Breastfeeding Medicine

Physicians blogging about breastfeeding

Should the AAP Sleep Alone?

with 32 comments

Some public health messages everyone can agree with: Never drink and drive. Always put your infant in a car seat. Other public health messages seem to ask us to do the impossible: Teenagers must never have sex. Mothers must never share a bed with their infants.

Advice around the US urges parents never to bed share, reinforced by the official stance of the American Academy of Pediatrics. Scary ads abound. One ad shows a queen-sized bed with a headstone in place of headboard reading “For too many babies last year, this was their final resting place.” Another shows a baby in an adult bed with a meat cleaver, stating “Your baby sleeping with you can be just as dangerous,” and another ad says “Your baby belongs in a crib, not a casket.”

The fact is, across the United States and the world, across all social strata and all ethnic groups, most mothers sleep with their infants at least some of the time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.1-4 Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far more likely to feed their babies at night on chairs and couches in futile attempts to stay awake, which actually markedly increases their infants’ risk of suffocation.5 According to a 2010 study of nearly 5,000 US mothers, “in a possible attempt to avoid bed sharing, 55% of mothers feed their babies at night on chairs, recliners or sofas. Forty–four percent (25% of the sample) admit that they [are] falling asleep with their babies in these locations.”6 This is truly disturbing.

The advice to never sleep with your baby has backfired in the worst possible way. Rather than preventing deaths, this advice is probably even increasing deaths. In another study, parents of two SIDS infants who coslept on a sofa did so because they had been advised against bringing their infants into bed but had not realized the dangers of sleeping on a sofa.5 In fact, deaths from SIDS in parental beds has halved in the UK from 1984-2004, but there has been a rise of deaths from cosleeping on sofas.7

In the US, bedsharing cannot often be discussed in pediatricians’ offices: without their professional organization to back them up, US pediatricians may feel uncomfortable mentioning the topic without liability fears, and parents may fear criticism if they ask about it. It is swept underground. Like most mammals, human mothers and infants are drawn to sleep next to one another, and infants and mothers sleep in synchrony when they sleep together.8,9 No amount of scary ads is likely to change what is almost certainly a deeply ingrained biological imperative.1 The lack of opportunity to discuss the issue with clinicians squanders an opportunity for education and balanced discussion.

In contrast, medical authorities in Canada, Great Britain and Australia have different messages than the American Academy of Pediatrics. They all acknowledge that most mothers do share a bed with their infant at least some of the time. If one chooses to bedshare, they educate the public on risks and on ways to markedly decrease the risk of infant death. Bedsharing should be avoided if a parent has used alcohol or sedating medication, if the mother is a smoker, if the baby is formula fed, if the bedding underneath is soft like a sheepskin or waterbed. No matter where a baby sleeps, he should not be in a room alone or placed on his stomach. Most of all, never sleep with an infant on a couch or recliner, the most dangerous place of all.

Some medical authorities acknowledge that there are even benefits to sharing a bed with an infant, such as ease of breastfeeding, increase in the number of nighttime breastfeedings and increased maternal rest.   Regardless, authorities other countries uniformly state parents should be told of the risks and benefits and be able to make their own informed decisions.

How unsafe is bedsharing anyway? Like many things in science and medicine, the answer is neither simple nor clear cut. The studies on “bedsharing” have often lumped beds and couches together when looking at infant deaths, making it impossible to distinguish the true risk. Often studies did not separate out whether the infants were breastfed or not, although breastfeeding cuts the risk of SIDS by nearly 75%.10 The one recent study that attempted to look at SIDS and bedsharing without other risk factors found an increased risk with bedsharing, but it turned out that information one of the biggest risk factors, consumption of drugs and alcohol, was not fully collected, and the risk of smoking was not fully adjusted for, per a statement from UNICEF UK.

In addition, research shows that bedsharing facilitates breastfeeding and is associated with longer breastfeeding duration.11-13 Breastfeeding mothers who try not to bedshare either end up giving up breastfeeding or bedshare anyway.13 The nutritional content of human milk necessitates frequent feeding both day and night and frequent close contact.

