Abstract

Purpose: To identify dental health advice

offered by healthcare providers (HCPs)
to mothers that cosleep and breastfeed
at night.
Study Design and Methods: Mothers were
recruited via local contacts, e-mail, and
support groups. In-person, digitally recorded
interviews were conducted with 14 cosleeping, breastfeeding mothers with children
from 6 months to 2 years. Interviews
included seven open-ended questions about
cosleeping patterns, night breastfeeding
patterns, and dental health advice offered
by HCPs. These HCPs included pediatricians,
family medicine physicians, midwives, and
obstetricians. Interviews were transcribed
verbatim and qualitative descriptive
analysis was done.
Results: The majority of women reported
keeping their child in bed with them for
most, if not all, of the night. All of the
mothers reported breastfeeding on demand.
Approximately half of the mothers did not
disclose their sleeping patterns to their
HCP. Mothers reported few HCPs initiated a
discussion on cosleeping or oral hygiene for
their child.
Clinical Implications: Mothers did not readily
share their cosleeping, nor did most HCPs
initiate a conversation about cosleeping and
dental hygiene. This qualitative study
identifies the need for education on
anticipatory guidance of oral hygiene
discussions from HCPs. As HCPs, it is our
responsibility to initiate the conversation
with the mother because this study
demonstrates that mothers will be unlikely
to do so.
Key words: Breastfeeding; Cosleeping; Infant
oral health and hygiene.

Katie M. Lapps Wert, DMD, Rochelle Lindemeyer, DMD, and Diane L. Spatz, PhD, RN-BC, FAAN

BREASTFEEDING,
CO-SLEEPING AND
DENTAL HEALTH ADVICE
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(Stephan & Hemmens, 1947). See Figure 1. Whenever a

child puts food or drink in his mouth, this causes a drop
in the pH of the mouth. The mouth has a neutral pH of
7, with a critical pH of 5.5. This pH of 5.5 is termed the
critical pH because below this pH is the danger
zone where tooth structure begins to break down
during the caries process (Stephan & Hemmens).
Therefore, frequency, repeated and prolonged exposure, along with increased access to feeding while bedsharing may invoke a significant or several prolonged
drops in the pH of the childs
mouth. This significant pH
drop increases the total time
throughout the night spent in
the danger zone of the
Stephan curve. Dental research
has shown this drop in pH is
especially significant if there is
already plaque on the teeth
that can then result in cavity
formation (Yonezu et al.,
2006).
The American Academy of
Pediatric Dentistry (AAPD)
recommends that a child is seen
by a dentist by the age of 1 or
with the eruption of the first
tooth (AAPD, 2009). Unfortunately, this guideline is not readily available to mothers and it is
common for dental care to be
initiated much later in childhood
(Divaris, Vann, Baker, & Lee,
2012). By age 1, not only have
several teeth erupted and are
therefore susceptible to caries,
but family patterns and habits
are well established. The purpose
of this study was to examine the
patterns of cosleeping, specifically bed-sharing, of women who
breastfeed ad libitum through the
night and to understand recommendations given by the womens healthcare providers
(HCPs) regarding the childs oral health.
Gary Roebuck / Alamy

osleeping is a common parenting choice in many

cultures and the norm in numerous countries.
Cosleeping is defined as an infant sleeping close
to his or her parent. A subset of cosleeping is
bed-sharing where the infant is put to sleep in the
parents bed with them. In the 2011 policy statement from the American Academy of Pediatrics (AAP),
healthy breastfeeding is promoted while encouraging
room-sharing without bed-sharing (AAP, 2011; Moon
2011). However, many families choose to cosleep, and
each has their own reasons behind this decision (Buswell &
Spatz, 2007). Similarly, each
family exhibits various degrees
and patterns of cosleeping
(McKenna, Mosko, & Richard,
1997). Research conducted in
the United States indicates that
mothers do choose to cosleep
despite warnings against it, that
cosleeping promotes breastfeeding, and that perhaps most
importantly that women should
receive individualized counseling regarding their practices
(Gettler & McKenna, 2011;
McKenna, 2014; Volpe, Ball, &
McKenna, 2013).
Research has shown that
cosleeping encourages ad libitum
breastfeeding (Mohebbi, Virtanen, Vahid-Golpayegani, & Vehkalahti, 2008). Human milks
ability to cause cavities (its cariogenicity) is a frequent topic of
debate in current dental research
(Arora et al., 2011). Although
one study claimed that human
milk is more cariogenic (Tyagi,
2008) than bovine milk, the main
consensus from dental research is
that human milk is less cariogenic
than bovine milk (Ribeiro &
Ribeiro, 2004; Yonezu, Yotsuya, & Yakushiji, 2006). Dental research has found that human milk is not cariogenic in
and of itself (Kramer et all 2007; Iida, Auinger, Billings, &
Weitzman 2007); however, it may be a contributing factor
to early childhood caries rather than the cause. In other
words, human milk was noted to be a contributing factor
to caries when other factors were present such as a
high-carbohydrate diet, low maternal socioeconomic
status, and low fluoride use (Weerheijm, UyttendaeleSpeybrouck, Euwe, & Groen, 1998; Sayegh, Dini, Holt, &
Bedi, 2005).
To put this finding into perspective, we can examine
the Stephan curve, which is used in dentistry to illustrate how frequency of food or drink intake is just as, if
not more, important as the presence of this food or
drink in the mouth when it comes to cavity formation

