Bed Sharing, Co-Sleeping, and Sudden Infant Death Syndrome (SIDS):
A Selected Annotated Bibliography

Bed sharing is a practice in which an infant shares the same sleep surface with another person, including the parents or siblings; it is often used interchangeably with co-sleeping. Co-sleeping is also used to mean having the infant sleep in a bassinet or crib that is directly next to the parents’ bed or in the same room. Abstracts of journal articles generally do not distinguish which definition is used in a particular article.

These articles have been selected by Resource Center staff from PubMed, a service of the National Library of Medicine that includes over 19 million citations from MEDLINE and other life science journals for biomedical articles back to 1948. PubMed includes links to full text articles and other related resources.

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Blabey MH, Gessner BD.
Infant bed-sharing practices and associated risk factors among births and infant deaths in Alaska.
Public Health Rep. 2009 Jul-Aug;124(4):527-34.

OBJECTIVE: The Alaska Division of Public Health has stated that infants may safely share a bed for sleeping if this occurs with a nonsmoking, unimpaired caregiver on a standard, adult, non-water mattress. Because this policy is contrary to recent national recommendations that discourage any bed sharing, we examined 13 years of Alaskan infant deaths that occurred while bed sharing to assess the contribution of known risk factors. METHODS: We examined vital records, medical records, autopsy reports, and first responder reports for 93% of Alaskan infant deaths that occurred between 1992 and 2004. We examined deaths while bed sharing for risk factors including sleeping with a non-caregiver, prone position, maternal tobacco use, impairment of a bed-sharing partner, and an unsafe sleep surface. We used Pregnancy Risk Assessment Monitoring System data to describe bed-sharing practices among all live births in Alaska during 1996-2003. RESULTS: Thirteen percent (n=126) of deaths occurred while bed sharing; 99% of these had at least one associated risk factor, including maternal tobacco use (75%) and sleeping with an impaired person (43%). Frequent bed sharing was reported for 38% of Alaskan infants. Among these, 60% of mothers reported no risk factors; the remaining 40% reported substance use, smoking, high levels of alcohol use, or most often placing their infant prone for sleeping. CONCLUSIONS: Almost all bed-sharing deaths occurred in association with other risk factors despite the finding that most women reporting frequent bed sharing had no risk factors; this suggests that bed sharing alone does not increase the risk of infant death.

Full text available online at: http://www.publichealthreports.org

Ball H.
Airway covering during bed-sharing.
Child Care Health Dev. 2009 Jun 15. [Epub ahead of print]

Background Parent-infant bed-sharing is a common practice in Western post-industrial nations with up to 50% of infants sleeping with their parents at some point during early infancy. However, researchers have claimed that infants may be at risk of suffocation or sudden infant death syndrome related to airway covering or compression in the bed-sharing environment. To further understand the role of airway covering and compression in creating risks for bed-sharing infants, we report here on a sleep-lab trial of two infant sleep conditions. Methods In a sleep-lab environment 20 infants aged 2-3 months old slept in their parents' bed, and in a cot by the bed, on adjacent nights. Infants' oxygen saturation and heart rate were monitored physiologically while infant and parental behaviours were recorded via ceiling-mounted infra-red cameras. Infants served as their own controls. Continuous 8-h recordings were obtained for covering of infant external airways, levels of infant oxygen saturation, infant heart rate, evidence of parental compression/overlying of infant, circumstances leading up to potential infant airway obstruction, and parental awareness of and responses to infant airway covering. Results The majority of infants (14/20) spent some part of the bed night with their airways (both mouth and nose) covered, compared with 2/20 on the cot night; however, no consistent effect on either oxygen saturation levels or heart rate was revealed, even during prolonged bouts of airway covering. All cases of airway covering were initiated by parents; 70% were terminated by parents, the remainder by infants. Seven bouts of potential compression were observed with parental limbs resting across infant bodies for lengthy periods, however, in only two cases was the full weight of a parental limb resting on an infant, both events lasting less than 15 s, both being terminated by infant movement. Conclusion Although numerous authors have suggested that bed-sharing infants face risks because of airway covering by bed-clothes or parental bodies, the present trial does not lend support to this hypothesis.

Full text available online at: http://www3.interscience.wiley.com

Vennemann MM, Bajanowski T, Brinkmann B, Jorch G, Sauerland C, Mitchell EA; GeSID Study Group.Collaborators (26)
Sleep environment risk factors for sudden infant death syndrome: the German Sudden Infant Death Syndrome Study.
Pediatrics. 2009 Apr;123(4):1162-70.

OBJECTIVE: Our goal was to investigate the risk factors for sudden infant death syndrome in the infants' sleep environment for a population in which few infants sleep prone as a result of education campaigns. METHODS: This was a population-based sudden infant death syndrome case-control study over 3 years (1998-2001) in Germany. RESULTS: There were 333 sudden infant death syndrome cases and 998 matched controls. Although only 4.1% of the infants were placed prone to sleep, those infants were at a high risk of sudden infant death syndrome. Those who were unaccustomed to sleeping prone were at very high risk, as were those who turned to prone. Bed sharing (especially for infants younger than 13 weeks); duvets; sleeping prone on a sheepskin; sleeping in the house of a friend or a relative (compared with sleeping in the parental home); and sleeping in the living room (compared with sleeping in the parental bedroom) increased the risk for sudden infant death syndrome; pacifier use during the last sleep was associated with a significantly reduced risk of sudden infant death syndrome. CONCLUSIONS: This study has clarified the risk factors for sudden infant death syndrome in a population where few infants sleep prone. This study supports the current recommendations of the American Academy of Pediatrics. This study has identified several novel risk factors for sudden infant death syndrome: an increased risk if the infants sleeps outside the parental home, death in the living room, and the high risk when sleeping prone on a sheepskin; however, because the numbers of cases in these groups are small, additional studies are needed to confirm these findings.

Full text available at: http://pediatrics.aappublications.org

Chianese J, Ploof D, Trovato C, Chang JC.
Inner-city caregivers' perspectives on bed sharing with their infants.
Acad Pediatr. 2009 Jan-Feb;9(1):26-32.