What is certainly clear and uncontroversial is that many other factors are much bigger risk factors for death than bedsharing itself. One of those risk factors, sleeping on the stomach, was the subject of the highly successful “Back to Sleep” marketing campaign. But one of the biggest risk factors, formula feeding, is not discussed at all in social marketing campaigns to prevent infant deaths. Instead we have scary ads about bedsharing. From all available social marketing evidence, it looks like it is easier to convince women to stick with breastfeeding than it is to convince them not to sleep with their babies. The lowest hanging social marketing fruit: Ads educating people about the dangers sofas and recliners would go a long way to decreasing risk of death, provided that women also got the message that a bed is a safer place to feed their baby than the couch or recliner.

Many new parents use sidecars that attach to the sides of adult beds, keeping the infant within easy reach for breastfeeding but still in a separate space. For reasons that are unclear, any findings of safety for in-home use of these popular devices has never been published, and even the AAP does not advocate for their testing. The AAP policy statement only says their use is “not recommended.” They were tested in hospitals and found to be safe and effective for increasing breastfeeding in the postnatal ward.14 Rather than spending money on scary ads, we should prioritize testing these devices for the home and regulate them for appropriate safety standards like cribs.

If advice not to bedshare may inadvertently end up decreasing breastfeeding duration, that would affect many diseases in addition Sudden Infant Death Syndrome and infant suffocation. Breastfeeding duration impacts obesity, a host of infections of infancy, and breastfeeding duration affects a host of maternal diseases as well. Suboptimal breastfeeding duration in the US results in nearly 5,000 excess cases of breast cancer per year, nearly 14,000 excess heart attacks per year, and over 50,000 excess cases of high blood pressure per year.15 Thus, any recommendations that may negatively impact breastfeeding must take into account all the health implications of breastfeeding, not just a single disease.

Telling mothers never to share a bed with their infants is a message doomed to fail, and has likely contributed to at least some infant deaths on sofas. Instead of showing scary ads of infants in beds with headstones and cleavers, we should be focusing educational efforts sleeping on couches and recliners, smoking, and in the presence of alcohol, drugs, and formula feeding. And of course, we should be supporting mothers to breastfeed.

Melissa Bartick, MD, MSc is an internist at Cambridge Health Alliance and Assistant Professor at Harvard Medical School. 

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

References

1.         Lahr MB, Rosenberg KD, Lapidus JA. Maternal-infant bedsharing: risk factors for bedsharing in a population-based survey of new mothers and implications for SIDS risk reduction. Matern Child Health J 2007;11:277-86.

2.         Jones-Vessey K, Avery M, Simsek F. Infant Bed Sharing: Results from the North Carolina Preganancy Risk Assessment Monitory System Survey, 2009-2010. Raleigh: State Health Center for Health Statistics; 2012.

3.         Kendall-Tackett K, Cong Z, Hale T. Mother-Infant Sleep Locations and Nighttime Feeding Behavior: U.S. Data from the Survey of Mothers’ Sleep and Fatigue. Clinical Lactation 2010;1.

4.         Declercq E, Sakala C, Corry MP, Appelbaum S, Herrlich A. Listening to Mothers III: New Mothers Speak Out. New York: Childbirth Connection; 2013.

5.         Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. BMJ 2009;339:b3666.

6.         Kendall-Tackett K, Hale TW. The use of antidepressants in pregnant and breastfeeding women: a review of recent studies. J Hum Lact 2010;26:187-95.

7.         Blair PS, Sidebotham P, Berry PJ, Evans M, Fleming PJ. Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK. Lancet 2006;367:314-9.

8.         McKenna JJ, Ball HL, Gettler LT. Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: what biological anthropology has discovered about normal infant sleep and pediatric sleep medicine. American journal of physical anthropology 2007;Suppl 45:133-61.

9.         McKenna JJ, Mosko SS. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. Acta Paediatr Suppl 1994;397:94-102.

10.       Hauck FR, Thompson JM, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics 2011;128:103-10.

11.       Gettler LT, McKenna JJ. Evolutionary perspectives on mother-infant sleep proximity and breastfeeding in a laboratory setting. American journal of physical anthropology 2011;144:454-62.

12.       McKenna J, Mosco S, Richard C. Bedsharing promotes breastfeeding. Pediatrics 1997;100:214-9.

13.       Ball HL. Breastfeeding, bed-sharing, and infant sleep. Birth 2003;30:181-8.

14.       Ball HL, Ward-Platt MP, Heslop E, Leech SJ, Brown KA. Randomised trial of infant sleep location on the postnatal ward. Arch Dis Child 2006;91:1005-10.

15.       Bartick M, Steube A, Schwarz EB, Luongo C, Reinhold A, Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gyencol 2013;0:1-9.

