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.

Why?

There is growing evidence that the Baby Friendly Hospital Initiative harms babies.

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.

Specifically:

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:

Print

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:

Print

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.

  • Clarene Wong

    I’m hoping the Dr weighs in on the trans woman who took a bunch of drugs in order to breastfeed

  • Tiffany Aching

    I suspect that many mothers simply aren’t aware of the risks. I gave birth 9 days ago and only one of the many many pediatric care professionals I have seen since (I’m in France and one of the many nice things in our healthcare system is the help new mothers receive ) asked me if I coslept and warned me against it. I had lots of (helpful and non judgemental) advice on breastfeeding but nobody gave me any guidelines for safe sleeping.

    I also think that the professionals explaining the guidelines should really insist more on the role of the partner. Nighttime feedings would be too exhausting if my husband didn’t do almost everything during the nights except breastfeeding our baby. He also told me I should wake him up if I was afraid of going to sleep while breastfeeding, which is very reassuring.

    • KeeperOfTheBooks

      Congrats on the new baby! I hope both of you are doing well. 🙂

      • Tiffany Aching

        Thank you so much ! We’re both very well, I feel very lucky to have a healthy, easy baby :).

        • KeeperOfTheBooks

          My second was like that; I joke that *he* sleep trained ME! Delightful.

  • borkborkbork

    When I go in for check ups, nurse midwives are always suggesting that I try co-sleeping as a way to get extra sleep while exclusively breastfeeding.

    That has always confused me. Exactly how would it allow me to get extra sleep? I still have to get up every couple hours, to check the baby’s diaper, burp her, cuddle her, and feed her. That involves being awake. When breastfeeding, I feel like I need both hands and all my wits just to keep the baby latched and positioned comfortably.

    Are there women who breastfeed while sleeping?

    That said, the idea of cosleeping doesn’t appeal to me. It feels much safer to have her safely in her bassinet right next to the bed, where I can see her, away from restless adult bodies and heavy blankets.

    Co-sleeping does not seem like a solution. I am not sure why it is being promoted as something that makes breastfeeding easier.

    • Tigger_the_Wing

      Good grief, they are really promoting something that is extremely dangerous, in order to make breastfeeding ‘easier’? If breastfeeding had been so difficult that it was necessary to risk my baby’s life in order to do it, then I’d have switched to formula in a heartbeat. Well, I did switch to formula for two of mine anyway, but you get what I mean.

  • Lurkerette

    I wonder if the deaths have less to do with breastfeeding and more to do with the back-to-sleep guidelines, which leave well-meaning parents so exhausted that they bedshare without a safe plan.

    • Tigger_the_Wing

      My older three were born in the early eighties, when the advice was to let babies sleep prone. My twins were born in the early nineties, when the advice had done a literal 180º turn, and the advice was to let them sleep supine. There is no way that I could compare the amount of sleep each got to their position.

    • What does babies sleeping on their backs have to do with making parents tired?

      Serious question. I’m not a parent. I don’t see the logical connection.

      • Merrie

        They don’t typically sleep as well on their backs, so are up more and requiring more attention from the parents.

  • ukay

    OT: https://www.theguardian.com/lifeandstyle/2018/feb/15/do-not-intervene-to-speed-up-birth-unless-real-risks-involved-advises-who

    Yippieayeyeah! What redundant advice! Interventions happen because of real risks or on maternal request. Women who have to give birth without access to a hospital have other worries than the right birth experience. It never gets old- prescribing the aspirations of the privileged to others who do not even have a choice.

    • Merrie

      What are they even talking about? What population?

      ““Many women want a natural birth and prefer to rely on their bodies to give birth to their baby without the aid of medical intervention,” says Ian Askew, director of the WHO’s department of reproductive health and research. He added: “Even when a medical intervention is wanted or needed, the inclusion of women in making decisions about the care they receive is important to ensure that they meet their goal of a positive childbirth experience.””

