>>Accepted by Pediatrics: in press
>>JmcKenna Ph.D. (University of Notre Dame)
>>Director, Mother-Baby Behavioral Sleep Laboratory
>>LGartner MD (University of Chicago)
>>Department of Pediatrics
>>
>>To The Editor:
>>We are writing to express our concern with several of the points raised in
>>the recent article by Drago and Dannenberg (Drago DA, Dannenberg AL. Infant
>>mechanical suffocation deaths in the United States, 1980-1997. Pediatrics
>>1999; 103:e59, 1). The authors suggest that the reported increase in infant
>>deaths by suffocation and "overlying" could be the result of "an increase
>>in the rate of infant-parent co-sleeping related to reported benefits,
>>including increased breastfeeding and reduction in the rate of SIDS... ."
>>They acknowledge that rates of co-sleeping are unknown and that this
>>association is theoretical. Furthermore, they provide none of the details
>>needed to support their conclusion and use "dangerous conditions" as a
>>proxy for the act of a mother and infant sleeping side-by-side-which is
>>universally, inherently adaptive and beneficial for both mothers-infants
>>alike in the overwhelming majority of situations.
>> Mother-infant co-sleeping evolved to protect and feed infants throughout
>>the night ( 2). Millions of mothers worldwide know that strong emotions
>>underlie and motivate co-sleeping, even though they may be unaware of
>>co-sleeping as a biologically appropriate arrangement which, in turn
>>induces important behavioral and physiological changes in both infants and
>>mothers. These changes have been reported in extensive peer-reviewed
>>laboratory studies (3-8) and include increased use of the safe, supine
>>infant sleep position , increased breastfeeding, increased infant movement,
>>arousal and awakenings during sleep, reduced deep and increased light
>>sleep, more affectionate and protective maternal interventions, increased
>>sensitivity to the presence of the co-sleeping partner, reduced infant
>>crying, fewer (infant) obstructive apneas in deep sleep, longer infant
>>sleep, and more positive evaluations by bedsharing mothers of their
>>nighttime experiences (3-8).
>> It has been estimated that more than half of the families in the United
>>States practice co-sleeping with infants for some period of time. Drago and
>>Dannenberg casually dismiss the biologically important role of co-sleeping
>>when they state: "New parents may take their infants to bed with them...for
>>feeding convenience." Catastrophic accidents in the co-sleeping
>>environment are tragic exceptions to the act of co-sleeping itself and are
>>almost always attributable to avoidable, unsafe conditions, most frequently
>>found in high risk populations where most such tragedies occur. In recent
>>years in Cook County, Illinois (Chicago), the medical examiner has found
>>that all overlying deaths were in situations in which the adult was
>>intoxicated with either alcohol or illegal drugs. We agree with the
>>authors and others that special precautions need to be taken to minimize
>>catastrophic accidents, but the need for such precautions is no more an
>>argument against all co-sleeping and, specifically, bedsharing, than is the
>>reality of infants accidentally strangling, suffocating or dying from SIDS
>>alone in cribs a reason to recommend against all solitary, unsupervised
>>infant sleep (cribs). The goal is to avoid dangerous adult beds, and
>>dangerous bedsharing conditions, while preserving the proven benefits of
>>cosleeping in safe beds involving safety-conscious adults, if that is the
>>parent's choice.
>> Breastfeeding (at an all time recorded high in the United States) and
>>co-sleeping in the form of bedsharing mutually reinforce each other(9, 10).
