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There are dissenting voices who criticise some of the standard approaches. These are included here for information

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SIDS is rare and there are ways to reduce the risk. If you want to know more about the research, see below. This is maybe not the column to read if you are feeling fragile as it’s very scientific and unempathic.

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Sudden infant death syndrome (SIDS) is a devastating and unexpected event in which a seemingly healthy infant dies during sleep in the first year of life. There is no warning or prior indication of any underlying disease.

It's one of the most significant causes of infant death after birth in developed countries, profoundly affecting families and their communities. Despite the previous significant decline in SIDS deaths in the Western world, recent investigations have reported a plateau in rates.

What we know

SIDS is complex, and the diagnosis is one of exclusion, meaning a complete post mortem examination and investigation of the circumstances of death aren't able to explain the cause of death.
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Many theories from both animal and human studies have attempted to understand what causes SIDS, with multiple abnormalities reported in a number of functions and systems in the body. This includes the brain, heart, lungs, gastrointestinal system, hormones, and immune system. As well as metabolic, infectious, nutritional, environmental and genetic factors.

One of the most influential hypotheses is the triple risk model which suggests an increased risk when an infant who is already at risk is exposed to certain stressors such as a lack of oxygen, at a particular age.

What we suspect

To date, the precise cause of death in SIDS has not been identified. But there is substantial evidence the syndrome results from a combination of circumstances where breathing and heart rate are compromised, in an infant who also has abnormalities in important brain function controlling these systems. These are in place at a specific period of postnatal development.

Many studies in SIDS victims have supported the concept that SIDS infants are not entirely "normal" prior to death. These infants have some form of underlying vulnerability exposing them to an increased risk for sudden death.
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It's thought SIDS, or at least some SIDS cases, are caused by some form of underlying neural (nerve) or systematic abnormality in the brainstem that impairs critical responses to life-threatening challenges. For example, a lack of oxygen during sleep.

This failure is thought to result from abnormalities in a network of neural pathways in the brainstem that control breathing, autonomic control (the regulation of our internal organs), and arousal. Abnormalities in various brainstem chemicals have been reported.

Carlo navarro/Unsplash, CC BY

Abnormalities in the expression of the brain chemical serotonin (the mood hormone) in the brainstem have been the most significantly and consistently observed in SIDS infants.

This system is a key player in regulating the brain's control of the upper airways (nose and respiratory tract), ventilation and gasping, keeping body temperature stable and ensuring the baby gets enough oxygen.

Abnormalities in this system have been reported in many studies of SIDS infants from varying ethnic, social and cultural backgrounds.

Given the complex role of this system in the brainstem, associated abnormalities are probably responsible for impaired defence mechanisms. This includes head-lifting, crying, gasping for air and arousal from sleep, in response to a lack of oxygen. But it's still not clear whether these abnormalities are the primary cause of SIDS, or a secondary symptom.
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A recent study has revealed promising findings in the quest to find out the cause of these brain chemical abnormalities in SIDS. In this study, some of the SIDS infants were found to have a significant developmental abnormality of another important chemical messenger, "Substance P", in multiple regions in the brainstem. These regions are intimately related to heart and breathing function and autonomic control.

This means abnormal Substance P transmission in the brainstem could result in dysfunction of critical responses to harmful situations, such as a lack of oxygen. So if an infant experiences a life threatening situation during sleep, they might not be able to execute the motor responses to protect themselves.

This abnormality could potentially explain why it's more dangerous for infants to sleep on their front, given it's been known for many years infants sleeping face down are at greater risk of SIDS.

It's thought if an infant has this underlying vulnerability in brain chemistry, and breathing becomes compromised by sleeping face down, the infant is then at greater risk of death because they can't respond in the normal way by lifting their head out of danger.

What we're yet to find out

Unfortunately, there are to date no tests or markers in the body that can help prevent or diagnose SIDS. But researchers from around the world are working towards using what we already know about SIDS and further trying to understand why SIDS occurs in some infants. And if we can find out who is more at risk, we could prevent future deaths with genetic screening for these brain chemical abnormalities.

Identifying a cause might also provide some form of closure for families who are left to make sense of, not only the death of their child, but the heartache that comes with the uncertain diagnosis of SIDS.

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What causes SIDS? What we know, don't know and suspect

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Sudden infant death syndrome (SIDS) is a devastating and unexpected event in which a seemingly healthy infant dies during sleep in the first year of life. There is no warning or prior indication of any underlying disease. It's one of the most significant causes of infant death after birth in developed countries, profoundly affecting families and their communities.

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Researchers currently use the Triple-Risk Model as a contextual construct for understanding SIDS deaths. The Triple-Risk Model describes the convergence of three conditions that may lead to the death of an infant from SIDS.

Vulnerable infant. An underlying defect or brain abnormality makes the baby vulnerable. In the Triple-Risk Model, certain factors-such as defects in the parts of the brain that control respiration or heart rate or genetic mutations-confer vulnerability.

Critical developmental period. During the infant's first 6 months of life, rapid growth and changes in homeostatic controls occur. These changes may be evident (e.g., sleeping and waking patterns), or they may be subtle (e.g., variations in breathing, heart rate, blood pressure, and body temperature). Some of these changes may destabilize the infant's internal systems temporarily or periodically.

Outside stressor(s). Most babies encounter and can survive environmental stressors, such as a stomach sleep position, overheating, secondhand tobacco smoke, or an upper respiratory tract infection. However, an already vulnerable infant may not be able to overcome them. Although these stressors are not believed to single-handedly cause infant death, they may tip the balance against a vulnerable infant's chances of survival.

According to the Triple-Risk Model, all three elements must be present for a sudden infant death to occur:

1. The baby's vulnerability is undetected.

2. The infant is in a critical developmental period that can temporarily destabilize his or her systems.

3. The infant is exposed to one or more outside stressors that he or she cannot overcome because of the first two factors.

If caregivers can remove one or more outside stressors, such as placing an infant to sleep on his or her back instead of on the stomach to sleep, they can reduce the risk of SIDS.

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Researchers currently use the Triple-Risk Model as a contextual construct for understanding SIDS deaths. The Triple-Risk Model describes the convergence of three conditions that may lead to the death of an infant from SIDS. Vulnerable infant. An underlying defect or brain abnormality makes the baby vulnerable.

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On why supine sleep might be protective

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This interesting article has some thoughtful comments on the statistics too.

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A baby's sleep position-whether on the back or the belly, in and of itself, may not be a huge deal-
provided, of course, that each baby spends ample time on the belly while awake. The reasons for this are discussed below. What IS a huge deal, however, is the fear about prone positioning (on the tummy) instilled in the minds of many parents as a result of never-ending cautions issued by countless health professionals in response to the "Back to Sleep" campaign. Unfortunately, too many parents now believe that putting a baby on its belly, while awake or asleep, could be dangerous and might even cause a baby to die of SIDS (Sudden Infant Death Syndrome), in spite of the fact that pediatricians have tried to undo some of the damage caused by in "supervised" Tummy Time to offset the consequences that have been caused by not enough time on the belly.

Any single death from SIDS is one too many. This is especially true in the minds and hearts of any parent who has lived through this unfathomably heartbreaking loss. Even discussing this subject is complicated, especially when we talk about "trade-offs" that can appear callous and indifferent. After all, saving lives is always a good thing, and in raising questions about any aspect of "back-to-sleep" policy, it's important to form an understanding of what lies buried under layers of a campaign that was originally fueled by good intentions, millions of Congressionally appropriated dollars, and professional policies that, by default, always remain above question.

The graph below shows the rate of SIDS between 1989 and 2006 , based on statistics from the Centers for Disease Control.

This chart reveals that SIDS had already been declining during the five years prior to the launching of the "Back to Sleep" campaign. This massive public education effort cautioned all parents to always place their babies to sleep on their backs (supine position). This was essentially a precautionary measure, since it was believed that a baby might not be as able to lift its head and rescue itself during a breathing emergency if lying on the belly (prone). Statistics gathered from other countries also suggested that more deaths may have occurred in babies sleeping prone than supine, although, as you will see, the difference was remarkably small.

At the same time that parents were warned not to place their babies on their stomachs to sleep, they were also told to remove all bedding and stuffed toys from the sleeping environment. Just how large a role this played in the initial drop in SIDS deaths due to removal of objects that could contribute to suffocation, will never be known, even though it can be impossible in many cases to distinguish between suffocation or SIDS as the cause of death. In fact, we still don't know what SIDS is, since it is, by definition, the lack of any diagnosis. Even if removing puffy bedding and stuffed toys played a role in the drop in deaths, any decrease in the number of deaths has been credited to back sleeping, and nothing else.

This next graph shows the number of babies during the same period of 1989 to 2006 who did NOT die of SIDS , based on the identical statistics.

People are often quite surprised to discover that at its peak in 1989, on 0.12% (or twelve-hundredths of one percent) of infant deaths were attributed to SIDS. Said another way-99.88% of all babies that year (and fewer in the years that followed) never died of SIDS. The odds of a baby dying of SIDS is equivalent to tossing ten quarters and having them all come up heads. This means that parents can put their babies to sleep in whatever position the baby seems to prefer (most babies do appear to sleep better on their bellies) while letting out a giant sigh of relief, along with that gnawing "SIDS fear" that's been lurking in the background of their minds.

One last detail: The warnings were so successful that 85% of babies now sleep on their backs, yet the rate of SIDS since 2001 has hardly budged. This means that the majority of SIDS deaths today are among babies sleeping on their backs. This has caused the campaign's name to be changed to "Safe Sleep," with greater emphasis being given by the medical policy makers on other factors such as encouraging breastfeeding and discouraging smoking.

It's rather absurd to imagine a baby at birth placed on its back atop the mother's body. We all understand in those early moments of life that it is through the front of the body that the baby is connected with the mother, who, let us not forget, is one with the earth.

Babies who sleep on their backs tend to also be restricted on their backs much of the while awake, whether on a flat surface or in some sort of carrier or device. Evidence is piling up that many such babies are developing a lengthy list of developmental delays and other issues, compared to their prone-sleeping counterparts. (1,2, 3, 4, 5).

