Hazardous Sleep Environment

by on April 2, 2015

in Monthly

Every March the American Academy of Pediatrics (AAP) holds their Annual Leadership Forum (ALF) in Chicago. The goal of this meeting is for pediatricians in leadership to assemble in one place and to discuss important topics which later are prioritized by the Board of the organization.

Recently the list of priorities included: early brain development, the impact of media on children, obesity, epigenetics (the science of how genes express themselves) and the impact of poverty on the health of children.

At this year’s meeting I was impressed by the discussion around infants dying in their beds.

The incidence of Sudden Infant Death has decreased over the past decade. (It is still the third leading cause of death with an incidence of 54 out of 100,000 babies) The practice of ensuring babies sleep on their backs was adopted by the AAP a number of years ago and at the that time a number of American pediatricians were upset with the recommendation—-they argued that the data for putting babies to sleep on their backs was generated in New Zeeland and not the USA. Fortunately, there is almost unanimous agreement now that the campaign to teach parents to let babies sleep on their backs has been successful.

However death to unintended suffocation and asphyxia remains a cause for concern. The incidence has not declined; in fact it has doubled from 7 per 100,000 babies to 16 per 100, 00 babies making it the fifth leading cause of death. A hazardous bedding environment is thought to play a major roll.

During the most recent ALF in Chicago I observed the hours and hours of debating and the discussion of official policy statement s and positions—often done by articulate and borderline obsessive compulsive experts, certain that their efforts will make a difference. But does it make a difference?

At this point it appears not to have made a difference because too many doctors in primary care fail to warn parents about the hazards of having stuffed toys, pillows or blankets in a crib and for some parents it makes no difference what experts have to say. If a parent is convinced that a baby needs the comfort of a softer bed, a pillow for a tired head and the comfort of a favorite blanket or toy they will provide that with good intentions. The good intentions may end with a bad situation of death by suffocation.
It is thought that babies, once they get older, can roll over and position themselves against objects such as pillows, loose bedding, bumper pads, stuffed toys, blankets and various other soft objects placed in cribs. They are still too young to reposition themselves and then face the risk of death by asphyxia/suffocation.

Research shows that many parents are concerned that babies placed on a firm surface will not be comfortable. These concerned parents may use a soft blanket or sheepskins under the baby to create a softer surface. Some parents also feel that a comfortable pillow may aid a baby in sleeping more peacefully.

Researchers have gathered plenty of data on sleep positions of babies as well as sleep locations, but it has only been recently that a wealth of data was collected about objects kept in cribs. As many as 50% of parents use thick blankets, cushions and pillows thinking it helps their babies sleep better. This practice is more common in some cultures. Many parents extrapolate from their own experience that these objects will help keep the baby warm and comfortable at night. Others know that to cover babies with thick blankets is dangerous, but they consider a blanket underneath the baby to be less hazardous.
Some parents, when surveyed, explained they try to keep blankets away from the baby’s head, or use blankets with breathing holes (e.g., crocheted)

Images from popular magazines targeted to women of childbearing age often show photos of infants sleeping with potentially hazardous bedding such as pillows and blankets.

Some babies share a bed with a parent and such a parent may be fearful that the baby will fall off the bed; they then build blanket rolls or place pillows by the side of the bed hoping that it may prevent falls. Instead this may put babies at risk for suffocation.
The solution to the recent increase in number of deaths due to unintended suffocation may be a more targeted campaigns— similar to the Back to Sleep Campaign (which taught families that babies should sleep on their backs) In the mid-nineties, when the AAP recommended that infants’ sleeping environments should be free of materials which may cause suffocation, there was a decline in the incidence of suffocation. The point is that such education works but it has to be sustained in order to save lives.

Canadian pediatricians also have a similar position regarding a safe sleeping environment (See http://www.cps.ca/documents/position/safe-sleep-environments-infants-children)

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