You are on page 1of 8

ARTICLE

Hypoxic and Hypercapnic Events in Young Infants


During Bed-sharing
AUTHORS: Sally A. Baddock, PhD,a,b Barbara C. Galland, WHAT’S KNOWN ON THIS SUBJECT: Sudden infant death
PhD,a David P.G. Bolton, MRCP, PhD,a Sheila M. Williams, syndrome remains the major cause of postneonatal death in
DSc,c and Barry J. Taylor, MBChB, FRACPa developed countries. Although infant-parent bed-sharing following
Departments of aWomen’s and Children’s Health, and cPreventive antenatal smoking or maternal consumption of alcohol on the
and Social Medicine, University of Otago, Dunedin, New Zealand; and bed-sharing night increases the risk of death, the mechanism is
bSchool of Midwifery, Otago Polytechnic, Dunedin, New Zealand
not known.
KEY WORDS
co-sleeping, infant, oxygen desaturation, rebreathing, WHAT THIS STUDY ADDS: Bed-sharing infants experienced more
thermoregulation, sudden infant death syndrome, sleep
oxygen desaturations and episodes of carbon dioxide rebreathing
ABBREVIATIONS than cot-sleeping infants but showed appropriate behavioral and
AS—active sleep
BS—bed-sharing
physiologic responses. A deficit in these responses in vulnerable
CI—confidence interval infants could link to increased risk of sudden infant death
CO2—carbon dioxide syndrome.
CS—cot-sleeping
HR—heart rate
QS—quiet sleep
Sao2—arterial oxygen saturation
SIDS—sudden infant death syndrome
Dr Baddock participated in the design and coordination of the abstract
study, conception of the behavioral data analysis, carried out the
OBJECTIVES: To identify desaturation events (arterial oxygen satura-
data collection, and drafted the manuscript; Dr Galland
participated in the conception and design of the study and tion [Sao2] ,90%) and rebreathing events (inspired carbon dioxide
helped to draft the manuscript; Dr Bolton participated in the (CO2) .3%), in bed-sharing (BS) versus cot-sleeping (CS) infants.
design of the study and helped edit the manuscript; Dr Williams
conducted the statistical analysis and helped edit the METHODS: Forty healthy, term infants, aged 0 to 6 months who regu-
manuscript; and Dr Taylor participated in the conception and larly bed-shared with at least 1 parent .5 hours per night and 40 age-
design of the study, obtained the funding and helped edit the matched CS infants were recruited. Overnight parent and infant
manuscript. Dr Baddock is guarantor for the study.
behavior (via infrared video), Sao2, inspired CO2 around the infant’s
www.pediatrics.org/cgi/doi/10.1542/peds.2011-3390
face, and body temperature were recorded during sleep at home.
doi:10.1542/peds.2011-3390
RESULTS: Desaturation events were more common in BS infants (risk
Accepted for publication Apr 20, 2012
ratio = 2.17 [95% confidence interval: 1.75 to 2.69]), associated partly
Address correspondence to Sally Baddock, PhD, School of
with the warmer microenvironment during BS. More than 70% of desat-
Midwifery, Otago Polytechnic, Private Bag 1910, Dunedin 9054,
New Zealand. E-mail: sally.baddock@op.ac.nz urations in both groups were preceded by central apnea of 5 to 10 sec-
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). onds with no accompanying bradycardia, usually in active sleep. Apnea
Copyright © 2012 by the American Academy of Pediatrics
.15 seconds was rare (BS infants: 3 events; CS infants: 6 events), as
was desaturation ,80% (BS infants: 3 events; CS infants: 4 events).
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose. Eighty episodes of rebreathing were identified from 22 BS infants and 1
FUNDING: Funding was obtained from the Health Research CS infant, almost all preceded by head covering. During rebreathing,
Council of New Zealand, University of Otago Research Grant, and Sao2 was maintained at the baseline of 97.6%.
a Fanny Evans Scholarship. The funders had no role in study
design; in the collection, analysis, and interpretation of data; or
CONCLUSIONS: BS infants experienced more oxygen desaturations pre-
in the writing of the report or the decision to submit the article ceded by central apnea, partly related to the warmer microenviron-
for publication. ment. Rebreathing occurred mainly during bed-sharing. Infants
were at low risk of sudden infant death syndrome and maintained nor-
mal oxygenation. The effect of repeated exposure to oxygen desatura-
tion in vulnerable infants is unknown as is the ability of vulnerable
infants to respond effectively to rebreathing caused by head covering.
Pediatrics 2012;130:237–244

