Most doctors, magazines, "experts", and so on will insist that people need to lay their babies on their backs to sleep. They claim that this reduces the chances a babe will die of SIDS. However, as far as I know, the actual cause(s) of SIDS remain unknown. There is only a correlation. Ditto for bed-sharing.
I want to know what REALLY causes SIDS. It's hard to go just by correlations. Of course, I try to do what's right by my children, but is there really need to panic if my child sleeps better on his tummy? Is his back going to squish his lungs so he can't breathe? Is his flat mattress going to go up his nose? What is the danger?
My big question is how valid are mandates based on correlation versus causation? Another example is the debate over vaccinations. Some families object to vaccinations because a few children have "become" autistic in correlation with their shots. However, there is no proof that the shots cause the autism. There IS proof that vaccinations cause people to develop immunities to disease. That is not a case of correlation.
What are Hatrack thoughts about rules based on correlation versus causation?
Posted by MrSquicky (Member # 1802) on :
I think that you might not understand the difference between the two. I don't really know a darn thing about SIDS, but the reason you are using to dismiss this stuff as correlation is not correct. One does not have to know how the causal factors work in order to label a relation due to causation.
Let me present a similar case. Back before germ theory, let's say that someone monitored the sanitary habits of surgeons and found that those with vigorous habits had a greatly reduced rate of patients getting infections. At this point, what they have is a correlation. However, when they start controlling for all other factors, this corellation approaches a point where they can say with confidence that they are likely seeing causation. This is so even though they don't actually know why more vigorous sanitary practices cause less infection.
Hatrack has internalized the idea that correlation is not causation, which is a wonderful thing and a cure for many common logic fallacies. However, it's much more correct to say that the correlation is not necessarily causation.
In the same way that every scientific theory is never actually proven and thus never more than a theory, we are incapable of directly observing causation. We can't see it, feel it, monitor it, or measure it. The only thing we can do is infer it. One of the major ways we do this is through careful treatment of correlated factors, generally by isolating them.
The classic scientific experiment uses the most powerful ways of dealing with correlation we have. In the theoretically pure case, an experimenter takes two identical situations and introduces a difference into them to see what the correlational effect on some other things are. Because this isolates all other possible causes of difference, the experimenter can reasonably claim to have demostrated causation.
If, in an admittedly unethical experiment, someone took a whole heap of babies of generally the same level of physical health and put some of them to sleep on their backs and some to sleep not on their backs and had all or a very large majority of the cases of SIDS in the non-backal babies, that person has a good reason to infer a causal relationship between some aspect of the different positions and SIDS, even if they don't know what the actual discriminating factor is.
Posted by password (Member # 9105) on :
I don't think the data on SIDS is that conclusive, though. There are levels of correlation... Posted by MrSquicky (Member # 1802) on :
As I said, I have no information of the state of SIDS research and what they can responsibly claim. I was just pointing out that the reason given for rejecting it wasn't correct.
Posted by Belle (Member # 2314) on :
The data on SIDS is certainly not conclusive. I heard that more than position, whether or not the baby slept with loose bedding in the crib was important.
As soon as my children were able to roll over, they all rolled over and slept on their stomach. When Natalie was born the recommendation was put them on their sides, and they even sold little bumpers you could use to prop them up on their sides. Inevitably, Natalie would squirm and move until the bumpers were moved away and she was comfortably sleeping on her stomach. Then they switched to saying you should let them sleep on their backs.
It's hard to know what to do. In my opinion, keeping loose bedding out of the crib and making sure the mattress is firm and there is no way the baby can slip down between the mattress and the crib are both good recommendations. Personally, I don't think any great harm came from letting my babies sleep on their stomachs. Well, obviously not, they're still here. But, I mean, I don't think position is of primary importance.
Then again, I'm just a mom with anecdotal evidence and that doesn't qualify me to make recommendations to you Jenny, except to say I share your frustration. It's hard to know exactly what to do but we all know we want to do what is best for our babies.
Posted by Ela (Member # 1365) on :
We do tell moms to sleep babies on their backs only, because studies have shown a lower rate of SIDS in babies who sleep on their backs.
