News: Bed-sharing raises cot death risk fivefold

Screams the BBC headline today, followed by "The risk applies even if parents avoid tobacco, alcohol and drugs - other factors firmly linked to cot deaths."

Several organisations have responded with statements highlighting why 15-26 year old data, collected in different countries at different time points, using different methods and definitions for data collection might not be the most reliable of evidence.  The first is a report from the fantabulous folk at ISIS, big thanks to them as they've saved me a lot of blogging time!

There's also one from UNICEF, and another from the NCT.

I think Isis cover the science side well in terms of picking apart why we shouldn't discount all the existing, contradictory studies because of this one piece, so here's a few thoughts of mine that sprang to mind:

Nestled within the study, researchers note:

• "Bottle feeding increases the risk of SIDS. When analysed as a single factor, the OR for bottle feeding is 2.9 (2.5 to 3.3), the multivariate AOR is 1.5 (1.2 to 1.8)."

But this didn't seem to make the headlines...Funny that...

Perhaps this is why the comments some have shared from parenting forums today, include those from  parents who cannot understand why anyone would consider bedsharing given the risks, whilst themselves exclusively bottle feeding?

On the subject of bedsharing and breastfeeding the researchers state:

"When the baby is breastfed and under 3 months, there is a fivefold increase in the risk of SIDS"

Cripes right!  I'm sure to make such a sweeping claim the authors must have carefully considered data surrounding breastfed infants?  

Let's check out their criteria!

"Breastfed: infant was being partially or completely breastfed at the time of death or interview." 

Meaning if the baby goes to the breast once per day for 5 mins he is, for the purpose of this study considered "breastfed", despite the fact other studies have suggested a dose related risk.  Should exclusive v mix fed be considered separately, it's entirely feasible that we would note even more statistically dramatic differences in outcome as have been highlighted in other studies.

• Suffocation or SIDS?  It seems researchers included cases where suffocation occurred, because the characteristics are similar.  Yet despite this there is no consideration for other pretty significant known risk factors:

• No mention of bedding or other variables...

Did the babies usually co-sleep and so the sleep space had been altered accordingly (removing pillows/preventing baby becoming wedged etc) or had the parent(s) brought the baby into bed occasionally or even for the first time that night?  Could any of the babies have been unwell during the day which in turn could have led to bedsharing when they typically didn't?

Were the babies swaddled?

What about room temps (which can vary massively depending upon location and are another known risk factor)   

What types of bedding were involved?

Without considering all of the above, the guideline is simply to cot sleep?  Despite the fact babies die in cots too.

As I was pondering how to conclude this post, this must read response paper plopped into my inbox - which neatly sums up all there really is to say on the subject.

So I'm going to close with some personal thoughts about sleep, based on my own two (ie entirely anecdotal).  

With number one we didn't co-sleep, we had a moses basket and then a cot.  I was exhausted from getting up frequently to feed (as newborns typically do so often!) and I nearly fell asleep numerous times during night feeds; something we know is a significant risk factor for SIDS.

Even with a moses basket you have to sit up, lean to reach them and then get up again when the feed has finished.  My daughter was windy and so often after getting settled we would have to "rinse and repeat" numerous times - all with that super responsive startle reflex young babies have when they are being lowered, arms flailing out to grasp as they panic they are being dropped.

If mum has to return to work you can see how easily the appeal of a bottle someone else can give, sleep training and a sleep "routine" become so normalised.  Indeed mothers who bed-share tend to breastfeed longer and maintain exclusive breastfeeding longer than those who do not.1–3  Therefore surely studies need to offset the increased rates of formula feeding, and thus increased risk of SIDS that may follow any recommendation that all should use cots?

The second time around we were more aware of the works of people like Mckenna, has considered different "cultural norms" and so we used a combination of a bedside cot and bed sharing between myself and the cot.  We ensured there were no gaps he could get wedged in, or soft bedding within his reach.

Night feeds were easy, no crying as I would rouse as he did.  No sitting up and getting in and out of bed meant neither of us woke fully, and thus needed much less settling (plus parents know young babies settle so much easier next to mum!).  Regardless of how many nightfeeds he had I was never shattered  - making continued breastfeeding with unrestricted night feeds easy despite returning to work part time, something UNICEF also acknowledge.

The unrestricted part may indeed be important as we also know from studies considering pacifier use that sucking to sleep can reduce SIDS risk if the pacifier is used at every sleep, indeed the Academy of Breastfeeding Medicine say:

"As exclusively breastfed infants feed frequently through the night, breastfeeding is thought to reduce SIDS by the same proposed mechanism as supine sleep and pacifiers, namely less deep sleep and frequent brief awakenings. Breastfed babies do not need artificial pacifiers to get stimulation since they already have the protective effect of suckling during the night."

A study promoted by FSID to support pacifier use also suggested increased risk of SIDS if an infant normally has a pacifier, but does not have one at the last sleep. The same may therefore potentially be true of "sleep training" a breastfed infant, if the techniques include "self soothing" or "teaching" the baby to sleep without sucking for fear of "bad habits".

Lastly we never needed to try and hinder his natural reflexes with techniques such as swaddling (something linked to increased respiratory rate 4–5).

None of this is considered in a study that didn't even separate out those exclusive breastfeeding from those having "some breastmilk", before making sweeping recommendations all babies should sleep alone.  Seriously?

References:

1. Ball HL 2003, Breastfeeding, bed sharing and infant sleep. Birth. 30(3): 181-188.
2. Blair PS, Heron J, Fleming PH 2010, Relationship between bed sharing and breastfeeding: Longitudinal, population-based analysis Pediatrics 126(5): e1119-e1126.
3. McCoy RC, Hunt CE, Lesko SM, Vezina R, Corwin MJ, Willinger M, Hoffman HJ, Mitchell AA 2004, Frequency of bed sharing and its relationship to breastfeeding Dev Behav Pediatr. 2004, 25(3): 141-14.
4. 11. Gerard CM, Harris KA, Thach BTT. Physiologic Studies in Swaddling: An ancient childcare practice, which may promote the supine for infant sleep. J Pediatr. 2002;141:398–404. [PubMed]
5. Narangerel G, Pollock J, Manaseki-Holland S, Henderson J. The effects of swaddling on oxygen saturation and respiratory rate of healthy infants in Mongolia. Acta Paediatrica. 2007;96:261–5.

FFS - UK Anti Bed Sharing Campaigns

I was stunned earlier in the week to be shown this campaign poster on the left from Hertfordshire Safeguarding Children Board.

Apparently it's not new, it has been used for around a year - and it isn't a stand alone piece of "anti bed sharing prophaganda" either.  

On the right below is a poster currently running in Birmingham:

Now on both posters the small print at the bottom clarifies that sleeping with your baby if you smoke, have had a drink or taken drugs is dangerous. 

Is that the message you instantly take from the main pictures?

The ironic thing about this second poster is that the small print confirms that a soft surface like a sofa poses the biggest risk of all - and indeed it does, but that's where mamas end up, sat trying desperately to stay awake.  The trouble is breastfeeding delivers a massive hit of hormones to both parties, which increase at night to relax and induce sleep - this can make it near impossible to stay awake, particularly if you're a tired new mum.  You can read all about the very real dangers of demonising safe bed sharing in a previous blog entry here.

But the one question I keep coming back to about these posters is why?  Why when budgets are tight and Lactation Consultant positions are vamooshing from hospitals, is money being spent on such campaigns.  Of course infant health and SIDS are hugely important, but what I mean is why pick this particular message to send?  

One might reasonably assume that bed sharing must be the biggest risk facing infants, but this simply isn't true - furthermore overlaying ie suffocation is not SIDS; a point that I think it's important to bear in mind.  

A 2009 study found that 54% of deaths occurred while the baby was co-sleeping with a parent. However:

"Although the risk was strong if they had crashed out on the sofa, it was only significant among those in a bed if the parent had drunk more than two units of alcohol or had been taking drugs."

Right so there wasn't an increased risk unless other risk factors discussed were involved.  Why don't the adverts feature a sofa and alcohol, wouldn't that send a clearer message about what is actually dangerous rather than a tiny message at the bottom?
EG:

Oh but wait, 46% of deaths were in a cot right?  

Professor Fleming, author of the research himself commented:

"You can say that half the deaths occurred while babies slept with their parents. You could also say that half the deaths occurred while babies were alone in their cots, he says, but: "I don't see anybody saying, 'Don't put your baby in a cot.'"

