Last week we received a number of questions about a statement released by a group of parents of children with disparate neuropsychological issues. The parents claimed that their children’s symptoms began after they began taking the over the counter laxative Miralax (polyethylene glycol 3350) and that the medication was at fault. Miralax is approved only for use in those age 17 or above, and the parents have expressed concern that they were instructed to give their children the laxative not approved for use in their age group.
This was cause for concern for many parents, especially those whose children have dealt with constipation. To answer our reader questions we reached out to François Lavallée, a pharmacist in the province of Quebec, Canada and who is also the father of two young children. Matthew Hartings, a professor of chemistry at American University in Washington, DC (and a dad as well), helped out with some of the chemistry.
We have received a number of questions from concerned parents about this story. Thank you for taking the time out of your schedule to speak with me.
I can see why parents would be concerned. I’m a parent myself and nobody wants to put their kids at unnecessary risk. I don’t doubt that the children of the parents coming forward have neuropsychological issues. When you are the parent to a child with neuropsychological issues, depending on the severity, it is very hard both physically and emotionally. I think what they are doing is noble because they want to prevent other children from experiencing something similar, but I’m not sure that the chemical component in Miralax, polyethylene glycol (PEG) 3350, is what has caused the symptoms they are describing.
Right now the symptoms that are being disclosed publicly by the parents are a little vague and aren’t consistent with each other. Some describe, the development of aggression and paranoia, others describe motor issues such as ticks. Usually when symptoms are caused by something children are exposed to there’s an identifiable pattern. It would be so simple if it were the case here, we could just ban that substance and be done with it.
In reality, considering the diverse symptoms reported at this time there is probably more than one cause. What makes it more difficult is that in some cases the individuals are now adults and are claiming the exposure as toddlers caused their symptoms. It is incredibly difficult to pinpoint a cause ten or fifteen years after the onset of symptoms. There may have genetic predispositions to some of these issues or the symptoms may have been acquired through another exposure through food, air, water, or other drugs.
I think parents need to exercise caution when they read things like this online. These articles often lead to really shocking information that’s completely out of context. The important context is usually at the bottom, but they know that most people don’t read articles all the way through. These websites prey on parents’ fears for clicks, and can cause them to panic when they don’t have to.
I think part of what makes this so shocking is the claim that the same chemical that’s in anti-freeze is also in a laxative that parents have been giving their children. Can you tell me a little more about PEG 3350 and antifreeze?
First, it’s important to know that this is not the same chemical that’s in antifreeze, but it is easy to confuse the two. Their names sound very similar. A number of the articles have confused the two chemicals which is why I really think parents need to exercise caution when reading things like this online.
Ethylene glycol is the chemical that is in antifreeze, it is highly toxic and we see kids sometimes ingest it accidentally if it’s in the garage or not properly secured because it has a sweet taste to it. Polyethylene glycol or PEG starts with “poly”, a prefix meaning “many” or “multiple”. In this case, it means many ethylene glycol molecules linked together, which makes it a different chemical, with different properties. As you can see here, the two chemicals have the same basic ingredient, simply repeated “n” times in the case of PEG:
Ethylene glycol: C2H4O + H2O → HO–CH2CH2–OH
Polyethylene glycol: HOCH2CH2OH + n(CH2CH2O) → HO(CH2CH2O)n+1H
Even though it is the same basic molecule as ethylene glycol repeated many times, PEG molecules have very different properties, depending on how many are linked together. The number 3350 refers to the weight of the molecule, which is an indication of its size, in this case, it’s a large molecule. PEG can be as small as 400 and as large as 15,000, but 3350 is a large molecule. The larger a molecule, the less likely it is to be absorbed by the body.
The weight of the molecule is very important. PEG 3350 behaves differently than PEG 400 does, and differently than Ethylene glycol does. What is applicable to one molecule may not apply to another. PEG 3350 is a very stable molecule, which means that it doesn’t change its state (or break down) easily.
Is it possible through some mechanism, that Polyethylene glycol is responsible for the development of the neuropsychological issues in children?
I would be very shocked if the symptoms were caused by PEG 3350. Because of PEG 3350s size, our body isn’t able to absorb it. Given these properties, it is highly unlikely that it causes these neurological symptoms. I did a review of the literature before we spoke and there’s nothing that supports PEG 3350 with lasting side effects or that explains how it could potentially cause it. Most reported side effects are linked to its laxative properties: abdominal discomfort, cramps, bloating, diarrhea.
