Co-Sleeping
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Is Sleep-Sharing Safe? Question I heard on the radio that some researchers now believe that babies who sleep in the same bed as their parents are in danger of being suffocated when an adult rolls over on them. Could this be true? Should I put my baby back in her crib? - Anonymous Answer by William and Martha Sears On September 29, 1999, a number of reports were published in newspapers all over the country carrying fearsome headlines like, "Hazards Associated with Children Placed in Adult Beds." TV news viewers were treated to similar histrionics as the world was told of a new study that suggests the family bed could be a dangerous place for infants. The day before this study broke, I was interviewed by The New York Times, The Washington Post and several other major newspapers. CNN sent a camera crew to our home for comments on this new research. Do parents who sleep with their infants need to worry? No! Here's the scoop. This study appeared in the October issue of The Archives of Pediatrics and Adolescent Medicine. Researchers at the U.S. Consumer Products Safety Commission (CPSC) reviewed death certificates from 1990 through 1997 and found 515 children under two years of age had died as they slept in adult beds. Of these deaths, 121 were caused by suffocation when a parent, another adult, or sibling sleeping in the same bed rolled over on top of the child. Three hundred and ninety-four were suffocated by bedding and bed structures; they fell between the mattress and side rail or wall, were smothered in water beds, or got their heads trapped in bed railings. Most of the deaths were of infants under three months. Like so much research, this is a helpful news/harmful news scenario. On one hand, it is important to remind the parents who share a bed with their babies - and there are many - that they need to take certain precautions. On the other, these reports have unnecessarily frightened the millions of parents who safely and responsibly sleep with their babies. While the CPSC is right to say that parents should be aware of the potential dangers of unsafe sleeping practices, it went too far in recommending that parents should never sleep with children under two years of age. Bad Science When science and commonsense don't match, suspect faulty science. Co-sleeping itself is not inherently dangerous. In fact, you could say that co-sleeping is inherently safer. The CPSC study estimates that 64 infants die every year as a direct result of sharing a bed with their parents. But a great many more infants die each year from SIDS (remember it used to be called "crib death") as they sleep alone in their cribs. While the authors of this study indicated that their conclusions were not statistically valid - they did not make any attempt to contrast these figures - it would have been helpful if they had made the point that the great majority of SIDS occurs in infants sleeping alone in cribs. Safe Sleep-Sharing Instead of trying to make parents afraid to sleep with their babies, a more thoughtful approach would be to teach parents who choose to co-sleep to do it safely. Here are the precautions for safe co-sleeping: * Put babies under six months to sleep on their backs and not their tummies, unless advised otherwise by your doctor (in a few medical conditions, tummy-sleeping is safer). * Don't sleep with your baby if you are under the influence of drugs or alcohol or any substance that could diminish your awareness of your baby. * Don't sleep with baby on soft surfaces, such as bean bags, water beds and couches. * Avoid crevices between mattress and wall or mattress and side rail. * Avoid side rails, head boards, and foot boards that have slats that could entrap baby's head. * Avoid putting your bed near curtains or blinds that have dangling strings that could strangle baby. * Only one baby in bed at a time, please. For parents who don't like sleeping apart from their baby, but do not want to, or are fearful of, sharing a bed with their infant, try the Arm's Reach Co-sleeper, the best co-sleeper I know of on the market today. This crib-like infant bed attaches securely and safely right next to an adult bed. This nighttime nurturing device gives both parent and child their own space, but keeps them within touching and nursing range. (For more information about co-sleepers, visit http://www.armsreach.com .) A Time-Tested Arrangement with Modern Benefits Despite the recent media frenzy over the so-called dangers of co-sleeping, the reality is that much of the world's population sleep with their babies and do it safely. How can a sleeping arrangement that has been practiced for centuries suddenly become "unsafe?" We believe that co-sleeping is the nighttime parenting style of the millennium for two reasons: more and more