Co-Sleeping & Suffocation
A Response to the Consumer Product Safety Commission Study
by API Staff
API News, June 2000
In the last issue of API News, we mentioned a study published in Pediatrics that discouraged co-sleeping because of potential hazards it presents to infants. Little did we know that this study would inspire the Consumer Product Safety Commission to do a similar study and conclude that bedsharing with infants is dangerous and should be strongly discouraged, if not banned. The pronouncement made media headlines across the country. Ann Brown, director of the Commission, appeared on talk shows and morning news programs to tell parents that, based on their findings, "there was no safe way for parents and infants to sleep together."
The CPSC's study found that 515 infant deaths had occurred in the years 1990-97 as a result of sleeping in adult beds. 394 of those deaths were a result of strangulation or entrapment in the bed structure or bedding. The remaining 121 were from inadvertent smothering called "overlying." The data was collected from a review of death certificates, coroner's reports and news accounts and the resulting conclusion of Dr. Suad Nakamura, the study's lead researcher, was that "placing children younger than 2 years to sleep in adult beds exposes them to potentially fatal hazards that are generally not recognized by the parent or caregiver."
This strong stance against bedsharing prompted outrage both from parents and a sizable group of experts who objected to the Commission's actions on many fronts. In a recent statement, Abraham Bergman, MD and his colleagues at the Harborview Injury Prevention and Research Center in Seattle said, "The original data that form the bases for these recommendations are seriously flawedó a classic case of 'garbage in, garbage out.'" Other experts such as Dr. Dean Edell (on his website) and Penelope Leach (Op Ed, New York Times, Oct. 1) objected to a government agency making pronouncements about parenting, especially when based on one "weak and culturally biased study." Even the New York Times and Reuters News Service ran articles that raised serious questions about the study's validity. The criticisms by researchers and parenting experts alike cluster around the following points:
Flawed data. Without accurate knowledge of how many parents sleep with their infants safely, there is no way to determine relative risk. While tragic, we cannot know how significant 121 deaths (over 7 years) really is. The term "overlying" itself is problematic and unreliable as a measurement. In a review of the CPSC data since 1995, Dr. Mary Ann O'Hara of the University of Washington found that "overlying" was a term used in some geographic areas but not others. There is also variation based upon race and social class. "The death of an infant with the same pathologic findings might be classified as overlaying or suffocation if the family is poor and/or minority, and SIDS or pneumonia if the family is white and/or middle class."
Missing information. Dr. David Servan-Schreiber, of the University of Pittsburg, says that "overlying" is a notoriously unreliable autopsy diagnosis. "It is frequently impossible to distinguish it from SIDS, which is much more common. It is impossible to interpret the results of a retrospective study based on death certificates rather than on a careful and systematic examination of the circumstances of each and every one of these tragic accidents." Death certificates and coroner's reports do not contain complete information about the circumstances of the event. "There was no systematic investigation of the role of drugs, alcohol or severe obesity in the study from which the CPSC derived its conclusion." Dr. James McKenna in a letter to Pediatrics (in press) submits that "in Cook County, IL (Chicago), the medical examiner has found that all overlying deaths were in situations in which the adult was intoxicated with either alcohol or illegal drugs." Without this critical information, which is absent from the study, it is impossible to determine the exact risks of bedsharing.
Throwing the baby out with the bathwater. Dr. Bergman states "That dangerous conditions can exist in the bedsharing environment is no more an argument against all bedsharing, than is the fact that babies strangle and die alone in cribs an argument against all solitary infant sleep." More than 90% of all SIDS deaths occur during what Dr. McKenna refers to as "unsupervised solitary sleep." The CPSC has made no moves to ban all cribs or carseats because children have died in them.
Overlooks proven benefits. The CPSC's evaluation includes no risk/benefit analysis and overlooks the many proven benefits to bedsharing. Dr. McKenna in the Mother-Infant Sleep Lab at Notre Dame has documented in several studies that "co-sleeping induces important behavioral and physiological changes in both infants and mothers...These include: increased use of the safe infant sleep position, increased breastfeeding, increased infant movement, reduced deep and increased light sleep, more affectionate and protective maternal interventions, increased sensitivity to the presence of the co-sleeping partner, reduced infant crying, fewer (infant) obstructive apneas in deep sleep, longer infant sleep and more positive evaluations by bedsharing mothers of their nighttime experiences."
Mistrusting of parents. The study seems to assume that parents cannot be trusted to look out for their infant. "Their analysis and recommendation simply assumes...that even a nonsmoking, breastfeeding mother who bedshares to protect and nurture her infant is no more than a passive lethal weapon...over which neither she nor her infant has any control. Such thinking is morally and scientifically bankrupt," says Dr. Bergman. "The researchers equate mothers with bed hazards." The CPSC was not able to see what many bedsharing parents have come to know: that sharing sleep makes parents more sensitive to their infants, not less.
Cultural bias. The hubbub over the CPSC study, while inspiring some encouraging debate, has betrayed at least two deeply held American values: early independence and consumerism. Most attachment-oriented behaviors focus on the resources of the parent themselves, not a product or gadget. It's essentially free. The simple act of co-sleeping says to the world that we allow our babies to be babies and we don't have to buy anything to do it.
For all of us, the CPSC study should be a lesson in critical thinking. Statistics can sound like fact, but if the study was not rigorously conducted, statistics are just numbers on a page.