Ear Piercing - What's right for one isn't the answer for all!

I am often asked by parents when I think it is the right time to pierce ears on children. I have never read a scientifically based report on the best time - and never expect to! This is very much a parent / family decision.

Parents Magazine online recently posted Ear Piercing for Kids to address some of the common questions and answers. Some of these answers have scientific basis-- such as the type of metal-- most do not.

There is not one age that is "best" to pierce an ear. Many people go through life without ears pierced. Some cultures pierce ears in the newborn period. Some families have a guideline of 7 or 10 years old. Some kids want their ears pierced, but cannot due to sports that will not allow studs in during practice/games/competitions and new studs cannot be removed. Seasons overlap, so there is no 6 week period allowing studs to remain in place. (Some sports will allow studs to be covered with a band aide, but not all, so be sure to ask your team's rules before piercing!)

What is right? It depends on your culture and goals.

I have my personal opinions and fears.

I have seen infants pull earrings out, so I very much worry about damage to the earlobe and the choking risk of any jewelry on infants. My worry is not so strong to refuse to pierce infants-- I have many patient families who prefer to pierce ears in infancy for many reasons, and for many it is culturally based. I want to support other cultures, so have not tried to dissuade these families and most infants do very well with it. And if I do it for one, I should do it for all, right?

The infection risk mentioned in the article above for the first couple of months makes sense, but to stop that risk at 6 months seems premature to me. My reason: at 6 months babies spend a lot of time with their hands in their mouths, then they grab their ears. The mouth is a germy place, and to put the saliva all over the freshly pierced ear seems a risk to me.

On a technical note, I am more nervous piercing infant earlobes than bigger kids. Older children who want their ears pierced will usually sit still-- scared maybe, but still.  Infants must be held and they are typically crying when held. A small variance in positioning on a small earlobe can grow to a more noticeable difference as the earlobe grows. Bigger earlobes are easier to mark and position earrings symmetrically. I think this is a big issue for me because I do not like the angle of my earring holes. (This is why I rarely wear earrings. I had mine pierced initially at about 6 years, I think. They got infected and I had to let them close and then they were later re-pierced. I am not sure if the original hole made the 2nd piercing more difficult or not, but the angle makes the earrings too upright for my liking.)

The more I type, the more I think I should start trying to talk families into waiting...

What do you think?

Will "Standing" Hurt a Baby's Legs?

I am surprised how often I am asked if having a baby "stand" on a parent's lap will make them bow legged or otherwise hurt them.

Old Wives Tales are ingrained in our societies and because they are shared by people we trust, they are often never questioned.

photo source: www.blog.rv.net/2009/01/pj-workout

Allowing babies to stand causing problems is one of those tales.  If an adult holds a baby under the arms and supports the trunk to allow the baby to bear weight on his legs it will not harm the baby. Many babies love this position and will bounce on your leg. It allows them to be upright and see the room around them.  Supported standing can help build strong trunk muscles.

Other fun activities that build strong muscles in infants:

• Tummy time: Place baby on his tummy on a flat surface that is not too soft. Never leave baby here alone, but use this as a play time. Move brightly colored or noisy objects in front of baby's head to encourage baby to look up at it. Older siblings love to lay on the floor and play with baby this way!
• Lifting gently: When baby is able to grasp your fingers with both hands from a laying position, gently lift baby's head and back off the surface. Baby will get stronger neck muscles by lifting his head. Be careful to not make sudden jerks and to not allow baby to fall back too fast.
• Kicking: Place baby on his back with things to kick near his feet. Things that make a noise or light up when kicked make kicking fun!  You can also give gentle resistance to baby's kicks with your hand to build leg muscles.
• Sitting: Allow baby to sit on your lap or the floor with less and less support from you. An easy safe position is with the parent on the floor with legs in a "V" and baby at the bottom of the "V". When fairly stable you can put pillows behind baby and supervise independent sitting. 
• Chest to chest: From day one babies held upright against a parent's chest will start to lift their heads briefly. The more this is done, the stronger the neck muscles get. This is a great cuddle activity too! 

What were your favorite activities to help baby grow and develop strong muscles?

Decisions Parents Make: Use all the facts

Parents struggle with decisions

I was recently asked to clarify a comment I made on facebook, and the comment deserves more than a quick facebook blurb.


The original post:

If you ever plan on having kids, PLEASE make sure you educate yourself about this!

