Co-Sleeping Solutions, Bed-sharing, Breastfeeding and SIDS

Most people are aware of the advice that:

'the safest place for your baby to sleep - night and day - is in a crib or cot in a room with you for the first six months.' ~ FSIDS

But how many people know that research indicates a link between bed-sharing and breastfeeding duration?  How many people are aware that formula feeding increases the risk of SIDS?  One study showed the risk increased by 50% (more on breastfeeding and SIDS here).  How many people are aware that research has also shown that exclusively breastfeeding mums who sleep with their babies get more sleep than other mothers?  Or that the quality of their sleep is better and that poor quality sleep has been linked to post-partum depression?

Not having to get up in the middle of the night to feed your baby makes breastfeeding SO much easier.  Night feeds are important for establishing and maintaining your supply of breast milk.  Prolactin levels are highest during the night-time, and this hormone helps the body to produce more milk.  Many mums start out giving a night-time bottle of formula in hopes that they will get more sleep, but in reality this can interfere with the cue-feeding process which is so important for your milk supply.  I personally doubt that I'd have managed to breastfeed for as long as I have without co-sleeping and bed sharing with my children.  However, lots of mums are - understandably - scared to share their beds with their babies.  They're frightened that they might accidentally hurt them whilst they're asleep.  We've all seen the stories in the press describing truly tragic situations where babies have died whilst in close proximity to a sleeping care-giver.

Images from a shocking 2010 Milwaukee campaign designed to discourage bed-sharing were shared worldwide on the internet.  Here are a couple in case you haven't seen them:

A picture may be worth a thousand words, but these pictures seem (to many) to present an very one-dimensional view of what is a complex and multi-faceted problem.  The sad fact is that babies die in cots too.  In fact, there is a body of evidence to support the view that safe co-sleeping is protective against SIDS.  One study of 200 SIDS deaths showed that only 22.5% of the deaths occurred during 'co-sleeping'.  Only 17.5% of the SIDS deaths (less than 1/5th) took place were actually sharing a bed with their parents. More information about this and other research is here.  


It's at this point that I find myself asking you to watch a news report aired (rather amazingly!) by FOX News.  The report lasts 9 minutes, but if you have time I urge you to watch it all (if you don't have time - scroll to around 6 minutes along and watch until the end).

Despite all the hype, it is starting to look like the (deliberately) provocative and shocking ad campaign in Milwaukee isn't even working.  In February of this year three babies tragically died in separate bed-sharing incidents in Milwaukee county in just 48 hours. 

One study - published recently in the Journal of the American Academy of Pediatrics - looked at how cultural behaviours impacted on SIDS rates.  Specifically it looked at why people from a Southern Asian culture living in one area of England had a lower SIDS rate than their white British counterparts.

“We found that Bradfordians of Pakistani origin follow Foundation Study of Infant Deaths’ guidelines closely in that they do not smoke or drink during or after pregnancy; they do not place their babies to sleep in separate rooms, and they have a high incidence of breast-feeding. However, we also found that it was much more common for Pakistani-origin mothers to share a bed with their baby. [...]  This finding was in comparison to some of the white British mothers who did drink, did smoke and were more likely to sofa-share with their infants. [...] we believe, given that Sudden Infant Death is rare in Bradford’s Pakistani community, this may indicate that infant and parent bed-sharing is safe when it is done under certain circumstances like those characteristics practiced among South Asian women described above." ~ Dr Eduardo Moya

The study's authors say:

'Caution is needed in generalising SUDI/ SIDS risk factors across populations with differing risk factor profiles, and care should be taken in adopting SUDI/ SIDS reduction guidelines from other contexts'  

http://www.pediatricsdigest.mobi/content/129/3/e673.short

In other words, there is a bigger picture here - so why are we always being told how DANGEROUS it is to bed-share?  Is the advice we're getting biased against bed-sharing?  
Well it would appear it is, yes.  


The reason?  


Well, in the case of the American Academy of Pediatrics at least, it seems to be because they don't believe parents are capable of making their own informed decisions.  


In the words of Dr Henry Krous, Consultant in Pediatric Pathology for the American Academy of Pediatrics (who advise parents not to bed-share):

"I don't think that a 15-pound, 11-month, 29-days-old baby sleeping in a corner of a king-sized bed with a sober, 95-pound mother is the same thing as a 3-week-old baby sleeping with a 300-pound intoxicated mother on a couch," he said. "In public health, it's not easy to get into subtleties. The most effective way is to discourage bed sharing altogether." http://www.post-gazette.com/stories/news/health/sharing-bed-with-baby-elicits-mixed-reactions-628036/

Of course if you are going to smoke or drink etc, DON'T BED-SHARE!  You're putting your child at risk.  Dr James McKenna says in the video above that you shouldn't bed-share at all if you're not breastfeeding - so fundamental is the affect of not breastfeeding on the mother/ baby dyad.

