The co-sleeping (or bed sharing) debate rages on, and for good reason. We (pediatricians and parents alike) want to keep our babies safe. With this most recent article on sleep safety and co-sleeping however, the conclusion seems a bit misleading. The unsafe sleep practices cited in this article, such as loose bedding, pillows, or sleeping with an intoxicated adult, clearly put an infant at risk for sleep related death.
But why is co-sleeping tied to unsafe sleep practices? They are not synonymous.
It led me to re-visit and re-read the significant studies on SIDS, bed sharing, and the AAP Policy statement on safe sleep recommendations. After review of the studies, the AAP concludes that “bed sharing, as practiced in the US, is more hazardous than an infant sleeping on a separate surface.” It seems the only logical and safe conclusion that can be drawn, but the studies are inherently limited. Limited by grouping any kind of sleep that is not in a crib as co-sleeping. This includes infants placed on water beds, couches, or other unsafe surfaces.
Clearly, not all co-sleeping is created equal.
Can co-sleeping be untied from the umbrella of unsafe sleep practices? Can we outline safe sleep guidelines for families who choose to co-sleep? Just as we outline safe crib sleeping guidelines, shouldn’t the same be done when it comes to co-sleeping?
Universal unsafe sleep practices include but are not limited to: placing a baby to sleep on his stomach, being exposed to second hand smoke, placing in infant on a too soft mattress, using loose blankets or pillows, allowing someone other than mom to sleep with the baby…the list goes on. These unsafe sleep practices apply to both crib and parental bed sleeping.
So, how can we study this better? How can we untie co-sleeping from “unsafe sleeping” and instead provide education and support to those families who choose to co-sleep?
I am adamant about sleep safety when it comes to infants. I would never want to recommend something that could potentially harm an infant. Herein lies the dilemma. Families co-sleep. They do. Speaking from personal experience, I can understand why and I believe it can be a valid and healthy sleep arrangement for babies and children. Only if done safely.**
I ask all these questions because I believe as parents, as educators, as doctors…we need more answers and more studies.
What do you think? Can co-sleeping be done safely? What is your experience with co-sleeping?
**Safe co-sleeping guidelines: Prepare your bed as you would prepare a crib for safety. Think bare, firm mattress with tight fitting sheet. No loose blankets or pillows. Place queen or king sized mattress on floor, pushed up against wall. Baby should sleep between mother and wall. No one else should ever sleep with an infant. Mothers should not sleep with baby if she smokes, has been drinking alcohol, or is under the influence of any sedating medications. Baby should always be placed on back to sleep.**
I've never co-slept, and when Kate was just a few months old and we were waiting for an upper GI, a dad was in there with his daughter because he had rolled over onto her while sleeping and broke her leg.
I know people who do it, and there were early mornings with Kate when I'd try to bring her into bed, but my kids have always equated our bed to playtime, so it really never was a viable option for us.
I did some co-sleeping with Q, particularly in the early morning hours, but I'm not a very deep sleeper so I always felt an awareness of him while I slept. I'm open to doing some co-sleeping with my daughter when she arrives, but it also depends on what's best for her, how she sleeps best. So, I think it's not for everyone, but I agree that it can be done safely and it's a shame that people are made to feel like they are doing something so terrible.
I co-sleep with my kids . I tried the crib, it didnt work out cos the baby kept screaming to be let out and would only sleep in my arms. Since I had to go to work I just put the baby in bed with me. To make sleep safe, I had to remove all pillows and extra bedding that I would normally sleep with.
There are definitely safe ways to carry out co-sleeping. It has been the norm in most Asian countries (I live in Singapore but originally came from the Philippines). I co-slept with my baby until she was about 10 months or so. It was the only way for both of us to get adequate sleep. Then we transitioned her to the crib but I still sleep in the same room up to now. So yes, I am still co-sleeping with my 18 month old toddler.
I agree, there should be set guidelines (like the ones you enumerated above) and more SUPPORT for safe co-sleeping practices. Accidents are bound to happen, to co-sleepers and non co-sleepers alike, hence, the need for SLEEP SAFETY guidelines.
Just like breastfeeding, co-sleeping is not for everyone.
There is certainly a spectrum of co-sleeping that ranges from extremely dangerous to mildly hazarous. Same can be said for driving, but driving is essential to daily life so the risk is necessary and the attempt is made to minimize the risk. If there were a completely safe alternative to driving that resulted in the same result (i.e. Getting from A to B in the same amount of time) with absolutely no risk, would any rational person choose to drive?
What is mom rolls over on baby? What if she nurses in this position and then falls asleep and suffocates baby? Why is the risk of death (even though it may be small if done correctly, it is MUCH greater than crib sleeping) acceptable when a completely safe alternative exists?
