Bed Sharing and SIDS

http://www.bmj.org/cgi/content/full/319/7223/1457

http://www.bmj.org/cgi/content/short/319/7223/1457

http://www.bmj.org/cgi/reprint/319/7223/1457

9/29/99
CPSC Warns Against Placing Babies in Adult Beds; Study finds 64 deaths each year from suffocation and strangulation

The U.S. Consumer Product Safety Commission (CPSC) is warning parents and caregivers about the dangers of placing babies to sleep in adult beds. A CPSC study published in the October issue of the Archives of Pediatrics and Adolescent Medicine found that placing babies to sleep in adult beds puts them at risk of suffocation or strangulation. This is a danger of which many parents and caregivers are unaware. The study revealed an average 64 deaths per year to babies under the age of 2 years placed to sleep in adult beds, including waterbeds and daybeds.

9/29/99
  Media Advisory from the SIDS Alliance on CPSC Report which strongly discourages bedsharing with infants under 2 years of age. "A review of the current scientific literature demonstrates that not only has bedsharing not been proven to be protective against SIDS but that it can, under a number of conditions, actually be hazardous."

Date: Tue, 30 Mar 1999

Bed sharing is a very interesting issue, which has received a lot of media attention in the last few years.

Throughout the ages, most babies slept with their mothers. This has led some researchers, notably Doctor James McKenna now at Notre Dame University, to ask if there is any survival advantage to a baby sleeping with his/her mother. This question prompted some very interesting research from his group, and others. He has found that when babies sleep with their mothers, there is an incredible amount of interaction which occurs between the two. There are more arousals (waking up during the night) of both mother and baby when they sleep together vs. sleeping apart. Any new mother could probably tell us that. There has been a suggestion that arousal may be an important mechanism to rescue babies from potentially dangerous situations during sleep. Thus, increasing arousal might be a good thing. Doctor Peter Fleming from the United Kingdom, has done similar studies, but he believes that it is usually the baby who wakes the mother, not the other way around. Thus, this would not likely have a protective effect on the baby. However, to date, there are no scientific studies which come close to proving that bed sharing, or these increases in arousal, or other aspects of bed sharing, may have any protective effect at reducing the risk for SIDS. Doctor McKenna has shown that infants who bed share are more likely to breastfeed. However, even breastfeeding, by itself, has not been shown to reduce the risk for SIDS. Therefore, any potential benefits of bed sharing with respect to SIDS remain only speculative. They have not been proven. There is currently no study which indicates that bed sharing reduces the risk for SIDS.

So, the next question is, "is bedsharing harmful"? This is more controversial. As far back as the Middle Ages, many people were worried about "maternal overlaying"; that is, the parent who sleeps with a baby might roll over on the baby and suffocate him/her. This probably does not happen frequently. Epidemiological studies came out in the 1980's which suggested that bedsharing might actually be associated with an increased risk for SIDS. That is, bedsharing might be dangerous. This was especially true if the parents smoke cigarettes (even if they do not smoke in bed). Since then, several studies have emerged. Some suggest an increased risk from bedsharing, and some do not.

As has been suggested on this Discussion forum, the answer probably lies in between. There can certainly be situations where bedsharing can be dangerous. Examples would include where parents are intoxicated or obtunded, perhaps somewhat obese, and they may roll onto a baby, but not be able to awaken in response to a baby's movements. Thus, bedsharing should not be done in combination with parental drug use, alcohol, etc. Bedsharing may also occur in an unsafe bed, such as a waterbed, or bed with soft padding. If a family decides on bedsharing, it should be done with all the recommendations for infant beds in mind. Thus, pillows, quilts, etc., should be removed. The mattress should be firm. Overheating should be avoided, and so on. However, it is important to recognize that sufficiently motivated families with resources probably can create a safe environment where bedsharing can occur, and the risk for SIDS would not be increased. In some cases, especially in lower socio-economic situations, bedsharing may occur in a dangerous setting. Many children may share a bed, which is soft, has multiple blankets or quilts, and may be associated with cigarette smoke, drugs, or alcohol. The term chaotic bedsharing has been used to describe this form of bedsharing, which is unsafe and likely to increase the SIDS risk.

With respect to SIDS, I think the following can be said about bedsharing. There is no evidence that bedsharing is protective or reduces the risk for SIDS. There are some theories, which are worthy of continued research, and which may provide us with more information on this issue. There are some situations where bedsharing is clearly dangerous. However, for families sufficiently motivated to share their bed with an infant, close attention should be paid to avoiding other known risk factors for SIDS.

I hope this is helpful.
Thomas G. Keens, M.D.
tkeens@CHLA.USC.EDU
Childrens Hospital Los Angeles
University of Southern California

7/25/97 Media Alert from SIDS Alliance on AAP Issues Policy and New Study Released on Bedsharing

Several studies have shown a low SIDS rate in countries/cultures where co-sleeping is a common practice. Some of these have to be looked at carefully because of differences in SIDS definitions and that sort of thing. However, even after allowing for such differences, it does seem that some countries in which co-sleeping is commonplace also have a low SIDS incidence.

In addition, several studies have looked specifically for an association between co-sleeping and SIDS and have not found one. Other studies that have found a correlation between infant/parent co-sleeping and SIDS have found it to be linked with other factors, such as smoking. Several articles have been published that collected reports of babies dying in what were called "dangerous sleeping environments", including adult beds. These are not epidemiologic studies but they do make the point that some sleeping environments *can* be dangerous. Finally, the CPSC study looked at this and reported widely, in numerous press releases (1995), that up to 30% of SIDS deaths may have been related to bedding material that is inappropriate (potentially harmful) for infants. On the other hand, some researchers point out that there are potential benefits of co-sleeping, with respect to breast feeding, parent-infant bonding, and other care-practice issues.

