Back to sleep

This is an advertisement for a five-part blog post by my wife, Elizabeth Fama. It’s over at Sensible Medicine, a great substack. Part 1 starts:

My first two children slept on their tummies as infants, uncontroversially. Dr. Spock endorsed stomach sleeping, my mother had slept my siblings and me that way, and my babies vastly preferred it.

But, beginning in the early 1990s, just before my third and fourth children were born, medical associations and the U.S. government launched a campaign called “Back to Sleep,” now rebranded as “Safe to Sleep,” urging me to sleep my babies on their backs.

The reason: putting babies to sleep on their tummies could cause SIDS, sudden infant death syndrome, every parent’s nightmare. I felt like a child endangerer when, exhausted and desperate for my own sleep, I rolled the next two fussy babies from their backs onto their bellies within a couple of weeks of their births. I vividly remember whisper-sobbing: please don’t die. They slept well and thrived.

When our first grandchild arrived, her parents and I dutifully put her on her back. Over the next six months, the baby’s sleep was so poor that my daughter wondered whether she might have a genuine sleep disorder. I also noticed that, although the baby was smart and engaged, she was weaker than her mom had been at each age, and she was hitting her gross-motor milestones much later. Was it due to individual variation in strength and motivation, or could back sleeping have something to do with it, or both?

I fell down a rabbit hole of research: What is the evidence about sleep position and SIDS? Are there costs to back sleeping? Does it make sense to apply the same advice unconditionally to all babies?

There are costs, I was surprised to learn. Babies don’t sleep well on their backs. (Maybe back sleep works because they don’t sleep!) Parents don’t sleep well when babies don’t sleep well, and postpartum depression is on the rise. Babies’ looking up, crawling and other development is delayed by back sleep. Everyone hates “tummy time.” There are many predictors of SIDS deaths as strong or stronger than back sleeping, including smoking (the parents, not the baby!), socioeconomic status, daycare, and whether the child has been sick lately. SIDS is very rare in some groups. SIDS is a “diagnosis of exclusion” not a disease with a known causal mechanism, and many deaths are misclassified as SIDS. All the studies are observational, leading to obvious questions about whether everything was properly controlled for. SIDS went down as back sleeping spread, but a lot of other things changed at the same time. Oh, and back sleeping is no guarantee. It just lowers probabilities.

Beth’s conclusion is nuanced. Yes, it seems likely that back sleeping reduces the chance of SIDS. She’s not a denier. But back sleeping has costs. And Beth (who wrote a lovely PhD thesis on costs vs. benefits of mammography screening) recognizes that decisions must balance costs and benefits. We could eliminate car crash deaths by never letting children out of the house. We don’t.

This is a bit of a story about public health

… a lot of money and a lot of public-policy muscle has gone into a campaign that doesn’t have robust evidence. That campaign is also silent on the costs of back sleeping, and just how variable the danger of SIDS is, instead promoting an overly simplified, one-size-fits-all message. (For instance, we should be talking to parents about, and energetically trying to understand why, 20.4% of SIDS deaths happen in childcare settings.)

And, I would add, emphasize not smoking, accident prevention, and all the other things a stressed parent can do to lower overall risks to the child.

My wish is that parents could be armed with better research and better information about the research we have, and then be trusted to make care decisions for their families.

The question a parent (or grandparent!) wants to know: Given my circumstances, how many of the other things I’m doing to reduce SIDS and other dangers (and how many I’m not), given my baby and her health history, what is the probability of SIDS? How much does back sleeping reduce it? To be balanced against, how hard is it for my kid and me, and how much sleep are we losing here? The medical evidence doesn’t give us a good sense of these conditional probabilities.

Beth was worried about posting the essay, given how quickly medical opinions lead to twitter outbursts and cancellations. Her biggest surprise is that many of the comments were quickly hijacked by… Readers who were upset that she didn’t write about whether childhood vaccines might cause SIDS? She’ll enjoy comments on other subjects.

Post #1 introduces. Post #2 describes the downsides of back sleeping. Post #3 tells you a lot about SIDS. Post #4 featured an evidence review and Post #5 is the conclusion. It got broken up because of Substack length limits. I encourage a beginning to end rabbit hole.

When she learned to roll over, here is how our granddaughter chose to sleep. Soundly, at last.