P.s. Great blog! I came up with a similar concept and stumbled upon yours just recently.
I co-slept with all three of my children. With the third we didn't even bother setting up the crib as we knew it wouldn't get used. We set up some of the guidelines you suggested – no big comforters or pillows and absolutely no co-sleeping if you are intoxicated or on medication. While I was co-sleeping I was nursing so drinking and medicated weren't really options.
My children went straight from our bed at about 15 months to a twin mattress on the floor in our room and then eventually to the bed in their room.
What can I say it worked for us. I never once felt like I was putting my child in any danger and I loved that I shared so many special moments with my child during that first year.
Great post. Always a long discussion when a family chooses to co-sleep. Challenging when recommendations attempt to be black and white in a gray world. In my early years of practice I might have agreed with Dr. Dad. Llistening to patients, determining their priorities and informing them of the risks and benefits when the evidence is messy is best in the long run.
Great guidelines on what constitutes safe co-sleeping! I wonder what the percentage of parents who do it safely are? Not to be negative, but I doubt it's in the majority. One thing you left off your list (although you've been supportive of them in the past) are co-sleepers which seem to combine the best of both worlds (safety of baby sleeping in it's own safe environment, yet within arm's reach of Mom!).
We're more of a partial co-sleeping family. Our kids start out the night in their own beds, but end up in our room at some point. My son then sleeps on a mattress on the floor next to our bed and my daughter come in bed next to me since I still nurse her. Since my children are fairly close in age, partial co-sleeping was the only way that we all would get the sleep we needed.
@Liz: This is why I firmly believe only baby and mom should co-sleep.
@flyrish:I agree. Every baby comes with unique set of sleep needs, and it's best to see what will work for your baby and you…safely
I finally ended up co-sleeping with my son, after much angst. So glad we did. My daughter? Didn't need it.
@Janie: Love your comment and concur on all counts.
@Dr.Dad: Thank you for your comment. So great to see a young physician and parent blogging, keep up the good work! You bring up salient points, however, not so sure the "completely safe" alternative is completely so. We are constantly revising our sleep safety rec's as crib recalls, new evidence comes to light. It still has yet to be shown that safe co-sleeping is a greater risk to infants than crib sleeping. We need more valuable and pertinent studies.
@making it work mom: This is pretty much how it played out with my son too. The nice thing was, the transition to his own bed was fairly easy. Worked for us too.
@Dr_Som: you summed it up well, it is challenging to try and give black and white rec's when the issue is so gray. Thanks for your insight and comment.
Regardless, co-sleeping. (rather than crib sleeping) is the alternative and it is not as safe. We had three babies die last month in a town of 250K from co-sleeping gone bad. You may advocate and explain a very specific, ultra-safe version of co-sleeping to your patient, but all the extra safety measures are lost when your patient tells their friend simply "our doctor says co-sleeping is fine!" You can advoate for safe co-sleeping but that's not what nds up being practiced the vast majority of the time.
I have always been on the paranoid side and never co-slept with any of my kids until my youngest. He was very clingy and had reflux and nursed all the time and I was exhausted. He slept with me often, I think it was out of survival for us!
This is an interesting article. I would like to see more research on this matter. However, the flaw in co-sleeping generally lies in the fact that most do not follows the guidelines as indicated. Most who co-sleep put the baby to sleep between mom and dad and they use pillows, sheets and the rest. They state that the baby doesn't move in his/her sleep and thus it is safe. Perhaps if co-sleepers followed the sleep guidelines, the babies would be as safe as those babies in a crib; however, where are the co-sleepers that follow these guidelines?
How many mothers do you think actually follow your co-sleeping guidelines? The harsh reality is they aren't – even among the best intentions. I have yet to meet a mother who always keeps blankets and pillows out of the bed. They're sleeping on quilted mattresses at best, pillow tops at worst. Some have a glass or two of wine or a beer now and then. Many take medications for allergies, colds, antidepressants – all which can interfere with normal arousal. And what about being "over-tired"? I have yet to meet a mother with an infant under four months of age who was never overtired. Instead of trying to package and "manage" a seemingly endless amount of risks, why not place the baby in a safe crib or bassinet *next* to the bed? Research has shown that a baby can receive the *exact* same benefits. This is particularly important for young infants who are less likely to live through the risks inherent in a sleeping environment made for adults.
I actually never referred to it as "co-sleeping" when my kids were babies and just would not sleep in their cribs no matter what I did and out of desperation they ended up in my bed. I used all precautions and basically really didn't sleep for the first year of each of my three children. However, I do realize the serious risk I took and looking back it scares me.
