American Academy of Pediatrics' Task Force on SIDS Fully Supports Breastfeeding

Dear Editor:

Dr. Lawrence's editorial, “Solomon's Wisdom,” ¹ describes her account of a May 19, 2014 meeting at the National Institutes of Health, to which breastfeeding and infant safe sleep experts were invited. She describes the program as being planned by the American Academy of Pediatrics' (AAP's) Task Force on SIDS [Sudden Infant Death Syndrome] and recalls that no breastfeeding advocates were invited to speak. She relates that the Task Force was unaware of the critical congenital heart disease campaign, with the implication that many deaths attributed to SIDS may be undiagnosed heart disease and could be averted with neonatal pulse oximetry screening. She advocates for full neonatal metabolic screening nationally, again implying that many SIDS cases are undiagnosed cases of metabolic disease. Finally, Dr. Lawrence describes an upcoming “final report” of the Task Force, in which there would be “vigorous” support against co-sleeping and no support of breastfeeding.

As members of the Task Force on SIDS, we must respectfully point out the inaccuracies in Dr. Lawrence's statements. Several Task Force members attended the meeting, convened by the National Institutes of Health to bring together key stakeholders from the breastfeeding community and Safe to Sleep^® campaign to determine best strategies to promote safe infant sleep and breastfeeding within the parameters of the AAP's safe infant sleep recommendations. Invited speakers included a lactation consultant (International Board-Certified Lactation Consultant) and a public health official, who shared their experiences promoting both breastfeeding and safe infant sleep messages, and one Task Force member.

Before a diagnosis for SIDS is made, a complete autopsy (including examination of the heart), review of the clinical history, and death scene investigation are required. The autopsy generally includes repeat newborn metabolic screening. If any condition (e.g., metabolic disorder, heart defect) is found during investigation of a sudden, unexpected infant death that is, in the opinion of the coroner or medical examiner, responsible for the infant's demise, the cause of death will be attributed to that condition. Thus, these cases are not considered SIDS and not included in SIDS statistics. An exception is prolonged Q-T syndrome, which is unlikely to be found at autopsy; however, it is also unlikely to be detected through newborn pulse oximetry. Therefore, although these newborn screenings result in early detection and prevention of early death, because the conditions discovered through these tests have been, for the last 20 years, largely already discovered at autopsy, these mandates will unfortunately not eliminate SIDS or other sleep-related infant deaths.

Dr. Lawrence alludes to the imminent release of the Task Force's “final report.” There is no such report currently pending. We refer readers to our current (2011) Policy Statement ² and Technical Report, ³ which were approved by the AAP Section on Breastfeeding before publication. In these reports, we strongly support breastfeeding: “Breastfeeding is associated with a reduced risk of SIDS. If possible, mothers should exclusively breastfeed or feed with expressed human milk (i.e., not offer any formula or other non–human milk–based supplements) for 6 months, in alignment with recommendations of the AAP.” ²

With regard to our “vigorous” campaign against co-sleeping, we strongly support the form of co-sleeping in which the infant sleeps within arm's reach of the parent in a safety-approved, bedside bassinet, portable crib, or crib, such that the infant is within sight, sound, and/or touch. This arrangement, supported by research, reduces the risk of SIDS and can aid in breastfeeding. However, we stand firmly by our recommendation against bedsharing for infants <1 year, which is based on well-designed, peer-reviewed, case-control studies. We agree that there are circumstances (e.g., one/both parents who smoke, parent who has consumed alcohol or sedating substances, on a couch/armchair, with pillows/blankets) that make bedsharing especially hazardous (all described in the 2011 recommendations). However, there is clear and consistent evidence that bedsharing (compared with roomsharing without bedsharing) increases the risk for SIDS and sleep-related deaths, even for infants who are breastfed and whose mothers do not smoke, who are at lower risk for SIDS. A recent meta-analysis of five major case-control studies (1,472 SIDS cases, 4,679 controls) examined the association between bedsharing and SIDS, with particular emphasis on lower-risk babies (i.e., breastfed, nonsmoking mothers). Even among these lowest-risk infants, bedsharing infants were at a fivefold higher risk for SIDS until 3 months. ⁴ We feel an obligation to provide this information to families to enable them to make informed choices; to not do so is, in our opinion, irresponsible. It is our sincere hope that breastfeeding and safe sleep advocates can work together to achieve our common goals of improving infant health and decreasing infant mortality.