Posted tagged ‘SIDS’

Mixed messages: Where should babies sleep?

June 12, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

A new study about the best place for babies to sleep – in their own rooms, or sharing a room with their parents – contradicts current AAP guidelines. But hopefully, in the long run, it will help more parents and babies get a better night’s sleep overall.

The most recent “safe sleep” guidelines were published in 2016. They stressed evidence-based recommendations for the safest way for babies to sleep: put down on their backs for every sleep, and on a firm, flat surface. Since bed sharing is has been shown to increase the risk of SIDS (especially in younger babies), it was also recommended that babies sleep on their own surface, designed for infants. And babies were supposed to sleep in their parents’ bedroom for at least the first six months of life, and ideally for 12 months.

It’s that last recommendation that I’ve never been completely happy about. The recommendation is based on three studies from the 1990s, all from Europe (where almost all babies slept in parents’ rooms, and, at the time, on their tummies.) In the aggregate, these studies showed fewer SIDS cases in babies sharing a room with their parents. But: there were very few SIDS cases to compare, and the one study that separated out babies by age at death showed that babies less than 4 months were safer in their own rooms (and less than 4 months is the peak time for SIDS.)  So the evidence, then, wasn’t very strong – but it was the best evidence at the time, and the AAP decided the “share room with parents” idea deserved to be a recommendation.

I also think the Academy was swayed by room sharing’s making nursing easier, which is true. Breastfeeding is associated with a decreased SIDS risk.

The “ideally until 12 months” part of the recommendation was especially problematic. SIDS rates are very low past 6 months, making conclusions about the effect of sleeping location for older infants tenuous at best. 12 months is also peak time for separation anxiety, and a terrible time to first put your child alone to bed. The AAP decided to extend the “ideal time” in parents’ room to 12 months to be extra cautious, but I’m not sure they considered the overall burden this could place on many parents and children in terms of overall quality of life.

Now, a new study throws a wrench into this “same room” recommendation. Researchers tracked the sleep habits of babies who slept in their parents’ rooms, versus their own rooms, and the results aren’t terribly surprising. Room sharing at 4 and 9 months is associated with less sleep for babies, and fewer long stretches of sleep. Babies seem less able to “consolidate” or organize their sleep into longer stretches if they’re sharing a room with parents. And: room sharing makes it more likely that babies will end up in known unsafe sleep positions – like sleeping directly in their parents’ beds. But wasn’t room sharing supposed to be safer?

It’s a mixed message, but it reflects that the evidence for this room sharing recommendation has never been very strong. With this new study, parents should feel more comfortable, and less guilty, if they choose to put babies in their own rooms to sleep.

Fisher-Price: Stop selling your unsafe Rock-n-Play Sleeper

October 3, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

The Rock-n-Play Sleeper, made by Fisher-Price, is marketed and sold as a “sleeper”. You can tell, because the word “sleeper” is in the name of the product. One might think that it’s a good, safe place for a baby to sleep. But it’s not. It’s long past time for Fisher-Price to stop selling it, or at least change its name and marketing.

I first wrote about the RnP in 2013, in one of my most-read and most-pingbacked posts. I closed the comments last year, mostly because everything that needed to be said had already been said. My favorite comment began “You sit are an idiot.” I was also accused of having a vendetta against the Rock-n-Play, a charge that I gladly accepted. I am, admittedly, against things that are spelled in an unnecessarily cutesy way, especially when they kill babies. I’ve since written related posts critical of Fisher-Price for selling a gizmo making it easy for newborns to use an iPad, and another post reviewing a study of 47 deaths among babies who were died while sleeping in unsafe devices.

Since the first post was published, I’ve heard from several people who have been actively pressuring Fisher-Price to change their ways. The most chilling calls have come from an attorney who’s representing a family whose child died in a Rock-n-Play. The autopsy report was heartbreaking – because the baby was sleeping on the curved, soft surface of the Rock-n-Play, his neck was bent forward, closing his airway. No airway, no breathing, dead baby. This same attorney has heard from several families who’ve had near-death experiences with their babies in a Rock-n-Play. One even documented that their baby’s breathing stopped several times a night while in the sleeper (and was normal when slept correctly, flat on his back, on a firm flat surface.)

