New AAP Sleep Guidelines, The Baby Box, and Questions Raised

In a tweet about the new sleep guidelines recently released by the American Academy of Pediatrics, a wise colleague in Scotland Suzanne Zeedyk asked, "How do we support parents without terrifying them?"

The evidence for "back to sleep" recommendations issued in the early 1990's was unequivocal; following the guidelines the rate of SIDS (sudden infant death syndrome) plummeted a dramatic 50%.   However, following the initial decline, the rate of SIDS has plateaued, leading the AAP to revisit sleep recommendations.

In a thorough document the AAP references the evidence for its  extensive (19 items) list of recommendations. There are two recommendations that I wish to explore in detail.

 It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.

Communities around the world are taking the lead of Finland, where the Baby Box has been issued to all families on the birth of a baby for over 75 years, a practice that led to a dramatic decrease in infant mortality, and is now embedded in a societal support for parents and children that extends well beyond the newborn period.  In my community in Western Massachusetts, Berkshire Baby Box is launching among the first countywide distributions of the box in the United States.

The box fits seamlessly with the new recommendations. With the firm mattress, fitted sheets and portability, the box allows families to follow these recommendations with ease. 

As a specialist in infant mental health, I well recognize the central role of sleep, both for parent and child, in healthy development. I work with many families where infants'  frequent night waking exacerbates parental depression and marital conflict, two factors known to have negative long-term effects on both mental and physical health. In these families, teaching a baby to sleep independently has been a lifesaver. 

In many American families both parents work and lack extended family for support. In such situations the natural frequent night waking of a baby who relies on a parent to fall asleep can place extreme stress on a family, negatively impacting relationships between parents and with older siblings. 

As I have written in all of my books, teaching independent sleep should never be done under the age of 4 months, the age at which most infants acquire the developmental capacity to self-soothe. However, I am concerned that the AAP recommendations, taken out of context, for a baby to sleep in the parents’ room for 6-12 months, will complicate these situations significantly. This issue is intimately intertwined with the second recommendation I wish to address:

Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and strangulation.

My concern here is with the "soft objects."

In 1953, D.W. Winnicott published his paper Transitional Objects and Transitional Phenomena in which he described, from his perspective as both pediatrician and psychoanalyst,  the significance of what many parents term  "lovey," or that particular soft object that has a seemingly magical power to comfort a young child. When my children were 4 months old, I bought them each a pair of puffalumps. These small soft lightweight animals immediately took on the role of transitional objects, comforting both children through many a challenge over the years, even making their way to college with my daughter. I learned that Fisher Price made a new line of large ones (the original were 8"-10") in 2006 that were subsequently discontinued. This is unfortunate in my view. When I speak with new parents, I recommend that when an infant turns 4 months, they introduce a small soft toy that does not pose any suffocation risk, that can serve as this transitional object. I recommend getting two so that one at a time can go in the wash, and in case one is lost.

This object is intimately intertwined with the issue not only of separate sleeping but also the way our culture places value on separateness and independence, a view that is in many ways unique to western culture. We value our children's independence and self-reliance. Sleeping independently is often the first of many such transitions in a typical American child's life. The transitional object can play a very important role in this process.

It may be that a change in this view is indicated. Perhaps we would find, as these recommendations are put in place, if they go together with national distribution of baby boxes, and the full range of government support given to families in countries like Finland, we would continue to see a decline in SIDS.

But the risk is that without attention to the social and cultural realities of raising children in a country that does not offer paid parental leave, does not invest in quality child care, and in general does not significantly support parents or children, these recommendations may leave parents in a difficult or even untenable bind.

The guidelines clearly ask that pediatricians to fall in line.

Health care professionals, staff in newborn nurseries and NICUs, and childcare providers should endorse and model the SIDS risk-reduction recommendations from birth

The guidelines do state: "Health care providers are encouraged to have open and nonjudgmental conversations with families about their sleep practices." However, the above recommendation makes me uneasy about what I hope is thoughtful questioning.  My anxiety, perhaps a mirror image of parental anxiety, leads me to add: Babies are to be put to sleep on their back. Smoking and bed sharing, as well as co-sleeping on a couch, are unequivocally to be avoided.

I feel pressure to have certainty on the subject.  I wonder if most parents and professionals feel the same pressure. Perhaps this wish for certainty is an inherent part of parental love. As I write in my recent book, The Silenced Child:

"When we become parents, we have the opportunity to open our hearts to a love unlike any other. But in opening ourselves to this love, we become vulnerable to loss. Loss is an inevitable part of parenting. That simple step of putting a baby to bed for the first time in his own room is full of poignancy. It is the first of many losses as our children grow up. The first day of kindergarten, going off to college, and all the many small steps toward becoming a separate, independent individual are mixed with ambivalence and loss for both parent and child. And though the idea is mostly out of our conscious awareness, in becoming parents we make ourselves vulnerable to an unlikely but real possibility of unbearable loss." 

Perhaps the 19 guidelines help to empower us, to assuage our feelings of helplessness in the face of this unthinkable possibility. 

Sleep is central to our emotional and physical well being. It represents complex issues around separation and independence that are inextricably linked with social and cultural support of parents and children.  I am hopeful that as these guidelines are implemented, we make room for discussion of these important and profound questions. They have bearing on the future of our children, and of our society as a whole.