BabyM is almost 14 months old already. It’s crazy how quickly the first year of his life flew by, and I know the subsequent years will be no different.

The upside of that passage of time is that we’re all sleeping pretty well now, and that is a wonderful thing. To be honest, though, I actually enjoyed watching my baby’s sleep develop this time around. I know that time softens my memories, but I already miss those quiet middle-of-the-night feedings with my baby.

Long-time readers of this blog know that I wrote a lot about sleep when Cee was a baby, in the early days of the blog. I also wrote about evidence-based sleep strategies for my book. I’ve read hundreds of papers on sleep since Cee was a baby, and that changed so much about my approach to M’s sleep. Lots of readers have asked me about how M’s sleep went, so I finally wanted to share his sleep story.

One thing that was different with M was that I was just super curious to observe him and watch how his sleep developed. After all of my reading on this topic, I’ve sort of become an infant sleep nerd. Would I see a strong day-night circadian rhythm emerge when the literature said it would? How would his nighttime sleep consolidate over those first few months? Most especially, would the information and recommendations in my book still feel true and relevant to me as I went through parenting an infant again? (Happily, yes!)

That sense of curiosity, paired with having gone through this before and knowing that it wouldn’t last forever, really helped me relax about M’s sleep. I also knew from the science that there was a wide range of normal for sleep development, and it isn’t always a linear, predictable process. Still, it was humbling to go through those early months again. No matter what we know or do, we all still have rough nights and tired babies who can’t nap and moments of uncertainty. That’s part of the landscape of newborn parenting.

One small thing that helped me with sleep this time around was the adoption of my new sleep mantra. I whispered it to M as I helped soothe him to sleep or when I put him down to rest on his own. I started making it part of my goodnight routine with Cee. I even say it to myself when it’s time to turn off my computer and phone and go to bed:

“It’s going to feel so good to rest.”

Right? It does feel good to rest. I want my children to appreciate the comfort of settling your body into that familiar nest of your bed and letting go of the day. I want them to recognize how much better we feel after having a good rest. In our family, I want to have a culture of valuing sleep for our health, well being, and just because it feels good. If my kids are protesting going to bed, it’s a reminder to them and to me why it’s important. Their bedtime isn’t just about staying on schedule or giving me my coveted quiet time in the evening (although I certainly appreciate this). It’s really about getting them the rest they need so that they can thrive in each coming day.

The other thing that made a big difference to M’s sleep development was giving him opportunities to fall asleep on his own from an early age. This was totally different from our strategy with Cee. With M, we gave him space to practice the process of falling to sleep in a supported way. I think that having this skill allowed his sleep to develop organically over the first year.

I have written more about how science shaped my infant sleep philosophy and how I put that into practice with M in two guest posts on Janet Lansbury’s site, Elevating Childcare, this week. The first post is about the science. The second post is about how we put it into practice to help M gradually learn some independent sleep skills. Please check them out if you want to read more, and feel free to leave your comments here or on Janet’s site.

There is a persistent myth about infant gut development that comes up in nearly every online discussion of starting solid foods. It’s the myth that infants have a “virgin” or “open” gut until around 6 months of age. I’ve received so many emails, Facebook posts, and comments about the virgin gut over the last few years that I thought it was finally time to take a look at the science – and lack thereof – behind this myth.

I have written before, in my book and on my blog, about the controversy around when to begin introducing solid foods to a baby. Some health organizations recommend 6 months of exclusive breastfeeding, while others recommend starting to offer solids between 4 and 6 months, following baby’s cues of readiness as your ultimate guide. Based on my analysis of the most current science, I believe that the second approach is more evidence-based and helps parents to focus on their baby’s unique development rather than the calendar. I also think that it’s just fine to wait until 6 months if that is your preference.

However, whenever I discuss this science, someone lectures me about infant gut development, and they usually send me a link to KellyMom’s page on the topic, which urges parents not to offer solids before 6 months. Here’s what it says:

“In addition, from birth until somewhere between four and six months of age babies possess what is often referred to as an “open gut.” This means that the spaces between the cells of the small intestines will readily allow intact macromolecules, including whole proteins and pathogens, to pass directly into the bloodstream. This is great for your breastfed baby as it allows beneficial antibodies in breastmilk to pass more directly into baby’s bloodstream, but it also means that large proteins from other foods (which may predispose baby to allergies) and disease-causing pathogens can pass right through, too.”

