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Lawrence M. Gartner, MD
Chairman, Executive Committee, Section on Breastfeeding
American Academy of Pediatrics
On behalf of the Leadership Group of the Section on Breastfeeding
American Academy of Pediatrics
To the Editor.—
The Section on Breastfeeding of the American Academy of Pediatrics welcomes the new policy statement from the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome1 regarding measures that may further reduce the risk of sudden infant death syndrome (SIDS), especially the recommendation for proximate sleeping arrangements for all infants. We must take exception, however, to the global recommendation against all bed sharing, because the data supporting this recommendation are relatively weak and not specific to the breastfeeding population. We would, for the same reasons, not promote bed sharing at this time. It is our opinion that a neutral position acknowledging the still-controversial nature of this issue would have been more appropriate.
With approximately half of all mothers in the United States practicing infant bed sharing at some time, it is more important, as a public health measure, to emphasize the specific factors in bed sharing that make it less risky and safer.2 Bed sharing under safe conditions may prove to be an important factor in the success of breastfeeding, particularly in its maintenance for at least 1 year and as long thereafter as the mother and infant desire. Breastfeeding, particularly in relation to duration, has been demonstrated to be life-saving and a significant factor in reducing infant mortality.3 The task force's advice to the mother to return the infant to a separate sleep location after the common practice of breastfeeding in bed may increase maternal anxiety about this practice and reduce breastfeeding duration. Mothers may choose the even riskier practice of breastfeeding infants in an upholstered chair or sofa, in which case, if they fall asleep with the infant in their arms, the infant is at truly great risk of being smothered or falling. Thus, the bed may be the safer alternative.
The recommendation against bed sharing carries yet another very serious risk that was not considered in the policy statement. Social services and police may interpret this recommendation such that any mother whose infant dies of whatever cause in the maternal-parental bed will be charged with child abuse, or worse, on that basis alone. Media reports of such actions may have the unanticipated consequence of reducing breastfeeding duration, thereby increasing, in turn, infant mortality and morbidity.
The Section on Breastfeeding is also concerned that the task force's policy statement will be misinterpreted as applying to infants in the immediate newborn period, and it should be clear that these recommendations are not relevant to hospital-room practices. Similarly, we wish to emphasize that pacifier use is recommended by the task force only starting at 1 month of age and only at the time of sleep and thus has no relevance to postpartum care of the newborn.
Of particular concern are the data from one of the studies cited by the task force that habitual pacifier use or dependence may actually increase the risk of SIDS if the pacifier is not used at the time of the last sleep (increased incidence of SIDS [odds ratio: 1.95]).4 Thus, habitual pacifier use may, paradoxically, increase risk for SIDS if the mother fails to insert a pacifier at sleep time. Furthermore, careful review of the cited pacifier and SIDS data also indicates that no distinction was made between those infants who were breastfed and those who were not, precluding any conclusion as to the value of pacifier use in the breastfeeding infant.5
Thus, we are of the opinion that the Task Force on Sudden Infant Death Syndrome should have given greater emphasis to positive protective prescriptive recommendations such as universal supine sleeping position,6 reduction of maternal smoking and use of other illicit or harmful substances, proper proximate sleeping arrangements, bedding, and infant clothing, and, most importantly, exclusive breastfeeding for the first 6 months of the infant's life and its continuation for 
1 year.7 Unfortunately, the media's response to the task force's statement has focused on the 2 controversial and problematic recommendations regarding pacifier use and bed sharing, diverting the public's attention from the task force's otherwise positive recommendations.
REFERENCES
This article has been cited by other articles:
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  B. M. Ostfeld, H. Perl, L. Esposito, K. Hempstead, R. Hinnen, A. Sandler, P. G. Pearson, and T. Hegyi Sleep Environment, Positional, Lifestyle, and Demographic Characteristics Associated With Bed Sharing in Sudden Infant Death Syndrome Cases: A Population-Based Study Pediatrics, November 1, 2006; 118(5): 2051 - 2059. [Abstract] [Full Text] [PDF]
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 P Fleming, P Blair, and J McKenna New knowledge, new insights, and new recommendations Arch. Dis. Child., October 1, 2006; 91(10): 799 - 801. [Full Text] [PDF]
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