This isn't surprising. On the back, a newborn is physically disconnected from whatever surface upon which she is lying. She startles easily in this position and doesn't sleep as soundly. One reason babies are swaddled, is to provide a sense of physical security and connection when they're on their backs.

On her belly, a baby's body more naturally settles in and connects through gravity to whatever surface she's lying on-a parent's body, a blanket on the floor, a mattress of some sort-each of which represents the Earth's gravitational and energetic field.

This surface provides a stable anchor into which she can surrender her weight and feel grounded- held, in fact-by this all-new world in which she finds herself. As her tiny body engages against this surface, she's likely to be aware of multiple sensations occurring inside her skin, a different experience than taking in external stimuli from outside of herself, as when she's lying on her back.

Identifiable scientific principles are at work that explain WHY belly-to-earth activity is so necessary (the subject of a later post) but for now, here's a bit of backstory for context:

his came about as an attempt to offset the 600% increase (8) in the number of babies who had developed flat areas on their heads known as that by 4-months of age, one should aim for a baby spending at least 20 minutes a day lying on the tummy. (9) -About ten years after the Back-to-Sleep campaign was launched, AAP launched an additional policy recommendation they called "Tummy Time." T plagiocephaly or This leaves 23 hours and 40 minutes of each day spent lying supine or reclining in some sort of sitting device. Unfortunately for many babies, especially those who are not "worn" frequently in cloth carriers upon a parent's body, this is just too little and too late. brachycephaly- or simply "flat heat syndrome." Current recommendations today at websites such as the Mayo Clinic recommend

- More recently, doctors and pediatric therapists have begun to double down on their efforts to get babies to do even more "tummy time." This comes in response to mounting evidence that supine (on the back) sleepers exhibit more motor and other developmental delays than prone (on the belly) sleepers (1-5). In fact, typical ages for accomplishing certain milestones of gross motor skills such as rolling over, sitting up, crawling, and walking have been adjusted to match this "new normal."

I have observed this repeatedly. Babies who have ample opportunities to move "against" the earth or some proxy surface of the earth , display many signs of greater physical activity and strength, from a very early age. Most especially, they are activating the deepest core muscles that will be called on to support the upright spine. Thus, the seeds are planted for natural, healthy development in all the ways that build a strong and flexible body, develop a fully functioning nervous system, and establish natural mechanical components that will support naturally aligned posture and good health in the months and years to come.

There's lot's more information about this in both of my books, Natural Posture for Pain-Free Living and Healthy Posture for Babies and Children .

Instinctive, belly-to-earth neurodevelopmental movements

should be the focus of close attention and study.

Until then, here's one final, very important thought to keep in mind:

is when a baby's sweet belly is in contact

with the mother's or father's body-

is a posture and movement coach. She is the author of Kathleen Porter Natural Posture for Pain-Free Living: The Practice of Mindful Alignment (Inner Traditions, 2006 & 2013) and Healthy Posture for Babies and Children (July 2017). She has traveled the world researching and observing populations who live in naturally aligned bodies and who move, work and age with ease. She is the creator of UpRightNOW , an online program she is developing for adults and children alike, and her company Natural Posture Solutions manufactures several small posture aids .
CLICK on IMAGES BELOW to READ MORE about BOOKS & PRODUCTS
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(1) American Academy of Pediatrics Task Force on Infant Positioning and SIDS: Positioning and SIDS. Pediatrics 89:1120- 1126, 1992 (Erratum in Pediatrics 90:264, 1992).

(2) Beth Ellen Davis, Rachel Y. Moon, Hari C. Sachs, Mary C. Ottolini: Effects of Sleep Position on Infant Motor Development. Pediatrics. 102:1135- 1140, 1998.

(3) Salls, J. S., Silverman, L. N., & Gatty, C. M. (2002). Brief Report-The relationship of infant sleep and play positioning to motor milestone achievement. American Journal of Occupational Therapy, 56, 577-580.

(4) Majnemer A, Barr RG: Association between sleep position and early motor development. J Pediatr 149:623-629, 2006.

(5) Jantz JW, Blosser CD, Fruechting LA. A motor milestone change noted with a change in sleep position.

(6) Rosemary SC Horne, PhD; Pratiti Bandopadhayay, MBBS; Jessica Vitkovic, BSc Hons; Susan M Cranage, RPSGT; T. Michael Adamson, FRACP. Effects of Age and Sleeping Position on Arousal from Sleep in Preterm Infants. Journal of Sleep. Vol. 25, No. 7, 2002

(7) http://www.cdc.gov/sids/data.htm

(8) Argenta LC, David LR, Wilson JA, Bell WO: An increase in infant cranial deformity with supine sleeping position. J Craniofac Surg 7:5-11, 1996.

(9) Jay L. Hoecker, M.D. Mayo Clinic: What's the Importance of Tummy Time for a Baby? http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/expert-answers/tummy-time/faq-20057755

(10) Bradley B. Randall, David S. Paterson, Elisabeth A. Haas, Kevin G. Broadbelt, Jhodie R. Duncan, Othon J. Mena, Henry F. Krous, Felicia L. Trachtenberg, and Hannah C. Kinney. Potential Asphyxia and Brainstem Abnormalities in Sudden and Unexpected Death in Infants. Pediatrics, November 2013

(11) http://www.ncbi.nlm.nih.gov/pubmed/16075152

(12) James J. McKenna* and Thomas McDade. Paediatric Respiratory Reviews. (2005) 6, 134-152

(13) Ralph Pelligra, Glenn Doman, and Gerry Leisman. A Reassessment of the SIDS Back to Sleep Campaign. TheScientificWorldJOURNAL(2005) 5, 550-557 ISSN 1537-744X; DOI 10.1100/tsw.2005.71

(14) http://www.heracliteanriver.com/?p=97

(15) Togari, H., Kato, I., Saito, N., and Yamaguchi, N. (2000) The healthy human infant tends to sleep in the prone rather than the supine position. Early Hum. Dev. 59(3), 151-158.

(16) Heather Catchpole. ABC http://www.abc.net.au/science/articles/2003/12/10/1006190.htm

(17) Nils J. Bergman. Proposal for mechanisms of protection of supine sleep against sudden infant death syndrome: an integrated mechanism review. International Pediatric Review Foundation. 2014.

(18) Nils J. Bergman.Hypothesis on supine sleep, sudden infant death syndrome reduction and association with increasing autism incidence. World Journal of Clinical Pediatrics. 5 (3) 330-342. August, 2016.

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Why Back-to-Sleep Recommendations Should Go Belly Up* | Natural Posture Solutions

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A baby's sleep position-whether on the back or the belly, in and of itself, may not be a huge deal- provided, of course, that each baby spends ample time on the belly while awake. The reasons for this are discussed below.

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Infographic on co-sleeping and cot deaths

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Infographic on co-sleeping and cot deaths

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This guide for health professionals gives the risks in a clear way.

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Unbiased, independent information based on research about biologically normal sleep for human babies. Several information sheets on safe sleep.

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The latest bed-sharing research is outlined here. For guidance on discussing co-sleeping with parents, read our Co-Sleeping and SIDS: A Guide for Health Professionals leaflet.
The Atlantic Divide: Contrasting U.K. and U.S. Recommendations on Cosleeping and Bed-Sharing
This Insights in Practice explores the current state of guidance regarding sudden infant death syndrome (SIDS) and cosleeping or bed-sharing in the United Kingdom and United States. The goal is to help lactation professionals and allied staff become aware of the larger contextual picture on this topic and to encourage reflection on how we educate new parents around infant sleep location. It explores how over the past 2 to 3 years, the nature and content of discussions on this topic have begun to shift, and agreements are emerging.
Ball, H, (2017). The Atlantic Divide: Contrasting U.K. and U.S. Recommendations on Cosleeping and Bed-Sharing, Journal of Human Lactation, doi.org/10.1177/0890334417713943 Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis
This review of 2,267 SIDS cases and 6,837 control infants explored the duration of breastfeeding required to confer a protective effect against Sudden Infant Death Syndrome (SIDS). It found that any breastfeeding for at least two months was associated with half the risk of SIDS. Greater protection was seen with increased duration, both with exclusive and any breastfeeding.
Thompson, JMD, et al (2017), Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis. Pediatrics, doi: 10.1542/peds.2017-1324 Who bed-shares and what is the relationship with breastfeeding duration?
This study explored the link between breastfeeding duration and bed-sharing frequency among women reporting a prenatal intention to breastfeed.

It was found that women with strong motivation to breastfeed frequently bed-share. The authors note that, given the complex relationship between bed-sharing and sudden infant death syndrome (SIDS), appropriate guidance balancing risk minimisation with support for breastfeeding mothers is crucial.
Ball, H. L. et al (2016). Bed-sharing by breastfeeding mothers: who bed-shares and what is the relationship with breastfeeding duration? Acta Paediatrica, DOI: 10.1111/apa.13354. SIDS and infant sleep ecology
In this article, the authors looked at Sudden Infant Death Syndrome (SIDS) from an evolutionary perspective. Comparative evolutionary studies indicate that human infants are poorly neurologically developed at birth, and thus require close physical contact for safety, physiological regulation and frequent feeding. The authors argue that species-specific sleep ecology involves close contact with a carer and frequent sleep arousals for the first 6 months of life.

The authors conclude that a more holistic view of infant sleep ecology is warranted, in order for clinicians to encourage parental proximity and responsive care, and educate parents about infant developmental needs.
Ball & Russell (2014), SIDS and infant sleep ecology. Evolution, Medicine and Public Health 146. doi: 10.1093/emph/eou023 Bed-sharing in the absence of hazardous circumstances
This study examined 400 cases of SIDS against 1386 comparable controls. Researchers found that the incidence of co-sleeping among the SIDS infants was significantly higher than for the controls. However when results were broken down to specific co-sleeping environments, it was found that co-sleeping on a sofa, or next to a parent who had drunk more than two units of alcohol carried a very high risk. Co-sleeping next to a smoker was significant for infants under three months, whilst the risk associated with bed-sharing in the absence of these factors was not significant overall, and was in the direction of protection for older infants (over three months).