That said, there was no such advice around when my kids were little, and they always slept on their tummies. I am not recommending sleeping babies on their tummies, though, just saying it has been done in the past.
As Belle has said, making sure the mattress is firm and that there is no way for baby to slip between the mattress and the side rails is important. Babies don't need heavy bedding and pillows, either. It's better to put a baby in a blanket sleeper for warmth then to use blankets. There was also some risk correlation for babies who were put to sleep on sheepskins, which were popular in certain circles when my kids were babies.
Once the baby is turning over by himself, you can't really force a baby to sleep on his back, and the risk of SIDS as a result of sleeping on the tummy should be lower, as such a baby should also be able to pick his head up.
Some experts feel that safe co-sleeping in conjunction with breastfeeding lowers the likelihood of SIDS. Here is a good references on that issue, see especially the safety guidelines for safe co-sleeping on that page :
No one really knows what causes SIDS, in spite of years of research on the issue. So far, all the experts can do is give information to help parents minimize the risk.
Posted by SenojRetep (Member # 8614) on :
The issue with determining the cause of SIDS (as with a lot of social/human science) is the inability to do a controlled experiment. You cannot ethically take a bunch of children and inflict the experiment Squick described, which would be the most scientifically valid method of experiment. Therefore the best you can do is observe large samples of them and hope that the lack of control is countered by regression to the mean and the law of large numbers. In the case of SIDS, the sample is not large enough, in my opinion, to be statistically persuasive.
On a personal note, we slept our daughter on her back or side, but if she ended up on her stomach by the end of the night we wouldn't flip her over. Our reasoning was it doesn't take much/any effort to do this (i.e. put her on her back), and it might help. But if it's the choice between having a screaming baby who won't sleep and the miniscule chance (and a dubious one at that) that back-sleeping prevents SIDS, I'd put her on her stomach. The vigor with which we are told to put baby on its back is evidence to me that humans are lousy at processing probabilities and utilities.
Posted by mistaben (Member # 8721) on :
Another problem with researching SIDS is that by the time medical personnel suspect SIDS, the baby's been moved all over the place. The evidence has been tampered with. But that's not likely to change. If your baby won't wake up, would you leave her lying there in the crib? Neither would I.
Posted by JennaDean (Member # 8816) on :
I put my babies on their backs because it was one of the few factors that we can control, that has been shown to be related to a decrease of SIDS. They did seem to sleep sounder on their tummies, but SIDS is such a baffling and scary thing that I was willing to do whatever might possibly prevent it. All of them turned over & began sleeping on their tummies by about 5 months, and at that point I stopped worrying.
Every family has to do what works. The only thing that bothered me was when other caretakers would tell me they were going to put my baby on its tummy. AFTER I'd explained repeatedly that I wanted it to sleep on its back! My mother would do that to me all the time. "She's asleep - I'm going to put her down on her tummy, is that okay?" No, mom, it wasn't okay last time and it's not okay today.
And one woman couldn't figure out why the mom of the baby she cared for got upset when she found out that the baby was sleeping on its tummy while in her care. Her excuse? "If God wants that baby to die, it's going to die and there's nothing you can do to prolong its life." !?!?! As if we shouldn't bother trying to be safe because it's not going to make any difference! What if God doesn't want you to die but you do something stupid that puts your life at risk? Should we say, "If God wants me to die, there's nothing I can do to stay alive, so there's no reason I should worry about walking out in front of traffic!"
(Sorry about the rant, that woman really got on my last nerve.)
Posted by ketchupqueen (Member # 6877) on :
My mom works craniofacial and has seen a huge rise in the last few years of positional skull malformations, some of which haven't been seen for too long and require a helmet to re-form them. She recommends using a side-sleeper and positioning the baby on alternating sides (or alternating between both sides and the back.) (If you're using a bassinet, since it's smaller, you can use very tightly rolled blankets or towels attatched to the frame with safety pins and alternate which way you lay the baby.) So that's what we did with my daugher-- until she started rolling over and laying on her tummy. At that point, my mom says the risk is much reduced anyway-- one of the big problems they've found in SIDS deaths is children who can't roll over can't reposition and regulate their own breathing if there is a problem. Besides that, soft objects and bedding should of course be kept out of the crib and bumpers should not be used (unless they're mesh) if your child likes to sleep with her face pressed up against the side of the crib, but other than that, all the recommendations are not really written in stone, and the situation should be individually considered to determine what would work for each family.