I’m not always a fan of lawyers and litigation, but this is a case where legal action might be the only way to compel Fisher-Price to adhere to the well-established guidelines for a safe sleep environment for babies. For now, they’re apparently still selling tons of these things, but a few big-money lawsuits may just open some eyes over at Fisher-Price, Inc. I hope so, before more families are misled into thinking the Rock-n-Play is a safe place for babies to sleep.

RnP

Die, rumor, die! Offgassing is not the cause of SIDS

August 11, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Leah wrote in: “I was wondering if you could shed some light on mattress wrapping to prevent off gassing and the New Zealand SIDS statistics. If there anything to this?”

Like a zombie rising from the grave to eat your brain, the “offgassing” hypothesis of SIDS is one of those rumors that just won’t stay in its grave. We can thank the internet for its unique ability to keep obviously wrong ideas alive, forever and ever. Every once in a while, someone stumbles on hoary old posts and “news” stories, reposts them on Twitbook or Faceter, and the idea arises again. There has got to be something better for all of us to be doing with our time!

It all started in 1989 when someone claimed that he had figure out the cause of SIDS. It was chemicals (fire retardants) used in crib mattresses, interacting with a fungus that released toxic gases. I’m not linking the sites that claim this, because I have no wish to perpetuate the rumor– if you want to find out more, Dr. Google will be your willing ally for your adventures. You’ll see that there are several sites that all reference each other, rather than any substantial published studies; many sell special mattress wrappings to keep the Evil Gasses at bay. You’ll see claims that no baby ever dies on a specially-wrapped mattress, and that the government and doctors has been hiding these statistics (because, presumably, we’re all in the pocket of “big mattress” and “fire fighters”.) You’ll also see claims, on those same sites, that HIV doesn’t cause AIDS and other, shall we say, “colorful” health beliefs. Seriously, if you do end up Googling this, you’ll want to put on a fresh tin foil hat first.

The facts of the matter are summed up here, in a document from First Candle. They’re a non-profit dedicated to fighting SIDS and providing support for grieving families. They point out some simple facts: the rate of SIDS dropped after “The Chemicals” were added to mattresses to prevent fires;  the fungus claimed to be associated with SIDS is almost never actually present in any mattresses; wrapping mattresses has never been shown to prevent SIDS, babies have in fact died on wrapped mattresses; and SIDS occurs at a similar rate in countries that do and don’t use flame-retardant chemicals in mattresses. There’s more to it, including summaries of multiple, well-funded investigations into the theory, but you get the point: there’s just no evidence, whatsoever, that toxic gasses from unwrapped mattresses are killing babies. Those that support the theory are not telling the truth.

There’s been good progress fighting SIDS in the 25 years since the “offgassing hypothesis” appeared – we now understand a lot of ways families can protect their children, and SIDS rates have fallen dramatically. This idea wasn’t an unreasonable hypothesis when it was proposed, but studies haven’t backed it up. It’s time for the Toxic Gas idea to stay buried and forgotten.

Ironic

Swings, slings, and car seats are not for sleeping

May 28, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

An April, 2015 report from the Journal of Pediatrics graphically illustrates the dangers of babies sleeping in gizmos not designed for sleep.

As I’ve written about before, the American Academy of Pediatrics has established specific guidelines on the safest ways for healthy babies to sleep. I last reviewed them in detail here. In summary, babies should always be put down on their backs to sleep on a firm, flat surface, like a crib or bassinet. Baby sleep positioners that hold an infant in place are a bad idea. Things that hold babies in an upright or semiupright position, like the Fisher-Price Rock ‘n Play Sleeper, are also a bad idea. Why?

They’re dangerous because little babies have big, heavy heads, and they lack the strength and muscle control to protect their little baby airways. If their heads fall forward, or their necks get entangled in a strap, they can die.

The new report (summarized here) points out that sleep-related deaths are the most common cause of death in infants from 1-12 months of age. The authors reviewed 47 deaths reported to the US government involving sitting or carrying devices, including car seats, slings, and bouncer-type devices.

I’m going to quote a few of the case histories, here. This material is cold and clinical and disturbing. Feel free to skip ahead a bit.

