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Co-sleeping with breastfed vs non breastfed infants 

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Co-sleeping with breastfed vs non breastfed infants 

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Co-sleeping in our culture vs other cultures 

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Co-sleeping in our culture vs other cultures 

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Why pediatricians don’t recommend co-sleeping 

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Why pediatricians don’t recommend co-sleeping 

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Developmental effects on infants who co-sleep 

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Developmental effects on infants who co-sleep 

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Publicity about bedsharing with an infant often raises concerns and warns parents against it. New mothers are left wondering what to do as babies have a biological need to feed during the night and mothers are hardwired to respond. Breastfeeding releases hormones which aid rest and relaxation in the nursing dyad and make mother and baby sleepy. If warnings about bedsharing lead mothers to stop taking their babies into bed with them, they will still need to feed their babies somewhere. This will probably be in a chair or on a sofa, which are riskier places to fall asleep with a baby than in a bed where appropriate measures have been taken.

Differentiating risks

When a baby dies suddenly and no other cause of death can be found, it is considered a SIDS death. The four biggest issues associated with SIDS are smoking,[i] laying a baby facedown for sleep,[ii] leaving a baby unattended[iii] and formula feeding.[iv] It happens in a small group of vulnerable babies who have very specific but undiagnosed health issues. Babies may become distressed if their need to be close to their mothers at night is denied and a vulnerable baby may also be more sensitive to stress. SIDS is different to the risk of Accidental Suffocation and Strangulation in Bed ( ASSB) which happens when a baby is in an unsafe sleep environment with an impaired carer.

The lowest SIDS rates in the world are in countries where bedsharing is traditional, for instance parts of Asia and South Asia.[v] It doesn't seem to be a matter of geography, as when people from low-risk cultures move to other countries and bring their traditions with them they also tend to bring a low rate of SIDS.[vi] The US has a higher rate of SIDS than just about anywhere else, given the prevalence of the four big risk factors mentioned above. Bedsharing is not one of them.

Premature and fragile babies

Premature babies are more vulnerable than full-term babies as they are not yet developed enough to regulate their own bodies, and can be more at risk of SIDS.[vii] However, hospitals are increasingly encompassing "Kangaroo Care" where a mother gets comfortable leaning back and holds her baby skin-to-skin under a blanket. Her body temperature, heartbeat and voice help regulate the baby's own breathing and a healthy sleep.

Kangaroo Mother Care can continue at home and some mothers like to keep their baby secure against them using a special wrapping technique. This can be used at night to keep a baby safe but it's important to be informed about this to ensure it is being done safely.

There is no research on the right time to start ordinary bedsharing with an older premature or fragile baby, as each baby will be ready at a different time. There will probably come a time when a mother can see her baby is ready.

Looking at the facts

Breastfeeding mothers and babies sharing sleep is a biologically normal behaviour, while formula feeding and separate sleep are departures from the norm. It is these behaviours that need to be shown to be effective and safe, not the other way round. In some reports on SIDS and other sleep related deaths, breastfeeding mothers who do not smoke and have not consumed alcohol or arousal-altering medications are considered a sub-group to be discounted from the analysis,[viii] whereas they should be the normal starting point. A first step in looking at infant deaths in adult beds would be to look at what was wrong with the beds, not what was wrong with the mothers. Sofas and chairs represent a much greater risk than safe bedsharing.

Research studies on the subject of bedsharing often use different and confusing definitions. Where the baby is sleeping, who with, and if the other person is awake, asleep, drunk, sober, an adult but not the mother, or even another child, is not always recorded. The 2013 article by Carpenter et al., Bed Sharing when parents do not smoke: is there a risk of SIDS?, combined five different studies with varying definitions, including different definitions of what was meant by bedsharing.[ix]

Even the 2014 NICE addendum on routine postnatal care of women and their babies states that their definition of co-sleeping includes sharing a bed or any other sleep surface such as a sofa or chair.[x]

Consistency in Data Collection

In various studies on SIDS there has been no consistency in the data collected, so there are missing variables which can make a significant difference to the results. One question which has sometimes been omitted is "how was the baby fed?", and this makes a big difference when talking about breastfeeding and bedsharing as opposed to formula feeding and bedsharing.

For example, in 2010 there was a campaign in Milwaukee County against bedsharing.[xi] When the statistics were investigated it was found that all the "bedsharing" deaths in the past year had involved adult alcohol use, a baby on a pillow, difficult living conditions and/or smoking. Every death involved a formula fed baby.

A 2009 study by public health officials in Alaska which aimed to tease apart known risk factors and look at them separately found that 99% of the babies who died had at least one of these risks: face down position, sleeping with someone other than the mother, maternal tobacco use, impaired bed partner, sofa or waterbed. It was not bedsharing per se, but the condition of the adult and safety of the sleeping environment that led to those deaths.[xii]

Gathering information at a death scene is complicated and research conclusions are only as good as the data collected. In some places infant deaths are investigated by a doctor with specialised training; other places don't require any special training. Some places have a death scene report form, but it isn't used everywhere and bedsharing is not always clearly defined. Some examiners record how the baby was fed, others don't. Some ask about smoking and some don't. Sometimes information given by the adults involved isn't accurate.

An often-cited 2009 study [xiii] did not collect data on alcohol consumption, as previous experience had demonstrated the difficulty of obtaining accurate information, thus ignoring a key variable for both SIDS and suffocation.

This huge range of approaches, definitions, levels of accuracy, detail and training provide the data for the "never bedshare" studies. When committees and support organisations include parents who have lost a baby to SIDS, it is understandable that strong emotions will be involved.

The NICE Addendum states " Due to the various methodological and study design issues of the included studies in this update mentioned above, the evidence base could only illustrate associations and a cause-effect relationship could not be inferred."[xiv]

Studies that use Clear Definitions

Four researchers who use very clear definitions in their studies are Drs. Helen Ball (UK), Nils Bergman (South Africa), Kathleen Kendall-Tackett and James McKenna (USA). Their conclusions support the safety and normalcy of bedsharing.

Dr. McKenna says that the amount of CO ² the mother expires in her breath acts to stimulate infant breathing. Expelled CO ² appears to act as a potential back-up, should the baby's own internal drive to breathe falter or slow, since the baby's nasal regions can both detect and respond to the presence of this gas by breathing faster.

He also says that babies who sleep with their mothers and breastfeed spend less time in the deepest stages of sleep (three and four), from which arousal is more difficult should the baby need to awaken quickly to terminate a dangerous apnoea. Instead, co-sleeping babies spend more time in lighter stages of sleep (one and two) which is thought to be physiologically more appropriate for young infants, and more natural and conducive to safe sleep for babies. The shorter durations of deeper stage sleep promoted by co-sleeping can potentially protect those infants born with arousal deficiencies (suspected to be involved in SIDS).[xv]

The NICE Addendum states " it would be inappropriate to use the term risk when considering SIDS and co-sleeping as the causes of SIDS are likely to be multi-factional and a possible causality link with co-sleeping is not clearly defined".[xvi] It goes on to say " It cannot be definitely stated that co-sleeping is a risk for SIDS. Some of the reviewed evidence showed that there is a statistical relationship between co-sleeping and SIDS. This means that, where co-sleeping occurs there may be an increase in the number of cases of SIDS. However, the evidence does not allow us to say that co-sleeping causes SIDS."[xvii]

In fact, no one has proposed a physiological mechanism that would cause a baby to die of SIDS just because he is next to his non-smoking mother, and since mothers and babies are hardwired to be together it wouldn't make any sense.

Practical solutions

Losing a baby is such an incredible tragedy that it is understandable to look for ways to prevent this. However, suggestions have to be "doable". Most breastfeeding mothers sleep with their babies at least some of the time and it is unrealistic to try to stop this. Creating one rule for a specific high-risk situation and applying it to everyone will not work. Tired mothers have to feed their babies somewhere and making everyone feel they are at risk can cause damage in other ways. Mothers may turn to formula or cereal in the hope of getting their baby to sleep longer; they may fall asleep in unsafe places or undertake a sleep-training programme which has associated risks.

Safe Sleep

While SIDS is something which affects a small group of vulnerable babies, parents need to be aware of ASSB (breathing hazard) risks. Making sure a bed is as safe as possible, free of suffocation and injury risks, having a smoke free home, not using arousal- altering medications or alcohol, and breastfeeding are all ways to ensure a healthy baby and his family get a good night's sleep. Even if a mother does not intend to bedshare, ensuring her sleeping area is safe will help on those nights when she finds herself nursing in bed and falling asleep.

Whilst no sleeping environment can be entirely risk-free, studies by Professor Helen Ball of Durham University have found that mothers who sleep with their breastfed babies in bed adopt a protective position that makes overlaying difficult and smothering by bedding unlikely. She has observed that babies "demonstrably do not overheat" and that they breastfeed more successfully and for longer, which has significant health benefits for mother and child.[xviii]

Policies designed to protect the health of a few babies may result in harm if applied to all. The blanket recommendation that parents "simply avoid bed-sharing" may well scare women into making decisions which are not right for them, their family or their baby, and could lead to babies being breastfed in places where it would be riskier for women to fall asleep. Ultimately, it could also lead to women stopping breastfeeding because they are too worried about where to feed.

Safe Sleep campaigns which tell mothers their baby should not sleep in their bed, a couch or a chair, give that mother no information about where she can feed her baby at night when she is likely to fall asleep. Mothers need to have a clear explanation of SIDS and ASSB risks, with different recommendations based on their different lives. They need full information about their options, not alarmist threat messages.

If this recommendation closes down the opportunity for discussions about safe bedsharing, it denies parents whose babies are at low risk for SIDS (healthy term births, breastfed babies with non-smoking, non alcohol-consuming parents) the opportunity to make an informed decision and may lead to parents feeling they need to lie about their choices.

It is vitally important that parents are aware of the need for safe sleeping arrangements and of circumstances which might cause risk. They need to know about the risks and benefits of co-sleeping and unsafe co-sleeping practices so they can make their own informed decisions. Trying to instigate a ban is not a reasonable or effective response to such an instinctive and natural human behaviour.