mothers are breastfeeding. Sleeping next to your baby makes breastfeeding easier. When baby is hungry, a mother can feed her baby without either member of the nursing pair fully awakening. Martha has dubbed night nursing the "lazy mom's option." She has slept with and night nursed most of our babies and woke up well-rested the next day. In this way, both baby's need for nighttime feeding and nurturing and mother's need for sleep can be met. The second reason why co-sleeping has become so popular is that more and more dual income parents are now separated from their infants during the day. Co-sleeping allows working parents to reconnect with their babies at night and make up for missed touch time during the day. Nighttime is a scary time for little people. When considering where baby should sleep, look at things from a baby's point of view. If you were an infant, would you rather sleep alone in a dark room "behind bars" in your crib or right next to your favorite person in the whole wide world and inches away from your favorite cuisine? The choice is obvious. But co-sleeping may not be for everyone. Each family needs to work out the sleeping arrangement that gives all family members the best night's sleep. Whatever nighttime arrangement you choose, do it wisely and safely. Sleep well! In response to the Consumer Product Safety Commission study and the Drago and Dannenberg study, which apparently both used the same set of incomplete data, are the following press release and letter to Pediatrics (currently in press). Press release--put out on Monday: Statement on sleeping locations and sudden death in infants From the Harborview Injury Prevention and Research Center Abraham B. Bergman, MD, Director of Pediatrics, Harborview Medical Center and Professor of Pediatrics, University of Washington Richard Harruff, MD, PhD, Medical Examiner of King County, Clinical Associate Professor of Pathology, University of Washington. MaryAnn O'Hara, MD Robert Wood Johnson Clinical Scholar, University of Washington Our points: While we applaud the CPSC for calling attention to environmental hazards to infants such as wedge spaces around mattresses/cushions, and the risks of strangulation from cords or widely spaced crib rails we condemn their campaign to implicate bed sharing, and use of an adult bed as a hazard for infants. The original data that form the bases for these recommendations are seriously flawed.; a classic case of "garbage in, and garbage out." The major flaws are: 1. Data: Though we know the number of infants said to have died in adult beds, we do not know the number of infants sleeping in adult beds who did _not_ die. In other words, before making statements of relative risk, it is necessary to know both the numerator (deaths), _and_ the denominator (infants who do not die.) 2. Certification of death: The CPSC depends entirely on what someone wrote as a cause on the death certificate. Death investigation and certification practices vary widely in the United States. Those who certify deaths range from coroners with no medical training to forensic pathologists. 3. Bias: In a review of CPSC data since 1995 one of us (MAO) found that the term "overlaying" was used in some geographic area, and not in others. The death of an infant with the same pathologic findings might be classified as overlaying or suffocation if the family is poor and/or minority, and SIDS or interstitial pneumonia if the family is white and/or middle class. 4. Who should make pronouncements on child-care practices: It is not appropriate for a government agency with scant medical expertise to provide advice on child-care practices on the basis of one study. A prestigious organization like the American Academy of Pediatrics should first review the evidence and make appropriate recommendations. Abraham B. Bergman , MD 206 731 5424 mailto:oscarb@u.washington.edu 9/24/99 Letter to Pediatrics, in response to Drago and Dannenberg, by Drs. Gartner and McKenna: currently in press Pediatrics JMcKenna (University of Notre Dame)
To The Editor: We are writing to express our concern with several of the points raised in the recent article by Drago and Dannenberg (Drago DA, Dannenberg AL. Infant mechanical suffocation deaths in the United States, 1980-1997. Pediatrics 1999; 103:e59, 1). The authors suggest that the reported increase in infant deaths by suffocation and "overlying" could be the result of "an increase in the rate of infant-parent co-sleeping related to reported benefits, including increased breastfeeding and reduction in the rate of SIDS... ." They acknowledge that rates of co-sleeping are unknown and that this association is theoretical. ****Furthermore, they provide none of the details needed to support their conclusion and use "dangerous conditions" as a proxy for the act of a mother and infant sleeping side-by-side-which is universally, inherently adaptive and beneficial for both mothers-infants alike in the overwhelming majority of situations.