      This seems like such a nonsensical quote from the WHO. Women in low-resource settings want to live through birth. If they don’t want a c/s it’s more likely to be because they don’t want to risk a VBAC with their next kid when they can’t easily access medical care, not because they don’t want to ruin their childbirth experience. It’s privileged women who have the “goal” of a “positive childbirth experience”, whatever that means. I love how this dude who has presumably never given birth himself is the head of the WHO’s department of reproductive health and supposedly an expert on women’s goals for childbirth.

      • kilda

        seriously. Women in most of the world have a “me and my baby alive afterward” goal, not a “positive childbirth experience” goal,

        • The Bofa on the Sofa

          According the bible, babies literally didn’t “count” until they were 1 month old (they also didn’t count if they were female, but that’s a separate issue).

          When Moses is told to count the members of the tribe, he is told to only count boys who are 1 month old or older. Why do you think that was? Maybe because it took a month before they could conclude that they were going to survive?

          You think they were concerned about a positive childbirth experience?

          There is another part of the bible where family members are “valued” in terms of how much they show you should give money to the church. Again, babies less than a month old are worth nothing. Only when they hit 1 month do babies become a value asset.

          • MaineJen

            One of the earliest signs that religion MIGHT not be for me was those long, long passages in the old testament, “So and so begat this many sons, such and such person begat that many sons.” I remember thinking ‘Man, they sure had a lot of boys. Didn’t anyone ever have daughters back then?’ It didn’t take me long to realize that yes, they did have daughters, but they didn’t bear mentioning.

            And thus, young MaineJen became a baby feminist.

          • Zornorph

            Yeah, what are the odds that Jacob had 12 children and every one was a boy? On the positive side, it seems the unmentioned daughters didn’t drop their sibling down a well and sell him as a slave. But if they had showed up in the narrative, it would have given all the schoolgirls who take part in Joseph and the Amazing Technicolor Dream Coat parts to play besides dressing in drag, being ‘hairy Ishmailites’ or purring ‘Lie with me’ as Ms. Pontiphar.

          • The Bofa on the Sofa

            You are one messed up dude….

          • borkborkbork

            I have to be an obnoxious know-it-all and jump in with a correction. At least one of Jacob’s daughters is named, and her name was Dinah. She gets her own horrifying story of brotherly betrayal to compete with Joseph’s.

            There – I finally made use of those twelve years of bible school that I was subjected to.

          • Allie

            I don’t find it obnoxious when you’ve literally been waiting years to make us of that. Way to go! Sharing knowledge is awesome, though it is important to get the timing and delivery right.

          • Eater of Worlds

            There’s a family that has been on TV that has a dozen boys…and one girl, the last child.

  • Jessica

    I wonder how much of the protective effect of breastfeeding on SIDS is a result of former SIDS deaths being reclassified as SIUD or as something else like suffocation. It seems like it would be hard to control for that issue (and I’m not aware of any evidence that it’s the class), but one can easily conceive of a more obvious explanation (such as being smothered in bed) in the case of a breastfeed infant who was co-sleeping.

  • Montserrat Blanco

    We offered a pacifier… to no avail. My son did not like it at all. In any case he was combo fed and never ever coslept with us. I was seriously afraid of rolling over him due to my sleep deprivation, so no cosleeping for us and he was always placed on his back on his crib.

    He is three years old now and only this winter started sleeping with blankets. Yes, I was pretty afraid of SIDS with a 28 weeks preemie.

    • The Bofa on the Sofa

      They make Halo sleep sacks that will go up to at least age 4. They have feet holes in the bottom.

      Our older guy slept in them until he was 4. Now he sleeps in his underwear, but still wraps himself up in the blanket.

      • Heidi

        Those early walker sleepsacking are also a good hack to keep toddlers out of their diapers during naps! I was pretty over going in his room to find poo smeared and sprinkled about.

        • seenthelight

          Yep, never had that with my kids thanks to sleep sacks! I was mentally prepared for it, too, because I’d seen it with younger siblings, but those sleep sacks kept them out altogether. In the winter, I’d put them in footies with the sleep sack on top.