Sweet Sleep

In 2014, a booked entitled Sweet Sleep was published by Pinter and Martin on behalf of La Leche League International. The book was written by four La Leche League Leaders, Diane Wiessinger, Diana West, Linda J. Smith and Teresa Pitman, who have decades of experience in helping mothers breastfeed. They have become highly knowledgeable about the topic of breastfeeding and bedsharing through 3 ½ years of research and reading, discussing and dissecting hundreds of scientific articles on this topic.

The Preface for the book was written by Professor Helen Ball, a member of LLLGB's Panel of Professional Advisors. Following her appointment as a Lecturer in Anthropology at Durham University in 1993, she began a programme of research on night-time infant care, and established the Parent-Infant Sleep Lab in 2000. Her research examines sleep ecology, particularly of infants, young children and their parents. This encompasses attitudes and practices regarding infant sleep, behavioural and physiological monitoring of infants and their parents during sleep, infant sleep development and the discordance between cultural sleep preferences and biological sleep needs.

Sweet Sleep extensively covers the subject of shared sleep, looks in detail at the facts surrounding this topic and offers information on how mothers and babies can safety sleep together and the many benefits to this. I am indebted to the book for providing many of the facts in this article.

La Leche League is dedicated to providing education, information and mother-to-mother support and encouragement to women who want to breastfeed.
Find LLL support here.

Written by Anna Burbidge on behalf of LLLGB, April 2017

Further reading
Safe Sleep and the Breastfed Baby
For healthcare professionals: Supporting Families With Sleep Sweet Sleep: Nighttime & Naptime Strategies for the Breastfeeding Family,Wiessinger, West, Smith, Pitman, LLLI London: Pinter & Martin, 2014
The Womanly Art of Breastfeeding, LLLI. London: Pinter & Martin, 2010.
Sleeping With Your Baby McKenna, JJ. Washington DC: Platypus Media, 2007.
Helping Your Baby to Sleep: Why Gently Techniques Work Best. Gethin, A. & Macgregor, B. Lane Cove AU: Finch, 2011.

A further excellent resource is www.isisonline.org.uk

[i] Zhang K., Wang X.: "Maternal Smoking and increased risk of sudden infant death syndrome: a meta analysis", Legal Medicine (Tokyo), 2013 (https://www.ncbi.nlm.nih.gov/pubmed/23219585); and Fleming P., Blair P.S.: "Sudden Infant Death Syndrome and parental smoking", Early Human Development, Volume 83, Issue 11 November 2007 (http://www.sciencedirect.com/science/article/pii/S0378378207001296).
[ii] Mitchell E.A. et al.: "Four modifiable and other major risk factors for cot death: the New Zealand Study", Journal of Paediatrics and Child Health, 1992 (https://www.ncbi.nlm.nih.gov/pubmed/1524879).
[iii] Carpenter R.G. et al.: "Sudden unexplained infant death in 20 regions in Europe: case control study.", Lancet, 2004 (https://www.ncbi.nlm.nih.gov/pubmed/14738790)
[iv] Hauck F.R. et al.: "Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis", Pediatrics, June 2011 (http://pediatrics.aappublications.org/content/early/2011/06/08/peds.2010-3000)
[v] Liamputtong P.: " Childrearing and Infant Care Issues: A Cross-Cultural Perspective", Hauppauge, NY: Nova, 2007 (https://www.novapublishers.com/catalog/product_info.php?products_id=5561).
[ vi] Ball H.L., Moya E., Fairley L. et al Infant care practices related to sudden infant death syndrome in South Asian and White British families in the UK.", Paediatric and Perinatal Epidemiology, January 2012 (https://www.ncbi.nlm.nih.gov/pubmed/22150702).
[vii] Malloy, M.H.: "Prematurity and sudden infant death syndrome: United States 2005-2007.", Journal of Perinatology 33, no. 6 (2013): 470-475 ( https://www.ncbi.nlm.nih.gov/pubmed/23288251)
[viii] La Leche League International: "Sweet Sleep - Nighttime & Naptime Strategies for the Breastfeeding Family", 2014, page 360 ( http://www.lllgbbooks.co.uk/store/p89/Sweet_Sleep%3A_Nighttime_%26_Naptime_Strategies_for_the_Breastfeeding_Family.html)
[ix] Carpenter R. et al.: "Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case-control studies.", BMJ Open, May 2013 ( http://www.ncbi.nlm.nih.gov/pubmed/23793691).
[x] National Institute for Health and Care Excellence: "Addendum to to Clinical Guideline 37, Postnatal Care - Routine postnatal care of women and their babies", December 2014 (https://www.nice.org.uk/guidance/cg37/evidence/full-guideline-addendum-485782238).
[xi] Goo.gl/9arQAT referenced in La Leche League International: "Sweet Sleep - Nighttime & Naptime Strategies for the Breastfeeding Family", 2014, page 364 ( http://www.lllgbbooks.co.uk/store/p89/Sweet_Sleep%3A_Nighttime_%26_Naptime_Strategies_for_the_Breastfeeding_Family.html)
[xii] Blabey M.H., Gessner D.G.: "Infant Bed-Sharing Practices and Associated Risk Factors Among Births and Infant Deaths in Alaska", Public Heath Reports 124, No 4, Jul-Aug 2009: 527-534 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693166/)
[xiii] Tappin D. et al.: "Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-control study.", Journal of Pediatrics 147, No1, Jul 2009: 32-7 (https://www.ncbi.nlm.nih.gov/pubmed/16027691).
[xiv] National Institute for Health and Care Excellence: "Addendum to to Clinical Guideline 37, Postnatal Care - Routine postnatal care of women and their babies", December 2014 ( https://www.nice.org.uk/guidance/cg37/evidence/full-guideline-addendum-485782238).
[xv] http://cosleeping.nd.edu
[xvi] National Institute for Health and Care Excellence: "Addendum to to Clinical Guideline 37, Postnatal Care - Routine postnatal care of women and their babies", December 2014 ( https://www.nice.org.uk/guidance/cg37/evidence/full-guideline-addendum-485782238).
[ xvii] Ibidem.
[xviii] See Parent-Infant Sleep Lab: https://www.dur.ac.uk/sleep.lab/

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Bedsharing, Breastfeeding and the risk of SIDS - La Leche League GB

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Publicity about bedsharing with an infant often raises concerns and warns parents against it. New mothers are left wondering what to do as babies have a biological need to feed during the night and mothers are hardwired to respond. Breastfeeding releases hormones which aid rest and relaxation in the nursing dyad and make mother and [...]

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Few parenting conversations in early childhood elicit as much angst and judgment as the one about our children's sleep: Where should they sleep, and how do we get them to sleep through the night? We label newborn babies as "good," or not, depending on how much they disturb us in the nighttime, or we believe babies' sleep is a reflection of our parenting competence.

But our beliefs and decisions about children's sleep are more a reflection of the culture we live in than the scientific evidence for what's best for children, says anthropologist James J. McKenna, in many of his 150 scientific articles on children's sleep. McKenna is director emeritus of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame, and author of Safe Infant Sleep: Expert Answers to Your Cosleeping Questions. He has devoted his career to understanding what happens to babies and their caregivers when they sleep together versus apart.

McKenna's conclusions, supported by research from other anthropologists and developmental scientists over the last 30 years, have thrown him into direct conflict with the American Academy of Pediatrics over recommendations about where babies should sleep. "Separately," say the pediatricians, while McKenna and his colleagues say, "Together, but safely." McKenna's easy-to-read book offers important insights about how cosleeping can be made safe and what kind of benefits it might promote for children's development and parents' well-being.

How did sleep become so controversial?

For most of human history, McKenna writes, parents slept close to their babies for their safety and protection, as well as for parents' own ease of breastfeeding and sleeping. The particular arrangements varied-some parents slept nestled with their babies on the same bed, mat, or rug; others placed their babies in a hammock or basket within arms' reach; still others placed them in a "sidecar" arrangement next to the adult bed. But all of them slept within sensory range of their babies.

About 500 years ago, Western societies diverged from the rest of the world regarding family sleep, McKenna explains. Historical records from northern Europe show that Catholic priests heard confessions from destitute women who had "overlain" onto their newborns, suffocating them in a desperate attempt to limit their family size-they just couldn't support another child. So the church ordered that babies should sleep in a separate cradle until the age of three.

Over time, other Western trends converged with that decree: Rising affluence and the value on independence and individualism made separate bedrooms fashionable. In addition, Freudian psychology privileged the marriage bed and claimed that babies would be harmed if they were exposed to parents' sexuality. Religious and psychological opinion said that children should not be coddled or indulged but required severe discipline to grow up ("spare the rod, spoil the child").

As recently as the 1960s, the kindly Dr. Spock recommended that newborns be trained to sleep alone, and if the baby's crying stressed the parents, they should place a towel under the door to block out the noise. In the 1990s, parents "Ferberized" their babies-letting them "cry it out" to sleep "independently," based on the book Solve Your Child's Sleep Problems by Richard Ferber.

The psychological benefits of cosleeping

Meanwhile, anthropologists observed that all mammals and primates, as well as the majority of non-Western societies around the world, coslept. Therefore, it was likely that the practice had some biological advantage.

One of McKenna and his colleagues' greatest scientific contributions has been to show how parents serve as a kind of biological "jumper cable," or outsourced regulator, to a newborn baby when she is completing her gestation outside her mother's body. When parents and babies sleep together, their heart rates, brain waves, sleep states, oxygen levels, temperature, and breathing influence one another.

To a biological anthropologist, this mutual influence implies that the offspring's growth is intended to occur most safely inside that biological system, near an adult's body, especially in the first few months of life while the baby's own physiology is the most immature. For example, animal studies found that when baby monkeys were separated from their mothers, their bodies went into severe stress. A small study of 25 four- to ten-month-old babies who were separated for sleep training showed that even though the babies' behavior quieted on the third night, their levels of cortisol (a stress hormone) remained high.

