Co-sleeping and suffocation
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COMMENTARY
Co-sleeping and suffocation Peter S. Blair
Accepted: 21 October 2014 Ó Springer Science+Business Media New York 2015
The diagnosis of SIDS is unique in that it is essentially saying ‘‘we don’t know why the baby died.’’ Unexpected by clinical history and after a thorough post mortem examination we have failed to demonstrate an adequate cause of death and it is on the basis of this Beckwith definition [1] that SIDS was first included as a separate category in the International Classification of Diseases in 1968. The only controversy stirred up by John Emery’s perceptive question following the 1989 meeting in Paris [2] is that it took 2 decades to realize we are dealing with such a conundrum. SIDS by definition has always been a diagnostic dustbin [1]. Perhaps at the outset there was hope that we may find a single definitive cause but after 50 years of research and more than 100 observational studies the one thing we can say with any certainty is that SIDS has multiple causal mechanisms. Historically a large proportion of these deaths are related to young infants being found in the prone position for sleep. Although observational studies are not in themselves designed to provide causal inference the intervention campaigns in different countries provide strong experimental evidence of a dramatic fall in the SIDS rate concomitant with a change in the way we place infants to sleep. Thus prone positioning is part of the causal pathway for some deaths but not in itself a cause of death. The residual deaths subsequent to the ‘‘Back to Sleep’’ campaigns have a greater proportion of infants who co-sleep
P. S. Blair (&) Level D, St Michael’s Hospital, University of Bristol, Southwell St, Bristol BS2 8EG, UK e-mail: [email protected]
and this perhaps is not surprising. Prone positioning has always been less prevalent among bed-sharing infants who are often placed supine or on their side to accommodate breastfeeding [3]. I’m not sure these co-sleeping deaths are so much an elephant in the room but rather a gray object only becoming larger because the room is shrinking and we now need to determine whether the gray object has a trunk and a tail. Certainly we have found a strong interaction between bed-sharing SIDS deaths and hazardous environments such as sofas or co-sleeping parents who have drunk alcohol or taken drugs that are suggestive of overlaying [4]. However bed-sharing, like prone positioning, is not a cause of death in itself and associations found at the population level do not directly translate into individual causal certification. In epidemiological studies, far from classifying every cosleeping death as SIDS, we go to great lengths using multi-disciplinary panels to exclude deaths with a full explanation, including overlaying deaths. The difficulty we all share on a case by case basis is what constitutes circumstantial evidence or a definitive cause. Lumping together the varying degrees of unexplained deaths under the rubric of SIDS has served us well; not least in the number of lives saved in th
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