PEDIATRICS Volume 130, Number 2, August 2012 237


Bed-sharing (BS) has special significance during BS. The aim of this study was to practice (bed-share or cot-sleep) in
in many cultures and is widely practiced investigate the usual sleep practices of their home. The details of recordings
for perceived benefits in parent/infant infants in their own home to identify have been described previously.16 Briefly,
bonding, encouraging breastfeeding, and compare desaturation events (ar- the first night involved video recording
and reducing maternal sleep disrup- terial oxygen saturation [Sao2] ,90%), and the second, both video and physio-
tion1–3 and infant stress.4 The proximity and rebreathing episodes (inspired logic recording. The latter data included
of mother and infant facilitates increased CO2 .3%) between BS infants and CS electrocardiogram, Sao2, and HR (Nellcor
interactions, waking, and breastfeed- infants that could improve under- N-200, Nellcor, Inc, Hayward, CA), re-
ing.5–9 Similar benefits also occur dur- standing of the impact of the different spiratory pattern via chest and ab-
ing early skin-to-skin contact.10 However, environments of BS and CS on infant dominal bands (Respitrace model 150;
many factors are associated with an in- physiology. Respitrace Co, NY), airflow via nasal
creased risk of sudden infant death syn- thermistors, and shin and rectal tem-
drome (SIDS) during infant–parent BS, METHODS perature. The level of CO2 in the mi-
including maternal smoking during pre- Participants croenvironment around the infant’s
gnancy,11 parental consumption of alcohol face was measured (NORMOCAP 200
The power calculation was based on
or sedative drugs,12 excessive parental OXY, Datex Instrumentation Corp, Helsinki,
a study identifying the frequency of
tiredness,13 sleeping on a couch,12,14 Finland) from air sampled through a
high-risk behavior in CS infants.27 From
young infant age,15 and excess bed- catheter attached to midway between
this data, we predicted 50% of BS
ding.13 In this context, it is important to the inner canthus of the infant’s eye
infants and 20% of CS infants were
determine behavioral and environmen- and the lateral edge of the nostrils.
likely to experience a potentially dan-
tal factors that affect infant physiology All leads were secured to allow moth-
gerous event. By using a binomial dis-
and that could increase the risk of SIDS. ers to handle infants freely during
tribution, it was suggested that 40 to 50
the night. All physiologic signals from
The presence of adults in bed, as well as infants were needed to show this dif-
the recording units were relayed
the use of adult bedding (eg, heavy du- ference at the 5% level of significance
through a portable polygraphic system
vets), expose infants to a different envi- with 80% power.
(BabyLog Link; Christchurch Hospital,
ronment compared with sleeping alone in Forty infants who regularly slept in the New Zealand) and stored on a laptop
a cot. A component of this is a warmer parental bed with 1 or both parents for computer. A small surveillance camera
microenvironment, thus raising periph- a minimum of 5 hours per night (BS) (Panasonic CEC-C38, Osaka, Japan) and
eral temperature of BS infants.16 The and 40 age-matched CS infants who infrared light source allowed record-
rectal–shin temperature difference, an slept in a cot or bassinette for at least ings on a video recorder (Panasonic AG-
indicator of thermal comfort,17 is smaller 5 hours per night were studied, as TL700, Osaka, Japan), set to “long play”
in BS infants, indicating a thermolytic previously described.5 Briefly, BS fami- (to enable 15 hours of recording on a
state, whereas in cot-sleeping (CS) in- lies were recruited through local post- 3-hour videotape), of the infant’s sleep
fants it is larger, indicating a state of natal groups and media advertising. CS position, movements, and parent–infant
thermogenesis.16 Patterns of thermo- infants matched for age and season of interactions, as previously described.5
regulation, sleep state, and breathing study were recruited from the postnatal Mothers completed a questionnaire pro-
are tightly linked,18 and elevated body ward of a local hospital. Infants were viding demographic information.
temperatures (hyperthermia) can trig- aged 0 to 6 months and were .37
ger periodic breathing in infants.19 weeks’ gestation (except 2 infants in
each group who were 28 and 32 weeks’ Data Analyses
Most studies of infant sleep physiology
are of solitary sleeping infants, with few gestation, respectively). Desaturation Events
studies describing infants’ responses to The study was approved by the South- A desaturation event was defined as
the BS environment. Polysomnographic ern Regional Health Authority Ethics Sao2 ,90%28,29 lasting for $1 second.
studies of infants at low risk of SIDS Committee, New Zealand (protocol 97/ The events were reviewed in association
report decreased time in quiet sleep 04/036). Informed consent was ob- with electrocardiogram, respiratory
(QS)20 and increases in arousals,21 peri- tained from the parents. pattern, airflow, and inspired CO2
odic breathing,22 inspired carbon dioxide data, and those attributed to move-
(CO2),23 heart rate (HR),24 peripheral16 Study Protocol ment artifact were discarded. For each
and axillary temperature,25 and synchro- Infants were monitored over 2 con- desaturation event, the following mea-
nicity of mother–infant sleep cycles26 secutive nights during their usual sleep sures were taken: the Sao2 nadir and

