Author Name:
Denise Pemberton RM/ IBCLC

Biography:

The subject of bed-sharing has received very bad press over recent years, particularly in newspapers where headlines such as “Babies safer in their cots” (Cole, 2001) are a common occurrence.

This can be very worrying for new parents, especially when the mother is breastfeeding as it is very common for a mum to fall asleep whilst breastfeeding. In fact it’s quite natural for a mum to do so as one of the breastfeeding hormones, oxytocin, induces sleep.
Also in the early days after a baby is born it is often difficult to settle the baby in a cot, even if it is next to the parents’ bed

There is much conflict even among “experts” around the pros and cons of bed-sharing, sometimes called co-sleeping, breastfeeding and the prevention of Sudden Infant Death Syndrome (SIDS).

This article will endeavour to bring some clarification to some of these issues, particularly for breastfeeding mums.

Following the Department of Health’s (DH) two pronged “Back to Sleep”, and “Feet to Foot” campaign, in 1991, deaths from Sudden Infant Death Syndrome (SIDS) were reduced by around 70% within a year of the campaign, from 2 per 1000 live births to 0.8 per thousand, as stated by the Foundation for the Study of Infant Deaths (FSID 2002a).

This campaign highlighted the dangers of babies sleeping prone, and recommended that babies’ bedding be placed at the foot of the cot to prevent the danger of slipping under the covers and the baby becoming overheated.

However despite this there are still 7 babies dying in the UK every week from SIDS (FSID, 2002a). SIDS is the leading cause of death in babies from one month to one year of age.

The Foundation for the Study of Infant Death recommends that a newborn baby sleeps in the same room as their parents for the first 6 months of life (FSID, 2002a). They recognize that bed-sharing occurs in parents’ own homes, whilst not advocating bed-sharing they give advice against it in specific circumstances.

They do however advise against bed-sharing in hospital, because of the presence of hard floors, narrow beds and newly delivered mothers who are extremely tired and may have had sedation during labour (FSID, 2002b).

Risk Factors for SIDS
The risk factors for SIDS include parents who smoke, are extremely tired, have consumed alcohol or are taking medication (FSID, 2002a).

The babies of mothers who smoke during pregnancy are up to 15 times more likely to die from SIDS than their non-smoking counterparts (FSID 2002c); yet only 9% of women surveyed in 1998 by the Department of Health knew that smoking in pregnancy increased the risk of SIDS (FSID, 2002c). The CESDI Sudden Unexpected Deaths in Infancy (SUDI) Studies (2000) found that babies who died were twice as likely to have been exposed to tobacco smoke, with the risk increasing with the number of hours of exposure.

Other significant risk factors are illness of either the mother or baby, and babies who are small or were born preterm (Barker, 1993).

Sofas and water-beds should be avoided with bed-sharing infants, because of the dangers of suffocation. Pillows should be kept to a minimum and sheets and blankets should be used instead of duvets to avoid overheating.

The room temperature should be maintained around 18 °C and the temperature adjusted with changes of lightweight bedding (Department of Health (DOH), 2000a). Bedding should not cover the infant’s head, wherever he or she is sleeping (FSID, 2002a).

If one parent takes the baby into bed, care should be taken to ensure that the other parent is aware of the presence of the baby and the importance of adapting their behaviour to the presence of the baby.

There are several factors which can help to minimize the risk of SIDS if bed-sharing is likely to occur.

Factors To Minimize Risks When Bedsharing:

• The mattress on the bed should be firm. Bed-sharing should never take place on a water-bed or sofa, or old sagging mattress
• Ensure that there are no gaps for the baby to become trapped in, and that the baby cannot roll or fall out of bed
• The room temperature should be maintained at a comfortable temperature – around 18°C
• In order to prevent overheating sheets and blankets should be used instead of a duvet. Do not allow bedding to cover baby’s head.
• Baby should not be overdressed, or swaddled. Care should be taken to ensure that the baby cannot become entangled in loose ties from nightwear.
• Pillows should be kept well away from the baby
• The baby is never left unattended in the bed
• If the partner is sharing the bed that he / she is aware that the baby is in the bed
• Pets are never allowed to share the bed
• If other children are sharing the bed there should be an adult between them and the baby
• Bottle feeding mothers and partners are informed of the protective ‘C’-shaped position for bed-sharing

Adapted from the UNICEF/FSID “Sharing a Bed With Your Baby” Leaflet  2001.