All women should receive

counseling about infant
oral health and hygiene.

Study Design and Methods

Institutional review board approval was obtained for this
study. Mothers were recruited by local contacts in person, via electronic methods, and through local support
groups with the intent of including women of diverse
ethnic and racial backgrounds. The consent form
explained study purpose and included an explanation of
the information that was to be recorded. A requirement
for participation was to speak and understand English or
have an authorized interpreter with them. No financial
compensation was given to mothers for participating.
Participant confidentiality was maintained during the
interview and data collection process by using numbers
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rather than names. Subjects' names remained confidential

through a password-protected electronic database. Other
than use of names to determine a mutually agreeable
interview time and location, no identifiable information
was linked to the qualitative data.
Interview questions were developed by the research team
using common subjects in breastfeeding and dental research. The questions sought to specifically identify patterns
of breastfeeding and cosleeping, as well as dental advice
rendered by HCPs. In-person, digitally recorded interviews
were conducted with 14 cosleeping, breastfeeding mothers
with children ranging in age from 6 months to 2 years.
All interviews were completed by one interviewer in a
setting neutral to both the interviewer and participant.
Each interview consisted of four demographic questions
and seven open-ended questions about cosleeping patterns, nighttime breastfeeding patterns, and dental health
advice offered by their HCPs. Interviews were recorded
on a handheld digital recorder and then downloaded immediately to a secure password-protected database. Each
interview lasted approximately 10 to 15 minutes. See
Table 1 for interview questions.
Methodology for analysis was conventional content
analysis (Downe-Wamboldt, 1992; Elo & Kyngs, 2008).
Interviews were transcribed verbatim by the first author,
who then performed first-level coding of the data (Elo &
Kyngs). These first-level codes were then compiled into
categories and subcategories by the research team and examined for similarities or dissimilarities. Following this
process, data were then abstracted into generic categories
and larger main themes, which were given a contextual
name derived from the data (Graneheim & Lundman,
2004). Data collection was completed once theme saturation occurred and no new themes continued to arise.
Rigor was maintained throughout via confirmability,
dependability, and transferability (Sandelowski, 1986).

FIGURE 1. The Stephan Curve

Measuring Cariogenicity
6.5

The research team kept an audit trail of research plans

and decisions. To maintain dependability, the researchers
met regularly as a team to discuss and assess issues related
to the consistency, similarities, and/or differences in the
data. The researchers ensured transferability by reporting
a detailed description of the studys sample, design,
approach, analysis, and findings.

Results
Brief demographic information was obtained from the
participants. Nine of the mothers were Caucasian, four
were African American, and one was Latina. Mean maternal age was 31 years (range 2341). Mean age of their
child was 13 months (range 621 months). The majority
of the mothers were highly educated; six had a masters
degree; four a bachelors degree; one an associates degree; and one had completed some college. These demographic data coincide with current breastfeeding research
with mothers that choose to cosleep. The HCPs discussed
by the mothers included pediatricians, family medicine
physicians, midwives, and obstetricians.
Eight themes emerged from the qualitative data:
Nighttime feeding patterns; Maternal wakefulness while
feeding; Healthcare professionals discussion of sleeping
location and breastfeeding; Avoidance of discussing
breastfeeding and cosleeping practices; Oral health advice by HCPs; Previous breastfeeding experience; Pattern
of cosleeping; and Cue to feed.
Themes

