A Three Part Webinar Series February-April 2018 · co-author of Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family Jane Herwehe, MPH Lead, Data Action Team

1. Systematically Assessing Safe Infant Sleep Interventions Using the Multi-

Sectoral Influences Matrix (M-SIM): Feb 20, 3:00-4:30 EST2. A Public Health Approach to Safe Sleep: Implementing and Evaluating a

Multi-Level Program: March 20, 3:00-4:30 EST3. Walking the Line Between Public Health Messages and Lived Experience:

Constructive Conversations and Unlikely Alliances: April 17, 3:00-4:30 EST

A Three Part Webinar Series February-April 2018

Presented by the Southeastern and Southwestern Injury Prevention Network and the Safe States Alliance

Terri Miller, MPH

Safe to Sleep Campaign

Georgia Department of Health

Linda Smith, MPH, IBCLC

co-author of Sweet Sleep: Nighttime and

Naptime Strategies for the Breastfeeding Family

Jane Herwehe, MPH

Lead, Data Action Team

Louisiana Office of Public Health

Bureau of Family Health

Today’s Presenters

https://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=sweet+sleep

Walking the Line Between Public Health Messages and Lived Experience:

Constructive Conversations and Unlikely Alliances

April 17, 2018

Linda J. Smith, MPH, IBCLC, LCCE

Co-Author, Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family

By La Leche League International and published by Random House/Penguin Books

5/23/2018 © Linda J. Smith / BFLRC 2018 4

No smoking

Breastfeeding mother

Sober parents

Healthy Baby

Supine sleep

Unswaddled

Safe surface

Compatible Goals

• We all want babies alive in the morning

• Formula-fed babies are more likely to die from all-causes, including SIDS and smothering (ASSB)

• AAP 2016: breastfeeding is #3 strategy to reduce risk• Supine sleep • Firm, flat surface• Breastfeeding

• 75% of breastfeeding mothers bedshare at least part of the time

• Blair, P. S., & Ball, H. L. (2004). The prevalence and characteristics associated with parent-infant bed-sharing in England. Arch Dis Child, 89(12), 1106-1110.


Compatible Goals

• “Increasing breastfeeding” and “Reducing infant deaths” are COMPATIBLE GOALS

• “Safe Sleep 7” - All 7 factors must be in place• No greater risk of SIDS than baby alone in a crib

• Suffocation risk ‘vanishingly small’

• Babies need to be touched

• 82.5% of US mothers initiated breastfeeding • https://www.cdc.gov/breastfeeding/data/nis_data/results.ht

ml (2014)


https://www.cdc.gov/breastfeeding/data/nis_data/results.html

AAP 2016 SIDS statementMoon, R. Y. (2016). SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment. Pediatrics, 138(5), e1-e34. doi:10.1542/peds.2016-2940


•Breastfeeding now #3 - up from#8•#1 -supine sleep•#2 -firm sleep surface

•Focus on exclusive breastfeeding for 6 months•70% reduction in risk

•Any Breastfeeding still better than no breastfeeding

Lori Feldman-Winter, MD, MPHUSBC Breastfeeding Media Networking Call, October 24, 2016 Used with permission from Brenda Bandy

Why bedsharing is controversial

• SIDS & suffocation are different and rare

• SIDS major risk factors:• Smoking: prenatal and postpartum smoking increases risk 2-

10 times • Formula-feeding more than doubles the risk of SIDS• Unattended (including daycare) or overheated (swaddled) are

risks• Prone position risky for ~5%, no known markers

• Suffocation risks: • Sofa with someone or alone• With drunk/impaired adult on any surface


Points of agreement

• Supine (face up) position for sleep

• Flat, firm, clean sleep surface

• Breastfeed

• Room-sharing for all sleep periods

• Smoke-free environment

• No couches/sofas

• No drunk/impaired bedpartners


Controversies and Flaws

• SIDS vs. SUID vs. ASSB – often conflated

• Bedsharing vs. co-sleeping vs. room-sharing

• Case-control studies vs. higher-quality evidence

• Gaps in research base (what isn’t studied)

• Realistic risk-reduction strategies for breastfeeding families

• Results of ‘abstinence’ messages and campaigns

• Multiple interested stakeholders incl. formula and crib mfg.

