Parents I work with every day are confused about how to safely breastfeed all night when they are exhausted, and how to make bed-sharing safer if they simply cannot stay awake and out of the bed for feedings. Our cultural and medical refusal to provide safer sleep guidelines for bed-sharing means there are tragic infant deaths we could be preventing. Though most “SIDS” deaths are of crib sleeping babies, a suffocation death can happen in a crib, a chair, a sofa or the parent bed. No sleeping space is inherently safe without the right precautions. I believe families deserve comprehensive, clear and concise guidelines for safer bed-sharing and I intend to offer them here by gelling together the information published by experts in the field of infant sleep and breastfeeding and my experience with real bed-sharing families as a breastfeeding counselor-educator and gentle sleep consultant. (Skip to Download Here)
“We recognize the fact that not only do mothers often inadvertently fall asleep with the infant in their bed, but many mothers choose to bed share. We thought it was prudent to provide guidance on making the bed-sharing arrangement as safe as possible and provide guidance on what populations are most at risk when bed sharing.”
Unfortunately, the actual AAP document falls quite short of actually providing that guidance or of making it clear that breastfeeding and bed sharing are inextricably linked to the point that bed sharing may be totally unavoidable for most breastfeeding families, as Feldman-Winter admitted in the NPR interview. What she has said she published, she has not. Instead, the document tells families that mothers must not fall asleep with baby in bed and if they do, they must return baby to baby’s own bed as soon as they realize they have fallen asleep while nursing. It contradicts itself by telling parents that breastfeeding very protective against SIDS but that breastfeeding parents should not bed-share; ignoring the truth that most breastfeeding parents do bed-share our of necessity. Like all of the sleep guidelines since the 90’s, we have told families the risks of bed-sharing without telling families how to bed share with less risk if they choose to. Since 2011, the medical establishment has vindicated rooming-in, and that is a step in the right direction (though co-sleeping is a confusing term because it includes rooming-in with baby sleeping nearby on her own sleep surface and also bed-sharing which was not recommended.).
The American Academy of Pediatrics knows the work of Dr. James McKenna and Dr. Helen Ball on the biological imperative and safety of bed-sharing and breastfeeding and the position of the Academy of Breastfeeding Medicine, but the plan so far has been to withhold information on safer sleep practices, in order to attempt to prevent bed-sharing as a means to prevent deaths that happen while bed-sharing, even though 45-75% of families report bed sharing “at least sometimes”.
This number is thought to be even higher due to underreporting and the stigma of bed-sharing; and many feel this number may be closer to 90 percent of breastfeeding families sharing the bed “at some point” in the night. Yet, “SIDS” is a death associated with crib sleeping and has no known smothering/axphyxiation cause and roll-over/smothering is more associated with bed-sharing. These are two totally different kinds of death with different dangers and risks and simply moving babies that bed-share into cribs does not prevent all possibility of infant sleep death- it merely may prevent a smothering death and introduce new and different risk factors in crib-sleeping.
I don’t know how the AAP keeps arguing with tired bed-sharing moms when the research says that bed-sharing prevents deeper sleep states that could cause SIDS (McKenna, 1990; Mosko, 1996; Richard, 1998), promotes physiological regulation of blood pressure, heart rate and more rhythmic breathing*(Farooqi, 1994; Mitchell, 1997; Mosko, 1996; Nelson, 1996; Skragg, 1996), increases breastfeeding success and duration (Clements, 1997; McKenna, 1994; Richard et al., 1996), increases maternal caregiving responsiveness (McKenna & Mosko, 1997), not to mention the fact that bed-sharing breastfeeding mothers report getting more sleep(McKenna & Mosko, 1997) and that lowers the risk of postpartum mood disorders. Some accidents will happen, but are we so obsessed with accidental sleep death that we are not doing the research to determine how many lives are being saved and health outcomes can be improved by bed-sharing?
We start with the fact that mothers are sleep-deprived before they even give birth.