When adults and babies sleep together, McKenna and his colleagues found, they do sleep more lightly and rouse more often. Though that might sound undesirable, it is safer, says McKenna, especially in the first few months of life, because it creates more opportunities for caregivers to check on their babies and for babies to recalibrate their breathing to the adult's breathing. For an added benefit, that lighter sleep, or REM (Rapid Eye Movement) sleep, is also important for synaptogenesis, the rapid growth of connections between neurons, in newborns.

At the same time, both adults and babies sleep longer overall when they bedshare, probably because caregivers don't have to get all the way up out of bed to feed and babies don't have to call out, wait for help, and settle back down. And that longer sleep has implications for parent-child interactions in the daytime. Research suggests that more well-rested parents make better decisions and, importantly, have better emotion regulation. Sleep deprivation also raises the risk of postpartum depression.

Fathers who bedshare benefit in other ways, too: One study found that when fathers slept close to their babies, their testosterone dropped more compared to fathers who slept separately. Men with lower testosterone tend to engage in more sensitive and responsive parenting, which means that bedsharing may make for better fathering.

Families who choose to cosleep beyond infancy but worry it makes children overly dependent can relax. On average, children who bedshare do tend to transition to sleeping independently about a year later than other children, but they may be more independent, self-reliant, and confident in their daily lives than children who did not bedshare.

A small study of 83 preschoolers found that children who slept alone from an early age fell asleep more on their own and slept more through the night, but the preschoolers who coslept from an early age were more likely to dress themselves, entertain themselves, and work out problems with peers on their own. Another study of 205 families showed that by age 18, children who bedshared did not differ from solitary sleepers in their sleep problems or mental health. In other words, as children grow, many different factors contribute to their well-being.

Modern bedsharing

Most parents have a natural inclination to sleep protectively near their babies, and data suggest that cosleeping is on the increase. In 2015, a U.S. Centers for Disease Control and Prevention survey found that more than half (61 percent) of American babies bedshare at least some of the time.

And while the American Academy of Pediatrics recommended in 2016 that parents and babies sleep in the same room together for at least the first six months of life, and preferably for the first year, they stopped short of recommending that parents and babies share the same bed. That makes for a gap between what most parents are doing and what they are officially "allowed" to do. As a result, many parents are afraid to let their pediatrician know they bedshare for fear of being criticized or, worse, reported to child protective services.

When that conversation is stopped, McKenna points out, parents are deprived of accurate information about what can make their bedsharing most safe and beneficial. To that end, his book offers guidance, even drawings, for every sleeping circumstance.

After the first six months of life when a baby's physiology is more settled, a variety of factors can come into play in the decision about where to sleep, like cultural beliefs, overall family well-being, and an individual baby's temperament or medical needs. For example, a family may decide that a biologically sensitive child may benefit more from remaining close to the parents longer; on the other hand, a coparent may need a separate sleeping arrangement in order to sleep better-and a happier parent is a better parent.

All the researchers agree, though, that families do better when the adults are intentional and in agreement about their choices. Importantly, McKenna normalizes expectations around sleep: Even by one year, not even half of babies sleep through the night, and eventually it is the quality of the parent-child relationship, not where it plays out, that matters most to a child's development.

It might seem like McKenna is pushing cosleeping, but he denies that. Instead, like a true anthropologist, he believes that only parents can truly know their families' specific needs, and they must be free to make the choices that best serve them-they simply have the right to be accurately informed about all the issues involved. Safe Infant Sleep should be in every pediatrician's office and available to any parent who wants to understand how their babies' sleep really works.

Greater Good wants to know: Do you think this article will influence your opinions or behavior?

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How Cosleeping Can Help You and Your Baby

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Few parenting conversations in early childhood elicit as much angst and judgment as the one about our children's sleep: Where should they sleep, and how do we get them to sleep through the night? We label newborn babies as "good," or not, depending on how much they disturb us in the nighttime, or we believe babies' sleep is a reflection of our parenting competence.

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Sudden infant death syndrome (SIDS) is defined as "the sudden and unexpected death of an infant under 12 months of age that remains unexplained after a review of the clinical history, complete autopsy and death scene investigation." Also known as crib death or cot death, SIDS is part of a larger subset of conditions known as sudden unexpected infant death (SUID).

Roughly 1,360 deaths were attributed to SIDS in 2017. Most of these deaths occurred between the ages of one and six months. While its specific cause is largely unknown, parents can reduce the risk of SIDS by preparing and maintaining a safe sleeping area for their infant. Read on to learn more about SIDS and how you can ensure the utmost safety for your sleeping infant.

SIDS Risk Factors

Recent studies suggest the following factors can put infants at greater risk of SIDS:

Side or stomach sleeping: Researchers have established a strong link between SIDS and sleeping position. The prone (stomach) and side positions increases the risk of hypercapnia, the buildup of carbon dioxide, and hypoxia, a deficiency of oxygen in the body's tissue. Additionally, stomach sleeping can decrease the infant's rate of heat loss and elevate their body temperature, causing them to overheat, and also affect how their cardiovascular system functions. The side sleeping position is considered just as dangerous, and infants are more likely to roll onto their stomachs when resting on their sides. Current guidelines recommend placing infants in the supine (back sleeping) position until they reach one year. This includes nightly sleeping and daytime naps.

Age: Infants younger than six months old represent roughly 90 percent of all SIDS-related deaths. It's believed the risk of SIDS peaks between one and four months. Additionally, preterm infants with low birth weights are considered at higher risk of SIDS. Consistent back sleeping is considered especially important for preterm infants.

Sleep environment: Per current guidelines for parents and caregivers, infants should sleep on firm, flat surfaces covered in fitted sheets. The baby's sleep area should not contain any soft blankets, pillows, toys, or bumper pads. A significant percentage of infants who die from SIDS are found with their heads covered by bedding items. Parents should also ensure there are not any gaps between the edge of the mattress and the crib; two fingers is considered the standard rule-of-thumb.

Bed sharing: While common practice for parents, sharing a bed with an infant is discouraged because adult beds are not optimized for child safety. The link between co-sleeping and SIDS is still under review, but this can increase the child's risk of strangulation, falling, and other hazards. Many adult mattresses are also outfitted with soft bedding, blankets or quilts that could cover the infant's head, and other materials that increase the risk of SIDS. However, parents are encouraged to share a bedroom with their infant while they sleep in a crib or bassinet. SIDS can occur suddenly and infants often make little to no noise, so sharing a room allows parents to keep an eye on their little one throughout the night. Parents should consider sharing a bedroom with their baby for at least the first six months, and up to one year if possible.

Tobacco: Nearly every major epidemiologic study involving SIDS has pinpointed smoking as a major risk factor. This includes expectant mothers smoking while pregnant; according to some studies, up to one-third of SIDS-related deaths could be prevented if mothers completely avoided smoking throughout their pregnancy. Exposing newborns and infants to cigarette smoke is also potentially dangerous. The risk of SIDS is particularly high for infants who share a bed with someone who smokes, even if they don't smoke while in bed.

Alcohol: Consuming alcohol while pregnant can increase the risk of SIDS for infants after they are born, some studies have shown. This includes alcohol use during the periods immediately prior to and following conception, as well as the first trimester.

Feeding: Babies who breastfeed are considered at lower risk for SIDS than those who do not drink breast milk. The risks are also lower for babies who are exclusively breastfed compared to those whose breast milk diet is supplemented with formula or solid food. Mothers should not breastfeed on chairs, sofas, and other upright surfaces where they could potentially fall asleep, as this is a suffocation risk for babies.

Some SIDS risks are suspected, but have not been studied extensively enough to draw a firm conclusion. For instance, studies have identified poor bedroom ventilation as a potential risk factor for SIDS, but more research is needed regarding this topic.

Other risk factors have been largely debunked. One prominent example is vaccines. Many infants receive several vaccines within the first six months of their life, when SIDS is most likely to occur. A wave of SIDS deaths occurred in the late 1970s, and at the time some suspected the deaths were related to the diphtheria-tetanus toxoids-pertussis vaccine. However, subsequent studies note there is no relationship between SIDS and any vaccines.

SIDS Trends

In 1994, the National Institute of Child Health and Human Development and the U.S. National Institute of Health spearheaded the "Back to Sleep" initiative to educate parents about SIDS and its risk factors. The campaign was based on a 1992 recommendation from the American Academy of Pediatrics (AAP), which stated infants were safest while sleeping on their back or side. This recommendation was later updated to state that only the back position was safe. Today, the same program operates under the name "Safe to Sleep."

In 1992, 120 infants died from SIDS per 100,000 live births. From 1992 to 2001, SIDS deaths in the U.S. decreased by 53 percent. This number remained constant for several years, and then further declines were reported between 2009 and 2013. As of 2017, the number of SIDS deaths per 100,000 live births has fallen below 40. Some studies suggest the decrease in SIDS cases is related to the growing number of parents who place their infants in the back sleeping position.

However, SIDS remains the leading cause of death for infants between the ages of 28 days and one year. Furthermore, some statistical studies have found disparities between different racial and ethnic groups. In surveys of mothers with varying racial and ethnic backgrounds, researchers have noted certain trends regarding co-sleeping with infants, placing infants on their backs for sleep, and the use of soft bedding in cribs. Socioeconomic factors may also be at play, as low-income families with more than one small child may resort to crib-sharing or bed-sharing in order to save space.

Boys are slightly more likely to die of SIDS than infant girls. Historically, it was believed infants were at higher risk of SIDS during colder times of the year, but more recent statistics show SIDS deaths are distributed more evenly between hotter and colder months.

How Can Parents Reduce the Risk of SIDS?

While much is still unknown about the cause of SIDS, today's experts advise parents to take the following measures in order to reduce their child's risk of SIDS.

Always place your infant in the supine (back) position for sleep. This applies to both daytime naps and nightly sleeping. That said, prone (stomach) positioning is considered relatively safe if the infant is awake, alert, and supervised, for example, when doing tummy time.