Wow, that does sound scary! I can see how this “open gut” idea would worry parents approaching the transition to solid foods. But here’s the thing: There are no references given to support these statements, and in all my reading of the research literature on readiness for solids, I have not encountered science backing this concern. Yet somehow this idea of the open gut comes up over and over in online discussions, complete with judgment for parents who offer solids before 6 months and non-evidence-based suggestions about how to “heal” a baby’s gut. All of this only serves to increase anxiety in parents, which is the last thing any of us need.

It’s time to get to the bottom of this. Let’s look at some science…

What do we mean when we talk about an “open” or “closed” gut? How do we measure this?

The lining of the small intestine serves a critical role in absorption of nutrients and in immune protection. Food and bacteria from the environment enter the GI tract, and the lining of that tract is what separates it from the body’s bloodstream. It’s important that this lining is selective about letting in the good stuff and keeping out the less desirable elements, as this interface is one of an infant’s most important barriers to infection (1).

The intestinal lining is composed of a single layer of epithelial cells, called enterocytes, arranged in many deep folds that serve to increase the surface area for nutrient absorption. Nutrients are absorbed across the intestinal enterocytes and into the blood stream.

The spaces between the enterocytes are joined by protein complexes, the most important of which are called tight junctions. Despite their name, these junctions are never a complete seal and let some particles through while excluding others, mostly on the basis of size and charge (2).

Researchers use the term intestinal permeability to describe how easily particles can cross the lining of the intestine and into the blood stream. Intestinal permeability is tested in research settings by giving a person an oral dose of two sugars, usually mannitol and lactulose (not to be confused with lactose, which is the major sugar found naturally in milk). Mannitol is the smaller of the two (molecular weight 182) and is absorbed through pores in the intestinal enterocytes. Lactulose is too large to fit through those pores (molecular weight 342), but some of it will sneak through the tight junctions to get into the bloodstream. Once in the blood, neither lactulose nor mannitol are further metabolized; they’re just filtered by the kidneys and excreted in the urine. So, if you give a person (including a baby) a dose of these two sugars and collect their urine, you can measure how much of each was absorbed in the small intestine. Results are usually expressed as a lactulose to mannitol ratio (L/M), with higher values representing greater intestinal permeability and lower values representing less intestinal permeability or a more “closed gut” (3,4).

Does intestinal permeability change in infancy?

Yes, but the timeline is different from KellyMom’s description.

The sugar absorption test has been used to measure the process and timing of gut closure in infants. Contrary to the KellyMom’s claims that this critical process happens between 4 and 6 months, studies show that the most important gut closure actually happens in the newborn period. For example, one study measured intestinal permeability in 72 healthy newborns on days 1, 7, and 30 of life and found that the biggest drop occurred within that first week of life (5).

Intestinal permeability is high at birth but quickly drops within the first week of life. (Data from Catassi et al. 1995)

Does whether an infant is breastfed or formula-fed affect intestinal permeability? Maybe a little, but the difference doesn’t last long. The study shown in the graph above found no difference in intestinal permeability in exclusively breastfed and formula-fed babies on day 1 or day 30. On day 7, intestinal permeability was slightly lower in breastfed compared with formula-fed infants, indicating that formula-feeding may slow the process of gut closure (5). It’s possible that this may contribute to the increased incidence of GI illness observed in formula-fed infants. But again, this difference is transient. By one month and beyond, there is no difference in intestinal permeability between breastfed or formula-fed infants (6).

Preterm infants have greater intestinal permeability at birth but have similar values as term infants by 3-6 days of life.⁷ The process of gut closure is delayed when preterm infants are fed only by IV rather than via the gastrointestinal tract (oral or tube-feeding), and at least partial human milk feeding rather than exclusive formula-feeding improves gut closure in these vulnerable babies (8,9).

