When you have a new baby, whether it's your first or fifth, you worry — you worry A LOT. Every parent worries; I'm a pediatrician and a mom, and I worry. This precious little being is mine, and my job is to keep her safe, healthy, and happy.

The first year of a baby's life will take you on a rollercoaster of emotions like you've never been on before — the sleepless nights, the crying, constant feeding, changing diapers… but today I want to address the issue of Sudden Infant Death Syndrome and breastfeeding vs. formula feeding.

I am 100% partial about being impartial about the way you choose to feed your child. Your lactation practices should be totally up to you. I intended to exclusively breastfeed and ended up switching to 100% formula — doesn't make me a bad parent, in fact, I did what was best for him (and me). But when you read articles titled "Does Formula Feeding Increase the Risk of SIDS?" or "The Risks of NOT Breastfeeding for Mothers and Infants," it sends chills down my spine.

What in the world are you supposed to think as a parent if you cannot breastfeed? If you adopted your child? If you cannot breastfeed your child for medical reasons? If you CHOOSE to formula feed? Seriously, parents do NOT need one more thing to freak out about, to feel guilty about. There's enough judgement surrounding formula and bottle feeding as it is, now you tell us we are endangering our babies' lives? That they might DIE if they are formula fed?

I am here to say FEEL NO GUILT! Feel no shame! Read the data, understand it, and know there are MANY other ways to protect your child from SIDS and anything else that comes her way.

What is SIDS? What do we know about what causes SIDS?

Sudden Infant Death Syndrome (SIDS) is the sudden and unexplained death of a baby younger than one year of age. A diagnosis of SIDS if the baby's death remains unexplained even after a death scene investigation, a review of clinical history, and an autopsy. But what causes SIDS? Currently, scientists believe there are several underlying causes likely to play the largest role in SIDS. This model is called the "triple risk model."

  1. A vulnerable developing period of life (especially under 6 months old).
  2. Exposure to some sort of environmental trigger (for example, tobacco smoke while in the womb).
  3. An underlying neurological, genetic or biological condition that makes it difficult for the baby to wake up.

The point of explaining this is to understand that SIDS is a mysterious, multifactorial process, and not one thing will cause it or prevent it, for that matter. We need to look at each baby, their risk of sudden infant death syndrome, and their environment. What role does breastfeeding vs. formula feeding play in this complicated syndrome?

What the Research Shows — and Doesn't

I was a researcher for years before going into pediatrics, and I can tell you that despite its best intentions, research is FLAWED. In particular, research done regarding the issue of the protective effect of breastfeeding and SIDS, which is mostly done as a review of previous studies (meta-analysis) or as "case control" studies. Even the authors explain the problems with these methods- response rate is in most cases not ideal, data is collected retrospectively, producing what's called "recall bias."

What do the studies show? Well, they show that one of the benefits of breastfeeding is associated with a risk reduction in SIDS of up to 50% at all ages. However, older studies do not delineate between exclusive and partial breastfeeding, but more recent studies show that while exclusive breastfeeding was associated with a slightly higher reduction in SIDS than those partially breastfed, any breastfeeding was found to have a protective effect. Studies show that the vast majority of SIDS deaths occur before 6 months of age, hence the recommendation by the WHO and the AAP for exclusive breastfeeding for the first 6 months of life.

How does breastfeeding protect a baby from SIDS? We don't know the answer to this question, but there are some theories:

  1. One likely mechanism is by breastmilk's immunologic properties- preventing even low- grade infections has been thought to be protective against SIDS.
  2.  Infant sleep studies have shown that breastfed infants are more easily aroused than formula fed infants.
  3. Some properties of breastmilk can influence a baby's brain development and result in reduced risk of SIDS.

The bottom line is that no one really knows, and some researchers even go as far as saying that the results might be explained by issues associated with breastfeeding (for example, having your baby sleeping near you in the same room) rather than human milk or the act of and duration of breastfeeding itself.