Quite!  Perhaps Hertfordshire or Birmingham's next campaign should be:

What's also interesting is that women most likely to fall asleep feeding are breastfeeding mothers.  Bottle feeding mums do not get the hit of sleepy hormones - and far fewer bed share anyway, so who exactly is the target audience for this ad campaign?  And what size is this audience?  Won't the vast majority of people pat themselves on the back for using a cot?

But does anyone mind if I mention at this point that non breastfed babies are at double the risk of SIDS.  Why no posters highlighting this key fact?  Perhaps the one below might suit?

No?

Can't see that hitting the surgeries any time soon can you?  Imagine the amount of people that would be upset by that message.  No, the co-sleeping posters are a much safer bet - but it's all about reducing key risks right? Consider how many people don't breastfeed compared to how many bed share and don't use a cot - which message do you think is likely to have the biggest impact on SIDS rates?

Hmmm but sending a message involving breastfeeding might mean the NHS have to step up and actually provide consistent effective support rather than being propped up by the voluntary organisations - and that would never do would it?

For the record I don't think such posters would be effective, I am not seriously putting these forward as "alternatives I would like to see".  I am attempting to highlight how inappropriate and offensive such tactics are.

What those producing posters like those at the top currently in use fail to consider, is that bed sharing is also known to protect breastfeeding rates.  Human infants feed frequently during the night and getting up, feeding, resettling can be exhausting - then we tell mums they have to stay awake when feeding, despite all the biological changes taking place to induce sleep?   Stopping breastfeeding with the belief this will create longer artificial sleep spells can follow, or because they're so scared about falling asleep feeding they mistakenly think a bottle will be "safer".  At what impact to the SIDS rate?

One study found:

Breast-fed babies develop a more energy-efficient and rhythmically functioning autonomic nervous system, which controls infant arousal, than bottle-fed babies, says Philip Zeskind, associate professor of psychology, who studied the sleep-wake patterns and heart rates of breast-fed and bottle-fed newborn infants.

"Our results suggest that the behaviors of breast-fed infants are physiologically more desirable. Feeding infants formula may make them sleep more and may disrupt the smooth running of their arousal systems."

Zeskind looked at babies in all stages of behaviour: deep sleep, dream sleep, drowsy, alert, fussing, and crying. Bottle-fed babies were found more often in the deep-sleep state, and breast-fed babies were more alert. Breast-fed babies also had lower heart rates, indicating better energy efficiency (read more here)

Indeed some sources suggest bed sharing may not be safe for those not breastfeeding - but it's easier to tackle the issue of the small number of people doing that with a blanket campaign, than it is to improve breastfeeding rates right?

As a final note - anyone find it bizarre that the angel baby in the Birmingham poster is wearing a disposable nappy?  It's great they're so gung ho about environmental issues.

RELATED POSTS: 

• Breastfeeding mums don't get less sleep! Myth Busted!
• Why sleep training is like crash dieting.
• Lucky apes can't read

Related Reading Elsewhere Online:

• Why babies should never sleep alone: A review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding

The Dangers Of Demonising Bed Sharing

To bed share or not to bed share - this is the question that is often hotly debated on parenting forums.  Guidelines often state "in a different bed in the same room", ie no sharing; which would appear to support the notion it's generally a risky business.

However what is the evidence behind these guidelines?  Explore it (including new research out this month) and we find a very different and more detailed picture about infant sleep; hence debate ensues.

The trouble is that just like the starting solids guideline - official recommendations have to be a short snappy piece of information that everyone can understand.  A guideline cannot be detailed, discuss different risk factors and provide information so parents can review and act accordingly.

Therefore don't bedshare is considered a "key" message.  A fact FSID don't dispute.

Joyce Epstein, director of FSID, says:

 "If you can get people's attention for more than three seconds you would like to give the whole story every time, but at what point do you lose everybody?"

But I'm not sure the message is actually all that safe - and here's why....

This is what the AAP guidelines actually state if you go beyond the bullet points:

"Bed Sharing 

There are some reports of infants being suffocated by overlying by an adult, particularly when the adult is in an unnaturally depressed state of consciousness, such as from alcohol or mind-altering drugs. Co-sleeping on sofas has emerged as a major risk factor in 1 study. 

Others have shown bed sharing with multiple family members in an adult bed to be particularly hazardous for the infant. Although overlying may be the mechanism in some of these cases, soft sleep surfaces, entrapment, and the likelihood of rolling to the prone position in such circumstances also may have a role. 

The risk of SIDS associated with co-sleeping is significantly greater among smokers.  Some behavioral studies have demonstrated that infants have more arousals and less slow-wave sleep during bed sharing, but no epidemiologic evidence exists that bed sharing is protective against SIDS. (remember the bold bit I will come back to that in a moment)"

But is there any evidence at all to suggest an infant is more likely to turn prone when co-sleeping than when in a cot?  Why don't the AAP tell us what the actual risks of co-sleeping are in a prepared environment ie not on a soft sleep surface (ie waterbed/pillows and heavy bedding near baby) no risks of entrapment/entanglement, no drugs/alcohol, no unplanned cosleeping ie mum falling asleep sitting up, baby next to mum alone and not in the middle of a family bed AND exclusively breastfeeding - where are these figures?

Now scroll down the AAP guidelines to "Proposed Mechanisms of SIDS":

"It is generally accepted that SIDS may be a reflection of a variety of causes of death. A leading hypothesis for a large proportion of SIDS cases is that SIDS may reflect a delayed development of arousal or cardiorespiratory control."

and

"The hypothesis is that certain infants, for reasons yet to be determined, may have a maldevelopment or delay in maturation of this region, which would affect its function and connectivity to regions regulating arousal. When the physiologic stability of such infants becomes compromised during sleep, they may not arouse sufficiently to avoid the fatal noxious insult or condition."

Right - but as nobody has done an epidemiological study to prove bedsharing is protective (remind me again where the studies are proving cot sleeping is protective?  Wasn't SIDS called cot death for long enough?), we don't acknowledge any link here? Has there been a a study proving safe bedsharing isn't protective?

Just this month a study published in Biological Psychiatry found:

"Heart rate variability in 2-day-old sleeping babies for one hour each during skin-to-skin contact with mother and alone in a cot next to mother's bed. Neonatal autonomic activity was 176% higher and quiet sleep 86% lower during maternal separation compared to skin-to-skin contact."

In basic terms this means separating mother and baby caused significantly more "anxious arousal" and less "quiet sleep".

Dr Bergman, co-author states:

"What is desirable for newborns is to have 'sleep cycling,' which means an even distribution between active sleep and quiet sleep, in periods of about one hour," 

"In our study, sleep cycling in separated babies was mostly absent, and in six of 16 babies that did show some quiet sleep when separated, it was shorter and shallower."

The scientists also noted concern that the disrupted sleep patterns and stress to the heart could make it difficult for them to form relationships.

This research addresses a strange contradiction: In animal research, separation from mother is a common way of creating stress in order to study its damaging effects on the developing newborn brain.

Dr Bergman added:

"When babies are smothered and suffer cot deaths, it is not because their mother is present.  It is because of other things: toxic fumes, cigarettes, alcohol, big pillows and dangerous toys."

 Dr. John Krystal, Editor of Biological Psychiatry, commented on the study's findings:

 "This paper highlights the profound impact of maternal separation on the infant. We knew that this was stressful, but the current study suggests that this is major physiologic stressor for the infant."

This larger study echoes what Dr Sears found when he conducted a very small experiment of his own:

"Our study revealed that Lauren breathed better when sleeping next to Martha than when sleeping alone. Her breathing and her heart rate were more regular during shared sleep, and there were fewer "dips," low points in respiration and blood oxygen from stop-breathing episodes. On the night Lauren slept with Martha, there were no dips in her blood oxygen. On the night Lauren slept alone, there were 132 dips. The results were similar in a second infant, whose parents generously allowed us into their bedroom."

Dr Mckenna has written extensively on the subject as to why he feels infants are more at risk sleeping alone - yet mainstream media and literature barely gives a nod to these significant findings.

He states:

"Mechanical breathing teddy bears placed next to apnoea-prone human newborns, which replicate what the mother’s body provides, have the effect of reducing infant apnoeas sometimes by as much as 40–60%, in addition to physically drawing infants to sleep next to them.39

Many studies similarly show that infant mammals, including human infants, appear to be pre-sensitised to receive sensory signals linking them to a co-sleeping partner.40–43  All have been shown to change infant physiology, including heart rate and breathing patterns including increased arousals yet the cessation of excessive night-time crying.

Until recently, all human infants experienced access to at least one cosleeping adult body, usually the mother 45,46 so it is not surprising that maternal contact stimulates a variety of significant ‘hidden regulatory processes’ that are clinically advantageous to infants."

