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Thursday
Jun052008

Faulty logic from the Ontario coroner regarding bed sharing

I don't know what the qualifications are to become a coroner in Ontario, but I doubt there is a required course in statistics (also known as quantitative methods). If it was required, then Ontario Coroner Dr. Bert Lauwers skipped a few too many classes, is purposely trying to deceive the public, or is blinded by cultural assumptions that are not allowing him to look at the numbers objectively.

The Ontario Coroner, along with the Paediatric Death Review Committee (PDRC) and Deaths Under Five Committee, released its Annual Report this month. Its ridiculous conclusions have been picked up once again this year by numerous media reports, including this National Post article entitled "Is sharing bed with baby deadly?" (article no longer available on-line - see this one instead:  "Sharing a Bed with Infant Can be Fatal, Warns Top Coroner").

The problem with the definition of SIDS and unsafe sleep environments

A finding that a baby died of Sudden Infant Death Syndrome (SIDS) in Ontario is a diagnosis of exclusion. This diagnosis is only given if there is no other possible explanation for the death. If a baby is found dead in an adult bed, it is not considered SIDS because it is considered an unsafe sleeping environment. This is perhaps a convenient way for Ontario to be able to brag that its SIDS statistics have gone down, but it is inflammatory and unfair to parents who have created a safe bed sharing environment and then have the misfortune to have their baby die of SIDS.

I wonder too what happens if there are two possible contributing factors. For example, a baby with respiratory problems is found dead in bed with its mother. Are the respiratory problems considered to be the cause of death or the bed sharing? Personally, I feel like I have a better chance of noticing that something is wrong with my baby if she is right next to me in bed than if she is on a separate sleep surface, whether in my room or in another room. I would be devastated if my baby died of SIDS while not sleeping with me and would wonder for the rest of my life if I could have perhaps done something to prevent her death if only she had been sharing the bed with me.

The other problem with the report's definitions is that all adult beds are lumped together as one category of unsafe sleep environment. However, there are many variations of adult beds. There are adult beds that are covered in adult bedding and pillows. There are water beds or other soft surfaces. There are beds with large cracks between the bed and the wall or the bed and the headboard where the baby can get caught. And then there are beds with firm mattresses, a tight sheet, no dangerous spaces where the baby can get caught and no adult bedding near the baby. I wonder how many of the 30 deaths that occurred in adult beds occurred in a safe adult bed and I wonder if that number is higher or lower than the number of babies that died of so-called SIDS in their cribs.

What's missing from the numbers?

I can gather from the data that the PDRC reviewed around 19% of deaths of children under 5 in Ontario. It is interesting to note that on page 14, the report indicates that 177 deaths were investigated (86 in 2006 and 91 in 2007) and on page 21 it indicates that 186 cases were reviewed during those same two years. If the totals are wrong, I already start to wonder about the validity of the detailed figures.

I don't know how many babies died in their sleep in Ontario in 2006 and 2007 (the period covered by the report). The PDRC report does not provide this information. Perhaps PDRC reviewed them all, but perhaps it did not.

Of the 186 cases reviewed by PDRC, 77 of them (41%) involved a so-called "unsafe sleep environment". How many of the other 109 deaths involved a so-called "safe sleep environment"? They don't tell us this.

Of the 77 deaths on a so-called unsafe sleep environment, 44 involved bed sharing, but only 30 involved an adult bed. Either the other 14 involved an adult crawling into the crib with the baby, or they are using the "bed sharing" to mean sleeping with the baby on any surface (which may or may not be a bed....could be a couch, could be the floor).

In 67 of the 77 deaths on a so-called unsafe sleep environment, the baby may not have been sleeping on its back (31 on stomach, 9 on side, and 27 unknown). So the death might have nothing to do with the unsafe sleep environment but might have everything to do with the sleep position.

In 14 cases out of 77, the parents reported drug or alcohol use. I wonder how many more of these cases involve unreported drug or alcohol use by the parents.

