Western societies

In Western societies the practice of mothers, fathers and infants sleeping together came to be thought of as unhealthy and dangerous. Western parents are taught that “co-sleeping” will make the infant too dependent on them, or risk accidental suffocation but these views are not supported by human experience worldwide, where for millions of years, infants as a matter of course slept next to at least one caregiver, usually the mother, in order to survive.

Many studies have shown that separation of the mother and infant has adverse consequences and anthropological considerations also suggest that separation between the mother and infant should be minimal. Although Western countries tend to stress autonomy from a very early age in many other cultures, both day and night, infants are rarely separated from their mother in the first year of life.

This arrangement helps regulate the infant’s breathing, heart rates and body temperature
and allows the caregiver to respond quickly if the infant cries, chokes, or needs its nasal passages cleared, its body cooled, warmed, caressed, rocked.

Human babies have a long period of development after birth, which takes place at a very fast rate, and requires a lot of energy. Like the time spent in deep sleep, the infant’s hunger cycle is short and although babies have good sensory development of touch, smell, taste, sight and sound, because they are unable to cling on they rely upon being carried in arms to remain close to their mothers.

All of which seems to indicate that the custom of separating infants from their parents is more the result of cultural history than of fundamental physiological or psychological infant needs.

Present-day UK sleeping arrangements — sleeping alone or in pairs in warm, quiet, private rooms with spacious beds — is a relatively recent historical development. Special rooms for bedrooms, special clothes for sleeping, and separate sleep locations for parents and children became popular as working people began to earn disposable income. As houses and living arrangements changed, so did our sleep behaviour, and our attitudes about infant sleep.

Nowadays parents can feel under pressure to help their babies become independent from an early age. Popular myths suggest ‘good’ babies sleep through the night, sleep alone, and do not require attention in the night. As a result, parents may try to ‘help’ their baby ‘sleep through’ as early as possible. But expecting a human baby to sleep alone, and for prolonged periods, is unrealistic and can be harmful. The mismatch in what today’s parents might expect or desire regarding infant sleep, and their baby’s biological abilities regarding sleep, may lead to unnecessary conflicts.

Around the world babies sleep in many different ways. In many places, babies and mothers are in continuous contact, regardless of time of day or night. Babies sleep on the mother’s body or close to her, often in some form of carrying device during the day, and in her sleep space at night. Babies fall asleep while their mother works and/or completes her daily activities. These babies do not require silence or darkness to sleep, and they are not expected or ‘trained’ to conform to a schedule.

Sleep, Health, Safety

Babies operate according to their internal biological rythms and may take several months for their daytime nightime sleep pattern to become established. Many parents need to be reassured that this is normal and those that are unhappy with their infants sleep development may need to re-assess their expectations regarding their babies sleep time and needs.

SIDS is the name given to the unexpected death of an infant for which there is no known cause. Such deaths commonly occur during sleep and can happen wherever babies sleep. No sleep environment is 100% risk-free, Guidance on reducing the risk of SIDS also covers keeping babies safe from sleep-related accidents. Accidents which can occur wherever babies sleep, and parents need to be aware of their baby’s sleep environment.

There are several ways in which a baby’s sleep affects their own health and that of their parents. Although Sudden Infant Death Syndrome is the most well known of these, sleep related accidental deaths and injuries also happen, and non-accidental harm can occur to infants in sleep-related settings. Lack of sleep related to caring for a baby can also affect parents’ health, particularly in the case of depression and accidents.

Falling asleep with a baby on a sofa or an arm-chair is associated with wedging and compression accidents where babies are trapped between the furniture and their parent’s body. Placing a baby alone on an adult bed is associated with accidents where babies fall and become trapped between the bed and a wall, or between the bars of an open headboard.

Babies can also be at risk when tiredness and frustration spill over into anger in situations where carers are sleep-deprived and/or infants cry inconsolably. Many parents experience momentary feelings of helplessness and desperation, especially when trying to cope alone.

Sleep is a developmental process, and newborn babies may sleep for 18 or so hours a day, but often for only for 2-3 hours at a time. During the first year overall sleep duration falls to around 15 hours, and the majority of sleep becomes concentrated during night-time as circadian rhythms develop.(Our body clock, the 24-hour cycle that rules us all and is affected by outside sources such as sun rise and time zones).

Night waking is normal during early infancy and healthy babies experience several awakenings a night at the close of sleep cycles. Newborn babies have very small stomachs and as human milk is quickly digested babies commonly need to feed frequently throughout the day and night-time.

