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The science behind the recommendations of the AAP for safe sleep Mother

The AAP has been updated Policy Statement on Safe Sleep of Infants was released this week (1). I wrote a short article about the policy update for this Washington Postbut I wanted to do a little bit more in science in a blog post.

As a side note, let me just say that being able to write for larger media is very exciting, but also very humiliating. A typical blog post for me is 2000 words, but I was asked to write 500-800 for the post. It is really hard to include in-depth scientific knowledge in such work, but I will continue to work on improving it. Can you still imagine me flinching when someone on Facebook said, "Where's the science ?!" about my article? But I would probably say the same thing and I know that many readers want to understand the evidence base behind these recommendations.

The updated policy statement was a two-year effort by the AAP Task Force on AAP to review the literature published since the last policy statement of 2011. The statement provides guidance on how to reduce the risk of SIDS and other sleep related deaths, such as suffocation and asphyxiation, together with sudden unexpected infant death or SUID. It is often very difficult to determine whether SIDS or accidental causes have led to death even after thorough investigation, and many of the risk factors for these types of deaths overlap. Every year, about 3,500 babies die of sleep-related SUID in the United States. As a parent, I know that one of my biggest fears was losing one of my babies in my sleep, and that number carries an incomprehensible amount of family tragedy and grief. The purpose of these guidelines is to prevent these deaths.

The AAP SIDS task force consists of a group of 5 paediatricians, most of whom have spent their careers studying SUID. For this 2016 revision, the Task Force also included breastfeeding researcher Lori Feldman-Winter. She told me that she was specifically invited to the Task Force to provide the group with more breastfeeding research and prospects, and to address the controversy surrounding the risks of the bedding community of breastfeeding mothers (more in a minute). The policy statement was also reviewed by the Department of Breastfeeding of the AAP. "The end product is really a heads-up encounter so we can feel good, which we cite as the best evidence and recommendations," Dr. Feldman-Winter.

The declaration of principle is enclosed technical report that's loaded with science (400 quotes), and it can be accessed and read by anyone interested (2). It is a difficult task for the AAP to make recommendations for the whole population, as there are big differences in terms of cultural practices and practical experience. However, I believe that these recommendations are thought-provoking and evidence-based and represent the best advice from the Task Force for parents.

Many of the recommendations for SUID prevention remain the same and should be known to parents, though they must always be repeated. Lay babies on their backs for each sleep, never on the stomach or on the side. Babies should sleep on a firm, flat surface without loose sheets, pillows, or toys. Breastfeeding, on-schedule vaccinations and regular prenatal care reduce the risk, as well as avoiding exposure to cigarettes, alcohol and drugs during pregnancy and after childbirth. I will insert the full list of recommendations at the end of this post, but I will use the rest of this post to take a closer look at the science behind the recommendations that have received the most attention in recent days.

Babies should sleep in the parents 'room near the parents' bed, ideally for the first year of life, but at least for the first 6 months.

Sharing rooms without sharing a bed was also recommended Policy Statement of AAP for 2011However, you did not specify how long this arrangement should take. I think many parents have overlooked the room layout recommendation in the past, but this revision gives it a new emphasis. Space division for 6-12 months is also recommended in other countries, including the UNITED KINGDOM. and Australia,

roomsharing2

Based on the new safe sleep policy of the AAP, this is an ideal sleeping environment. Image courtesy of the Safe to Sleep® campaign; Eunice Kennedy Shriver National Institute for Child Health and Human Development, http://www.nichd.nih.gov/sids

Studies have shown that space division without bed division at least since the mid-90s protects against SIDS. The following I wrote in a blog post from last year on "Room Sharing":

One of the biggest case control Combined SIDS data from 20 different regions of Europe allow researchers to study 745 SIDS cases and associated risk factors (3). The authors of this study estimated that 36% of SIDS deaths could have been prevented if the infants had not fallen asleep in a separate room, and 16% could have been prevented if the infants had not gone to bed. Together, this means that more than half of their deaths could have been prevented if all infants in that study slept in the same room as their parents but not in the same bed.