 

 

Written by melissabartick

April 9, 2014 at 6:05 am

Posted in In the news, policy

32 Responses

Subscribe to comments with RSS.

  1. Reblogged this on Ann Friedmann MD and commented:
    This is an excellent commentary on bedsharing.

    Ann Friedmann MD

    April 9, 2014 at 6:37 am

  2. Excellent blog, Melissa Bartick … thank you. AAP should review and revise its draconian stance, in its 2011 statement, against ALL bed-sharing as unsafe. Rather than “shame and blame” parents for doing what they’ve been doing for millennia … let’s “re-frame” the teaching and messaging so families get good information, and can learn how to safely accomplish parenting, night feeding, and sleeping.

    ECBrooks

    April 9, 2014 at 7:07 am

  3. Thank you, thank you for a clear voice of reason about this important topic that affects every mother and baby.

    Sue Petracek, IBCLC

    April 9, 2014 at 8:12 am

  4. Excellent blog Melissa — thank you. Shared with Infant Sleep Info Source (www.isisonline.org.uk) followers.

    Helen Ball

    April 9, 2014 at 8:13 am

    • Dr. Ball, I am a big fan of your work, including your cost work. You are an inspiration. Thank you for all you do!

      melissabartick

      April 9, 2014 at 8:05 pm

  5. Yes, yes, yes, thank you for addressing this! I fully agree and discuss these exact points with all parents in my office. Almost all are surprised to learn that sofa/chair sleeping is much more dangerous than bed sharing. I urge moms to bed share safely (no blankets or pillows near baby, sleep between mom and edge of the bed, away from dad and from wall) if they feel like they will fall asleep while breastfeeding. Thank you again.

    Christina Dalton, DO

    April 9, 2014 at 9:10 am

  6. Wonderful essay, Dr. Bartick. Thank you!!

    Nikki Lee

    April 9, 2014 at 9:33 am

  7. Wonderful essay, Dr. Bartick. Thank you!! A working mother who is struggling to maintain a milk supply at her workplace is undermined when she is frightened into getting out of bed at night to breastfeed. She gets no ease anywhere and will bail out of breastfeeding. Let’s give our working mothers a break and teach them how to bed-share safely.

    • This working mother wholeheartedly agrees. Bedsharing made all the difference.

      Val

      April 9, 2014 at 3:50 pm

  8. Excellent! Thank you! This message has been so hammered into new mothers with NO education or tips on how to handle the increased sleep deprivation and breastfeeding challenges. Advocates in our state commonly cite an increased risk in preemies. It would be helpful to have referenced preemies and any changes in bed sharing risks.

    The county “reviewers” that visit homes never say “this SIDS baby might have been saved if the mother breastfed.”

    Julie

    April 9, 2014 at 10:11 am

  9. The extreme scare tactics about “co-sleeping” also tend to leave out the enormous protective effect of room-sharing, and probably encourage frightened parents to put the baby in that “safe” crib in a separate room, thus increasing SIDS risk by as much as 100%!

    Christine

    April 9, 2014 at 11:38 am

  10. If your baby dies in your bed, and you were there when it happened, it’s not SIDS. If I had to guess, over 95 percent of the time the parent knows exactly what killed the baby in that case or the cause is discovered soon afterward. To say there’s a SIDS rate in a parental bed that’s high enough to be worth mentioning is to be a tad disingenuous. Although I think a lot of people are using it for shorthand for “baby died in its sleep” now, but that’s not what SIDS is; it’s a sudden death of an infant for no identifiable reason.

    I was reading several years ago that young infants in cribs by themselves sleep more deeply than infants in bed with Mom or in a crib right next to Mom’s bed (which frankly also counts as co-sleeping) because Mom’s making noises and there’s just enough disturbance to baby’s sleep that they never go very deeply under–but for young babies, being very deeply asleep is *dangerous* because neurologically they’re not done “cooking” yet and they can’t self-regulate adequately enough. Some of them “forget” to breathe when they’re that far under, in a manner of speaking.

    Not only should moms cosleep but during the day, when a young baby’s napping, it’s not the greatest idea to put them by themselves in their own room at that time either. In a bassinet out in the living room or in a sling on Mom’s body are probably the best places. They will sleep through noise if you keep them accustomed to noise. They heard it all the time when they were still in utero anyway.