**** Mother-infant co-sleeping evolved to protect and feed infants throughout the night ( 2). Millions of mothers worldwide know that strong emotions underlie and motivate co-sleeping, even though they may be unaware of co-sleeping as a biologically appropriate arrangement which, in turn induces important behavioral and physiological changes in both infants and mothers. These changes have been reported in extensive peer-reviewed laboratory studies (3-8) and include increased use of the safe, supine infant sleep position, increased breastfeeding, increased infant movement, arousal and awakenings during sleep, reduced deep and increased light sleep, more affectionate and protective maternal interventions, increased sensitivity to the presence of the co-sleeping partner, reduced infant crying, fewer (infant) obstructive apneas in deep sleep, longer infant sleep, and more positive evaluations by bedsharing mothers of their nighttime experiences (3-8). It has been estimated that more than half of the families in the United States practice co-sleeping with infants for some period of time. Drago and Dannenberg casually dismiss the biologically important role of co-sleeping when they state: "New parents may take their infants to bed with them...for feeding convenience." Catastrophic accidents in the co-sleeping environment are tragic exceptions to the act of co-sleeping itself and are almost always attributable to avoidable, unsafe conditions, most frequently found in high risk populations where most such tragedies occur. In recent years in Cook County, Illinois (Chicago), the medical examiner has found that all overlying deaths were in situations in which the adult was intoxicated with either alcohol or illegal drugs. We agree with the authors and others that special precautions need to be taken to minimize catastrophic accidents, but the need for such precautions is no more an argument against all co-sleeping and, specifically, bedsharing, than is the reality of infants accidentally strangling, suffocating or dying from SIDS alone in cribs a reason to recommend against all solitary, unsupervised infant sleep (cribs). The goal is to avoid dangerous adult beds, and dangerous bedsharing conditions, while preserving the proven benefits of cosleeping in safe beds involving safety-conscious adults, if that is the parent's choice. Breastfeeding (at an all time recorded high in the United States) and co-sleeping in the form of bedsharing mutually reinforce each other(9, 10). That is, studies show that bedsharing increases the frequency and duration of nightly breastfeeding, while breastfeeding makes bedsharing convenient for mothers thereby increasing the chances of its adoption as a routine practice(4). Maintenance of breastfeeding is a proven preventive action against increased infant illness and death, even in developed countries, and a significant factor in reducing maternal illness. It is unfortunate that Drago and Dannenberg were unable to report the specific conditions and /or circumstances in which alleged overlaying and other bedsharing infant deaths occurred. It is those specific conditions that transform co-sleeping (in the form of bedsharing) into something potentially dangerous. Of the total bedsharing deaths they report it is important to know, for example, how many infants were found lying prone, or were sleeping on sagging mattresses, on waterbeds, or sofas--- all highly risky forms of co-sleeping. Of the bedsharing deaths how many mothers smoked during their pregnancies, or smoked at the time of the infant's death, laid their babies prone for sleep, were intoxicated, used drugs, or were perhaps unaware that the baby was sleeping alongside? Was there a previous infant or child death in the family, suggesting possible infanticide, or a Munchausen-by-proxy syndrome? Of even greater importance is the question: how many of these overlays involved nonsmoking, non-intoxicated, breastfeeding mothers? These data are critical to assess the actual causes of death. Mere location of infant sleep is insufficient for assessing the actual cause of the tragedy. Furthermore, it is important to recognize that an infant can die from SIDS while bedsharing without any contributory role from co-sleeping. Most adults die in bed, but we do not indict the bed as a factor in causing the death. Cultural biases against mother-infant co-sleeping in our society make it very difficult to think of a bedsharing death simply as yet another tragic SIDS. All too frequently the assumption is that the adult in the bed probably overlaid the baby either accidentally or purposefully. Unfortunately, autopsy examination is unable to differentiate between "SIDS" and suffocation