The hypothesis put forward by some is that if improperly stored PEG 3350 breaks down into ethylene glycol and that this degradation combined with prolonged exposure in chronically constipated children causes the symptoms being reported. I am skeptical of this hypothesis due to the stability of PEG 3350. As I mentioned before PEG 3350 is very stable, so it would take a lot for it to break down due to improper storage.
I do understand that in 2008 trace amounts of ethylene glycol (15 µg/ml) were found in eight bottles of Miralax. This is a very small amount and is essentially harmless to an adult. But the question is, is that amount enough to cause problems in a child, especially if the child is exposed daily and over a long period of time (for example years). This is not something that I know the answer to as ethylene glycol toxicity is usually seen in the hospital, so I asked Matthew Hartings, a professor of chemistry at American University in Washington, DC.
Matthew confirmed what I thought, which is that the dose found in the bottles is not enough to be toxic to a child in a single dose. Matthew calculates that for a child to consume a toxic dose of ethylene glycol at the doses found in the bottles, they would need to consume 1L of the powdered product. The product isn’t available for retail consumer purchases in packages that large. He also says that ethylene glycol does not bioaccumulate so it’s unlikely that prolonged exposure to ethylene glycol could cause problems through that mechanism.
Matthew and I both agree that the ethylene glycol should not be in the bottles period and it’s not a good thing and it’s unacceptable that the manufacturer couldn’t account for how it got there. It’s never a good thing when something that shouldn’t be in a product winds up in it, even if the dose isn’t enough to cause harm.
So what exactly does PEG 3350 do, and why is it in laxatives?
It’s an osmotic laxative, which means that it attracts water. Our intestines are very good at absorbing water, which is part of their jobs, but when a child (or an adult) becomes constipated their stools become very hard with very little water in them, and it makes them difficult and sometimes painful to pass. PEG 3350 holds water in the intestines which allow the stool to soften, which makes it easier to pass normally. It is a passive laxative, which means that it doesn’t cause the intestines to contract or actively push stool through. This is why it has been used so much for children. It is important to note that the main reason why it can express an osmotic force to retain water in the intestines is that it isn’t absorbed by the body. It goes right through, from one end to the other.
Part of the concern seems to be that a medication that is only indicated for adults has been used for children, why has it been recommended off-label for use in children?
We knew that it is safe as a one-time use to empty a child’s bowels before a procedure. As we know it is safe in a large dose at one time, some doctors and pharmacists started to extrapolate that knowledge and say, maybe it is safe in a small dose over a longer period of time.
At the beginning of my career, I didn’t see PEG 3350 used very much in children in part because the product was new to the market. At first I started seeing individual clinics using it and then [a large area pediatric hospital] started using it, shortly after it became much more common.
This isn’t to say that PEG 3350 hasn’t been studied in children. It has been studied extensively and has shown to be safe and more effective than a placebo. But it hasn’t gone through the same level of trials that we require before approving a drug for adults. I know in the United States the Food and Drug Administration (FDA) is funding a study of the long-term safety of the use of PEG 3350 in children with chronic constipation, at the Children’s Hospital of Philadelphia (CHOP), but I don’t know what prompted the study. I see it as a good thing that can help confirm safety in longer-term use. The more studies we have, the more confident we can be in a product’s safety.
I think a lot of parents are wondering why doctors are recommending medication for children that isn’t approved for children.
As you know, it’s very difficult to get approval to test drugs on children. It’s pretty obvious why. Would you allow someone to test a drug on your child? You don’t know what the drug will do to your child. No one would sign their child up for that. It’s not ethical, so we don’t test drugs on children in large trials. Unfortunately what this means is that we sort of test things in the real world. We take that little bit of information that we have in one area and we extrapolate it and then we report on what we find until we have enough data to have something similar to a clinical trial, then there’s usually a reclassification.