What about later in infancy? Studies on this question show a very gradual decline (if at all) in intestinal permeability over the first several years of life. There is no gut closure door slamming shut on the 6-month birthday. In the graph below, I’ve plotted intestinal permeability by age from two studies (10,11).

Over the first few years of life, a very gradual process of gut closure occurs. Some fine print about this figure: The Noone study actually used a different sugar absorption test, so these values may not be directly comparable, but you can see the same trend in both studies. The data from Noone are individual children, and those from Kalach are averages given in a group of children in each age group.

Another study (3) established a reference value for normal intestinal permeability measured by the sugar absorption test (lactulose/mannitol) among healthy children as 0.033 (average of 30 children with mean age of 5 years), and you can see that most of the babies in the above graph actually reached that degree of gut closure by 3 months. The reference value for intestinal permeability in adults established in the same study was just a tad lower at 0.027.

In other words, when it comes to readiness for solid foods, gut closure is probably irrelevant. It happens long before today’s parents are offering bites of banana or oatmeal.

KellyMom also claims that an infant’s “open gut” allows breast milk antibodies to pass directly into the bloodstream. That actually doesn’t happen in human infants – except for maybe in the first few days of life when intestinal permeability is truly high (and the evidence isn’t clear on that point). Instead, human babies get maternal antibodies (IgG) into their bloodstream when they cross the placenta during pregnancy, which is why maternal immunization for pertussis and flu during pregnancy is so effective at protecting babies from infection after birth. This is different from many other species of animals, in which IgG can’t cross the placenta and are instead transferred to baby via milk (especially colostrum) after birth (12,13).

The most important antibody type in human milk is secretory IgA, which coats mucosal surfaces such as the lining of the GI tract and can protect against infection in that way. However, IgA can’t be absorbed into the blood in human babies. This post on The Scientific Parent explains how this works in humans in more detail: Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick?

The idea of an open gut being a problem for a baby also sounds eerily familiar to the woo-filled claims of “leaky gut syndrome” being the cause of a remarkable number of unrelated disorders.² The leaky gut as a cause of disease and all of its proposed cures are pseudoscience, too. In other words, if you see mention of a gut that is described as leaky, open, or virgin, just run. You’re probably not reading information that is grounded in science.

What IS important for gut readiness for solid foods?

When infants start eating solid foods, they are shifting from the relatively simple diet of easy-to-digest breast milk and/or formula to a more complex diet with a variety of foods (with milk still being an important one). These foods require more work to digest, which means greater activity of a suite of digestive enzymes. In addition, the kidneys have to work a bit harder to excrete metabolites from these foods. How do we know that infants have the capacity to adapt to a more complex diet by 4 months of age?

Here’s the opinion of European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHN; PDF):

“The available data suggest that both renal function and gastrointestinal function are sufficiently mature to metabolise nutrients from complementary foods by the age of 4 months. With respect to gastrointestinal function, it is known that exposure to solids and the transition from a high-fat to a high-carbohydrate diet is associated with hormonal responses (eg, insulin, adrenal hormones) that result in adaptation of digestive functions to the nature of the ingested foods, by increasing the maturation rate of some enzymatic functions and/or activities. Thus, to a large degree gastrointestinal maturation is driven by the foods ingested.” ⁽¹⁴⁾

This is a recurring theme in nutritional biology – that it is only by exposure to a type of food that the GI tract can actually become efficient at digesting it. This is one reason why the transition to solids may give you some interesting diapers, from very messy to very solid, as the GI tract adapts to digesting these new foods. That’s good reason to introduce new foods gradually and in small quantities at the beginning, but it isn’t a good reason to avoid feeding them at all.

OK, maybe not the best choice for a baby new to solid foods, but this guy really thinks he’s ready to try some marble rye.

If a baby’s GI tract was really too immature to handle solids by 4 months, we would also expect to see more GI illness and food allergies developing in babies starting solid foods at that age. However, this is not what we observe. Most studies find no difference in risk of GI infection whether babies start solids between 4 and 6 months or after 6 months (15-17).

