Co-sleeping

Curriculum Objectives: 1.) To understand the definition of co-sleeping. 2.) To become aware of cultural beliefs about co-sleeping. 3.) To be familiar with benefits and dangers of co-sleeping. 4.) Be able to counsel parents on recommended sleeping habits. 5.) Be able to educate parents on co-sleeping and its relation to SIDS.

Clinic Case: A new mother presents to her sons first well child care visit after being discharged from the hospital. The baby is 4 days old. She has a few questions regarding the babys sleep environment. The mother asks about the safest placed for the baby to sleep. Although while in the hospital the residents recommended placing the child flat on his back in a crib or basinet, mom hands you an article she found on the internet titled, The benefits of co-sleeping: lower your babys risk of stress disorders, SIDS, and more. What is the definition of co-sleeping? Co-sleeping is an umbrella term that includes the practice of bed sharing with a caretaker or other family members, proximate sleeping arrangements, and room sharing during sleep. It is further defined as an isolated event occurring under extraordinary circumstances such as illness, also known as reactive co-sleeping. It can be an occasional phenomenon occurring on a regular nightly basis, described as habitual co-sleeping. In addition, a distinction is sometimes made between all-night and part-night co-sleeping. What are the cultural practices? A baby must not sleep in an empty room alone, and an adult must keep watch next to it. (Korean Proverb) Co-sleeping of infants and parents is common and accepted in the majority of cultures around the world. The prevalence of regular bed sharing was 18.2% and as high as 55.8% in 7-yearolds in a recent study conducted in urban mainland China. Research has shown that in Korea, 73.5% of mothers approved bed sharing between ages 3 and 6 years of age. Many Asian societies emphasize cultivating mutual dependence, not independence as appropriate developmental goals. Co-sleeping in the United States has been associated with child sleep problems, low socio-economic status, single parent status, parent shift work, and family

history of co-sleeping. African Americans, Hispanic, and South-east Asians have higher rates of co-sleeping. As many as 50% to 70% of African American families habitually co-sleep with their infant children.

What are the American Academy of Pediatrics guidelines on co-sleeping with an infant? One serious potential consequence of co-sleeping, an increase risk of sudden infant death syndrome, has been debated in literature over the past several years. Large-scale epidemiologic studies have shown that high risk situations like maternal obesity, smoking, alcohol, drug use, overcrowding and the use of non-bed sleeping surfaces like couches and chairs may increase the risk of accidental suffocation. Many of these contexts are particularly prevalent in urban poor families. These findings have prompted the AAP to issue a recommendation against bed sharing with an infant in the first year of life. What are the potential benefits of co-sleeping? Supporters of co-sleeping believe this practice encourages breastfeeding by making nighttime breastfeeding more convenient and easier for a nursing mother to get her sleep cycle in sync with her baby's. Co-sleeping helps babies fall asleep more easily, especially during their first few months and also helps them fall back asleep when they wake up in the middle of the night. Many think that it helps babies get more nighttime sleep. Some people believe that cosleeping has a calming effect on the infant and as a result reduces the incidence of stress disorders later in the childs life. Finally, bed sharing helps parents who are separated from their babies during the day regain closeness with their infant. How does co-sleeping affect infant independence? According to Dr. Calvin Colarusso, Clinical Professor of Psychiatry at the University of California, San Diego, the major task of parents is to assist young children in the process of separation-individuation. He asserts that this process of independence begins by solitary sleeping. According to Dr. Martin Stein, Professor of Pediatrics at the same institution, it is an oversimplification to state that a specific event is required for successful individuation. He feels that as long as the infant is independent in many other tasks, co-sleeping can be thought of as psychological refueling or rapprochement that allows the child greater psychological energy to be directed to daytime functions that lead to separation and individuation. Other researchers have added that no study has shown that the goals for separateness and

