Human Mother-Infant Breastsleeping slides

Setting the stage: Human MotherInfant Breastsleeping (Part 1)
James J. Mckenna, Ph.D
Does A Safe Infant Sleep Environment
Look Like?”
www.nichd.nih.gov/publications/pubs/Documents/Safe_Sleep_Environment_English_2013.pdf
What exactly are we talking about here?
Its more than you realize.
We are talking about who has the authority and right to make decisions about
where your infant sleeps. It’s a relational issue, a personal issue as well as a
matter of health and well being.
The AAP and NICHD is to eradicate an evolved set of human emotionally
based, appropriate responses to infants which are basic human proclivities, a
set of behaviors which define us as human.
To do so they are controlling what is talked about, the discourse, to limit it to
simply whether to bedshare or not. And in so doing so they use a limited and
select set of findings to justify it, ignoring and dismissing and all other lines of
evidence which challenge its veracity and accuracy.
The fundamental unit: mothers sleeping next to their babies
breastfeeding throughout the night representing humankinds
oldest and most successful
sleep and feeding arrangement
Dr. Sarah Blaffer Hrdy and newborn daughter, Katrinka, 1976
Can Human Instinct and Appropriate Parental Inclinations Be Expunged,
Suppressed or Eradicated? More Importantly, Should They? IS
criminalizing bedsharing on the agenda?
Unacceptable: “No Exceptions”
But, by what account and
whose authority?
And this is what public health agencies spend money
on: Cosleeping Tombstone (for headboard)
City of Milwaukee: Anti- bedsharing Campaign.
Anne Benton: “Bedsharing is dangerous…as
far as we are concerned there is no debate…”
What does this say both about our culture and informed
choice?
Who followed up with…Mothers Body being
Depicted as No More Protective That An Inert
Metal Cleaver?
The cleaver
represents
the mother
sleeping
next to her
infant
Who designed
such an
offensive
poster…
Alone, back, crib……??
A,B,C.s of “Safe Infant
Sleep?”
“NO
EXCEPTIONS”
Baltimore Anti-bedsharing Campaign.
What was this mother told? What actually happened? “Alone” Crib”? “No exceptions”?
“No exceptions”? Who
is this poster talking to? By what
rights or authority do these civil-county personnel
make this declaration and such an insulting remark?
The American Academy of Pediatric and NICHD’s
“safe to sleep campaign” aims to eradicate
bedsharing?
Will this seven person committee succeed?
since babies do not get cultural memos and are contact
seekers, especially babies,
and mothers and fathers are biologically designed to
respond to their infant’s needs, and breastfeeding and
cosleeping are functionally interdependent,
AND there is absolutely no consensus…
‘(it is highly unlikely and for all good reasons)
WAS THERE AN ALTERNATIVE? OF COURSE.
A more efficacious set of recommendations is needed, to
resonate with parental experiences and emotions
A best public health strategy regarding bedsharing..?
Why not begin by asking those most effected.
•
OBJECTIVE: To understand parents' motivations for bed sharing with their infants
aged 1-6 months, their beliefs about safety concerns, and their attitudes about bedsharing advice.
•
METHODS: Researchers conducted 4 focus groups with primary caregivers of infants
ages 1-6 months who regularly shared beds with their infants.
•
Recruited participants from an inner-city primary care center in Pittsburgh, serving
primarily African American families who received medical assistance.
•
Chianese J, Ploof D, Trovato C, Chang JCInner-city caregivers' perspectives on bed sharing with their infantsAcad
Pediatr. 2009 Jan-Feb;9(1):26-32 Department of Pediatrics, University of Pittsburgh School of Medicine,
Pittsburgh, PA 15213, USA.
Conclusion..Consistent with predictions the
emerge when human biology and not a priori
ideologies are front and center.
• “Parents' motivation to bed share outweighed the
concerns and the warnings of others. An understanding
of parents' perspectives on bed sharing should inform
counseling to promote safe sleeping practices.”
Which means what?
• Harm reduction strategies (as opposed to negative
message saturation) are needed;
• The approach teaches safer infant sleep across all
environments meaning it is ethically and morally
appropriate especially since sleep environments
are fluid.
• Most babies do a little of everything: cosleep,
bedshare and sleep alone. In fact the majority of
American babies bedshare, intermittently;
Who bedshares?
How many?
How difficult is it to know?
But first…Where does your baby sleep?
(ooh, that’s a hard one!)
Ball (1999) found that she would have missed 40% of parents who
bedshare regularly had she not probed and/or re-phrased the
questions about 3 times!
1. Parents respond with answers reflecting where the infant is
supposed to sleep, and not where the baby actually sleeps;
2. Parents respond with answers reflecting where the infant
begins the night but not with answers as to where the baby finishes
the night as it is relocated often after the first feed;
3. Parents would rather lie than invite criticism/censure or have
to defend themselves;
(McKenna and Volpe, 2007, Infant Behavior and Development)
What Does Co-sleeping Look Like?
• Keep in mind that there are as many ways to
cosleep as there are cultures practicing it…
born to cosleep
This is what
life looks like,
a little messy
but a starting
point for
learning about
what parents
do, how they
live with their
infants and
children
From: “The
Science of Shared
Sleep.” Mothering
Magazine (2009)
Lee T. Gettler and
James J. McKenna
Home Studies (Dr.Helen Ball) Durham, England
What Does Human Co-sleeping Look Like?
Diversity of co-sleeping
In all it’s forms….
Koala
Maori, New Zealand
napping desert Aborigine
recliner co-sleeping (unsafe)
Unsafe Bedsharing Occurs Under A Variety
of Social and Structural Conditions
Fluffy Beds, Infant Alone
Overcrowded
Real Care vs. Perception of Care
(Ideal vs. Practice)
• Mother alert to SIDS
safety, places infant on
pillow face down.
• 47% (n=102) of young
teen moms do not
follow what they
previously described
claim is “safe sleep”
procedures
Normative Nighttime Behavior
• Babies can’t seem
to get too close…
Recliners not so good..a
threat to breastfeeding
mothers actually…
Variations of Safe/Unsafe Sleep Practices
Infra-red Video Studies: Crib-Solitary and
Bedsharing ( HD 39456-01 )
Examples:
1.Solitary-crib baby placed
prone, face down;
2. Neck-wrap, head covering,
pillow, solitary, crib baby;
3.Bottle-feed bedshare between
pillow, teen mom ,lack of
maternal response;
4.Breast feeding mothers, high
level of responsivity to infant;
To be fair…Solitary Sleep
And breastsleeping means what?
• In the absence of all know hazardous factors…
Breastsleeping refers to a sober breastfeeding
mother sleeping and feeding along side and in
relationship to her infant on the same surface.
And Why Do We Need It?
Because of the way breastfeeding inclines mothers
to bedshare…changing infant and maternal
physiology and behavior in potential adaptive ways..
Assuring back sleeping, safer body orientations,
safer sleep-wake architecture, enhancing milk
production, more efficient metabolism,enhancing
sleep, increasing feeding frequency, changing
mother’s hormonal status, essentially becoming
one and the same, an integrated adaptive system,
(not two) maximizing infant safety.
Introducing new term: Breastsleeping: to dramatize biological and behavioral
differences between bottle feeding bedsharing and breastfeeding/bedsharing. A new
discourse!