Bed-sharing and the promotion of breastfeeding

Bed-sharing has been associated with continuation of breastfeeding, (McKenna, 1997). While many parents may not intend to bed-share with their babies, Ball (1999) states that most parents do it, at least partially, particularly when breastfeeding, possible reasons include frequency of night-time feeds.

There is evidence that breastfeeding mothers naturally adapt the sleep environment to their baby, by adopting a characteristic position, lying on her side facing the baby, with her upper arm above the baby’s head, and her knees drawn up under his or her feet, forming a “C-shape”. This positioning appears to facilitate breastfeeding whilst also protecting the baby from being rolled onto or moving up or down the bed (Blair et al, 1999; Ball, 2001). This position has not been observed in mothers who are feeding their babies with breast-milk substitutes or with fathers (Ball, 2001).

Cultural Issues
Separation of mothers and infants is seen as the norm within our society (Rapley, 2002). There is an expectation that night-time feeds will decline following the first month, (Ball, 1999) and, unless parents have incorporated bed-sharing into their night-time routine they often seek alternative solutions, such as giving breast-milk substitutes at night or early weaning onto solid food.

Expectations are on mothers to “return to normal” quickly, to rate themselves according to “how good” their baby is, and how quickly he or she sleeps “through the night”. They may feel tired with night-time feeding, and guilty at taking the baby into bed, although there is evidence which shows that mothers who regularly co-sleep with their baby, sleep as well as, if not better than, their counter-parts whose babies sleep in a cot (Blair et al, 1999).

The Baby Friendly Initiative
Implementation of the World Health Organization / United Nations International Children’s Emergency Fund (WHO/UNICEF) “Ten Steps to Successful Breastfeeding” (UNICEF UK Baby Friendly Initiative, 2001), since the mid 1990s, has led to a change in culture within many maternity units, throughout the UK.

This has been from a culture of separation to one of togetherness of mother and baby, as described by Rapley (2002). This is significant in the implementation of step four – skin-to-skin contact and the initiation of breastfeeding.

Skin-to-skin contact is useful for unsettled babies, and those who are slow to initiate feeding. It also helps to reduce supplementation of breastfeeding babies with breast-milk substitutes, as, if a baby can be settled close to his or her mother, they are both more rested and feeding is more likely to be facilitated, (WHO 1998).

Step 7 – rooming in - i.e. mothers and babies remaining together 24 hours a day has also been cited as one of the factors in the increased incidence, and focus on bed-sharing (FSID, 2002b).

While being a focus for breastfeeding promotion the Baby Friendly Initiative has worked to develop clear guidance for health professionals and parents on the issue of prevention of SIDS.

A sample policy and an information leaflet for parents have been developed and are available on the Baby Friendly website. It is not necessary for mothers and infants to co-sleep for a health care facility to be awarded Baby Friendly Accreditation, and, where there is a policy on co-sleeping, the aim is to promote safe practice and informed choice for parents.

The benefits of and contra-indications to bed-sharing are outlined below:

BENEFITS:

• Facilitates breastfeeding on demand
• Promotes early feeding in babies who are reluctant to feed
• Skin-to-skin contact helps to settle an unsettled baby 
• Reduces chance of supplementation with formula milk
• Breastfeeding mothers lie in protective ‘C’ shape position 
• Promotes prolonged and exclusive breastfeeding 
• Frequently occurs when mother feeding her baby at night 

HAZARDS:

• Either parent a smoker
• Alcohol consumption
• Parent extremely and unusually tired for any reason
• Taking of any medication which could affect level of consciousness
• Illness of parent including diabetics with unstable blood glucose or Epileptics
• Illness / fever in baby
• A baby who was born pre-term or small

Latest advice

The latest recommendations for the prevention of SIDS are that the safest place for a baby to sleep is in a cot by his or her parents’ bed for the first 6 months of life (FSID 2003).
This has been incorporated into Department of Health Guidance and the National Institute for Health and Clinical Excellence (NICE) guideline for postnatal care.

They recommend that while it is acceptable for a baby to be fed or cuddled in the parents’ bed, they should be returned to the cot before the parent sleeps.

