1. Section Editor(s): Verklan, M. Terese PhD, CCNS, RNC, FAAN

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Breasts may be lethal? I have recently heard of 2 incidences of newborns being suffocated when breast-feeding. One case involved a mother who was exhausted after feeding her newborn every 11/2 to 2 hours for the past 60 hours or so. It is believed that she fell asleep while the newborn was feeding and did not wake up until the morning. It was obvious that the baby did not survive the night. In the second case, the neonate was approximately 4 hours old when the parents excitedly summoned the postpartum nurse to check him because "he didn't look right." The nurse remembers seeing his legs looking mottled and dusky and that she had to lift the breast off his head and chest. He was in cardiopulmonary arrest and survived extensive resuscitation with major neurologic sequelae. Both mothers had had a lactation consultant spend some time instructing them on how to breast-feed, describing several positions to enhance latching for the baby and comfort for the mother. I believe both were being held in the football hold, but I am not 100% sure. I do know that both mothers were primiparas wanting to provide the best nutrition for these babies.


Being curious about the incidence of babies being suffocated by the breast, I went to the literature. I searched on many terms, such as "breast-feeding and suffocation," "unexpected neonatal death," "breast-feeding and neonatal mortality," "neonatal life-threatening event," "neonatal unexpected collapse," and "breast-feeding and neonatal resuscitation," in the academic and LexisNexis databases. Few articles were located, which may mean that the event is very uncommon, it is not reported when it does happen, or I did not search on all the correct terminology.


Researchers conducted a prospective study involving 47 maternity hospitals/units to determine the incidence of life-threatening events and unexpected deaths in healthy newborns during the first 2 hours after birth.1 They found an incidence rate of 0.032 per 1000 live births and 3 associated risk factors that included a primiparous mother, skin-to-skin contact, and the mother left alone with the newborn.1 It was concluded that the nursing staff need to monitor the mother closely when in a skin-to-skin position with her baby.


Becher et al2 reviewed cases referred through the British Paediatric Surveillance Unit of healthy term neonates who "collapsed" within 12 hours of life and required resuscitation. They found a very similar incidence rate of 0.035 per 1000 live births, in which the neonates had no underlying condition contributing to the event. Identified risk factors included a primiparous mother who was left alone by nursing staff and who did not recognize that her baby was being suffocated.2 It was concluded that breast-feeding and the prone position were significant factors. The authors recommended that the appropriate surveillance be used for the first-time mother or "where the ability to assess the baby may be impaired."2(pF30) I am assuming this to mean that the mother is too tired herself to pay close attention to the baby during breast-feeding.


Poets et al3 analyzed cases of sudden infant death or severe apparent life-threatening events reported to the Surveillance Unit for Rare Pediatric Concerns in Germany for the year 2009. They determined the incidence to be 2.6 per 10 000 live births (0.026/1000), with the majority of incidents occurring within the first 2 hours of life. The neonates were most commonly found on the mother's chest or abdomen, or skin-to-skin facing the mother. In approximately 41% of the cases, the mother did not notice her baby was experiencing any problem, despite her being awake.3 The researchers also recommended that closer monitoring of these mother-baby dyads should be done.3


Feldman and Whyte4 reported 2 cases of healthy term newborns found unresponsive while breast-feeding in the side-lying position during a routine check by the nurse. Both mothers were primiparous and had fallen asleep with their babies at the breast. Importantly, one of the babies was 45 hours old. One neonate could not be resuscitated, and the other survived with extensive neurologic morbidity.


Being a neonatal clinical nurse specialist, I make no claims at being an expert at breast-feeding. However, in keeping with the philosophies of our professional organizations, I am an advocate of breast-feeding as the optimal avenue to provide the best nutrition and growth environment for the mother-baby dyad. Nurses and lactation consultants instruct the mother on a variety of positions for holding the baby to the breast in order to find the technique that works best for themselves and their babies. The side-lying position is one of these positions. Many advocate this position because it facilitates the mother's rest and comfort especially after cesarean delivery,4 and it may also decrease maternal fatigue.5 Perhaps, it is time to examine the intervention, as it is one of the consistent factors reported with accidental suffocation.


Given the rarity of the situation, it would be extremely difficult to design an experimental protocol in order to determine the precise sequences of events. And I am not suggesting that the outcome variables be suffocation or not suffocation!! What I am suggesting is that the positions used for breast-feeding are conducive to nursing research and that we do need to know the positive and negative aspects of all of them. Given that we are using evidence-based practice interventions today as much as possible, perinatal researchers need to closely scrutinize the different practices taught to mothers and develop the science behind these "routine" interventions. Perhaps, one of you reading this article will have your interests piqued and will undertake the research question for the health of our mothers, babies, and their families.


-M. Terese Verklan, PhD, CCNS, RNC, FAAN


Professor and Neonatal Clinical Nurse Specialist


University of Texas Medical Branch


School of Nursing and Graduate School of Biomedical Sciences


Galveston, Texas




1. Dageville C, Pignol J, De Smet S. Very early neonatal apparent life-threatening events and sudden unexpected deaths: incidence and risk factors. Acta Paediatr. 2008;97:866-869. [Context Link]


2. Becher J-C, Bhushan SS, Lyon AJ. Unexpected collapse in apparently healthy newborns-a prospective national study of a missing cohort of neonatal deaths and near-death events. Arch Dis Child Fetal Neonatal Ed. 2012;97:F30-F34. [Context Link]


3. Poets A, Steinfeldt R, Poets CF. Sudden deaths and severe apparent life-threatening events in term infants within 24 hours of birth. Pediatrics. 2011;127:e869-e873. [Context Link]


4. Feldman K, Whyte RK. Two cases of apparent suffocation of newborns during side-lying breast-feeding. Nurs Womens Health. 2013;17:337-341. [Context Link]


5. Milligan RA, Flenniken PM, Pugh LC. Positioning intervention to minimize fatigue in breast-feeding women. Appl Nurs Res. 1996;92:67-70. [Context Link]