All studies confirm that bedsharing increases breast
feeding frequency and duration (below..McKenna et al
1997, see also Ball 2003, Baddock 2006, Young 1999)
From: McKenna et al. Pediatrics 1997
“Bedsharing Promotes Breastfeeding”
Breastfeeding Intervals
Reduced By Co-sleeping
Fig. 5 Mean interval between breastfeeds (with SE) for routine solitary
sleepers (while sleeping separately, n = 16) and routine bedsharers (while
bedsharing, n = 20), averaged over all three laboratory nights. Statistical
trend towards between group difference, ^P < 0.10. LT Gettler and JJ
McKenna Am J Phys Anthropol. 2011 March; 144(3): 454–462.
Breastfeeding
frequencies double or
triple while cosleeping
Fig. 4 Mean number of breastfeeds per night (with SE) for routine
solitary sleepers (while sleeping separately, n = 16) and routine
bedsharers (while bedsharing, n = 20), averaged over all three
laboratory nights. Significant between group difference, **P < 0.01.
LT Gettler and JJ McKenna Am J Phys Anthropol. 2011 March; 144(3):
454–462.
RB First BN
4
2
1
0
1
2
3
4
5
6
7
8
9
10
# of feeds
RS First SN
4
3
# of infants
# of infants
3
2
1
0
1
2
3
4
5
6
# of feeds
7
8
9
10
H.L. Ball (2003) Breastfeeding, Bed-Sharing, and Infant Sleep. BIRTH 30:3
Does all that breastfeeding, or
breastfeeding at all, really matter that
much?
Yes, it really does, to both the infant
and mother…
Breast Feeding Matters In All Areas Of
Infant Mortality Especially Effecting
African Americans
• “Breastfed infants are 80% less likely to die before
age 1 year than those who never breast fed, even
controlling for low birthweight”;
– For every 100 deaths in the formula-fed group, there were
20 deaths in the breast fed group
– Using breast feeding as the normative behavior (20 deaths
in the first year) the formula group with 100 deaths, had five
times as many deaths or a 500% increase in mortality..
– Forste et al 2001:108 291-296Pediatrics
Forste et al. 2001
“Analysis of infant mortality indicated that breast
feeding accounts for race difference in infant
mortality in the United States at least as well as low
birth weight does”
Pediatrics 2001;108:291-296
Did I mention breastfeeding, breastfeeding, breastfeed
makes infant sleep safer?
Breastfeeding increased
protection against SIDS!!
“Infants who are formula fed are twice as likely to die of SIDS than breastfed
infants.”
Case control study of 333 cases of SIDS matched against 998 age -matched
controls in Germany, from 1998-2001
Vennemann MM, Bajanowski T, Jorch G, Mitchell EA. Does Breastfeeding reduce the Risk of Sudden Infant
Death Syndrome?” Pediatrics Vol.123, March 2009, pp e406-410
Also…bedsharing makes both mothers and babies happy..is emptionally reassuring..contributes to women
validating their role, and attaching in way permitting parents to enjoy their infants…
Breastsleeping Part 2…..Setting the stage
It would appear that….mothers are “value
added” ..and not an added threat, or a
natural pathology if sleeping on the same
surface with their infant when appropriate
precuations are taken
Consider how we know…from studies of
infants and parents from a human
biological perspective
In other words….
Does the evolution of infants and
parents support the legitimacy of
breastsleeping ?
Lest take a look….
Let’s look at BABIES
Our babies are cute and fat for a reason!
(9 to 12 % fat)
Look out! contact-seeker
aboard
“What’s not to love
about me..You’ll do
my bidding, won’t
ya?”
Except when they are not….
For example…What exactly are the careeliciting characteristics i.e. that evokes
the “cute response”?
1.
2.
3.
4.
5.
6.
7.
Bigger heads than predicted by body size; long trajectory
of brain growth..
Lack of hair, or mature hair, baldness?
Bigger eyes (and ears) relatively, positioned lower in
middle of face,
Locomotor awkwardness (wobbling)
Chubby cheeks, rounded (soft) curves;
High pitched voice, soft voice; soft skin..
Olfactory cues? How babies smell
Cute Response?
Making babies
irrisistible
WE feel good when watching and
engaging with babies
Dopamine reward system
kicks in…..
Oxytocin in Mothers, Fathers, and Singles
400
Plasma Oxytocin, pM
Male
350
Female
300
250
200
Singles
Second Month
Sixth
Parents
Courtesy of Feldman et al.
Month
Do partnering and fatherhood cause T
to decline? Fathering in the Philipines
Gettler et al 2011ΔT (2009T – 2005T) regressed on change in P/fatherhood.
•Models adjusted for psychosocial stress and sleep quality.
PNAS
AM T
PM T
(N=839 men)
Gettler et al., 2011
*** p < 0.001
Dad’s evolved a
paternal biology!
2012 Gettler LT, McKenna JJ,
Agustin SS, McDade TW, Kuzawa
CW. (2012)
“Does cosleeping contribute to
lower testosterone levels in
fathers? Evidence from the
Philippines.” Plos One 7:9; e41559
Yes, it does, reflecting a response
designed to maximize male
sensitivity to needs of their babies
T also lower among cosleeping fathers
120
106.1
98.8
PM T (pg/mL)
100
85.5 *
80
60
40
20
0
Solitary
sleepers
Roomsharers Same surface
cosleepers
< 0.05
•AdGettler , McKenna et al (2011)* pPlos
One
Gettler et al., 2012
Is T lower among fathers providing
childcare?
Gettler
al.2012 care.
2009 T regressed on self-reported involvement in
dailyetphysical
•Adjusted for psychosocial stress, sleep quality, and number of children.
* p < 0.05
Gettler et al., 2011
3-day separation:
induces physiological
changes (immune,
system, heart rate,
sleep, cortisol, loss of body
temperature..
anaclitic
depression:
•hyperactivity
•conservationwithdrawal;
•death or recovery
Breathing mechanical Teddy Bear!
(reduces infant apneas by 60%)
(Evelyn Thoman 1985)
Encephalization (increasing brain size) came in
conflict with structural constraints imposed by the
bipedal pelvis leading to higher maternal metabolic
costs requiring earlier births…
Human (hominini) ancestors intensified this micro-environment:
• 4-6 million years ago…the shift from quadrapedalism to bipedalism by an extinct
arboreal primate ancestor required the co-evolution of a suite of what was to
become social and biological changes that came to define our species
Enter…human biology…
• The human
“obstetrical
dilemma”;
• Human Fetal Head
Size Exceeds
Outlet Dimensions
With Emergence of
Bipedalism
Percentage of Adult Brain Size:
Chimpanzee Infant Human Infant
At Birth
3 months
6
9
1 year
2
4
8-9
45
50
60
65
70
75
85
100
25
35
45
50
60
70
80
95
*(100% at 14-17 years)
“For species such as primates, the
mother IS the environment.”
Sarah Blaffer Hrdy, Mother Nature (1999)
Nothing an infant can or cannot do makes sense, except in
light of mother’s body
Babies Celebrated, Beatrice Fontanel and Claire D’Harcourt, © 1998 Harry N. Abrams, Inc.