OBJECTIVE: To understand parents' motivations for bed sharing with their infants aged 1-6 months, their beliefs about safety concerns, and their attitudes about bed-sharing advice. METHODS: We conducted 4 focus groups with primary caregivers of infants ages 1-6 months who regularly shared beds with their infants. We recruited participants from an inner-city primary care center in Pittsburgh, serving primarily African American families who received medical assistance. Discussions were audiotaped and transcribed. Two investigators coded the transcripts and identified themes in an iterative process to achieve agreement between coders. RESULTS: A total of 28 caregivers aged 17-50 participated. The majority were African American (86%), female (93%), single (50%), and high school graduates (71%). Eleven percent of participants breast-fed their infants. We identified 5 themes, common to all groups, to explain parents' motivations for bed sharing: 1) better caregiver and infant sleep, 2) convenience, 3) tradition, 4) child safety, and 5) parent and child emotional needs. Parents expressed divergent views about the safety of bed sharing: 1) ambivalence regarding balancing risks of overlaying and suffocation with benefits of bed sharing, or 2) assertion that bed sharing poses no risks for their child. Common to all groups was the finding that clinicians' advice against bed sharing did not influence parents' decision, but advice to increase safety when bed sharing would be appreciated. CONCLUSIONS: Parents' motivation to bed share outweighed the concerns and the warnings of others. An understanding of parents' perspectives on bed sharing should inform counseling to promote safe sleeping practices.

Full text available at: http://www.sciencedirect.com

Johnston JT, Johnston EA.
On bed sharing.
J Obstet Gynecol Neonatal Nurs. 2008 Nov-Dec;37(6):619-21; author reply 621.

Comment on:
* J Obstet Gynecol Neonatal Nurs. 2008 May-Jun;37(3):274-81.

Full text available at: http://www3.interscience.wiley.com

Hauck FR, Signore C, Fein SB, Raju TN.
Infant sleeping arrangements and practices during the first year of life.
Pediatrics. 2008 Oct;122 Suppl 2:S113-20.

OBJECTIVES: Our goal was to examine the sleeping arrangements for infants from birth to 1 year of age and to assess the association between such arrangements and maternal characteristics. METHODS: Responses to the 3-, 6-, 9-, and 12-month questionnaires from the Infant Feeding Practices Study II were analyzed to assess sleep arrangements, including bed sharing, the latter defined as mother ever (in a given time frame) slept with the infant on the same sleeping surface for nighttime sleep. Women were also asked about the reasons for bed sharing or not bed sharing. RESULTS: Approximately 2300 women responded at 3 months, and 1800 at 12 months. At 3 months, 85% of the infants slept in the same room as their mother, and at 12 months that rate was 29%. At 3 months, 26% of the mothers did not use the recommended supine position for their infant's nighttime sleep. The rate of noncompliance increased to 29% by 6 months and 36% by 12 months. The bed-sharing rates were 42% at 2 weeks, 34% at 3 months, and 27% at 12 months. Approximately two thirds of those who bed shared with their infant also shared the bed with their husband or partner, and 5% to 15% shared it with other children. The major reasons for bed sharing were to calm a fussy infant, facilitate breastfeeding, and help the infant and/or mother sleep better. The major reasons for not lying down with the infant were safety concerns. Non-Hispanic black mothers were more likely than non-Hispanic white mothers to use nonsupine infant sleep positions and to bed share. CONCLUSIONS: More than one third of the women in this cohort were noncompliant with safe-sleeping guidelines when their infant was 3 months old. Health care providers need to advise parents of current recommendations and discuss the risks and benefits of their choices for infant sleeping practices.

Full text available at: http://pediatrics.aappublications.org

Fu LY, Colson ER, Corwin MJ, Moon RY.
Infant sleep location: associated maternal and infant characteristics with sudden infant death syndrome prevention recommendations.
J Pediatr. 2008 Oct;153(4):503-8. Epub 2008 Jun 25.

OBJECTIVE: To identify factors associated with infant sleep location. STUDY DESIGN: Demographic information and infant care practices were assessed for 708 mothers of infants ages 0 to 8 months at Women, Infants and Children centers. Generalized linear latent mixed models were constructed for the outcome, sleeping arrangement last night (room-sharing without bed-sharing versus bed-sharing, and room-sharing without bed-sharing versus sleeping in separate rooms). RESULTS: Two-thirds of the mothers were African-American. A total of 48.6% mothers room-shared without bed-sharing, 32.5% bed-shared, and 18.9% slept in separate rooms. Compared with infants who slept in separate rooms, infants who room-shared without bed-sharing were more likely to be Hispanic (odds ratio [OR], 2.58, 95% CI 1.11-5.98) and younger (3.66- and 1.74-times more likely for infants 0-1 month old and 2-3 months old, respectively, as compared with older infants). Compared with infants who bed-shared, infants who room-shared without bed-sharing were more likely to be 0 to 1 month old (OR, 1.57; 95% CI, 1.05-2.35) and less likely to be African-American (OR, 0.43; 95% CI, 0.26-0.70) or have a teenage mother (OR, 0.37; 95% CI, 0.23-0.58). CONCLUSIONS: Approximately one-third of mothers and infants bed-share, despite increased risk of sudden infant death syndrome (SIDS). The factors associated with bed-sharing are also associated with SIDS, likely rendering infants with these characteristics at high risk for SIDS.

Full text available at: http://www.jpeds.com

Academy of Breastfeeding Medicine Protocol Committee.Collaborators (8)
ABM clinical protocol #6: guideline on co-sleeping and breastfeeding. Revision, March 2008.
Breastfeed Med. 2008 Mar;3(1):38-43.

ABM clinical protocol #6: guideline on co-sleeping and breastfeeding. Revision, March 2008.

Full text available online at: http://www.liebertonline.com

McKenna JJ, Ball HL, Gettler LT.
Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: what biological anthropology has discovered about normal infant sleep and pediatric sleep medicine.
Am J Phys Anthropol. 2007 Nov 28;Suppl 45:133-61.

