Posted tagged ‘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

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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.

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.

Sleep aids for children

January 13, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

J-Mom wrote: “My 10 year old son often has trouble falling or staying asleep, mostly due to anxiety.  My son has not had any help from melatonin in the past.  We do several things to help him fall asleep, back scratch, singing softly, white noise machine, but some days are just impossible for him to sleep.  His doctor mentioned using a magnesium supplement as a natural sleep aid.  Do you have any experience with trying magnesium in kids?  Some cursory research I did suggests that it’s effective in cases of a Mg deficiency. Do some people use it even if no deficiency is found? Do you have to test them first? Any thoughts on this?  Thanks!”

The best ways to help a child relax and sleep are simple steps that J-Mom is probably already doing:

Have a set, relaxing bedtime routine.

Avoid screens for 1-2 hours before bedtime.

Set a consistent time for bed and waking.

Get plenty of exercise (though not in the few hours before bedtime)

Make the bedroom comfortable and happy.

Still, some kids even with great routines can still have trouble falling asleep or staying asleep. That can be especially so for children who are anxious—sometimes worries become magnified at night. Anxiety that causes significant day or night symptoms really should be discussed with a child’s pediatrician, and may need to be treated to help overcome its effect on sleep.

But to answer J-Mom’s question, what other kinds of sleep aids are there for children?

Melatonin is probably the most popular. What’s widely sold is a synthetic version of a natural human hormone that seems important in regulating sleep cycles and setting our “biologic clock” for the day. We know that children with damage to the part of the brain that makes melatonin have problems with sleep cycles, so why not give a little extra to help everyone sleep better?

In general, melatonin seems pretty safe for most people. It can have interactions with some medications, and there is some evidence that in at least some children it might increase the risk of seizures (though that is not seen commonly). There also isn’t great long-term data on daily melatonin use in kids. So I’d treat melatonin with respect, like any other medication: use it only if necessary, at a minimum dose, for a minimum amount of time.

J-Mom also asked about magnesium supplementation. Deficiencies of both magnesium and calcium have been linked to poor sleep in animal and observational studies, and magnesium supplementation in at least one study did seem to help elderly people sleep better. However, I couldn’t find any good evidence that magnesium supplements will help children sleep. An ordinary-dose magnesium supplement is unlikely to be harmful, so trying one isn’t unreasonable. Blood tests for magnesium levels can be deceptive—a one-time test may miss some people who are truly deficient, so testing children for blood magnesium levels is unlikely to be useful.

Chamomille and valerian are two herbs that have some evidence as sleep aids in adults, though again, studies in children are lacking. They’re both probably safe. One “natural product” that had once been touted as a sleep aid is Kava (sometimes called Kava-Kava), which has been linked to liver toxicity and many drug interactions, and should be avoided.

If a child is having significant sleep concerns, this ought to be discussed with a doctor. In addition to anxiety, medical things including asthma, allergies, sleep apnea, and restless leg syndrome can interfere with sleep. Though sedatives and sleep drugs are rarely used in pediatrics, there are often lifestyle changes and simple steps that can make a big difference. Though some natural sleep remedies are probably safe enough to try, they’re not the best way to help most children sleep better.

Regular bedtimes improve behavior in kids

October 28, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

A British study published this month in Pediatrics confirmed what Grandmas have been saying: regular bedtimes can help children behave.

Researchers followed a cohort of 10,230 children born in 2000-2002, performing structured interviews at home visits by study nurses every few years through age 7. They asked about bedtime routines—what time the children went to bed, and whether that was a fairly regular time, or whether the time varied on different days. Validated questionnaires were also administered to help determine if behavioral problems were present, including questions about conduct problems, emotional difficulties, and trouble with peer relationships.

It turns out that the exact bedtime, itself, didn’t matter very much. Earlier bedtimes had a very mild and inconsistent effect of overall behavior. However, what did matter was how consistent the bedtimes were. More consistency across the years of the interviews was correlated with better behavior, and there was even a dose effect. The more years of irregular bedtimes, the worse the behavior seemed to be.

Now, there may be some reverse causality here—perhaps the ill-behaved children ended up with irregular bedtimes because their parents couldn’t get them to bed, instead of the other way around. But another observation from this study strengthens the case for a causal relationship: over time, if bedtimes become more regular, behavior does improve.

Early to bed, early to rise makes a man healthy wealthy and wise. But if you want a well-behaved child, it may be more important to have a regular bedtime than an early bedtime.

Score another one for Grandma!

Will cry-it-out hurt your baby?

May 16, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jess, like many parents, has been hearing conflicting information about what crying can do to your baby. She wrote: “So, my husband and I accidentally let our kiddo (5.5 months) cry it out. So of course, I’m spending all sorts of time on Google finding out that I’ve caused long-term damage to my son and he’ll be more likely to get ADHD and be dumber now that I’ve let him cry. I know the studies on cortisol show that some longer-term stress may be evident (at least for a few days), but are there any other real, scientific studies that show long-term damage due to cry it out? I’m pretty sure the other studies cited in the article above are irrelevant to this–am I right? I know you’ve written about cry it out before, but with all the hype, can you clarify?”