Biology of Mother’s Milk Predicts
Mothering Behavior
• Feed and Leave
Species
– (Ungulates)
• Contact, Co-sleeping,
And Carry Species
– (Primates—Humans)
• High fat
• High protein
• Low carbohydrate
• Low fat
• Low protein
• High carbohydrate
• High calorie = long
feeding interval;
• Low calorie = short
feeding interval;
(carried infants cry in mothers absence
(to avoid predators nested infants do not
defecate or cry in mother’s absence)
and defecate spontaneously)
The human
adaptation:
human babies
need to be fed
and in
contact..quite
continuously..
Balinese
Mom
and
Baby:
the dyad
is the
unit!
Why do we need this concept?
• The AAP has put themselves and parents (and
lactation consultants) around the world in
untenable positions;
– Advocating six months to a year of breastfeeding and
taking away from them the best way they can achieve
it, by bedsharing;
– Forcing lactation consultants to remain silent and to
say nothing about safe bedsharing, causing them to
face moral-ethical dilemmas preventing them from
teaching what they know about safer bedsharing, with
their jobs on the line if they do;
Why do we need this concept?
• Because breastsleeping represents a suite of behaviors that are
biologically appropriate and predictable and inherently beneficial to
mother and infants alike, and millions of mothers in the western world are
now practicing breastsleeping and need support;
• Because “safe infant sleep campaigns” and epidemiological studies need
to stop reducing any and all bedsharing to the same overall risk, collapsing
all forms of same surface co-sleeping into one unacceptably unsafe
category;
• Because the science of pediatric sleep must move beyond thinking that
measurements derived from the solitary, bottle fed infants represents
human-wide normative data..the gold standard…
• Because we will never discover how to arrange the safest bedsharing
environment unless we explore it and recognize that breastfeeding has
changed things permanently requiring more objective scientific research
focusing on the extraordinary physiological and psychological benefits that
can accrue to mother sand infants who breastsleep;
What do we have such
discord/disagreement on the
bedsharing issue?
• Because bedsharing is not really a discrete variable at all, but is
composed of many different intersecting variables that determine
outcomes;
• Because of evolved human emotions, both the infants, and parents
instinctually –biologically based continue to find expression
regardless of whether or not the environment is appropriate;
• Because the science of infant sleep got started on the wrong foot:
social ideologies and values were used to make a priori fallacious
assumptions about normal , helthy infant sleep and how to study it
—driven by ideas about who we want babies to become and how
to get them there…paradigms are now in conflict;
• From the beginning the scientific question should have been, not is
it safe to sleep with your baby, but is it safe not to….
• Because external authorities have gone to far in trying to
appropriate decision making a out social relational matters..
Breastsleeping vs.bottle feeding
bedsharing:
• Breastsleeping:
• -avoids prone sleep
Mothers body arched around infant, mostly face-to face;
– Lighter stage 1 -2 sleep; less deep sleep, stage 3-4
– More sleep stage changes;
– More simultaneous activity time;
– More arousals (transient and epochal)
– More breastfeds longer durations of breasfeedin over months g
– -great sensitivity to partner induced arousals;_
– More stage shifts;
– More inspections, monitoring, visual checking
– More sleep, less infant crying ;
– Higher body temperature due to more arousals
– Sources: McKenna et al 2007; Ball 2003
In other words…
• “There is no such thing as infant sleep, there is
no such thing as breastfeeding, there is only
breastsleeping” JJ McKenna and LTGettler
• Only one fully integrated adaptive system, i.e.
breastsleeping!
• in press Acta Paediatrica
What Makes Bedsharing i.e. Breastsleeping Safer ?
When is co-sleeping (any kind) more risky?
An Evidence Based Perspective on SIDS and SUID
Don’t sleep with your baby or put the baby down in an
adult bed. The only safe place for a baby to sleep is in a
crib that meets current safety standards and has a firm
tight-fitting mattress.”
Ann Brown September 29, 1999 to US Media Press
Conference.
or
“There is no such thing as a baby, there is a baby and
someone” D.Winnecott
?
Factors/Processes Determining Where Baby
Really Sleeps?
Cultural-Historical
least relevant
Scientific
Public
Health
Where babies
actually sleep is
determined by…
Infant and Parental
Biology Including
Feeding Method
Family
including economic status
most relevant
References:
Ball 2007; Baddock et al.2007; McCoy et al. 2007; McKenna and Volpe 2006
What Is Co-sleeping?
“When my two lovely
daughters are sleeping at
the same time”
Robert Hahn, Ph.D.
(Center for Disease Control )
Bobby Bowdin….Florida State
University Head Football Coach
“I slept in the same bed with my
grand daddy..and then in the
same bed with my four cousins..I
never slept alone t’il I got
married”!
South Bend Tribune.. 9/29/2000
Safe infant sleep begins with
• A smokeless gestation! A smokeless, postgestation!
• A non smoke filled environment (postnatally);
• Breastsleeping (which entails supine
sleep)
– The absence of all known hazardous factors
especially such as drugs, alcohol, parental
indifference, and knowledge of constructing a
maximally safe bedsharing environment…
Home Studies (Dr.Helen Ball) Durham, England
What Does Human Co-sleeping Look Like?
Diversity of co-sleeping
In all it’s forms….
Koala
Maori, New Zealand
napping desert Aborigine
recliner co-sleeping (unsafe)
Unsafe Bedsharing Occurs Under A Variety
of Social and Structural Conditions
Fluffy Beds, Infant Alone
Overcrowded
Real Care vs. Perception of Care
(Ideal vs. Practice)
• Mother alert to SIDS
safety, places infant on
pillow face down.
• 47% (n=102) of young
teen moms do not
follow what they
previously described
claim is “safe sleep”
procedures
Normative Nighttime Behavior
• Babies can’t seem
to get too close…
Recliners not so good..a
threat to breastfeeding
mothers actually…
Variations of Safe/Unsafe Sleep Practices
Infra-red Video Studies: Crib-Solitary and
Bedsharing ( HD 39456-01 )
Examples:
1.Solitary-crib baby placed
prone, face down;
2. Neck-wrap, head covering,
pillow, solitary, crib baby;
3.Bottle-feed bedshare between
pillow, teen mom ,lack of
maternal response;
4.Breast feeding mothers, high
level of responsivity to infant;
To be fair…Solitary Sleep
A little epidemiology…
can it support breastsleeping?
CESDI/SUDI research
•
•
•
•
•
•
17 million people in 5 regions of England over 3 years
325 infant deaths, 1300 controls
Prone sleeping position – clear risk
Smoke in the house – clear risk
Couches – clear risk of entrapment
ZERO SIDS deaths among sober, non-smoking co-sleeping,
breastfeeding mothers & babies on safe surfaces
• “There is no evidence that bed sharing is hazardous for infants of
parents who do not smoke”
•
Blair PS, Fleming PJ, Bensley D, Smith I, Bacon C, Taylor E, Berry J, Golding J, Tripp J. Smoking and the sudden
infant death syndrome: results from the 1993-5 case-control study for confidential inquiry into stillbirths and deaths
in infancy. BMJ 1996;313:195-198.
Arnestad: Norway 1984-1998
• Increased risk:
– Smoking during pregnancy
– Maternal disease during pregnancy
– Young maternal age
– Infants who never woke at night
• >50% deaths in prone position
• “We found no risk of SIDS for infants who usually co-slept. The
increase in co-sleeping as a usual mode of sleep in the control
group, over the time period studied, could not be related to changes
in the SIDS rate for the region.”