238 BADDOCK et al
ARTICLE

duration, simultaneous HR (from elec- data for both members of the pair were BS mothers (8% vs 25%) than among
trocardiogram), and inspired CO2. Apneas not always available. The data were CS mothers. The majority of mothers
associated with desaturation events therefore analyzed as 2 groups, and were of European descent, with 10%
were identified and the duration (from a form of regression analysis, adjusted of BS mothers and 18% of CS mothers
the end of the preceding inspiration for infant age and season, was used to identifying as Maori (indigenous New
until the end of the next inspiration) take the matching into account for all Zealanders). Maternal alcohol consump-
measured. Apnea was described as comparisons. Desaturation events were tion was minimal in both groups, ranging
central if there was a flattened trace analyzed by using Poisson or logistic from rarely to 3 glasses of wine or beer
($3 seconds) for both chest and ab- regression to estimate the relative risk per week; 17 of 40 BS mothers and 15 of
dominal movement as well as nasal or odds ratio for the BS group for the 40 CS mothers reported no alcohol
airflow, and as obstructive if respiratory variables based on counts or categories, consumption during pregnancy.
effort was evident without nasal airflow. with the CS group used as the reference.
For the 30 seconds preceding the desa- All comparisons were adjusted for infant
Desaturation Events
turation event, the mean HR, sleep state, age, season of study, and multiple events
and rectal and shin temperatures were per infant but not for breastfeeding There were more desaturation events in
measured. QS was indicated by periods because all BS infants and 35 of the 40 CS BS infants: 255 events were identified
of regular breathing accompanied by infants were breastfed. Almost all re- from 39 BS infants and 123 events from
low HR variation, while active sleep breathe events were observed in the BS 40 CS infants. There was no difference
(AS) was indicated by periods of ir- infants, and thus a group comparison on logistic regression between BS and
regular breathing and HR.18 was not possible. All rebreathe events CS infants with respect to the charac-
were analyzed as 1 group. Regression teristics of events. Most events (85% in
Rebreathing Events analysis, adjusting for multiple events each group of infants) comprised a
Sections of recording in which CO2 was per infant, was used to investigate drop in Sao2 to between 90% and 85%.
.3% were identified (above the level changes in HR, breathing rate, and SaO2 A drop to ,80% was rare (BS infants:
known to stimulate ventilation30). The associated with rebreathe events. Sep- 3 events; CS infants: 4 events). Duration
rebreathe event duration encompassed arate analyses of infants of smoking of events ranged from 2 to 16 seconds,
the rise and fall of that event. The dura- mothers was not possible due to the with 70% lasting ,5 seconds. A central
tion of each rebreathe event, and mean small number of smokers. apnea of 5 to 10 seconds preceded 70%
and maximum CO2 levels, were mea- of desaturation events. Few apneas of
sured. A free of movement artifact 30- .15 seconds were recorded (3 BS in-
RESULTS fants; 6 CS infants). Events mainly oc-
second sample free of movement artifact
that included the maximum level of CO2 BS infants were aged 0 to 6 months, and curred in AS in both groups (AS: BS 61%
was identified, and mean values were CS infants were matched for age and and CS 87%; QS: BS 39% and CS 13%)
calculated for Sao2, HR, respiration rate, season of study. There were no signif- with CS infants less likely than BS in-
and CO2. A 30-second baseline CO2 period icant differences between groups with fants to begin an event in QS (odds ratio:
was identified in the same behavioral respect to mean 6 SD for the following 0.2 [95% confidence interval [CI]: 0.05–
sleep state preceding the rebreathe event. characteristics: infant study weight 0.79]). CIs are large due to the effect of
(BS infants: 6580 6 1301 g; CS infants: multiple observations per infant.
Co2 Cumulative Exposure 6594 6 1265 g), gestation (BS infants: Table 1 shows that the estimated mean
TheBabyLogsoftwarewasusedtoidentify 39.8 6 2.7 weeks; CS infants: 39.5 6 2.7 number of desaturation events (per
all episodes in which CO2 averaged over weeks), birth weight (BS infants: 3583 6 infant per night) were 6.8 for BS infants
5 seconds exceeded either 2%, 3%, or 4% 735 g; CS infants: 3562 6 671 g), or and 3.1 for CS infants, giving a relative
for a minimum of 3 seconds. Episodes maternal age (BS infants: 28 6 5.6 risk of 2.17 (adjusted for sleep time).
during awake time or due to movement years; CS infants: 30 6 5.5 years). The The ratio was practically the same
artifact were deleted, and a cumulative ratio of the number of males compared (2.15) in the 51 infants for whom tem-
time was calculated for each level of CO2. to females was 0.6 for BS infants, 0.55 perature data were available (the lesser
for CS infants. All mothers had some numbers due to parents’ reluctance
tertiary education, most infants were to have infant rectal temperature mea-
Statistical Analyses breastfed (BS infants: 100%; CS infants: sured). Adjusting for the mean overnight
Although BS and CS infants were 88%), and maternal smoking in the sec- rectal–shin temperature difference re-
matched for age and season of study, ond trimester was less common among duced the risk ratio from 2.15 to 1.54,