The authors argue that public health strategy should therefore focus on making parents aware of specific hazardous co-sleeping environments to avoid: sofa-sharing, alcohol, drugs, smoking, or co-sleeping if the infant is pre-term.
Blair, P. S. et al (2014) 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. DOI: 10.1371/journal.pone.0107799 Unicef UK Baby Friendly Initiative statement on bed-sharing research
Read our statement in response to a 2013 study on bed-sharing and SIDS (pdf download): Carpenter R, McGarvey C, Mitchell EA 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. doi:10.1136/bmjopen-2012-002299
Infant care practices related to SIDS in South Asian and White British families
This is by far the largest comparative study of ethnic differences in infant care in the UK to date, and the size of the sample is a major strength. The researchers report that South Asian infant care practices were more likely to protect infants from the most important SIDS risks such as smoking, alcohol consumption, sofa-sharing and solitary sleep. These differences may explain the lower rate of SIDS in this population and this study identifies these issues as clear targets for SIDS risk reduction among White British families.
Ball HL, Moya E, Fairley L et al (2011) Infant care practices related to sudden infant death syndrome in South Asian and White British families in the UK. Paediatric and Perinatal Epidemiology. DOI: 10.1111/j.1365-3016.2011.01217.x Does sidecar crib use affect breastfeeding duration?
A randomised trial of 1,204 pregnant women intending to breastfeed was carried out at the Royal Victoria Infirmary in Newcastle to determine whether the use of sidecar cribs on the postnatal wards affected breastfeeding duration. The authors conclude that the use of sidecar cribs does not affect breastfeeding duration or rates of exclusive breastfeeding or the frequency of bed-sharing once home.
Helen L Ball, Martin P Ward-Platt, Denise Howel, Charlotte Russell (2011). Randomised trial of sidecar crib use on breastfeeding duration (NECOT). Arch Dis Child, doi:10.1136/adc.2010.205344.
Relationship between bed-sharing and breastfeeding: This study investigated nocturnal bed-sharing of 14,062 live births at 5 time points from birth to 4 years of age.

The researchers identified 4 mutually exclusive groups, broadly described as nonsharers (66%), early bed sharers (only in infancy) (13%), late bed sharers (after the first year) (15%), and constant bed sharers (throughout the 4 years) (6%). The boy/girl ratio and the proportion of families of nonwhite ethnicity were slightly higher in all 3 bed-sharing groups, compared with the non-bed-sharing group. Higher maternal educational achievement and higher social class were positively associated with early bed sharing, negatively associated with late bed sharing, and not associated with constant bed sharing. The 3 bed-sharing patterns were related significantly to breastfeeding at 12 months. The prevalence of breastfeeding was significantly higher among the groups that shared beds constantly or early for each of the first 15 months after birth.

The authors state it is difficult to be precise about the dominant direction of the relationship between bed-sharing and breastfeeding, whether mothers share beds because they are breastfeeding or whether bed-sharing makes breastfeeding more likely to be successful. They conclude that risk reduction messages to prevent sudden infant deaths should be targeted more appropriately to unsafe infant care practices such as sleeping on sofas, bed-sharing after the use of alcohol or drugs, or bed-sharing by parents who smoke, and that advice on whether bed-sharing should be discouraged needs to take into account the important relationship with breastfeeding.
Relationship Between Bed Sharing and Breastfeeding: Longitudinal, Population-Based Analysis. Peter S. Blair, Jon Heron, and Peter J. Fleming; Pediatrics. published online 18 October 2010, 10.1542/peds.2010-1277. Breastfeeding to help babies sleep
Researchers found that concentrations of the three nucleotides most strongly associated with sleep and sedation (5'UMP, 5'AMP and 5"GMP) varied according to time of day. Concentrations of 5'AMP were highest at the beginning of the night, while levels of 5'GMP and 5'UMP increased as the night wore on. These sedatives were found at much lower concentrations in milk expressed during the day.

Nutritional Neuroscience, DOI: 10.1179/147683008X344174; Neuroendocrinology Letters, vol 28, p 360
Link between alcohol or drug use and increased risk of SIDS
This study investigated the factors associated with sudden infant death syndrome (SIDS) in 80 infants and two control groups. They found that many of the deaths in a co-sleeping environment could be explained by a significant interaction between co-sleeping and recent parental use of alcohol or drugs (31 per cent vs 3 per cent random controls) and the increased proportion of SIDS infants who had co-slept on a sofa (17 per cent vs 1 per cent).With regard to the infant's sleeping environment, the authors conclude that the major influences on risk were from factors which would be amenable to change. Parents need to be advised never to put themselves in a situation where they might fall asleep with a young infant on a sofa and that they should never co-sleep with an infant in any environment if they have consumed alcohol or taken drugs.
Blair PS, Sidebo P, Evason-Coombe C et al (2009) Hazardous co-sleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. BMJ; 339:b3666 Does breastfeeding reduce the risk of SIDS?
The German Study of Sudden Infant Death is a case-control study of 333 infants who died of SIDS. The authors say this study shows that breastfeeding reduced the risk of sudden infant death syndrome by around 50% at all ages throughout infancy and for as long as the infant is breastfed. They highlight that the implication of their findings is that breastfeeding should be continued until the infant is six months of age as the risks of SIDS are low by that stage. They therefore recommend including the advice to breastfeed through six months of age in sudden infant death syndrome risk-reduction messages.
M M Vennemann, T Bajanowski, B Brinkmann, G Jorch, K Yücesan, C Sauerland, E A Mitchell and the GeSID Study Group (2009) Does Breastfeeding Reduce the Risk of Sudden Infant Death Syndrome? PEDIATRICS Vol. 123 No. 3 March 2009, pp. e406-e410 Benefits and harms associated with bed-sharing
A systematic review of the literature concludes that the evidence consistently suggests an association between bed sharing and SIDS among smokers, with the evidence not consistent for non-smokers. The evidence also suggests that bed sharing may be more strongly associated with SIDS for younger infants. The review identified a positive association between bed sharing and an increase in the rate and duration of breastfeeding. It is interesting to note that the study defined bed sharing as the practice of sharing a sleep surface and did not therefore identify those cases when the baby was asleep with a parent on a sofa.
Horsley T et al. (2007) Benefits and harms associated with the practice of bed sharing. Arch Pediatr Adolecs Med; 161 (3): 237-245 Mother and infant co-sleeping:
A review of the evidence relating to the sleep practices of parents and infants over the last 20 years provides interesting reading and challenges normal wisdom related to infant sleep. The authors examine the historical and evolutionary background to assess mother and infant shared sleep, especially with regard to the impact on breastfeeding and the reduction of SIDS.
McKenna JJ et al. (2007) Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: what biological anthropology has discovered about normal infant sleep and paediatric sleep medicine. American Journal of Physical Anthropology; 50: 1 Breastfeeding and bed-sharing in England
This study of 1,356 infants found that almost half of all neonates bed-shared at some time with their parents and that on any one night in the first month over a quarter of parents slept with their baby. Breastfeeding was strongly associated with bed-sharing, both at birth and at 3 months.
Blair PS and Ball HL (2004). The prevalence and characteristics associated with parent-infant bed-sharing in England. Arch Dis Child 89:1106-1110 Attitudes and experiences of bed-sharing in Northeast England
This year-long study found that parents pursued a heterogeneous array of night-time parenting strategies and that 65 per cent of the sample had actually bed-shared. Parents with no previous intention to do so slept with their babies for a variety of reasons. Ninety-five per cent of the bed-sharing infants slept with both mother and father. Breastfeeding was significantly associated with co-sleeping.
Hooker E, Ball HL, Kelly PJ (2001). Sleeping like a baby: attitudes and experiences of bedsharing in northeast England.Med Anthropol 19: 203-222.
Similar findings were observed in this study: Ball HL, Hooker E, Kelly PJ (1999). Where will the baby sleep? Attitudes and practices of new and experienced parents regarding co-sleeping with their newborn infants. American Anthropologist 101: 143-51.

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Research on Bed Sharing, Infant Sleep and SIDS - Baby Friendly Initiative

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The Atlantic Divide: Contrasting U.K. and U.S. Recommendations on Cosleeping and Bed-Sharing This Insights in Practice explores the current state of guidance regarding sudden infant death syndrome (SIDS) and cosleeping or bed-sharing in the United Kingdom and United States.

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Research on where babies sleep around the world

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Research on where babies sleep around the world

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(Mostly with their mums)

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Parents everywhere tend to think that the way they raise their children is the best way, and Americans are no exception. Contemporary American parents seek to optimize their children's lives, treat them as equals, and reduce their risk of harm to zero; anything less may seem negligent. Yet many of the practices Americans hold as sacred are quite rare in other countries - and the burdens Americans place on themselves are often unwarranted.

One of the major challenges in the first year of parenting, any new mom or dad can tell you, is training a child to sleep. American middle-class parents routinely put their infants to sleep in a separate bed or a separate room, on the assumption that there might be serious risks to having the baby next to them. This is largely due to expert advice: The American Academy of Pediatrics advises against parent-child co-sleeping, or "bed-sharing," citing safety concerns from accidental suffocation or falls. Doctors worry that tired - or intoxicated - parents will roll onto their infants in the middle of the night without realizing it. Putting babies in cribs or cots in a separate room is also customary in Britain, Germany and other parts of Western Europe.

In most of the rest of the world...parents think it's downright cruel to put a baby in a separate room or even a separate bed. Who would be so heartless?

In most of the rest of the world, however, parent-child co-sleeping is well-established, as we have found in our studies in Africa (Nigeria, Kenya and Zambia), Asia (Nepal, India) and Latin America (Mexico, Colombia) and as other anthropologists have reported from other sites in those areas. Indeed, many parents think it's downright cruel to have a baby sleep alone. Who would do such a heartless thing?

Of course non-Western countries tend to have higher infant mortality rates, but there's no reason to think that has anything to do with co-sleeping. In Japan - a large, rich, modern country - parents universally sleep with their infants, yet their infant mortality rate is one of the lowest in the world - 2.8 deaths per 1,000 live births versus 6.2 in the United States - and their rate of sudden infant death syndrome, or SIDS, is roughly half the U.S. rate.

There's reason to believe that co-sleeping isn't just safe, but also beneficial. The biological anthropologist James McKenna, who has investigated mother-child co-sleeping at his Mother-Baby Sleep Laboratory at the University of Notre Dame, has provided detailed evidence of the physiological synchronization between mother and infant when they sleep together, especially when the mother also breastfeeds responsively. He considers this arrangement optimal and calls it "breastsleeping."

