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“Evidence Based” Perspectives On What Makes Bedsharing With Exclusive Breastfeeding Safer? What Makes Bedsharing Dangerous Don’t sleep with your baby or.

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Presentation on theme: "“Evidence Based” Perspectives On What Makes Bedsharing With Exclusive Breastfeeding Safer? What Makes Bedsharing Dangerous Don’t sleep with your baby or."— Presentation transcript:

1 “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 ?

2 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)

3 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”

4 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)

5 “Bowlby looked forward to a time when children’s rights would be respected universally without the need to ‘‘champion’’ them, a task to which he was uniquely suited by his life experience, his endowment, and his distinguished nature.” ‘ A tribute to the legacy of John Bowlby at the centenary of his birth’ SEBASTIAN KRAEMER1, HOWARD STEELE2, & JEREMY HOLMES3 Attachment & Human Development, December 2007; 9(4): 303 – 306

6 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

7 What Is Co-sleeping? “When my two lovely daughters are sleeping at the same time” Robert Hahn, Ph.D. ( Center for Disease Control )

8 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

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10 Diversity of Co-sleeping ( requires taxonomic distinctions) Co-bedding twins (within sensory range) partial, mixed bedsharing with Dad

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

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13 In all it’s forms…. Maori, New Zealand recliner co-sleeping (unsafe) napping desert Aborigine Koala

14 To be fair…Solitary Sleep But look at the damage it has done, thinking it is “normal”

15 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.

16 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)

17 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

18 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 is Critical..who controls the discourse?

19 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

20 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.”

21 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..

22 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)

23 is the human mother’s sleeping body an inherent lethal weapon against which she and her infant need to be protected…?

24 The co- sleeping debate: two faces, two “truths” in one.. do you see them.. ( a young and and old woman, in one face?)

25 SUDI/SIDS : benefits-risks continuum Two distinct bedsharing subgroups Less Risk (protective?)More Risk Elected Breast feeding Non-smokers Stiff mattress Non-elected Bottle fed Smokers Risk ‘factors”

26 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

27 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

28 take…for example, the article by Person et al take a look at how the numbers are presented, interpreted..and the conclusion reached..the data do not match the conclusions Infants 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%

29 “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 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.

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33 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!

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35 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..

36 inspired by cross-species, cross-cultural, developmental, historical and evolutionary studies…. a little experiment…. A little research…

37 University of Notre Dame Mother-Baby Behavioral Sleep Laboratory (morning wake up) first time mothers, teen moms… Research funded by NICHD RO1

38 What Science Tells Us …

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40 Baby Room Infra Red and Audio Revolving Camera/Close- Up Capacities

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

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43 Variations of Safe/Unsafe Sleep Practices Infra-red Video Studies: Crib-Solitary and Bedsharing ( HD ) 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;

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45 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…

46 “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 for injuries to 0.84% (95%CI: ) 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: E …url:http://www/pediatrics.org/cgi/content/full/113/e435

47 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.

48 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”

49 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 < LT Gettler and JJ McKenna Am J Phys Anthropol March; 144(3): 454–462. Breastfeeding frequencies double or triple while co- sleeping

50 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 < LT Gettler and JJ McKenna Am J Phys Anthropol March; 144(3): 454–462. Breastfeeding Intervals Reduced By Co-sleeping

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52 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 Vennemann MM, Bajanowski T, Jorch G, Mitchell EA. Does Breastfeeding reduce the Risk of Sudden Infant Death Syndrome?” Pediatrics Vol.123, March 2009, pp e

53 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: Pediatrics

54 Forste et al “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:

55 “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 for injuries to 0.84% (95%CI: ) 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: E …url:http://www/pediatrics.org/cgi/content/full/113/e435

56 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 Baby Mom Baby Mom Baby wake sleep

57 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: Mosko, S., Richard, C., McKenna, J., Infant Arousals in the Bedsharing Environment: Implications for Infant Sleep Development and SIDS. Pediatrics 100 (2) McKenna J, Mosko S, and Richard, C, Bedsharing Promotes Breast Feeding. Pediatrics 100 (2)

58 Figure Synchronous breathing pauses of cosleeping mother-infant pairs. McKenna, JJ and Mosko, S. (1990). Human Nature 1 (3). Baby > Mom >

59 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.

60 Body- Facial Orientations Amongst 24 Solitary Sleeping and Bedsharing Mothers and Infants Research funded by National Institutes of Child Health and Human Development RO

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

62 EFFECTS OF BEDSHARING ON INFANT SLEEP Bedsharing Night vs. Solitary Night Total Wakefulness During Sleep  14%0.008 Sleep Stage %’s (of TST) % Stage 3-4  4%<0.001 % Stage 1-2  3% % Stage REM Mean Stage Durations Stage 3-4  16% Stage 1-2  16% Stage REM  26% Waking Arousal Frequency (/hr) Stage 3-4 EWs  38% TAs --* -- Stage 1-2 EWs TAs Stage REM EWs  35% p<0.001 TAs 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)

63 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% % Stage 1-2  4% % Stage REM Mean Stage Durations Stage 3-4  25% Stage 1-2  30%<0.001 Stage REM Waking  62%<0.001 Arousal Frequency (/hr) Stage 3-4 EWs  67%<0.001 TAs Stage 1-2 EWs  37%<0.001 TAs  28%<0.001 Stage REM EWs TAs Table reflects results of 2x2 repeated measures ANOVA (laboratory sleeping condition x routine sleeping condition). (*see Mosko, Richard, McKenna 1997 Sleep 20 (2) )

64 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 )

65 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-Hellwig Discover Magazine 1992 Mother-infant Simultaneous Polysomnography

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67 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:

68 Chicago Infant Mortality Study, 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):

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70 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

71 inspired by cross-species, cross-cultural, developmental, historical and evolutionary studies…. a little experiment…. A little research…

72 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-Hellwig Discover Magazine 1992 Mother-infant Simultaneous Polysomnography

73 145.90

74 2.64

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

76 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 Jan-Feb;9(1):26-32 Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.

77 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.”


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