PEDIATRICS Volume 130, Number 2, August 2012 239


TABLE 1 Number of Desaturation Events per Night in BS Infants and CS Infants, Including the TABLE 3 Characteristics of Rebreathe
Effect of Overnight Temperature Events
Event No. of Infants Estimated Group Mean Risk Ratio P Characteristic Median Range
(Range) (95% CI)
Event duration, min 4 1–59
BS CS Maximum event CO2, % 4 3–5.7
Mean event CO2, % 2.5 1.7–4.7
No. of desaturation events/night Total event duration/infant, min 19 3–154
All 79 6.8 (0–44) 3.1 (0–16) 2.17 (1.75–2.69) ,.001
n = 23 infants, n = 80 observations.
With temperature data 51 8.5 (0–44) 3.8 (0–16) 2.15 (1.69–2.73) ,.001
Adjusted for rectal–shin 51 7.7 (0–44) 3.6 (0–16) 1.54 (1.17–2.02) .002
temperature difference CO2 Cumulative Exposure
Adjusted for age, season, and multiple events per infant.
The cumulative time infants were ex-
posed to .2%, .3%, or .4% CO2 is
indicating that a large part of the dif- event), a decrease to ,70% of base- illustrated in Fig 2. Twenty-seven BS
ference in desaturation events per line occurred for 1 BS event. HR did not infants were exposed to at least 2%
night was associated with the warmer drop to ,90 beats/min during any CO2 compared with only 2 CS infants,
temperature of the BS infants (smaller desaturation. and similarly marked differences were
rectal–shin temperature difference). seen at levels .3%; 1 BS infant was
Furthermore, we calculated that for a 1 Rebreathing Events exposed to .4% CO2 for 4 minutes and
degree decrease in rectal–shin temper- 1 CS infant for 13 minutes.
Eighty rebreathe events were identified
ature difference (ie, warmer microenvi- from 22 BS infants and 1 CS infant
ronment), desaturation events increased DISCUSSION
(Tables 3 and 4). Although the median
by 60% (95% CI: 31–96). duration of an event was 4 minutes, the This study found that infants who bed-
The desaturation events were not as- maximum lasted 59 minutes. The mean share experienced more episodes of
sociated with elevated inhaled CO2 or level of CO2 varied from 1.7% to 4.7%. mild oxygen desaturation associated
with significant changes in HR. The The median total duration of rebreathing with the warmer microenvironment
level of CO2 30 seconds before desatu- per infant per night was 19 minutes, and responded more frequently to re-
ration events was ,0.5% for .70% of but 1 infant (who spent most of the breathe stimuli compared with infants
events in each group (Table 2). A small night with head covered by over- who slept in a cot. More severe desat-
change in HR of 630% from baseline bedding) reached 154 minutes. Mean uration events (,80%) and longer
occurred during the majority of desat- respiration rate increased from 32 apneic events (.15 seconds) were
uration events (HR increased in 175 of to 38 breaths per minute (P , .001), rare but occurred in both groups of
378 events and decreased in 188 of 378 and mean SaO2 was maintained at infants. Infants in this study were
events), whereas an increase of .30% the baseline level of 97.6%, while heart healthy and, based on demographic
from baseline occurred in 4 events rate increased slightly (126 to 129 characteristics, at low risk for SIDS,
(BS infants: 3 events; CS infants: 1 beats/min). and they responded appropriately to
The majority of events (70%) were as- the potential stressors. Epidemiologic
TABLE 2 No. (%) of Desaturation Events sociated with head covering. Of the 5 BS evidence identifies an increased risk
Associated With Varying Levels of associated with BS for vulnerable in-
CO2 at the Infant’s Face infants who spent some time sleeping
prone, events occurred only in 1 while fants, and we hypothesize that an infant
CO2 (%) BS (n = 30) CS (n = 24)a P
face-down into a pillow and another who does not adjust to the microenvi-
0–0.4 200 (78) 84 (71) — ronment created during BS could be at
0.5–0.9 39 (15) 25 (21) — with face into the mother’s chest. Events
1.0–1.4b 9 (4) 8 (7) .79 also occurred in 1 side-sleeping infant increased risk.
1.5–1.9b 2 (1) 1 (1) — with face into a tri-pillow, and in 1 in-
2–2.9b 5 (2) 0 — Rebreathing
.3 0 0 —
fant while the mother breathed directly
Total no. 255 118 — over the infant’s face. Rebreathing BS infants were exposed to more re-
of events events were recorded in 1 CS infant. breathe events than CS infants, com-
Multiple logistic regression adjusted for season, age, and This infant was swaddled in a muslin monly associated with head covering by
multiple events per infant was used for comparison.
a CO data missing for 5 CS desaturation events. No desa-
2
wrap and repeatedly pushed the wrap bedding or mothers’ clothing (during
turation events were identified in the remaining 9 BS over the face (Fig 1). Two CS infants supine or side positioning), and less
infants and 16 CS infants.
b Categories combined into 1 category for analysis due to slept prone for the entire night, but no frequently by the infant’s face into a pil-
low numbers. rebreathing events were identified. low (during prone or side positioning).

