Revisiting SIDS & Back Sleeping: More questions than answers

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Losing a child to Sudden Infant Death Syndrome (SIDS) is a horrifying event for a parent, made all the worse by the fact that there is no known cause that can explain why a baby dies for no apparent reason. Concerned that the common practice of prone sleeping (on the stomach) might contribute to SIDS, the American Academy of Pediatrics launched the “Back to Sleep” campaign in 1992 and, from that time forward, along with its counterparts in select countries, AAP has recommended that all babies sleep on their backs at all times.

Since then, the number of SIDS deaths has been reported reduced by half, and supine sleeping has been credited with successfully saving many babies’ lives. Parental compliance over the past two decades has risen consistently, with over 85% of babies now being put to sleep on their backs. This is essentially a complete flip in numbers from the approximately same percentage of babies who slept in a prone position prior to 1992. Even with the current cultural shift toward more natural, holistic practices, rarely does a young mother or father today question the wisdom of back sleeping (though grandmothers and older aunties often do), and any parent who does openly give voice to concerns about this practice is likely to be met with admonishments from other parents about taking risks with the baby’s life. Indeed, it is far more typical for parents today to experience a nagging fear that their own baby might fall victim to this sudden unexplained death, especially if put to sleep in on its tummy.

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Although I will raise questions in this post about these practices, it is not my intention to downplay the seriousness of SIDS. I witnessed firsthand a mother’s unfathomable despair one night when I was working as an admitting clerk at a small maternity hospital in Honolulu. One night when I was working, a woman’s screams suddenly filled the empty lobby, and when I ran to her to help, she placed the lifeless body of her baby in my arms. Later, when my own children were babies I would sometimes remember this other young mother and her anguish at losing a child so unexpectedly. I’d barely heard of SIDS until that night in 1974, but no one had to tell me this was a parent’s worst nightmare. As yet, no measures had been put in place in an attempt to prevent SIDS, and since my children were all born well before 1992, there was never the slightest suggestion that they should not sleep on their tummies. As I looked into this more deeply, I began to see how capable, caring doctors, motivated by the best ideals, have unwittingly created a state of irrational fear in many parents minds about something that turns out to be a rather rare event. The  “Back to Sleep” campaign has come at a cost, and the real achievements of this campaign might not even be what we’ve thought.

What follows is a list of facts related to SIDS and back sleeping that cannot be brushed aside and which indicate that more in-depth research is needed. In order for the medical community to continue to recommend supine sleeping with full confidence, this practice must be able to withstand closer scrutiny, especially when considering the contradictory evidence detailed below.

— 4,891 babies were reported to have died of SIDS in 1992, when the “Back to Sleep” campaign was first launched. It’s no wonder that doctors and researchers have been so committed to doing everything possible to reduce the number of babies who die each year of SIDS. Pediatricians across America have been so effective in getting their message across, that, not only is there extremely high compliance on the part of parents today, there is almost unanimous consensus that SIDS poses a very real threat to any baby allowed to sleep in a prone position. It can come as a surprise to find out that the 4,891 SIDS babies who died in 1992 represent only 0.12% or twelve hundredths percent of all babies born that year, as indicated in the graph below. Parents who have feared that their babies might roll over onto their stomachs and die while sleeping, are often relieved to discover that, even when SIDS was at its highest count, 99.88% of all babies survive infancy. In fact, the percentage of babies dying of SIDS is so small as to barely show up on a graph. An expectant mother can also find reassurance in knowing that the chances of her baby dying of any cause, including SIDS, congenital problems, prematurity, low birth weight, and accidents, is less than one percent.