Nighttime Feeding Patterns

The majority (n = 10) of mothers reported feeding
between two to five times per night. One mother said
regarding her nighttime feeding patterns, ...every two to
three hours for maybe five minutes at a time. Three
mothers reported that the child fed more than five times
throughout the night. A mother goes on to explain,
Well, the frequency is frequent. I would say probably
once every two hours from her bedtime onward. Her
bedtime is typically around 8:15 p.m. and it goes on all
night and a good duration of each nursing session is short
probably between five and 10 minutes. These patterns
exhibited by the mothers demonstrate more frequent, but
relatively short feedings because of the on-demand
breastfeeding style that is encouraged with cosleeping.

6.0
pH
5.5

5.0

10

15

Minutes after sucrose rinse

Note. Adapted from Stephan & Hemmens (1947).
Used with permission.

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Maternal Wakefulness While Feeding

Nine mothers reported being awake and fully aware
while nursing throughout the night. A mother described
it as, I have never been unaware of a feeding and my
husband backs this up. Although not every mother
reported being fully aware and awake, five mothers
reported that they were aware but not fully awake. One
mother put it into words by saying, She will wake me
up. Yeah. I mean you are kind of in and out of sleep-and
not fully aware. No mothers reported being totally
unaware of breastfeeding. This finding is noteworthy
because once a mother is aware or awake during a feeding, recommendations can be followed for hygiene

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following that feeding. All of the mothers in our study

were aware or awake enough to be proactive with dental
health following night feedings.
Healthcare Professionals Discussion of Sleep
Location and Breastfeeding
Six mothers reported that their HCP initiated no discussion regarding cosleeping and nighttime breastfeeding.
One mother stated, No, I cant remember it even being
a question-the question about co-sleeping... Only five
mothers reported that their HCPs discussed cosleeping
and night breastfeeding. This lack of conversation limits
amount of anticipatory guidance that can be offered to
these mothers.
Avoidance of Discussing Breastfeeding
and Cosleeping Practices
Eight participants reported avoiding the subject of cosleeping and nighttime breastfeeding with their HCPs.
They admitted to avoiding the subject and intentionally
not telling their HCPs the truth. One participant stated,
I know what the formal recommendation is. I am very
aware of it and I just ignore it. So I just say no. If they
say, is he sleeping on his own? I say yes. I lie.
Although the majority of participants avoided the
subject, withheld information, or were partially honest
with their HCPs, five mothers reported being completely
honest and forthright about sleeping and breastfeeding
patterns with their providers. One mother described,
Like, I thought there would be some friction and there
wasnt. [The pediatrician] was actually supportive. Similar to the lack of conversation initiation by the HCPs,
dishonesty by the mothers makes providing an individualized preventive plan and discussion very difficult, if not
impossible.
Oral Health Advice by Healthcare Providers
The majority (n = 12) of mothers received no oral health
advice from their HCPs. One mother explains, The pediatrician has not discussed oral healthcare. Just recently
at our six month appointment she discussed pros and cons
of fluoride supplementation, but beyond that has not discussed any... no recommendations so far after nursing or
feeding. Another mother stated her pediatrician did offer
some oral hygiene instructions, but these were not very
in-depth, and did not address her specific suggestions
based on the mother choosing to cosleep and breastfeed at
night. The mother clarifies, So, her pediatrician, umm, I
think she asked me if I am brushing her teeth...[she said it]
was not great for her teeth to be nursing through the
night, but I was not sure that was true. Interviewer: Did
she offer any oral health suggestions if you were still currently co-sleeping and night nursing? A: No. None of the
mothers reported an in-depth discussion of oral health or
hygiene instructions initiated by their HCPs.
Previous Breastfeeding Experience
The majority (n = 8) of the mothers had no prior personal breastfeeding experience. Five of these mothers

TABLE 1. Interview Guide

Do you have any prior breastfeeding experience?
If so, please describe.
Tell me about your decision to cosleep.
Please describe, in detail, your pattern of cosleeping.
Please explain the childs position in the bed
How much of the night the child is in the bed
Do you breastfeed your child during the night? If so,
please describe in detail the frequency and duration
that is common.
What are the babys nighttime feeding cues? Are you
aware he is feeding?
Have you had any discussion with your healthcare
provider about cosleeping? Please explain.
Has your healthcare provider ever discussed your childs
dental health with you? Please describe.