Avoid smoking during pregnancy and do not expose your infant to cigarette smoke.

Do not drink alcohol or use illegal drugs at any point of your pregnancy.

Share the bedroom with your infant sleeping in a crib or bassinet for a minimum of 6 months and up to a year, rather than sharing a bed with them.

Breastfeed your child, if possible. Remove soft bedding from your mattress before breastfeeding in bed, and avoid breastfeeding on upright sofas and chairs.

Furthermore, the U.S. Consumer Product Safety Commission (CPSC) offers the following SIDS prevention guidelines for cribs and bassinets:

According to the most recent reports, the safest surfaces for infants are flat and rigid with inclines of 10 degrees or less. Soft surfaces increase the risk of SIDS.

Never place pillows, quilts, or soft bedding in the baby's crib or bassinet.

Measure gaps between the mattress and crib to ensure they do not measure more than two fingers thick.

When assembling the crib or bassinet, follow instructions carefully and make sure each step is completed. Contact the manufacturer if you have leftover parts, a part is missing, or if you encounter any other problems during the setup process - and do not let the infant sleep in the crib or bassinet until the issues have been resolved.

Never use modified cribs or bassinets, or models that are older than 10 years.

Do not place the crib or bassinet near windows with blinds or curtain cords, as these can be strangulation hazards. Also, be mindful of baby monitor cords.

Additionally, follow proper instructions when assembling play yards and other structures for your child.

Frequently Asked Questions
When can my infant sleep on their side or stomach?
According to current guidelines, infants should continue to be placed to sleep in the supine (back) position until they reach at least one year of age. Once an infant can roll from the prone (stomach) to supine (back) position and from the supine position to the prone position without assistance, the infant should be safe to sleep in any position they prefer.
Isn't side sleeping healthier for newborns?
There is a persistent belief among U.S. infant caregivers and nursery staff that positioning newborns on their side helps clear amniotic fluid from their airway. However, the AAP states there is no evidence the side position is more beneficial in this regard. Parents should place their baby in the supine position as soon as the child can sleep in a crib or bassinet. Skin-to-skin care is recommended from the time the mother awakes after giving birth until the infant is ready for a crib or bassinet.
If I use a baby monitor, can I place my infant's crib/bassinet in a separate room?
Many infants who die from SIDS do so without making noise or struggling. Therefore, a baby monitor - particularly one without video surveillance - may not alert you of hazardous situations. Most experts agree sharing a room with your baby's crib or bassinet is the safest method for at least the first 6 months of life, if not the first year.
Will drinking a little bit in the first trimester increase my infant's risk of SIDS?
The information and data pertaining to drinking during pregnancy can be somewhat conflicting. According to the Centers for Disease Control (CDC), women should not consume alcohol at any point of their pregnancy, including the time of conception. Alcohol consumption is considered a major risk factor for SIDS.
Where can I find a safe crib or bassinet for my child?
As of 2011, crib manufacturers must adhere to specific guidelines mandated by the CPSC. However, you should keep in mind that the mattress you choose for your child is also crucial to reducing their risk of SIDS. Refer to these crib safety mandates and the additional CPSC guidelines listed earlier in this guide when determining whether a crib or bassinet is safe for your child.

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Sudden Infant Death Syndrome (SIDS) and Sleep | Sleep Foundation

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Sudden infant death syndrome (SIDS) is defined as "the sudden and unexpected death of an infant under 12 months of age that remains unexplained after a review of the clinical history, complete autopsy and death scene investigation." Also known as crib death or cot death, SIDS is part of a larger subset of conditions known as sudden unexpected infant death (SUID).

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Is Sleeping With Your Baby As Dangerous As Doctors Say?

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Many doctors in the U.S. say the practice puts an infant at risk of sleep-related death. A close look at the research reveals a different picture.

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Why is co-sleeping dangerous for babies?

There are plenty of ways parents can bond with a new baby, but co-sleeping (or sharing a bed) should never be one of them.

Sleeping next to your newborn is dangerous and can even be fatal, says pediatrician Rebecca Reamy, M.D. She's seen babies die from suffocation and other causes after co-sleeping. Lately, those cases have been on the rise at her hospital.

Where should your baby sleep?

"The best place for a baby is in a crib or a bassinet," Dr. Reamy says. When babies are young, she encourages parents to keep the crib or bassinet in their bedroom. Still, infants should never sleep in their parents' bed .

Suffocation is a common culprit in co-sleeping deaths. However, the practice poses other dangers for children, too, like rolling off the bed or becoming trapped between the mattress and headboard.

Educating parents about safe sleep for babies

At her hospital, Dr. Reamy and her colleagues talk to parents about the safest ways to care for their newborns. Still, she recognizes that even well-intentioned parents may only absorb some things at a time.

"The problem is, how much do you remember when you just had a baby and you're exhausted?" she says. "You can't retain everything."

She and other doctors push the message as often as possible. Dr. Reamy is also an advocate of Safe to Sleep , a public health campaign promoting the best ways for babies to rest.

She says that when pediatricians and other providers repeat warnings about co-sleeping, they help new parents who may misunderstand or need reminders. As babies grow into toddlers, parents can decide the best ways for them to sleep, but in infancy, they should be put to bed the same way.

Baby sleep safety: What puts your child at risk?

Co-sleeping - even only on a couch - is always a bad idea. Parents should also avoid the following:

Crib bumpers. "There's absolutely no use for them," Dr. Reamy says. "There's a significant danger of suffocation." Unfortunately, she adds, retailers continue to stock bumpers and photograph them in cribs. Parents should note that not everything sold for babies is safe for them.

Blankets and pillows. "Babies don't need blankets," Dr. Reamy says. A fitted sheet is all an infant requires in the crib; anything else could endanger them.

An overly warm room is unsafe for babies. They should wear just one more layer than adults.

The safest sleep position for your baby

A baby's sleeping position is also crucial: Parents should always put their babies to sleep on their backs. While they're awake, babies should have regular tummy time, which promotes neurodevelopment and prevents heads from becoming misshapen.

If parents are concerned about the affordability of cribs and bassinets, they can talk to doctors about reduced-cost or free options. Federal programs can help, and some hospitals offer free bassinets.

Dr. Reamy knows that caring for a newborn can be overwhelming, but the baby's sleep routine doesn't have to be. She recommends that every parent follow the ABCs of infant sleep: alone, on their back, and in a crib.

Need to book an appointment with a Piedmont physician? Save time, book online .

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Why is co-sleeping dangerous for babies?

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There are plenty of ways parents can bond with a new baby, but co-sleeping (or sharing a bed) should never be one of them. Sleeping next to your newborn is dangerous and can even be fatal, says Rebecca Reamy, M.D., chief of pediatrics at Piedmont Columbus Regional.

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Co-sleeping is a topic that's sparked considerable debate among parents, pediatricians, and researchers. Supporters emphasize its benefits, like better sleep for both parents and babies. However, concerns about SIDS risk and other safety issues have led others to warn against it.

In this post, we'll look at the current safety guidelines and provide useful tips for parents considering co-sleeping. Plus I'll share what I did with my own kids when they were babies!

What is Co-Sleeping?

Co-sleeping is when parents share a sleeping space with a baby or young child -usually up to the first year of life. Many parents decide to share a room for even longer.

Some define co-sleeping as having the baby within arm's reach, while others define it as parents and baby sleeping in the same room. When room-sharing, the baby may sleep next to the parent's parents' bed or in a bed or crib across the room. Room-sharing is fairly well-accepted - at least for the first six months of life.

However, bedsharing is more controversial. Bedsharing is just like it sounds - sleeping with the baby in the same bed. It's more common than you might think. The U.S. Centers for Disease Control and Prevention (CDC) put out a survey of caregivers in 2015.

Over half the caregivers surveyed (61%) reported bedsharing at least some of the time.

Benefits of Co-Sleeping

Co-sleeping with a baby can have physical and emotional benefits for both parents and baby:

Increased Bonding

Co-sleeping can enhance the bond between parents and baby. The closeness increases the opportunities for interaction, like nursing and comforting. Sleeping near parents at night can also provide a sense of security for the baby. This feeling of safety may lead to better emotional development and reduced separation anxiety.

Co-sleeping makes nighttime breastfeeding more convenient. It can make mothers decide to breastfeed for longer (6+ months) because it's easier to keep up with it night after night.

A 1997 study even found that bedsharing infants breastfed more often and for longer. They had more breastfeeding episodes and spent three times the amount of time during the night compared to separate sleepers.

Lowered Risk of SIDS

One side benefit is that breastfeeding may reduce the risk of sudden infant death syndrome (SIDS). A German study found that formula-fed babies not only had an increased risk of SIDS, - they had DOUBLE the risk compared to breastfed babies.

Sleeping near parents may also reduce the risk of SIDS. Sleeping in close proximity helps regulate the baby's breathing and body temperature. Healthy breathing patterns can also reduce the risk of SIDS.

Benefits Bite Development

More convenient breastfeeding can have even farther-reaching benefits. A 2022 study found that co-sleeping as babies benefitted their bite development as toddlers.

Children who practiced co-sleeping as babies were less likely to use a pacifier or suck their thumbs. As a result, they weren't as likely to develop an overbite, crossbite, or open bite. They ended up having better facial development due to co-sleeping.

Better Sleep For Parents

Having the baby nearby can make nighttime caregiving tasks like feeding and comforting easier and quicker. As a result, parents may be more likely to get restful sleep.

Is Co-Sleeping Safe?

New parents may wonder whether bedsharing is safe. Bedsharing is actually the biological norm and has been common throughout history. Western societies have just moved away from it for the sake of convenience. It can be safe as long as parents follow certain practices.

One of those practices is breast-feeding. Breastfed babies have a symbiotic relationship with their mothers and can safely bedshare. However, formula-fed babies are safer in a side sleeper or in a crib next to the mother.