• Arnestad AM, Andersen A, Vege Å, Rognum TO. Changes in the
epidemiological pattern of sudden infant death syndrome in
southeast Norway, 1984–1998: implications for future prevention
and research. Arch Dis Child 2001;85:108–115).
Chicago Infant Mortality Study, 19931996
• 260 deaths, matched controls; 75% black
• High risk: prone position, soft surface, pillow use, covers over
head/face, Sick in the 2 days prior to death
• “Bedsharing was only a risk when infant was sleeping with
people other than the parents. Because there were few
mother-father bed sharers, the findings were driven by the
mother-infant dyad. These results are reassuring and
consistent with laboratory studies demonstrating that more
maternal inspections, more infant arousals, and less deep
sleep among infants may occur when mothers and infants
sleep together routinely.”
• Hauck FR, Herman SM, Donovan M et al. Sleep environment
and the risk of Sudden Infant Death Syndrome in an urban
population: the Chicago Infant Mortality Study. Pediatrics
2003;111(5):1207-1214.
BLAIR ET AL 2014 Only in the presence of known
hazards is bedsharing a risk!
• Parents of 400 SIDS infants and 1386 controls
provided information from five English health
regions between 1993–6 (population: 17.7 million)
and one of these regions between 2003–6
(population:4.9 million).
• Bed-Sharing in the Absence of Hazardous Circumstances: Is There a Risk of
Sudden Infant Death Syndrome? An Analysis from Two Case-Control Studies
Conducted in the UK
Peter S. Blair mail, Peter Sidebotham, Anna Pease, Peter J. Fleming
Published: September 19, 2014
(Plos One)
Bed-Sharing in the Absence of Hazardous Circumstances: Is There a Risk of Sudden Infant Death Syndrome? An Analysis
from Two Case-Control Studies Conducted in the UK
Peter S. Blair mail,
Peter Sidebotham,
Anna Pease,
Peter J. Fleming
Published: September 19, 2014
DOI: 10.1371/journal.pone.0107799
(Plos One)
• The multivariable risk associated with bed-sharing
in the absence of these hazards was not
significant overall (OR = 1.1 [95% CI: 0.6–2.0]),
• for infants less than 3 months old (OR = 1.6 [95%
CI: 0.96–2.7]), and was in the direction of
protection for older infants (OR = 0.1 [95% CI:
0.01–0.5]).
Bedsharing is protective
• “Conversely, bed-sharing in the absence of
other hazards was significantly protective for
infants older than 3 months; a finding that
was unexpected and has not been previously
reported to our knowledge.”
• (Blair et al. 2014)
How do mothers and babies effect
each other behaviorally and
physiologically and, especially, their
breastfeeding behavior when
bedsharing?
Do the Laboratory Studies support
breastsleeping?
A little research on the biology and
behavior of breastsleeping mother
baby pairs
Lounge-TV Room- Kitchenette
Baby Room
Infra Red and Audio
Revolving Camera/CloseUp Capacities
Parental Bedroom With Infra Red Lights, Audio
Recording Devices And Cameras Embedded in Ceiling
Bathroom with Shower
Recording-Observing Station
Observing and Physiologically Recording Babies And
Mothers Sleeping and Breastfeeding (Together and
Apart)
Polysomnagrahic studies of
bedsharing and solitary
sleeping mother and infants
over three successive nights
in sleep laboratory with
infra red filming
Photo :Max Aguillero-Hellwig
Discover Magazine 1992
Mother-infant Simultaneous Polysomnography
37 Routinely Bedsharing (RB)or
Routine Solitary Sleeping (RS) MotherInfant Pairs, Rotating between
bedsharing night (BN) and solitary
sleeping night (SN) for three
Consecutive Nights in Sleep Lab: Two
nights of their normal routine one
night is experimental night
Infants 6 to 14 weeks of age;
Exclusively breasfeeding
Observing and Physiologically Recording Babies
And Mothers Sleeping and Breastfeeding
(Together and Apart)
•
•
•
•
•
•
•
•
•
•
•
•
Photo :Max Aguillero-Hellwig
Discover Magazine 1992
Mother-infant Simultaneous Polysomnography
•
Lighter sleep (less stage3-4, more satge1-2)
More Diverse Sleep (greater number of stage
changes)
Longer Sleep In Minutes
Breastfeeding Doubles or Triples
Increased Interactions, Vocalizations,
Movements
Physiological Unpredictability For Both
Sleep Positions and Mutual Orientations
Change
More transient and epochal mutual arousals
or partner -induced arousals
Increased Sleep-Wake Stage Synchrony
Less crying, More Maternal Interventions
More Heart Rate and Breathing Variability
Sub-normal body Temperatures in Solitary
Sleeping Infants
Shift in average duration, frequency, and
distribution of obstructive and central apneas
per stage of sleep
Contrast solitary infant sleep with this..long term
multi- sensory stimuli and affection (over time)
What does breastsleeping look like, what is different about it?
Sleep position: the safer back position
is adopted as a part of breastsleeping
without instruction
In our breastsleeping studies and those of Helen Ball not one mother
placed her position in the prone position (it just doesn’t work)
Many place babies in the side position, but the infants do not turn (or
fall) onto their stomachs because of the precise kind of side position
they assume, and motherspresence..its more looking toward her rather
than sleeping on their shoulders
Any other relevant changes increasing
the adaptive value of breastsleeping?
Co-sleeping in the form of Bedsharing:
Increased protection for arousal deficient
infants?
Over 8 hours of sleep approximately 12% of the
time mothers and infants are doing the exact
same thing at the same time, because the other is
doing it.
Body- Facial Orientations Amongst 24
Solitary Sleeping and Bedsharing
Mothers and Infants
Fig. 1 Routine Solitary Sleepers on
their Bedsharing Night
Fig. 3 Routine Solitary
Sleepers on
their Solitary Night
100
Infant Facing
Mother
80
% of
Night
60
Infant Facing
Away
40
20
% of
Night
100
80
60
40
20
0
1 2 3
0
1
2
3
4
Mother-Infant Pair
Fig. 2 Routine Bedsharers
on their
Bedsharing Night
% of
Night
100
90
80
70
60
50
40
30
20
10
0
Infant Facing
Mother
Infant Facing
Away
1
2
3
4
5
6
7
Mother-Infant Pair
4
5
MotherInfant
5
Infant
Facing Left
Infant
Facing Up
Infant
Facing Right
Fig. 4 Routine Bedsharers on
their Solitary Night
100
80
% of 60
Night 40
20
0
1 2 3 4 5 6 7
Mother-Infant
Pairs
Research funded by National Institutes of Child
Health and Human Development RO1 27482
Infant Facing
Left
Infant Facing
Up
Infant Facing
Right
EFFECTS OF BEDSHARING ON INFANT SLEEP
Bedsharing Night vs. Solitary Night
Total Wakefulness During Sleep
14%
0.008
Sleep Stage %’s (of TST)
% Stage 3-4
4%
<0.001
% Stage 1-2
3%
0.036
% Stage REM
--Mean Stage Durations
Stage 3-4
16%
0.027
Stage 1-2
16%
0.005
Stage REM
26%
0.001
Waking
--Arousal Frequency (/hr)
Stage 3-4
EWs
38%
0.014
TAs
--*
-Stage 1-2
EWs
--TAs
--Stage REM
EWs
35%
p<0.001
TAs
--Table reflects results of 2x2 repeated measures ANOVA (laboratory sleeping condition x routine sleeping
condition). Entries show significant (p<0.05) effects of laboratory condition (BN vs SN). (Mosko et al 1996)
EFFECTS OF BEDSHARING ON MATERNAL SLEEP
Bedsharing Night vs Solitary Night p value
Total Sleep Time (TST)
--Total Wakefulness During Sleep
--Sleep Stage %’s (of TST)
% Stage 3-4
4%
0.001
% Stage 1-2
4%
0.014
% Stage REM
--Mean Stage Durations
Stage 3-4
25%
0.002
Stage 1-2
30%
<0.001
Stage REM
--Waking
62%
<0.001
Arousal Frequency (/hr)
Stage 3-4
EWs
67%
<0.001
TAs
--Stage 1-2
EWs
37%
<0.001
TAs
28%
<0.001
Stage REM
EWs
--TAs
--Table reflects results of 2x2 repeated measures ANOVA (laboratory sleeping condition x routine sleeping
condition).
