“Evidence Based” Perspectives On What Makes Bedsharing With Exclusive Breastfeeding Safer? What

Makes Bedsharing Dangerous

Don’t sleep with your baby or put the baby down in an adult bed. The only safe place for a baby to sleep is in a crib that meets current safety standards and has a

firm tight-fitting mattress.”

Ann Brown September 29, 1999 to US Media Press Conference.

or

“There is no such thing as a baby, there is a baby and someone” D.Winnecott ?

American Academy Of Pediatrics New SIDS

Prevention Recommendations(I served as an ad hoc expert member)

***proximate but separate sleep for baby;

i.e. parent-infant co-sleeping!

no side position sleeping;

cuddling but no bedsharing

pacifers for sleeping infants, after breast feeding is established;

more holding and carrying

(but no bedsharing, described as hazardous)

What is Safe: Who Decides?•

What is Safe: Who Decides? Should Huggies Be Asked to Remove this Ad?

“We all need to contact Huggies and request that the ad be removed.” from Cribs for Kids”

Where the controversies lie?

• Bedsharing safety..how safe is safe? Informed parents ? or medical authorities decide?

• Evidence (whose) ? What kind of evidence is privileged or prioritized? Only Epidemiology? Laboratory? Home Studies? Ethological? Evolutionary? Cross-cultural?

• Who decides which lines of evidence are unimportant to recommendations?

• Who decides which risks are worth taking and what risks are worth investing in to eliminate?

• Whose civil rights are at stake here as regards public condemnations/denigrations of bedsharing and the witholding of safety information to reduce bedsharing risks?

(General Questions)

“Bowlby looked forward to a time when children’s rights would be respected universallywithout the need to ‘‘champion’’ them, a task to

which he was uniquely suited by his lifeexperience, his endowment, and his

distinguished nature.”

‘A tribute to the legacy of John Bowlby at the centenary ofhis birth’

SEBASTIAN KRAEMER1, HOWARD STEELE2, & JEREMY HOLMES3Attachment & Human Development,

December 2007; 9(4): 303 – 306

When up, is not up, and when down is not down.. i.e. when what is biologically “good” for infants is conceptualized as “bad”, what is “normal” is considered

“abnormal”, when infant “adaptive” responses are interpreted as “deficiencies”

Solitary Infant sleep

(separation and autonomy) is

“good”

Social, infant “co-sleeping”

(interdependence) is bad

What Is Co-sleeping?

“When my two lovely daughters are sleeping at the same time”

Robert Hahn, Ph.D. (Center for Disease Control )

Bobby Bowdin….Florida State University Head

Football Coach“I slept in the same bed with my

grand daddy..and then in the same bed with my four cousins..I

never slept alone t’il I got married”!

South Bend Tribune.. 9/29/2000

Diversity of Co-sleeping(requires taxonomic distinctions)

Co-bedding twins

(within sensory range)

partial, mixed

bedsharing with Dad

Parent -infant co-sleeping is biologically and psychologically expectable, if not

inevitable?

In all it’s forms….

Maori, New Zealand

recliner co-sleeping (unsafe)napping desert Aborigine

Koala

To be fair…Solitary Sleep

But look at the damage it has done, thinking it is “normal”

We have a long way to go….

Present medical-cultural milieu: warn mothers about what their their bodies do TO their

infants, rather than what theirr bodies do FOR their babies

• “Babies Sleep Safest Alone.”– New York State Public Health Campaign

• “For you to rest easy, your baby must rest alone.”– Philadelphia Public Health Campaign.

• “We know the value of holding your child, cuddling your child, loving your child. But if you take the baby to bed with you and fall asleep, you are committing a potentially lethal act” – Deanne Tilton Durfee, Director of the Los Angeles

County Inter-Agency Council on Child Abuse and Neglect. Los Angeles Times 4/24/08.

City of Milwaukee: Anti- bedsharing Campaign. Anne Benton: “Bedsharing is dangerous…as far as we are concerned there is no debate…”

Implication: a good parent would never take their baby to bed with them..A responsible parent would never do this..which means only irresponsible parents would and should therefore be subject to prosecution and/or having their infant removed by child protective services.