When we asked mothers of the Gusii tribe in Kenya, where co-sleeping is common, whether their babies slept through the night, they didn't know what we were talking about - why should babies wake up? When we compare Gusii and American mothers, it is the Americans who seem to make infant care more complicated and difficult by putting their infant to sleep in a separate room, setting the stage for sleep disruption due to infant crying.

American parents may also worry that sharing a bed increases a child's dependence on his parents, yet Japanese children appear to be just as mature and independent as American children.

Christine Gross-Loh writes in her 2013 book, "Parenting Without Borders": "After years of living [in Japan] on and off, my husband and I (and even our kids) have noticed that most children - the same children who sleep with their parents every night - take care of themselves and their belongings, work out peer conflicts, and show mature social behavior and self-regulation at a young age. Japanese parents expect their kids to be independent by taking care of themselves and being socially responsible. They expect them to help contribute to the household or school community by being capable and self-reliant."

All things considered, we have to agree with McKenna's conclusion: the proven benefits of mother-infant co-sleeping far outweigh the largely imaginary risks. Putting a baby in a separate room at night encumbers parents and leads to their exhaustion without guaranteeing the safety or future character development of their children.

American parents also add to their burdens in other ways that are rare elsewhere in the world: for example, by offering their toddlers choices (about what to eat, what to wear, even where to cross the street), by making chores and responsibilities optional, and by fostering the child's early speech development without rules to restrain interrupting adult conversation.

The anthropologist Margaret Mead once proposed that human diversity in child rearing was like a grand experiment enabling American parents to "read the answers" to their questions - without having to try them out at home. We no longer believe that reading the answers is as simple as Mead implied in 1930, but if Americans looked to parents in other cultures, they would perhaps realize that the "best" way to raise a child is not necessarily the most difficult, and ease up a bit.
Robert LeVine is professor of education and human development, emeritus, at Harvard University. Sarah LeVine is a former research fellow in human development at Harvard University. They are the authors of "Do Parents Matter? Why Japanese Babies Sleep Soundly, Mexican Siblings Don't Fight, and American Families Should Just Relax." Follow the Opinion section on Twitter @latimesopinion or Facebook. MORE OPINION Why does Edward Snowden get more high-profile support than Chelsea Manning? Could a Clinton presidency unleash a post-gender society? Not a chance Here's a way to celebrate the Rams' L.A. return - by finally honoring the men who desegregated football 70 years ago

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It's OK to sleep next to your infant child. It's even beneficial.

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Parents everywhere tend to think that the way they raise their children is the best way, and Americans are no exception. Contemporary American parents seek to optimize their children's lives, treat them as equals, and reduce their risk of harm to zero; anything less may seem negligent.

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When a mum quits smoking, she's making one of the biggest changes she can to improve her health, and the health of her baby. Any accurate information that those involved in breastfeeding support can give her, will support her to maintain that change. The hardest time to make or maintain behaviour changes are when one is HALT: hungry, angry, lonely or tired - and new mothers often experience some or all of these.[1]

Quitting smoking

There is a persistent myth that abruptly quitting smoking may cause harm. In fact, while it may make symptoms such as coughing worse in the short term, this is a sign that the body's natural responses are recovering and becoming unsuppressed by the effects of smoking. Additionally, abrupt quit is statistically the most successful way to quit smoking.
Many people believe that cutting down will provide protection for themselves and their families, but in fact most people will smoke in a compensatory way - taking more, deeper and longer held drags, thereby maintaining the levels of nicotine and other chemicals inhaled.[2] Therefore, when wanting to quit one should use whatever method of quitting you believe will have the best chance of success in your particular case!

Will a baby be harmed by their mother quitting smoking abruptly?

No. There is evidence that nicotine exposure prenatally and through breastmilk may cause babies to undergo some symptoms of withdrawal when their mothers stop smoking. However, this must be weighed against the health risks to the baby if the mother continues to smoke. If a mother who is quitting smoking chooses to use nicotine replacement therapy while breastfeeding, her baby will receive a tapering dose of nicotine (as product strength and/or frequency of use is reduced), which could help to minimise withdrawal.[3]

The components of cigarette smoke

There are three main problematic components in cigarette smoke: tar (the link between smoking and cancer), carbon monoxide (the link with heart disease, stroke and the main cause of damage in unborn babies) and nicotine.

Tar passes from the lungs to the bloodstream and is deposited all around the body. I have searched for information about whether tar passes into breastmilk and haven't been able to find anything relevant. While it may be present in milk, it will certainly be present in second hand smoke. All information confirms that if a mother cannot quit smoking, then breastfeeding is protective against the chemical exposure the baby will be experiencing.

Nicotine in concentrated form is a poison - but when you have been regularly been exposed to it your body develops tolerance - the main problem with it in the form that it is in cigarettes is that it is extremely addictive.

If one chooses to use nicotine replacement therapy (NRT), one is using nicotine in a clean form, a less addictive delivery method (the more quickly it gets to your brain, the more addictive it is, and when smoked it takes less than seven seconds), and lower amounts than if smoking is continued - and with a tapering dosage.

(In the UK) all NRT is licensed for use in breastfeeding, with the recommendation that using the intermittent products (gum etc.), instead of the patches, allows mothers to minimise nicotine exposure by timing dosage. Nicotine has a half life of around 90 minutes, so smoking or using NRT just after a feed will allow mothers to minimise the nicotine transmitted to the baby.[4] However - the exposure to a small amount of nicotine is hugely less harmful than exposure to continued smoking, so the mother should do whatever best increases her chances of success.

When choosing to use NRT, caregivers need to be aware that what is a therapeutic amount of nicotine for them would be a significant overdose for someone who is not used to it - in fact, the residue left in discarded NRT would be enough to cause harm to a baby or child. Occasionally, patches become unstuck from their original owner in bed and stuck on to other people sharing the space - apparently a part used patch or a piece of gum can make an adult feel like they are having a heart attack, so the effect on a baby would be severe. Just as smoking materials are kept out of reach, pre- and post- use NRT needs to be kept securely away from babies and children.

Electronic cigarettes (or vaping)

Public Health England has recently released an evidence summary relating to e-cigarettes. Its conclusion is that current evidence indicates that using an e-cigarette is around 95% safer than a conventional cigarette.[5] Using an e-cigarette will not expose a baby to tar or carbon monoxide. Ambient levels of nicotine are much reduced compared with that in the air or household surfaces of a household where cigarette smoking takes place. This is because 85% of smoke released by cigarettes is sidestream smoke - the smoke that is released by a burning cigarette when it is not being smoked.

E-cigarettes are regulated by general consumer products law which is enforced by trading standards - this means it is easier for companies to bring products to market with much less testing and control than if products were regulated as medicines - it's responsive rather than proactive. If you are going to use an e-cigarette, choose one that has a kitemark or CE mark as that gives you a guarantee that what it says on the label is what is in it, and the electrical components are safe.[6]

The vapour itself is usually made from propylene glycol and glycerine - and as far as we know that doesn't cause anything more serious than occasional throat irritation. There is a need for research on long term lung exposure safety.

E-cigarettes come in a range of flavours including menthol - peppermint oil is sometimes associated with reduced milk supply. If you are concerned you might check your preferred brand to see if it actually contains peppermint oil or a synthetic. Menthol cigarettes are linked to higher rates of lung cancer, but that is because the mint numbs the throat, enabling smoke to be drawn in deeper/ held longer. That wouldn't be an issue with e-cigarettes.

ASH (Action on Smoking and Health) have a good online factsheet giving an introduction to e-cigarettes: http://ash.org.uk/search/?q=e%20cigarette&x=0&y=0

NICE (National Institute for Health and Care Excellence) now takes a harm reduction approach to e-cigarettes - they cannot recommend an unlicensed product, but are clear that they are less harmful than smoking. We know that many women quit smoking when pregnant and lapse after their baby has been born.[7] If a mum who has quit smoking conventional cigarettes and is now using an e-cigarette, her baby isn't being exposed to the chemicals in smoke - she has to weigh up how she feels about maintaining her successful quit versus risk of lapse if she stops using it.

Co-sleeping and smoking or vaping

Maternal (and to a lesser extent paternal or other parent present in the bed) smoking has long been clearly linked to increased risk of SIDS. Exposure to nicotine damages babies' ability to develop normal robust neurological processes to protect their breathing and respond if it is compromised. It also decreases lung function and increases sleep related respiratory problems. According to evidence examined by the WHO, it is unclear how much of this risk is down to tobacco smoking during pregnancy damaging the foetus's development, and how much is down to exposure to second hand smoke after birth.[8]

This has implications for where babies sleep when their mothers smoked during pregnancy, even if the mother quit smoking at (or before) birth and is not now smoking. Additionally, sleep changes related to smoking such as apnoeas may take time to resolve after quitting smoking, and these may make the mother less responsive to her baby.

Cannabis and breastfeeding

Most times, cannabis is smoked together with tobacco - this means that all the health impact of tobacco is present, only with the additional effect that when joints are smoked, each inhalation is usually taken deeper and held for longer. This increases the lung exposure to harm. Because of the higher levels of oil in cannabis, it is usually estimated that each joint smoked is the equivalent of 5-7 cigarettes.[9]

The effects of cannabis in breastmilk on babies' development are controversial. Some studies indicate that there is no impact on babies' long term development, others find that motor development at the age of one is slightly reduced in babies who were regularly exposed.[10] Additionally, most babies who are exposed to THC (see below) via breastmilk will also have been exposed foetally, making it difficult to determine what changes have occurred when.[11]

The active intoxicant in cannabis is delta-9-tetrahydrocannabinol (THC) - this is fat soluble, is stored in the body's fat reserves and transfers into breastmilk. The immediate effects on babies can be sedation, weakness and poor feeding pattern.[12] Because THC is stored and released slowly, among heavy, regular cannabis users the levels of THC in breastmilk can be eight times the levels in blood serum.

A mother who is intoxicated by cannabis use will sleep more deeply - plus her baby will also face the raised SIDS risk factors relating to tobacco use. Therefore co-sleeping would be clearly contraindicated.