      • demodocus

        My 1 year old is so freaking -tall- that she’s in 3t clothes. I’m glad she’s already showing signs of interest in using the toilet.

      • BeatriceC

        Sleep sacks weren’t a thing when my kids were babies, so pardon if this is a stupid question. What’s the advantage of a sleep sack over a heavy winter weight footed pajama? Even though there wasn’t a “no blanket” thing back when my kids were small, keeping them covered with a blanket was impossible, so they never used them anyway, and put them in heavy weight footed pj’s to keep them warm.

        • The Bofa on the Sofa

          For babies, probably not much different. But for older kids, the ones with foot holes, his feet stuck out and he liked that.

          Our kids wore pjs under their sleep sacks.

        • swbarnes2

          Sleep sacks have flaps with Velcro for easy swaddling

        • Who?

          And is there anything cuter (from someone who is pretty much immune to cute) than a sleepy baby in a pair of footed pjs?

        • AlisonCummins

          Toddlers can’t climb out of their cribs in a sleep sack. If they’ve always been in sleep sacks, they’ll think they’re normal and that not being able to climb out of the crib is normal. If you try to make an older child who is used to climbing out of the crib wear a sleep sack for the first time they are likely to protest, so best to start young.

          Also, nighttime diaper changes might be easier.

        • Heidi

          The infant versions, well some of them, have it where you can swaddle them safely. My husband and I could never figure out a blanket swaddle anyway.

        • Merrie

          I put my kid in a sleep sack over pajamas so he can have an extra layer.

        • Ms. Sweaterfan

          We have some warm footed jammies and some sleep sacks and we pretty much just use them interchangeably (it’s not cold enough where I live to need to double up) but I’ve found that sleep sacks make middle of the night diaper changes go a little quicker since you don’t have to wrestle wiggly feet back into individual pajama legs 🙂

        • Montserrat Blanco

          Not a great difference, in very cold places some parents use both things at a time. For us, the sleep sack worked great but other parents here use the PJs, the result is the same.

        • Allie

          The sleep sacks offer easy access so that, in theory anyway, you could check/change a sleeping baby. I was never able to get from theory to practice on that one, though.

      • Montserrat Blanco

        Thanks for the suggestion!

  • demodocus

    One of the adorable things from my daughter’s early weeks was her trying so hard to stick her thumb in her mouth and having -terrible- aim. She usually got it there, eventually, Pacifiers just wouldn’t do once she was consistent at it.

    • Gæst

      When my son was only a few weeks old he somehow grasped a pacifier in his hand and I have a video of him trying to get it in his mouth in all the wrong ways. It’s cute, and hard to believe any of it was intentional.

      • Ms. Sweaterfan

        So cute! My son is not a fan of pacifiers except to hold and maybe bite (on the wrong side) so even when he was very tiny he would get mad if you tried to put it in his mouth and he would only take it if you handed it to him XD

  • David Whitlock

    Use of pacifiers seems to strongly reduce the incidence of SIDS.

    http://onlinelibrary.wiley.com/doi/10.1111/jpc.12402/full

    • Tiffany Aching

      I really don’t get the no pacifier thing. First of all, while I can understand why people find plausible the nipple confusion thing when it comes to bottle vs breast, it seems a bit silly to think that a baby won’t know the difference between something that delivers milk and something that doesn’t.
      And even if it were true, the proven benefits of the pacifier so overwhelmingly outweigh the supposed risks that it should be a no brainer.

  • kilda

    “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].”

    Wow. There’ s a piece of info that the NCB/lactivist crowd hasn’t exactly been highlighting.

    • Ms. Sweaterfan

      Not quite as dramatic thankfully, but when I gave birth a nurse walked over and placed my newborn on my chest without warning and he almost slipped onto the floor because he was still slippery and I was pretty out of it from pushing for over 3 hours! The nurse had to catch him and I still think of that moment with horror. I had never expressed any desire for immediate skin-to-skin but I guess the nurse thought it was so important that she should do it without asking!