Cosleeping Tombstone (for headboard)

Wisconsin Campaign: Mothers Body is Depicted as No More Protective That An

Inert Metal Cleaver?

The cleaver represents the mother sleeping next to her infant

Baltimore Anti-bedsharing Campaign. (This woman’s baby died in Milwaukee)

What was this mother told? What actually happened? “Alone” Crib”? “No exceptions”? Who is this poster talking to? By what rights or authority do these civil-county personnel make this declaration?

Controlling what is talked about isCritical..who controls the discourse?

Jill Porter City wakes up to infant co-sleeping danger

2 MORE DEATHS TRIGGER ACTION

“NOW THEY GET IT”

. “City officials called a hasty press conference yesterday to warn the public that sleeping with an infant puts the baby at risk of sudden death.

Because, since Saturday, two more babies have died in Philadelphia while sleeping with

other people. ….”

Philadelphia Daily News 10-06-2004

Nothing illustrates the philosophical differences better than this:

Following the tragic death of a bedsharing infant whose teen mother drank 18 cans of beer before retiring to

bed with her infant,

Then President of a national SIDS organization wrote to the Editor of the San Antonio Tribune, 2000, saying:

• “Sharing an adult bed with an infant is not cool, nor is it an indicator of educated parenting.”

Continuing the history of moral judgments by external anonymous medical

authorities essentially dictating to parents what is and is not acceptable infant

care…stigmatizing any refutation and implying

that parents have no civil rights, no ‘knowledge’ or jurisdiction in these

areas..

The problem is..our culture places infants at odds with their biology because..

“ …There would be little if any difficulty exchanging a Cro-

Magnon and a modern infant, but great incongruity in making

the same switch amongst adults of both cultures.”

David Barash: The Tortoise and The Hare (1987)

is the human mother’s sleeping body

an inherent lethal weapon against which she and her infant need to

be protected…?

The co-sleeping debate: two faces, two “truths” in one..

do you see them.. ( a young and and old woman, in one face?)

SUDI/SIDS :benefits-risks continuumTwo distinct bedsharing subgroups

Less Risk (protective?) More Risk

ElectedBreast feedingNon-smokersStiff mattress

Non-electedBottle fedSmokersRisk ‘factors”

At the population level “outcomes” are not explained by “practice”

(Black Box)who? what? how,

why?

What kind of relationship is brought to bed to share ?

Maternal Motivation and Purpose? Feeding?

How is bedsharing outcomes linked to quality of attachment, maternal motivation, mental health, knowledge of adverse risk factors?

LEADS TO BENEFITS?

LEADS TO DEATH?

(Bedsharing As Each Family Practices It)

How linked to family characteristics including feeding method?

or

Double standard of “cause” “diagnosis” and “remedy” of crib vs. co-sleeping

deaths must be challenged• Infant dies sleeping

prone in crib– Cause: sleeping

prone…

– Diagnosis: SIDS

– Remedy: turn infants supine, educate and inform

• A tragic problem to be solved

• Infant dies sleeping prone in bed with parents– Cause: bedsharing– Diagnosis: Asphyxiation by

overlay– Remedy: eliminate all

bedsharing, retract safety information on safer bedsharing, condemn the practice;

• A deadly practice to eliminate

take…for example, the article by Person et al 2002..take a look at how the

numbers are presented, interpreted..and the conclusion reached..the data do not

match the conclusionsInfants sleeping alone..29/56 deaths

Cribs..19 (65% of total)

Adult bed… 5 (17% of total)

Couch..3 (10.3% of total)

Car seat 1, dresser drawer 1 (each 3.4%)

