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Rise in Infant Suffocations Renews Debate On Bed-Sharing

By Rob Stein
Washington Post Staff Writer
Monday, January 26, 2009

Infant deaths blamed on accidental strangulation and suffocation in bed have increased sharply in the United States, federal health officials are reporting today, reigniting a heated debate over the rising number of parents who sleep with their babies.

An analysis of death certificates nationwide found that the rate of fatalities attributed to unintentional suffocation and strangulation in the first year of life quadrupled between 1984 and 2004.

While such tragedies remain relatively rare, and the study did not examine what is causing the increase, the trend roughly coincided with a sharp rise in bed-sharing, which has become more popular to help mothers bond and breast-feed. Such deaths can occur when a sleeping parent rolls on top of a baby, a pillow falls on an infant's face, a blanket gets wrapped around the child's neck or when the baby gets wedged between a mattress and a wall.

"There's been a huge increase in the reports of these deaths," said Carrie K. Shapiro-Mendoza of the Centers for Disease Control and Prevention in Atlanta, who led the study being published in the February issue of the journal Pediatrics. "The message for the public is that accidental suffocation and strangulation is potentially preventable by providing babies with a safe sleep environment."

Shapiro-Mendoza and her colleagues found that the rate of accidental strangulation and suffocation deaths increased from 2.8 to 12.5 per 100,000 live births during with the 20-year study period, increasing the number of deaths from 103 in 1984 to 513 in 2004.

Most of the increase occurred after 1996, which is about the same time deaths from sudden infant death syndrome (SIDS) appeared to plateau after falling by about half, the result of a nationwide campaign to encourage parents to put their babies to sleep on their backs. It also coincided with efforts to investigate sudden infant deaths more thoroughly.

The findings provide the first national confirmation for a trend that has been suspected by officials in many cities, including in the District, in recent years. The risk is highest among African Americans, the study found.

"We're seeing a lot more of these cases," said Rachel Moon of Children's National Medical Center, a spokeswoman for the American Academy of Pediatrics who helps review infant deaths for the D.C. medical examiner's office. "These kinds of deaths have been skyrocketing. I think we should be really worried."

The findings prompted several experts to call for increased efforts to discourage parents from sleeping in the same bed with their babies or in other unsafe places, such as couches, and to educate parents about how they can sleep near their children safely.

"Strangulation deaths are going up and bed-sharing is going up," said John Kattwinkel of the University of Virginia, who chaired an American Academy of Pediatrics panel that recommended against bed-sharing in 2005. "It's certainly logical to draw a conclusion that there is a link. Parents should not bed-share with their babies."

Instead, experts recommend that babies sleep in the same room as their parents, perhaps in a crib or bassinet adjacent to the bed to facilitate breast-feeding. But babies should have a separate sleep surface with a firm mattress and be placed on their backs with no blankets, pillows, stuffed animals or other objects that could suffocate them.

"There is probably nothing more devastating than finding a dead infant in the morning," Kattwinkel said. "We should do everything we can to avoid it."

But proponents of bed-sharing challenged the link between the practice and the increased deaths from accidental strangulation and suffocation. There could be other explanations, they said, and bed-sharing has many benefits, including helping mothers to breast-feed and form crucial bonds with their children.

"Babies are much safer with their parents," said Jan Hunt of the Natural Child Project in Sunriver, Ore. "That is where they were meant to be. That's where they have been for eons. It's safe. It's natural. It meets many, many needs."

Others said the key is to teach parents how to sleep safely with their babies.

"Parents are sleeping with their babies because this is what they are designed to do. This is what they are supposed to do," said anthropologist James J. McKenna of the University of Notre Dame. "There are many ways mothers sleep with their babies. Some are dangerous, and some are very safe and beneficial."

Shapiro-Mendoza and others said the increase in suffocations and strangulations could be due at least in part to a shift in classifying deaths that previously would have been attributed to SIDS.

"We can't tell from these data exactly what the reason is," she said. "It could be we are doing more thorough death-scene investigations. I can't prove that either way."

But the increase in bed-sharing could also be playing a role, Shapiro-Mendoza and others said. A 2003 national survey found that the percentage of babies sleeping with a parent or other caregiver more than doubled between 1993 and 2000. The practice was especially common among younger and poorer women, those living in the South, African Americans, and Asian Americans. Another study released at the same time found that about half of babies in the District shared a bed with a parent or another adult.

"There's a lot more bed-sharing. People are just not being careful," said Moon, of Children's National Medical Center.

While more-affluent women may bed-share to help bond and breast-feed, poorer women often share a bed for other reasons, Moon said.

"There's something we call chaotic bed-sharing. You share a bed not because you make a conscious choice to bed-share, but because you have no other options. Maybe you can't afford a crib," Moon said, noting that nonprofit groups have been distributing free cribs to help address the problem. "Maybe you only have one bed or you just fall asleep and are not really paying attention to safety issues."

In the new study, the death rate from accidental strangulation and suffocation was 27.3 per 100,000 live births among African Americans, compared with 8.5 among whites, with boys younger than 4 months being the most vulnerable.

Yvette Clinton-Reid, who chairs a committee that reviews infant deaths for the District's medical examiner, said about five babies die from accidental suffocation and strangulation in the city each year, with most cases occurring in the poorest wards.

"Part of it is economics and part of it is just cultural beliefs," Clinton-Reid said. "Women think their infants are safer sleeping in bed with them."

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