Should the AAP Sleep Alone?

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.