Twenty years ago a new area of inquiry was launched when anthropologists proposed that an evolutionary perspective on infancy could contribute to our understanding of unexplained infant deaths. Here we review two decades of research examining parent-infant sleep practices and the variability of maternal and infant sleep physiology and behavior in social and solitary sleeping environments. The results challenge clinical wisdom regarding "normal" infant sleep, and over the past two decades the perspective of evolutionary pediatrics has challenged the supremacy of pediatric sleep medicine in defining what are appropriate sleep environments and behaviors for healthy human infants. In this review, we employ a biocultural approach that integrates diverse lines of evidence in order to illustrate the limitations of pediatric sleep medicine in adopting a view of infants that prioritizes recent western social values over the human infant's biological heritage. We review what is known regarding infant sleeping arrangements among nonhuman primates and briefly explore the possible paleoecological context within which early human sleep patterns and parent-infant sleeping arrangements might have evolved. The first challenges made by anthropologists to the pediatric and SIDS research communities are traced, and two decades of studies into the behavior and physiology of mothers and infants sleeping together are presented up to the present. Laboratory, hospital and home studies are used to assess the biological functions of shared mother-infant sleep, especially with regard to breastfeeding promotion and SIDS reduction. Finally, we encourage other anthropologists to participate in pediatric sleep research using the unique skills and insights anthropological data provide. By employing comparative, evolutionary and cross-cultural perspectives an anthropological approach stimulates new research insights that influence the traditional medical paradigm and help to make it more inclusive. That this review will potentially stimulate similar research by other anthropologists is one obvious goal. That this article might do so makes it ever more possible that anthropologically inspired work on infant sleep will ultimately lead to infant sleep scientists, pediatricians, and parents becoming more informed about the consequences of caring for human infants in ways that are not congruent with their evolutionary biology. (c) 2007 Wiley-Liss, Inc.

O'mara L.
Review: bed sharing between parents and infants exposed to smoke may increase the risk of sudden infant death syndrome.
Evid Based Nurs. 2007 Oct;10(4):119.
Comment on:
* Arch Pediatr Adolesc Med. 2007 Mar;161(3):237-45.

Full text available online at: http://ebn.bmj.com

Ustunyurt E, Kaymak O, Iskender C, Ustunyurt OB, Celik C, Danisman N. Ruys JH, de Jonge GA, Brand R, Engelberts AC, Semmekrot BA.
Bed-sharing in the first four months of life: a risk factor for sudden infant death.
Acta Paediatr. 2007 Aug 20; [Epub ahead of print].

Aim: To investigate the risk of sudden infant death in the Netherlands during bed-sharing in the first half year of life and the protective effect of breastfeeding on it. Methods: During a 10-year period between September 1996 and September 2006 nationwide, 213 cot deaths were investigated. Results and discussion: Of 138 cot deaths of less than 6 months of age, 36 (26%) bed-shared. In a reference group of 1628 babies from infant welfare centres only 9.4% were bed-sharing in the night prior to the interview. After correction for smoking of one or both parents the odds ratio for cot death during bed-sharing with parents decreased with age from 9.1 (CI 4.2-19.4) at 1 month, to 4.0 (CI 2.3-6.7) at 2 months, to 1.7 (CI 0.9-3.4) at 3 months and to 1.3 (CI 1.0-1.6) at 4 through 5 months of age. The excess risk (OR > 1) associated with bed-sharing is itself not significantly influenced by the presence or absence of breastfeeding. Conclusion: Bed-sharing is a serious risk factor for sudden infant death for all babies of less than 4 months of age. From 4 months onwards bed-sharing did not contribute significantly to the risk of cot death anymore in our study.

Full-text available at: http://www.blackwell-synergy.com/

Pasquale-Styles MA, Tackitt PL, Schmidt CJ.
Infant death scene investigation and the assessment of potential risk factors for asphyxia: a review of 209 sudden unexpected infant deaths.
J Forensic Sci. 2007 Jul;52(4):924-9. Epub 2007 Jun 6.

At the Wayne County Medical Examiner Office (WCMEO) in Detroit, Michigan, from 2001 to 2004, thorough scene investigations were performed on 209 sudden and unexpected infant deaths, ages 3 days to 12 months. The 209 cases were reviewed to assess the position of the infant at the time of discovery and identify potential risk factors for asphyxia including bed sharing, witnessed overlay, wedging, strangulation, prone position, obstruction of the nose and mouth, coverage of the head by bedding and sleeping on a couch. Overall, one or more potential risk factors were identified in 178 of 209 cases (85.2%). The increasing awareness of infant positions at death has led to a dramatic reduction in the diagnosis of sudden infant death syndrome at the WCMEO. This study suggests that asphyxia plays a greater role in many sudden infant deaths than has been historically attributed to it.

Full text available online at: http://www3.interscience.wiley.com

Schluter PJ, Paterson J, Percival T.
Infant care practices associated with sudden infant death syndrome: Findings from the Pacific Islands Families study.
J Paediatr Child Health. 2007 May; 43(5):3488-93.

Aim: To report infant care practice prevalence for known modifiable sudden infant death syndrome (SIDS) risk factors among a generally disadvantaged yet low-SIDS rate population of mothers with Pacific infants. Methods: The Pacific Islands Families study follows a cohort of Pacific infants born at a large tertiary hospital in South Auckland, between 15 March and 17 December 2000. Maternal self-report of infant care practices was undertaken at interview 6 weeks post-partum. Results: Overall, 1376 mothers self-reported upon their care practices for infants with median age of 7 weeks. Current maternal smoking was reported by 29%. Of infants: 50% were fully breastfed; 1% were placed prone to sleep; 50% usually bed-shared with their mother and 12% usually bed-shared with a mother who smoked; and 94% usually and 1% occasionally slept in the same room as their mother. Except for room sharing (P = 0.09), there were significant differences in these practices between the three major Pacific Island ethnic subgroups (all P < 0.001). Conclusion: Adoption of bed-sharing and room-sharing practices appears to be saving Pacific infants' lives, even though the New Zealand Cot Death Association has discouraged bed-sharing and not actively promoted room sharing. Mothers need to receive adequate information antenatally about the risks and benefits of room-sharing, bed-sharing and safe-sleeping practices and environments should they decide or have no option but to bed-share.