By the time babies are 3 months old some (but not all) begin to start settling (sleeping through a night-time feed for a stretch of up to 5 hours). By the time they are 5 months old half of them may have started to sleep for an eight-hour stretch on some nights. Generally, though, babies do not sleep all night-every night until they are close to a year old. One study investigating infant sleep duration found that 27% of babies had not regularly slept from 10pm to 6am by the age of 1 year. 13% of babies had not regularly slept through for 5 hours or more by the age of 1 year.?

However it is normal for babies – especially breastfed babies – to wake and feed at night throughout at least the first year.?Encouraging babies to ‘sleep through’ before they are ready to do so makes it difficult to keep on breastfeeding, and may encourage babies to develop mature sleep patterns out of sequence with their other circadian patterns such as those controlling the regulation of temperature, hormone production, and the genes that control our biological rhythms.

Why Babies Sleep As They Do

One thing that is clear from considering the anthropology of infant care is that how we feed babies is intimately linked to how babies sleep, and what is biologically normal in an evolutionary sense. For this reason the information presented in ISIS (Infant Sleep Information Source)will often discuss differences in sleep behaviour between babies who are fed human milk, and those who are fed infant formula, as formula (which is based on cow’s milk or soya protein) is a recent invention, and therefore is a type of food that babies have not biologically evolved to expect.

Vulnerable Human Babies and their Large Brains

Humans fit in to the mammalian precocial pattern in some ways (in which the young are relatively mature and mobile from the moment of birth) We are usually born singly, have good sensory development (sight, hearing etc) at birth and are fed with milk that is similar in composition to other precocial mammals, that of high calorie, low fat, quickly and easily digested. However we also have a smaller proportion of our adult brain development completed by the time of birth than do other primates, which means human babies have some secondarily altricial traits (where the young are born helpless).

In particular we are unable to cling or walk for months following birth, and are less able than other primates to regulate some of our biological systems — including temperature control, heart rate and breathing. This means that human infants are totally dependent on their caregiver to keep them close, to provide warmth and protection, to ensure frequent access to maternal milk, and to help regulate aspects of their physiology.

Where Babies Sleep

Nowadays we are able to keep babies alive, warm, fed, and safe, without their mothers’ bodies. Cribs were constructed, formula was devised, incubators were invented, and over the past century products became central in infant care. How we incorporate babies into our 21st century world, and how we might adapt today’s lifestyles to accommodate our babies needs, are not things we often think about — but perhaps we should. Where we expect, encourage, and enable babies to sleep is just one of these issues.

Finding the right path through all the potential risks and hazards for babies in today’s environment can seem difficult. And even when you have thought ahead and planned carefully to avoid the known risks, how do you cope with a baby who suddenly won’t or can’t sleep in the proper place, in the approved way, at the appropriate time?

How can you make the other options as safe as possible, and prevent yourself from doing something dangerous? What are the least risky next options?

Room-Sharing

Having your baby sleep near you reduces the risk of Sudden Infant Death Syndrome and makes night-time care easier.

Having your baby sleep in a cot in the same room as you until they are 6 months old is a key piece of advice given to new parents. There are two main reasons for this:

Firstly, a number of studies across Europe, in England, the United States and New Zealand have shown that babies sleeping in their parents’ room have a lower risk of sudden infant death syndrome (SIDS) compared to babies sleeping in a separate room. The amount by which room sharing reduces the risk of SIDS is large:

A study looking at SIDS cases in 20 locations across Europe estimated that 36% of SIDS deaths could have been prevented if the baby had slept in a cot in the same room as the parents.?
Secondly, research on mothers and babies after delivery suggests that compared to sleeping baby alone, sharing a room has other benefits, such as:

• Night-time feeding is easier
• Babies cry less when close to their parent/s.
• More sleep for parents and babies.
• Parents’ Bed

Babies sometimes sleep with their parents. This has pros and cons that everyone should be aware of.

Many parents bring their baby into their bed to sleep, but for the majority of babies this is not where they always or usually sleep. Bed-sharing mostly happens for part of the night, or for a couple of nights a week. Sleeping with baby in an adult bed (bed-sharing) is common. Studies have found that around 50% of all UK babies have bed-shared by the time they are 3 months old.?

Official advice discourages bed-sharing when it can be dangerous.

Some studies have found an increased risk of SIDS for babies who sleep with parents.