(*see Mosko, Richard, McKenna 1997 Sleep 20 (2) 142-150)
Baby >
Mom >
Figure Synchronous breathing pauses of cosleeping
mother-infant pairs.
McKenna, JJ and Mosko, S. (1990). Human Nature 1 (3).
Mom
wake
Wake
Baby
Mom
Baby
Mom
sleep
Baby
Mom
Baby
Mom
Baby
All-night sleep-wake histograms for five (A-E) cosleeping
pairs. Mosko, McKenna et al (1993). Journal of Behavioral Medicine 16
(6). Note the synchronicty of awakenings
During co-sleeping maternal-infant behavior and
physiology becomes entwined…by way of synchronous
partner induced arousals and communication
• 60 % of all maternal arousals during
bedsharing are explained by the infant having
aroused first, within +/- 2 seconds while..
40% of all infant arousals during bedsharing
are explained by the mother having aroused
within +/- 2 seconds
•
•
1996 Mosko, S, Richard, C and McKenna, J; Drummond, S, Infant Sleep Architecture During Bedsharing and Possible
Implications for SIDS. Sleep 19:677-684
1997 Mosko, S., Richard, C., McKenna, J., Infant Arousals in the Bedsharing Environment: Implications for Infant
Sleep Development and SIDS. Pediatrics 100 (2) 841-849
1997 McKenna J, Mosko S, and Richard, C, Bedsharing Promotes Breast Feeding. Pediatrics 100 (2) 214-219
American Academy Of Pediatrics
New SIDS Prevention
Recommendations
(I served as an ad hoc expert member)
***proximate but separate sleep for baby;
i.e. parent-infant co-sleeping!
no side position sleeping;
cuddling but no bedsharing
pacifers for sleeping infants, after breast feeding is
established;
more holding and carrying
(but no bedsharing, described as hazardous)
How and why did all of this happen?
SUDI/SIDS :
benefits-risks continuum
Two distinct bedsharing subgroups
Elected
Breast feeding
Non-smokers
Stiff mattress
Less Risk (protective?)
Non-elected
Bottle fed
Smokers
Risk ‘factors”
More Risk
Double standard of “cause” “diagnosis” and
“remedy” of crib vs. co-sleeping deaths must be
challenged
• Infant dies sleeping
prone in crib
– Cause: sleeping
prone…
– Diagnosis: SIDS
– Remedy: turn infants
supine, educate and
inform
• Infant dies sleeping prone
in bed with parents
– Cause: bedsharing
– Diagnosis: Asphyxiation by
overlay
– Remedy: eliminate all
bedsharing, retract safety
information on safer
bedsharing, condemn the
practice;
• A tragic problem to be • A deadly practice to
eliminate
solved
“Evidence is not a neutral concept, and
the production of evidence is politically
laden with various groups standing to
gain or lose from the adoption of their
particular “take’ on evidence” (Homer
and Broom 2012” 170).
What exactly is evidence based
medicine, according to its “father”
“At the most basic level evidencebased practice is the integration of
best research with clinical expertise,
patient values, and available
resources” (Institute of Medicine
2001).
What IS Evidence Based medicine? David Sackett, William
Rosenberg J A Muir Gray R Brian Haynes W Scott Richardson
And from the father of evidence-based medicine, Davis Sacket:
BMJ VOLUME 312 13, AJANuARY1996
Pg. 72
Evidence based medicine is not "cookbook" medicine. Because it requires a
bottom up approach that integrates the best external
evidence with individual clinical expertise and patients' choice, it cannot result in
slavish, cookbook approaches to individual patient care. External clinical evidence can
inform, but can never replace ,individual clinical expertise ,and it is this expert that
decides whether the external evidence applies to the individual patient at all and,if
so,how it should be integrated into a clinical decision. Similarly, any external guideline
must be integrated with individual clinical expertise in deciding whether and how it
matches the patient's clinical state, predicament, and preferences, and thus whether it
should be applied. Clinicians who fear top down cookbooks will find the advocates of
evidence based medicine joining to man the barricades.
The cosleeping
debate: two
faces, two
“truths” in
one..
do you see
them.. ( a
young and
and old
woman, in
one face?)
Controlling the discourse..what is talked about as regards the
causes of bedsharing risks and what to do about them…This is
social judgment and social privilege, not science!
Following the tragic death of a bedsharing infant whose
teen mother drank 18 cans of beer before retiring to
bed with her infant,
Marian Sokol (then) President of SIDS Alliance writes to
the Editor of the San Antonio Tribune, 2000
• “Sharing an adult bed with an infant is not cool,
nor is it an indicator of educated parenting.”
• ??
What explains this way of thinking ?
A little cultural history..,
out of what historical context did
present ways of thinking emerge
Western Values favoring: individualism autonomy, specialness of conjugal pair,
notion of romantic love, sexual privacy, adoption of bottle feeding, scientific bias
and ignorance, given our culture…the solitary sleeping infant remains the “gold
standard” for studying normal , healthy infant sleep? Rise of experts? Loss of
instictual knowledge?
Limitations…Sleep Science From An
Anthropological Point of View
(there is no theory around which to interpret clinical events or
research results, a “snapshot- in- time” approach to infants )
non-evolutionary;
(a)theoretical..the infant is defined by and suspended in contemporary
time and space and has no continuity to its unique evolutionary past
scientific reductionism? Good?
NO! Not Suited for understanding the role of physiological regulatory effects
Limitations of Western Pediatric SIDS And
Sleep Research From An Anthropological
Point of View
Are adult- centric and ethnocentric..the “fallacy” of western medical
normalcy..according to George Williams…
not inclusive, holistic, no cross-cultural studies of human infants
Western “medical authoritative knowledge..” is hierarchical..it dismisses
parental knowledge which is subordinated to “official” knowledge dispensed
my “medical authorities” or civil authorities (Bridget Jordan)
Parent -infant co-sleeping is biologically and
psychologically expectable, if not inevitable?
Helping and Supporting Breastsleeping
Mothers, Fathers and Babies: What To Say?
