ILCA Responds to Policy Statement by AAP Task Force on SIDS

The sudden unexpected death of an otherwise healthy infant is a tragedy no family should have to experience. In an effort to continue to reduce rates of sudden infant death syndrome (SIDS*) in the United States, the American Academy of Pediatrics Task Force on SIDS has issued a revised set of recommendations that have provoked controversy because of their potential impact on breastfeeding families. 1 Specifically, concerns about the new recommendations to increase the use of pacifiers and to discourage bed sharing have been raised by the Academy of Breastfeeding Medicine, as well as other breastfeeding advocacy groups. 2-4 Because these recommendations will be used to determine standards of practice among physicians, it is important that lactation consultants understand their basis and significance for breastfeeding families.  

The International Lactation Consultant Association (ILCA) recognizes that much of the controversy surrounding the recommendations results from inconsistency in research findings related to breastfeeding and pacifier use, bed-sharing/co-sleeping and SIDS. Inconsistent results in breastfeeding related research often occur due to lack of a clear definition of breastfeeding. 5 Comparing children who were "never" breastfed to those who were "ever" breastfed combines highly varied practices into the same groups, potentially mixing children who breastfed once in the hospital with those who exclusively breastfed for several months. Well-designed research trials should define both exclusivity and duration of breastfeeding. 5 Very few of the dies cited in the AAP policy statement defined either exclusivity or duration. The baby who is exclusively breastfed for 6 months is the appropriate reference model. 6,7

There have been many studies examining the association between pacifier use and breastfeeding duration among both term and preterm infants.  Many of the observational studies indicate that pacifier use, at any stage of lactation, is associated with reduced breastfeeding exclusivity or duration. 8-18 However, randomized controlled trials indicate that pacifier use, after the first month postpartum, is not significantly associated with shorter breastfeeding duration. 19-21    It is possible that pacifier use is an indicator for breastfeeding difficulties rather than a cause of problems or that other factors contribute to both pacifier use and early weaning.  On the basis of the evidence from the randomized trials examining the association between pacifier use and reduced risk for SIDS, 22 the AAP committee recommended that pacifiers be avoided by breastfeeding families in the first month postpartum to ensure that breastfeeding is well established.  Lactation consultants will play an important role in ensuring that pacifier use after the first month does not interfere with successful lactation.  

ILCA applauds the AAP for recommending sleeping in close proximity to one's infant to reduce risk of SIDS. Advising against any bed-sharing for the breastfed infant is highly controversial. 7,23 The breastfed infant is more likely to sleep supine and suckle frequently through the night, naturally achieving the potentially SIDS reducing goals of less deep sleep and frequent brief arousals.  Given the need for night feeds in the early months postpartum, bed-sharing is used as a means by parents to reduce the time they spend awake during the night.  In a study of over 10,000 families, breastfeeding parents were 3 times more likely than bottle-feeding parents to bed-share. 24   The potential effects of the guidelines on breastfeeding duration and exclusivity have yet to be explored.  It is important that lactation consultants educate themselves about all the options for sleeping arrangements for families and to follow-up on any breastfeeding-related concerns. 

ILCA continues to recommend exclusive breastfeeding for 6 months followed by the addition of complementary, age-appropriate solids and continued breastfeeding for 2 years and beyond. In keeping with the new AAP guidelines:

· Pacifiers should be avoided until breastfeeding is well established.
· Mothers who are having difficulty with breastfeeding should be closely monitored, particularly if they choose to use pacifiers.
· Infants should sleep in close proximity to their mothers though not necessarily in the same bed.
· Further research is needed on the sleeping practices of healthy infants and the association between co-sleeping and infant feeding patterns.
· Infants should never sleep with other children, with parents who smoke or abuse drugs or alcohol, on couches or other locations where entrapment might occur.
· Infants should always be placed on their backs to sleep, on a firm mattress without any pillows or other soft, loose bedding.  

Community education efforts should focus strongly on increasing exclusive breastfeeding for the first 6 months of life, decreasing parental smoking and smoking during pregnancy and educating parents, non-parental caregivers and hospital staff about the dangers of non-supine sleep positions for infants.

While the new guidelines remain controversial, the recommendations to avoid pacifiers in the first month and encourage parents to sleep in the same room with their infants are positive steps toward the promotion of breastfeeding.  Lactation consultants must continue to call for research in these important areas of SIDS prevention.  As the evidence-base grows, it will be the responsibility of the AAP to refine their guidelines in line with research outcomes.