@Dalia: It wasn't something I set out to do either. My son would not sleep in his crib nor a bedside cosleeper. I tried and was exhausted. He wanted my arms 24/7. He needed that sleep touch and comfort. After much angst and months of sleep deprivation, I realized I could make safe sleep environment for him next to me. Once we did, we all slept much better.
My daughter was a great sleeper from the start. She slept in a bassinet next to our bed. I loved that too. Every baby is different, that's for sure.
I'd like to see statistics comparing babies who died while engaged in safe bedsharing (which would be impossible – how does one quantify that?) vs. babies who died in a crib, particularly with a bottle propped or unsafe blankets/pillows/bumpers in there (same thing – impossible to truly quantify). Cribs can be used poorly as well, but studies do show that a breastfeeding mother and her baby regulate one another's breathing and that mothers are very much in tune with their babies while asleep. That said, it ain't for everyone for sure, and it is practiced unsafely far too often. But I absolutely have seen/heard tragic stories in the media of babies dying in cribs as well. There is no option that comes with guarantees – if someone could guarantee that a baby would never ever die by sleeping in a certain way, we'd have our perfect answer, wouldn't we?
More studies would be great, I agree.
I think the illegal drug/drunk driving analogies are extreme examples, but they do illustrate the point I am trying to make – that you can minimize risk but not eliminate it when you are doing something inherently dangerous and despite one's intention or precautions you are doing something risky.
Babies die in cribs, too. The difference, however, is that if you follow all of the safe crib guidelines (right crib construction, flat, tight sheet, no pillows, bumpers, stuffed animals, etc.) then you can be GUARENTEED that your baby is as safe as possible (not that they won't die but that you have done everything you possibly can to prevent that). On the other hand, you can significantly minimize the risk with co-sleeping, but you cannot eliminate the possibility that something terrible could happen (mom rolls over, baby suffocates while nursing on a drowsy/sleeping mom, etc.). With a crib, at the end of the day you can confidently tell yourself that you have done everything you can to protect your child. You cannot say the same for co-sleeping because there is a safer option available.
p.s. Thanks for the discussion. I am sincerely enjoying it and I hope others are too. I appreciate your experience as a mom and someone who has been in the trenches as a pediatrician much longer than myself! (and I am incredibly jealous of a 20+ comment blog post, something I hope for someday myself!)
@Doctor Dad: Well, I do have you to thank for that
(the 20+comments).
Melissa – you really can't compare a "safe" crib to an adult bed. They are unlike things. Parents aren't getting into cribs to sleep with their infants; they are bringing the infant to sleep with them. Cribs are designed and manufactured with infants in mind; adult beds were never intended to accommodate infants and this is part of what makes them inherently dangerous. For example, the design of the adult mattress surface is contraindicated for infants and cannot be found in crib mattresses available for purchase. Further, I can tell you that the latest research and Child Fatality Review statistics from across the US are showing it is *very* rare for a baby to die a sleep related death (SIDS, suffocation) in a safe crib environment. The same cannot be said for bedsharing.
“The risk of suffocation was approximately 40 times higher for infants in adult beds compared with those in cribs. The increase in risk remained high even when overlying deaths were discounted (32 times higher) or the estimate of rates of bedsharing among living infants doubled (20 times higher). “(Pediatrics. 2003 Oct;112(4):883-9.Where should infants sleep? A comparison of risk for suffocation of infants sleeping in cribs, adult beds, and other sleeping locations. Scheers NJ, Rutherford GW, Kemp JS.)
Thank you for all your comments, insights, and important information.
These studies are vital to infant safety. However, the limitations of them are real. Safe co-sleeping has not been studied as its own entity. It is often grouped with very unsafe sleep practices.
This is exactly why I think we need safe co-sleeping guidelines and support for co-sleeping families. Sleep safety is paramount and I do believe this can be achieved in both a safe crib and a safe co-sleeping environment.
Dr. Mom,
Given that this is a public forum, I'd like to respectfully offer a few final points.
There are dozens of studies that have looked at infant sleep related deaths. A few do show bedsharing to be of low risk under certain conditions but a dozen+ others do not. The one thing that does seem to stand out is that the danger is especially notable for babies under 4 months of age. This has shown to be true even in "safe" (non-smoking, non-dangerous bedding, etc.)environments.
The research is there – if you want to accept the information it has to offer.
As a pediatric professional, you are certainly very entitled to your opinions but I think it would be fair and ethical to note that the NICH, AAP, First Candle/SIDS Alliance, CJ Foundation for SIDS and hundreds of experts and child fatality review teams that deal with infant death every across the US would disagree with your statements.
