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The space between…


The readers of Don’t Forget the Bubbles are clearly well educated and try their best to keep up to date with the literature.  We do what we can to help bring the latest research to you to help reduce the knowledge translation window (and have a new project on the horizon to help even more). Those of us who are involved in FOAMed scour the literature to see what is bubbling to the surface but unfortunately, the general public does not. Whilst I might peruse 40-50 medical journals a month the layperson may only have one source of medical information.  

Imagine my surprise when I saw this tweet from Tim Horeczko:-


I’ve written about SIDS before and have a special interest in the subject.  I’d even spotted an interesting article to write about for this site as one of this month’s free to download papers from the Journal of Paediatrics and Child Health.

Griffin J, Heald A, Davidson L, Kent AL. A prospective audit of adherence to safe sleeping guidelines in a general paediatric ward and special care nursery. Journal of Paediatrics and Child Health. 2016 May 1;52(5):529-33.

In 1946 an American paediatrician, Dr. Benjamin Spock, published a book Baby and Child Care, that would become a worldwide best-seller. According to the New York Times, it outsold nearly every book except the Bible.  In the days before the internet, it was the source of information for mothers on how to care for their children. So when the 1958 edition suggested that children should not sleep on their backs because:-

“if [an infant] vomits, he’s more likely to choke on the vomitus…”

Parents adhered to his advice.  By 1970 evidence had mounted that this was not the case and that by sleeping on their back a child was much less likely to die of SIDS than if sleeping prone. Spock’s book did not make this change in recommendations until the 1990’s.  A 2005 systematic review suggested that 60,000 SIDS deaths could have been avoided if the popular source of information had kept up to date with the literature.

What are the current guidelines?

In 1992 a National Infant Sleep Position Household Survey showed that only 13% of parents placed their children on their backs to sleep. By 2006 this figure was up to 75%.

What should you do…

  • Sleep baby on the back from birth
  • The head and face should be uncovered
  • Keep the baby smoke free, before and after birth
  • Provide a safe sleeping environment every time
  • They should sleep in their own safe sleeping place, in the same room, for the first six to twelve months

The Griffin et al audit of safe sleeping practices revealed an 83% compliance in the Special Care Nursery and an 82% compliance in the General Paediatric Ward for children under the age of 1 year. There were no incidences of sharing a sleeping surface. (Editors note: I am using this term as co-sleeping can be confused to mean sleeping in the same room). The main risks, in terms of non-compliance with guidelines, were leaving soft toys in the bed or leaving hats on infants

Sharing a sleep surface can increase the risk of Sudden Unexplained Death in Infancy (SUDI) especially in children less than three months of age.  Giant-sized beds were not designed for small infants and may contain any number of unexpected hazards. An analysis by Carpenter et al. found that infants in adult beds were at increased risk (especially if parents were under the influence of drink or drugs) of:-

  • Being laid upon by an unaware parent
  • Being edged between the mattress and pillows or the wall
  • Becoming entrapped in bed railings
  • Becoming covered with adult sheets, blankets, and duvets

That is not to say that bringing in an unsettled child into bed does not have its benefits. We know that it:-

  • Improves breastfeeding
  • Improves maternal sleep
  • Enhances bonding between mother and infant
  • Improves infant settling

The benefits only outweigh the risks though if the parents stay awake.

The Op-Ed piece in the LA Times by Robert and Sarah LeVine takes umbrage with the recommendations of the American Academy of Pediatrics regarding safe sleeping. They cite that co-sleeping is practiced throughout the non-Western world with no adverse effects. Using an anthropological argument they suggest that infants that sleep with their parents are better adjusted, more likely to take care of themselves and be better socially adjusted when older. If one skims the headline and the article itself one would believe that sharing a sleeping surface is a harmless thing to do.

As healthcare practitioners, it is our job to educate the public, be they the parents of the children we see or our friends on what is right. We need to learn from history and not repeat the mistakes made. So how do we do this? We can use social media, as suggested by Ken Milne of the SGEM to cut the knowledge translation window but I am curious just how far our reach extends.  As I prepared this article I saw series of tweets remind practitioners not to provide codeine-based analgesia to children. We covered this on DFTB two years ago!

As Tim Horeczko would say, “You are the champion of the child in front of you.

Selected references

Spock B. Baby and Child Care. London, UK: The Bodley Head; 1958

Gilbert R, Salanti G, Harden M, See S. Infant sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002. Int J Epidemiol. 2005;34(4):874–887

Carpenter, R., McGarvey, C., Mitchell, E. A., Tappin, D. M., Vennemann, M. M., Smuk, M., & Carpenter, J. R. (2013). Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies. BMJ Open, 3(5), e002299

Colvin JD, Collie-Akers V, Schunn C, Moon RY. Sleep environment risks for younger and older infants. Pediatrics. 2014 Aug 1;134(2):e406-12.

Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine. 2011 Dec 1;104(12):510-20.




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3 thoughts on “The space between…”

  1. Thanks for your comments, Kath.

    I have spent many a night with our little ones in bed with us, partly due to previous circumstances, and partly due to extreme tiredness. I agree that the paternalistic approach is not the way to go and that acknowledging the challenges of getting enough sleep hold for new parents (and old ones too sometimes). Stating that it does happen and that there are ways of reducing risk is the way to go.

    Perhaps in the same way that we use brief interventions to suggest cutting down on smoking and alcohol on an opportunistic basis we can use presentations to the ED to reinforced safe sleeping practice?

  2. Hi Andy and Tim,

    Thank-you for bringing up this interesting topic. Whilst I agree with you that the Op-ed article is simplistic in its arguments in favour of co-sleeping (the implication I took to mean sharing a sleeping surface), as clinicians, I think we need to avoid a dogmatic approach.
    Current available evidence suggests that an optimal sleeping arrangement is baby on separate sleeping surface, in the same room as parents, for the first 6 months. But I can assure you, simply being told, “It’s not ok. It is not safe”, will not be taken well by a number of women (especially coming from a man). Many of the women I know who co-sleep already feel guilty about it. They came to that arrangement because it was the only way that mother and baby got any sleep. We can either condemn them, or recognise that co-sleeping is a reality and offer advice and resources in a harm-minimisation fashion.
    Regarding knowledge translation: if we are truly serious about knowledge translation to the general public then we need to recognise the various facets of lay knowledge. The reality is we are but one source of information. We like to think our training makes our knowledge superior. But this paternalistic attitude runs the risk of alienating those who need us most.

  3. Tim Horeczko aka Andy Tagg Super Fan

    Dr Tagg — thank you for this great piece, and thank you for your generosity.

    Agreed — some media pander, some slander, and some just wander. Using our best common sense and verifying are our best defenses against the dark arts of misinformation.

    The problem: it’s just so easy to be passive, and consume “information”. We’re all guilty — distracted, reactive to the fresh meat offered. Thanks for the reminder for us all. Knowing this, we can be understanding and supportive of confused or misinformed families. More importantly, we can be corrective of dangerous or risky practices.

    “Seek First to Understand, Then to be Understood.”