Monday, February 25, 2008

Unintended consequences of child "safety"

Others have written about this issue before, so I'll just recap -- if children, particularly in rear-facing car seats, are placed in the front seat of a car, the air bags in a crash can kill them. So laws were passed in the mid-1990s to require children to ride in back seats, away from the dangers of air bags.

As a consequence, now more and more children are dying of being forgotten and overheating in the back seats, particularly young children in car seats. Sometimes they fall asleep, and often it's because of a change in routine -- say, the father is supposed to drop the baby off at daycare that day because the mother is busy, and he forgets and goes to work as usual instead.

From 1990-1992, 11 children died of hyperthermia in vehicles. Now the average is 36 each year. You can find these statistics in various places: here's one.

And this increase in hyperthermia deaths is due to protection from airbag deaths -- so how many children are being saved? From 1998, there have been 113 confirmed air bag deaths (and granted that there could certainly be deaths that were due to air bags but not correctly attributed) -- of these, 66 were children, and only 15 were infants in rear-facing carseats.

So more children are dying with the new laws than were dying before; they're just dying in a different way, and with the blame on a different source (car/air-bag manufacturers vs. parents/caregivers).

This is not to say that children should not be placed in rear seats, because certainly they're safer in a car accident, and there should be installed some sort of warning system for children left in car seats, but it's an interesting (horrifying) unintended consequence of a safety campaign.

It makes me think of the recent crusades against cosleeping, trying to get parents to put their children in their own cribs, such as the Back to Sleep campaign from the National Institute of Health.

Even if we accept the argument that crib sleeping is safer than co-sleeping (and I don't), what are the unintended consequences of recommending that babies be placed away from parents?

I think there are several benefits of cosleeping and several negative consequences of sleeping apart, some of which are perhaps less measurable than others, such as trust in parents' care and thereby confidence and positive mental health later in life.

But I want to look at just one: breastfeeding. Especially considering that AAP guidelines recommend pacifier use in addition to crib sleeping to prevent SIDS, what are the short- and long-term effects of this "safety" campaign on children's health and development?

Speaking as a nursing mother who feeds her baby several times a night, I can't imagine how sleep-deprived I would be if I hadn't learned how to feed Mikko lying down. What are the rates of breastfeeding with cosleeping vs. with baby in the same room but a different bed vs. with baby in a different room? I would imagine that the farther the baby gets from the mother, the less convenient breastfeeding is. The less convenient, the more likely that night nursing decreases. This in turn can decrease the milk supply, and all of these factors together could lead to early weaning. (Research from Dr. McKenna bears this out: cosleeping babies breastfeed twice as long as noncosleepers.)

So, this begs the questions: Which is more dangerous, cosleeping (assuming it is dangerous) or failure to breast feed? Which causes more deaths and ill health, cosleeping or failure to breast feed? How many children are we purportedly saving from SIDS and suffocation only to lose to asthma, allergies, developmental problems, diabetes, cancer, infections, meningitis, obesity, respiratory illnesses, digestive problems, mental health issues, and other ill effects of inadequate feeding -- including...SIDS? (See: Health Risks of Not Breastfeeding and Formula Feeding Doubles Infant Deaths in America -- and bottle feeding is even more dangerous worldwide.)

Obviously, an apparent suffocation or SIDS death in an adult bed is more immediate and horrifying than an early-adult death years later from cancer, and it seems easier in a cosleeping death to place the blame than a baby who dies from an illness that possibly could have been prevented by breastfeeding. Some deaths are just considered worse than others, and when a baby dies because a parent left him or her in a car to overheat, or when a baby dies because an inebriated parent rolls on top of him or her on a couch, it's easy to point the finger. When a baby dies of an infection, it's the disease that gets the blame, not the parent.

The CPSC blames sleeping in adult beds for 64 infant deaths a year in the U.S., and this statistic doesn't consider whether the parents were safely cosleeping (many were absolutely not) or whether in fact some of the "suffocation" deaths were due to other factors, such as SIDS, which would surely have been fingered if these deaths had occurred in cribs. suggests that over 1,000-9,000 infant deaths in the U.S. could be prevented each year with universal breastfeeding.

Any infant death is a tragedy, and if you're one of the statistics it doesn't matter whether your baby's chances of death were great or slim. I'm certainly not suggesting that we should start blaming more parents or encourage dangerous practices since everything carries some degree of danger. But let's please start promoting practices that help parents give their babies the safest and best care. Just because babies die in rear-facing seats due to parental forgetfulness, we don't suggest that the babies not be placed in those carseats -- we simply need to come up with better ways to keep them as safe as possible. Since cosleeping leads to breastfeeding, and breastfeeding is what babies need, then we should be doing all we can to encourage safe cosleeping, not discourage the practice. It's strange that we as a society seek to avoid one type of death and thereby allow many more others.