Additionally, and this is unfortunate to say, there isn’t a lot of money in pediatric drugs for large pharmaceutical companies. Kids are only kids for a little while, so it doesn’t offer a good return on investment for them. Another deterrent for companies to invest and develop drugs for kids is that they don’t like to be sued, so they will usually go for the safest patients to treat: Adults with functioning kidneys and liver. Kids, the elderly, pregnant women, people with kidney or liver disease, are all populations that are less researched, so treatment is trickier.
As companies hate to get sued, they will put on their labels only what they studied and they know it is safe. That is common sense. But when a label says “Use for no more than 7 days without a doctor’s advice”, it doesn’t mean the product is poison if used for 8 days. It means if you need to use it for longer, you might have a more serious issue and should be examined by a doctor. Once you’ve been examined and it has been confirmed that everything is in order, under the doctor’s advice, you can use the product for longer, as long as there is a proper follow-up.
What are some things that parents can do to manage constipation at home if they don’t want to use an over the counter laxative like Miralax?
The most important thing is that parents talk to their doctor or pharmacist first if they have concerns about chronic constipation in their children. They best know your child’s medical history and are most familiar with the various treatment options.
With that said, there are some first-line defense options that parents can try at home if they have a concern about acute constipation. These are things like prune or pear juice, or simply adding more of these fruits into their child’s diet, which I know can be difficult if their child is a picky eater. They can also ensure their child gets plenty of water and plenty of exercise, as those both really help with constipation.
Originally Posted at TheScientificParent.org
Choosing the Right Water Flotation Device for Your Child this Summer
As a professional lifeguard, one of the most common questions I get from parents is, “what’s a safe flotation device we can use at the beach or pool this summer?” There is a lot of confusion around this topic and most parents don’t realize that the right or wrong flotation device can mean the difference between life and death. Any person (including children) who cannot swim, is a weak swimmer, or is fearful around water should wear an appropriate flotation device.
Buying a flotation device for your child is a daunting task, you walk into a store and are presented with seemingly infinite choices which can range from blow-up inner tubes with the latest and greatest cartoon character, to water wings, noodles, and life jackets.
A number of parents opt for the ever-popular water wings, which many of us grew up wearing. While these may appear as a good option because of their popularity, they’re really more of a toy than a safety device. Water wings are not an approved flotation device and can easily slip off, restrict the movement of a child’s arms, unexpectedly leak air, and can actually hinder a child’s attempts to swim. Another popular product is bathing suits that have flotation built into them, but like water wings, the floaties can ride up or slide out.
So the question remains, which one do you choose?
The answer comes down to one simple question that parents need to ask: is the flotation device both tested and approved by the United States Coast Guard (USCG)? When I ask parents this I usually get a strange look. “What does that even mean?” When you are looking for a safety flotation device for your child, you need to look for the USCG stamp of approval (see pink image below).
Yes, that usually means I recommend life jackets – and no, they are not just for boating.
Before moving forward, it is important to mention that regardless of the device you choose, it should never be a substitute for constant supervision of your child around any type of water.
When making their selection, parents need to determine the intended purpose of the device; if it is solely for fun and recreation in a controlled environment with constant supervision, then the toy devices mentioned above may be acceptable to use as toys. However, if the purpose is to add an additional layer of safety to ensure that a child remains safer in the water, look for that USCG stamp that assures it is a safety enhancement. When properly selected and used, life jackets will provide a secure tight fit, good buoyant flotation which supports the user, and not greatly reduce arm movement.
When shopping for these types of devices, parents need to be cognizant of a few factors:
USCG -approved devices have a designated weight range assigned to them. Parents should choose one that fits their child’s current weight. This is important to ensure a secure fit and the proper amount of flotation.
There are five types of USCG approved flotation devices. Each type has different advantages and disadvantages which you can read about here. Parents should choose a device based on the planned activity and the design of the device being used. Types 1-3, and some type 5 are vest-style devices and can be suitable for children depending on their weight class, but type four devices are not suitable for weak swimmers or children, as they are designed as throwable devices, like life preserver rings.
Make sure the device being used is in good working order. Ensure that the device is not missing any buckles, discolored, or ripped/torn anywhere.