How Do We Explain Inappropriate Rhetoric
Concerning ‘Safe Infant Sleep’
(If You Missed
This Mornings Lectures 
James J. McKenna, Ph.D
University of Notre Dame
Breastfeeding: Baby’s Natural Choice Conference
August 26, 2015
“There is no such thing as a baby, there is a baby
and someone”
D.Winnecott
An anthropological observation:
Until recent historic periods in the western
industrialized world
• ….no human (primate) ancestral or modern infant ever slept
separated from its caregiver…
– Most human infants know only social proximity and/or continuous
contact, with someone
– And nobody ever asked: where will my baby sleep, how will my
baby feed, how will I lay my baby down for sleep (most still
don’t)…so inevitable was breastfeeding with back sleeping and
cosleeping..
– The problem with asking such questions is that you have to
answer them, and, thus, the possibility exists , that without any
data or scientific investigations, your answer can be wrong. And
we got it wrong!
With Respect To Infant Sleep
Western Parents Remain …
the most exhausted
the least satisfied
the most obsessed
the most “well read”
the most opinionated
the most judgmental
Because western traditional models of infant
sleep place infants (and parents) in conflict with
their evolved emotions and best interests…
And, yet, guess what determines more than
anything where a baby sleeps?
Cultural-Historical
least relevant
Scientific
Public
Health
Where babies
actually sleep is
determined by…
Infant and Parental
Biology Including
Feeding Method
Family
including economic status
most relevant
References:
Ball 2007; Baddock et al.2007; McCoy et al. 2007; McKenna and Volpe 2006
Estimates of how many parents bedshare vary
between 42 to 77% of new parents in the USA (it is
common)
• 3,952 841 Total US
babies born 2012 CDC
National Vital Statistics Report
#9 Martin et al
• If 22% =869, 625, 002
bedsharers..
• 42 % =1,660,193
bedsharing babies;
• 50% =1,976,420
• 77% new mothers
initiate breastfeeding in
the USA, 70-80 percent
of whom are known to
bedshare suggesting as
many as 3,043,687 are
at least intermittently
bedsharing;
• Do others know where your baby
sleeps?
• Please don’t whisper it, or tell
only your closet friends.
• Scream it out!! Tell your physician.
• Why data on bedsharing rates is
suspect? Need to ask the question
in several ways. In any event,
bedsharing is highly likely to be
under counted no matter what.
Courtesy of
Kathy KendallTackett
This is the fundamental inseparable biological unit… mother
and infant and the fundamental sleep and feeding
arrangement… humankinds oldest and most successful
Recall the critical significance of mother (and others) as a regulator of infant physiology
And this is what we get
Unacceptable: “No Exceptions”
But, by what account and
whose authority?
But this is what we hear about this image and
arrangement…Present medical-cultural milieu:
warn mothers about what their bodies do TO their infants,
rather than what they do FOR their infants
•
“Babies Sleep Safest Alone.”
–
New York State Public Health Campaign
•
“For you to rest easy, your baby must rest alone.”
–
Philadelphia Public Health Campaign.
•
“We
know the value of holding your child, cuddling your
child, loving your child. But if you take the baby to bed
with you and fall asleep, you are committing a
potentially lethal act”
– Deanne Tilton Durfee, Director of the Los Angeles
County Inter-Agency Council on Child Abuse and
Neglect. Los Angeles Times 4/24/08.
And this is what public health agencies spend money
on: Cosleeping Tombstone (for headboard)
City of Milwaukee: Anti- bedsharing Campaign.
Anne Benton: “Bedsharing is dangerous…as
far as we are concerned there is no debate…”
What does this say both about our culture and informed
choice?
Who followed up with…Mothers Body being
Depicted as No More Protective That An Inert
Metal Cleaver?
The cleaver
represents
the mother
sleeping
next to her
infant
Who designed
such an
offensive
poster…
Alone, back, crib……??
A,B,C.s of “Safe Infant
Sleep?”
“NO
EXCEPTIONS”
Baltimore Anti-bedsharing Campaign.
What was this mother told? What actually happened? “Alone” Crib”? “No exceptions”?
“No exceptions”? Who
is this poster talking to? By what
rights or authority do these civil-county personnel
make this declaration and such an insulting remark?
What explains this way of
western thinking ? out of what
historical context did present
ways of thinking emerge?
A little cultural history…
Western Values favoring individualism, separation, autonomy, specialness of conjugal
pair, original sin, notion of romantic love, adoption of bottle feeding, medical
authoritative knowledge, sexual privacy issues, rise of parenting experts, scientific
parenting, distorted belief systems about infant sleep development and connections
with morality…the’good baby syndrome’
The cultural undermining of western maternal knowledge
and confidence
Benjamin Spock writing to mothers in: Baby Care says…
“You know more than you think you do….
don’t be afraid to trust your common sense. Bringing up
baby won’t be a complicated job if you take it easy, trust
your own instincts, and follow the directions your doctor
gives you!
cited by tina thenevin,1993, mothering and fathering
John Watson…believed no child could get
too little affection
“Never hug and kiss them…..Never let them sit in your
lap. If you must, kiss them once on the forehead when
they say goodnight. Shake hands with them in the
morning. Give them a pat on the head if they have
made and extremely good job of a difficult task”
(Watson, 1928, quoted by Hardyment, 1983, p. 175).
Limitations of Western Pediatric SIDS And
Sleep Research From An Anthropological
Point of View
Are adult- centric and ethnocentric..the “fallacy” of western medical
normalcy..according to George Williams…
not inclusive, holistic, no cross-cultural studies of human infants
Western “medical authoritative knowledge..” is hierarchical..it dismisses
parental knowledge which is subordinated to “official” knowledge dispensed
my “medical authorities” or civil authorities (Bridget Jordan)
Limitations…Sleep Science From An
Anthropological Point of View
(there is no theory around which to interpret clinical events or
research results, a “snapshot- in- time” approach to infants )
non-evolutionary;
(a)theoretical..the infant is defined by and suspended in contemporary
time and space and has no continuity to its unique evolutionary past
scientific reductionism? Good?
NO! Not Suited for understanding the role of physiological regulatory effects
Teach what
this crazy
cartoon
means!
Model #1
snapshot in
time..
What you see is
what you get??
NO!
An
evolutionary
perspective:
babies bring
something
irrepressible
into their life
and
environment..
Model #2 present
babies share in, and
exhibit, continuity
with previous
ancestral infant
forms
Infants are inherent contact
seekers, and negotiate
where they sleep
This perspective is
played out every
night, all over
America
This is what it all
comes back to..our
cultural history..
The western solitary
sleeping infant ,bottlefed,
as normal…disarticulated
from the mother’s body…
an infant in crisis,
biologically…in an
ecologically invalid
environment..
Formula and cow’s milk
made it possible to “Sleep
Like This”
Does A Safe Infant Sleep Environment
Look Like?”
Producing this…
www.nichd.nih.gov/publications/pubs/Documents/Safe_Sleep_Environment_English_2013.pdf
• And this:
• In the wake of local
infant “cosleeping”
deaths, regional health
departments have
translated AAP
Statement into “One
Message”
•
Courtesy of Kathy Kendall-Tackett
Never Bedshare
One problem is that…….culturally favored
child care practices change independent of,
and much faster than,
infant biology….
