Firstly, I by no means feel anything I say here is going to change anyone’s minds in regards to my advice or books.
Why would you think this Tizzie? People have asked for further explanation for the basis of some elements of your advice - I absolutely think many are open to re-evaluating ideas should that be forthcoming. My opinions have changed numerous times over the years as I have learnt and read more, studied more research from respected sources - to be closed to new evidence and change is I think a potentially dangerous position, and one which underestimates readers.Parents hear they should try to ‘exclusively breastfeed’ their baby until six months. But on the other hand allergy experts recommend introducing solids between four to six months as research is increasingly suggesting this reduces the risk of food allergies.
Exclusive breast-feeding for six months is a WHO recommendation, and is aimed at reducing serious illnesses, such as severe diarrhoea, in developing countries where contaminated water. In most of Australia, the UK and Ireland water is clean and so it’s safe to introduce solids at 16 weeks but unfortunately all the advice just makes new parents lives hard and confusing.I'm not entirely sure research is increasingly suggesting starting solids before gut closure reduces allergies - at least non I have seen. Nor is the WHO guideline purely about contaminated water (although this is a common myth/misconception). I think I have pretty much covered everything I could say on that subject here and here which address the points made. I do agree that is another area confusing for parents as discussed in my post; however UK guidance from the DOH, UNICEF and WHO is consistent.
So back to blanket recommendations!
"This confused one mum Fleur who posted on Facebook saying:But I clarified below how Fleur had reached 13.6:
If you use her special bamboo blankets that she recommends, at the max 16 layers, at approx 0.6 tog each, that would put your child under a massive, surely dangerous 13.6 tog…. to put that in perspective, the average adult duvet here in the UK is 11-13 tog, which is considered ‘winter weight.’The math here is totally incorrect. IF and I say IF a parent is using the maximum of 16 layers which when using my recommended blanket is highly unlikely the total tog rating would be 9.6 – quite a difference to 13.6!"
“On my calculation of the tog rating – Tizzie’s fans have repeatedly told me that the tog rating of her bamboo blankets is 0.64 tog x 16= 10.24 tog (apparently she has had them tested.) and a cotton sheet folded in 2, at approx 0.2 tog (x2= 0.4 tog). I also included in my calculations the toggage (made up word, lol) of the ‘safe sleeping bags’ that she sells, which will be either 1 tog or 2 tog, depending which one you choose, and the tog of the ‘double wrap’ which again, equates to 4 layers in itself (2 inside wrap pieces and 2 outside fold over bits) which again, could be anywhere from 1 tog to 4 tog, depending on the material used). I didnt include the tog of a vest, a sleepsuit or a nappy. That was how i worked out the approx 13+ tog. What Fleur has stated in her clarification is fine but adults also dress themselves similarly for bed, use a sheet and many adults sleep next to another person which provides extra warmth under their 11-13 tog duvets, yet we expect our babies to sleep in much less……..
" My recommended range of blankets have been tested at 0.6 tog – that means we could place up to 9.8 layers of these recommended blankets over the baby. I am aware this is less than the 16 that I said was the maximum but in reality the majority of my clients don’t use that many layers. But I do not believe that a baby would come to any harm if the baby was 100% healthy, sleeping supine and with the head and face uncovered under 16 layers of my recommended blankets. You may choose to disagree… but can you show me research that can prove or deny this?Yes this would be 6 layers less than your recommended maximum (not including clothes). Whether the "majority of your clients use that many layers" is I think an aside, as using your guidance they could. It appears as though you are asking me to show research that can prove or deny your statement you don't believe a baby would come to harm under heavier tog - but with all due respect I think the onus should really be on the person giving advice to present the evidence supporting it?
However, I have found something that I think is appropriate:
BMJ 301 : 85 doi: 10.1136/bmj.301.6743.85 (Published 14 July 1990) Research Article
Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study.