Sleeping while full-term pregnant proves extremely difficult for most mothers do to an inability to get comfortable or to anxiety about the impending birth. As soon as baby arrives, mom is sleep-deprived from the heroic birth. Then, baby needs to eat at least every 2 hours, and hopefully more frequently to establish breastfeeding. And then begins months of sleep depravation for most. Our brains are hopefully overloaded on the bonding hormone oxytocin and not able to process much or engage in critical thinking or questioning. We need very clear instructions and education from care providers about sleep and breastfeeding. Instead, we have gotten one-size-fits-all anti-bed-sharing back-to-sleep propaganda. Lactation professionals, Postpartum doulas, and sometimes even pediatricians will even shy away from the topic of sleep position all together for fear of not giving the proper information or endangering a child or disregarding the mother’s exhaustion.
We do not need our care providers telling us that we will probably fall asleep in bed with baby but that it is unsafe, and that accidentally falling asleep on a chair or sofa is worse but that they need to breastfeed and that means they need to be breastfeeding all through the night. This is crazy-making. This is a recipe for parental anxiety, postpartum mood disorders and ending breastfeeding. We need to be using a harm-reduction method of providing information on How to Create A Safer Bed-Sharing Environment for Your Breastfed Baby.
We need to talk about Sudden Unexplained Infant Death and suffocation like we talk about STDs and “safer sex”. People die from sexually transmitted diseases; but sex itself is normal and healthy and no matter how much some cultures may teach abstinence, people are going to have sex anyway. No matter how much crib-sleeping propaganda our government pays for, some people are going to bed-share anyway. Not because we don’t mind risking our babies lives; but because it is our biological instinct to nurse our babies through the night, to remain connected to them, to listen to them breathe. How can we make it safer? I wanted to write a guide that would use positive language free of the word “Don’t” and full of details. This guide is not intended to convince anyone to breastfeed, it is for any family who carefully choose bed-sharing or who suddenly find themselves doing so out of necessity.
How to Create A Safer Bed-Sharing Environment for Your Breastfed Baby.
as compiled by Moorea Malatt of SavvyParentingSupport.com
- Do make sure your bed sharing baby is exclusively or primarily fed breastmilk and is fed at breast on the nights bed-sharing occurs. Do make sure baby is either on their back or on their side toward you while attached to breast.
- Sleep on a firm mattress, not a waterbed or a soft memory foam mattress, a giant pillow, a beanbag or a sheepskin.
- Keep loose blankets, stuffed animals and pillows away from baby. And keep any “co-sleeping” props, pillows or devices out of the bed as well. They may make you feel safer but they actually make baby less safe.
- Keep just one pillow for your head rather than extra pillows near baby.
- If you will fall asleep during breastfeeding, do move to your safer bed-sharing arrangement rather than falling asleep on a sofa or soft chair.
- Bottom sheet should fit the mattress tightly. Top sheet and any blankets should be tucked tightly under the mattress at bottom so they are less likely to be pulled up over baby.
- Make sure there are no spaces between the mattress and frame, mattress and headboard or wall and frame where baby could become trapped. The safest way to make sure of this is to use a mattress directly on the floor.
- Do put clothing and socks on baby if the room is cold enough for you to need a warm blanket and leave the warm blanket off of the baby. If the room is very warm, baby should be naked or in cotton t-onesie along with our body heat- to avoid overheating. Ideal temperature for infant sleep is 67-70 degrees F.
- Make sure there is no nicotine in the home. Bedsharing parents should be nicotine-free and anyone else in the home should smoke outside and change clothes before coming into the family bedroom or holding baby.
- Be sober and free from alcohol or mild-altering substances, medicinal sleep aids or impairing medications. If you take these substances, they can make your baby dangerously drowsy through your breastmilk hours later. Check with your provider or pharmacist to see if any of your medications or over-the-counter medications can make you or your baby drowsy. Some parents need a bit of help falling asleep but the best bet is to follow circadian rhythms by exposing your body to light and dark at proper times. You give natural melatonin to your baby through your breast milk when you do this and baby will fall asleep easier as well.
- Due to the fact that many mothers use prescription painkillers in the first few days after birth; and that the first few days require skin-to-skin and constant breastfeeding as well as rest, do make sure you have a family member or caregiver assisting in the home to supervise sleeping safety these first few days. Do end the painkiller usage as soon as possible if bed-sharing.
- Make sure you do not have a sleep disorder of any kind. If your adult bed partner has a sleep disorder of any kind or snores, put your body between the baby and your adult bed partner.