(ideologies or goals that underlie recommendations
are often historical and ideological in origin but
passed off as, if not confused for, scientific
findings)
Leading to this …Components/Implications
of “medical authoritative knowledge”
 Decision making
hierarchy, distributed-physician at top;
 “The power of
authoritative medical
knowledge is not that it
is correct but that it
counts.” Bridget
Jordan..
 Invalidates other knowledge
systems;
 Woman’s knowledge counts
for nothing-Women must
override instincts as physician
always knows best;
 We are taught not to trust
what our bodies tell us, but
rather trust technology to do it
better; objects but not
persons..speaking of which..
 Recall the child’s book “Good
Night Moon” ?? not a person
in sight! The rabbit appears to
be an orphan..says goodnight
to only inert lifeless objects
And this..Culture Producing Science Producing Culture:
How A Folk Myth Achieved Scientific Validation
#5: To produce
“healthy” infant
sleep, replicate the
test condition
#4: Publish
clinical model
on what
constitutes
desirable,
healthy infant
sleep.
#1: Initial test condition—infant
sleeps alone, is bottle fed, and has
little or no parental contact
“Scientific”
validation of solitary
infant sleep as
“normal” and
“healthy”
#2: Derive
measurements
of infant sleep
under these
conditions
Solitary infant
sleep becomes the
“gold standard”
#3: Repeat measurements across ages,
creating an “infant sleep model”
Current western infant sleep research paradigm:
Prioritizes infant “sleep consolidation” at the expense
of nighttime breastfeeding!
• one-size- must- fit- all approach (dismisses heterogeneity)
• devoid of relational-emotional aspects including unique infant
“intrinsic” factors
–
–
–
–
Infant sleep personality-temperament
How infant articulates with unique needs of parents
Devoid of underlying biology of emotions
Devoid of an evolutionary perspective;
• Current models either ignore altogether the critical relationship between
nighttime breastfeeding and infant sleep;
• or minimize its significance of breastfeeding to infant-maternal health..
seeing anything that threatens early sleep consolidation as negative….too
much breastfeeding is to be avoided or ”dealt with”
What parents must understand is:
The need to re-do (re-think) re-study western
concepts of “healthy” “normal” infant sleep.
Things like:
•
•
Infants rarely have sleep problems, parents do..!
Western parents suffer from a variety of damaging diseases not the least of
which is.. the disease of false and unrealistic expectations..a cultural and
not a biological model of infant’s sleep patterns;
• the disease of confusing their own needs with that of their infants
“best”needs..;
• the “die”model of sleep--the only “good” sleep is an uninterrupted
one;
• that infant sleep behavior correlates with good moral character,
and general future social skills and competencies…in domains
other than sleep;
• the presumption of an adversarial relationship existing between
infants and parents as regards sleep..Consider the book title:
“Winning Bedtime Sleep Battles”..and “Babywise” ;
• If its good fo rbabies to sleep alone, then its only a small step away
from concluding that…good babies do so (showing slippage from a
perceived medical “good” to a perceived “moral good”
Explain To Parents Why Western Parents Are the Most
Exhausted And Disappointed Parents In The World: Babies
do not read cultural memos or wish lists that have nothing
to do with who they are (as babies)
• suffer from the disease of misinformed expectations
• devoid of the “relational” familial factors (where baby sleeps and
feeds as regards parental emotions and goals;)
• devoid of intrinsic (infant) factors (temperament, personality ,
sensitivities);
• categorizes infant’s inability to follow cultural model as…”disease”,
sleep disorder, immaturity, and, thus, infant becomes a “patient”;
• promotes one- size- should- fit- all;
• promotes one sleeping arrangement as a moral issue and gives it a
specific set of inappropriate meanings;
• Taught even before they meet their babies..to be prepared to meet
an adversary and that they must “win the bedtime battle”
By the way…did you know that…
• “Self-soothing” is a recent cultural innovation that offers no
inherent advantage, or acquired skill or benefit to an
infant’s personality, development or psychological strength;
it does not reflect any future skill that will be unavailable to
any infant who fails to self-soothe by some imposed
deadline. It is not a human developmental milestone.
• Dr. Tom Anders simply used it to describe babies that wake
up and “signal” wanting contact or intervention, compared
with infants who wake up and fall back to sleep without
any. He does not like the false implications implied by
professionals as to what they say it means! It has done
nothing but make infants and parents unhappy, in one way
or another…
Remember that biology still is important and is not
subject to a cultural nullification..or to
memos..especially, babies don’t read cultural
memos, and parents care about what babies feel..
“ …There would be little if any difficulty
exchanging a Cro-Magnon and a modern
infant, but great incongruity in making the
same switch amongst adults of both cultures.”
David Barash: The Tortoise and The Hare (1987)
Realize That How One Interprets Infant Sleep
Related Behaviors Depends on Initial
Assumptions As To What is Normal
•
If to the researcher cosleeping/breastfeeding is normative,
appropriate and expectable
(biologically) then..
– Babies accepting separation and
isolation without protesting do so
at their own peril;
– Or--Infants who accept separation
without protesting are
developmentally immature and not
adapted vigorously;
– Infants who “sleep through the
night’ at young ages are “at risk”;
– Infants resting body temperature
while sleeping alone is subnormal;
– Infant night wakings are
advantageous especially when
associated with breastfeeding..
•
If co-sleeping/breastfeeding is not
normative, appropriate and expectable
biologically then..
– Night wakings are a problem to be
eliminated, as are feedings..as soon as
possible;
– Protesting sleep isolation is a
“problem to be solved” a disorder..a
developmental deficiency;
– Infants sleeping through the night
represents adaptation, not a potential
risk I.e. spending sleep time in deep
sleep rather than light sleep;
– Co-sleeping infants experience
hyperthermia;
– Any and every problem associated with
co-sleeping becomes an indictment
against the practice, and proof the
practice should be eliminated rather
than a problem to be solved
Though you would never know it…
Those international organizations who
oppose the AAP recommendation include:
UNICEF, WHO, La Leche League International,
Academy of Breastfeeding Medicine,
International Lactation Consultants Assoc.
Attachment Parenting and research scientists
involved in studies of human development,
anthropology, developmental psychology and
allied disciplines..
Who Exactly Is The Academy of
Pediatrics (the AAP)?
•
•
•
•
•
The recommendations were written primarily by one person in consultation
with a lead SIDS scientist from the National Institutes of Health, and six other
persons on the SIDS and Infant Sleep Committee.
The committee remains a hand-picked insular group, medically trained
scientists and SIDS experts.
Nobody outside the AAP, no scientist from other related fields of interest or
research or viewpoints were part of the decision making. Based ALL on
epidemiological studies exclusively;
The Breastfeeding sub- section of the American Academy of Pediatrics does
not agree nor support the unqualified recommendation against bedsharing for
breastfeeding mothers whose babies are are at extreme low risk.
There is large disagreement within the SIDS research community with no
consensus on this issue, and even more disagreement with the AAP expressed
by various medically trained health professionals, international organizations
(UNICEF, WHO) and research scientists involved in studies of human
development, including SIDS research findings.