Infants co-sleeping..27/56 deaths 48%

“These findings support recent studies that suggest that co-sleeping or placing an infant in an adult bed

is a potentially dangerous practice” T.Person W.Levezzi and B.Wolf 2002 Arch Pathol Lab Med

vol 126 Macrh 2002. • Of 27 co sleeping deaths…

– 14 slept with adults,– 7 of which were intoxicated..bringing unexplained co-sleeping deaths

down to 20

• of these 20-- – 9 babies died while sleeping on a couch (known to be extremely

dangerous) bringing total down to 11 co-sleeping deaths …

• of these 11,– 4 babies were sleeping with their twin sibling in cribs..bringing total to 7

• Of the original undifferentiated “co-sleeping deaths” 7 infants died while sleeping with an adult in a bed..but no “risk factors” or other confounding variables are reportedincluding feeding method, infant sleep position and/or maternal smoking.

Sleeping arrangements are on a nighttime and weekly basis very fluid and changeable.

Where babies begin their sleep is not necessarily if at all where they end it, especially but not exclusivey amongst breastfeeding mothers. Ball and Hooker (1999) found that had they not videotaped and re-asked about where the baby slept they would have missed about 40% of the true bedsharing amongst her families studied.

If the case control studies where parents are asked where their baby slept on a reference night and the parents responded as inaccurately as did Ball’s families, many of the epidemiological studies showing bedsharing risks would disappear. No studies tested for the accuracy of interpretations of responses from parents who babies lived!

Recall our “two models” ? How One Interprets Infant Sleep Related Behaviors

Depends on Initial Assumptions

• If to the researcher co-sleeping/breastfeeding is normative, appropriate and expectable (biologically) then..– Babies accepting separation and isolation without

protesting do so at their own peril; – Or--Infants who accept separation without protesting are

developmentally immature and not adapted vigorously;– Infants who “sleep through the night’ at young ages are

“at risk”;– Infants resting body temperature while sleeping alone is

sub-normal;– Infant night wakings are advantageous especially when

associated with breastfeeding..

inspired bycross-species, cross-cultural,

developmental, historical and evolutionarystudies…. a little experiment….

A little research…

University of Notre Dame

Mother-Baby Behavioral

Sleep Laboratory

(morning wake up)

first time mothers, teen moms…

Research funded by

NICHD RO1

What Science Tells Us …

Baby Room

Infra Red and AudioRevolving Camera/Close-Up Capacities

Parental Bedroom With Infra Red Lights, Audio Recording Devices And Cameras Embedded in Ceiling

Variations of Safe/Unsafe Sleep PracticesInfra-red Video Studies: Crib-Solitary and

Bedsharing ( HD 39456-01 )Examples:

1.Solitary-crib baby placed prone, face down;

2. Neck-wrap, head covering, pillow, solitary, crib baby;

3.Bottle-feed bedshare between pillow, teen mom ,lack of maternal response;

4.Breast feeding mothers, high level of responsivity to infant;

Why Is Breast Feeding So Important to the Bedsharing

Issue?• Mother-infant co-sleeping with breast feeding

is an integrated, inherently adaptive system, mutually reinforcing, appropriate, predictable;

• Changes social and biological characteristics of infant and maternal sleep (connectedness-sensitivities) of co-sleeping dyad..different from bottle feeding pairs…

• Functional landscape of bed environment i.e. “outcomes” different from non-breast feeding-bedsharing contexts…

“Breast Feeding and the Risk of Post-neonatal Death In the United States”

• Studied 1204 infants who died between 28 days and 1 year from causes other than congenital anomaly/tumor.and (7740 children who lived at 1 year) (controls);

• Calculated odds specific odd ratios for ever/never breast feeding amongst all children …race-birth weight specific analysis--and duration-response effects;

• Longer breast feeding associated with lower risk: odds ratio range from:– .59 95% CI 0.38-0.94 for injuries to 0.84% (95%CI:.67-1.05) for

sudden infant death syndrome (SIDS); (Amin Chen and Walter J.Rogan)

– “Breast feeding has the potential to save or delay ~720 post=neonatal deaths in the United States each year

– Pediatrics (2004) 113: E435-439…url:http://www/pediatrics.org/cgi/content/full/113/e435

Characteristic Differences Between Breast and Formula Fed Infants Pertinent To Understanding Outcomes

In discourse about the safety of bedsharing (one form of co-sleeping) the effect of feeding method is either dismissed or overlooked.