Parents often ask if life jackets restrict the child’s ability to learn to swim or inhibits a child’s “natural swimming instincts.” The answer to that question depends on what the true purpose of the child being in the water is. A child needs time and proper instruction to learn the coordination skills involved in swimming efficiently. So long as your child is in the water with a qualified swim instructor in a controlled environment they shouldn’t require a life jacket. But let’s say you take the same child to the beach or to grandma and grandpa’s pool just for fun. That environment is less controlled and much can happen in the blink of an eye. For fun around the water, an approved flotation device is the way to go, especially if you want to safeguard for if your child accidentally falls in or suddenly can’t touch the bottom.
When looking at water safety and safer swimming in a broader context, having a proper flotation device is only one step in ensuring a safe water experience. No matter where you choose to swim, nothing is more effective than having your eyes on your child at all times. Even if you are swimming at a location where lifeguards are present, keeping constant watch over your child is the best way to keep them safe. Last year I was lifeguarding for a pool party and a parent came up to me at the end of the party. He said that he always felt like his kids were in good hands and he didn’t need to always keep an eye on them. Though I appreciated the confidence in our skills, I explained to him that lifeguards are responsible for watching everyone and we are human so errors can happen. Always watching your children in any situation is the best solution. If lifeguards are not present, a designated “water watcher” should be used. This person’s job is to keep an eye on everyone in the water and make sure everyone stays safe.I often hear from parents that their child will not wear a life jacket and this is a valid argument. If you can’t get your child to wear the life jacket, then obviously it can’t help them. In cases like this encourage parents to think creatively when it comes to this issue. When teaching a water exploration lesson to toddlers last week, I noticed that a parent brought in a flotation item that had a cartoon character on it and the child was excited to wear it in the water. My initial thought was that this was going to be another unapproved toy. To my surprise, the USCG stamp of approval was on the device. As an example, these images of a Puddle Jumper alongside this article show something both “fun” and USCG approved – and sometimes something as simple as the right color or fun cartoon character can make a child interested in wearing the life jacket. I encourage parents to put the time and effort into finding a device that is both approved by the USCG and that your child will want to wear, because they do exist.
The National Drowning Prevention Alliance released a position paper in 2009 on the concept of layers of protection. Do not just rely on one safety step, such as flotation devices or supervision alone, the more safety steps are taken will limit the risk of a tragedy. Other important factors include choosing a safe location to swim, teaching children and adults swimming and water safety, knowing what to do in an emergency, and preventing unapproved access to the water. Every safety step counts for a safer summer of swimming!
Update 7.13.16 | Thanks to TheScientificParent.org reader Ashley who pointed out that puddle jumpers are not approved personal flotation devices for use by children in Canada. Transport Canada advises when parents are choosing a water flotation device for their children they should look at the label to ensure it has been approved by Transport Canada, the Canadian Coast Guard or Fisheries and Oceans Canada.
Alga, A. & Collins, M. (2014) Best life jackets for infants, toddlers, and preschoolers. Lucie’s List, Retrieved from http://www.lucieslist.com/lucies-list-blog/2014/06/18/best-life-jackets-for-infants-toddlers-and-preschoolers/
American Red Cross (n.d.) Home pool safety: Maintaining a safe environment around your home swimming pool. Retrieved from: http://www.redcross.org/prepare/disaster/water-safety/home-pool-safety
Balint, V. L. (2014). Do water wings prevent drowning? Raising Arizona Kids. Retrieved from: http://www.raisingarizonakids.com/2014/03/water-wings-floaties-help-prevent-drowning/
Boyse, K. (2010). Water and pool safety. University of Michigan Health System. Retrieved from: http://www.med.umich.edu/yourchild/topics/water.htm
National Drowning Prevention Alliance (2009). Layers of protection around aquatic environments to prevent child drowning. Retrieved from: http://ndpa.org/resources/safety-tips/layers-of-protection/
REI (n.d.). PFDs for kids: How to choose. Retrieved from: http://www.rei.com/learn/expert-advice/kids-personal-flotation-device.html
United States Coast Guard (2014). PFD selection, use, wear, and care. Retrieved from: http://www.uscg.mil/hq/cg5/cg5214/pfdselection.asp#faq
Adam B. Katchmarchi
Adam B. Katchmarchi is a doctoral student at West Virginia University in the Coaching and Teaching Studies Department. His research focuses on drowning prevention education and best practices of managing risk around water. He has worked with hundreds of parents over the years teaching water safety and swimming to children and adults. He is an American Red Cross Instructor Trainer in Swimming and Water Safety Instruction and Lifeguarding Instruction. Adam is currently on the Board of Directors for the National Drowning Prevention Alliance and will begin his term as Vice President of the organization this summer. He is an active advocate for enhancing safety around all bodies of water. http://twitter.com/drownalliance
When Are Frequent Ilnesses Signs of a Compromised Immune System
It’s cold and flu season and around this time of year I start seeing parents in my office concerned that their child is “always sick,” and that there must be something wrong with their child’s immune system or that they have a “low immune system.” I don’t doubt these parents when they say that their kids are always sick. As I mentioned in a previous post:
“The average child experiences between 6-10 viral upper respiratory infections a year. The average duration of each cold is 7-14 days. That means, on average, infants and toddlers can be sick for 4-6 months each year. Statistically, this means that 50% of children will be sick more than this. Parents, you’re not imagining things when you think your kids are sick all the time. Sometimes they are, and that’s not abnormal.”