Full-text available at: http://www.blackwell-synergy.com

Lahr MB, Rosenberg KD, Lapidus JA.
Maternal-infant bedsharing: risk factors for bedsharing in a population-based survey of new mothers and implications for SIDS risk reduction.
Matern Child Health J. 2007 May; 11(3):277-86.

OBJECTIVES: Maternal-infant bedsharing is a common but controversial practice. Little has been published about who bedshares in the United States. This information would be useful to inform public policy, to guide clinical practice and to help focus research. The objective was to explore the prevalence and determinants of bedsharing in Oregon. METHODS: Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) surveys a population-based random sample of women after a live birth. Women were asked if they shared a bed with their infant "always," "almost always," "sometimes" or "never." RESULTS: 1867 women completed the survey in 1998-99 (73.5% weighted response rate). Of the respondents, 20.5% reported bedsharing always, 14.7% almost always, 41.4% sometimes, and 23.4% never. In multivariable logistic regression, Hispanics (adjusted odds ratio [ORa] 1.69, 95% Confidence Interval [CI] 1.17-2.43), blacks (ORa 3.11, 95% CI 2.03-4.76) and Asians/Pacific Islanders (ORa 2.14, 95% CI 1.51-3.03), women who breastfed more than 4 weeks (ORa 2.65, 95% CI 1.72-4.08), had annual family incomes less than $30,000 (ORa 2.44, 95% CI 1.44-4.15), or were single (ORa 1.55, 95% CI 1.03-2.35) were more likely to bedshare frequently (always or almost always). Among Hispanic and black women, bedsharing did not vary significantly by income level. Bedsharing black, American Indian/Alaska Native and white infants were much more likely to be exposed to smoking mothers than Hispanic or Asian/Pacific Islander infants (p < .0001). CONCLUSIONS: Bedsharing is common in Oregon. The women most likely to bedshare are non-white, single, breastfeeding and low-income. Non-economic factors are also important, particularly among blacks and Hispanics. Campaigns to decrease bedsharing by providing cribs may have limited effectiveness if mothers are bedsharing because of cultural norms.

Horsley T, Clifford T, Barrowman N, Bennett S, Yazdi F, Sampson M, Moher D, Dingwall O, Schachter H, Cote A.
Benefits and harms associated with the practice of bed sharing: A systematic review.
Arch Pediatr Adolesc Med. 2007 Mar; 161(3):237-45.

Objective: To examine evidence of benefits and harms to children associated with bed sharing, factors (eg, smoking) altering bed sharing risk, and effective strategies for reducing harms associated with bed sharing. Data Sources: MEDLINE, CINAHL, Healthstar, PsycINFO, the Cochrane Library, Turning Research into Practice, and Allied and Alternative Medicine databases between January 1993 and January 2005. Study Selection: Published, English-language records investigating the practice of bed sharing (defined as a child sharing a sleep surface with another individual) and associated benefits and harms in children 0 to 2 years of age. Data Extraction: Any reported benefits or harms (risk factors) associated with the practice of bed sharing. Data Synthesis: Forty observational studies met our inclusion criteria. Evidence consistently suggests that there may be an association between bed sharing and sudden infant death syndrome (SIDS) among smokers (however defined), but the evidence is not as consistent among nonsmokers. This does not mean that no association between bed sharing and SIDS exists among nonsmokers, but that existing data do not convincingly establish such an association. Data also suggest that bed sharing may be more strongly associated with SIDS in younger infants. A positive association between bed sharing and breastfeeding was identified. Current data could not establish causality. It is possible that women who are most likely to practice prolonged breastfeeding also prefer to bed share. Conclusion: Well-designed, hypothesis-driven prospective cohort studies are warranted to improve our understanding of the mechanisms underlying the relationship between bed sharing, its benefits, and its harms.

Full-text available at: http://archpedi.ama-assn.org

Baddock SA, Galland BC, Taylor BJ, Bolton DP.
Sleep arrangements and behavior of bed-sharing families in the home setting.
Pediatrics. 2007 Jan; 119(1):e200-7.

Objectives: We aimed to provide a quantitative analysis of the sleep arrangements and behaviors of bed-sharing families to further understand the risks and benefits as well as the effects of infant age and room temperature on bed-sharing behaviors. Methods: Forty infants who regularly bed shared with > or = 1 parent > or = 5 hours per night were recruited. Overnight video of the family and physiological monitoring of the infant was conducted in infants' homes. Infant sleep position, potential for exposure to expired air, head covering and uncovering, breastfeeding, movements, family sleep arrangements, responses to the infant, and interactions were logged. Results: All infants slept with their mother. Fathers were included in 18 studies and siblings in 4. Infants usually slept beside the mother, separated from the father/siblings (if present), facing the mother, with head at mothers' breast level, touching, or with mother cradling. Median overnight breastfeeding duration was 40.5 minutes. Mothers commonly faced their infant, but infants were rarely in a position that potentially exposed them to maternal expired air. Fathers were seldom in contact with the infant during sleep. Of the 102 head-covering episodes observed in 22 infants, 80% were because of changes in adult sleep position. Sixty-eight percent of head uncovering was facilitated by the mother; half of these events were prompted by the infant. A 1 degree C increase in room temperature decreased infant head covering by 0.2 hours. Conclusions: The mother-infant relationship is of prime importance during bed sharing, whether the father is present or not. The focus around breastfeeding often dictates the sleep position of the infant and mother, though room temperature may also influence this. In colder rooms infants tend to spend more time with their face covered by bedding. Frequent maternal interactions rely on the ability of the mother to arouse with little stimulation. Mothers, perhaps impaired by alcohol, smoking, or overtiredness, may not be able to respond appropriately.