Dr Mckenna has also noted the mother's sleep patterns differ when separated from her infant:

"We found that bed-sharing infants face their mothers for most of the night, and that mother and infant are highly responsive to each other's movements, wake more frequently, and spend more time in lighter stages of sleep than they do while sleeping alone.  Co-sleeping makes it easier for a mother to detect and respond to an infant in crisis."

Interestingly mum also hits more restful sleep phases for longer.

So here we have internationally recognised doctors (not just a random unqualified baby tamer who has written a book) stating actually co-sleeping may be protective against SIDS.  That cot sleep may in fact be more risky?

This all seems rather a far cry from "don't bedshare" doesn't it?

However, people are comfortable demonising bed sharing....

On 14th July 2009 here is what hit the news:

"Co-sleeping dangers.  54% of cot deaths due to co-sleeping! More than half of cot deaths happen when a baby is sleeping with a parent, a study has revealed."

At a glance that leaves many parents content they use a cot and off they go..

But even if we take this statement at face value and look no further - it's surely immediately obvious that if 54% of infants were co-sleeping, 46% were in a cot?  Hardly a compelling demonstration of cot safety?

The professor involved with this study was not happy at the headlines however. He hit back in a Guardian article days later. They reported:

"Yes – the study found that 54% of cot deaths occurred while the baby was co-sleeping with a parent. But although the risk was strong if they had crashed out on the sofa, it was only significant among those in a bed if the parent had drunk more than two units of alcohol or had been taking drugs."

Professor Fleming himself commented:

"You can say that half the deaths occurred while babies slept with their parents. You could also say that half the deaths occurred while babies were alone in their cots, he says, but: "I don't see anybody saying, 'Don't put your baby in a cot.'"

Quite!

When babies are shown to have suffocated due to a fabric comforter - the guidelines are updated to say don't use comforters.  Ditto cot bumpers and duvets/pillows under one year old.  Yet when a baby has been shown to become entangled and suffocated on inappropriate bedding when bedsharing, the guideline isn't "address the problem",  but "don't bedshare!"

There is also an underlying assumption cots are safe. This article highlight two strangulation deaths of infants with the electrical cords from baby monitors. This the risk of blind cord strangulation when unsupervised (including in cots) I have read stories of babies pulling heavy or dangerous items in on top of themselves, or worse this poor boy who died after becoming entrapped when climbing out.  Yet nobody ever suggests not using a cot, instead parents are advised to ensure appropriate measures are taken to make the area safer.

Furthermore going back to the study, if only 54% were co-sleeping to start with, once you remove known risk factors and compare the revised figure with those sleeping in a cot, the picture is very different.

What's really interesting is that same study found ONE QUARTER of infants were swaddled. A whole 25% - yet where was the news article highlighting this? Why are popular parenting books who are so anti cosleeping, still promoting swaddling without any mention of this? (nor is this the only study that has demonstrated a link as the second half of this article highlights)

Even if we move the debate away from the simple argument of which location is safer in terms of statistical outcome. We also need to consider the knock on effect, and therefore possible risks associated with where parents place their baby to sleep.

We know that when we tell parents co-sleeping is unsafe, many decide their baby will sleep in a cot. The very real danger with this is that a parent falls asleep sitting up in bed, or on a sofa. Something the above study found was a massive risk factor with regard to SIDS. Every parent of course believes they would never fall asleep when feeding - yet nature delivers a huge hit of sleepy hormones when mum breastfeeds (strange if mum isn't supposed to be sleeping on the job ;)) and despite best intentions many many mums report accidentally falling asleep - including myself (who didn't co-sleep due to ignorance and official guidelines with my first).

One mum commented she had to play with her iphone to ensure she stayed awake, others try moving from bed to an upright chair to prevent temptation.

The knock on effect of this may be minimal if you have a baby who only rouses infrequently.  Throw a frequent waker into the mix however and there is a good chance the mum will a) become overly tired which in itself is listed as a SIDS risk, b) give up breastfeeding believing she needs more sleep to function than the current (PITA) night ritual provides.

Yet not breastfeeding is not only linked with SIDS but other significant health outcomes too.  In fact the one significant risk factor the vast majority of studies fail to adjust for is feeding method ie breastfed, breastmilk or formula.  Those that have demonstrate a compelling link - therefore any that do not, are potentially fundamentally flawed from the start?  The definitions of co-sleeping and bedsharing are often blurry, known risk factors not adjusted for and so are parents really getting the big picture?

Professor Fleming shares the same concerns with regard to the "no bedshare" message::

"The study showed that sleeping with the baby on a sofa really is a risk. Yet seven of the parents whose baby died say they had gone to the sofa to feed, aware that bedsharing is said to be dangerous, and had fallen asleep.

Any advice to discourage bedsharing may carry with it the danger of tired parents feeding their baby on a sofa, which carries a much greater risk than co-sleeping in the parents' bed," 

To sum up a quote from Dr Mckenna:

"The possible hazards of co-sleeping must be assessed. Is the environment otherwise safe, with appropriate bedding materials? Do the parents smoke? Do they use drugs or alcohol? (These appear to be the main factors in those rare cases in which a mother inadvertently smothers her child.) Since co-sleeping was the ancestral condition, the future for our infants may well entail a borrowing back from ancient ways."

  UNICEF Bedsharing Guidelines

Contradictions in Tizzie Hall's response to FSID

So the feedback I'm receiving from mothers, includes a little confusion over a couple of points Tizzie made in regard to the FSID reply.  I suspect we will not receive further clarification from Tizzie, but I figured we could note the questions anyway :)  We welcome discussion via the comments section - unfortunately Tizzie has felt it necessary to censor responses on her web page so only those who do not question/disagree can reply; I am happy for everyone to have their say here as long as it remains polite and civil.  Name calling or aggressive posts will be removed.

Firstly, this is from one of my earlier posts, a point raised by Fleur and includes Tizzie's reply in red:

“On my calculation of the tog rating – Tizzie’s fans have repeatedly told me that the tog rating of her bamboo blankets is 0.64 tog x 16= 10.24 tog (apparently she has had them tested.) and a cotton sheet folded in 2, at approx 0.2 tog (x2= 0.4 tog). I also included in my calculations the toggage (made up word, lol) of the ‘safe sleeping bags’ that she sells, which will be either 1 tog or 2 tog, depending which one you choose, and the tog of the ‘double wrap’ which again, equates to 4 layers in itself (2 inside wrap pieces and 2 outside fold over bits) which again, could be anywhere from 1 tog to 4 tog, depending on the material used). I didn't include the tog of a vest, a sleepsuit or a nappy. That was how i worked out the approx 13+ tog. What Fleur has stated in her clarification is fine but adults also dress themselves similarly for bed, use a sheet and many adults sleep next to another person which provides extra warmth under their 11-13 tog duvets, yet we expect our babies to sleep in much less…….. 

So this appears to confirm that Fleur's calculation of 13+ tog was accurate?

You can see the sleeping bag and wrap that goes under the blankets here as Fleur describes.  The bedding guide states ALL infants should be swaddled until they show signs of trying to roll swaddled.

I must admit a thought I had upon watching this was how can the baby show hunger cues if they cannot get out of the swaddle? (as Tizzie claims in the clip) If babies love having their arms restricted, why would they try to get them free?  Why not swaddle with arms out so baby is comfortable and can easily demonstrate when hungry?  In the womb an infant's arms are never restricted in this way.

Tizzie goes on to say:

"My recommended range of blankets have been tested at 0.6 tog – that means we could place up to 9.8 layers of these recommended blankets over the baby. I am aware this is less than the 16 that I said was the maximum but in reality the majority of my clients don’t use that many layers. But I do not believe that a baby would come to any harm if the baby was 100% healthy, sleeping supine and with the head and face uncovered under 16 layers of my recommended blankets. You may choose to disagree… but can you show me research that can prove or deny this?

Yet on the FSID reply Tizzie states:

"I do not, for the majority, recommend covering with 10 tog or MORE of bedding. So therefore my recommendations I believe are consistent with FSID guidelines"

For the majority?  How does this make recommendations consistent.

Confused? 

Fleur was:

"The thing is, she (Tizzie) is not including the tog of the sleeping bag, the double wrap swaddle or the baby's clothing in her calculations! Yes, her layers of blankets at the maximum usage equates 9.6 togs at 0.6 tog each (although she actually had them tested at 0.64 tog each, meaning it's actually 10.24 tog), but then forgets about everything else.... A sleeping bag can be anywhere from 0.5 tog to 2.5 tog depending, (Tizzie recommends 1 tog in summer & 2 tog in winter) and then the double wrap is a special swaddle which has 4 layers over the baby, which again adds anywhere between 1 and 4 tog.... Plus a sleepsuit, vest and nappy, which would be approx another 2-3 tog, equals WAY above the 10 tog max that FSID said was a major risk!"