The biggest UK SIDS study (the CESDI study) which collected data between 1993 and 1996 found no increased SIDS risk with bed-sharing for non-smokers, or for babies aged more than 14 weeks.?
The most recent UK study (conducted between 2003 and 2006) found that smoking, alcohol use and sofa-sharing explained the risk associated with SIDS deaths that happened when babies were co-sleeping? with an adult.?
The Scottish cot-death study (conducted between 1996 and 2000) found that bed-sharing was associated with a greater risk of SIDS for babies aged under 11 weeks. In this study no data are reported for smoking in pregnancy, or alcohol consumption.?
The Irish cot death study (conducted between 1994 and 2001) found bed-sharing was associated with greater risk of SIDS for babies under 10 weeks of age, but not for babies older than 10 weeks or for babies whose mothers did not smoke in pregnancy.?
The most recent studies have shown that most bed-sharing deaths happen when an adult sleeping with a baby has been smoking, drinking alcohol, or taking drugs (illegal or over-the-counter medicines) that make them sleep deeply.

If you smoke, drink alcohol, or take drugs or medication your baby will have a lower risk of unexpected death if s/he sleeps on a separate surface such as a cot next to your bed.

Though many may assume that co-sleeping means that parents and baby share the same bed, Dr. William Sears, a well-known pediatrician and author of many parenting books, defines co-sleeping as sleeping within arm’s reach of the baby.

People bed-share for many reasons; the most common reason is to breastfeed in the night. Breastfed babies need to nurse frequently because human milk is easily digested, and frequent nursing helps mothers to make sufficient milk.

Bed-sharing is strongly associated with breastfeeding: 70-80% of breastfed babies sleep with their mother or parents some of the time in the early months, and many studies have found that mothers and babies who bed-share breastfeed for much longer than those who sleep apart.?

Other people bed-share for bonding, especially if they have to leave their baby during the day; others do so when their baby is ill, to be able to pay close attention; sometimes people bed-share because they cannot afford a cot/crib.?

Sometimes people fall asleep with their babies accidentally or without meaning to. This can be very dangerous, especially if it happens on a couch/sofa where a baby can get wedged or trapped between the adult and the cushions.

Before you bed-share, consider whether YOU are happy it is safe for YOUR baby.

Room Alone

Having a baby sleep in a separate room increases the risk of Sudden Infant Death Syndrome (SIDS) and makes it more difficult to respond quickly to their needs.

Official guidelines tell parents to keep babies in their parent(s) room until they are 6 months old. This is because the risk of SIDS (cot death) is greater for babies who sleep on their own compared to sleeping in the presence of an adult.

The largest UK study (CESDI)? found that out of 321 babies whose death was classified as SIDS, 114 died when they were alone in a room, compared to 81 who were room-sharing.
Despite this advice some parents have their baby sleep in its own room from birth because they have prepared a room for the baby, and others move their baby to a separate room at around 3 months of age (babies are most at risk of SIDS at 2-3 months of age).

Sometimes this is because there is no room for a cot/crib in the parents’ room when a baby outgrows a Moses basket. Other times it is because the baby is preventing one or both parents from sleeping.

These are other options you could consider:

1. If there is no room for the baby’s cot in your room, could you fit a single bed in the baby’s room where a parent could sleep near to the baby?
2. If the baby is disturbing one parent who needs to be alert for work, could that parent sleep in a separate room for a while instead of the baby?
3. Newborn babies wake frequently and need feeding and attention at night for several months. If a baby is in a separate room it can be difficult to know when it wakes or needs attention. Baby monitors allow you to hear your baby, but many models don’t allow the baby to hear you and know that you are nearby.

In order to get their parents’ attention babies who are in a separate room may have to cry loudly and it can take a long time to calm them down enough to feed or to return to sleep. While self-soothing is something babies can start to do when they are older, young babies may not be ready to self soothe, or to sleep for long periods, and there is a lack of evidence about the harms or benefits of sleep training regimes that involve leaving babies alone to cry.

Sofa-Sharing

Adults sometimes fall asleep with babies on sofas. This can be very hazardous.

Sleeping with a baby on a sofa or an armchair can be very dangerous for babies because the risk of suffocation, or becoming trapped, is much greater on a sofa or arm-chair than in a bed.

Babies can become wedged between a parent’s body and the back of a couch or the arm of a chair and the weight of the adult’s body can prevent them from breathing.

A recent UK study (conducted between 2003 and 2006) found that 16% of SIDS babies had died while sleeping with an adult on a sofa. In comparison only 1% of the control babies (a matched-comparison group of babies who did not die) slept on a sofa with an adult.

This increase has happened at a time when SIDS deaths in all other environments have been falling (associated with parents placing their babies to sleep on their backs instead of their fronts). It may be due to an increase in parents choosing to feed and settle babies on the sofa rather than in the parents’ bed.

The sofa is the only sleep environment in which SIDS deaths have increased in recent years, up from 6% in 1993-6 to 16% in 2003-6.

