More Research on SIDS and Plagiocephaly
Published February 4, 2009
“I do not think it is a medical problem - it is more of a cosmetic one. Mothers may feel it is a syndrome and a problem when it really is nonsense.”
Dr. Peter Fleming, back sleep advocate, on his view of deformational plagiocephaly
http://www.guardian.co.uk/society/2003/jul/08/lifeandhealth.sciencenews
Considering we have an epidemic in the U.S. and the U.K. of plagiocephaly and torticollis which is associated with the SIDS prevention advice and that studies have shown Social Skills Delays and Motor Skills delays are also associated with this advice I am calling for more long-term studies to be done on both the safety and effectiveness of this advice. I also believe that more funding on how to figure out which infants are at a high risk of SIDS is necessary and that the treatment of all infants who have plagiocephaly (even mild) should be paid for by their respective governments.
A. DEVELOPMENTAL DELAYS AND SIDE EFFECTS:
Infants who sleep supine compared to infants who sleep in the prone position are impacted in the following ways:
- Social skills delays at 6 months (Dewey, Fleming, et al, 199
- Motor skills delays at 6 months (Dewey, Fleming, et al, 199
- Increased rates of gastroesophageal reflux (GER) (Corvaglia, 2007)
- Below norm AIMS scores (Majnemer, Barr, 2005)
- Milestone delays (Davis, Moon, et al., 199
- Increased duration of sleep apnea episodes during REM sleep at both 2.5 months and 5 months (Skadberg, Markestad, 1997)
- 6% decrease in sleep duration (Kahn, Grosswasser, et al.,1993)
B. PLAGIOCEPHALY AS AN INDICATOR OF STRICT ADHERENCE TO BACK SLEEP ADVICE:
I am not suggesting that correlation equals causality or that plagiocephaly is a cause but rather a marker:
- 1 in 300 infants had plagiocephaly in 1974 (Graham, Gomez, et al., 2005)
- 1 in 60 infants had plagiocephaly in 1996 (Graham, Gomez, et al., 2005)
“Infants with deformational plagiocephaly were found to have significantly different psychomotor development indexes and mental developmental indexes when compared with the standardized population.”
Kordestani, et al. in their study “Neurodevelopmental Delays in Children with Deformational Plagiocephaly”
C. RELIABILITY OF SIDS STATISTICS:
“A lot of us are concerned that the rate (of SIDS) isn’t decreasing significantly, but that a lot of it is just code shifting,’ said John Kattwinkel, chairman of the Centers for Disease Control and Prevention’s special task force on SIDS.”
Scripps Howard News Service Interview
http://www.shns.com/shns/g_index2.cfm?action=detail&pk=SIDS-10-08-07
"Federal records show a dramatic decline in reported cases of SIDS, dropping from 4,895 cases in 1992 to only 2,247 in 2004, the most recent year for which complete data is available. The records reviewed by Scripps showed that cases of SIDS virtually disappeared in some states and cities over the last several years, but closer examination of the data makes it evident that thousands of those lives have not been ‘saved,’ but rather lost under another name. Coroners and medical examiners said SIDS was responsible for nearly 80 percent of all sudden infant deaths 15 years ago and only 55 percent in 2004. What increased during this time were diagnoses that CDC statisticians labeled as "threats to breathing" and ‘other ill-defined causes of mortality.’"
Bowman and Hargrove, Scripps Howard News Service
D. OBSERVATIONS BY MEMBERS OF THE HEALTHCARE PROFESSION:
“There are indications of a rapidly growing population of infants who show developmental abnormalities as a result of prolonged exposure to the supine position.”
Dr. Ralph Pelligra regarding the impact of the Back to Sleep Campaign
http://cgi.thescientificworld.co.uk/cgi-bin/processHtml.pl?Id=2005.03.71.html&format=Dreamweaver
“Since the implementation of the “Back to Sleep” campaign, therapists are seeing increasing numbers of kindergarten-aged children who are unable to hold a pencil.”
Susan Syron, Pediatric Physical Therapist
“In its fundamental purpose it has been largely successful. The incidence of SIDS has been reduced dramatically. However, as many orthotists can attest, this important gain has not been without its lesser comorbidities. The one we tend to think of has been the rapid increase in the incidence of positional plagiocephaly and positional brachycephaly. However, there have been whispers and rumors of other effects.”