Full-text available at: http://www.pediatrics.org

Thoman EB.
Co-sleeping, an ancient practice: issues of the past and present, and possibilities for the future.
Sleep Med Rev. 2006 Nov 15; [E-pub ahead of print]

Co-sleeping-infants sharing the mother's sleep space-has prevailed throughout human evolution, and continued over the centuries of western civilization despite controversy and blame of co-sleeping mothers for the deaths of their infants. By the past century, "crib death" was recognized, later identified as Sudden Infant Death Syndrome (SIDS), and generally found to occur more frequently during bed sharing. Pediatricians warned parents of the dangers of SIDS and other risks of bed sharing, and the frequency of bed sharing decreased markedly over the years. However, during recent decades, bed sharing began to increase, though major issues were raised, including: whether bed sharing actually exacerbates or is protective against the occurrence of SIDS, whether the practice facilitates breast feeding, whether bed sharing is beneficial for an infant's development, and other concerns. Dissention may soon be diminished by use of a crib which opens at the mother's bed-side and is becoming a popular approach to mother-and-infant closeness through the night.

Full-text available at: http://www.sciencedirect.com

Ostfeld BM, Perl H, Esposito L, Hempstead K, Hinnen R, Sandler A, Pearson PG, Hegyi T.
Sleep environment, positional, lifestyle, and demographic characteristics associated with bed sharing in sudden infant death syndrome cases: A population-based study.
Pediatrics. 2006 Nov; 118(5):2051-9.

Background: In 2005, the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome recommended that infants not bed share during sleep. Objective: Our goal was to characterize the profile of risk factors associated with bed sharing in sudden infant death syndrome cases. Design/Methods: We conducted a population-based retrospective review of sudden infant death syndrome cases in New Jersey (1996-2000) dichotomized by bed-sharing status and compared demographic, lifestyle, bedding-environment, and sleep-position status. Results: Bed-sharing status was reported in 239 of 251 cases, with sharing in 39%. Bed-sharing cases had a higher percentage of bedding risks (44.1% vs 24.7%), exposure to bedding risks in infants discovered prone (57.1% vs 28.2%), and lateral sleep placement (28.9% vs 17.8%). The prone position was more common for bed-sharing and non-bed-sharing cases at placement (45.8% and 51.1%, respectively) and discovery (59.0% and 64.4%, respectively). In multivariable logistic-regression analyses, black race, mother <19 years, gravida >2, and maternal smoking were associated with bed sharing. There was a trend toward less breastfeeding in bed-sharing cases (22% vs 35%). In bed-sharing cases, those breastfed were younger than those who were not and somewhat more exposed to bedding risks (64.7% vs 45.1%) but less likely to be placed prone (11.8% vs 52.9%) or have maternal smoking (33% vs 66%). Conclusions: Bed-sharing cases were more likely to have had bedding-environment and sleep-position risks and higher ratios of demographic and lifestyle risk factors. Bed-sharing subjects who breastfed had a risk profile distinct from those who were not breastfed cases. Risk and situational profiles can be used to identify families in greater need of early guidance and to prepare educational content to promote safe sleep.

Full-text available at: http://www.pediatrics.org

Mace S.
Where should babies sleep?
Community Pract. 2006 Jun; 79(6):180-3.

An average of six babies dies unexpectedly each week. Sudden infant death syndrome is the predominant cause but many deaths are recorded as unascertained. Medical experts continue to research the causes of these infant deaths, and advice to parents is constantly being evaluated and revised in an attempt to reduce the numbers even further. Bed shadng or co-sleeping is a topic that triggers debate and conflict of advice between health professionals, which may leave parents confused. Bed sharing is known to be dangerous when the mother smokes but there are other factors which are also dangerous and need to be considered before an informed decision is made. This article reviews some of the most relevant research in order to give health professionals the knowledge needed to aid parents in making their decision. Three main areas were studied because of their relevance to bed-sharing and sudden infant death syndrome. These were sleep position, smoking and alcohol consumption and breastfeeding. Recent concerns highlighting sofa sleeping are also considered.

Baddock SA, Galland BC, Bolton DP, Williams SM, Taylor BJ.
Differences in infant and parent behaviors during routine bed sharing compared with cot sleeping in the home setting.
Pediatrics. 2006 May; 117(5):1599-607.

Objectives: To observe the behavior of infants sleeping in the natural physical environment of home, comparing the 2 different sleep practices of bed sharing and cot sleeping quantifying to factors that have been identified as potential risks or benefits. Methods: Forty routine bed-sharing infants, aged 5-27 weeks were matched for age and season of study with 40 routine cot-sleeping infants. Overnight video and physiologic data of bed-share infants and cot-sleep infants were recorded in the infants' own homes. Sleep time, sleep position, movements, feeding, blanket height, parental checks, and time out of the bed or cot were logged. Results: The total sleep time was similar in both groups (bed-sharing median: 8.6 hours; cot-sleeping median: 8.2 hours). Bed-sharing infants spent most time in the side position (median: 5.7 hours, 66% of sleep time) and most commonly woke at the end of sleep in this position, whereas cot-sleeping infants most commonly slept supine (median: 7.5 hours, 100%) and woke at the end of sleep in the supine position. Prone sleep was uncommon in both groups. Head covering above the eyes occurred in 22 bed-sharing infants and 1 cot-sleeping infant. Five of these bed-sharing infants were head covered at final waking time, but the cot-sleeping infant was not. Bed-sharing parents looked at or touched their infant more often (median: 11 vs 4 times per night) but did not always fully wake to do so. Movement episodes were shorter in the bed-sharing group as was total movement time (37 vs 50 minutes respectively), whereas feeding was 3.7 times more frequent in the bed-sharing group than the cot-sleeping group. Conclusions: Bed-share infants without known risk factors for sudden infant death syndrome (SIDS) experience increased maternal touching and looking, increased breastfeeding, and faster and more frequent maternal responses. This high level of interaction is unlikely to occur if maternal arousal is impaired, for example, by alcohol or overtiredness. Increased head covering and side sleep position occur during bed-sharing, but whether these factors increase the risk of SIDS, as they do in cot sleeping, requires further investigation.

Full-text available at: http://www.pediatrics.org

McGarvey C, McDonnell M, Hamilton K, O'Regan M, Matthews T.
An 8 year study of risk factors for SIDS: bed-sharing versus non-bed-sharing.
Arch Dis Child. 2006 Apr; 91(4):318-23. E-pub 2005 Oct 21.

