Objectives. To ascertain whether the number of sudden infant deaths as a result of suffocation in cribs, in adult beds, on sofas or chairs, and on other sleep surfaces was increasing whether attributable to increased reporting, diagnostic shift, or an actual increase in suffocation deaths and to compare the risk of reported accidental suffocation for infants on sleep surfaces designed for infants with the risk on adult beds.
Methods. We reviewed all accidental suffocation deaths among infants ≤11 months of age reported to the United States Consumer Product Safety Commission from 1980 through 1983 and 1995 through 1998. We compared infants’ ages and other demographic data, the sleep location and surface used, and the reported mechanism or pattern of death. For 1995–1998, we used data on sleep location from an annual survey of randomly selected households of living infants younger than 8 months, collected as part of the National Infant Sleep Position Study at the National Institute of Child Health and Human Development, to calculate risk for death as a result of suffocation in cribs, in adult beds, and on sofas or chairs.
Methods. The number of reported suffocation deaths by location were compared between the 1980s and 1990s using logistic regression modeling to calculate odds ratios (OR), 95% confidence intervals (CI), and P values. Comparative risks for suffocation deaths on a given sleep surface for infants in the 1990s were examined by calculating rates of death per 100 000 exposed infants and comparing the 95% CI for overlap.
Results. From the 1980s, 513 cases of infant suffocation were considered; from the 1990s, 883 cases. The number of reported suffocation deaths in cribs fell from 192 to 107, the number of reported deaths in adult beds increased from 152 to 391, and the number of reported deaths on sofas or chairs increased from 33 to 110. Using cribs as the reference group and adjusting for potential confounders, the multivariate ORs showed that infant deaths in adult beds were 8.1 times more likely to be reported in the 1990s than in the 1980s (95% CI: 3.2–20.3), and infant deaths on sofas and chairs were 17.2 times more likely to be reported in the 1990s than in the 1980s (95% CI: 5.0–59.3). The sleep location of a subset of cases from the 1990s, 348 infants younger than 8 months at death, was compared with the sleep location of 4220 living infants younger than 8 months. The risk of suffocation was approximately 40 times higher for infants in adult beds compared with those in cribs. The increase in risk remained high even when overlying deaths were discounted (32 times higher) or the estimate of rates of bedsharing among living infants doubled (20 times higher).
Conclusions. Reported deaths of infants who suffocated on sleep surfaces other than those designed for infants are increasing. The most conservative estimate showed that the risk of suffocation increased by 20-fold when infants were placed to sleep in adult beds rather than in cribs. The public should be clearly informed of the attendant risks.
Comments
Safety is the issue, not where a child sleeps.
Dr. Kemp:
If soft pillows and plush bedding are the culprits, rather than adult beds per se, than perhaps that is what should be communicated. Instead, your study concludes that sleeping in any adult bed is not safe for a child. That is akin to saying that riding in a car is not safe for a child, therefore no child should ride in a car, without mentioning that the situation can be made much safer by using a car seat and proper restraints. Children can sleep safely in adult beds if pillows and soft bedding are kept away from the child's face, and if their parents are alcohol- and drug-free. (I am not going to address the many benefits of cosleeping vs crib-sleeping, but parents do consider both benefits AND risks when making decisions about where their child sleeps -- just as people weigh risks and benefits in other situations.)
How many of the children who died in adult beds were left alone in them, and how many were sleeping with their parent or parents at the time? Had any of the parents been drinking or taking narcotics? This information would be a valuable addition to your research, as would an inclusion of estimates on the reduction in SIDS deaths due to cosleeping.
I agree with previous letters: there will always be risk. Just because there have been reports of infants dying suddenly during breastfeeding in an adult bed does not mean I should stop breastfeeding my daughter in our bed. People drop dead while exercising and no one encourages us not to exercise! Parents would be better served by being educated on the safest ways to put their children to sleep, whether they choose to cosleep or use a crib.
Concerns about Infant Sleep Article
As the mother of three beautiful girls I can fully understand your concern about infant suffocation and see why you recommended the crib as the safest place for infants. On the other hand, it seems you need to recognize your own biases in favor of cribs and against co-sleeping. If you were not so, then you would more carefully seperate the many variables and risks associated with co-sleeping as mentioned by earlier respondents and also recommend ways to make co-sleeping more safe rather than not an option at all. You give no recognition at all to the important benefits of bonding, breastfeeding and better sleep that many parents enjoy through co-sleeping. A more careful study and more thoughtful recommendations would be the best way to empower parents to keep their children safe and do what is right for their individual family. We co-slept with each of our daughters for the first two years of their lives and cannot imagine having to put them into a crib instead of snuggling and nursing with them for all those nights. There are many things in life that have inherent risk, but as with most things, it cannot always be all or none. We have to minimize the risks and decide what is right for our family. Please help us to minimize the risk, but not our options. Thank you.
Bed Sharing or not?
In addition to the queries already brough up by previous respondants, I would like to query the 'responsibility' of any care-givers (if, indeed the babies were placed in adult beds with care-givers,rather than in adult beds on their own).
It has already been shown that infants who bed-share with adults who smoke, drink heavily or take recreational drugs are more likely to die. This new study does not appear to take into account such data. Without a more detailed explanation of the data that has been used for such studies there is a serious likelyhood that parents are given misleading information. Parents have a right to make informed choices about how to care for their children, but informed choice can only take place when all variables have been accounted for before results are released to the press.
Authors' Response
Dr. Harris worries because many of our findings that reached the very stringent criteria for significance of p < .001 in bivariate analysis had slightly less significant p values in our multivariate models – generally between .001 and .05. However, several additional associations between non-heterosexuality and punishment by authorities that were of borderline significance in the bivariate analysis emerged as highly significant in the multivariate models, which take confounders into account. Moreover, almost all of our analyses – including those with p values above .001 – showed similar trends: LGB youth suffered more punishments. We continue to believe that the strength and consistency of our findings warrants quite firm conclusions.
