Should Your Baby Sleep in Your Room? For How Long? Balancing Sleep, Safety, and Sanity
**10/24/16 – This post has been updated to reflect the AAP’s 2016 Policy Statement on preventing SIDS and other sleep-related deaths. The AAP now recommends roomsharing for at least the first 6 months of life and preferably the first year. I’m glad to see this greater emphasis on roomsharing; it is evidence-based and yet overlooked by many families. The research reported here remains relevant and includes discussion of why roomsharing may protect babies, for how long, and why there may be a sleep tradeoff with roomsharing.**
There is no doubt that having a new baby changes everything about sleep. Between fussing, feeding, diapering, and soothing, it is broken into fragments, and the sum of all of those pieces doesn’t usually feel like enough. There’s also your baby’s safety to consider. Nobody likes to think about SIDS, but it is the most common cause of death in babies beyond the newborn period (1), and we want to do everything we can to prevent it. If we could, we might sit awake and watch our babies breathe all night, but of course, we need to sleep, too.
In balancing the need for sleep and safety considerations, one of the factors that parents consider is how close to sleep to their babies. Roomsharing is associated with a lower risk of SIDS. However, some parents find that they sleep better when the baby sleeps in a separate room. Others sleep best with their babies close to them. There are also cultural expectations that influence sleep practices, with roomsharing (and often bedsharing) being the norm in many parts of the world but less common in the U.S. and other Western countries beyond the newborn period (2,3). When I asked readers on my Facebook page about their experiences, the responses were across the map. (I will share some of those responses, with permission, throughout this post.)
In this post, I want to take a closer look at the science behind roomsharing. How does it affect the sleep of babies and parents when they sleep close or apart? How does it protect babies from SIDS? For how long is this important?
(Note that bedsharing raises different questions for sleep quality and safety, and those are beyond the scope of this post. I discuss bedsharing safety in this and this post, and devote most of a chapter to it in my book.)
What is the official advice on roomsharing?
The American Academy of Pediatrics recommends roomsharing without bedsharing as an ideal sleep environment (4). Ideally, they recommend that parents roomshare for the first year of life but note that it is most important in the first 6 months of life, as that is when most SIDS deaths occur. In the U.K., both the National Health Service and UNICEF U.K. recommend roomsharing for at least the first 6 months. In Australia, parents are advised to roomshare for the first 6-12 months. (International readers, can you share the official advice about roomsharing where you live in the comments?)
Roomsharing is associated with a lower risk of SIDS. But why? And for how long?
Several studies have found that infants are less likely to die of SIDS when they are sleeping in the same room as their parents, and this is the basis of the recommendation to roomshare with your baby.
One of the largest case control studies of SIDS combined data from 20 different regions of Europe, allowing researchers to look at 745 SIDS cases and the risk factors associated with them (12). The authors of this study estimated that 36% of SIDS deaths could have been prevented if infants weren’t placed for sleep in a separate room, and 16% could have been prevented if infants weren’t bedsharing. Together, this means that if all of the infants in this study had slept in the same room as their parents, but not the same bed, more than half of their deaths might have been prevented. (As a side note, I think it is interesting that there seems to be much more angst and controversy over the recommendation to not bedshare than the recommendation to roomshare, even though parents may struggle to follow both.)
This same protective effect of roomsharing has been observed in several other case control studies conducted in Scotland, England, and New Zealand (13-15). The English study found a dramatic 10-fold increased risk of SIDS associated with babies sleeping in their own room. Importantly, at least one study has shown that when infants share a bedroom with other children, it is not protective (15). Instead, the presence of an adult caregiver seems to be important.
It’s important to point out that these case control studies can only show correlations, not causation, and the factors surrounding these unexpected infant deaths are complex. It’s possible that it isn’t sleeping in a separate room that is the true risk factor, but rather that families who tend to move their babies to separate rooms are more likely to have some other unrelated and unidentified risk factor. We just don’t know. Still, this is a consistent finding, and there is a plausible mechanism for protection from SIDS.
How might roomsharing protect infants from SIDS?