They warn parents never to sleep with a baby on a sofa or in an armchair, and outline that babies are at an increased risk of SIDS especially if under 11 weeks of age and if either parent is a smoker, has drunk alcohol, has taken any medication to make them sleep more heavily or is very tired.

They also state that is if a baby has become accustomed to using a pacifier whiles sleeping, it should not be stopped suddenly during the first 26 weeks of life (NICE, 2006).

NICE also recommend that all healthcare providers ensure that an externally evaluated breastfeeding programme such as the UNICEF UK Baby Friendly Initiative is implemented and that women are involved in planning their care to meet their needs and the needs of their babies.

UNICEF UK warns against making general statements against bed-sharing (2005). They recommend antenatal and early postnatal discussion with all mothers of the benefits and contraindications to bed-sharing, including use of the UNICEF/FSID leaflet.

The UNICEF Baby Friendly Initiative/FSID “Sharing a Bed with your Baby” leaflet has been updated, most recently being written specifically for breastfeeding mothers. This is available from the UNICEF UK Baby Friendly Initiative.


Summary

The important messages are:

• that parents are aware that sleeping with their baby in the same room as them for the first six months of life is protective against SIDS;
• that parents are aware that sharing a sofa or armchair increase the risk of SIDS more than sharing a bed;
• that they are aware of issues like smoking, alcohol, medications and overtiredness which increase the risk of SIDS;
• that they are given the safety messages of how to make the bed as safe as possible in case bed-sharing occurs, particularly if they are breastfeeding.

REFERENCES

Ball, H.L. Hooker, E. Kelly, P.J. (1999) Where will the baby sleep? Attitudes and practices of new and experienced parents regarding co-sleeping with their new-born infants. American Anthropologist 101 (1): 143-151

Ball, H.L. (2001) Parent-infant behaviour during bed-sharing UNICEF UK Baby Friendly Initiative Conference 2001.

Barker, W. (1993) Small Infants should not sleep in their parents’ bed. British Medical Journal 315:17-20

Blair, P.S. Fleming, P.J. Smith, I.J. Platt, M.W. Young, J. Nadin, P. Berry, P.J. Golding, J. (1999) Babies sleeping with parents; case-control study of factors influencing the risk of sudden infant death syndrome. British Medical Journal 319:1457-62.

Cole, N. (2001) Coroner’s warning reinforced by health chief “Babies safer in their cots” Scunthorpe Telegraph Tuesday March 27, 2001

Department of Health (2000a) Reduce the Risk of Cot Death. London: Crown Copyright, Department of Health.

Department of Health (2000b) The Sudden Unexpected Deaths in Infancy. The CESDI /SUDI Studies. London: The Stationary Office.

FSID (2002a) What is cot death? Is cot death on the decline? Foundation for the Study of Infant Death website – http://www.sids.org.uk/fsid/cot.htm

FSID, (2002b) Bed-sharing – a wonderful experience or a danger to babies? FSID News 66 Foundation for the Study of Infant Death

FSID (2002c) Nicotine and cot death. Statement from the Foundation for the Study of Infant Death on the use of nicotine gum/patches during pregnancy. Foundation for the Study of Infant Death website http://www.sids.org.uk/fsid/nicotine.htm

FSID (2003) BabyZone – How to keep your baby safe and healthy London: Foundation for the Study of Infant Death

McKenna, J.J., Mosko, S.S. and Richard, (1997), Bedsharing Promotes Breastfeeding. Pediatrics 100(2): 214-219

NICE (2006) Routine postnatal care of women and their babies London: National Institute for Health and Clinical Excellence

Rapley, G. (2002) Keeping mothers and babies together – breastfeeding and bonding.
Midwives Vol 5. No 10 October 2002:332-334

UNICEF UK Baby Friendly Initiative (2001) Implementing the Baby Friendly Best Practice Standards London: UK Baby Friendly Initiative.

UNICEF UK Baby Friendly Initiative Website - http://www.babyfriendly.org.uk
UNICEF UK Baby Friendly Initiative (2005) UNICEF and NCT Joint Statement on mother-infant bed sharing UNICEF UK Baby Friendly Initiative Website http://www.babyfriendly.org.uk/press.asp#20050928
WHO (1998) Evidence for the Ten Steps to Successful Breastfeeding. Family and Reproductive Health, Division of Child Development. Geneva: World Health Organisation.