Hobart2 SIDS Afternoon _PPT_ - U

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					      Back To The Future
Breast Feeding, Co-sleeping and
An Evidenced Based Perspective

           James J.McKenna Ph.D.
          Professor of Anthropology
     Chair, Department of Anthropology
   Director, Mother-Baby Behavioral Sleep
          University of Notre Dame
 At long
Co-sleeping      The Consumer
finally works!   Product Safety
                 is finally happy!
Understanding infant sleep/SIDS depends on
           four domains, yet….
                    infant needs/characteristics
                    in relationship
                    to parental emotions,
                    responses                         Experimental
                                                    Medical Ecology..
        Family Ecology                                 how is sleep
        size, SES,                                       studied?
        ethnicity                                  (solitary, bottle fed)
        beliefs,          Cultural Ecology
                            physical setting
                            values, ideology
                            medical views
                            (presumed values)                      only two domains
                                                                   are used
    “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)
•   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
   – .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-
     For the Human Infant….
• Sleep location (next to mother,
• Method and form of nighttime feeding
  (breast feeding)

• Sleep position (supine or back)
   – represent the three fundamental aspects
     of normal, healthy sleep
 ..the cultural dismantling of this
    biologically inter-dependent
     system led to the deaths of
thousands of western infants from
  SIDS, accidental asphyxiations
         and/or other SUDI
   (i.e. from social to isolated infant sleep, from
breast feeding to bottle-formula infant feeding, from
            supine to prone infant sleep,
The cultural dismantling reassembling of
   the mother-infant nighttime dyad
 i.e. from solitary sleep …to social infant sleep--
      from bottle feeding …to breastfeeding

   from prone …to supine infant sleep position
               What to recommend?
• Room sharing;
                                    •   Avoid bedsharing if history of
• Breast Feeding                        maternal smoking before or after
• Proximity-sleeping, daytime           pregnancy;
  skin to skin carrying, massage;   •   Avoid placing infants on or near
  supine infant sleep;                  pillows, sleeping next to other
                                        children, near cords;
• Avoid dangerous furniture like
  soft mattresses and dangerous     •   If drugs are used, or alcohol, or if
                                        excessively tired avoid bedsharing;
  furniture arrangements (pull
  beds apart, take frame off, and   •   Avoid infant bedsharing with
                                        individuals other than the mother;
  to place in center of room)
                                    •   Use light blankets--infant sleep
• Keep beds away from walls;            suits
                                    •   Couch, sofa, recliner waterbed
                                        cosleeping are all dangerous and
                                        should be avoided;
 The co-
debate: two
faces, two
“truths” in
do you see
them.. ( a
young and
and old
woman, in
one face?)
   Routinely bedsharing/breast feeding
  infants (findings published in refereed
Stage 1-2 (light) sleep
Stage 3-4 (deep) sleep
Breast Feeding
Non-breast feeding interventions
Sensitivity to mother
Sleep duration
   Co-Sleeping with breast feeding
promotes the safer supine infant sleep
    Infant Sleep Position And
    Sleeping Arrangement
  70                                     RB-BN
  50                                     RS-SN
       Prone      Supine    Right Side   Left Side

                                                 Richard et. al 1996,
Mom                                                                          Wake

Baby                                                                         Sleep




Figure 2. All-night sleep-wake histograms for five (A-E) cosleeping pairs.
Mosko, McKenna et al (1993). Journal of Behavioral Medicine 16 (6).
Figure 5. Polygraphic recording showing a maternal TA followed and overlapped by an
 infant TA while cosleeping. Note the two brief breathing pauses which occur as the
                               infant returns to sleep.
Mosko, McKenna et al (1993). Journal of Behavioral Medicine 16 (6).
Number of Maternal Arousals
  With Temporal Overlap

  60                                  RB-BN
  50                                  RS-BN
  40                                  RS-SN