Background: It is unclear if it is safe for babies to bed share with adults. In Ireland 49% of sudden infant death syndrome (SIDS) cases occur when the infant is bed-sharing with an adult. Objective: To evaluate the effect of bed-sharing during the last sleep period on risk factors for SIDS in Irish infants. Design: An 8 year (1994-2001) population based case control study of 287 SIDS cases and 831 controls matched for date, place of birth, and sleep period. Odds ratios and 95% confidence intervals were calculated by conditional logistic regression. Results: The risk associated with bed-sharing was three times greater for infants with low birth weight for gestation (UOR 16.28 v 4.90) and increased fourfold if the combined tog value of clothing and bedding was > or =10 (UOR 9.68 v 2.34). The unadjusted odds ratio for bed-sharing was 13.87 (95% CI 9.58 to 20.09) for infants whose mothers smoked and 2.09 (95% CI 0.98 to 4.39) for non-smokers. Age of death for bed-sharing and sofa-sharing infants (12.8 and 8.3 weeks, respectively) was less than for infants not sharing a sleep surface (21.0 weeks, p<0.001) and fewer bed-sharing cases were found prone (5% v 32%; p = 0.001). Conclusion: Risk factors for SIDS vary according to the infant's sleeping environment. The increased risk associated with maternal smoking, high tog value of clothing and bedding, and low z scores of weight for gestation at birth is augmented further by bed-sharing. These factors should be taken into account when considering sleeping arrangements for young infants.

Full-text available at: adc.bmjjournals.com/

Alm B, Lagercrantz H, Wennergren G.
Stop SIDS--sleeping solitary supine, sucking soother, stopping smoking substitutes.
Acta Paediatr. 2006 Mar; 95(3):260-2.

The recognition of prone sleeping and maternal smoking as modifiable risk factors for sudden infant death syndrome (SIDS), has drastically decreased SIDS incidence. However, during the last years other factors have become necessary to consider to further reduce the risk of SIDS. Side sleeping implies a greater risk than supine sleeping but is still common. Bed sharing may increase the risk of SIDS, while use of a pacifier seems to be protective. Replacement of maternal smoking with nicotine substitutes is not harmless. Conclusion: To further reduce the risk of SIDS, exclusive supine sleeping should be encouraged and side sleeping discouraged. When the breast-feeding is established, a pacifier can very well be used at bedtime. Bed sharing can increase the risk of SIDS if the infant is below 2-3 months of age, especially if the mother is a smoker. Any nicotine use should be avoided during pregnancy and breast-feeding.

Full-text available: taylorandfrancis.metapress.com

Glasgow JF, Thompson AJ, Ingram PJ.
Sudden unexpected death in infancy: place and time of death.
Ulster Med J. 2006 Jan;75(1):65-71.

In recent years, many babies who die of Sudden Unexpected Death in Infancy (SUDI) in Northern Ireland are found dead in bed--i.e. co-sleeping--with an adult. In order to assess its frequency autopsy reports between April 1996 and August 2001 were reviewed and linked to temporal factors. The day and month of death, and the place where the baby was found were compared to a reference population of infant deaths between one week of age and the second birthday. Although the rate of SUDI was lower than the UK average, 43 cases of SUDI were identified, and two additional deaths with virtually identical autopsy findings that were attributed to asphyxia caused by suffocation due to overlaying. Thirty-two of the 45 (71%) were less than four months of age. In 30 of the 45 cases (67%) the history stated that the baby was bed sharing with others; 19 died sleeping in an adult bed, and 11 on a sofa or armchair. In 16 of the 30 (53%) there were at least two other people sharing the sleeping surface, and in one case, three. SUDI was twice as frequent at weekends (found dead Saturday-Monday mornings) compared to weekdays (p<0.02), and significantly more common compared to reference deaths (p<0.002). Co-sleeping deaths were also more frequent at weekends. Almost half of all SUDI (49%) occurred in the summer months--more than twice the frequency of reference deaths. While sharing a place of sleep per se may not increase the risk of death, our findings may be linked to factors such as habitual smoking, consumption of alcohol or illicit drugs as reported in case-control studies. In advising parents on safer childcare practices, health professionals must be knowledgeable of current research and when, for example, giving advice on co-sleeping this needs to be person-specific cognisant of the risks within a household. New and better means of targeting such information needs to be researched if those with higher risk life-styles are to be positively influenced.

Lahr MB, Rosenberg KD, Lapidus JA.
Bedsharing and maternal smoking in a population-based survey of new mothers.
Pediatrics. 2005 Oct; 116(4):e530-42.