The International Lactation Consultant Association is a worldwide network of lactation professionals. For more information on increasing exclusive breastfeeding, see ILCA's Clinical Guidelines for the Establishment of Exclusive Breastfeeding published in 2005, available at www.ilca.org .

1. AAP Task Force on Sudden Infant Death Syndrome. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding Sleeping Environment, and New Variables to Consider in Reducing Risk. Pediatrics November 2005; 116(5):1245-1255

2. Academy of Breastfeeding Medicine. Breastfeeding Is Associated with a Lower Risk of SIDS.  http://www.breastfeedingtaskforla.org/SIDS/AAP-SIDS-ABM-response.htm

3. La Leche League International. LLLI Responds to AAP Policy Statement on Sudden Infant Death Syndrome  http://www.lalecheleague.org/Release/sids.html

4. US Breastfeeding Committee. Mixed Credibility of the Revised AAP SIDS Prevention Recommendations. http://www.usbreastfeeding.org/News-and-Events/USBC-SIDS-PR-10-17-2005.pdf

5. Labbok MH, Coffin CJ. A call for consistency in definition of breastfeeding behaviors. Soc Sci Med 1997; 44:1931-1932.

6. World Health Organization. The Global Strategy for Infant and Young Child Feeding, 2003.World Health Organization, Geneva.

7. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, et al. Breastfeeding and the use of human milk. Pediatrics 2005; Feb 115(2), 496-506.

8. Vogel AM, Hutchison BL, Mitchell EA. The impact of pacifier use on breastfeeding: A prospective cohort study. J Paediatr Child Health. 2001; 37: 58-63.

9. Ullah S, Griffiths P. Does the use of pacifiers shorten breastfeeding duration in infants? Br J Community Nurs. 2003; 8: 458-463.

10. Soares ME, Giugliani ER, Braun ML, Nunes Salgado AC, De Oliveira AP, De Aguiar PR. Pacifier use and its relationship with early weaning in infants born at a Child-Friendly Hospital. J Pediatr (Rio J). 2003; 79: 309-316.

11. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics. 2003; 112: 607-619.

12. Gorbe E, Kohalmi B, Gaal G, Szantho A, Rigo J, Harmath A, Csabay L, Szabo G. The relationship between pacifier use, bottle feeding and breastfeeding. J Matern Fetal Neonatal Med. 2002; 12: 127-131.

13. Binns CW, Scott JA. Using pacifiers: what are breastfeeding mothers doing? Breastfeed Rev. 2002; 10: 21-25.

14. Levy SM, Slager SL, Warren JJ, Levy BT, Nowak AJ. Associations of pacifier use, digit sucking, and child care attendance with cessation of breastfeeding. J Fam Pract. 2002; 51: 465.

15. Marques NM, Lira PI, Lima NC, da Silva NL, Filho MB, Huttly SR, Ashworth A. Breastfeeding and early weaning practices in northeast Brazil: a longitudinal study. Pediatrics. 2001; 108: E66.

16. Aarts C, Hornell A, Kylberg E, Hofvander Y, Gebre-Medhin M. Breastfeeding patterns in relation to thumb sucking and pacifier use. Pediatrics. 1999; 104: e50.

17. Barros FC, Victora CG, Morris SS, Halpern R, Horta BL, Tomasi E. Breastfeeding, pacifier use and infant development at 12 months of age: a birth cohort study in Brazil. Paediatr Perinat Epidemiol. 1997; 11: 441-450.

18. Nelson E, Ly-Mee Y, Williams S, and the International Child Care Practices Study Group Members. International Child Care Practices Study: Breastfeeding and Pacifier Use. Journal of Human Lactation 2005; 21: 289-295.

19. Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effects of bottles, cups, and dummies on breastfeeding on preterm infants: a randomized controlled trial. BMJ, doi: 10.1136/bmj.38131.675914.55 (published 18 June 2004).

20. Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, Jane F. Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial. JAMA. 2001; 286: 322-326.

21. Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, Lawrence RA. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics. 2003; 111: 511-518.

22. Hauck FR, Omojojun OO, Siadaty MS. Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A Meta-analysis. Pediatrics November 2005; 116: e716-721.

23. McKenna JJ, McDade T. Why babies should never sleep alone: A Review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Pediatric Respiratory Reviews 2005; 6:134-152 (available on line at www.sciencedirect.com )

24. McCoy RC, Hunt CL, Lesko SM et al.  Frequency of bedsharing and its relationship to breastfeeding. Developmental and Behavioral Pediatrics 2004; 25: 141-149.

            URL: http://www.pediatrics.org/cgi/content/full/113/5/e435

*The term SIDS also refers to sudden unexplained infant death (SUID).