• Disparities related to social/cultural practices and beliefs

• Research from UK on multi-ethnic populations and postnatal ward equipment/situations


Breastfeeding requires intimate physical contact

• “Suckling frequency in the early post-partum period is a well known predictor of successful breastfeeding initiation.

• Sleeping newborn babies in close proximity to their mothers (bedding-in) facilitates frequent feeding in comparison with rooming-in.”

• Ball HL, Ward Platt MP, Heslop E, Leech SJ, Brown KA. Randomised trial of infant

sleep location on the postnatal ward. Arch Dis Child. Jul 18 2006.


Breastfeeding and Bedsharing are Linked

• “Breastfeeding and bed-sharing are very clearly intertwined:• 72% of infants who breastfed for 1 month or more were

bed-sharers• 38% of formula-fed babies bed-shared”

• Blair PS & HL Ball (2004) "The prevalence & characteristics associated with parent-infant bed-sharing in England“ Archives of Disease in Childhood. 89:1106-110

• “The prevalence of breastfeeding was significantly higher among the groups that shared beds constantly or early for each of the first 15 months after birth.

• Conclusions: Advice on whether bed sharing should be discouraged needs to take into account the important relationship with breastfeeding.”

• Blair, P. S., Heron, J., & Fleming, P. J. (2010). Relationship Between Bed Sharing and Breastfeeding: Longitudinal, Population-Based Analysis. Pediatrics, peds.2010-1277. doi: 10.1542/peds.2010-1277


Bedsharing and breastfeeding • “There is no evidence that bed sharing is hazardous for infants of parents who do not

smoke” • Blair PS, Fleming PJ, Bensley D, Smith I, Bacon C, Taylor E, Berry J, Golding J, Tripp J. Smoking and

the sudden infant death syndrome: results from the 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. BMJ 1996;313:195-198.

• “65% of breastfed babies slept with parents all or part of the night (33% of formula-fed babies). … significantly longer duration of BF among mothers [in low-income classes] who were bed-sharers”

• Ball HL. Breastfeeding, bed-sharing and infant sleep. Birth 2003;30(3):181-188.

• “Bedsharing was only a risk when infant was sleeping with people other than the parents. Because there were few mother-father bed sharers, the findings were driven by the mother-infant dyad. These results are reassuring and consistent with laboratory studies demonstrating that more maternal inspections, more infant arousals, and less deep sleep among infants may occur when mothers and infants sleep together routinely.”

• Hauck FR, Herman SM, Donovan M et al. Sleep environment and the risk of Sudden Infant Death Syndrome in an urban population: the Chicago Infant Mortality Study. Pediatrics2003;111(5):1207-1214.

• Bedsharing by breastfeeding mothers with their infants, in the absence of the above mentioned risk factors, has not been shown to be associated with a significantly increased risk of unexpected infant death.

• Fleming, P., Pease, A., & Blair, P. (2015). Bed-sharing and unexpected infant deaths: what is the relationship? Paediatr Respir Rev, 16(1), 62-67.


• Objective To quantify the influence of bedsharing on breastfeeding duration.

• Results Longer duration of bedsharing, indicated by a larger cumulative bedsharing score, was associated with a longer duration of any breastfeeding but not exclusive breastfeeding, after adjusting for covariates. Breastfeeding duration was longer among women who were better educated, were white, had previously breastfed, had planned to breastfeed, and had not returned to work in the first year postpartum.

• Conclusions and Relevance Multiple factors were associated with breastfeeding, including bedsharing. Given the risk of sudden infant death syndrome related to bedsharing, multipronged strategies to promote breastfeeding should be developed and tested.