So if it’s normal for kids to be almost continually sick this time of year, when should parents worry that their child’s immune system may not be working as well as it should?
There are two main types of immune deficiencies. The first type is secondary or acquired immunodeficiencies. These are the most common. This type of immune deficiency is caused when your child is fighting another illness like cancer, HIV, or is taking certain medications that can suppress the immune system. We’re not going to talk about these today. The second type is primary immunodeficiencies (PID), which are far more rare and genetic (meaning we’re born with them). These are the disorders that parents say they’re most concerned about when they tell me their child is always sick.
PIDs, especially the more severe forms, is quite rare in the general population. There are roughly 180 distinct PIDs, however, as a category, only about 0.0087% of the population has any one of those 180 PIDs. That’s about one out of 1,200 people, but this changes dramatically based upon the type of PID as some are much rarer than others.
Primary immune deficiencies arise when parts of the immune system are not being produced, or are not functioning appropriately. This leaves holes in the normal defense system, making the body more susceptible to infections. Depending upon where and to what degree the defect occurs, the impact can range from mild to very severe.
As I mentioned before, PIDs are genetic, but that doesn’t mean that they’re all inherited or passed from parent-to-child. Some may arise from spontaneous gene mutations with no family history at all. Some appear early in infancy with severe life-threatening infections, whereas others are very subtle and go undetected until adulthood.
So when should you worry that your child’s immune system is deficient? Unfortunately, there’s no easy answer, but there are some indicators in the first years of life that your child needs to be evaluated by a pediatric allergist/immunologist:
- Positive Newborn Screening: As of this writing, 32 states screen for Severe Combined Immune Deficiency, which is an exceptionally rare condition that can cause death by one year of age from severe illness. If your baby’s newborn screening is positive for this, you need to see a pediatric immunologist immediately.
- Family History: If you or if certain blood relatives have been diagnosed with a PID or receive immunoglobulin replacement therapy.
- Failure to Thrive: If your baby fails to gain weight, meet their milestones, suffers from severe skin rashes, recurrent diarrhea, and frequent or invasive infections like sepsis or pneumonia.
- Opportunistic Infections: If your infant or child has suffered from recurrent opportunistic infections, such as fungal infections like thrush, that have affected more than just their tongue or mouth, this is cause for concern.
- Frequent Use of Antibiotics: If your infant or child has required multiple courses of antibiotics each year for confirmed infections such as pneumonia (diagnosed by chest x-ray), ear infections requiring placement of ear tubes, or sinus infections that will not resolve on their own.
- Confirmed Comorbidities: When two conditions tend to occur together we call these conditions “comorbid”. Some conditions, such as DiGeorge syndrome, are known to be comorbid with PIDs.
Most of these warning signs aren’t subtle, and statistically speaking PIDs are incredibly rare. As a board-certified pediatric allergist/immunologist, I have received specialized training to identify children with possible PIDs, but sometimes a child with one of these conditions won’t have any of these warning signs. Sometimes the parents bring them in because their gut tells them that something isn’t quite right, and as the parents tell me more about their child’s issues my radar starts to go off. What are those signs?
- Infections that require treatment with intravenous antibiotics, especially more than once.
- Infections that occur in unusual sites, like internal organs, gums or skin abscesses (non-MRSA, or antibiotic-resistant staph, which is a common infection).
