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Monday, December 1, 2014

SIDS, Sleeping Position, and Single-factor Theories

I had a disagreement last week with I had submitted, and a moderator had  posted, a piece discussing whether the research evidence actually supports the idea that the use of supine sleeping positions for young babies is the cause of a reduction in Sudden Infant Death Syndrome (SIDS) over the last 20 years. People at skepticink apparently thought it was dangerous to babies even to talk about this possibility, took down my post, and have been unwilling to discuss the issue with me. As for me, my opinion is that it is dangerous to refuse to discuss controversial questions. If I had proposed that parents switch babies used to supine sleep over to a prone sleep position, that would have been dangerous, as it increases the risk of SIDS dramatically (see “The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk” (2005), Pediatrics, 116, 1245-1255), but I did not do that, nor give any other recommendations about sleeping conditions.

My attention was  called back to this issue by an article in the New York Times (Saint Louis, C.,
“Federal study finds 55 percent of infants sleep with soft bedding, raising risk of death “, Dec. 1, 2014, p. A21 , reporting on a recent article in Pediatrics. The study used data from the 1993-2010 National Infants Sleep Position Study, which interviewed about 19,000 parents by telephone and examined changes in sleep practices year by year. The study reported that the use of soft bedding, blankets, and pillows, decreased by 23% between 1993 and 2000, but has not decreased much further, with 55% of infants in the United States still experiencing this known SIDS risk factor.

Could the problem here be that most of us, unless we try quite hard, tend to select one factor that we think causes an outcome, and to ignore all the other related factors? Few medical or developmental events have a single cause, so we are likely to be mistaken if we concentrate too hard on one factor. In addition, the great majority of developmental events are not only caused by more than one factor, they are also influenced by the ways those factors interact with each other--  the whole of the causes being rather more than the sum of their parts. Causes thus become too complex to lend themselves to easy solutions or slogans, but we tend to choose easy solutions anyway, even though that choice can make us neglect other important points.

From the earliest research on SIDS, it’s been clear that although prone sleeping position appears to play a role in sudden infant deaths, there is a list of further factors that have important effects. These are discussed in some detail in the 2005 Pediatrics article I mentioned earlier, so I will just list them: the use of soft bedding (an important point in the early New Zealand research on SIDS), exposure to tobacco smoke, failure to immunize, failure to breastfeed, failure to use pacifiers, overheating, premature birth and/or low birth weight.  Yet, as the recent study showed, the use of soft bedding continues; resistance to immunization is still present and even fostered by state laws supporting parental choice in medical care; smoking remains common in some populations, especially among the young mothers whose babies may have additional SIDS risk factors. As for the use of pacifiers, which would be an easy recommendation to make and carry out, there is still a sense of repugnance about them and a feeling that parents who give a pacifier have somehow failed.

Given this list of risk factors for SIDS, why is “Back to Sleep” the great recommendation to the public? The slogan sounds good (the baby will go back to sleep if she awakens in the night, it seems to imply) , and it provides a simple solution that appears to make it unnecessary to worry about stopping smoking or deciding to immunize. It’s hard to conceive a similar catchy slogan for avoiding soft bedding--  “Be Hard on Your Baby” doesn’t really work. Besides, once people have developed a single-factor belief about SIDS, another slogan will probably not catch on.

Please notice: I am not saying that I think babies should sleep in one or the other of the possible positions. I am saying that the claimed success for “Back to Sleep” (and there are reasons to question that success) may have occurred at the expense of forgetting about other SIDS risk factors.

I also want to comment on a nonfatal but problematic outcome of “Back to Sleep”. Parents who use the supine sleep position for their babies most often do not do the second part: “Tummy to Play”.  As a result, there have been considerable increases in the incidence of head shapes made asymmetrical by a baby’s constant lying position, and a tendency to delays in motor development milestones. I will be commenting on those issues in the next few days.

N.B. I now see that on Facebook Ed Clint of Healthy Skeptic has said that my statements about SIDS and sleeping position are comparable to someone without good evidence saying that all the statements of climate scientists are wrong. No, actually, what it's like is a student of the climate saying that more factors than human activity are responsible for global warming, and in order to understand the impact of human actions we must take into account what the other factors are and how they operate.   

5/20/15: For anyone who thinks I am way out of line to look at diagnostic categories as an issue here, you might have a look at,  pp 11-12.

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