From the study:
RESULTS: Compared with the control infants the infants who had died from the sudden infant death syndrome were more likely to have been more heavily wrapped (relative risk 1.14 per tog above 8 tog; 1.03 to 1.28; p less than 0.05), and to have had the heating on all night (relative risk 2.7; 1.4 to 5.2; p less than 0.01)
These differences were less pronounced in the younger infants (less than 70 days) than the older ones.
CONCLUSION: Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days. Educating parents about appropriate thermal care and sleeping position of infants may help to reduce the incidence of the sudden infant death syndrome.
From your webpage: "In the UK parents put a lot more clothing on their babies at night, and I believe the temperature of their homes is actually warmer than the night time temperature in most of the homes I visit in Australia. In the UK they have a different type of central heating which keeps the house at a more even temperature throughout the night.
I am not sure if it is even the warmth the babies like or if it is that with more layers on they feel cosier and more secure. But I do know that the extra layers can stop babies from waking at night."
But surely you need to be pretty sure it's the warmth to make the recommendations you do?
Your comments re blankets I found a little confusing, as in your original statement it said:
But if your blanket is 0.6 tog, compared to the average figure you quoted of 1.5-2 tog of a standard blanket, why would the mothers need more standard blankets to achieve the same warmth? Surely they would need less? You stated above 16 x 0.6 = 9.6 tog, whereas 16 x 1.5-2 (the figure you quoted as the tog of a standard blanket) comes to 32 tog based on 2 tog blankets.
Are we now disputing average tog rating is 1.5-2 per blanket?
"To get the same warmth you might have to use 20 blankets but the weight would be far too much to have on a baby and in my opinion would be unsafe" - The logic of mothers need far more of another brand is only applicable though when comparing to the specific (unidentified) blanket you tested at 0.2.
To go back to my orignial question how have you decided upon 16 layers - not 15 or 17? ie how via observation does one calculate X amount is unsafe via Y not being? I genuinely struggle to see how this could be established via observational means unless you have observed infants have suffered at 17 layers? Have you weighed 15 blankets v 17 and established 16 was a safe weight and if so how? Did you record these observations, create data you can share? (I think this is what parents are asking)
Yes I think perhaps observations is the only term if you don't have "paper evidence" - because evidence is by definition something that furnishes proof which anecdotal evidence does not. I think it really is key we appreciate the difference - ie I could observe locally that the rate of gastroenteritis wasn't higher in non breastfed infants, luck of the draw could mean the group of infants I happened to deal with don't contract the illness. In contrast masses of "paper evidence" that explore large numbers to an appropriate scientific model, find that rates are increased even when numerous other factors are accounted for, and other research exploring the constituents of breastmilk fills the gaps as to why. The point is unless we know how these observations were noted, what factors were accounted and controlled for, who the study group was and so on and so forth - observations are pretty meaningless; they needed to be clearly identified as opinion, not evidence based guidelines.
A number of mums on Facebook have also commented that their infants rolled prone as soon as possible completely unrelated to temperature - they did the same in the hot temperatures of Spain as they did the UK. Some also noted their children had shoulder/neck discomfort which is surely another viable reason why an infant may not want to back sleep?
I'm also not sure that because an infant loses less thermal heat when prone - we can therefore assume this means they roll when cold (although it indeed may!) or demonstrates safety of increased layering supine. If thermal heat is less well retained when baby is on back - this is absolutely an interesting factor that should be taken into account when conducting research. But we also have to filter in to the big picture other associated risk factors I think, such as feeding method, central heating and also fully explore co versus cot sleeping (particularly given the experiment Sears conducted on his daughter's oxygen sats). I'm not sure we can cherry pick bits we feel are more relevant and discount the rest.
Lastly I also note the bedding guide states you recommend swaddling infants until they show signs of wanting to roll over - yet this also now seems recognised as a potential SIDS risk factor too? From the link you shared (ISPID):
Parents should be aware of the potential risks of swaddling their infant, particularly of the use of heavy materials for swaddling.