Phil Stevens, MEd, CPO regarding side effects of the Back to Sleep Campaign.
http://www.oandp.com/edge/issues/articles/2006-12_02.asp
E. PELAYO LETTER TO THE JOURNAL OF PEDIATRICS AND THE REPLY TO HIS CONCERNS:
“The potential implications of a SIDS risk-reduction strategy
that is based on a combination of maintaining a low
arousal threshold and reducing quiet (equivalent to
slow-wave sleep) in infants must be considered. Because
SWS is considered the most restorative form
of sleep and is believed to have a significant role in
neurocognitive processes and learning, as well as in
growth, what might be the neurodevelopmental consequences
of chronically reducing deep sleep in the first
critical 12 months of life?”
Dr. Raphael Pelayo, Stanford University
“physiologic studies demonstrate that infants who sleep
supine have decreased sleep duration, decreased non-
REM sleep, and increased arousals; this effect peaks at
2 to 3 months of age and is not evident at 5 to 6 months
of age, thus coinciding with the peak incidence for
SIDS at 2 to 4 months of age. The SIDS risk-reduction
strategy of supine sleep will result in a lower arousal
threshold and a reduction in quiet sleep.”
U.S. SIDS Task Force (chaired by Dr. John Kattwinkel)
F. THE THEORETICAL MECHANISM OF HOW SLOW WAVE SLEEP IMPACTS MEMORY AND LEARNING:
In a currently utilized model that explains the process in which slow wave sleep is involved in memory consolidation the hippocampus acts as a temporary storage facility for new memories which are then transferred to the neocortex during slow wave sleep (SWS) [8]. In this model, acetylcholine acts a feedback loop inhibitor inside the hippocampus during REM sleep and wakefulness. The activity during the high cholinergic wakefulness period is believed to provide an environment which allows for the encoding within the hippocampus of new declarative memories. The low cholinergic environment during SWS is thought to then allow these memories to be transferred from the temporary storage of the hippocampus to their permanent storage environment in the neocortex and for memory consolidation [9, 10].
A significant way of decreasing slow wave sleep in infants is by changing their sleeping position from prone to supine. It has been shown in studies of preterm infants [11, 12], full-term infants [13, 14], and older infants [15], that they have greater time periods of quiet sleep and also decreased time awake when they are positioned to sleep in the prone position.
8. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351–359.
9. Buzsáki, G. 1989. Two-stage model of memory trace formation: A role for “noisy” brain states. Neuroscience 31: 551–570.
10. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351–359.
11. Myers MM, Fifer WP, Schaeffer L, et al. Effects of sleeping position and time after feeding on the organization of sleep/wake states in prematurely born infants. Sleep 1998;21:343–9.
12. Sahni R, Saluja D, Schulze KF, et al. Quality of diet, body position, and time after feeding influence behavioral states in low birth weight infants. Pediatr Res 2002;52:399–404.
13. Brackbill Y, Douthitt TC, West H. Psychophysiologic effects in the neonate of prone versus supine placement. J Pediatr 1973;82:82–4.
14. Amemiya F, Vos JE, Prechtl HF. Effects of prone and supine position on heart rate, respiratory rate and motor activity in full term infants. Brain Dev 1991;3:148–54.
15. Kahn A, Rebuffat E, Sottiaux M, et al. Arousal induced by proximal esophageal reflux in infants. Sleep 1991;14:39–42.
G. POSSIBLE CONFLICTS OF INTEREST BY CHIEF ADVOCATES IN THE U.S. AND U.K.:
In the U.S. the primary advocate of the SIDS Back to Sleep Campaign has been Dr. John Kattwinkel. He had a 3 day old daughter die in 1966 which is a tragedy. Unfortunately, he may have a bias toward preventing SIDS (good for a lay person but not for serious research) and disregards developmental delays.
In the UK the primary advocate of the Cot Death Back sleeping campaign has been Peter Fleming who is now credited with saving 100,000 babies lives worldwide. To give up the honor of having saved 100,000 babies lives worldwide creates a bias in my opinion.
I. CONCLUSION
More long-term research needs to be conducted on the safety and effectiveness of the SIDS Back to Sleep Campaign.
BTW, I’m well aware the articles I quote draw different conclusions. Many will say that all these infants need is more "Tummy Time". But, The study on “tummy time” never used babies who always slept on their stomachs - the Methodology of the Majnemer study states all babies used were ones that initially were put to sleep on their backs.
The SIDS Advocates will also say the delays are only "Mild and Transient".
But, they can't cite a lont-term study because they’ve never studied the impact of the Back to Sleep Campaign past the age of 18 months. Considering most psychologists and doctors will tell you it’s nearly impossible to diagnose a child with many developmental delays prior to the age of three your quote “Mild and Transitor” should be changed to:
MILD AND TRANSITORY AS TESTED IN ONE STUDY UNTIL INFANTS WERE 18 MONTHS OF AGE.