>> That is, studies show that bedsharing increases the frequency and duration
>>of nightly breastfeeding, while breast feeding makes bedsharing convenient
>>for mothers thereby increasing the chances of it's adoption as a routine
>>practice(4). Maintenance of breastfeeding is a proven preventive action
>>against increased infant illness and death, even in developed countries,
>>and a significant factor in reducing maternal illness. It is unfortunate
>>that Drago and Dannenberg were unable to report the specific conditions and
>>/or circumstances in which alleged overlaying and other bedsharing infant
>>deaths occurred. It is those specific conditions that transform co-sleeping
>>(in the form of bedsharing) into something potentially dangerous. Of the
>>total bedsharing deaths they report it is important to know, for example,
>>how many infants were found lying prone, or were sleeping on sagging
>>mattresses, on waterbeds, or sofas--- all highly risky forms of
>>co-sleeping. Of the bedsharing deaths how many mothers smoked during their
>>pregnancies, or smoked at the time of the infant's death, laid their babies
>>prone for sleep, were intoxicated, used drugs, or were perhaps unaware that
>>the baby was sleeping alongside? Was there a previous infant or child death
>>in the family, suggesting possible infanticide, or a Munchausen-by-proxy
>>syndrome? Of even greater importance is the question: how many of these
>>overlays involved nonsmoking, non-intoxicated, breastfeeding mothers? These
>>data are critical to assess the actual causes of death. Mere location of
>>infant sleep is insufficient for assessing the actual cause of the
tragedy.
>> Furthermore, it is important to recognize that an infant can die from SIDS
>>while bedsharing without any contributory role from co-sleeping. Most
>>adults die in bed, but we do not indict the bed as a factor in causing the
>>death. Cultural biases against mother-infant co-sleeping in our society
>>make it very difficult to think of a bedsharing death simply as yet another
>>tragic SIDS. All too frequently the assumption is that the adult in the bed
>>probably overlaid the baby either accidentally or purposefully.
>>Unfortunately, autopsy examination is unable to differentiate between
>>"SIDS" and suffocation in the absence of physical signs of injury. A priori
>> assumptions make it less likely that an accurate assessment will be
>>achieved.
>> The distinction between co-sleeping and particular forms of it, like
>>bedsharing , was introduced several years ago as a way to make more precise
>>the discourse surrounding co-sleeping and SIDS (11,12 ) and to help clarify
>>and potentially reconcile the legitimate diverse positions argued by
>>researchers in this controversial area. The authors erroneously use these
>>terms interchangeably. Co-sleeping takes hundreds of different forms
>>worldwide and no single outcome necessarily can be associated with it.
>>Differential outcomes for different types of co-sleeping, including
>>different types of bedsharing, can be predicted only by considering both
>>the nature of relationships involved while co-sleeping (what happens
>>between the caregiver and infant once in bed, or outside of the bed) and
>>the qualities of the physical environment and social circumstances within
>>which particular types of infant care (as, for example, breast feeding) are
>>integrated with, or are absent from, the act of co-sleeping.
>> That a proactive, involved and nurturing caregiver changes the outcomes in
>>the co-sleeping environment are suggested by the New Zealand
>>epidemiological study showing that when infants sleep in the same room with
>>their mothers, but not when sleeping in a room with siblings, they are four
>>times less likely to die from SIDS (13). Similarly, the CESDI (Great
>>Britain) epidemiological study shows that infants who sleep in a separate
>>room alone are more likely to die from SIDS than are infants of nonsmoking
>>mothers who are brought in and out of their mother's bed throughout the
>>night for breastfeeding, and who are kept in the room, close to the mother
>>all night long (14). Moreover, Japan exhibits the lowest SIDS rates in the
>>world and, there, mother-infant co-sleeping (on floor positioned futons) is
>>the cultural norm! By distinguishing between co-sleeping in a generic sense
>>and particular forms of co-sleeping (such as safe bedsharing, exhibited by
>>breastfeeding, nonsmoking mothers sleeping on firm mattresses versus unsafe
>>bedsharing, exhibited by non-breast feeding, smoking mothers sleeping on
>>soft, over-blanketed beds) health professionals can preserve and
>>acknowledge the importance of parents and infants sleeping within arms
>>reach--within proximity (co-sleeping).