Myths about Circumcision You Likely Believe | Psychology Today

www.psychologytoday.com

CIrcumcision does great harm to babies By Darcia Narvaez, Ph.D....

My reply:
This is one way to use "studies" to distort facts. This article has so many inaccuracies I don't know where to start. 

One of the great things about our country is we have freedom of speech.  I highly support everyone being able to state their opinion, including those who disagree with my opinion.  But I also think we all need to look at opinions as opinions, not as hard fact.  Read articles critically and form your own opinion. Read articles from both sides of the line before you draw your conclusion.  When authors have an agenda (which is why most writers write, including myself here) you must be able to see when they are able to share both sides of a story and when they are simply stating the facts that support their cause.  I am not saying that it is wrong to just state your opinion, just that readers must know how to filter the information. I personally dislike/hate when an argument is actually based on emotion and fears, but comes off as science.  Too many parents are made to feel guilty because they have made a choice for their child that differs from a friend or relative. They read something that differs from what they did and they feel like they made the wrong choice. Regret is a dangerous thing, and is often misplaced.

The intent of my facebook comment above is not to support or discourage circumcision, but rather to warn that when authors have a strong agenda, the methods of persuasion often cause doubt and guilt in readers. I do not find this to be helpful in any way. Data and statistics can be used to distort reality, especially when studies are hand picked to only discuss the ones that support your cause and the ones supporting the contrary are omitted. This includes not only circumcision, but also breastfeeding, vaccines, home schooling, discipline, religion, government, and many, many other topics. 

The first clue that this is an article with a cause is the title and subtitle: “Myths about Circumcision You Likely Believe  CIrcumcision does great harm to babies”.  Simply reading this title alerts the reader that the author is going to persuade you that circumcision is a bad thing.  Their argument is one side of the circumcision debate, but you need to read the counter point from someone who supports circumcision before you make a decision.  

As a disclaimer and credentials for why I feel I can give an educated opinion:  I am a pediatrician who has performed many circumcisions during my 13+ years of private practice. I let parents make the decision to do or not do the circumcision and do not try to sway their decision in any way. I invite parents to watch every time, and nearly half of boys have one or both parents present. Typically parents are impressed by the overall brief procedure. Many have commented that it wasn’t as bad as they thought it would be. I have never had anyone comment how bad it was and have never had anyone (parents, nurses, medical students, or nursing students) become physically ill from watching. I admit that it could be awkward for a parent to express negative comments, so they could simply keep their thoughts to themselves, but experience tells me that when people are upset about things, they tend to complain.  So the many positive comments without any negative comments supports that parents have a generally good feeling about their decision even after watching the procedure.  Note: parents are self selecting here. The parents who don’t want a circumcision in the first place don’t agree to the procedure, and the parents who don’t want to watch are not able to comment on the actual procedure.

Starting with myth 1.  The foreskin is the distal skin of the penis and is removed during the circumcision. It is true that it is adhered to the glans of the penis in a newborn, and there are several means to break these adhesions. This is the most painful part of the circumcision in my opinion (but with adequate pain relief, this pain is diminished/eliminated-- see #3).  As for the surface area of the foreskin in an adult male, I do not see how that accounts for anything about a newborn’s circumcision. A newborn does not have 15 square inches removed. Adult males have wide variation in penile size, and therefore foreskin size.  What has been documented is the more foreskin surface area, the more likely a male will suffer from sexually transmitted diseases:

• Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis: Tobian A.A.R. et al. (2009) 

• Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters) 

• Foreskin surface an  HIV acquisition  

Myth #2.  Procedures hurt, but that doesn’t mean pain isn’t managed. I agree that anesthesia helps, and this has been shown by several studies. The small study by Lander the author mentions shows that the best form of pain control is with the ring block, which injects lidocaine around the base of the penis. However the only form of anesthetic mentioned in the Myth article is the dorsal block, stating that it is the most common. In reading the article by Narvaez, it is stated that one patient in Lander's study suffered a seizure. Reading Lander’s summary, it appears the baby had apnea and loss of tone in the limbs. While this could represent a seizure, it could also be a choking episode, which is common with newborns feeding or crying. I have seen these in many newborns not associated with any procedure. It is difficult to presume it was a seizure from this documentation, and the conclusion of a direct cause/effect from the procedure cannot  be certain. The small sample size of the study limits the validity and generalizability of any findings, including problems encountered. I personally use sucrose pacification (sugar water on a parent or nurse finger or a pacifier) plus a ring block. Neither of these were mentioned by the author. Sucrose pacification has been shown to help with painful procedures the first 4 months of life. I use it to decrease the pain associated with the injection of lidocaine for the ring block and throughout the procedure. I find that babies tolerate the procedure very well the large majority of the time. What also wasn’t mentioned is that there are many types of circumcisions. Training of the physician typically dictates method used, but they each have their own risks and benefits and pain scores.