BTW, the 18 month old back sleepers in that study (Fleming) still had developmental delays but they were lags that weren’t statistically signifcant.
Dr. Peter Fleming, back sleep advocate, on his view of deformational plagiocephaly
http://www.guardian.co.uk/society/2003/jul/08/lifeandhealth.sciencenews
Considering we have an epidemic in the U.S. and the U.K. of plagiocephaly and torticollis which is associated with the SIDS prevention advice and that studies have shown Social Skills Delays and Motor Skills delays are also associated with this advice I am calling for more long-term studies to be done on both the safety and effectiveness of this advice. I also believe that more funding on how to figure out which infants are at a high risk of SIDS is necessary and that the treatment of all infants who have plagiocephaly (even mild) should be paid for by their respective governments.
A. DEVELOPMENTAL DELAYS AND SIDE EFFECTS:
Infants who sleep supine compared to infants who sleep in the prone position are impacted in the following ways:
- Social skills delays at 6 months (Dewey, Fleming, et al, 199
- Motor skills delays at 6 months (Dewey, Fleming, et al, 199
- Increased rates of gastroesophageal reflux (GER) (Corvaglia, 2007)
- Below norm AIMS scores (Majnemer, Barr, 2005)
- Milestone delays (Davis, Moon, et al., 199
- Increased duration of sleep apnea episodes during REM sleep at both 2.5 months and 5 months (Skadberg, Markestad, 1997)
- 6% decrease in sleep duration (Kahn, Grosswasser, et al.,1993)
B. PLAGIOCEPHALY AS AN INDICATOR OF STRICT ADHERENCE TO BACK SLEEP ADVICE:
I am not suggesting that correlation equals causality or that plagiocephaly is a cause but rather a marker:
- 1 in 300 infants had plagiocephaly in 1974 (Graham, Gomez, et al., 2005)
- 1 in 60 infants had plagiocephaly in 1996 (Graham, Gomez, et al., 2005)
“Infants with deformational plagiocephaly were found to have significantly different psychomotor development indexes and mental developmental indexes when compared with the standardized population.”
Kordestani, et al. in their study “Neurodevelopmental Delays in Children with Deformational Plagiocephaly”
C. RELIABILITY OF SIDS STATISTICS:
“A lot of us are concerned that the rate (of SIDS) isn’t decreasing significantly, but that a lot of it is just code shifting,’ said John Kattwinkel, chairman of the Centers for Disease Control and Prevention’s special task force on SIDS.”
Scripps Howard News Service Interview
http://www.shns.com/shns/g_index2.cfm?action=detail&pk=SIDS-10-08-07
"Federal records show a dramatic decline in reported cases of SIDS, dropping from 4,895 cases in 1992 to only 2,247 in 2004, the most recent year for which complete data is available. The records reviewed by Scripps showed that cases of SIDS virtually disappeared in some states and cities over the last several years, but closer examination of the data makes it evident that thousands of those lives have not been ‘saved,’ but rather lost under another name. Coroners and medical examiners said SIDS was responsible for nearly 80 percent of all sudden infant deaths 15 years ago and only 55 percent in 2004. What increased during this time were diagnoses that CDC statisticians labeled as "threats to breathing" and ‘other ill-defined causes of mortality.’"
Bowman and Hargrove, Scripps Howard News Service
D. OBSERVATIONS BY MEMBERS OF THE HEALTHCARE PROFESSION:
“There are indications of a rapidly growing population of infants who show developmental abnormalities as a result of prolonged exposure to the supine position.”
Dr. Ralph Pelligra regarding the impact of the Back to Sleep Campaign
http://cgi.thescientificworld.co.uk/cgi-bin/processHtml.pl?Id=2005.03.71.html&format=Dreamweaver
“Since the implementation of the “Back to Sleep” campaign, therapists are seeing increasing numbers of kindergarten-aged children who are unable to hold a pencil.”
Susan Syron, Pediatric Physical Therapist
“In its fundamental purpose it has been largely successful. The incidence of SIDS has been reduced dramatically. However, as many orthotists can attest, this important gain has not been without its lesser comorbidities. The one we tend to think of has been the rapid increase in the incidence of positional plagiocephaly and positional brachycephaly. However, there have been whispers and rumors of other effects.”
Phil Stevens, MEd, CPO regarding side effects of the Back to Sleep Campaign.
http://www.oandp.com/edge/issues/articles/2006-12_02.asp
E. PELAYO LETTER TO THE JOURNAL OF PEDIATRICS AND THE REPLY TO HIS CONCERNS:
“The potential implications of a SIDS risk-reduction strategy
that is based on a combination of maintaining a low
arousal threshold and reducing quiet (equivalent to
slow-wave sleep) in infants must be considered. Because
SWS is considered the most restorative form
of sleep and is believed to have a significant role in
neurocognitive processes and learning, as well as in
growth, what might be the neurodevelopmental consequences
of chronically reducing deep sleep in the first
critical 12 months of life?”