240 BADDOCK et al
ARTICLE

TABLE 4 Baseline and Rebreathing Events: Mean 6 SD Values for SaO2, Breathing, and HR the bedding and the infant’s face.38
Event Baseline Rebreathing Event, Difference 95% CI P Infants often remained head covered
CO2 = 0.5% CO2 = 3% for extended periods of time (up to
SaO2, % 97.6 6 1.1 97.6 6 1.2 0.06 6 0.9 –0.2 to 0.3 .637 59 minutes) and maintained oxygen
Breaths per minute 32 6 7 38 6 8 5.6 6 6.0 4 to 7 ,.001
saturation.
HR, beats/min 126 6 12 129 6 11 2.9 6 6.5 1 to 5 .003
n = 23 infants, n = 80 observations. Data are presented as mean 6 SD values for 30-second periods during baseline We and others have shown that in-
conditions and 30-second periods during rebreathing events. creased head covering in BS infants
compared with CS infants is due to in-
creased mobility of the bedding.31,36 We
demonstrated here that infants main-
tained their SaO2, in part due to an in-
creased rate of breathing, as also
shown by Ball.31 The ventilatory re-
sponse to asphyxia is mainly an in-
crease in tidal volume,38 but we could
not measure this because we used an
uncalibrated respitrace system. Our
data indicate that normal homeostatic
FIGURE 1 respiratory responses to the re-
CS infant with head covered by muslin wrap. breathe environment protected these
infants.
However, infants with hypoxemia re-
sulting from an infection may not re-
spond as well,39 and whether the
degree of chronic hypoxia that some BS
infants are exposed to is sufficient
to blunt ventilatory responses is un-
known. The vulnerability of the non-
responsive infant may lie in intrinsic
abnormalities of formation, or imma-
turity of development of certain brain
regions that subserve respiratory and
FIGURE 2 cardiovascular control,40–43 which may
Percentage of infants exposed to varying levels of CO2 over the night’s recording. Numbers in pa- be due to or aggravated by external
rentheses represent the range of minutes of duration of exposure to the corresponding level of Co2.
factors such as maternal smoking
during pregnancy44,45 or prematurity.
Ball31 has also reported more head or the cumulative impact of repeated
covering. The basis for the rebreathe exposure to a mildly hypoxic environ- Desaturation Events
events may be the head covering per ment,37 although, conversely, low levels Desaturation events to ,90% were
se32–35 or the mother breathing over the of CO2 may be protective because of the seen more often in BS infants than in
infant.23 In response, infants may either stimulatory effect of the CO2 on venti- CS infants, although the importance of
increase ventilation effectively33 or re- lation.23 Rebreathe events were iden- this event as a risk factor for SIDS is
move themselves from the rebreathe tified in only 1 CS infant, who was unclear. Episodic apnea46 and periodic
situation or prompt action by the swaddled in a muslin wrap and who breathing47 occur in normal infants
mother.36 Mothers also spontaneously pulled the wrap over her face several and are not observed more frequently
remove bedding during head covering times. Furthermore, there were some in future SIDS victims,48 albeit that an
events,36 indicating the importance of periods when the head could be cov- increase in obstructive apneas has
a responsive mother during BS. Re- ered but with relatively little accumu- been reported.48 We note that almost
breathing may be hazardous due to the lation of CO2, most likely explained by all of the desaturation events in our study
potential asphyxial microenvironment the existence of air channels between were preceded by central apnea and

PEDIATRICS Volume 130, Number 2, August 2012 241


were accompanied by the observation respiration. Whether this also occurs data per study on family behavior,
of a warmer microenvironment, as in older infants is unknown, but it is environmental factors, and infant phys-
similarly observed by Richard et al.22 probably less of a concern in healthy iology. Although the sample size for
Oxygen saturation levels of ,80% were infants with maturation of cardiore- temperature analysis was reduced to
not common and occurred in 2% of spiratory control. 51 infants, it remained considerably
the infants (3 events in BS infants with larger than similar published stud-
4 events in CS infants). Even in these Sleep Architecture ies.12,8,31,59 We monitored infants in
more severe events, desaturation was BS infants have less QS than CS infants, their home, where families might be