Myth #3.  See also #2. I do not know where the 45% of doctors using anesthesia number comes from. In my geographic area at the 4 hospitals in which I take care of newborns, anesthesia of some sort is used by all physicians doing circumcisions to my knowledge. In my area it is typically the pediatrician who performs the circumcision, and few obstetricians do it, not OBs.  As for it taking 30 minutes to achieve anesthesia, I have no idea where that number came from.  Local anesthetics have rapid onset once injected. Lidocaine takes 0.5-1 minute, prilocaine 1-2 minutes.  Topical preparations do take longer and should be placed at least 30 minutes prior to the procedure, and they are much less effective in general than injectable anesthetics.  

Myth #4. I cannot understand how this can be reliably tested. The process of birth itself is traumatic. The large majority of boys in the United States are circumcised, but I do not need to treat the majority of boys for Post Traumatic Stress Disorder. The choice of pain relief by Taddio in his studies (referenced in the Myth article) was a topical anesthetic, which is not as effective as other forms of anesthesia. This highlights that you can formulate the methods of your study to get the answer you are looking for, not necessarily the whole truth of the matter. If Taddio really wanted to prove that anesthesia made a difference, the choice of anesthesia should have either included several types ~ or at least the most efficacious, not the least.  Linking long term effects to a single newborn experience would be impossible in my humble opinion because there are too many confounding factors and it is impossible to isolate a single cause/effect relationship.  This is simply a ploy to get parents to regret a choice they have made for their children. This is horrendous in my opinion. We have many opportunities to feel guilt, please do not try to make parents feel guilty about a choice they have made that can impact the health of their son.

Myth #5. Yes, some babies sleep comfortably during the procedure. I have many parents that can agree with this statement after watching their sons undergo the circumcision.  Their babies did not cry themselves to sleep or go into a shock state. They were just sleepy babies. Most do not sleep ~ after all we are stimulating them by moving them around, washing the area, and otherwise touching them.

Myth #6. There are risks to all procedures. A physician should discuss the risks and benefits prior to the procedure. Parents have the right and responsibility to make choices for their children.  Of the complications listed, these are not unique to circumcised males. 

• Meatal stenosis is a narrowing of the urethra that both boys and girls can have, not necessarily after circumcision.  It can be a complication of circumcision from irritation, but is rare.

• Adhesions are NORMAL.  I mentioned above (Myth 1) that they must be broken to remove the foreskin. Without a circumcision they tend to release by 6 years of age. Some circumcised boys re-attach the foreskin without any need to do anything since they typically release on their own by 6 years of age. This is especially common if the pubic fat pad pushes the skin of the penis up and buries the penis (see next item).  While some physicians recommend breaking these adhesions, I have found that it is not required to break these attachments in most cases. This has been validated by Ponsky et al at Penile adhesions after neonatal circumcision. Rarely boys develop bridging adhesions which are different, and these do need to be repaired. 

• Buried penis is common when infants have a thick fat pad at the base of the penis. This happens in both circumcised and uncircumcised boys. It has nothing to do with the amount of foreskin removed. The worst I ever saw was in an uncircumcised toddler. He suffered complications to the point where he needed a circumcision as a preschooler to resolve the problems. This required general anesthesia which involved greater risk than neonatal circumcision.

• Infections are possible any time the skin is broken, yet I have never seen an infected circumcision. It is a risk that should be discussed prior to the procedure so parents know how to identify it early and seek help.  Poor sterile technique has been associated with infection and has made the news earlier this year. If done in a hospital setting with proper technique this risk is minimized. Those having a bris should find a qualified mohel with a good record for safety and proper hygiene.

• Death is very rare. Risk factors, such as family history of bleeding disorders should be discussed prior to the procedure. Vitamin K should be given prior to procedures to decrease risk of bleeding. After the circumcision the site should be routinely checked by trained persons to assess for bleeding. See also infection risk above.

Of course no mention of benefits was made by the author. This unbalanced view does not allow a full disclosure of both sides. 