The same protective effect of room sharing has been observed in several other case-control studies Scotland. England, and New Zealand (4-6). The English study showed a dramatically tenfold increased risk of SIDS when babies sleep in their own room. At least important a study has shown that toddlers sharing a bedroom with other children have no protection.6 Instead, the presence of an adult caregiver seems important.

Why does the sharing of spaces protect you? We do not know, but it is a strong and lasting effect. The ongoing hypothesis (again from my previous post):

Babies sleeping closer to their mothers have a greater sensory exchange (through sounds, touch when a parent examines the baby, etc.) and thus spend more time in light sleep and shorter periods of arousal to protect them from SIDS (5-7).

Most roomsharing studies have examined only one-year deaths without attempting to analyze the data by age. A New Zealand study (6 The 1996 study found that sharing rooms in infants less than 13 weeks, 13 to 19 weeks, and 20 weeks and older provides equal protection. Without further evidence, the AAP could not claim that space sharing at any age is becoming less important, which is why it was wary of recommending it for the entire first year. (And caution is needed when talking about preventing the deaths of children, right?) They find that most SIDS deaths occur in the first 6 months. Therefore, the sharing of space at this time is most important.

SIDS deaths by age

Adapted from AAP, Technical Report: SIDS and other infant sleep related deaths: Extension of recommendations for a safe sleep environment for infants. Pediatrics 128, e1341-67 (2011).

It is worth noting that most of our understanding of how to reduce the risk of SIDS and other sleep-related deaths comes from case-control studies or case series, observational studies that simply can not distinguish causality and correlation. We are limited to this type of study design because, fortunately, SIDS is relatively rare and it is virtually impossible to perform prospective cohort studies or randomized controlled trials of SIDS. The evidence for the sharing of spaces can not tell us for sure if this is the case causes a lower risk for SIDS, only that it is correlated at a lower risk of SIDS. There might be a confusing factor here – something else that room sharing parents tend to do – or it could have a real effect. In both cases, the AAP recommends sharing rooms by providing the best recommendation that they can make on the basis of the best data proven.

There is also evidence that most US parents do not share much more than the first few months of life. A study published in Pediatrics magazine in August found that out of 160 babies in Pennsylvania, 55% of the three- and 74% of the six-month-olds do not share a room with their parents. Several studies Show that parents who share rooms, especially in later childhood, have more sleep disturbances and are more likely to sleep stressed relationships with their partners (again, this is a correlation that is not necessarily caused by the sharing of spaces). Sleep training is usually more successful when babies sleep in their own rooms. It will be interesting to see if the stronger recommendation on room layout causes a cultural change in the sleeping environment for babies.

Bed linen is not recommended.

The advice of the AAP against sharing bedding is probably the most controversial recommendation, also because so many families are doing it anyway. For some, it is a cultural norm, and for others, it is seen as a way to connect with their babies and make nighttime breastfeeding easier. Others only strive for a good night's sleep without putting the baby to bed. The AAP, however, reiterates its position that, according to current knowledge, sharing bedding poses a risk to babies.

Decades of studies on SIDS and other sleep related deaths indicate that sharing bedding is associated with many of these deaths. It is disputed whether the bedding itself is the danger or other circumstances that can be associated with the bedding – soft mattresses, loose linen, drug or alcohol consumption or sleeping on a sofa or armchair.

Two studies on this issue have been published since the policy statement of the 2011 AAP, but came to conflicting results. A 2013 study Led by Bob Carpenter, he concluded that without these other risks, the likelihood of dying from SIDS has still increased 2.7-fold. Breastfed babies less than 3 months of age have a 5-fold increase in probability over room clearance without bedding. However, this study has been criticized for lacking many real-world data on drug use and alcohol use by parents. And then a 2014 study Under the direction of Peter Blair, it was found that the risk of SIDS sharing a bed was not significantly increased, as there are no other risks with younger babies.