- Infections with unusual organisms, which require appropriate cultures from the site of infection.
- Infections of unusual frequency. While the average child has between 6-10 upper respiratory infections each year, if that number is closer to 20, or if it regularly takes more than three weeks to recover from each infection, I start to get concerned.
When I speak with concerned parents many of them understandably want to tell me everything, concerned that a small detail could be key in properly diagnosing their child. They’re often frustrated when I only ask about certain issues or don’t give some symptoms as much weight as the parents have. As an immunologist, I am extremely picky when taking a history. What I need to see are lab results and confirmed diagnoses.
I know that antibiotics are unfortunately often overprescribed for routine viral infections, so when a parent tells me that their child has been on antibiotics six times this year, I can’t give that information much weight unless it’s backed up with other historical details or test results confirming frequent bacterial infections. Many walk-in clinics or emergency rooms may diagnose a child with pneumonia just by listening to their lungs, but that doesn’t actually confirm pneumonia. What I need to see are the chest x-rays that are consistent with the diagnosis. I need to know that your doctor recorded a fever when they saw your child for an ear infection and that your child was in discomfort, not just that the eardrum was red (especially if they weren’t complaining about it beforehand). If your child has recurrent skin abscesses, I need to see the results from the cultured bacteria to determine if the bacteria are consistent with the type of bacteria we see when the immune system isn’t functioning.
I know this is frustrating for parents, especially if the necessary some of these steps haven’t been taken before they arrive at my office. Testing for PIDs can be invasive, uncomfortable and stressful for children, and the last thing I would want to do is to subject any child to those tests if it wasn’t necessary. So before I can tell if your child requires further testing, I need you to arm me with as much data as possible.
I’m rarely able to give parents a diagnosis or next steps the first time we meet. It takes time to carefully review all of the concerns and then thoughtful consideration about if and what testing should be performed. Sometimes we check labs just to help rule out a scary diagnosis and provide reassurance to parents. Sometimes we decide to perform watchful waiting, knowing that some kids just have bad luck and suffer from a few severe infections in a row. Again, while blood draws and other tests may be no big deal for most adults, for kids they can be terrifying and painful. As a father of two, the last thing I’d want is for my own children to go through that unless it was necessary.
When I tell concerned parents that their child’s medical history and symptoms likely aren’t indicative of a primary immune deficiency, what are some of the other reasons their child is so sick? Before we worry about PIDs we need to first consider the secondary causes of frequent infections. Are they in daycare or have siblings in school? If so, then they are exposed to tons of ‘normal’ infections. Exposure to tobacco smoke in the home or car, underlying chronic health conditions such as allergies, asthma, cystic fibrosis, congenital heart disease, kidney disease, etc. can all lead to increased infections. Additionally, the waiting rooms in hospitals and doctor’s offices are cesspools! People are usually there because they’re sick; every surface they touch is a reservoir of germs. Door handles, chair armrests, magazine covers, the pen you use to check-in are all covered in germs. If your child is at the doctor’s office being treated for one infection then quickly develops another infection, it is likely due to exposure to all the germs in health care facilities. I’ve seen countless kids develop vomiting/diarrhea days after being treated by their doctor for a respiratory illness.
If you have concerns about your child’s health it’s always OK to call your child’s doctor to talk through your concerns and see if a referral to a pediatric allergist/immunologist is appropriate. Hopefully, this post puts your mind at ease or at the very least arms you with more information.
Originally posted at http://thescientificparent.org/frequent-illnesses-immune-system-low-compromised/ by Dr. Dave Stuckus, MD
Is Cosleeping Really Unsafe?
This post was written in response to a question by TheScientificParent.org reader Kate.
It has been every parent’s worst nightmare for generations – finding their infant dead suddenly and unexpectedly. As a father of two, I remember the sleepless nights alternating between crying infants and complete silence, wondering if my boys were actually breathing. The fear is palpable. As a pediatrician who has had to pronounce infants dead and as a member of the team in my county that reviews infant deaths, I have far too often seen the grief and confusion when that fear becomes a reality.