• A significant decrease in sexually transmitted diseases has been shown among circumcised men. 

• Urinary tract infection risk can be decreased in infants. 

• Phimosis and balanoposthitis are infections caused by improper cleaning of the uncircumcised foreskin. I have seen phimosis once when working as a nurse assistant in a nursing home. It was painful and a horrible consequence of care takers not knowing how to care for the uncircumcised penis. Can this be prevented? Yes. But in our country where most men are circumcised, it is not common knowledge. 

• Improved hygiene in general is easier in circumcised males. I have instructed many families on how to care for the penis, but find that many boys don’t care for themselves properly as they become independent in the shower. Parents need to discuss this with their uncircumcised sons often!

• A decrease in penile cancer risk after circumcision.  

My intent on writing this is not to support or condemn circumcision, it is to simply show how only looking at one side of any conflict can lead to confusion and misinformation.  Learn to look at both sides of an argument to make a better informed decision that is right for you! Don't judge others for their decisions, and don't feel regret for decisions you made based on the information you had!

Injuries from pacifiers, bottles and sippy cups?

Just last month I saw an article about a child who was nearly scalped by his sippy cup during a car accident. The article was about the dangers of projectile objects in the car.  (For the full article, see the link.)

Now an article is released in Pediatrics on the numbers of injuries associated with bottles, pacifiers, and sippy cups during the past nearly 20 years.  The authors studied ER visits after children under 3 years of age were injured by one of these items designed for infants through preschoolers.  They did not include children who went to their own doctor or whose injuries were more minor and did not require medical attention, but the numbers were much higher than expected.  Nearly 200 young children a month visit an ER for injuries due to one of these items.  Lacerations were the most common injuries, especially to the mouth.  Injuries occurred mostly from falling, not product malfunctions.  They were most common in the 1-2 year age group, when kids are starting to walk around (and run!)

Take home message: use these items wisely.

Pacifiers are a great soothing tool to help infants and young children fall to sleep.  Limit them to sleep.  When kids are up playing, they don't need them.   This has been my advice for years due to the fact that keeping the paci in the bed also decreases risk of infections and aides in getting rid of it at an earlier age.  Now I have another reason!

Bottles are an essential source of nutrition for most infants.  Feeding time is also a comfort time.  Infants should be held for all feedings initially, then older infants can be seated if they are not still held. They do not need to walk around with a bottle in their mouth ever!  Eating on the go is unhealthy for us all.  We should sit at the table and eat.  (This might also decrease choking, as kids running around with food in their mouth are more likely to choke than those seated at a table.)  Toddlers should learn this habit young as well.  Once they are a year of age they should transition away from a bottle. 

Sippy cups also do not need to be carried around throughout the day. I often see kids with drinks other than water being carried around much of the day.  They simply don't need to do this: it is bad for their teeth and it increases overall calorie intake, contributing to obesity. Toddlers and older children can be offered drinks with meals, while seated at the table.  If thirsty between meals, have them sit and relax with their drink.  That is a good habit for us all, but our on-the-go society easily helps us forget the basics. 

Our kids teach us many things about life.  Maybe we can learn from them with these simple rules.  We can all sit to enjoy our meals and snacks and stop eating on the run!  We'll be healthier in many ways!

Car Seat Confusion and Booster Boo Boos

Happy in her rear-facing seat!

Many parents are confused by car seat rules, regulations, and recommendations.  For many it is a rite of passage with the first birthday to turn kids around forward facing.  Then they move to a booster before kindergarten and they lose the booster on their 8th birthday.

What is magic about any age that allows a child to sit in the next level of seating?  Kids vary greatly in their size at these ages, yet age seems to determine seating for many kids.  We don't pick clothing based on age. Shoes are not worn based on age. Why don't we fit kids into cars as carefully as we fit them into clothing?

There is so much misinformation out there, it's no wonder people are confused!  And it's not only confusion, but parents make choices based on so many other factors.  For some it is convenience for themselves ~ it's easier to let a child self buckle in a booster.  Sometimes the numbers of kids combined with the size of the car simply don't allow rear facing for the tots.  Many parents simply want to give up the fight with kids as they fight to grow up into the next step.  So many temptations for parents to move onto the next level before kids are ready.  I understand, really! It was a fight to get my kids into car seats (forward and backwards) as infants and toddlers.  They would arch their back and I felt like I would break them as I pushed on their middle to force them back while I pulled on arms and buckles to force them in.  I can't tell you how many times my daughter at 10 years/5th grade complained that she was "the only one still in a booster!"  She just recently (finally) can fit into some seats without a booster, but the seat needs to be narrow.  Thank you, growth spurt!