Dr. James McKenna is Director of the Mother-Baby Sleep Laboratory at the University of Notre Dame and is widely considered a leading co-sleeping expert. He explains that there are several reasons why co-sleeping with breastfed infants versus bottle fed are not the same:

"Breastfeeding changes where and how the baby is placed next to the mother, to begin with, and the infant's arousal patterns, how sensitive the baby and the mother are to each other's movements and sounds and proximities, as well as the infant's and the mother's sleep architecture (how much time each spends in various sleep stages and how and when they move out of one sleep stage into another) are very different between bottle feeding and breastfeeding mother-infant pairs."

The American Academy of Pediatrics (AAP) still advises against bedsharing In their 2022 updated guidelines. They warned that it increases the risk of SIDS. But SIDS is more of a concern when bed sharing with preterm and low birth weight infants. Healthy, full-term babies are not as much at risk as long as parents follow safe sleep practices.

Dr. McKenna has also gone over the research supposedly linking SIDS to co-sleeping. He says the interpretations of co-sleeping and SIDS study results have many inaccuracies and inconsistencies.

There are always examples of people who don't follow safe bedsharing practices. However, that doesn't mean no one should do it. And it's important to note that suffocation from unsafe co-sleeping is not SIDS (Sudden Infant Death Syndrome), even though the two often get lumped together.

Safe Co-Sleeping Practices

Here are some safe bedsharing practices. Keep in mind these apply to daytime naps as well as nighttime:

Breastfed babies may be safest sleeping next to their mothers (rather than fathers)

Infants under a year shouldn't sleep with older children

Babies need to be placed on a firm sleep surface (not a waterbed or couch)

Make sure the headboard and footboard don't have openings where the baby could get trapped at night. The mattress should fit snugly against the headboard to ensure safe infant sleep.

Sheepskins are not a good idea; nor are weighted blankets, quilts, or pillows. They may increase the risk of overheating and suffocation. Stick with lightweight baby blankets.

A well-fitted baby sleeping bag can help give the baby separate bedding to avoid suffocation

Remove anything that could be a strangulation risk like jewelry, pacifier clips, and teething necklaces

Some parents opt to use a bedside bassinet, keeping the sleeping baby nearby while giving them their own space.

The Lullaby Trust out of the UK has also put together a guide on safe mattresses and bedding options for co-sleeping. They emphasize using a firm, flat mattress and avoiding soft or bulky bedding.

What About Teaching Independence?

Some parents may worry that their child will never leave their bed. However, many of the ideas from baby sleep training apply here. A good way to start is by gradually transitioning your baby to their own sleep space. Start with a few minutes in their crib or bassinet. Then gradually increase the amount of time sleeping on their own.

Be responsive to your baby's needs during the transition time. Comfort them if they become upset, but encourage them to settle back to sleep in their own sleep space. A favorite blanket or stuffed animal can help with self-soothing and falling back asleep if they wake up during the night.

Another concern is that co-sleeping as babies would set up children to be less independent as they get older. The good news is that research has found it to be quite the opposite. Early co-sleepers were more self-reliant and more independent as preschoolers than children who didn't co-sleep as babies.

Co-sleeping and bedsharing are common practices around the world. They aren't new concepts. You might be surprised how many world leaders throughout history bedshared with their mothers as infants.

It Isn't All or Nothing

It's important to remember that it doesn't have to be "all or nothing." Once the baby is sleeping through the night, it may be time to gradually work toward moving the baby to his or her own room. Parents can use co-sleeping as a part of baby-led sleep training.

There may also be times when it isn't ideal for a baby to sleep in the adult bed. For example, if a parent has a respiratory illness or the flu, it's probably best to let the infant sleep alone in a crib or bassinet. A night when one or both of the parents have had alcohol is another time to sleep separately.

Many parents simply don't feel comfortable bedsharing. That's completely okay! Parents who are heavy sleepers, on certain medications, dealing with an illness, etc., may not want a baby in bed with them. Whatever the case, there's no judgment here. Room sharing is still an excellent option.

What I Do/Did

When my children were babies, I bedshared with them for the first several months. I had gotten used to the baby being close by in utero, so it was a natural transition to have them sleep right next to me in bed. As the baby started moving around more, I also started to feel more comfortable having them sleep on their own.

Of course, sleeping arrangements will depend on each individual baby and family. Do what works best for you.
What do you think about co-sleeping? Did you practice bed-sharing or room-sharing with your little ones? Share with us below!

About Katie Wells

Katie Wells, CTNC, MCHC, Founder of Wellness Mama and Co-founder of Wellnesse, has a background in research, journalism, and nutrition. As a mom of six, she turned to research and took health into her own hands to find answers to her health problems. WellnessMama.com is the culmination of her thousands of hours of research and all posts are medically reviewed and verified by the Wellness Mama research team. Katie is also the author of the bestselling books The Wellness Mama Cookbook and The Wellness Mama 5-Step Lifestyle Detox.

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Co-sleeping Benefits and Risks (Plus How to Safely Do it)

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Curious about sharing your space with your baby? Here are the benefits of co-sleeping plus how to safely do it, and when not to.

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Safe Cosleeping is Better for Babies’ Development than Sleep Training

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Safe Cosleeping is Better for Babies’ Development than Sleep Training — Developmental Science

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Over twenty years ago, when our children were born, my husband Arjun and I had the sleep debate that many American parents still have today: Where should we put the baby to sleep at night?   Arjun grew up in India, and though he’d slept apart from his parents, his ayah (nanny) had

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why pediatricians don’t recommend cosleeping

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It's a familiar scene for sleep-deprived parents everywhere: They put down the baby in the bassinet to sleep, and those tiny eyes flutter shut. Then they flutter back open and the crying starts. The only thing perhaps more harrowing than those long wakeful nights of a baby's first year is the fear that one day the child won't wake up.

A notable, if subtle, change in sleep guidelines released Monday by the American Academy of Pediatrics acknowledges the reality of those long nights and what parents should do if they can't always follow the guidelines to the letter. The goal is to reduce the risk of sleep deaths in babies.

"We recognize the fact that not only do mothers often inadvertently fall asleep with the infant in their bed, but many mothers choose to bed share," says Lori Feldman-Winter, a co-author of the new guidelines and a professor of pediatrics at Cooper University Health Care in Camden, N.J. "We thought it was prudent to provide guidance on making the bed-sharing arrangement as safe as possible and provide guidance on what populations are most at risk when bed sharing."

An estimated 3,500 infants die each year from deaths related to sleep. Together, these are called sudden unexpected infant deaths, which includes both sudden infant death syndrome and deaths from suffocation, asphyxiation, strangulation and other preventable deaths.

As before, relying on years of strong evidence about the risk factors for these deaths, the AAP recommends that infants be placed to sleep on their backs on a firm mattress in their own crib or bassinet, with no blankets, sheets, pillows, stuffed animals, crib bumpers, positioners or other items. The group recommends against parents and infants sharing a bed, sometimes called co-sleeping, because of a significantly increased risk of death from suffocation or other causes.

Bed sharing has been an area of controversy because some parents insist, contrary to the evidence, that it's safer than having an infant sleeping on a separate surface. Other parents feel they simply cannot get sleep without bed sharing.

The issue has been complicated by an incomplete and sometimes contradictory evidence base, making it difficult to tease out the risks of bed sharing compared with other risk factors. So the AAP hired an independent statistician to review studies that looked at similar data and came to slightly different conclusions.

"Upon further review of the available evidence, it is clear that we cannot safely recommend bed sharing because of the hazard," Feldman-Winter says. "The hazards are particularly in infants under 4 months of age."

But she noted that several studies conducted since the last AAP recommendations have highlighted bed sharing's popularity both in the U.S. and abroad.

"I am pleased to see an acknowledgement that despite the clear, elevated, independent risk of bed sharing with an infant, a high proportion of parents - even the most well-educated ones - end up bed sharing with their babies, whether they intend to or not," says Daniel Flanders, a pediatrician in Toronto. "This doesn't make them bad parents; it simply reflects the fact that some medical recommendations are easier to follow than others."

The populations at greatest risk are those under 4 months old and those born prematurely or with a low birth weight. Putting a baby to sleep on his or her back as well as breast-feeding, routine immunizations and using a pacifier all reduce the risk of both SIDS and death during bed sharing, though none of those can eliminate the risk. Similarly, prenatal and postpartum smoking and parental use of alcohol, illicit drugs or medications causing drowsiness all increase the risk of infant sleep death, but abstaining from these cannot eliminate bed-sharing risks.

"We hear a lot of myths - 'I'm not overweight, I'm not drunk, I'm not high, I'm breast-feeding, and therefore nothing bad is going to happen me,' " explains Elizabeth Murray, a pediatrician in emergency medicine at Golisano Children's Hospital in Rochester, N.Y. Of the many resuscitations of infants she has attempted over the years, she says she hears the same thing from every parent: "We didn't think it was going to happen to us."

While the AAP continues to recommend against bed sharing, the statement also points out that the risks of sleeping together on a sofa or couch are far greater.

"When feeding occurs during the night, we recognize that mothers might be sleepy when they're feeding their baby, but if they fall asleep and the baby falls asleep with them, it's much more hazardous if they're feeding in the couch or an armchair than in the adult bed," Feldman-Winter says.

Previous studies have shown some sleep deaths occurred when parents took their baby to the living room to avoid bed sharing when they fed or calmed them, and then they fell asleep with the baby.

The updated recommendation, then, is that mothers feed their baby in bed and then place the baby on its own sleep surface afterward. If the mother falls asleep by accident, it's not as hazardous as it would be on a couch. When she wakes again, she should immediately place the baby back in its own bed, since the risk of death increases with the duration of bed sharing.

Mothers who choose to bed share or who may accidentally fall asleep should also make sure they have a firm mattress - no pillow top, water bed or other nonfirm surface - and remove pillows, comforters, blankets, loose sheets and anything from the infant's sleep area that could lead to suffocation or difficulty breathing. The bed should also be moved away from the wall so the infant cannot become trapped.