were not regularly surrounded by people who were

breastfeeding as an example. In contrast, three of the
mothers had not breastfed before, but had been surrounded by family or friends that breastfed extensively.
One of the mothers described when asked about previous
breastfeeding experience, [Not personally]. But yes, every female in my family breastfed. I was breastfed. All the
children in my family, they are breastfed, so...
The remaining mothers interviewed had either breastfed one child previous to the one discussed in the interview (n = 4) or multiple children (n = 2). Yes. I have two
other children I breastfed as well. It should be noted
that the mothers that have a previous history of successful breastfeeding may have been more motivated and
confident in their decision to bed-share and nurse ad libitum throughout the night.
Pattern of Cosleeping
Four of the mothers stated that their baby starts out in a
crib in his or her own room or in the parents room, but
then switches to sleeping in the bed at some point in the
night. Per one mother, So, when I put him down he usually goes to sleep between 7:00 and 8:00. Now he is in a
crib in our room, he will wake up to be fed around midnight and then I will bring him into the bed.
Other mothers had their child in the bed the entire
night. A mother explained: Well we both go to bed at
8:00 and hewe sleep on our sides facing each other.
The position of the child in the room or in the bed will
greatly affect the childs access to feed ad libitum throughout the night.
Cue to Feed
The question about the cue to feed was added after the
first interview. Nine mothers reported that their baby
had a combination of a verbal and physical cue to breastfeed during the night. One mother goes on to explain,
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Clinical Implications for Healthcare Providers

Initiate the conversation with the mother regarding
cosleeping, night breastfeeding, and oral hygiene.
Encourage honesty regarding cosleeping and night
breastfeeding, even when choices may not be what are
recommended by AAP. A supportive environment is the
only way education can be given to parents in their
real-life situations.
Give oral hygiene anticipatory guidance regarding
specific recommendations for mothers who breastfeed
at night.
Encourage a dental visit and establishment of a dental
home no later than the age of 1.

Well she starts stirring in her sleep and I wake up right

away before she wakes up...then she fully wakes up and
starts whimpering and whining for a snack and then she
gets fed and she falls back to sleep while she is eating.
Two mothers reported physical cues from their child to
breastfeed. A mother described, He grabs for my
breasts.