When it comes to risk for food allergies, recent research suggests that introducing solids, including common allergens, between about 4 and 6 months may actually reduce the risk of food allergies. (I give more details on this, with lots of references, in this post.) A study just published found that babies who start solid foods at 4 or 5 months have significantly lower risk of eczema compared with babies exclusively breastfed for 6 months (18). (Eczema in infancy is often associated with later development of allergies (19).) The development of a baby’s digestive and immune systems are interwoven processes, and exposure to food proteins during the 4-6 month period seems to help steer the immune system towards tolerance of foods rather than reactivity to them.

All of this doesn’t mean that you need to rush your baby to start solid foods. It just means that you can cross the open gut off your list of things to worry about. Anytime in the 4-6 months range is a great time to try offering your baby solid foods, following your baby’s signs of developmental readiness and interest in eating solids as your guide.

I ran across this video when I was looking for images to accompany this post. It’s a little off-topic, but it made me laugh a little, because I don’t think I could ever call M’s gut “virgin,” whatever that means. And I don’t think that’s a bad thing. (Please rest assured that M and our dog have a mutual appreciation for this licking ritual.)

References:

1. Battersby, A. J. & Gibbons, D. L. The gut mucosal immune system in the neonatal period. Pediatr. Allergy Immunol. 24, 414–421 (2013).
2. Odenwald, M. A. & Turner, J. R. Intestinal permeability defects: is it time to treat? Clin. Gastroenterol. Hepatol. Off. Clin. Pract. J. Am. Gastroenterol. Assoc. 11, 1075–1083 (2013).
3. van Elburg, R. M. et al. Repeatability of the sugar-absorption test, using lactulose and mannitol, for measuring intestinal permeability for sugars. J. Pediatr. Gastroenterol. Nutr. 20, 184–188 (1995).
4. Corpeleijn, W. E., van Elburg, R. M., Kema, I. P. & van Goudoever, J. B. Assessment of intestinal permeability in (premature) neonates by sugar absorption tests. Methods Mol. Biol. Clifton NJ 763, 95–104 (2011).
5. Catassi, C., Bonucci, A., Coppa, G. V., Carlucci, A. & Giorgi, P. L. Intestinal permeability changes during the first month: effect of natural versus artificial feeding. J. Pediatr. Gastroenterol. Nutr. 21, 383–386 (1995).
6. Colomé, G. et al. Intestinal permeability in different feedings in infancy. Acta Paediatr. 96, 69–72 (2007).
7. Van Elburg, R. M., Fetter, W. P. F., Bunkers, C. M. & Heymans, H. S. A. Intestinal permeability in relation to birth weight and gestational and postnatal age. Arch. Dis. Child.-Fetal Neonatal Ed. 88, F52–F55 (2003).
8. Rouwet, E. V. et al. Intestinal permeability and carrier-mediated monosaccharide absorption in preterm neonates during the early postnatal period. Pediatr. Res. 51, 64–70 (2002).
9. Taylor, S. N., Basile, L. A., Ebeling, M. & Wagner, C. L. Intestinal Permeability in Preterm Infants by Feeding Type: Mother’s Milk Versus Formula. Breastfeed. Med. 4, 11–15 (2009).
10. Kalach, N., Rocchiccioli, F., Boissieu, D., Benhamou, P.-H. & Dupont, C. Intestinal permeability in children: variation with age and reliability in the diagnosis of cow’s milk allergy. Acta Paediatr. 90, 499–504 (2001).
11. Noone, C., Menzies, I. S., Banatvala, J. E. & Scopes, J. W. Intestinal permeability and lactose hydrolysis in human rotaviral gastroenteritis assessed simultaneously by non-invasive differential sugar permeation. Eur. J. Clin. Invest. 16, 217–225 (1986).
12. Van de Perre, P. Transfer of antibody via mother’s milk. Vaccine 21, 3374–3376 (2003).
13. Udall, J. N. & Walker, W. A. The physiologic and pathologic basis for the transport of macromolecules across the intestinal tract. J. Pediatr. Gastroenterol. Nutr. 1, 295–301 (1982).
14. Agostoni, C. et al. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J. Pediatr. Gastroenterol. Nutr. 46, 99–110 (2008).
15. Cohen, R. J., Brown, K. H., Dewey, K. G., Canahuati, J. & Landa Rivera, L. Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomised intervention study in Honduras. The Lancet 344, 288–293 (1994).
16. Dewey, K. G., Cohen, R. J., Brown, K. H. & Rivera, L. L. Age of introduction of complementary foods and growth of term, low-birth-weight, breast-fed infants: a randomized intervention study in Honduras. Am. J. Clin. Nutr. 69, 679–686 (1999).
17. Quigley, M. A., Kelly, Y. J. & Sacker, A. Infant feeding, solid foods and hospitalisation in the first 8 months after birth. Arch. Dis. Child. 94, 148–150 (2009).
18. Turati, F. et al. Early weaning is beneficial to prevent atopic dermatitis occurrence in young children. Allergy (2016). doi:10.1111/all.12864
19. Dharmage, S. C. et al. Atopic dermatitis and the atopic march revisited. Allergy 69, 17–27 (2014).

