Why Rates of Bedsharing With Infants are Rising, While U.S. Health Policy Advocates Condemn it
Formal health agencies recommend against bedsharing with infants.
Bedsharing rates are increasing despite the fact that it is discouraged.
Some reasons parents choose bedsharing include breastfeeding, attachment concerns, and cultural pressures, and because it feels natural to them.
“Bedsharing” refers to a parent (usually the mother) and infant sharing the same adult bed for all or part of the night. Arguments against bedsharing include value-driven concerns about children’s independence, as well as medical concerns about sudden infant death syndrome (SIDS). For more than a decade the American Academy of Pediatrics (AAP, 2011) has recommended that safe infant sleep occurs alone, supine, and in a safety-approved crib, among other conditions. The U.S. Consumer Safety Products Commission (1999) warns parents about possible infant deaths when sleeping on adult beds. Yet bedsharing rates have risen over the past two decades (Colson et al., 2013), with most of the increase occurring since the publication of these recommendations. One study found rates as high as 88% in a sample from New Orleans (Weimer et al., 2002). Why are family practices and public health advice increasingly diverging on this topic?
Reasons Families Bedshare
Ease of breastfeeding. Breastfeeding and bedsharing (BNB) are closely related, as documented by a voluminous research literature. Infants of BNB mothers nurse more often at night and for a much longer duration than do solitary sleepers. Any bedsharing during the first year significantly increases the length of breastfeeding, which shows a dose–response relationship (Huang et al., 2013). Breastfeeding rates decline after solitary sleeping begins, and they increase when bedsharing starts later in infancy
BNB mothers also benefit from more quantity and quality of sleep than non-BNB mothers. Even though BNB mothers nurse their infants more often, they don’t have to wake fully, and so they get more total sleep. This is partly because of the characteristic sleeping posture of BNB mothers in which the baby is supine (see McKenna & McDade, 2005), a universal posture for sleeping with a breastfeeding infant adopted by women around the globe. In this position, the infant cannot slip too far below covers, is protected from adult pillows, and cannot be overlain by the mother, who can check on the infant any time. So ease of both breastfeeding and parent sleep contribute to parents’ decision to bedshare against professionals’ recommendations.
Attachment. Many mothers report bedsharing to facilitate attachment, and there is research to support that position. Mileva-Seitz and colleagues (2016) found that bedsharing infants had a lower risk of insecure attachment than solitary sleepers; infants who had never bedshared were more likely to be resistantly attached at 14 months. Thus, infants left to self-soothe from birth and fall back asleep independently were actually more likely to exhibit “clingy” behavior a year later, which suggests that continuing physical contact into nighttime care may increase attachment between mother and infant. Or, parents who bedshare may exhibit more parental flexibility, being more sensitive and responsive to the infant’s needs, which is supported by the fact that circadian rhythms are undeveloped before 3–4 months of age; this means that infants likely cannot distinguish between daytime consistent responding (considered good practice) and nighttime consistent not responding (recommended as “sleep training”). Instead, infants may perceive the differences as inconsistent, undependable attention to their daytime and nighttime cries, thus making insecure attachment more likely (Blunden, Thompson, & Dawson, 2011).
Culture and demographics. Infant sleep is a biopsychosocial phenomenon, influenced by cultural norms, expectations, and practices (Owens, 2005). While bedsharing rates are rising overall in the U.S., it is more common among Black, Hispanic, and Asian infants than for Non-Hispanic White infants. It is more common in families in which the mother is single and younger than 20, and for families with younger infants. In addition, bedsharing is more likely for mothers with low education, in low-income households, and in the U.S. West and South (Salm Ward & Ngui, 2015). Also, breastfeeding mothers and highly educated mothers who engage in “attachment parenting” are likely to bedshare.
Culture also shapes sleep and wake practices, such as whether sleep for adults or infants occurs in a continuous uninterrupted period or is broken into shorter segments. Many U.S. parents are encouraged to “sleep train” infants to sleep through the night, consolidating all infant nighttime sleep into one long sleep bout like that of adults (Blunden, et al. 2011). This advice encourages infant “independence” as early as possible, an important cultural value. However, no evidence exists that solitary sleeping promotes independence, and it is an unfounded assumption that “independent” behaviors in infancy (e.g., solitary sleeping) lead to independent behaviors at later ages or in other areas of life (e.g., self-care) (McKenna & McDade, 2005). Many infants who bedshare also exhibit independent sleep behaviors like falling asleep alone, sleeping through the night, and falling back asleep unaided upon waking. Studies have found that preschool children who bedshared in infancy demonstrated more independent behavior in other areas of development, like dressing themselves and working out problems in social relationships with peers without adult intervention (Keller & Goldberg, 2004).