That's my mom's opinion on the subject. Seems like good advice to me.
[ February 13, 2006, 10:36 AM: Message edited by: ketchupqueen ]
Posted by Mrs.M (Member # 2943) on :
Aerin won't sleep on her back, which is very common for preemies. Since she's on an apnea monitor, I can put her on her tummy (approved by my pediatrician and resp. therapist). We do have a sleep positioner, but just because it makes Aerin feel more secure.
BTW, a huge number of the babies who died on their tummies were also the children of smokers, which appears to be the biggest risk factor. I just read an article about the rise "couch death." It seems that an increasing number of babies are dying of SIDS while sleeping with their parents on couches. The article mentioned that the majority of these parents were smokers.
Many of the NICU and PCN nurses expressed doubt to me that sleeping on the back reduces the risk of SIDS. As one nurse pointed out, babies have died of SIDS in the NICU - there just isn't enough information about the cause to definitively identify signigicant risk factors.
Posted by Miriya (Member # 7822) on :
As a parent I think it is important to take all these recommendations with a grain of salt. While sleeping on the back is associated with a reduced risk of SIDS, we don't know why. It could be helpful for a subset of babies, possibly the ones who can't lift their own heads like KQ mentioned, but not necessarily for all.
"Peep", my fourth child currently six weeks old, struggles with allergies. He throws up maybe 50 times a day. If I lay him on his back, he chokes as a result of his frequent spitting up. Not only is this dangerous but he wakes up constantly. He really needs to sleep prone. He wakes less frequently and it seems to soothe his upset tummy. Clearly, for HIM, sleeping on his back ISN'T best.
All my kids learned to flip onto their tummies by about 3 maybe 4 months rendering the whole discussion moot anyhow. I think parents should consider the recommendations and then make the decision that is right for their babies.
Posted by Belle (Member # 2314) on :
Miriya brings up a good point, babies with reflux problems should not be placed on their backs. Daniel had problems with reflux and we had to let him sleep on his stomach.
Mrs. M, one of my old high school buddies was a NICU nurse, and she said the same thing. That she doubted position was as important as other factors. Your point about smoking is an important one.
Posted by romanylass (Member # 6306) on :
I'm not a doctor, but al I have read ( and that is a lot) has led me to beleive that the single most controllable factor in preventing SIDS is not smoking.
Last year I found this article on the implication of automonic nervous sysytem dysfunction in causing SIDS/SIUDS. Of course, you can't test for it beforehand. Mybe someday we'll be able to and place these babies on a monitor.
quote:Originally posted by JennaDean: And one woman couldn't figure out why the mom of the baby she cared for got upset when she found out that the baby was sleeping on its tummy while in her care. Her excuse? "If God wants that baby to die, it's going to die and there's nothing you can do to prolong its life." !?!?! As if we shouldn't bother trying to be safe because it's not going to make any difference! What if God doesn't want you to die but you do something stupid that puts your life at risk? Should we say, "If God wants me to die, there's nothing I can do to stay alive, so there's no reason I should worry about walking out in front of traffic!"
(Sorry about the rant, that woman really got on my last nerve.)
My husband's best friend and his wife have this same attitude. It drives me crazy, mostly because they just lost their daughter to stillbirth and they still have this same attitude. "Why bother trying to prevent it? If their gonna die, their gonna die." Grrrr!
Posted by Synesthesia (Member # 4774) on :
That attitude disturbs me...
Reading about this makes me so TERRIFIED to have a child....
Posted by TomDavidson (Member # 124) on :
quote:My mom works craniofacial and has seen a huge rise in the last few days of positional skull malformations, some of which haven't been seen for too long and require a helmet to re-form them.
Sophie's head is actually slightly deformed for exactly this reason, although we declined the God-awful helmet and, with hair, it's pretty much unnoticeable.