not associated with bradycardia. The possibly affording protection due to more likely to carry out usual nighttime
lowest HR recorded in any event was increased arousability in AS.20 However, practices. Our design allowed obser-
90 beats/min. This finding is consis- depression of the hypoxic ventilator vation of infants in their usual sleep
tent with other studies of healthy response occurs in AS,56 and desatu- arrangement rather than a crossover
infants, and apnea without bradycar- ration events were more common in design that requires infants to sleep
dia is considered a normal event.47,49,50 our study in AS. Interestingly, BS infants both in their usual arrangement and
Richard and Mosko24 have reported had a larger percentage of desatura- an assigned arrangement.7,8,31 There
a higher HR with less HR variability in tion events in QS than did CS infants. is evidence to indicate differences in
BS infants compared with CS infants, Richard et al22 reported increased behavior between regular bed-sharers
partly explained by the higher axillary apneas in QS in BS infants associated and occasional bed-sharers.21 Lastly,
temperature. It is of interest that ani- with elevated axillary temperature in we have reported previously that
mal studies have shown that repeated QS only, suggesting a link between the sensors did not affect infant
episodes of hypoxia blunt arousal desaturations, temperature, and sleep behavior.16
responses.37 We suggest that frequent state.
desaturations in vulnerable BS infants Limitations
could be a contributory factor in their Sleep Position The sample population was largely
risk for SIDS. at low risk of SIDS. The low number
Prone sleeping infants up to 5 months of
age and supine infants at 2.5 months are of maternal smokers among the bed-
Thermal Microenvironment
very limited in their ability to remove sharers, together with the high stan-
Thick bedding on adult beds raises dard of maternal education and high
blankets from over their head.57 In this
the in-bed temperature while infant– breastfeeding rate, suggests our sam-
study, few infants were placed prone to
mother contact reduces the surface ple did not cover the full spectrum of
sleep in either group, but the micro-
area available for heat loss,51 leading bed-sharers in which social depriva-
environment could be similar to BS in
to increased infant peripheral tem- tion, low maternal education, smoking,
terms of the warmer microenviron-
perature.16,52 Warmer temperatures and lack of breastfeeding are other key
ment and potential for rebreathing.34,58
can trigger periodic breathing in pre- factors in sudden deaths associated
Increased arousals21 may not be suffi-
mature infants at near term age19 but with BS.60 The main reasons for BS in
cient to protect the infant if the head is
not in very premature infants at 5 days our group were related more to par-
also covered by bedding. We have pre-
of age.53 Body heat loss (and thus en- enting style5 rather than to cultural or
viously reported if the infant’s head is
ergy expenditure) rather than body economic influences.
covered, the mother is involved in
temperature is also associated with
uncovering of the head ∼60% of the
increased frequency and duration of
time, either initiating action herself or CONCLUSIONS
apneic events in premature infants.54
after prompting by the infant.36 This
Skin-to-skin contact in premature in- The presence of the mother and other
suggests a mechanism for the risk of
fants has been shown to have a greater bed-partners, and the physical envi-
BS with a mother impaired by alcohol
effect on bradycardia and desatura- ronment of the adult bed clearly led to
or drugs12 who may be unable to re-
tions than hyperthermic conditions a different sleep environment for the BS
spond to her infant.
induced by elevated incubator tem- infant compared with the CS infant,
perature.55 In that study, skin-to-skin resulting in beneficial and potentially
contact did not raise core tempera- Strengths compromising situations. Infant ho-
ture, but the semi-upright infant posi- We had a large sample size, and mon- meostatic responses and frequent ma-
tion during skin-to-skin contact was itored 40 BS infants and 40 CS infants, ternal interactions seemed to keep
suggested to contribute to the unstable producing ∼10 hours of overnight these low-risk infants safe. However, we