Objective: Sudden infant death syndrome (SIDS) remains the number 1 cause of postneonatal infant death. Prone infant sleep position and maternal smoking have been established as risk factors for SIDS mortality. Some studies have found that bedsharing is associated with SIDS, but, to date, there is only strong evidence for a risk among infants of smoking mothers and some evidence of a risk among young infants of nonsmoking mothers. Despite the lack of convincing scientific evidence, bedsharing with nonsmoking mothers remains controversial. In some states, nonsmoking mothers are currently being told that they should not bedshare with their infants, and mothers of infants who died of SIDS are told that they caused the death of their infant because they bedshared. The objective of this study was to explore the relationship between maternal smoking and bedsharing among Oregon mothers to explore whether smoking mothers, in contrast to nonsmoking mothers, are getting the message that they should not bedshare. Methods: Oregon Pregnancy Risk Assessment Monitoring System surveys a stratified random sample, drawn from birth certificates, of women after a live birth. Hispanic and non-Hispanic black, non-Hispanic Asian/Pacific Islander and non-Hispanic American Indian/Alaskan Native women, and non-Hispanic white women with low birth weight infants are oversampled to ensure sufficient numbers for stratified analysis. The sample then was weighted to reflect Oregon's population. In 1998-1999, 1867 women completed the survey (73.5% weighted response). The median time from birth to completion of the survey was 4 months. Women were asked whether they shared a bed with their infant "always," "almost always," "sometimes," or "never." Frequent bedsharing was defined as "always" or "almost always"; infrequent was defined as "sometimes" or "never." Results: Of all new mothers, 35.2% reported bedsharing frequently (always: 20.5%; almost always: 14.7%) and 64.8% infrequently (sometimes: 41.4%; never: 23.4%). Bedsharing among postpartum smoking mothers was 18.8% always, 12.6% almost always, 45.1% sometimes, and 23.6% never; this was not statistically different from among nonsmoking mothers. Results for prenatal smokers were similar. When stratified by race/ethnicity, there was no association between smoking and bedsharing in any racial or ethnic group. In univariable and multivariable logistic regression, there were no statistical differences in frequent or any bedsharing among either prenatal or postpartum smoking mothers compared with nonsmokers; the adjusted odds ratio for postpartum smokers who frequently bedshared was 0.73 (95% confidence interval [CI]: 0.42-1.25) and for any bedsharing was 1.05 (95% CI: 0.57-1.94). Results for prenatal smoking were similar. This is the first US population-based study to look at the prevalence of bedsharing among smoking and nonsmoking mothers. Bedsharing is common in Oregon, with 35.2% of mothers in Oregon reporting frequently bedsharing and an additional 41.4% sometimes bedsharing. There was no significant association between smoking and bedsharing for either prenatal or postpartum smokers among any racial or ethnic group. Smoking mothers were as likely to bedshare as nonsmoking mothers. The frequency of bedsharing in Oregon was similar to estimates from other sources. Our study has the advantage of being a population-based sample drawn from birth certificates, weighted for nonresponse. Conclusions: Although a number of case series have raised concerns about the safety of mother-infant bedsharing, even among nonsmoking mothers, this has not yet been confirmed by careful, controlled studies. There have been 9 large-scale case-control studies of the relationship between bedsharing and SIDS. Three case-control studies did not stratify by maternal smoking status, but found no increased risk for SIDS. Six case control studies reported results stratified by maternal smoking status: 1 study, while asserting an association, provided an unexplained range of univariable odds ratios without CIs; 3 found no increased risk for older infants of nonsmoking mothers; and 2 found a risk only for infants <8-11 weeks of age. Despite the preponderance of evidence that bedsharing by nonsmoking mothers does not increase the risk for SIDS among older infants, the recent specter of bedsharing as a cause of SIDS, based on uncontrolled case series and medical examiners' anecdotal experience, has led some medical examiners to label a death "suffocation" or "overlay asphyxiation" simply because the infant was bedsharing at the time of death. This "diagnostic drift" may greatly complicate future studies of the relationship between bedsharing and SIDS. Epidemiologic evidence shows that there is little or no increased risk for SIDS among infants of nonsmoking mothers but increased risk among infants of smoking mothers and younger infants of nonsmoking mothers. It seems prudent to discourage bedsharing among all infants <3 months old. Young infants brought to bed to be breastfed should be returned to a crib when finished. It would be worthwhile for other researchers to reanalyze their previous data to evaluate the consistency of the interaction of young infant age and bedsharing. Large controlled studies that include infants who are identified as dying from SIDS, asphyxia, suffocation, and sudden unexplained infant death, analyzed separately and in combination, are needed to resolve this and other issues involving bedsharing, including the problem of diagnostic drift. Recommendations must be based on solid scientific evidence, which, to date, does not support the rejection of all bedsharing between nonsmoking mothers and their infants. Cribs should be available for those who want to use them. Nonsmoking mothers should not be pressured to abstain from bedsharing with their older infants; they should be provided with accurate, up-to-date scientific information. Infants also should not co-sleep with nonparents. In Oregon, if not elsewhere, the message that smoking mothers should not bedshare is not being disseminated effectively. Because it is not known whether the risk caused by smoking is associated with prenatal smoking, postpartum smoking, or both, bedsharing among either prenatal or postpartum smokers should be strongly discouraged. Much more public and private effort must be made to inform smoking mothers, in culturally competent ways, of the very significant risks of mixing bedsharing and smoking. Public health practitioners need to find new ways to inform mothers and providers that smoking mothers should not bedshare and that putting an infant of a nonsmoking mother to sleep in an adult bed should be delayed until 3 months of age.

Full-text downloading available at: pediatrics.aappublications.org/cgi/reprint/116/4/e530

Tappin D, Ecob R, Brooke H.
Bedsharing, roomsharing, and Sudden Infant Death Syndrome in Scotland: A case-control Study.
J Pediatr. 2005 Jul; 147(1):32-7.

Objective: To examine the hypothesis that bed sharing with an infant is associated with an increased risk of sudden infant death syndrome (SIDS). Study design: A 1:2, case: control study in Scotland UK, population 5.1 million, including 123 infants who died of SIDS between January 1, 1996 and May 31, 2000, and 263 controls. The main outcome measure was sharing a sleep surface during last sleep. Results: Sharing a sleep surface was associated with SIDS (multivariate OR 2.89, 95% CI 1.40, 5.97). The largest risk was associated with couch sharing (OR 66.9, 95% CI 2.8, 1597). Of 46 SIDS infants who bed shared during their last sleep, 40 (87%) were found in the parents' bed. Sharing a bed when <11 weeks (OR 10.20, 95% CI 2.99, 34.8) was associated with a greater risk, P = .010, compared with sharing when older (OR 1.07, 95% CI 0.32, 3.56). The association remained if mother did not smoke (OR 8.01, 95% CI 1.20, 53.3) or the infant was breastfed (OR 13.10, 95% CI 1.29, 133). Conclusions: Bed sharing is associated with an increased risk of SIDS for infants <11 weeks of age. Sharing a couch for sleep should be strongly discouraged at any age.

Full-text available at: journals.elsevierhealth.com/periodicals/ympd

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.
Pediatr Respir Rev. 2005 Jun; 6(2): 134-52.