>> Drago and Dannenberg speculate that the increase in overlay deaths in the
>>last decade might be attributed to the promulgation and acceptance of
>>McKenna's documented benefits of co-sleeping in the form of safe
>>bedsharing. At very least, information on why the parents or caregivers
>>overlain infants elected to bedshare as well as data on whether or not they
>>did so safely on the night the infant died would be required before such an
>>assertion could be proven. Sound scientific methods and procedures were
>>used in all of McKenna's studies and all work was peered-reviewed on
>>multiple occasions. It is true that the AAP Committee on Infant Sleep
>>Position sees no reason to recommend bedsharing as a way to reduce SIDS
>>(and, at this point, neither does McKenna). It is also true that the AAP
>>committee warns appropriately (as does McKenna and colleagues) that under
>>special unsafe circumstances bedsharing can increase SIDS risk;
>>nevertheless, there remain valid, peer-reviewed data which justify
>>scientific speculation that under safe bedsharing/cosleeping circumstances
>>(especially where breastfeeding is involved) infants may have an increased
>>chance to avoid a SIDS death. This speculation emerged initially from a
>>detailed peer-reviewed monograph, which proposed a theoretical model and a
>>series of testable hypotheses, all of which integrated cross-cultural SIDS
>>epidemiology, and developmental, experimental, and evolutionary data (15).
>>It led to two pilot studies of mother-infant co-sleeping (16, 17) and a
>>carefully controlled NICHD funded scientific study which documented
>>significant physiological and behavioral changes in sleep, arousal, and
>>feeding patterns induced by the presence of a breastfeeding, co-sleeping
>>mother (18). At least ten peer reviewed articles have been published, two
>>of which appeared in Pediatrics.
>> The criticisms we raise should not detract from the value of other
>>information Drago and Dannenberg present concerning the etiologies of
>>infant mechanical suffocation. What are evident from this report is that
>>no sleep environment is risk free, and that much more can be done to
>>educate parents as to how to provide safer sleeping environments.
>>Furthermore, it is clear that the types of precautions required to maximize
>>safety under different sleeping conditions (both social and solitary) are
>>shown often to be the same: mattresses should be firm and tight fitting to
>>their frames, infants should not be overwrapped, or their heads covered by
>>blankets, placed prone for sleep or permitted to sleep on pillows etc. And
>>while some precautions are unique to bedsharing, does not negate the
>>validity of the choice, when practiced safely. At this point in the history
>>of western societies, where an unprecedented convergence of cultural
>>practices is underway--- not the least of which involve sleeping
>>arrangements--- it is critical that clinicians and researchers broaden
>>their thinking about what constitutes appropriate and desirable childhood
>>sleep practices. Failure to do so will continue to limit both the accuracy
>>of pediatric sleep science and the effectiveness of care. As we move into
>>the next millennium infant-parent co-sleeping with breastfeeding is likely
>>to become more, not less common (19). We look forward to the time when we
>>join the rest of the world and regard infant parent co-sleeping not as
>>pathology, but as an appropriate and potentially rewarding choice for fully
>>informed parents when practiced safely.
>>
>>James J. McKenna, Ph.D.Director, Mother-Baby Behavioral Sleep Laboratory
>>University of Notre Dame
>>
>>Lawrence M. Gartner, M.D.
>>University of Chicago
>>References Cited
>>1.Drago, DA, Dannenberg, AL Infant mechanical suffocation deaths in the
>>United States,1980-1999. Pediatrics 103:5: e59, 1999
>>2.Konner MJ. Evolution of human behavior development. In RH Munroe,
>>RL Munroe, JM Whiting, eds. Handbook of Cross-Cultural Human Development.
>>New York; Garland STPM Press, 1981:3-52.
>>3. McKenna JJ, Mosko S, Richard C, Drummond S, Hunt L, Cetal M, Arpaia J;
>>Mutual behavioral and physiological influences among solitary and
>>co-sleeping mother-infant pairs; implications for SIDS; Early Human
>>Development 1994;38:182-201.
>>4. McKenna J, Mosko S, Richard C. Bedsharing promotes breast feeding,
>>Pediatrics 1997:100:214-219
>>5. Richard C, Mosko S, McKenna, J . Sleeping position, orientation,
>>and proximity in bedsharing Infants and mothers Sleep 1996 19:667-684.