Because there is often mention in the car seat instruction manual that kids can turn around at 1 year and 20 pounds, many parents think kids must turn around at that age/size. This is not true per car seat safety testing (unless the seat is older and has lower size restrictions- and then it should be replaced).  It is not required by law in any state or safe by safety standards to turn around at this age/size.  The head size of toddlers is still very large compared to their body. The force on the spinal cord is much greater for a toddler in a forward facing crash due to the larger head and lower muscle strength compared to older children and adults.

The two biggest concerns I hear from parents about rear facing seats:

1. The kids hate being rear facing.
2. The legs are too long.

I find that many kids are perfectly happy rear facing. Others are not happy being strapped in period.  Either way, sometimes what kids like isn't what's best for them. I just want kids to be the safest they can be!

Parents worry that once the legs can reach past the seat that rear facing is not safe.  That sounds reasonable: the long legs would be squished or uncomfortable for kids.  While it is true that most kids will outgrow the rear-facing seat due to height before weight, it is okay to remain rear facing as long as  they fit the limits posted on the side of the car seat.  Read your manual.  If you can't find it, look online.  Studies have shown that kids are 5 times safer rear facing! Even if they kick the back of the seat.  In Sweden they keep kids rear facing until 4 years of age!

There are many sources of confusion with car seats and boosters.  The law does not equal the recommendations by safety experts and it differs from state to state.  The law is the minimum requirement for buckling kids in car seats. The law does not necessarily mean the safest way to buckle the kids up.  Car seats and boosters vary by age and size limitations, there is no standard.  Cars vary in the size and angles of their seats, making the car seat or booster fit differently in every model of car.

The law often does not support the best safety standards:

• Most states (29) do not require kids to wear helmets on bicycles, yet we know that they save lives. 
• Only 20 states require all motorcyclists to wear helmets.
• Only two states prohibit children under 1 year from riding on a bicycle/carrier.
• Three states have no booster seat laws.
• Only 5 states have seat belt requirements in school buses.
• Kansas law allows tots to turn forward facing at 1 year and 20 pounds and allows kids over 4 years to ride in booster seats.

My recommendations:

• Keep kids rear facing until they are at the maximum height and weight of their rear-facing car seat. If the car seat does not allow rear facing until at least 2 years and 30 pounds, buy another seat.  
• Kids can be forward facing in a 5 point harness from 2 years/30 pounds (or bigger if your seat allows rear facing longer) until they are at least 40 pounds and 4 years of age (many seats will harness larger children).  The harness is always safer, but when a child can sit still, not unbuckle self inappropriately, sit without leaning forward/to the side, and the shoulder and lap belts fit them appropriately, then they can sit in a booster with the seat belt.
• Kids can sit without a booster when they can pass the 5 Step Test.  For more on why they shouldn't graduate out of a booster too soon, check out this great page on The Car Seat Lady.
• Kids should never sit in the front seat until they are teenagers (or the size of a teen).  
• Never turn off the air bag to allow kids to sit up front. Think for a minute: why are airbags there in the first place? To save lives! People in the front seat are MUCH more likely to be injured/killed in a crash. If the child is too short and the airbag will hit them in the face instead of the chest, they need to be in back!  
• Never buy a used car seat or booster seat from someone you don't know well. You cannot guarantee it has not been in an accident and you should not use a seat after an accident.
• Do not use expired car seats.  They expire in 5-8 years due to breakdown of the materials of the seat, older technology, and unavailability of replacement parts. Check the labels on the seat for expiration date or use 6 years from date of manufacture.
• NEW addition based on a reader's Facebook comment: Do not use bulky clothing or padding under the seatbelt. Kids are much safer if they are buckled in snugly, then a blanket or cover can be placed over the belt if needed for warmth. Don't believe me? Buckle your child in with the coat and/or sweaters on, then take them out without changing the seatbelt tightness. Put them back in and buckle, again without changing the belt tightness. See how much extra belt there is? With the force of an accident they can move too much!

I wonder how long it will be before the safety recommendations are even stricter:  rear facing until 4 years like Sweden?

I always joke that the babies born today will drive backwards by joystick by the time they can drive!