SIDS-ChartWEB

— According to a statement from the Centers for Disease Control, “Since 1998, it appears that medical examiners and coroners have moved away from classifying deaths as SIDS and calling more deaths accidental suffocation or unknown cause, suggesting that diagnostic and reporting practices have changed.” This statement calls into question the accuracy of the figures that have been used in determining the reported decline in the number of SIDS cases. According to John Kattwinkel, M.D., chairman of the Centers for Disease Controls special task force on SIDS, “A lot of us are concerned that the rate (of SIDS) isn’t decreasing significantly, but that a lot of it is just code shifting.” If this is so, then the 50% decline that is so frequently referenced as a result of babies sleeping on their backs, must be reconsidered.

—Twenty years after “Back to Sleep, there are still no standardized diagnostic and reporting criteria between one local health department and another, further muddying the statistical waters and raising questions about the data on death certificates that vary widely from one jurisdiction to another. The fact that the SIDS rate is 12 times greater in Mississippi than New York is likely to be a function of differences in reporting. “I simply don’t put any credibility on any research that uses any of those numbers anymore,” says Theresa Covington, director of the National Center for Child Death Review Policy and Practice. 

— Supine sleeping is widely credited as being the reason for the success of the “Back to Sleep” campaign in reducing SIDS cases by over 50%. Even if the 50% decrease were, in fact, a credible figure, it is pertinent to note that not all 50% reductions are equal. If the rate of SIDS changed from 20% to 10% of the total population of babies born in a given year, that would be a hugely significant reduction. However, the 50% rate drop that’s been reported relative to SIDS is from 0.12% to 0.05%, representing a far smaller fraction of babies born.

— At its peak in 1983, SIDS had already been on a trajectory of decline for the decade leading up to the “Back to Sleep” campaign. Because of the apparent lack of credible statistics, there is no way of knowing whether the number of SIDS cases has actually dropped, and, if so, if this is the result of this earlier trend, or if something else is behind it.

— “Back to Sleep” put a spotlight on such safe sleeping practices as removing pillows, stuffed animals, fluffy bedding, and bumper cushions from cribs, as well as the increased use of sleep sacks and parents becoming more alert to the risks of babies sleeping on soft couches, sheepskin rugs, and such. The real success of “Back to Sleep” may be that it has served to raise awareness about improved safe sleeping practices—no small accomplishment—as this is sure to have contributed greatly to the overall safety and well-being of babies.

— The San Diego SIDS/Sudden Unexplained Death in Childhood Research Project recorded risk factors for 568 SIDS deaths from 1991 to 2008 based upon standardized death scene investigations and autopsies. Risks were divided into intrinsic (eg, male gender) and extrinsic (eg, prone sleep). The study determined that “between 1991–1993 and 1996–2008, the percentage of SIDS infants found prone decreased from 84.0% to 48.5%.” What this appears to be saying is that 1) “Back to Sleep” succeeded in getting babies onto their backs; and 2) ultimately, 51.5% of babies who died of SIDS were NOT on their stomachs. Not surprisingly, this study acknowledged that a number of risk factors “had changed”. According to Henry Krous, director of the research project, most babies had two or more risk factors. “What that says to us,” Krous elaborated, “is that Back to Sleep should emphasize multiple risk factors.”

— 44% of babies who died of SIDS in Kings County, Washington at the time of one study had an upper respiratory infection during a two-week period leading up to their death.

— According to the World Health Organization, “there is substantial evidence to conclude that maternal smoking causes a 4-fold increase in SIDS cases.”

— According to the Centers for Disease Control, smoking during pregnancy substantially raises the risks of SIDS.

— Increased awareness of the multiple benefits of breastfeeding have led to new findings that babies who are breastfed have up to a 70% decrease in the incidence of SIDS. Also, breastfeeding mothers often practice bed-sharing with their babies, which might help explain why more SIDS deaths occur in cribs than in adult beds.