All studies confirm that bedsharing increases breast feeding frequency and duration

(below..McKenna et al 1997, see also Ball 2003, Baddock 2006, Young 1999)

From: McKenna et al. Pediatrics 1997 “Bedsharing Promotes Breastfeeding”

Fig. 4 Mean number of breastfeeds per night (with SE) for routine solitary sleepers (while sleeping separately, n = 16) and routine bedsharers (while bedsharing, n = 20), averaged over all three laboratory nights. Significant between group difference, **P < 0.01. LT Gettler and JJ McKenna Am J Phys Anthropol. 2011 March; 144(3): 454–462.

Breastfeeding frequencies double or

triple while co-sleeping

Fig. 5 Mean interval between breastfeeds (with SE) for routine solitary sleepers (while sleeping separately, n = 16) and routine bedsharers (while bedsharing, n = 20), averaged over all three laboratory nights. Statistical trend towards between group difference, ^P < 0.10. LT Gettler and JJ McKenna Am J Phys Anthropol. 2011 March; 144(3): 454–462.

Breastfeeding Intervals Reduced By Co-sleeping

Breastfeeding increased protection against SIDS!!

“Infants who are formula fed are twice as likely to die of SIDS than breastfed infants.”

Case control study of 333 cases of SIDS matched against 998 age -matched controls in Germany, from 1998-2001

Vennemann MM, Bajanowski T, Jorch G, Mitchell EA. Does Breastfeeding reduce the Risk of Sudden Infant Death Syndrome?” Pediatrics Vol.123,

March 2009, pp e406-410

Breast Feeding Matters In All Areas Of Infant Mortality Especially Effecting

African Americans

• “Breastfed infants are 80% less likely to die before age 1 year than those who never breast fed, even controlling for low birthweight”;– For every 100 deaths in the formula-fed group, there were

20 deaths in the breast fed group– Using breast feeding as the normative behavior (20 deaths

in the first year) the formula group with 100 deaths, had five times as many deaths or a 500% increase in mortality..

– Forste et al 2001:108 291-296Pediatrics

Forste et al. 2001

“Analysis of infant mortality indicated that breast feeding accounts for race difference in infant

mortality in the United States at least as well as low birth weight does”

Pediatrics 2001;108:291-296

“Breast Feeding and the Risk of Post-neonatal Death In the United

States”• Studied 1204 infants who died between 28 days and 1 year from causes other

than congenital anomaly/tumor.and (7740 children who lived at 1 year) (controls);

• Calculated odds specific odd ratios for ever/never breast feeding amongst all children …race-birth weight specific analysis--and duration-response effects;

• Longer breast feeding associated with lower risk: odds ratio range from:– .59 95% CI 0.38-0.94 for injuries to 0.84% (95%CI:.67-1.05) for

sudden infant death syndrome (SIDS); (Amin Chen and Walter J.Rogan)

– “Breast feeding has the potential to save or delay ~720 post=neonatal deaths in the United States each year

– Pediatrics (2004) 113: E435-439…url:http://www/pediatrics.org/cgi/content/full/113/e435

All-night sleep-wake histograms for five (A-E) cosleeping pairs. Mosko, McKenna et al (1993). Journal of Behavioral Medicine 16 (6). Note the synchronicty of awakenings

Mom

Baby

Wake

Mom

Mom

Baby

Mom

Baby

Mom

Baby

Baby

wake

sleep

During co-sleeping maternal-infant behavior and physiology becomes entwined…by way of synchronous partner induced arousals and

communication

• 60 % of all maternal arousals during bedsharing are explained by the infant having aroused first, within +/- 2 seconds while..40% of all infant arousals during bedsharing are explained by the mother having aroused within +/- 2 seconds

• 1996 Mosko, S, Richard, C and McKenna, J; Drummond, S, Infant Sleep Architecture During Bedsharing and Possible Implications for SIDS. Sleep 19:677-684 1997 Mosko, S., Richard, C., McKenna, J., Infant Arousals in the Bedsharing Environment: Implications for Infant Sleep Development and SIDS. Pediatrics 100 (2) 841-849

•  1997 McKenna J, Mosko S, and Richard, C, Bedsharing Promotes Breast Feeding. Pediatrics 100 (2) 214-219

Figure Synchronous breathing pauses of cosleeping mother-infant pairs.

