Stop scaring parents about Sudden Infant Death Syndrome says Bríd Hehir

The cot death guilt-trip

In particular, parents who smoke have been subjected to relentless guilt-tripping by the media and health professionals alike. A leaflet produced by the Foundation for the Study of Infant Deaths (FSID) claims that 'Smoking in pregnancy increases the risk of cot death' and that 'Babies exposed to cigarettes after birth are also at an increased risk of cot death'. By implication a parent who continues to smoke at home is irresponsible and might even be accused of abusing her child.

However, the causes of SIDS are more complex and contestable than the anti-smoking crusade suggests. Sleeping position, temperature and toxic gas from plastic mattresses have all been posited as explan-ations. Yet many experts insist that smoking parents are to blame. In 1996, following the Confidential Enquiry into Stillbirths and Deaths in Infancy, Professor Peter Fleming of Bristol's Royal Hospital for Sick Children asserted that 'smoking is the most important preventable factor in cot deaths aside from sleeping on the front. If we took smoking out of the equation we would reduce cot deaths by about 61 per cent'.

But all that has definitely been established is an association between parents who smoke and those who suffer a cot death - and an association is not a cause. At the very least it is difficult to separate smoking from other factors linked to cot death, such as parental poverty. As scientist Barry Richardson (who believes cot death is caused by chemicals in mattresses) argues, 'I think it is fashionable to blame all health problems on smoking. The high proportion of SIDS households with smokers does not mean that smoking is a cause of SIDS, although it may be a risk factor. It should have been stressed that smoking is more usual in families with low family incomes' (Nursery World, 22 August 1996).

Even Professor Fleming has previously stated that 'analysis showed that neither the sex of the infant nor maternal smoking had any significant effect on the odds ratio' (Lancet letters, 18 March 1995). Most research suggests that low birth weight, prematurity and poor growth in the womb are factors. SIDS is also more likely if the mother is young, if the family has a low income and in households with several children. Professor Fleming's own investigations confirmed that most deaths occur among the socio-economically deprived.

The link drawn between smoking and SIDS also leaves unexplained the fact that cot deaths increased during a steady decline in smoking. Smoking was at its peak in 1948 in Britain, when 84 per cent of all adults smoked. Cot deaths were virtually unknown then - SIDS was first described in 1953. Between 1972 and 1988, smoking numbers dropped from 52 to 33 per cent of the population, yet SIDS was at its highest between 1986 and 1988 (1569 babies died from SIDS in 1987). In add-ition, the number of cot deaths has since fallen, while smoking levels remained more or less the same.

Despite the lack of hard evidence that smoking causes cot death, and despite the fact that more babies survive than ever, the campaign around SIDS has had a profound influence on parents and prospective parents.

It has helped to generate a sense of insecurity among parents who fear a tragedy that is extremely unlikely to happen. This can only undermine their enjoyment of a baby's early life and potentially make them over-attentive and over-protective. Furthermore in the unusual but awful event of a baby's death parents do not need to be prompted to blame themselves: they are already agonised enough by the possibility that they could have done something to prevent the death.

The campaign also fuels the debate about parental responsibility, making parents who smoke feel unnecessarily guilty. This effect can only be reinforced by the recent shift in the Foundation for the Study of Infant Deaths to focus more on parenting in general. In their April 1997 conference FSID placed less emphasis on smoking as such and more on the relationship of parenting practices to infant death. While they insist that parents should not be blamed, and that families living in difficult social circumstances are more at risk, the stress on parenting practices can only serve to point the finger. It is even worse than emphasising smoking alone, because it suggests that a whole range of normal parenting behaviours could cause an infant's death.

Parents are now routinely accused of child neglect and abuse, blamed for failing to bring up their children as law-abiding citizens, and for putting their children's mental and physical health at risk by feeding them a diet of violent television and chips. The cot death campaign only reinforces the sentiment that many parents cannot be trusted to raise their children safely and need to be constantly monitored and educated. This in turn generates an unhealthy atmosphere of anxiety, where parents who want to be seen as responsible are under pressure to cosset and over-protect their children, instead of letting them breath life.

Bríd Hehir has been a practising Health Visitor in London for 15 years

Cuddly image, scary message: the Foundation for the Study of Infant Deaths