By Dr. Melissa Bartick
Every new parent has heard the dire warning: Never sleep with your baby.
State and local health departments in Massachusetts and around the U.S. have prioritized this message. Millions of dollars have been invested in promoting it, and millions more spent on giving away cribs to poor families. It all comes from the official recommendations of the influential American Academy of Pediatrics published in 2011.
Some localities have even backed this message up with scary ads: a baby in an adult bed with a meat cleaver, stating “Your baby sleeping with you can be just as dangerous,” and another ad that says “Your baby belongs in a crib, not a casket.”
The problem with this widespread advice is that the AAP’s statement from which it comes is based on just four papers. Two of the studies are misrepresented, and actually show little or no risk of sharing a bed when parents do not smoke, and two of the studies do not collect data on maternal alcohol use, a known and powerful risk factor.
In addition, the AAP statement ignores many other more recent excellent papers that are not even mentioned or cited. My colleague, Linda J. Smith, and I recently published an analysis of all AAP’s statement and all the literature to date, "Speaking out on Safe Sleep: Evidence-Based Sleep Recommendations." Along with this dissection of the AAP statement, we found that that any risk of death from a parent sharing a bed with an infant is greatly overshadowed by other risks that get far less attention.
We concluded that the only evidence-based universal advice to date is that sofas are hazardous places for adults to sleep with infants; that exposure to smoke, both prenatal and postnatal, increases the risk of death; and that sleeping next to an impaired caregiver increases the risk of death.
Formula feeding increases the risk of Sudden Infant Death Syndrome. No sleep environment is completely safe. But public health efforts must address the reality that tired parents must feed their infants at night somewhere and that sofas are highly risky places for parents to fall asleep with their infants.
The fact is, across the United States and the world, across all social strata and all ethnic groups, most mothers sleep with their infants at least some of the time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.
When You Avoid Bed Sharing
Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far more likely to feed their babies at night on chairs and couches in futile attempts to stay awake, which actually markedly increases their infants’ risk of suffocation.
According to a 2010 study of nearly 5,000 US mothers, “in a possible attempt to avoid bed sharing, 55% of mothers feed their babies at night on chairs, recliners or sofas. Forty–four percent (25% of the sample) admit that they [are] falling asleep with their babies in these locations.” Rather than prompting an immediate review of its original 2005 infant sleep recommendations, the AAP chose to completely ignore this data when it rewrote its sleep recommendations it published in 2011.
As states have adopted the AAP 2011 recommendations, the advice to never sleep with your baby has backfired in the worst possible way. Rather than preventing deaths, this advice is probably even increasing deaths. Included in 2009 study that the AAP even cited in its statement for other conclusions, parents of two SIDS babies who slept with their infant on a sofa did so because they had been advised against bringing their infants into bed but had not realized the dangers of sleeping on a sofa. In fact, deaths from SIDS in parental beds has halved in the UK from 1984-2004, but there has been a rise of deaths from cosleeping on sofas.
In contrast, medical authorities in Canada, Great Britain, and Australia have different messages than the American Academy of Pediatrics. They all acknowledge that most mothers do share a bed with their infant at least some of the time. If one chooses to bedshare, they educate the public on risks and on ways to markedly decrease the risk of infant death.
In addition, research shows that bedsharing facilitates breastfeeding and is associated with longer breastfeeding duration.
Breastfeeding mothers who try not to share a bed with their baby either end up giving up breastfeeding or bed share anyway. The nutritional content of human milk necessitates frequent feeding both day and night and frequent close contact.
The Formula Risk
But one of the biggest risk factors, formula feeding, is not discussed at all in social marketing campaigns to prevent infant deaths. It may be more effective to support women to stick with breastfeeding than it is to convince them not to sleep with their babies.
If advice not to bedshare may inadvertently end up decreasing breastfeeding duration, that would affect many diseases in addition to Sudden Infant Death Syndrome and infant suffocation. Breastfeeding duration impacts obesity, a host of infections of infancy, and breastfeeding duration affects a host of maternal diseases as well.
Suboptimal breastfeeding duration in the U.S. results in nearly 5,000 excess cases of breast cancer per year, nearly 14,000 excess heart attacks per year, and over 50,000 excess cases of high blood pressure per year. Thus, any recommendations that may negatively impact breastfeeding must take into account all the health implications of breastfeeding, not just a single disease.
Telling mothers never to share a bed with their infants is a message doomed to fail, and has likely contributed to at least some infant deaths on sofas.
The lowest hanging social marketing fruit: Ads educating people about the dangers sofas and recliners would go a long way to decreasing risk of death, provided that women also got the message that a bed is a safer place to feed their baby than the couch or recliner. If we are serious about preventing infant deaths, we should be also focusing on parental smoking and supporting mothers to breastfeed and decreasing sleeping with a parent under the influence of alcohol or drugs.
The AAP is in the process of revising its safe sleep recommendations, and this effort could not come too soon. Let’s hope that they take into account all available literature and the unintended consequences of their current recommendations to make sure their recommendations do not result in unintended deaths.
Melissa Bartick, M.D., M.Sc, is an assistant professor of medicine at Harvard Medical School and internist at Cambridge Health Alliance.