In light of this contradictory evidence, the AAP commissioned a biostatist who was not invested in this area to review these two studies. His conclusion? Both studies were small and had limitations. They used different control groups, which might have led Blair's study to underestimate the risk, and Carpenter's study overestimated the risk so that the actual risk might be somewhere in between. Faced with this uncertainty, Feldman-Winter said: "Based on the evidence available, we can not rule out the risk of sharing bedding."

The AAP notes that some situations make bedding more dangerous: if one or both parents are smokers, even if the mother smoked during pregnancy; in preterm or low birth weight; in babies under 4 months; any alcohol or drug use that may affect the arousal; if there are several bedfellows, especially if one of them is not a parent (including other children or pets). Linen on very soft surfaces such as waterbeds, sofas or armchairs is extremely dangerous, and loose sheets or pillows add to the risk.

However, when parents fall asleep breastfeeding their babies, it is safer to do so in a well-made bed than on a couch or chair.

This is a nuanced but important change in the recommendation of the AAP. It was also pointed out in the 2011 policy statement that parents should not sleep on a couch or chair with a baby, but anyone who has gone through early childhood knows there is a high likelihood that it will eventually happen. "I think what people really wanted after the last policy statement was what to recommend to do, "said Dr. Feldman-Winter.

If you are in a precarious situation where you may fall asleep while feeding your baby, it is safer to do so on a carefully arranged bed than on a couch or chair, according to AAP.

ONE 2014 case series The Pediatrics study found that 1,024 babies died on a couch or armchair in the US between 2004 and 2012.8th These are avoidable deaths. Other studies I found that sleeping with a toddler on a couch or chair increases the risk of death by 50- to 60-fold, which is several times the risk of bed-sharing.4.5

When feeding your baby in bed, make sure it is as safe as possible. "We also recommend keeping the bed as risk-free as possible by removing pillows and blankets, as well as loose sheets and loose linens, as well as having a firm mattress," said Dr. Feldman-Winter.

Ideally, according to the AAP, put your baby back in his own bed after feeding. When you fall asleep, you move your baby as soon as you wake up. I like the suggestion from Elissa Strauss slate To do this: Ask your partner to sound an alarm every time you feed them and help him move the baby if both of you fall asleep.

You do not need fancy monitors, appliances or mattresses to provide your baby with a safe sleeping environment.

Dr. Moon told me the following about creating a safe sleeping space for your baby: "You do not need much to prepare a safe sleeping environment for your baby, you want a flat, solid surface, and with firm I mean hard … Ideally a cot, a travel cot, a playpen or a bassinet, you want the mattress suitable for this device, you want a tight-fitting leaf, and then you just want the baby, you do not want anything else in the crib, so naked is best. Ideally, the sleeping place in the parents' room should be close to the parent's bed. "

There are a lot of other products that promise or imply that your baby sleeps better or is safer when using the device. There is no evidence that a device can reduce your baby's risk of SIDS. None. Not the breathable mattresses that I wrote about for slate, Not the Rock n & # 39; play, Not baby swings or child seats. The infant care market is largely unregulated. Moon, and there is no formal process to test these products for safety. We generally do not know that a product is dangerous until it causes injury or death and a recall occurs. So stick to a simple, firm, flat, blanket and bed sheet-free bed for your baby.

It has also not been shown that expensive monitors that monitor your baby's vital signs increase the baby's safety during sleep. Paediatricians fear that they might give parents a false sense of security. "I've heard many times that when I buy a $ 500 worth of monitor, I do not have to follow the other sleep guidelines to help my baby sleep prone, as she has a pulse oximeter all the time. Kansas City pediatrician said Dr. Natasha Burgert, "You think I'm exempt from these other suggestions because I outsmarted the system with this technology."