                                         *note sensitivity
  10                                     of routine
   0                                     bedsharing mother
       Mom     Baby    Same   Total      waking to infant
       First   First   Time              arousal
                                         (no habituation!)
Mean Duration of Stage 3-4 Sleep: Why
            Important ?
                                 •   Schechtman et al. report that, at
                                     3-4 months of age, siblings of
                                     SIDS victims display increased
                     *p<.o27)        integrated delta amplitude, in
15              RB                   early morning hours compared
                RS                   with controls;
14                               •   Siblings of SIDS and ALTE
                                     infants: deficient arousal
13                                   responses to hypoxia or
12                               •   SIDS victims: more difficulty
                                     awakening from sleep, fewer
11                                   movements;

     Bedshare         Solitary
       Night           Night
  Figure 3. Simultaneous Activity Time (SAT) of co-sleeping and non-co-sleeping infants (paired with
                                 mothers) as a function of sleep stage.

 Figure 4. Simultaneous Activity Time (SAT) of co-sleeping and non-co-sleeping mothers (paired with
                                 infants) as a function of sleep stage.
McKenna et al (1990). American Journal of Physical Anthropology 83: 331-347.
          Evidence -Based Science:

    Infants sleeping alone in a room by
themselves are at least twice as likely to die
 from SIDS than are infants sleeping in the
company (same room) as a committed adult

  Sources: Great Britain (Blair et al 1999), New
Zealand (Mitchell and Scragg 1995), and European
  Collaborative Study (Carpenter press,
breast feeding remained undistinguished in
  the sample, as was type of bedsharing

   “..It the mother smoked significant risks were associated
with bedsharing, especially in the first few weeks of life (at 2
  weeks 27.0(13.3-54.9). This OR was partly attributable to
 consumption of alcohol..Mothers alcohol consumption was
   significant only when the baby bed-shared all night ,OR
  increases by 1.66 (1.66-2.38) per drink). For mothers who
did not smoke during pregnancy, OR for besharing was very
small (at two weeks 2.4 (1.2-4.6) and only significant during
                           16% percent
 the first eight weeks of life. About
of cases were attributable to bedsharing
and roughly 36% to the baby sleeping in
            a separate room.
is the human mother’s sleeping
 an inherent lethal weapon against
 which she and her infant need to be
                       SIDS,SUDI, OID Research Issues

    Sleep Lab Component: At the non-population level,
       “outcomes” are not fully explained by “practice” ?

Who, and what
kind of                    (Bedsharing or other)
relationship is
brought to bed ?                                        Good?
                              (Black Box)
                            who? what? why?
How is bedsharing                                       Bad?
linked to quality of
maternal mental
health, motivation                How linked to
and other                         family
characteristics of                characteristics ?
daytime behavior.
Underlying non-conscious cultural ideologies about the
normalcy of solitary sleeping infants leads to….

A double standard used in assess
 the causes of and remedies for
 infant deaths in cribs vs. infant
  deaths in adult beds or during
How scientific bias works:

• When an infant dies sleeping prone in a crib, the
  contributing cause of death is not assumed to be the
  crib, but sleeping prone;

• When an infant dies sleeping prone in an adult bed,
  even when the infant died alone, the contributing cause
  of death is said to be “bedsharing”
Alaska SIDS/ Pediatrics Gessner
    et al. 2000:108:923-927
•   “Recently, researchers using the Consumer Product Safety Commission data--
    with limited information on some pertinent risk factors, such as parental drug
    use have recommended against bedsharing.
          • “Our data do not support this recommendation. Almost all SIDS deaths
            associated with parental bedsharing occurred in conjunction with a history
            of parental drug use and occurred in association with prone sleep position
            or sleeping on sleep surfaces such as a a couch or water bed”.

