New evidence-based protocol for healthcare providers offers guidance on how to help families sleep safely.
The majority of healthcare providers in the U.S. sternly warn parents to never put an infant in an adult bed. Powerful public health campaigns promote the ABCs of infant sleep - Alone. Back. Crib. - to stress the importance of keeping infants from sleeping beside an adult or in an adult bed. Yet statistics show that the majority of babies do spend at least some of the night in bed with mom. (1)
There are many reasons for parents to keep their babies close at night. Some want the warmth and security that comes with close contact. Some feel that their baby will be safer if they can keep a protective eye on them during the night. Some don’t have a crib or extra bed for the baby. Some simply fall asleep feeding or cuddling their child.
Many breastfeeding mothers find that they get more sleep if they feed the baby in bed, instead of having to get up to feed and then wait for the baby to fall back to sleep. The data show that mothers who breastfeed and bedshare find it easier to continue nursing for at least one year, which the American Academy of Pediatrics states as optimal for the health of both mother and child.
Standard safety recommendations insist that sharing a bed with an infant is dangerous and potentially fatal, but scientists who study mother/infant bedsharing have spent decades arguing that this warning is not necessarily appropriate, depending on the context of how and when bedsharing is practiced. Based on this argument, a new protocol for healthcare providers has just been published in the prestigious Journal of Breastfeeding Medicine, a publication of the Academy of Breastfeeding Medicine.
New Guidelines Recognize a Safe Form of Bedsharing
The protocol, “Bedsharing and Breastfeeding,” was written by some of the world’s foremost experts in a variety of related fields, combining their critical knowledge of SIDS rates, the physiology and behavior of mothers and infants, the relationship between breastfeeding and bedsharing, parental views on bedsharing behavior, and risk factors for sleep-related injury or death. The protocol presents evidence-based recommendations synthesized by an international collaboration of authorities who conducted a rigorous review of the literature.
Aimed at physicians and other health care professionals caring for families who have initiated breastfeeding, this groundbreaking protocol recognizes that bedsharing promotes breastfeeding. This is also the first document from a major medical group to endorse bedsharing.
The protocol proposes that the concept of “breastsleeping,” developed in 2016 by Drs. James J. McKenna and Lee T. Gettler, should be seriously considered as a distinct, legitimate, and safe way for an infant to sleep. It occurs when a mother elects to bedshare, and does so on a firm adult mattress beside her breastfed infant. Research has conclusively shown that breastfeeding increases the safety of bedsharing and is associated with a lower risk of Sudden Infant Death Syndrome (SIDS). However, the definition of breastsleeping also contains an important qualifier: it can only occur under conditions that are free from known safety hazards.
“As the person charged with seeing the protocol through to fruition from writing to approval, I found the process of achieving consensus on the evidence and recommendations to be both challenging and rewarding. We are especially satisfied that this protocol represents the best evidence-based and practical recommendations for clinicians. We hope this protocol will be widely used.” (2)
- Melissa Bartick, MD, MSc, Harvard Medical School
Reducing Risks, Reducing Deaths
According to the Centers for Disease Control and Prevention, 3,600 infants succumbed to sleep-related deaths in 2017, with 38% attributed to SIDS. Another 26% were considered to be cases of suffocation or strangulation during sleep. Harsh recommendations against bedsharing were put in place in an effort to reduce this number. However, these recommendations are often ignored, with the popularity of bedsharing rising in both the U.S. and abroad.
In response, the focus for some researchers has been to try to pinpoint the preventable risk factors for bedsharing deaths. It is clear that safety must be a priority when considering bedsharing. No adult should sleep next to a child without strict adherence to safety guidelines. These include (but are not limited to):
Sleep only on a firm mattress; no waterbeds, sofas, recliners, or soft mattresses
Make sure there are no gaps between the bed and the wall or other furniture
Ensure there are no other children or pets in the bed
Do not bedshare if any adult in the bed has used alcohol, drugs, tobacco products of any kind, or any drug or medication that causes drowsiness
Be sure no one in the bed has long hair left down or pajamas with strings
Remove all heavy blankets, extraneous pillows, and stuffed toys from the bed
Do not bedshare with a premature baby or one with congenital conditions
A more extensive list of safely guidelines can be found in the ABM protocol and in Dr. McKenna’s book, Safe Infant Sleep.