Dr. Raphael Pelayo, Stanford University
“physiologic studies demonstrate that infants who sleep
supine have decreased sleep duration, decreased non-
REM sleep, and increased arousals; this effect peaks at
2 to 3 months of age and is not evident at 5 to 6 months
of age, thus coinciding with the peak incidence for
SIDS at 2 to 4 months of age. The SIDS risk-reduction
strategy of supine sleep will result in a lower arousal
threshold and a reduction in quiet sleep.”
U.S. SIDS Task Force (chaired by Dr. John Kattwinkel)
F. THE THEORETICAL MECHANISM OF HOW SLOW WAVE SLEEP IMPACTS MEMORY AND LEARNING:
In a currently utilized model that explains the process in which slow wave sleep is involved in memory consolidation the hippocampus acts as a temporary storage facility for new memories which are then transferred to the neocortex during slow wave sleep (SWS) [8]. In this model, acetylcholine acts a feedback loop inhibitor inside the hippocampus during REM sleep and wakefulness. The activity during the high cholinergic wakefulness period is believed to provide an environment which allows for the encoding within the hippocampus of new declarative memories. The low cholinergic environment during SWS is thought to then allow these memories to be transferred from the temporary storage of the hippocampus to their permanent storage environment in the neocortex and for memory consolidation [9, 10].
A significant way of decreasing slow wave sleep in infants is by changing their sleeping position from prone to supine. It has been shown in studies of preterm infants [11, 12], full-term infants [13, 14], and older infants [15], that they have greater time periods of quiet sleep and also decreased time awake when they are positioned to sleep in the prone position.
8. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351–359.
9. Buzsáki, G. 1989. Two-stage model of memory trace formation: A role for “noisy” brain states. Neuroscience 31: 551–570.
10. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351–359.
11. Myers MM, Fifer WP, Schaeffer L, et al. Effects of sleeping position and time after feeding on the organization of sleep/wake states in prematurely born infants. Sleep 1998;21:343–9.
12. Sahni R, Saluja D, Schulze KF, et al. Quality of diet, body position, and time after feeding influence behavioral states in low birth weight infants. Pediatr Res 2002;52:399–404.
13. Brackbill Y, Douthitt TC, West H. Psychophysiologic effects in the neonate of prone versus supine placement. J Pediatr 1973;82:82–4.
14. Amemiya F, Vos JE, Prechtl HF. Effects of prone and supine position on heart rate, respiratory rate and motor activity in full term infants. Brain Dev 1991;3:148–54.
15. Kahn A, Rebuffat E, Sottiaux M, et al. Arousal induced by proximal esophageal reflux in infants. Sleep 1991;14:39–42.
G. POSSIBLE CONFLICTS OF INTEREST BY CHIEF ADVOCATES IN THE U.S. AND U.K.:
In the U.S. the primary advocate of the SIDS Back to Sleep Campaign has been Dr. John Kattwinkel. He had a 3 day old daughter die in 1966 which is a tragedy. Unfortunately, he may have a bias toward preventing SIDS (good for a lay person but not for serious research) and disregards developmental delays.
In the UK the primary advocate of the Cot Death Back sleeping campaign has been Peter Fleming who is now credited with saving 100,000 babies lives worldwide. To give up the honor of having saved 100,000 babies lives worldwide creates a bias in my opinion.
I. CONCLUSION
More long-term research needs to be conducted on the safety and effectiveness of the SIDS Back to Sleep Campaign.
BTW, I’m well aware the articles I quote draw different conclusions. Many will say that all these infants need is more "Tummy Time". But, The study on “tummy time” never used babies who always slept on their stomachs - the Methodology of the Majnemer study states all babies used were ones that initially were put to sleep on their backs.
The SIDS Advocates will also say the delays are only "Mild and Transient".
But, they can't cite a lont-term study because they’ve never studied the impact of the Back to Sleep Campaign past the age of 18 months. Considering most psychologists and doctors will tell you it’s nearly impossible to diagnose a child with many developmental delays prior to the age of three your quote “Mild and Transitor” should be changed to:
MILD AND TRANSITORY AS TESTED IN ONE STUDY UNTIL INFANTS WERE 18 MONTHS OF AGE.
BTW, the 18 month old back sleepers in that study (Fleming) still had developmental delays but they were lags that weren’t statistically signifcant.
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