For centuries we’ve struggled to understand the cause of, and even define what Sudden Infant Death Syndrome (SIDS) is. Over the years, the fear SIDS (sometimes known as cot death or crib death) has spawned multiple attempts by researchers and device makers to develop products to prevent SIDS – including apnea monitors, sleep positioners, or wedges. None of these interventions have been demonstrated to reduce the risk of SIDS. But what has been shown to reduce an infant’s risk of SIDS is very simple and many parents aren’t aware of it.
Since a consensus conference in 1991, Sudden Infant Death Syndrome (SIDS) has been defined as a death of an infant under one year of age that cannot be explained after a thorough investigation which includes an autopsy, a scene investigation, and a review of the medical and social histories. SIDS is one type of Sudden and Unexpected Infant Deaths (SUID). The reasons why the authorities need to investigate when an infant dies unexpectedly include ensuring no foul play was involved or whether or not a preventable genetic condition (like certain heart arrhythmias) occurred that impact future deaths in a family.
The majority of infants who die from SIDS have underlying risk factors that can be addressed to reduce the risk of death. Some children are likely born with intrinsic and undetected brain stem abnormalities that make them more susceptible to sudden death and despite risk factor modification, these infants still may die. Some researchers are looking into the role the inner ear plays in SIDS, but the research so far is in its preliminary stages. Unfortunately for many families, approximately 5% of SIDS cases involve otherwise healthy infants with no underlying risk factors. I’m going to focus on the 95% in this post because the majority of these deaths can be prevented.
Improved death scene investigations over the past 2 decades have shown us that most SUIDs are a result of infants being placed in unsafe sleep positions. Improved examinations by death investigators and Child Fatality Review Teams have shown that for most infants who die of SIDS and a vast majority of infants who die of asphyxiation (also known as suffocation) or undetermined causes are found in an unsafe sleep position. The Back to Sleep campaign started in the 1990s after studies showed that infants placed on their back to sleep had a reduced risk of dying from SIDS. Between 1992 and 2001 the Back to Sleep campaign reduced the risk of SIDS by over 50%.
Unfortunately one of the worst sleep environments for a child is to co-sleep in an adult bed, or more specifically co-bed. We’ve designed adult beds to be comfy and welcoming for us at the end of a hard day, with pillows, blankets and soft mattresses, but these are all major asphyxiation risks for an infant not old enough to roll over or lift their head. Asphyxia while co-bedding can occur from 3 primary mechanisms – the parent rolling over on the child and restricting breathing, the child rolling or being rolled between the bed and a wall, or a child suffocating on soft bedding like blankets or pillows.
But these methods are not how most high-risk infants who asphyxiate while co-bedding die: Most die from carbon dioxide poisoning, by regularly re-breathing in their own or their parents exhaled breath. Any object near the mouth and nose of an infant can create an air pocket in which the exhaled air gets trapped. The infant then re-breathes air with a higher concentration of carbon dioxide. As the carbon dioxide level increases in the bloodstream and oxygen levels decrease, the infant is more likely to stop breathing and die.
These mechanisms for death can also occur in an adult bed without an adult and on other surfaces with an adult-like a couch. It is very easy for an infant to roll off the chest of a sleeping adult and get wedged between the parent and the side of the couch.
Due to an increase in the number of cases of Accidental Strangulation and Suffocation in Bed (ASSB), which have quadrupled from 1984-2004, the number of total infant deaths has stopped decreasing since 1998 despite the drop in SIDS cases. The number of deaths in unsafe environments, like co-bedding in adult beds, is staggering. A report out of Michigan in 2011 demonstrated that 83% of their infant deaths were a result of sleep related asphyxiation. Even looking only at SIDS cases, well designed epidemiological studies have demonstrated there is an increased risk of SIDS from co-bedding by itself after controlling for other risk factors, such as family history and smoking.
Despite the overwhelming body of research showing the deadly risks of co-bedding, many lactation consultants and some prominent anthropologists strongly believe co-bedding reduces the risk of death and increases the length of breastfeeding. While co-bedding may increase the length of breastfeeding and breastfeeding has been shown to independently reduce an infant’s risk of SIDS, the risks of sleeping in an adult bed outweigh the benefits gained by breastfeeding. Many co-bedding proponents claim that so long as the parent removes soft objects or strangulation risks from the bed (such as excessive throw pillows, heavy blankets or pillows and blankets with tassels) that co-bedding is safe. Unfortunately, these individuals have failed to understand the bigger picture and the lessons learned from Child Fatality Review.
