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Given the reduction in SIDS rates, it is unlikely that larger population based case-control studies will be possible in the future. The difficulty in recruiting control families may also limit the interpretation of the results; weighting the random process by socioeconomic status may offset some of the selection bias but does not rule out the possibility that our random control families were different from the population by measures other than occupational status. Our second control group, that of high risk families, was therefore important as not only were their characteristics more similar to those of the families with SIDS infants but they also had more in common with deprived families—a group potentially under-represented in control groups in previous studies.
Another limitation is that we did not interview the control families at weekends, when alcohol and drug use may be more common. However, an analysis restricted to deaths and reference sleeps that occurred only during the week suggests the combined effect of cosleeping and alcohol or drug use was still highly significant. Despite these limitations, that the differences for almost all factors investigated were similar in magnitude between the SIDS infants and the high risk control infants to those observed between SIDS infants and the randomly selected control infants is important.
Despite their similar socioeconomic backgrounds, the high risk control infants were as different from the SIDS infants in many important risk factors as were the random control infants, confirming that the risk factors for SIDS are not merely surrogate markers for aspects of social deprivation. The proportion of both SIDS and control infants put or found in the prone position were no different from those in our earlier Confidential Enquiry into Stillbirths and Deaths in Infancy study, suggesting that the reduction in SIDS rates may be caused by something else.
One possible contributing factor may be the reduction in prevalence of infants sleeping on their side, which has more than halved among both SIDS infants and control infants compared with such infants in our earlier study.
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Also, notably fewer infants are now exposed to environmental tobacco smoke, at least a threefold reduction among both SIDS infants and randomly chosen controls , although maternal smoking during pregnancy remains an important risk factor. The thermal insulation of bedding plus clothing used in both SIDS infants and control infants has fallen progressively, from 10 tog and 8 tog, respectively, in the Avon studies in the s 20 to 5 tog and 4 tog in the Confidential Enquiry into Stillbirths and Deaths in Infancy study, 3 and to 3 tog and 2.
Swaddling infants may be a potential new risk factor; a recent review suggests that this may be a risk factor only in combination with the prone sleeping position, 21 although most swaddled SIDS infants in this study were found supine. The reduction in the peak age of deaths in the present study is notable, with the SIDS rate among older infants having fallen more than among the younger infants. This may be important in understanding the increased proportion of deaths while bed sharing, as such deaths have previously been reported to be more common among younger SIDS infants.
The fall in SIDS rate despite a fall in prevalence of dummy use does not support the hypothesis that dummies are directly involved in a potentially protective mechanism against SIDS. Several epidemiological studies on SIDS have found either no evidence or weak evidence of a risk from parents habitually consuming alcohol. Published data on the use of drugs and the risk of SIDS are even more sparse, and more difficult to collect given the often illegal nature of their use. Studies have tended to concentrate on the effects in utero 32 33 34 and the potential risk associated with habitual use 35 rather than investigating any interaction with cosleeping.
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The findings suggest that much of the risk associated with cosleeping may be explained by the circumstances in which the SIDS infants were found. A significant risk was associated with cosleeping on a sofa or on any surface with a parent who had consumed alcohol or drugs. In the absence of any evidence that the parent had laid on the infant, from investigation of the scene and circumstances or from postmortem examination, it is a simplistic and unjustified assumption that all unexpected deaths in potentially risky cosleeping environments are caused by overlaying or entrapment.
Indeed in this investigation of all sudden unexpected deaths in infants the multiprofessional review process attributed only three deaths to unintentional asphyxiation. These deaths were thus not labelled as SIDS and are not included in the present analysis.
It would be wrong to apportion blame on an individual basis without sufficient evidence, but this does not mean we can ignore the patterns we observe at a population level. Almost regardless of the pathophysiological processes leading to infant deaths in risky cosleeping environments we should remind parents that such cosleeping practices are risky. The increased risk of unintentional suffocation in such circumstances needs to be reinforced. Despite the small numbers in this study the interaction between cosleeping and recent use of alcohol or drugs by the parents remained significant in the multivariable analysis.
This finding was significant regardless of which control group was used for comparison, suggesting that we are not merely measuring aspects of deprivation but identifying specific circumstances that put infants at risk. The strong association between alcohol consumption, use of drugs, and smoking may explain in part the interaction found previously between cosleeping and smoking.
In certain cultures bed sharing is common and the prevalence of SIDS is high. These include the African black populations in the United States and Maori and Aboriginal populations.
It is not bed sharing that distinguishes these cultures but other mediating factors such as smoking and use of alcohol and drugs, which in conjunction with cosleeping may put infants at risk. Using our longitudinal data from Avon over the past 20 years we have already shown an increase in infant deaths while cosleeping on a sofa.
It is the only infant sleeping environment in which the SIDS rate has increased in recent years, and it equates to an increase from 24 to 42 deaths a year in England and Wales during a period when the SIDS rate has halved; about one sixth of SIDS infants are now found cosleeping on a sofa. Similar proportions have been reported in Scotland 5 and Northern Ireland 37 but were not found in a recent German study, 38 which may suggest this practice is culture specific. Cosleeping on a sofa was an uncommon practice among the control families, and it was not a regular practice even among the parents of 13 SIDS infants in this study.
Alcohol or drugs were a feature in half of these deaths, and in seven cases the parents wanted to feed their infant and inadvertently fell asleep.
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This raises two important points. Firstly, it is not enough to advise against cosleeping on a sofa; health professionals must advise parents to avoid putting themselves in the position where this could happen.
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Anecdotally, two of the families of SIDS infants who had coslept on a sofa informed us that they had been advised against bringing the baby into bed but had not realised the risks from falling asleep on the sofa. Some of the risk reduction messages seem to be getting across and may have contributed to the continued fall in the SIDS rate. Identifying emerging dangers and re-emphasising ones already observed within the infant sleeping environment may further reduce the number of deaths from SIDS.
This is clearly illustrated in the current polarised debate surrounding cosleeping. Based on evidence from research into SIDS it is questionable whether advice to avoid bed sharing is generalisable and whether such a simplistic approach would do no harm. A better approach may be to warn parents of the specific circumstances that put infants at risk.
Parents need to be advised never to put themselves in a situation where they might fall asleep with a young infant on a sofa. Parents also need to be reminded that they should never cosleep with an infant in any environment if they have consumed alcohol or drugs.
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It is unclear which risk reduction messages have contributed towards this continued fall in rates. A higher proportion of the residual SIDS deaths now occur among more deprived families and those who cosleep with their infant. Many of the deaths while cosleeping occurred in potentially hazardous environments, including a sofa or shared surface with an adult who had recently consumed alcohol or narcotics. Advising parents to avoid risky cosleeping environments might reduce the SIDS rate even further.
We thank the professionals from all the agencies in the south west of England who contributed to these studies, particularly the bereaved and control families. Contributors: All authors contributed to the design of the study, revised the article, and approved the final version. PB carried out the initial analysis. PJF is guarantor. Ethical approval: This study was approved by the south west multicentre research ethics committee and by each constituent local research ethics committee. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.
Skip to main content. Research Hazardous cosleeping Article Related content Metrics Responses Peer review. Abstract Objectives To investigate the factors associated with sudden infant death syndrome SIDS from birth to age 2 years, whether recent advice has been followed, whether any new risk factors have emerged, and the specific circumstances in which SIDS occurs while cosleeping infant sharing the same bed or sofa with an adult or child.
Methods From January to December we carried out a population based case-control study of all sudden unexpected deaths in infancy in the counties of Gloucestershire, Wiltshire, Bristol, Somerset, Devon, and Cornwall, in the south west of England.