So what do these statistics really tell us about the safety of co-sleeping? It tells us that a lot of parents are still not knowledgeable about how to create a safe co-sleeping environment. It tells us that many of them are co-sleeping on truly unsafe sleep surfaces like couches. It tells us that many of them are using drugs or alcohol. It tells us that they are not placing their babies to sleep on their back.

However, it does not tell us how many babies died in a safe bed sharing arrangement, where the mattress was firm, there are no crevices the baby could get caught in, there was no adult bedding around the baby, the baby was dressed appropriately for the temperature, the parents were not smoking or using drugs or alcohol, etc. And if we then look at the percentage of such deaths among all safe co-sleeping environments compared to the number of deaths among safe crib sleeping environments, what would the results be? Obviously these numbers are impossible to attain because we do not know what percentage of co-sleeping environments are safe and we don't know what percentage of crib sleeping environments are safe.

That said, the numbers that are provided by the report leave much to be desired and could be much improved. It would be helpful to see where there are multiple contributing factors versus just one, for example.

Why telling parents not to bed share is not the solution

Since it is impossible to come up with perfect statistics on the safety of various sleep environments and since we know that different sleep arrangements work for different families, perhaps berating parents for bed sharing is not the best solution for reducing the number of sleep related infant deaths.

We know that cars are dangerous. Lots of people die in car accidents. But the coroner does not broadcast messages that we need to abandon our cars and start walking instead. We recognize that people are going to drive cars. We recognize that this is a convenient means of transportation. We recognize that it is the only reasonable way for some people to get around depending on where they live and where they need to go. So we come up with ways to make car travel as safe as possible and we educate people about it. There are still idiots that don't follow those rules, but when they die or cause someone else's death, we don't rush once again to ban cars.

Bed sharing is similar. Lots of people do it. Lots of people in North America do it, but even more people do it in other countries around the world. A crib is virtually unheard of in many cultures and putting a child in a separate space is considered odd and cruel. Bed sharing is convenient when breastfeeding and helps encourage mothers to continue breastfeeding and still get a good night's sleep. Many babies are not able to sleep soundly on their own and need someone else with them to get a good night's sleep. So rather than telling people not to bed share, perhaps the coroner's office (and others that are on the same bandwagon) should focus their efforts on educating parents about how to do it safely.

And speaking of the safety of driving versus bed sharing, if I didn't share a bed with my children and had to spend a good portion of the night going back and forth between my bed and a crib and a rocker for breastfeeding, I would be a much bigger danger to myself, my children, and other people on the road because I'd be likely to fall asleep at the wheel.

Further good reading on the same topic

Last year when the Ontario coroner's equally inflammatory report came out, John Hoffman wrote an excellent commentary called "Let Co-Sleeping Families Lie" for Today's Parent. Obviously the coroner did not get the message, but I loved what John had to say.

Although not based on the Ontario example specifically, Dr. Sears wrote a response to similar types of reports produced in other jurisdictions: Safe Sleeping with Your Baby - The Latest Research.

Mothering Magazine also has a statistics-based article on the subject that comes to the conclusion that Co-Sleeping is Twice as Safe as Crib Sleeping.

Dr. McKenna's commentary and observations from his sleep lab at the University of Notre Dame on the possibility of a mother overlaying or suffocating her baby show that the risks are extremely minimal. In particular, this quote paraphrases my thoughts on the subject very well:
In my own work I stress that a distinction must be made between the inherently protective and beneficial nature of the mother-infant cosleeping/breast feeding context, and the conditions (of the mother and the physical setting including equipment) within which it occurs - which can range from extremely safe to unsafe and risky.
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Reader Comments (26)

I can appreciate the sentiments in your article. As a person who works daily with parents who have had an infant die suddenly and unexpectedly, I can speak extensively about the difficulties of experiencing an infant death.

