Updated: Sep 24, 2020
“I breastfeed and sleep with my baby. I just don’t tell my pediatrician about it.”
(FaceBook post, January 2020, name withheld for confidentiality)
I read this mom’s statement on a popular local breastfeeding FaceBook group, and realized from the online discussion that followed, just how many parents are bedsharing with their infants and keeping it a secret. This concerned me for two reasons: 1) these parents feel like they have to hide their real behaviors from their doctor which is based largely on mistrust in our healthcare system and, 2) we are missing a critical opportunity for education and support.
It is not surprising that some infant sleep recommendations seem to conflict with what some parents feel are “natural” or what may be a “common” experience. I sometimes hear phrases like, “Sleeping with your baby is done all over the world and other countries have lower SIDS rates than the US, so it's safe,” and “it’s natural for families to sleep together” or, “sleeping with your baby could kill them.” Whenever there is discord between what people have experienced or understand as “normal” and an opposite recommendation from an authority figure, the emotional connection will define what action is taken; what feels better based on what is desired, is what directs people to do. Often, this creates polarized groups or “camps,” which can get labeled as either “safe” or “dangerous” based on emotions, rather than evidence or research. Bedsharing* is one such hot topic with limited or contradictory evidence (statistics, reports, or behavioral results) from quality studies supporting both positions of either sleeping with, or sleeping separately from your baby.
Parents often ask me if it’s ok for them to fall asleep with their baby. My answer used to depend on assessing multiple different factors, “dancing” between both positions, which created a very confusing, non-standard answer. Until now.
New Bedsharing* Recommendation
In January this year, the Academy of Breastfeeding Medicine (ABM) shook the pediatric establishment by releasing a new protocol offering evidence-based recommendations on safe bedsharing for breastfeeding moms and babies in the home setting. The ABM recommends that all families be counseled about safe sleep in a way that invites discussion without judgment or condemnation, and parents should also be presented with clear and specific guidelines on how to sleep safely with infants.
Bedsharing has always been associated with more moms initiating breastfeeding and longer and more exclusive breastfeeding, which directly improves moms’ and babies’ health over their whole lives. Separate, but close-proximity-to-mom sleeping locations, may support longer and more exclusive breastfeeding as well. But separate sleep (even if the baby is room-sharing), is also associated with early weaning, or reduced milk supply due to less frequent nighttime breastfeeding, and unintentional bedsharing which occurs more often in unsafe/hazardous conditions.
What about SIDS?
The fear of sleep-related infant death (like SIDS) or infant suffocation has been the main argument against bedsharing. Many medical and public health organizations in the US (AAP, CDC, March of Dimes) who strongly support breastfeeding, warn that bedsharing can lead to a higher risk of SIDS and recommend babies should sleep in their own crib or bassinet in the same room as the parent and within arms reach, but not in the same bed as the parent. They are very clear in their statements and are not open to bedsharing at all.
In contrast to these recommendations, the new ABM protocol states that current evidence does not support the conclusion that bedsharing with breastfeeding infants (“breastsleeping”) causes SIDS when known hazards are not present. The idea of educating parents about known hazards is a very key point!
Will I Ever Sleep Again? (Yes, you will!)
Most parents admit to falling asleep with their baby on occasion, because, let’s get real, the intensity of sleep deprivation with a new baby is more shocking than anything we could have imagined. At times, there is nothing that can keep us awake while nursing! No one functions well without sleep; we tend not to make the best decisions or process new information well without adequate sleep, and there are concerns about long-term consequences to both parents and infants without a full night’s sleep. This is when unintentional bedsharing happens, often when we just fall asleep in dangerous places, like on the couch or in a recliner with the baby—very unsafe.
While we all long for a full night’s sleep and reminisce about how we used to sleep in on Saturday mornings, we can adapt and change our idea of what “sleeping through the night means.” Addressing our expectations and modifying how we sleep (more naps and shorter sleep periods) will help you get used to different sleep patterns and still be able to function well.
New babies are not designed to sleep in the same way as adults. Because they have small stomachs, grow so fast, and utilize breastmilk more effectively, breastfed babies must eat frequently to nourish their bodies with enough calories to optimize their development. Breastfed babies need to eat about 8-12 times every 24 hours, and depending on the baby’s stomach size and mom’s milk storage capacity (how much milk the breasts can hold at any time), some babies continue that frequent eating pattern for months. Some babies start sleeping for longer periods of time (like 4-5 hours at a time) within 1-2 months of age. Also, newborns and young babies tend to sleep through their meals and the surge of oxytocin with the release or “let down” of your milk makes everyone sleepy.