Another relevant point from the same source:
Ultimately, I wonder how much is down to different fundamental beliefs about infant sleep.. Are young infants meant to sleep for huge stretches? (despite this currently being the social trend and most acceptable to the expectations of the majority of mothers, ie what sells). It's rarely what happens as the norm for breastfed infants without some sort of training, which it surely would be if that's how infants were supposed to sleep. We also know some mothers can struggle to maintain a milk supply and an infant their weight gain if night feeds cease early (prolactin levels are highest at night). In younger infants longer/deeper sleep spells have also been linked to SIDS and it seems normal, if not desirable for an infant to rouse and signal frequently. I'm not for a second suggesting anyone leaves an infant cold, but I'm not sure an infant not waking because they are hotter therefore shows this baby is more content or even was cold! Infants can sleep longer sleep spells for other reasons - a drop in calories is a perfect example. We could (as many parents do) assume the infant would wake if hungry, the fact they're sleeping long spells shows they must be happy! In reality the infant starts to conserve energy and the consequence is a long sleep spell - perhaps long sleep is a consequence of too much bedding?
In contrast Tizzie feels:
I would encourage readers to check out the full reply here: http://blog.saveoursleep.com/2011/07/28/in-responce-to-%E2%80%98the-analytical-armadillos%E2%80%99-blog/
REPLY RECEIVED FROM TIZZIE HALL:
Tizzie has notified me via email that she will not be responding further to any questions or discussions on this or other topics raised in her books. I have been silenced from sharing any further details as she insists the email remains confidential; the only bit I am allowed to share is that she would not be answering further questions from myself or other bloggers.
COMMENT FROM DR FLANDERS MD, FRCPC
I am not sure if it is even the warmth the babies like or if it is that with more layers on they feel cosier and more secure. But I do know that the extra layers can stop babies from waking at night."
But surely you need to be pretty sure it's the warmth to make the recommendations you do?
"We have observed that many of you have been trying to achieve the total tog of the Save Our Sleep® recommended blankets with other brand blankets but we do not advise that you do this. This is because you need to use too many layers of other blankets to achieve the same warmth as the Save Our Sleep® blankets for your baby to sleep safely.""If you do a search on the average tog of a blanket it is 1.5-2 tog, as stated above. My recommended blankets have been tog tested to 0.6 tog I have had other blankets tog tested and some blankets have come back with results of 0.2 tog and one blanket came back at 4.5 tog "
But if your blanket is 0.6 tog, compared to the average figure you quoted of 1.5-2 tog of a standard blanket, why would the mothers need more standard blankets to achieve the same warmth? Surely they would need less? You stated above 16 x 0.6 = 9.6 tog, whereas 16 x 1.5-2 (the figure you quoted as the tog of a standard blanket) comes to 32 tog based on 2 tog blankets.
Are we now disputing average tog rating is 1.5-2 per blanket?
"Analytical Armadillo are you trying to imply that the one and only reason I recommend layering blankets if for financial gain…..really? If this would be putting babies at risk would this not be professional suicide on my behalf…? What could I possibly have to gain from that? I am trying to keep this professional but implying financial gain is my main goal while risking baby safety is insulting."
I don't think I implied any such thing, other than this is the price of the blankets and buying a lot would work out expensive. I think this is something you acknowledge yourself Tizzie as I've seen you state on FB if people can't afford the blankets they are better buying second hand from other mums than to use an alternative brand?
"Secondly In order to state using different brands or more blankets is unsafe – one must have identified and proven (i.e. tested) what is safe?"
"The weight of the blankets I recommend are the same as a blanket I have had tested which came back at 0.2 tog. To get the same warmth you might have to use 20 blankets but the weight would be far too much to have on a baby and in my opinion would be unsafe so this is why I suggest using the blankets I have tested because you can use less blanket which in return is less weight on the baby but the same warmth."Well yes, if you used 0.2 tog blankets it of course follows you would need more than if using 0.6 tog; however until now the average tog rating of a blanket has been discussed at 1.5-2 tog. I'm not sure how the fact yours weighs the same as one blanket you tested at 0.2 is really relevant, because according to an "average", it also has to mean a significant amount on the market are a lot warmer than 0.2 tog to obtain a 1.5-2 average? Therefore it also potentially means people could use less blankets (and therefore less weight) to obtain the same warmth as with (your recommended) 0.6 tog blanket? Say this one at 3.7 tog or the ones they refer to at the bottom of the page ranging from 1.7-2.6 - then parents could just add a thinner layer or two if required?
