IJE Advance Access originally published online on August 5, 2005
International Journal of Epidemiology 2005 34(5):1166; doi:10.1093/ije/dyi155
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Published by Oxford University Press on behalf of the International Epidemiological Association
Letter to the Editor |
Infant sleeping position and sudden infant death syndrome: a systematic review
Authors' response to letter from Guntheroth and Spiers
1 Centre for Evidence-based Child Health, Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK. E-mail: R.Gilbert{at}ich.ucl.ac.uk
2 MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge CB2 2SR, UK
We agree with Guntheroth and Spiers1 that delays in the 1980s and 90s by national policy bodies in implementing ‘back to sleep’ advice caused thousands of avoidable deaths worldwide. However, our study highlights the much greater loss of life owing to the flawed introduction of advice favouring front sleeping in the early 1970s. Introduction of changes in practice should be based on the evidence by which benefits outweigh harms. Yet when UK clinicians started to recommend front sleeping to prevent cot death, the two studies that addressed this question at the time showed unequivocally no evidence of benefit.2,3 This point was made in the report of the UK study.2 In addition, when these two studies were put together, there was statistically significant evidence of harm.4 No evidence of benefit combined with evidence of serious harm should cause a ‘pause for thought’ even for those that dispute the findings. Consequently, we do find it surprising that it took 16 years for further studies to be published and that it was investigators outside the orbit of the UK and US research communities who performed these studies.5–7 We argue that had simple methods of reviewing and combining what was already known from research been used in 1970 60 000 deaths would have been avoided. This is an underestimate as we left out cot deaths classified as other causes before SIDS was widely used for death registration and deaths before 1970.
During the 1990s, evidence-based health care and national technology assessment bodies were established in many countries to challenge the introduction of interventions that were not based on evidence of overall benefit. As our study shows, waiting for evidence of harm can take years for avoidable deaths to accumulate to a level sufficient to overturn established practice. We also showed that evidence of harm might be attenuated when uptake of health advice is high, possibly owing to a ‘healthy adopter’ phenomenon.
We recognize that medical attitudes to science in the 1960s and 1970s meant that patho-physiological reasoning took precedence over clinical research findings that showed what actually happened when babies were placed on the front. The adoption of harmful advice was a collective failure of professional culture and would have been hard for any individual clinician or researcher to avert. The point of our report is not to attribute blame, but to illustrate the dangers of public health recommendations that are not based on sound evidence from systematic reviews and careful weighing of benefits and harms.
References
1 Guntheroth WG, Spiers PS. Infant sleeping position and sudden infant death syndrome: a systematic review. Int J Epidemiol 2005;34:1165–66.
2 Carpenter RG, Shaddick CW. Role of infection, suffocations and bottle-feeding in cot death: an analysis of some factors in the histories of 110 cases and their controls. Br J Prev Soc Med 1965;19:1–7.[Web of Science][Medline]
3 Froggatt P. Epidemiological aspects of the Northern Ireland study. In: Bergman AB, Beckwith JB, Ray CG (eds). Sudden Infant Death Syndrome. Proceedings of the Second International Conference On Causes Of Sudden Death in Infants. Seattle: University of Washington Press, 1970, pp. 32–46.
4 Gilbert RE, Salanti G, Harden M, See S. Infant sleeping position and the sudden infant death syndrome: systematic review of observational studies and historical review of recommendations from 1940 to 2002. Int J Epidemiol 2005;34:874–87.
5 Beal SM. Sudden infant death syndrome: epidemiological comparisons between South Australia and communities with a different incidence. Aust Paediatr J 1986;22(Suppl.1):13–16.
6 Tonkin SL. Epidemiology of cot deaths in Auckland. N Z Med J 1986;99:324–26.[Web of Science][Medline]
7 Senecal J, Roussey M, Defawe G, Delahaye M, Piquemal B. Procubitus et mort subite inattendue du nourrison. Arch Fr Pediatr 1987;44:131–36.[Web of Science][Medline]
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