Cannabis suppresses prolactin production, which may affect milk production. There is some evidence of this in animal studies, however human studies have found no difference in weaning age between cannabis using and non-cannabis using mothers.[13] [14]

If breastfeeding is well established, then prolactin suppression may not affect breastmilk production.

Researchers are divided on whether the risks to the baby of cannabis exposure - including currently unidentified long-term developmental risks - are outweighed by the protective effects of breastmilk. Effects are dose-related, meaning that the risks to an infant of occasional exposure are very different to those who are regularly and chronically exposed.[15]

Shisha

Shisha or waterpipe smoking involves flavoured tobacco being placed on a disk of charcoal which is then lit. The smoke is drawn through water and into the mouth. Sometimes tobacco free preparations are smoked via a waterpipe. The burning of charcoal produces a dense smoke containing a lot of carbon monoxide. Additionally, sessions are often long. These effects combined mean that in one shisha session you can absorb the equivalent amount of smoke as in 100 cigarettes.[16] Anyone wanting to decide whether their shisha smoking was affecting their baby via breastmilk would need to consider whether the exposure was one-off or long term. With occasional use, mothers would need to think about whether their co-sleeping risk was temporarily increased while they were affected by carbon monoxide.

Written by Rebecca Coyle, edited by Ruth Lewis
Originally published in LLLGB's Leader publication FEEDBACK
Copyright LLLGB 2016

Further reading
Smoking and breastfeeding https://www.laleche.org.uk/smoking-breastfeeding/
Marijuana and breastfeeding http://breastfeeding.support/smoking-weed-while-breastfeeding/

[1] http://www.chinnstreetcounseling.com/zomerland/zomerland_11.shtml
[2] http://www.ncsct.co.uk/usr/pub/Briefing%202.pdf
[3] http://www.medicines.org.uk/emc/medicine/15340/SPC/NiQuitin+21+mg+transdermal+patches
[4] https://www.health-e-learning.com/resources/articles/40-social-drugs-and-breastfeeding
[5] https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update
[6] http://www.bsigroup.com/en-GB/about-bsi/media-centre/press-releases/2015/july/E-cigarettes-guidance-published/
[7] http://www.who.int/tobacco/publications/gender/en_tfi_gender_women_pregnancy_postpartum_smoking_cessation.pdf
[8] http://www.who.int/tobacco/media/en/mitchell.pdf
[9] http://www.nhs.uk/news/2012/06june/Pages/cannabis-lung-health-risks-underestimated.aspx
[10] http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~HqAUxb:1
[11] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809366/?tool=pubmed
[12] http://www.health-e-learning.com/resources/articles/40-social-drugs-and-breastfeeding
[13] http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~HqAUxb:1
[14] http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~HqAUxb:1
[15] http://www.health-e-learning.com/resources/articles/40-social-drugs-and-breastfeeding
[16] https://www.bhf.org.uk/heart-health/risk-factors/smoking/shisha

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Smoking, Vaping, Cannabis and Breastfeeding - La Leche League GB

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When a mum quits smoking, she's making one of the biggest changes she can to improve her health, and the health of her baby. Any accurate information that those involved in breastfeeding support can give her, will support her to maintain that change. The hardest time to make or maintain behaviour changes are when one ...

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As parent, you won't need telling that you could do with some more sleep. You may be so tired that you can barely remember your own name, let alone where you've put your car keys.

Though a good night's sleep is the obvious remedy, this can sometimes seem impossible when you've got a baby to look after. Here's how to get through the days that follow those sleepless nights.

What are the effects of sleep deprivation?

If you have four or five nights of broken sleep, you'll feel sleep deprived. If you have a newborn, it can be perfectly normal to have weeks or even months when you don't get more than four hours of unbroken sleep.

If you're sleep deprived you'll have slower response times and find concentrating difficult. You may find yourself giving up on tasks before they're complete. Or you may struggle on even though whatever you're doing won't turn out well.

Apart from extreme tiredness, signs of sleep deprivation include:

feeling grumpy, stressed or more emotional

clumsiness or disorientation

having problems communicating

finding it hard to concentrate

being less or more hungry than usual (Beattie et al 2014).

Getting through the day when you feel as if you're moving through treacle, and everything looks foggy, isn't easy. We have some tips that may help you to cope.
How can I get going in the morning?

Don't hit the snooze button. Sit up as soon as your alarm goes off and gather your thoughts before you get up. Turn on the radio and don't let yourself slide back under the duvet if it means you'll be late for work or for an appointment.

Keep a glass of water next to the bed and have a few sips to help you to wake up. If your partner is there to look after your baby, jump straight into the shower and choose an invigorating shower gel. Then slather on some body lotion, as the stroking action will get your circulation going.

It's tempting to rely on caffeine for an immediate boost. But while the first coffee may kick-start your day, too much caffeine throughout the day can keep you awake at night (Drake et al 2013).

If you're breastfeeding and avoiding caffeine, or just want to cut down, a glass of sparkling water or a caffeine-free herbal tea may perk you up.

How can I stay alert and focused?
At home
Even if vigorous exercise is the last thing you feel like doing, it will get your blood flowing and energise your body.

Try a few star jumps, or run around the garden or up the stairs a few times. Or turn up your favourite music, dance, and shake out that tiredness. Your baby or toddler will enjoy all that entertainment too!

Prioritise tasks so you get the most important ones done first. Write a list of things that need doing every day, but be realistic. Even if it's just one thing, such as vacuuming, it will give you something to focus on and help you to prioritise. But if you don't achieve that one thing, don't be too hard on yourself. Sometimes just functioning is enough of an achievement!

Make life easier for yourself. Shop online for food. Ask for help from friends or family, and accept help when they offer. Take turns with your partner to have a lie-in, and try to stick to a regular bedtime, even if your sleep does usually end up being interrupted.

Go easy on yourself. If you get the chance during the day while your baby or toddler naps, try putting your feet up for 10 minutes and take some deep breaths to recharge your batteries. Better still, you might even drop off too!

At work

If you've just gone back to work after maternity leave, you could try to have a lunchtime nap somewhere quiet. Set your phone alarm, though, so you don't nap for too long. A short sleep can recharge your batteries, but do keep it short.

If you work in an office and you're feeling drowsy at your desk, open a window. Or take a five-minute break and run up and down the stairs a few times to wake yourself up before going into a meeting. Organise your diary and set up automated reminders. Plan your day so the toughest tasks or meetings are tackled in the morning. Try to prioritise work before you go home so you can get straight on with your to-do list in the morning, when you'll be at your most productive.

If you work part-time, ask to change your hours or your shift pattern so that you're at work when your energy levels are at their highest. Try not to work with heavy machinery or potentially dangerous equipment if you're not at your most alert, as you could be endangering yourself or others if you make a mistake.

Whether you're at home or at work, aim to eat a healthy diet. Snack on energy-giving foods such as a handful of nuts, a banana, or wholemeal toast and baked beans. Many parents find that what they eat affects how they feel at the end of a sleep-deprived day. High-sugar, high-fat options may provide comfort, but they can leave you feeling more lethargic.

What happens if I feel drowsy while driving?

If you feel drowsy while you're driving, open the window immediately and get a blast of fresh air. If you're on your own, pull over at a safe place, lock the doors and have a short nap of about 15 minutes. If you have your baby or toddler with you and she won't nap alongside you, take her out of the car and have a short walk together in the fresh air. Driving while you're sleepy reduces your reaction time, makes you less vigilant, and affects your ability to make decisions (ROSPA 2011).

You could step out of the car and stretch, or have a cold drink or a coffee to give you a boost. But remember that these are temporary measures. If you feel very tired before you set off, consider leaving the journey until you've had some rest and are more alert.

How can I be less grumpy with everyone?

Don't be too proud to apologise for your sharp tongue. Your partner will understand if you explain how tired you feel. Try to steer clear of emotionally draining situations when you're already feeling below par.

If you and your partner have a disagreement, take a couple of deep breaths and think before you speak. Remind yourself not to let petty irritations turn into huge rows. As annoying as that damp towel on the bedroom floor is, it's probably not worth having a row about it.

Why can't I do even simple things?

When even basic tasks are a struggle to complete, try hard to concentrate and take extra care. Maybe you've knocked over the milk and splashed yourself with boiling water while making a cup of tea. Or perhaps you've dropped yet another glass while trying to get some water.

Try to slow down. Even the smallest task needs your concentration when you're sleep deprived. Focus on what you're doing.

Accept that some things won't get done. Clothes in the laundry basket don't all have to be ironed. You don't have to vacuum as often as you used to.

How can I get back to sleep after feeding my baby?

Try having a warm glass of milk to soothe yourself back to sleep. Dairy products contain an amino acid called tryptophan, which can help your brain to produce sleep-inducing chemicals. A few drops of lavender oil on your pillow can also help to relax you.

Try not to turn things over in your head and become stressed. If you're really struggling to nod off, try using some of the relaxing exercises that you may have learned during your antenatal classes or pregnancy yoga.

Be reassured that even though this exhausting time feels as though it will never end, it's only temporary. The good news is that your baby will soon begin to sleep through the night, which means you will, too.

Last reviewed: August 2015

References

Beattie L, Kyle SD, Espie CA, et al. 2014. Social interactions, emotion and sleep: A systematic review and research agenda. Sleep Med Rev 27(24C):83-100

Drake C, Roehrs T, Shambroom J, et al. 2013. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med 15;9(11):1195-200

ROSPA. 2011. Driver fatigue and road accidents. Royal Society for the Prevention of Accidents. www.rospa.com [pdf, accessed August 2015]

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As parent, you won't need telling that you could do with some more sleep. You may be so tired that you can barely remember your own name, let alone where you've put your car keys. Though a good night's sleep is the obvious remedy, this can sometimes seem impossible when you've got a baby to look after.

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A brief summary of research information on infant sleep and feeding

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A brief summary of research information on infant sleep and feeding

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School of Health & Social Care, Swansea University

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This leaflet offers helpful, practical advice to parents on looking after their baby at night.

The resource covers a range of topics including getting some rest, night feeding, safe sleeping environments and helping baby to settle. It is endorsed by the Lullaby Trust, the Royal College of Midwives (RCM), the Institute of Health Visiting (iHV) and the Community Practitioners and Health Visitors Association (CPHVA).