But what if you don't smoke, and you don't drink, and you don't take drugs, and you do breastfeed etc?

Cars can be pretty dangerous, but it's understood that the risk of death and injury can be reduced by (for example) the proper use of car seats and seatbelts.  Most people take care to do this.  Most people don't drink and drive.  We don't tell people never to drive with their kids in the car and we don't guarantee that they'll never have an accident, but almost everyone is informed about how to reduce the risk.  Blanket statements against bed-sharing seem to me a bit like banning kids from cars because *some* people won't bother using the right car seat, or will drink and drive.  We have all been taught to 'buckle up' before driving anywhere - so can't we also be educated to create safer co-sleeping environments?  Those same parents who the AAP believe can't make reasoned decisions about safe co-sleeping are driving their kids around every day.

And what about the risks of *not* sleeping with your baby?  Risks such as:

• possible decreased breastfeeding/ breastfeeding cessation and the associated risks of formula feeding for both mother and baby 
• poorer quality of sleep for the infant/ increased strain on the baby's nervous system
  'Maternal-neonate separation is associated with a dramatic increase in HRV power, possibly indicative of central autonomic arousal.  Maternal-neonate separation also had a profoundly negative impact on quiet sleep duration.  Maternal separation may be a stressor the human neonate is not well-evolved to cope with and may not be benign.'  http://www.sciencedirect.com/science/article/pii/S0006322311006391
• poorer quality of sleep for the breastfeeding mother and increased maternal fatigue
  'The marked difference between the groups was in the amount of slow-wave sleep (SWS).  The breastfeeding mothers got an average of 182 minutes of SWS.  Women in the control group had an average of 86 minutes.  And the exclusively bottle-feeding women had an average of 63 minutes. [...] slow-wave sleep is an important marker of sleep quality, and those with a lower percentage of slow-wave sleep report more daytime fatigue.'  http://www.scienceandsensibility.org/?p=1398
• may have an impact on mother/ infant bonding  http://www.bellybelly.com.au/baby-sleep/cosleeping-is-it-part-of-bonding
• increased risk of falling asleep in a high-risk place (eg. a sofa) 
  'Any advice to discourage bedsharing may carry with it the danger of tired parents feeding their baby on a sofa, which carries a much greater risk than co-sleeping in the parent's bed' http://www.guardian.co.uk/lifeandstyle/2009/oct/16/sudden-infant-death-syndrome-children
  
  

So what if (like me) you're a breastfeeding mum and you've weighed up the information and made an informed decision to bed share.  How does it work in practice?

First of all you need to plan your sleeping space carefully:

~ Ensure you have a firm mattress - the sleeping surface should not be too soft.

~ Use minimal pillows.

~ Give your baby as much room as possible.

~ Ensure the room is not too hot. 

~ Make sure your baby isn't over-dressed - remember they will be getting your body heat too.

~ Use light sheets and don't use duvets.

~ Make sure there are no gaps where the baby could become trapped (make sure your mattress is a good fit!)

~ Keep bed covers low on the bed away from your baby - wear a cardigan if you find your top half getting a bit cold.

~ Make sure your other half knows the baby is sleeping with you.

~ Position yourself between the baby and anyone else sharing the sleeping surface.

~ Don't put the baby to bed on his/ her own.

~ If you have long hair tie it back and if you have large breasts or are overweight, consider that this may affect your awareness of where your baby is in the bed.

You should not share a bed with your baby if:

~ you or your partner smoke, have consumed alcohol, are taking medication or are very deep sleepers normally.

~ you are ill or exceptionally tired.

~ your baby was of low birth weight or was premature (in the early months).

~ your baby is ill.

~ you also share your bed with pets.

More information on creating safe sleeping environments is here,  here, and here.

A few other things:  

• Avoid using baby 'sleep positioners' - these have been linked to cases of suffocation.
  http://www.recalllawsuit.com/2010/09/sleep-positioner-recall-lawsuit/
  http://www.cpsc.gov/cpscpub/prerel/prhtml10/10358.html
  http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm227575.htm
• Avoid cot bumpers -  'Cot bumpers are not recommended because babies can overheat or get tangled in the fastenings.' 
  http://www.nhs.uk/conditions/pregnancy-and-baby/pages/what-you-need-for-baby.aspx
• Avoid the use of stuffed toys, quilts and comforters   http://raisingchildren.net.au/articles/sudden_infant_death_syndrome_(sids).html http://media.clinicallactation.org/fall10/KKT%20tear%20sheet_FINALrevised.pdf
• Put your baby to sleep on their back 
• The American Academy of Pediatrics recommends that parents give a dummy at night (see here for more info) since studies have shown it has a protective effect.  But I have to ask: what's the dummy imitating?  Isn't the real thing (suckling at the breast) likely to be at least as protective?  Certainly it doesn't bring with it the same potential risks*. 