Mother and baby napping togetherChinese mother and baby sleeping

— Bed-sharing is considered a risk for SIDS according to the American Academy of Pediatrics, yet an article published in Pediatrics, the official journal of AAP, states that “there are many cultures where bed-sharing is the norm and SIDS rates are low.” A comprehensive study that gathered data from 17 countries concluded, “Although these results should not be used to imply that any particular child care practice either increases or decreases the risk of SIDS, these findings should help to inject caution into the process of developing SIDS prevention campaigns for non-Western cultures.” This view might indicate that the insistence with which bed-sharing has been discouraged by the medical establishment is now softening, although it is likely to be a long time before the many parents who routinely follow doctors’ recommendations will regain confidence in letting their babies sleep with them and/or sleep on their stomachs.

— Especially significant to this discussion are findings that indicate that an abnormality in an area of the brainstem that is responsible for stabilizing the body’s autonomic functions such as breathing, heart rate, temperature and the ability to arouse from sleep is a key factor in babies who die of SIDS. Further, a dangerous drop in serotonin levels may play a substantial role in SIDS. Coupled with the fact that SIDS babies had lower levels of the serotonin-producing enzyme tryptophan hydroxylase, or TPH2, suggests the possibility that, early screening blood tests could allow for intervention strategies at some point. “I think the message is there is something inherently wrong in some of these babies,” says Richard Martin, MD, director of neonatology at Rainbow Babies and Children’s Hospital and professor of pediatrics at Case Western Reserve University in Cleveland. According to Hannah Kinney, MD, Neuropathologist and Lead SIDS Researcher at Children’s Hospital Boston, “These findings provide evidence that SIDS is not a mystery but a disorder that we can investigate with scientific methods, and some day, may be able to identify and treat.”

— A recent Time magazine article asks why, if most babies (85% plus) are now put to sleep on their backs, 2,500 infants still die of SIDS. Although this article and others like it repeat the, as yet, unquestioned belief that back-sleeping has been responsible for reducing SIDS deaths by half, the asking of this question is yet another indication that the emphasis (and evidence) is shifting away from an almost singular focus on back-sleeping.

— UK research scientist Barry Richardson claims that SIDS is the direct result of toxic nerve gases being produced through the action of fungus in mattresses that are frequently used to make mattresses fire-retardant. In a book called The Cot Death Cover-up, New Zealand chemist Jim Sprott explores this theory in greater detail, claiming that chemical compounds containing phosphorus, arsenic and antimony have been added to mattresses as fire retardants since the early 1950′s. These assertions have led to a number of parents subscribing to the practice of mattress “wrapping” as a way to seal off the mattress and protect their babies from the supposed toxic gases.

— In addition to taking all these factors into consideration, there is simply no conclusive proof that putting babies to sleep on their backs reduces the incidence of SIDS.  Still, one might be left wondering why anyone would bother to raise all these questions. After all, wouldn’t it be wise to err on the side of caution, just to be safe?

Just to be safe is exactly the point. When we remind ourselves that we, as humans, are creatures of nature who are part of a larger natural order, and that there is a process of physical development that is meant to unfold in a prescribed way, then it stands to reason that in the case of an otherwise normally healthy baby (who is breastfed, who is not exposed to second hand smoke, who does not have an abnormality in the brainstem . . . ) certain interventions could occur that might disrupt the babies natural process of development. For instance, if we were to manipulate the usual sleeping positions of the infants of another species, we might not be surprised to observe anomalies arising in them.

I want to be clear about one thing:  I am a great believer in scientific study. Science plays an important role in helping us understand ourselves and our world, and in improving our lives in many ways. I see science as fundamental to the quality of our lives and to protecting and preserving our global environment.

Here’s where I start to get a bit uncomfortable, though—when our relationship with science puts its power outside of the natural world. It is too easy to run into trouble when we rely on partially-understood statistics and constructs and are willing to experiment with age-old practices that we may not have taken the time to comprehend.

Multiple studies have shown that many babies who sleep on their backs show evidence of delayed motor development. This typically shows up in such milestones as being late to turn over, late to sit up, late to crawl, and such. Some doctors, believing that these babies catch up by 12 to 18 months of age, have begun to adjust the “normal” range for reaching these milestones. Besides motor delays, a long list of problems including plagiocephaly (flat head syndrome), torticollis, autism spectrum disorders, ADHD, dyslexia, vision problems and sleep problems, have skyrocketed in number over the past two decades—precisely the same timeframe since the advent of Back-to-Sleep. Just to be safe means we owe it to our children to pause long enough to ask questions and look even more closely at what, if any, correlation there might be. 

