I am being contacted by an increasing number of mothers, concerned and confused by blanket guidelines provided by "Tizzie Hall, International Baby Whisperer and author of Save Our Sleep (SOS)". These guidelines are so different to the information provided by other sources of SIDS guidance, and some mothers are concerned babies could be at risk of overheating - a factor we often hear linked with SIDS. Tizzie Hall appears to claim the opposite however, that being cold is a bigger risk factor for SIDS.

Some mums claim they have asked Tizzie for evidence to support the blanket recommendations via her Facebook page, but have not received a satisfactory response.

Therefore I thought I would create a blog post to openly and clearly ask both Tizzie Hall, and the Foundation for the Study of Infant Deaths (FSID) for further information, evidence & guidance.

It is unfair that mothers receive such conflicting information and clarification is needed as to what evidence shows is safest for the prevention of SIDS.

A Facebook group named "The Dangers of Baby Training" sums up the problem neatly:

As an example, in a room heated to 20* C in the winter or cooled to 22*C in the summer, Tizzie hall suggests for those of us in the UK & ireland to use a vest, a sleepsuit/babygro, a 'double wrap' swaddle, a cotton sheet folded into 2, and 4 layers of blankets, preferably bamboo. Our UK/Ireland SIDS & government guidelines suggest a room temp of between 18-20*C, with your child wearing a vest, sleepsuit/babygro, a light swaddle or light sleeping bag (never both, as shown in TH's video guide on youtube), 1 cotton sheet and 1 lightweight blanket....and never advocates the use of more than 4 layers, even in the coldest of conditions. Why is there such a big difference?

Earlier this week, Tizzie's forum was available to non subscribed members, where apart from clarifying the maximum blanket layers that should be used

"on a newborn to 3 month old baby sleeping in a bassinet is 10 layers, a newborn to 3mth old baby sleeping in cot is 12 layers and a baby 4 months and over is 16 layers". (no reference to room temperature was made)

also stated:

"Tizzie’s safe bedding guide is written on the amount of layers NOT how many tog those layers add up to. When we talk about references to the tog of a quilt in relation to the amount of bedding needed to keep your baby sleeping warm and safely this is an example to demonstrate that babies do require bedding to sleep safely. Cotton or Bamboo cellular blankets will trap warm air in to keep your baby warm enough to sleep safely with more efficiency than a adult quilt does. We do not need to achieve the same tog rating as a 14 tog quilt but we need to achieve the same warmth which is quite different when using cotton/bamboo blankets.

It was available here - but the page has since changed to read:

Access Denied

Error

Only members with sufficient permission can access this page.

with an option to login, so it appears one needs to register and pay now to obtain this post.

This confused one mum Fleur who posted on Facebook saying:

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.'

It does seem very confusing, if a mum creates 13.6 tog from layering, and if the above comments are correct that "cotton or bamboo cellular blankets will trap warm air in with more efficiency than a quilt would of the same tog", doesn't that mean the 13.6 tog of blankets will make baby even hotter than an equivalent quilt would? It then gets more confusing as it states the aim is not to achieve the same tog rating as a duvet, because achieving the same warmth is different with blankets - but the layers can easily add up to the same tog rating as a duvet, no?

EDIT - I THOUGHT THESE CALCULATIONS WERE INCORRECT AS 0.6 TOG X 16 DOES NOT ADD UP TO 13.6 TOG. I CHECKED FLEUR'S CALCULATIONS AND THE TOTAL TOG OF 16 BLANKETS BASED ON THE TOG FLEUR QUOTED OF 0.6 IS 9.6.

So I checked with Fleur:

"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.

Vest	0.2
Babygro	1
Jumper	2
Trouser	2
Nappy (disposable)	2 (less when wet)
Sleep suit	4
Sheet	0.2

I'm optimistic however that Tizzie Hall will have evidence to share with us, because of the next half of her comment:

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. Using anymore than the recommended amounts listed above is not safe.