SIDS is officially defined as the sudden death of an infant under one year of age when the cause of death remains unexplained after investigation. In other words, we don’t know what causes SIDS, and it may be that there are several different mechanisms. Current hypotheses about causes of SIDS focus on respiratory and cardiovascular control and failure of arousal responses.
Some factors that increase the risk of SIDS are also known to impair infant arousals from sleep. For example, preterm birth, exposure to tobacco smoke during pregnancy or after birth, and infection all decrease an infant’s arousals and increase the risk of SIDS. The same is true for infants who sleep prone (on tummy) or are formula-fed. These babies sleep more deeply and are more difficult to arouse, leaving them more vulnerable to SIDS (16).
Those factors have all been subject to controlled studies of infant arousals, but we know less about roomsharing. Researchers hypothesize that babies sleeping in closer proximity to their mothers have more sensory exchange (from noises, a touch when a parent checks the baby, etc.) and thus spend more time in light sleep and have more short arousals that protect them from SIDS (14, 15, 17). These brief awakenings were probably too short to be captured by the actigraphs (which only recorded awakenings longer than 5 minutes) in the recent Israeli study, but they may have been one reason why the mothers woke more often.
This brings us full circle to the problem of roomsharing sometimes compromising sleep for parents. The very thing about roomsharing that is disruptive to parents might actually be protecting their babies.
How long is roomsharing important? Unfortunately, there aren’t good data on this question. Most studies that find a protective effect of roomsharing haven’t analyzed their data to specifically test if there is an age where the risk of sleeping separately disappears. To my knowledge, the only study to look at this question was published almost 20 years ago in New Zealand (15). It compared the protection of roomsharing in infants aged less than 13 weeks, 13-19 weeks, and 20 weeks and older, and found that roomsharing was equally protective in these three age groups. We don’t have data to tell us if that protection becomes less important at 5 months or 6 months or beyond.
What we do know is that most SIDS cases occur between 1 and 4 months of age, with less than 10% occurring after 6 months of age (18). Any protective effects of roomsharing are probably most important in those first 6 months of life.
How does roomsharing with your baby affect sleep?
A study published last month in the journal Sleep Medicine is the largest and best-designed study to investigate this question (5). The study followed 153 middle-class Israeli families, all consisting of married couples having their first baby. Sleep was evaluated in the mothers in the third trimester of pregnancy and again in both mothers and babies at 3 months and 6 months postpartum. The moms and babies wore actigraphs for 5 nights in a row at each time point, and the mothers also kept sleep diaries for each night. I do not understand why, in 2015, researchers don’t care more about fathers’ sleep, but it wasn’t even considered in this study.
The families in this study weren’t advised where their babies should sleep – they each made their own choices. At 3 months, most babies (76%) were sleeping in their parents’ room. At this age, 58% of infants were fully breastfed and 25% were partially breastfed. At 6 months, 50% were roomsharing; 32% were fully breastfed, and 28% were partially breastfed.
Bedsharing didn’t seem to be common in this study – just 7 and 8 infants were reported to be bedsharing at 3 and 6 months, respectively. However, this was determined in a single question asking moms where the baby slept, with the following choices: (a) Infant crib in a separate room; (b) Infant crib in parent’s room; or (c) parents’ bed. I’d be willing to bet that a lot of roomsharing infants were also partial bedsharers, maybe coming into bed with parents at some point in the night, and that wasn’t captured in this study. Regardless, the paper reports no differences in sleep patterns between roomsharing and bedsharing infants, so these two groups were combined for all the data analyses.
Feeding method mattered in this study. Breastfeeding moms and babies had more fragmented sleep, and babies breastfed at 6 months were more likely to be roomsharing at that age. Because of this effect, feeding method was controlled for in the analysis of sleep patterns.
So, how did roomsharing affect sleep? The roomsharing moms had more fragmented sleep than those whose babies slept in a separate room. They didn’t sleep less overall – both groups of moms had an average nighttime sleep of just under 6.5 hours – but roomsharing moms woke more often and spent more time awake during the night. Their longest uninterrupted sleep period during the night was on average 2 hours and 20 minutes at both 3 and 6 months, compared with about 2 hours and 47 minutes in the moms who didn’t roomshare. Again, this difference was found after accounting for the effects of breastfeeding or formula-feeding on sleep.