Health officials in some Western countries promote the message that sleep contact between the mother and infant increases the chances of the infant dying from sudden infant death syndrome (SIDS). But the research on which this message is based only indicates that bed-sharing can be dangerous when it occurs in the context of extreme poverty or when the mother is a smoker or takes alcohol and/or drugs.

Some researchers have attempted to export this message to other cultures. However, in Japan, for example, where co-sleeping is the norm, SIDS rates are among the lowest in the world..

The Foundation for the Study of Infant Deaths (FSID) and the department say categorically that the safest place for a baby is in a cot in the parents’ bedroom. Babies must sleep alone.
However advice to discourage bed sharing may carry with it the danger of tired parents feeding their baby on a sofa, which carries a much greater risk than sleeping in the parents’ bed,”

Although most new parents think that they will never sleep with their baby, research shows that many do so for various reasons. On any given night a fifth of all UK babies spend at least part of the night sleeping with one or both of their parents. In addition to the increased risk of SIDS that is associated with bed-sharing and smoking, alcohol and drug use, there is also a risk of accidents when adults sleep on the same surface as a baby.

In order to reduce the chance of accidents it is important parents are informed about bed-sharing safety, whether or not they intend to do it, as parents sometimes fall asleep with their babies when they don’t mean to – especially during night-time feeds.

The National Childbirth Trust (NCT), the country’s leading parenting organisation (and champions of breastfeeding) claim;

“It is clear from surveys that around half of parents sleep with their babies at some point in the first six months, and around a quarter do so routinely, so we need to help them to do this in the safest way possible.”

For those mothers that do co sleep ‘don’t smoke, drink or take drugs’ is consistently repeated especially for those who breastfeed.

Benefits:

• Many parents, both those who consider themselves to be attachment parents and those who do not, believe that shared sleep has many advantages and claim
• Infants who co-sleep go to sleep faster and stay asleep longer. More mothers who co-sleep report feeling better rested. It promotes breastfeeding by making night feedings easier. Some research suggests that infants who co-sleep have stronger emotional relationships with their parents and with other people.

Safety Recommendations

The Department of Health advises that bed-sharing should be avoided if one or both parent

• Is a smoker.
• Has consumed alcohol.
• Has taken any drugs, prescription or otherwise, that affect perception, cause drowsiness or affect depth of sleep.
• Is excessively tired to the extent that this might affect being able to respond to the baby.

The risks of co-sleeping are also increased if your baby:

• Was born premature (37 weeks or less).
• Had a low birth weight (less than 2.5kg or 5.5lb).
• Has a fever or any signs of illness.

If you co-sleep, you need to:

• Make sure your baby can’t fall out of bed.
• Keep your baby cool by using sheets and blankets rather than a duvet.
• Always put your baby to sleep on her back rather than her front or side.
• If she is in a cot by the side of your bed, make sure she can’t wriggle down under the blanket by putting her in the ‘feet to foot’ position with her feet at the bottom of the cot, rather than her head at the top.
• Don’t use a pillow – babies don’t need a pillow until they are one year old.
• Never risk falling asleep with your baby on a sofa or armchair.

For those parents who do routinely sleep with their baby in bed the most important thing is do it in the safest possible way. Women who breastfeed and co-sleep generally have a ‘c’ shape around their baby so she is protected from the pillow or blanket covering her face.

‘The few psychological studies which are available suggest that children who have “co-slept” in a loving and safe environment become better adjusted adults than those who were encouraged to sleep without parental contact or reassurance.

Sleep laboratory studies have shown that co-sleeping, instead of sleeping in separate rooms, almost doubled the number of breast-feeding episodes and tripled the total nightly duration of breast-feeding. Infants cried much less frequently when sleeping next to their mothers, and spent less time awake.Scientific studies of mother and infants sleeping together have shown how tightly bound together the physiological and social aspects of the mother-infant relationship really are’.

Resources and Information about bed-sharing safety

NCT – www.nct.org.uk / UNICEF/FSID ‘Sharing a Bed with you Baby’ leaflet available on many websites /‘Caring for your baby at night’ leaflet on the UNICEF website / http://www.isisonline.org.uk, (Infant sleep information source) / Dr. James J. McKenna Professor of Anthropology and the Director of the Center for Behavioral Studies of Mother-Infant Sleep, Notre Dame University cosleeping.nd.edu /Dr.Peter Fleming, Professor of Infant Health and Developmental Physiology University of Bristol

ISIS – www.isisonline.org.uk
ISIS is a collaboration between Durham University Parent-Infant Sleep Lab, La Leche League, NCT, and UNICEF UK Baby Friendly Initiative, funded by a grant from the ESRC (Economic and Social Research Council).

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Editor, Peter Walker, February 2013
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