Has breastfeeding promotion led to a dramatic rise in babies dying in their sleep?

Sweet Newborn Baby Girl Asleep in Crib

The headlines are chilling: Dramatic’ rise in babies dying in their sleep: Harvard study warns safe-sleep guidelines have done nothing to reduce infant deaths in 25 years.

Sudden deaths in newborns have not fallen in the last 25 years despite safe sleep guidelines, according to new research.

In fact, the rate of babies dying from suffocation has increased since safe-sleep recommendations were published in 1992.


[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is growing evidence that the Baby Friendly Hospital Initiative harms babies.[/pullquote]

According to study author Dr. Ronald Kleinman:

He pinpoints the increase in public health campaigns promoting breastfeeding as a factor that may have led to more mothers sleeping with their babies in their beds.

‘Overall, we think it is possible certain neonatal practices resulting in unsafe sleep circumstances both during and after the birth hospitalization, along with pacifier avoidance, may have inadvertently interfered with the implementation of safe-sleep messages and prevented a decrease in the death rate,’ he said.


The researchers believe several recommended practices designed to promote breastfeeding, the importance of which they fully support, may inadvertently contribute to the risks.

The practice of skin-to-skin care, in which an infant is placed in a prone position on the mother’s chest has been noted in other reports to have a strong association with SUPC [sudden unexplained postnatal collapse].

If the mother is also exhausted or sedated, she may even fall asleep with the infant on her chest resulting in co-bedding, an established risk factor for SIDS.

Another recommendation that may have unintended consequences is avoiding the use of pacifiers, which some breastfeeding advocates suggest eliminating and the AAP advises should not be used until breastfeeding is well established.

As pacifier use is strongly associated with a reduced risk of SIDS, the authors feel that recommendation should be reconsidered.

According to the paper itself:

The percentage of SUIDs attributed to MSBC/ASSB [Mechanical Suffocation Bed or Cradle/Accidental suffocation and strangulation in bed] increased over time in both the neonatal and postneonatal populations, from 2.1% in the neonatal population and 3.4% in the postneonatal population in 1995, to 22.7% and 24.9%, respectively, in 2014, representing an 11-fold proportionate increase in the neonatal population and a 7-fold proportionate increase in the postneonatal population. Neonatal increases ex- ceeded postneonatal increases in 13 of the 20 years. SUIDs attributable to MSBC/ASSB were significantly higher in 2014 compared with 1995 (P < .0001; OR 9.7; 95% CI 8.1-11.7). SUIDs attributable to MSBC/ASSB did not differ signifi- cantly between postneonatal and neonatal populations (P = .14; OR 1.2; 95% CI 0.9-1.5).

The accompanying graph tells the tale:


Or does it?

Look closely at the scales on either side of the graph. They are deeply misleading because they don’t measure rates but rather measure the proportion of deaths represented by sudden unexpected infant death. The distinction is crucial.

Here’s what it looks like when you graph RATES of sudden unexpected infant death over time:


The purportedly dramatic rise almost completely disappears.

That’s not the only problem with the study.

The authors acknowledge:

Although the deaths reported in the included age range and ICD codes assigned to them are consistent with the most commonly accepted definition of SUPC, the lack of a single specific ICD code for SUPC is a limitation. Miscoding of inpatient deaths during the birth admission could result in failure to capture SUID/SIDS cases. Location (hospital or home) is not available in the CDC WONDER database. In addition, because the detailed circumstances of the reported deaths cannot be ascertained from the CDC WONDER site data, MSBC/ASSB codes may be an imperfect marker for deaths owing to unsafe sleep conditions.

In other words, it is impossible to tell whether the increased proportion of deaths from mechanical or accidental suffocation is due to a real increase or better coding of sudden unexplained infant deaths. Though the study echoes the findings from other US and European studies, the conclusions we can draw from this data are limited.

That doesn’t let breastfeeding promotion off the hook, though. Another new study, The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature, just published in the Journal of Perinatology calls into question nearly every facet of the Baby Friendly Hospital Initiative. It is based solidly on multiple studies. Though the conclusions are more measured, they are equally devastating.

The evidence on rooming in and encouragement of skin to skin show significant risk of serious injury and death:

There are multiple reports on cases of sudden unexpected postnatal collapse in the neonate (SUPC) since 1994. Sudden Infant Death Syndrome (SIDS) differs from SUPC as the latter tends to occur in term or near-term infants who were well at birth and collapses unexpectedly in a state of cardiorespiratory compromise within the first 7 days of life. As the BFHI expands in the US, there is also a growing concern of the associated risks because of the increase in the reported cases of SUPC.

The emphasis on exclusive breastfeeding is also harming babies.

As the BFHI was implemented, health care facilities started to restrict the access to feeding supplements. Conversely, the lack of adequate feeding supplementation may result in excessive weight loss and hyperbilirubinemia among other medical conditions. Therefore, this generated a controversy regarding the safe use of supplemental formula while at the same time focusing on increasing breastfeeding rates.

Flaherman et al. performed a randomized control trial (RCT) in 2013 which gave limited formula feedings to 40 term infants with ≥ 5% of weight loss at 24 to 48 h of age by using a syringe. They found that these infants had decreased formula intake at 1 week of life and continued breastfeeding for longer duration to 3 months of age. A similar trial in 2016 by Stranak et al. with 100 infants, found no differences in the rate of breast feeding initiation and its duration. Schbiger et al. randomized 602 infants to either restrictive supplement or pacifiers vs. conventional feeding practices during the first 5 days of life (supple- mentation after breastfeeding and pacifiers were offered without restriction). When comparing the groups, the study did not find a difference in breastfeeding rates at six months of life …

The avoidance of pacifiers isn’t merely unsupported by the scientific evidence; pacifiers actually have important benefits:

Medical benefits associated with the use of pacifiers include providing comfort, contributing towards neurobehavioral organization, and reducing the risk of SIDS.

Crucially the existing data indicated that the BFHI increases DOESN’T increase breastfeeding rates:

Robert et al. in Belgium reported their experience with over a thousand infants and observed that being born in a BFHI facility did not influence the breastfeeding rates and duration. A survey from 6752 women in Australia showed that infants born at a BFHI hospital had lower odds of breastfeeding at 1 and 4 months of age. The conclusion conveyed was that in places where breastfeeding rates are high and evidence-based practices that support breastfeeding are in place, the BFHI accreditation does not have an influence on breastfeeding rates. This finding was also supported by the study of Yotebieng et al.

The authors conclude:

…[T]he Ten Steps are in urgent need of an update. Moreover, evidence is non-conclusive and not in full support of the BFHI as a program that can successfully increase initiation and long-term breastfeeding rates. Therefore, using the increase of breastfeeding initiation rates does not serve as a suitable or appropriate outcome to reflect the success of the BFHI. Consequently, it would be problematic to regard the BFHI as best practice for the improvement of breastfeeding initiation rates and duration.

The Baby Friendly Hospital Initiative is not based on scientific evidence, harms babies, and doesn’t accomplish its stated goal of increasing breastfeeding rates. It should be dramatically revised immediately, or better yet, it should be ended.