Some mums also questioned the statement that the majority of clients don't use that many layers.  Here is the quote from Tizzie's forum that opened the initial blog piece.

"We have noticed with the increased membership to our new forum area that there are quite a few of you who are using more than the total recommended amount of blanket layers. I know we are normally suggesting that baby’s are cold and you need to add layers, and in many cases this is correct but we do need to let you know that there is a limit to amount of layers that you should be using with your babies.
Tizzie recommends that the maximum blanket layers that should be used on a newborn to 3 month old baby sleeping in a bassinet is 10 layers, a newborn to 3mth old baby sleeping in cot is 12 layers and a baby 4 months and over is 16 layers.
Tizzie’s safe bedding guide is written on the amount of layers NOT how many tog those layers add up to."

Togs or layers?  But research generally examines tog - the recognised measurement of insulation (regardless of whether that is made of bamboo, fleece or wool!)

Too many blankets at least appears to be an ongoing issue according to other mothers.  This was taken from Tizzie's Facebook group back in March 2011 - the reply is from a frequently posting fan but despite Tizzie/her admin team moderating other posts, no warning/editing/deletion happened to this reply:

"Q ~ 'I've recently started my 7 month old on s.o.s routine. Day 4 and our nights are getting so much better. Before starting bub was waking every 2 hours sometimes less. My partner and I were exhausted. The first night he slept for 4 hours before needing to be resettled, second night was 7 hours and last night was 9.5 hours. Praying tonight is 12. Two little issues, first my boobs are killing me in the mornings now- I'm so engorged. And the second issue is that i think he is getting cold at night. I sleep him in a long sleeve onesie, a sleeping bag and a cellular blanket but he manages to wriggle out from under the blanket and when i go in to check on him he is sleeping on top of the blanket, and he is cold to touch.'

A ~ Do you have the bedding guide from the SOS website? It shows you what to dress bubs in for temps in various states. Best $9 you'll ever spend! Need to make sure everything is 100% cotton (incl. mattress protector) otherwise bubs will sweat. Most of us use many more blankets than the guide, every bubs is different eg. I'm in Sydney and in a room of 24.2C my 6m has 12 blankets on + the clothing, bag and wrap mentioned in the guide."

Copied from here

Fleur goes on to add:

"I asked about why use both before (sleeping bag AND wrap) and was told it was because it prevented babies from rolling onto their tummies much longer than 1 or the other. The FSID leaflet I have states to use one or the other, and that if the room is 18-20 then you shouldn't need any other bedding. It also has a temp guide and it's own bedding guide which says 1 cotton sheet, then as the temp gets colder, it suggests to add 1-4 layers of lightweight cotton blankets. 4 was the absolute max they advised." 

Sure enough here it is:

Tizzie then says:

"I would like to point out that if the above study was undertaken on baby’s 3 months and under, which I suspect it was then I do not recommend more than 12 layers for baby in cot and 10 layers for a baby in moses basket"

Yet the study I quoted in my previous reply showed overheating risks were elevated in older infants, not younger:

"Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days."

 BMJ 301 : 85 doi: 10.1136/bmj.301.6743.85 (Published 14 July 1990) Research ArticleInteraction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study

Could someone also clarify - are ALL Tizzie's blankets 0.6 tog? I keep reading about her "recommended 0.6 tog blanket", but she has five listed in her shop and none have the tog value labelled.

Several mums also commented on the statement:

"My confusion comes because research I have read by Monique P L’Hoir states “ we hypothesized that turning prone is prostponed when a sleeping bag was used, and even more so if the baby was tucked in with a blanket as well.”

Firstly, a hypothesis is a proposed explanation for a phenomenon - one then has to test whether the hypothesis is true for it to become evidence.  Secondly the article that contains the above can be found here but it doesn't discuss using both a swaddle and a sleeping bag and sheets and blankets; does anyone have a link to research supporting this?

Another issue not addressed is that of swaddling.  Tizzie herself directed mothers towards the International Society for the Study and Prevention of Perinatal and Infant Death (ISPID).  Their website states all mothers should be advised of the potential risks of swaddling; yet Tizzie's bedding guide that recommends all infants are swaddled and doesn't mention any risks.  They state:

"Numerous studies have documented a "tranquil" behavioural state and longer sleep periods in swaddled infants [10-14]. Thus, despite the unknown effects on the risk for SIDS, swaddling is becoming increasingly popular as a settling technique in the Netherlands, the United Kingdom and the United States [15, 16].

These findings logically suggest that infant swaddling would increase infant sleep time by preventing awakening. However this may not be a desirable outcome, as the pathogenesis of SIDS is thought to involve an impaired ability to arouse from sleep in response to a life threatening respiratory or cardiovascular challenge [17]. Arousal from sleep in infants is a hierarchical response proceeding from sub-cortical activation involving changes in heart rate and breathing, to full cortical arousal involving changes in brain activity; and this progression has been reported to be incomplete in infants who later died of SIDS [18]. Infant swaddling has been shown to minimise arousals from sleep, crying time, spontaneous startles and the progression to full arousal [1, 12, 14, 19]."

Tizzie seems to feel that FSID are led by sleeping bag companies:

"I can’t help but wonder here if it is FSID who are suggesting a sleeping bag or bedding or if it is the sleeping bag companies suggesting this…. "

and 

"They (FSID) might not have had time to do there own research and their recommendations might be based on what a sleep bag company has recommended to them. My advice is based on years of my study and observation of how babies sleep".

So perhaps FSID may clarify this?  I shall email them and ask!


UPDATE: A mum called Julie from Facebook has contacted a company called "Little Bamboo" to enquire as to the tog of their blankets. They sell a 120 x 150 cm bamboo blanket (100% bamboo with 100% cotton trim) at £14.95 here and have confirmed this is 0.6 tog (interestingly it looks very much like the blanket Tizzie lists for £46.30 here and Tizzie sells other items from the Little Bamboo range) This may be helpful to mums shopping for a cheaper alternative.

I also want to add details I have received via email - relevant excerpts below:

I've been wading through a number of research articles over this weekend (I'm an academic in a School of Public Health) 

The Fleming et al (1990) article you refer to regarding the increased risk at >10 tog clearly states that it is the COMBINED tog of BOTH clothing and bedding that needs to be taken into consideration, and as you've noted yourself, Tizzie does not include clothing or the sleep sack as part of her tog calculations. The article also indicates the relative risk increases from 8 tog, and is significantly higher at 10 tog or above.
I note that you have referred to the fact that older infants are more at risk of overheating than younger, and that Tizzie advocates putting MORE layers on older infants than younger. I thus found the following quote from Fleming et al (1990) particularly significant: 

"Unexpected findings were that among the infants who had died the older infants tended to be more heavily wrapped than the young ones, though no such trends were noted among the control infants, and that the increased risk of sudden unexpected death with overwrapping was significant for only the older infants. The higher ratio of mass to surface area in the older infants, together with their higher metabolic rates, may make them more vulnerable to the effects of increased thermal insulation".

Tizzie still does not provide any research evidence that turning prone is in response to temperature, and again in this regard is contradictory. She argues that babies are less able to regulate their temperatures effectively until they are 18 months old (again, her one size fits all approach), yet at the same time argues that babies are all apparently spinning over in a desperate attempt to get warm. Infants do in fact have the ability to thermoregulate and some research suggests they are more efficient at thermoregulation during sleep than adults. One of the risks of sleeping prone means that babies lose less heat from their bodies, so keeping them supine is obviously preferable. What is astounding is that advising placing excessive layers of blankets on a baby in fact reduces or perhaps removes the very reason why supine sleeping is protective, namely, the ability to dissipate excess heat.

I also want to copy a comment from the blog into the post:

"Not to add to your confusion: but Tizzie's understanding of tog is also fundamentally flawed, so her calculations are largely meaningless.
Tog is the level of thermal insulation offered by any one "covering device", if you will (I can't think of a better term!), and takes into account only that one garment. e.g. a 5 tog duvet is, indeed, 5 tog. However, tog can ONLY be measured in this way, by assessing the individual piece. The way that the material lies, the gaps inbetween individual layers, etc. all come into play when combining layers.
Essentially, what this means is that 2 x 2 tog does NOT necessarily equal 4 tog... and when so many layers are taken into account it's actually highly UNlikely that it would be a simple calculation. 15 x 1 tog blankets is very likely to have its own distinct tog rating of 20+ tog.
It's fundamentally simplistic and flawed thinking that makes someone like Tizzie Hall especially dangerous. Her words seem - to anyone not clever enough or simply not inclined to question - to "make sense" or be logical when they are in fact nothing of the sort. They're pseudoscience at best, outright guesses as a middle ground, and blatant lies at worst."