Caring For Your Baby At Night: A Guide for Parents

Printed copies are available for £15 per pack (1-9 packs) or £11 per pack (10 or more packs). There are 50 leaflets per pack and this price includes P&P within UK. Order using the Baby Friendly Resources order form, which you can download from our Resources page.

Our accompanying health professionals' guide supports professionals who will be using Caring For Your Baby At Night with new parents. It looks at the evidence underpinning the recommendations in the leaflet and offers guidance on discussing these issues.

2017 update: following feedback from clinicians, this leaflet has been updated to include an illustration of lying down breastfeeding.

Health professional's guide to Caring for your baby at night

Get the latest news and research updates from Baby Friendly

Sign up today

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Caring for your baby at night leaflet - Baby Friendly Initiative

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The resource covers a range of topics including getting some rest, night feeding, safe sleeping environments and helping baby to settle. It is endorsed by the Lullaby Trust, the Royal College of Midwives (RCM), the Institute of Health Visiting (iHV) and the Community Practitioners and Health Visitors Association (CPHVA).

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This infographic by a father, shows how sleep varies day to day from birth onwards. Newborn is at the middleMidnight is at the top, blue represents sleep and beige  awake time.

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This article looks at human babies sleep needs compared to other species of mammal

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"It is a primitive need of the child to have close and warm contact with another person's body while falling asleep.... The infant's biological need for the caretaking adult's constant presence is disregarded in our Western culture, and children are exposed to long hours of solitude owing to the misconception that it is healthy for the young to sleep ... alone."
-Anna Freud, daughter of Sigmund Freud

Where should babies sleep? In Western cultures, like those in the US and Europe, the answer is usually in a crib, by itself, often in another room. But why? Two adults in a romantic relationship often share a bed - how does it make sense that a tiny, vulnerable person has to sleep alone?

In other parts of the world, this is not even a question - babies sleep with someone. Even in Western cultures the idea of solitary infant sleep has only become expected during the last hundred years or so.

To understand biologically normal sleep for human babies, we need to first look at our cousins in the animal kingdom. Some mammals give birth to atricial infants after a short gestation - deaf, hairless and sightless, they develop rapidly in nests or a pouch. Others are precocial, well developed and able to stand or hold on to their mothers almost immediately after birth.

Like many primates, humans are mostly precocial, but also have atricial traits like not being able to walk or cling, mainly due to being born with only 25% of their brain capacity (for more information, see Babies Need to Be Held, 10-14-17). Primate infants even rely on contact with their caregivers to regulate their heart rate, temperature and breathing.

All land mammal mothers sleep close to their babies, although some, like deer and rabbits, have high fat milk that allows them to hide their babies for long periods while they forage for food. The young of these "feed and leave" species don't cry or defecate in mother's absence so as not to draw the attention of predators.

However, contact/carry species like marsupials and primates (including humans) do eliminate spontaneously and cry when separated from their mothers. This, along with low fat milk that necessitates frequent feeding, means that these babies need to be kept close at all times, including at night. A human baby who wakes up and cries to protest being alone does so for a very good reason - survival!

In addition to physical regulation, primate infants also need contact for psychological wellbeing. This was first demonstrated by Harry Harlow with his famous experiment in which rhesus monkey babies separated from their mothers clung to a cloth covered "surrogate mother" rather than a wire one that dispensed food. More recent research points to a spike in cortisol in babies left to cry without being comforted, which could effect an infant's developing brain.

From studying primates and the few remaining hunter-gatherer cultures, anthropologists have concluded that it is biologically normal for a human baby to sleep next to another person, usually it's mother. So how did solitary infant sleep come to be considered normal and desirable in Western societies? We will explore that in the next What Babies Need.

Liedloff, J. (1986) The Continuum Concept: In Search of Happiness Lost.

McKenna, J. (2007) Sleeping with Your Baby: A Parent's Guide to Cosleeping.

Pitman, T., Smith, L., West, D., Wiessinger, D. (2014) Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family. La Leche League International.

Small, M. F. (1999). Our babies, ourselves: How biology and culture shape the way we parent.

Ball, H., McKenna, J., Gettler, L. (2007) Yearbook of Physical Anthropology. "Mother-Infant Cosleeping, Breastfeeding and Sudden Infant Death Syndrome: What Biological Anthropology Has Discovered About Normal Infant Sleep and Pediatric Sleep Medicine."

Freud, A. (1965). Normality and Pathology in Childhood.

Fuentes, A., Gray, P., Narvaez, D., McKenna, J., Valentino, K. eds. (2014) Ancestral Landscapes in Human Evolution: Culture, Childrearing and Social Wellbeing.

Gettler, L, McKenna, J. (2007) Textbook of Human Lactation. "Mother-Infant Cosleeping with Breastfeeding in the Western Industrialized Context: A Bio-Cultural Perspective."

Kendall-Tackett, K., Middlemiss, W. (2014) The Science of Mother-Infant Sleep: Current Findings on Bedsharing, Breastfeeding, Sleep Training, and Normal Infant Sleep.

McKenna, J., Smith, E., Trevathan, W. eds. (2008) Evolutionary Medicine and Health: New Perspectives.

Tomori, C. (2017) Nighttime Breastfeeding: An American Cultural Dilemma.

https://www.isisonline.org.uk/

https://cosleeping.nd.edu/

Bed-Sharing and Co-Sleeping: Research Overview

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"It is a primitive need of the child to have close and warm contact with another person's body while falling asleep.... The infant's biological need for the caretaking adult's constant presence is disregarded in our Western culture, and children are exposed to long hours of solitude owing to the misconception that it is healthy for...

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Why? Babies and mothers are different and these differences affect baby's need for night feedings. Some babies really do need to breastfeed at night, at six months, eight months, and beyond. This is in part because if their mother has a small "breast storage capacity" and tries to sleep train her baby, her milk production will slow, along with her baby's growth. To find out what this means and if this applies to you, you need to know the basics of how milk production works.
Degree of Breast Fullness
Two basic dynamics are major influencers of milk production. The first, "degree of breast fullness," refers to a simple concept: Drained breasts make milk faster and full breasts make milk slower. Whenever your breasts contain enough milk to feel full, your milk production slows.1 The fuller your breasts become, the stronger the signal your body receives to slow milk production.
Breast Storage Capacity
This second basic dynamic refers to a physical characteristic known as breast storage capacity, which varies among mothers.2 This physical difference explains why feeding patterns can vary so much among mothers and why one breastfed baby does not need to breastfeed at night while another one does.

Breast storage capacity is the amount of milk your breasts contain in your milk-making glands at their fullest point of the day. Storage capacity is not related to breast size, which varies mainly by how much fatty tissue is in your breasts. In other words, smaller-breasted mothers can have a large storage capacity and larger-breasted mothers can have a small capacity.

Both large-capacity and small-capacity mothers produce plenty of milk for their babies. But their babies feed differently to get the daily volume of milk they need.3 After baby's first month, a mother with a large storage capacity may notice that her baby:

Is satisfied with one breast at most or all feedings.

Is finished breastfeeding much sooner than other babies (sometimes just five minutes).

Gains weight well on fewer feedings per day than the average eight or so.

Sleeps for longer-than-average stretches at night.

If this describes your breastfeeding experience, your baby may already be sleeping for longer stretches at night than other babies you know. But if after the first month of life your baby often takes both breasts at feedings, feeds on average longer than about 15 to 20 minutes total, typically takes eight or more feedings per day, and wakes at least twice a night to breastfeed, your breast storage capacity is likely to be small or average.

Again, what's important to a baby's healthy growth is not how much milk he receives at each feeding, but rather how much milk he consumes in a 24-hour day. Breastfed babies of both large- and small-capacity mothers receive plenty of milk, but their breastfeeding patterns will necessarily differ to gain weight and thrive.4 For example, a baby whose mother's breasts hold six ounces or more (180 mL) may grow well with as few as five feedings per day. But to get this same 30 ounces (900 mL) of milk, if a mother's breasts hold only three ounces (90 mL), a baby with a small-capacity mother will need to feed ten times each day. (This may not apply in the same way to a mother who's pumping.)
How These Dynamics Affect Night Feedings
How does this apply to night feedings? A mother with a large storage capacity has the room in her milk-making glands to comfortably store more milk at night before it exerts the amount of internal pressure needed to slow her milk production. On the other hand, if the baby of the small-capacity mother sleeps for too long at night, her breasts become so full that her milk production slows.

In other words, if you are a mother with an average or small breast storage capacity, night feedings may need to continue for many months in order for your milk production to stay stable and for your baby to thrive. Also, because your baby has access to less milk at each feeding, night feedings may be crucial for him to get enough milk overall. Again, what's important is not how much milk a baby receives at each individual feeding, but how much milk he consumes in a 24-hour day. If a mother with a small storage capacity uses sleep training strategies to force her baby to go for longer stretches between feedings, this may slow her milk production and compromise her baby's weight gain.

Each mother-baby pair is unique. Babies will outgrow the need for night nursings at different ages, so a simple rule of thumb doesn't consider either the emotional needs of the baby or his physical need for milk.
References
1Daly, S. E., Kent, J. C., Owens, R. A., & Hartmann, P. E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis, Experimental Physiology, 81(5), 861-875.

2Cregan, M. D., & Hartmann, P. E. (1999). Computerized breast measurement from conception to weaning: clinical implications. J Hum Lact, 15(2), 89-96.

3Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day, Pediatrics, 117(3), e387-395.

4Kent, J. C. (2007). How breastfeeding works. Journal of Midwifery & Women's Health, 52(6), 564-570.

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Has somebody told you that your baby doesn't need to breastfeed at night past a certain age? This age often varies by advisor. However, science tells us that in many cases, this simply isn't true. Why? Babies and mothers are different and these differences affect baby's need for night feed

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When will my baby sleep through the night?

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When will my baby sleep through the night?

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Should my baby be sleeping through the night?

It's so common for mothers to worry when their babies don't sleep through the night. After all, everyone knows they're "supposed to." Some doctors recommend nighttime weaning and "cry it out" methods if your baby is not sleeping through the night by 6 months or even earlier. Even when the mom herself has no problems with baby nursing at night, she still worries that this is a problem, since American society seem to consider it one. There are books all over the bookstores with advice on solving so-called "sleep problems."