Anonymous said...

Great Blog!

I have a blog that I just started which is dedicated to detailing the negative unintended consequences of the SIDS Prevention "Back to Sleep" campaign:

I think one of the things people should be aware of is that Dr. John Kattwinkel who chaired the AAP SIDS Task Force that changed the sleep position of U.S. infants in 1992 had a 3 day old daugher die in 1966. I think he's biased and never lets any of the unintended consequences see the light of day because he's so obsessed with preventing SIDS at all costs. Unfortunately, his personal tragedy I think makes him biased and he's still in charge of the SIDS task force to this very day 17 years later. I've only seem him make note of the death of his 3 day old daughter once in a Dartmouth Alumni magazine. Here is some other information I've found:

Back sleep (aka supine sleep) is associated with social skills delays at 6 months, motor skills delays at 6 months, deformational plagiocephaly (flat head syndrome), torticollis (tightening of neck muscles), decreased sleep duration, increase sleep awakenings, increase episodes of sleep apnea (lack of oxygen), shoulder retraction, and temperomandibular jaw disorder. Stomach sleep has none of those negative effects and also helps prevent hip subluxation, increases sleep duration by 8% to 16%, decreases awakenings by 40%, decreases infant screaming episodes, and lessens colic. The SIDS prevention "Back to Sleep" campaign statistics are misleading, overstated, and not even applicable to 99% of babies. Before 1993 over 70% of American babies slept on their stomachs, 13% slept on their backs, and the rest slept on their sides. Since 1993 there has been a 500% increase in plagiocephaly as well as a huge increase in developmental delays and disorders. If a parent decides to put their infant to sleep on their stomach they should watch them first or have the baby sleep on it's own stomach on the parents chest to see that the infant is ok. Sorry for writing so much. Good Luck.

“Since the implementation of the "Back to Sleep" campaign, therapists are seeing increasing numbers of kindergarten-aged children who are unable to hold a pencil.”
Susan Syron, Pediatric Physical Therapist

“There are indications of a rapidly growing population of infants who show developmental abnormalities as a result of prolonged exposure to the supine position.”
Dr. Ralph Pelligra regarding the impact of the Back to Sleep Campaign

Dr. John Kattwinkel is in charge of advocating the Back to Sleep Campaign and will tolerate no criticism of it whatsoever. Unfortunately, I think he is biased because of his own personal tragedy.

"Why should she be a beautiful, healthy-looking girl and be dead two days later?"
Dr. John Kattwinkel on the death of his 3 day old baby daughter in 1966

"The Academy was looking for someone who didn't have an agenda. So they chose me."
Dr. John Kattwinkel on being chosen to head the 1992 American Academy on Pediatrics Task Force on SIDS Prevention

"Federal records show a dramatic decline in reported cases of SIDS, dropping from 4,895 cases in 1992 to only 2,247 in 2004, the most recent year for which complete data is available. The records reviewed by Scripps showed that cases of SIDS virtually disappeared in some states and cities over the last several years, but closer examination of the data makes it evident that thousands of those lives have not been ‘saved,’ but rather lost under another name. Coroners and medical examiners said SIDS was responsible for nearly 80 percent of all sudden infant deaths 15 years ago and only 55 percent in 2004. What increased during this time were diagnoses that CDC statisticians labeled as "threats to breathing" and ‘other ill-defined causes of mortality.’"

Lauren Wayne said...

Hi, Tom!

Thanks so much for the information -- I'll be sure to check out your blog.

It's so interesting (and yet so sad) that there are these unintended consequences. It's usually well-meaning people behind it, but they get these "safety" agendas that often just make things worse. It reminds me of the nurse in the hospital who insisted our son needed formula because colostrum wasn't cutting it, when that's of course ridiculous -- but that kind of thing happens all the time, and can often cause true health problems (in that case, breastfeeding issues), rather than a little crankiness for a couple days.

I thought your mention of all the developmental delays was very interesting, and I have definitely heard anecdotally that many babies prefer to sleep on their stomachs. I remember my little brother did, as that was pre-SIDS campaign.

This is so awful to think about, too, but I wonder how many "SIDS" deaths are due to child abuse, and mislabeled. And I think mislabeling is what happens to a lot of cosleeping deaths, as I mentioned in my post -- a ped or coroner hears "sleeping in adult bed" and assumes that it was the adult's fault.

I feel for Dr. Kattwinkel's loss and any parent who's lost a baby -- I'm sure it does make you safety-obsessive. But it's too bad that the conclusion of the safety campaigns is not always the safest solution after all.

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