SIDS advice: has it gone too far?

Sudden Infant Death Syndrome, also known as crib death, is the unexpected death of an apparently healthy infant under one year of age. About 150 Canadian babies die of SIDS every year; most are between the ages of two and four months. SIDS is not a diagnosis; it simply means the baby’s death cannot be explained, even by an autopsy.

I get uneasy when experts from a specialized field dispense parenting advice based on their narrow realm. I call it tunnel vision advice. It seeks to solve one problem, but sometimes ignores relevant knowledge from other sources, and how well the advice fits with the realities of life.

This is where we are these days with the advice around “safe sleep,” aimed at reducing the incidence of sudden infant death syndrome (SIDS) as well as accidental smothering. Scientists, physicians and public health professionals quite rightly want to solve the tragic mystery of SIDS; they’ve done reams of research to identify factors common to the babies who have died. This is good. One finding has undoubtedly saved lives: Since they started telling us to put babies on their backs for sleep, the North American SIDS rate has been cut in half.

But, as research identifies more associations, the directions keep piling up. Moreover, they’re getting complicated, with more potential for undesirable side effects. And they could start to undermine the instincts parents must develop about how to care for their children.

Pacifier politics

For me, the last straw was the recommendation from the American Academy of Pediatrics (AAP) that parents give their babies pacifiers to protect against SIDS. This was part of the AAP’s new guidelines, released in October, to reduce the incidence of SIDS. The document covered everything: back sleeping, where babies should sleep, the dangers of maternal smoking, right down to the firmness of mattresses and thickness of bumper pads. But the recommendation about pacifiers caught the eye of the news media.

The AAP did not say babies must have pacifiers; rather, “consider offering a pacifier at nap time and bedtime.” That boiled down to headlines, however, like “Pacifiers May Decrease SIDS Risk” (Fox News, October 11).

To me, there’s a huge difference between telling parents to put babies on their backs and to offer a pacifier. The “Back to Sleep” campaign came out of a broad, worldwide scientific consensus; in contrast, there is nothing resembling scientific consensus about the alleged protective effect of pacifiers.

Experts around the world have looked at the same research and have drawn different conclusions. In fact, the pacifier-SIDS issue was debated at an international meeting of SIDS experts in Canada last summer. According to Aurore Côté, a paediatric specialist in respiratory medicine at McGill University Health Centre, the consensus was that there isn’t enough evidence to recommend pacifiers to prevent SIDS, and that more research was needed.

There’s more. Experts from New Zealand, England and the Netherlands pulled out of a review of pacifier-SIDS research because they disagreed with some conclusions drawn by Fern Hauck, the American paediatrician who went on to be lead author of that paper. Hauck’s article in the journal Pediatrics provided much of the basis for the AAP’s recommendation.

The three dissenters acknowledge that research has found an association between pacifier use and an apparent reduction in SIDS risk. But they say there are too many questions to be answered, including risks of pacifier use, before giving parents advice — a position they argue in a separate paper submitted for publication.

Another leading SIDS expert, British paediatrician Peter Fleming, thinks the risk of not using a pacifier may apply mainly to babies who habitually use them, then don’t, for whatever reason. In some studies, the rate of usual pacifier use was the same in babies who died of SIDS as it was in control groups of healthy infants of the same age from the same population. The most noticeable difference was in the “last sleep,” as the researchers call it (for SIDS babies, the sleep in which they died; for the control group, the last sleep before the parents were interviewed). The babies who died were less likely to have had a pacifier the last time they went to sleep.

Hauck thinks this finding is unimportant, but Fleming isn’t so sure. He says sucking seems to help babies regulate their breathing, a conclusion he’s drawn by observing videotapes of babies sleeping. “While sucking, sleeping infants breathed more slowly and deeply and had fewer episodes of minor obstructed breathing,” he says. But other kinds of sucking (on fingers, thumb, mom’s empty breast) do this as well as pacifiers.

Here’s what particularly concerns Fleming: While watching the videotaped babies who used pacifiers, he noticed they seemed to have forgotten how to suck their thumbs and fingers, something all babies do in the womb. “I’m concerned that increased pacifier use could suppress a fundamental human behaviour, and we don’t know what the adverse consequences might be,” he says.

Other research has shown that changes in routine seem to increase the risk of SIDS: babies sleeping on the stomach when they usually sleep on the back, bed sharing when they don’t normally bed share, even sleeping on the back when they normally sleep on the stomach. Perhaps suddenly having to do without a pacifier also falls into this category? No one can say, but advice to use pacifiers is premature.