"Previous iterations of SIDS reduction guidelines have not really acknowledged the reality that for some families, it is virtually impossible to make it through the night without bringing baby into bed," Flanders says. This has led to a situation where parents feel ashamed or frustrated discussing their baby's sleep arrangements with their primary care doctors - and a missed opportunity to reduce risk.

"We make the statement for the first time that health care providers should first and foremost have open and nonjudgmental conversations with families about their individual preferences, sleep patterns, sleep environment and be able to have a dialogue about doing the best they can do," Feldman-Winter says.

Jaime Friedman, a pediatrician and partner at Children's Primary Care Medical Group in San Diego, is among the pediatricians welcoming this change.

"I think it's a sign, like they did with the media guidelines, that the AAP is more in tune with what's happening with parents," Friedman says. "You can look at the data and say this is the best thing to do, but if you're in the home, things are very different."

In addition to recommendations for those who end up bed sharing, the revised guidelines emphasize the importance of breast-feeding and skin-to-skin contact in reducing SIDS risk. A period of neurodevelopmental vulnerability is thought to be a major factor in SIDS, and both skin-to-skin contact and breast-feeding contribute to neurodevelopmental maturity and normal respiratory breathing patterns, Feldman-Winter explained.

In addition, breast-feeding reduces the risk of infections, and breast-feeding babies have different feeding patterns, sleeping patterns and sleep states, which may explain the reduced risk.

Another change in the guidelines is the recommendation that babies sleep in their own bed in their parents' room for at least their first six months, preferably up to one year. That recommendation comes from evidence that room sharing reduces the risk of SIDS, but Friedman questions how realistic that is in practice.

"I see families where they can't get the kid to go into the bassinet next to the bed because the baby wants to be in the bed with the parent," she says. "Sometimes that doesn't improve until they get the kid into their own room."

The recommendations reiterate that baby sleep monitors do not reduce the risk of SIDS. By contrast, regular prenatal care does reduce risk. They also emphasize that commercial devices sold in stores, including crib bumpers, are not recommended if they do not adhere to the safe sleep guidelines.

The most significant change, however, appears to be the shift in tone toward understanding parents who may not feel they can follow every recommendation.

"When parents feel comfortable and safe to discuss their baby's sleep environment with their physician, the chances of successfully catalyzing risk-reducing behaviors are maximized," Flanders says.
Tara Haelle is the co-author of The Informed Parent: A Science-Based Resource for Your Child's First Four Years. She's on Twitter: @tarahaelle

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New Guidelines Acknowledge The Reality: Babies Do Sleep In Mom's Bed

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There's no question bed sharing increases the risk of sudden death, pediatricians say. New guidelines are aimed at reducing that risk as much as possible in the first year of a child's life.

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PLoS One. 2014; 9(9): e107799.

Jacobus van Wouwe, Editor

Abstract

Objective

The risk of sudden infant death syndrome (SIDS) among infants who co-sleep in the absence of hazardous circumstances is unclear and needs to be quantified.

Design

Combined individual-analysis of two population-based case-control studies of SIDS infants and controls comparable for age and time of last sleep.

Setting

Parents of 400 SIDS infants and 1386 controls provided information from five English health regions between 1993-6 (population: 17.7 million) and one of these regions between 2003-6 (population:4.9 million).

Results

Over a third of SIDS infants (36%) were found co-sleeping with an adult at the time of death compared to 15% of control infants after the reference sleep (multivariate OR = 3.9 [95% CI: 2.7-5.6]). The multivariable risk associated with co-sleeping on a sofa (OR = 18.3 [95% CI: 7.1-47.4]) or next to a parent who drank more than two units of alcohol (OR = 18.3 [95% CI: 7.7-43.5]) was very high and significant for infants of all ages. The risk associated with co-sleeping next to someone who smoked was significant for infants under 3 months old (OR = 8.9 [95% CI: 5.3-15.1]) but not for older infants (OR = 1.4 [95% CI: 0.7-2.8]). The multivariable risk associated with bed-sharing in the absence of these hazards was not significant overall (OR = 1.1 [95% CI: 0.6-2.0]), for infants less than 3 months old (OR = 1.6 [95% CI: 0.96-2.7]), and was in the direction of protection for older infants (OR = 0.1 [95% CI: 0.01-0.5]). Dummy use was associated with a lower risk of SIDS only among co-sleepers and prone sleeping was a higher risk only among infants sleeping alone.

Conclusion

These findings support a public health strategy that underlines specific hazardous co-sleeping environments parents should avoid. Sofa-sharing is not a safe alternative to bed-sharing and bed-sharing should be avoided if parents consume alcohol, smoke or take drugs or if the infant is pre-term.

Introduction

In the last 25 years the number of deaths due to Sudden Infant Death Syndrome (SIDS) in England & Wales has fallen from around 1600 deaths a year in 1988 to around 250 deaths a year in 2010 [1]. This 85% fall in SIDS rates has been accompanied by changes in the characteristic profile of these deaths. The proportion of deaths in families from deprived socio-economic backgrounds, among mothers who smoke during pregnancy and among pre-term infants has risen, while the peak age of death among SIDS infants found sleeping next to a parent has fallen from 3 to 2 months [2]. The Back to Sleep campaign, initiated in the UK in 1991, advising parents to avoid placing infants in the prone position for sleep has had a dramatic effect on the number of SIDS deaths occurring in a cot but less effect on co-sleeping deaths [2] which now account for 30-50% of all SIDS deaths [3]-[6]. Previously we have demonstrated that a proportion of these co-sleeping deaths occurred while the parent and infant slept on a sofa or chair [7] as well as a significant interaction between co-sleeping and parents recently consuming alcohol or drugs [8]. Studies have also shown an increased risk when infants slept with parents who habitually smoked [6]-[8]. However the question remains as to whether there is still a residual risk of bed-sharing in the absence of these hazardous circumstances. This question is important as it is central to public health strategy in terms of whether one should take a blanket approach to advise against bed-sharing in any circumstances as chosen for example by the American Academy of Paediatrics [9], or acknowledge that bed-sharing is a common practice and specifically target hazardous circumstances as adopted by UNICEF UK in their 'Caring for your baby at night' leaflet [10].

Attempts have recently been made to answer this question by amalgamating findings from previous SIDS case-control studies around the world [11] but this investigation suffered from a lack of data on hazardous co-sleeping circumstances or which parent the infant was sleeping next to. These limitations plus imputing values from whole studies where the data are missing has led to major concerns about the conclusions drawn [12]-[14]. We have previously carried out two population-based case-control studies which have collected these data in more detail; combining these data will give us more power to assess the risk associated with different circumstances of co-sleeping. The aim of this individual-level analysis, combining findings from both studies, is to quantify whether there is a risk of SIDS associated with co-sleeping in the absence of known hazards and explore the interactions with other known significant predictors of SIDS to better understand the potential risks to the infant and implications for future research.

Methods

Ethical approval

This study was approved by the each regional research ethics committee and by each constituent local research ethics committee for the two studies.

Both case-control studies have been fully described elsewhere [8.15] and used the same study design, similar protocols and many of the same questions and categorical responses. Both studies are population based and collected data on all sudden unexpected deaths in infancy in a defined area over a defined period and used multi-disciplinary panels to categorise the deaths as either explained or unexplained SIDS deaths (the latter being used in the analysis). The study area for the more recent investigation was one of the same English regions used in the earlier larger investigation. At this moment in time our second investigation is the most recent case-control study conducted in this field. Full ethical approval was given for both studies.

The first study was a large population control study conducted in five former English health regions (South West, Trent, Yorkshire, Wessex and Northern regions) in 1993-6 from a total study population of 17.7 million. Data were collected using a questionnaire used by research interviewers and from medical records. Bereaved families were visited within 1-2 days of the death for a narrative account and again within two weeks to complete the questionnaire. Four controls for each case were selected. The health visitor for the infant who died was asked to identify two babies on their case list born in the two weeks before the index baby and two babies born in the two weeks after the index baby. The interviewer visited each control family within a week of the index death to collect the same data as for the index case. A period of sleep (the "reference sleep") was identified in the control infant's life in the 24 hours before the interview, corresponding to the time of day during which the index baby had died.

The second study was conducted from 2003 to 2006 in the South West Region of England with a population of 4.9 million and the cause of death was established in the same way. The control infants were weighted to be comparable with the maternal social class distribution of mothers with dependent children in Avon from the 1991 census. The age of the infants at interview and the time of day of the reference sleep were weighted to reflect approximately the ages and times of day at which infants had died.

All deaths across both studies were classified according to the Avon clinico-pathological system [16] by a multidisciplinary committee after a full paediatric necropsy to a standard protocol. Guidelines for strengthening the reporting of observational studies in epidemiology were followed [17].

Variable definition

Co-sleeping (which includes bed- and sofa-sharing) was defined as infants sharing the same surface with at least one adult for sleep. Sofa-sharing was defined as infants sleeping on a chair or sofa (settee) with an adult. Bed-sharing was defined as infants sharing the parental bed with at least one adult. We took care to identify which adult was sleeping next to the infant; thus if the infant was sleeping between the parents we would use data on alcohol consumption or smoking from both, but if the infant was sleeping adjacent to one parent or alone with one parent then we would just use the data pertaining to that parent. The alcohol limit of no more than two units prior to the last sleep was based on recent UK recommendations of the maximum daily intake for women. Recent drug consumption was only collected in the second study so did not form part of this analysis, though has been published elsewhere [8].

The different hazards associated with co-sleeping were not mutually exclusive; some infants, for instance, slept on a sofa with an adult who smoked and had consumed lots of alcohol. These interactions have previously been explored so for this analysis a hierarchical approach of categorisation of co-sleeping was adopted based on the strength of risk reported from the two studies [8], [15] to ease interpretation of the findings. Thus sofa-sharing, quantified as the highest risk from our previous studies, was categorised regardless of whether the parents consumed alcohol or smoked, bed-sharing and alcohol consumption of more than two units was categorised regardless of smoking status and the remaining bed-sharers were categorised into smokers and non-smokers. Thus the final category representing bed-sharing in the absence of known hazards were those parents who did not co-sleep on a sofa, had not consumed more than two units of alcohol and who did not smoke. This hierarchical approach lends itself to quantifying the risks associated with three previously identified dangerous co-sleeping environments whilst also quantifying the risk of bed-sharing in the absence of these conditions.

