Forwarding this as I think of interest to the list. A very interesting and information response – thanks Caroline for passing it on.
On 31/10/2016 12:44, "Caroline Homer" <[log in to unmask]> wrote:
Dear colleagues
In response to this email trail, I asked my colleague Prof Jeanine Young (University of the Sunshine Coast) who led the Australian College of Midwives Position Statement for her views. I attach her response below. She is happy to be contacted individually if you have questions as she is not on this list. Her email is Jeanine Young <[log in to unmask]>.
Caroline Homer
Dear Caroline
I think all statements are saying the same thing (RCM and UNICEF and ACM and SIDS and Kids)- we all acknowledge the safest place for a baby is in a separate sleeping space in close proximity to a parent but all acknowledge that parents will fall asleep with babies whether intended or not.
What is changing is the acknowledgement that the message never bedshare is not working and may create greater risk.
I attended the biannual ISPID ISA conference in Uruguay, in September 2016 just before the release of the revised AAP guidelines. We presented our preliminary work on the Pēpi-Pod® Program and the Qld SUDI study.
The tide appears to be turning in the international community with regard to the initial ‘simple’ message of tell parents never to bed-share. This has not worked over the last 10 years and it was acknowledged that babies still continue to die in unsafe sleeping environments in which there are other risk factors present, despite this ‘simple’ message (risk elimination approach). The vast majority of deaths are in families who have complex needs and are socially vulnerable. It was acknowledged in a forum that focussed on bed-sharing data that the simple message is not appropriate across cultures and that other interventions and support are needed for complex families who may have no choice but to bed-share as they have no room for a separate sleep space (eg smokers living in a small caravan may not have room for a cot in their living environment).
Death data overwhelmingly demonstrates that an infant death to a non-smoking, breastfeeding mother is a very rare event. For example, of SUDI deaths in Qld between 2012-2014 there were 152, of which 135 were sleep related. 43% were in shared sleeping situations (n=58), the rest were not. Of those 58 babies, when we considered risk factors of smoking, not breastfeeding and prone position – only 1 baby was in a shared situation in which there he was breastfed, mother was a non-smoker and he was placed supine to sleep. This baby was Indigenous, male and born preterm and low birth weight (SGA). No babies had no known risk factors present. The Victorian retrospective case series published earlier this year also supports these findings (Bugeja, Dwyer, McIntyre, Young Stephan and McClure 2016).
The revised AAP guidelines published in October 2016 are more in keeping with current risk minimisation guidelines than before (AAP 2011 which stated do not bedshare) due to the acknowledgement that a breastfeeding mother may fall asleep when feeding her baby. Due to the increase of sofa sharing and lounge chair deaths associated with feeding a baby and falling asleep, with parental narratives in death scene investigations indicating this was because they had been told not to bedshare, it has been acknowledged that the initial ‘never bedshare’ message was oversimplified and may in fact cause greater harm. The Carpenter analysis from 2013 (which was cited as stating risk is increased regardless of non-smoking and breastfeeding) has been regarded as somewhat limited given it imputed 60% of missing data particularly from studies which did not collect data on alcohol consumption. A subsequent review in 2014 of studies which collected data in similar ways (included in our ACM statement) supports the current ACM Statement conclusion of risk minimisation.
The revised guidelines states: The safest place for an infant to sleep is on a separate sleep surface designed for infants close to the parents’ bed. However, the AAP acknowledges that parents frequently fall asleep while feeding the infant. Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep. It is important to note that a large percentage of infants who die of SIDS are found with their head covered by bedding. Therefore, no pillows, sheets, blankets, or any other items that could obstruct infant breathing or cause overheating should be in the bed. Parents should also follow safe sleep recommendations outlined elsewhere in this statement. Because there is evidence that the risk of bed-sharing is higher with longer duration, if the parent falls asleep while feeding the infant in bed, the infant should be placed back on a separate sleep surface as soon as the parent awakens.
This is also consistent with our Australian SIDS and Kids (now Red Nose Foundation) Bedsharing statement that was revised last year which clear states the support of a risk minimisation approach – consistent with the ACM statement
The focus has moved now to ensuring widespread awareness of
• the dangers of falling asleep on a sofa,
• avoiding bed-sharing if either parents smokes, takes prescription or illicit drugs that may reduce consciousness or drinks alcohol
• sleeping with a premature or low birth weight baby (this of course provides an excellent opportunity to educate about safe sleeping during KMC in SCBUs and NICUs although clinicians rarely seem to make this link)
The revised AAP guidelines (2016) also referred to devices that make bedsharing safe.
There is insufficient evidence to recommend for or against the use of devices promoted to make bedsharing “safe.” There is no evidence that these devices reduce the risk of SIDS or suffocation or are safe. Some products designed for in-bed use (in-bed sleepers) are currently under study but results are not yet available.
“some products designed for in bed use are currently under study’ was an indirect reference to the NZ Pēpi-Pod® Program and Wahakura programs – recently associated with the 29% reduction in infant mortality seen in NZ, Mitchell et al 2016 (June), Acta Paediatrica) and our Qld Pepi-Pod Program. Several sites in the UK, Canada and the US are about to take up similar programs of in bed sleep enablers and targeted safe sleep education for vulnerable families due to the preliminary results with these devices. We will be able to geographically map services which are using our program (over 25 communities in Qld, with several services integrating into health service delivery following the trial with all other participating sites expressing a desire to continue with funding available. The Rural Doctors Association of Qld Foundation have, as of last week, donated money to us to purchase another 100 pods to continue our program while WA, Victoria and NSW departments of health are making enquiries into trial. SA has purchased 20 Pepi-Pods and are able to trial also.
I am proud that the ACM guidelines 2014 clearly stated and supported the need for a risk minimisation approach as this is now being viewed by the international community as the way forward. Midwives caring for families are in unique position as an advocate, educator and health promoter for vulnerable families and therefore should express their views as to safe options for families particularly when current evidence does not demonstrate that the risk elimination approach is working.
Professor Jeanine Young
School of Nursing and Midwifery
University of the Sunshine Coast
Caroline Homer RM PhD
Professor of Midwifery, Centre for Midwifery, Child and Family Health
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-----Original Message-----
From: [log in to unmask] [mailto:[log in to unmask]] On Behalf Of Darlene Nnanyelugoh
Sent: Friday, 28 October 2016 6:19 AM
To: GANM (Global Alliance for Nursing and Midwifery)
Subject: [ganm] Controversy Surrounding Bed-Sharing
Because the infant sleeping recommendations you shared are from physicians (specifically the American Academy of Pediatrics), I did a little search on official stances from midwifery organizations.
Per the Australian College of Midwives (ACM), ACM “does not support a risk elimination approach in which all parents are informed not to bed-share or co-sleep with their baby under any circumstances.” This is in conflict with the physicians’ recommendation that parents should not bed-share with their infant. ACM does acknowledge though that bed-sharing increases the risk of Sudden Infant Death Syndrome.
Even among midwives there is some disagreement on co-sleeping. The U.K.’s Royal College of Midwives (RCM) recommends that “the safest place for baby to sleep is in a cot in his or her parent's room and not in the bed with parents.”
How can we gain consensus in the global midwifery community? And what should we be telling parents?
Link to ACM position: https://www.midwives.org.au/resources/acm-position-statement-co-sleeping-and-bed-sharing
Link to RCM position: https://www.rcm.org.uk/content/do-not-sleep-in-bed-with-baby-say-midwives-20-05-13
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