McKenna, JJ and Mosko, S. (1990). Human Nature 1 (3).

Baby >

Mom >

Over 8 hours of sleep approximately 12% of the time mothers and infants are doing the exact

same thing at the same time, because the other is doing it.

Body- Facial Orientations Amongst 24 Solitary Sleeping and Bedsharing

Mothers and Infants

Research funded by National Institutes of Child Health and Human Development RO1 27482

Co-sleeping in the form of Bedsharing: Increased protection for arousal deficient

infants?

EFFECTS OF BEDSHARING ON INFANT SLEEPBedsharing Night vs. Solitary Night

Total Wakefulness During Sleep 14% 0.008Sleep Stage %’s (of TST)

% Stage 3-4 4% <0.001 % Stage 1-2 3% 0.036 % Stage REM -- --

Mean Stage Durations Stage 3-4 16% 0.027 Stage 1-2 16% 0.005 Stage REM 26% 0.001 Waking -- --

Arousal Frequency (/hr)Stage 3-4

EWs 38% 0.014TAs --* --

Stage 1-2EWs -- --TAs -- --

Stage REMEWs 35% p<0.001TAs -- --

Table reflects results of 2x2 repeated measures ANOVA (laboratory sleeping condition x routine sleeping condition). Entries show significant (p<0.05) effects of laboratory condition (BN vs SN). (Mosko et al 1996)

EFFECTS OF BEDSHARING ON MATERNAL SLEEP Bedsharing Night vs Solitary Nightp value

Total Sleep Time (TST) -- -- Total Wakefulness During Sleep -- --Sleep Stage %’s (of TST)

% Stage 3-4 4% 0.001% Stage 1-2 4% 0.014% Stage REM -- --

Mean Stage DurationsStage 3-4 25% 0.002Stage 1-2 30% <0.001Stage REM -- --Waking 62% <0.001

Arousal Frequency (/hr)Stage 3-4

EWs 67% <0.001TAs -- --

Stage 1-2EWs 37% <0.001TAs 28% <0.001

Stage REMEWs -- --TAs -- --

Table reflects results of 2x2 repeated measures ANOVA (laboratory sleeping condition x routine sleeping condition).(*see Mosko, Richard, McKenna 1997 Sleep 20 (2) 142-150)

Pacifiers and SIDS• Some studies seemed to find pacifier use

protective against SIDS (Mitchell, Fleming)– Babies given pacifiers on reference night less

likely to die than babies without pacifiers– All pacifier users in CDESDI/SUDI study were

artificially fed – statistically removed all breastfeeding babies

• L’Hoir (Netherlands) “recommended dummy use for BoF babies” (Eur J Pediatr 1999)

Observing and Physiologically Recording Babies And Mothers Sleeping and

Breastfeeding (Together and Apart)

• Lighter sleep (less stage3-4, more satge1-2)• More Diverse Sleep (greater number of stage

changes) • Longer Sleep In Minutes• Breastfeeding Doubles or Triples• Increased Interactions, Vocalizations,

Movements• Physiological Unpredictability For Both• Sleep Positions and Mutual Orientations

Change • More transient and epochal mutual arousals

or partner -induced arousals • Increased Sleep-Wake Stage Synchrony• Less crying, More Maternal Interventions• More Heart Rate and Breathing Variability• Sub-normal body Temperatures in Solitary

Sleeping Infants• Shift in average duration, frequency, and

distribution of obstructive and central apneas per stage of sleep

Photo :Max Aguillero-HellwigDiscover Magazine 1992

Mother-infant Simultaneous Polysomnography

Carpenter: 20 regions of Europe

• 745 cases, 2411 controls, 60 variables• 62%: prone sleeping or bedcovers over baby’s head

