SIDS and Bedsharing: A Pediatrician’s Perspective
I’ve been thinking about bedsharing and sleep safety for the last few months. I have devoted an entire chapter of my book to this topic. Not only is it an important question for parents, but it’s an issue with so much complexity — wrinkles and folds of factors like breastfeeding, bonding, instinct, culture, and just plain reality.
I think it is vitally important to understand the relationship between bedsharing behavior and risk of SIDS and accidental deaths. But our ability to tease apart every factor that might impact sleep safety is imperfect; there will always be factors that aren’t quantified in these studies, not to mention the fact that case control studies have some inherent limitations. You’ve probably heard about the study published this week by Carpenter et al. in BMJ. It combines 5 historic case control data sets from Europe, the U.K., and Australasia to specifically look at the risk of bedsharing in breastfed babies in nonsmoking households. It concludes that bedsharing poses an increased risk of SIDS, even in these ideal situations. I think it’s an important study, but it also has some limitations and doesn’t answer all of our questions with certainty. In fact, no study will probably ever do that. (You can read some critiques of the Carpenter study here and here.)
But even if we accept that bedsharing increases a baby’s risk of dying unexpectedly during sleep, we still have to answer the bigger question of how we translate this information to families living in the real, difficult world of infant sleep. Many families value bedsharing as a cultural practice; others choose it because it feels right. Still others bedshare because it is the only way that anyone gets any sleep at night, and we all know that sleep deprivation carries some risk, too, as does falling asleep on a couch with your baby. This is the reality.
Pediatricians face this reality in their clinics every day, when they talk with parents of new babies about sleep. In my book, one of the questions I explore is how pediatricians handle this conversation, given that their professional organization, the American Academy of Pediatrics, recommends against bedsharing. Several months ago, I sent some questions to one of my favorite pediatrician bloggers, Dr. Melissa Arca of Confessions of a Dr. Mom. She had initially agreed to a Q&A, but then she didn’t respond with her answers. It was the height of the busy flu season, and I figured that she was just busy. Then, this week, she surprised me with her responses. She had been thinking about bedsharing given the news of this recent study, and she was inspired to restart this conversation. We’ve cross-posted our Q&A on both our blogs. Check out her post for more about her initial hesitancy to address these questions, and please feel free to share your experiences in the comments below.
Alice: How did sleep look for your two children?
Melissa: My first child was a challenge to say the least. He is the one who made me question the safety of bed-sharing in the first place. For the first 6 months of his life, sleep was virtually non-existent (or at least that’s the way it felt to me) because he needed my arms and constant soothing throughout the night. But I was terrified to bedshare. I was literally at the end of my sleep deprivation rope. I had tried everything. And instead of listening to my instincts, I was fighting them. Because I was scared.
I never envisioned myself as a bedsharing parent. As a pediatrician, I was adamantly against it. But it was exactly what my baby needed and we struggled and limped along until I finally realized that.
My second child was a breeze and that’s no lie. She was always (and still is) an “easy sleeper”. She needed her space and showed clear signs of being tired. When she was tired, that was it. I didn’t need to bedshare with her. She slept in her own bassinet next to our bed during her first few months of life before being transitioned to her own room.
They could not have been more different in the sleep department. Same parents. Same environment. Different children.
Alice: As a pediatrician, how did you feel about bedsharing before having children? Did becoming a mother change that?
Melissa: I didn’t think it was safe. At all. I had read the studies and the official recommendations. Back to sleep, crib and/or bassinet in the same room with no hazards such as loose bedding, pillows, etc.
I never thought in a million years I would have become a bedsharing parent. But kids don’t have our same agendas. They don’t read the books or the studies. And when it comes to sleep…nothing could be more variable. The only constant is that we all need it.
Alice: You’ve written on your blog about your decision to finally bedshare with your first child. What kind of responses did your receive from other pediatricians and parents to your posts?
Melissa: Most reactions have been…yeah, I’ve been there. Or…I had a baby like that too. But, I’ve received some criticism too. Honestly, I think it happens to more families than are willing to admit it. It’s still taboo, particularly in the medical field. With good reason, for sure; but I think we need to talk about it. We need to address the issue. Not simply say…don’t do it, it’s not safe.
This is not a one size fits all situation. There are so many factors at play. So from a practical standpoint, we need to be willing to hear parents out and meet them where they are.
Alice: Do you believe that bedsharing can be safe if practiced with care?
Melissa: I think it can be made “safer”. I still believe that the AAP recommendations against it and safe sleeping tips such as back to sleep, sleeping in a separate crib or bassinet but in the same room as parents, and the guidelines for keeping loose bedding, etc out of baby’s crib is the safety gold standard.
BUT…there are thousands of families who choose to bedshare and are committed to it. They will continue to do so in spite of recommendations against it. As a pediatrician and first time mom, I found myself at this very crossroad. For me, bedsharing was born out of sheer need…and a nagging instinct that I had been fighting. Still, it took me 6 months to finally feel good about doing it.