Posted by Shan (Member # 4550) on :
I did the co-sleep/breastfeed-on-demand thing and I observed a couple of things:
A. I woke up before the sleep monitor anytime there was a pause in his breathing. B. Even with some sleep apnea, and my hyper-alertness, I still got more sleep than my girlfriends who put babies in cribs and bottlefed.
*shrugs*
Different strokes for different folks.
Mrs. M is quite correct -- there's more data as relates to smoker-parents and SIDs, than anything else.
Posted by ketchupqueen (Member # 6877) on :
My mom says there was a study saying that moms who co-slept got more sleep. They got a slightly lower "quality" of sleep, but there was a big enough difference in quantity to make up for it. And I always woke up at the first sound, movement, or change in breathing when I'd fall asleep nursing Ems (she usually slept in a bassinet right next to our bed, but I'd fall right back to sleep while she was nursing.) One time KPC fell asleep holding her on the couch, and since she was asleep too, I went to pick her up and put her in the crib, and he tightened his arms in his sleep and started awake, thinking that she was slipping. I think many parents have this kind of awareness to their child.
Posted by ketchupqueen (Member # 6877) on :
quote:Sophie's head is actually slightly deformed for exactly this reason, although we declined the God-awful helmet and, with hair, it's pretty much unnoticeable.
If it's not noticeable with hair, the clinics my mom works at would probably not even suggest a helmet (a band would be an option if you were worried, but not absolutely necessary; slight malformation often self-corrects anyway, especially once sleeping position is varied.) But there are kids whose heads are malformed severely enough that it could actually alter their skull and/or brain development.
Posted by ClaudiaTherese (Member # 923) on :
quote:Originally posted by ketchupqueen: But there are kids whose heads are malformed severely enough that it could actually alter their skull and/or brain development.
Malformation purely secondary to sleeping/resting position in an otherwise healthy child can cause problems with brain development?
The neurosurgeon I trained under stated that this would not occur. That is, while training the residents to identify which cases should be referred for further evaluation, he trained us how to distinguish between early fusion, etc., and positional malformations, as he didn't even need to see the latter.
If anyone has references, I'll do some reading up on it this weekend.*** That's interesting.
(As regards various other topics such as SIDS and co-sleeping, I'm not sure I want to get into the political wrangles that go along with these discussions. However, should anyone ever want to know why I think the Back to Sleep campaign is important, how to minimize risks associated with co-sleeping (and how I think to most appropriately interpret the literature about it), or other pediatric hot topics, feel free to email.
My basic take on this: I'm glad so many people love kids and worry about doing what's best for them. If people didn't care, we wouldn't even have these controversies.)
-------------------------------------------------
*** Edited to add: Specifically, I'm interested in assessments of functional outcomes in "positional plagiocephaly" (i.e., changed head shape secondary to sleeping/resting position). In the review of the literature I just did, all the long-term studies I found showed only aesthetic differences, and in time, all of those self-corrected to the point of imperceptability.
Thanks!
[ February 11, 2006, 10:21 AM: Message edited by: ClaudiaTherese ]
Posted by ketchupqueen (Member # 6877) on :
CT, it's very rare. But they do not all self-correct in time, and there is worry about the kids' development, probably more related to the immobilization that causes it than the actual malformation of the skull. Sorry, should have been more clear in my wording. Posted by Mrs.M (Member # 2943) on :
I can't believe I forgot to mention reflux babies. They should never be placed on their backs to sleep, as they could choke to death on their spitup. Those babies should be put on their sides (or tummies, if they're on an apnea monitor and it's been cleared by a physician and/or resp. therapist).
They're very diligent about turning the babies in the NICU so that they don't develop any skull malformities, but preemies heads are softer than term babies, so it's more important. I was very worried about Aerin's head because she hated to sleep on her left side, to the point where she would desat if they didn't move her. Her head is fine, though. Actually, it's perfectly shaped due to a combination of the C-Section and the NICU nurses.