For ease of interpretation the variables adjusted for in the multivariable analysis were dichotomised using standard definitions if available or previous definitions used in the earlier studies. These included four infant characteristics: low birthweight (<2500 g), pre-term infants (<37 weeks gestational age), gender, and whether the infant was still being breastfed when the final sleep occurred; three maternal characteristics: larger families defined as three children or more including the index infant, younger mothers aged 21 years or younger, and poor education at 16 years defined as below the General Certificate of Secondary Education level or no qualifications; and six factors pertaining to the time around the last sleep: parental report of the infant being unwell using specific signs and symptoms and scoring more than eight on the Babycheck [18], infant placed in the prone or side sleeping position, infants swaddled and use of a dummy (called a pacifier in the US). Although significant in the univariable analysis the use of pillows, tog values of infant bedding and clothes and softness of the mattress were not significant in the multivariable model, however the use of an infant or adult duvet and infants found with head or face covered by bedding were significant and have been adjusted for in the multivariable results.

An analysis of younger and older infants dichotomised around the median age allowed comparison with observations made in previous studies.

Statistical methodology

In the first study controls were individually matched to SIDS infants for age and time of day (night time or day-time sleep) the death occurred; while for the second study, these variables were weighted rather than individually matched. Thus all univariable odds ratios quoted are adjusted for these two factors. In the multivariable analysis factors found to be significant in the previous two studies were included where available and interactions with co-sleeping investigated. The factor representing infants who slept in a different room from the parents is slightly different as it is mutually exclusive with co-sleeping and thus interacts with the reference group rather than the different co-sleeping groups. This factor was therefore added separately to the final model to observe the effect. Odds ratios (OR), 95% confidence intervals (CI) and p-values for the univariable and multivariable analysis were calculated by logistic regression using the statistical package SPSS. Models were constructed using the backward stepwise procedure for variables significant at the 5% level in the univariable analysis. Any variables with more than 5% missing data among the cases or controls were tested at the end of the modelling process.

Results

Of the 405 SIDS infants and 1387 controls in the two studies we had data on the sleep environment in which the infant was found for 400 SIDS infants (98.8%) and 1386 controls (99.9%). Over a third of SIDS infants (36%) were found co-sleeping with an adult at the time of death compared to 15% of the controls after reference sleep. The overall risk of SIDS for infants who co-slept was more than threefold and almost fourfold when adjusted for other factors associated with SIDS ( Table 1 ).

Table 1

SIDS

Controls

Univariable Risk*

Multivariable Risk †

By different co-sleeping environments

When categorised by co-sleeping environment, the multivariable risk of co-sleeping with an adult on a sofa or chair, or with an adult who had consumed more than two units of alcohol was 18 times greater than those who did not co-sleep; and four times greater for those who slept next to a parent who smoked. There was no significant multivariable risk of bed-sharing in the absence of these hazards (OR = 1.1 [95% CI: 0.6-2.0]). Including a variable for infants sleeping in a separate room in the multivariable model alters the reference group and increased the risk associated with each co-sleeping environment; OR = 28.8 [95% CI: 10.9-76.1] for those who co-slept on a sofa or chair, OR = 29.7 [95% CI: 12.0-73.6] for those who slept next to someone who consumed more than two units of alcohol and OR = 6.2 [95% CI: 10.9-76.1] for those who slept next to someone who smoked. The risk associated with those who bed-shared in the absence of these hazards increased but was not statistically significant (OR = 1.6 [95% CI: 0.9-3.2], p = 0.14). None of the variables significant in the multivariable model had more than 5% missing data and over 95% of the data were used in the final model presented.

The interactions between variables used in the model and whether the infant was found co-sleeping were examined in Table 2 . There was no interaction between co-sleeping and low birth weight, and although the risk for pre-term infants who co-slept was more marked (OR = 7.0 [95% CI: 3.0-16.4]) than those who did not (OR = 3.9 [95% CI: 2.6-5.8]), the interaction did not reach statistical significance (p = 0.20). Co-sleeping in general was more common among males, and interestingly any male predominance among SIDS infants was confined to those who did not co-sleep. Similarly breastfeeding was more common among those who co-slept and its protective effect was only found among those who slept alone (OR = 0.3 [95% CI: 0.2-0.5]). There was no significant interaction with maternal characteristics and co-sleeping, although larger families, younger mothers and poorer maternal education were slightly more prevalent in those who did not co-sleep. There was no significant interaction between co-sleeping and several of the factors observed at the time of the last sleep, although the prevalence of day-time sleeps and infants found with head covered by bedding was lower for both SIDS infants and controls who co-slept. The difference in infants being unwell or using a duvet was slightly more marked among those who did not co-sleep but the interaction was not significant. A significant interaction was found with dummies in that the apparent protective effect was mainly confined to those who co-slept (OR = 0.3 [95% CI: 0.2-0.5]) although was just significant for those who did not (OR = 0.8 [95%CI: 0.6-0.997]). Interestingly the risk associated with placing infants prone was absent among those who co-slept (OR = 0.4 [95% CI: 0.2-1.2]) but strongly significant among those who did not (OR = 11.3 [95% CI: 7.0-18.4]), yielding a highly significant interaction (p<0.0001). There was also a strong interaction (p<0.0001) with infant age; co-sleeping was a much greater risk for those infants younger than the median age of 98 days (OR = 3.3 [95% CI: 2.1-5.3]).

Table 2

Infants who co-slept

Infants who did not co-sleep

Interaction*

SIDS

Controls

SIDS

Controls

P-value

Maternal Characteristics

Poor maternal education †

53/135

39.3%

30/211

14.2%

101/247

40.9%

232/1169

19.8%

0.27

Factors at the time of the last sleep

Infant being unwell ‡

41/145

28.3%

31/213

14.6%

87/255

34.1%

161/1173

13.7%

0.27

Table 3 splits the data to look at the risk of co-sleeping in younger and older infants; dichotomising by using the median of 98 days old. Overall the risk of co-sleeping among the younger infants increased to fivefold while the risk among the older infants became non-significant. Looking in more detail at the different co-sleeping environments, the numbers in some of the categories were very small so caution needs to be taken regarding the point estimates. The risk of co-sleeping with a parent on a sofa or chair was high regardless of infant age. The risk of bed-sharing next to a parent who had consumed more than two units of alcohol was higher among younger infants, but still a six-fold risk among older infants. The risk of bed-sharing next to a parent who smoked was largely confined to the younger infants while the risk of bed-sharing in the absence of these hazards was not quite significant among the younger infants (OR = 1.6 [95% CI: 0.96-2.7]) and seemingly protective among the older infants, albeit the numbers are very small. Only one SIDS death (0.6%) occurred beyond 3 months of age when bed-sharing in the absence of alcohol, smoking or sofa-sharing compared to 8.5% amongst the controls; even if we just use the upper confidence interval, the risk of SIDS halved in this particular group of infants (OR = 0.1 [95% CI: 0.01-0.5]).

Table 3

Younger infants (<98 days)

Older infants (≥98 days)

SIDS

Controls

OR [95% CI]*

P-value

SIDS

Controls

OR [95% CI]*

P-value

Different co-sleeping environments

N

(%)

N

(%)

N

(%)

N

(%)

Discussion

There was no significantly increased risk for SIDS associated with bed-sharing in the absence of sofa-sharing, alcohol consumption and smoking. In infants aged less than 3 months the same proportion of SIDS infants and control infants bed-shared in the absence of these hazardous conditions and the difference was not significant. Conversely, bed-sharing in the absence of other hazards was significantly protective for infants older than 3 months; a finding that was unexpected and has not been previously reported to our knowledge. Notably, the risk associated with infants co-sleeping on a sofa or sleeping next to an adult in the parental bed who had consumed more than two units of alcohol was a magnitude higher than most risk factors associated with SIDS. Both of these environments pose a risk to the infant regardless of infant age. The reasons as to why infants are at increased risk when sleeping next to a smoker are not clear, but this risk seems to be far greater in the younger infants.

There are limitations to this secondary analysis of observational data, not least the attendant bias that such studies introduce. We have largely established potential associations rather than definitive causal factors and can only interpret the findings in terms of the factors we have recorded. The studies are also ten years apart although many of the risk factors are in the same direction and for some the magnitude has changed very little. Combining observational data from different SIDS studies can be difficult [11] but was less of a problem for this analysis as many of the questions and responses were worded exactly the same with similar study protocols and the same techniques for identifying and defining the deaths. The same comprehensive notification system was in place for both studies and the multi-disciplined panel of experts used the same classification system to clearly identify SIDS [16]. There was also a relatively small amount of missing data allowing us to conduct the analysis without the need to impute. Information on recent parental drug consumption needs to be collected when investigating co-sleeping deaths; this renders our current observations a conservative estimate of potential hazardous environments. Data on recent drug consumption, collected in our second study, suggests at least some of the risk we currently apportion to bed-sharing and smoking also involves the use of recreational drugs [8]. The combined dataset is relatively large for case-control studies and is population-based with very few missed deaths during the study period but is only large enough to look at a dichotomy of interactions amongst the multiple categories of co-sleeping deaths and even then the numbers for some categories may be small as reflected by the large confidence intervals of risk estimates.