Huang, Y., Hauck, F. R., Signore, C., et al. (2013). Influence of bedsharing activity on breastfeeding duration among US mothers. JAMA Pediatrics, -. doi:10.1001/jamapediatrics.2013.2632

AAP Policy Supports Integration


New language about feeding at night acknowledges that “parents frequently fall asleep while feeding infant”, including greater emphasis on couch/chair being MOST dangerous and states that less hazardous to fall asleep while in adult bed◼ New language added about what to do to make adult

bed less risky

◼ Also includes specific instances to avoid bedsharing at all times

Lori Feldman-Winter, MD, MPHUSBC Breastfeeding Media Networking Call, October 24, 2016 Used with permission from Brenda Bandy

Changes in AAP Policy


Prior framing was leading to black and white view, but changes in framing and added detail clearly open the door to education w/ risk reduction messages

New evidence presented recommending skin-to-skin care for all mothers and newborns, immediately following birth, and to continue for at least an hour

Insufficient evidence to recommend for/against use of devices to make bedsharing safe:◼ Bedside sleepers now have CPSC standards and “may be considered by some parents as an

option”

Call to doctors to “have open and nonjudgmental conversations with families” (see AAP press release) opens up opportunity to have conversations with parents

Lori Feldman-Winter, MD, MPHUSBC Breastfeeding Media Networking Call, October 24, 2016

https://www.isisonline.org.uk/image-archive/images/image-19/

Used with permission from Brenda Bandy

AAP SIDS Policy Oct. 2016

• “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.”

• Moon, R. Y. (2016). SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment. Pediatrics, 138(5), e1-e34. doi: 10.1542/peds.2016-2940


What Policies FAIL TO ADDRESS

• Where a mother CAN sleep while breastfeeding safely

• Naps and unplanned sleep times/places

• Importance of touch and STS contact

• Differences between BF and non-BF babies• baby’s arousal and orientation to mother

• mothers’ arousal and response to baby

• Difference in touch needs of some babies

• Difference in sleep needs of some mothers


Does “never bedshare” work?“When mothers are unwilling/unable to get up & breastfeed, they:

1. Feed the baby formula

2. Undertake ‘infant-training’ program

3. Sleep next to the baby”

1. Ball, HL (2003) “Breastfeeding, bed-sharing & infant sleep”. Birth, 30 (3): 181-188


If bedsharing is deemed “risky”…

• Where should mother GO for night feeds?

• “Although the number of deaths in the parental bed has fallen, the number of co-sleeping deaths on a sofa has worryingly risen in recent years.”

• Blair, PS, Sidebotham P, Berry PJ, Evans M, Fleming PJ. Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK. Lancet. Jan 28 2006;367(9507):314-319.


Making BF difficult increases risks

• Exclusive breastfeeding for 6 months: • 24-hour breastfeeding on cue

• No bottles or pacifiers

• That means AT NIGHT TOO

• And mother needs her rest too!



No smoking

Breastfeeding mother

Sober parents

Healthy Baby

Supine sleep

Unswaddled

Safe surface

The Safe Sleep Seven and Sweet Sleep book©2014 La Leche League International

Diane WiessingerDiana WestLinda J. SmithTeresa Pittman

http://www.llli.org/sweetsleepbook



Safe Sleep Seven ©2014 La Leche League International

• No Smoking

• Sober Parents

• Breastfeeding Mother

• Healthy Baby

• On his/her back

• Lightly Dressed (not swaddled)

• Safe Surface


Safe Surface Checklist©2014 La Leche League International

• Avoid smothering risks:• Sofas & recliners• Softness & sagginess• Spaces between mattress

& headboard, walls, side rails

• Bedpartner who thrashes or sleeps exceptionally soundly

• Other children• Pets that could interfere

• Clear your bed of:• Unused pillows• Stuffed toys• Heavy covers &

comforters• Anything that dangles or

tangles

• Check for possible hazards• Distance to the floor• Landing surface• Sharp, poking or pinching

places


Cuddle Curl confirmed in studies

https://www.dur.ac.uk/resources/isis.online/RMP-15mid.jpg

Richard, C., Mosko, S., McKenna, J., & Drummond, S. (1996). Sleeping position, orientation, and proximity in bedsharing infants and mothers. Sleep, 19(9), 685-690.

Ball, H. L. (2003). Breastfeeding, bed-sharing, and infant sleep. Birth, 30(3), 181-188.


Bottom line:

“Baby-proof the bed because sleep happens.”

