To minimize the risk of crib death, the nation's largest organization of pediatricians is recommending that babies be put to sleep with pacifiers and in their own beds, despite intense opposition from advocates of breast-feeding and the "family bed."
The American Academy of Pediatrics, hoping to settle some of the most hotly debated and emotional issues related to the care of newborns, is for the first time endorsing routine pacifier use and explicitly advocating a ban on babies sleeping with their parents. In both cases, evidence suggests the precautions would cut the risk of suffocation, the group said.
In an eagerly awaited set of recommendations being unveiled today, the influential group's first new guidance in five years also reasserts its long-standing policy that babies always sleep on their backs, saying for the first time that even sleeping on the side is too dangerous. Babies should, however, sleep in the same room as their parents, the academy concludes.
The recommendations come as more and more American women are juggling the competing demands of work and motherhood. That has led to increasing numbers of new mothers to sleep with their babies in what some advocates call the family bed, as mothers search for any additional time to bond with newborns.
But an expert committee convened by the academy concluded that the new recommendations are necessary to save more infants from crib death, known formally as sudden infant death syndrome (SIDS). Although the number of babies dying mysteriously in the first few months of life has plummeted in the past decade, recent statistics show the decline has flattened out at about 2,500 U.S. deaths a year.
"We're concerned the SIDS rate has plateaued. It's been cut, but there are still a lot of babies that are dying," said John Kattwinkel of the University of Virginia in Charlottesville, who chaired the five-member panel that will unveil its recommendations at an academy meeting in Washington. "We think if more mothers stopped . . . taking their babies to bed with them and used pacifiers, we'd be doing a heck of a lot to get at this problem."
While praised by SIDS activists and other pediatricians, the guidance to parents, grandparents, babysitters, day-care centers and other caregivers drew criticism from proponents of breast-feeding and bed sharing. The evidence that pacifiers are helpful and bed sharing is dangerous is far from conclusive, they said, adding that the recommendations will hinder breast-feeding and mother-child bonding, which are clearly beneficial.
"I'm very disappointed," said James J. McKenna, director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame in Indiana. "I really fear this is just another step of inappropriately medicalizing decisions that are best made within the home."
SIDS is a mysterious condition in which otherwise healthy babies stop breathing in their sleep, usually between the second and sixth months of life. Although the cause remains unclear, research has suggested that it may strike babies who have not yet fully developed the ability to rouse themselves when they have trouble breathing, perhaps from getting stuck under pillows and blankets. SIDS deaths dropped dramatically after the academy and other groups began a campaign encouraging caregivers to put babies to sleep on their backs.
After reviewing the latest scientific studies, the panel concluded that enough evidence has accumulated to conclude it is dangerous for babies and parents to sleep in the same bed.
"There are a lot of safety issues surrounding a baby in an adult bed," said Rachel Moon of the Children's National Medical Center in Washington, a panel member. "A baby can roll over and get caught between the soft mattress and headboard or footboard and suffocate. Babies can fall off the bed. They can get smushed if the parent rolls over on top of them. They can get smushed between pillows and soft bedding, and suffocate."
But studies also show that it is safer for babies to sleep in the same room as their parents, rather than in another room. That way, parents are more likely to awaken if their baby is struggling.
"When everyone is in the same room, there are little awakenings throughout the night. For the baby, that allows them to arouse more easily and get out of any problem situations that may arise," Moon said. "The safest place for the baby to be is in the parents' room next to the parents' bed but on a different sleep surface, like a bassinet or crib next to the bed or even attached to the bed."
The pediatricians withdrew a previous recommendation that it was acceptable to let babies sleep on their sides, based on recent studies indicating that this, too, is hazardous.
"The side position is unstable. Babies can roll onto their bellies, which puts the babies at very high risk for SIDS," Moon said.
The panel reaffirmed previous recommendations, such as urging mothers not to smoke and not allowing babies to sleep with blankets, soft pillows and stuffed animals, and it concluded that routine pacifier use could further reduce the risk. It remains unclear why pacifiers help, but some research suggests it may affect babies' sleep patterns in ways that allow them to awaken more easily.
Pacifier use has been controversial because of concerns that it may increase the risk of dental problems and infections, and also make breast-feeding less successful. The panel concluded that these risks are small, and that any potential problems with breast-feeding could be overcome by acclimating babies in the first month, before starting pacifier use.
But breast-feeding advocates said they believe the recommendations about bed sharing and pacifier use would make it harder for mothers to breast-feed, which has a host of health benefits, including possibly reducing the risk of SIDS.
"Children that are breast-fed are significantly healthier than children who are not breast-fed, so anything that would put a shadow on women breast-feeding would be a big concern," said Katy Lebbing of the La Leche League, which is a strong advocate of breast-feeding.
Panel members agreed that breast-feeding is beneficial but contend that mothers can still breast-feed successfully if babies sleep in their own space.
"Because there's some issues in terms of nipple confusion in the beginning, it's probably best to wait with the pacifier a few weeks until you and the baby have the breast-feeding thing down pat," Moon said.
Advocates of the family bed said sharing a bed can be done safely and that the practice promotes bonding between mother and child, which is crucial for healthy emotional development.
"It's always best to have Mom close to the baby," said Miranda Barone, a psychologist at California State University at Long Beach. "Babies need to be near their mothers. It's just a natural condition. We've evolved this way over millions of years."
Panel members said parents can bond in safer ways.
"You can carry your baby and not just use the car seat all the time. There are lots of things you can do to attach with your baby," Moon said. "It doesn't have to be just at night."