    Dana

    April 9, 2014 at 6:26 pm

  11. Thank you for a wonderful article. I recognize the ads, and I’m sad to say, Milwaukee has turned a blind eye to education. A journalist did a presentation showing that all of the “co-sleeping” deaths at that time were strictly formula fed babies. I wish I could still teach safe co-sleeping/bed sharing.

    Christine Raasch

    April 9, 2014 at 7:46 pm

  12. Bravo! Thank you. Thank you for standing up and being the voice of reason.

    Toshia Parker

    April 10, 2014 at 1:19 am

  13. This conversation is long overdue. I feel like “we”, in trying to stay within the guidelines of the recommendation of the AAP, do our new Mom/baby couplets a huge disservice! I encourage more full and open real conversations like this. It will not only save lives, but will decrease the deep exhaustion that most separate-sleeping mothers experience. Lets take what is really happening in the bedroom out into the open and help these parents make truly safer, fully informed decisions for their families. I have felt that the standard medical questioning around this issue bullies parents into secrecy. It is time for change. Thank you Melissa for publicly voicing what I have long wanted to discuss openly.

    Judith Fayre

    April 10, 2014 at 7:29 am

  14. Thank you so much – the timing is perfect as I received a message today from a Certified Nurse Educator suggesting all mothers who have a child die of SIDS while bedsharing (regardless of safety precautions taken) be charged with criminal negligence or manslaughter!!! When did we get so far away from reason?

    Tracy Cassels

    April 10, 2014 at 5:02 pm

  15. So what should parents know if they do want to cosleep? What techniques or approaches are effective? What about blankets? There is a lot of information about what NOT to do, but no information about what TO do.

    Jarren

    April 11, 2014 at 10:15 am

  16. I’m just a little guy in the big huge massive debate over this topic. When trying to seek out clarification and guidance on this topic, and how it relates to my community in Memphis, TN, I look to the ABM, AAP, etc. I look for guidance in textbooks such as Riordan’s Breastfeeding and Human Lactation, 4th Edition that are on my bookshelf and blogs such as this one.

    Our community is diverse but has a large, poor, young, and under-educated population that different organizations try to reach with public health messaging campaigns. The state, medical professionals, and various child health organizations promote anti-bedsharing messages in their quest to lower our awful infant mortality rates.

    We have low breastfeeding initiation rates and there are organizations and individuals doing their best with the available resources to improve these too. I volunteer in my area and have now been caught in the middle of this debate due to my proposal to screen a breastfeeding documentary that includes the co-sleeping debate. Is this movie really that controversial? One movie that potentially damaging? Please forgive me, I am just trying to understand. Does this movie have the power to set our community back 20 years? Is censoring any mention of this topic in the best interest of our community? What about the overwhelming amount of media that we do not control and what damage are those messages doing? Is there any way to promote a discussion about the topic without everyone getting upset? Is there no middle ground? These are a few of the questions that are swirling in my head.

    The last thing I want to do is make the infant mortality numbers rise here by bringing a film here that is damaging! So, although it is frustrating after the work I’ve done to move the project forward, I want what is best for my community. I’m just not sure what exactly that is in this case so I look to wiser, more knowledgeable sources.

    Please remember that a lot of people out there come to the Academy of Breastfeeding Medicine for guidance, clarification, and support. People like me are trying to support, protect, and promote breastfeeding effectively in our own ways. We love babies and moms and want to move the needle in the right direction.

    Courtney Costrino, Certified Lactation Counselor
    bedsharing stay-at-home mom & volunteer

    Courtney Costrino

    April 12, 2014 at 12:35 pm

  17. Thank you Dr. Bartick for your wonderful article. I wonder you haven’t included a discussion on Carpenter’s paper (1) which is one with a very dramatic impact among European Pediatric circles and being used, despite a lot of flaws and wrong conclusions, as a base for arguments against bed-sharing by many Pediatric Associations.
    As a member of APILAM, ABM as well, which is a NPO in charge of the website on Medication & BF http://www.e-lactancia.org with free information for nursing mothers and health care professionals around the world (myself I am responsible for the English version), I would highly appreciate your authorization to publish in our blog a Spanish translated version of your assay. Our Spanish page has more than 4000 visits every day and the English version about 1000 visits. I hope your article would be accessed by many people who otherwise would not have this opportunity. Thanks again.
    (1) http://bmjopen.bmj.com/content/3/5/e002299.full

    Leonardo Landa-Rivera

    April 13, 2014 at 5:05 am

  18. Congratulations on a great blog, Melissa. It’s tough in a pediatrics practice to have an honest discussion about co-sleeping with the parents of a newborn, knowing that an organization as authoritative as the American Academy of Pediatrics has taken such a strong position against the co-sleeping practice. Yet a discussion we absolutely must have, and the pediatrician should not wait for the parents to initiate it; it’s the pediatrician’s job to bring it up.