I appreciate your respectful tone and sharing of information, however, I feel compelled to respond because I am not simply begging these questions to be contrary or controversial.
Bed sharing is common in the US and fits many families for a variety of reasons.
It has not all been said and done and there are many experts, researchers, and medical professionals who feel the same.
The study you speak of did control for maternal smoking but not for other confounding "unsafe" bedsharing practices.
I realize our aim is the same: infant sleep safety. So I do hope more studies, information, and education continues to be brought forth and provided to families.
This is definitely a complex issue, as is highlighted by this very recent news article about a mom in Reno, Nevada who lost her baby:
Reno mom whose baby died raises co-sleeping issue http://bit.ly/ln5kY5
The article seems to imply that five other deaths in the county in the past year were related to cosleeping too.
Thank you for sharing this story @About Pediatrics. This is a devastating and tragic story indeed. Yes, the issue is complex. It makes me wonder how we can make our public health message stronger and more relevant.
I would really appreciate an article about co-sleeping with an older child. A bit of a background; my husband and I are both disabled and though a horrific misunderstanding in January of 2009, Social Services took my two year old away from us, kidnapped him.:
http://www.mamasick.com/2010/09/finally-ready-to-tell-our-story/
Every since then, this little boy who would sleep through the night even if he was sick has never had a good sleep since. He has been dx with Tourette's Syndrome, OCD, Anxiety and some possible sensory issues.
He has also been the victim of two bullying incidents.
He started to sleep in bed with me when he was so afraid to sleep alone, he would tic until one or two in the morning and finally pass out. I could not bear to see him him suffer. When I took him in my bed, he was finally able to relax and sleep. He is scared to death, night or day, to be left in a room alone.
We have tried therapists and hypnotherapists and since he is not yet five, we are reluctant to medicate him.
All of those who are still shaking their head at me, you could not let yourself in good conscince (sp?) let your child suffer the way mine has. You would do anything you can to give him peace.
However I know that this can not always be. Any advice would be appreciated.
I can only share from my personal experiences. I am not a doctor or professional…just a mom of seven kids. I co-slept with all five of the children I gave birth to, keeping safety in mind. They were never injured or harmed in any way.I found I was more rested than my early attempts at placing them in the crib and getting up to nurse every few hours. My children seemed more content and nursed less frequently through the night when they slept by my side, rather than alone in a crib.
I really believe it to be an individual choice. Parents have to examine all aspects and determine what is the safest and healthiest experience for their child and family! Do you take medications which would prevent you from easily awakening? Are you a heavy or light sleeper? Are you able to safely remove all bedding which could prove to be detrimental to your child's health?
There are many children who die nationwide in their own cribs…alone. Stories of children who die due to co sleeping. Accidents happen in many forms, and the best we can do as parents is to educate ourselves, take the most safety precautions we can, and live our lives.
I am thankful we co-shared our bed with our children!There are many successful stories of co-sleeping and family beds, but it is not for everyone.
I can tell you there is nothing sweeter as a parent than to have your teen come into your room, eyes full of tears and say "Mama I need you to hug me" as she crawls in beside you, just like she did when she was little. She is an adult now and says knowing she could sleep with us when needed, helped her feel more secure as a child and led her to being an independent adult! We considered the family bed a safe and healthy part of their childhood.
I co-bedded with all four of my children and would do it again. I nursed and waking up every 3-4 hours to feed is exhausting. It was the only way I could sleep and still have energy to take care of the kids during the day. I never came anywhere near smothering any of my kids. I was one of those moms that would wake up if I heard an change in their breathing so no I would not have smothered my baby. I also would wake up when they had a fever. I could feel it in their little hands and feet.
I am inclined to think that it is parents under some kind of influence that hurt their child while sleeping.
I had very happy well adjusted kids and people always commented on how happy they were and how well behaved they were.
Just saying. It worked for me. I am glad I did it. I was told in the birthing classes that you would only hurt your child if you were under the influence and not to sleep with them at that time.
Dr Mom,
I am not sure if you are still monitoring this specific topic but I want to chime in. I may go to your contact. I feel that we are doing our families a disservice by not providing them with ALL the information to make an informed choice. Informed consent is the norm these days, is it not? I have found very little on studies done on safe bed sharing. It is often that co sleeping gets lumped into the unsafe sleeping paradigm. I slept with my daughter, woke at the slightest interruption in her breathing or movement, even when I was sleep deprived. I believe in the stress reduction that touch provides. Curious about this whole scenario and how to balance out the ethical dilemma of providing parents with the best information without compromising the infant’s safety. I am a nurse in grad school to become a FNP. Thanks for your blog