Does this difference in sleep patterns really matter? The researchers asked the moms to rate the quality of their sleep from 1 to 10, with 10 being the best sleep. At 3 months, the roomsharing moms rated their sleep quality a bit lower than the solitary sleeping moms (6.58 vs. 7.20, p<0.05). At 6 months, there was no significant difference in these ratings. The roomsharing moms did nap more during the day at 6 months, so that might have helped them compensate. This makes the difference in sleep quality appear to be pretty small, but it’s also important to remember that all of these measures are reported as averages. Some moms might find that roomsharing really disrupts their sleep and others not at all, so the average doesn’t tell the whole story.
One interesting finding that I didn’t see reported in the news stories on this study: Roomsharing was associated with a lower risk of depression at 3 months and lower risk of anxiety at 6 months. This doesn’t mean that roomsharing directly improves mothers’ mental health – it’s just a correlation – but it is worth noting. Other studies have found the opposite – that roomsharing or bedsharing are associated with greater risk of depression (6,7).
What about the babies? How did they sleep? In the Israeli study, roomsharing or sleeping in a different room actually didn’t seem to affect the babies’ sleep as measured by the actigraphs. However, when babies slept separately, their moms weren’t aware of some of their wakings. That is, the actigraph recorded some wakings that weren’t noticed by the moms, so the babies must have put themselves back to sleep without calling for help from a parent in the next room. With roomsharing, those wakings are more likely to wake the mother and disrupt her sleep.
One of the big limitations of this study was that it didn’t ask moms why they chose their sleep arrangements. However, roomsharing or not wasn’t related to the babies’ sleep patterns so was most likely driven by maternal preference. Supporting that, the moms who had a harder time sleeping in pregnancy and at 3 months were more likely to roomshare at 6 months. We have no way of knowing if the roomsharing moms would actually sleep better if their babies were in a separate room. Maybe they made that choice because it was the best way for them to sleep. Maybe putting their babies in a separate room would have caused more anxiety and interfered with their sleep in some other way. Sleep is very personal, and where a baby sleeps in a complex decision.
Still, other studies, including across cultures, have found this general pattern that roomsharing or bedsharing is associated with the baby waking more often (or more noticeably) during the night, which in turn is likely to wake the parents (8-11). I also wonder how roomsharing might affect the development of self-soothing and consolidation of sleep, since sleeping separately likely gives babies more opportunities to fall back to sleep on their own after a normal night waking.
So, what’s a parent to do?
The AAP recommends that parents roomshare with their babies for the first year, and at least the first 6 months, and that’s a great goal. I also think that we have to recognize that sleep deprivation is serious; it can threaten both mental and physical health and even be deadly if it causes a car accident, for example. Some parents may really struggle to get enough sleep with the baby in the room, as noted by Katherine Stone of Postpartum Progress in response to the new AAP recommendations. It’s important to be informed about the protective association of roomsharing, but if you’re struggling with this recommendation, it’s worth weighing the options with your pediatrician.
For my part, I had planned to roomshare with BabyM for the first 6 months. It worked very well for the first few months, but between about 4 and 5 months, we went through a rough patch with sleep. He seemed to wake more often in response to our noises, and I was waking more listening to his noises. I had been coping well with sleep so far, but at that stage, I think I really hit a wall of cumulative sleep debt where I felt like I wasn’t functioning well during the day at all. Around 5 months, we moved BabyM out of our room. It was clear that this gave him space to do more self-soothing during the night, and he had fewer wakings that required our help. I also slept better, and it felt like our whole family functioned better.
All else being equal, I knew that BabyM would have been safer sleeping in our room for longer, night wakings and all. But all else is never equal in parenting, and there could be some real risks associated with my sleep deprivation. And while there might have been a slight risk to moving him to his own room, his overall risk of SIDS at that age was very, very low, considering that he was breastfed, sleeping in a safe crib, and living in a non-smoking family. But still, after seeing the 2016 AAP recommendations, I think I would have tried to keep him in our room much longer, certainly until 6 months. That highlights how useful these recommendations can be — sometimes just having a specific guideline can help us stick to a plan even when things get tough.
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