Don't let your kids take the lead with decisions. Don't do what the neighbors do. Do what you know is safest for your children.  Their lives may depend on it!

For more information and state specific laws:

Helmet Use Laws

Child Passenger Safety Laws

How Boosters Work

The Importance of Rear-Facing video with crash test views forward vs backward

New SIDS Prevention Guidelines

As pediatricians we practice a lot of preventative medicine.  Our patients are generally young and healthy... and we want them to stay that way!  One way we do this is to discuss safety at well visits.  We try to share safety tips on our facebook page, website, and here.

A big safety issue is the sleep position of babies.  Most parents by now have heard that it is safer to put babies to sleep on their back, not belly.  Occasionally we hear of young babies sleeping on their stomachs because parents have realized they sleep longer that way, and they do.  But this is dangerous. Babies don't wake up as much when on their stomach, this is true.  Some babies simply don't wake up.  Please put your babies on their back to sleep!

Parents often want to sleep with their babies because it also is associated with longer sleep time for the baby and more convenience for the parent (especially the breastfeeding mother).  Despite ease and convenience, this is not a safe sleeping arrangement for babies. Arguments that this is safe because world wide many families share beds is not often a valid argument. Americans tend to sleep on a bed with a headboard and bedding.  Babies can get their head stuck between the mattress and headboard (or wall).  They can suffocate from the bedding.  Parents can roll over in their sleep and smother the baby.  There are simply safer options for all to sleep better.

Recently the American Academy of Pediatrics (AAP) released new Sudden Infant Death Syndrome (SIDS) prevention guidelines.  AAP SIDS prevention Guidelines that are based on strong evidence:

• Back to sleep every time.
• Use a firm sleep surface covered with a fitted sheet.
• Room share without bed share (put the baby in a crib or bassinet near the parent bed).
• Keep soft objects and loose bedding out of the crib.
• Pregnant women should receive routine prenatal care.
• Avoid smoke exposure during pregnancy and after birth.
• Breastfeed.
• Consider a pacifier at nap and bed times, but do not attach it to the infant or infant's clothing or stuffed toys.
• Avoid overheating.
• Do not use home cardiorespiratory monitors as a strategy to reduce SIDS.

Other recommendations based on limited evidence:

• Immunize in accordance with the AAP and CDC guidelines.
• Avoid commercial devices marketed to reduce the risk of SIDS (postitioners, co-sleepers, wedges).
• Supervised, awake tummy time is recommended to help development and reduce the risk of  positional plagiocephaly (a misshapen head from laying on one side routinely).

Other issues addressed:

• Co-sleepers are not recommended.
• Absolutely no bed sharing the first 3 months.
• No bed sharing at any age if a person in the bed is a smoker.
• No bed sharing with anyone who is excessively tired.
• No bed sharing with someone who is using medications that increases drowsiness or impairs alertness (pain medicications, alcohol, illicit drugs, certain antidepressants).
• No bed sharing with anyone who isn't a parent. This includes no bed sharing with siblings or other children.
• No bed sharing with multiple persons.
• No bed sharing on a soft surface (waterbed, old mattress, sofa, armchair)
• No bed sharing on a surface with soft bedding, including pillows, heavy blankets, quilts, comforters.
• Because of the high correlation with SIDS and suffocation on couches and armchairs, infants should not be fed on these when the parent is extremely tired and at risk of falling asleep.
• When choosing a crib, be sure it has not been recalled and all the parts are put together properly.
• Use only mattresses designed for infants.  Do not add any comforters, quilts, pillows, or other soft bedding to the sleep area.
• Bumper pads are not recommended.
• Infants should wear clothing that will keep them warm (not excessively hot) and that will not cover the head/face.
• Keep dangling cords or window coverings away from the sleep area.
• If infant slings are used, it is important to keep the infant's head up and above the fabric so the face is visible (unless currently breastfeeding).  
• Infants should not routinely sleep in car seats or other sitting devices (strollers, carriers, or backpacks/slings).

NOT safe!!!!!!
Picture actually taken to show the person who gave the comforter and bumper pad set, then it was put away. 

Keep your baby safe by placing her in a safe place at all times.  It only takes one accident to have life-ending consequences.  To say that you've always slept with your babies and they are fine, so it's not a problem for babies to sleep with their parents is like saying you never wear a seatbelt and haven't had any problems.  Just wait until that first crash...