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Subject:
From:
Kathy Dettwyler <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Wed, 22 Mar 2000 08:48:48 -0600
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>James McKenna sent me his letters, and said it was fine to post them to
>LactNet.
>
>Kathy Dettwyler
>
>
>>In press Pediatrics
>>
>>
>>Sleep Location and Suffocation: How Good is the Evidence?
>>
>>To the Editor -
>>In their article "Infant Mechanical Suffocation Deaths in the United
>>States, 1980-1997" Drago and Dannenberg analyze a case series of 2178
>>infant deaths that they classified as "suffocation" based on the Consumer
>>Product Safety Commission's (CPSC) Death Certificate File (DCF), providing
>>a sobering reminder of environmental hazards to infants, such as wedge
>>spaces around mattresses/cushions and strangulation risks from cords or
>>widely spaced crib rails.1  However, the data do not necessarily support
>>their recommendations that "bed sharing and the use of adult beds for
>>infants should be discouraged" or that regulations should "forbid the use
>>of a bed for an infant or toddler."  Such recommendations require knowledge
>>of the relative risk of different sleeping locations (e.g. cribs vs.
>>playpens vs. beds, etc), information which is not discernable from the
>>CSPC-DCF for two reasons.  First, the denominator is unknown (the
>>proportion of time infants in the population spent in each location).  We
>>will focus on the second and more complicated issue of numerator
reliability.
>>Concerns about the reliability of case definition stem first from
>>variability in the gathering, interpretation, and reporting of information
>>to the CPSC.2, 3  Variation arises from 1) inconsistent data collection
>>procedures, 2) disparate qualifications of those who investigate and
>>certify death, with certifiers ranging from coroners with no medical
>>training to forensic pathologists and 3) lack of objective criteria to
>>distinguish suffocation from sudden infant death syndrome (SIDS).4  As an
>>example of possible resulting classification bias, O'Hara noted a
>>geographic clustering of the suffocation subcategory "overlaying" on review
>>of the CPSC-DCF data since 1995.  Certifiers from areas where the term was
>>used most frequently related by phone interview that they would not
>>diagnose SIDS in the context of co-sleeping, assuming sleep location to be
>>a possible contributory factor.  In contrast, some other certifiers
>>classify an infant death in any location as SIDS unless evidence of a
>>specific etiology is found.  Only the former cases would likely be
>>classified as a type of "suffocation" in the authors' analysis, increasing
>>both the number of deaths ascribed to suffocation and the apparent
>>percentage of suffocation deaths involving beds and co-sleeping.
>>Classification is also limited by the scant amount of information provided
>>to the CPSC, consisting only of a code for the cause of death (E-code), a
>>one-line narrative, and demographic information.  Based on such sparse
>>data, the authors note that their classifications proved to be inaccurate
>>for half of the subset (18/38) of crib-related deaths that were compared
>>with in-depth investigations by the CPSC.1  Unfortunately, no validation of
>>accuracy was presented for the cases involving beds and/or more speculative
>>mechanisms of death (e.g. case # 9734052045: "baby found unresponsive,
>>father slept in same bed: asphyxiation by overlay [sic]"5).  Reasons to
>>question classifications related to beds and co-sleeping include 1) the
>>inability of E-codes to distinguish beds from cribs, 2) possible use of the
>>general term "bed" in the narrative to refer to a variety of specific
>>sleeping locations, 3) lack of any information about co-existing
>>environmental risks (e.g. caregiver intoxication), and 4) the potential for
>>cultural beliefs about proper sleep location to influence the
>>interpretation of death circumstances.
>>History has humbled us with the hazards of making strong recommendations
>>about infant sleep without an adequate empiric basis.  One example is the
>>widespread recommendation in the 1950s to place infants prone, followed
>>decades later by the recognition that prone sleeping is a major risk factor
>>for SIDS.6  Similarly, premature recommendations about optimal infant sleep
>>location might 1) unnecessarily limit cultural choices about infant care,
>>2) subject parents to unfounded guilt/blame, 3) obscure the need for
>>further research, and 4) inadvertently compromise child health.  This is
>>particularly important in light of evidence7-10 suggesting that co-sleeping
>>may be protective against SIDS.  In addition, co-sleeping facilitates
>>breastfeeding,11 which in turn has significant benefits for maternal and
>>child health.12  Until better data are available to determine the impact of
>>infant sleeping location on overall infant health, we should focus our
>>recommendations on evidence-based information about infant sleep position
>>and environment.
>>                                                                              (final 8.4.99)
>>MARYANN O'HARA, M.D., M.St.
>>Robert Wood Johnson Clinical Scholars Program, University of Washington,
>>Seattle, WA 98195
>>
>>RICHARD HARRUFF, M.D., Ph.D.
>>Acting Chief Medical Examiner, Public Health Department, Seattle, WA 98104
>>President-elect of the Washington SIDS Foundation
>>
>>JOHN E. SMIALEK, M.D.*
>>DAVID R. FOWLER, M.B. ChB.M.**
>>*Chief and **Deputy Chief Medical Examiners
>>Office of Chief Medical Examiner for the State of Maryland, Baltimore, MD
>>21201
>>
>>Corresponding author:  Dr. O'Hara, RWJCSP, UW Health Sciences Center, Box
>>357183, Seattle, WA 98195 Phone: 206-616-8724, Fax: 206-685-2473, e-mail:
>>[log in to unmask]
>> References
>>
>>1.    Drago DA, Dannenberg AL. Infant mechanical suffocation deaths in the
>>United States, 1980-1997. Pediatrics 1999; 103:e59
>>2.    US Consumer Product Safety Commission. A description of the Death
>>Certificate Project and its data files. Washington, DC, 1998
>>3.    Sturner WQ. Common errors in forensic pediatric pathology. Am J Forensic
>>Med Pathol 1998; 19:317-320
>>4.    Sheers NJ. Infant Suffocation Project: fiscal year 1993 status report.
>>Washington, DC: US Consumer Product Safety Commission, 1993
>>5.    US Consumer Product Safety Commission. Death Certificate File.
>>Washington, DC, 1995-1998
>>6.    Mitchell EA, Ford RP, Taylor BJ, et al. Further evidence supporting a
>>causal relationship between prone sleeping position and SIDS. J Paediatr
>>Child Health 1992; 28:S9-12
>>7.    Farooqi S. Ethnic differences in infant care practices and in the
>>incidence of sudden infant death syndrome in Birmingham. Early Hum Dev
>>1994; 38:209-13
>>8.    Mosko S, Richard C, McKenna J, Drummond S, Mukai D. Maternal proximity
>>and infant CO2 environment during bedsharing and possible implications for
>>SIDS research. Am J Phys Anthropol 1997; 103:315-28
>>9.    Mosko S, Richard C, McKenna J. Infant arousals during mother-infant
>>bed-sharing: implications for infant sleep and sudden infant death syndrome
>>research. Pediatrics 1997; 100:841-849
>>10.   McKenna JJ, Thoman EB, Anders TF, Sadeh A, Schechtman VL, Glotzbach SF.
>>Infant-parent co-sleeping in an evolutionary perspective: implications for
>>understanding infant sleep development and the sudden infant death
>>syndrome. Sleep 1993; 16:263-82
>>11.   McKenna J, Moso S, Richard C. Bedsharring promotes breastfeeding.
>>Pediatrics 1997; 100:214-219
>>12.   American Academy of Pediatrics.  Working Group on Breastfeeding.
>>Breastfeeding and the use of human milk. Pediatrics 1998; 100:1035-1039
>>
>>
>>
>>
>>
>>
----------------------------------------------------------------------------
-------
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

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