In Defence of Bedsharing - Dispelling the Shoddy Science and Examining the Facts

We need to inform parents about their choices instead of scaring them into avoiding bedsharing.

The latest draft guidance issued by the National Institute for Health and Care Excellence (NICE) recommends that parents should be warned not to share a bed with their baby for the first year of life in order to reduce the risk of sudden infant death syndrome (SIDS).

Unfortunately, the evidence used to support this approach is severely flawed. First, much of the research into bedsharing is inadequate as it includes all cases of parents sleeping with their babies, whether in bed, on a sofa, an armchair, or elsewhere. The draft guidance also lumps intentional, intended bedsharing with unintentionally falling asleep on an unsuitable surface, as the NICE website states that co-sleeping is "falling asleep with an infant in a bed or on a sofa or chair". In reality, falling asleep with a baby on a sofa is not safe bedsharing, and should not be compared with instances of safe, intentional bedsharing.

Second, much of the research available confuses SIDS with other sleep risks including wedging, entrapment, falling and strangulation.

Now let's be clear here. SIDS deaths are unexplained. Therefore unsafe sleep surfaces and dangers to breathing are causes of infant deaths but not causes of SIDS. Regarding SIDS, the NICE website states that "No-one knows why this happens" - but the organisation still continues to infer that bedsharing causes SIDS.

Professor Mark Baker, NICE's clinical practice director, states: "The recommendations we are developing aim to help healthcare professionals inform parents and carers of the likely risks associated with co-sleeping, according to the best available evidence." However the website fails to cite this research, so it's not clear which study Prof. Baker is referring to. Let's look at a few examples here.

A study by Widener University's School of Nursing and the Women and Children's Health Services states that: "While no mothers intended to bed-share with their infants immediately after delivery, 60 percent reported bed-sharing at some time at one month after discharge and 9 percent at three months. Only 19 percent of mothers reported receiving information about infant sleeping practices from their physician and 22 percent from their nurse." Instead of concluding that mothers are going to bedshare whether they intend to or not, and recommending that parents are advised on safe sleep practices from the beginning, the researchers instead point to bedsharing as the problem: "Interventions aimed at teaching new mothers about responding to infant cues and ways to manage a fussy infant may minimize the rate of bed-sharing." This suggests an inherent bias on the part of the researchers, perhaps because they approached the study with the view that bedsharing is to blame for SIDS.

Another shoddy study, by the University of Glasgow, found that "the largest risk was associated with couch sharing", however it classed sleeping on a couch as an example of bedsharing, and therefore concluded that "bedsharing is associated with an increased risk of SIDS for infants [under] 11 weeks of age". In addition, few variables were taken into account, for example whether the baby died from entrapment or suffocation (both likely scenarios when sleeping on a couch), whether the parents were intoxicated, etc. In fact, since more babies die in their sleep on New Year's Eve in the US than any other time of year, this suggests that intoxication plays a large role in the baby-parent sleep debate, and that more parents need to be made aware of this correlation regardless of where the baby usually sleeps.

This is by no means all of the research on the subject but it does give a general idea of how incorrect assumptions in research can lead to flawed conclusions.

Now on to the more thorough research. A study by the Alaska Division of Public Health examined 13 years of Alaskan infant deaths that occurred while bedsharing. They looked at how many deaths were related to known risk factors and found that:

"13 percent of deaths occurred while bedsharing; 99% of these had at least one associated risk factor, including maternal tobacco use (75%) and sleeping with an impaired person (43%)... 60% of mothers reported no risk factors; the remaining 40% reported substance use, smoking, high levels of alcohol use, or most often placing their infant prone [face-down] for sleeping."

This indicates that advice to parents on safe bedsharing would almost certainly reduce instances of baby deaths. The research concludes that "Almost all bed-sharing deaths occurred in association with other risk factors despite the finding that most women reporting frequent bed sharing had no risk factors; this suggests that bed sharing alone does not increase the risk of infant death."

In addition to this, new research has found that some babies have a genetic predisposition to SIDS, which means that SIDS is probably unrelated to where the baby sleeps. You can view these findings in more detail here.

In terms of effective preventative measures, something that is not being discussed enough is how the baby is fed. When a baby sleeps in a cot (s)he is more likely to be formula fed, as shown by this study, but breastfeeding the baby actually decreases the risk of SIDS. Therefore, if NICE aims to reduce infant death by using thorough research, the organisation should be recommending breastfeeding to reduce the risk of SIDS, since there is strong scientific support for the correlation thanks to The New Zealand Cot Death Study and The German Study of Sudden Infant Death. The NHS already recommends breastfeeding to reduce SIDS risk.

It is in this vein that UNICEF, regarding the proposed NICE guidelines, has stated: "Although there is evidence that breastfeeding and bed-sharing have an interdependent relationship, we are disappointed that this is considered to be outside of the remit of the current draft..."

NICE describes its aim as being: "to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence." However, if passed the guidance on bedsharing will likely lead to more instances of SIDS, not less, because many the sleep-deprived parents who have been told not to bedshare will likely end up unintentionally falling sleeping on an unsuitable surface with the baby instead. Simple precautions on how to bedshare safely would eliminate this problem completely, and ensure safe sleeping practices in bed even mum never intends to do it.

The American Academy of Pediatrics (AAP) is attempting to address this problem: "The AAP... is expanding its recommendations from focusing only on SIDS to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths, including SIDS."

Since the number of mothers who bedshare is on the increase, probably because mums get more sleep when they bedshare, we need to inform parents about their choices instead of scaring them into avoiding bedsharing. Our health advisers expect us to respect the research when they clearly haven't looked at it closely themselves. One can only hope that they do so soon and that these misguided guidelines do not make it past draft form.

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