The hazardous circumstances in which some co-sleepers were found and the interaction of significant predictors of SIDS with co-sleeping suggests we need to look closer at accidental asphyxia as a potential causal mechanism in these deaths. Our UK definition of SIDS adheres strictly to the Avon clinic-pathological classification [16] system using a multi-disciplinary panel to review every death in both studies and this analysis excludes explained deaths but it is recognised that without such thorough review some of these deaths may be classed as accidental or come under the wider umbrella of Sudden Unexpected Deaths in Infancy in other countries. Infants placed prone, male preponderance and lack of breastfeeding are common predictors of SIDS deaths and the absence of significance in these factors among those found co-sleeping may suggest a different mode of death than those SIDS infants found in a cot [19] although this could equally be related to the practice of co-sleeping itself. In a large cohort of healthy infants we have previously shown that parents are more likely to bedshare with a male infant and more likely to breastfeed [20] and this is reflected among the controls in this analysis ameliorating significance in these factors. In a longitudinal investigation of consecutive SIDS deaths over a 20 year period [2] we have also shown that co-sleeping breastfeeding mothers were less likely to place infants prone prior to the " Back to Sleep" campaign which partly explains the smaller reduction in these deaths than in cot-sleeping infants after the campaign. The lower proportion of SIDS infants using dummies for the last sleep was mainly restricted to those who co-slept and this novel finding was unexpected. The difference in prevalence of habitual dummy use between case and control infants is almost absent in our studies which may suggest the differences found for the last sleep is a marker of change in routine and co-sleeping in the parental bed or on a sofa might be an indicator of disruption in infant care practices that otherwise would largely go unmeasured. The interaction with young infant age suggests vulnerability, especially when we take into account the hazardous circumstances in which some of these deaths occur, thus the possibility that the causal mechanism of death in such circumstances may be different to that for solitary sleeping infants [21] needs further investigation.

An important implication of our findings is that to give blanket advice to all parents never to bed-share with their infant does not reflect the evidence. There is a danger that such advice could influence parents to seek alternative, more dangerous sleep surfaces such as a sofa. In our study in 2003-6 a number of families whose infants died informed us that they had been advised not to bed-share and thus fed the infant (and fell asleep) on a sofa. Aggressive anti-bed-sharing campaigns in both the United States and the United Kingdom depicting parental bed headboards as tombstones, mothers as meat cleavers sleeping next to the infant and parents as ogres in fairytales have been roundly condemned by the SIDS research community [22] but even a more conservative campaign can give the impression that bed-sharing is somehow innately wrong. Of course we should inform the public about risks that can be associated with bed-sharing, but bed-sharing is a widespread socio and cultural norm [23], [24]; giving across the board advice to simply not do it negates the option of highlighting the specific and highly significant risks we have found. There is also ample evidence of an interdependent positive relationship between bed-sharing and breastfeeding [20], [25] with its inherent advantages to the infant that needs to be considered in addition to the possible risk of SIDS.

Conclusion

The evidence presented here is in line with the current public health messages promoted by the UK Lullaby Trust in their 'Safer sleep for babies' advice, and as outlined by UNICEF UK in their 'Caring for your baby at night' leaflet for parents, and their health professional guidelines [10]. In the UNICEF leaflet bed-sharing is acknowledged as something parents do either intentionally or unintentionally. The leaflet makes clear that bed-sharing is inappropriate if parents consume alcohol, take drugs or smoke, or if the infant is pre-term. The leaflet also makes clear that sofa-sharing is not a safe alternative to bed-sharing. The risk of bed-sharing and SIDS in the absence of these hazardous conditions appears to be minimal; more effort therefore needs to go into advising parents on the very real dangers associated with bed-sharing in these particular hazardous conditions.

Funding Statement

The two studies were funded by both cot death charities the Foundation for the Study of Infant Deaths (FSID) now the Lullaby Trust and Babes in Arms. There was also funding received from the Department of Health (England) and the Charitable Trusts of University Hospitals Bristol. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

The authors confirm that all data underlying the findings are fully available without restriction. Anonymised data from the combined studies are held at the University of Bristol and Professor Peter Fleming ( ku.ca.sirb@gnimelf.retep) is responsible for them.

References

1. (2012) ONS Statistical Bulletin: Unexplained death in infancy. England & Wales 2010. 21 st August 2012.

8. Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, et al. (2009) Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. BMJ 2009 339: b3666 doi:[[ 10.1136/bmj.b3666 PubMed] PMC free article] [ Google Scholar]

11. Carpenter R, McGarvey C, Mitchell E, Tappin D, Vennamann MM, et al. (2013) Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case-control studies. BMJ Open 2013 3: e002299 doi:[[ 10.1136 PubMed] PMC free article] [ Google Scholar]

12. Renz-Polster, De Bock F (2013) More questions than answers. BMJ Open published online June 10 2013.

13. Blair PS, Fleming PJ, Ashmore S (2013) A lack of data and questionable emphasis. BMJ Open published online May 22, 2013.

14. Russell CK, Ball H (2013) Bed-sharing when parents do not smoke: is there a risk? BMJ Open published online May 23, 2013.

20. Blair PS, Heron J, Fleming PJ (2010) Relationship between bed sharing and breastfeeding: longitudinal, population-based analysis. Pediatrics 2010; 126 (5): : e1119-26. Epub 2010 Oct 18. [[ PubMed] Google Scholar]

22. (2013) Statement from the International Society for the study and Prevention of perinatal and Infant Death (ISPID). 'Fear-based prevention strategies may be harmful and should be stopped' found at: http://www.ispid.org/id_statements.html.

25. Howel D, Ball H (2013) Association between Length of Exclusive Breastfeeding and Subsequent Breastfeeding Continuation. J Hum Lact. 2013 Jul 2. [Epub ahead of print]. [ PubMed]

Articles from PLOS ONE are provided here courtesy of PLOS

# data[].attributes.attachment_link.title
Bed-Sharing in the Absence of Hazardous Circumstances: Is There a Risk of Sudden Infant Death Syndrome? An Analysis from Two Case-Control Studies Conducted in the UK

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The risk of sudden infant death syndrome (SIDS) among infants who co-sleep in the absence of hazardous circumstances is unclear and needs to be quantified.Combined individual-analysis of two population-based case-control studies of SIDS infants and controls ...

# data[].attributes.attachment_link.readable_text
For the overwhelming majority of mothers and babies around the globe today, cosleeping is an unquestioned practice. In much of southern Europe, Asia, Africa and Central and South America, mothers and babies routinely share sleep. In many cultures, cosleeping is the norm until children are weaned, and some continue long after weaning. Japanese parents (or grandparents) often sleep in proximity with their children until they are teenagers, referring to this arrangement as a river - the mother is one bank, the father another, and the child sleeping between them is the water. Most of the present world cultures practice forms of cosleeping and there are very few cultures in the world for which it would ever even be thought acceptable or desirable to have babies sleeping alone.

Cosleeping is practiced in a variety of ways around the world. In Latin America, the Philippines, and Vietnam, some parents sleep with their baby in a hammock next to the bed. Others place their baby in a wicker basket in the bed, between the two parents. In Japan, many parents sleep next to their baby on bamboo or straw mats, or on futons. Some parents simply room-share by putting the baby in a crib or bassinet that is kept within arm's reach of the bed. Most cultures that routinely practice cosleeping, in any form, have very rare instances of SIDS. SIDS occurrences are among the lowest in the world in Hong Kong, where cosleeping is extremely common.

Cosleeping is actually more common in the U.S. than most people believe. The typical American home has a room that contains a crib for the baby, and parents report that the baby sleeps in the crib. Yet when researchers ask specific questions about who sleeps where, it turns out that the majority of mothers sleep with their young children at least some of most nights. Parents present themselves as having babies who sleep alone, following the societal norm of the baby in the baby's room and the couple in the master bedroom, but that is not an accurate representation of what is really happening.

The Centers for Disease Control (CDC) in Atlanta collects data that provide information on all means of prenatal and well-baby stressors. Through this, we know that cosleeping is not unusual for American families at all. Roughly 68% of babies enjoyed cosleeping at least some of the time. Further analyses of the data show us that about 26% of infants coslept "always" or "almost always." Combining them with the babies who cosleep "sometimes," it appears that 44% of US babies from 2-9 months old are cosleeping in an adult bed at any given time. ¹

Japan, another industrialized country, not only has one of the lowest infant mortality rates (less than 3 infants per 1000 live births compared with around 7 for the United States), but one of the lowest SIDS rates in the world (between .2 and .3 babies per 1000 live births compared with approximately .5 per 1000 infants for the US). The Japan SIDS Family Organization reported that SIDS rates continue to decline in Japan as maternal smoking approaches practically 0, and exclusive breastfeeding reaches around 70-75 % . In fact, one report shows that as bedsharing and breastfeeding increased and as maternal smoking decreased, SIDS rates decreased. This suggests yet again that it is not necessarily bedsharing, but how it is practiced, that can be dangerous.

Interestingly, it may be that Japanese bedsharing rates do not differ all that much from those in the US, but the cultural acceptance of cosleeping as the norm is very different. In 1998, 60% of parents said they practiced bedsharing in Japan, only about 16% more than US parents. This means that the practice of cosleeping does not necessarily vary a great deal from culture to culture, but rather that the social acceptance of cosleeping is what varies.

¹ Whiting, J. W. M. (1981). "Environmental constraints on infant care practices." Handbook of Cross-Cultural Human Development. R. H. Munroe, R. L. Munroe, and B. B. Whiting, editors. New York: Garland STPM Press.

Dr. James J. McKenna is a Professor of Anthropology and the Director of the Mother-Baby Behavioral Sleep Laboratory, Notre Dame University.

Reprinted with permission of the author from Sleeping With Your Baby: A Parent's Guide To Cosleeping by James J.McKenna (2007). Platypus Press.

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Cosleeping Around The World - The Natural Child Project

# data[].attributes.attachment_link.description
For the overwhelming majority of mothers and babies around the globe today, cosleeping is an unquestioned
practice. In much of southern Europe, Asia, Africa and Central and South America, mothers and babies
routinely share sleep. In many cultures, cosleep­ing is the norm until children are weaned, and some continue
long after weaning. Japanese parents (or grand­parents) often sleep in proximity with their children until
they are teen­agers, referring to this arrangement as a river - the mother is one bank, the father another,
and the child sleeping between them is the water. Most of the present world cultures practice forms of
cosleep­ing and there are very few cultures in the world for which it would ever even be thought acceptable
or desirable to have babies sleeping alone.