Let’s consider for a moment that movement activity of a specific kind, such as that done in a prone “belly-to-Earth” position, is essential to establishing complex connections in the brain through a physical process already underway when a baby is born. (Details of this process can be read here and here). Can we really afford to experiment with imposing sudden and dramatic changes on certain activities that have been commonly practiced for countless generations? Might we run the risk of creating bigger problems than the ones we are trying to solve? Are those children who, in alarmingly high numbers now struggle with neurodevelopmental disorders, simply the canaries in the coal mine? Are they warning us of more serious problems ahead if we (meaning all of us) continue to ignore our innate connection to the natural world?  SIDS, as horrific and heartbreaking as it really is, may end up being overshadowed by the totality of unprecedented health problems that, in part, may be the result of inadvertent disruption of the natural human design.

Taking all this into account, let’s not be afraid to ask these questions, and for the sake of our children, and without casting blame, let’s move forward and work together to get them answered.

 

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Felicia L. Trachtenberg, Elisabeth A. Haas, Hannah C. Kinney, Christina Stanley and Henry F. Krous (2012). Risk Factor Changes for Sudden Infant Death Syndrome After Initiation of Back-to-Sleep Campaign. Pediatrics, 10.1542.  630-638.

Nelson E.A., Taylor B.J., Jenik A, Vance J, Walmsley K, Pollard K, et. al. (2001). International Child Care Practices Study: infant sleeping environment. Early Human Development, 62(1):43-55.

Rochman, Bonnie (2012, March 26). Back to Sleep: Why Are 2,500 Babies Still Dying of SIDS Each Year Time online.

Hargrove, Thomas and Bowman, Lee (2007, October 20). Exposing Sudden Infant Deaths. Gettysburg Times. p. C-1

John Kattwinkel, Fern R. Hauck, Rachel Y. Moon, Michael Malloy and Marian Willinger (2006). Bed-Sharing with Unimpaired Parents is Not a Risk For SIDS: In Reply. Pediatrics, 117, 994.

Bergman AB; Ray CG; Pomeroy MA; Wahl PW; Beckwith JB (1972). Studies of the sudden infant death syndrome in King County, Washington. Pediatrics, 49(6), 860-70.

 Sudden Infant Death Syndrome and Smoking, 113 Am J Epidemiology (5) 583 (May 1981)

National Institutes of Health. (2003) Safe Sleep for Your Baby: Ten Ways to Reduce the Risk of Sudden Infant Death Syndrome (SIDS).  National Institutes of Health, National Institute of Child Health and Human Development.

U.S. Department of Health and Human Services (2006).  The Health Consequences of Involuntary Exposure to Tobacco Smote: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Bergman AB, Wiesner LA. (2006). Relationship of Passive Cigarette-smoking to Sudden Infant Death Syndrome.” Pediatrics; 58: 665-668

E.A. Mitchell, J. Milerad, (1999) Smoking and Sudden Infant Death Syndrome. World Health Organization, Background paper.  http://www.who.int/tobacco/media/en/mitchell.pdf
Hannah C. Kinney, George B. Richerson, Susan M. Dymecki, Robert A. Darnall, and Eugene E. Nattie
(May 29, 2009). The Brainstem and Seratonin in the Sudden Infant Death Syndrome.:  Annual Review of Pathology: Mechanisms of Disease 

Kinney HC, Randall LL, Sleeper LA, Willinger M, Belliveau RA, Zec N, Rava LA, Dominici L, Iyasu S, Randall B, Habbe D, Wilson H, Mandell F, McClain M, Welty TK. Serotonergic brainstem abnormalities in Northern Plains Indians with the sudden infant death syndrome. Journal of Neuropathology and Experimental Neurology 2003; 62: 1178-1191.

Panigraphy A, Filiano J, Sleeper LA, et al. (2000). Decreased serotonergic receptor binding in rhombic lip-derived regions of the medulla oblongata in the sudden infant death syndrome. Journal of Neuropathology and Experimental Nurology, 59, 377-384.

Salls JS, Silverman LN, Gatty CM. The relationship of infant sleep and play positioning to motor milestone achievement (2002).    American Journal of Occupational Therapy; 56: 577-580.

Davis B.E, Moon R.Y, Sachs H.C and OttolinI M.C. Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Effects of sleep position on infant motor development. (1998) Pediatrics; 102(5):1135-40

Monson RM, Deitz J, Kartin D. The relationship between awake positioning and motor performance among infants who slept supine (2003). Pediatric Physical Therapy; 15: 196-203.

Kinney HC, Filiano JJ. Brain research in the sudden infant death syndrome. In: Kraus HF, Byard RW, editors. Sudden infant death syndrome: a diagnostic approach. London: Chapman and Hal; 2001.

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8 responses

  1. Very good article. Knee jerk reactions such as back to sleep are always discovered to be draconian in the end. While using a shotgun to target 0.12% on faith, we very real condemn millions of americans to suffer flat head syndrome (as did my daughter), and promote disability to the whole population. It is not natural to sleep in the same positive every night which is why we don’t. Statements by doctors that flathead syndrome “its just cosmetic”, are just complete baloney- they just read a script provided to them and have no idea.

  2. I agree with a lot of your article, but one thing stands out for me.
    “Multiple studies have shown that many babies who sleep on their backs show evidence of delayed motor development. This typically shows up in such milestones as being late to turn over, late to sit up, late to crawl, and such. Some doctors, believing that these babies catch up by 12 to 18 months of age, have begun to adjust the “normal” range for reaching these milestones. Besides motor delays, a long list of problems including plagiocephaly (flat head syndrome), torticollis, autism spectrum disorders, ADHD, dyslexia, vision problems and sleep problems, have skyrocketed in number over the past two decades—precisely the same timeframe since the advent of Back-to-Sleep. ”

    This is also the same time frame as the introduction of GMOs into our .diets, especially soy in baby formula. It is also the same time frame, as you mentioned, as.an increase in fire retardants in baby clothes and other pollutants in baby bottles, cleaning supplies in the home. All the above mentioned syndromes, I believe, are related in what we force our children to inject, breath, etc.

  3. Has anyone done any research to the connection between incidence with SIDS and time of vaccinations? I think there is merit in the mattress-wrapping theory. We don’t know what all is in these mattresses, especially new ones.( older ones seem to pose less of a problem, as out gassing has occurred over time.i also think that prone sleeping is a safeguard to prevent a baby from aspirating it’s vomit during sleep…how many babies spit up after a feed, and mom puts them to bed? The baby has no way to clear his airway if he spits up. Prone sleeping babies can pick their heads up and move them. Yes, even newborns…

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  5. I was scoffed at by the NIH and AAP for suggesting that choanal atresia may be a contributing factor in SIDS. We have received hundreds of emails, phone calls, and letters from parents concerning CA. Out of all of them only a few, 3 or 4 were infants diagnosed at birth. The rest were diagnosed weeks, months, and even years later.

  6. I found my baby not breathing after I put it down to sleep at night this is going back fourty odd years ago my father brought him back to life but we didn’t know how long he was like that and he was slow atdoing everything he ddidn’t walk until he was two and a half and he left school at fourteen because he couldn’t do the work but I was just glad to have him alive as my brother had lost one in a cot death and my brother in law had lost a twin to cot death they even put the other twin in hospital to try and find out why the other twin was alive but they didn’t find out anything so you see we had a few baby’s die of cot death and I wouldn’t want it to happen again and now I have grand children

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