The protocol is a profound departure from the longstanding, one-size-fits-all recommendations against bedsharing. The authors state, "Existing evidence does not support the conclusion that bedsharing among breastfeeding infants (i.e., breastsleeping) causes Sudden Infant Death Syndrome (SIDS) in the absence of known hazards.” They stress that “bedsharing evolved from innate human biological and behavioral mechanisms. It is not a singular, discrete, or coherent practice, but is composed of a diverse range of behaviors, some of which may carry risks, making it particularly important to discuss bedsharing safety."
The publication of this protocol will likely provide opportunities for better funding and further research on the subject of breastsleeping. If it continues to appear that breastsleeping itself, without any of the known preventable risks, does not increase the risk of SIDS or infant death in general, the protocol demands that breastsleeping should be incorporated into the infant sleep conversation as a safe and beneficial option for families.
“This is a most welcome balanced statement that emphasizes the positive value of safe bedsharing.”(3)
- Arthur I. Eidelman, MD, Editor-in-Chief of Breastfeeding Medicine
Encouraging Open and Nonjudgmental Conversations
This new protocol encourages healthcare providers and public health officials to review their current recommendations and examine the many variations, risk factors, and individual circumstances that have led the majority of parents to dismiss the current guidelines and choose to bedshare anyway. The authors emphasize that bedsharing recommendations cannot be simple or hard-lined. They must take into account “the mother's knowledge, beliefs, and preferences and acknowledge the known benefits as well as the risks." The authors further note that parents are more likely to follow safety recommendations that are tailored to their specific needs and allow them to make their own choices.
This brings us to another main point from the protocol, which is that "ending stigma around bedsharing and educating all parents about safe bedsharing have the potential to reduce infant deaths.” Moving away from the message that a baby should only sleep in a crib and encouraging parents who bedshare to talk about it freely will help make bedsharing safety guidelines more accessible. It may even generate meaningful data for further research, since bedsharing families who are too afraid to reveal their true sleeping arrangements may feel more comfortable sharing their experience if they know they will not be shamed for their choices.
The protocol advocates for pediatricians to stop focusing on bedsharing prevention and instead teach parents risk-reduction strategies. It provides examples for healthcare providers, showing how to determine—through conversation and open-ended questions—the best recommendation for each individual family, and how to communicate the appropriate safety information to parents. The protocol even presents ideas for larger structural changes that could lower sleep-related deaths. These include developing policies to reduce smoking and address racial disparities that affect health outcomes related to bedsharing safety, like breastfeeding and prematurity rates.
Educating parents about their expanding options for safe sleeping arrangements and encouraging respectful, two-way conversations between families and their healthcare providers can help everyone involved in newborn care keep babies safe and help families thrive.
Read more about safe bedsharing:
ABM Protocol: Press Release
ABM protocol: Bedsharing and Breastfeeding
Dr. McKenna’s new book: Safe Infant Sleep: Expert Answers to Your Cosleeping Questions.
(1) Bombard, Jennifer M., et al. “Vital Signs: Trends and Disparities in Infant Safe Sleep Practices — United States, 2009–2015.” Morbidity and Mortality Weekly Report, 67(1); 39-46. January 12, 2018.
(2) Bartick, Melissa. “Academy of Breastfeeding Medicine Publishes New Bedsharing Guidelines.” Breastfeeding Medicine: Physicians blogging about breastfeeding. January 7, 2020.
(3) Ryan, Kathryn. “New Recommendations Released on Bedsharing to Promote Breastfeeding.” Mary Ann Liebert Newsroom. January 7, 2020.
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