242 BADDOCK et al
ARTICLE

suggest that it is potentially hazardous during pregnancy, is perhaps the most the specific mechanism(s) leading to
for an infant to sleep in the same bed as important message, as well as avoiding their increased vulnerability.
their parent, if the infant and/or mother consumption of alcohol or sedating
are unresponsive. We acknowledge that drugs on the BS night; keeping the ACKNOWLEDGMENTS
BS is a practice valued by many; thus, it infant’s face clear; and avoiding the use We thank the families that participated
is important to identify the specific dan- of thick insulation as overbedding. in this study and Charrissa Makowhar-
gers related to this practice. Keeping the Studies with high-risk infants are re- emahihi and Amanda Phillips for re-
infant smoke-free at all times, including quired to advance understanding of search assistance.

REFERENCES
1. Abel S, Park J, Tipene-Leach D, Finau S, Hazardous cosleeping environments and 23. Mosko S, Richard C, McKenna J, Drummond
Lennan M. Infant care practices in New risk factors amenable to change: case- S, Mukai D. Maternal proximity and infant
Zealand: a cross-cultural qualitative study. control study of SIDS in south west England. CO2 environment during bedsharing and
Soc Sci Med. 2001;53(9):1135–1148 BMJ. 2009;339:b3666 possible implications for SIDS research.
2. Tipene-Leach D, Abel S, Finau SA, Park J, 13. Blair PS, Fleming PJ, Smith IJ, et al. Babies Am J Phys Anthropol. 1997;103(3):315–328
Lenna M. Maori infant care practices: im- sleeping with parents: case-control study of 24. Richard CA, Mosko SS. Mother-infant bed-
plications for health messages, infant care factors influencing the risk of the sudden sharing is associated with an increase in
services and SIDS prevention in Maori com- infant death syndrome. CESDI SUDI research infant heart rate. Sleep. 2004;27(3):507–511
munities. Pac Health Dialog. 2000;7(1):29–37 group. BMJ. 1999;319(7223):1457–1461 25. Richard CA. Increased infant axillary tem-
3. Ball HL. Reasons to bed-share: why parents 14. Tappin D, Ecob R, Brooke H. Bedsharing, peratures in non-REM sleep during mother-
sleep with their infants. J Reprod Infant roomsharing, and sudden infant death infant bed-sharing. Early Hum Dev. 1999;55
Psychol. 2002;20(4):207–222 syndrome in Scotland: a case-control study. (2):103–111
4. Morgan BE, Horn AR, Bergman NJ. Should J Pediatr. 2005;147(1):32–37 26. McKenna JJ, Mosko SS. Sleep and arousal,
neonates sleep alone? Biol Psychiatry. 15. Carpenter RG, Irgens LM, Blair PS, et al. synchrony and independence, among moth-
2011;70(9):817–825 Sudden unexplained infant death in 20 re- ers and infants sleeping apart and together
5. Baddock SA, Galland BC, Bolton DP, Williams gions in Europe: case control study. Lancet. (same bed): an experiment in evolutionary
SM, Taylor BJ. Differences in infant and 2004;363(9404):185–191 medicine. Acta Paediatr Suppl. 1994;397:
parent behaviors during routine bed shar- 16. Baddock SA, Galland BC, Beckers MG, Taylor 94–102
ing compared with cot sleeping in the home BJ, Bolton DP. Bed-sharing and the infant’s 27. Waters KA, Gonzalez A, Jean C, Morielli A,
setting. Pediatrics. 2006;117(5):1599–1607 thermal environment in the home setting. Brouillette RT. Face-straight-down and face-
6. Ball HL. Breastfeeding, bed-sharing, and Arch Dis Child. 2004;89(12):1111–1116 near-straight-down positions in healthy,
infant sleep. Birth. 2003;30(3):181–188 17. Clark RP, Edholm OG. Man and His Thermal prone-sleeping infants. J Pediatr. 1996;128
7. McKenna JJ, Mosko SS, Richard CA. Bed- Environment. London, UK: Edward Arnold (5 pt 1):616–625
sharing promotes breastfeeding. Pediat- Ltd; 1985 28. Brouillette RT, Morielli A, Leimanis A, Waters
rics. 1997;100(2 pt 1):214–219 18. Tappin DM, Ford RP, Nelson KP, et al. KA, Luciano R, Ducharme FM. Nocturnal
8. Pollard K, Fleming P, Young J, Sawczenko A, Breathing, sleep state, and rectal temper- pulse oximetry as an abbreviated testing
Blair P. Night-time non-nutritive sucking in ature oscillations. Arch Dis Child. 1996;74 modality for pediatric obstructive sleep ap-
infants aged 1 to 5 months: relationship (5):427–431 nea. Pediatrics. 2000;105(2):405–412
with infant state, breastfeeding, and bed- 19. Berterottière D, D’Allest AM, Dehan M, 29. Urschitz MS, Wolff J, Von Einem V, Urschitz-
sharing versus room-sharing. Early Hum Gaultier C. Effects of increase in body Duprat PM, Schlaud M, Poets CF. Reference
Dev. 1999;56(2–3):185–204 temperature on the breathing pattern in values for nocturnal home pulse oximetry
9. Gettler LT, McKenna JJ. Evolutionary per- premature infants. J Dev Physiol. 1990;13 during sleep in primary school children.
spectives on mother-infant sleep proximity (6):303–308 Chest. 2003;123(1):96–101
and breastfeeding in a laboratory setting. 20. Mosko S, Richard C, McKenna J, Drummond 30. Haddad GG, Leistner HL, Epstein RA, Epstein
Am J Phys Anthropol. 2011;144(3):454–462 S. Infant sleep architecture during bed- MA, Grodin WK, Mellins RB. CO2-induced
10. Moore ER, Anderson GC, Bergman N. Early sharing and possible implications for SIDS. changes in ventilation and ventilatory pat-
skin-to-skin contact for mothers and their Sleep. 1996;19(9):677–684 tern in normal sleeping infants. J Appl
healthy newborn infants. Cochrane Data- 21. Mosko S, Richard C, McKenna J. Infant Physiol. 1980;48(4):684–688
base Syst Rev. 2007;(3):CD003519 arousals during mother-infant bed sharing: 31. Ball H. Airway covering during bed-sharing.
11. Scragg R, Mitchell EA, Taylor BJ, et al; New implications for infant sleep and sudden Child Care Health Dev. 2009;35(5):728–737
Zealand Cot Death Study Group. Bed shar- infant death syndrome research. Pediat- 32. Campbell AJ, Bolton DP, Williams SM, Taylor
ing, smoking, and alcohol in the sudden rics. 1997;100(5):841–849 BJ. A potential danger of bedclothes cov-
infant death syndrome. BMJ. 1993;307(6915): 22. Richard CA, Mosko SS, McKenna JJ. Apnea ering the face. Acta Paediatr. 1996;85(3):
1312–1318 and periodic breathing in bed-sharing and 281–284
12. Blair PS, Sidebotham P, Evason-Coombe C, solitary sleeping infants. J Appl Physiol. 33. Chiodini BA, Thach BT. Impaired ventilation
Edmonds M, Heckstall-Smith EM, Fleming P. 1998;84(4):1374–1380 in infants sleeping facedown: potential