There has been much controversy over whether infants should co-sleep or bedshare with an adult caregiver and over whether such practices increase the risk of SIDS or fatal accident. However, despite opposition from medical authorities or the police, many western parents are increasingly adopting night-time infant caregiving patterns that include some co-sleeping, especially by those mothers who choose to breast feed. This review will show that the relationships between infant sleep patterns, infant sleeping arrangements and development both in the short and long term, whether having positive or negative outcomes, is anything but simple and the traditional habit of labeling one sleeping arrangement as being superior to another without an awareness of family, social and ethnic context is not only wrong but possibly harmful. We will show that there are many good reasons to insist that the definitions of different types of co-sleeping and bedsharing be recognized and distinguished. We will examine the conceptual issues related to the biological functions of mother-infant co-sleeping, bedsharing and what relationship each has to SIDS. At very least, we hope that the studies and data described in this paper, which show that co-sleeping at least in the form of roomsharing especially with an actively breast feeding mother saves lives, is a powerful reason why the simplistic, scientifically inaccurate and misleading statement 'never sleep with your baby' needs to be rescinded, wherever and whenever it is published.

Full-text available at: http://www.sciencedirect.com

Blair P, Ward Platt MP, Smith IJ, Fleming PJ.
Sudden Infant Death Syndrome and sleeping position in pre-term and low birthweight infants: An opportunity for targeted intervention.
Arch Dis Child. 2005 May 24; [E-pub ahead of print]

Aims: Few families now place their infant prone to sleep but many still use the side position, despite strong evidence of a significant association with Sudden Infant Death Syndrome (SIDS). Some maternity hospital staff still advise the side position to parents of pre- term infants. We report the combined effects of SIDS risk factors in the sleeping environment for infants who were "small at birth" (i.e. pre-term [<37weeks], low birth-weight [<2500g] or both). Methods: A three year population-based, case- control study, with parental interviews after each death and reference sleep of age-matched controls. Based in five former Health Regions in England (population 17.7 million) with 325 cases and 1300 controls. Results: Of the SIDS infants 26% were "small at birth" compared to 8% of the controls. The most common sleeping position was supine, both for controls (69%) and those SIDS infants (48%) born at term or >/=2500g, but for "small at birth" SIDS infants the commonest sleeping position was side (48%). The combined effect of the risk associated with being "small at birth" and factors in the infant sleeping environment remained multiplicative despite controlling for possible confounding in the multivariate model. The risk of SIDS associated with being "small at birth" and being put down in the side position (multivariate OR=14.96[95% CI:5.10-43.93]), bed-sharing with parents who habitually smoke (multivariate OR=37.41[95%CI:5.83-239.86]) or being a routine dummy user who did not use a dummy for the last sleep (multivariate OR=17.50 [95%CI:6.14- 49.86]) were each more than multiplicative. For those "small at birth" SIDS who slept in a room separate from the parents the large combined effect (multivariate OR=79.45[95%CI: 18.03-350.20]) showed evidence of a significant interaction (p=0.047). No excess risk was identified from bed-sharing with non-smoking parents for infants born at term or birthweight >/=2500g (multivariate OR=1.12[95%CI:0.30-4.27]). Conclusion: The combined effects of SIDS risk factors in the sleeping environment and being pre-term or low birthweight generate high risks for these infants. Their longer postnatal stay allows an opportunity to target parents and staff with risk reduction messages.

Full-text available at: adc.bmjjournals.com/

Alexander RT, Radisch D.
Sudden infant death syndrome risk factors with regards to sleep position sleep surface, and co-sleeping.
J Forensic Sci. 2005 Jan; 50(1):147-51.

We present a study of 102 Sudden Infant Death Syndrome (SIDS) deaths using retrospective review of medical examiner autopsy reports. The prevalence of sleep related risk factors with regards to sleep surface, sleep position, and co-sleeping were determined in a population of infants less than 1-year-old. Of the 102 SIDS deaths, 67 (65.7%) were not in a crib, 63 (61.8%) were prone, and 48 (47.1%) were co-sleeping. However, 94 (92.2%) of these deaths had at least one risk factor present. Only 8 (7.8%) infants had slept alone, in a crib or bassinet, and on their back or side. Infants less than 4-months-old had a higher rate of co-sleeping (54.7%) than the older infants (25.9%), and a higher frequency of heart malformations at post-mortem examination. The older infants were more likely to exhibit pulmonary and tracheal inflammation, and neuropathology.

Full-text available at: journalsip.astm.org/JOURNALS/FORENSIC/jofs_home.html

Bredemeyer SL.
Implementation of the SIDS guidelines in midwifery practice.
Aust J Midwifery. 2004 Nov; 17(4):17-21.

The literature suggests that midwives strongly influence parenting practices immediately after birth and during early postnatal management of the newborn. Midwives must therefore be aware of the current evidence and public health recommendations for reducing the risk of Sudden Infant Death Syndrome (SIDS) and provide consistent information about use of the supine position. Midwives must also include information about environmental factors that are also known to increase the risk of SIDS such as exposure to cigarette smoke, covering the infant's face during sleep and other potential unsafe sleeping practices such as co-sleeping and bed sharing with their infant. The position midwives use to settle infants and place them for sleep is an important example for parents. The position favored by midwives when placing a newborn to sleep will have a significant impact on parental practice after discharge home. A standardized evidenced based approach to the SIDS Guidelines immediately after birth will facilitate consistency in practice and uniformity in the message parents are given about safe sleeping practices for their newborn infant.

Mesich HM.
Mother-infant co-sleeping: understanding the debate and maximizing infant safety.
MCN Am J Matern Child Nurs. 2005 Jan-Feb; 30(1): 30-7;

Mother-infant co-sleeping is debated fervently in the research literature. While studies abound, there is no precise answer to this conundrum, and parents continue to ask nurses for their best opinions about the safety of co-sleeping. The puzzling results of these studies have occurred partly because of: (1) retrospective study designs, (2) lack of control over covariables, (3) misclassification of infant deaths, and (4) unknown prevalence of co-sleeping practices. This article describes the salient issues nurses need to understand in the mother-infant co-sleeping debate, and suggests ways that nurses can help parents to modify risk factors and safety measures if they desire co-sleeping.

Full-text available at: http://www.mcnjournal.com

August 2009

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