An 11-month-old boy was placed with a bottle in a car seat for a nap at a home day care center. He was covered with a fleece blanket. The chest buckles were secured, but the lower buckles were unsecured. One hour and 20 minutes later, the child care provider went into the room to check on the child. She saw that he had slipped down in his car seat, such that at least one strap was up against his neck, his color was pale, and he was gasping for breath. EMS was called and the victim was transported to a hospital, where he was declared dead.

A mother was attending a breastfeeding class with her 26-day-old son. She was wearing a cloth baby sling that was placed like a sash across her chest. The child was breastfeeding inside the sling. The child stopped nursing and was believed to have fallen asleep. Approximately 10 minutes, later the mother noticed that her son was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated. The child was transported to a hospital and pronounced dead.

A 3-month-old boy was placed for sleep on his back in a bouncer. The father buckled the infant into the seat with the restraint belt and placed a blanket on him up to his waist. Ninety minutes later, the father found the victim face down and unresponsive, with his neck over the top of the bouncer. 911 was called and CPR started; the baby was pronounced dead at the scene. The detective related that the victim had apparently rolled over and pushed up to the top of the bouncer by pushing on the blankets.

An 8-month-old girl was sleeping unattended in a stroller at the mother’s workplace. The restraint belt was not fastened. The mother returned to the room after 5 minutes and found her partially hanging out of the stroller, her head wedged between the lower edge of the tray and the front edge of the seat. She was unconscious and not breathing, so CPR was initiated. She was resuscitated but was in a vegetative state, and life support was withdrawn 2 days later.

Some important lessons can be learned from the details of the report. Death can occur quite quickly—deaths in car seats and strollers were reported after a minimum of only 4 or 5 minutes. And they can occur at almost any age, from 10 days old in a sling to 2 years old in a car seat.

About half of the time, car seat deaths were caused by strangulation on unfastened straps. You might think that once a car seat is out of a moving vehicle, it would be safe to undo the straps—but those same straps that are so effective in keeping a child safe in a crash can strangle a baby. Many of the other deaths were caused either by positional asphyxia, with the head falling forward to close off the airway, or by a device tipping over and smothering the baby.

There’s some good news buried in this report, too. There were no deaths using a sling for breastfeeding—only when the babies were sleeping in a sling. And almost all of the car seat deaths were when using a car seat outside of a car. Based on this and other reports, the correct use of a car seat in a vehicle (baby strapped into the car seat correctly, and car seat strapped into the car correctly) is very safe. It’s the unintended use of car seats and other devices as sleeping devices in homes and daycares that’s dangerous. As the authors conclude, “It is possible that most, if not all, of these deaths might have been prevented had the device been used properly and/or had there been adequate supervision.”

When I’ve written about safe sleeping before, I’ve gotten many colorful comments from people who say that their babies have unique health circumstances, and that their own pediatricians have made recommendations that differ from the usual guidelines. (That’s my translation of their comments, which are more-typically worded “You are an idiot.” or “How dare you question the advice of my pediatrician who has won a Nobel Prize and you are an idiot.”) The AAP sleep guidelines are for routine, healthy babies. If you think your babies need to sleep in a manner different from the typical guidelines, I suggest you speak their pediatricians about it, as soon as they return from Stockholm.

 

edit 4/12/2016: A reader sent me this link, about a baby who died in a car seat. An entirely preventable, tragic death: http://www.popsugar.com/moms/Baby-Died-From-Sleeping-His-Car-Seat-40838059.

Infant recliners kill babies

June 9, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Last time I objected to an infant recliner, I got all sorts of colorful comments*. I was even accused of having a “personal vendetta” against one of them, because I said that they’re not appropriate or safe to use as routine sleepers for babies. Of course, most of the time, having your baby sleep semi-upright in a cushy sling will probably work out fine. Most of the time. Until it doesn’t.

The “Nap Nanny”, sold between 2009 and 2012, was one of those baby recliner-things. It was sold as a way to help babies sleep. Predictably, what happened happened: babies died. Six of them became entrapped or otherwise suffocated in the “Nap Nappy,” or in another version called the “Nap Nanny Chill.” It was recalled last year, but they’re still out there and in use. Another baby just died in it.