in the absence of physical signs of injury. A priori assumptions make it less likely that an accurate assessment will be achieved. The distinction between co-sleeping and particular forms of it, like bedsharing , was introduced several years ago as a way to make more precise the discourse surrounding co-sleeping and SIDS (11,12 ) and to help clarify and potentially reconcile the legitimate diverse positions argued by researchers in this controversial area. The authors erroneously use these terms interchangeably. Co-sleeping takes hundreds of different forms worldwide and no single outcome necessarily can be associated with it. Differential outcomes for different types of co-sleeping, including different types of bedsharing, can be predicted only by considering both the nature of relationships involved while co-sleeping (what happens between the caregiver and infant once in bed, or outside of the bed) and the qualities of the physical environment and social circumstances within which particular types of infant care (as, for example, breast feeding) are integrated with, or are absent from, the act of co-sleeping. That a proactive, involved and nurturing caregiver changes the outcomes in the co-sleeping environment are suggested by the New Zealand epidemiological study showing that when infants sleep in the same room with their mothers, but not when sleeping in a room with siblings, they are four times less likely to die from SIDS (13). Similarly, the CESDI (Great Britain) epidemiological study shows that infants who sleep in a separate room alone are more likely to die from SIDS than are infants of nonsmoking mothers who are brought in and out of their mother's bed throughout the night for breastfeeding, and who are kept in the room, close to the mother all night long (14). Moreover, Japan exhibits the lowest SIDS rates in the world and, there, mother-infant co-sleeping (on floor positioned futons) is the cultural norm! By distinguishing between co-sleeping in a generic sense and particular forms of co-sleeping (such as safe bedsharing, exhibited by breastfeeding, nonsmoking mothers sleeping on firm mattresses versus unsafe bedsharing, exhibited by non-breast feeding, smoking mothers sleeping on soft, over-blanketed beds) health professionals can preserve and acknowledge the importance of parents and infants sleeping within arms reach--within proximity (co-sleeping). Drago and Dannenberg speculate that the increase in overlay deaths in the last decade might be attributed to the promulgation and acceptance of McKenna's documented benefits of co-sleeping in the form of safe bedsharing. At very least, information on why the parents or caregivers overlain infants elected to bedshare as well as data on whether or not they did so safely on the night the infant died would be required before such an assertion could be proven. Sound scientific methods and procedures were used in all of McKenna's studies and all work was peered-reviewed on multiple occasions. It is true that the AAP Committee on Infant Sleep Position sees no reason to recommend bedsharing as a way to reduce SIDS (and, at this point, neither does McKenna). It is also true that the AAP committee warns appropriately (as does McKenna and colleagues) that under special unsafe circumstances bedsharing can increase SIDS risk; nevertheless, there remain valid, peer-reviewed data which justify scientific speculation that under safe bedsharing/cosleeping circumstances (especially where breastfeeding is involved) infants may have an increased chance to avoid a SIDS death. This speculation emerged initially from a detailed peer-reviewed monograph, which proposed a theoretical model and a series of testable hypotheses, all of which integrated cross-cultural SIDS epidemiology, and developmental, experimental, and evolutionary data (15). It led to two pilot studies of mother-infant co-sleeping (16, 17) and a carefully controlled NICHD funded scientific study which documented significant physiological and behavioral changes in sleep, arousal, and feeding patterns induced by the presence of a breastfeeding, co-sleeping mother (18). At least ten peer reviewed articles have been published, two of which appeared in Pediatrics. The criticisms we raise should not detract from the value of other information Drago and Dannenberg present concerning the etiologies of infant mechanical suffocation. What are evident from this report is that no sleep environment is risk free, and that much more can be done to educate parents as to how to provide safer sleeping environments. Furthermore, it is clear that the types of precautions required to maximize safety under different sleeping conditions (both social and solitary) are shown often to be the same: mattresses should be firm and tight fitting to their frames, infants should not be