First, please ignore what everyone else says about your baby's sleep habits and what is "normal." These people are not living with you or your baby. Unless your doctor sleeps in the next room and your baby is keeping him awake every night, he has no reason to question a healthy baby's sleep habits. If you and your baby enjoy nighttime feedings, then why not continue? It's a great way to have time with her, particularly if you are apart during the day.

Every baby is different, and some sleep through the night earlier than others (schedules or food usually have nothing to do with this). Your baby may be hungry (keep in mind that breastmilk digests in less than 2 hours) or she may just want time with you. Babies whose mothers work during the week often nurse more at night and on weekends, perhaps to reconnect with mom.

Many doctors tend to look at night nursing only from a nutritional standpoint, but this is only part of the story. After the first few months, your baby will begin to associate the breast with far more than just a way to satisfy hunger and thirst. It becomes a place of comfort, security, warmth, closeness, and familiarity. The act of nursing is not just nourishing; it is nurturing. Keep in mind that these needs are every bit as real as baby's physical ones, and having them met is every bit as needful to baby's overall development.

If the amount that your child sleeps and nurses at night isn't a major problem for you, then there's no reason to try to change anything. You are NOT doing a bad thing by nursing on cue; you are doing a wonderful thing for your baby. When you comfort baby at night, you are not teaching her a bad habit: you are teaching her that you are there for her when she needs you - Is security a bad habit?

What is normal when it comes to baby's sleep?

It is common for breastfed babies to not sleep through the night for a long period of time. On the other hand, some breastfed babies start sleeping through the night when a few months old.
Both of my children nursed once (occasionally more) at night through their second year. Since this doesn't bother me, I did doing nothing to change it. We co-sleep, and neither my baby nor I generally wake up completely when she nurses. Both started sleeping through the night on their own, when they were ready.
Your baby will begin to comfort herself and to sleep for longer stretches at her own developmental pace. If your baby wants to nurse at night, it is because she DOES need this, whether it's because she is hungry or because she wants to be close to mom. Beginning to sleep through the night is similar to a developmental milestone (like walking or toilet training) that your baby will reach when she is ready. Trying to force baby to reach this before her time may result in other problems later on.

If you can try to take a more relaxed approach and trust that it will come in time, you'll see your baby eventually become a good sleeper. You'll be able to rest peacefully in your heart and mind knowing that she reached this in her own time when she felt secure enough to do so, not because he had no other choice but to quiet herself because no one would come.

Probably one of the main reasons that night-waking babies are such a big issue is that parents don't have realistic expectations of the sleep patterns of babies. We are bombarded with magazine articles and books that perpetuate the myth that babies should not have nighttime needs. Babies were designed to wake up often at night to feed and cuddle- keep in mind that many adults wake during the night, too. If our expectations for babies were not so different from our babies' expectations for themselves, much of this "problem" might disappear.

See Studies on normal infant sleep for more information on what is normal.

Why do babies wake at night?

Babies wake at night for many reasons, and they often start waking at night after sleeping through for a few weeks or months. Some of the reasons for night waking (in no particular order) are:

baby wants more time with mom

developmental advances (for example: waking more often right before or after learning to turn over, crawl or talk)

illness, allergy, diaper rash, eczema

hunger (including growth spurts)

reverse cycling: Some babies whose moms are away during the day prefer to reject most/all supplements while mom is away, and nurse often during the evening and night. If mom is very busy during the day or if baby is very distracted, this can also lead to reverse cycling.

When your child nurses more often at night, go through this checklist to see if you can figure out what might be going on. Sometimes there may be more than one thing causing the night waking.

What about giving formula or solids at night to help baby sleep better?

See Will giving formula or solids at night help baby sleep better?

Gentle methods for encouraging less night nursing

See Night Weaning, which also includes many suggestions for maximizing sleep in younger babies who still need to breastfeed frequently.

Does night waking last forever?

Remember that night waking in babies and young children is normal and temporary!

Children grow out of night waking, even when we do nothing to discourage it. This period of time will be a very tiny part of your child's years with you.

Your goal is to maximize sleep for everyone in the family, while respecting the needs of your child.

If you're meeting this goal, then ignore anyone who suggests that you do things differently. If your sleep situation is not working (or stops working) then you can always do things differently. All parents find that they change the way they do things as their child grows older and reaches different developmental stages - sleep is just another thing that changes as your child grows.

More information

@

What is normal when it comes to night waking?

Do Older Babies Need Night Feedings? by Nancy Mohrbacher, IBCLC, FILCA

The myth of baby sleep regressions - what's really happening to your baby's sleep? by Pinky McKay, IBCLC

Is Your Baby Sleeping Through the Night Yet? by Jennifer Rebecca Thomas, MD, FAAP, IBCLC

5 Cool Things No One Ever Told You About Nighttime Breastfeeding from Breastfeeding Chicago

Night Waking: or, "Will I Ever Get A Good Night's Sleep Again?" by Anne Smith, IBCLC

Pillow Talk: Helping your Child Get a Good Night's Sleep By Paul M. Fleiss, author of Sweet Dreams: A Pediatrician's Secrets for Baby's Good Night's Sleep

FAQ on Sleeping through the Night from LLL

Myth: Good Babies Sleep Through by Linda J. Smith, BSE, FACCE, IBCLC

Rethinking "Healthy" Infant Sleep by James J. McKenna, Ph.D.

Slumber's Unexplored Landscape- an interesting article that discusses sleep research and "normal" sleep patterns

Controlled crying

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Sleeping Through the Night * KellyMom.com

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It's so common for mothers to worry when their babies don't sleep through the night. After all, everyone knows they're "supposed to." Some doctors recommend nighttime weaning and "cry it out" methods if your baby is not sleeping through the night by 6 months or even earlier.

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Breastfeeding is an amazing tool to help settle children at night. As a mother of four I have found that by far the easiest way to get my children to sleep at night was by breastfeeding them (well into the toddler years). Similarly when my children woke at night breastfeeding was by far the quickest and easiest way to get them back to sleep and resulted in more sleep for us all.

Science has found a link between an increased number of night wakings and breastfeeding. There is however also evidence to suggest that overall the length of wakings is less for breastfed infants which may actually lead to breastfeeding mothers getting *more* sleep than their formula feeding counterparts. For any parent who has both bottle and breastfed the ease of being able to breastfeed instantly compared with the time taken to make up and cool a bottle of milk is obvious. For this reason a night waking breastfed infant tends to require less overall parental input at night than a child who is formula fed.

Despite the widespread belief that formula fed babies sleep for longer than breastfed babies, research has found that any initial difference disappears by toddlerhood.

Many sleep experts claim that infants no longer require night feeds after six months of age. This is an incredibly naive belief. Nobody knows when a child is capable for sleeping long stretches of time without milk apart from the child itself. In addition this belief assumes that the night feed is providing nothing more than nutrition. The reality however is that night feeding allows a complex mix of emotional and physical needs to be met. The actual reality of night weaning readiness, in my opinion, occurs at some point between six months and four years of age.

While there is no guarantee that night weaning will result in improved sleep, for many families this is the case. I feel I should however point out that for many night weaning makes no (positive) difference. For some families it can even make the whole situation much worse, with night wakings increasing and parents left unable to settle the child as quickly and easily as they would have done if they were still breastfeeding at night.

For these reasons I would urge you to really think about night weaning and the potential impact on your family before you begin it. You should ask yourself these questions:
1. Why am I considering night weaning?
The only correct answer here is "because it feels right for me". If a seed of doubt has been planted by a doctor, health visitor, friend, family member or baby sleep expert don't proceed any further. Your child is normal. It is normal to feed at night well into the toddler years. Your child won't need to feed at night forever. Ignore the ill informed comments and carry on doing what works for your family.
2. Am I considering night weaning because I am exhausted?
This isn't a great reason to night wean in my experience. Sometimes night weaning can cause a child to wake more. Sometimes you are left with a child you can no longer settle at night without the ease of breastfeeding. Night weaning takes a lot of work - emotionally and physically with no guarantee of success. You may be better to look elsewhere to help with your exhaustion first. Is there anything you can downsize in your life? Are there any ways of taking more 'me time' and nurturing yourself? Are there any voluntary organisations near you who can help?
3. Am I considering night weaning because I am going back to work soon?
This is by far the most common reason people approach me for help with night weaning. I refer you to point number 2 above. In addition if you are returning to work, particularly full time, night times are an important time for your child to reconnect with you. Allowing them to stay close to you and feed at night can help to soothe any disconnect they may have felt by being away from you during the day. It can also help breastfeeding to continue while you are at work.
4. Am I considering night weaning because I am pregnant or want another baby?
Fertility/return of periods aside it is perfectly possible to continue night time feeding an older baby or toddler whilst pregnant or with a newborn. As with point number 3 this can help the older child to still feel connected, reducing any emotional effects (and resulting difficult behaviour - which often includes sleep regression) once a new family member arrives. See also point number 2.

If you still feel ready to progress with night weaning you need to put a plan into place. My personal opinion is that night weaning should never be considered before six months of age, and ideally not until a child is over one year.
Things to think about are:
1. Slowly conditioning your child to take comfort from objects that are not your breasts. More on this in a minute.

2. Finding time in your diary when nothing else is happening (no holidays/starting childcare etc.). If you are bedsharing/cosleeping do not be tempted to move your child our of your bed/room either before, or at the same time as, night weaning. The move to their own bed/room should happen after night weaning is established.

3. Helping older children to understand what is about to happen. I like this book.
Step by Step Night Weaning Plan.
If you would like to learn more about infant sleep, including many more sleep tips c heck out my latest book, available HERE:

p.s: Did you like this post? Want to read more similar content and receive weekly top tips, reader Q&As, hear my take on current parenting research and enter the odd competition? Then why not sign up to my new FREE WEEKLY NEWSLETTER and get the latest in gentle parenting delivered straight to your inbox. I promise I will never share your email with anybody else and if you don't like what I send you can unsubcribe straight away!

About SarahOckwell-Smith

Sarah Ockwell-Smith, Parenting author and mother to four.