Most parents report that their baby tends to sleep better when they are together, or fuss and wake up as soon as they are placed in their own crib or bassinet. Some parents choose to share the same bed with their children for years. Some parents state that sleeping with their baby is too disruptive and they sleep better separately. Whatever the preference, or choice is, it is critical that everyone know what the recommendations are for safe sleep and feel safe discussing it with their healthcare providers. Hiding if we are sleeping with our baby does not allow us to learn safe practices which actually does put our baby at risk. We must be able to share our experiences with, and seek advice from the professionals that can help us keep our babies safe through decisions and actions that promote health and wellbeing for both parents and babies. The ABM’s new protocol provides tools for us to evaluate if bedsharing is safe for each of our families on an individual basis.
Safe Bedsharing Advice
The ABM summarizes two key sets of advice for bedsharing. The first list names factors that increase the risk of SIDS, or hazards to avoid. The second list shares elements of safe bedsharing in order of importance. Both lists must be considered together for safe bedsharing.
HAZARDOUS RISK FACTORS OR CIRCUMSTANCES TO AVOID WITH BEDSHARING:
Sharing a sofa with a sleeping adult
Infant sleeping next to an adult who is impaired by alcohol or drugs
Infant sleeping next to an adult who smokes
Sleeping in the prone (face-down, or on the stomach) position
Never initiating breastfeeding
Sharing a chair with a sleeping adult
Sleeping on soft bedding
Being born preterm or of low birth weight
ELEMENTS OF SAFE BEDSHARING ADVICE (in order of importance):
Never sleep with infants on a sofa, armchair, or unsuitable surface, including a pillow
Place infants to sleep away from any person impaired by alcohol or drugs
Place infants supine (face-up, on the back) for sleep
Place infants to sleep away from secondhand smoke and away from a caregiver/parent who routinely smokes, including clothing or objects that smell of smoke. Bedsharing with a mother who smokes is not recommended.
The bed should be away from walls and furniture to prevent wedging of the infant’s head or body.
The bed’s surface should be firm, just as with a crib, without thick covers like duvets or donnas, pillows or other objects that could cause accidental head covering and smothering.
The infant should not be left alone on an adult bed.
Use the C-position (“cuddle curl”) with the infant’s head across from the adult’s breast, adult’s legs and arm(s) curled around the infant, infant on their back, away from the pillow is the optimal position (see photo).
There is not enough evidence to make recommendations on multiple bed sharers or the position of the infant in bed with respect to both parents when hazardous risk factors are not present.
In summary, breastfeeding reduces the risk of SIDS and supports lifelong health for both mom and baby. Do not bedshare with a premature baby (or low birth weight), if you or your partner smokes, or if you have taken any drugs or alcohol. Bedsharing can be safe when known hazards are not present and parents make the intentional choice to share a bed with their baby.
No parent or family member should ever have to endure the indescribable pain of losing a child to a SIDS/SUID event. Those that have suffered a child’s death would do anything to prevent it and all of these recommendations are intended to continue reducing any chance of this happening. It’s vital that we establish trusting relationships with our healthcare providers so that open dialogue and discussions can provide education, compassion and support for families. Everyone wants to keep our babies safe. Let’s keep talking!
Here are some other resources for you to explore:
Interactive videos and handouts explaining all the critical points of separate safe sleep environments (what used to be known as the “back to sleep” campaign):
*Definitions (per the ABM protocol)
Bedsharing: an infant sharing an adult bed with an adult for sleep (sleeping next to a caregiver) on a mattress or futon
Co-sleeping: term that may include both sleeping on a shared surface and sleeping in proximity but not necessarily on a shared sleep surface (not used in this blog)
Breastsleeping: a term that describes a biologically based model of sustained contact between the mother and infant, in which sleeping and breastfeeding are combined, assuming no hazardous environmental risk factors are present. The mother/baby pair feed frequently throughout the night while lying in bed together.
Separate Sleep: room-sharing without bedsharing
Solitary Sleep: infant sleeps in a separate room from parents
SIDS/SUID/SUDI: sudden infant death/sudden unexpected infant death/sudden unexpected death in infancy (all relate to an infant death that is unexplained after a case review when the cause of death is unknown)
ASSB: infant death due to asphyxia, strangulation or suffocation in a bed, crib, sofa or armchair