- Make sure your Infant less than one year-old does not sleep next to older siblings or pets. If you have a “family bed” the older sibling should sleep on the other side of the parent or far side of the bed.
- Make sure that if you choose to bed-share with baby, your doing so makes you feel less anxious rather than more anxious. This will protect your postpartum mental health as well as allow you to have some quality rest in between feeds.
As James J. McKenna of the Mother-Baby Behavioral Sleep Lab at Notre Dame University suggests:
In sum, overwhelmingly, bed-sharing deaths are associated with at least one independent risk factor associated with an infant dying. These include an infant being placed prone (on its stomach) and placed in an adult bed without supervision, or no breastfeeding, or other children in the bed, or infants being placed in an adult bed on top of a pillow, or who bed share even though their mothers smoked during the pregnancy therein compromising potentially the infants ability to arouse (to terminate too little oxygen, or to terminate an apnea). Drug use and alcohol have historically been associated with poor outcomes for bed sharing babies so if drugs and/or alcohol are present, please don’t bed share.
Academy of Breastfeeding Medicine Protocol #6: Guideline on Co-Sleeping and Breastfeeding:
Research continues to show the strong relationship between breastfeeding and bed sharing/co-sleeping. A study of bed sharing and breastfeeding in the United States found that infants who routinely shared a bed with their mothers breastfed approximately three times longer during the night than infants who routinely slept separately. There was a twofold increase in the number of breastfeeding episodes, and the episodes were 39% longer….Because breastfeeding is the best form of nutrition for infants, any recommendations for infant care that impede its initiation or duration need to be carefully weighed against the many known benefits to infants, their mothers, and society.
In closing, bed-sharing is not right for every family. Each family needs better prenatal access to information on weighing risks and benefits and that should include clear and concise information on safer bed-sharing. All breastfeeding education should also include information on safer bed-sharing as the two are inextricably tied together in the exhaustion of early parenting.
The articles and studies that informed this writing:
Ball, Helen; Bed Sharing And Safety; Infant Sleep Source online. https://www.dur.ac.uk/resources/isis.online/pdfs/ISIS_bed-sharing_2014.pdf
Bartick, Melissa MD, MSc; Should the AAP Sleep Alone? The Academy of Breastfeeding Medicine blog, April 2014
Blair PS, Fleming PJ, Smith IJ, et al. Babies sleeping with parents: Case-control study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI research group. BMJ 1999;319:1457–1461
Carpenter R.G. et al., “Sudden Unexplained Infant Death in 20 Regions in Europe: Case Control Study,” Lancet 2004; 363: 185-191.
Colson, Eve et al; Trends and Factors Associated with Bed-Sharing: The National Infant Sleep Position Study 1993-2010. Journal of the American Medical Association Pediatrics (JAMA); 2013 Nov; 167(11): 1032–1037. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3903787/
Fleming P, Blair P, Mckenna J. New knowledge, new insights, and new recommendations: Scientific controversy and media hype in unexpected infant deaths. Arch Dis Child. 2006;91(10):799-801.
Forbes, JF et al, “The Cosleeping Habits of Military Children,” Military Medicine 157 (1992): 196-200.
Heron, P, Non-Reactive Cosleeping and Child Behavior: Getting a Good Night’s Sleep All Night, Every Night, Master’s thesis, Department of Psychology, University of Bristol, 1994.
McKenna JJ, What Every Health Professional Should Know http://cosleeping.nd.edu/what-every-health-professional-should-know/
McKenna, Ball & Gettler (2007) Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: What biological anthropology has discovered about normal infant sleep and pediatric sleep medicine Yrbk Phys Anthropol 50:133-161
McKenna, J., et al, “Experimental studies of infant-parent co-sleeping: Mutual physiological and behavioral influences and their relevance to SIDS (sudden infant death syndrome).” Early Human Development 38 (1994)187-201.
McKenna JJ, McDade T. Why babies should never sleep alone: a review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Paediatr Respir Rev. 2005 Jun;6(2):134-52.
Richard C et al., “Sleeping Position, Orientation, and Proximity in Bedsharing Infants and Mothers,” Sleep 19 (1996): 667-684.
Tappin D, Ecob R, Brooke H. Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: A case-control study. J Pediatr 2005;147:32–37.
Task Force on Sudden Infant Death Syndrome; The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 2005;116:1245–1255.