If this doesn’t scare you, it should.

In 2016, I wrote a post on the risk of sudden unexpected postnatal collapse (SUPC) in newborns being associated with kangaroo mother care recommended for the promotion of breastfeeding and a variety of other health measures. My take-home point was that there is a need to rationally weigh the meager benefits in term, healthy (and typically unmonitored) newborns in the context of the risk of death and disability from cardiorespiratory insufficiency. In that post, I also made a brief reference to the risk of newborn falls. Today, inspired by a paper in this month’s Pediatrics, I’ll discuss this problem in a bit greater detail.

Unfortunately, falls during the newborn hospitalization period are more common than most people realize. Thankfully not so common that I can’t joke about it to help ease the anxiety of an occasional mother whose baby I’m separating her from for the first time (“Don’t worry, I haven’t dropped one yet.”). But I’ll probably stop doing even that after reading this report.

Newborn falls, which can result in fractures and injury to the brain, are believed to occur somewhere between 200 and 1,600 times each year according to the available data. But because there are roughly 4 million babies born each year, and the fact that there is no national reporting system in place, they likely occur much more frequently than that. And they are likely on the rise. Based on what we know about reported cases, they almost always happen when the mother falls asleep while holding her baby. Not surprisingly, they also tend to occur at night.

There are many potential factors that might increase the risk of a newborn fall, the most important being maternal fatigue. With rare exception, mothers in the postpartum period tend to experience fatigue, but there are additional variables that might play a role in just how tired a new mom is. For example, how rested was she prior to delivery? What time of day (or night) did she deliver? What complications occurred around delivery that may increase sleepiness, such as blood loss, prolonged or difficult labor, or a need for sedating pain medications? Are there maternal complications that require more frequent checks, and thus interruptions of sleep? And are there psychosocial factors that may interfere with mother’s ability to rest after delivery, such as anxiety, an abusive partner, or frequent visits from well-meaning family members?

One potential factor that I have worried about for many years is the emphasis on “rooming-in”. Mothers are increasingly encouraged to keep the baby in the hospital room as much as possible, rather than the hospital nursery. Many hospitals have gone so far as to restrict access to the nursery, or in some cases to do away with them entirely, and I worry that they aren’t taking maternal fatigue and increased risk of SUPC and newborn falls into account. In more and more facilities, these steps are being taken in an effort to be in compliance with the draconian criteria set forth by the Baby-Friendly Hospital Initiative (BFHI) to improve breastfeeding success, which is a laudable goal but a misguided approach.

The “Ten Steps to Successful Breastfeeding” put forth by the BFHI, one of which focuses on 24-hour rooming-in, have never been appropriately studied yet they are even promoted by the Surgeon General. BFHI accreditation is optional, and costs thousands of dollars to complete and maintain each year. In my perhaps cynical opinion, however, the impetus for many hospitals to do this is more about marketing than actual patient care. Check out Harriet Hall’s 2016 post for a bit more background on BFHI and some more detail regarding my concerns with their increasing popularity.

In the new report, the authors reviewed adverse event reports that involved newborn falls from January of 2011 through February of 2018:

In this series, we review a cluster of neonatal falls temporally associated with policy and practice changes to promote breastfeeding. This represents a reported increase in neonatal falls that began within 1 year of commencing a longitudinal project to improve breastfeeding rates through achievement of the Baby Friendly USA 10 Steps to Successful Breastfeeding

So within a year of initiating changes to meet BFHI criteria, the biggest being encouraging rooming-in for all mothers, there were 3 falls, one of which resulting in a skull fracture and post-traumatic seizures. All 3 occurred between midnight and 6 AM and could reasonably be blamed on excessive maternal fatigue. In response, the hospital educated parents and staff on fall prevention, relaxed on the rooming-in thing, and instituted new protocols geared at reducing maternal fatigue. No falls occurred during the remainder of the study period.

So what does it all mean? The authors of the paper were careful in their wording and did not make any firm claims regarding a causal relationship between BFHI-induced practice changes and newborn fall risk. This is understandable with such a small number of events, and to be honest it is difficult to get anything published that might even remotely come across as anti-breastfeeding. The falls occurring after the switch over absolutely could have just been a coincidence, but it would be unreasonable to disagree with their concern and their call for improved surveillance, particularly as more hospitals attempt to achieve BFHI accreditation.

In my opinion, however, the data is clear that strict adherence to BFHI recommendations that involve more, and especially forced, rooming-in, and skin-to-skin without appropriate education and monitoring increases the risk of SUPC. And this is a direct result of mother’s falling asleep while their baby is pressed against their chest. So it is a very reasonable conclusion to draw that these babies would also be at increased risk of falling off of mother’s hospital bed and onto the hard floor. And of course, this risk doesn’t go away at discharge so families should always be educated on ways to reduce the risk of infant fall injuries.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.