Posted by ClaudiaTherese (Member # 923) on :
Thanks for the clarification, ketchupqueen. I was ready to start shooting off concerned emails on Monday. *smile
If otherwise healthy babies really were able to get brain development problems secondary to positional plagiotherapy, then we really would have needed to change that point of training.
Posted by Jenny Gardener (Member # 903) on :
Little Crow is usually put down on his side. I do co-sleep, the same way I did with his sister. I sleep with a certain part of me always aware of what he is doing - a movement, a change in breathing. It's like I'm a human baby monitor. I've noticed Crow's breathing patterns have gone from kinda hitchy (when we first brought him home) to strong and steady. We have a very stiff mattress and keep bedding away from his face. Sometimes during the day, I do put him on his stomach because he is a spitty baby. I've seen him throw up when he was on his back (changing or playing), and it alarmed me. He can throw up a LOT, through both mouth and nose. It scares him, too. I can see how that would be dangerous if he were on his back.
Still, I'm sure "Back to Sleep" has helped save many babies. I just wanted to make sure I'm not putting my little guy at a tremendous risk.
Posted by ClaudiaTherese (Member # 923) on :
(I love the name Little Crow! )
Again, I repeat that I am so glad that so many people love and care for children enough to work so hard at figuring out what the right thing to do may be.
For what it's worth, the most recent evidence-based review regarding pre-term infants and sleep position:
There is widespread concern about gastroesophageal reflux (GER) in preterm infants. This article reviews the evidence for this concern. GER is common in infants, which is related to their large fluid intake (corresponding to 14 L/day in an adult) and supine body position, resulting in the gastroesophageal junction’s being constantly "under water." ... A critical review of the evidence for potential sequelae of GER in preterm infants shows that 1) apnea is unrelated to GER in most infants, 2) failure to thrive practically does not occur with GER, and 3) a relationship between GER and chronic airway problems has not yet been confirmed in preterm infants. Thus, there is currently insufficient evidence to justify the apparently widespread practice of treating GER in infants with symptoms such as recurrent apnea or regurgitation or of prolonging their hospital stay, unless there is unequivocal evidence of complications, eg, recurrent aspiration or cyanosis during vomiting. Objective criteria that help to identify those presumably few infants who do require treatment for GER disease are urgently needed.
Surveys of cause of death in various countries have been unable to demonstrate a link between reflux/aspiration and SIDS. Prone position for sleep (infant on his or her back) is the safest position for almost all infants. However, there is extensive data that shows that many healthcare providers are not familiar with or misinterpret the evidence-based literature (in particular, there were studies of Missouri nurses, although there also similar studies of child care centers, other nurses, etc.).
Is there an interest in a summary review of the literature regarding SIDS? I honestly am not sure whether this would be welcomed or helpful, as it really is an emotionally charged topic. Again, I think this is so because people care so deeply, and that is a good thing. I'm happy to refamiliarize myself with the data and summarize it here, but not if that's going to lead to somebody feeling criticized or challenged.
Sleep position of one's child is an individual decision. I think it's helpful to have the most accurate and up-to-date information available, but that can be outweighed by the very real (and justified) sense of condescension and arrogance of the medical profession. (That is, I'm sympathetic to the position many parents are placed in when they try to discuss this with physicians, and I'm aware that sometimes just throwing out more information comes across as being yet more dismissive or condescending. I do not want to be responsible for that! )
Posted by Ela (Member # 1365) on :
I am so glad you posted that information, CT.
Posted by Belle (Member # 2314) on :
I'm with Jenny on this. Regardless of what the literature says, when you run to the crib because you hear a horrible ghastly choking sound and see milk coming up out of your babies mouth and nose while he's on his back - your first reaction is to turn him over.
I don't think there is enough literature in the world to convince me he was better off on his back with his reflux, not when putting him on his tummy helped his sleeping and helped the spitting up, plus when he did spit up, it went straight out away from his face and he wasn't lying on his back choking in it.
Maybe I over-reacted, maybe I should have put him on his back after all, but like I said - instinct took over and said "That baby will choke on his back."