The AAP’s updated policy statement on safe infant sleep was released this week (^1). I wrote a brief article about the policy update for the Washington Post, but I wanted to dig into the science a bit more in a blog post.

As a side note, let me just say that the opportunity to write for larger media outlets is very exciting, but also very humbling. A typical blog post for me is 2000 words, but I was asked to write 500-800 for the Post. It’s really hard to include in-depth science in a piece like that, but it’s something that I will keep working to improve. Still, can you imagine how I cringed when someone commented on Facebook, “Where is the science?!” about my article? But I probably would say the same thing, and I know that many readers want to understand the evidence base behind these recommendations.

The updated policy statement represented a 2-year effort by the AAP’s Task Force on SIDS to review literature published since the last policy statement, issued in 2011. The statement includes advice on how to reduce the risk of SIDS and other sleep-related deaths such as suffocation and asphyxiation, together considered sudden unexpected infant deaths, or SUID. It is often very difficult to determine whether SIDS or accidental causes caused a death, even after a thorough investigation, and many of the risk factors for these types of deaths overlap. About 3,500 infants die of sleep-related SUID in the U.S. each year. As a parent, I know that losing one of my babies during sleep was one of my greatest fears, and that number holds an incomprehensible amount of tragedy and grief for families. The goal of these guidelines is to prevent those deaths.

The AAP’s Task Force on SIDS is a group of 5 pediatricians, most of them having spent their careers studying SUID. For this 2016 revision, the Task Force also included breastfeeding researcher Lori Feldman-Winter. She told me that she was invited to the Task Force specifically to bring more research and perspective on breastfeeding to the group and to help address the controversy around the risks of bedsharing by breastfeeding mothers (more on that in a minute). The policy statement was also reviewed by the AAP’s Section on Breastfeeding. “The final product is really a meeting of the minds so that we can feel good about what we’ve put forth as the best evidence and the recommendations that follow,” Dr. Feldman-Winter said.

The policy statement is accompanied by a technical report that is loaded with science (400 citations), and it can be accessed and read by anyone interested (^2). It’s a tough job for the AAP to issue recommendations for an entire population, knowing that there are big differences in cultural practices and real-world experience, but my opinion is that these recommendations are thoughtful and evidence-based and represent the Task Force’s best advice for parents.

Many of the recommendations on SUID prevention remain the same and should be familiar to parents, although they always bear repeating. Place babies on the back for every sleep, never on the stomach or side. Babies should sleep on a firm, flat surface with no loose bedding, pillows, or toys. Breastfeeding, immunizing on schedule, and getting regular prenatal care all reduce the risk, as does avoiding exposure to cigarettes, alcohol, and drugs in pregnancy and after birth. I’ll put the full list of recommendations at the bottom of this post, but I’ll use the rest of this post to take a closer look at the science behind the recommendations that have received the most attention in the past few days.

Babies should sleep in the parents’ room, close to the parents’ bed, ideally for the first year of life but at least the first 6 months.

Roomsharing without bedsharing was also recommended in the AAP’s 2011 policy statement, but they didn’t specify how long this arrangement should last. I think many parents overlooked the roomsharing recommendation in the past, but this revision gives it new emphasis. Roomsharing for 6-12 months is also recommended in other countries, including the U.K. and Australia.