Paediatricians should not hold judgmental talks with parents about sleeping safety

This is an important addition to the policy statement. Why? Because I know from experience that it can be difficult to follow any recommendation for a safe sleep every night in a toddler, even if you are well informed about the risks. Sleep is a biological need, and sleep deprivation also involves very real risks. Parents often make desperate decisions, but a better approach is to rationally weigh risks and benefits and create a plan for sleep that minimizes risk. Paediatricians can be an important resource in this conversation. If you are thinking about sleep, they should be able to help you sleep better and safer for your family.

Here is the complete list of safe sleep recommendations from the AAP 2016 Policy Statement:

A-level recommendations

  • Fall asleep again with every sleep.
  • Use a firm mattress.
  • Breastfeeding is recommended.
  • It is recommended to share the room with the toddler on a separate sleeping area.
  • Keep soft objects and loose sheets away from the sleeping area of ​​the child.
  • Consider offering a pacifier at lunchtime and bedtime.
  • Avoid exposure to smoke during pregnancy and after childbirth.
  • Avoid alcohol and drug use during pregnancy and after childbirth.
  • Avoid overheating.
  • Pregnant women should seek and receive prenatal care on a regular basis.
  • Infants should be immunized according to the recommendations of AAP and CDC.
  • Do not use cardiorespiratory home monitors as a strategy to reduce the risk of SIDS.
  • Providers of health services, neonatal and intensive care workers, and childcare providers should support and model the recommendations for SIDS risk reduction from birth.
  • Media and manufacturers should follow the guidelines for safe sleep in their news and advertising.
  • Continue the Safe Sleep Campaign and focus on ways to reduce the risk of all infant-related deaths, including SIDS, suffocation, and other accidental deaths. Paediatricians and other primary care providers should actively participate in this campaign.

B-level recommendations

  • Avoid using commercially available equipment that does not meet the recommendations for safe sleep.
  • To facilitate development and minimize the development of positional plagiocephaly, a supervised watchfulness period is recommended.

C-level recommendations

  • Continue to explore and monitor the risk factors, causes and pathophysiological mechanisms of SIDS and other infant-related deaths with the ultimate goal of completely eliminating these deaths.
  • There are no indications that Swaddling is recommended as a strategy to reduce SIDS risk.

What questions do you have regarding the prevention of SIDS and other sleep related deaths?

references:

  1. AAP's Task Force for Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe sleep environment for infants. pediatrics e20162938 (2016). doi: 10.1542 / peds.2016-2938
  2. Moon, R. Y. & AAP's Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Evidence base for 2016 Updated recommendations for a safe sleep environment for infants. pediatrics e20162940 (2016). doi: 10.1542 / peds.2016-2940
  3. Zimmermann, R.G. et al. Sudden unexplained infant deaths in 20 European regions: case-control study. lancet 363, 185-191 (2004).
  4. Tappin, D., Ecob, R. & Brooke, H., Sharing, Roomsharing and SIDS in Scotland: A case-control study. J. Pediatr. 147 32-37 (2005).
  5. Blair, P.S. et al. Parents sleeping with parents: case-control study of factors that influence the risk of sudden infant death syndrome. Br. Med. J. 319, 1457-1462 (1999).
  6. Scragg, R.K. et al. Room layout and prone position of the child in case of sudden infant death. New Zealand Cot Death Study Group. Lancet Lond. Engl. 347, 7-12 (1996).
  7. McKenna, J.J., Ball, H.L., and Gettler, L.T. Maternal-infant sleep, breastfeeding, and sudden infant death syndrome: what findings does biological anthropology have on normal infant sleep and pediatric sleep medicine? At J Phys Anthr. Supplement 45, 133-61 (2007).
  8. Rechtman, L.R., Colvin, J.D., Blair, P.S. & Moon, R.Y., Sofas and Infant Mortality. pediatrics 134 e1293 – e1300 (2014).

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