Study Demonstrates Why ABC Recommendations Must Change

The ABC recommendation (Alone, Back, Crib) has been ineffective in reducing infant deaths, and yet the American Academy of Pediatrics (AAP) continues to issue it.1 US trends in sudden unexpected infant death have not substantially changed since 1998,1 a period which saw increasingly strong recommendations against bedsharing.2 The most recent AAP recommendation against bedsharing was drawn only from a statistical analysis of 2 papers of combined case-control studies.1 The evidence from the extensive anthropologic, physiologic, and epidemiologic literature on bedsharing was omitted from consideration. This body of literature informs the safe sleep guidelines for the United Kingdom3 and recommendations from the Academy of Breastfeeding Medicine.2The Academy of Breastfeeding Medicine promotes physiologic infant care, in which the normal mother-infant sleep physiology is side lying breastfeeding with proximate sleep.2 This practice allows mothers and infants to get quality sleep and awake refreshed. Mothers in the study are describing normal physiology when they say that their infants can only sleep when being held and that they and their infants sleep best when they sleep together.The subjects in the study4 tell the authors exactly why ABC fails. Mothers say it is "unrealistic." In other words, mothers cannot comply with ABC because it conflicts with normal mother-infant sleep physiology, evolved over millennia of human history.The mothers in the study illustrated how ABC's simplistic message could inadvertently encourage dangerous behavior. ABC implies that any surface besides a crib is equally bad, leaving mothers to sometimes turn to very hazardous situations to cope. This is precisely what mothers in this study did, sleeping with their infants on sofas or placing their infants on pillows. The study actually illustrates how infants will continue to die under current AAP guidelines because the ABC does not address the behaviors most likely to result in infant death, such as sofa-sharing. Mothers seek hazardous alternatives because ABC is "unrealistic," yet realistic, physiologic, and safe alternatives are not provided. This study should be a wake-up call to shift immediately away from ABC, as other health authorities have done.2,3The study does not distinguish feeding types, a major flaw. Breastfeeding mothers sleep in a way that may protect infants from sleep-related death,5 whereas formula feeding mothers may sleep in way that might be potentially hazardous, such as putting their infants on pillows or near pillows.6 Separating breastfeeding mothers from their infants at night removes this protection and potentially increases the risk of death.2To decrease infant deaths, campaigns for safe sleep should accommodate normal mother-infant sleep physiology, with an emphasis on safe bedsharing and avoiding hazards, such as sofas and infants sleeping on pillows. If AAP is serious about reducing infant deaths, it must change its safe-sleep strategy as soon as possible to one that is evidence-based. AAP should review all the evidence in an unbiased fashion, using a new team who understands the importance aligning parents' needs with normal physiology, instead of continually trying to alter ingrained normal human behavior in pursuit of an outdated objective that has repeatedly been proven to fail.