    I usually end my conversation about safe co-sleeping considerations by giving parents a copy of the relevant page of the Academy of Breastfeeding Medicine’s co-sleeping protocol. This document, however, is obviously not meant to be a patient information brochure. Perhaps it is time for ABM to start printing patient educational brochures for dissemination in medical practices, and a good place to start would be a brochure on co-sleeping.

    gcalnen

    April 13, 2014 at 1:07 pm

  19. […] experts are now starting to think that the blanket (no pun intended) advice to never bedshare has backfired, specifically in cases where parents fell as sleep with babies on couches or chairs because they […]

  20. Gracias! Thank you Dr. Bartick for a great blog! It should be about providing families with information on safe sleep and assessing the current living situation of each family. Especially the families who do not have a nursery or a crib.

    Brenda Reyes

    April 14, 2014 at 1:01 pm

  21. […] This blog was previously published by the Academy of Breastfeeding Medicine on April 9, 2014 here. […]

  22. Thank you for this! It’s so refreshing to see an MD making this case. Your points and analysis (and even your analogy to teenage abstinence!) are the same ones I made in a post last year: http://www.redwineandapplesauce.com/2013/05/20/another-study-supports-the-public-health-communitys-blind-spot-on-cosleeping-and-bedsharing/

    It’s so frustrating to see this topic swept under the rug which, as you note and I also noted, likely *contributes* to deaths in the same way that abstinence-only education contributes to teen pregnancies. It’s maddening to me that the AAP does not revisit their recommendations on this topic and take a less black-and-white, tone-deaf approach.

    Tara Haelle

    April 17, 2014 at 11:05 pm

  23. […] time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.1-4 Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far […]

  24. I am a longtime nurse and IBCLC and founder of Lactnet.i have seen that bed/ tombstone ad in Baltimore in a bus shelter in Baltimore. I. Eleven that a serious side effect of the bed sharing witch hunt is an increase in maternal pp depression, triggered by sleep deprivation.i had a client recently who was so terrified to sleep that she and her husband stayed up all night in turn so that someone could watch the baby sleep. An unsustainable dangerous practice for anyone who has to drive, make good decisions, or work around machinery especially.i think that to ignore the risks of formula /artificial infant food and to demonize Breastfeeding is a travesty…Kathleen Bruce RN, IBCLC, Vermont

    Kathleen b bruce

    April 19, 2014 at 9:00 am

  25. […] Should the AAP Sleep Alone?, Breastfeeding Medicine — Why the AAP’s recommendation to never sleep with your baby may cause more harm than good. […]

    Saturday Surfing

    April 20, 2014 at 1:13 am

  26. SIDS does not equal suffocation. It is very important to make the distinction. If a child died in bed or on the couch of suffocation, then that is not an unknown cause. I think we need to be clear about this because SIDS is more likely to happen when the child is sleeping alone and stops breathing and has no one there to notice.

    J.K.

    April 29, 2014 at 2:42 pm

  27. I have five children and my youngest child is now three months old. I saw my OB yesterday and he asked how I was doing with the sleep deprivation. I explained I had never experienced it because I have always slept with my children. They never even cry at night — I wake up and feed them as soon as I sense they are beginning to fidget, then fall asleep as they nurse. He said he didn’t understand why co-sleeping was such a big deal, as so many other cultures around the world do it and have done so since the beginning of time.

    The best baby gift I ever got was the lactation nurse who taught me how to feed my first baby while lying on my side. I feel terrible for young mothers who are so afraid their babies are going to die in the night and who suffer needlessly from sleep deprivation.

    We have a King size bed so there is plenty of room, and I make sure the baby is away from pillows and extra blankets. I am also careful to not take sleeping medications that would make my sleep unnaturally heavy. And once the baby can truly sleep through the night, they are in the crib for the duration — usually around eight months.

    nicky

    April 30, 2014 at 5:26 pm


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 661 other followers

%d bloggers like this: