Minimising risks around infant sleep: Safer sleep spaces
Nothing in life is risk-free. Every day we make choices which come with an element of risk. You have done some of these today. We get in cars and drive them. We fly around the world in planes. We eat popcorn. We walk on the beach barefoot. We eat deep fried foods.
When it comes to our babies, the amount of information about sleep is overwhelming. When it comes to safe sleep practices, it can be terrifying. But it shouldn’t be.
SIDS is defined as the sudden and unexpected death of an infant under one year of age with an onset of a fatal episode occurring during sleep, that remains unexplained after a thorough investigation.
In 2020, 25 deaths were attributed to Sudden Infant Death Syndrome (SIDS) across Australia
SUDI is a broad term used to describe the sudden and unexpected death of a baby for which the cause is not immediately obvious. SUDI includes deaths from SIDS as well death from other unexpected causes such as drowning.
In 2020, there were 100 SUDI deaths across Australia
https://rednose.org.au/page/facts-and-figures
Any infant life lost is a disaster but in high income countries like Australia in the 21st century it is extraordinarily rare.
If you were having a baby in the early 20th century, one of the greatest risk to their life in the early years was infection. Before the creation of antibiotics, particularly the discovery of penicillin in 1928 - the year my father was born, simple colds could become life-threatening. Diseases we consider to be minor today would take infant’s lives swiftly. Mothers did not expect all their babies to survive the first year or life or even the first five years.
Today the World Health Organization states:
Globally, infectious diseases, including acute respiratory infections, diarrhoea and malaria, along with pre-term birth complications, birth asphyxia and trauma and congenital anomalies remain the leading causes of death for children under 5.
Immunisation, antibiotics, and pregnancy and childbirth interventions, have reduced most of these for families in countries like Australia and New Zealand, the US and UK. Which heightens our attention to other risks to infant life. Particularly Sudden Infant Death Syndrome (SIDS), previously referred to as Cot Death.
Early in the 1970s, a US congressional committee called it “one of the last great unresolved childhood catastrophes” and announced federal funding. Meanwhile, bereaved parents were organising too. In 1971 the Foundation for the Study of Infant Deaths was set up in the UK by a grandmother determined to explain her grandson’s death. (It recently rebranded itself as The Lullaby Trust, because it believed its previous name was too austere and off-putting.) A decade later there was an international federation of similar organisations. In 1984, Bristol doctor Peter Fleming, working closely with the trust, set up the Avon infant mortality programme.
The SIDS epidemic can be dated from the time it first appeared on death certificates in 1970, until the public health campaign in 1991. In Britain alone, it probably cost 10,000 lives. It is still hard to explain how it happened. The first recorded advice to put babies to sleep on their front is from 1943.
Parenting manuals have a lot to answer for. They brought useful advice and reassurance, true. But along with those came an epidemic that killed tens of thousands of babies. Sudden infant death syndrome – Sids – is always a tragedy, but it is no longer commonplace. It became an epidemic between 1970 and 1991, and, at its peak, babies in some of the world’s richest countries were dying at the rate of one in every 250 live births each year. The rate in the last year for which figures were available in England and Wales only, 2013, is one in every 3,000.
Rates of SIDS significantly changed when one simple change was promoted in the 1990s:
In Australia:
Kaarene Noelle Fitzgerald founded the Sudden Infant Death Research Foundation Inc in 1977, the day after her son, Glenn, died. This then cascaded on to her co-founding the National SIDS Council of Australia, SIDS International and then the Global Strategy Task Force on SIDS. In 1988 Australia’s first ever signature day, Red Nose Day, was conceived and has grown to become one of Australia’s highest profile fund raising days with a 97% prompted recognition rate. Over the past 30 years, through the Safe Sleeping program, SIDS and Kids have reduced the infant mortality rate in Australia by around 84%, an outstanding achievement..
In the US:
The Safe to Sleep® campaign began in 1994, as the Back to Sleep campaign, then named for its main recommendation for all healthy babies to be placed on their backs to sleep to reduce the risk of Sudden Infant Death Syndrome (SIDS).
Led by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), part of the National Institutes of Health, and other collaborating organizations, the campaign was expanded and renamed Safe to Sleep® in 2012 to address not only SIDS, but also other sleep-related infant deaths.
Ongoing research has identified other risk factors for SIDS and also identified practices reducing risk of SUDI, including Fatal Sleep Accidents.
At the same time high-risk environments for sharing sleep surfaces have been identified:
Co-sleeping is associated with an increased risk of sleep-related death in certain hazardous circumstances. Hazardous circumstances include sofa-sharing, co-sleeping in a chair, infant tobacco exposure, co-sleeping with an adult impaired by alcohol, and co-sleeping with a low-birthweight or preterm infant
A videographic study of bedsharing families showed that 71% of formula-feeding infants had their heads at the level of the mother's face, with their heads on pillows or between the parents’ pillows, but every breastfed infant's head was at the level of the mother's chest
Formula fed babies have been observed to have their heads level with the mother’s head while sleeping, near or on pillows
Breastfed babies sleep with their heads close to the mother’s breast
When you take away known risks which you can control, what remains is a relatively low-risk environment for sharing a sleep space with a breastfed infant. Breastsleeping. As Dr James McKenna explains:
And breastsleeping means what?
In the absence of all know a hazardous factors...
Breastsleeping refers to a breastfeeding mother sleeping and feeding along side and in relationship to her infant i.e. cosleeping, (either same surface, or separate surface cosleeping)
Why?
Because of the way nighttime contact and proximity changes infant and maternal behavior, sleep-wake architecture, milk production, and metabolism, feeding frequency, mother's hormonal status, infants hormonal status, essentially becoming one and the same, integrated adaptive system, maximizing infant safety.
Led to: "There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping" (McKenna and Gettler 2016 Acta Paediatrica, 2016)
James McKenna PhD Santa Clara University University of Notre Dame, Emeritus