Challenge the AAP as Regards Their
Failure to Implement evidence based
medicine? Davis Sackett says…
• Reach consensus before recommendations are put forth;
• Do not rely exclusively on case control studies (epidemiology),
as epi findings are supposed to generate hypothesis
• Respect patient values (it is primary and a beginning point) ;
• Leave room for clinical judgments;
• Respect exceptions to population-based recommendations;
accept importance between clinical judgment and the
experiences and emotions of those for whom the
recommendations are intended;
Sackett DL Stryuss SE, Richardson WS et al Evidence Based Medicine: how to
practice and teach EBM 2nd Edition Edinbugh Churchill Livingstone , 2000
Though you would never know it
• The AAP claims to be fighting the formula
companies, as formula is a risk factor for
SIDS…
• and, yet, they accept sponsorship by those
same companies and AAP physicians present
talks sponsored by formula companies;
What We Can We Do? Think Not What You Want
But What Might Work Best
• Educate , educate, educate in bidirectional ways (EBM);
Respect and Converse at the familial level…share,
discuss in comfortable venues..!
• Use harm reduction strategies..Assume parents
bedshare (they mostly do)
• Begin with the family with human behavior, what people
feel…bottom up…
• Don’t confuse science with social-political ideologies
however well-intentioned ..science will always win;
• Trust families to make good decisions when given all of
the information..not full proof, but compliance will be
increased where there is trust..
Nor would you know this..
• Each of those AAP committee members who wrote those
recommendations could be replaced by researchers with equal
talents, backgrounds, publications, and statuses in the field.
• These replacements would not have supported the sweeping
recommendation against any and all bedsharing, nor would they
support policies that prevent safer bedsharing information from
being shared.
• In fact, it would have been recommended that all parents receive
proactive safety information on bedsharing, but it would be
suggested that only breastsleeping dyads practice it;
• The AAP sub-committee on breastfeeding does not support the
statement on bedsharing produced by the AAP.
born to breastfeed…contact, co-sleeping
engagement
Life, as we
know it…a
visually rich,
ethnographic
study?
From: “The
Science of Shared
Sleep.” Mothering
Magazine (2009)
Lee T. Gettler and
James J. McKenna
Pediatrics…. Oct 18, 2010 ( P.Blair, J. Heron and
P.Fleming: Population-Based Analysis Relationship
Between Bed Sharing and Breastfeeding:
Longitudinal, Population-Based Study
“Given the likely beneficial effects of bed sharing on
breastfeeding rates and duration, risk reduction
messages to prevent sudden infant deaths would be
targeted more appropriately to un- safe infant care
practices such as sleeping on sofas, bed sharing after
the use of alcohol or drugs, or bed sharing by parents
who smoke” (Blair, Heron and Fleming 2010:1125).
DOI: 10.1542/peds.2010-1277 published online Oct 18, 2010; Pediatrics Peter S.
Blair, Jon Heron and Peter J. Fleming
What to insist on in public dialog and be
responsive to misinformation in the media
• Encourage parents to talk openly and freely as to their nighttime
practices, especially if bedsharing; silence promotes the notion of
the ‘exotic’..or that what you are doing is intrinsically wrong;
• Please don’t whisper or tell only your trusted friends that you sleep
with baby;
• Don’t allow someone to dominate discussions against bedsharing;
• Affirm the rights of parents to read evidence on their own and to
come to a decision that is family specific, good for their own babies
and families…
• Remind parents that where their baby sleeps is a decision only
theirs to make..and NO external authorities have rights over them or
their babies as regards sleeping arrangements..it is not a pathology
it has been presented as one, but it is not one.
Recall
this:
Model #1
Zero to One
year old babies.
(Developmental
age alone is all
this physician
needs.)
Model #2
How did human
evolution, the
physician ponders,
influence how this
baby will respond
to what I
recommend?
How One Interprets Infant Sleep Related
Behaviors Depends on Initial Assumptions As
To What is Normal
•
If to the researcher cosleeping/breastfeeding is normative,
appropriate and expectable
(biologically) then..
– Babies accepting separation and
isolation without protesting do so
at their own peril;
– Or--Infants who accept separation
without protesting are
developmentally immature and not
adapted vigorously;
– Infants who “sleep through the
night’ at young ages are “at risk”;
– Infants resting body temperature
while sleeping alone is subnormal;
– Infant night wakings are
advantageous especially when
associated with breastfeeding..
•
If co-sleeping/breastfeeding is not
normative, appropriate and expectable
biologically then..
– Night wakings are a problem to be
eliminated, as are feedings..as soon as
possible;
– Protesting sleep isolation is a
“problem to be solved” a disorder..a
developmental deficiency;
– Infants sleeping through the night
represents adaptation, not a potential
risk I.e. spending sleep time in deep
sleep rather than light sleep;
– Co-sleeping infants experience
hyperthermia;
– Any and every problem associated with
co-sleeping becomes an indictment
against the practice, and proof the
practice should be eliminated rather
than a problem to be solved
Some Critical Beginning
Tid Bits
•
•
•
•
•
•
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Sleep environments are fluid: most infants experience a range of
different sleeping arrangements!
Human infants are contact seekers, their survival depends on it.
Parents are designed biologically to please their infants, meet their
needs, to select what works for them but to exhibit trade-offs,
regarding which risks they can accept. Parents prioritize and
differentiate between risks and do it better oif given all and not delected
information;
Biggest Increases in bedsharing rates have occurred amongst upper
and middle class whites who breastfeed (and their babies have the
highest survival rates) but in all groups bedsharing is increasing despite
ten years of “authorities” arguing against it;
At least 40 percent (Ball et al 1999) of bedsharing parents do not
perceive nor answer that they necessarily bedshare;
Public health strategies that have best chance to work for the
greatest number of persons must be parent-centered not
authoritative nor medically-centered?
Risk-harm reduction or risk elimination, exposure saturation to “just
don’t do it” ?
Stress the
importance of
carrying baby on
hip..having baby
engage physically
on the parents
body (for muscular
development,
preventing
flattening of head
shape, and
intellectual
development).
Get baby our of
hard sitting objects
permitting full use
of head to permit
double s-curvature
of spine to
develop, required
for walking.
Involve babies
in normative
activities..chit
chat, social
encounters…wit
h others
Never say..”Shush..the baby is sleeping!” And, about walkies –
talkies..lets get it right..
Turn amplifier
around!
Family
voices
If having to use walkie -talkies turn the amplifier around and place it near the baby
pumping sounds into baby’s room. Its proactive! Babies respond to human voices in
clinically positive ways.It should be more protective than a reactive, inert receiver!!!)
What Can We Do To Reduce Infant Deaths! Think
Not What You Want But What Might Work Best
• Educate , educate, educate in bidirectional ways (EBM); Respect
and Converse at the familial level…share, discuss in comfortable
venues..!
• Use harm reduction strategies that worked for sex workers, sex
education reducing teen pregnancy, needles for drug users, free
condoms to reduce male-male transmission of HIV;
• Begin with where a the family is, what people feel…want, can do,
bottom up…NOT top down, this is evidence based medicine
• Don’t confuse science with social-political ideologies however wellintentioned ..Science will always win;
• Trust families to make good decisions when given all of the
information..not full proof, but compliance will be increased where
there is trust..
• Health disparities including differential SIDS/SUDI deaths are due to
impoverishment, structural racism, access to resources, control over
one’s own affairs
Encourage new safe co-sleeping furniture
designed for quick breastfeeding retrieval-return
Maori Wahakura: woven flax
bassinet (1 to 6 months). Is
placed between parents or on
side of mother.