What we need to focus on is Safe Sleep for an infant. Since we don't yet know the cause of SIDS, the diagnosisd is subject to interpretation to the many different coroners and medical examiners around the world. That's exactly why the CJ Foundation for SIDS convened a panel of some of the best researchers and pathologists around the world and proposed a tier system of diagnosis.

Unfortunately, this system has not been adopted by most countries - yet.

While your auguments may have some merit, your statement "I would be devastated if my baby died of SIDS while not sleeping with me and would wonder for the rest of my life if I could have perhaps done something to prevent her death if only she had been sharing the bed with me." is offensive. An infant death is devastating. Period.

Further, it is inappropriate to compare the beds and sleeping practices in North America withthe rest of the world. Most infants around the world do not sleep on mattresses with pillows and blankets like we do. A pallet or mat on the floor is not a comparable surface. Also, in some countries around the world, infants are positioned perpendicular to the parents and above their heads so that a roll over is much less likely.

With education, we can make bedsharing less dangerous, but we cannot make it safe. Why not place your infants crib right next to your bed so that you can quickly and easily respond to your infant but have them sleep in their own safe sleep place? Room sharing has proven to be protective and is an acknowledged form of "Co-sleeping".

I can't speak for the deaths in Ontario; however, I review the deaths in Illinois in the U.S. Rarely do infant deaths occur in safe bedding situations - regardless of the diagnosis. Even cribs can be unsafe with bumpers, quilts, toys, laundry etc.

Exhausted parents don't always understand that infants cannot push away or move away from an obstruction. So, the best advice is keep baby close, but in a separate space until they are old enough to freely move around their space. Bring baby into the adult bed to play, cuddle and breastfeed, then move them to a nearby safe crib.

June 6, 2008 | Unregistered CommenterPam

Thank you for your comments Pam.

I agree that an infant death is devastating. Period.

In the same way that you found my opinion offensive, most co-sleepers that make a point of creating a safe family bed are offended by reports that assume that a shared bed is an unsafe bed.

I am glad that infant deaths rarely occur in safe bedding situations. I know that cribs can be unsafe too when used incorrectly. But the Ontario coroner does not lump safe and unsafe crib deaths together - it seperates them into two categories - unsafe and SIDS. However, if the death occurs in an adult bed, it appears to automatically be classified as an unsafe sleep environment rather than a possible SIDS death.

I agree that bed sharing in other countries is perhaps different from bed sharing in North America. Perhaps we can learn from them and find ways to make our bed sharing safer. However, according to the Ontario coroner, a pallet or mat on the floor with the baby sleeping perpendicular above the parents head would also be considered unsafe. If it isn't a crib free of all obstructions, it is an "unsafe sleep environment". Given the multicultural environment that we live in (Toronto is I believe the most multicultural city in the world), such a North American cultural bias is not appropriate.

With regards to your question about why I don't put my baby in a crib next to my bed. I have a few reasons, I'm sure others have other reasons too. In my case, my babies always woke up if I moved them after they had nursed to sleep. They also often needed to be able to feel some part of my body against them to sleep soundly. The crib also doesn't fit into our room. I would need to buy a new house if I wanted to fit an adult bed and a crib in the same room.

Different parents have different reasons for bedsharing. I just wish there was more education about the aspects of an adult bed that can be dangerous, rather than just assuming that an adult bed is dangerous. Period.