I also found no studies evaluating the protective nature of babies who are exclusively fed expressed breastmilk in a bottle, so again, lots of confusion in the science and case-control studies. And while yes, I must agree with the finding that breastfed babies might experience a protective effect on SIDS, one cannot imply that formula feeding, in turn, has a causative effect on SIDS.

SO, what CAN you do to reduce your baby's risk of SIDS?

Good news! There are LOTS of things we can do as parents to provide our babies with a safe sleep environment. In fact, the American Academy of Pediatrics (AAP) revised their safe sleep guidelines in 2016. There are many recommendations for a safe infant sleeping environment. Here are the highlights of what you need to know:

  • Back to sleep for every sleep — one of the most effective ways to reduce the risk of SIDS. Babies should be placed flat on their back for daytime and nighttime sleep position until 1 year of age. Once an infant can roll from back to front and front to back, you do not need to turn your baby to the back position.
  • Use a firm sleep surface — the safest place for your baby to sleep in is a firm sleep surface (mattress in a safety-approved crib) covered by a fitted sheet with NO other bedding or soft objects. I know, I know. I still wonder myself, after all these years of recommendations, why does the baby bedding company make crib bumpers and pillows and blankets? Put it all in the crib and take that Pinterest baby nursery picture before your baby is born then save them for the toddler years, because the fact is a large percentage of infants who die of SIDS are found with their head covered by bedding.
  • Breastfeeding is recommended — here is it again! OK fine, the official recommendation is to exclusively breastfeed until your baby is 6 months of age, not weaning to formula or food until after that, but we know any amount of breastfeeding has been shown to have a protective effect for child health.
  • It is recommended that infants sleep in the parents' room, close to the parents' bed, but on a separate sleep surface, ideally for the first year of life, but at least for the first 6 months — This means no bed-sharing or sofa-sleeping! Confession: I would have had a REALLY hard time with this one. My kids were born way before this recommendation, and I could NOT sleep a wink with my babies in my room!
  • Consider offering a pacifier at nap time and bedtime — although the mechanism in unclear, pacifier use seems to have a protective effect on SIDS, even if it falls out of your baby's mouth after baby is asleep. Phew! This means no need to go in the room to reinsert the pacifier 5-10 times a night!
  • Avoid smoke exposure during pregnancy and after birth — this one's a biggie. Maternal smoking during pregnancy and smoke exposure after birth are considered major risk factors for SIDS. Reason 1,978,335 to quit smoking.
  • Avoid overheating and head covering in infants — in general, infants should be dressed appropriately for the environment, with no greater than one extra layer of clothing than an adult would wear. There are no official recommendations for room temperature, but most of the literature supports a room temperature of between 68-72 degrees F. Over bundling and covering the face and head should be avoided.
  • Pregnant women should obtain regular prenatal care- there is substantial evidence linking a lower risk of SIDS for infants whose mothers get regular prenatal care.

The AAP describes 19 recommendations to reduce the risk of SIDS and other sleep-related infant deaths. For a full list, see https://pediatrics.aappublications.org/content/138/5/e20162938

The Bottom Line

To me, it's clear that understanding the science of SIDS is VERY unclear. As parents, we strive to provide a safe environment for our children, especially during these most vulnerable months. With that said, know that the issue of SIDS risk is multifactorial and no one single action can cause it or prevent it. Do your best to follow as many guidelines as you possibly can, but do NOT beat yourself up about your choice or circumstances surrounding how and what you feed your baby. Love, hold and care for your baby as only you can, and I wish you and your little one a safe and sound sleep.

Sources:

https://pediatrics.aappublications.org/content/138/5/e20162938

https://www.childrenshospital.org/conditions-and-treatments/conditions/s/sudden-infant-death-syndrome-sids/symptoms-and-causes

https://pediatrics.aappublications.org/content/123/3/e406

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/

https://www.forbes.com/sites/tarahaelle/2017/10/31/any-breastfeeding-even-partial-cuts-sids-risk-in-half/?sh=36dbe90b2519

The content on this site is for informational purposes only and not intended to be a substitute for professional medical advice, diagnosis or treatment. Discuss any health or feeding concerns with your infant's pediatrician. Never disregard professional medical advice or delay it based on the content on this page.