The American Academy of Pediatrics has several recommendations for parents who want to reduce their infant’s risk of SIDS and SUIDs, in addition to placing your infant on their back to sleep in a crib or bassinet of their own:
- Sleeping on a firm surface and avoiding soft objects in the crib
- Avoiding exposure to tobacco smoke
- Room sharing without bed-sharing (place the bassinette next to the adult bed)
The research is clear: Very few infants die alone, on their back, and in a safe crib, and the majority of these deaths are preventable. I understand why some parents may want to co-bed or find themselves unintentionally co-bedding. Co-bedding can make parents feel closer to their infant, it also may make it easier for some parents to extend breastfeeding during the night and to get a little extra sleep. As a parent, I understand the exhaustion parents feel in the first weeks and months of life, and I’m not trivializing that, but the research is clear: Very few infants die alone, on their back, and in a safe crib, and the majority of these deaths are preventable.
For more information on safe sleep go to:
- Safe to Sleep: Public Education Campaign.
- Cribs for Kids: Helping Every Baby Sleep Safer.
- First Candle: Helping Babies Survive and Thrive.
- Reduce the Risk of SIDS.
- Center for Infant & Child Loss Safe Sleep Video
- Safe to Sleep: Public Education Campaign. Led by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Accessed 06/22/2015.
- Cribs for Kids: Helping Every Baby Sleep Safer. Accessed 06/22/2015.
- First Candle: Helping Babies Survive and Thrive. Accessed 06/22/2015.
- Reduce the Risk of SIDS. Healthy Children,Org – by the American Academy of Pediatrics. Accessed 06/22/2015.
- Center for Infant & Child Loss Safe Sleep Video. Accessed 06/22/2015.
- Leslie Waghorn. Has A Seattle Doctor Found The Cause of SIDS? The Scientific Parent.
- Willinger, M. James, LS. Catz, C. Defining The Sudden Infant Death Syndrome (SIDS): Deliberations of an Expert Panel Convened by the National Institute of Child Health and Human Development. Pediatric Pathology. 1991 Sep-Oct;11(5):677-84. Accessed 06/22/2015.
- Ostfeld, B., et al. Concurrent Risks in Sudden Infant Death Syndrome. American Academy of Pediatrics. Vol. 125 No. 3 March 1, 2010
pp. 447 -453 (doi: 10.1542/peds.2009-0038). Accessed 06/22/2015.
- The National Center for the Review and Prevention of Child Deaths. Accessed 06/22/2015.
- Laughlin, J., et al. Prevention and Management of Positional Skull Deformities in Infants. American Academy of Pediatrics. Vol. 128 No. 6 December 1, 2011 pp. 1236 -1241 (doi: 10.1542/peds.2011-2220). Accessed 06/22/2015.
- Kemp J.S., et al. Unintentional Suffocation by Rebreathing: A Death Scene and Physiologic Investigation of a Possible Cause of Sudden Infant Death. Journal of Pediatrics. 1993 Jun;122(6):874-80. Accessed 06/22/2015.
- Shapiro-Mendoza, C.K., et al. US Infant Mortality Trends Attributable to Accidental Suffocation and Strangulation in Bed From 1984 Through 2004: Are Rates Increasing? American Academy of Pediatrics. Vol. 123 No. 2 February 1, 2009, pp. 533 -539. (doi: 10.1542/peds.2007-3746) . Accessed 06/22/2015.
- Michigan Child Death State Advisory Team Tenth Annual Executive Report. 2011. Accessed 06/22/2015.
- Carpenter, R., et al. Bed Sharing When Parents Do Not Smoke: Is There A Risk Of SIDS? AN Individual Level Analysis of Five Major Case – Control Studies. Paediatrics. Volume 3, Issue 5. BMJ Open 2013;3:e002299 doi:10.1136/bmjopen-2012-002299. Accessed 06/22/2015.
- SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. American Academy of Pediatrics. Vol. 128 No. 5, pp. 1030 -1039. November 1, 2011 (doi: 10.1542/peds.2011-2284). Accessed 06/22/2015.
Author: Scott Krugman, MD, MS, FAAP
Originally posted at https://www.thescientificparent.org/crib-notes-is-cosleeping-really-unsafe/
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