June 6, 2008 | Unregistered Commenterphdinparenting

Thanks for clearing up some of the confusion that the Canadian article purposefully relayed. It’s a scare tactic. As for Pam's comment, I think it's "offensive" to know that the CJ foundation has access to information that would solve SIDS and they cover it up. This action kills kids purposefully not accidentally. Crib sleeping has their own accidental deaths, properly diagnosed SIDS cases, child abductions, and fire related deaths. Every article they endorse offers only that Bed-sharing is dangerous and impossible. They never pay any attention to people who can co-sleep or bed-share safely. In fact, they say it can’t be done safely by anyone. Maybe in IL, the CJ foundation is doing what they feel is needed through comforting families, but they are omitting things they don't want to talk about purposefully. SIDS is way further from being solved than when it was first discovered and called crib death. That was the common factor in all the unexplained child deaths, cribs. However, being that descriptive about the most common factor in these unexplained deaths started hurting crib sales, so it changed to SIDS. Period. And, as for the back to sleep campaign, maybe the “great” reduction in SIDS deaths was a little far reaching. The back to sleep campaign was actually solving misreported positional asphyxiation. Today it’s accepted that corners have made errors in their SIDS diagnosis. Is it impossible that corners were making those same mistakes back then, and the “large” number reduction of SIDS was really just a reduction in positional asphyxiation? OK, so the next natural step for SIDS organizations, and yes they are funded by the people selling cribs, is to start slamming a parenting practice that has no unexplained deaths. I’m tired of hearing “we don’t know why SIDS happens” from people who know that SIDS does not happen while bed-sharing. Why would the people who see SIDS cases most often point to a place that unexplained deaths do not happen? Why? How did they come up with “crib sleeping is safer when done next to an adult”? I could go on with this comment, but there are other things to do…so…3 main points that any SIDS organization will not give any attention to…and I know this because I personally contacted the head of the National Association of Medical Examiners and she refused…

1.They will not talk about the numbers of children who “for no known reason” expire in a crib. These are actual SIDS deaths, properly diagnosed, and in a safety approved crib.

2. How many properly diagnosed SIDS, actual unexplained deaths, are found in a parent’s bed? None. There is always an explanation and a solution to accidental suffocation.

3. All SIDS organizations are for very good reasons funded, in one way or another, by the crib industry. And, they do not report about where properly diagnosed SIDS are physically found and they pay no attention the problems associated with cribs.

Keep up the good work!

Go to www.co-sleepingsurvey.com

June 6, 2008 | Unregistered CommenterHugh

I very much enjoyed your eloquent commentary. After having heard Dr. James McKenna speak in person, I am astounded at the misinformation in the public health system when it comes to the best sleep environment for babies. As Dr. McKenna quoted, "Nothing about a baby makes sense apart from the mother's body." That includes sleeping. Everything from the way babies sleep on their sides when breastfeeding, to the responsiveness to the mother's CO2, to the rapid digestion of breastmilk to encourage frequent waking.

I, too, have had babies who wake whenever moved. Falling asleep while baby nurses is one of the most satisfying and natural feelings of life with an infant. And the long periods of non-nutritive sucking is beneficial to the absorption of nutients, as well.

I was reading a new magazine called ParentsCanada, edited by Dr. Marla Shapiro. They had a "safe sleep" issue, in which Dr. Shapiro wrote of finding her own baby dead in the crib of SIDS. She then went on to list all the "safe sleep" procedures about using cribs. I know it was probably heartless of me at the time, but I just felt like: "It didn't work the first time. If she had kept her child with her it may have survived."

The thing that bugs me the most is that the "state" is so intent on dictating how parents must raise their kids. There is more than one right way to parent, and being responsive to the needs of the infant should always take priority.

June 10, 2008 | Unregistered CommenterJulie

Thanks for the article and the support of co-sleeping. We've done co-sleeping for several years and we agree with you that it seems far safer than having baby in a crib. This coroner's report is misleading and the media is jumping in and intimidating people who just want to do the humane and natural thing with their babies. There's a safe way to co-sleep and that's what should be discussed in the media, not just a blanket condemnation.

June 14, 2008 | Unregistered CommenterRoberta

I just found this Government of Ontario press release from a few years back - http://www.health.gov.on.ca/english/media/articles/archives/ar_03/100903_ar.html. It certainly puts a different spin on SIDS than they do today. It says:

"SIDS, also commonly referred to as "crib death" is the leading cause of death in Canada for infants between one month to one year of age. SIDS affects one out of every 2,000 infants and is most common in male babies than in female."