We know the safest way for babies to be put down to sleep is flat on their backs, on a firm surface. Not semi-upright, or in a sling-shaped thing. Once babies can roll over on their own, they should be allowed to do so, without straps or other devices to hold them in place. I don’t know how all of the babies died in the Nap Nanny, but the most recent case I linked to seems to have involved entanglement in the straps.

Using a recliner or car seat or similar device as a routine sleep positioner is a mistake. It will probably work fine, most of the time—very much like driving with your child in your lap instead of a car seat. Or not getting vaccines on time. Those decisions, most of the time, will work out fine. Until they don’t.

*Most of the comments objecting to my last article on sleep positioning were from families with babies had specific medical diagnoses, and were told to use a reclined position for sleeping by their docs. I’m not addressing babies with special situations or diagnoses here—I’m talking about ordinary, healthy babies.

 

Flat head? Helmets aren’t the answer

May 15, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

International campaigns to reduce the incidence of Sudden Infant Death Syndrome (SIDS) have been very successful, with reductions of 50% or more in just about every country that’s pursued public education campaigns. Putting babies “back to sleep” is now ingrained in the public psyche. It’s saving lives.

But an unintended consequence has been an increase in babies with flattened heads. Doctors, who need a different word for everything, call this “plagiocephaly”, and it’s almost always caused by prolonged periods of unequal pressure on the growing cranium. If Junior sleeps on his back with his head turned to his right, the back/left of his head will always be pressed down into the bed. Over time, that side will become flatter. Over more time, if steps aren’t taken to correct this, the left ear and the left side of the forehead will shift forward. Viewed from above, the head of a baby with this kind of “positional plagiocephaly” will look like a parallelogram.

This kind of plagiocephaly—caused by pressure on the head, in the shape of a parallelogram—does not cause any developmental or brain problems. The significance is entirely cosmetic. If severe, it can be quite noticeable, but mild to moderate plagiocephaly has minimal if any cosmetic impact and no health consequences whatsoever.

Still, moderate-to-sever plagiocephaly is noticeable, and parents and pediatricians have been eager to find ways to correct it. One treatment that’s become very common is the use of a custom-made, lightweight fiberglass “helmet” that’s worn throughout the day and night. As baby’s head continues to grow, the thinking goes, it will grow into the nice round shape of the inside of the helmet. Problem solved?

But what seems to work, or what you think is likely to work, might not really work. That’s what practicing medicine is all about. We have to test our therapies and ideas, studying them objectively and impassively. We want it to work, it seems like it works, it makes sense that it does work. But does it really make any difference?

Researchers from The Netherlands just published a randomized clinical study, “Helmet therapy in infants with positional skull deformation: randomised controlled trial”. 84 infants who were already enrolled in conservative programs to address moderate-to-severe skull deformity were randomized at 5 months of age to either get fitted with a molding helmet, or to just continue monitoring alone. Helmets were worn for 23 hours a day for six months, with the helmets being re-fashioned and adjusted as the children grew.

Some red flags popped up early on. 403 infants were deemed eligible for the study, but only 21% of their parents agreed to participate—most of the parents did not want to consider joining a study where there child could be randomized to not receiving a helmet. And as the study went on, 100% of the helmet children reported what were considered significant side effects, including skin irritation, pain, decreased cuddling, and unpleasant odors from the helmets.

Still, almost all of the families assigned helmets completed the study and were compliant with therapy, and almost all of them had a full reassessment at 24 months of age to compare helmeted children with those that were just watched. What was found was stark. Use of the helmet made no difference in any measure of head shape. Unbiased observers, who didn’t know which treatment group the children were in, found that measures of head asymmetry were identical. The helmets just didn’t make any difference. Among children who wore a helmet versus those who didn’t, the same degree of improvement was seen, though complete resolution of head asymmetry was seen in only about 24% of patients in both groups. Overall, parents from both groups were equally satisfied with the improvement in their childrens’ head shape.