Linda J. Smith, MPH, IBCLC

USBC Infant Sleep Constellation


Resources and references

• Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family (2014). www.llli.org/sweetsleepbook

• http://www.isisonline.org.uk/ ISIS provides information about normal infant sleep based upon the latest UK and world-wide research

• University of Notre Dame Mother-Baby Behavioral Sleep Laboratory http://www.nd.edu/~jmckenn1/lab

• Durham University Parent-Infant Sleep Lab http://www.dur.ac.uk/sleep.lab/

• Academy of Breastfeeding Medicine Protocol on Co-Sleeping www.bfmed.org

• McKenna, James. Sleeping with Your Baby. Washington, DC: Platypus Media 2007 http://www.platypusmedia.com/node/70

• Ball H, Inch S, Copeland M. The Benefits of Bedsharing (video) http://www.markittelevision.com/breastfeeding_titles.html



http://www.isisonline.org.uk/

http://www.nd.edu/~jmckenn1/lab

http://www.dur.ac.uk/sleep.lab/

http://www.bfmed.org/

http://www.platypusmedia.com/node/70

http://www.markittelevision.com/breastfeeding_titles.html

Georgia Safe to Sleep Campaign

Provides tools and resources that strengthen

policy, provide consistent education and

change infant sleep environments to:

• Prevent infant sleep-related deaths in Georgia

• Empower professionals to educate parents

• Empower families to make informed decisions

about infant sleep

• Increase access to resources that support

behaviors that protect infants from sleep-related

deaths

What are some of the things

that we “know”?

According to the Vital Signs report using the

most recent data from PRAMS from 2015,

researchers found that, nationally:

– One in five (22%) mothers reported not placing

their baby on his or her back to sleep.

– More than half of mothers (61%) reported bed

sharing with their baby.

– Two in five (39%) mothers reported using soft

bedding in the baby’s sleep environment.

As of 2016, Georgia averaged

3 infant deaths per week

due to sleep-related causes.

The majority of these deaths were

considered preventable.

0

10

20

30

40

50

60

70

80

Ever Breastfed Breastfeeding at 6

months

Exclusive

Breastfeeding at 3

months

Exclusive

Breastfeeding at 6

months

Georgia Percent Breastfeeding Rates

Source: CDC Breastfeeding Report Card, 2014

Lower-Income Status

Draft: (5/10/2016) Office of Health Informatics for Planning (OHIP), GA DPH

Maternity Leave

Georgia Safe to Sleep Campaign’s

Approach

• Recognize when past language hasn’t been as supportive as it could have been.

• Focus on our shared goals

• Focus on Harm Reduction

• Focus on Health Equity

• Less personal opinion or hyperbolic scare tactics

Risk reduction is a behavioral change concept.

1) Individuals make their own choices about what they are

willing/able to change.

2) Informed choice is our goal.

Reducing

protection

(Increasing

risk)

Increasing

Protection

(Reducing risk)

Harm Reduction Model

Unsafe Safe

Sleep-Related Deaths by Age in Months,

GA, 2014, n=158

Source: GA Child Fatality Review File, 2014

11

3534

2523

13

54

23 3

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5 6 7 8 9 10

Nu

mb

er

of

Death

s

Age in Months90% of infant sleep-related deaths

occur prior to 6 months of age.

0

50

100

150

200

250

300

350

400

450

405

141

71 65

43

17 14 11 9 7 1 1

Nu

mb

er

Location at Time of Death

Location at time of Infant Sleep-related Death

5 Year Totals 2009-2013

Source: GA Child Fatality Review File, 2009-2014

Next Steps:

Let’s look at the messages -

• How can we create health education that

is supportive and empowering to ALL

mothers/caregivers/families?

• We want to continue to encourage

breastfeeding while also acknowledging

possible barriers present due to socio-

economic factors and infant health.

Examples of mutually supportive

messages already out there –

Dr. James McKenna• Regardless of whether an infant sleeps…all infants

should follow these same guidelines: infants should always sleep on their backs, on firm surfaces, on clean surfaces, in the absence of (secondhand) smoke, under light (comfortable) blanketing, and their heads should never be covered.

• The bed should not have any stuffed animals or pillows around the infant and never should an infant be placed to sleep on top of a pillow or otherwise soft bedding.