Mothers report that it feels “natural” to have the baby close. That mothers report it feels natural to have their baby close through the night is not surprising. Among primates, human infants are least neurologically mature at birth. Anthropologists note that BNB coevolved with human maternal and infant physiology, serving as a developmental bridge between the complete maternal regulation of the infant’s prenatal environment and the continuing maternal regulation of the infant’s postnatal environment and continuing development (McKenna & McDade, 2005). In fact, the newborn period and the first few months of life are now widely considered a “fourth trimester,” a period that shares more similarities to prenatal life than to later postnatal life (Montagu, 1961). For example, the newborn’s immature thermoregulatory system is aided by contact with the mother’s body to maintain a stable body temperature (its absence requires a warmed cot right after birth); infants warmed skin-to-skin with their mother’s body have more stable blood glucose levels (necessary for brain development and function; Winberg, 2005). Full-term infants who bedshared have shown more regulated breathing and a faster heart rate than solitary sleepers, which reflects more physiological reactivity (McKenna & McDade, 2005) and suggests that bedsharing provides continued, seamless opportunities for postnatal physiological regulation and neurological development in the infant.
What About SIDS?
In the U.S., the AAP discourages bedsharing because of a higher risk of SIDS, yet infant sleep is highly organized, clearly occurring worldwide in countless cultural and societal contexts. In most of the world’s cultures today (more than two-thirds, according to Schon, 2007), however, and throughout human evolutionary history, bedsharing has been an acceptable, normative practice. The countries today that have the highest rates of bedsharing (Japan, Hong Kong, and China) also have the lowest rates of SIDS (Blair et al., 2009).
Many researchers (e.g., Blair et al., 2009; Gessner & Porter, 2006) have argued that, in the absence of other risk factors (e.g., sofa sleeping, smoking, alcohol or drug use), bedsharing poses no additional risk of SIDS. Mileva-Seitz and colleagues (2017) recently reviewed 659 published bedsharing studies and called for more integrated research, concluding that strong recommendations against bedsharing are not evidence based.
Recommendations for safe infant solitary sleep abound. According to the AAP, sleeping alone in an approved crib is just a first step to ensure infant safety; the infant must also lie supine, without pillows, comforters, or bumper guards, and must not be overdressed. The crib should be in the parent’s bedroom to allow for frequent checking, among other recommendations. As Family Science professionals, it is important for us to recognize that some families will choose bedsharing. It is important to continue to provide information about how to put the infant to sleep safely alone, but also about how to safely bedshare with infants when appropriate. Appropriate conditions might include, for example, breastfeeding, nonsmoking mothers who lay the infant supine on a firm mattress, with no pillows or comforters, taking measures to make sure the infant can’t fall off the bed or get caught in bed gaps. For effective, safe infant sleep, public health advocates would probably achieve greater success if they were to consider the personal and cultural considerations that influence families as they choose how to structure infant sleep. Ignoring the very real reasons families choose to bedshare discounts individual needs and experiences, devalues cultural practices, and fails to provide safe sleeping information for bedsharing families.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. (2011). Technical Report: SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics, 128(5), e1341–e1367. doi:10.1542/peds.2011-2285
Blair, P. S., Sidebotham, P., Evason-Coombe, C., Edmonds, M., Heckstall-Smith, E. M. A., & Fleming, P. (2009). Hazardous cosleeping environments and risk factors amenable to change: Case-control study of SIDS in south west England. BMJ, 339, 1–11. doi:10.1136/bmj.b3666
Keller, M. A., & Goldberg, W. A. (2004). Co-sleeping: Help or hindrance for young children’s independence? Infant and Child Development, 13, 369–388. doi:10.1002/icd.365
McKenna, J. J., & McDade, T. (2005). Why babies should never sleep alone: A review of the co-sleeping controversy in relation to SIDS, bedsharing and breastfeeding. Paediatric Respiratory Reviews, 6, 134–152. doi:10.1016/j.prrv.2005.03.006
Mileva-Seitz, V. R., Bakermans-Kranenburg, M. J., Battaini, C., & Luijk, M. (2017, April). Parent–child bed-sharing: The good, the bad, and the burden of evidence. Sleep Medicine Reviews, 32, 4–27. http://dx.doi.org/10.1016/j.smrv.2016.03.003
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