Professor Schumm criticizes our statistical methods. Our analysis relied on methods that are absolutely standard in the medical literature, i.e. bivariate analyses (Table 2) to describe the actual outcomes in the population, and multiple logistic regression to assess the independent contribution of LGB status after control for potential confounders such as differences in the rate of misbehaviors between heterosexual and LGB adolescents (Table 3). These methods are not only familiar to most Pediatrics readers, but also easy to interpret; the actual rates of punishment can be read directly off Table 2, while Table 3 provides the odds ratios for LGB as compared to other youth, which for the relatively rare events studied, differs little from the clinically familiar concept of relative risk.
Schumm suggests that modest effect sizes for each of the six individual punishments we studied indicate that discrimination against LGB youth is not really important. But even a modest excess in each individual type of punishment means that overall, LGB youth suffer many more punishments. Moreover, even a modest increase in unjustified school expulsion or criminal conviction is of great clinical significance.
Schumm also combed through the subgroup analyses included in our appendices, seeking findings (all of them non-significant at the p < .001 level) that differ from those reported in the body of the paper. Because the cell sizes of these subgroups are small, our data cannot tell us whether the differences seen in these subgroups are due to sample fluctuation or true effects. Both the far more extensive subgroup analyses that were included in the original, longer, version of our paper (and Ms. Himmelstein's thesis on which the paper was based ("Scared Straight: Institutional Sanctions against LGBTQ Youth," Himmelstein, 2009)), and the consistency of the trends among the vast majority of the subgroups examined lend support to the conclusions drawn in the paper. Nevertheless, further research should explore whether and why significant variation in these trends exists among specific subgroups.
Conflict of Interest:
None declared
Co-sleeping benefits outweigh risks
This study fails to mention some important facts. The study looks only at babies who died of suffocation and does not include those who died of SIDS (ie death from no known reason). In the US in 1997 (one of the years in the study), 50 infants died from crib suffocation, compared with 2705 who died from SIDS, mostly alone in cribs. A substantial body of research shows that co-sleeping dramatically reduces the risk of SIDS in infants. If those 2705 babies had been sleeping close to a responsible caregiver, far fewer of them would have died. Cribs are not safe substitutes for caregivers.
The study also makes the assumption that babies who died in adult beds did so during the night while adults were sleeping in the bed with them. The conclusion makes it clear that the risk of suffocation increased when infants were "placed to sleep on adult beds". No mention of the close presence of a responsible caregiver. A US Consumer Product Safety Commission review of infant suffocation deaths in the US from 1980 to 1999 found that 92 % of babies died while alone. Most of these deaths happened when the baby became stuck or got something pressed against the face or neck. The majority of these deaths could have been prevented by following co-sleeping guidelines issued by many organisations.
Media articles about the study state that 25.5 per 100,000 babies in the United States died sleeping in adult beds, compared to 0.63 per 100,000 deaths among babies sleeping in cribs. If figures for SIDS are added in, 34.1 per 100,000 deaths occurred among babies in cribs. So , if you take SIDS into consideration and the fact that many suffocation deaths could have been prevented, the figures are very different.
In percentage terms, 0.0341% of deaths occurred in cribs and 0.0255% occurred in adult beds (the majority of which could have been prevented). These percentages hardly justify the alarmist comments made by the author of the study, nor his conclusions that babies are safer in cribs. Dr Kemp obviously holds strong views on the subject of co-sleeping and has allowed his feelings to influence this study, which looks at a very small part of the whole picture.
The study may have achieved its objectives, but it has done nothing to achieve the larger objective of reducing infant death.
Anna Young, Victoria, BC Canada
Re: Bedsharing and breastfeeding
I'm always alarmed when raw data for suffocation deaths is lumped for statistical analysis. I did not (yet) purchase the full article online -- - I've read only the abstract.
As a mother who breastfed both children in a family bed situation 16 and 18 years ago, I am discouraged that no analysis was made of breastfeeding vs. bottlefeeding in the data collected. Breastfeeding mothers are highly aware of the baby's positioning and safety during the night, as opposed to what I believe the awareness level is of non- breastfeeding parents.
In earlier published data collection on "family bed" suffocations, I also recall that drug- or alcohol-impaired adult presence in the bed with infants has a high correlation with suffocation or other injurious outcomes. Even crib-sleeping babies who are "safer" from suffocation can still be endangered and accidentally killed by impaired parents... Ignoring this data is not responsible when formulating statements on the safety of babies.
When trumpeting these statistical analyses to the popular press (where I became aware of them)as proof of the dangers of family bed situations (the common arrangement in most of the world), you could also mention the possible contributing factors that weren't considered.
Jeanean Slamen Houston, Texas
Bedsharing and breastfeeding
Dear sirs,
As a breastfeeding mother, i have found that all the information that I have read on bedsharing makes a total distinction between whether the mother is breast or bottle feeding. Only breastfeeding infants are recommended to share the mother's bed as bottle feeding mothers have been found to treat the infant as another adult in the bed and turn their backs on them in their sleep (amongst other things). Have you been able to determine the SIDs rate between bottle feeding and breast feeding infants? Have you been able to determine the SIDS rate between those deaths where the parents have followed all the guidelines (UNICEF) and those where they haven't? Surely this is more important to parents to enable them to make a properly informed choice of place to sleep their infant?
Sarah Husband,
UK housewife and mother to 4 week old Megan who are both enjoying breastfeeding and bedsharing.