Recently strong recommendations have come out against co-sleeping. Articles written for medical practitioners have stated flatly that doctors should recommend to parents "NEVER let your baby sleep in an adult bed" (or something to that effect). It seems that the argument runs something like this... Yes, there may be some benefits of co-sleeping... however, there clearly are potential dangers of having infants sleep in beds and on bedding materials designed for adults. So, until the issue is cleared up, it is recommended that infants sleep in properly designed, CPSC-approved cribs, with approved mattresses, with bedding material designed for infants, and without potentially hazardous materials such as bumpers, thick blankets, comforters, pillows, etc.

Someone pointed out (I don't recall the reference) that co-sleeping in other cultures differs considerably co-sleeping in the USA. Putting a baby into a double, queen, or king-sized bed, 2-3 feet off the floor, with a soft mattress, mattress pads, thick covers, blankets, pillows, comforters, etc... may be quite different from co-sleeping as practiced in Asian countries for example. It may well be the case that infant-parent co-sleeping can be safe when we know how to do it safely. Americans may need to *learn how to co-sleep with an infant safely* before it can be recommended.

Thanks,

John L. Carroll, M.D.
The Johns Hopkins Children's Center
Baltimore, MD

As I stated in my earlier response, I am not convinced that co-sleeping, in and of itself, either is protective or carries an increased risk for SIDS. Please note that this is just my opinion at the present time, and I could be wrong. Some Asian countries, such as China, Hong Kong, and Japan have a low reported SIDS rates and predominately co-sleeping for infants. Your question, I assume, is are these causally related?

First, these countries also have almost universal back sleeping, which is also associated with a lower risk. Which of these has the greater influence may be difficult to sort out. However, we do have good epidemiologic evidence that back sleeping is associated with a reduced SIDS risk.

Second, I think there are a number of other issues which may play a role in the reported SIDS rates from these countries, and I would submit that we may not have an accurate idea of their SIDS rates.

A specific example is Japan. I was privileged to be invited to Japan in September, 1995, and had the opportunity to spend some time with Japan's leading SIDS researcher, Professor Hiroshi Nishida. His belief was that the SIDS rate in Japan was not as low as reported. Because the Japanese did not believe that SIDS was a problem there, they did not make the diagnosis. With his efforts, and the efforts of others, to increase public and professional awareness about SIDS, the SIDS rate has risen. Thus, there are differences in diagnostic standards and the use of the diagnosis. One of the goals of the Pathology Working Party of the SIDS Global Strategy Task Force is to develop a death scene and autopsy protocol which would be used world-wide, to improve the uniformity of how the SIDS diagnosis is made. Then, statistics between different countries may be more comparable.

I hope this helps. Thank you.

Tom Keens
Children's Hospital Los Angeles

I believe that some of the most innovative research on bed sharing (or co-sleeping) is being done by Doctor James McKenna (Pomona College) and his collaborators at the University of California, Irvine. At the Fourth SIDS International Conference, they presented work suggesting a slight possible increase in apneas in babies who sleep in the same bed with their mother, vs. the same baby sleeping alone. I do not think the increase was clinically significant. Ultimately, I predict that there will be no effect (beneficial or detrimental) of bed sharing on SIDS or apnea.

Researchers from New Zealand have found in epidemiological studies that bed sharing AND cigarette smoking is associated with a marked increased risk for SIDS. Bed sharing alone (with non-smoking parents) is probably not associated with an increased risk. They found no protective effect of bed sharing.

Historically, there has been concern that bed sharing might result in "maternal overlaying", where the adult sleeping in the bed with an infant may roll over and smother a baby. It continues to be debated whether this really occurs. However, if an adult in bed with an infant is obese (a lot of tissue to mold over the baby's face) and is obtunded (drunk or drugged) so that the adult does not react to an infant's struggles, overlaying is a 'theoretical' possible cause of death.

Doctor McKenna's work did show that the MOTHER had increased arousals in response to the baby during sleep with bed sharing. Interestingly, the baby's arousals were not increased. Thus, bed sharing may not have the hypothesized effect of increasing a baby's arousals to prevent SIDS. However, the apparent heightened awareness of the mother to the baby in bed with her appears to make 'maternal overlaying' a very rare event.

I hope this helps. Thanks.

Tom Keens
Children's Hospital Los Angeles

I think an important point about co-sleeping, that many fail to mention, is the fact that co-sleeping infants tend to sleep on their backs not their stomachs. This way they have easier access to the food source, their mother's breast. As we all know back sleeping reduces the risk of SIDS, and that may be why we see less SIDS in co-sleeping cultures. It could also be the results of poor data collection and misdiagnosis or other factors not fully understood yet. Dr. James McKenna's research addresses that fact that co-sleeping infant spend less time in the deep stages of sleep than infants who sleep alone. Since SIDS occurs in the deeper stages of Sleep, he seem to think that this may be a protective factor for infants. I think the important fact is that no one can say for sure that co-sleeping prevents SIDS - they can only quote statistics. One more point is that babies do die of SIDS while sleeping with their parents.

I personally practiced co-sleeping with both of my children and found it to be a wonderful experience. However, co-sleeping is not for every family, anyone who feels uncomfortable with it should not co-sleep, nor should they be made to feel guilty or be called a bad parent. Good parents raise their children in many different ways.

Elsa Weber, M.S., CHES.
Health Education Specialist