Clinical Nursing Implications

This qualitative study identifies the need for education
about anticipatory guidance and timing of oral healthcare and hygiene discussions from HCPs. The AAPD recommends the first dental visit by age 1 (AAPD, 2009).
Primary HCPs have the opportunity to examine an infant
several times within the critical first year of life, prior to
the establishment of a dental home. During this first year,
family patterns and habits will be set. Although the dentist will see the child regularly starting at the age of 1,
these primary HCPs have numerous well-child checks, in
addition to sick visits, where they have regular contact
and valuable teaching time with that parent and child
prior to that first birthday.
All of the mothers in the study reported keeping their
child in bed with them for most, if not all, of the night.
Numerous studies show that when a child is in the bed
with the mother, breastfeeding occurs more frequently
than if the mother had to get up to feed the child in his
own room (Blair, Heron, & Fleming 2010; McKenna
et al., 1997). Breastfeeding episodes tend to be frequent
throughout the night with cosleeping as reported by the
mothers in our study. This frequency of exposure to human milk leads to a repeated drop in the childs mouth
pH into the danger zone of the Stephan curve, potentially increasing the risk of dental caries. Although the
true cariogenicity, or cavity-causing ability, of human
milk is low, this frequent drop in pH caused by night
feeding complicates the situation. For example, children
who breastfeed at night and have teeth often consume
other fermentable carbohydrates throughout the day,
similar to other children their age who have teeth that
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are not breastfed or even bottle fed. These carbohydrates are found in many foods such as fruit, crackers,
pretzels, puffs, candy, bread, flavored milk, and juice to
name a few, and these carbohydrates will get incorporated into the plaque on the childs teeth throughout the
day. If this plaque is not properly brushed or flossed off
of the teeth prior to bedtime, it becomes a feast for the
cavity-causing bacteria in the mouth to cause cavities
once the pH of the mouth drops again. Although the
cariogenicity of human milk alone is found to be low
from study to study, plaque from solid foods together
with frequent and prolonged exposure to human milk
complicates the analysis of caries risk (Weerheijm et al.,
1998). Human milk alone may not be implicated in
forming caries, but human milk in the presence of a
carbohydrate-laden plaque does increase a childs caries
risk (Weerheijm et al.). If a toddler who has plaque on
their teeth from eating throughout the day is exposed
repeatedly to human milk, a drop in pH in the mouth
occurs. This frequent drop throughout the night helps
the pH of the mouth to linger in that low pH danger
zone where the enamel of teeth starts to break down in
the presence of cavity-causing bacteria and carbohydrates that have been left on the teeth from the day.
Because of this unique situation, all breastfeeding
mothers could benefit from individualized oral hygiene
instruction, especially once teeth begin erupting around
7 months old. Mothers who breastfeed children with
teeth throughout the night need to know how important it is to start out with a clean slate at bedtime. It
is imperative that the nighttime brushing routine is effective to remove plaque from every surface of the
teeth, including in between the teeth with flossing. All
of the mothers in this study could benefit from targeted
oral hygiene instructions in general, especially regarding instructions after feedings. The mothers in our
study were at least somewhat aware or awake to follow given instructions after a nighttime feeding. With
proper instruction, all of the mothers in this group
would be sufficiently alert to provide oral hygiene following feedings.
Brushing twice a day is encouraged as soon as a tooth
erupts, if not before, to clean the gums and tongue of
milk or formula residue (AAPD, 2009). This can help to
reduce the plaque on the teeth that makes them more
susceptible to the caries process once in the presence of
human milk (Hallonsten et al., 1995). If the child is starting the night with no plaque on the teeth because of good
brushing and flossing habits prior to bed, that child is
already less susceptible to caries while nursing on demand throughout the night, even with the drop in pH in
the mouth (Weerheijm et al., 1998). Mothers should be
instructed to wipe the teeth off at the end of the feeding,
rather than letting the milk residue sit on the teeth. A
mother can keep a clean washcloth and water next her
bed and quickly rub as many of the surfaces of the teeth
as possible once the child finishes a feeding. Although
this may not be as thorough as brushing the teeth
properly, this extra step should help to rid the teeth of

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excess milk residue without completely disrupting the

child. These recommendations would be invaluable to
cosleeping, breastfeeding mothers and the health of their
childs teeth.
Our qualitative study of 14 mothers suggests that few
HCPs initiated a conversation about dental health
recommendations. All women should receive oral hygiene advice tailored to their particular needs. Healthcare
providers have earlier contact with mothers than dentists. This pattern of frequent well visits and longstanding
relationship creates the responsibility for the mother and
childs HCP to be involved in and even initiate this
conversation.
Healthcare providers need to discuss cosleeping and
doing so safely with parents instead of just telling them
not to do it (which is not effective) (Bartick & Smith,
2014). An honest discussion initiated by HCPs about
sleeping and breastfeeding patterns will allow tailored
recommendations regarding specific practices in the
home. These early conversations can help create healthy
habits from the beginning. Establishment of
healthy habits including brushing of the infants teeth
prior to bedtime and wiping the teeth following
breastfeeding will lead to a routine of good oral health
practices. Dentists and HCPs must provide evidencebased advice to mothers regarding infant oral health
and hygiene.
Katie M. Lapps Wert is an Associate Pediatric Dentist,
North Penn Pediatric Dental Associates, and was Chief
Dental Resident (2012-2013) at The Children's Hospital
of Philadelphia and The University of Pennsylvania
School of Dental Medicine, Philadelphia, PA.
Rochelle Lindemeyer is an Associate Professor of
Pediatric Dentistry, and Director, Pediatric Dental
Residency Program, The University of Pennsylvania
School of Dental Medicine, The Childrens Hospital of
Philadelphia, Philadelphia, PA.
Diane L. Spatz is a Professor of Perinatal Nursing &
Helen M. Shearer Professor of Nutrition at the University
of Pennsylvania School of Nursing & Nurse Researcher
& Manager of the Lactation Program at the Childrens
Hospital of Philadelphia, Philadelphia, PA. She can be
reached via e-mail at spatz@nursing.upenn.edu
The authors declare no conflict of interest.
DOI:10.1097/NMC.0000000000000129
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