So if SIDS, i.e. CRIB death, is the number one cause of death of Canadian infants, then perhaps we should be encouraging more parents to get their babies out of cribs and into a safe bed sharing arrangement.

June 16, 2008 | Unregistered Commenterphdinparenting

Thanks so much for this great article!

In response to the poster who was offended by your statement that if your baby died in a crib, you'd wonder if he might have lived if you'd had him in the bed with you -- I'm offended that people are more concerned about protecting feelings than they are about protecting babies.

To absolutely refuse to consider what might have prevented a death, simply to prevent anyone from feeling guilty, is crazy. For one thing, I think a parent could eventually work past the guilt by accepting that she followed what she thought was the best advice at the time.

I think parents can realize they were wrong about something and heal. We all make errors in judgment.

But great harm is being done to many families, through this blanket prohibition of co-sleeping. It's a wonderful thing for many families, my own included!

If people are so concerned about "protecting feelings" -- why not more respect for the feelings of all the families -- and especially all the babies -- who love co-sleeping?

July 27, 2008 | Unregistered Commentermammal_mama

[...] Faulty logic from the Ontario coroner regarding bed sharing:This was my coming out of hiding post I guess. Prior to this post, it was mostly a handful of my friends that were reading the blog and maybe a Google search or two on something I’d written.  I was on vacation on the other side of the world and my sister-in-law e-mailed me an article on co-sleeping that had been in the National Post after reading a few of my first blog posts. I remembered reading about the coroner’s report on the same topic the previous year and remembered how it made my blood boil. But I was too busy caring for a newborn and a busy 2.5 year old at the time, so I didn’t have a chance to do anything about it other than blow smoke out of my ears. Well this year, I wasn’t going to sit back and take it anymore. I wrote and wrote and wrote. And you read and read and read. I was glad to see this post doing well on the search engines so that people searching on the topic after hearing about the coroner’s report hopefully found my post too. [...]

[...] a lot of publicity about co-sleeping being dangerous. I addressed a lot of those myths in my post Faulty logic from the Ontario coroner regarding bed sharing. However, if you implement a few simple guidelines, then it can be safe to sleep with your baby and [...]

[...] him and his newborn lying on top of the toddler. Cute, but yikes!  I hate it when people (like the Ontario coroner) claim that co-sleeping is unsafe when only certain types of co-sleeping are unsafe. But if those [...]

[...] went over the top trying to scare people out of co-sleeping using misinformation. I wrote about the faulty logic of the Ontario coroner and Mama Luxe from the blog Mama Saga posted a great back and forth on her correspondence with the [...]

[...] January 9, 2009 by phdinparenting When a baby is on the way, most parents spend hours, days or weeks preparing a beautiful nursery with a gorgeous crib. Society tells us that babies sleep on their own, in a crib, in a different room from their parents. More recently, health authorities have started suggesting that the safest place for a baby to sleep is in a crib in the parents room, because proximity to the parents is important but many consider bed sharing to be dangerous. But in attachment parenting circles, co-sleeping is quite popular and there is great opposition to the faulty conclusion that bed sharing is unsafe. [...]

[...] When a baby is on the way, most parents spend hours, days or weeks preparing a beautiful nursery with a gorgeous crib. Society tells us that babies sleep on their own, in a crib, in a different room from their parents. More recently, health authorities have started suggesting that the safest place for a baby to sleep is in a crib in the parents room, because proximity to the parents is important but many consider bed sharing to be dangerous. In attachment parenting circles though, co-sleeping is quite popular and there is great opposition to the faulty conclusion that bed sharing is unsafe. [...]

[...] him and his newborn lying on top of the toddler. Cute, but yikes!  I hate it when people (like the Ontario coroner) claim that co-sleeping is unsafe when only certain types of co-sleeping are unsafe. But if those [...]

[...] a lot of publicity about co-sleeping being dangerous. I addressed a lot of those myths in my post Faulty logic from the Ontario coroner regarding bed sharing. However, if you implement a few simple guidelines, then it can be safe to sleep with your baby and [...]