This confused the founder of Dispelling Breastfeeding Myths:

"What I'd REALLY like to know is whether her products conform to BS8510 (describes tog testing for baby products, the concern here being to ensure that babies do not overheat)? Otherwise how is a parent to have any clue about the level of thermal insulation their child is going to experience when layering up her products? That's the whole reason for the tog system in the first place... She says her blankets work in a different way - but BS 8510: 2009 'specifies requirements for the safety of sleep bags for the use of children with a minimum weight of 4 kg designed to provide sufficient warmth SO AS TO REMOVE THE NEED FOR ADDITIONAL BEDDING when sleeping in a cot or similar product in which a child is contained.'

Tizzie doesn't advise anyone uses blankets other than her own brand? Why - if a mum needs to use more than the 10-16 layers recommended to achieve the same warmth as the branded blankets - there surely must be a unique factor? Ultimately the tog rating of blankets is comparable, regardless of brand. (In case anyone wonders, blankets range from £18.50 - £46.30 each depending upon which you choose. This makes the cost of 16 blankets £296-£740.80, not including spares for washing ie if they vomit to manipulate as Tizzie confirms they may, or sheets.)

Secondly In order to state using different brands or more blankets is unsafe - one must have identified and proven ie tested what is safe? Otherwise how could you know that more or different brands would be unsafe? Plus I'm sure nobody would give parents so directly contradicting official SIDS advice without having hard evidence, because that would be madness right?

And it does directly contradict FSID as they state:

Babies who get too hot are at an increased risk of cot death. They can get too hot because the room is too hot or because they have too much bedding or clothing. The ideal room temperature is 16-20ºC.

In 2008 researcher at the University of Calgary showed that thermal stress, can lead to an increased risk of Sudden Infant Death Syndrome (SIDS). Increased ambient temperature such as over-wrapping a baby at night time or increasing the room temperature can affect the baby's pattern of breathing.
Australia's Practical Parenting magazine published the following, and is based on baby wearing nappy/vest/babygro plus a cotton sheet:

Room temp	No of blankets
12 ⁰	4 layers
14 ⁰	3-4 layers
16 ⁰	3 layers
18 ⁰	2 layers
20 ⁰	1-2 layers
22 ⁰	1 layer
24 ⁰	Sheet only

Here is the information from Gro-bag (a company that makes baby sleeping bags)

and details of what should go with the recommended tog sleeping bag:

I decided to try and ask Tizzie Hall direct on her Facebook page:

and a close up of my message:

The response wasn't under my post, but as a new message:

So I went to visit the page I was told to and you too can read it here

"As all of you know before giving any advice I do countless hours of research so I stand by all of my advice. These ladies don’t seem to be aware of the current SIDS guidelines stating as long as your babies head and face are uncovered and you are using cotton or bamboo bedding then it is perfectly safe to layer up the amount of these blankets to keep your baby warm. My opinion and research shows this in return keeps our babies in the safe back sleeping position. Also it is now clear overheating is only cited a risk factor and not as big a factor as was first thought but we do live in a generation with parents so scared of over heating their babies they are doing the opposite and under heating them which in my opinion a greater factor because a cold baby will roll to his or her tummy and sleep face down in the mattress.

These concerned parents may not be aware of my research that shows that if a baby is cold and not warm enough in bed they will, as soon as they are able, roll to their tummy, tuck their knees and arms in under their body, stick their bottom in the air with their face pressed down in the mattress to try and warm up, which of course we know is a very dangerous sleeping position for a baby and toddler. New research shows this causes less oxygen to get to the brain and could be connected to SIDS.

Link to research http://pediatrics.aappublications.org/cgi/content/abstract/127/3/e558
Having had a personal experience of loosing a sibling to SIDS I am passionate about baby safety and ensuring everything I recommend down to the bodysuit your baby wears and the toys your baby plays with are the safest on the market."

So of course I checked out the quoted research.

Cerebral Oxygenation Is Depressed During Sleep in Healthy Term Infants When They Sleep Prone

SUBJECTS AND METHODS: Seventeen healthy term infants (8 girls and 9 boys) were recruited as study participants. Infants were studied at ages 2 to 4 weeks, 2 to 3 months, and 5 to 6 months by use of daytime polysomnography, with additional measurements of blood pressure

RESULTS: In infants who slept in the prone position, tissue oxygenation index was lower in both quiet sleep and active sleep at age 2 to 4 weeks and in quiet sleep at age 2 to 3 months. Tissue oxygenation index was lower in active sleep compared with quiet sleep in infants aged 2 to 4 weeks (P < .05). When the infants reached 5 to 6 months of age, tissue oxygenation index was greater in active sleep, as there was a profound decrease in tissue oxygenation index during quiet sleep over this period.