Adapted from: Maximizing the chances of Safe Infant Sleep in the Solitary and Cosleeping (Specifically, Bed-sharing) Contexts, by James

J. McKenna, Ph.D. Professor of Biological Anthropology, Director, Mother-Baby Sleep Laboratory, University of Notre Dame.

- Continued

• Bedsharing: It is important to be aware that adult beds were not designed to assure infants safety!

– (Dr. McKenna adds the bold lettering and exclamation point)

• 8 points to follow including: Bottle feeding babies should always sleep alongside the mother on a separate surface rather than in the bed.

Safe Sleep 7 – Smart

Steps to SAFER

bedsharing

Mom must be exclusively breastfeeding a full term baby and still follow the bulk of the other American Academy of Pediatrics recommendations for safe infant sleep

i.e. no smoking, baby on back, no overheating, no alcohol, drugs or smoking, no super soft mattress, no extra pillows, no toys, no heavy covers, clear of strings and cords

In addition to: pack the cracks use rolled towels or baby blankets, cover the baby not the head

2016 American Academy of Pediatrics

Level A Recommendations– Back to sleep for every sleep.

– Use a firm sleep surface.

– Breastfeeding is recommended.

– Room-sharing with the infant on a separate sleep surface is recommended.

– Keep soft objects and loose bedding away from the infant’s sleep area.

– Consider offering a pacifier at naptime and bedtime.

– Avoid smoke exposure during pregnancy and after birth.

– Avoid alcohol and illicit drug use during pregnancy and after birth.

– Avoid overheating.

– Pregnant women should seek and obtain regular prenatal care.

– Infants should be immunized in accordance with AAP and CDC recommendations.

Example –

Baby-Friendly United Kingdom

Continued

How can we help to move families

closer to safe sleep or safer sleep?

• Acknowledge they might not follow every recommendation every single time. This doesn't make them bad parents or certain to kill their infant; it makes them human.

• Acknowledge that every baby is different and every family is different therefore, a single solution will not work for every situation.

• Even if it isn’t easy, our job is give families all the information and to make it as clear and easy to understand as possible…and then allow them to make their own decisions.

The M-SIM’s value in facilitating Constructive Conversations and forging Unlikely Alliances

Jane Herwehe, MPH

Bureau of Family Health

Office of Public Health

The M-SIM…

Multi-sectoral Influences Matrix (M)-SIMIssue: Breastfeeding and Safe Sleep

Environmental Contextual FactorsIdentified levels of social influence

Product/Policy Physical/BuiltHistoric Phase

Current Phase

Future Phase

Assumptions:

Fleshing out the M-SIM

Issue: Unsafe sleep environments are a leading cause of infant death; need for prevention strategies; breastfeeding as a protective factor, breastfeeding and co-sleeping

Policy: Recommendations: how to create safe sleep environments; sleep surface, co-sleeping, sleep position

Products: cribs, crib alternatives, adult beds, sofas, chairs

Historic: breastfeeding as protection, co-sleeping, cribs, side cars, portable cribs alternatives;

Current: context and community sentiment; other investments in prevention

Future: recommendations for breastfeeding parents

Influencers:

• Parents and Caregivers

• Health care providers – birthing facilities/prof. orgs

• Lactation Experts

• Breastfeeding Advocates

• Children and Family Services

• American Academy of Pediatrics

• Academic researchers

• National Organizations

• Product manufacturers

• Media and Marketing Professionals

How an M-SIM can be helpful in this work:

Using the M-SIM…• Offers a structured, systematic

approach

• Identifies who should be part of the process

• Facilitates diversity of thought

• Helps identify the main issues, shared goals and generate questions in need of answering

• Focuses on the environmental aspects as well as policy

• Creates awareness of what we know/don’t know and who should be involved (concept of Cultural humility)

• Allows exploration of influencer perspectives -breastfeeding and non-breastfeeding parents and advocates

• Ensures equal representation from all voices – one voice not louder than another

• Gains perspective of providers and families on acceptable, workable solutions

• Guides the group in learning to think collaboratively-toward reaching shared goal –healthy moms and healthy babies

Thank you for your attention.

Questions??

Documents

A Three Part Webinar Series February-April 2018 · co-author of Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family Jane Herwehe, MPH Lead, Data Action Team