      • The Bofa on the Sofa

        I am not sure, but I don’t think “slippery baby fell off of mom’s chest and crashed to the floor while attempting skin-to-skin” really constitutes SUPC (particularly, the “unexplained” part).

        So your incident would be in addition to this SUPC association

      • Kelly

        The last time I gave birth, they finally had a questionnaire about those kind of things. I gratefully declined. Skin to skin does not interest me and I got yelled at by a nurse because I didn’t have the baby directly on my skin with the previous one. Nope, If they are cold, put them in the warmer and don’t stress me out about doing something correctly or not.

        • StephanieA

          I found skin to skin just kind of gross (our hospital places baby on chest right after delivery for at least an hour). The combination of skin to skin, me sweating from hormones, and my son being damp from birth made me so itchy. He was skin to skin for over an hour and it still took me longer to bond with him than my older son, who I did not do skin to skin with.

          • Zornorph

            I find the idea that you have to put your baby on your bare skin right away really weird and it would never be something I would want to do. I waited until Boy-O was all clean and all the fuss was done and he and I were alone in our room and then I opened my shirt, stripped him to his diaper and just lay reclined at 45 degrees in bed with the sheets over us for about and hour just holding him and singing to him. I wasn’t the last bit tired at that point, so no risk of me going to sleep. I just wanted some quiet time alone with him after waiting for him for so long.
            But here’s the thing I will freely admit – it was for me, not for him. I think he’d have been just as happy in that airline drink cart that they had next to the bed and we have had many other times where we could ‘bond’. This was 100% about my needs and desires and he’d have been perfectly fine without me doing it.

          • The Bofa on the Sofa

            But here’s the thing I will freely admit – it was for me, not for him.

            This is one thing that I have said. I do not disagree that many women find skin-to-skin very nice, and therefore can understand their desire to have it.

            But let’s not confuse that with “important” regarding the well-being of the baby, and, even in terms of the mother, it’s more about expectation. If mom wants it and it can’t happen, that is not ideal.

          • EmbraceYourInnerCrone

            See I do not get this, why do they assume everyone wants this? “It promotes breastfeeding” So what…

          • The Bofa on the Sofa

            Yeah, that’s the other part of the issue. Begging the question.

          • Eater of Worlds

            I can only think that it encourages a mother to try breastfeeding if she’s naked and the baby is already lying there, and not for any other reason. I can’t see how it would make breastfeeding work if there are latching issues, or work to encourage anything but starting to breastfeeding (how can it encourage longer breastfeeding?).

            Also, if they try to say “thats how women used to do it” or “that’s natural” to have an unclean baby slapped on your chest, I’d like them to prove it. I don’t know any mammal animal mothers that don’t start cleaning up their babies right away. Even gorillas and chimps start licking the baby right away. Heck, if we use them as a model we should give birth standing on our heads like this chimp did https://www.youtube.com/watch?v=9bF_T3wBE14

            I would think that cleaning up baby is more “natural” by making sure that the baby is dry so it doesn’t get chilled because it’s damp and in times when this was an issue, a baby that is cleaned up right awy is going to attract fewer predators. I honestly can’t think of any benefit to not cleaning the baby off right away. And really, is a 5 minute bath going to somehow destroy the bond a mother has with her baby (no) or a breastfeeding relationship (no)?

    • Mel

      The only place I’ve done skin-to-skin was in the NICU with my son – and it’s a completely different ball of wax. The nursing staff and all educational materials stated that doing skin-to-skin was ok while we were in the NICU because the babies were attached to pulse oximeters and there were nurses in the room to help out if we managed to start to smother our kids.

      Doing skin-to-skin at home or even while tired in the NICU was strongly discouraged.

      Perhaps we should require that all postpartum medical professionals spend some time in a NICU to see why the NICUs have all of these rules…

  • The Bofa on the Sofa

    it would be problematic to regard the BFHI as best practice for the improvement of breastfeeding initiation rates and duration.

    Ouch