overwrapped, or their heads covered by blankets, placed prone for sleep or permitted to sleep on pillows etc. And while some precautions are unique to bedsharing, does not negate the validity of the choice, when practiced safely. At this point in the history of western societies, where an unprecedented convergence of cultural practices is underway--- not the least of which involve sleeping arrangements--- it is critical that clinicians and researchers broaden their thinking about what constitutes appropriate and desirable childhood sleep practices. Failure to do so will continue to limit both the accuracy of pediatric sleep science and the effectiveness of care. As we move into the next millennium infant-parent co-sleeping with breastfeeding is likely to become more,not less common (19). We look forward to the time when we join the rest of the world and regard infant parent co-sleeping not as pathology, but as an appropriate and potentially rewarding choice for fully informed parents when practiced safely. James J. McKenna, Ph.D.Director, Mother-Baby Behavioral Sleep Laboratory University of Notre Dame Lawrence M. Gartner, M.D. University of Chicago Web links: http://www.pediatrics.org/cgi/content/full/103/5/e59 Pediatrics -- Drago and Dannenberg 103 (5): e59 http://www.aap.org/advocacy/releases/mayinf.htm AAP News Release - Infants at Increasing Risk of Suffocation Death References Cited 1.Drago, DA, Dannenberg, AL Infant mechanical suffocation deaths in the United States,1980-1997. Pediatrics 103:5: e59, 1999 2.Konner MJ. Evolution of human behavior development. In RH Munroe, RL Munroe, JM Whiting, eds. Handbook of Cross-Cultural Human Development. New York; Garland STPM Press, 1981:3-52. 3. McKenna JJ, Mosko S, Richard C, Drummond S, Hunt L, Cetal M, Arpaia J; Mutual behavioral and physiological influences among solitary and co-sleeping mother-infant pairs; implications for SIDS; Early Human Development 1994;38:182-201. 4. McKenna J, Mosko S, Richard C. Bedsharing promotes breast feeding, Pediatrics 1997:100:214-219 5. Richard C, Mosko S, McKenna, J . Sleeping position, orientation, and proximity in bedsharing Infants and mothers Sleep 1996 19:667-684. 6. Mosko S, Richard C, McKenna J. Infant arousals during mother-infant bedsharing; implications for infant sleep and SIDS research. Pediatrics 1997, 100: 5; 841-849 7. Richard C Mosko S, McKenna J. Apnea and periodic breathing in the bedsharing infant. Amer J Applied Phys 1998 84;4:1374-1380 8. Mosko S, Richard C, McKenna J, Drummond S. Infant sleep architecture during bedsharing and possible implications for SIDS; Sleep 1996;19:677-684. 9. Ross Mothers Survey (1997). Published and available through Ross Laboratories. Ross Products Division of Abbot Laboratories. 10. Mitchell, EA, Scragg L, Clements M. Factors related to infant bedsharing.NZ Med J 1994; 107: 466-467. 11. . McKenna JJ, Thoman E, Anders T, Sadeh A, Schechtman V, Glotzbach S. Infant-parent co-sleeping in evolutionary perspective: Implications for understanding infant sleep development and the Sudden Infant Death Syndrome (SIDS). Sleep 1993;16:263-282. 12. McKenna JJ; (1995); The potential benefits of infant-parent co-sleeping in relation to SIDS prevention; overview and critique of epidemiological bed sharing studies; In Sudden Infant Death Syndrome: New Trends in the Nineties. TO Rognum, ed. Oslo: Scandinavian University Press, 1995:256-65. 13. Mitchell EA, Thompson JMD. Cosleeping increases the risks of the sudden infant death; syndrome, but sleeping in the parent's bedroom lowers it. In: Rognum TO Sudden Infant Death Syndrome in the Nineties. Oslo: Scandinavian University Press, 1995, 266-269. 14. Fleming P, Blair P. Safe environments for infant sleep: community and laboratory investigations or folk wisdom? Symposium on Breast Feeding, Parental Proximity and Contact in Promoting Infant Health. Paper Delivered University of Notre Dame, South Bend, September 1998. 15. McKenna JJ. An anthropological perspective on the sudden infant death syndrome (SIDS); The role of parental breathing cues and speech breathing adaptations; Medical Anthropology 1986; 10:9-53. 16. McKenna JJ, Mosko S, Dungy C, McAninch P. Sleep and arousal patterns of co-sleeping human mothers/infant pairs; A preliminary physiological study withimplications for the study of Sudden Infant Death Syndrome (SIDS); American Journal of Physical Anthropology 1990;83:331-347. 17. Mosko S, McKenna JJ, Dicker M, Hunt L. Parent-infant co-sleeping: the appropriate context for the study of infant sleep and implications for SIDS research; Journal of Behavioral Medicine 1993;16(3):589-610. 18. McKenna, JJ Mosko S, Richard C Breast Feeding and mother-infant cosleeping in relation to SIDS prevention. In: Evolutionary Medicine; Eds W Trevathan, Smith N, McKenna J. Oxford University press: Oxford 1999, PP 53-74 |