Tizzie Hall responds to FSID (PART 4)

Some mums have noted that comment moderation is in place on Tizzie Hall's own website - therefore I have reproduced an excerpt of her post with a link to the rest, you are welcome to comment here :)

Thank you Prof Haycock

July 30th, 2011

I would like to thank Prof Haycock for taking the time to respond to the questions posed by Analytical Armadillo in concerns to my bedding advice. My official response is below. 
FSID believes that it is vital that all parents are offered safe sleep advice which is supported by independent, peer-reviewed scientific research. Babies are all very different so it is important for parents to be aware of their baby’s temperature by feeling their tummy or the back of their neck – not their hands or feet – and if they do feel hot they should remove a layer.
Here is our advice:
1. Babies do not need hot rooms and all night heating is rarely necessary.  Keep the room at a temperature between 16-20ºC.  18ºC (65ºF) is just right.  20 degrees is what I recommend in Australia and other areas on this side of the world and after a recent trip to the UK and Ireland I will now be recommending 18 degrees for that side of the world. My advice is consistent with FSID guidelines.
2. Adults find it difficult to judge the temperature in the room, so use a room thermometer in the rooms where your baby sleeps I always recommend my parents measure the room temperature with a room thermometer to establish the ambient temperature of the room. I recommend a room thermometer in my online store.
Taken from my bedding guide –
“ I suggest having a baby’s room cooled to 22 degrees centigrade in summer (if you are using air conditioning), or warmed to 20 degrees centigrade in winter. If you do not have hydronic heating, I suggest you use an oil-filled column heater. I do not advise using ducted heating in a baby’s room due to the dust it blows around. A good way of keeping an eye on the temperature is to use a room thermometer.” Please note:  to clarify one point above, I have found that if you set your air-conditioning to 22 degrees when trying to cool a room it gives a actual room temperature of 20 degrees.
My advice is consistent with FSID guidelines.
3. When you check your baby, if they are sweating or their tummy feels hot to the touch, take off some of the bedding or clothing. Don’t worry if their hands or feet feel cool, this is normal. I clearly state in my bedding this exact same thing. Here is the direct quote - 
Please note: Using the above guides, you will still need to watch your individual baby and adjust the bedding if your baby appears too hot or cold. Here are a couple of pointers to tell if your baby is too hot or cold. 
Signs of a baby who is too hot might include:
• the baby will be waking and moaning,
• having a sweaty back
• having sweaty or wet clothes.
• Shallow, rapid breathing
Signs that your baby is too cold might include:
• Moving all around the cot
• Never laying still
• Rolling on to their tummy
• Catnapping in the day, or
• Waking from 4am (but more often 5am)
You might also need to adjust the recommended bedding depending on the humidity level where you live as well.
The sheets and blankets in your child’s cot should be made from cotton or bamboo.
Tips:
• Never tuck a sleeping bag in under the mattress because this will restrict your little one’s movement and is dangerous.
• The most important rules to remember to protect your little one from SIDS are to have a totally smoke-free pregnancy and environment for your baby, and to always place a baby in the safe sleeping position on their back to sleep
• Toddlers over 18 months appear to be better at controlling their own body temperature while they sleep so might need less bedding.
• To see how I set a cot up with bedding please visit my BLOG February 2010
My recommendations are consistent with FSID guidelines.
 4. Use lightweight blankets or a baby sleeping bag. If your baby feels too warm, reduce the number of layers or use a lower tog baby sleeping bag. In warm summer weather, your baby may not need any bedclothes at all. Do not use a duvet, quilt or pillow for babies under 12 months. 
I am confused by the word “or” used here; “Use lightweight blankets or a baby sleeping sack” My confusion comes because research I have read by Monique P L’Hoir states “ we hypothesized that turning prone is prostponed when a sleeping bag was used, and even more so if the baby was tucked in with a blanket as well.” This statement is in line with what my observations have shown. Although I have also seen that if more lightweight bedding is used this may delay the baby rolling to their tummy for even longer. I can’t help but wonder here if it is FSID who are suggesting a sleeping bag or bedding or if it is the sleeping bag companies suggesting this….
For the research see information heading 134s COT DEATH AND SLEEPING SACKS the very last line states “we hypothesized that turning prone is prostponed when a sleeping back was used, and even more so if the baby was tucked in with a blanket as well.” http://www.ispid.org/fileadmin/user_upload/textfiles/SIDSI2006finalabstractbook.pdf
My recommendations is to use layers of lightweight 100% cotton or bamboo blankets and watch your baby for signs of being too hot or too cold as stated above. From my bedding guide–
 “So why not just add more clothing under the sleeping bag and then eliminate the need for blankets? The reason I recommend using bamboo or cotton blankets along with a safe sleeping bag, and not normally using more than two layers of clothing underneath the sleeping bag, is because I feel more than two layers under a sleeping bag causes a risk of its own. You might for example, as advised by some sleeping bag manufacturers, add extra layers under your baby’s sleeping bag. Then, when you go in to check your little one at night and discover he feels too hot, you may decide not risk lifting him to remove some clothing layers because you are scared of waking him. You and I would like to think we would put safety first, but it’s important to remember that some nights we might feel too tired to risk waking our sleeping baby. In my opinion this is a far more dangerous situation than using bamboo or cotton blankets that can be added and removed as needed. On the other hand, if you found your baby was too cold without enough layers under his sleeping bag you might just grab the nearest thing – for example a quilt or polyester blanket – and throw it over your baby. A safer approach is to have the correct safe bedding at hand and educate the people who are around your baby at sleep times about how to put your little one to bed safely. My advice is consistent with FSID recommendations.
5. Even in winter, babies who are unwell and feverish need fewer clothes and bedclothes. Currently I do not have this warning in my bedding guide but as a result of this blog I have now realised that some parents are confused how to dress their babies and what to cover them with when unwell so I will be adding a paragraph to explain that less bedding and clothing is needed when a baby is unwell. My advice will be updated to include this FSID recommendation.
6. Babies need to lose excess heat from their heads. Make sure their head cannot be covered by the bedclothes by sleeping them ‘feet to foot’ (with their feet to the foot of the cot) so they don’t wriggle down under the covers.
Taken from my safe bedding guide –

• The most important rules to remember to protect your little one from SIDS are to have a totally smoke-free pregnancy and environment for your baby, and to always place a baby in the safe sleeping position on their back to sleep