All this tells us is that oxygenation index for a young infant is reduced in the prone position. Isn't that the whole point of the "Back To Sleep" campaign? Again Tizzie stated: my research that shows that if a baby is cold and not warm enough in bed they will, as soon as they are able, roll to their tummy, tuck their knees and arms in under their body, stick their bottom in the air with their face pressed down in the mattress to try and warm up.

THIS is the research we would like to see Tizzie please?

Otherwise it's just confusing for parents:

"Once a baby is strong enough to roll onto his stomach by himself, you don't need to worry about him staying on his back all night. This is especially true if he's been enjoying playtime on his tummy during the day, can hold his head up well, and can roll from his tummy onto his back again by himself."

Fern R. Hauck, M.D., M.S professor of family medicine and public health sciences at the University of Virginia

"Losing sleep because your former back snoozer is now flipping onto his tummy? You probably don't need to risk waking him by trying to roll him back. If your baby can get himself onto his tummy, he can usually get himself off it, because rolling from back to tummy is the tougher milestone (try it yourself and you'll see what we mean).
By the time your baby has mastered rolling around, the SIDS risk has dropped dramatically"

Learning to Roll Over, By Anita Sethi, Ph.d

Has Tizzie measured the vital statistics of infants under 16 blankets? Unless the blankets are weighless, what is the impact of the weight of this on top of baby to their oyxgen sats?

I hope we can obtain some evidence and further clarification for mothers and will update should either party respond!

PS Sears also conducted a small experiment with fascinating results:

"In 1992 we set up equipment in our bedroom to study eight-week-old Lauren's breathing while she slept in two different arrangements. One night Lauren and Martha slept together in the same bed, as they were used to doing. The next night, Lauren slept alone in our bed and Martha slept in an adjacent room. Lauren was wired to a computer that recorded her electrocardiogram, her breathing movements, the airflow from her nose, and her blood oxygen level. The instrumentation was painless and didn't appear to disturb her sleep.

A technician and I observed and recorded the information. The data was analyzed by computer and interpreted by a pediatric pulmonologist who was "blind" to the situation—that is, he didn't know whether the data he was analyzing came from the shared-sleeping or the solo-sleeping arrangement.

Our study revealed that Lauren breathed better when sleeping next to Martha than when sleeping alone. Her breathing and her heart rate were more regular during shared sleep, and there were fewer "dips," low points in respiration and blood oxygen from stop-breathing episodes. On the night Lauren slept with Martha, there were no dips in her blood oxygen. On the night Lauren slept alone, there were 132 dips. The results were similar in a second infant, whose parents generously allowed us into their bedroom."

UPDATE ONE
I posted a link to my blog in the hope of a response, but I then checked back and it has been deleted.

I am unsure why Tizzie Hall would simply delete a polite post asking for clarification on her methods? I have emailed her a link to this blog, just in case her admin team is deleting these message, unaware how this appears.

UPDATE TWO:
I have received a reply to my email giving a reason why Tizzie hasn't yet answered - however they have marked the email CONFIDENTIAL, so I guess I can't share any more than that! Should I receive an answer from Tizzie answering any points raised in the blog, I will advise that unless the confidential disclaimer is removed from her email, thus allowing me to share the contents with readers - I will not be able to post in on the blog as an official response.

UPDATE THREE:

I have received a (very speedy) response from FSID, excerpt below:

"We have read your article and are more than willing to respond, my colleague who would normally do this is out of the office today, so we will let you have something shortly."

UPDATE FOUR:
FSID Excerpt: Dear Analytical Armadillo.

Thank you very much for your email. So sorry for the delay, but our Scientific Adviser, Prof Haycock, is preparing a detailed response with all the research references for you. I’m hoping he will send me the document by Friday.

UPDATE FIVE: Tizzie Hall submits a formal reply:
http://blog.saveoursleep.com/2011/07/28/in-responce-to-‘the-analytical-armadillos’-blog/