A friend of mine is working on a project called “Guilt Free Childbirth”, meant to dispel the guilt and hand-wringing that so many families seem to experience during and after childbirth. What if I need a c-section? What if I can’t do it “naturally”? What if I can’t “bond” instantly with my baby?

This cry-it-out worry—I think I could make an entirely new blog, “Guilt Free Parenting,” just to try to dispel this nonsense. Parents are so saturated with messages telling you that everything—I mean everything—we do is wrong, it’s a wonder we don’t all just curl up in a ball in the closet sucking our thumbs.

Wait, thumbsucking. That’s bad, too.

Anyway: the sky isn’t falling. We are not raising warped, worthless, sick, incompetent kids. There are always things parents could do better (including me!), but that doesn’t mean that if we don’t do everything “right”, our kids will suffer.

Back to cry-it-out: babies don’t always learn to sleep straight through the night on their own, and there are several competing “methods” to help nudge them towards independence. Some parents are very eager to help train, others take a more “easy-going” approach. How you tackle this depends on how parents feel about the importance of a good night’s sleep, and also on the temperament of the baby. I am not going to declare that any one method is perfect for everyone.

But if sleeping through the night is a priority, I have offered up one simple solution that works well for many families. Yes, there is crying. No, I don’t think there is any good evidence that shows any lasting ill effects from letting your baby cry some. There are certainly lots of web sites, pro and con, and lots of people with strong opinions—sometimes they’ll even comment in ALL CAPS for emphasis. But you are not damaging your child by letting tears fall without instant intervention.

Babies have been crying for many, many years. It is how they get our attention. If crying were so damaging, well, I don’t think any of us would have survived.

Jess included an example of reporting that stressed the damage done by cry-it-out sleep training, a list of 10 reasons it’s bad for babies. Most of the reasons were undocumented opinions from the author, who has clearly made up her mind on this issue. The references that were included are rife with methodologic issues—especially retrospective bias (of course parents with children who are thought of as problematic are going to report more sleep issues, in retrospect, when asked), or skim though the complex issue of cause-and-effect. That is, did the excessive crying cause the later problems, or are children who are temperamentally difficult more likely to resist sleep and more likely to later experience emotional problems? One thing may not cause the other, even if they are correlated.

Studies of levels of the cortisol rely on that hormone as a biomarker of stress, and cortisol does indeed increase with stress in humans and other animals. But is that bad? Didn’t human babies always have stress in their lives? Some studies point out that cortisol can change the way brains develop, or can perhaps contribute to the pruning of interconnections between neurons- but that is a normal process that occurs in the development of the human brain. Interfering with this process by avoiding undue “stress” may actually be harmful in the long run.

Or maybe not. I am not saying that babies need to cry to be healthy. Certainly I spent a lot of time holding and reassuring my babies (and even babies in my practice!) But these studies that some claim show cry-it-out = bad for babies, it’s a stretch. And it is not something that parents ought to be worrying about.

Though there aren’t a lot of great, long-term, clinical studies of the consequences of these different sleep approaches, one published last year was reassuring—a method that allowed more crying didn’t lead to scary consequences later.

Also: there are consequences to poor sleep, both for babies and for parents. Underslept babies are fussy and unhappy. Underslept parents are irritable and miserable, and may be more likely to get in car accidents, get divorced, or smack their child. It’s not unreasonable for parents to want to take an active role in pushing towards a good night’s sleep.

A great website with far more detail and insight into baby sleep issues is at www.troublesometots.com—including a detailed guide to one common-sense way to help babies learn to sleep better. Yes, there may be some crying. It’s OK.

Trouble falling asleep? Turn off those screens!

April 4, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Lots of people, kids and adults, seem to be having trouble falling asleep. Now, one solution would be to go to med school and do a residency—you’d be so exhausted, you could fall asleep while talking to your spouse (while you yourself were talking. Good trick.) But that would be impractical, and we’d end up with too many dermatologists. Instead, a recent study has found that there might be a simpler solution. Just turn off those screens!

The study, from New Zealand, looked at sleep habits of about 2000 children from age 5-18, correlating bedtime routines with what’s called sleep latency: how long it took them to fall asleep. The data and conclusions are simple: the kids who spent more of their presleep time watching TV took the longest to fall asleep; the kids who watched the least TV right before bed fell asleep the quickest.

It makes sense. For most of human history, our circadian rhythms were controlled by the sun. When there was light, it was day. Darkness means night. Now, we spend a tremendous amount of time not only under artificial light, but even worse, staring into light sources. Your TV, your phone, your iPad, computer monitors—all of them create light. When you stare at light, your brain thinks it’s daytime. No sleepy. Get it?

That doesn’t even include the stimulating effect of TV shows and crazy video game entertainment. I’m thinking that couldn’t help anyone sleep well, either.

The research was done on kids, but almost certainly applies to adults as well. Want to fall asleep better? Get more exercise (earlier in the day), stay off caffeine (that applies to everyone else but me, I have condition*). And turn off the TV and other video sources for a few hours before bedtime.

You can use that time to read one of your new medical textbooks!

*”I have condition” is an homage to my dad, who used this overall excuse for almost, well, anything. Try it sometimes, it works great!