AAP Task Force on SIDS Reponds to La Leche League Statement

In early January, the La Leche League International released a statement on the American Academy of Pediatrics’ updated Safe Sleep policy. The AAP Task Force on SIDS has released a response to that statement to clarify several points in the press release.

The AAP Task Force on SIDS appreciates the press release from La Leche League International regarding the 2016 updated recommendations for a safe infant sleeping environment and the positive response from LLLI.

However, we would like to clarify some points from the press release that are causing confusion.

1. “The revised policy states more clearly that their recommendation against bedsharing is for infants younger than four months, which is an important clarification often missed by parents and healthcare providers.”

This is not true. We do not recommend bedsharing for any infants. However, infants younger than 4 months are at substantially increased risk when bedsharing, so we specifically mention this group, along with some other groups. It does not follow that we believe bedsharing to be acceptable once the infant is older than 4 months.

2. “LLLI particularly applauds the AAP for recognizing the need for a safe place for drowsy nighttime breastfeeding sessions since hormones released during breastfeeding can make a mother sleepy: ‘Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep.’”

This statement implies that the AAP condones infants falling asleep in the parental bed while breastfeeding. While evidence suggests that it is less hazardous for an infant to fall asleep on the adult bed than a couch or sofa, it is not as safe as a separate sleep surface in the parental bedroom. Falling asleep while feeding the infant in bed is still a less-than-ideal situation that parents should avoid whenever possible. The AAP policy further states, “If the parent falls asleep while feeding the infant in bed, the infant should be placed back on a separate sleep surface as soon as the parent awakens.”

3. “This updated policy also recognizes that breastfeeding and bottle-feeding behaviors are different and have different risk factors. Breastfeeding mothers and babies have unique protective behaviors during bedsharing. They automatically assume a position ― baby near breast, mother’s arm and leg providing a sheltering ‘cove’ as she lies on her side ― that protects against suffocation risks. Bottle-feeding mothers tend to place their baby higher in the bed, near or on the pillows, which is not in that protective cove and thus increases suffocation risk. The breastfeeding mother also tends to rouse frequently, often without realizing it, to feed and monitor the baby’s position, temperature, and condition. These automatic behaviors are not routinely seen with bottle-feeding.”

This paragraph implies that all of the language about breastfeeding dyads automatically assuming a protective position in bed is contained in the AAP policy about safe infant sleep. It is not. The AAP is very pro-breastfeeding and recognizes that breastfeeding independently lowers the risk of SIDS; however, the mechanism(s) underlying the protection offered by breastfeeding are unknown. The above paragraph implies that nothing bad can happen while breastfeeding because of a primal instinct that will keep babies out of trouble. We know that breastfed infants can succumb to a sleep-related death; this has been reported many times. The implication that death will not occur while breastfeeding, while it may be the LLLI’s position, is not the AAP’s position.

4. “Studies disagree on whether or not keeping the baby in the bed increases Sudden Infant Death Syndrome (SIDS) risk. However, there is evidence that the suffocation risk on a properly prepared adult mattress without gaps or excess bedding poses no greater than the suffocation risk of a properly prepared crib.”

We know of no evidence to this effect, and the AAP policy statement makes no claims about this.

5. “Because any parent can fall asleep during nighttime feedings, LLLI and the AAP agree that responsible child-proofing includes making every parent’s bed as safe as possible, regardless of how and where a family plans to feed the baby.”

While the AAP would agree that any surface where a child is placed should be made as safe as possible, there are no data as to whether it is possible to make an adult bed safe for an infant. Most of the quantitative data from case-control studies about what makes a sleep environment safe (e.g., firm surface, no loose or soft bedding) come from data from solitary sleeping infants. “Responsible child-proofing” implies that one can entirely prevent all injury. Our guidelines recognize the reality that parents and infants may fall asleep on the same surface and provide some guidance regarding potentially mitigating harm.

The Ohio Chapter, American Academy of Pediatrics offers providers a wealth of safe sleep resources for parents. On our Safe Sleep webpage, you may find the “Prescription for Safe Sleep” to share with your patients, more information on the new AAP policy statement, and much more.


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