I couldn't have done something too wrong, he's five years old and healthy. Posted by ketchupqueen (Member # 6877) on :
If stomach-sleeping helps, I say, go for it. Although when an adult is unconscious and vomiting, you're supposed to turn them on their side so they won't choke; would side-sleeping (which is also supposed to be safer than stomach sleeping) work? Side-sleepers are pretty inexpensive and very effective.
Posted by Space Opera (Member # 6504) on :
Both of my two older children slept on their tummys. With Boy Opera, the whole "Back to Sleep" campaign hadn't yet begun, and with Operaetta it was just beginning. Space Space Baby has actually slept reclined in a bouncy seat till tonight - he's too long to sleep curled up in the bouncy now. We're putting him on his back, but since he rolls from back to tummy I imagine he'll end up how he wants.
I want to co-sleep, but we've got a pillow topped mattress that I feel is way too squishy to put a little one on.
space opera
Posted by Belle (Member # 2314) on :
I never found the side-sleeping bolsters to be effective. The baby almost always wriggled enough to slide down on their stomachs anyway.
Maybe I just wasn't an effective swaddler or something. Posted by rivka (Member # 4859) on :
Or maybe you had wiggly babies.
Posted by Jenny Gardener (Member # 903) on :
Space Opera, you might want to look into a nifty little device called the "Arm's Reach co-sleeper". It's like a mini-crib that you can put right beside your bed.
Posted by Space Opera (Member # 6504) on :
Jenny, we actually bought one but returned it once we discovered that the sheets were $15 apiece and that we needed approximately $60 worth of height adjusters to make it level with our bed. On top of the $130 price tag it was too much! Space Space Baby has a pack and play set up right beside our bed to sleep in, so that's our compromise.
space opera
Posted by Mrs.M (Member # 2943) on :
quote:A critical review of the evidence for potential sequelae of GER in preterm infants shows that 1) apnea is unrelated to GER in most infants, 2) failure to thrive practically does not occur with GER, and 3) a relationship between GER and chronic airway problems has not yet been confirmed in preterm infants. Thus, there is currently insufficient evidence to justify the apparently widespread practice of treating GER in infants with symptoms such as recurrent apnea or regurgitation or of prolonging their hospital stay, unless there is unequivocal evidence of complications, eg, recurrent aspiration or cyanosis during vomiting. Objective criteria that help to identify those presumably few infants who do require treatment for GER disease are urgently needed.
I'm not sure that I totally agree with this. I spent so much time watching Aerin desat while she refluxed and, later, watching her pulse ox go up and down (I called it the reflux roller coaster). There were so many preemies with respiratory problems exacerbated by their reflux - one of Aerin's neighbors would brady and apnea almost every time they fed her. The doctors and nurses all told me that it's very common for preemies with reflux to take much longer to get off respiratory support. I heartily agree that objective criteria are urgently needed, though.
Of course, there's a big difference between SIDS and AoP (Apnea of Prematurity).
I don't want to give the impression that I'm against the back to sleep campaign. If Aerin was a healthy term baby, I'd definitely put her on her back. I registered for mesh bumpers because I read a study that indicated that SIDS could be caused by babies not having a supply of fresh air, like when they press their faces against their bumpers. I don't use talcum powder because I read another study about that being related to SIDS. I don't allow smokers anywhere near Aerin, although that is also because of her prematurity.
CT, you bring up a very good point about arrogance in medical professionals (it's not just doctors - I've seen it in nurses, too). I'm very lucky to have had doctors that weren't arrogant or condescending, who explained everything I needed to know and were very receptive to my suggestions. However, I have noticed that doctors tend to be very casual about reflux.
I couldn't co-sleep if I wanted to (which I don't). We have a pillow-top mattress and our dogs sleep in our bed with us. According to my neonatologists and pediatrician, co-sleeping is not recommended for preemies.
Posted by Ela (Member # 1365) on :
quote:Originally posted by ketchupqueen: ... side-sleeping (which is also supposed to be safer than stomach sleeping)...
Not anymore. The AAP's latest recommendation is to sleep infants on their backs, not their sides or stomachs.
Posted by ketchupqueen (Member # 6877) on :
Really? Is that recent? The nurses in the hospital when Ems was born put her on her side (which was fine with me.)
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