>>6. Mosko S, Richard C, McKenna J. Infant arousals during mother-infant
>>bedsharing; implications for infant sleep and SIDS research. Pediatrics
>>1997, 100:
>>5; 841-849
>>7. Richard C Mosko S, McKenna J. Apnea and periodic breathing in the
>>bedsharing infant. Amer J Applied Phys 1998 84;4:1374-1380
>>8. Mosko S, Richard C, McKenna J, Drummond S. Infant sleep architecture
>>during bedsharing and possible implications for SIDS; Sleep
>1996;19:677-684.
>>9. Ross Mothers Survey (1997). Published and available through Ross
>>Laboratories. Ross Products Division of Abbot Laboratories.
>>10. Mitchell, EA, Scragg L, Clements M. Factors related to infant
>>bedsharing.NZ Med J 1994; 107: 466-467.
>>11. . McKenna JJ, Thoman E, Anders T, Sadeh A, Schechtman V, Glotzbach S.
>>Infant-parent co-sleeping in evolutionary perspective: Implications for
>>understanding infant sleep development and the Sudden Infant Death Syndrome
>>(SIDS). Sleep 1993;16:263-282.
>>12. McKenna JJ; (1995); The potential benefits of infant-parent co-sleeping
>>in relation to SIDS prevention; overview and critique of epidemiological
>>bed sharing studies; In Sudden Infant Death Syndrome: New Trends in the
>>Nineties. TO Rognum, ed. Oslo: Scandinavian University Press, 1995:256-65.
>>13. Mitchell EA, Thompson JMD. Cosleeping increases the risks of the sudden
>>infant death; syndrome, but sleeping in the parent's bedroom lowers it. In:
>>Rognum TO Sudden Infant Death Syndrome in the Nineties. Oslo: Scandinavian
>>University Press, 1995, 266-269.
>>14. Fleming P, Blair P. Safe environments for infant sleep: community and
>>laboratory investigations or folk wisdom? Symposium on Breast Feeding,
>>Parental Proximity and Contact in Promoting Infant Health. Paper Delivered
>>University of Notre Dame, South Bend, September 1998.
>>
>>15 McKenna JJ. An anthropological perspective on the sudden infant death
>>syndrome (SIDS); The role of parental breathing cues and speech breathing
>>adaptations; Medical Anthropology 1986; 10:9-53.
>>16. McKenna JJ, Mosko S, Dungy C, McAninch P. Sleep and arousal patterns of
>>co-sleeping human mothers/infant pairs; A preliminary physiological study
>>with implications for the study of Sudden Infant Death Syndrome (SIDS);
>>American Journal of Physical Anthropology 1990;83:331-347.
>>17. Mosko S, McKenna JJ, Dicker M, Hunt L. Parent-infant co-sleeping: the
>>appropriate context for the study of infant sleep and implications for SIDS
>>research; Journal of Behavioral Medicine 1993;16(3):589-610.
>>
>>18. McKenna, JJ Mosko S, Richard C Breast Feeding and mother-infant
>>cosleeping in relation to SIDS prevention. In: Evolutionary Medicine; Eds
>>W Trevathan, Smith N, McKenna J. Oxford University press: Oxford 1999, PP
>>53-74
>>19. McKenna, J. Cultural Influences on infant and childhood sleep biology
>>and the science that studies it: Toward a more inclusive paradigm. In:
>>Sleep In Development and Pediatrics. JLoughlin Carroll J, Marcus C; Marcel
>>Dekker : New York, in press.
>>>
>
>
----------------------------------------------------------------------------
-------
Katherine A. Dettwyler, Ph.D. email:
[log in to unmask]
Anthropology Department phone: (409) 845-5256
Texas A&M University fax: (409) 845-4070
College Station, TX 77843-4352
http://www.prairienet.org/laleche/dettwyler.html
***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html
|