independence are obtained in the individual by separate sleeping arrangements for parents and children. What are the dangers of co-sleeping? The U.S. Consumer Product Safety Commission (CPSC) warns parents not to place their infants to sleep in adult beds, stating that the practice puts babies at risk of suffocation and strangulation. According to the CPSC, at least 515 deaths were linked to infants and toddlers under 2 years of age sleeping in adult beds from January 1990 to December 1997. 121 of the deaths were attributed to a parent, caregiver, or sibling rolling on top of or against a baby while sleeping. More than 75% of the deaths involved infants younger than 3 months old. In 2003, one study compared the risk of suffocation in cribs and adult beds. For infants under 8 months of age the risk of death in cribs during a 4-year period (1995-1998) was significantly lower than the risk of death in adult beds. They also found an increase in the number of reported suffocation deaths from the 1980s to the 1990s involving adult beds. Increased reporting and diagnostic shift are thought to explain these findings. Unexplained deaths that were once diagnosed as SIDS are now being reported as cases of accidental suffocation. Adult beds propose many hidden hazards for infants. Suffocation can occur when an infant gets trapped or wedged between a mattress and headboard, wall, or other object. Soft bedding such as pillows, blankets, and quilts are common on adult beds, which can also lead to suffocation if a baby is face-down. Finally, strangulation in a bed frame can occur when part of an infant's body can pass through an area allowing the babys head to become trapped. Can co-sleeping cause Sudden Infant Death Syndrome? Several studies have been done in an attempt to answer this question. Bed sharing has not been proven to reduce the risk for sudden infant death syndrome (SIDS) and might actually increase SIDS risk, according to an AAP policy statement published in the August 1997 Pediatrics. "While the practice of bed sharing has been shown to offer certain benefits, no scientific studies have demonstrated that such co-sleeping reduces SIDS," the policy states. In large epidemiologic studies of SIDS, it seems that sleeping in a parents room without bedsharing confers the least risk. Sharing a sleep surface with a caregiver has the most risk and sleeping in another room is considered intermediate risk. What are some other options for parents who desire to sleep next to their infant?

A bassinet, play yard, or crib next to your bed can help maintain the desired closeness, which can be especially important if you are breastfeeding. The AAP states that having an infant sleep in a separate crib, bassinet, or play yard in the same room as the mother reduces the risk of SIDS. Parents can also buy a device that looks like a bassinet or play yard but lacks one side. It is then which attached to the bed and allows a caregiver to be next to the infant while eliminating the possibility of rolling over onto the child.

If parents still decide to co-sleep with their child what are some safe recommendations you can tell them?

Always place the baby on his or her back to sleep to reduce the risk of SIDS. Always leave the child's head uncovered while sleeping. Make sure the bed's headboard and footboard don not have openings or cutouts that could trap the baby's head. Make sure the mattress fits snugly in the bed frame so that the baby won't become trapped in between the frame and the mattress. Don't place a baby to sleep in an adult bed alone. Don't use pillows, comforters, quilts, and other soft or plush items on the bed. Don't drink alcohol or use medications or drugs that may keep someone from waking and may cause the person to roll over onto, and therefore suffocate, the baby. Don't place the bed near draperies or blinds where the child could be strangled by cords.

In conclusion, the AAP does not recommend bed sharing with an infant in the first year of life. However, because there is evidence condemning and also supporting co-sleeping, families should be given the pros and cons. It is important to maintain the role as the medical informant and keep the lines of communication open so that families continue their alliance with the physician.

References 1. Cortesi, F et al. Cosleeping and Sleep Behavior in Italian School-Aged Children. Journal of Developmental and Behavioral Pediatrics. February 2004; vol 25: 28-33. 2. Stein, Martin T. et al. Cosleeping (Bedsharing) Among Infants and Toddlers. Journal of Developmental and Behavioral Pediatrics. April 2001; vol 22: s67-s71. 3. Owens, Judith A. Cosleeping. Journal of Developmental and Behavioral Pediatrics. August 2002;vol 23: 254-255. 4. Kelley, C. Should Infants Sleep with their Parents? Archives of Pediatrics and Adolescent Medicine. Nov 2000; vol 154: 1171-1173. 5. AAP Task force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing Concepts of SIDS: Implications for Infant Sleeping Environment and Sleep Position. Pediatrics. Mar 2000; vol105, No. 3: 650-656. 6. Scheers, NJ et al. Where Should Infants Sleep? A Comparison of Risk for Suffocation of Infants Sleeping in Cribs, Adult Beds, and Other Sleeping Locations. Pediatrics. October 2003; vol 112, No. 4: 883-889.

Amy Francis DO Reviewed by Kyran Quinlan