Breastfeeding Notably Absent In Review Of SIDS
Sudden Infant Death Syndrome (SIDS) is the subject of a review article by Hannah Kinney, MD and Bradley Thach, MD published in the August 20, 2009 issue of The New England Journal of Medicine.
Surprisingly, no mention is made of the role of breastfeeding.
Described by Kinney and Thach as, “[O]ne of the most mysterious disorders in medicine,” no single definition of SIDS is universally accepted. Currently SIDS is recognized as the sudden and unexplained death of an infant between one month and one year of age. Since the discovery that the prone sleeping position more than triples the risk for SIDS, the American Academy of Pediatrics (AAP) in 1992 recommended that all US infants be placed on their backs to sleep. As a result, the incidence of SIDS among US infants has decreased by nearly 50 percent from 1990 to 2005. Despite these reductions, SIDS remains the leading cause of postneonatal death in US children and the third leading cause of infant mortality overall.
Not surprising, given that only 11 percent of US babies are breastfed exclusively for six months.
The cause of SIDS remains unclear. Recent theoretical models include the Triple-Risk Model proposed in 1994. It focuses on the interaction between three factors—an underlying vulnerability, a critical developmental period, and an exogenous stressor. According to the Triple-Risk Model, “[S]IDS does not cause death in normal infants but, rather, only in vulnerable infants with an underlying abnormality.”
Notably absent among the “Recommendations for Risk Reduction and Counseling” is any mention of breastfeeding. Despite the fact that breastfeeding has been shown to reduce the risk of SIDS by nearly 50 percent at all ages throughout infancy. Moreover, research shows that 13 percent of all infant and young child deaths, the equivalent of 1.3 million lives, could be saved each year if 90 percent of children were breastfed exclusively for 6 months.
I am not suggesting that we discount the importance of placing babies on their back to sleep, or using a lightweight blanket or sleep sack to prevent overheating, or choosing a bed with a firm mattress that fits tight against the bed frame, or keeping babies within arms’ reach day and night. But we shouldn’t underestimate the role of breastfeeding—a strategy that has been shown to be the most cost effective of all child survival strategies.
The cause of SIDS is unclear as are the mechanisms for why breastfeeding decreases the risk of SIDS. Some data suggest that breastmilk contains immunologic components that prevent infection and inhibits the release of proinflammatory cytokines which are proteins that cause respiratory and cardiac dysfunction. In other words, breastmilk may help prevent the defective cardiorespiratory state that Kinney and Thach theorize may play a role in SIDS.
Obviously more data is needed, but in the meantime, the protective effects of breastfeeding should not be ignored but rather recognized as a (S)trategy for preventing (I)nfant (D)eath and (S)aving babies.
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I read your comments with interest. While I completely agree with you that breastfeeding is best for baby, I have never seen the triple risk model described as you have described it. The underlying vulnerability that many researchers are looking at resides in the brain stem – not in breastfeeding vs bottle feeding. The peak age for SIDS is 2-4 months not 4-6 months. Also, the critical development period is the first 6 months of life. Finally, the environmental stressors include a potential illness, but the primary ones focused on are things like belly sleeping, smoke exposure, over heating etc.
Don’t misunderstand, I am completely in favor of exclusive breastfeeding. But, in my own personal circumstance, my baby died of SIDS despite being exclusively breastfed. She is not alone. I know of many SIDS moms that breastfed their babies. Breastfeeding is NOT the only answer to the SIDS question. It may be a factor. We know that it is better for over all infant health.
One negative is that many lactation professionals advocate bedsharing as the only means of successfully breastfeeding. Breast feeding can be successfully accomplished without placing baby in a potential dangerous adult environment.
I don’t think anyone can imagine what it’s like to lose a child to SIDS, unless they too have experienced such a loss. Your experience is why SIDS research is so important.
However, I must admit that I too was dismayed to find that a comprehensive review of SIDS would fail to even mention breastfeeding, given that breastfeeding has been shown to reduce the risk for SIDS.