Education needs to start with pediatricians. From my experience, they will simply tell parents that babies should be in cribs, period, ignoring the fact that parents (whether "natural parenting" types or not) are increasingly likely to co-sleep with kids of all ages. What peds need to do is hand out information to parents on how to co-sleep safely so everyone has those guidelines. Perhaps a pamphlet needs to be included with the bag of junk the hospital sends home with parents. The governments of the U.S. and Canada simply need to accept the fact that it happens and campaign to make sure it happens safely.

Kudos to a terrifically logical blog.

June 1, 2009 | Unregistered CommenterAndi Beard

@Andi Beard: We did get a pamphlet. One that said "don't sleep with your baby". Ugh. I did write up some guidelines and tips for safe co-sleeping for those that are interested: http://www.phdinparenting.com/2009/01/11/co-sleeping-safety/" rel="nofollow">Co-Sleeping Safety

June 1, 2009 | Unregistered Commenterphdinparenting

[...] Birth Plan: Yes or No?, to explain about Lactivism and the Homelessness Problem and to analyze the faulty logic of the Ontario Coroner on co-sleeping, not just once but [...]

If it weren't for bedsharing, I would have 2 dead children. Both my oldest & youngest son have stopped breathing in their sleep. My oldest because he was choking due to reflux & my youngest because he had several episodes of newborn apnea. With both of them, I noticed immediately & was able to get them breathing again.

The first time it happened with my new baby, I woke up in terror with the thought "He's not breathing" already in my head. It felt like forever, but it was probably less than a minute to get him breathing again. Even in my sleep I knew exactly what was wrong & that I needed to wake up because he was right next to me & a part of my brain was constantly monitoring him.

I knew co-sleeping was safe, but I now firmly believe that crib sleeping is inherently unsafe. Babies are designed/evolved to sleep with their mothers so they can be protected even in sleep.

July 7, 2009 | Unregistered CommenterLisa

[...] went over the top trying to scare people out of co-sleeping using misinformation. I wrote about the faulty logic of the Ontario coroner and Mama Luxe from the blog Mama Saga posted a great back and forth on her correspondence with the [...]

[...] (meaning they don’t know why the baby died). When a baby dies in bed with its parents, the Ontario coroner simply calls it an unsafe sleep environment. This is unfair to parents who do make the effort to create a safe sleep environment and also [...]

[...] SIDS (meaning they don’t know why the baby died). When a baby dies in bed with its parents, the Ontario coroner simply calls it an unsafe sleep environment. This is unfair to parents who do make the effort to create a safe sleep environment and also [...]

[...] Studies that link bed-sharing with SIDS often do not adequately take into account important aspects when analysing their findings, such as weight, smoking, alcohol and drug consumption in the parents. All of which are risk factors when sharing a bed with your baby. Furthermore, there is a real problem with some of the research which doesn’t adequately define SIDS – for example, a baby being trapped on a sofa and dying of asphyxiation, or a baby in bed with a parent and dying as a result of overlaying, is not SIDS. SIDS, by definition, is a death which cannot be adequately explained by medical history, a post-mortem examination, or a death scene investigation. However, it appears that an autopsy cannot always discern between SIDS and asphyxiation18. For more information on this subject, see http://www.phdinparenting.com/2008/06/05/faulty-logic-from-the-ontario-coroner-regarding-bed-sharing... [...]

[...] practices and bankrupt companies that make products that support those practices. I’ve written about this before as it relates to co-sleeping and I’m saddened and angry to have to write about it as [...]

[...] sure that I buy the argument that co-sleeping is unsafe. For one thing, as John Hoffman and Annie of PhD in Parenting outline, when a baby dies in an adult bed there is no distinction made between a safe co-sleeping [...]

[...] when they are left alone. Promise, you will all get way more sleep when you put baby next to you. Yes, it is safe. At least as safe (if not actually safer) than [...]

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