This entry was posted in Babies, Toddlers and tagged baby sleep, baby won't sleep, gentle sleep coach, gentle sleep training, night weaning, nightweaning, sleeping through the night, stop night feeds, stopping night feeds, toddler sleep, toddler won't sleep, weaning baby from the breast, weaning toddler from the breast. Bookmark the permalink.

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How to gently night wean a breastfed baby or toddler

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Breastfeeding is an amazing tool to help settle children at night. As a mother of four I have found that by far the easiest way to get my children to sleep at night was by breastfeeding them (well into the toddler years). Similarly when my children woke at night breastfeeding was by far the quickest and easiest...

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As pediatric occupational and physical therapists who work mainly with infants, we've witnessed a time in history where the amount of baby equipment being used by many parents and child care centers has sky-rocketed. This trend is having developmental implications for some infants. Parents of newborns are vulnerable and need to have reliable information from professionals to combat the heavy marketing to which they are subjected.

Of all the pieces of new equipment that have been marketed to parents over the years, we can't think of any that we would deem as necessary for a baby's development. That said, equipment can be an aid to a parent and thus has a role in infant care when used with understanding and used minimally. A savvy parent has been educated and is able to make decisions that are best for their baby and family. Note, equipment is defined as bouncy seats; swings; jumpers; Exersaucers; and sleep positioners such as the Snoo. It can also loosely include such items as the Magic Merlin and others that are designed as a transition item for going from swaddling to being out of swaddling (that will be the subject of another post).

Please know we understand that while a parent may desire to meet their infant's needs in a certain manner, the realities of one's circumstances may make that impossible. Having multiples, a baby with medical issues and the pandemic are significant factors that make handling the needs of an infant (or infants) more challenging than in years past.

A word about sleep and parenting, as the main purpose of the Snoo is to increase parental sleep. While it is a reasonable expectation that during portions of the first year of life and beyond, sleep for a parent may be far less than desirable, there is a point where it's a necessity for a parent to sleep. Please take that into account as we discuss the Snoo below. We can equip you with knowledge, but each parent then needs to take the knowledge and tailor it to their situation; Implementing it in a way that works for their family. We have no judgement. We simply want to give parents information based on the year in, year out experience of the occupational and physical therapists in our clinic, who regularly hear from parents the phrase, "I wish I would have known this sooner." Once equipped with the information, you have our full support and encouragement to do what you deem best for your infant and your situation. You also have our respect for your love for your baby, your determination, resourcefulness and willingness to sacrifice.

The Snoo has a lovely aesthetic. It is beautifully marketed and was developed by a pediatrician. However, based on the babies we see in our clinic every day, the marketing is highly misleading. Hopefully the information presented here will dissuade parents from investing in this expensive piece of equipment that is not in the best interest of some infants.

Before specifics though, let's discuss the term, "not in the best interest of some infants." What that means is that as humans we are highly resilient and despite non-optimal caregiving practices there are many infants that will develop normally. The issue is that some infants will not, and it is very difficult, often impossible, to determine which infants will be impacted and which will not. Some issues are related to head shape, slowed development and may be more obvious. Other issues such as temporomandibular dysfunction or impaired bonding are more difficult to pinpoint and won't be seen for years but can be very serious.

Five reasons to consider before purchasing a Snoo Reason 1: There is the potential for negative impact on bonding with your baby due to use of the Snoo.
While there are many products that are not developmentally desirable, the Snoo is designed to interrupt caregiving practices believed to support bonding. Bonding is foundational during the first months of life. That is, during those first months of life a baby learns that "when I cry someone comes and tends to me." (As an aside, an 18-month-old has learned this well and it's not uncommon for a toddler to use this mechanism to delay bed time; to wake up parents during the night to play; and on and on. That is an entirely different phase of development that has its own recommendations which differ based on culture and parental style.)

What we are talking about here are the first months of life, and while culture and parental style influence bonding traditions, it is fairly straight forward. The baby cries and learns that someone comes and tends to them. Through the generations, tending to a crying baby at night consists of feeding, a diaper change and movement, warmth and vocal assurance by the parent to the baby that all is well. Babies sometimes get sensorily disorganized and need the parent's hold to reorient themselves and return to a calm sleep state.

These (hopefully) brief check-ins between parent and infant are physical in nature meaning that the baby is moved during the diaper change and feeding, and is picked up and goes from a horizontal position to vertical when up on the parent's chest with patting or rocking. There is the parent's warmth, smell and auditory assurance. There is the kinesthetic assurance from being held tightly and patted. These experiences offer crucial bonding and the infant is learning.

The opposite end of the spectrum are babies who are in orphanages and are not often held and do not fully bond with caregivers. They are at high risk for reactive-attachment disorder. That is a serious issue with lifelong implications related to character development and the ability to have healthy relationships.

There is a spectrum of care. On one end, the baby is being fully tended to, and on the other end a baby's basic needs for feeding and diapering are met but without the ability for individualized, consistent care and far less opportunities for bonding. It is widely understood that being in an orphanage where individualized care is not feasible puts a baby at risk for deleterious effects (some orphanages are able to provide far better care than others due to resources). Where is the line between that dangerous level of care and ideal care? Between a baby having good enough care and care that isn't good enough? The answer is probably highly individualized for each baby. Some babies are resilient even in poor-care environments. Others are highly vulnerable.

So how does all of this relate to the Snoo? The Snoo design harnesses the infant to the sleep surface in a manner different than traditional swaddling. When the device senses movement or crying, it begins to jostle. If the movement and crying persist, the device continues to increase the level of jostling and rocking and adds white noise that gets louder and louder. At some point, the infant will stop crying. In our view, some infants stopped crying because they were lulled back sleep while other infants stopped crying because they learned, "I cried and no one came and so I gave up." In both cases, the baby is back asleep, and it is impossible to know which baby has no ill-consequences and which does. In all cases, the baby remains in the horizontal position, their limbs do not move, they do not feel the warmth, get patted by or hear the voice of their parent. Their diaper isn't checked and they are not given the opportunity to feed.

Reason 2: The Snoo may increase the risk for head shape issues.
In our clinical experience, those infants prone to having head shape issues will often have them exacerbated by being in the Snoo. Please note that head shape issues are not only a cosmetic issue, as research correlates certain head shape issues with long-term alignment of the jaw, eyes and ears which can have pain and functional implications such as temporomandibular dysfunction.
Reason 3: The Snoo also limits a baby's ability to move.
Traditional swaddling is helpful and organizing for many infants. This differs from the harness system used with the Snoo. Traditional swaddling is removed around 3 months of age so the baby can safely roll to his or her sides and eventually roll over. The Snoo markets that it impedes rolling and thus is safer from a SIDs perspective. This is in opposition to the American Academy of Pediatrics which recommends placing an infant on her back to sleep AND that when the infant independently repositions her or himself to their sides or tummy, it is safe and desirable to allow this.

As occupational and physical therapists we strongly agree that at around three months of age it is important for an infant to be placed on their back but be free to reposition him or herself independently. When this is impeded, rolling when awake is delayed. This often leads to delayed crawling and exploration of one's environment. Please note that a baby that sits or walks early but did not crawl for a significant period of time is not an ideal developmental trajectory (also the subject of a future blog post).
Reason 4: It is a very expensive.
Each family needs to consider if those resources would be better spent in other ways such as investing in a night nanny or a consult with infant sleep experts, on savings for higher education later on, or an emergency fund in case of job loss or car repairs, etc.
Reason 5: The marketing promotes strict adherence to their protocol, including bringing or rentng a Snoo when out of town.
This lays the foundation for creating sleep issues later as the infant is not learning how to sleep in various environments.

If a baby falls asleep in a car seat, we recommend moving the baby to a flat surface to sleep immediately upon returning home. This is for the baby's head shape and development. It is also to support the baby as she or he learns how to sleep with some noise, some movement, and some changes in environment. That will be a baby who grows into a toddler and preschooler that can sleep at grandma's house, on vacation, and so on.

While schedules and routines are very important for young children it is advised to not be overly rigid. When adhered to with complete rigidity, schedules and routines can lay a foundation for the child to have limited flexibility with schedules changing. When a baby is moved occasionally during sleep, it can help lay the foundation for the child to be adaptable to changes. (Not to say that blame for a poor sleeping preschooler is to be placed on a parent's shoulders. All small humans are learning so very much and get stuck in some areas. Some are picky eaters; others have trouble sleeping; some get frustrated very easily; some are shy; some don't like the dark; and on and on).

Note 1: The Snoo is similar to the Fisher-Price Rock 'n Play in that occupational and physical therapists and pediatricians sounded an alarm bell. Parents raved about the benefits of the Rock 'n Play while pediatricians and occupational and physical therapists were citing many concerns. This went on for years. On April 12, 2019, Fisher-Price recalled all Rock 'n Plays, advising that consumers should immediately stop using the product. The Snoo is similar in that many professionals have reservations and concerns and see negative impacts. See also: Dr. Natasha Burgert and Dear Fisher-Price®... - KCKidsDoc and The Fisher-Price Rock 'n Play Sleeper is NOT for sleeping | The Pediatric Insider (wordpress.com)

Note 2: If you already have the Snoo and after reading this post are feeling defensive or worried about the effects, please know that that is part of parenting. It's good to learn as much as possible but the information is not always available before decisions are made. Or the information was available and your understanding or ability to utilize it wasn't there. It's okay! Parenting entails constant course adjustments. Every parent is doing the best that they can while facing new developmental phases and novel situations and with that often comes course corrections and at times of regret. It's okay! Just change course when you need to.

We hope this information and the tone it is presented in has been helpful. Having a baby while being heavily marketed to and while receiving loads of information from well-meaning family members and friends makes for a challenge for any parent. Pat yourself on the back as you are seeking out sources of information that are experienced and want the best for you and your baby. Again, know that we have compassion for parents and caregivers of newborns and you have our admiration and encouragement!
Susan Klemm MS, OTR/L Stacy Conder, PT March 2021

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Five reasons not to purchase a Snoo: From a group of pediatric occupational and physical therapists | Carolina Kinder Development | Charlotte

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As pediatric occupational and physical therapists who work mainly with infants, we've witnessed a time in history where the amount of baby equipment being used by many parents and child care centers has sky-rocketed. This trend is having developmental implications for some infants. Parents of newborns are vulnerable and need to have reliable information from professionals [...]