|Where a baby sleeps is not as simple as current
medical discourse and recommendations against cosleeping in some western societies
want it to be. And there is good reason why. I write here to explain why the
pediatric recommendations on forms of cosleeping such as bedsharing will and should
remain mixed. I will also address why the majority of new parents practice
intermittent bedsharing despite governmental and medical warnings against it.
Definitions are important here. The term cosleeping refers to any situation in
which an a committed adult caregiver, usually the mother, sleeps within close enough
proximity to her infant so that each, the mother and infant, can respond to each
other's sensory signals and cues. Room sharing is a form of cosleeping, always
considered safe and always considered protective. But it is not the room itself that
it is protective. It is what goes on between the mother (or father) and the infant
that is. Medical authorities seem to forget this fact. This form of cosleeping is
not controversial and is recommended by all.
Unfortunately, the terms cosleeping, bedsharing and a well-known dangerous form
of cosleeping, couch or sofa cosleeping, are mostly used interchangeably by medical
authorities, even though these terms need to be kept separate. It is absolutely
wrong to say, for example, that "cosleeping is dangerous" when
room-sharing is a form of cosleeping and this form of cosleeping (as at least three
epidemiological studies show) reduce an infant's chances of dying by one half.
Bedsharing is another form of cosleeping which can be made either safe or unsafe,
but it is not intrinsically one nor the other. Couch or sofa cosleeping is, however,
intrinsically dangerous as babies can and do all too easily get pushed against the
back of the couch by the adult, or flipped face down in the pillows, to suffocate.
Often news stories talk about "another baby dying while cosleeping" but
they fail to distinguish between what type of cosleeping was involved and, worse,
what specific dangerous factor might have actually been responsible for the baby
dying. A specific example is whether the infant was sleeping prone next to their
parent, which is an independent risk factor for death regardless of where the infant
was sleeping. Such reports inappropriately suggest that all types of cosleeping are
the same, dangerous, and all the practices around cosleeping carry the same high
risks, and that no cosleeping environment can be made safe.
Nothing can be further from the truth. This is akin to suggesting that because
some parents drive drunk with their infants in their cars, unstrapped into car
seats, and because some of these babies die in car accidents that nobody can drive
with babies in their cars because obviously car transportation for infants is fatal.
You see the point.
One of the most important reasons why bedsharing occurs, and the reason why
simple declarations against it will not eradicate it, is because sleeping next to
one's baby is biologically appropriate, unlike placing infants prone to sleep or
putting an infant in a room to sleep by itself. This is particularly so when
bedsharing is associated with breast feeding.
When done safely, mother-infant cosleeping saves infants lives and contributes to
infant and maternal health and well being. Merely having an infant sleeping in a
room with a committed adult caregiver (cosleeping) reduces the chances of an infant
dying from SIDS or from an accident by one half!
In Japan where co-sleeping and breastfeeding (in the absence of maternal smoking)
is the cultural norm, rates of the sudden infant death syndrome are the lowest in
the world. For breastfeeding mothers, bedsharing makes breastfeeding much easier to
manage and practically doubles the amount of breastfeeding sessions while permitting
both mothers and infants to spend more time asleep. The increased exposure to
mother's antibodies which comes with more frequent nighttime breastfeeding can
potentially, per any given infant, reduce infant illness. And because co-sleeping in
the form of bedsharing makes breastfeeding easier for mothers, it encourages them to
breastfeed for a greater number of months, according to Dr. Helen Ball's studies
at the University of Durham, therein potentially reducing the mothers chances of
breast cancer. Indeed, the benefits of cosleeping helps explain why simply telling
parents never to sleep with baby is like suggesting that nobody should eat fats and
sugars since excessive fats and sugars lead to obesity and/or death from heart
disease, diabetes or cancer. Obviously, there's a whole lot more to the story.
As regards bedsharing, an expanded version of its function and effects on the
infant's biology helps us to understand not only why the bedsharing debate refuses
to go away, but why the overwhelming majority of parents in the United States (over
50% according to the most recent national survey) now sleep in bed for part or all
of the night with their babies.
That the highest rates of bedsharing worldwide occur alongside the lowest rates
of infant mortality, including Sudden Infant Death Syndrome (SIDS) rates, is a point
worth returning to. It is an important beginning point for understanding the
complexities involved in explaining why outcomes related to bedsharing (recall, one
of many types of cosleeping) vary between being protective for some populations and
dangerous for others. It suggests that whether or not babies should bedshare and
what the outcome will be may depend on who is involved, under what condition it
occurs, how it is practiced, and the quality of the relationship brought to the bed
to share. This is not the answer some medical authorities are looking for, but it
certainly resonates with parents, and it is substantiated by scores of studies.