– “Twice the risk (36% of cases vs 16%) if the baby slept in another room, away from the mother”

• Odds ratio for smokers was 11.3 times greater than for nonsmokers– “substantial risk attributable to smoking by one or both

parents” (77% had maternal smoking)– “all night bedsharing should be discouraged for all mothers

who smoke”• Method of feeding was not reported• Carpenter RG, Irgerns ALM, Blaire PS, England PD, Fleming P, Jorch G,

Schreuder P. Sudden unexplained infant death in 20 regions in Europe: case control study. Lancet 2004;363:185-91.

Chicago Infant Mortality Study, 1993-1996

• 260 deaths, matched controls; 75% black• High risk: prone position, soft surface, pillow use, covers over

head/face, Sick in the 2 days prior to death• “Bedsharing was only a risk when infant was sleeping with

people other than the parents. Because there were few mother-father bed sharers, the findings were driven by the mother-infant dyad. These results are reassuring and consistent with laboratory studies demonstrating that more maternal inspections, more infant arousals, and less deep sleep among infants may occur when mothers and infants sleep together routinely.”

• Hauck FR, Herman SM, Donovan M et al. Sleep environment and the risk of Sudden Infant Death Syndrome in an urban population: the Chicago Infant Mortality Study. Pediatrics 2003;111(5):1207-1214.

the “articulated” mother-infant unit is the appropriate micro-environment within which the infants and mothers biology and

behavior is being mutually regulated

HERE MOTHER

AND BABY

FACE EACH OTHER

(FEO), AS IS TYPICAL

inspired bycross-species, cross-cultural,

developmental, historical and evolutionarystudies…. a little experiment….

A little research…

Observing and Physiologically Recording Babies And Mothers Sleeping and Breastfeeding

(Together and Apart)

• Lighter sleep (less stage3-4, more satge1-2)• More Diverse Sleep (greater number of stage

changes) • Longer Sleep In Minutes• Breastfeeding Doubles or Triples• Increased Interactions, Vocalizations,

Movements• Physiological Unpredictability For Both• Sleep Positions and Mutual Orientations

Change • More transient and epochal mutual arousals

or partner -induced arousals • Increased Sleep-Wake Stage Synchrony• Less crying, More Maternal Interventions• More Heart Rate and Breathing Variability• Sub-normal body Temperatures in Solitary

Sleeping Infants• Shift in average duration, frequency, and

distribution of obstructive and central apneas per stage of sleep

Photo :Max Aguillero-HellwigDiscover Magazine 1992

Mother-infant Simultaneous Polysomnography

145.90

2.64

The Research From: Sleep, Pediatrics, Archives Dis Child., Acta.Pedatrica, Ear. Human Development, Jour Beh Med., Ped Resp. Reviews, Inf Child

Dev.,

A best public health strategy regarding bedsharing..? Why not begin by asking those

most effected.• OBJECTIVE: To understand parents' motivations for bed sharing with their

infants aged 1-6 months, their beliefs about safety concerns, and their attitudes about bed-sharing advice.

• METHODS: Researchers conducted 4 focus groups with primary caregivers of infants ages 1-6 months who regularly shared beds with their infants.

• Recruited participants from an inner-city primary care center in Pittsburgh, serving primarily African American families who received medical assistance.

• Chianese J, Ploof D, Trovato C, Chang JCInner-city caregivers' perspectives on bed sharing with their infantsAcad Pediatr. 2009 Jan-Feb;9(1):26-32 Department of Pediatrics, University of Pittsburgh School of

Medicine, Pittsburgh, PA 15213, USA. 

Conclusion..Consistent with predictions the emerge when human biology and not

a priori ideologies are front and center.

• “Parents' motivation to bed share outweighed the concerns and the warnings of others. An understanding of parents' perspectives on bed sharing should inform counseling to promote safe sleeping practices.”