As long as the cause of SIDS remains unclear, it’s essential that parents be informed of all behaviors that might decrease their baby’s risk for SIDS, including breastfeeding.
I agree with your statement that, “Breastfeeding is NOT the only answer to the SIDS question.” Seldom are there simple solutions to complex problems. But if, as you suggest, breastfeeding may be a factor in the prevention of SIDS, then clearly, it should be identified along with all the other possible factors.
I understand your concern that many lactation professionals advocate bedsharing as the only means of successfully breastfeeding. But as a lactation professional that has not been my experience. I truly believe that it is neither the role nor the responsibility of any health care provider to tell parents how to parent their children. Rather it is our responsibility to give parents the knowledge they need to keep their children healthy and safe. This would include knowing the risks associated with bedsharing and the benefits associated with breastfeeding.
I hope you will agree that like SIDS there is much to be learned about the biological and physiological implications of breastfeeding and human milk.
PS. Thank you for pointing out that the peak age for SIDS is 2-4 months not 4-6 months.
Over the past years I have come across a number of additional theories/studies that could explain some SIDs deaths. One is the “toxic fumes from the mattress” theory, in which (in several studies), older mattresses or mattresses previously used by a different family are more often a factor in SIDs deaths than new mattresses. In Australia, they lowered SIDs rates by encouraging families to cover mattresses with a cover that prevents gases from escaping and being inhaled by babies. Another pertains to research the videotaped mothers and babies cosleeping and found that breastfeeding mothers typically slept in positions safer for their babies than bottle-feeding mothers. Bottle-feeding mothers typically placed their babies so that the head was close to level with mother’s head, presumably so she could see baby’s face. Breastfeeding mothers tended to place their babies so that the head was close to the breast, and to sleep curled around the baby, creating a tent effect with the bedclothes that prevented them touching baby’s face. Another theory offered by chiropractors is a subtle injury in the spine or cranium as a result of a challenging delivery or manipulation that is latent but later on causes death. One of my teachers said that any child who had a traumatic birth (physically and/or psychologically) has an increased risk of SIDs. Then there’s the theory that the part of the brain that is supposed to wake a baby when he/she stops breathing isn’t adequately developed and so apnea turns into death if not discovered immediately. I suspect that all of these theories have some merit, and together with the more well-known ones, could account for the vast majority of SIDs deaths. What is sad, to me, is that more of this information is not made available to parents so that they can make more informed choices (e.g., not using cousin Joe’s hand-me-down crib mattress without the right kind of cover).
I agree with Pam’s comments, the triple risk model has far more to do with neurological changes and rapid maturation during the first 6 months of life, hence the critical development period piece of the triple risk model. Underlying vulnerabilities are thought to be with brain stem abnormalities or possibly other factors such as low birth weight or prematurity; and environmental challenges have to do with factors such as sleep environment or 2nd hand smoke. We support breastfeeding, but we must make sure that accurate information is being presented. And, it is very possible to breastfeed and NOT share a bed with your baby.
Thank you for letting us know that you found some of the content unclear. If you were confused, it is likely other mothers were too. It was not our intent to misrepresent the Triple Risk Model, rather we tried to draw attention to the fact that breastfeeding could play a role in both neurological development and infection risk, key elements of the proposed model.
I certainly agree that mothers and babies can breastfeed and not share a bed. I realize that bed-sharing is a controversial topic, one that has been discussed extensively on baby gooroo. However, there is no mention of bed-sharing in our discussion of the SIDS review article, only a reminder that babies should be kept within arms’ reach during the day and at night. This can be easily accomplished by placing the baby in a crib, cradle, or bassinett next to the bed or in a side-car sleeper that attaches to the side of the bed.
Like you, we want to make sure that the information we share is accurate. Which is why the absence of breastfeeding in the SIDS review article was so disturbing. I hope you will agree that until researchers determine the cause of SIDS, parents need to be aware of every strategy that may reduce the risk for SIDS, breastfeeding among them.