PEDIATRICS Volume 130, Number 2, August 2012 243


significance for sudden infant death syn- 43. Paterson DS, Trachtenberg FL, Thompson 52. Bystrova K, Matthiesen AS, Vorontsov I,
drome. J Pediatr. 1993;123(5):686–692 EG, et al. Multiple serotonergic brainstem Widström AM, Ransjö-Arvidson AB, Uvnäs-
34. Bolton DP, Taylor BJ, Campbell AJ, Galland abnormalities in sudden infant death syn- Moberg K. Maternal axillar and breast
BC, Cresswell C. Rebreathing expired gases drome. JAMA. 2006;296(17):2124–2132 temperature after giving birth: effects of
from bedding: a cause of cot death? Arch 44. Richardson HL, Walker AM, Horne RSC. delivery ward practices and relation to
Dis Child. 1993;69(2):187–190 Maternal smoking impairs arousal pat- infant temperature. Birth. 2007;34(4):291–
35. Paluszynska DA, Harris KA, Thach BT. In- terns in sleeping infants. Sleep. 2009;32(4): 300
fluence of sleep position experience on 515–521 53. Rieger-Fackeldey E, Schaller-Bals S, Schulze
ability of prone-sleeping infants to escape 45. Campbell AJ, Galland BC, Bolton DP, Taylor A. Effect of body temperature on the pat-
from asphyxiating microenvironments by BJ, Sayers RM, Williams SM. Ventilatory tern of spontaneous breathing in extremely
changing head position. Pediatrics. 2004; responses to rebreathing in infants ex- low birth weight infants supported by
114(6):1634–1639 posed to maternal smoking. Acta Paediatr. proportional assist ventilation. Pediatr Res.
2001;90(7):793–800 2003;54(3):332–336
36. Baddock SA, Galland BC, Taylor BJ, Bolton
DPG. Sleep arrangements and behavior of 46. Hoppenbrouwers T, Hodgman JE, Arakawa 54. Tourneux P, Cardot V, Museux N, et al. In-
K, Harper R, Sterman MB. Respiration fluence of thermal drive on central sleep
bed-sharing families in the home setting.
Pediatrics. 2007;119(1). Available at: www. during the first six months of life in normal apnea in the preterm neonate. Sleep. 2008;
infants. III. Computer identification of breath- 31(4):549–556
pediatrics.org/cgi/content/full/119/1/e200
ing pauses. Pediatr Res. 1980;14(11):1230– 55. Bohnhorst B, Gill D, Dördelmann M, Peter
37. Johnston RV, Grant DA, Wilkinson MH, Walker
1233 CS, Poets CF. Bradycardia and desaturation
AM. Repetitive hypoxia rapidly depresses
47. Horemuzova E, Katz-Salamon M, Milerad J. during skin-to-skin care: no relationship to
arousal from active sleep in newborn lambs.
Breathing patterns, oxygen and carbon di- hyperthermia. J Pediatr. 2004;145(4):499–
J Physiol. 1998;510(pt 2):651–659
oxide levels in sleeping healthy infants 502
38. Patel AL, Harris K, Thach BT. Inspired CO(2)
during the first nine months after birth. 56. Horne RS, Parslow PM, Harding R. Postnatal
and O(2) in sleeping infants rebreathing
Acta Paediatr. 2000;89(11):1284–1289 development of ventilatory and arousal
from bedding: relevance for sudden infant
48. Franco P, Szliwowski H, Dramaix M, Kahn A. responses to hypoxia in human infants.
death syndrome. J Appl Physiol. 2001;91(6): Respir Physiol Neurobiol. 2005;149(1–3):
Decreased autonomic responses to ob-
2537–2545 257–271
structive sleep events in future victims of
39. Parkins KJ, Poets CF, O’Brien LM, Stebbens sudden infant death syndrome. Pediatr 57. Skadberg BT, Markestad T. Consequences
VA, Southall DP. Effect of exposure to 15% Res. 1999;46(1):33–39 of getting the head covered during sleep in
oxygen on breathing patterns and oxygen infancy. Pediatrics. 1997;100(2). Available
49. Hunt CE, Corwin MJ, Weese-Mayer DE, et al;
saturation in infants: interventional study. at: www.pediatrics.org/cgi/content/full/100/
Collaborative Home Infant Monitoring Eval-
BMJ. 1998;316(7135):887–891 2/E6
uation (CHIME) Study Group. Longitudinal
40. Duncan JR, Paterson DS, Hoffman JM, et al. assessment of hemoglobin oxygen satura- 58. Kemp JS, Thach BT. A sleep position-
Brainstem serotonergic deficiency in sud- tion in preterm and term infants in the first dependent mechanism for infant death on
den infant death syndrome. JAMA. 2010;303 six months of life. J Pediatr. 2011;159(3): sheepskins. Am J Dis Child. 1993;147(6):
(5):430–437 377–383.e1 642–646
41. Broadbelt KG, Barger MA, Paterson DS, 50. Ramanathan R, Corwin MJ, Hunt CE, et al; 59. McKenna J, Mosko S, Richard C, et al. Ex-
et al. Serotonin-related FEV gene variant in Collaborative Home Infant Monitoring Eval- perimental studies of infant-parent co-sleeping:
the sudden infant death syndrome is uation (CHIME) Study Group. Cardiorespi- mutual physiological and behavioral influ-
a common polymorphism in the African- ratory events recorded on home monitors: ences and their relevance to SIDS (sudden
American population. Pediatr Res. 2009;66 comparison of healthy infants with those at infant death syndrome). Early Hum Dev. 1994;
(6):631–635 increased risk for SIDS. JAMA. 2001;285 38(3):187–201
42. Filiano JJ, Kinney HC. A perspective on neu- (17):2199–2207 60. James C, Klenka H, Manning D. Sudden in-
ropathologic findings in victims of the sud- 51. Karlsson H. Skin to skin care:heat balance. fant death syndrome: bed sharing with
den infant death syndrome: the triple-risk Arch Dis Child Fetal Neonatal Ed. 1996;75 mothers who smoke. Arch Dis Child. 2003;
model. Biol Neonate. 1994;65(3–4):194–197 (2):F130–F132 88(2):112–113

244 BADDOCK et al