And taken from my SIDS article – http://www.saveoursleep.com.au/reading/free/sids.asp Which can be found under ‘Free Reading’ on my website –
Make sure your baby’s face and head stay uncovered while your baby is sleeping. A good way to ensure this is to put your baby’s feet at the bottom of the cot so that she can’t slip down underneath the bedclothes. Tuck in bedclothes securely so they can’t become loose. Never put quilts, doonas, duvets, pillows, lambskins or cot bumpers in a cot or under the sheet covering the mattress.
My grandmother says I should put a hat on my five-week-old baby to make him sleep better. What do you think? This is a question posed to me which is on my website and my answer to the question is below – this FAQ is also in my book.
I have heard this a few times and believe it to be a very dangerous old wives’ tale. You should most definitely not put a hat on your baby to help him sleep as this could cause your baby to overheat and will increase the risk of SIDS. If your baby is too hot and needs to cool down, he will need to be able to lose that heat through his head. You may put a hat on your baby if you are outdoors in cold weather, but take it off once inside.
My advice is consistent with FSID guidelines.
 7. Babies should never sleep with a hot water bottle or electric blanket, or next to a radiator, heater or fire, or in direct sunshine. I do not recommend any of these things but do not state this in my bedding guide. My advice will be updated to include this FSID recommendation.
8. When it’s warm, you can cool the room where your baby sleeps by closing the curtains and opening the windows during the day.  Offer your baby plenty to drink, and in very hot weather, sponge them down regularly with tepid water.  Use a fan but do not place it directly onto your baby. I concur as stated in my bedding guide.
My advice is consistent with FSID guidelines.
9. Remove hats and extra clothing as soon as you come indoors or enter a warm bus, train or shop, even if it means waking your baby. I have shown an example above where I also recommend this. My advice is consistent with FSID guidelines.
10. A car can become very hot in the summer. Avoid direct sunlight on your baby.  In winter, keep the heating low, and remove your baby’s outdoor clothing.  A thermometer may be helpful. I believe we have addressed this above. I will add the point about babies getting hot in cars to my SIDS article.  My advice is consistent with FSID guidelines
Research Evidence:
The most important publication implicating over-wrapping of babies as a risk factor for SIDS is the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report ¹ which had a very large dataset. Some of the data in the report had been published before. ^2-4 In the chapter Thermal Environment and Arrangement of Bedding the authors state
 “For both the usual sleep and last/reference sleep, the SIDS infants were wrapped significantly more warmly than the control infants. The difference in the distribution of tog values remained significant when adjusted for socio-economic status. Notably twice as many SIDS infants put down for the last/reference sleep were covered by 10 tog or more bedding, and three times as many were found this way compared to the control infants.” – I do not, for the majority, recommend covering with 10 tog or MORE of bedding. So therefore my recommendations I believe are consistent with FSID guidelines. I recommend in my guide 6 layers of 0.6 tog blankets which is 3.6 tog plus a doubled over sheet of 0.4 tog totalling 4.0 tog and a maximum of 16 layers at 0.6 tog with is 9.6 tog include the doubled over sheet at 0.4 tog which is 10 tog. I note the above statement is 10 or more so I will adjust my maximum layers for a baby over 4 months sleeping in a cot to 15 layers as 16 layers equals 10 tog. I would like to point out that if the above study was undertaken on baby’s 3 months and under, which I suspect it was then I do not recommend more than 12 layers for baby in cot and 10 layers for a baby in moses basket – total 6.4 tog and 7.6 tog respectively (including doubled over sheet calculated to .4 tog) I also strongly advise my parents to begin with my recommended bedding, not my maximum bedding and watch their baby’s for signs of being too hot or too cold and add or remove the bedding as needed. My advice is 99% consistent with that of the current research outlined here  and I will adjust the maximum layers for a baby over 4 months sleeping in a cot to 15 layers of my recommended blankets.
To Note: You may argue that the ‘standard blanket layer’ is 1.5 to 2.0 tog however it is my belief that this average would have been achieved by evaluating the broad range of blankets on the market – cotton, bamboo, wool, polyester, polar fleece etc. I have not been able to find an answer to ‘what is the average tog of a cotton or bamboo blanket?’ so therefore I can only go with what the range of blankets I recommend have been tog tested too. I have made it clear in my bedding advice as taken from my bedding guide – “The sheets and blankets in your child’s cot should be made from cotton or bamboo”
 CESDI indicated that worrying about overheating might actually be protective:
“Significantly more control than index mothers worried about their baby getting too hot, suggesting a protective effect…”
It was the mothers of the SIDS infants who worried most about their baby being too cold:
27.8% of the mothers of SIDS infants compared to 15.8% of controls. I would argue that parents following my routines and advice could be more aware of the dangers of both overheating and underheating than parents not following my advice because of the emphasis and importance I stress in bedding and setting up a safe sleeping environment. I would argue that you would find my parents would be monitoring their babies on a very regular basis.


CONTINUES HERE: http://blog.saveoursleep.com/2011/07/30/thank-you-prof-haycock/#respond


You can read Contradictions in Tizzie Hall's response to FSID HERE

FSID's formal reply to request for guidance re Tizzie Hall's advice (PART 3)

As those who have been following this blog know - I recently asked both Tizzie Hall and FSID for guidance regarding bedding and SIDS.  If you missed that post you can read it here.


Tizzie Hall replied here & I responded again to Tizzie here.


FSID have now also sent me a formal reply from Prof Haycock which you can read below :)  It includes both FSID's official advice and also the relevant research supporting.  Huge thank you to FSID for taking the time to respond with such detailed information and evidence.

FSID believes that it is vital that all parents are offered safe sleep advice which is supported by independent, peer-reviewed scientific research. 

Babies are all very different so it is important for parents to be aware of their baby’s temperature by feeling their tummy or the back of their neck - not their hands or feet - and if they do feel hot they should remove a layer. 

Here is our advice:

1. Babies do not need hot rooms and all night heating is rarely necessary.  Keep the room at a temperature between 16-20ºC.  18ºC (65ºF) is just right. 

2. Adults find it difficult to judge the temperature in the room, so use a room thermometer in the rooms where your baby sleeps 

3. When you check your baby, if they are sweating or their tummy feels hot to the touch, take off some of the bedding or clothing. Don't worry if their hands or feet feel cool, this is normal. 

4. Use lightweight blankets or a baby sleeping bag. If your baby feels too warm, reduce the number of layers or use a lower tog baby sleeping bag. In warm summer weather, your baby may not need any bedclothes at all. Do not use a duvet, quilt or pillow for babies under 12 months. 

5. Even in winter, babies who are unwell and feverish need fewer clothes and bedclothes. 

6. Babies need to lose excess heat from their heads. Make sure their head cannot be covered by the bedclothes by sleeping them 'feet to foot' (with their feet to the foot of the cot) so they don't wriggle down under the covers. 

7. Babies should never sleep with a hot water bottle or electric blanket, or next to a radiator, heater or fire, or in direct sunshine. 

8. When it's warm, you can cool the room where your baby sleeps by closing the curtains and opening the windows during the day.  Offer your baby plenty to drink, and in very hot weather, sponge them down regularly with tepid water.  Use a fan but do not place it directly onto your baby. 

9. Remove hats and extra clothing as soon as you come indoors or enter a warm bus, train or shop, even if it means waking your baby. 

10. A car can become very hot in the summer. Avoid direct sunlight on your baby.  In winter, keep the heating low, and remove your baby's outdoor clothing.  A thermometer may be helpful. 

Research Evidence:

The most important publication implicating over-wrapping of babies as a risk factor for SIDS is the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report ¹ which had a very large dataset. Some of the data in the report had been published before. ^2-4 In the chapter Thermal Environment and Arrangement of Bedding the authors state 

 “For both the usual sleep and last/reference sleep, the SIDS infants were wrapped significantly more warmly than the control infants. The difference in the distribution of tog values remained significant when adjusted for socio-economic status. Notably twice as many SIDS infants put down for the last/reference sleep were covered by 10 tog or more bedding, and three times as many were found this way compared to the control infants.”

CESDI indicated that worrying about overheating might actually be protective:

“Significantly more control than index mothers worried about their baby getting too hot, suggesting a protective effect…”

It was the mothers of the SIDS infants who worried most about their baby being too cold:
27.8% of the mothers of SIDS infants compared to 15.8% of controls. 

There is no scientific evidence to suggest babies roll over because they are cold, indeed, the peak age of death for SIDS infants is 2-3 months, an age when most babies are unable to roll.

Two other studies examined the relationship between wrapping and SIDS risk, one from Tasmania ⁵ and one from New Zealand ⁶. Both of these found that the risk was only significant for infants slept prone, but the numbers were relatively small. The New Zealand study also found an interaction between over-wrapping and maternal smoking. 

There is also evidence to show that overheating interacts adversely with infection so it would be unsafe to overwrap a baby who was unwell and there are two studies that show that SIDS may occur against a background of minor illness^7-8: 

The current evidence-based advice is that over-wrapping increases the risk of SIDS especially for infants slept prone, who are unwell and for those of smoking mothers. All parents should check that their baby is not too hot by feeling their tummy or the back of their neck.  FSID encourages parents to follow the Reduce the Risk guidelines because they are supported by externally reviewed, scientific studies conducted by leading SIDS researchers. 

1. Fleming PJ, Bacon C, Blair PS, Berry PJ, editors. Sudden unexpected deaths in infancy. The CESDI SUDI studies 1993-1996. London: The Stationery Office, 2000.
2. Fleming P, Berry J, Gilbert R, Rudd P. Bedding and sleeping position in the sudden infant death syndrome. Bmj 1990;301(6756):871-2.
3. Gilbert R, Rudd P, Berry PJ, Fleming PJ, Hall E, White DG, et al. Combined effect of infection and heavy wrapping on the risk of sudden unexpected infant death. Arch Dis Child 1992;67(2):171-7.
4. Fleming PJ, Blair PS, Bacon C, Bensley D, Smith I, Taylor E, et al. Environment of infants during sleep and risk of the sudden infant death syndrome: results of 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. Bmj 1996;313(7051):191-5
5. Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med 1993;329(6):377-82.
6. Williams SM, Taylor BJ, Mitchell EA. Sudden infant death syndrome: insulation from bedding and clothing and its effect modifiers. The National Cot Death Study Group. Int J Epidemiol 1996;25(2):366-75.
7. Stanton AN, Downham MA, Oakley JR, Emery JL, Knowelden J. Terminal Symptoms in children dying suddenly and unexpectedly at home. Preliminary report of the DHSS multicentre study of postneonatal mortality. Bmj. 1978 Nov 4;2(6147):1249- 51.
8. Gilbert RE, Fleming PJ, Azaz Y, Rudd PT. Signs of illness preceding sudden unexpected death in infants. Bmj. 1990 May 12;300(6734):1237-9. 