If you're not entirely comfortable having your baby IN your bed full-time, then one really good compromise is to 'side-car' their cot to your bed.  At the end of the day, we all have to make the decisions we're most comfortable with, and which work best for our families.  You may, or may not, feel ok about sharing a bed.  In my case, I actually felt safer with my babies snuggled in bedside me.  I felt they were more relaxed, their breathing seemed less ragged, they slept better, and this made me feel more relaxed too - but we're all different.  


And finally, for anyone wondering about the whole issue of S-E-X - the Analytical Armadillo wrote a great piece about sharing the parental bed, which you can find here.

'We've got to get these babies out of the bed.  Why?  Who said?  Where's the evidence?  That is not a medical truth.  That's not even a scientific truth.  That's a cultural choice and a construction, and parents at the very least ought to know the difference.' 

~ Dr James McKenna (Professor of Anthropology and the Director of the Center for Behavioral Studies of Mother-Infant Sleep, Notre Dame University and recognized as the world’s leading authority on mother-infant co-sleeping, in relationship to breastfeeding and SIDS) 

‘When babies are smothered and suffer cot deaths, it is not because their mother is present. It is because of other things: toxic fumes, cigarettes, alcohol, big pillows and dangerous toys.’

~ Dr Nils Bergman  (Pioneer of 'Kangaroo Mother Care', International speaker and educator)

'Parents need information with which to make informed decisions, and should be encouraged to weigh up any potential risks and benefits of bed-sharing in light of their own individual circumstances'

~ Prof Helen Ball   (of the Parent Infant Sleep Lab Durham University, a leading researcher and speaker on the behaviour and physiology of infant and child sleep) 

Some members of the DBM facebook group kindly sent me photos of their bedrooms to give you an idea of how some breastfeeding families co-sleep in the real world. 
Please note: these photographs are real-life examples, not recommendations.

This instructional video below shows one way to securely side-car a cot.  You can also buy specially designed side-car cots such as the 'arm's reach co-sleeper'.

Do you co-sleep?  Do you bed-share?  

How does it work for you?

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Links and further reading:

http://www.isisonline.org.uk

http://www.unicef.org.uk/BabyFriendly/News-and-Research/Research/Bed-sharing-and-infant-sleep/
http://www.naturalchild.org/james_mckenna/cosleeping.pdf
http://thebabybond.com/Cosleeping&SIDSFactSheet.html
http://www.bednest.com/documents/bed-sharing-and-co-sleeping-article.pdf
http://www.bbc.co.uk/health/physical_health/conditions/cotdeath2.shtml

http://www.parentingscience.com/bed-sharing.html
http://viewer.zmags.com/publication/29e55b27#/29e55b27/8

http://www.phdinparenting.com/2009/01/11/co-sleeping-safety/#.T3xRd_BSS_g

http://www.drmomma.org/2010/01/turn-your-crib-into-cosleeper.html

NCT Arm's reach co-sleeper: http://www.nctshop.co.uk/Arms-Reach-Universal-Co-Sleeper-Bedside-Cot/productinfo/4367/

http://www.attachmentparenting.org/support/articles/artbenefitscosleep.php

http://www.askdrsears.com/topics/sleep-problems/co-sleeping-yes-no-sometimes

http://www.phdinparenting.com/2010/05/05/fox-news-video-on-bed-sharing/#.T33_cPBSS_h

http://www.guardian.co.uk/lifeandstyle/2009/oct/16/sudden-infant-death-syndrome-children
http://www.thefoodoflove.org/breastfeed-in-your-sleep.htm

My thanks to Dr James McKenna for his kind assistance in helping me to locate some of the information for this blog.

*'Breastfeeding is important to the proper development of the swallowing action of the tongue, proper alignment of the teeth, and the shaping of the hard palate.(4-5) Bottle-feeding, pacifier use, and infant habits such as excessive thumb-sucking, arm-sucking, etc., can cause tongue thrusts and malocclusions. Occlusion and a high palate impact the flow of air through the airway and thus may contribute to Obstructive Sleep Apnea.' 

http://www.brianpalmerdds.com/bfing_reduces.htm