"To get the same warmth you might have to use 20 blankets but the weight would be far too much to have on a baby and in my opinion would be unsafe" - The logic of mothers need far more of another brand is only applicable though when comparing to the specific (unidentified) blanket you tested at 0.2.
To go back to my orignial question how have you decided upon 16 layers - not 15 or 17? ie how via observation does one calculate X amount is unsafe via Y not being? I genuinely struggle to see how this could be established via observational means unless you have observed infants have suffered at 17 layers? Have you weighed 15 blankets v 17 and established 16 was a safe weight and if so how? Did you record these observations, create data you can share? (I think this is what parents are asking)
"I do have evidence it is just not in a formal official paper, perhaps observations is a better term. I would be more than happy to help FSID or SIDS and Kids in Australia conduct further study into the effect of thermal layering and SIDS as long as they also investigated my belief that a cold baby will roll to the prone position as soon as he/she possibly can."
A number of mums on Facebook have also commented that their infants rolled prone as soon as possible completely unrelated to temperature - they did the same in the hot temperatures of Spain as they did the UK. Some also noted their children had shoulder/neck discomfort which is surely another viable reason why an infant may not want to back sleep?
I'm also not sure that because an infant loses less thermal heat when prone - we can therefore assume this means they roll when cold (although it indeed may!) or demonstrates safety of increased layering supine. If thermal heat is less well retained when baby is on back - this is absolutely an interesting factor that should be taken into account when conducting research. But we also have to filter in to the big picture other associated risk factors I think, such as feeding method, central heating and also fully explore co versus cot sleeping (particularly given the experiment Sears conducted on his daughter's oxygen sats). I'm not sure we can cherry pick bits we feel are more relevant and discount the rest.
"My recommendation of a room temp of 20 degrees falls within these parameters, and after my recent trip home to Ireland I will also be editing my recommendations for this area and saying that ideal room temperature in Ireland and the UK is 18 degrees. I fully support the statement that too much bedding, clothing or possibly (but not proven) more importantly the incorrect material of bedding and clothing can cause thermal stress. However my recommendations will NOT cause a baby to overheat. I clearly state in my bedding guide what signs a parents should look for in a hot baby and a cold baby and to adjust the layers accordingly. I have not found using only my recommended bedding ( a 100% cotton mattress protector, 100% cotton or bamboo sheets, all 100% cotton or bamboo clothing and only 100% cotton or bamboo blankets) within my guidelines to cause a baby to get too hot. Of course each baby is different which is why I have written my bedding guide and encourage parents to only try more bedding one layer at a time if their baby continues to shows signs of being cold."I think it's excellent you are updating your recommendation to sit with current government guidance. I think the problem is though Tizzie, that whilst you clearly state your recommendations will NOT cause a baby to overheat, mothers need hard evidence, from appropriately qualified people demonstrating this. Also the feedback from some mothers on your FB group (and on another discussing your advice) seems to be that their infants did get very hot and a not insignificant number repeatedly wriggled out of blankets. If an infant does indeed roll when cold, surely they can also attempt to remove themselves from some layers if they're hot? But tips were given to tuck the blankets in more firmly.. Also on your group when mothers have reported continued waking - an often noted response from other fans is "try another layer or two of blankets" - not "did your baby feel cold"; which would seem a much more appropriate response?
Lastly I also note the bedding guide states you recommend swaddling infants until they show signs of wanting to roll over - yet this also now seems recognised as a potential SIDS risk factor too? From the link you shared (ISPID):
Parents should be aware of the potential risks of swaddling their infant, particularly of the use of heavy materials for swaddling.