• “Because of these findings the state of Alaska does not counsel
  caregivers to avoid bedsharing with their infants. Instead, a simple
  message consistent with the existing data has been developed:
  infants should sleep in the supine position and in their or with an
  unimpaired caregiver on an adult non-water mattress” Gessner et
  al 2000: 926).
       “Association Between Sudden Infant death
    Syndrome, Prone Sleep Position, Bedsharing, and
     Sleeping Outside of An Infant Crib in Alaska”
                  (Gessner et al 2000).
                                             • Of 40 infants who slept with a
•   Of 60 infants who slept alone 57%
    had a parent with a documented             parent at the time of death,
    history of drug use;                       only 1 infant who slept supine
•   --contrasted with 93% who slept            with a non-drug using parent
    with a parent who had a                    was identified;
    documented history of drug use;          • While 2 infants (1.7%) died
•   In addition, dead infants who slept        alone in a crib while sleeping
    with a parent in Alaska, had a high        supine to non-drug using
    percentage of other examined risk          parents;
    factors: 11 slept prone, 9 abnormal
    physiological attributes, 7 slept on a
    waterbed, 1slept the floor, 1 in a
    sleeping bag;
           Fighting Against Scientific
       Distortions of the Bedsharing Issue
Contributions by:
Peter Fleming                       Rodney Ford
James McKenna                       Katie Ramos
Helen Ball                          Miranda Barone
Barry Taylor                        Patty Donahue
Sally Baddock
                                    Martin Ward
Ed Mitchell
David Tepene-
      We need to reach consensus on how to reconcile human
      infant needs and biology with the complexity of current
    cultures: The following constituencies must all participate in
           a multi-facetted, cross-disciplinary discourse :
•    Physiological (biological) studies of     • Lactation consultants and
     infant sleep while bedsharing amongst
     breast feeding and non-breast feeding
                                                 studies of the biological links
     dyads;                                      between infant sleep proximity
•    Ethnographic-home data on parental
                                                 and breast feeding promotion;
     decision making, sleep behavior, and      • Case control studies with
     sleeping arrangements;                      standardized definitions and
•    Coroners, pathologists, forensic            new variables;
     scientists, members of infant and fetal   • Those most effected by public
     death review committee members;
                                                 health recommendations
                                                 including local citizens, WHO,
                                                 UNICEF, DHHS
As a public health issue, why bedsharing
 and prone sleep are not comparable..
no scientific or public     prone sleep is a simple discrete
                               identifiable factor, the baby either
  health consensus             sleeps on it’s stomach, or is found
                               on its stomach, or not; bedsharing
  exists;                      is heterogenous, it consists of many
mother-infant cosleeping       diverse behaviors.. It is not
                               coherent, nor homogenous, nor
  (albeit not on beds) is      does it have a singular “risk factor”
  natural and
  appropriate, indeed
  necessary, prone sleep
  is neither;
   Bedsharing: What Does It
Consist Of Can It Be made Safe?
“Bedsharing” is not sofa or couch   • Critical factors: Is breast
  sleeping, or recliner sleeping      feeding involved? Maternal and
                                        infant sensitivity to movement and
  (these are dangerous forms of         arousals and infant positioning is
  cosleeping, i.e. examples of          altogether different from mother-baby
  dangerous cosleeping as               bottle feeding pair;
  compared with bedsharing          •   Maternal smoking before or after
                                        bedsharing..highly risky!
  made safe)
                                    •   Smoking mothers use heavier
Types of furniture? furniture           blankets..are cold more frequently (cf.
  arrangements? bedding material        Peter Fleming) ;
  and positions?                    •   Arousal patterns of infants whose
                                        mothers smoked are depressed;
***Who is in bed and why? the       •   Bottle fed infants do not arouse as
   nature of the relationship           much nor as quickly compared with
                                        breast fed infants (Horne 2004)
   brought into bed to share
           Public Health Tips
• Infants encounter         • “safe “ bedsharing is
  several different sleep     not an
  environments                oxymoron…(despite
  ..regardless of how the     claims to the
                              contrary…)there is an
  parents classify            enormous range of
  themselves…need             safety factors that
  safety information on       differentiate
  all of them, including      bedsharing
  safe bedsharing             environments…
Multi-facetted Discourse on Bedsharing: Who
(else) And What (else) Must Be Considered?
• Physiological (biological)        • Lactation consultants and
  studies of infant sleep while       studies of the biological links
  bedsharing amongst breast           between infant sleep proximity
  feeding and non-breast feeding      and breast feeding promotion;
  dyads;                            • Case control studies with
                                      standardized definitions and
• Ethnographic-home data on           new variables;
  parental decision making, sleep   • Those most effected by public
  behavior, and sleeping              health recommendations
  arrangements;                       including local citizens, WHO,
                                      UNICEF, DHHS