Tizzie replies to FSID here. 

Armadillo Reply to Tizzie Hall's Official Response (PART 2)

Firstly I would really like to thank Tizzie Hall, for taking time from her schedule to reply to my blog post - and provide further information for parents who had raised concerns.  I would like to reply to some of the points Tizzie made (I have changed the lilac font Tizzie used for a darker shade to make for easier reading; blue = Tizzie Hall's official response):

Firstly, I by no means feel anything I say here is going to change anyone’s minds in regards to my advice or books.

Why would you think this Tizzie?  People have asked for further explanation for the basis of some elements of your advice - I absolutely think many are open to re-evaluating ideas should that be forthcoming.  My opinions have changed numerous times over the years as I have learnt and read more, studied more research from respected sources -  to be closed to new evidence and change is I think a potentially dangerous position, and one which underestimates readers.

Parents hear they should try to ‘exclusively breastfeed’ their baby until six months. But on the other hand allergy experts recommend introducing solids between four to six months as research is increasingly suggesting this reduces the risk of food allergies.

Exclusive breast-feeding for six months is a WHO recommendation, and is aimed at reducing serious illnesses, such as severe diarrhoea, in developing countries where contaminated water. In most of Australia, the UK and Ireland water is clean and so it’s safe to introduce solids at 16 weeks but unfortunately all the advice just makes new parents lives hard and confusing. 

I'm not entirely sure research is increasingly suggesting starting solids before gut closure reduces allergies - at least non I have seen.  Nor is the WHO guideline purely about contaminated water (although this is a common myth/misconception).  I think I have pretty much covered everything I could say on that subject here and here  which address the points made.  I do agree that is another area confusing for parents as discussed in my post; however UK guidance from the DOH, UNICEF and WHO is consistent.

So back to blanket recommendations!

"This confused one mum Fleur who posted on Facebook saying:
If you use her special bamboo blankets that she recommends, at the max 16 layers, at approx 0.6 tog each, that would put your child under a massive, surely dangerous 13.6 tog…. to put that in perspective, the average adult duvet here in the UK is 11-13 tog, which is considered ‘winter weight.’The math here is totally incorrect. IF and I say IF a parent is using the maximum of 16 layers which when using my recommended blanket is highly unlikely the total tog rating would be 9.6 – quite a difference to 13.6!"

But I clarified below how Fleur had reached 13.6:

“On my calculation of the tog rating – Tizzie’s fans have repeatedly told me that the tog rating of her bamboo blankets is 0.64 tog x 16= 10.24 tog (apparently she has had them tested.) and a cotton sheet folded in 2, at approx 0.2 tog (x2= 0.4 tog). I also included in my calculations the toggage (made up word, lol) of the ‘safe sleeping bags’ that she sells, which will be either 1 tog or 2 tog, depending which one you choose, and the tog of the ‘double wrap’ which again, equates to 4 layers in itself (2 inside wrap pieces and 2 outside fold over bits) which again, could be anywhere from 1 tog to 4 tog, depending on the material used). I didnt include the tog of a vest, a sleepsuit or a nappy. That was how i worked out the approx 13+ tog. What Fleur has stated in her clarification is fine but adults also dress themselves similarly for bed, use a sheet and many adults sleep next to another person which provides extra warmth under their 11-13 tog duvets, yet we expect our babies to sleep in much less…….. 

Just to be clear then - Fleur's maths is correct? As when she clarifies how she came to this you state it is fine.  So (I think) we have 13.6 confirmed approximate tog (based on your recommended 0.6 tog blanket), NOT including a vest, sleepsuit or nappy - so can we potentially add another 3 tog there?

" My recommended range of blankets have been tested at 0.6 tog – that means we could place up to 9.8 layers of these recommended blankets over the baby. I am aware this is less than the 16 that I said was the maximum but in reality the majority of my clients don’t use that many layers. But I do not believe that a baby would come to any harm if the baby was 100% healthy, sleeping supine and with the head and face uncovered under 16 layers of my recommended blankets. You may choose to disagree… but can you show me research that can prove or deny this?

Yes this would be 6 layers less than your recommended maximum (not including clothes).  Whether the "majority of your clients use that many layers" is I think an aside, as using your guidance they could.  It appears as though you are asking me to show research that can prove or deny your statement you don't believe a baby would come to harm under heavier tog - but with all due respect I think the onus should really be on the person giving advice to present the evidence supporting it?

However, I  have found something that I think is appropriate:

BMJ 301 : 85 doi: 10.1136/bmj.301.6743.85 (Published 14 July 1990) Research Article
Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study.

From the study:

RESULTS: Compared with the control infants the infants who had died from the sudden infant death syndrome were more likely to have been more heavily wrapped (relative risk 1.14 per tog above 8 tog; 1.03 to 1.28; p less than 0.05), and to have had the heating on all night (relative risk 2.7; 1.4 to 5.2; p less than 0.01)
These differences were less pronounced in the younger infants (less than 70 days) than the older ones. 

CONCLUSION: Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days. Educating parents about appropriate thermal care and sleeping position of infants may help to reduce the incidence of the sudden infant death syndrome.

From your webpage: "In the UK parents put a lot more clothing on their babies at night, and I believe the temperature of their homes is actually warmer than the night time temperature in most of the homes I visit in Australia. In the UK they have a different type of central heating which keeps the house at a more even temperature throughout the night.

I am not sure if it is even the warmth the babies like or if it is that with more layers on they feel cosier and more secure. But I do know that the extra layers can stop babies from waking at night."

But surely you need to be pretty sure it's the warmth to make the recommendations you do?  

Your comments re blankets I found a little confusing, as in your original statement it said:

"We have observed that many of you have been trying to achieve the total tog of the Save Our Sleep® recommended blankets with other brand blankets but we do not advise that you do this. This is because you need to use too many layers of other blankets to achieve the same warmth as the Save Our Sleep® blankets for your baby to sleep safely."

"If you do a search on the average tog of a blanket it is 1.5-2 tog, as stated above. My recommended blankets have been tog tested to 0.6 tog I have had other blankets tog tested and some blankets have come back with results of 0.2 tog and one blanket came back at 4.5 tog "

But if your blanket is 0.6 tog, compared to the average figure you quoted of 1.5-2 tog of a standard blanket, why would the mothers need more standard blankets to achieve the same warmth?  Surely they would need less?  You stated above 16 x 0.6 = 9.6 tog, whereas 16 x 1.5-2 (the figure you quoted as the tog of a standard blanket) comes to 32 tog based on 2 tog blankets.

Are we now disputing average tog rating is 1.5-2 per blanket?

"Analytical Armadillo are you trying to imply that the one and only reason I recommend layering blankets if for financial gain…..really? If this would be putting babies at risk would this not be professional suicide on my behalf…? What could I possibly have to gain from that? I am trying to keep this professional but implying financial gain is my main goal while risking baby safety is insulting."

I don't think I implied any such thing, other than this is the price of the blankets and buying a lot would work out expensive.  I think this is something you acknowledge yourself Tizzie as I've seen you state on FB if people can't afford the blankets they are better buying second hand from other mums than to use an alternative brand? 

"Secondly In order to state using different brands or more blankets is unsafe – one must have identified and proven (i.e. tested) what is safe?"

"The weight of the blankets I recommend are the same as a blanket I have had tested which came back at 0.2 tog. To get the same warmth you might have to use 20 blankets but the weight would be far too much to have on a baby and in my opinion would be unsafe so this is why I suggest using the blankets I have tested because you can use less blanket which in return is less weight on the baby but the same warmth."

Well yes, if you used 0.2 tog blankets it of course follows you would need more than if using 0.6 tog; however until now the average tog rating of a blanket has been discussed at 1.5-2 tog. I'm not sure how the fact yours weighs the same as one blanket you tested at 0.2 is really relevant, because according to an "average", it also has to mean a significant amount on the market are a lot warmer than 0.2 tog to obtain a 1.5-2 average? Therefore it also potentially means people could use less blankets (and therefore less weight) to obtain the same warmth as with (your recommended) 0.6 tog blanket?  Say this one at 3.7 tog or the ones they refer to at the bottom of the page ranging from 1.7-2.6 - then parents could just add a thinner layer or two if required?