Recently, the American Academy of Pediatrics (AAP) SIDS Sub-Committee for whom I
served (ad hoc) as an expert panel member recommended that babies should sleep close
to their mothers in the same room but not in the same bed. While I celebrated this
historic room-sharing recommendation, I disagreed with and worry about the
ramifications of the unqualified recommendation against any and all bedsharing.
Further, I worry about the message being given unfairly (if not immorally) to
mothers; that is, no matter who you are, or what you do, your sleeping body is no
more than an inert potential lethal weapon against which neither you nor your infant
has any control. If this were true, none of us humans would be here today to have
this discussion because the only reason why we survived is because our ancestral
mothers slept alongside us and breastfed us through the night!
I am not alone in thinking this way. The Academy of Breast Feeding Medicine, the
USA Breast Feeding Committee, the Breast Feeding section of the American Academy of
Pediatrics, La Leche League International, UNICEF and WHO are all prestigious
organizations who support bedsharing and which use the best and latest scientific
information on what makes mothers and babies safe and healthy. Clearly, there is no
What we do agree on, however, is what specific "factors" increase the
chances of SIDS in a bedsharing environment, and what kinds of circumstances
increase the chances of suffocation either from someone in the bed or from the bed
furniture itself. For example, adults should not bedshare if inebriated or if
desensitized by drugs, or overly exhausted, and other toddlers or children should
never be in a bed with an infant. Moreover, since having smoked during a pregnancy
diminishes the capacities of infants to arouse to protect their breathing, smoking
mothers should have their infants sleep alongside them on a different surface but
not in the same bed.
My own physiological
studies suggest that breastfeeding mother-infant pairs exhibit increased
sensitivities and responses to each other while sleeping, and those sensitivities
offers the infant protection from overlay. However, if bottle feeding, infants
should lie alongside the mother in a crib or bassinet, but not in the same bed.
Prone or stomach sleeping especially on soft mattresses is always dangerous for
infants and so is covering their heads with blankets, or laying them near or on top
of pillows. Light blanketing is always best as is attention to any spaces or gaps in
bed furniture which needs to be fixed as babies can slip into these spaces and
quickly to become wedged and asphyxiate. My recommendation is, if routinely
bedsharing, to strip the bed apart from its frame, pulling the mattress and box
springs to the center of the room, therein avoiding dangerous spaces or gaps into
which babies can slip to be injured or die.
But, again, disagreement remains over how best to use this information. Certain
medical groups, including some members of the American Academy of Pediatrics (though
not necessarily the majority), argue that bedsharing should be eliminated
altogether. Others, myself included, prefer to support the practice when it can be
done safely amongst breastfeeding mothers. Some professionals believe that it can
never be made safe but there is no evidence that this is true.
More importantly, parents just don't believe it! Making sure that parents are in
a position to make informed choices therein reflecting their own infant's needs,
family goals, and nurturing and infant care preferences seems to me to be
Our Biological Imperatives
My support of bedsharing when practiced safely stems from my research knowledge
of how and why it occurs, what it means to mothers, and how it functions
biologically. Like human taste buds which reward us for eating what's overwhelmingly
critical for survival i.e. fats and sugars, a consideration of human infant and
parental biology and psychology reveal the existence of powerful physiological and
social factors that promote maternal motivations to cosleep and explain parental
needs to touch and sleep close to baby.
The low calorie composition of human breast milk (exquisitely adjusted for the
human infants' undeveloped gut) requires frequent nighttime feeds, and, hence, helps
explain how and why a cultural shift toward increased cosleeping behavior is
underway. Approximately 73% of US mothers leave the hospital breast feeding and even
amongst mothers who never intended to bedshare soon discover how much easier breast
feeding is and how much more satisfied they feel with baby sleeping alongside often
in their bed.