- Current research suggests that it is safest to swaddle infants from birth and not to change infant care practices by beginning to swaddle their infant at 3 months of age when SIDS risk is greatest.
Another relevant point from the same source:
Numerous studies have documented a "tranquil" behavioural state and longer sleep periods in swaddled infants [10-14]. Thus, despite the unknown effects on the risk for SIDS, swaddling is becoming increasingly popular as a settling technique in the Netherlands, the United Kingdom and the United States [15, 16].
These findings logically suggest that infant swaddling would increase infant sleep time by preventing awakening. However this may not be a desirable outcome, as the pathogenesis of SIDS is thought to involve an impaired ability to arouse from sleep in response to a life threatening respiratory or cardiovascular challenge [17]. Arousal from sleep in infants is a hierarchical response proceeding from sub-cortical activation involving changes in heart rate and breathing, to full cortical arousal involving changes in brain activity; and this progression has been reported to be incomplete in infants who later died of SIDS [18]. Infant swaddling has been shown to minimise arousals from sleep, crying time, spontaneous startles and the progression to full arousal [1, 12, 14, 19].
How do we know this isn't also why infants with extra blankets stop waking?
Ultimately, I wonder how much is down to different fundamental beliefs about infant sleep.. Are young infants meant to sleep for huge stretches? (despite this currently being the social trend and most acceptable to the expectations of the majority of mothers, ie what sells). It's rarely what happens as the norm for breastfed infants without some sort of training, which it surely would be if that's how infants were supposed to sleep. We also know some mothers can struggle to maintain a milk supply and an infant their weight gain if night feeds cease early (prolactin levels are highest at night). In younger infants longer/deeper sleep spells have also been linked to SIDS and it seems normal, if not desirable for an infant to rouse and signal frequently. I'm not for a second suggesting anyone leaves an infant cold, but I'm not sure an infant not waking because they are hotter therefore shows this baby is more content or even was cold! Infants can sleep longer sleep spells for other reasons - a drop in calories is a perfect example. We could (as many parents do) assume the infant would wake if hungry, the fact they're sleeping long spells shows they must be happy! In reality the infant starts to conserve energy and the consequence is a long sleep spell - perhaps long sleep is a consequence of too much bedding?
In contrast Tizzie feels:
"I am not sure if it is even the warmth the babies like or if it is that with more layers on they feel cosier and more secure. But I do know that the extra layers can stop babies from waking at night."The expectation is sleep patterns comparable to that of an adult and if this doesn't happen there must be a reason, something that needs "fixing".
I would encourage readers to check out the full reply here: http://blog.saveoursleep.com/2011/07/28/in-responce-to-%E2%80%98the-analytical-armadillos%E2%80%99-blog/
REPLY RECEIVED FROM TIZZIE HALL:
Tizzie has notified me via email that she will not be responding further to any questions or discussions on this or other topics raised in her books. I have been silenced from sharing any further details as she insists the email remains confidential; the only bit I am allowed to share is that she would not be answering further questions from myself or other bloggers.
COMMENT FROM DR FLANDERS MD, FRCPC
"Tizzie may or may not realize that she is attempting to manage quite a conflict of interest. When one stands to profit financially from the advice one offers, it becomes very difficult to maintain credibility. Medical advice NEEDS to be derived from solid scientific research that is free (to whatever extent possible) from bias. Tizzie may feel like she's contributing meaningfully to society by 'keeping babies safe' with her blankets. But the subconscious (perhaps conscious) drive to profit financially can undermine this ideal. There is a long and unfortunate history of industry tainting medical science, which repeats itself over and over again. Most recent case in point: http://nyti.ms/qZwZuh
Do be careful, Tizzie."
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What do you think? Do you feel reassured by Tizzie's reply? Has it brought anything to the table you weren't aware of and which makes sense to you? Let me know below :)
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