"To get the same warmth you might have to use 20 blankets but the weight would be far too much to have on a baby and in my opinion would be unsafe" -  The logic of mothers need far more of another brand is only applicable though when comparing to the specific (unidentified) blanket you tested at 0.2.

To go back to my orignial question how have you decided upon 16 layers - not 15 or 17?  ie how via observation does one calculate X amount is unsafe via Y not being?  I genuinely struggle to see how this could be established via observational means unless you have observed infants have suffered at 17 layers?  Have you weighed 15 blankets v 17 and established 16 was a safe weight and if so how?  Did you record these observations, create data you can share? (I think this is what parents are asking)

"I do have evidence it is just not in a formal official paper, perhaps observations is a better term. I would be more than happy to help FSID or SIDS and Kids in Australia conduct further study into the effect of thermal layering and SIDS as long as they also investigated my belief that a cold baby will roll to the prone position as soon as he/she possibly can."

Yes I think perhaps observations is the only term if you don't have "paper evidence" - because evidence is by definition something that furnishes proof which anecdotal evidence does not.  I think it really is key we appreciate the difference - ie I could observe locally that the rate of gastroenteritis wasn't higher in non breastfed infants, luck of the draw could mean the group of infants I happened to deal with don't contract the illness.  In contrast masses of "paper evidence" that explore large numbers to an appropriate scientific model, find that rates are increased even when numerous other factors are accounted for, and other research exploring the constituents of breastmilk fills the gaps as to why.   The point is unless we know how these observations were noted, what factors were accounted and controlled for, who the study group was and so on and so forth - observations are pretty meaningless; they needed to be clearly identified as opinion, not evidence based guidelines.

A number of mums on Facebook have also commented that their infants rolled prone as soon as possible completely unrelated to temperature - they did the same in the hot temperatures of Spain as they did the UK.  Some also noted their children had shoulder/neck discomfort which is surely another viable reason why an infant may not want to back sleep?

I'm also not sure that because an infant loses less thermal heat when prone - we can therefore assume this means they roll when cold (although it indeed may!) or demonstrates safety of increased layering supine.  If thermal heat is less well retained when baby is on back - this is absolutely an interesting factor that should be taken into account when conducting research.  But we also have to filter in to the big picture other associated risk factors I think, such as feeding method, central heating and also fully explore co versus cot sleeping (particularly given the experiment Sears conducted on his daughter's oxygen sats).  I'm not sure we can cherry pick bits we feel are more relevant and discount the rest.

"My recommendation of a room temp of 20 degrees falls within these parameters, and after my recent trip home to Ireland I will also be editing my recommendations for this area and saying that ideal room temperature in Ireland and the UK is 18 degrees. I fully support the statement that too much bedding, clothing or possibly (but not proven) more importantly the incorrect material of bedding and clothing can cause thermal stress. However my recommendations will NOT cause a baby to overheat. I clearly state in my bedding guide what signs a parents should look for in a hot baby and a cold baby and to adjust the layers accordingly. I have not found using only my recommended bedding ( a 100% cotton mattress protector, 100% cotton or bamboo sheets, all 100% cotton or bamboo clothing and only 100% cotton or bamboo blankets) within my guidelines to cause a baby to get too hot. Of course each baby is different which is why I have written my bedding guide and encourage parents to only try more bedding one layer at a time if their baby continues to shows signs of being cold."

I think it's excellent you are updating your recommendation to sit with current government guidance.  I think the problem is though Tizzie, that whilst you clearly state your recommendations will NOT cause a baby to overheat, mothers need hard evidence, from appropriately qualified people demonstrating this.  Also the feedback from some mothers on your FB group (and on another discussing your advice) seems to be that their infants did get very hot and a not insignificant number repeatedly wriggled out of blankets.  If an infant does indeed roll when cold, surely they can also attempt to remove themselves from some layers if they're hot?  But tips were given to tuck the blankets in more firmly..  Also on your group when mothers have reported continued waking - an often noted response from other fans is "try another layer or two of blankets" - not "did your baby feel cold"; which would seem a much more appropriate response?

Lastly I also note the bedding guide states you recommend swaddling infants until they show signs of wanting to roll over - yet this also now seems recognised as a potential SIDS risk factor too?  From the link you shared (ISPID):

Parents should be aware of the potential risks of swaddling their infant, particularly of the use of heavy materials for swaddling.

• Current research suggests that it is safest to swaddle infants from birth and not to change infant care practices by beginning to swaddle their infant at 3 months of age when SIDS risk is greatest.

Do you make parents aware of potential risks and also clarify they should not commence this practice if they find your advice after the newborn period?

Another relevant point from the same source:

Numerous studies have documented a "tranquil" behavioural state and longer sleep periods in swaddled infants [10-14]. Thus, despite the unknown effects on the risk for SIDS, swaddling is becoming increasingly popular as a settling technique in the Netherlands, the United Kingdom and the United States [15, 16].

These findings logically suggest that infant swaddling would increase infant sleep time by preventing awakening. However this may not be a desirable outcome, as the pathogenesis of SIDS is thought to involve an impaired ability to arouse from sleep in response to a life threatening respiratory or cardiovascular challenge [17]. Arousal from sleep in infants is a hierarchical response proceeding from sub-cortical activation involving changes in heart rate and breathing, to full cortical arousal involving changes in brain activity; and this progression has been reported to be incomplete in infants who later died of SIDS [18]. Infant swaddling has been shown to minimise arousals from sleep, crying time, spontaneous startles and the progression to full arousal [1, 12, 14, 19].

How do we know this isn't also why infants with extra blankets stop waking?

Ultimately, I wonder how much is down to different fundamental beliefs about infant sleep..  Are young infants meant to sleep for huge stretches? (despite this currently being the social trend and most acceptable to the expectations of the majority of mothers, ie what sells).  It's rarely what happens as the norm for breastfed infants without some sort of training, which it surely would be if that's how infants were supposed to sleep.  We also know some mothers can struggle to maintain a milk supply and an infant their weight gain if night feeds cease early (prolactin levels are highest at night).  In younger infants longer/deeper sleep spells have also been linked to SIDS and it seems normal, if not desirable for an infant to rouse and signal frequently.  I'm not for a second suggesting anyone leaves an infant cold, but I'm not sure an infant not waking because they are hotter therefore shows this baby is more content or even was cold!  Infants can sleep longer sleep spells for other reasons - a drop in calories is a perfect example.  We could (as many parents do) assume the infant would wake if hungry, the fact they're sleeping long spells shows they must be happy!  In reality the infant starts to conserve energy and the consequence is a long sleep spell - perhaps long sleep is a consequence of too much bedding?

In contrast Tizzie feels:

"I am not sure if it is even the warmth the babies like or if it is that with more layers on they feel cosier and more secure. But I do know that the extra layers can stop babies from waking at night."

The expectation is sleep patterns comparable to that of an adult and if this doesn't happen there must be a reason, something that needs "fixing".

I would encourage readers to check out the full reply here: http://blog.saveoursleep.com/2011/07/28/in-responce-to-%E2%80%98the-analytical-armadillos%E2%80%99-blog/


REPLY RECEIVED FROM TIZZIE HALL:
Tizzie has notified me via email that she will not be responding further to any questions or discussions on this or other topics raised in her books.  I have been silenced from sharing any further details as she insists the email remains confidential; the only bit I am allowed to share is that she would not be answering further questions from myself or other bloggers.

COMMENT FROM DR FLANDERS MD, FRCPC

"Tizzie may or may not realize that she is attempting to manage quite a conflict of interest. When one stands to profit financially from the advice one offers, it becomes very difficult to maintain credibility. Medical advice NEEDS to be derived from solid scientific research that is free (to whatever extent possible) from bias. Tizzie may feel like she's contributing meaningfully to society by 'keeping babies safe' with her blankets. But the subconscious (perhaps conscious) drive to profit financially can undermine this ideal. There is a long and unfortunate history of industry tainting medical science, which repeats itself over and over again. Most recent case in point: http://nyti.ms/qZwZuh
Do be careful, Tizzie."

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What do you think?  Do you feel reassured by Tizzie's reply?  Has it brought anything to the table you weren't aware of and which makes sense to you? Let me know below :)

Related Posts:

Tizzie Hall & FSID, a formal request for information please

FSID's formal reply to request for guidance re Tizzie Hall's advice