But it's not just breastfeeding that promotes bedsharing. Infants usually have
something to say about it too! And for some reason they remain unimpressed with
declarations as to how dangerous sleeping next to mother can be. Instead,
irrepressible (ancient) neurologically-based infant responses to maternal smells,
movements and touch altogether reduce infant crying while positively regulating
infant breathing, body temperature, absorption of calories, stress hormone levels,
immune status, and oxygenation. In short, and as mentioned above, cosleeping
(whether on the same surface or not) facilitates positive clinical changes including
more infant sleep and seems to make, well, babies happy. In other words,
unless practiced dangerously, sleeping next to mother is good for infants. The
reason why it occurs is because… it is supposed to.
Recall that despite dramatic cultural and technological changes in the
industrialized west, human infants are still born the most neurologically immature
primate of all, with only 25% of their brain volume. This represents a uniquely
human characteristic that could only develop biologically (indeed, is only possible)
alongside mother's continuous contact and proximity—as mothers body proves still
to be the only environment to which the infant is truly adapted, for which even
modern western technology has yet to produce a substitute.
Even here in whatever-city-USA, nothing a baby can or cannot do makes
sense except in light of the mother's body, a biological reality apparently
dismissed by those that argue against any and all bedsharing and what they call
cosleeping, but which likely explains why most crib-using parents at some point feel
the need to bring their babies to bed with them —findings that our mother-baby
sleep laboratory here at Notre Dame has helped document scientifically. Given a
choice, it seems human babies strongly prefer their mother's body to solitary
contact with inert cotton-lined mattresses. In turn, mothers seem to notice and
succumb to their infant's preferences.
There is no doubt that bedsharing should be avoided in particular circumstances
and can be practiced dangerously. While each single bedsharing death is tragic, such
deaths are no more indictments about any and all bedsharing than are the three
hundred thousand plus deaths or more of babies in cribs an indictment that crib
sleeping is deadly and should be eliminated. Just as unsafe cribs and unsafe ways to
use cribs can be eliminated so, too, can parents be educated to minimize bedsharing
Moving Beyond Judgments to Understanding
We still do not know what causes SIDS. But fortunately the primary factors that
increase risk are now widely known i.e. placing an infant prone (face down) for
sleep, using soft mattresses, maternal smoking, overwrapping babies or blocking air
movement around their faces. In combination with bedsharing, where more vital normal
defensive infant responses and may be more important to an infant (like the ability
to arouse to bat a blanket which momentarily falls to cover the infants face when
its parent moves or turns) these risks become exaggerated especially amongst
unhealthy infants. When infants die in these obviously unsafe conditions, it is here
where social biases and the sheer levels of ignorance associated with actually
explaining the death become apparent. A death itself in a bedsharing environment
does not automatically suggest, as many legal and medical authorities assert, that
it was the bedsharing, or worse, suffocation that killed the infant. Infants in
bedsharirng environments, like babies in cribs, can still die of SIDS.
It is a shame and certainly inappropriate that, for example, the head
pathologists of the state of Indiana recommends that other pathologists assume SIDS
as a likely cause of death when babies die in cribs but to assume asphyxiation if a
baby dies in an adult bed or has a history of "cosleeping". By assuming before
any facts are known from the pathologist's death scene and toxicological report
that any bedsharing baby was a victim of an accidental suffocation rather than from
some congenital or natural cause, including SIDS unrelated to bedsharing, medical
authorities not only commit a form of scientific fraud but they victimize the doomed
infant's parents for a third time. The first occurs when their baby dies, the second
occurs when health professionals interviewed for news stories (which commonly
occurs) imply that when a baby dies in a bed with an adult it must be due to
suffocation (or a SIDS induced by bedsharing). The third time the parents are
victimized is when still without any evidence medical or police authorities suggest
that their baby's death was "preventable," that their baby would still be
alive if only the parents had not bedshared. This conclusion is based not on the
facts of the tragedy but on unfair and fallacious stereotypes about bedsharing.
Indeed, no legitimate SIDS researcher nor forensic pathologist should render a
judgment that a baby was suffocated without an extensive toxiological report and
death scene investigation including information from the mother concerning what her
thoughts are on what might or could have happened.
Whether involving cribs or adult beds, risky sleep practices leading to infant
deaths are more likely to occur when parents lack access to safety information, or
if they are judged to be irresponsible should they choose to follow their own and
their infants' biological predilections to bedshare, or if public health messages
are held back on brochures and replaced by simplistic and inappropriate warnings
saying "just never do it." Such recommendations misrepresent the true
function and biological significance of the behaviors, and the critical extent to
which dangerous practices can be modified, and they dismiss the valid reasons why
people engage in the behavior in the first place.