So what really should be done to deal with positional plagiocephaly? First, a fear of plagiocephaly should not discourage parents from setting their babies down to sleep on their backs. Safe sleeping is preventing thousands of SIDS deaths. But are ways to encourage safe sleep that won’t increase your baby’s risk of a flat head. Rotate the position of sleep, by putting Junior’s head on alternating nights and naps first at one end, then the other end of the crib. Junior will turn his head to look into the room, at the interesting parts. If his head is always on top of the bed, he’ll be looking over the same shoulder all of the time. Sometimes, place him with his head at the bottom of the crib.

Don’t use any sleep positioners—they’re not needed, and make sleep more dangerous. Don’t routinely sleep your child in a car seat, bouncy seat, or sling-shaped positioner—these can all increase the risk of plagiocephaly, and are not safe. Encourage tummy time when infants are young, and upright/sitting play when they’re a little older and ready for it.

Some children with plagiocephaly have a physical problem with the muscles in their necks, which prevents equal rotation to either side. These babies sit with their heads cocked to one side, and sometimes have a thickening you can feel in the muscle along one side of the neck. This is called “torticollis,” and can usually be treated with physical therapy.

If you’re concerned about your child’s head shape, make sure to bring it up with your doctor. Rarely, head shape problems can be a sign of a medical problem that needs to be addressed. Usually, though, a few simple steps at sleep and play times can help head shapes improve—apparently, just as much as an expensive, sweaty, unpleasant head helmet. Sometimes less is more. You don’t have to have your child helmeted for six months to get a fine looking head. Nice to know, and one less thing to worry about!

Is Tummy Time really essential?

March 17, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Fiona has had it with “Tummy Time”! She wrote: “Doctors, prenatal classes, books, other Mums all stress that it’s vital for preventing a flat head and strengthening muscles.  But my little monkey screams blue murder the second I put her on her tummy.  What’s the evidence behind this (fairly recent?) exhortation to put babies on their tummies for a few minutes every day? Have people always done it, and if not, were kids in times gone by somehow delayed in their motor development? My instinct says no, but the call for tummy time seems to be so ubiquitous. And if it’s so important, how do we convince the babies who resist? Mine spends much of her awake hours sitting upright in a sling so I guess she gets a neck workout that way and isn’t lying on her back all the time risking flat-headedness, but it’d be nice to be reassured!”

Tummy time isn’t supposed to be “torture time.” If your baby absolutely hates it, pick her up. There’s no great evidence that it’s necessary at all.

The growing enthusiasm for tummy time began with recommendations in the 1990s that babies be put down to sleep on their backs, rather than their tummies. This led to a dramatic drop in deaths from SIDS, but an increase in what’s formally known as “positional plagiocephaly”, or flat little heads. It turns out that when Junior sleeps on her back, especially with her head turned to the same side all the time, that side gets kind of flatter. There’s no significant medical issue here—heads flattened in this manner don’t cause brain damage or developmental problems—but in severe cases it can be noticeable.

There are good ways to prevent flat heads. The AAP recommends alternating head positions from night to night, and periodically changing around the positioning of the crib so interesting things aren’t always in the same position (you can accomplish the same things by alternating which end of the crib is “up”, or which end the head and feet point to.) And, yes, as part of the anti-flat-head routine, the AAP recommends “a certain amount” of supervised “tummy time” when Junior is awake. They acknowledge that there’s no evidence that this helps, and no studies have shown how much tummy time is ideal, or at what ages it’s needed. It’s more of a common-sense thing. More time on tummy means less time on back, which should not only prevent flat heads but also facilitate motor development by giving Junior a chance to work on her push-ups. So for the many babies who don’t mind some tummy time, I think it’s probably a good idea.

If you’ve got a baby who’s starting to look a little flat in the head department, talk with your pediatrician. Re-orient the crib to encourage Junior to look the other way, and try to alternate head positions and increase tummy time. Your pediatrician should also check for torticollis, a muscular condition that makes in difficult for babies to turn their heads in both directions. Rarely, a molding helmet can be used to help heads grow more round in shape, but beware that companies are marketing these directly to parents, and many babies with mild asymmetry really don’t need anything special, just some repositioning and time to grow and develop.

But for babies like Fiona’s, who absolutely hate tummy time, there’s no reason to think it’s critical. I’d try to make tummy time more fun, if possible, by lying down with the baby so she could see me. But bottom line: if she’s hysterical, pick her up. This issue is not worth any misery.