For bedsharing families I think we have a responsibility to discuss safety issues with them. We need to advise them the safest way to do so. There are so many variables involved when it comes to bedsharing that makes studying it and having safe bedsharing guidelines difficult from a public health perspective. That alone makes it inherently risky.
But it doesn’t mean that we shouldn’t try. We absolutely should. Removing some of the added risks that can go along with bedsharing (such as heavy blankets, other children, exposure to second-hand smoke etc.) will reduce the risk of SIDS and accidental suffocation. So we should be having these discussions.
We know that bedsharing can look very different from one family to the next. It can be absolutely dangerous for one infant but relatively safe for another. One thing parents should know is that bedsharing cannot be an afterthought nor an act of desperation…this is very dangerous. Safe bedsharing is really an overhaul of the whole sleep environment. You cannot simply take your baby and put him/her in your bed without any preparation. So parents really have to be committed to it and be willing to take the proper safety precautions.
Alternatively, exhausted parents who are too frightened to bedshare may fall asleep holding their babies in their arms on couches, chairs, or in their beds. You can imagine how dangerous that can be for an infant. Before I embarked on bedsharing, I found myself in these very situations.
Alice: The AAP recommends against bedsharing in their policy statement on prevention of SIDS/suffocation deaths. Do you think this recommendation is appropriate? Do you share the AAP recommendation with the families in your practice?
Melissa: Yes and I do share these recommendations with my families. But I also ask them what sleep looks like in their house. How is everyone sleeping? Where do they sleep? Does anyone smoke? Where do they want baby to sleep and have they taken the proper precautions to make sure baby’s sleep environment is as safe as possible?
This allows for a more open, honest, and insightful discussion on what’s really going on in the home instead of simply spouting off the way they should be doing things.
Alice: Do you find it difficult to reconcile the realities of infant sleep practices among your patients with the AAP’s recommendation? Do you feel that the AAP’s stance against bedsharing puts you in a tight place?
Melissa: Sometimes an awkward place, yes. I agree with the AAP but I don’t think it sheds light on the whole story. Families are dynamic, babies are ever changing, and no two are alike. There is no possible way to control for all the factors involved here. But we should be able to come up with universal safe sleep guidelines for ALL babies, not just the ones sleeping in cribs or bassinets.
Alice: Do you believe that bedsharing can be beneficial to babies and families? Are there disadvantages to bedsharing that you think parents should be aware of?
Melissa: Yes. If it works for the families and babies seem to be thriving, absolutely. But parents need to be happy with it, not resenting every second of it. Breastfeeding moms tell me how wonderful it is and that they get more sleep that way.
The disadvantages are the inherent risk factors. I really stress to parents that bedsharing is a sleep overhaul for everyone. In order to make it the safest possible and eliminate some of these added risks they need to be willing to make some dramatic changes in their own sleep environment since baby will be there with them.
Here’s what “safe bedsharing” looks like to me:
- a firm mattress on the floor as the sleeping surface (eliminates fall and entrapment risks)
- baby sleeps between mom and edge of bed without anyone else in the bed (no pets, siblings, or dad…I know, sorry)
- no maternal smoking, alcohol, or sedating medications
- no loose bedding or comforters
- baby is always put on his/her back to sleep
- ideally, this is a breastfeeding baby, and if parents can put off bedsharing until 4 months of age when the risk of SIDS goes way down that is ideal too.
Alice: Is there anything else you’d like to share about your experiences with infant sleep as a pediatrician or as a parent yourself?
Melissa: We need to remember that it’s not one size fits all. We really need to take into consideration each unique baby and the sleep needs of both the parents and the baby. However, safety should always be paramount and this is where things become murky. The evidence that we have so far is stacked against bedsharing (but again, I think there are just too many factors to control for). I don’t think we’ll ever get the sleep studies that we want or need.
So the bottom line for me is: stick to the AAP sleep recommendations. Bedside bassinets are great for proximity and ease of breastfeeding. However, if you find yourself (like me) with a baby who needed constant contact and/or you are committed to bedsharing, make sure you take the necessary precautions. Know the risks and know what you can do to minimize them.
And this is where we (as pediatricians and public health advocates) can really help these families. We need to be willing to discuss the issues surrounding bedsharing beyond the standard it’s not safe, so don’t do it. A chronically sleep deprived mom and/or parent is dangerous for babies too. I think we can really have a positive impact on all babies by addressing these particular safety issues head on. After all, we are working towards the same goal…bringing up healthy and happy babies.
Thank you, Melissa, for sharing your perspective as a pediatrician and parent.
What about you, dear readers? How do you feel about the safety of bedsharing? If you bedshare, do you discuss safety with your pediatrician? Where else do you go for advice on sleep safety?