Based on the AAP’s new safe sleep policy, this is an ideal sleep environment. Image courtesy of the Safe to Sleep® campaign; Eunice Kennedy Shriver National Institute of Child Health and Human Development, http://www.nichd.nih.gov/sids

Studies have shown roomsharing without bedsharing to be protective against SIDS since at least the mid-1990’s. Here’s what I wrote about roomsharing in a blog post from last year:

One of the largest case control studies of SIDS combined data from 20 different regions of Europe, allowing researchers to look at 745 SIDS cases and the risk factors associated with them (^3). The authors of this study estimated that 36% of SIDS deaths could have been prevented if infants weren’t placed for sleep in a separate room, and 16% could have been prevented if infants weren’t bedsharing. Together, this means that if all of the infants in this study had slept in the same room as their parents, but not the same bed, more than half of their deaths might have been prevented.

This same protective effect of roomsharing has been observed in several other case control studies conducted in Scotland, England, and New Zealand (^4–6). The English study found a dramatic 10-fold increased risk of SIDS associated with babies sleeping in their own room. Importantly, at least one study has shown that when infants share a bedroom with other children, it is not protective.⁶ Instead, the presence of an adult caregiver seems to be important.

Why is room-sharing protective? We don’t know, but it is a strong and consistent effect. The running hypothesis (again from my previous post):

Babies sleeping in closer proximity to their mothers have more sensory exchange (from noises, a touch when a parent checks the baby, etc.) and thus spend more time in light sleep and have more short arousals that protect them from SIDS (^5–7).

Most of the studies that have looked at roomsharing have just looked at all deaths under one year of age without trying to parse the data by age. One New Zealand study (⁶ published in 1996 found that roomsharing was equally protective in infants aged less than 13 weeks, 13-19 weeks, and 20 weeks and older. Without more evidence, the AAP couldn’t say that roomsharing becomes less important at any age, so they took the cautious approach of recommending it for the entire first year. (And caution is what we want when we’re talking preventing infant deaths, right?) They do note that most SIDS deaths occur in the first 6 months, so roomsharing is most important during this time.

Adapted from AAP, Technical Report: SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 128, e1341–67 (2011).

It’s worth noting that most of our understanding of how to reduce the risk of SIDS and other sleep-related deaths come from case control studies or case series, observational studies that simply can’t distinguish causation from correlation. We’re limited to these types of study designs because, thankfully, SIDS is relatively rare, and it would be virtually impossible to conduct prospective cohort studies or randomized controlled trials on SIDS. The evidence on roomsharing can’t tell us for sure that it causes a lower risk of SIDS, just that it is correlated to a lower risk of SIDS. There could be a confounding factor here – something else that roomsharing parents are more likely to do – or it could be a true effect. Either way, in recommending roomsharing, the AAP is making the best recommendation that they can based on the best evidence that they have.

Evidence also shows that most parents in the U.S. are not roomsharing much beyond the first few months of life. A study published this August in Pediatrics found that among 160 Pennsylvania babies, 55% of 3-month-olds and 74% of 6-month-olds weren’t sharing a room with their parents. Several studies show that parents who roomshare–especially in later infancy–experience more disrupted sleep and are more likely to have stressed relationships with their partners (again, this is a correlation, not necessarily caused by roomsharing). Sleep training is also usually more successful when babies sleep in their own rooms. It will be interesting to see if the stronger roomsharing recommendation will create a cultural shift in sleep environments for babies.

Bedsharing is not recommended.

The AAP’s advice against bedsharing is probably the most controversial recommendation, in part because so many families do it anyway. For some, it is a cultural norm and for others, it is seen as a way of bonding with their babies and facilitating nighttime breastfeeding. Others find that they just struggle to get a reasonable night of sleep without bringing the baby into bed. Still, the AAP is reaffirming their stance that bedsharing is a risk to babies, based on the current evidence.

It’s very clear from decades of studies of SIDS and other sleep-related deaths that bedsharing is associated with many of these deaths. What is controversial is if it is bedsharing itself that is the hazard or if it is other circumstances that might accompany bedsharing – soft mattresses, loose bedding, drug or alcohol use, or sleeping on a sofa or armchair.

Two studies addressing this question were published since the AAP’s 2011 policy statement, but they came to contradictory conclusions. A 2013 study led by Bob Carpenter concluded that, in the absence of these other risks, bedsharing still increased the odds of dying of SIDS by 2.7-fold, and in breastfed babies younger than 3 months old, the odds increased to 5-fold compared to babies roomsharing without bedsharing. However, this study was criticized for lacking much real data on parental drug and alcohol use. And then, a 2014 study led by Peter Blair found that the risk of SIDS wasn’t significantly increased with bedsharing in the absence of other risks, even in younger babies.

Given this conflicting evidence, the AAP commissioned a biostatistician who is not invested in this field to review these two studies. His conclusion? Both of these studies were small, and both had limitations. They used different control groups, which may have pushed Blair’s study towards underestimating the risk and Carpenter’s study towards overestimating the risk, so the real risk may lie somewhere in between. Given this uncertainty, Feldman-Winter said, “we can’t, based on the available evidence, rule out the fact that there is a hazard to bedsharing.”

The AAP notes that some situations make bedsharing more dangerous: when either or both parents are smokers, including if the mother smoked in pregnancy; with babies who were born preterm or low birth weight; in babies less than 4 months old; with any alcohol or illicit drug use that might impair arousal; when there are multiple bedsharers, especially if one of them is not a parent (including other children or pets). Bedsharing on very soft surfaces such as waterbeds, sofas, or armchairs is exceptionally dangerous, and loose bedding or pillows further increase the risk.

But, if parents fall asleep while feeding their babies, it is safer for this to happen in a carefully arranged bed than on a couch or chair.

This is a nuanced but important change in the AAP’s advice. The 2011 policy statement also advised that parents should not sleep on a couch or a chair with a baby, but anyone who has been through the early infancy period knows that there is a good chance of this happening at some point. “I think that what people really wanted after the last policy statement was recommendations on what to do,” said Dr. Feldman-Winter.

So, this time around, the AAP states that if you are in this precarious situation where you know that you may fall asleep while you feed your baby, that it is safer for that to happen on a carefully arranged bed than on a couch or chair.

A 2014 case series published in Pediatrics found that 1,024 infants died while sleeping on a couch or armchair in the U.S. between 2004 and 2012.⁸ These are preventable deaths. Other studies have found that sleeping with an infant on a couch or chair increases the risk of death by as much as 50- to 60-fold, many times the risk of bedsharing.^4,5

If you do feed your baby in bed, arrange it to be as safe as you can. “We also make recommendations about keeping the bed as risk-free as possible by removing pillows and blankets and loose sheets and loose bedding, and also having a firm mattress,” said Dr. Feldman-Winter.

Ideally, the AAP says, you place your baby back in their own bed once you’re done feeding. If you fall asleep, you move your baby as soon as you awaken. I like Elissa Strauss’s suggestion at Slate on this: involve your partner by asking him or her to set an alarm for each feeding and help you move the baby should you both fall asleep.

You don’t need fancy monitors or devices or mattresses to create a safe sleep environment for your baby.

Here’s what Dr. Moon told me about creating a safe place for your baby to sleep: “You don’t need much to prepare a safe sleep environment for your baby. You want a flat, firm surface, and by firm I mean hard…. Ideally a crib, a portable crib, a playpen, or a bassinet. You want the mattress to be fitted for that device. You want a tight-fitting sheet. And then you just want the baby. You don’t want anything else in the crib, so bare is best. Ideally, we want the sleep place to be in the parents’ room, close to the parents’ bed.”

There are a ton of other products out there that promise or imply that your baby will sleep better or be safer if you use their device. There is no evidence that any device can reduce your baby’s risk of SIDS. None. Not the breathable mattresses, which I wrote about for Slate. Not the Rock n’ Play. Not baby swings or carseats. The market for infant care products is largely unregulated, Dr. Moon told me, and there is not a formal process for testing these products for safety. We generally don’t know that a product is hazardous until it causes injuries or deaths and a recall is issued. So, stick with a basic firm, flat, blanket and bedding-free bed for your baby.

Expensive monitors that track your baby’s vital signs also have not been shown to keep babies any safer when they sleep, and pediatricians worry that they might give parents a false sense of security. “I’ve heard many times that if I buy a $500 monitoring device, I don’t have to do the other sleep guidelines, that my baby can sleep prone [stomach down] because they have a pulse oximeter on them all the time,” said Kansas City pediatrician Dr. Natasha Burgert. “They think, I’m exempt from those other suggestions, because I have outsmarted the system by using this technology.”

Pediatricians should have non-judgmental conversations with parents about sleep safety

This is an important addition to the policy statement. Why? Because I know from experience that it can be hard to follow every safe sleep recommendation every night with a young infant, even when you are well-educated about the risks. Sleep is a biological need, and sleep deprivation also has very real risks. Parents are often making decisions in desperation, but a better approach is to rationally weigh risks and benefits and make a plan for sleep that reduces the risks as much possible. Pediatricians can be a great resource in that conversation, and if you’re concerned about sleep, they should be able to help you move towards better, safer sleep for your family.

Here is the full list of safe sleep recommendations from the AAP’s 2016 policy statement:

A-level recommendations

• Back to sleep for every sleep.
• Use a firm sleep surface.
• Breastfeeding is recommended.
• Room-sharing with the infant on a separate sleep surface is recommended.
• Keep soft objects and loose bedding away from the infant’s sleep area.
• Consider offering a pacifi er at naptime and bedtime.
• Avoid smoke exposure during pregnancy and after birth.
• Avoid alcohol and illicit drug use during pregnancy and after birth.
• Avoid overheating.
• Pregnant women should seek and obtain regular prenatal care.
• Infants should be immunized in accordance with AAP and CDC recommendations.
• Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.
• Health care providers, staff in newborn nurseries and NICUs, and child care providers should endorse and model the SIDS risk-reduction recommendations from birth.
• Media and manufacturers should follow safe sleep guidelines in their messaging and advertising.
• Continue the “Safe to Sleep” campaign, focusing on ways to reduce the risk of all sleep-related infant deaths, including SIDS, suffocation, and other unintentional deaths. Pediatricians and other primary care providers should actively participate in this campaign.

B-level recommendations

• Avoid the use of commercial devices that are inconsistent with safe sleep recommendations.
• Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly.

C-level recommendations

• Continue research and surveillance on the risk factors, causes, and pathophysiologic mechanisms of SIDS and other sleep-related infant deaths, with the ultimate goal of eliminating these deaths entirely.
• There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS.

What questions do you have about prevention of SIDS and other sleep-related deaths?

References:

1. AAP’s Task Force on Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics e20162938 (2016). doi:10.1542/peds.2016-2938
2. Moon, R. Y. & AAP’s Task Force on Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment. Pediatrics e20162940 (2016). doi:10.1542/peds.2016-2940
3. Carpenter, R. G. et al. Sudden unexplained infant death in 20 regions in Europe: case control study. Lancet 363, 185–191 (2004).
4. Tappin, D., Ecob, R. & Brooke, H. Bedsharing, Roomsharing, and Sudden Infant Death Syndrome in Scotland: A Case-control Study. J. Pediatr. 147, 32–37 (2005).
5. Blair, P. S. et al. Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome. Br. Med. J. 319, 1457–1462 (1999).
6. Scragg, R. K. et al. Infant room-sharing and prone sleep position in sudden infant death syndrome. New Zealand Cot Death Study Group. Lancet Lond. Engl. 347, 7–12 (1996).
7. McKenna, J. J., Ball, H. L. & Gettler, L. T. Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: what biological anthropology has discovered about normal infant sleep and pediatric sleep medicine. Am J Phys Anthr. Suppl 45, 133–61 (2007).
8. Rechtman, L. R., Colvin, J. D., Blair, P. S. & Moon, R. Y. Sofas and Infant Mortality. Pediatrics 134, e1293–e1300 (2014).

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