States Breastfeeding Committee recommends caution before
advising pacifiers for breastfeeding infants even after one month of
age. It also emphasizes the importance of closeness to one's infant
and supports the statement of the Section on Breastfeeding of the AAP that
mother and infant sleep in close proximity.

The United States Breastfeeding Committee is a national committee made
up of over 30 organizations that promote, protect, and support
breastfeeding.

1.      AAP Task Force on Sudden Infant Death Syndrome. The Changing
Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts,
Controversies Regarding Sleeping Environment, and New Variables to
Consider in Reducing Risk. Pediatrics November 2005; 116(5):1245-1255
2.      American Academy of Pediatrics, Section on Breastfeeding,
Policy
Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2005;
115(2):496-506
3.      Chen A, Rogan WJ. Breastfeeding and the Risk of Postneonatal
Death in the United States. Pediatrics 2004; 113:e435-439

URL: http://www.pediatrics.org/cgi/content/full/113/5/e435

4.      McKenna JJ, McDade T. Why babies should never sleep alone: A
Review of the co-sleeping controversy in relation to SIDS, bedsharing
and breast feeding. Pediatric Respiratory Reviews 2005; 6:134-152
(available on line at www.sciencedirect.com)

United States Breastfeeding Committee (USBC)

2025 M Street, NW, Suite 800

Washington, DC 20036

General: (202) 367-1132

Fax: (202) 367-2132

office@usbreastfeeding.org <mailto:office@usbreastfeeding.org>

www.usbreastfeeding.org